Cyclothymic disorder, also known as cyclothymia, is an under-diagnosed and under-studied illness. Many people receive the right diagnosis after many years of being sick (and possibly misdiagnosed).
Cyclothymic disorder is typically thought of as a mild mood disorder, but it can actually be very serious, severe, and debilitating. According to the Diagnostic and Statistical Manual of Disorders (DSM 5), cyclothymic disorder is characterized by numerous periods of hypomanic symptoms that don’t meet criteria for a full episode for hypomania and numerous periods of depressive symptoms that don’t meet criteria for major depression for at least 2 years.
The depressive and hypomanic states are highly variable in their duration, severity, and symptoms. Depressive periods tend to be mild to moderate with symptoms of anguish, despair, and fatigue. Hypomanic periods are particularly hard to detect because they’re brief and typically “dark,” such that symptoms include irritability, impulsivity, unpredictability, hostility, and risk taking.
Mood fluctuations tend to be abrupt, and depressive mixed states—when both depressive and hypomanic symptoms are present—occur regularly. Cyclothymia also can progress into bipolar disorder.
Individuals with cyclothymia have a tendency to over-react to both positive and negative events. That is, when something positive happens, individuals can quickly become joyful, enthusiastic, excessively euphoric, and impulsive. When something negative happens, individuals might experience anguish, desperation, sadness, and, sometimes, suicidal thoughts.
Individuals with cyclothymia also report low self-worth, guilt, insecurity, dependence, extreme irritability, and anxiety. Symptoms can take a significant toll on relationships.
According to a 2015 review article, “the moodiness, impulsivity, and interpersonal problems of cyclothymic patients are similar to those described in DSM 5 cluster B personality disorder.”
The research on cyclothymic disorder, particularly its treatment, has been scarce. However, we do know that medication, psychoeducation, and therapy can be very helpful. So even though more data and well-designed studies are needed, you can absolutely get better, make significant progress, and recover.
The research on evidence-based psychotherapy for cyclothymia is virtually nonexistent. Experts on cyclothymic disorder have stressed the importance of psychoeducation—which should be different from psychoeducation for bipolar disorder.
According to a 2017 article, “psychoeducational models for BD I cannot fit with the main psychological, behavioral and interpersonal features related to cyclothymia and may induce in cyclothymic patients the unpleasant feeling of not being understood.”
Articles on cyclothymia mention the development of a psychoeducation program by the Anxiety and Mood Center team in Paris, France. It consists of six weekly 2-hour sessions, where individuals learn about causes, medication, monitoring mood swings, identifying warning signs, coping with early relapse, and establishing healthy routines. They also explore emotional dependency, sensitivity to rejection, and excessive people-pleasing behavior, along with addressing thoughts and interpersonal conflict.
Cognitive behavior therapy (CBT) also might be valuable. CBT can be adapted to help individuals with cyclothymia with specific concerns. For example, CBT can help with recording mood and energy and establishing daily routines that help with circadian rhythms. This is important because sleep problems are common in cyclothymia (and can mess with one’s mood). In particular, people frequently have delayed sleep phase disorder (DSPD)—the inability to fall asleep at a conventional time with wake-ups that are much later than a person prefers.
CBT also can address distorted beliefs about mood; reduce co-occurring anxiety; rebuild self-esteem; restore social support; and work on issues with abandonment, self-sacrifice, dependence, and the need for control.
Currently, no medication has been approved for cyclothymic disorder by the U.S. Food and Drug Administration (medication, however, can be prescribed “off label”). The research on pharmacological treatment for cyclothymia is very limited, and most of the recommendations come from small naturalistic studies and clinical experience.
Specifically, the mood stabilizers lithium, valproate (Depakote), and lamotrigine (Lamictal) have shown mild to moderate efficacy in preventing depressive, mixed, and hypomanic episodes.
It’s common for cyclothymic disorder to co-occur with other conditions, such as anxiety and substance use, and can dictate the type of medication prescribed. For instance, valproate appears to be more effective than lithium in alleviating anxiety and panic attacks. It’s also helpful for easing inner tension, which frequently occurs in mixed depressive states and ultra-rapid cycling. If alcohol use disorder is present, the anticonvulsant drug gabapentin may help.
There’s debate over the use of antidepressants for cyclothymia. While tricyclic antidepressants (TCAs) have shown some positive results for depression, selective serotonin reuptake inhibitors (SSRIs) may worsen cyclothymia, triggering hypomania, mixed mania, long-term instability, and rapid cycling, and increasing risk for suicide. SSRIs also have been associated with a “wear off” effect: symptoms return or a relapse occurs when a person has had successful treatment. And antidepressants might trigger severe manic or mixed episodes in some individuals.
This is why experts advise against prescribing antidepressants, especially as an initial medication. It’s best for antidepressants to be used as a second- or third-line treatment and only for long-lasting severe depressive or anxious symptoms when mood stabilizers haven’t worked.
However, individuals with cyclothymic disorder have typically already tried antidepressants, because they usually seek professional help for depressive or anxious symptoms.
If antidepressants are prescribed to treat depressive symptoms in someone with cyclothymia, it’s imperative they’re carefully monitored.
Individuals with cyclothymic disorder tend be more sensitive to side effects and adverse reactions, such as skin reactions, thyroid dysfunction, and polycystic ovarian syndrome. Which is why experts noted that it’s vital to “go slow and stay low.” In other words, it’s important for individuals to take lower doses of medication and have regular check-ins with their doctor.
Antipsychotics might be helpful, as well, but should also be prescribed in low doses. Quetiapine (Seroquel, at 25 to 50 mg/day) and olanzapine (Zyprexa, at 2-6 mg/day) may help in reducing irritability, impulsivity, and other excitatory symptoms during an acute hypomanic or mixed period.
Consider a workbook. For example, The Cyclothymia Workbook: How to Manage Your Mood Swings and Lead a Balanced Life features cognitive-behavioral exercises.
Track your symptoms. Try to keep a daily record of your mood, thoughts, sleep, anxiety, energy, and any other relevant symptoms or concerns. This can help to spot patterns, specific triggers, and stressors. And it can give you valuable information on whether the medication you’re taking is reducing your symptoms. There are many tracking apps on the market, such as eMoods, Daylio Journal, and iMood Journal.
Create and maintain routines. Routines are helpful in giving your days (and your mood) some much needed structure and stability. They also promote better sleep and reduce anxiety. For instance, you can establish a relaxing bedtime routine, along with going to sleep and waking up at the same time. If that doesn’t help you sleep or you have a sleep disorder, consider seeing a sleep specialist. You also might set a short morning routine, which includes showering, meditating, and savoring your breakfast at the table. Take some time to consider the kinds of self-care practices you’d like to incorporate into your day to day.
Avoid drugs and alcohol. Both trigger or exacerbate mood swings, anxiety, sleep issues, and other symptoms. If you’re having a hard time getting or staying sober, seek professional help. Work with a clinician who specializes in treating substance use disorders.
Turn to healthy coping strategies. It’s important to find healthy ways to process your emotions and manage stress (which can spark symptoms). For instance, you might set a timer for 20 minutes and journal what you’re feeling (without judgment). You might paint, practice gentle yoga, dance, do a high-intensity workout, or listen to a guided meditation. You can find a variety of guided meditations at Tara Brach’s website and in this article on Mindful.org.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Hantouche, E.G., Majdalani, C., Trybou, V. (2007, May 3-5). Psychoeducation in group-therapy for cyclothymic patients; a novel approach. The 7th International Review of Bipolar Disorders. Rome, Italy.
Perugi, G., Hantouche, E., & Vannucchi, G. (2017). Diagnosis and Treatment of Cyclothymia: The “Primacy” of Temperament. Current neuropharmacology, 15, 3 372–379. DOI:10.2174/1570159X14666160616120157.
Perugi, G., Hantouche, E., Vannucchi, G., Pinto, O. (2015). Cyclothymia reloaded: A reappraisal of the most misconceived affective disorder. Journal of Affective Disorder, 183, 119-133. DOI: 10.1016/j.jad.2015.05.004.
Perugi, G., Vannucchi, G., and Mazzarini, L. (2017). The treatment of cyclothymia. In André F. Carvalho and Eduard Vieta (Eds.), The Treatment of Bipolar Disorder: Integrative Clinical Strategies and Future Directions (pp. 1-18). Oxford, United Kingdom: Oxford University Press. DOI: 10.1093/med/9780198748625.001.0001.
Totterdell P., Kellett S., Mansell W. (2012). Cognitive behavioural therapy for cyclothymia: Cognitive regulatory control as a mediator of mood change. Behavioural and Cognitive Psychotherapy, 40, 4, 412-24. DOI: 10.1017/S1352465812000070.