The human brain is an amazing organ that helps us become concert pianists, vascular surgeons, rocket scientists and emotionally connected human beings with families, dreams and ordinary lives. But within all that complex wiring, sometimes things go wrong, leading to mental health disorders. Cyclothymia is just one of many ways the brain and its vast capacity can occasionally cause problems for an individual.
“Cyclothymic disorder is actually a subset of bipolar disorder, according to the DSM-5,” says Dr. Cathleen Marie Adams, a pediatric psychiatrist with Geisingerin Danville, Pennsylvania. (The DSM-5 is the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, a catalog used by clinicians to help identify and treat mental health problems.) “To understand cyclothymic disorder, you need to have an understanding of bipolar disorder.”
The National Institute of Mental Health reports that “bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks.” There are four primary types of bipolar disorder, all featuring “clear changes in mood, energy and activity levels.” These four types are:
— Bipolar I disorder.
— Bipolar II disorder.
— Cyclothymic disorder (or cyclothymia).
— Other specified and unspecified bipolar and related disorders.
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Bipolar I Disorder
This disease is “defined by manic episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care,” the NIMH reports. Depressive episodes typically last at least two weeks and having symptoms of both mania and depression simultaneously is possible.
” Bipolar I disorde r means having periods of mania as well as depression,” Adams says. Mania is defined as a period where “mood is elevated” to an excessive point. People experiencing manic symptoms may become irritable, have very high levels of energy and engage in “a lot of goal-directed activity,” which isn’t always a positive thing, as these goals may revolve around risky activities that may be self-destructive or dangerous to the person’s health and safety.
Other symptoms of mania can include “inflated self-esteem or grandiosity and a decreased need for sleep even after having very little sleep.” This can lead to a situation where someone might be taken with the notion of “staying up all night to write the next great American novel when that person has only ever successfully written an essay,” Adams says.
People experiencing a manic episode also usually have “racing thoughts and excessive involvement in risk-taking. Those periods have to last longer than a week,” and a patient with bipolar I disorder will experience them “every day for most of the day. It’s a pretty significant episode of mania. These people are often so impaired they’re hospitalized.”
People with bipolar I will also have periods of excessive depression that can be debilitating and equally as severe as their manic episodes but on the opposite end of the mood spectrum. Lethargy, a loss of interest in subjects and activities that used to be enjoyable and sometimes suicidal thoughts and actions can all occur during a depressive episode in people with bipolar I disorder.
Bipolar II Disorder
This mood disorder is somewhat less severe than bipolar I, with episodes of elevated mood that don’t quite reach the level of mania. Called hypomanic episodes, they can still be dangerous, disruptive and distressing.
Also called cyclothymia, this illness also causes hypomanic and depressive episodes that cycle through and last two years or more, but the symptoms don’t meet the diagnostic criteria to be classified as bipolar I or II. Dr. Philip R. Muskin, a psychiatrist at New York-Presbyterian and Columbia University Irving Medical Center and outgoing secretary of the American Psychiatric Association, says people with cyclothymic disorder have mood fluctuations that cycle through. “That’s why it’s called cyclothymia,” and while these fluctuations may look a bit like bipolar disorder, “they don’t meet the full criteria for a manic or depressive episode that a bipolar person experiences.”
These cycles tend to be unpredictable, but Muskin notes that it’s “not just a day of feeling blue or more animated. These symptoms can last for weeks.” Often a coworker, friend or partner will notice the cycle when the individual with the disorder does not. “Maybe you’re a little more irritable or tough to handle. Your tolerance for annoyances may go down. You may be much more interested in sex than is typical for you, and your partner may find that’s not OK,” he says.
In the hypomanic phases, you might feel on top of the world, but don’t reach the point of psychosis that a person with bipolar disorder may achieve. During depressive periods, you may feel “dangerously or profoundly depressed and experience changes in appetite or sleep, feelings of guilt or worthlessness,” Muskin says.
Other Specified and Unspecified Bipolar and Related Disorders
These disorders don’t meet the diagnostic criteria of the other, more defined disorders, but are mood disorders that likely require treatment.
Consequences of Cyclothymia
Although some people refer to cyclothymia as a “light version” or “less severe” case of bipolar disease, this description may do a disservice to some patients with cyclothymia. “I wouldn’t call it “bipolar lite. It’s a real form of a mood disorder,” and not just a lighter version of something else, Muskin says. “People who have a mood disorder have problems with interpersonal relationships,” and these disorders can cause damage to marriages and partnerships, professional careers, even family connections.
“Even if you’re a really nice person, when you get depressed maybe you’re less nice,” Muskin says, and that can put a strain on interpersonal relationships, in part because it can sometimes be difficult for loved ones to understand what you’re going through and be supportive if you’re down in the dumps and feeling very gloomy and negative.
On the flip side, if you’re feeling manic, “you might empty the bank account or really unpleasantly demand sex from your partner,” Muskin says. In some cases, a person experiencing the hypomania of cyclothymia pursues sexual encounters outside of a committed relationship. “What if your partner finds out you’ve been unfaithful” during an episode? “That can be very disruptive,” but it may be difficult for someone without the condition to fully understand what’s happening and why. But as Muskin notes, cyclothymia is “an illness” that lies outside the conscious control of the person with the disease.
Dr. Charles Herrick, a psychiatrist and chairman of psychiatry at Western Connecticut Health Network, says that although science still isn’t sure exactly what causes cyclothymia, it seems that it tends to run in families. If you have a family member with cyclothymia or a bipolar disorder, you’re at greater risk of developing it, too, suggesting a genetic component to the disorder.
But genetics aren’t the only risk factor. “Environmental factors and stressful or traumatic events also play a role,” says Dr. Vinay Saranga, psychiatrist and founder of Saranga Comprehensive Psychiatry. In addition, these mood disorders may occur on something of a spectrum, he says, with cyclothymic people having a “15 to 50 percent higher risk of developing full-blown bipolar I disorder.”
The Mayo Clinic reports that in order for a diagnosis of cyclothymia to be made, patients must have the following:
— Several periods of hypomanic symptoms and periods of depression over at least two years with highs and lows occurring during at least 50 percent of that time.
— Periods of stable mood lasting less than two months at a stretch.
— Symptoms causing a significant impact in social, work, school or other settings.
— Symptoms that don’t fit a diagnosis of bipolar disorder.
— Symptoms that aren’t caused by substance use or a medical condition.
Because cyclothymia shares symptoms with several other mental health disorders — depression, anxiety and seasonal affective disorder, to name just three — arriving at an accurate diagnosis can be challenging. Saranga says cyclothymia is considered rare. About “0.4 percent to 1 percent of people will experience cyclothymia in their lifetimes, and it typically begins in adolescence or into early adulthood.” However, because it can be challenging to diagnose, Saranga notes that actual incidence rates could be higher and either the disorder is overlooked — ascribed to ‘normal’ mood fluctuations — or misdiagnosed as depression, anxiety, a sleep disorder, ADHD, bipolar disorder or another mental illness.
To add to the complexity, one or more of these conditions and others may also be present in people with cyclothymia. “There’s also often comorbid substance use, anxiety disorders and sleep disorders. Children with cyclothymia are more likely to have ADHD,” and thyroid abnormalities can also masquerade as mood disorders or occur alongside them. Therefore, if you suspect you may be dealing with cyclothymia it’s critical that you receive a full medical work-up to rule out any other or underlying medical conditions that could be causing or contributing to your experience of symptoms. “Your doctor should perform a thorough physical exam to rule out any medical issues,” Saranga says.
Your doctor will also take a complete medical history, a psychological history and a family history to get a clearer picture of what’s going on. Saranga notes that most patients with cyclothymic disease will seek help from a doctor when in the midst of a depressive episode. “No one’s seen them in their hypomanic state, so they’ll often get misdiagnosed with major depression because we didn’t know they had hypomania as well. But a good mental health provider would get a good history to assess for that history of manic symptoms.”
Still, he says “it’s not always an easy thing to pick up on in the history, because some patients like (the hypomanic episodes) because they’re getting a lot done. They’re productive and talkative. They’re having a good time. They’re more productive at work and their boss is happy with them.” This is why it’s so important to be as honest and forthcoming with your doctor as you can be when describing what you’re experiencing so that you can get the right help.
Herrick agrees that arriving at the right diagnosis can be challenging, because some of the symptoms can be subjective and determining whether they signal a problem isn’t always a straightforward question. “The softer the symptoms are, the more difficult the diagnosis becomes,” he says. Typically, patients will seek help with what they perceive as negative symptoms. “People tend to focus on the distressing feelings and they want them to go away and they need help. The challenge for health care professionals is to obtain a clear history and understand whether this is depression, dysthymia (mild depression), bipolar depression or cyclothymic depression because that will change the ways you’ll approach treatment.”
For example, if a person with cyclothymia is treated with an antidepressant, “it’s less likely to be effective,” Herrick says. Plus, “there’s a small but possible chance of it making you cycle more and creating greater irritability or instability in your moods. That’s why it’s important that clinicians ask questions about their past moods in order to distinguish a straightforward depression from cyclothymia or bipolar disorder.”
In addition, many of the medications used to treat various mental illnesses have side effects such as nausea, dizziness, constipation, dry mouth, feeling mentally fuzzy or ‘out of it,’ weight gain, loss of libido and other potentially distressing problems, so using only what’s needed is a smart approach.
There is no cure for cyclothymia, but treatment can help you live a relatively normal life. Managing your cyclothymia also reduces your risk of developing bipolar I or II disorder later in life.
If you receive a diagnosis of cyclothymia, it’s important that you receive treatment, Muskin says. Although there’s still a troubling stigma around mental illness, it’s important to realize that it’s a medical issue, just like any other disease. “Mental illness is a real illness that’s no different from diabetes. It deserves respect and treatment,” he says, adding that you wouldn’t try to just “get over” a diagnosis of diabetes. Rather, you’d take your insulin or other medications as directed. The same should be true of cyclothymia and, indeed, any other mental illness.
Cyclothymia is usually managed through a combination of medications and talk therapy. The Mayo Clinic reports that currently “no medications are approved by the Food and Drug Administration specifically for cyclothymia, but your doctor may prescribe medications used to treat bipolar disorder. These medications may help control cyclothymia symptoms and prevent periods of hypomanic and depressive symptoms.”
Saranga says mood stabilizers, such as lithium-based medications, are often administered to help a person regain balance. Anti-seizure medications, such as divalproex sodium or valproic acid, may also help. Other antipsychotic medications and sleep aids may also be used in some instances, again to help stabilize the person’s moods and alleviate the worst symptoms.
In addition to medications, most people with cyclothymia will undergo psychotherapy. Cognitive behavioral therapy, a common form of talk therapy, can help patients learn coping strategies and how to avoid triggers that can worsen symptoms. This approach helps patients “look for thought patterns that can be managed and changed into more positive ways of thinking and being,” Saranga says.
If the disorder is diagnosed in a child or adolescent, often family counseling will be part of the treatment protocol, Adams says. “Often, it’s not clear that the diagnosis is present until well into adulthood, although in children, there are instances where we do see kids who meet the criteria. The treatment for children is similar (to that in adults), although there’s a much greater role of family therapy, as with many other mental health problems,” she says. Sometimes referred to as interpersonal and social rhythm therapy, this approach helps the patient find a routine while educating other family members in how best to support the cyclothymic person.
People with mood disorders should carefully follow their doctors’ instructions. Any medications you’re prescribed are powerful and should be taken as directed. Skipping doses can be dangerous. You should also avoid using alcohol and illegal or recreational drugs. These can negatively interact with your medications and can trigger a shift in mood or exacerbate symptoms.
You should also keep a journal of your moods, thoughts and feelings so you can chart how they change and cycle. This may offer you advance warning if you’re headed for a hypomanic or depressive episode and allow you to get the right help to alleviate symptoms. You should also know how you’re sleeping. “Keeping good track of your sleep patterns can help you see red flags for if you’re going into a manic or depressive episode,” Saranga says. Your partner may notice that you’re sleeping more restlessly, which should prompt you to contact your doctor for advice on how to handle a potential exacerbation of symptoms.
Many patients with cyclothymia also benefit greatly from maintaining a strict daily routine. Having a regular wake and sleep time and getting plenty of exercise can help stabilize your moods. Joining a support group or connecting with other people who have the same condition can also help you feel less alone as you navigate the ups and downs of the disease.