This programme is a treatment manual for mental health professionals. It assumes clinical training in cognitive behavioural therapies and in psychoeducation for mood disorders, work in liaison with a psychiatrist or a doctor, and a supervision framework. It does not replace your clinical judgement or your professional ethical responsibility. The diagnostic criteria are rephrased here in our own words, never reproduced. Two warnings specific to this indication. A hypomanic, manic or major depressive episode changes the diagnosis and the treatment: it is reported to the psychiatrist, section 40. And suicide risk exists in this disorder, particularly in lows and mixed periods: it is asked about regularly, section 9.
1. The programme at a glance
Indication. Adult with cyclothymic disorder, outside a full episode, followed by a psychiatrist or a doctor.
Reference model. Cognitive behavioural therapy for mood disorders adapted to chronic instability: psychoeducation, daily mood monitoring, regular rhythms, work on the thoughts and behaviours of highs and lows, emotion regulation, work on rejection sensitivity, and well-being therapy.
Format. Sixteen sessions over five to seven months, weekly and then spaced out. Sessions of 50 minutes. One session with someone close if the person wishes. Booster sessions.
Targeted mechanism. Reduce the amplitude and consequences of mood variations by making the waves visible, stabilising rhythms, reducing emotional and interpersonal reactivity, limiting decisions made at the crest or in the trough of a wave, and developing well-being.
| Phase |
Session |
Topic |
Session output |
| I. Understanding |
1 |
Meeting |
Reason for consulting and consequences gathered |
|
2 |
Assessing |
Differential diagnosis, risks, comorbidities |
|
3 |
Understanding cyclothymia |
Model explained, life chart sketched |
|
4 |
Observing mood |
Daily log started |
| II. Recognising |
5 |
The highs |
Signs and thoughts of highs |
|
6 |
The lows |
Signs and thoughts of lows |
|
7 |
Rhythms and sleep |
Fixed times, daily anchors |
| III. Regulating |
8 |
When emotion overflows |
One reaction broken down, one skill chosen |
|
9 |
Rejection sensitivity |
One interpretation loosened |
|
10 |
Mid-point review |
Log reviewed, plan revised |
|
11 |
Before deciding |
Delay rule written |
|
12 |
Substance use and stimulants |
One goal chosen |
| IV. Consolidating |
13 |
Well-being |
Well-being diary started |
|
14 |
My plan |
Plan for highs, lows and emergencies |
|
15 |
Who I am, beyond the waves |
What I keep of my temperament |
|
16 |
Review and next steps |
Measures repeated, boosters scheduled |
What the person takes away. Seven printable worksheets, listed in section 42: my waves, my daily log, my highs and my lows, when emotion overflows, before deciding, my well-being, my plan.
What sets this programme apart from the other manuals on this site. Three things. A chronic, fluctuating disorder, in which you are not preparing for an episode but for a way of living with waves. A central place for emotional and interpersonal reactivity, which often does the most damage. And attention to what the person wants to keep of their intensity.
2. Before you begin
Who this programme is for
Psychologists, psychiatrists and psychotherapists trained in cognitive behavioural therapies. It is not intended for patients or for their families.
The four preliminary decisions
1. Is there a full episode now, or in the history? If so, the diagnosis needs revisiting, and this site's bipolar disorder manual is a better fit. Section 7.
2. Has suicide risk been assessed? Section 9.
3. Is a doctor involved? For assessment, any medication, and in particular an antidepressant prescription. Section 13.
4. What else is present? Substance use, attention deficit, personality disorder, anxiety. Section 8.
What this programme does not treat
Bipolar I or II disorder, which has its own manual.
Borderline personality disorder in the foreground, which has its own manual; the two can coexist.
Severe, unstabilised addiction.
What this programme is not
It is not work that seeks to make the person "even" or to remove their intensity. Nor is it psychoeducation rushed through in two sessions: chronic instability is worked on over time.
How to use it
Read sections 3 to 15 first, then sections 33 to 36 before the first session. Section 43 sets out what not to let go.
3. The clinical picture
Numerous, long-lasting waves
High periods: energy, confidence, many ideas, reduced need for sleep, sociability, plans, spending, irritability, sometimes disinhibition. They stay short of a hypomanic episode, in intensity, duration or number of symptoms.
Low periods: fatigue, loss of interest, pessimism, withdrawal, guilt, hypersomnia, sometimes thoughts of death. They stay short of a major depressive episode.
Frequent and often abrupt variations, sometimes over a few days or a few hours, sometimes triggered by an event, sometimes with no apparent reason.
Mixed periods, in which energy and agitation accompany a dark mood.
Reactivity
Many people describe intense emotional reactivity: emotions that rise quickly and strongly, and come down slowly. And marked interpersonal sensitivity: the slightest criticism, the slightest delay in a reply, the slightest sign of distance triggers a drop or anger.
What people describe
"I never know how I'm going to wake up." "People tell me I have an impossible character." "I start everything and finish nothing." "When things are good, I'm the funniest person at the party; three days later, I can't answer the phone." And often a deep weariness with this instability, and with the image it gives.
What you see in the consulting room
A person who comes because of a low period, a break-up, conflicts at work, substance use, or because someone close has pushed them to. The highs are rarely the reason: they are often experienced as the "real" person.
Epidemiology
Cyclothymia affects around 0.4 to 1% of the population over the lifetime depending on the study, probably more if one includes forms seen in consultations for depression. It usually begins in adolescence or early adulthood, often insidiously. Its frequency is comparable in men and women in the general population.
Course
Chronic, with variations over the years. A risk of progression to bipolar I or II disorder, estimated within a wide range, of the order of 15 to 50% depending on studies and populations. An often underestimated impact on relationships, studies, work and health.
4. An unrecognised disorder
Why this section exists
Because cyclothymia is often diagnosed late, after years of consultations for other reasons, and the person has often internalised the idea that they have "a nasty temper".
Why it gets missed
Highs are not reported: they are experienced as good times.
Lows look like depressions and are treated as such.
Interpersonal reactivity suggests a personality disorder.
Restlessness and difficulties with organisation suggest an attention deficit.
Substance use masks the picture.
Chronicity makes it look like a character trait.
What this changes for you
You actively look for highs, including by asking those close to the person. You trace the history of mood over years. And you help the person distinguish what belongs to a disorder that can be worked on from what belongs to their personality.
What you say
"What you're describing has a name. It isn't a character flaw: it's a mood that varies a lot and often, and has done for a long time. Today we know better how to help steady it."
5. The model
A temperament and triggers
A vulnerability — often familial, biological, linked to temperament — makes mood more sensitive to triggers: disruptions to sleep and rhythms, interpersonal events, stress, substance use, stimulants, seasons, certain medications.
The circle of highs
A trigger — a success, a new encounter, a short night — increases energy. Thoughts speed up and become more optimistic; the person sleeps less, takes on more commitments, seeks out more stimulation. Lack of sleep and overload feed the high, until exhaustion or a crash.
The circle of lows
A trigger — a criticism, a failure, the fatigue that follows a high — brings mood down. Thoughts become negative about oneself and the future; the person withdraws, abandons what they had started, sleeps too much. Withdrawal and shame about unkept commitments feed the low.
Interpersonal reactivity
Rejection sensitivity leads to ambiguous signals being quickly read as signs of disinterest or criticism. Emotion rises fast; the reaction — anger, withdrawal, an impulsive message — sometimes produces the feared rejection, and confirms the belief.
The cost of the waves
Decisions made at the crest or in the trough of a wave — resignations, break-ups, spending, commitments — leave consequences that in turn become triggers.
What the model explains to the person
That their waves have identifiable triggers. That sleep and rhythms dampen them. That their thoughts change with mood, and can be treated with caution at the crest and in the trough. That their reactivity can be worked on. And that their intensity is not the problem: amplitude and damage are.