Anxiety & Mood
Mania, hypomania and cyclothymia: what they are
What mania, hypomania and cyclothymia are, how they differ, why hypomania often goes unnoticed, what can trigger an episode and how they are treated.
Mania is a period of unusually elevated or irritable mood and high energy that lasts at least a week, or leads to a hospital stay, and seriously disrupts life. Hypomania is the milder form: it lasts at least four days and does not cause serious impairment. Cyclothymia means milder but ongoing mood swings for at least two years. All three belong to the bipolar spectrum, and all three can be treated.
What mania is
In everyday language, “mania” means a passion or an obsession. In psychiatry it is something else: a mood episode. A manic episode requires [1]:
a mood that is unusually elevated or irritable, clearly different from your usual self,
a duration of at least 7 days in a row, or less if a hospital stay is needed,
at least three of the symptoms in the next section, or four if the mood is only irritable,
serious difficulty at work or in relationships, or the need for a hospital stay.
Mania can also bring psychotic symptoms, such as grandiose ideas that have no basis in reality. Mania is considered an emergency and often needs a hospital stay [1].
Symptoms: how it shows in daily life
Much more self-confidence than usual, even grandiose ideas.
Less need for sleep: a few hours are enough and you do not feel tired.
Talkativeness: you talk a lot and fast, and find it hard to stop.
Racing thoughts, or thoughts that jump from one topic to another.
Being easily distracted.
Many plans and activities at once, or restlessness without a purpose.
Risky choices: sudden spending, investments or decisions that cost you later.
Hypomania: what it is
Hypomania has the same symptoms in a milder form. It differs in three ways [1]:
it lasts at least 4 days in a row,
it is not severe enough to cause serious impairment or a hospital stay,
by definition, it has no psychotic symptoms.
Because it often feels like a “really good patch”, full of energy and productivity, the person often does not see it as a problem. Hypomania, together with episodes of depression, characterises bipolar II disorder [1].
Mania or hypomania? The differences at a glance
Duration: mania lasts at least 7 days, or less if a hospital stay is needed; hypomania lasts at least 4 days.
Effect on life: mania causes serious impairment; hypomania does not.
Psychotic symptoms: they may occur in mania; they do not occur in hypomania.
Hospital stay: often needed in mania; not needed in hypomania.
Where it belongs: mania belongs to bipolar I disorder; hypomania, together with depression, to bipolar II disorder.
Cyclothymia: when the ups and downs last for years
In everyday Greek, people call someone “cyclothymic” when their mood changes abruptly. Cyclothymic disorder is something more specific [2]:
for at least two years, on most days, there are periods with hypomanic symptoms and periods with depressive symptoms that do not meet the criteria for a full episode,
the mood does not stay stable for more than two months in a row,
the ups and downs genuinely make life harder and are not caused by another condition.
Its frequency in the general population is estimated at 0.4% to 1% [2]. A 2012 review notes that it is rarely diagnosed, even though it may be the most common form of the bipolar spectrum [4].
How common it is
In a survey of the World Health Organization’s World Mental Health initiative, with 61,392 adults from 11 countries [3]:
0.6% had had bipolar I disorder at some point in their lives,
0.4% had had bipolar II disorder,
1.4% had had milder forms, below the full criteria,
in total, 2.4% had had some form of the bipolar spectrum.
Fewer than half had ever received treatment for their mental health. The most common co-occurring conditions were anxiety disorders, especially panic attacks [3].
Why hypomania goes unnoticed
Bipolar disorder is often first diagnosed and treated as depression alone. In a review of 59 studies with more than 40,000 people, the median delay from the start of symptoms to diagnosis was 6.7 years [5]. Onset peaks between the ages of 15 and 25.
Before starting treatment for depression or for ADHD, I check for periods of hypomania: with questions about sleep and energy, with the HCL-32 hypomania questionnaire [6] and, where possible, with information from someone close to you. If bipolar disorder is suspected, we stabilise the mood first, because some treatments can trigger mania.
What can trigger an episode
Loss of sleep. In a study of 3,140 people with bipolar disorder, sleep loss as a trigger for an episode of elevated mood was reported more often by women and by people with bipolar I disorder. The researchers recommend caution wherever sleep is disrupted, such as with shift work and travel abroad [7].
Antidepressants without protection. In a review of 109 clinical trials with 114,521 adults with bipolar disorder or depression, mania or hypomania occurred in 12.5% of those taking antidepressants, compared with 7.5% of those who were not [8]. Because of this risk, in bipolar disorder antidepressants are not used on their own in most patients.
How it is treated
Acute mania. The main treatment is medication: a mood stabiliser, such as lithium or valproate, or an antipsychotic. Valproate should not be used in women who could become pregnant [1].
Preventing relapse. Mood stabilisers and antipsychotics, alone or in combination. For lithium there is strong evidence that it prevents manic, depressive and mixed relapses [1].
Psychotherapy alongside medication. In an analysis of 39 randomised trials with 3,863 patients, structured psychotherapy together with medication was linked to fewer relapses than medication with simple support or usual care. Psychoeducation with practice in illness-management skills worked better in a group or with the family than one-to-one [9].
Medication is changed or stopped only with the doctor who follows your care, never on your own.
From the start, we make an “if… then…” plan together: which early signs show that your mood is rising, for example less sleep without feeling tired, and what we do then. Sleep, a steady routine and limits on alcohol and substances are part of the treatment, not advice on the side.
Mania, hypomania or ADHD?
ADHD can look like hypomania: energy, talkativeness, impulsivity, distractibility. The key difference is time. ADHD is present more or less continuously from childhood. Mania and hypomania come in episodes, with a beginning and an end, and make you seem different from your usual self. More in the article ADHD or bipolar disorder?.
In hypomania, certainty is not proof. “I feel that everything will go perfectly” is a feeling, not an assessment of reality. That is why we work early on how you will recognise it, before it turns into a decision.
When to ask for help
You have had days with very little sleep but no tiredness, a lot of energy and plans that are not like you.
People around you say that you are “not yourself”, that you talk non-stop or spend too much.
You have depression that keeps coming back, and in the past you have had periods of “very good mood”.
There is bipolar disorder in your family and you recognise such ups and downs.
You are taking an antidepressant and suddenly feel too much energy or irritability. Do not stop the treatment on your own; talk to your doctor straight away.
Safety: If someone has not slept for days, is making dangerous decisions, is saying things that do not make sense, or is a danger to themselves or others, get help immediately: 166 (ambulance, EKAV) or 112. If you have thoughts of harming yourself, call 166, 112 or the Suicide Prevention Line 1018.
How I can help
Book a psychiatric assessment, at the practice in Trikala or online. See also the page on bipolar disorder, which describes the treatment. If you live far away, the assessment can also take place by video call: see how working with an online psychiatrist works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Jain A, Mitra P. Bipolar Disorder. StatPearls, NCBI Bookshelf. Last updated 20 February 2023. https://www.ncbi.nlm.nih.gov/books/NBK558998/
Bielecki JE, Gupta V. Cyclothymic Disorder. StatPearls, NCBI Bookshelf. Last updated 17 July 2023. https://www.ncbi.nlm.nih.gov/books/NBK557877/
Merikangas KR, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011. https://doi.org/10.1001/archgenpsychiatry.2011.12
Van Meter AR, Youngstrom EA, Findling RL. Cyclothymic disorder: a critical review. Clin Psychol Rev. 2012. https://doi.org/10.1016/j.cpr.2012.02.001
Scott J, et al. A systematic review and meta-analysis of delayed help-seeking, delayed diagnosis and duration of untreated illness in bipolar disorders. Acta Psychiatr Scand. 2022. https://doi.org/10.1111/acps.13490
Angst J, et al. The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord. 2005. https://doi.org/10.1016/j.jad.2005.05.011
Lewis KS, et al. Sleep loss as a trigger of mood episodes in bipolar disorder: individual differences based on diagnostic subtype and gender. Br J Psychiatry. 2017. https://doi.org/10.1192/bjp.bp.117.202259
Tondo L, Vázquez G, Baldessarini RJ. Mania associated with antidepressant treatment: comprehensive meta-analytic review. Acta Psychiatr Scand. 2010. https://doi.org/10.1111/j.1600-0447.2009.01514.x
Miklowitz DJ, et al. Adjunctive Psychotherapy for Bipolar Disorder: A Systematic Review and Component Network Meta-analysis. JAMA Psychiatry. 2021. https://doi.org/10.1001/jamapsychiatry.2020.2993
