The affective temperaments (hyperthymia, cyclothymia and dysthymia) are basically subsyndromal mood disorders that run in the family trees of patients with major mood illness, and they are easily mistaken for personality disorders, in both directions. Whether to treat them at all is a real question: there is no good treatment literature to point to, and below research-grade severity we should be very loath to prescribe.
What they are
Hyperthymia, cyclothymia and dysthymia are basically subsyndromal mood disorders found in the family trees of patients with major mood illness. They are very easily mistaken for personality disorders.
“Hyperthymia, Cyclothymia, Dysthymia, the affective temperaments, which are basically subsyndromal mood disorders that you find in the family trees of patients with major mood illness. These are very easily mistaken for personality disorders”
58:47Diagnostic Hierarchy Explained: Why Patients Get 5 DiagnosesNov 2026Guest episode Hyperthymia can be mistaken for narcissistic personality and cyclothymia for borderline personality, and the misdiagnosis can go both ways.
“For instance, hyperthymia and narcissistic personality, cyclothymia and borderline personality. And the misdiagnosis can go both ways”
59:05Diagnostic Hierarchy Explained: Why Patients Get 5 DiagnosesNov 2026Guest episode
Whether to treat them
There is a real question whether temperaments should be treated at all, and whether they are actually pathological. It makes a lot of sense, perhaps, not to treat some patients with affective temperaments.
“There's a real question about whether you should even treat temperaments, whether they are actually pathological. I think it makes a lot of sense, perhaps not to treat some patients with affective temperaments”
1:00:55Diagnostic Hierarchy Explained: Why Patients Get 5 DiagnosesNov 2026Guest episode If something is subsyndromal, below a research-grade level of pathology and severity, be very loath to prescribe medication: there is not enough evidence for it.
“if we think something is subsyndromal, if we think something is not at the level of a Research grade, let's call it, level of pathology and severity, then we should be very loathe to prescribe medication because there's not enough evidence for that”
1:02:11Diagnostic Hierarchy Explained: Why Patients Get 5 DiagnosesNov 2026 What we have struggled with is the lack of a good literature to point to: we have a decent flow chart of treatment options for each diagnosis, but not for the temperaments.
“With the temperaments, the thing I struggled with was not having a good literature to be able to point to as to like, what are, you know, I have a decent flow chart for the treatment options for each diagnosis”
1:00:23Diagnostic Hierarchy Explained: Why Patients Get 5 DiagnosesNov 2026
It also comes up on
- ADHDA half-joking rule: MDD, GAD and ADHD in the same patient is a cyclothymia. Maybe that is true 50 percent of the time.
- Bipolar disorderDo not treat the mood du jour. Stop the cycling, then reassess: there may still be a depressive component, such as a dysthymia tied to childhood trauma, to address without restarting the cycling.
- Borderline personality disorderDo not assume a personality disorder means no other condition. In uncomplicated cases the most common are PTSD and perhaps dysthymia.
- Major depressive disorderAsk whether they can identify particular episodes, or whether it has been there all their life without much fluctuation. That helps separate major depression from dysthymia or another condition.
- Major depressive disorderA half-joking rule: MDD, GAD and ADHD in the same patient is a cyclothymia. Maybe that is true 50 percent of the time.
From these episodes
- Diagnostic Hierarchy Explained: Why Patients Get 5 DiagnosesNov 2026 · 5 points
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.