Less severe hypomanic and mini-depressive periods follow an irregular course, with each period lasting a few days. Cyclothymic disorder is commonly a precursor of bipolar II disorder. But it can also occur as extreme moodiness without being complicated by major mood disorders. In such cases, brief cycles of retarded depression accompanied by low self-confidence and increased sleep alternate with elation or increased enthusiasm and shortened sleep. In another form, low-grade depressive features predominate; the bipolar tendency is shown primarily by how easily elation or irritability is induced by antidepressants. In chronic hypomania, a form rarely seen clinically, elated periods predominate, with habitual reduction of sleep to < 6 h. Persons with this form are constantly overcheerful, self-assured, overenergetic, full of plans, improvident, overinvolved, and meddlesome; they rush off with restless impulses and accost people.
Although cyclothymic and chronic hypomanic dispositions contribute to success in business, leadership, achievement, and artistic creativity in some persons, they more often have serious detrimental interpersonal and social sequelae. Cyclothymic instability is particularly likely to be manifested in an uneven work and schooling history; impulsive, frequent changes of residence; repeated romantic or marital breakups; and an episodic pattern of alcohol and drug abuse.
Patients should be taught how to live with the extremes of their temperamental inclinations, although living with cyclothymic disorder is not easy because of the resulting stormy interpersonal relations. Jobs with flexible hours are preferred. Patients with artistic inclinations should be encouraged to pursue such careers because the excesses and fragility of cyclothymia are better tolerated in such circles.
The decision to use a mood stabilizer depends on the balance between the functional impairment produced by unpredictable mood swings and the social benefits or creative spurts the patient may receive from hypomanic swings. Divalproex 500 to 1000 mg/day is better tolerated than equivalent doses of lithium. Antidepressants should be avoided because of the risk of switching and rapid cycling.