|ICD-9||296.0 Single manic episode, 296.4 Most recent episode manic, 296.6 Most recent episode mixed|
Mania is the mood of an abnormally elevated arousal energy level. Although it is often thought of as a "mirror image" to depression, the heightened mood can be either euphoric or irritable and, indeed, as the mania progresses, irritability becomes more prominent and can eventuate in violence. Although bipolar disorder is by far the most common cause of mania, it is a key component of other psychiatric conditions (e.g., schizoaffective disorder, bipolar type; cyclothymia) and may occur secondary to neurologic or general medical conditions, or as a result of substance abuse.
The nosology of the various stages of a manic episode has changed over the decades. The word derives from the Greek μανία (mania), "madness, frenzy" and the verb μαίνομαι (mainomai), "to be mad, to rage, to be furious". In current DSM-V nomenclature, hypomanic episodes are separated from the more severe full manic episodes, which, in turn, are classified as either mild, moderate, or severe (with or without psychotic features). Kraepelin, however, divided the “manic states” into four forms – hypomania, acute mania, delusional mania, and delirious mania – and noted that his observation revealed “the occurrence of gradual transitions between all the various states.” In a similar vein, Carlson and Goodwin, in their elegant paper of 1973, divided a manic episode into “three stages”: hypomania, or stage I; acute mania, or stage II; and delirious mania, or stage III. Although this "staging" of a manic episode is not used for the diagnosis of mania, it is very useful from a descriptive and differential diagnostic point of view. Mania may be caused by drug intoxication (notably stimulants, such as cocaine and methamphetamine), medication side effects (notably SSRIs), and malignancy (the worsening of a condition), to name but a few. Mania, however, is most commonly associated with bipolar disorder, a serious mental illness in which episodes of mania may alternate unpredictably with episodes of depression or periods of euthymia. Gelder, Mayou, and Geddes (2005) suggest that it is vital that mania be predicted in the early stages because otherwise the patient becomes reluctant to comply with the treatment. Those who never experience depression also experience cyclical changes in mood. These cycles are often affected by changes in sleep cycle (too much or too little), diurnal rhythms, and environmental stressors.
The cardinal symptoms of mania are the following: heightened mood (either euphoric or irritable); flight of ideas and pressure of speech; and increased energy, decreased need for sleep, and hyperactivity. These symptoms are most plainly evident when the mania is relatively mild (of no more than hypomanic intensity).
Mania varies in intensity, from mild mania (hypomania) to delirious mania, marked by such symptoms as a dreamlike clouding of consciousness, florid psychotic disorganization, and incoherent speech. Standardized tools such as Altman Self-Rating Mania Scale and Young Mania Rating Scale can be used to measure severity of manic episodes. Because mania and hypomania have also been associated with creativity and artistic talent, it is not always the case that the clearly manic bipolar person needs or wants medical help; such persons often either retain sufficient self-control to function normally or are unaware that they have "gone manic" severely enough to be committed or to commit themselves. Manic persons often can be mistaken for being on drugs or other mind-altering substances.
In a mixed state, the individual has co-occurring manic and depressive features, which can occur either simultaneously or in very short succession. Dysphoric mania is primarily manic, whereas agitated depression is primarily depressed. This has caused speculation amongst doctors that mania and depression are two independent axes in a bipolar spectrum, rather than opposites.
The mixed state can put a patient at greater suicide risk. Feelings of depression on its own is a risk factor, but when coupled with increased energy, agitation, and impulsivity, the patient is more likely to engage in dangerous behaviour, including self-injury or suicide.
Hypomania is a lowered state of mania that does little to impair function or decrease quality of life. It may, in fact, increase productivity and creativity. In hypomania, there is less need for sleep and both goal-motivated behaviour and metabolism increase. Though the elevated mood and energy level typical of hypomania could be seen as a benefit, mania itself generally has many undesirable consequences including suicidal tendencies, and hypomania can, if the prominent mood is irritable rather than euphoric, be a rather unpleasant experience. By definition, hypomania cannot feature psychosis, nor can it require psychiatric hospitalisation (voluntary or involuntary).
A single manic episode, which does not result from substance abuse and cannot be accounted for by a general medical condition, is sufficient to diagnose bipolar I disorder. Hypomania may be indicative of bipolar II disorder or cyclothymia. However, if prominent psychotic symptoms are present for a duration significantly longer than the mood episode, a diagnosis of schizoaffective disorder is more appropriate. Several types of "mania" such as kleptomania and pyromania are related more closely to obsessive-compulsive disorder than to bipolar disorder, depending on the severity of these disorders. For instance, someone with kleptomania who suffers from impulses to steal things such as pencils, pens, and paper-clips is better diagnosed with a form of OCD.
Hyperthyroidism can produce similar symptoms to those of mania, such as agitation, elevated mood, increased energy, hyperactivity, sleep disturbances and sometimes, especially in severe cases, psychosis.
Signs and symptoms
A manic episode is defined in the American Psychiatric Association's diagnostic manual as a period of seven or more days (or any period if admission to hospital is required) of unusually and continuously effusive and open elated or irritable mood, where the mood is not caused by drugs/medication or a medical illness (e.g., hyperthyroidism), and (a) is causing obvious difficulties at work or in social relationships and activities, or (b) requires admission to hospital to protect the person or others, or (c) the person is suffering psychosis.
To be classed as a manic episode, while the disturbed mood and an increase in goal directed activity or energy is present at least three (or four if only irritability is present) of the following must have been consistently present:
- Inflated self esteem or grandiosity
- Decreased need for sleep (e.g., feels rested after 3 hours of sleep.)
- More talkative than usual or pressure to keep talking.
- Flights of ideas or subjective experience that thoughts are racing.
- Increase in goal directed activity, or psychomotor agitation.
- Distractibility (too easily drawn to unimportant or irrelevant external stimuli.
- Excessive involvement in activities that have a high degree for painful consequences.(e.g., extravagant shopping, sexual adventures or improbable commercial schemes).
Though the activities one participates in while in a manic state are not always negative, those with the potential to have negative outcomes are far more likely to.
The World Health Organization's classification system defines a manic episode as one where mood is higher than the person's situation warrants and may vary from relaxed high spirits to barely controllable exuberance, accompanied by hyperactivity, a compulsion to speak, a reduced sleep requirement, difficulty sustaining attention and, often, increased distractibility. Frequently, confidence and self-esteem are excessively enlarged, and grand, extravagant ideas are expressed. Behavior that is out of character and risky, foolish or inappropriate may result from a loss of normal social restraint.
Some people also have physical symptoms, such as sweating, pacing, and weight loss. In full-blown mania, often the manic person will feel as though his or her goal(s) trump all else, that there are no consequences or that negative consequences would be minimal, and that they need not exercise restraint in the pursuit of what they are after. Hypomania is different, as it may cause little or no impairment in function. The hypomanic person's connection with the external world, and its standards of interaction, remain intact, although intensity of moods is heightened. But those who suffer from prolonged unresolved hypomania do run the risk of developing full mania, and indeed may cross that "line" without even realizing they have done so.
One of the most signature symptoms of mania (and to a lesser extent, hypomania) is what many have described as racing thoughts. These are usually instances in which the manic person is excessively distracted by objectively unimportant stimuli. This experience creates an absent-mindedness where the manic individual's thoughts totally preoccupy him or her, making him or her unable to keep track of time, or be aware of anything besides the flow of thoughts. Racing thoughts also interfere with the ability to fall asleep.
Mania is always relative to the normal rate of intensity of the person being diagnosed with it; therefore, an easily angered person may exhibit mania by getting even angrier even more quickly, and an intelligent person may adopt seemingly "genius" characteristics and an ability to perform and to articulate thought beyond what they can do in a normal mood. A very simple indicator of mania would be if a noticeably clinically depressed person becomes suddenly and inordinately energetic, cheerful, aggressive, or "happy". Other often-less-obvious elements of mania include delusions (of grandeur, potential, persecution, arrogance), hypersensitivity, hyper-vigilance, hypersexuality, hyper-religiosity, hyperactivity, impulsiveness, compulsion to over explain (keep talking with rapid speech), grandiose ideas and plans, and difficulty falling asleep or decreased need for sleep (e.g. feeling rested after 3 or 4 hours of sleep). The afflicted person's eyes may look, as well as feel abnormally "wide" or "open", rarely blinking; this sometimes contributes to clinicians' misconception that a manic patient is under the influence of a stimulant drug when the patient is either not on any mind-altering substances, or is in fact under the influence of a depressant drug in a misguided effort to stave off destructive and unwanted manic impulses. In manic and hypomanic cases, the afflicted person may engage in out-of-character behaviour, such as questionable business transactions, wasteful expenditures of money (e.g., excessive shopping sprees or unnecessary purchases), risky sexual activity, recreational drug abuse, excessive gambling, reckless behavior (such as fast, reckless driving or daredevil activity), abnormal social interaction, or highly vocal arguments uncharacteristic of previous behaviours. These behaviours may increase stress in personal relationships, lead to problems at work and increase the risk of altercations with law enforcement. There is a high risk of impulsively taking part in activities potentially harmful to self and others.
Although "severely elevated mood" sounds somewhat desirable and enjoyable, the experience of mania is ultimately often quite unpleasant and sometimes disturbing, if not frightening, for the person involved and for those close to them, and it may lead to impulsive behaviour that may later be regretted. It can also often be complicated by the sufferer's lack of judgment and insight regarding periods of exacerbation of characteristic states. Manic patients are frequently grandiose, obsessive, impulsive, irritable, belligerent, and frequently deny anything is wrong with them. Because mania frequently encourages high energy and decreased perception of need or ability to sleep, within a few days of a manic cycle, sleep-deprived psychosis may appear, further complicating the ability to think clearly. Racing thoughts and misperceptions lead to frustration and decreased ability to communicate with others.
There are different "stages" or "states" of mania. A minor state is essentially hypomania and, like hypomania's characteristics, may involve increased creativity, wit, gregariousness, and ambition. Full-blown mania will make a person feel elated, but perhaps also irritable, frustrated, and even disconnected from reality. These latter two stages are often referred to as acute (stage II) and delirious, or Bell's (stage III).
The biological mechanism by which mania occurs is not yet known. Based on the mechanism of action of antimanic agents (such as antipsychotics, valproate, tamoxifen, lithium, carbamazepine, etc.) and abnormalities seen in patients experiencing a manic episode the following is theorised to be involved in the pathophysiology of mania:
- Dopamine D2 receptor overactivity (which is a pharmacologic mechanism of antipsychotics in mania)
- GSK-3 overactivity
- Protein kinase C overactivity
- Inositol monophosphatase overactivity
- Increased arachidonic acid turnover
- Increased cytokine synthesis
Before beginning treatment for mania, careful differential diagnosis must be performed to rule out non-psychiatric causes.
When the manic behaviours have gone, long-term treatment then focuses on prophylactic treatment to try to stabilize the patient's mood, typically through a combination of pharmacotherapy and psychotherapy. The likelihood of having a relapse is very high for those who have experienced two or more episodes of mania or depression. While medication for bipolar disorder is important to manage symptoms of mania and depression, studies show relying on medications alone is not the most effective method of treatment. Medication is most effective when used in combination with other bipolar disorder treatments, including psychotherapy, self-help coping strategies, and healthy lifestyle choices.
Lithium is the classic mood stabilizer to prevent further manic and depressive episodes. A systematic review found that long term lithium treatment substantially reduces the risk of bipolar manic relapse, by 42%. Anticonvulsants such as valproate, oxcarbazepine and carbamazepine are also used for prophylaxis. More recent drug solutions include lamotrigine, which is another anticonvulsant. Clonazepam (Klonopin) is also used. Sometimes atypical antipsychotics are used in combination with the previous mentioned medications as well, including olanzapine (Zyprexa) which helps treat hallucinations or delusions, Asenapine (Saphris, Sycrest), aripiprazole (Abilify), risperidone, ziprasidone, and clozapine which is often used for people who do not respond to lithium or anticonvulsants.
Verapamil, a calcium-channel blocker, is useful in the treatment of hypomania and in those cases where lithium and mood stabilizers are contraindicated or ineffective. Verapamil is effective for both short-term and long-term treatment.
Antidepressant monotherapy is not recommended for the treatment of depression in patients with bipolar disorders I or II, and no benefit has been demonstrated by combining antidepressants with mood stabilizers in these patients.
Society and culture
In Electroboy: A Memoir of Mania by Andy Behrman, he describes his experience of mania as "the most perfect prescription glasses with which to see the world...life appears in front of you like an oversized movie screen". Behrman indicates early in his memoir that he sees himself not as a person suffering from an uncontrollable disabling illness, but as a director of the movie that is his vivid and emotionally alive life. "When I'm manic, I'm so awake and alert, that my eyelashes fluttering on the pillow sound like thunder" . Many people who are artistic and do art in various forms have mania. Winston Churchill had periods of manic symptoms that may have been both an asset and a liability.
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