In mania the life-time risk of manic episode is about 0.81%. This disorder tends to occur in episodes lasting usually 3-4 months, followed by complete clinical recovery. The future episodes can be manic, depressive or mixed. A manic episode is typically characterized by the following features (which should last for at least one week and cause disruption in occupational and social activities).
Sign & symptoms:
|● Socially inappropriate behaviour|
|● Reduced sleep|
|● Increased appetite|
|● Increased libido|
|Thinking and speech|
|● Flight of ideas|
|● Expansive ideas|
|● Grandiose delusions|
This term refers to a state in which manic symptoms are present and noticeable, but they do not cause a serious degree of functional impairment.
● Mild mania:
Physical activity and speech are increased, mood is labile, mainly euphoric but at times irritable, ideas are expansive, and the patient often spends more than he can afford. By definition, there is significant social impairment in this and the other patterns of mania.
● Moderate mania:
There is marked over-activity with pressure and disorganization of speech, the euphoric mood is increasingly interrupted by periods of irritability, hostility, and depression, and grandiose and other preoccupations may become delusional.
● Severe mania:
There is frenzied overactivity, thinking is incoherent and delusions become increasingly bizarre, and hallucinations are experienced. Very rarely, however, the patient becomes immobile and mute instead of overactive and talkative (manic stupor).
DSM-IV diagnostic criteria for mania:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (e.g. feels rested after only 3 hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli)
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
C. The symptoms do not meet criteria for a Mixed Episode.
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism).
Differential diagnosis of manic disorders:
● Endocrine disorders such as Hypothyroid
● Abuse of stimulant drugs
Treatment of mania:
General aspects of the treatment of mania:
Milder manic episodes may be treated as an outpatient, but more severe disorders with associated loss of judgement will almost always need initial treatment as an inpatient. When the disorder is more severe, compulsory admission is likely to be needed.
Almost all patients with a manic episode will need drug treatment (Antipsychotic drugs). The clinical status should be monitored frequently. Progress is judged not only by the mental state and general behaviour, but also by the pattern of sleep and by the regaining of any weight lost during the illness. As progress continues, antipsychotic drug treatment is reduced gradually.
It is important, however, not to discontinue the drug too soon, otherwise relapse may occur. During treatment a careful watch should be kept for the appearance of depressive symptoms because transient but profound depressive mood change and depressive ideas are common among manic patients.
In either case, suicidal ideas may appear. A sustained change to a depressive syndrome may require treatment, including with antidepressant drugs which should be used cautiously to avoid precipitation of a manic relapse.
Specific treatments for mania:
Anti-psychotic drugs have an established place in the treatment of mania. An atypical anti-psychotic, such as olanzapine, quetiapine, or risperidone, is therefore usually the first-choice treatment. Anti-psychotics should generally not be used to control behaviour because the doses required for this effect are high and adverse effects are therefore more likely. A benzodiazepine such as lorazepam or diazepam should be used instead.
Lithium is effective in mania, but less so than anti-psychotic drugs, and it can be difficult to use safely in severely disturbed patients. It is therefore used mainly in patients with milder manic episodes, especially when it is intended to continue the treatment in the long term to prevent relapse.
It is also used in combination with antipsychotics—caution is required when used in combination with haloperidol because extrapyramidal effects occur commonly.
Valproate is effective in acute mania. It is slightly less effective than antipsychotics, but causes fewer adverse effects. Thus, it may be particularly useful in patients who are not currently taking a long-term mood stabilizer, and who have a mild manic illness without psychotic features. An advantage of valproate over lithium in the acute phase is that a high loading dose can be given, which leads to a more rapid response and shorter hospital stays.
Carbamazepine is another anti-epileptic drug that can be used in mania.
Clinical experience indicates that ECT has a powerful therapeutic effect in mania. Nevertheless, ECT is not a first-line treatment; its use is mainly in the uncommon cases when antipsychotic drugs are ineffective and the patient is so seriously disturbed that to spend time trying further medication or awaiting natural recovery is not justified.
Psychiatry, Fourth Edition – Oxford Medical Publications -SRG-by John Geddes, Jonathan Price, Rebecca McKnight