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The Recognition and Management of Mania

Authors: William Coryell, MDFaculty and Disclosures


The Phenomenology and Diagnosis of Mania

A manic episode distinguishes bipolar I disorder, a condition estimated to have a lifetime prevalence of 1.6% in the United States.[1] In contrast to the female predominance that characterizes other affective disorders, the sex ratio of bipolar I disorder is nearly even. Onset occurs most often in the 20s, but childhood and adolescent onsets have been increasingly recognized in the past decade with the realization that the phenomenology and course at these ages differ from typical presentations in adults.[2-5] Numerous medical conditions can produce manic syndromes,[6] and the first occurrence of a manic episode in older individuals should invite a careful screening for underlying conditions.

Some manic episodes develop with remarkable speed, although gradual onsets spanning weeks to months occur as well. An individual being treated for depression may abruptly switch into a manic phase and mania may evolve quickly to depression.

The DSM-IV definition of mania lists 8 symptoms and requires euphoria or irritability. Either of these may occur alone or in combination with the other, and either may be ascertained by the patient's subjective report or by clinical observation.

Patients with mania experience the decreased sleep that is present in many other disorders. The distinguishing quality in mania is the absence of resultant fatigue. A useful probe is, "Have you found that you need less sleep than usual to feel rested and energetic?"

A decreased need for sleep is typically accompanied by another manic symptom -- increased activity. Whereas individuals with depression or anxiety disorder who are unable to sleep often remain in bed and brood about their need for sleep, manic patients are likely to be up and busy at night. Increased activity should be apparent to others in the patient's environment to be included as a manic symptom.

Manic patients may or may not acknowledge racing thoughts, but the examiner often appreciates a flight of ideas on interview. The patient typically moves rapidly from one topic to another but, in contrast to the thought disorder of schizophrenia, the connection between thoughts is usually perceptible. Patients with pressured speech are not simply circumstantial, but speak rapidly and expressively. In clinical settings, such patients are more likely than other patients to address all present and to be socially intrusive.

Grandiosity may shade from modest overestimation of talent, intelligence, or economic prospects to grandiose delusions in which the individual has worldwide or cosmic importance. These beliefs are often complicated by persecutory delusions that may then dominate the clinical picture.

The sense of optimism and invulnerability that accompanies grandiosity often combines with increased activity to fuel reckless behavior. This feature is responsible for much of the morbidity consequent to manic episodes. Excessive spending is perhaps its most common form, but patients often also come to regret impulsive sexual liaisons, abrupt travel, ill-advised business decisions, and excessive alcohol use.

The distinction between bipolar I disorder and bipolar II disorder hinges on the boundary between mania and hypomania. Patients with mania experience a mood disturbance that is, according to DSM-IV, "sufficiently severe to cause marked impairment in occupational functioning or unusual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features." Those with hypomania do not, by definition, have this level of severity. This may seem an arbitrary separation of syndromes, but the results of family[7] and follow-up studies[8,9] support its validity. Bipolar II disorder occurs far more frequently in the families of bipolar II probands than in the families of bipolar I probands, and patients with only a history of hypomania are much more likely to develop manic episodes during extended follow-up periods than are those with histories of mania.

Table of Contents

  1. The Phenomenology and Diagnosis of Mania
  2. Prognosis
  3. The Management of Acute Mania
  4. Maintenance