Some manic episodes develop with amazing swiftness, although onset may be gradual, lasting for months. Individuals being treated for depression may evolve quickly into mania and mania may sharply switch back to depression. The DSM requires euphoria and/or irritability to be present for there to be a diagnosis of mania. During an episode of mood disturbance, there are some listed symptoms and signs and three of them must be present to a significant degree to make a diagnosis [7].

• There is a decreased need for sleep. In mania, unlike other disorders, there is no resultant fatigue and patients feel well rested after 3 hours sleep.
• There is also increased activity as patients with mania are almost always up and about at night. This has to be apparent to others apart from the patient for it to be considered a symptom.
• There will also be racing thoughts which can be elicited during the history taking. Flight of ideas is seen commonly.
• Patients also have a short attention span and lack the ability to concentrate for a period of time. This may be attributed to the racing thoughts.
• Pressured speech is also present and patients speak rapidly and expressively.
• Delusions of grandeur may range from modest overestimation of talents to grandiose delusions where the individual has global or supernatural importance. They are often complicated by persecutory delusions.
• There is extreme involvement in pleasurable but reckless behavior. The patients, due to grandiose delusions have a false sense of invulnerability and optimism that causes this behavior. This is responsible for much of the morbidity associated with mania.

• Pressured Speech

  She presented with a predominantly expansive mood, psychomotor agitation, disorganized and pressured speech, flight of ideas, grandiosity, delusions, and auditory hallucinations. [ncbi.nlm.nih.gov]

  speech, they are speaking rapidly their thoughts and their words are crashing into one another and coming so quickly and they tend to jump from idea to idea with no real organization so individuals with extreme a manic episode will have this pressured [youtube.com]

  Symptoms: These includes excitement, irritability, reduced sleep time, increased activity, short attention span, elevated self-esteem, pressured speech and reckless behavior. [symptoma.com]

  […] which is difficult to interrupt (pressured speech) Rapid thinking Increased sense of perceptual and intellectual acuity Increased impulsivity Not infrequently paranoia and delusions of grandeur or persecution are present, less frequently auditory, visual [hopkinsguides.com]

• Asymptomatic

  LV typically is characterized by red-brown papules, which coalesce to form a well-demarcated scaly, asymptomatic plaque. The plaque gradually expands by development of new papules at the periphery. [hindawi.com]

  Countries that have flattened their epidemiological curves have done so through aggressive testing, which is important because so many people who have the virus are asymptomatic. [pressherald.com]

  [Crossref] Werschler WP, Elgart ML, Williams CM (1990) Progressive asymptomatic annular facial skin lesions. Cutaneous tuberculosis (lupus vulgaris). Arch Dermatol 126: 1227-1230. [oatext.com]

  The lesions were asymptomatic except for mild itching. There was no history of trauma prior to the onset of the lesions or the past history suggestive of tuberculosis of any part of the body. [idoj.in]

  Lupus vulgaris (LV) is the morphological variant of cutaneous tuberculosis (TB), which occurs in persons with moderate immunity and high-degree of tuberculin sensitivity. [1] Clinically, it presents with asymptomatic brownish to red solitary plaque with [e-ijd.org]

• Weight Loss

  Acetyl-l-carnitine (ALC) is widely recognised as a safe dietary supplement to aid weight loss. [ncbi.nlm.nih.gov]

  […] crying Difficulty making decisions Irritability Increased need for sleep Insomnia or excessive sleep A change in appetite causing weight loss or gain Thoughts of death or suicide Attempting suicide Patients with depression can also become psychotic and [my.clevelandclinic.org]

  The clinical depression symptoms seen with bipolar disorder are the same as those seen in major depressive disorder and include: Decreased appetite and/or weight loss, or overeating and weight gain Difficulty concentrating, remembering, and making decisions [webmd.com]

  […] of appetite, weight loss, poor concentration, aggression, excessive sociability, getting dominating and demanding, detachment from reality, feeling on top of the world — until it all comes crashing down. [thehindu.com]

  There was no history of weight loss, fever, cough, diabetes and hypertension. There was a history of treatment for primary pulmonary tuberculosis 5 years previously. [smjonline.org]

• Quickening

  […] mental disorder: Major mood disorders Bipolar disorder (previously known as manic-depressive disorder) is characterized by an elated or euphoric mood, quickened thought and accelerated, loud, or voluble speech, overoptimism and heightened enthusiasm and [britannica.com]

  If this film doesn't make you smile, then you've probably never felt your pulse quicken or experienced butterflies in your stomach when you lay eyes on the object of your affection. [amazon.com]

• Osteoporosis

  Other complications of hyperthyroidism include: Heart problems such as fast heart rate, abnormal heart rhythm, and heart failure Osteoporosis Surgery-related complications, including: Scarring of the neck Hoarseness due to nerve damage to the voice box [medlineplus.gov]

• Distractibility

  CONCLUSIONS: The finding of decreased mPFC activation during self-referential processing in mania may reflect decreased self-focus and high distractibility. [ncbi.nlm.nih.gov]

  Most frequently observed are patients with predominantly depressed mood and poverty of thought who simultaneously manifest restlessness and dysphoric energy, or patients with depressed mood who also exhibit flight of ideas, distractibility, anxiety and [hopkinsguides.com]

  Symptoms of hypomania can include the following: How you might feel Happy, euphoric or a sense of wellbeing Very excited, like you can't get your words out fast enough Irritable and agitated Increased sexual energy Easily distracted, like your thoughts [mind.org.uk]

• Flight of Ideas

  She presented with a predominantly expansive mood, psychomotor agitation, disorganized and pressured speech, flight of ideas, grandiosity, delusions, and auditory hallucinations. [ncbi.nlm.nih.gov]

  The patient demonstrates flight of ideas, pressure of speech, disinhibition, punning, grandiose delusions, and second person auditory hallucinations. His presentation is consistent with mania. [youtube.com]

  When flight of ideas is severe, speech may become disorganized and incoherent. A person in a manic episode may easily lose attention. [psychcentral.com]

• Euphoria

  Mania Definition Mania is an abnormally elated mental state, typically characterized by feelings of euphoria, lack of inhibitions, racing thoughts, diminished need for sleep, talkativeness, risk taking, and irritability. [medical-dictionary.thefreedictionary.com]

  These beliefs are frequently accompanied by feelings of euphoria and intense pleasure. Nothing seems impossible and every problem has a solution. The person may feel an urgent need to initiate projects or activities. [web.archive.org]

  […] noun mass noun 1 Mental illness marked by periods of great excitement or euphoria, delusions, and overactivity. [en.oxforddictionaries.com]

  And if you're like some people with bipolar disorder, you may enjoy the feelings of euphoria and cycles of being more productive. [mayoclinic.org]

  […] scientist, Cecilia Kass (Moss) escapes in the dead of night and disappears into hiding, aided by her sister (Harriet Dyer, NBC’s The InBetween), their childhood friend (Aldis Hodge, Straight Outta Compton) and his teenage daughter (Storm Reid, HBO’s Euphoria [youtube.com]

• Delusion of Grandeur

  […] of grandeur or persecution are present, less frequently auditory, visual, or olfactory hallucinations. [hopkinsguides.com]

  Some common examples include delusions of grandeur (believing that you are famous, publicly important, or chosen by God), persecutory or paranoid delusions (suspecting that you are being spied on or followed), jealous delusions (being convinced that your [psychologytoday.com]

  Delusions of grandeur may range from modest overestimation of talents to grandiose delusions where the individual has global or supernatural importance. They are often complicated by persecutory delusions. [symptoma.com]

  Bipolar mania symptoms often include an abnormal increase in energy or activity, delusions of grandeur, and racing thoughts. The type of bipolar disorder depends on the severity and length of a manic episode. [medicalnewstoday.com]

• Psychiatric Manifestation

  Psychiatric manifestations of systemic lupus erythematosus (SLE) that are commonly preceded by organic syndromes include confusional states, anxiety disorder, cognitive dysfunction, mood disorder and psychosis. [ncbi.nlm.nih.gov]

  Huffman J, Stern TA: Acute psychiatric manifestations of stroke: a clinical case conference. Psychosomatics 2003;44:65–75. Gafoor R, O’Keane V: Three case reports of secondary mania: evidence supporting a right frontotemporal locus. [doi.org]

• Sexual Dysfunction

  dysfunction Dry mouth Constipation Blurred vision Dealing with antipsychotic-induced erectile dysfunction Sexual and erectile dysfunction is a common side effect of antipsychotic medications, one that often deters bipolar disorder patients from continuing [web.archive.org]

• Irritability

  KEYWORDS: Adolescence; bipolar disorder; cardinal symptoms; childhood; irritability; mania [ncbi.nlm.nih.gov]

  These factors represent 'elated mania', 'irritable mania' and 'psychotic mania'. The first factor represented irritable mania with high loadings from irritability, and increased motor activity/energy. [bmcpsychiatry.biomedcentral.com]

  The DSM requires euphoria and/or irritability to be present for there to be a diagnosis of mania. [symptoma.com]

  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. [web.archive.org]

  A person in a manic state is full of energy or very irritable, may sleep far less than normal, and may dream up grand plans that could never be carried out. [health.harvard.edu]

• Excitement

  FootballMania is an exciting sweepstakes fundraiser based on professional football. [charitymania.com]

  If a person becomes manic, they may notice that they are: Very happy and excited Irritated with other people who don't share their optimistic outlook Feeling more important than usual Full of new and exciting ideas Moving quickly from one idea to another [awp.nhs.uk]

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  […] mn 1. frenzy चर संज्ञा Frenzy is great excitement or wild behaviour that often results from losing control of your feelings. 'Get out!' [collinsdictionary.com]

  Play as Sonic, Tails, & Knuckles as you race through all-new Zones and fully re-imagined classics, each filled with exciting surprises and powerful bosses. [sega.com]

• Agitation

  Manic-depressives and agitated depressives were also excluded. Patients with mania and/or psychomotor agitation had predominantly right hemisphere lesions. [ncbi.nlm.nih.gov]

  They may also display inappropriate anger, or agitation, and even lash out and become violent in some cases. For example, a person with mania in a bar might pick a fight for no reason. [gulfbend.org]

• Hyperactivity

  Our results are in agreement with the hypothesis that hyperactive/novelty-seeking features may represent an adaptive substrate in certain conditions of social change. [ncbi.nlm.nih.gov]

  It is characterized by persistent or elevated expansive mood, hyperactivity, inflated self esteem, etc., but of less intensity than mania.) Severe mania may have psychotic features. [medical-dictionary.thefreedictionary.com]

  The first is rapid control of hyperactivity, sleeplessness, irritability and psychotic features. The second is selection of mood stabilizers. Many patients initially refuse oral medication so parenteral antipsychotics should be used. [symptoma.com]

• Confusion

  H2 receptor antagonists can be associated with central adverse drug reactions (ADRs), like confusion, delirium, hallucinations, slurred speech or headaches. [ncbi.nlm.nih.gov]

  […] of secondary mania are narrowed to those without the confused state.[1] The second argument is harder to dispute, as it is possible that secondary mania is late-onset bipolar disorder. [en.wikipedia.org]

  And not to be confused with Venom: funeral Pyre from the nineties that pitted Venom against Punisher. I mean, for a start, this comic doesn’t have Punisher in it. Or, for that matter, Venom. [bleedingcool.com]

  Here’s more information about some projects currently underway: Spermatophores Ring in Spring MCHT land steward Kirk Gentalen is on the lookout for the harbinger of mid-late early spring (yes that’s confusing) and finds it in spermatophores. [mcht.org]

  Call us and speak with a live, knowledgeable person…no automated response or confusing phone menus. Learn more about us. We are a proud member of the Better Business Bureau’s Online Reliability Program. [charitymania.com]

Patient should be screened for alcohol and substance abuse. Laboratory investigations like liver and renal function are also important to establish a baseline. MRI could also be done. Although its role remains unclear, some have reported that there is hyperintensity in the temporal lobes of patients with mania [8].

ECG is also required to establish a baseline as some drugs used in management have cardiovascular effects. EEG should also be done for baseline assessment before interventions like electroconvulsive therapy.

• Hypoglycemia

  In addition to directly causing neuronal atrophy, stress and glucocorticoids also appear to reduce cellular resilience, thereby making certain neurons more vulnerable to other insults, such as ischemia, hypoglycemia, and excitatory aminoacid toxicity. [ncbi.nlm.nih.gov]

There are two goals of treatment. The first is rapid control of hyperactivity, sleeplessness, irritability and psychotic features. The second is selection of mood stabilizers.

Many patients initially refuse oral medication so parenteral antipsychotics should be used. Intramuscular zisparodone can be used. Haloperidol, the most popular of the atypical psychotics can also be used. When typical psychotics are used, their increased risk of extrapyramidal symptoms should be considered and a low dose anticholinergic agent should be given along with it to reduce this risk.

Patients on rapidly increasing doses of high potency neuroleptics should be closely monitored as there is an increased risk of neuroleptic malignant syndrome.

When patients can tolerate orally, atypical antipsychotics are preferable because their acute side effects are less problematic. Although no one drug has a clear benefit over another, rapidly dissolving form of olanzapine may be preferable to increase compliance and reducing the incidence of ‘cheeking’ of drugs [9].

The preferred and most popular mood stabilizer is lithium. Several trials have shown its prophylactic efficacy. Mood stabilizers should be introduced as soon as patient is willing to accept oral medication. Valproate is another mood stabilizer that has proven efficacy [10].

Single manic episodes usually resolve over time with or without treatment, but these single occurrences are rare. It is also rare for individuals to experience only manic episodes as many manic patients usually experience depressive phases. Most bipolar patients have more morbidity from depression than from mania [5].

There is no evidence to show a variation in course or outcome relative to age or sex. Mania developed in childhood is indicative of more long term morbidity than that developed later in life. Patients who experience discrete episodes of mania or depression have shorter, less frequent episodes than those who switch directly from one pole to the other [6].

Lastly, the presence of psychotic features portend a more long-term morbidity.

The exact cause or biochemical pathway by which mania occurs is unknown. It is a psychiatric disease but a lot of factors have been implicated in its etiology. These factors could be genetic as there is an increased risk in individuals who have first degree relatives with the condition. It could also be biochemical caused by therapeutic and recreational drugs. Other factors could be neurophysiologic, psychodynamic and environmental [2].

A manic episode differentiates bipolar 1 disorder which is said to have a lifetime prevalence of 1.6% in the US. Unlike many other mood disorders that affects more women than men, this condition affects male and female individuals equally. First age of onset is usually in the 20s. First occurrence of a manic episode in an older individual should be properly screened for underlying diseases [3].

The pathophysiology behind mania is still unclear. The mechanism of action of antimanic agents and the behavior of patients experiencing a manic episode has been used to arrive at some postulates. One of the theorems is overactivity of dopamine D2 receptors. There is also overactivity of Glycogen synthase kinase 3 as well as Protein kinase C and Inositol monophosphate. There is also increased arachnoid acid turnover and increased cytokine synthesis. Imaging studies have shown that the left amygdala is more active in women who have mania than the orbitofrontal cortex [4].

There is no known way to prevent the primary episode but prevention of secondary manic episodes requires absolute drug compliance.

It is a symptom for many different psychiatric and organic disorders, mania is often a manifestation of an underlying disease or condition. It is usually a part of the more expansive bipolar affective disorder where it alternates with depression. Mania is often analyzed collectively, whether as a single entity or part of an entity, like one end of the bipolar spectrum [1].

Definition: Mania is defined as a period of persistently and abnormally elevated, irritable or expansive mood lasting at least one week or requiring hospitalization.It hardly occurs alone and is most times followed by depression in what is known as manic depressive episodes.

Causes: There are several factors that could contribute to this condition. It could be familial as there is an increased risk if first relatives suffer from it. It could also be cause by drugs, either legal or illegal drugs. Environmental factors as well as psychological and brain lesions could cause it.

Symptoms: These includes excitement, irritability, reduced sleep time, increased activity, short attention span, elevated self-esteem, pressured speech and reckless behavior.

Diagnosis: This is done clinically and is based on the history and physical examination. Patients must fit a diagnostic criteria to be said to have mania.

Treatment: This involves the use of medications, first to control the hyperactivity, irritability and sleeplessness and then to stabilize the patient’s mood. It is important that these drugs are taken religiously to avoid a relapse.

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2. Greenwood TA, Badner JA, Byerley W, et al. Heritability and linkage analysis of personality in bipolar disorder. J Affect Disord 2013; 151:748.
3. Duax JM, Youngstrom EA, Calabrese JR, Findling RL. Sex differences in pediatric bipolar disorder. J Clin Psychiatry. Oct 2007;68(10):1565-73.
4. Garrett A, Chang K. The role of the amygdala in bipolar disorder development. Dev Psychopathol. Fall 2008;20(4):1285-96.
5. Harrow M, Goldberg JF, Grossman LS, Meltzer HY. Outcome in manic disorders. A naturalistic follow-up study. Arch Gen Psychiatry 1990; 47:665.
6. Faraone SV, Biederman J, Wozniak J, Mundy E, Mennin D, O'Donnell D. Is comorbidity with ADHD a marker for juvenile-onset mania?. J Am Acad Child Adolesc Psychiatry. Aug 1997;36(8):1046-55. 
7. Skjelstad DV, Malt UF, Holte A. Symptoms and signs of the initial prodrome of bipolar disorder: a systematic review. J Affect Disord 2010; 126:1.
8. Arnone D, Cavanagh J, Gerber D, et al. Magnetic resonance imaging studies in bipolar disorder and schizophrenia: meta-analysis. Br J Psychiatry 2009; 195:194.
9. Singh MK, Ketter TA, Chang KD. Atypical antipsychotics for acute manic and mixed episodes in children and adolescents with bipolar disorder: efficacy and tolerability. Drugs. Mar 5 2010;70(4):433-42.
10. Bowden CL, Brugger AM, Swann AC, et al. Efficacy of divalproex vs lithium and placebo in the treatment of mania. The Depakote Mania Study Group. JAMA 1994; 271:918.