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Mania

Manias

Mania is derived from the Greek word for madness and frenzy. It is defined as a period of persistently and abnormally elevated, irritable or expansive mood lasting for at least one week or that requiring hospitalization.


Presentation

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.
Weight Loss
  • Acetyl-l-carnitine (ALC) is widely recognised as a safe dietary supplement to aid weight loss.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected can be a sign of depression) Either insomnia or sleeping too much Either restlessness or slowed behavior Fatigue or loss of energy[mayoclinic.org]
  • Behavior that is out of character and risky, foolish or inappropriate may result from a loss of normal social restraint. [2] Some people also have physical symptoms, such as sweating, pacing, and weight loss.[en.wikipedia.org]
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]
  • Symptoms: These includes excitement, irritability, reduced sleep time, increased activity, short attention span, elevated self-esteem, pressured speech and reckless behavior.[symptoma.com]
  • Pressured speech Pressured speech is the tendency to talk very quickly and loudly. It often goes hand in hand with racing thoughts. Someone with this symptom may urgently state all of their ideas, possibly without making sense.[medicalnewstoday.com]
  • Speech disruptions may include: Rapid, pressured speech (as if you cannot get enough words in) Incoherent speech (often described as rambling and persistent) Clang associations (a serious condition in which words that sound similar are grouped together[verywellmind.com]
Restless Legs Syndrome
  • RESULTS: A patient with bipolar I disorder was hospitalized with a manic episode characterized by agitation and insomnia after taking pramipexole for restless leg syndrome (RLS) in combination with olanzapine.[ncbi.nlm.nih.gov]
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]
  • When flight of ideas is severe, speech may become disorganized and incoherent. A person in a manic episode may easily lose attention.[psychcentral.com]
  • ., feels rested after only 3 hours of sleep) (3) more talkative than usual or pressure to keep talking (4) flight of ideas or subjective experience that thoughts are racing (5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant[web.archive.org]
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]
Euphoric Mood
  • On day 4, the patient exhibited a euphoric mood, with persistent laughing, expansive self-esteem, extreme talkativeness, flight of ideas, distractibility, and psychomotor agitation.[ncbi.nlm.nih.gov]
  • When an individual experiences a discrete period of persistent and pervasive manic (elated, irritable or euphoric) mood , this term may be applied. The individual may be diagnosed with one of the bipolar disorders.[web.archive.org]
Grandiose Ideas
  • Included are such symptoms as persecutory delusions (not directly related to grandiose ideas or themes), thought insertion, and delusions of being controlled. .x5--In Partial Remission: Symptoms of a Manic Episode are present but full criteria are not[web.archive.org]
Short Attention Span
  • Symptoms: These includes excitement, irritability, reduced sleep time, increased activity, short attention span, elevated self-esteem, pressured speech and reckless behavior.[symptoma.com]
Sexual Dysfunction
  • […] bipolar disorder include: Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ariprazole (Abilify) Ziprasidone (Geodon) Clozapine (Clozaril) Common side effects of antipsychotic medications for bipolar disorder Drowsiness Weight gain Sexual[web.archive.org]
Excitement
  • FootballMania is an exciting sweepstakes fundraiser based on professional football.[charitymania.com]
  • 259.00 Dallas MANIA August 23-25, 2019 • 280 Sessions • 70 Presenters • 24 CECs/CEUs: SCW, AFAA, ACE, NASM, ACSM & AEA • 18 Pre-Convention Certs • 17 Workshops every hour • 3 Full Days • 1 Exciting Expo![scwfit.com]
  • 296.0 Delirium, delirious 780.09 manic, maniacal (acute) (see also Psychosis, affective) 296.0 Disease, diseased - see also Syndrome Bell's (see also Psychosis, affective) 296.0 Disorder - see also Disease manic (see also Psychosis, affective) 296.0 Excitement[icd9data.com]
  • […] ma·nia \ ˈmā-nē-ə, -nyə \ 1 : excitement manifested by mental and physical hyperactivity, disorganization of behavior, and elevation of mood specifically : the manic phase of bipolar disorder 2 a : excessive or unreasonable enthusiasm a mania for saving[merriam-webster.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]
Irritability
  • KEYWORDS: Adolescence; bipolar disorder; cardinal symptoms; childhood; irritability; mania[ncbi.nlm.nih.gov]
  • 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]
  • ; indeed, as the mania intensifies, irritability can be more pronounced and result in violence, or anxiety.[en.wikipedia.org]
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]
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]
  • 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]
  • 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]
Insomnia
  • RESULTS: A patient with bipolar I disorder was hospitalized with a manic episode characterized by agitation and insomnia after taking pramipexole for restless leg syndrome (RLS) in combination with olanzapine.[ncbi.nlm.nih.gov]
  • Mania: An abnormally elevated mood state characterized by such symptoms as inappropriate elation, increased irritability, severe insomnia, grandiose notions, increased speed and/or volume of speech, disconnected and racing thoughts, increased sexual desire[medicinenet.com]
  • Advertisement 5 of 10 Fotolia Mania symptom: sleeplessness We're not talking garden variety insomnia here.[health.com]
  • Insomnia A quick, slick highlight from Roufusport, a gym known for their flashy techniques. A challenger emerges for Vasily Kamotskiy. Jon Jones’ latest scandal is really the best headline yet.[mmamania.com]

Workup

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.

Treatment

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].

Prognosis

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.

Etiology

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].

Epidemiology

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].

Sex distribution
Age distribution

Pathophysiology

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].

Prevention

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

Summary

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].

Patient Information

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.

References

Article

  1. Goldberg JF, Harrow M, Grossman LS. Recurrent affective syndromes in bipolar and unipolar mood disorders at follow-up. Br J Psychiatry 1995; 166:382.
  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.

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Last updated: 2019-07-11 22:55