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For further information, see CMDT Part 25-12: Mood Disorders (Depression & Mania)

Key Features

Essentials of Diagnosis

  • Mood ranging from euphoria to irritability

  • Sleep disruption

  • Hyperactivity

  • Racing thoughts

  • Grandiosity or extreme overconfidence

  • Variable psychotic symptoms

General Considerations

  • Often combined with depression

  • May occur alone, together with depression in a mixed episode, or in cyclic fashion with depression

  • In almost all cases, the manic episode is part of a broader bipolar (manic-depressive) disorder

Clinical Findings

Symptoms and Signs

  • Mood change characterized by

    • Elation with hyperactivity

    • Overinvolvement in life activities

    • Increased irritability

    • Flight of ideas

    • Easy distractibility

    • Little need for sleep

  • The overenthusiastic quality of the mood and the expansive behavior initially attract others

  • The irritability, mood lability with swings into depression, aggressive behavior, and grandiosity usually lead to marked interpersonal difficulties

  • Activities may occur that are later regretted, eg

    • Excessive spending

    • Resignation from a job

    • Hasty marriage or divorce

    • Sexual acting out

    • Exhibitionistic behavior

    • Alienation of friends and family

  • A typical manic episode can include

    • Gross delusions

    • Paranoid ideation of severe proportions

    • Auditory hallucinations usually related to some grandiose perception

  • The episodes begin abruptly (sometimes precipitated by life stresses) and may last from several days to months

  • Manic patients differ from schizophrenic patients in that the former use more effective interpersonal maneuvers, are more sensitive to the social maneuvers of others, and are more able to utilize weakness and vulnerability in others to their own advantage

Differential Diagnosis

  • Bipolar disorder (manic-depression)

  • Substance abuse, eg, cocaine

  • Hypomania

  • Cyclothymic disorder (depression and hypomania)

  • Schizophrenia

  • Hyperthyroidism

  • Substance abuse, eg, cocaine, amphetamines

  • Medications, eg, corticosteroids, thyroxine

  • CNS disease, eg, complex partial seizures, tumor, neurosyphilis, HIV

  • Personality disorder, eg, borderline, narcissistic

Diagnosis

Laboratory Tests

  • Serum thyroid-stimulating hormone

  • Complete blood count

  • Blood urea nitrogen

  • Serum creatinine

  • Serum electrolytes

  • Urinalysis

Treatment

Medications

  • Antipsychotics

    • Initial treatment for acute symptoms includes

      • Olanzapine, 5–20 mg orally

      • Risperidone, 2–3 mg orally

      • Aripiprazole, 15–30 mg orally

    • A benzodiazepine (eg, clonazepam) may be used in conjunction with these agents, if indicated

    • When behavioral control is immediately necessary, the following may be used repeatedly until symptoms subside

      • Olanzapine, 2.5–10 mg intramuscularly or

      • Haloperidol, 5–10 mg orally or intramuscularly

    • The dosage of the antipsychotic may be gradually reduced after lithium or another mood stabilizer is started

    • Maintenance treatments for bipolar disorder to prevent subsequent cycles of mania and depression include

      • Olanzapine

      • Quetiapine

      • Ziprasidone

      • Aripiprazole

      • Risperidone (the long-acting injectable)

  • Valproic acid helps acute manic or hypomanic symptoms

    • First-line treatment for mania

    • Dosage

      • Started at 750 mg/day orally, then titrated to achieve therapeutic serum levels

      • Oral loading in acutely manic bipolar patients in an inpatient setting (initiated ...

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