Mania

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

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

Laboratory Tests

• Serum thyroid-stimulating hormone

• Complete blood count

• Blood urea nitrogen

• Serum creatinine

• Serum electrolytes

• Urinalysis

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 at a dosage of 20 mg/kg/day) can safely achieve serum therapeutic levels in 2–3 days

  • Gastrointestinal symptoms and weight gain are the main side effects

• Lithium is used for maintenance and manic episodes

  • Common starting dose: 300–900 mg orally daily, with trough blood levels measured after 4–5 days of treatment

  • Significantly decreases the frequency and severity of both manic and depressive attacks

  • Bipolar disease can be managed long-term with lithium alone in many patients, but some will require continued or intermittent use of an antipsychotic or lamotrigine to help prevent depressive episodes

• Carbamazepine is used in the treatment of bipolar patients who cannot be satisfactorily treated with lithium (nonresponsive, excessive side effects, or rapid cycling

  • Dosage: Starts at 400–600 mg orally daily and is increased slowly to therapeutic levels

  • Can be effective in conjunction with lithium, although there have been reports of reversible neurotoxicity with the combination

• Oxcarbazepine

  • A derivative of carbamazepine

  • May have efficacy in acute mania

  • Appears to be safer than carbamazepine due to its lower risk of hepatotoxicity

• Lamotrigine is used for the maintenance treatment of bipolar disorder

  • Dosing starts at 25–50 mg/day orally and is titrated upward slowly to decrease the likelihood of rash

  • Slower titration and a lower total dose are indicated for patients taking valproic acid

Prevention

• Lithium (1200–1800 mg/day orally targeted to therapeutic serum level) as prophylaxis can limit the frequency and severity of mood swings in 50–70% of patients

Prognosis

• Good with adequate treatment; however, maintaining patient adherence to treatment is often quite challenging

When to Refer

• All manic patients should be under the care of a psychiatrist

When to Admit

• Most patients with new onset mania should be admitted for initiation of treatment and for monitoring until the symptoms are brought under control