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

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

• Mania is often combined with depression; that is, the manic episode is often part of a broader bipolar (manic-depressive) disorder

• COVID-19 pandemic has undoubtably increased the risk of depression

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)

• Hypomania

• Cyclothymic disorder (depression and hypomania)

• Schizophrenia

• Hyperthyroidism

• Substance abuse (eg, cocaine, amphetamines)

• Medications (eg, corticosteroids, thyroxine)

• CNS disease (eg, complex partial seizures, brain 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

• Mania due to bipolar disorder

  • Use antipsychotic drugs or high-potency benzodiazepines to immediately treat the excited or psychotic manic stage

    • For immediate behavioral control, when necessary, intramuscular olanzapine (2.5–10 mg intramuscularly) or haloperidol (5–10 mg orally or intramuscularly); may be repeated as needed until symptoms subside

    • Clonazepam (1–2 mg orally every 4–6 hours; up to 16 mg/day) may be used instead of or in conjunction with a neuroleptic to control acute manic symptoms

    • Olanzapine (5–20 mg orally), risperidone (2–3 mg orally), or aripiprazole (15–30 mg orally), may be used along with clonazepam to treat the agitated or psychotic manic state

  • Valproic acid (750 mg/day orally divided and titrated to therapeutic levels) can be loaded to therapeutic levels over 2–3 days

  • Lithium (1200–1800 mg/day targeted to therapeutic serum ...