Mania
Outline:
- Overview
- Incidence
- Diagnostic criteria
- Causes of mania
- Pathophysiology
- Stages of mania
- Diagnosis
- Differential diagnosis
- Treatment
- Outcomes
- Prevention
- Conclusion
- References
Overview:
Mania is a period of changing normal behaviour of a person affecting their functions and lasts for 1 week or more. Manic episodes involve disturbance of behaviour, mood, sleep, and perception. Recurrence of manic episodes is diagnostic for Bipolar disorder which is a severe chronic mood disorder characterized by alternating episodes of mania, hypomania, and depression. For diagnosis of bipolar I disorders, a single manic episode is almost sufficient to make the diagnosis.
Incidence:
Mania can occur as a part of other mental disorders. Acute mania is a phase of bipolar disorder I therefore, incidence of mania is related to bipolar disorder. Studies show that from mid-1970s to 2000, in the US , the rates of mania were about 0.4-1.6% affecting adults. Some researchers studying bipolar disorder in the late 1990s to 2000, show elevated rates from 5 to 7%. An annual rate of first-bipolar manic episodes is about 5 per 100,000 of population. First-manic episode occurs equally in both males and females. Moreover, some studies show that episodes are earlier in males by 5 years. Manic episodes occur maximumly between 21-25 years. About 1% of stroke patients, patients with epilepsy or infections of the brain, traumatic head injury, patients with tumours, neurosurgery, 2–12% of patients with movement disorders such as Huntington’s disease experience episodes of mania. A systematic literature review of 18 studies in a sample of 1519 older psychiatric inpatients aged 60 to 96 years, the prevalence of late-life mania was 6.0%. The mean prevalence of late-onset mania in bipolar elderly inpatients was 44.2%.
Diagnostic criteria of mania:
Manic episode is diagnosed when patients experience sudden abnormal change in mood or persistent goal-directed behaviour that becomes irritable or expansive known as euphoria that at least lasts for one week or more, and for any duration when sometimes patients need hospitalization as mood disturbances can cause impairment in occupation functions and may cause harm to self or others.
The hallmark diagnostic criteria of mania according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) include the following:
- Elevated or expansive mood
- Distractibility
- Impulsivity
- Irritability
- Rapid speech
- Increase in goal-directed activity (at school or work, socially, and sexually)
- Racing thoughts and flight of ideas
- Decreased need for sleep ( less than 3 hours)
- Mood lability
- Increased talkativeness or pressure to keep talking
- Grandiosity or increased self-esteem
- Psychomotor agitation
Three of the previous criteria are required for the diagnosis or four of them if only irritable mood is present.
Causes of mania :
The specific cause of mania is not clear however, different factors may cause the condition which include:
- Family history of bipolar disorder
- Disturbance in the brain chemical functions
- Medications (such as: alcohol, antidepressants, recreational drugs, cimetidine, corticosteroids, cyclosporine, captopril, methylphenidate, bromide, baclofen, bromocriptine, disulfiram, metrizamide, hydralazine, procyclidine, procarbazine, levodopa, isoniazid) as a side effect
- Difficult and Traumatic life events (such as: death of a relative, divorce, abuse, trauma, loss of money, childbirth)
- Stressful conditions
- A highly stimulating environment (e.g., lots of noise, bright lights or large crowds)
- Disturbance in sleep cycle and lack of sleep
- Mania may occur as a part of other mental disorders including: bipolar disorder, schizoaffective disorder, postpartum psychosis, seasonal affective disorder, other physical or neurologic condition including: stroke, brain injury, brain tumours, dementia, lupus or encephalitis, thyroid disorders
Bipolar disorder is one of the most common causes in which patients experience alternating episodes of mania and depression over several weeks and manic episodes may be unpredictable. In 2011, the WHO ranked bipolar disorder as one of the 20 leading causes of disability.
See: Bulimia nervosa
Pathophysiology:
The mechanism of mania and bipolar disorder is still unclear. Some studies have shown changes in specific brain regions including: hippocampus, prefrontal cortex, basal ganglia, amygdala, anterior cingulate. In case of bipolar disorder, prefrontal cortex (PFC) and hippocampus are hypoactive whereas amygdala is hyperactive explaining the executive functions and elevated emotional level during manic episodes.
Other suggested mechanisms include:
- Dysregulation in the function of synaptic neurotransmitters specifically , glutamate action on its NMDA receptors.
- At the molecular level, disturbed translation regulation function of microRNA leading to dysregulation of synaptic plasticity may be one of the mechanisms.
- Some studies suggest lateralized disruption of limbic circuits.
- Researchers have shown that there is reduced activity in right ventral PFC and increased activity in the left amygdala, left Anterior Cingulate Cortex (ACC), and left basal ganglia in primary idiopathic mania.
Stages of mania:
Three stages of mania may be experience: hypomania, acute mania, and delirious mania.
- Hypomania (Stage I): It is a mild form of mania that may not cause significant symptoms. It affects sleep and activity and may increase impulsivity, however it usually doesn’t require hospitalization.
- Acute Mania (Stage II): It involves significant impulsivity, elevated energy, decrease sleep, rapid speech, inappropriate behaviour, and symptoms of psychosis for which hospitalization may be necessary.
- Delirious Mania (Stage III): It is the most severe stage. Additional symptom is delirium which is decrease connection to reality, temporary confusion, psychosis , and other symptoms of mania so many patients require hospitalization to prevent injury due to the high level of disorientation.
Diagnosis:
- Medical history (family history, medication history, herbal supplement intake.)
- Blood tests(complete blood count (CBC), complete metabolic panel (CMP)) to rule out other conditions.
- Thyroid panel and a urine drug screen.
- CT or MRI for brain imaging in case of organic cause of manic symptoms, especially in elderly or very young patients (>60 or <13 years old).
- Referral to mental health specialist who makes the diagnosis according to the criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, DSM-5.
Differential diagnosis:
- Hallucinogens and stimulant intoxication including caffeine, amphetamine (methamphetamine), cocaine, nicotine, and PCP.
- Mental disorders including: major depressive disorder, severe anxiety, schizophrenia, severe obsessive-compulsive disorder, and mixed mood disorders.
- Excessively elevated human growth hormone and steroids may cause irritability, aggression, anxiety similar to mania.
- Personality disorders including histrionic and borderline personality may cause bizarre behaviour, mood lability, anger, and inappropriate dress.
- Physiologic disorders including hyperaldosteronism, hyperthyroidism, hypercortisolaemia, acromegaly, hypertensive urgency, tumours in the brain, major neurocognitive disorders, HIV encephalopathy, Fahr disease, Acquired immunodeficiency syndrome (AIDS), and tertiary syphilis, vitamin B12 and niacin deficiency, and delirium.
- Cyclothymic disorder in which patients experience severe mood swings that involve hypomanic episodes on and off for at least 2 years without remitting for more than 2 consecutive months leading to occupational and social impairment.
- Mania may be a symptom of Alzheimer’s disease. In case of frontotemporal dementia, Disinhibition is one of the core symptoms .
- The presence of depressive symptoms, relative absence of stereotypy, a positive history of psychiatric illness, and male gender in frontal lobe syndrome suggest psychiatric origin symptoms of dementia.
- Circadian rhythm desynchronization.
- Oppositional defiant disorder (in children).
- Medications (as mentioned before) and substance abuse ( cocaine, alcohol, amphetamine, opiates).
- Paediatric Attention Deficit Hyperactivity Disorder (ADHD).
- Lyme Disease.
- Multiple Sclerosis.
See: Violence, Stress, and their relation to COVID-19
Treatment:
- For acute bipolar mania, pharmacotherapy is one of the main treatments options. Lithium and anticonvulsants (valproate or carbamazepine) as first-line monotherapy, typical antipsychotics (e.g., haloperidol and chlorpromazine), and atypical antipsychotics (e.g., risperidone, ziprasidone, aripiprazole, olanzapine, clozapine, quetiapine, and asenapine.) recommended by recent guideline for adult with acute mania.
- Psychotherapy and psychoeducation can be useful in identifying triggers of manic episodes.
- Cognitive behavioural therapy may be useful in changing the inappropriate perception of the surrounding life events.
- Family therapy may help family members to understand the behaviour of patients and deal with them.
- Electro-convulsant therapy (ECT) is rarely used in severe cases of mania or depression.
Outcomes of mania:
Mania affects social and occupational functions and may cause harm to both the patient and other people. These problems include : job loss, financial loss, problems at work, problems in relationships, and ruining reputation.
Acute bipolar mania is considered medical emergency requires psychiatric hospitalization due to hyperactive and impulsive activity and sometimes involving the intervention of law enforcement agencies as a result of dangerous behaviour.
Studies of first-episode mania have shown that about 87.5% of syndromal recovery rate was achieved within the first year (patients do not fulfil the diagnostic criteria), the symptomatic recovery rates were 62.1% within the first year (symptomatically free), and the recurrence rates of manic, mixed or depressed episode over the same period were about 41%.
Comorbid illness, history of abuse, psychosis, low socioeconomic status, and young age of onset may be associated with poor outcomes.
Prevention:
- Sticking to treatment plan.
- Avoiding triggers of mania.
- Avoiding alcohol and medications that may lead to manic episodes and may cause side effects such as confusion.
- Maintaining regular enough sleep.
- Creating some self-care methods and specific routines to prevent mood swings.
Conclusion:
Mania is usually associated with other mental disorders. It is important to notice the triggers that may cause manic episodes including stressful conditions. The diagnosis and treatment of mania are considered a challenge as the mechanism of the condition is not clear.
See: Violence, Stress, and their relation to COVID-19
References:
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9054678/
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(15) What Causes A Manic Episode? | Signs, Symptoms, & Treatment For Mania. The Recovery Village Drug and Alcohol Rehab. Medically Reviewed By Benjamin Caleb Williams, RN.
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