Continuing Education Activity

Mania is a period of 1 week or more in which a person experiences a change in normal behavior that drastically affects their functioning. Mania can be distinguished from hypomania in that hypomania does not cause a major deficit in social or occupational functioning, and involves a period of at least 4 days rather than at least 1 week. The defining characteristics of mania include increased talkativeness, rapid speech, a decreased need for sleep, racing thoughts, distractibility, increase in goal-directed activity, and psychomotor agitation. Some other hallmarks of mania are an elevated or expansive mood, mood lability, impulsivity, irritability, and grandiosity. This activity illustrates the clinical features of mania, reviews the evaluation and diagnosis, and highlights the role of the interprofessional team in the management of affected patients.

Objectives:

• Identify the etiology of mania.
• Explain the presentation of a patient with mania.
• Describe the treatment and management options available for mania.
• Outline some interprofessional team strategies for improving care coordination and communication to advance the treatment of mania and improve outcomes.

Introduction

Mania, or a manic phase, is a period of 1 week or more in which a person experiences a change in behavior that drastically affects their functioning. Mania is different from hypomania because hypomania does not cause a major deficit in social or occupational functioning, and it is a period of at least 4 days rather than 1 week. The defining characteristics of mania are increased talkativeness, rapid speech, decreased need for sleep, racing thoughts, distractibility, increase in goal-directed activity, and psychomotor agitation. Some other hallmarks of mania are an elevated or expansive mood, mood lability, impulsivity, irritability, and grandiosity. If the individual experiencing these symptoms requires hospitalization, then this period automatically qualifies as true mania and not hypomania, even if the symptoms are present for less than one week.[1][2]

Mania must be distinguished from heightened energy and altered functioning that arises from substance use, medical conditions, or other causes. Mania is a "natural" state which is the characteristic of bipolar I disorder. A single manic phase is sufficient to make the diagnosis of bipolar I disorder, although most cases of bipolar I also involve hypomanic and depressed episodes.[3][4][5]

Many families bring their loved ones to the emergency room due to the excessive behavioral changes they have noticed over a brief period. Patients amid a manic phase commonly engage in goal-directed activities that may result in harmful consequences, such as spending excessive money, starting businesses unprepared, traveling, or promiscuity. Many patients engage in property damage or even harm themselves or others through verbal or physical assaults. They may also become highly aggressive, agitated, or irritable. Although the patient may have poor insight and may not recognize they are behaving out of the norm, it becomes apparent to family or friends that this behavior may be due to mental illness.[6]

Mania also commonly presents with psychotic features, which include delusions or hallucinations. Many patients endorse grandiose delusions, believing they are high-level operatives such as spies, government officials, members of secret agencies, or that they are knowledgeable professionals (even when they have no such background). These individuals may also experience auditory or visual hallucinations, which only present when they are in the manic phases. Some of the most common delusions are delusions of paranoia, in which patients believe that people are stalking, targeting, or surveilling them. They may believe this to be done by government agencies, gangs, or others. These patients are highly unlikely to respond to outsiders’ views on their psychosis as well as their mania. A component of the manic phase is that generally, the individuals themselves do not realize what is happening (poor insight). The problem is mainly noticed by others, including family members, friends, and even strangers or police.

Rapid cycling in bipolar disorder is defined as having at least 4 or more mood episodes in a 12-month period. These mood episodes may be manic, hypomanic, or depressive but must meet their full diagnostic and duration criteria. These episodes must be separated by periods of partial or full remission of at least 2 months or be separated by a switch to an episode of opposite polarities, such as mania or hypomania to major depressive episodes. Switching from mania to hypomania or vice-versa would not qualify because they are not opposite polarity. Rapid cycling bipolar disorder patients have been found to be more resistant to pharmacotherapy.

Etiology

The etiology of mania, and more generally, bipolar I disorder, are not known. There is strong evidence that the cause is a combination of genetic, psychological, and social factors. There have been multiple studies involving families which show a definite genetic component. In a study involving monozygotic twins, it was revealed that up to 80% of twins are concordant for the disorder when one of the siblings is positive for the disorder. This is also evidence of environmental influences since there is not a 100% concordance between monozygotic twins. Multiple studies have shown that several allele frequencies are involved in both bipolar I disorder and schizophrenia. There is also extensive anecdotal evidence that stressful life events and other psychosocial factors contribute to the onset and frequency of manic phases.[7][8]

Epidemiology

Mania is the diagnostic criteria for bipolar I disorder, so the epidemiology of bipolar I disorder also tells us about the prevalence of mania. The lifetime prevalence of bipolar disorder is about 4 percent. Men and women are equally likely to be affected. However, women are much more likely to experience many mood episodes in a given year (rapid cycling). The median age of onset of bipolar disorder is around age 25. Men typically have an earlier age of onset than women. Studies have shown that men usually initially present with a manic episode while women present with a depressive episode. Almost two-thirds of bipolar patients have at least 1 close relative who was also diagnosed with the disease or with unipolar depression.

Pathophysiology

The pathophysiology of mania and bipolar disorder, in general, has been shown in some studies to involve specific brain regions; however, the exact mechanisms involved are still unknown. In functional studies as well as structural studies, bipolar disorder patients have shown alterations in the amygdala, hippocampus, basal ganglia, prefrontal cortex, and the anterior cingulate. The amygdala is hyperactive in patients with BD, and the hippocampus and prefrontal cortex are hypoactive. This increased activity in the amygdala along with decreased activity in cortical regions may be the reason why the executive function is impaired in mania while the emotions are heightened and unrestrained.

History and Physical

Taking the history of a patient with suspected mania requires asking about the primary characteristics of mania such as a recent change in sleep, activity, appetite, irritability, among others. The common mnemonic "DIG FAST" is used to aid clinicians in remembering to ask about Distractibility, Irresponsibility or Irritability, Grandiosity, Flight of ideas, increased Activity, decreased Sleep, and excessive Talkativeness. The evaluation must include the full DSM-5 criteria. As listed in the DSM-5, a manic episode is diagnosed if the patient experiences an abrupt change in mood described as euphoric or angry that lasts at least one week, or any amount of time if the patient requires hospitalization.[9]

Evaluation

When a patient presents with mania, there should be an extensive evaluation to rule out other differentials. A complete blood count (CBC), complete metabolic panel (CMP), thyroid panel, and a urine drug screen are some of the basic laboratory values needed in assessing a manic patient. Brain imaging in the form of a CT or MRI would be important in determining any organic cause of manic symptoms, especially in elderly or very young patients (>60 or <13 years old).

Treatment / Management

In general, a manic patient should be treated with both a medication that alleviates the acute mania as well as concomitant medication for maintenance stabilization to prevent future mood episodes. 

Mania in bipolar I disorder was first treated with medications such as lithium, valproic acid, and carbamazepine. The treatments were focused on mood stabilizers and anticonvulsants which had shown efficacy in mood stabilization. Today, the class of mood stabilizers subsumes more than just lithium and antiepileptics--it includes many second-generation neuroleptics as well. A large metanalysis of medications used in acute mania showed that atypical antipsychotics were more effective than mood stabilizers for this purpose but not necessarily for maintenance of bipolar disorder. Examples of effective medications are risperidone, olanzapine, and haloperidol. Lithium, quetiapine, and aripiprazole were comparatively effective. Valproic acid, carbamazepine, and ziprasidone were more efficacious than placebo but less so than their previously mentioned competitors. Gabapentin, lamotrigine, and topiramate showed no difference when compared to placebo for treating mania. Clozapine and electroconvulsive therapy have shown many benefits for treatment-resistant mania but are less commonly used. Lastly, psychoeducation and psychotherapy are powerful long-term tools for patients with bipolar disorder as well as for their families or caregivers.

Differential Diagnosis

There are numerous differential diagnoses in the assessment of patients who present with symptoms like mania. Patients can be exhibiting numerous other physiologic and psychiatric disorders. One of the most common situations that may mimic mania is caffeine or other stimulant intoxication, especially cocaine, amphetamine (including methamphetamine), PCP, and nicotine. Hallucinogens can also produce similar symptoms. Excessive steroid and human growth hormone use may lead to aggression, irritability, anxiety and may look very similar to mania. The main mental illnesses which mimic bipolar mania are schizophrenia, severe anxiety, severe obsessive-compulsive disorder, or major depressive disorder with psychotic features. Any mixed mood disorder should be in the differential for bipolar disorder, especially when psychosis is present. Personality disorders such as histrionic and borderline personality can have similar presenting symptoms to phases of bipolar, including mood lability, anger dysregulation, inappropriate and outlandish dress, as well as bizarre behavior. Physiologic conditions that may mimic mania include hyperthyroidism, hypertensive urgency, hypercortisolemia, hyperaldosteronism, masses or tumors in the brain, major neurocognitive disorders, acromegaly, and delirium.

Prognosis

The prognosis of manic patients is favorable, granted they are adherent to medications and therapy. Some factors associated with a poorer outcome are a history of abuse, psychosis, low socioeconomic status, comorbid illness, or young age of onset.

Complications

The sequelae from a manic episode can be detrimental. Those suffering from mania often act with impropriety, ruining reputations and careers. More consequential complications include physical harm to others and self.

Deterrence and Patient Education

It is important for patients to be educated regarding the episodic nature of mania as well as how to identify the initial manifestations, heralding an oncoming episode.

Pearls and Other Issues

One of the major illnesses which may mimic bipolar disorder and have manic-like symptoms is cyclothymic disorder. Cyclothymic patients may have large mood swings which do not meet the full criteria for a manic or hypomanic episode. These patients may also have many periods of depression. The criteria for cyclothymic disorder involve having many hypomanic or depressed symptoms on and off for at least 2 years that do not remit for more than 2 consecutive months. The symptoms in cyclothymia must cause significant social or occupational impairment and cannot be better explained by substance abuse.

Enhancing Healthcare Team Outcomes

Manic patients are very difficult to manage and hence an interprofessional team consisting of a mental health nurse, psychologist, psychiatrist, and primary care provider is required. Once the acute episode is managed, patients will need a prophylactic agent to prevent a recurrence. Unfortunately, patient compliance with medications is low and relapses are common.

The outcomes for patients with mania are guarded. Those who do no comply with treatment eventually run into problems with the law and/or are forced to take medications via injection.[10]