Mania

Mania, also known as manic syndrome, is a mental and behavioral disorder.

It is defined as a state of abnormally elevated arousal, affect, and energy level.

A manic episode is defined in the American Psychiatric Association:  as a period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day where the mood is not caused by drugs/medication or a non-mental medical illness is causing obvious difficulties at work or in social relationships and activities, or requires admission to hospital to protect the person or others, or the person is suffering psychosis.

WHO’s definition of a  a manic episode is one where mood is higher than the person’s situation warrants and is accompanied by hyperactivity, a compulsion to speak, a reduced sleep requirement, difficulty sustaining attention, and/or often increased distractibility, confidence and self-esteem are excessively enlarged, and grand, extravagant ideas are expressed, behavior that is out-of-character and risky, foolish or inappropriate may result from a loss of normal social restraint.

To be classified as a manic episode: disturbed mood and an increase in goal- directed activity or energy is present, and at least three or four of the following:

Inflated self-esteem or grandiosity.

Decreased need for sleep 

More talkative than usual, or acts pressured to keep talking.

Flights of ideas or subjective experience that thoughts are racing.

Increase in goal-directed activity, or psychomotor acceleration.

Distractibility 

Excessive involvement in activities with a high likelihood of painful consequences.

Activities participated in while in a manic state are not always negative,  it are far more likely.

It is a state of heightened overall activation with enhanced affective expression together with lability of affect.

Manic episodes are experienced as rapidly changing emotions, moods and is highly influenced by surrounding

The heightened mood with mania can be either euphoric or dysphoric.

As mania intensifies, it can manifest as profound irritability resulting in anxiety or anger.

The symptoms of mania include elevated mood, flight of ideas and pressure of speech, increased energy, decreased need and desire for sleep, and hyperactivity. 

In full-blown mania, there are progressive  exacerbations that  become obscured by other signs and symptoms, such as delusions and fragmentation of behavior.

Mania is a syndrome associated with multiple causes. 

The majority of cases of mania occur in the context of bipolar disorder.

It is a key finding of other psychiatric disorders: schizoaffective disorder, bipolar type, and multiple sclerosis.

Medications may perpetuate a manic state: prednisone; substances prone to abuse, and stimulants, such as caffeine and cocaine. 

Hypomanic episodes are separated from the more severe full manic episodes, which, in turn, are characterized as either mild, moderate, or severe.

Mania is divided into three stages: 

Hypomania, or stage I

Stage I corresponds with hypomania and may feature typical hypomanic characteristics, such as gregariousness and euphoria. 

Acute mania, or stage II

Delirious mania, or stage III. 

In stages II and III mania, however, the patient may be extraordinarily irritable, psychotic or even delirious. 

These latter two stages are referred to as acute and delirious, respectively.

It varies in intensity: mild mania (hypomania) to delirious mania, marked by such symptoms as disorientation, florid psychosis, incoherence, and catatonia.

Mania and hypomania are  associated with creativity and artistic talent, and

such persons often either retain sufficient self-control to function normally or are unaware that they have mania severely enough to be treated.

Manic persons are often mistaken for being under the influence of drugs.

In a mixed affective state, the individual, meets criteria for a hypomanic or manic episode, and experiences three or more concurrent depressive symptoms: two independent axes in a unipolar—bipolar spectrum.

A mixed affective state, increases the risk for completed suicide. 

Depression coupled with an increases energy and goal-directed activity, increasing the patient likeliness of acting with violence on suicidal impulses.

((Hypomania)) , is a lowered state of mania that does little to impair function or decrease quality of life.

Hypomania May actually increase productivity and creativity. 

Hypomania, is associated with less need for sleep and it increases goal-motivated behavior and metabolism.

Mania has undesirable consequences:  including suicidal tendencies.

Hypomania can, if the prominent mood is irritable as opposed to euphoric, an unpleasant experience. 

Hypomania based positivity ,

may make one more engaging and outgoing, and to have a positive outlook in life.

When exaggerated in hypomania, however, such a person can display excessive optimism, grandiosity, and poor decision making, often with little regard to the consequences.

A single manic episode, without an accompanying association: substance disorders, pharmacologics, or general medical conditions is often sufficient to diagnose bipolar I disorder. 

Hypomania may be indicative of bipolar II disorder. 

Manic episodes are often complicated by delusions and/or hallucinations,

If the psychotic features persist for a duration significantly longer than the episode of typical mania, a diagnosis of schizoaffective disorder is more appropriate. 

B12 deficiency, and hyperthyroidism can produce similar symptoms to those of mania, such as agitation, elevated mood, increased energy, hyperactivity, sleep disturbances and sometimes, especially in severe cases, psychosis.

Mania may be accompanied by 

physical symptoms of stress, such as sweating, pacing, and weight loss. 

The manic person feels as their goals are of paramount importance.

There  are no consequences that need restraint in mania patients seeking their pursuits.

Hypomania may cause little or no impairment in function. 

The hypomanic individual’s connection with the external world, and its standards of interaction, remain intact, although intensity of moods is heightened. 

In patients with prolonged unresolved hypomania there is a  risk of developing full mania.

Manic persons are excessively distracted by objectively unimportant stimuli.

Manic patient experience creates an absent-mindedness where their thoughts totally preoccupy them, making them unable to keep track of time, or be aware of anything besides the such thoughts, and racing thoughts also interfere with the ability to fall asleep.

An indicator of a manic state would be if a clinically depressed patient suddenly becomes inordinately energetic, enthusiastic, cheerful, aggressive, or happy.

Less obvious and common elements of mania include delusions of grandeur or persecution, hypersensitivity, hypervigilance, hypersexuality, hyper-religiosity, hyperactivity and impulsivity, a compulsion to over explain grandiose schemes and ideas, a decreased need for sleep, engaging in out-of-character behavior, risky sexual activity, abuse of recreational substances, excessive gambling, reckless behavior, abnormal social interaction or highly vocal arguments. 

Mania  behaviors may increase stress in personal relationships, lead to problems at work, and increase the risk of altercations with law enforcement. 

There is a high risk of impulsively taking part in activities potentially harmful to the self and others.

The experience of mania is ultimately often quite unpleasant and sometimes disturbing, if not frightening, for the person involved and for those close to them

Mania is associated with impulsive behavior that may later be regretted. 

It is often be complicated by the sufferer’s lack of judgment and insight regarding periods of exacerbation of characteristic states. 

Manic patients are frequently:  grandiose, obsessive, impulsive, irritable, belligerent, and often in denial that anything is wrong with them. 

Within a few days of a manic cycle, sleep-deprived psychosis may appear, further impairing the ability to think clearly, along with racing thoughts and misperceptions lead to frustration and decreased ability to communicate with others.

A common trigger of mania is antidepressant therapy: the risk of switching while on an antidepressant is between 6-69 percent. 

Dopaminergic drugs such as reuptake inhibitors and dopamine agonists may also increase risk of switch to mania, as well as glutaminergic agents and drugs that alter the HPA axis. 

Lifestyle triggers of mania include: irregular sleep-wake schedules and sleep deprivation, as well as extremely emotional or stressful stimuli.

CLOCK and DBP polymorphisms have been linked to bipolar in population studies, and behavioral changes induced by knockout are reversed by lithium treatment. 

Metabotropic glutamate receptor 6 has been genetically linked to bipolar disorder.

Metabotropic glutamate receptor 6 is found to be under-expressed in the cortex. 

Pituitary adenylate cyclase-activating peptide has been associated with bipolar in gene linkage studies.

Mania may be associated with strokes: especially cerebral lesions in the right hemisphere.

Deep brain stimulation of the subthalamic nucleus in Parkinson’s disease has been associated with mania.

Mania can also be caused by physical trauma or illness. 

When the causes are physical, it is called secondary mania.

The neurocognitive profile of mania is highly consistent with dysfunction  in neuroimaging studies in the right prefrontal cortex.

Evidence from post-mortem studies and the putative mechanisms of anti-manic agents point to:

Abnormalities in GSK-3, dopamine, Protein kinase C and Inositol monophosphatase play roles in mania mechanisms.

Increased thalamic, and bilaterally reduced inferior frontal gyrus activation on neuro imaging studies.

Increased activity in the amygdala and other subcortical structures such as the ventral striatum.

Reduced connectivity between the ventral prefrontal cortex and amygdala 

suggesting a general dysregulation of subcortical structures by the prefrontal cortex.

Mania tends to be associated with right hemisphere lesions, while depression tends to be associated with left hemisphere lesions.

Autopsy examinations of bipolar disorder demonstrate increased expression of Protein Kinase C (PKC).

Antimanic drugs also demonstrate PKC inhibiting properties.

Manic episodes may be triggered by dopamine receptor agonists.

Some evidence suggests mania is associated with behavioral and neural reward hypersensitivity.

The left frontal EEG activity reflects of behavioral activation system activity, and supports a role for reward hypersensitivity in mania. 

There is a report of  an association between manic traits and feedback negativity during receipt of monetary reward or loss. 

Neuroimaging finds elevated orbitofrontal cortex activity to monetary reward, suggesting reward hyperactivity in mania.

The acute treatment of a manic episode of bipolar disorder involves the utilization of either a mood stabilizer: carbamazepine, valproate, lithium, or lamotrigine; or an atypical antipsychotic: olanzapine, quetiapine, risperidone, or aripiprazole.

Long-term treatment urilizes prophylactic treatment to try to stabilize the patient’s mood, via a combination of pharmacotherapy and psychotherapy. 

Relapse likelihood is very high for those who have experienced two or more episodes of mania or depression. 

Medication use for bipolar disorder is important to manage symptoms of mania and depression, however, relying on medications alone is not the most effective method of treatment. 

The most efficacious management includes drugs, when used in combination with other bipolar disorder treatments, including psychotherapy, self-help coping strategies, and healthy lifestyle choices.

Lithium is the major mood stabilizer to prevent further manic and depressive episodes. 

The long term lithium treatment substantially reduces the risk of bipolar manic relapse, by 42%.

Prophylactic anticonvulsants such as valproate, oxcarbazepine, lamotrigine and topiramate are also used.

Long-acting benzodiazepines, particularly clonazepam, are used after other options have failed.

In urgent circumstances, lorazepam, combined with haloperidol, is used to promptly alleviate symptoms of agitation, aggression, and psychosis.

Antidepressant monotherapy is not recommended for the treatment of depression in patients with bipolar disorders I or II.

Some atypical antidepressants, however, such as mirtazepine and trazodone have been occasionally used after other options have failed.

Evidence suggests that people in the creative industries suffer from bipolar disorder more often than those in other occupations.

Affects 1% of the population.

Associated with episodes of depression.