Mania

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Mania is a state of abnormally elevated or irritable Mood (psychology)|mood , arousal, and/ or energy levels. In a sense, it is the opposite of depression. Mania is a criterion for certain psychiatric diagnoses. The word derives from the Greek language|Greek "µa??a" ( mania ), "madness, frenzy", Henry George Liddell, Robert Scott, A Greek-English Lexicon , on Perseus Digital Library and that from the verb "µa???µa?" ( mainomai ), "to be mad, to rage, to be furious"., Henry George Liddell, Robert Scott, A Greek-English Lexicon , on Perseus Digital Library

In addition to mood disorders, persons may exhibit manic behavior because of drug intoxication (notably stimulants, such as cocaine and methamphetamine), medication side effects (notably steroids and SSRIs), and malignancy. But mania is most often associated with bipolar disorder , where episodes of mania may alternate with episodes of Major depressive episode|major depression . Gelder, Mayou, and Geddes (2005) suggest that it is vital that mania be predicted in the early stages because otherwise the patient becomes reluctant to comply to the treatment. The criteria for bipolar disorder do not include depressive episodes, and the presence of mania in the absence of depressive episodes is sufficient for a diagnosis. Regardless, those who never experience depression also experience cyclical changes in mood. These cycles are often affected by changes in sleep cycle (too much or too little), diurnal rhythm s, and environmental Stress (biological)|stressors .

Mania varies in intensity, from mild mania ( hypomania ) to full-blown mania with psychotic features, including hallucinations, delusion of grandeur, suspiciousness, catatonic behavior, aggression, and a preoccupation with thoughts and schemes that may lead to self neglect.Semple, David. "Oxford Hand book of Psychiatry" Oxford press,2005. Standardized tools such as Altman Self-Rating Mania Scale and Young Mania Rating Scale can be used to measure severity of manic episode. Because mania and hypomania have also been associated with Creativity and mental illness|creativity and artistic talent, Kay Redfield Jamison|Jamison, Kay R. (1996), Touched with Fire|Touched with Fire: Manic-Depressive Illness and the Artistic Temperament , New York: Free Press (publisher)|Free Press , ISBN 0-684-83183-X it is not always the case that the clearly manic bipolar person needs or wants medical help; such persons often either retain sufficient self control to function normally or are unaware that they have "gone manic" severely enough to Involuntary commitment|be committed or to Voluntary commitment|commit themselves . Manic persons often can be mistaken for being on drugs or other mind-altering substances.

Classification

Mixed states

Mania can be experienced at the same time as depression, in a mixed episode . Dysphoric mania is primarily manic and agitated depression is primarily depressed. This has caused speculation amongst doctors that mania and depression are two independent axes in a bipolar spectrum , rather than opposites.

There is an increased probability of suicide in the mixed state, as depressed individuals who are also manic have the energy needed to commit the act and the thoughts of depression that would lead them initially to suicide.

Mania can be the result of using drugs. Quitting drugs can create situations in one's mind similar to the symptoms of mania, such as constant racing of the mind. A diagnosis of mania in these situations is often temporary.

Hypomania

Hypomania is a lowered state of mania that does little to impair function or decrease quality of life. In hypomania there is less need for sleep, and both goal-motivated behavior and metabolism increase. Though the elevated mood and energy level typical of hypomania could be seen as a benefit, mania itself generally has many undesirable consequences including suicidal tendencies.

Associated disorders

A single manic episode is sufficient to diagnose Bipolar I Disorder . Hypomania may be indicative of Bipolar II Disorder or Cyclothymia . However, if prominent psychotic symptoms are present for a duration significantly longer than the mood episode, a diagnosis of Schizoaffective Disorder is more appropriate. Several types of "mania" such as kleptomania and pyromania are related more closely to obsessive-compulsive disorder than to bipolar disorder, depending on the seriousness of these disorders. For instance, someone with kleptomania who suffers from impulses to steal things such as pencils, pens, and paperclips is better diagnosed with a form of OCD.

B₁₂ deficiency can also cause characteristics of mania and psychosis.

Signs and symptoms

A manic episode is defined in the American Psychiatric Association 's DSM-IV-TR|diagnostic manual as a period of seven or more days (or any period if admission to hospital is required) of unusually and continuously effusive and open elated or irritable mood, where the mood is not caused by drugs/medication or a medical illness (e.g., hyperthyroidism ), and (a) is causing obvious difficulties at work or in social relationships and activities, or (b) requires admission to hospital to protect the person or others, or (c) the person is suffering psychosis .

To be classed as a manic episode, while the disturbed mood is present at least three (or four if only irritability is present) of the following must have been consistently prominent: grand or extravagant style, or expanded self-esteem; reduced need of sleep (e.g. three hours may be sufficient); talks more often and feels the urge to talk longer; ideas flit through the mind in quick succession, or thoughts race and preoccupy the person; over indulgence in enjoyable behaviors with high risk of a negative outcome (e.g., extravagant shopping, sexual adventures or improbable commercial schemes).

If the person is concurrently depressed, they are said to be having a mixed episode .

The World Health Organization 's ICD|classification system defines a manic episode as one where mood is higher than the person's situation warrants and may vary from relaxed high spirits to barely controllable exuberance, accompanied by hyperactivity, a compulsion to speak, a reduced sleep requirement, difficulty sustaining attention and, often, increased distractability. Frequently, 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.

Some people also have physical symptoms, such as sweating, pacing, and weight loss. In full-blown mania, often the manic person will feel as though his or her goal(s) trump all else, that there are no consequences or that negative consequences would be minimal, and that they need not exercise restraint in the pursuit of what they are after. DSM-IV Hypomania is different, as it may cause little or no impairment in function. The hypomanic person's connection with the external world, and its standards of interaction, remain intact, although intensity of moods is heightened. But those who suffer from prolonged unresolved hypomania do run the risk of developing full mania, and indeed may cross that "line" without even realizing they have done so.AJ Giannini. Biological Foundations of Clinical Psychiatry, NY Medical Examination Publishing Company, 1986.

One of the most signature symptoms of mania (and to a lesser extent, hypomania ) is what many have described as racing thoughts . These are usually instances in which the manic person is excessively distracted by objectively unimportant stimuli.Lakshmi N. Ytham, Vivek Kusumakar, Stanley P. Kutchar. (2002). ''Bipolar Disorder: A Clinician's Guide to Biological Treatments'', page 3. This experience creates an absentmindedness where the manic individual's thoughts totally preoccupy him or her, making him or her unable to keep track of time, or be aware of anything besides the flow of thoughts. Racing thoughts also interfere with the ability to fall asleep.

Mania is always relative to the normal rate of intensity of the person being diagnosed with it; therefore, an easily-angered person may exhibit mania by getting even angrier even more quickly, and an intelligent person may adopt seemingly "genius" characteristics and an ability to perform and to articulate thought beyond what they can do in a normal mood. A very simple indicator of mania would be if a noticeably clinical depression|clinically depressed person becomes suddenly and inordinately energetic, cheerful, aggressive, or "happy". Other often-less-obvious elements of mania include delusions (of grandeur, potential, persecution or otherwise), hypersensitivity, hypervigilance , hypersexuality , hyper- religiosity , hyperactivity , impulsiveness, talkativeness, an internal pressure to keep talking (over-explanation) or rapid speech, grandiose ideas and plans, and decreased need for sleep (e.g. feeling rested after 3 or 4 hours of sleep). The afflicted person's eyes may look, as well as feel abnormally "wide" or "open", rarely blinking; this sometimes contributes to clinicians' misconception that a manic patient is under the influence of a stimulant drug when the patient is either not on any mind-altering substances, or is in fact under the influence of a depressant drug in a misguided effort to stave off destructive and unwanted manic impulses. In manic and hypomanic cases, the afflicted person may engage in out-of-character behavior, such as questionable business transactions, wasteful expenditures of money, risky sexual activity, recreational drug abuse, abnormal social interaction, or highly vocal arguments uncharacteristic of previous behaviors. These 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 self and others.
Although "severely elevated mood" sounds somewhat desirable and enjoyable, 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, and it may lead to impulsive behavior that may later be regretted. It can also 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 frequently deny anything is wrong with them. Because mania frequently encourages high energy and decreased perception of need or ability to sleep, within a few days of a manic cycle, sleep-deprived psychosis may appear, further complicating the ability to think clearly. Racing thoughts and misperceptions lead to frustration and decreased ability to communicate with others.

There are different "stages" or "states" of mania. A minor state is essentially hypomania and, like hypomania's characteristics, may involve increased creativity, wit, gregariousness, and ambition. Full-blown mania will make a person feel elated, but perhaps also irritable, frustrated, and even derealization|disconnected from reality .

Treatment

Before beginning treatment for mania, careful differential diagnosis must be performed to rule out non-psychiatric causes.

Acute mania in bipolar disorder is typically treated with mood stabilizer s or antipsychotic medication. Note that these treatments need to be prescribed and monitored carefully to avoid harmful side-effects such as neuroleptic malignant syndrome with the antipsychotic medications. It may be necessary to temporarily admit the patient involuntarily until the patient is stabilized. Antipsychotics and mood stabilizer s help stabilize mood of those with mania or depression. They work by blocking the receptor for the neurotransmitter dopamine and allowing serotonin to still work, but in diminished capacity.

When the manic behaviours have gone, long-term treatment then focuses on prophylactic treatment to try to stabilize the patient's mood, typically through a combination of pharmacotherapy and psychotherapy . The likelihood of having a relapse is very high for those who have experienced two or more episodes of mania or depression. While medication for bipolar disorder is important to manage symptoms of mania and depression, studies show relying on medications alone is not the most effective method of treatment. Medication is most effective when used in combination with other bipolar disorder treatments, including psychotherapy , self-help coping strategies, and healthy lifestyle choices.

Lithium salt|Lithium is the classic mood stabilizer to prevent further manic and depressive episodes. Anticonvulsants such as valproic acid , oxcarbazepine and carbamazepine are also used for prophylaxis . More recent drug solutions include lamotrigine , which is another anticonvulsant. Clonazepam (Rivotril, Ravotril or Rivatril) is also used. Sometimes atypical antipsychotics are used in combination with the previous mentioned medications as well, including olanzapine (Zyprexa) which helps treat hallucinations or delusions, aripiprazole (Abilify), risperidone , ziprasidone , and clozapine which is often used for people who do not respond to lithium or anticonvulsants.

Verapamil , a calcium-channel blocker, is useful in the treatment of hypomania and in those cases where lithium and mood stabilizers are contraindicated or ineffective. Verapamil is effective for both short-term and long-term treatment.

Medications

The biological mechanism by which mania occurs is not yet known. One hypothesised cause of mania (among others), is that the amount of the neurotransmitter serotonin in the temporal lobe may be excessively high. Dopamine , norepinephrine , glutamate and gamma-aminobutyric acid also appear to play important roles. Imaging studies have shown that the left amygdala is more active in women who are manic and the orbitofrontal cortex is less active.

Antidepressant monotherapy is not recommended for the treatment of depression in patients with bipolar disorders I or II, and no benefit has been demonstrated by combining antidepressants with mood stabilizers in these patients.

Society and culture

In Electroboy: A Memoir of Mania by Andy Behrman , he describes his experience of mania as "the most perfect prescription glasses with which to see the world...life appears in front of you like an oversized movie screen". Behrman indicates early in his memoir that he sees himself not as a person suffering from an uncontrollable disabling illness, but as a director of the movie that is his vivid and emotionally alive life. "When I'm manic, I'm so awake and alert, that my eyelashes fluttering on the pillow sound like thunder" .

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