Mania


Mania is a psychiatric behavioral syndrome defined as a state of abnormally elevated arousal, affect, and energy level. During a manic episode, an individual will experience rapidly changing emotions and moods, highly influenced by surrounding stimuli. Although mania is often conceived of as a "mirror image" to depression, the heightened mood can be dysphoric as well as euphoric. As the mania intensifies, irritability can be more pronounced and result in anxiety or anger.
The symptoms of mania include elevated mood, flight of ideas, pressure of speech, increased energy, decreased "need" and desire for sleep, and hyperactivity. They are most plainly evident in fully developed hypomanic states, however, in full-blown mania, these symptoms become progressively exacerbated. In severe manic episodes, these symptoms may even be obscured by other signs and symptoms characteristic of psychosis, such as delusions, hallucinations, fragmentation of behavior, and catatonia. As a result, discernment is significantly reduced. More than 5% of the general human population has experienced mania or hypomania in some degree.

Classification

Mixed states

In a mixed affective state, the individual, though meeting the general criteria for a hypomanic or manic episode, experiences three or more concurrent depressive symptoms. This has caused some speculation, among clinicians, that mania and depression, rather than constituting "true" polar opposites, are, rather, two independent axes in a unipolar—bipolar spectrum.
A mixed affective state, especially with prominent manic symptoms, places the patient at a greater risk for suicide. Depression on its own is a risk factor but, when coupled with an increase in energy and goal-directed activity, the patient is far more likely to act on suicidal impulses.

Hypomania

, which means "less than mania", is a lowered state of mania that does not always impair function or decrease quality of life. Although creativity and hypomania have been historically linked, a review and meta-analysis exploring this relationship found that this assumption may be too general and empirical research evidence is lacking.
In hypomania, there is less need for sleep and both goal-motivated behaviour and metabolism increase. Some studies exploring brain metabolism in subjects with hypomania, however, did not find any conclusive link; while there are studies that reported abnormalities, others failed to detect differences. Though the elevated mood and energy level typical of hypomania could be seen positively, mania itself generally has many undesirable consequences, including suicidal tendencies. Hypomania can also have these effects, if the prominent mood is irritable as opposed to euphoric. In addition, the intense cases of hypomania can lead to problems. Where trait-based positivity for a person could make them more engaging, outgoing, and cause them to have a positive outlook in life, exaggerated in hypomania, such a person can display excessive optimism, grandiosity, and poor decision-making, often with little regard to the consequences.

Associated disorders

A single manic episode, in the absence of secondary causes, 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; and if the psychotic features persist for a duration significantly longer than the episode of typical mania, a diagnosis of schizoaffective disorder is more appropriate.
Certain obsessive–compulsive spectrum disorders as well as impulse-control disorders share the suffix "-mania," namely, kleptomania, pyromania, and trichotillomania. Despite the unfortunate association implied by the name, however, no connection exists between mania or bipolar disorder and these disorders.
Evidence indicates a vitamin B12 deficiency can also cause symptoms characteristic of mania and psychosis. 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. Postpartum psychosis can also cause manic episodes.

Signs and symptoms

A manic episode is defined in the American Psychiatric Association's diagnostic manual as a "distinct 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, and: 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 has psychosis.
To be classified as a manic episode, while the disturbed mood and an increase in goal-directed activity or energy is present, at least three of the following must have been consistently present:
  1. Inflated self-esteem or grandiosity.
  2. Decreased need for sleep.
  3. More talkative than usual, or acts pressured to keep talking.
  4. Flights of ideas or subjective experience that thoughts are racing.
  5. Increase in goal-directed activity, or psychomotor acceleration.
  6. Distractibility.
  7. Excessive involvement in activities with a high likelihood of painful consequences..
Though the activities one participates in while in a manic state are not always negative, those with the potential to have negative outcomes are more common.
If the person is concurrently depressed, they are said to be having a mixed episode.
The World Health Organization's International Classification of Diseases 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, is accompanied by hyperactivity, a compulsion to speak, a reduced sleep requirement, difficulty sustaining attention, and/or often increased distractibility. 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 their goal are of paramount importance, 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. 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 with prolonged unresolved hypomania do run the risk of developing full mania, and may do so without even realizing they have.
One of the signature symptoms of mania is what many have described as racing thoughts. These are usually instances in which the manic person is excessively distracted by objectively unimportant stimuli. This experience creates an absent-mindedness where the manic individual's thoughts totally preoccupy them, making them 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.
Manic states are always relative to the normal state of intensity of the affected individual; thus, already irritable patients may find themselves losing their tempers even more quickly, and an academically gifted person may, during the hypomanic stage, adopt seemingly "genius" characteristics and an ability to perform and articulate at a level far beyond that which they would be capable of during euthymia. A very simple indicator of a manic state would be if a thus far clinically depressed patient suddenly becomes inordinately energetic, enthusiastic, cheerful, aggressive, or "over-happy".
Other, often less obvious, elements of mania include delusions, hypersensitivity, hypervigilance, hypersexuality, hyper-religiosity, hyperactivity and impulsivity, a compulsion to over explain, grandiose schemes and ideas, and a decreased need for sleep. In the case of the latter, the eyes of such patients may both look and seem abnormally "wide open", rarely blinking, and may contribute to some clinicians' erroneous belief that these patients are under the influence of a stimulant drug, when the patient, in fact, is either not on any mind-altering substances or is actually on a depressant drug.
Individuals may also engage in out-of-character behavior during the episode, such as questionable business transactions, wasteful expenditures of money, risky sexual activity, abuse of recreational substances, excessive gambling, reckless behavior, abnormal social interaction, or highly vocal arguments. These behaviours 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 often quite unpleasant and sometimes frightening, for the person involved and for those close to them, and it may lead to impulsive behaviour that may later be regretted. It can also often be complicated by the individual's lack of judgment and insight regarding periods of exacerbation of characteristic states. Manic patients may 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.
Mania may also, as earlier mentioned, be divided into three "stages". Stage I corresponds with hypomania and may feature typical hypomanic characteristics, such as gregariousness and euphoria. 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.