Mania
Encyclopedia
Mania, the presence of which is a criterion for certain psychiatric diagnoses, is a state of abnormally elevated or irritable mood
, arousal, and/ or energy levels. In a sense, it is the opposite of depression. The word derives from the Greek
"μανία" (mania), "madness, frenzy" and that from the verb "μαίνομαι" (mainomai), "to be mad, to rage, to be furious".
In addition to mood disorders, individuals may exhibit manic behavior as a result of drug intoxication (notably stimulants such as cocaine or methamphetamine), medication side effects (notably steroids), or malignancy. However, mania is most often associated with bipolar disorder
, where episodes of mania may alternate with episodes of major depression
. Gelder, Mayou and Geddes (2005) suggests that it is vital that mania is predicted in the early stages because the patient becomes reluctant to comply to the treatment. The criteria for bipolar do not include depressive episodes and the presence of mania in the absence of depressive episodes is sufficient for a diagnosis. Regardless, even those who never experience depression experience cyclical changes in mood. These cycles are often affected by changes in sleep cycle (too much or too little), diurnal rhythms and environmental stressors.
Mania varies in intensity, from mild mania known as 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. Standardized tools such as Altman Self-Rating Mania Scale
and Young Mania Rating Scale can be used to measure severity of manic episode. Since mania and hypomania have also been associated with creativity and artistic talent, it is not always the case that the clearly manic bipolar person will need or want medical assistance; such people will often either retain sufficient amount of control to function normally or be unaware that they have "gone manic" severely enough to be committed
or to commit themselves
('commitment' means admission to a psychiatric facility
). Manic individuals can often be mistaken for being on drugs
or other mind-altering substances.
, 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 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 OCD
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.
's 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 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 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. 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.
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. 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. But perhaps the easiest indicator of mania would be if a noticeably clinically depressed
person becomes suddenly cheerful, optimistic, happy, and full of energy. Other elements of mania may include delusions (of grandeur, potential, or otherwise), hypersensitivity, 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). 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 disconnected from reality
.
Some medications may cause symptoms that mimic mania. Some medications may trigger a manic episode through hyperarousal of the limbic system and subsequent sleep deprivation. These may include: amphetamines and other stimulants (Provigil, Nuvigil, Adipex), caffeine (caffeine/taurine energy drinks), cocaine and various illegal drugs, serotonin reuptake inhibitors (SSRI, SNRI), tricyclic compounds (TCA,excluding carbamazepine), steroid medications (Prednisone, oral cortisone), serotonin agonists, dopamine agonists (Mirapex, Sinemet), and several other groups of medicines. One common over the counter medication group that can be stimulating in large doses is cough and cold medications that contain agents meant to stimulate blood vessels which shrink nasal mucosa thereby enlarging space for nasal air flow (decongestants).
For example, Phenylpropanolamine
(PPA) is a sympathomimetic drug similar in structure to amphetamine which was formerly present in over 130 medications, primarily decongestants, cough/cold remedies, and anorectic agents.
A report on PPA, from the Dept. of Psychiatry, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Pharmacopsychiatry 1988 stated:
PPA is no longer available in any medication in the United States as of the year 2000.
must be performed to rule out non-psychiatric causes.
Acute mania in bipolar disorder
is typically treated with mood stabilizer
s and/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
.
Lithium is the classic mood stabilizer to prevent further manic and depressive episodes. Anticonvulsants such as valproic acid
and carbamazepine
are also used for prophylaxis. More recent drug solutions include lamotrigine
. Clonazepam
(Rivotril, Ravotril or Rivatril) is also used.
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.
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.
, 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" .
Mood (psychology)
A mood is a relatively long lasting emotional state. Moods differ from emotions in that they are less specific, less intense, and less likely to be triggered by a particular stimulus or event....
, arousal, and/ or energy levels. In a sense, it is the opposite of depression. The word derives from the Greek
Greek language
Greek is an independent branch of the Indo-European family of languages. Native to the southern Balkans, it has the longest documented history of any Indo-European language, spanning 34 centuries of written records. Its writing system has been the Greek alphabet for the majority of its history;...
"μανία" (mania), "madness, frenzy" and that from the verb "μαίνομαι" (mainomai), "to be mad, to rage, to be furious".
In addition to mood disorders, individuals may exhibit manic behavior as a result of drug intoxication (notably stimulants such as cocaine or methamphetamine), medication side effects (notably steroids), or malignancy. However, mania is most often associated with bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
, where episodes of mania may alternate with episodes of major depression
Major depressive episode
A major depressive episode is the cluster of symptoms of major depressive disorder. The description has been formalised in psychiatric diagnostic criteria such as the DSM-IV and ICD-10, and is characterized by severe, highly persistent depression, and a loss of interest or pleasure in everyday...
. Gelder, Mayou and Geddes (2005) suggests that it is vital that mania is predicted in the early stages because the patient becomes reluctant to comply to the treatment. The criteria for bipolar do not include depressive episodes and the presence of mania in the absence of depressive episodes is sufficient for a diagnosis. Regardless, even those who never experience depression experience cyclical changes in mood. These cycles are often affected by changes in sleep cycle (too much or too little), diurnal rhythms and environmental stressors.
Mania varies in intensity, from mild mania known as hypomania
Hypomania
Hypomania is a mood state characterized by persistent and pervasive elevated or irritable mood, as well as thoughts and behaviors that are consistent with such a mood state...
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. Standardized tools such as Altman Self-Rating Mania Scale
Altman Self-Rating Mania Scale
The Altman Self-Rating Mania Scale is an five-item self-reported diagnostic scale to assess the level of mania and hypomania symptoms for patients diagnosed with bipolar disorder...
and Young Mania Rating Scale can be used to measure severity of manic episode. Since mania and hypomania have also been associated with creativity and artistic talent, it is not always the case that the clearly manic bipolar person will need or want medical assistance; such people will often either retain sufficient amount of control to function normally or be unaware that they have "gone manic" severely enough to be committed
Involuntary commitment
Involuntary commitment or civil commitment is a legal process through which an individual with symptoms of severe mental illness is court-ordered into treatment in a hospital or in the community ....
or to commit themselves
Voluntary commitment
Voluntary commitment is the act or practice of a person being admitted to a psychiatric hospital, or other mental health facility, voluntarily, and without the process of involuntary commitment...
('commitment' means admission to a psychiatric facility
Psychiatric hospital
Psychiatric hospitals, also known as mental hospitals, are hospitals specializing in the treatment of serious mental disorders. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients...
). Manic individuals can often be mistaken for being on drugs
DRUGS
Destroy Rebuild Until God Shows are an American post-hardcore band formed in 2010. They released their debut self-titled album on February 22, 2011.- Formation :...
or other mind-altering substances.
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 spectrumBipolar spectrum
The bipolar spectrum refers to a category of mood disorders that feature abnormally elevated or depressed mood. These disorders range from bipolar I disorder, featuring full-blown manic episodes, to cyclothymia, featuring less prominent hypomanic episodes, to "subsyndromal" conditions where only...
, 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 DisorderBipolar I disorder
Bipolar I disorder is a mood disorder that is characterized by at least one manic or mixed episode. There may be episodes of hypomania or major depression as well...
. Hypomania may be indicative of Bipolar II Disorder
Bipolar II disorder
Bipolar II disorder is a bipolar spectrum disorder characterized by at least one hypomanic episode and at least one major depressive episode; with this disorder, depressive episodes can be more frequent and are more intense than hypomanic episodes...
or Cyclothymia
Cyclothymia
Cyclothymia is a mood and mental disorder in the bipolar spectrum that causes both hypomanic and depressive episodes. It is defined medically within the bipolar spectrum and consists of recurrent disturbances between sudden hypomania and dysthymic episodes. The diagnosis of cyclothymic disorder is...
. However, if prominent psychotic symptoms are present for a duration significantly longer than the mood episode, a diagnosis of Schizoaffective Disorder
Schizoaffective disorder
Schizoaffective disorder is a psychiatric diagnosis that describes a mental disorder characterized by recurring episodes of elevated or depressed mood, or of simultaneously elevated and depressed mood, that alternate with, or occur together with, distortions in perception.Schizoaffective disorder...
is more appropriate. Several types of Mania such as kleptomania
Kleptomania
Kleptomania is an irresistible urge to steal items of trivial value. People with this disorder are compelled to steal things, generally, but not limited to, objects of little or no significant value, such as pens, paper clips, paper and tape...
and pyromania
Pyromania
Pyromania in more extreme circumstances can be an impulse control disorder to deliberately start fires to relieve tension or for gratification or relief. The term pyromania comes from the Greek word πῦρ . Pyromania and pyromaniacs are distinct from arson, the pursuit of personal, monetary or...
are related more closely to OCD
Obsessive-compulsive disorder
Obsessive–compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry, by repetitive behaviors aimed at reducing the associated anxiety, or by a combination of such obsessions and compulsions...
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 AssociationAmerican Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
's 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 or a medical illness (e.g., hyperthyroidism
Hyperthyroidism
Hyperthyroidism is the term for overactive tissue within the thyroid gland causing an overproduction of thyroid hormones . Hyperthyroidism is thus a cause of thyrotoxicosis, the clinical condition of increased thyroid hormones in the blood. Hyperthyroidism and thyrotoxicosis are not synonymous...
), 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
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
.
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
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
's classification system
ICD
The International Statistical Classification of Diseases and Related Health Problems is a medical classification that provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease...
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. Hypomania
Hypomania
Hypomania is a mood state characterized by persistent and pervasive elevated or irritable mood, as well as thoughts and behaviors that are consistent with such a mood state...
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.
One of the most signature symptoms of mania (and to a lesser extent, hypomania
Hypomania
Hypomania is a mood state characterized by persistent and pervasive elevated or irritable mood, as well as thoughts and behaviors that are consistent with such a mood state...
) is what many have described as racing thoughts
Racing thoughts
Racing thoughts refers to the rapid thought patterns that often occur in manic, hypomanic, or mixed episodes. While racing thoughts are most commonly described in people with bipolar disorder, they are also common with anxiety disorders, such as OCD...
. These are usually instances in which the manic person is excessively distracted by objectively unimportant stimuli. 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. But perhaps the easiest indicator of mania would be if a noticeably clinically depressed
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
person becomes suddenly cheerful, optimistic, happy, and full of energy. Other elements of mania may include delusions (of grandeur, potential, or otherwise), hypersensitivity, hypersexuality
Hypersexuality
Hypersexuality is extremely frequent or suddenly increased sexual urges or sexual activity. Hypersexuality is typically associated with lowered sexual inhibitions. Although hypersexuality can be caused by some medical conditions or medications, in most cases the cause is unknown...
, hyper-religiosity
Religiosity
Religiosity, in its broadest sense, is a comprehensive sociological term used to refer to the numerous aspects of religious activity, dedication, and belief . Another term that would work equally well, though is less often used, is religiousness...
, 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). 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
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
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
Hypomania
Hypomania is a mood state characterized by persistent and pervasive elevated or irritable mood, as well as thoughts and behaviors that are consistent with such a mood state...
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 disconnected from reality
Derealization
Derealization is an alteration in the perception or experience of the external world so that it seems unreal. Other symptoms include feeling as though one's environment is lacking in spontaneity, emotional coloring and depth. It is a dissociative symptom of many conditions, such as psychiatric and...
.
Cause
Mania is a complex neurophysiological phenomenon. Predisposing factors to develop mania are primarily genetic and are no longer considered to be psychological, although stress triggers to a particular manic episode may include significant psychological and social conflicts. The primary trigger for (and the primary symptom of) acute mania is sleep deprivation. Social problems, medications, or illness may initiate manic hyperarousal but genetic predisposition or brain illnesses are most likely to be the main causations for classic and persistent manic symptoms. Some medications, including all stimulants, may mimic manic symptoms but differ substantially in duration and intensity compared with true manic episodes. The primary mediator of all mood disease is the brain's limbic system. A full description of the cause of mania is complex and should be referenced elsewhere.Some medications may cause symptoms that mimic mania. Some medications may trigger a manic episode through hyperarousal of the limbic system and subsequent sleep deprivation. These may include: amphetamines and other stimulants (Provigil, Nuvigil, Adipex), caffeine (caffeine/taurine energy drinks), cocaine and various illegal drugs, serotonin reuptake inhibitors (SSRI, SNRI), tricyclic compounds (TCA,excluding carbamazepine), steroid medications (Prednisone, oral cortisone), serotonin agonists, dopamine agonists (Mirapex, Sinemet), and several other groups of medicines. One common over the counter medication group that can be stimulating in large doses is cough and cold medications that contain agents meant to stimulate blood vessels which shrink nasal mucosa thereby enlarging space for nasal air flow (decongestants).
For example, Phenylpropanolamine
Phenylpropanolamine
Phenylpropanolamine , also known as the stereoisomers norephedrine and norpseudoephedrine, is a psychoactive drug of the phenethylamine and amphetamine chemical classes which is used as a stimulant, decongestant, and anorectic agent. It is commonly used in prescription and over-the-counter cough...
(PPA) is a sympathomimetic drug similar in structure to amphetamine which was formerly present in over 130 medications, primarily decongestants, cough/cold remedies, and anorectic agents.
A report on PPA, from the Dept. of Psychiatry, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Pharmacopsychiatry 1988 stated:
- We have reviewed 37 cases (published in North America and Europe since 1960) that received diagnoses of acute mania, paranoid schizophrenia, and organic psychosis and that were attributed to PPA product ingestion. Of the 27 North American case reports, more reactions followed the ingestion of combination products than preparations containing PPA alone; more occurred after ingestion of over-the-counter products than those obtained by prescription or on-the-street; and more of the cases followed ingestion of recommended doses rather than overdoses.
- Failure to recognize PPA as an etiological agent in the onset of symptoms usually led to a diagnosis of schizophreniaSchizophreniaSchizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
or mania, lengthy hospitalization, and treatment with substantial doses of neuroleptics or lithium.
PPA is no longer available in any medication in the United States as of the year 2000.
Treatment
Before beginning treatment for mania, careful differential diagnosisDifferential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
must be performed to rule out non-psychiatric causes.
Acute mania in bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
is typically treated with mood stabilizer
Mood stabilizer
A mood stabilizer is a psychiatric medication used to treat mood disorders characterized by intense and sustained mood shifts, typically bipolar disorder.-Uses:...
s and/or antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
medication. Note that these treatments need to be prescribed and monitored carefully to avoid harmful side-effects such as neuroleptic malignant syndrome
Neuroleptic malignant syndrome
Neuroleptic malignant syndrome is a life- threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs...
with the antipsychotic medications. It may be necessary to temporarily admit the patient involuntarily until the patient is stabilized. Antipsychotics and mood stabilizer
Mood stabilizer
A mood stabilizer is a psychiatric medication used to treat mood disorders characterized by intense and sustained mood shifts, typically bipolar disorder.-Uses:...
s help stabilize mood of those with mania or depression. They work by blocking the receptor for the neurotransmitter dopamine
Dopamine
Dopamine is a catecholamine neurotransmitter present in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this substituted phenethylamine functions as a neurotransmitter, activating the five known types of dopamine receptors—D1, D2, D3, D4, and D5—and their...
and allowing serotonin
Serotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
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
Pharmacotherapy
Pharmacotherapy is the treatment of disease through the administration of drugs. As such, it is considered part of the larger category of therapy....
and psychotherapy
Psychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
.
Lithium is the classic mood stabilizer to prevent further manic and depressive episodes. Anticonvulsants such as valproic acid
Valproic acid
Valproic acid is a chemical compound that has found clinical use as an anticonvulsant and mood-stabilizing drug, primarily in the treatment of epilepsy, bipolar disorder, and, less commonly, major depression. It is also used to treat migraine headaches and schizophrenia...
and carbamazepine
Carbamazepine
Carbamazepine is an anticonvulsant and mood-stabilizing drug used primarily in the treatment of epilepsy and bipolar disorder, as well as trigeminal neuralgia...
are also used for prophylaxis. More recent drug solutions include lamotrigine
Lamotrigine
Lamotrigine, marketed in the US and most of Europe as Lamictal by GlaxoSmithKline, is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used as an adjunct in treating depression, though this is considered off-label usage...
. Clonazepam
Clonazepam
Clonazepamis a benzodiazepine drug having anxiolytic, anticonvulsant, muscle relaxant, and hypnotic properties. It is marketed by Roche under the trade name Klonopin in the United States and Rivotril in Australia, Brazil, Canada and Europe...
(Rivotril, Ravotril or Rivatril) is also used.
Verapamil
Verapamil
Verapamil is an L-type calcium channel blocker of the phenylalkylamine class. It has been used in the treatment of hypertension, angina pectoris, cardiac arrhythmia, and most recently, cluster headaches. It is also an effective preventive medication for migraine...
, 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 neurotransmitterNeurotransmitter
Neurotransmitters are endogenous chemicals that transmit signals from a neuron to a target cell across a synapse. Neurotransmitters are packaged into synaptic vesicles clustered beneath the membrane on the presynaptic side of a synapse, and are released into the synaptic cleft, where they bind to...
serotonin
Serotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
in the temporal lobe
Temporal lobe
The temporal lobe is a region of the cerebral cortex that is located beneath the Sylvian fissure on both cerebral hemispheres of the mammalian brain....
may be excessively high. Dopamine
Dopamine
Dopamine is a catecholamine neurotransmitter present in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this substituted phenethylamine functions as a neurotransmitter, activating the five known types of dopamine receptors—D1, D2, D3, D4, and D5—and their...
, norepinephrine
Norepinephrine
Norepinephrine is the US name for noradrenaline , a catecholamine with multiple roles including as a hormone and a neurotransmitter...
, glutamate and gamma-aminobutyric acid
Gamma-aminobutyric acid
γ-Aminobutyric acid is the chief inhibitory neurotransmitter in the mammalian central nervous system. It plays a role in regulating neuronal excitability throughout the nervous system...
also appear to play important roles. Imaging studies have shown that the left amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...
is more active in women who are manic and the orbitofrontal cortex
Orbitofrontal cortex
The orbitofrontal cortex is a prefrontal cortex region in the frontal lobes in the brain which is involved in the cognitive processing of decision-making...
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 BehrmanAndy Behrman
Andy Behrman was born 1962 and is an American writer of non-fiction as well as a mental health advocate and national speaker who maintains a website at www.electroboy.com. He is the author of Electroboy: A Memoir of Mania, a chronicle about his experiences with Manic Depression, published by Random...
, 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" .
See also
- Abnormal psychologyAbnormal psychologyAbnormal psychology is the branch of psychology that studies unusual patterns of behavior, emotion and thought, which may or may not be understood as precipitating a mental disorder...
- Bipolar disorderBipolar disorderBipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
- Clinical depressionClinical depressionMajor depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
- CyclothymiaCyclothymiaCyclothymia is a mood and mental disorder in the bipolar spectrum that causes both hypomanic and depressive episodes. It is defined medically within the bipolar spectrum and consists of recurrent disturbances between sudden hypomania and dysthymic episodes. The diagnosis of cyclothymic disorder is...
- HyperthymiaHyperthymic temperamentHyperthymic temperament or hyperthymia is characterized by a personality style or set of personality traits that include* increased energy and productivity* short sleep patterns...
- HypomaniaHypomaniaHypomania is a mood state characterized by persistent and pervasive elevated or irritable mood, as well as thoughts and behaviors that are consistent with such a mood state...
- International Society for Bipolar DisordersInternational Society for Bipolar DisordersThe International Society for Bipolar Disorders is a non-profit organization based in Pittsburgh, Pennsylvania, USA, where it was founded June 17, 1999 . The society focuses on research and education in bipolar disorders....
: - MonomaniaMonomaniaIn 19th century psychiatry, monomania is a single pathological preoccupation in an otherwise sound mind. Emotional monomania is that in which the patient is obsessed with only one emotion or several related to it; intellectual monomania is that which is related to only one kind of delirious idea...
- PyromaniaPyromaniaPyromania in more extreme circumstances can be an impulse control disorder to deliberately start fires to relieve tension or for gratification or relief. The term pyromania comes from the Greek word πῦρ . Pyromania and pyromaniacs are distinct from arson, the pursuit of personal, monetary or...
- Social maniaSocial maniaSocial manias are mass movements which periodically sweep through society, sometimes on a world-wide basis. They are characterized by an outpouring of enthusiasm, mass involvement and millennialist goals. Social manias are contagious social epidemics, and as such they should be differentiated from...
- TrichotillomaniaTrichotillomaniaTrichotillomania, which is classified as an impulse control disorder by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat....
- Young Mania Rating ScaleYoung Mania Rating ScaleThe Young Mania Rating Scale is an eleven-item, multiple-choice diagnostic questionnaire which psychiatrists use to measure the severity of manic episodes in patients...
Further reading
- Expert Opin Pharmacother. 2001 December;2(12):1963–73.
- Schizoaffective Disorder. 2007 September Mayo Clinic. Retrieved October 1, 2007.
- Schizoaffective Disorder. 2004 May. All Psych Online: Virtual Psychology Classroom. Retrieved October 2, 2007.
- Psychotic Disorders. 2004 May. All Psych Online: Virtual Psychology Classroom. Retrieved October 2, 2007.
- Increased concentrations and lateral asymmetry of amygdala dopamine in schizophrenia. 1983 October Nature. Retrieved October 2, 2007.
- Risperidone therapy in treatment refractory acute bipolar and schizoaffective mania. 1996 January Psychopharmacology Bulletin. Retrieved October 2, 2007.