Mania

Mania, also known as manic syndrome, is

a state of abnormally elevated arousal,
affect, and energy level, or "a state of
heightened overall activation with
enhanced affective expression together
with lability of affect."[1] Although mania is
often conceived as a "mirror image" to
depression, the heightened mood can be
either euphoric or irritable; indeed, as the
mania intensifies, irritability can be more
pronounced and result in violence, or
anxiety.
 Mania
Other names Manic syndrome, manic
episode

Graphical representation of mania and

hypomania

Specialty Psychiatry

The symptoms of mania include

heightened mood (either euphoric or
irritable); flight of ideas and pressure of
speech; and increased energy, decreased
need for sleep, and hyperactivity. They are
most plainly evident in fully developed
hypomanic states; in full-blown mania,
however, they undergo progressively
severe exacerbations and become more
and more obscured by other signs and
symptoms, such as delusions and
fragmentation of behavior.[2]

Mania is a syndrome with multiple causes.

Although the vast majority of cases occur
in the context of bipolar disorder, it is a key
component of other psychiatric disorders
(such as schizoaffective disorder, bipolar
type) and may also occur secondary to
various general medical conditions, such
as multiple sclerosis; certain medications
may perpetuate a manic state, for example
prednisone; or substances of abuse, such
as caffeine, cocaine or anabolic steroids.
In the current DSM-5, hypomanic episodes
are separated from the more severe full
manic episodes, which, in turn, are
characterized as either mild, moderate, or
severe, with specifiers in regard to certain
symptomatic features (e.g. catatonia,
psychosis). Mania is divided into three
stages: hypomania, or stage I; acute
mania, or stage II; and delirious mania
(delirium), or stage III. This "staging" of a
manic episode is very useful from a
descriptive and differential diagnostic
point of view.

Mania varies in intensity, from mild mania

(hypomania) to delirious mania, marked by
such symptoms as disorientation, florid
psychosis, incoherence, and catatonia.[3]
Standardized tools such as Altman Self-
Rating Mania Scale[4] and Young Mania
Rating Scale[5] can be used to measure
severity of manic episodes. Because
mania and hypomania have also long been
associated with creativity and artistic
talent,[6] 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 be
committed or to commit themselves.
Manic persons often can be mistaken for
being under the influence of drugs.

Classification
Mixed states

In a mixed affective state, the individual,

though meeting the general criteria for a
hypomanic (discussed below) 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 completed
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 with
violence on suicidal impulses.

Hypomania
Hypomania, which means "less than
mania",[7] is a lowered state of mania that
does little to impair function or decrease
quality of life.[8] It may, in fact, increase
productivity and creativity. 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
as there are those that reported
abnormalities while some failed to detect
differences.[9] 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, and hypomania can, if the
prominent mood is irritable rather than
euphoric, be a rather unpleasant
experience. In addition, the exaggerated
case of hypomania can lead to problems.
For instance, positivity for a person could
make him engaging and outgoing, having a
positive outlook in life.[10] When
exaggerated in hypomania, such person
can display excessive optimism,
grandiosity, and poor decision making,
often without regard to the
consequences.[10]
Associated disorders

A single manic episode, in the absence of

secondary causes, (i.e., substance use
disorder, pharmacologic, general medical
condition) is sufficient to diagnose bipolar
I disorder. Hypomania may be indicative of
bipolar II disorder. Manic episodes are
often complicated by delusions and/or
hallucinations; should the psychotic
features persist for a duration significantly
longer than the episode of mania (two
weeks or more), a diagnosis of
schizoaffective disorder is more
appropriate. Certain "obsessive-
compulsive spectrum" disorders as well as
impulse control disorders share the name
"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. B12 deficiency can also
cause symptoms characteristic of mania
and psychosis.[11]

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.[12][13]
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 (or any duration if hospitalization is
necessary),"[14] 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.[15]

To be classed as a manic episode, while

the disturbed mood and an increase in
goal directed activity or energy is present
at least three (or four if only irritability is
present) of the following must have been
consistently present:

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., feels
rested after 3 hours of sleep).
3. More talkative than usual or pressure
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 (too easily drawn to
unimportant or irrelevant external
stimuli).
7. Excessive involvement in activities
with a high likelihood of painful
consequences.(e.g., extravagant
shopping, improbable commercial
schemes, hypersexuality).[15]

Though the activities one participates in

while in a manic state are not always
negative, those with the potential to have
negative outcomes are far more likely.

If the person is concurrently depressed,

they are said to be having a mixed
episode.[15]

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
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.[2]

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.[16]
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.[17]

One of the 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.[18] This
experience creates an absent-mindedness
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.

Manic states are always relative to the

normal state of intensity of the afflicted
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 heretofore
clinically depressed patient suddenly
becomes inordinately energetic, cheerful,
aggressive, or "over happy." Other, often
less obvious, elements of mania include
delusions (generally of either grandeur or
persecution, according to whether the
predominant mood is euphoric or irritable),
hypersensitivity, hypervigilance,
hypersexuality, hyper-religiosity,
hyperactivity and impulsivity, a compulsion
to over explain (typically accompanied by
pressure of speech), grandiose schemes
and ideas, and a decreased need for sleep
(for example, feeling rested after only 3 or
4 hours of 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, in a
misguided attempt to ward off any
undesirable manic symptoms. Individuals
may also engage in out-of-character
behavior during the episode, such as
questionable business transactions,
wasteful expenditures of money (e.g.,
spending sprees), risky sexual activity,
abuse of recreational substances,
excessive gambling, reckless behavior
(such as "speed driving" or daredevil
activity), abnormal social interaction (as
manifest via, for example, over familiarity
and conversing with strangers), 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.[19][20]

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 behaviour 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.

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 (or Bell’s), respectively.

Cause
Various triggers have been associated
with switching from euthymic or
depressed states into mania. One
common trigger of mania is
antidepressant therapy. Studies show that
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. Other
medication possibly include glutaminergic
agents and drugs that alter the HPA axis.
Lifestyle triggers include irregular sleep
wake schedules and sleep deprivation, as
well as extremely emotional or stressful
stimuli.[21]

Various genes that have been implicated

in genetic studies of bipolar have been
manipulated in preclinical animal models
to produce syndromes reflecting different
aspects of mania. 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, and found to be under-
expressed in the cortex. Pituitary
adenylate cyclase-activating peptide has
been associated with bipolar in gene
linkage studies, and knockout in mice
produces mania like-behavior. Targets of
various treatments such as GSK-3, and
ERK1 have also demonstrated mania like
behavior in preclinical models.[22]

Mania may be associated with strokes,

especially cerebral lesions in the right
hemisphere.[23][24]
Deep brain stimulation of the subthalamic
nucleus in Parkinson's disease has been
associated with mania, especially with
electrodes placed in the ventromedial
STN. A proposed mechanism involves
increased excitatory input from the STN to
dopaminergic nuclei.[25]

Mania can also be caused by physical

trauma or illness. When the causes are
physical, it is called secondary mania.[26]

Mechanism
The mechanism underlying mania is
unknown, but the neurocognitive profile of
mania is highly consistent with
dysfunction in the right prefrontal cortex, a
common finding in neuroimaging
studies.[27][28] Various lines of evidence
from post-mortem studies and the
putative mechanisms of anti-manic agents
point to abnormalities in GSK-3,[29]
dopamine, Protein kinase C and Inositol
monophosphatase.[30]

Meta analysis of neuroimaging studies

demonstrate increased thalamic activity,
and bilaterally reduced inferior frontal
gyrus activation.[31] Activity in the
amygdala and other subcortical structures
such as the ventral striatum tend to be
increased, although results are
inconsistent and likely dependent upon
task characteristics such as valence.
Reduced functional connectivity between
the ventral prefrontal cortex and amygdala
along with variable findings supports a
hypothesis of general dysregulation of
subcortical structures by the prefrontal
cortex.[32] A bias towards positively
valenced stimuli, and increased
responsiveness in reward circuitry may
predispose towards mania.[33] Mania
tends to be associated with right
hemisphere lesions, while depression
tends to be associated with left
hemisphere lesions.[34]
Post-mortem examinations of bipolar
disorder demonstrate increased
expression of Protein Kinase C (PKC).[35]
While limited, some studies demonstrate
manipulation of PKC in animals produces
behavioral changes mirroring mania, and
treatment with PKC inhibitor tamoxifen
(also an anti-estrogen drug) demonstrates
antimanic effects. Traditional antimanic
drugs also demonstrate PKC inhibiting
properties, among other effects such as
GSK3 inhibition.[28]

Manic episodes may be triggered by

dopamine receptor agonists, and this
combined with tentative reports of
increased VMAT2 activity, measured via
PET scans of radioligand binding,
suggests a role of dopamine in mania.
Decreased cerebrospinal fluid levels of the
serotonin metabolite 5-HIAA have been
found in manic patients too, which may be
explained by a failure of serotonergic
regulation and dopaminergic
hyperactivity.[36]

Limited evidence suggests that mania is

associated with behavioral reward
hypersensitivity, as well as with neural
reward hypersensitivity.
Electrophysiological evidence supporting
this comes from studies associating left
frontal EEG activity with mania. As left
frontal EEG activity is generally thought to
be a reflection of behavioral activation
system activity, this is thought to support a
role for reward hypersensitivity in mania.
Tentative evidence also comes from one
study that reported an association
between manic traits and feedback
negativity during receipt of monetary
reward or loss. Neuroimaging evidence
during acute mania is sparse, but one
study reported elevated orbitofrontal
cortex activity to monetary reward, and
another study reported elevated striatal
activity to reward omission. The latter
finding was interpreted in the context of
either elevated baseline activity (resulting
in a null finding of reward hypersensitivity),
or reduced ability to discriminate between
reward and punishment, still supporting
reward hyperactivity in mania.[37]
Punishment hyposensitivity, as reflected in
a number of neuroimaging studies as
reduced lateral orbitofrontal response to
punishment, has been proposed as a
mechanism of reward hypersensitivity in
mania.[38]

Diagnosis
In the ICD-10 there are several disorders
with the manic syndrome: organic manic
disorder (F06.30 ), mania without
psychotic symptoms (F30.1 ), mania with
psychotic symptoms (F30.2 ), other manic
episodes (F30.8 ), unspecified manic
episode (F30.9 ), manic type of
schizoaffective disorder (F25.0 ), bipolar
affective disorder, current episode manic
without psychotic symptoms (F31.1 ),
bipolar affective disorder, current episode
manic with psychotic symptoms (F31.2 ).

Treatment
Before beginning treatment for mania,
careful differential diagnosis must be
performed to rule out secondary causes.
The acute treatment of a manic episode of
bipolar disorder involves the utilization of
either a mood stabilizer (valproate, lithium,
lamotrigine, or carbamazepine) or an
atypical antipsychotic (olanzapine,
quetiapine, risperidone, or aripiprazole).
Although hypomanic episodes may
respond to a mood stabilizer alone, full-
blown episodes are treated with an
atypical antipsychotic (often in
conjunction with a mood stabilizer, as
these tend to produce the most rapid
improvement).[39]

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.[40]
Lithium is the classic mood stabilizer to
prevent further manic and depressive
episodes. A systematic review found that
long term lithium treatment substantially
reduces the risk of bipolar manic relapse,
by 42%.[41] Anticonvulsants such as
valproate, oxcarbazepine and
carbamazepine are also used for
prophylaxis. More recent drug solutions
include lamotrigine and topiramate, both
anticonvulsants as well.

In some cases, long-acting

benzodiazepines, particularly clonazepam,
are used after other options are
exhausted. In more urgent circumstances,
such as in emergency rooms, lorazepam
has been used to promptly alleviate
symptoms of agitation, aggression, and
psychosis. Sometimes atypical
antipsychotics are used in combination
with the previous mentioned medications
as well, including olanzapine which helps
treat hallucinations or delusions,
asenapine, aripiprazole, 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.[42] Verapamil is effective for
both short-term and long-term
treatment.[43]

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. Some atypical
antidepressants, however, such as
mirtazepine and trazodone have been
occasionally used after other options have
failed.[44]
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".[45] 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. There is some evidence that
people in the creative industries suffer
from bipolar disorder more often than
those in other occupations.[46]Winston
Churchill had periods of manic symptoms
that may have been both an asset and a
liability.[47]

English actor Stephen Fry, who suffers

from bipolar disorder,[48] recounts manic
behaviour during his adolescence: "When I
was about 17 ... going around London on
two stolen credit cards, it was a sort of
fantastic reinvention of myself, an attempt
to. I bought ridiculous suits with stiff
collars and silk ties from the 1920s, and
would go to the Savoy and Ritz and drink
cocktails."[49] While he has experienced
suicidal thoughts, he says the manic side
of his condition has had positive
contributions on his life.[48]

Etymology
The nosology of the various stages of a
manic episode has changed over the
decades. The word derives from the
Ancient Greek μανία (manía), "madness,
frenzy"[50] and the verb μαίνομαι
(maínomai), "to be mad, to rage, to be
furious".[51]

See also
Abnormal psychology
 Adult attention deficit hyperactivity
disorder
Bipolar disorder
Cyclothymia
Hyperthymia
Hypomania
International Society for Bipolar
Disorders:
Major depressive disorder
Young Mania Rating Scale

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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.
Sajatovic, Martha; DiBiovanni, Sue Kim;
Bastani, Bijan; Hattab, Helen; Ramirez,
Luis F. (1996). "Risperidone therapy in
treatment refractory acute bipolar and
schizoaffective mania".
Psychopharmacology Bulletin. 32 (1):
55–61. PMID 8927675 .

External links
 Look up mania in Wiktionary, the free
dictionary.

Bipolar Mania Symptoms

Depression and Bipolar Support
Alliance

Classification D
ICD-10: F06.30 , F30.1 ,
F30.2 , F30.8 , F30.9 ,
F31.1 , F31.2 •
ICD-9-CM: 296.0 ,
296.4 , 296.6 •
MeSH: D001714
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