281 Manic Episode

DSM-IV-TR criteria

• A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
• B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

• inflated self-esteem or grandiosity
• decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
• more talkative than usual or pressure to keep talking
• flight of ideas or subjective experience that thoughts are racing
• distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
• increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
• excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

• C. Mood disturbance is severe enough to cause marked impairment in occupational function, social activities, or relationships, or severe enough to necessitate hospitalization to prevent harm to self or to others.
• D. At no time have delusions or hallucinations been present for two weeks in the absence of prominent mood symptoms.
• E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hypothyroidism)
• F. No organic factor is known that initiated or maintained the disturbance.

• NOTE: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.

Associated features

• Many individuals do not realize that they are ill and will resist to be treated. They become impulsive in decisions and will chose to be somewhere that is nowhere near any relatives or those that they are in close relationship. They sometimes choose to change their physical appearance to be appealing (that is out of character) to the opposite sex. Individuals may become more sexually active (hypersexuality). They may become involved in activities in a strange way (giving candy,money,or advice to complete strangers). They may involve themselves in foolish unethical impulses such as claiming the victory in something that was not theirs to begin with. They may become hostile, threaten or physically assault others, or suicidal.
• His/her mood may quickly move from anger to depression. The more that Manic develops the more likely that they will increase the amount of stimulants that they use and will prolong the episode.
• In the Manic Episodes it may involve the norepinephrine, serotonins, acetycholine, dopamine, or gamma-aminobutyric acid neurotransmitters systems in some abnormality.
• When they have delusions and hallucinations they are mood-congruent. For example a person with a elated mood may think or believe he has special powers.
• Many manic depressive episodes may be trigged by the following: fatigue, medications, alcohol, drug abuse, and stress

Child vs. adult presentation

• Manic episodes in adolescents are more likely to include psychotic features and may be associated with school truancy, antisocial behavior, school failure, or substance abuse that is in social situations. A significant minority of adolescents appear to have a history of long-standing behavior problems that precede the onset of a frank Manic Episode. It is unclear whether these problems represent a prolonged prodrome to Bipolar Disorder or an independent disorder.

Gender and cultural differences in presentation

• It affects people in all race categories from Caucasians to Asians.
• Latinos and Mediterranean cultures complain about nerves and headaches.
• Chinese and Asian cultures complain about weakness, tiredness, or imbalance.
• Middle Eastern cultures complain about problems of the heart or heartbreak.

Epidemiology

• In many instances (50-60%), a Major Depressive Episode immediately precedes or immediately follows a Manic Episode, with no intervening period of euthymia. It should be noted that the causes of the episodes should not be better accounted by, or completely caused by things such as medications/substances or other medical conditions.

Etiology

• The mean age of onset is the early 20’s, but some cases start in adolescents and others start after age 50. Manic episodes typically begin suddenly, with a rapid escalation of symptoms over a few days. Frequently, episodes occur following psychosocial stressors. Manic Episodes usually last from a few weeks to several months and are briefer and end more abruptly than Major Depressive Episodes.
• Manic Depression can also be recognized as Bipolar Disorder based on the sudden/dramatic mood swings that can change at any moment or time.

Empirically supported treatments

• Valproate has been known to be effective in treating acute mania and has sedative properties. It has a response rate of 2/3. Atypical antipsychotics can also be a useful alternative since these drugs typically have reasonably short negative side effects. Clonazepam and Lorazepam can be used for patients that are agitated or overactive to make sure they get some sleep.

Manic depressives may be triggered by a change in the seasons. The summer months is more common for episodes of mania.

Draft Criteria for Bipolar I Disorder

• Retain structure, with changes limited to the definitions of mood episodes that define each.

Diagnostic criteria for Bipolar I Disorder, Most Recent Episode Manic

1. Currently (or most recently) in a Manic Episode (see Criteria for Manic Episode).
2. There has previously been at least one Major Depressive Episode (see Criteria for Major Depressive Episode), Manic Episode (see Criteria for Manic Episode), or Mixed Episode (see Criteria for Mixed__Specifier__).
3. The mood episodes in Criteria A and B are not better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.

Specifiers and/or current features have not yet been reviewed by the Workgroup for bipolar disorder. It is anticipated that specifiers and/or features that apply across the mood disorders will be consistent across major depression and bipolar disorder. The bipolar specific rapid cycling specifier is under review to consider whether to keep as is, eliminate, or modify

Additional Information

Impulsivity is a prominent component of the manic syndrome, so manic features during depressive syndromes may be associated with impulsivity and its consequences, including increased risk of substance abuse and suicidal behavior (Swann, Gerard, Steinberg, Schneider, Barrattt, & Dougherty, 2007). Manic episodes can be mild but are usually quite common in bipolar disorder. The findings indicated that long term depressed patients with manic symptoms susceptibility to impulsivity (Swann, et al., 2007). This usually included patients who had a history of alcohol abuse, head trauma, and suicide attempts. “The results showed that the presence of manic symptoms during depressive episodes was related to greater current and lifetime behavioral risk. Manic symptoms appear to be a dimensional component of bipolar depressive episodes, but may have a threshold of severity associated with increased impulsivity and associated behavioral risks. This may reflect a combination of depression with trait impulsivity. While manic symptoms were associated with more severe previous complications, their predictive value, and the validity of a subtype of depression defined on the basis of manic symptoms, must be confirmed prospectively (Swann, et al., 2007).”