Mania

This article is an expansion of a section entitled Mania from within the main article Bipolar disorder. For the classical mythological figures named Mania, see Mania (mythology).
Greek letter 'psi'
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Manic episode
Classification and external resources
ICD-10 F30
ICD-9 296.0 Single manic episode, 296.4 Most recent episode manic, 296.6 Most recent episode mixed

Mania (from Greek μανία[1] and that from μαίνομαι - mainomai, "to rage, to be furious") is a severe medical condition characterized by extremely elevated mood, energy, unusual thought patterns and sometimes psychosis. There are several possible causes for mania including drug abuse and brain tumours, but it is most often associated with bipolar disorder, where episodes of mania may cyclically alternate with episodes of major depression. These cycles may relate to diurnal rhythms and environmental stressors. Mania varies in intensity, from mild mania (known as hypomania) to full-blown mania with psychotic features (hallucinations and delusions).

Manic patients may need to be hospitalized to protect themselves and others. Mania and hypomania have also been associated with creativity and artistic talent.[2]

Contents

Symptoms

Symptoms of mania include rapid speech, racing thoughts, decreased need for sleep, hypersexuality, euphoria, impulsiveness, grandiosity, and increased interest in goal-directed activities.[3] Mild forms of mania, known as hypomania, cause little or no impairment, but some people who suffer from prolonged hypomania may develop full mania.[4]

Another symptom of mania is racing thoughts during which the sufferer is excessively distracted by unimportant stimuli.[5] This negative experience creates an inability to function and 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 neurological pattern of thoughts.

Manic symptoms include irritability, anger or rage, delusions, hypersensitivity, hypersexuality, hyper-religiosity, hyperactivity, impulsiveness, racing thoughts, talkativeness, pressure to keep talking or rapid speech, and grandiose ideas and plans, decreased need for sleep (e.g. feels 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, abnormal social interaction, or highly vocal arguments uncharacteristic of previous behaviors. These behaviors increase stress in personal relationships, problems at work and increases the risk of altercations with law enforcement as well as being at 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 often quite unpleasant and sometimes disturbing, if not frightening, for the person involved (and those close to them), and 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 symptoms. 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. For example, a minor state may involve increased creativity, wit, gregariousness, and ambition. However, a more serious state of mania may involve lack of good judgment, lack of ability to focus, and even psychosis. The victim of mania may feel elated; however, he/she may also feel irritable, frustrated, and may experience derealization.

Mixed states

Main article: Mixed episode

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.

Hypomania

Main article: Hypomania

Hypomania is a lowered state of mania that does little to impair function or decrease quality of life[6]. In hypomania there is less need for sleep, goal motivated behavior and increased metabolism. 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.

B12 deficiency can also cause symptoms of mania and psychosis.[7][8]

Prominent hypomaniacs likely include Endymion (a mythological figure, probably describing the real person/s), Rudyard Kipling, Vincent Van Gogh, John Keats, Andy Warhol.

Medical 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 stabilizers 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 stabilizers 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 symptoms of mania 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.

The calcium-channel blocker, verapamil is useful in the treatment of hypomania and in those cases where lithium and mood stabilizers are contraindicated or ineffective.[9]. Verapamil is effective for both short-term and long-term treatment. [10]

Psychopharmacology

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. This is likely to be only part of the puzzle. Dopamine, norepinephrine, glutamate and gamma-aminobutyric acid also appear to play important roles. The temporal lobe is involved in speech, listening, reading, word association and contains the amygdala, the almond shaped emotional center for the brain. The left amygdala is more active in women who are manic and the orbitofrontal cortex is less active (2005). Emotional stimulation creates the ability for life events to be stored more vividly in the memory. In women, the amygdala becomes similar to one of a woman during sex combined with menstruation.

Bipolar disorder is different for men than it is for women. Mania affects the hypothalamus and the pituitary-adrenal-axis by causing it to secrete hormones in different amounts, that accounts for hypersexuality, changes in metabolism, and misdiagnosis as hormonal imbalance. Because the hormone problem stems from a neurological problem hormone therapy isn't the best solution. If serotonin levels are stable, hormones secreted by the pituitary gland will stabilize. Bipolar disorder is similar to a thought disorder combined with hypothyroidism and hyperthyroidism.

In the study done by Brentwood VA Medical Center in Los Angeles, California, patients with bipolar II took antidepressants to measure their effect on mania. One third of bipolar patients developed antidepressant induced mania from their healthy state and one fourth developed antidepressant induced rapid cycling from their healthy state. For those with type II bipolar disorder, antidepressants decrease the gaps between the depression and mania (1995).

Mania and over the counter drugs

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:

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 schizophrenia 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.

Personal accounts

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" (2002). 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" (2002).

See also

Caveat: See "Symptoms" above.

References

  1. ↑ Mania, Henry George Liddell, Robert Scott, A Greek-English Lexicon, at Perseus
  2. ↑ Jamison, Kay R. (1996), Touched with Fire: Manic-Depressive Illness and the Artistic Temperament, New York: Free Press, ISBN 0-684-83183-X
  3. ↑ DSM-IV
  4. ↑ AJ Giannini. Biological Foundations of Clinical Psychiatry, NY Medical Examination Publishing Company, 1986.
  5. ↑ Lakshmi N. Ytham, Vivek Kusumakar, Stanley P. Kutchar. (2002). Bipolar Disorder: A Clinician's Guide to Biological Treatments, page 3.
  6. ↑ NAMI (July 2007). "The many faces & facets of BP". Retrieved on 2008-10-02.
  7. ↑ Sethi NK, Robilotti E, Sadan Y (2005). "Neurological Manifestations Of Vitamin B-12 Deficiency". The Internet Journal of Nutrition and Wellness 2 (1). 
  8. ↑ Masalha R, Chudakov B, Muhamad M, Rudoy I, Volkov I, Wirguin I (2001). "Cobalamin-responsive psychosis as the sole manifestation of vitamin B12 deficiency". Israeli Medical Association Journal 3: 701–703. 
  9. ↑ AJ Giannini, WA Price. Antimanic effects of verapamil . American Journal of Psychiatry. 141:160-1604,1984.
  10. ↑ AJ Giannini, RS Taraszewski, RH Loiselle. Verapamil and lithium in maintenance therapy of manic patients. Journal of Clinical Pharmacology. 27:980-985,1987.

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