Mania

Mania is a mental state in which motivation, energy, mood and/or thinking are elevated. The need for sleep is reduced, thought content is more grandiose, speed of thinking is increased, but thoughts remain connected (‘flight of ideas’), distractibility is high, libido is increased, behaviour is more socially disinhibited (including excessive spending of money), judgment is impaired and often the person is more physically active than usual. The person is often intolerant of challenge and may become aggressive if frustrated. This can pose a major problem for ‘significant others’ when faced with very inappropriate behaviour.

The separation of mania and hypomania is the subject of some variation. Some authorities maintain that manic symptoms which do not significantly impair function or require hospitalisation constitute hypomania. Others insist that mania is defined by the presence of psychosis and that absence of psychotic symptoms and signs in a patient with manic symptoms constitutes hypomania. The latter definition is more objective and more coherent than relying upon decisions regarding admission to hospital and the severity of disruption in life function, but the former is more commonly used in the literature.

Upon mental state examination, the person may appear obviously euphoric, but if the thought content is more anxiety provoking or hostile, the facial expression may change accordingly. They may present with dramatic choice of clothing or none at all. Physical and intellectual capacity during a state of mania can be exceptionally high for that individual, sometimes with remarkable feats of ability. Assessment is usually facilitated by the person’s lack of inhibition, but insight may be poor and the diagnosis of mania may evoke rage and denial. The decision to seek help usually comes from a relative or other interested person rather than the patient.

Depressed phase of bipolar disorder

The clinical presentation is essentially the same as in depressive disorders (see Ch 6), but is more likely to be severe, and associated somatic (melancholic) features are more likely. Abrupt onset of a severe melancholic depression in a young person (particularly an adolescent) may be a harbinger of bipolar disorder, and careful monitoring of antidepressant response (to check for manic switch) is required. ‘Atypical’ depressive clinical features are more common in bipolar disorders than other mood disorders. The different phases of illness are shown in Figure 7.1.

FIGURE 7.1 Different types of bipolar disorder mood profile

Mixed bipolar states

Manic or hypomanic symptoms may arise simultaneously with depressive symptoms in a mixture which is easily overlooked. Sometimes, manic and depressive symptoms will arise in close succession and at other times symptoms of mania or hypomania may be present and combined with depressed mood or negative thought content. The affect is often irritable rather than euphoric.