Mania

Etiology

The etiology of mania, and more generally, bipolar I disorder, are not known. There is strong evidence that the cause is a combination of genetic, psychological, and social factors. There have been multiple studies involving families which show a definite genetic component. In a study involving monozygotic twins, it was revealed that up to 80% of twins are concordant for the disorder when one of the siblings is positive for the disorder. This is also evidence of environmental influences since there is not a 100% concordance between monozygotic twins. Multiple studies have shown that several allele frequencies are involved in both bipolar I disorder and schizophrenia. There is also extensive anecdotal evidence that stressful life events and other psychosocial factors contribute to the onset and frequency of manic phases.[7][8]

Epidemiology

Mania is the diagnostic criteria for bipolar I disorder, so the epidemiology of bipolar I disorder also tells us about the prevalence of mania. The lifetime prevalence of bipolar disorder is about 4 percent. Men and women are equally likely to be affected. However, women are much more likely to experience many mood episodes in a given year (rapid cycling). The median age of onset of bipolar disorder is around age 25. Men typically have an earlier age of onset than women. Studies have shown that men usually initially present with a manic episode while women present with a depressive episode. Almost two-thirds of bipolar patients have at least 1 close relative who was also diagnosed with the disease or with unipolar depression.

Pathophysiology

The pathophysiology of mania and bipolar disorder, in general, has been shown in some studies to involve specific brain regions; however, the exact mechanisms involved are still unknown. In functional studies as well as structural studies, bipolar disorder patients have shown alterations in the amygdala, hippocampus, basal ganglia, prefrontal cortex, and the anterior cingulate. The amygdala is hyperactive in patients with BD, and the hippocampus and prefrontal cortex are hypoactive. This increased activity in the amygdala along with decreased activity in cortical regions may be the reason why the executive function is impaired in mania while the emotions are heightened and unrestrained.

History and Physical

Taking the history of a patient with suspected mania requires asking about the primary characteristics of mania such as a recent change in sleep, activity, appetite, irritability, among others. The common mnemonic "DIG FAST" is used to aid clinicians in remembering to ask about Distractibility, Irresponsibility or Irritability, Grandiosity, Flight of ideas, increased Activity, decreased Sleep, and excessive Talkativeness. The evaluation must include the full DSM-5 criteria. As listed in the DSM-5, a manic episode is diagnosed if the patient experiences an abrupt change in mood described as euphoric or angry that lasts at least one week, or any amount of time if the patient requires hospitalization.[9]

Evaluation

When a patient presents with mania, there should be an extensive evaluation to rule out other differentials. A complete blood count (CBC), complete metabolic panel (CMP), thyroid panel, and a urine drug screen are some of the basic laboratory values needed in assessing a manic patient. Brain imaging in the form of a CT or MRI would be important in determining any organic cause of manic symptoms, especially in elderly or very young patients (>60 or <13 years old).

Treatment / Management

In general, a manic patient should be treated with both a medication that alleviates the acute mania as well as concomitant medication for maintenance stabilization to prevent future mood episodes. 

Mania in bipolar I disorder was first treated with medications such as lithium, valproic acid, and carbamazepine. The treatments were focused on mood stabilizers and anticonvulsants which had shown efficacy in mood stabilization. Today, the class of mood stabilizers subsumes more than just lithium and antiepileptics--it includes many second-generation neuroleptics as well. A large metanalysis of medications used in acute mania showed that atypical antipsychotics were more effective than mood stabilizers for this purpose but not necessarily for maintenance of bipolar disorder. Examples of effective medications are risperidone, olanzapine, and haloperidol. Lithium, quetiapine, and aripiprazole were comparatively effective. Valproic acid, carbamazepine, and ziprasidone were more efficacious than placebo but less so than their previously mentioned competitors. Gabapentin, lamotrigine, and topiramate showed no difference when compared to placebo for treating mania. Clozapine and electroconvulsive therapy have shown many benefits for treatment-resistant mania but are less commonly used. Lastly, psychoeducation and psychotherapy are powerful long-term tools for patients with bipolar disorder as well as for their families or caregivers.

Differential Diagnosis

There are numerous differential diagnoses in the assessment of patients who present with symptoms like mania. Patients can be exhibiting numerous other physiologic and psychiatric disorders. One of the most common situations that may mimic mania is caffeine or other stimulant intoxication, especially cocaine, amphetamine (including methamphetamine), PCP, and nicotine. Hallucinogens can also produce similar symptoms. Excessive steroid and human growth hormone use may lead to aggression, irritability, anxiety and may look very similar to mania. The main mental illnesses which mimic bipolar mania are schizophrenia, severe anxiety, severe obsessive-compulsive disorder, or major depressive disorder with psychotic features. Any mixed mood disorder should be in the differential for bipolar disorder, especially when psychosis is present. Personality disorders such as histrionic and borderline personality can have similar presenting symptoms to phases of bipolar, including mood lability, anger dysregulation, inappropriate and outlandish dress, as well as bizarre behavior. Physiologic conditions that may mimic mania include hyperthyroidism, hypertensive urgency, hypercortisolemia, hyperaldosteronism, masses or tumors in the brain, major neurocognitive disorders, acromegaly, and delirium.

Prognosis

The prognosis of manic patients is favorable, granted they are adherent to medications and therapy. Some factors associated with a poorer outcome are a history of abuse, psychosis, low socioeconomic status, comorbid illness, or young age of onset.

Complications

The sequelae from a manic episode can be detrimental. Those suffering from mania often act with impropriety, ruining reputations and careers. More consequential complications include physical harm to others and self.