What are the signs and symptoms of mania and how is it managed?

Signs and Symptoms of Mania

Mania is characterized by distinct episodes with marked changes in mood, energy, behavior, and sleep that represent a significant departure from an individual's baseline functioning, with increased energy/activity being the core feature rather than mood changes alone. 1, 2

Core Symptoms of Mania

The DSM criteria for mania include the following key symptoms:

Primary Symptoms (at least one must be present)

• Elevated/euphoric mood - Marked euphoria and grandiosity 1
• Irritability - Often more common than euphoria, especially in younger patients 1
• Increased energy/activity - Most correlated with overall severity of manic symptoms 2

Associated Symptoms (at least three additional symptoms if euphoric mood; four if only irritable mood)

• Sleep disturbance - Marked decrease in need for sleep without feeling tired 3, 1
• Racing thoughts/flight of ideas - Rapid shifts in thinking and speech 3
• Pressured speech/talkativeness - More talkative than usual or pressure to keep talking 3, 4
• Distractibility - Attention easily drawn to unimportant stimuli 3
• Increased goal-directed activity - Psychomotor agitation or increased purposeful activity 3, 4
• Grandiosity - Inflated self-esteem or unrealistic beliefs about one's abilities 3, 4
• Risky behavior - Excessive involvement in pleasurable activities with high potential for painful consequences 5

Factor Analysis of Manic Symptoms

Research has identified three clinically meaningful subtypes of mania 6:

1. Irritable Mania - Characterized by irritability, increased motor activity/energy, and disruptive aggressive behavior
2. Elated Mania - Characterized by elevated mood, language abnormalities/thought disorder, increased sexual interest, and poor insight
3. Psychotic Mania - Characterized by abnormalities in thought content, appearance, poor sleep, and speech abnormalities

Diagnostic Considerations

• Manic symptoms must represent a marked change from the individual's baseline functioning 3, 1
• Symptoms must be evident and impairing in different realms of the person's life (not isolated to one setting) 3
• Duration must meet DSM criteria (at least 7 days or requiring hospitalization for mania; at least 4 days for hypomania) 3
• Symptoms must not be attributable to substance use, medication effects, or medical conditions 7

Management of Mania

Pharmacological Treatment

For acute mania in well-defined bipolar I disorder, pharmacotherapy is the primary treatment. 3

First-line medications include:

• Lithium - Approved for acute mania and maintenance therapy (down to age 12) 3
• Valproate - Approved for acute mania in adults 3
• Atypical antipsychotics:
  • Risperidone - Effective in doses of 1-6 mg/day for acute manic or mixed episodes 8
  • Olanzapine - Effective in doses of 5-20 mg/day for acute manic or mixed episodes 9
  • Other options: Aripiprazole, quetiapine, ziprasidone (all FDA-approved for acute mania) 3

Treatment Selection Considerations

Medication choice should be based on 3:

1. Evidence of efficacy
2. Phase of illness
3. Presence of confounding presentations (e.g., rapid cycling, psychotic symptoms)
4. Side effect profile and safety
5. Patient's history of medication response
6. Patient/family preferences

Special Populations

• Adolescents: Similar treatment approach as adults, with lithium approved down to age 12 3
• Children: Caution must be taken when diagnosing bipolar disorder in very young children 3
• Mixed episodes: May require combination therapy 3, 9

Differential Diagnosis

Several conditions can present with manic-like symptoms 7:

• Substance-induced mood disorder (particularly amphetamine or cocaine use)
• Acute schizophrenia
• Medical conditions (e.g., viral encephalitis)
• Medication side effects

Monitoring and Follow-up

• Regular assessment of symptom response
• Monitoring for side effects of medications
• Adjustment of medication dosages as needed
• Long-term maintenance treatment to prevent recurrence

Remember that accurate diagnosis is essential, as misdiagnosis can lead to inappropriate treatment and poorer outcomes 5.