Symptoms of Mania
Mania is characterized by abnormally and persistently elevated, expansive, or irritable mood, accompanied by increased energy, decreased need for sleep, racing thoughts, and impaired judgment, representing a significant departure from baseline functioning and causing marked impairment. 1
Core Clinical Features
- Mood changes - Marked euphoria, grandiosity, and irritability are cardinal symptoms of mania 1
- Increased energy/activity - This is considered the core feature of mania, more so than mood changes 2
- Decreased need for sleep - A hallmark sign that distinguishes mania from other conditions 1, 3
- Racing thoughts - Often accompanied by pressure of speech and flight of ideas 1, 3
- Impaired judgment - Leading to risky behaviors and poor decision-making 3, 4
- Psychomotor agitation - Increased goal-directed activity 1, 5
- Distractibility - Difficulty maintaining attention 1
- Talkativeness - More talkative than usual or pressure to keep talking 1, 6
- Excessive involvement in pleasurable activities with high potential for painful consequences 1
Diagnostic Criteria
For a formal diagnosis of mania, the American Academy of Child and Adolescent Psychiatry requires:
- A distinct period of abnormally and persistently elevated, expansive, or irritable mood with increased activity or energy 1
- Episode lasting at least one week (or any duration if hospitalization is required) 1, 5
- At least three of the symptoms listed above (four if the mood is only irritable) 1
- Symptoms represent a clear change from usual behavior 1
- Symptoms cause marked impairment in functioning 1, 5
Presentation Variations
- In adolescents: Mania frequently presents with psychotic symptoms, markedly labile moods, and/or mixed manic and depressive features 1
- In younger children: Changes in mood, energy levels, and behavior are often more labile and erratic rather than persistent 1
- Irritability and belligerence are more common than euphoria in juvenile presentations 1, 7
- Mixed states: Complex syndrome with both manic and depressive symptoms occurring nearly every day for at least a one-week period 5
- Psychotic features: One quarter to two thirds of all manic episodes are associated with delusions, while 13% to 40% are associated with hallucinations 5
Differential Diagnosis
- ADHD: Can appear similar but represents a distinct condition 1, 7
- Disruptive behavior disorders: May present with irritability and emotional reactivity 1
- Posttraumatic stress disorder: Can mimic manic symptoms 1
- Pervasive developmental disorders: May present with emotional dysregulation 1
- Organic causes: Neurological disorders must be ruled out 1
Clinical Course and Prodromal Symptoms
- Bipolar disorder with manic episodes is cyclical in nature 1
- Common prodromal symptoms of mania include 8:
- Decreased need for sleep
- Increased activities
- Being more sociable
- Racing thoughts
Treatment Approaches
- Lithium is indicated for the treatment of manic episodes and as maintenance therapy to reduce the frequency and intensity of future episodes 3
- When given to a patient experiencing a manic episode, lithium may produce a normalization of symptomatology within 1 to 3 weeks 3
- Current treatments aim to control agitation, impulsivity, aggression, and psychotic symptoms to help patients regain their pre-morbid functionality 5
Clinical Pitfalls to Avoid
- Failing to distinguish between irritable mania and common anger problems 1
- Confusing manic symptoms with those of ADHD 1, 7
- Not recognizing that acute psychosis in an adolescent may be the first presentation of mania 1, 7
- Applying adult diagnostic criteria to children without considering developmental context 1
- Overlooking that most patients show syndromal remission but incomplete functional recovery after the first episode of mania 5