What qualifies as mania with psychosis?

What Qualifies as Mania with Psychosis

Mania with psychosis is diagnosed when a patient meets criteria for a manic episode AND exhibits delusions, hallucinations, or other psychotic symptoms during that episode, with psychotic features occurring in approximately 50% or more of patients with bipolar mania. 1, 2

Core Diagnostic Features

Manic Episode Criteria

The following symptoms must be present for a significant period during at least a 1-month period 3:

• Marked euphoria, grandiosity, and irritability with associated racing thoughts, increased psychomotor activity, and mood lability 1
• Marked sleep disturbance as a hallmark sign 1
• Significant departure from baseline functioning and mental status 1

Psychotic Features That Qualify the Episode

At least two of the following psychotic symptoms must be present 3:

• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms

Only ONE symptom is required if: 3

• Delusions are bizarre, OR
• Hallucinations include a running commentary, OR
• Two or more voices are conversing

Additional Qualifying Features

• Paranoia, confusion, and/or florid psychosis may be present 1
• Symptoms must persist for at least 6 months total, including active phase with or without prodromal/residual phases 3
• Marked deterioration in functioning below the level achieved before onset 3

Age-Specific Presentations

Adolescents

• Mania is frequently associated with psychotic symptoms, markedly labile moods, and/or mixed manic and depressive features 1
• Florid psychosis including hallucinations, delusions, and thought disorder is common 1
• More chronic and refractory to treatment than adult-onset 1

Children

• Symptom presentations vary from classic adult descriptions 1
• Irritability, belligerence, and mixed manic-depressive features are more common than euphoria 1
• Changes in mood, energy, and behavior are markedly labile and erratic rather than persistent 1

Critical Diagnostic Distinctions

Psychotic Mania vs. Schizophrenia

Common pitfall: Psychotic mania has been and continues to be frequently misdiagnosed as schizophrenia 4. Historically, approximately 50% of adolescents with bipolar disorder may be originally misdiagnosed as having schizophrenia 1.

Key differentiators:

• Awareness and level of consciousness remain intact in psychosis, unlike delirium 1, 3
• Bipolar disorder tends to have a cyclical course similar to adult reports 1
• Psychotic features in mania contribute substantially to overall impairment but do not necessarily correlate with mania severity scores 5

Psychotic Mania vs. Psychotic Depression

• Mood-congruent or mood-incongruent psychotic features can occur in both 1
• Family psychiatric history may help differentiate, though increased family history of depression is found in schizophrenic youth 1
• Longitudinal reassessment is essential to ensure diagnostic accuracy 1

Severity and Functional Impact

• Patients with psychotic features have significantly greater overall impairment (lower Global Assessment Scale scores) compared to those without psychotic features 5
• Psychosis factor scores correlate significantly with overall impairment but not specifically with mania severity scores 5
• Psychotic features are associated with a greater number of weeks ill during follow-up 6

Essential Exclusion Criteria

Before diagnosing mania with psychosis, rule out 3:

• Schizoaffective disorder
• Mood disorders with psychotic features as primary diagnosis
• Delirium (symptoms should not be better explained by delirium) 1, 3
• Secondary causes: substance-induced psychoses, medically-induced psychoses 3

Medical Conditions to Exclude 1:

• Seizure disorders
• CNS lesions (brain tumors, congenital malformations, head trauma)
• Toxic encephalopathies (amphetamines, cocaine, hallucinogens, PCP, corticosteroids)
• Infectious diseases (encephalitis, meningitis, HIV-related syndromes)
• Metabolic disorders (endocrinopathies, Wilson's disease)

Treatment Implications

• Treatments that successfully treat mania also reduce psychosis scores 5
• Changes in psychosis factor scores correlate significantly with changes in mania rating scale scores regardless of treatment 5
• For primary psychotic disorders, use mood stabilizers (valproic acid, lithium) combined with atypical antipsychotics (risperidone, aripiprazole) 1, 3
• Atypical antipsychotics are preferred over first-generation antipsychotics due to lower risk of extrapyramidal symptoms 1