Symptoms of Manic Episodes
Manic episodes are characterized by marked euphoria, grandiosity, and irritability, accompanied by racing thoughts, increased psychomotor activity, mood lability, and marked sleep disturbance as a hallmark sign. 1
Core Mood Symptoms
The primary mood changes in mania include: 1
- Marked euphoria - an abnormally and persistently elevated or expansive mood
- Grandiosity - inflated self-esteem that represents a marked departure from baseline functioning
- Irritability - often more prominent than euphoria, especially in younger patients
These mood changes must represent a significant departure from baseline functioning and be evident across different realms of the person's life. 2
Associated Cognitive and Behavioral Symptoms
Racing thoughts and flight of ideas are characteristic cognitive features. 1 The FDA label for lithium specifically identifies these as typical manic symptoms: pressure of speech, motor hyperactivity, flight of ideas, and poor judgment. 3
Additional symptoms include: 1
- Increased psychomotor activity - excessive energy and goal-directed behavior
- Decreased need for sleep - not just insomnia, but reduced sleep requirement without fatigue
- Mood lability - rapid shifts in emotional state
- Distractibility - attention too easily drawn to irrelevant stimuli
- Poor judgment leading to reckless behavior
- Aggressiveness and possibly hostility 3
Psychotic Features
Paranoia, confusion, and/or florid psychosis may be present in severe cases. 1 One quarter to two-thirds of all manic episodes are associated with delusions, while 13% to 40% involve hallucinations. 4 These psychotic symptoms can be mood-congruent or mood-incongruent. 4
Age-Specific Presentations
Adults
In adults, mania presents as a cyclical disorder with distinct episodes representing clear departures from baseline functioning. 1 Severe cases may progress to catatonia. 1
Adolescents
Mania in adolescents is frequently associated with psychotic symptoms, markedly labile moods, and/or mixed manic and depressive features. 1 The presentation tends to be more chronic and refractory to treatment than adult-onset cases. 1
Children
Juvenile mania, especially in younger children, often presents with symptom patterns that vary from classic adult descriptions. 1 Key differences include: 1
- Markedly labile and erratic mood changes rather than persistent elevation
- Irritability and belligerence more common than euphoria
- High rates of comorbid disruptive behavior disorders
- Rapid cycling patterns
Critical Diagnostic Pitfalls
Manic grandiosity and irritability must present as marked changes in mental and emotional state, not merely reactions to situations or temperamental traits. 2 This distinction is crucial to avoid overdiagnosis, particularly in children.
In very young children (preschoolers), the diagnostic validity of bipolar disorder has not been established, requiring extreme caution. 1 Highly volatile and reactive toddlers require assessment and intervention, but whether they have true bipolar disorder remains unestablished. 1
Mixed Episodes and Complications
Mixed episodes combine manic symptoms with significant depressive features occurring nearly every day for at least one week. 4 These presentations have: 4
- The most prolonged duration of bipolar episodes
- More frequent psychotic features than pure mania
- High suicidality risk - the combination of manic impulsivity with depressive symptoms substantially increases suicide risk 5
- Poor response to treatment
Treatment Implications
For well-defined DSM-IV-TR Bipolar I Disorder with mania, pharmacotherapy is the primary treatment. 1 Standard therapy includes lithium, valproate, and/or atypical antipsychotic agents. 1
FDA-approved first-line options include: 1
- Lithium (approved down to age 12 for acute mania and maintenance)
- Atypical antipsychotics: aripiprazole, valproate, olanzapine, risperidone, quetiapine, and ziprasidone for acute mania 1
When given during a manic episode, lithium may produce normalization of symptomatology within 1 to 3 weeks. 3 Typical manic symptoms that respond include pressure of speech, motor hyperactivity, reduced need for sleep, flight of ideas, grandiosity, elation, poor judgment, aggressiveness, and hostility. 3
Duration and Course
DSM-IV criteria require a distinct period lasting at least one week (or any duration if hospitalization is necessary). 4 Without treatment, mania theoretically resolves within 1-3 months, though psychiatric hospitalization is common in severe cases due to functional impairment. 4