How do you assess for mania in a psychiatric patient?

Assessment of Mania in Psychiatric Patients

Assess for mania by obtaining a detailed timeline from family members regarding onset of symptoms, sleep patterns, and changes in goal-directed activity, as patients with acute mania typically lack insight into their condition and denial of symptoms is common. 1

Core Diagnostic Approach

Essential Clinical Features to Identify

The three defining symptoms that establish a diagnosis of mania are:

• Elevated, expansive, or irritable mood
• Hyperactivity (increased goal-directed activity)
• Rapid or pressured speech 2

A patient requires at least two of these three core symptoms to meet diagnostic criteria for mania. 2 Grandiosity and flight of ideas are strongly associated with mania but do not contribute to its diagnostic definition. 2

Critical Historical Information

Obtain collateral history from family members focusing on:

• Timeline of symptom onset and progression 1
• Sleep patterns (decreased need for sleep, not just insomnia) 3
• Changes in goal-directed activity and new activities with painful consequences 4
• Baseline personality and recent behavioral changes 1

Family psychiatric history is crucial—specifically assess for bipolar disorder and psychotic mood disorders in first-degree relatives, as this increases diagnostic accuracy. 1

Comprehensive Symptom Assessment

Beyond the three core diagnostic symptoms, evaluate for these additional features reported by historical experts:

• Grandiosity (reported by all historical textbook authors) 4
• Irritability (universal finding) 4
• New activities with painful consequences (universal finding) 4
• Impulsivity and hypersexuality 4
• Mood lability and altered moral standards 4
• Increased humor and hypergraphia 4
• Vigorous physical appearance 4

The Young Mania Rating Scale (YMRS) should be used at each visit to objectively track symptom severity, as parent/family reports are more reliable than patient self-report in manic patients who lack insight. 1

Medical Clearance and Differential Diagnosis

Focused Medical Assessment

History and physical examination have 94% sensitivity for identifying acute medical conditions in psychiatric patients, making them the highest-yield screening tools. 5 The neurologic examination is the most commonly deficient component and must be performed thoroughly. 5

Routine laboratory testing has extremely low yield (0.8-1.8% clinically meaningful results) in alert, cooperative patients with normal vital signs and noncontributory history/physical examination. 5

Selective Laboratory Testing

Order laboratory tests only when indicated by history, physical examination, or specific risk factors:

• Thyroid function tests if history suggests thyroid disease 5
• Urine drug screen only if results will change management 5
• Pregnancy test in females of childbearing age 1

For patients over 65 years, with substance use history, disorientation, or lower socioeconomic status, more extensive testing may be warranted. 5

Distinguishing Delirium from Mania

Delirium presents with impaired attention and waxing/waning course, whereas mania maintains clear sensorium despite behavioral disturbance. 5 Delirium is primarily a disturbance of attention, not memory, and may include tremor, increased muscle tone, visual hallucinations, and impaired speech. 5

Structured Assessment Tools

The Mini International Neuropsychiatric Interview (M.I.N.I.) module for DSM-5 'With Mixed Features' demonstrates good concurrent validity (Cohen's kappa 0.60) with sensitivity of 0.91 and specificity of 0.70 for detecting mixed features in manic episodes. 6

Use standardized rating scales including:

• Young Mania Rating Scale (YMRS) - 11-item scale ranging 0-60 7, 8
• Brief Psychiatric Rating Scale (BPRS) for psychotic features 7
• Clinical Global Impressions (CGI) severity scale 7

Common Pitfalls to Avoid

Do not rely solely on patient self-report, as denial of symptoms is not a contraindication to treatment and patients often present with acute psychosis lacking insight. 1

Avoid missing medical causes by failing to perform thorough neurologic examination—this is the most commonly deficient component of medical screening. 5

Do not order routine laboratory panels in alert patients with normal vital signs and noncontributory examination, as false-positive results are 8 times more common than true-positive results. 5

Recognize that 80% of medical conditions requiring acute treatment should be identified by history and physical examination alone. 5