Mania is part of the spectrum of affective (or 'mood') disorders seen in psychiatry. It can be considered as being the opposite of depression, with the patient demonstrating a mood that is elated, with overactivity and disinhibition. As with most areas of psychiatry, there is a grading of severity for mania, and this is dictated by the symptoms that the patient exhibits. 'Hypomania' is the term used to describe the milder form of mania that is seen, but the dividing line between mania and hypomania is often arbitrary. Hypomania lasts a shorter time than full-blown mania and is less severe, with no psychotic features and less disability. Hypomania can be distinguished from normal happiness by its persistence, non-reactivity (i.e., not provoked by good news, not affected by bad news) and presence of a slight social disability.
The symptoms of mania are broadly categorised into behavioural, emotional, cognitive and biological symptoms. If the mania is severe enough, it can often develop into a psychosis, with the patient experiencing delusions and hallucinations that cause them lose touch with reality.
Behaviour
Behaviourally, the patient is overactive and easily distracted; they will often be juggling many different projects at the same time, but these will often be left unfinished as new interests catch their imagination. Sometimes the patient is so constantly active and on the go that they become physically exhausted. Patients also become more sociably disinhibited, increasing both social and sexual contact with others. They may dress in brightly coloured and (for women) revealing clothing, though as the illness progresses their appearance often becomes untidy and dishevelled. The patient is often extravagant, spending far more money than they earn on both themselves and others. One family's first realisation of their son's mania was when a bill arrived from a near-by Porsche dealership, where he'd placed four separate orders in the same week. This loss of judgement with regard to social, sexual and financial affairs can be catastrophic; it is not unusual for a manic patient to recover from illness only to find themselves unemployed and friendless with an unplanned pregnancy and deep in debt.
Emotion
Patients have, in contrast to depression, an elevation of mood. The patient seems cheerful and optimistic, and this is often infectious, with others regarding the manic individual as being a great source of fun and frivolity. However, the patient is often very irritable in addition to this euphoria, and they can be quick and easy to displease. They can also be very hostile toward others, particularly if they feel that another person has transgressed against them. There is commonly a lability of mood, and patients can often experience short, intense episodes of depression before once again returning to their euphoric state.
Cognitive
In a period of mania there is an increased speed of thought process. This manifests externally as speech that is loud, pressured, rapid and copious; as the disorder worsens, people will begin to find it hard to follow the patient's train of thought.
The contents of the thoughts are expansive; patients will believe that their ideas are original and brilliant, their opinions important and their work outstanding. Patients become overoptimistic about themselves and their abilities, and it is not uncommon for patients to give up their stable jobs to pursue risky business ideas or to go travelling. These grandiose thoughts can progress to grandiose delusions, where the patient will believe that they are a great religious prophet or state leader. These beliefs can be accompanied by delusions of persecution, where patients believe that others are conspiring against them because of their importance. These delusions are not usually fixed, and the patient can go from believing that he is the Archangel Gabriel to believing that he designed the Concorde within the course of a week.
Biological
Patients usually have an increased appetite, but often lose weight over the course of their illness due to poor self care, reduced food intake and increased activity levels. There is excessive energy and decreased need for sleep, and this is often the first symptom noticed by patient's relatives.
Psychosis
In severe cases of mania, the patient may enter a state of psychosis. In this condition, as well as grandiose delusions and delusions of persecution, they can experience visual and auditory hallucinations such as music and voices. A small sub-set of patients (10-15%) experience schizophrenia-like symptoms (Kurt Schneider's first rank symptoms of schizophrenia).
Variants
- rapid-cycling – the patient swings frequently from depression to mania. This can be anything from once a month to once an hour in its severity.
- mixed affective state – features of mania and depression are seen in the same episode.
- cyclothymia – a personality trait that exhibits spontaneous swings in mood that are not sufficiently severe or persistent enough to warrant another diagnosis.
- drug abuse – acute intoxication with recreational drugs such as amphetamines, MDMA and cocaine can mimic mania.
Bipolar Disorder
While it is theoretically possible that mania can be a unipolar illness (i.e., the patient only experiences mania, never depression), practically all patients who have a bout of mania will eventually go on to experience a bout of depression. For this reason, anyone who experiences an episode of mania is considered to have bipolar disorder (or as it used to be known, manic-depressive illness), even if they've never had a depressive episode.
Bipolar disease has two variants: type I and type II. Patients with bipolar I experience episodes of depression and mania, sometimes with psychosis, in contrast to patients with bipolar II who experience episodes of depression and hypomania. The lifetime risk for bipolar disease lies between 0.3 and 1.5%, and it has an even sex distribution. There is no variation across socio-economic class or race. The mean age of onset is usually 21yrs, though this may be misleading as many patients do not present with their first episode; it is now realised that bipolar disease may be more common in pre-teens and teenagers than previously thought but that it is either not recognised, not reported or it is mistaken for other disorders such as attention deficit hyperactivity disorder (ADHD) or borderline personality disorder.
A lot of the details with regard to bipolar illness are currently unknown. Twin and adoption studies have shown that bipolar disease does have a heavy genetic component, but what this might be is as yet unclear. The neurochemistry of mania is also unknown, but there is a theory that, like schizophrenia, it linked to excessive dopamine activity. However, there is currently little hard evidence to back this up. Most of the theories investigating mood disorders are currently focused on understanding the nature of depression; this may not be such a bad thing. It might be that by working out why a person's mood can go down, we can extrapolate to work out why it can go up.
The average length of a manic episode is around 6 months, with and without treatment. Treatment of a manic episode is a combination of a mood stabiliser (examples include lithium, sodium valproate and carbamazepine) in combination with an anti-psychotic (olanzapine, quetiapine and risperidone). Once the patient has recovered from the manic episode they continue with a maintenance therapy of one or more of the mood stabilisers, occasionally in combination with a low-dose anti-psychotic in order to prevent relapse.
Bipolar illness is chronic, and recurrence is the rule; the long-term prognosis following a manic episode is poor. Less than 20% of those with bipolar I achieve a period of 5 years of clinical stability with good social and occupational performance. Over a 25-year period, the average bipolar patient will experience 10 further episodes of mood disturbance.
References:
- Gelder M, Mayou R, Cowen P, 2001,
Shorter Oxford Textbook of Psychiatry
, 4th edition, Oxford, 277-279
- Wright P, Stern J, Phelan M, 2000,
Core Psychiatry
, 1st edition, W.B. Saunders, 294-298
Okay, from here on in it all gets a bit GTKY. I apologise. While I don't mind other's GTKY, I'm personally happy to keep myself to myself. However, from experience, in psychiatry you can read around a subject as much as you like, but you won't really begin to understand until you read about / see someone's actual experience of mental illness.
I first read about mania in my first year of university. I'd had several episodes of depression by this point, which had started at a relatively young age. My first reaction to reading about mania was 'lucky bastards.' The idea of someone being ill because they were too happy of all things blew my mind and made me incredibly jealous.
And life continued, as it does, until May of 2004. My depression was making another visit, the second since starting university, and I finally caved in. I'd never sought treatment before, but I finally went to my GP to ask for anti-depressants. In retrospect, this was at the same time the best and worst decision of my life. Within two weeks of starting treatment, I was bouncing off the walls. I have no problem explaining this feeling to anyone who's ever dabbled with speed or coke, but explaining it to the more sensible members of society requires a little more effort.
The most obvious problem (to everyone else at least) was that I was talking way too much. I've never been one to keep quiet, but suddenly I was talking constantly, about anything, everything and nothing. A nearly never-ending stream of consciousness. And for those unlucky enough to be subjected to this barrage, there wasn't just quantity, there was volume.
As for what was going in inside of my head... well, it was wonderful. Strange, but wonderful. My brain was always slightly faster than average, but now it was going at speeds that I'd never experienced before; it was like riding a wave of thoughts. I stopped sleeping because there was so much to do all of a sudden. I couldn't sit still, and I mean this both figuratively and literally. Attempting to sit down with my parents for dinner one night nearly resulted in the table being overturned because I was twitching so much.
However, I knew this was all very wrong, and so went back to see my GP two days after all these symptoms made themselves apparent. It is not an uncommon situation for a patient to be flicked into a temporary hypomania after starting anti-depressants; normality is usually restored within a few days of stopping treatment. She stopped my medication and referred me to see a psychiatrist for further treatment of the depression.
This being the NHS, that appointment took a little while to come around. In the meantime I carried on as before; but not quite as before. The feeling of pure energy that I'd experienced before had dissipated, but I certainly wasn't right. The problem with mania is that it can be so insidious in its development. There was a lot going on in the two months before I first saw my shrink. Both my friends and myself had various regional placements for our course, and the end of year exams were closing on us, so no one really noticed that I was slowly going loopy.
The first time I saw my shrink, he came to the conclusion that I had a personality disorder. He found it hard to believe that the person sitting in front him, bouncing up and down in her chair, talking nineteen to the dozen, and frankly obnoxious in character could be anything else. He grudgingly believed my tale of depression (of which there was no evidence) and started me on a low dose mood stabiliser. It was only when I next saw him two months later that the alarm bells began, finally, to ring.
My mania was now obvious to all except myself. I had changed from being a relatively laid-back and easy-going personality to being quick to anger and vicious with it. Everything irritated me, no one could do anything right anymore. My brother got shouted at for putting the milk in the wrong place in the fridge. My mother would receive a barrage of abuse because I perceived that she'd looked at me the wrong way. My father just took to avoiding me completely.
The only person who didn't notice my irritability was me. I felt great. Better than great. It was summer, the sun was out and there was so much to do; how could I not be feeling grand? My social disinhibition is something that I look back on with a fair bit of embarrassment; while I've always been a bit of an unintentional flirt, I suddenly became the scarlet hussy that Jordan only wishes she could be. As for money... I managed to blow £3000 in two months; twice the amount that I'd managed to earn in the same time. If you were to ask me what I'd spent it on, I'd struggle to tell you. A lot of drinking and good times. A motorbike for my brother. An iPod. Books and CDs. A new tattoo and body piercing. God knows. All I do know is that the last two items on that list are a constant reminder of the results of having too much money and not enough sense. Or in my case, no money and even less sense.
I can't remember a lot of last year; most of it's a blur. I don't know if this is a result of the medication that I had to take, or a feature of the mania itself, but I'm glad. I think I did and said a lot of things that I'd rather I didn't remember. I managed to insult a lot of people; I lost one of my best friends because I flirted with her boyfriend. I propositioned my married boss. I was unacceptably over familiar when speaking to my course tutor.
It all came to a head halfway through October. I'd taken a year out to complete a degree in Neuroscience. It of course goes without saying that I was going to get a 1st for this degree. I was the best person on that course; could practically do it with my eyes shut. (I remember, with an inward cringe now, having a conversation with my shrink about how you would diagnose grandiose thoughts in a medical student in the top 15% of her year who plans on training as a neurosurgeon. At the time he just shrugged and moved the conversation elsewhere; not a hard task considering how easily distracted I was. Retrospect gives me the answer: When she believes she can still complete her degree and get a 1st, despite being on medication that makes her sleep for 16 hours a day.
Twenty-twenty hindsight's a bit of a bastard, if you'll pardon my French.)
I'd started hearing music and voices. This is something that I've never told my shrink, though I'm sure he knows. I didn't at the time regard this as being at all unusual. Especially not the music; I've always been able to hear music that wasn't there. As a child, lying in bed, I'd often have to get up in the night and go round the house checking all the radios were off. Again, using that wonderful twenty-twenty hindsight of mine, I can see that this was all an early manifestation of my disease. One example amongst many. And then, a week later, my mind finally broke. I believe I used the term 'riding a wave of thoughts' earlier. To continue the surfing analogy, this would be the point in the game where I wiped out. Up until this point, the thoughts in my head, while extremely fast, had been coherent. Now, suddenly, I'd misplaced my footing and fallen. The thoughts were still coming thick and fast, but I was no longer able to deal with them. Instead of riding them, they were attacking me. I was drowning in them.
This story ends with me phoning my shrink in tears and begging him to make it all stop. The prescription for my anti-psychotics arrived in the post in the next day.