Which behavior would be most characteristic of a patient during a manic episode?

Major Depression

The mainstay of major depressive disorder is a major depressive episode. The DSM-5 provides criteria according to a threshold of symptoms, yet all mood disorders have to be understood as lying on a continuum. Therefore, even individuals who do not meet all criteria have to be carefully followed, and in many cases preventive treatment is warranted.

At least five or more of the following symptoms during the same 2-week period are required: (1) depressed mood most of the day, nearly every day (sadness, feelings of emptiness, and tearfulness); (2) marked diminished interest or pleasure in almost all activities; (3) significant weight loss or weight gain or fluctuations in appetite; (4) insomnia or hypersomnia; (5) psychomotor retardation or agitation nearly every day; (6) fatigue or loss of energy; (7) feelings of worthlessness and/orinappropriate guilt; (8) inability to concentrate, think, and make decisions; and (9) recurrent thoughts of death and/or suicidal ideations. These symptoms (1) cause significant distress or impairment in social, occupational, and/or personal functions and (2) are not due to a general medical condition. In the DSM-5, contrary to previous classifications, bereavement and depression are not mutually exclusive. In fact, bereaved individuals can also develop major depression, which would warrant additional medical treatment (seeTable 1). The following are some forms of manifestations:

Major depressive disorder, single episode: Episodes may occur only one time in life or may occur again years later, usually triggered by major stressful events.

Major depressive disorder, recurrent type: Episodes reoccur at shorter intervals. Often the distance between episodes shortens with advancement in age. The first few episodes are more likely to be triggered by stressful life events, while in time the condition becomes self-maintained and self-triggered.

Depressive disorder with catatonic features (motoric immobility, catalepsy, stupor, extreme opposition, posturing, and echolalia).

Major depression occurring after giving birth may predict further depressive episodes years later. Postpartum depression has also been associated with bipolar disorder.

Depressive disorder can also take a chronic course. Some patients present withmelancholic features (profound loss of pleasure, depression worse in the morning, early morning awakening, severe psychomotor retardation, severe anorexia, and weight loss). Melancholia may be a predictor of relatively good response to medications.Atypical depression features are characterized by inverted functional shift (weight gain and increased appetite, craving for sweets, hypersomnia, leaden paralysis, and long-standing interpersonal rejection sensitivity).Table 2 presents the subtypes (specifiers) of mood disorders according to the DSM-5. These subtypes are encountered both in unipolar and in bipolar mood disorders. Under these new DSM-5 classifications, conditions such as catatonia, seasonal affective disorders (SAD), and atypical depression may occur both in individuals with unipolar disorder and in individuals with bipolar disorders.

Definition of Terms

Manic episode

The main feature of a manic episode is an elevated mood associated with increased energy and physical as well as mental activity. Other features are also part of the clinical picture such as diminished need for sleep, increased libido, and increased risk taking. Delusions and hallucinations can be present in the severe forms of mania.

It must last at least several days to satisfy diagnosis criteria but can last for weeks or even for months before mood and behavior go back to normality. Manic episodes are usually followed by a depressive episode.

About half of BDs start with a manic episode. The peak of onset episode is between 15 and 25 years of age.

Euphoric, or classical, mania refers to a manic episode with elated mood and exaggerated optimism. This is in contrast to dysphoric mania, which manifests itself with inner tension, anxiety, and aggressive verbal and physical behaviors.

Mania

It is widely believed that there is a significant risk that tricyclic antidepressants can precipitate mania or rapid cycling in up to 10% of patients, and that various factors increase this possibility, including being female or younger, having an earlier onset of illness, and having a positive first-degree family history. Biochemical susceptibility factors have been alleged to include patients with a low urinary excretion of the noradrenaline metabolite methoxyhydroxyphenol glycol (MHPG); the risk is possibly greater in patients taking tricyclic antidepressants rather than MAO inhibitors, and particularly in the case of clomipramine. The data on which these conclusions were based have now been rigorously analysed [101] in a review of the controversy surrounding the alternative suggestion that the so-called switch effect is a random manifestation of bipolar illness. There is a paucity of both prospective and long-term placebo-controlled studies, and existing research has suffered from unrepresentative samples and poor definition of manic outcomes. The reviewers concluded that “…some bipolar patients and few, if any, unipolar patients become manic when they are treated with antidepressants. A small number of patients develop rapid cycling.”

This more cautious conclusion is supported by the results of a prospective study of 230 carefully selected patients with recurrent depression (at least two episodes, with an average of six) who took imipramine (200 mg/day) for an average of over 46 weeks [102]. Mania and hypomania were defined and measured by the Raskin rating scale. Only six patients (2.6%) developed hypomania, and four of these did so after withdrawal. Younger patients, women, and those with a previous history of hypomania (bipolar II) were no more likely to switch than unipolar patients.

These results suggest that the risk of mania or hypomania in the long-term treatment of recurrent unipolar depressed patients is relatively small. The 12 placebo-controlled studies of acute treatment in less carefully defined samples support higher incidence rates (around 6–7% for hypomania and 1–2% for mania), but these figures may be inflated owing to the inclusion of bipolar patients with a high risk of a spontaneous switch [101].

Changes in mood

Manic episodes are characterised by an elated mood, described by some as ‘feeling high’. Elation can, of course, be a normal mood state, and in mania is distinguished from normal cheerfulness because it is persistent, out of context and may be extreme.

People experiencing manic episodes are often infectiously happy. However, their mood can be labile, and brief periods of sadness, fearfulness, anger or irritability are common, typically lasting less than a minute and being followed by a rapid return to elation. In some cases, elation does not occur and irritability and anger are the predominant emotions.

Mania

In a double-blind trial, patients with bipolar I disorder were randomized to aripiprazole (n = 175) or haloperidol (n = 172) for an acute manic or mixed episode [26]. At week 12, significantly more patients taking aripiprazole (50%; average daily dose, 22 mg) were in remission compared with those taking haloperidol (28%; average daily dose, 11 mg). Overall, 208 patients (60%) withdrew during the study period (aripiprazole, 49%; haloperidol, 71%). There were extrapyramidal adverse effects in the two groups (aripiprazole, 24%; haloperidol, 63%); mean change in weight from baseline at week 12 was not significantly different in the two groups (aripiprazole + 0.3 kg, haloperidol -0.1 kg); serum prolactin concentrations fell from baseline with aripiprazole (-13 ng/ml) and rose with haloperidol (+ 7.7 ng/ml). Insomnia was more frequent with aripiprazole (14%) than with haloperidol (7.1%). The non-availability of anticholinergic medication specified in the study protocol and the limited dosage range permitted for haloperidol could have affected the results.

Bipolar disorder

Manic episodes are typically characterized by a fairly abrupt decreased need for sleep and decreased total sleep time in a 24-h period.17 There appears to be a bidirectional relationship between mania and insomnia such that insomnia may cause mania, while mania further exacerbates insomnia. Because of this, treatments for mania include early and aggressive treatment of sleep disturbance. During a manic episode, the polysomnogram shows finding similar to that of major depression, with the one potential exception being the significantly truncated total sleep time. Of note, mood stabilizers such as lithium increase slowing sleep, delay REM sleep onset, and suppress total REM sleep.

Clinical presentation

A manic episode is not a disorder in itself, but manic symptoms arise in the context of a bipolar disorder. Bipolar disorder is a severe and chronic mood disorder characterized by alternating mood episodes containing depressive episodes, then manic or hypomanic episodes, with euthymic states of mind with normal functioning in between.

The symptoms of mania include elevated, expansive, or irritable mood, racing thoughts, difficulty maintaining attention, inflated self-esteem, severe sleep disturbances, and often also psychotic features. These manic symptoms have a significant impact on daily life and functioning. During a severe manic episode, the majority of patients lack insight. Some illicit stimulant drugs may induce manic symptoms.

Manic Episode

Manic episodes (MEs) are distinct periods of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) (Box 29–5). If the mood is irritable, four of the following are needed, otherwise three of the following2:

Inflated self-esteem or grandiosity.

Decreased need for sleep (e.g., feels rested after 3 hr of sleep).

More talkative than usual or pressure to keep talking.

Flight of ideas or subjective experience that thoughts are racing.

Distractability (i.e., attention too easily drawn to unimportant or irrelevant external stimuli).

Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.

Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

In MEs, the symptoms do not meet criteria for a mixed episode (defined later). The disturbance is sufficiently severe to cause marked impairment in occupational function or in usual social activities or relationships with others or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. Note that the symptoms noted previously are essentially the same for hypomania episodes (discussed in a later section), BUT in hypomania, there is NO marked impairment, need for hospitalization, or psychotic features.

Drugs for Bipolar Disorder

Manic disorder or bipolar disorder is a unique diagnostic condition. A genetic component is suspected. Bipolar disorder is characterized by mood swings with alternating cycles of depression and mania. Abnormalities on several chromosomes have been demonstrated and there is an increased rate of maternal transmission rate with several of these.

Lithium salts are important for treating mania, but Li+ alone may be inadequate treatment for 50% of patients exhibiting bipolar disorder. In addition to the antimanic effects of Li+, evidence suggests Li+ may also exert neuroprotective actions that may be prophylactic in unipolar and bipolar disorders and possibly in neural degenerative disorders such as Alzheimer disease. Other agents can be used to control manic patients temporarily while Li+ therapy is being instituted and to treat individuals for whom Li+ alone proves ineffective. Typical and atypical antipsychotic drugs are used in most patients during initiation of therapy. More recently, valproate and carbamazepine have been used in the treatment of bipolar disorder.

Clinical manifestations

Bipolar I disorder is defined by at least one full-fledged manic episode and usually depressive episodes. To be “full-fledged,” the manic episode must disrupt normal social and occupational functioning. In general, bipolar disorders start with acute symptoms that are followed by repeated courses of remission and relapse. The remissions are often complete, yet many patients have residual symptoms. Relapses are episodes of severe symptoms. These may be manic, depressive, hypomanic, or mixtures of manic and depressive features. The episodes may last from a few weeks to as long as 6 months, with depressive episodes usually lasting longer than manic episodes. From the start of onset of one episode to the start of onset of the next, cycles vary between patients. Some have infrequent cycles that are low in number over a lifetime. Others have quickly cycling forms, usually more than 4 per year. Only a small number of patients have alternating manic and depressive episodes in each cycle. The majority has one type of cycle that predominates over the other. Some people become severely impaired in their ability to consistently engage in meaningful and productive work. Suicide is a significant problem with bipolar disorders.

Manic episodes involve 1 or more weeks of continually elevated, expansive (extremely emotional), or irritable moods. There is ongoing, increased activity that is focused on goals, plus three or more additional symptoms, which include:

Decreased need for sleep

Distractibility

Excessive actions with a high potential for negative outcomes, such as poor investment decisions, impulsive purchasing, and reckless driving

“Flight” of ideas, or thoughts that seem to be racing

Greater amount of talking than normal

Inflated grandiosity or self-esteem

In a manic phase, the patient may have intense amounts of energy and be excessively and impulsively seeking pleasurable activities of high risk. These can include sexual promiscuity, gambling, excessive impulsive spending sprees, or dangerous sporting activities. A patient’s ability to consider any possible self-harm may be impaired. The symptoms are extremely severe, and normal ability to function at home, at work, or at school is jeopardized. Often, severe financial consequences occur because of these out-of-control behaviors.

The patient is highly excitable, often dresses in clothing of very intense or bright colors (which externalizes such internal excitability) or those that are more flamboyant that normal, and may be very authoritative. Speech patterns become very fast, without stopping. Clang associations may be made, in which words are expressed based on how they sound as opposed to their meaning. For example, someone in the fit of mania may utter a series of rhyming words instead of stringing together a series of words that form a complete thought. Distraction levels are high, with expression of thoughts and words seemingly chaotic and nonsensical. However, many patients say that they feel mentally normal while this is occurring. A person may lack insight into their own behavior and become intrusive upon others without realizing they are being intrusive. If interpersonal friction occurs, the patient may feel as if he or she is being treated badly or persecuted by others. They can become dangerous to those around them and to themselves. The patient may feel as if thoughts are racing. Physicians perceive this as “flights of ideas.” A more severe manifestation is manic psychosis. Psychotic symptoms may appear to resemble schizophrenia. For example, the patient may have severe persecutory or grandiose delusions, and sometimes have hallucinations. An example of a common delusion is the patient believing to be a religious figure, or being monitored by the government. Activity levels are greatly increased, often involving fast body movements, singing, using offensive language, and even screaming. There is increased mood lability, and irritability is usually more pronounced. If delirious mania appears, there will be a total loss of coherence in thoughts and actions.

A hypomanic episode is less extreme, with some amount of mania lasting for 4 or more days. Behaviors are still very different than when the patient is not experiencing an episode, and three or more of the same symptoms of mania must be present. In hypomania, the patient’s mood is more positive. There is a decreased need for sleep and acceleration of psychomotor activities. Sometimes, hypomanic periods help patients to adapt well since there is high energy, confidence, creativity, and social engagement that are higher than normal. Many patients wish to remain in this state of euphoria, as it is self-perceived as a pleasant state of cognitive and behavioral activation. Some can function very well. Most patients do not have any extreme impairment in functioning. For some, however, hypomania results in irritability, distractibility, and mood lability, which may not be well received by others or the patient.

A depressive episode in a bipolar condition has features resembling major depression. Within the same 2-week period, a depressive episode must include five or more of the following, with one feature including depressed mood for most of the day, or loss of interest or pleasure in all or nearly all activities for most of the day:

Diminished ability to think or concentrate, or being indecisive

Fatigue or loss of energy

Feelings of worthlessness or extreme, inappropriate guilt

Insomnia that is often sleep-maintenance insomnia—or hypersomnia

Psychomotor agitation or slowing that can be seen by others, but is not reported by the patient

Recurring thoughts of death or suicide, an actual suicide attempt, or a specific suicide plan

Weight gain or loss of 5% or greater, or changes in appetite

Psychotic features are more common in bipolar depression than they are in unipolar depression.

Mixed features may also occur, in which there are three or more depressive symptoms present for most days of a manic or hypomanic episode. This is often hard to diagnose, and may change into a state that continuously cycles. Prognosis for this is worse than for pure manic or hypomanic states, and risk of suicide is very high.

Significant point

The length and frequency of cycles among manic/hypomanic, depressive, or mixed episodes in bipolar disorder differ between patients. There may be only a few cycles over a lifetime, while the rapid-cycling forms result in more than four episodes per year. Only a few patients experience alterations between mania and depression in each cycle. In most cycles, either mania or depression is the predominant manifestation.