Abstract
Mania is the pathognomonic feature of Bipolar I Disorder and is characterized by changes in mood, behavior, sleep, energy and cognition. Manic symptoms can cause significant disruption in patients’ lives, including impacting ability to maintain employment and interpersonal relationships. Mania can lead to potentially devastating personal and financial consequences and requires careful evaluation and management.
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Keywords
- Pathognomonic Feature
- Manic Symptoms
- Patient Mania Treatment
- Current Medication List
- Suicide Risk Assessment
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
Introduction
Mania is the pathognomonic feature of Bipolar I Disorder and is characterized by changes in mood, behavior, sleep, energy and cognition. Manic symptoms can cause significant disruption in patients’ lives, including impacting ability to maintain employment and interpersonal relationships. Mania can lead to potentially devastating personal and financial consequences and requires careful evaluation and management.
Signs/Symptoms
The Diagnostic Statistical Manual-5 of the American Psychiatric Association lists the following sign and symptoms , noting that three or more are required for the diagnosis (four are required if the mood is only irritable). The symptoms must be present for most of the day for at least 7 days, or any amount of time if the patient has been psychiatrically hospitalized.
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Abnormally elevated, expansive or irritable mood
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Inflated self-esteem or grandiosity
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Decreased need for sleep (tireless insomnia)
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More talkative than usual or pressure to keep talking
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Flight of ideas or racing thoughts
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Distractibility
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Increase in goal-directed activity or psychomotor agitation
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Excessive involvement in activities that have a high potential for painful consequences (spending significant amounts of money, sexual risk-taking)
Differential
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Psychiatric
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Hypomanic Episode (symptoms must be present for most of the day for 4 days, generally less severe than Manic episode)
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Generalized Anxiety Disorder
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Panic Disorder
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ADHD
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Personality Disorder with rapid change in mood (E.g. affective instability of Borderline Personality Disorder)
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Non-psychiatric
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Substance-induced
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Prescription medications: psychostimulants, steroids
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Recreational substances: amphetamine, cocaine, alcohol, phencyclidine
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Cushing’s Syndrome
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Multiple Sclerosis
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Traumatic brain injury
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Cerebrovascular accident
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Electrolyte abnormalities
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Hyperthyroidism
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Dementia
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Delirium
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Akathisia: medication side-effect
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Initial Workup
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HPI:
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Actual symptoms
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Precipitating or exacerbating events
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Duration
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Timing
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Severity
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Be sure to utilize collateral sources of information (family members, friends) if available
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Suicide Risk (Suicide Risk Assessment, see Chap. 4)
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Substance use (including caffeine)
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Current medication list, as well as supplements
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Past psychiatric and medical history
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Family psychiatric and medical history
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Physical Exam:
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Full system exam including Mental Status Exam
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Review vital signs
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Laboratory evaluation should be directed based on history, physical exam, vital signs and differential diagnosis. Common studies to narrow the differential include:
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TSH
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CBC
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BMP
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Urine toxicology (if the patient is denying substance use but substance use is suspected)
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Treatment
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If the patient is primarily agitated, see “Agitation” for treatment recommendations
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If the manic symptoms are found to be substance-induced, see corresponding chapters for specific substance treatment recommendations
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Do not give antidepressants to a patient if there is concern for mania
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If the patient has a known Bipolar Disorder and is on a medication regimen currently, could give dose of current regimen. There is controversy as to how to discontinue an antidepressant. If the patient is on an antidepressant, it is probably most wise to begin a taper rather than abruptly discontinue. The exception is the self-tapering fluoxetine.
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If the patient is not on a current medication regimen, could consider loading dose of valproic acid (30 mg/kg), especially if the patient is suspected to remain in the emergency environment for a significant period of time
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Could consider initiation of an antipsychotic that has been found to be helpful for manic phase of bipolar disorder such as olanzapine
Tool
Tool #2
Mnemonic Device for Mania
“DIG FAST”
Distractibility and easy frustration
Indiscretion and erratic disinhibited behavior
Grandiosity
Flight of ideas
Activity is significantly increased
Sleep need is decreased (total sleep decreased without daytime fatigue)
Talkativeness is greatly increased (hyperverbal, pressured)
References
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
Kemp DE, Johnson E, Wang WV, Tohen M, Calabrese JR. Clinical utility of early improvement to predict response or remission in acute mania: focus on olanzapine and risperidone. J Clin Psychiatry. 2011;72(9):1236–41.
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Kieltyka, C.A., Nordstrom, K.D. (2018). Mania. In: Nordstrom, K., Wilson, M. (eds) Quick Guide to Psychiatric Emergencies. Springer, Cham. https://doi.org/10.1007/978-3-319-58260-3_9
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DOI: https://doi.org/10.1007/978-3-319-58260-3_9
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