Keywords

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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.

  • Abnormally elevated, expansive or irritable mood

  • Inflated self-esteem or grandiosity

  • Decreased need for sleep (tireless insomnia)

  • More talkative than usual or pressure to keep talking

  • Flight of ideas or racing thoughts

  • Distractibility

  • Increase in goal-directed activity or psychomotor agitation

  • Excessive involvement in activities that have a high potential for painful consequences (spending significant amounts of money, sexual risk-taking)

Differential

  • Psychiatric

    • Hypomanic Episode (symptoms must be present for most of the day for 4 days, generally less severe than Manic episode)

    • Generalized Anxiety Disorder

    • Panic Disorder

    • ADHD

    • Personality Disorder with rapid change in mood (E.g. affective instability of Borderline Personality Disorder)

  • Non-psychiatric

    • Substance-induced

      • Prescription medications: psychostimulants, steroids

      • Recreational substances: amphetamine, cocaine, alcohol, phencyclidine

    • Cushing’s Syndrome

    • Multiple Sclerosis

    • Traumatic brain injury

    • Cerebrovascular accident

    • Electrolyte abnormalities

    • Hyperthyroidism

    • Dementia

    • Delirium

    • Akathisia: medication side-effect

Initial Workup

  • HPI:

    • Actual symptoms

    • Precipitating or exacerbating events

    • Duration

    • Timing

    • Severity

    • Be sure to utilize collateral sources of information (family members, friends) if available

  • Suicide Risk (Suicide Risk Assessment, see Chap. 4)

  • Substance use (including caffeine)

  • Current medication list, as well as supplements

  • Past psychiatric and medical history

  • Family psychiatric and medical history

  • Physical Exam:

    • Full system exam including Mental Status Exam

    • Review vital signs

  • Laboratory evaluation should be directed based on history, physical exam, vital signs and differential diagnosis. Common studies to narrow the differential include:

    • TSH

    • CBC

    • BMP

    • Urine toxicology (if the patient is denying substance use but substance use is suspected)

Treatment

  • If the patient is primarily agitated, see “Agitation” for treatment recommendations

  • If the manic symptoms are found to be substance-induced, see corresponding chapters for specific substance treatment recommendations

  • Do not give antidepressants to a patient if there is concern for mania

  • 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.

  • 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

  • Could consider initiation of an antipsychotic that has been found to be helpful for manic phase of bipolar disorder such as olanzapine

Tool

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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)