What is a Manic Episode?
A manic episode is an affective disorder characterized by a pathologically elevated mood background and an increase in the volume and pace of physical and mental activity.
The mood of the patient is raised inadequate to the circumstances and can vary from careless gaiety to almost uncontrollable arousal. A rise in mood is accompanied by increased vigor, leading to hyperactivity, excessive volume and speed of speech production, an increase in vital drives (appetite, sex drive), and a reduced need for sleep. Perception disorders may occur. Normal social inhibition is lost, attention is not maintained, there is marked distractibility, high self-esteem, super-optimistic ideas and ideas of greatness are easily expressed. A patient has many plans, but none of them is fully implemented. Criticism is reduced or absent. The patient loses the ability to critically assess his own problems; inadequate actions with negative consequences for social status and material well-being are possible; they can perform extravagant and impractical actions, waste money or be aggressive, amorous, hypersexual, playful in inappropriate circumstances.
In some manic episodes, the patient’s condition can be described as irritated and suspicious, rather than elevated. 86% of patients with bipolar disorder experience mania with psychotic symptoms throughout their lives. At the same time, increased self-esteem and ideas of superiority turn into delusional ideas of grandeur, irritability and suspicion are transformed into delusions of persecution. In severe cases, expansive-paraphrenic experiences of grandeur or delusions about noble origins can occur. As a result, leaps of thought and verbal pressure, the speech of the patient is often incomprehensible to others.
Manic episodes are much less common than depression: according to various sources, their prevalence is 0.5-1%. Separately, it should be noted that a manic episode in cases where one or more affective episodes (depressive, manic or mixed) have already occurred in the past are diagnosed within the framework of bipolar affective disorder and are not considered independently.
Today, quite conventionally, there are three severity of manic disorders:
- Hypomania
- Mania without psychotic symptoms
- Mania with psychotic symptoms
Hypomania is a mild degree of mania. There is a constant light mood elevation (at least for several days), increased vigor and activity, a sense of well-being and physical and mental productivity. Increased sociability, talkativeness, excessive familiarity, increased sexual activity and reduced need for sleep are also often noted. However, they do not lead to serious disruption or social rejection of patients. Instead of the usual euphoric sociability, irritability, increased self-esteem and rude behavior can be observed.
Concentration and attention can be upset, thus reducing the opportunities for both work and leisure. However, such a state does not prevent the emergence of new interests and vigorous activity or a moderate propensity to spend.
Mania without psychotic symptoms is a moderate degree of mania. The mood is raised inadequate circumstances and can vary from careless gaiety to almost uncontrollable arousal. Elevation of mood is accompanied by increased vigor, leading to hyperactivity, speech pressure and reduced need for sleep. Normal social inhibition is lost, attention is not maintained, there is marked distractibility, increased self-esteem, super-optimistic ideas and ideas of greatness are easily expressed.
Perception disorders may occur, such as experiencing color as especially bright (and usually beautiful), concern about the fine details of a surface or texture, subjective hyperacusis. The patient may take extravagant and impractical steps, mindlessly spend money or may become aggressive, amorous, playful in inappropriate circumstances. In some manic episodes, the mood is more irritated and suspicious than upbeat. The first attack occurs more often at the age of 15-30 years, but can be at any age from childhood to 70-80 years.
Mania with psychotic symptoms is a severe degree of mania. The clinical picture corresponds to a more severe form than mania without psychotic symptoms. Increased self-esteem and ideas of greatness can develop into nonsense, and irritability and suspicion – into the delirium of persecution. In severe cases, marked delusions of grandeur or noble descent are noted. As a result, leaps of thought and speech pressure patient’s speech becomes obscure. Heavy and prolonged physical exertion and agitation can lead to aggression or violence. Neglect of food, drink and personal hygiene can lead to a dangerous state of dehydration and neglect. Delusions and hallucinations can be classified as appropriate or inappropriate.
Manic episodes, if not treated, have a duration of 3-6 months with a high probability of relapse (manic episodes recur in 45% of cases). Approximately 80-90% of patients with manic syndromes eventually develop a depressive episode. With timely treatment, the prognosis is quite favorable: 15% of patients recover, 50-60% recover not fully (numerous relapses with good adaptation between episodes), in one third of patients there is a likelihood of the disease becoming chronic with persistent social and labor maladjustment.
Causes of the Manic Episode
The etiology of the disorder is currently not fully understood. According to most neurologists and psychiatrists, genetic factors play the most important role in the occurrence of the disease, this assumption is indicated by the high frequency of the disorder in the families of patients, the increased likelihood of developing the disease with an increase in the degree of kinship, and a 75% chance of developing the disease in monozygous twins. However, the provoking influence of environmental changes is not excluded. Among the possible etiological factors, there are: metabolic disorders of biogenic amines (serotonin, norepinephrine, dopamine), neuroendocrine disorders, sleep disorders (shortened duration, frequent awakenings, disturbed sleep-wake rhythm), and even psychosocial factors.
Symptoms Manic Episode
Criteria for a manic episode:
- high self-esteem a sense of self-worth or grandeur;
- reduced need for sleep;
- increased talkativeness, obsession in conversation;
- jumps of thoughts, feeling of “flight of thought”;
- attention imbalance;
- increased social, sexual activity, psychomotor excitability;
- involvement in risky operations with securities, thoughtlessly large expenditure, etc.
A manic episode may include delirium and hallucinations including
To diagnose mania, you must have at least three of these symptoms, or four, if one of the symptoms is irritability, and the duration of the episode must be at least 2 weeks, but the diagnosis can be made for shorter periods, if the symptoms are unusually severe and come quickly.
Diagnosing Manic Episode
When diagnosing a manic episode, the clinical method is the main one. In it the main place belongs to questioning (clinical interview) and objective observation of the patient’s behavior. With the help of the inquiry, a subjective history is collected and clinical facts that determine the patient’s mental state are identified.
An objective history is collected by examining medical records, as well as from conversations with the patient’s relatives.
The purpose of collecting anamnesis is to obtain data on:
- hereditary mental illness;
- patient’s personality, features of his development, family and social status, transferred exogenous hazards, features of response to various everyday situations, mental trauma;
- features of the patient’s mental state.
When taking a history of a patient with a manic episode, attention should be paid to the presence of such risk factors as:
- episodes of affective disorders in the past;
- affective disorders in family history;
- history of suicide attempts;
- chronic somatic diseases;
- stressful changes in life circumstances;
- alcoholism or drug addiction.
Additional methods of examination include clinical and biochemical blood tests (including glucose, ALT, AST, alkaline phosphatase; thymol test);
Treatment of Manic Episode
Treatment in the manic state is usually stationary, the length of hospital stay depends on the rate of symptom reduction (on average, 2-3 months). Treatment is possible in semi-stationary or outpatient settings.
In the system of therapeutic measures there are three relatively independent stages:
- relief therapy aimed at treating the current condition;
- treatment or stabilizing (supportive) therapy aimed at preventing the exacerbation of a previous condition;
- prophylactic therapy aimed at preventing relapse (recurrence).
At the stage of treatment therapy, lithium salts (lithium carbonate, lithium oxybate), carbamazepine, and valproic acid salts (sodium valproate) are the drugs of choice.
For sleep disorders, hypnotics (hypnotics) are added to nitrazepam, flunitrazepam, temazepam, etc.
In severe psychomotor agitation, aggressiveness, the presence of manic-delusional symptoms, antipsychotics are prescribed (usually haloperidol, which, if necessary, is administered parenterally), the dose of which is gradually reduced to the full extent as the therapeutic effect is achieved. For rapid reduction of psychomotor arousal, zuclopentixol is used. The use of neuroleptics is necessary due to the fact that the effect of mood stabilizers appears only after 7-10 days of treatment. In motor arousal and sleep disorders, neuroleptics with a sedative effect (chlorpromazine, levomepromazine, thioridazine, chlorprothixene, etc.) are used.
In the absence of effect in the first month of treatment, a transition to intensive therapy is needed: alternation of high doses of incisive neuroleptics with sedatives, the addition of parenterally administered anxiolytics (phenazepam, lorazepam). In cases of resistant mania, combination therapy with lithium salts and carbamazepine, lithium salts and clonazepam, lithium salts and valproic acid salts is possible.
At the second stage, the use of lithium salts should continue on average 4-6 months to prevent the exacerbation of the condition. Lithium carbonate or its prolonged forms are used; the concentration of lithium in the plasma is maintained in the range of 0.5-0.8 mmol / l. The question of stopping the therapy with lithium drugs is solved depending on the characteristics of the course of the disease and the need for preventive therapy.
The minimum duration of maintenance therapy is 6 months after the onset of remission. With the abolition of therapy is considered appropriate to slowly reduce the dose of the drug for at least 4 weeks.