Manic Episode

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:

  1. hereditary mental illness;
  2. patient’s personality, features of his development, family and social status, transferred exogenous hazards, features of response to various everyday situations, mental trauma;
  3. 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:

  1. episodes of affective disorders in the past;
  2. affective disorders in family history;
  3. history of suicide attempts;
  4. chronic somatic diseases;
  5. stressful changes in life circumstances;
  6. 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.

Nightmares

Causes of Nightmares

Deeply repressed phobias, complexes, aggression can be expressed in stereotypical horrors in a dream.

Symptoms of Nightmares

Terrible and disturbing, often stereotypically repeated dreams, the contents of which the patient remembers well. It seems the pursuit, the end of the world, the metamorphosis of objects. The patient is afraid to fall asleep, as this dream can see. In children, fragments of images of sleep can intrude into reality.

Diagnostics Nightmares

Dense and anxious dreams, which the patient remembers in great detail. Clinical signs:

  1. Awakening (in the second half of sleep) with detailed and lively reproduction of dreams of bright frightening content.
  2. When you wake up, you quickly reach a normal level of wakefulness and orientation.
  3. Disorders lead to marked distress.

Differential diagnostics

Nightmares may be present in the initial stages of depression, other endogenous psychosis, and chronic pain. Usually the type of dream suggests its symbolic significance.

Nightmare Treatment

Psychotherapy, psychoanalysis, deepening of sleep with antidepressants and tranquilizers, carbamazepine are used.

Hysterical Personality Disorder

Causes of Hysterical Personality Disorder

Disorder, associated with the education of the “idol of the family” type or as a result of cultivating demonstrative traits in families in which parents try to realize their own claims for leadership in children. More common in women.

Symptoms of Hysterical Personality Disorder

Since childhood, there is a desire to be in the center of attention of children and adults, the thirst for praise and evaluation. The refusal of adults to fulfill desires in a child meets a protest reaction with a demonstration of a fall, rolling of eyes, intermittent breathing. Character is marked by demonstrativeness, theatricality, extraverted behavior in excitable, emotional personalities. Patients are not able to maintain deep long-term affection. Characterized by frequent demonstrations of bouts of irritability, tears and accusations, if the person is not the center of attention or does not receive praise or approval. The suggestibility and orientation to authorities are enhanced, the influence of surrounding circumstances or circumstances is easily formed. Excessive physical preoccupation and constant manipulative behavior to meet their needs are typical. Facial expression is characterized by excessive vividness, paramimia are possible, an expansive gesture. Bright colors and extravagance prevail in clothes and cosmetics. The pursuit of occupations that satisfy the need for demonstration. High susceptibility to dissociative disorders, including motor and disorders of consciousness, as well as the use of alcohol and other psychoactive drugs. Many mental phenomena in hysterical individuals resemble paroxysmal, therefore they are close to the epileptic circle.

Diagnosis of Hysterical Personality Disorder

It should be distinguished from organic dissociative disorders characteristic of some endocrine diseases, in particular, thyrotoxicosis and organic disorders as a result of head injuries. These disorders are characterized, in addition to hysterical characteristics, by dysmnesic, dysphoric and asthenic states, as well as by typical data of additional methods of research (neurology, EEG, CT).

Treatment for Hysterical Personality Disorder

Psychoanalysis, focused on clarifying the internal sensations of the patient, pharmacotherapy. Therapy with antiparoxysmal agents, in particular diphenin and carbamazepine.

Stuttering

What is Stuttering?

Characteristic features – frequent repetition or prolongation of sounds, syllables or words; or frequent stops, indecision in speech with violations of its smoothness and rhythmic flow.

Causes of Stuttering

The exact etiological factors are not known. Put forward a number of theories:

  • The theory of “block stuttering” (genetic, psychogenic, semantogennaya). The basis of the theory is cerebral dominance of speech centers with constitutional predisposition to the development of stuttering due to stress factors.
  • Theories of the beginning (include the theory of failure, the theory of needs and the theory of anticipation).
  • The theory of learning is based on an explanation of the principles of the nature of reinforcement.
  • Cybernetic theory (speech is an automatic process of the type of feedback. Stuttering is explained by the breakdown of feedback).
  • Theory of changes in the functional state of the brain. Stuttering is a consequence of incomplete specialization and lateralization of language functions.

Recent studies suggest that stuttering is a genetically inherited neurological disorder.

Prevalence

Stuttering suffers from 5 to 8% of children. The disorder is 3 times more common in boys than in girls. In boys, it is more stable.

Symptoms of Stuttering

Stuttering usually begins before the age of 12 years, in most cases there are two acute periods – between 2-4 and 5-7 years. It usually develops over several weeks or months, starting with repeating the initial consonants or whole words that are the beginning of a sentence. As the disorder progresses, repetitions become more frequent with stuttering on more important words and phrases. Sometimes it may be absent when reading aloud, singing, talking to pets or inanimate objects. The diagnosis is made when the duration of the disorder is at least 3 months.

Clonic-tonic stuttering (disturbed rhythm, tempo, fluency of speech) – in the form of a repetition of initial sounds or syllables (logos), at the beginning of speech clonic convulsions with the transition to tonic.

Tonic-clonic stuttering is characterized by a rhythm disturbance, smoothness of speech in the form of hesitations and stops with frequent vocal enhancement and pronounced breathing disorders associated with speech. There are additional movements in the muscles of the face, neck and limbs.

During stuttering, there are:

  • Phase 1 – preschool period. The disorder appears sporadically with long periods of normal speech. After this period, recovery may occur. During this phase, stuttering occurs when children are agitated, distressed, or when they need to talk a lot.
  • Phase 2 occurs in primary school. The disorder is chronic with very short periods of normal speech. Children are aware and painfully experiencing their disadvantage. Stuttering concerns the main parts of speech – nouns, verbs, adjectives and adverbs.
  • Phase 3 occurs after 8-9 years and lasts until adolescence. Stuttering occurs or increases only in certain situations (call to the board, buying in a store, talking on the phone, etc.). Some words and sounds are more difficult than others.
  • Phase 4 occurs in late adolescence and in adults. Expressed fear of stuttering. Typical are word substitutions and bouts of wordiness. Such children avoid situations that require verbal communication.

The course of stuttering is usually chronic, with periods of partial remission. From 50 to 80% of children with stuttering, especially in mild cases, recover.

Complications of the disorder include a decline in school performance due to shyness, fear of speech disorders; restrictions in the choice of profession. For those suffering from chronic stuttering, frustration, anxiety, and depression are typical.

Diagnosis of Stuttering

Spastic dysphonia is a speech disorder similar to stuttering, but is characterized by the presence of a pathological breathing pattern.

Unclear speech, in contrast to stuttering, is characterized by erratic and disrhythmic speech patterns in the form of quick and sharp flashes of words and phrases. When speech is unclear, there is no awareness of his lack, while those who stutter are acutely aware of their speech disorders.

Stuttering Treatment

Includes several directions. The most typical is distraction, suggestion and relaxation. Stutterers are taught to speak simultaneously with the rhythmic movements of the arms and fingers, or in a slow and monotonous manner. The effect is usually temporary.

Classical psychoanalysis, psychotherapeutic methods are not effective in the treatment of stuttering. Modern methods are based on the point of view that stuttering is a form of learned behavior that is not associated with neurotic manifestations or neurological pathology. Within these approaches, it is recommended to minimize the factors that increase stuttering, reduce secondary disturbances, convince the stutterer to talk, even with stuttering, freely, without constraint and fear, in order to avoid secondary blocks.

An effective method of self-therapy based on the premise that stuttering is a specific behavior that can be changed. This approach includes desensitization, reducing emotional reactions, fear of stuttering. Since stuttering is what a person does, and a person can learn to change what he does.

Drug treatment is of an auxiliary nature and is aimed at alleviating the symptoms of anxiety, expressed fear, depressive manifestations, and facilitating communicative interactions. Soothing, sedative, fortifying agents (valerian, motherwort, aloe vera, multivitamins and B vitamins, magnesium preparations) are applicable. In the presence of spastic forms, antispasmodics are used: mydocalm, sirdalud, myelostane, diafene, amisyl, theofedrin. Tranquilizers are used with caution, mebikar 450-900 mg / day is recommended, with short courses. Significant effect is brought by courses of dehydration.

Alternative options for drug treatment:

  • In the clonic form of stuttering, pantogam is used from 0.25 to 0.75 – 3 g / day., Courses lasting 1-4 months.
  • Carbamazepines (predominantly tegretol, timonyl, or finlepsin retird) with 0.1 g / day. up to 0.4 g / day. within 3-4 weeks, with a gradual reduction of the dose to 0.1 g / day. as a supportive treatment, with a duration of up to 1.5 – 2 months.

Complex treatment of stuttering also includes physiotherapeutic procedures, courses of general and specialized speech therapy massage, speech therapy, psychotherapy using the suggestive method.