Mania, defined as “a state of heightened overall activation with enhanced affective expression together with lability of affect,” is fundamentally characterized by a pathological elevation of mood. Patients often report a sense of elation, and a euphoric mood has been traditionally associated with mania. However, the heightened mood can also be irritable; indeed, as the mania progresses, not only does irritability – which can eventuate in full-blown rage and dangerous hostility – become more prominent, but the mood is often labile, and patients may switch erratically between euphoria and irritability. Fleeting depressive symptoms may also be observed. The other cardinal features include flight of ideas and pressure of speech; and increased energy, decreased need for sleep, and hyperactivity. In addition, inflated self-esteem or grandiosity is almost always seen, as are distractibility, poor judgement and lack of insight, dishinibition, and “excessive involvement in pleasurable activities that have a high potential for painful consequences,” which can prove disastrous. Their thoughts are, at the least, rapid, and patients may complain of having thoughts that race in a disorganized progression, on pell-mell. When more severe, flight of ideas can degenerate into loosening of associations, wherein the connections between the patient’s successive ideas have no conceivable connection. Patients may also become psychotic.
A manic patient may appear well-groomed but display a dramatic change in appearance (e.g., a drastic change in wardrobe, make-up, or hairstyle; they may be festooned with ribbons and excessive jewelry). The manic will probably be extremely talkative and initially might seem more clever or entertaining; however, conversation eventually becomes tangential with puzzling leaps from one subject to another, and the patient’s speech may become incredibly rapid and almost unstoppable. Often, a manic patient has an inflated sense of self-confidence, to the point of feeling invincible. The patient may take on too many projects without actually bringing any of them close to completion, engage in risky sexual activities, spend too much money, and land into conflict with the law. Upon recovery, patients often feel remorse and shame over what they have done.
For the mood disorders, DSM-IV describes several types of episodes. These episodes are not disorders in themselves, but descriptions of discrete syndromes, which can form the building blocks of actual disorders.
For a Manic Episode, DSM-IV lists the following criteria:
- The symptoms must last for at least one week (or any duration if hospitalization is necessary)
- Three or more of the following symptoms (at least 4 if the mood is only irritable):
- decreased need for sleep
- pressured speech
- racing thoughts or flight of ideas
- increased activity or agitation
- increased engagement in pleasurable but risky activities
- The symptoms cause impairment in social or occupational functioning.
- The symptoms are not secondary (the direct result of a substance or general medical condition)
Mania may occur secondary to a host of general medical or neurological conditions, or as a result of substance abuse or as a side-effect of certain medications. However, it is most commonly associated with bipolar I disorder, a severe mental illness characterized by the occurrence of at least one full manic or mixed-manic episode during the patient's lifetime.
In current DSM-5 nomenclature, although the same diagnostic criteria is used for both hypomanic and full manic episodes, hypomanic episodes are separated from manic ones, which, in turn, are characterized as either mild, moderate, or severe (with or without psychotic features). However, manic episodes may be "staged" as follows: hypomania, or stage I; acute mania, or stage II; and delirious mania, or stage III. This "staging" of a manic episode is very useful from a descriptive and differential diagnostic point of view, in particular allowing for a more thorough consideration of the more extreme manifestations, which in current nomenclature would simply be classed as "severe with psychotic features."
Allied to the "staging" of a manic episode are the cardinal symptoms: heightened mood (either euphoric or irritable); flight of ideas and pressured speech; and increased energy, decreased need for sleep, and hyperactivity. These cardinal symptoms are most plainly evident in hypomania; in stages II and III, however, these symptoms undergo a progressively severe exacerbation and become increasingly obscured by psychotic symptoms and disorganized or fragmented behaviour. However, once the peak of the severity of the individual patient's episode has been reached, patients retrace the symptoms seen in the earlier escalation: thus, a patient whose episode peaked in acute, or stage II, mania would gradually settle back into stage I, or hypomania, before more or less returning to euthymia.