Mania and Hypomania

Mania is usually grouped with bipolar disorder as nearly all cases with mania will go on to experience episodes of depression. Bipolar disorder has a point prevalence of 1.3% in the adult population in England and Wales.¹

It is important to obtain a history from relatives or carers, as patients can often exert some control over their symptoms, and appear temporarily better than they actually are.

Also see articles on Bipolar and Manic Depression, Rapid Tranquilisation and Compulsory Hospitalisation.

Mania

Consists of elevated mood, physical and mental over-activity, and self-important ideas.

• Patients usually appear cheerful and euphoric, but may be irritable, which can quickly turn into anger.²
• Insight is often impaired - but again this may change with the patient's mood.
• Speech is rapid and copious ("pressure of speech"); and may rapidly flit from one subject to another ("flight of ideas"). There may be "clang associations" - connections between words dictated by chance similarities in word sounds rather than their meanings (e.g. rhyming or punning).
• Mood may even vary during the day and sleep is often reduced whilst appetite may be increased.
• Sexual desires may be increased, uninhibited, and contraception may be neglected.
• There is increased activity including excessive involvement in pleasurable activities without thought for consequences (e.g. spending spree resulting in excessive debts). Patients can become physically exhausted.
• The self-important ideas may take the form of grandiose delusions and other delusions (such as persecution) may occur, as may hallucinations (e.g. voices).

Hypomania

Is a term used to describe a lesser degree of mania, which involves a persistent mild elevation of mood, alternating with irritability, increased activity and energy, inability to concentrate, flight of ideas, and insomnia; however, without hallucinations or delusions.³

• Hyperthyroidism
• Anorexia nervosa
• Illicit drug use
• Other psychotic disorders, e.g. schizophrenia, schizoaffective disorder, cyclothymia
• Medications, e.g. steroids, isoniazid, L-Dopa, sympathomimetic amines
• Renal failure
• Thyrotoxicosis
• Cerebral insults, e.g. neoplasm, infarcts

ICD-10 requires at least two episodes in which a person's mood and activity levels are significantly disturbed (one of which must be mania or hypomania). In comparison, the DSM-IV requires only one episode and divides bipolar disorder into types I and II.⁴ ICD-10 further divides bipolar disorder into:

• Currently hypomanic
• Currently manic
• Currently depressed
• Mixed disorder
• In remission

Three of the following symptoms confirm mania:

• Grandiosity/inflated self-esteem
• Decreased need for sleep
• Pressured speech
• Flight of ideas (rapidly racing thoughts and frequent changing of their train of thought)
• Distractibility
• Psychomotor agitation
• Excessive involvement in pleasurable activities without thought for consequences (e.g. buying spree resulting in excessive debts)

There may also be psychotic symptoms, e.g. delusions and hallucinations.

The manic episode is mixed if there are associated depressive symptoms.

Patients should be referred for a specialist mental health assessment and development of a care plan, if any of the following are or have been present:

• Episodes of overactive disinhibited behaviour (mania or hypomania) ± episodes of depression lasting > 4 days and not entirely explained by drug misuse
• A history of recurrent depressive episode on three or more occasions in the context of a history of overactive, disinhibited behaviour
• Overactive, disinhibited behaviour and a first period of depression before the age of 25 years

It is essential to refer patients who have a family history of affective disorder, particularly bipolar disorder, or if two or more of the above are present.

Mania accounts for 1 in 7 psychiatric emergencies. It requires urgent control and patients may be violent. Liaise with a consultant psychiatrist - always consider hospital admission (as insight is usually lost) and record assessment of any suicidal ideas.

1. Aims of treatment are to reduce symptoms rapidly and ensure safety of the patient and others. If the patient is violent or poses a danger to self or others then refer urgently for psychiatric assessment and consider use of the Mental Health Act (MHA) if they are unwilling to be admitted voluntarily.
2. Try to convince patients to have oral therapy voluntarily. In A&E, therapy can be given under coercion under Common Law if it is deemed that not doing so would cause harm to the patient or others.
3. If acute control is needed then use one or more of the drugs discussed below. Use oral preparations in preference to IM, as absorption varies and it is therefore difficult to determine response. Rapid tranquilisation (parenteral administration of tranquilising drugs) may be needed - remember, if the patient refuses, you may need to either use Common Law (allows treatment in an emergency) or to use the MHA . Ensure circumstances are well documented, including whether the MHA or Common Law was used.

Drugs Used

• Atypical antipsychotics, e.g. olanzapine, quetiapine, risperidone. These are used as their onset is quicker and they have lower incidence of extra-pyramidal side-effects.
• Benzodiazepines, such as lorazepam, may be needed to aid sleep or reduce agitation.
• Mood stabilisers can also be used (usually under specialist guidance). They include lithium, which has a slower onset of action, so tends only to be used alone if less severe symptoms are present, and valproate (but not in females of child-bearing age).
• Carbamazepine is sometimes used as a first line treatment and again only under specialist supervision.

Rapid tranquilisation

See Rapid Tranquilisation Article.

Discussed more fully in the Bipolar and Manic Depression article: for more detail click here.

Once patient has settled a complete assessment can be made (history, examination and investigations).

• Full history - include illicit drug use and previous episodes. Previous response to therapy if applicable; try to get collateral story.
• Full examination - including BP, neurological examination, and weight measurement.
• Investigations - including FBC, U&E, creatinine, LFT, TFT, CXR and ECG. May need more specific investigations, e.g. MRI scan.
• Also consider toxicology screen and send urine and/or blood as appropriate.

Medications from the acute phase will continue for the short-term and then treatment is altered, e.g. addition of lithium. There has been recent NICE guidance - discussed more fully in bipolar disorder.⁴

Patients may be managed as an out-patient, which may involve shared care between primary and secondary care.