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.

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 to anger²
• Insight is impaired
• 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 vary during the day, sleep is often reduced, and increased activity may lead to physical exhaustion
• Appetite may be increased, and food eaten greedily
• Sexual desires may be increased, uninhibited, and contraception may be neglected
• There may be excessive involvement in pleasurable activities without thought for consequences (e.g. buying spree resulting in excessive debts)
• The self important ideas may take the form of grandiose delusions; 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, insomnia; but without hallucinations or delusions.³

• Hyperthyroidism
• Anorexia nervosa
• Illicit drug use
• Other psychotic disorders e.g. schizophrenia, schizoaffective disorder, cylothymia
• 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 type I and II.⁵ 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.⁶

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 rapidly reduce symptoms 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 if they are unwilling to be admitted voluntarily.
2. Try to convince patients to have oral therapy voluntarily - coercive treatment should only be a last resort. Coercive treatment should only be done as a last resort and in the emergency setting. This should be done under Common Law and documented as such.
3. If need acute control then use one or more of the following drugs discussed below. Use oral preparations in preference to IM as absorption varies therefore difficult to determine response. Rapid tranquilisation (parenteral administration of tranquilizing drugs) may be needed - remember if patient refuses, you may need to either use Common law (allows treatment in an emergency) or to use the mental health act . Ensure circumstances are well documented, including whether MHA or Common law was used.

Drugs Used

• Atypical Antipsychotics - e.g. olanzapine, quetiapine, risperidone. Used as their onset is quicker and they have lower incidence of extra-pyramidal side effects.
• Benzodiazepines may be needed to aid sleep or reduce agitation - eg lorazepam
• Mood stabilizers - usually lithium (slower onset of action so only use alone if less severe symptoms). Valproate is an alternative (not in females of child-bearing age).
• Carbamazepine is sometimes used as a first line treatment and only under specialist supervision.

See related article: Rapid tranquilisation

Rapid Tranquilisation

Discussed more fully in the bipolar disorder article.

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 and E, Creatinine, LFT, TFT, CXR and ECG. May need more specific investigations, e.g. MRI scan.
• Consider toxicology screen

Medications from the acute phase will continue for the short-term and then treatment altered e.g. addition of lithium. There has been recent NICE guidance - discussed more fully in bipolar disorder.⁵

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