Mania & Hypomania

Epidemiology
■Lifetimeprevalence 1%
■No sex difference

■Age: mean 21yrs.

 Mania: Core features
■ Elation of MOOD
■ Increased activity

■ Self importance ideas

Clinical Features
■ MOOD
❑ Elation
■ Cheerful
■ Optimistic
■ Infectious
■ Rarely interrupted by brief episode s of
depression
❑ Irritable late in the course of the episode
Disorders of Emotion
■ Euphoria: Exaggerated feeling of well-being that is
inappropriate to real events. Can occur with drugs such as
opiates, amphetamines, and alcohol.
■ Elevated mood: Air of confidence and enjoyment; a mood
more cheerful than normal but not necessarily pathological.
Occurs in mania & hypomania.
■ Elation: is an extreme degree of happy mood which, like
depression, is coupled with other changes, including increased
feelings of self-confidence and wellbeing, increased activity, and
increased arousal. Occurs in mania when not grounded in
reality.
■ Expansive Mood: expression of euphoria with an
overestimation of self-importance
 Clinical Features
■ Appearance & behavior
❑ Reflects the prevailing mood
❑ Clothes:
■ bright colors, & ill-assorted
■ More severe stages : untidy & disheveled
❑ Overactivity leading to physical exhaustion sometimes
❑ Increased appetite & greedy eating with little attention to
conventional manners
❑ Increased sexual desires & uninhibition
❑ Reduced sleep: wakes up early lively & energetic & noisy
Clinical Features
■ Speech & thoughts
❑ Speech
■ Rapid & copious

■ Flight of ideas in severe cases: rapid change that are difficult to

follow, but when recorded & reviewed found understandable

❑ Thoughts (Expansive Ideas)
■ Ideas are original & important

■ Over-expenditure

■ Reckless decisions about important aspects of life

■ Grandiose delusions

■ Persecutory delusions (less often)

■ Delusion of passivity & reference rarely

Clinical Features
■ Perception
❑ Hallucinations
■ Auditory

■ Consistent with the mood usually (mood-congruent)

Other features
❑ Loss of insight
❑ Can exhibit some control over their symptoms for a short time
Diagnostic Criteria for Manic Episode DSM-5

■ Elevated mood with 3 or more of these 7 for one week

■ The mnemonic: DIGFAST
1. Distractibility

2. Indiscretion : or Inhibition lost

3. Grandiosity

4. Flight of Ideas

5. Activity increased

6. Sleep decreased

7. Talkativeness
 Diagnostic Criteria for Manic Episode DSM-5
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1
week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the
mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet criteria for a mixed episode.
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or
in usual social activities or relationships with others, or to necessitate hospitalization to prevent
harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
 Diagnostic Criteria for Hypomanic Episode (DSM-5)
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is
clearly different from the usual nondepressed mood.
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the
mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the
person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person
when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to
necessitate hospitalization, and there are no psychotic features.
F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or
other treatment) or a general medical condition (e.g., hyperthyroidism).
Diagnostic Criteria for Bipolar I Disorder (DSM-5)
A. Presence of only one manic episode and no
past major depressive episodes.
Note: Recurrence is defined as either a change
in polarity from depression or an interval of at
least 2 months without manic symptoms.
B. The manic episode is not better accounted for
by schizoaffective disorder and is not
superimposed on schizophrenia,
schizophreniform disorder, delusional disorder,
or psychotic disorder not otherwise specified.
 Diagnostic Criteria for Bipolar II Disorder (DSM-5)
A. Presence (or history) of one or more major depressive
episodes.
B. Presence (or history) of at least one hypomanic episode.
C. There has never been a manic episode or a mixed
episode.
D. The mood symptoms in Criteria A and B are not better
accounted for by schizoaffective disorder and are not
superimposed on schizophrenia, schizophreniform disorder,
delusional disorder, or psychotic disorder not otherwise
specified.
E. The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
Criteria for Mixed Episode (DSM-5)
A. The criteria are met both for a manic episode and for a
major depressive episode (except for duration) nearly
every day during at least a 1-week period.
B. The mood disturbance is sufficiently severe to cause
marked impairment in occupational functioning or in usual
social activities or relationships with others, or to
necessitate hospitalization to prevent harm to self or
others, or there are psychotic features.
C. The symptoms are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication,
or other treatment) or a general medical condition (e.g.,
hyperthyroidism).
Etiology
■ Genetic
❑ First degree relatives: 10–15% risks.
❑ Monozygotic twins: 33–90% concordance
❑ Dizygotic twins: 23% concordance.
■ Biochemical
❑ Dysregulation (overactivity) of neurotransmitters at brain
synapses: Noradrenaline (NA), serotonin (5HT) and dopamine
(DA) all have been implicated.
❑ Neuroendocrinal dysfunction (HPA axis): Given the effects of
environmental stressors and exogenous steroids, role has been
suggested for glucocorticoids and other stress related hormonal
responses.
 Etiology: Psychodynamic Factors

■ Defense against underlying depression.

■ Carl Abraham: manic episodes may reflect an inability to tolerate a
developmental tragedy, such as the loss of a parent.
■ The manic state may also result from a tyrannical superego, which
produces intolerable self-criticism that is then replaced by euphoric
self-satisfaction.
■ Bertram Lewin: manic patient's ego as overwhelmed by pleasurable
impulses, such as sex, or by feared impulses, such as aggression.
■ Melanie Klein: Mania is a defensive reaction to depression.
 Bipolar I Disorder, Course

■ most often starts with depression (75 percent of the time in women, 67
percent in men)
■ recurring disorder.
■ Most patients experience both depressive and manic episodes, although
10 to 20 percent experience only manic episodes.
■ The manic episodes typically have a rapid onset (hours or days), but may
evolve over a few weeks.
■ An untreated manic episode lasts about 3 months
■ Of persons who have a single manic episode, 90 percent are likely to have
another.
■ As the disorder progresses, the time between episodes often decreases.
■ After about five episodes, the interepisode interval often stabilizes at 6 to 9
months.
■ four or more episodes per year (rapid cyclers) (5 to 15 percent)
Bipolar I Disorder, Course
Prognosis
■ poorer prognosis than do patients with major depressive
disorder.
■ poor prognostic factors: premorbid poor occupational status,
alcohol dependence, psychotic features, depressive features,
interepisode depressive features, and male gender.
■ Good prognostic factors: short duration of manic episodes,
advanced age of onset, few suicidal thoughts, and few
coexisting psychiatric or medical problems.
■ About 7 percent of patients do not have a recurrence of
symptoms; 45 percent have more than one episode, and 40
percent have a chronic disorder.
■ Patients may have from 2 to 30 manic episodes, although the
mean number is about 9.
TREATMENT
■ Hospitalization
❑ Risk of suicide or homicide,
❑ patient's grossly reduced ability to get food and
shelter,
❑ the need for diagnostic procedures.
❑ History of rapidly progressing symptoms and
the rupture of a patient's usual support
systems
Pharmacotherapy: Acute phase
■ Lithium Carbonate
❑ Prototypical “mood stabilizer”
❑ Because the onset of antimanic action with lithium can be
slow, it usually is supplemented in the early phases of
treatment by atypical antipsychotics, mood-stabilizing
anticonvulsants, or high-potency benzodiazepines
❑ Therapeutic lithium levels are between 0.6 and 1.2 mEq/
L.
❑ The acute use of lithium has been limited in recent years
by its unpredictable efficacy, problematic side effects, and
the need for frequent laboratory tests.
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Pharmacotherapy: Acute phase
■ Valproate: typical dose is 750 to 2,500 mg per day.
■ Carbamazepine: . typical doses to treat acute mania range
between 600 and 1,800 mg per day
■ Clonazepam and Lorazepam
■ high-potency benzodiazepine
■ used in acute mania
■ Both may be effective and are widely used for adjunctive
treatment of acute manic agitation, insomnia, aggression, and
dysphoria, as well as panic attacks.
■ The safety and the benign side effect profile of these agents
render them ideal adjuncts to lithium, carbamazepine, or
valproate.
Pharmacotherapy: Acute phase
■ Atypical and Typical Antipsychotics
■ all of the atypical antipsychotics olanzapine,
risperidone, quetiapine, ziprasidone, and
aripiprazole have demonstrated antimanic efficacy
and are FDA approved for this indication.
■ Compared with older agents, such as haloperidol
(Haldol) and chlorpromazine (Thorazine), they have
a better side effect profile.
■ Some patients, require maintenance treatment with
an antipsychotic medication.
 Treatment of Acute Bipolar Depression
■ The relative usefulness of standard antidepressants in bipolar illness, in
general, and in rapid cycling and mixed states, in particular, remains
controversial because of their propensity to induce cycling, mania, or
hypomania.
■ antidepressant drugs are often enhanced by a mood stabilizer in the first-
line treatment for a first or isolated episode of bipolar depression.
■ A fixed combination of olanzapine and fluoxetine (Symbyax) has been
shown to be effective in treating acute bipolar depression for an 8-week
period without inducing a switch to mania or hypomania.
■ If no response, lamotrigine or low dose ziprasidone (20 to 80 mg per day)
may prove effective.
■ Electroconvulsive therapy may also be useful for bipolar depressed patients
who do not respond to lithium or other mood stabilizers and their adjuncts,
particularly in cases in which intense suicidal tendency presents as a
medical emergency.
Maintenance Treatment of Bipolar Disorder
■ Two goals
❑ Achieve euthymia

❑ Reduce unwanted side effects

■ Lithium (recommended range for maintenance

treatment is 0.4 to 0.8 mEq/L), carbamazepine, and
valproic acid, alone or in combination, are the most
widely used agents in the long-term treatment of
patients who are bipolar.
■ Lamotrigine is also effective in bipolar depression
Thank you