MANIA

MR. SIDAVEERAPPA. B. TUPPAD ASST. PROFESSOR DEPARTMENT OF PSYCHIATRY SIONS BAGALKOT

MANIA DEFINITION
Mania is a type of mood disorder characterized by over-activity, mood change (elevated, expansive and irritable) and self important ideas An alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

 Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition Either primary or secondary in nature
Primary mania: is an affective or mood disorder Secondary mania: occurs secondary to a variety of organic disorders ex: drug intake, infections, neoplasm, epilepsy, or metabolic disturbances

The patient will be excessively happy and energetic Occurs as a part of bipolar disorder, very rarely patients get only recurrent attacks of mania alone without any h/o depressive episodes

 Life time risk of manic episode is about 0.8-1% Tends to occur in episode lasting usually 3-4 months, followed by complete recovery Further episodes can be either manic or depressive

F30-F39 Mood (Affect) disorders

F30F31F32F33F34Manic episode Bipolar affective disorder Depressive episode Recurrent depressive episode Persistent mood disorder
Cyclothymia Dysthymia

ICD-10 CLASSIFICATION OF MANIA

Hypomania Mania without psychotic symptoms Mania with psychotic symptoms Manic episode unspecified
Different forms are:
Hypomania Manic excitement

CLINICAL FEATURES
The following Clinical Features should last for at least one week and cause disruption in occupational and social activities 1. Elevated, Expansive or irritable mood
Four stages of Elevated mood depending on the severity of manic episode;
Stage I: Euphoria: (mild elevation of mood)- increased sense of psychological wellbeing & happiness and not keeping with ongoing events. This is seen in hypomania Stage II: Elation: (moderate elevation of mood)- feeling of confidence and enjoyment along with increased psychomotor activities. This is classical of mania. Stage III: Exaltation: (severe elevation of mood)- intense elation with delusions of grandiosity; seen in severe mania Stage IV: Ecstasy: (very severe elevation of mood) intense sense of rapture or blissfulness; seen in delirious or stuporous mania

 Expansive mood is unceasing and unselective enthusiasm for interacting with people and surrounding environment Irritable mood when the person is stopped from doing what he wants There may be rapid, short-lasting shifts from euphoria to depression or anger

2. Psychomotor activity
Increased Psychomotor activity ranging from
Over activeness and restlessness to manic excitement where the person is on-the-toe-on-the-go (i.e., involved in ceaseless activities) Activities are goal oriented and based on external environmental cues Rarely, a manic patient may go in to stuporous state (manic stupor)

3. Speech and thought

More talkative Describes thought racing in mind Pressure of speech and loud speech Uses Playful language with punning, rhyming, joking and teasing Flight of ideas---- incoherence Prolixity- Less severe and more ordered flight in the absence of pressure of speech Delusions of grandiosity with markedly inflated self-esteem Delusions of persecution (I am great so the people against me ) Hallucinations (auditory and visual) god appeared before me and spoke to me
since these psychotic symptoms are in keeping with the mood state, so these are called as mood congruent psychotic features

Distractibility

4. Goal-directed activity
Person is usually alert, trying to do many things at one time In hypomania ability to function becomes much better and there is a marked increased in productivity and creativity. Many artists and writers have contributed significantly in such periods Decrease in functional ability in later stages Increase in sociability even with previously unknown people. The person becomes impulsive, shows disinhibition, and becomes hypersexual High risk activities like buying sprees, reckless driving, foolish business investments, distributing money and personal articles to unknown persons Dressings :
Gaudy (showy in tasteless way) and Flamboyant cloths, although in severe mania there may be poor self care, Excessive make up and wearing ornaments.

5. Other features
Reduced sleep (< 3Hrs) Increased appetite but later there is usually decreased food intake, due to marked over activity Insight is absent Poor judgment Impairment in occupational functioning

6. Absence of an underlying organic cause

If manic episode is secondary to an organic cause, a diagnosis of organic mood disorder should be made

ETIOLOGY
Currently UNKNOWN however some theories are propounded to explain
Biological theories
Genetic hypothesis
Very important as predisposing factors for mood disorders Life time risk for 10 relatives of pt with BPMD is 25% as compared to general population which is 7% Life time risk for children having one parent mood disorder is 27% and of both parents with mood disorder is 74% Concordance rate for monozygotic twins is 65% & dizygotic twins is 15%

Biochemical theories: imbalance of biogenic amines in the brain

NE and 5-HT are elevated in mania Dopamine, GABA, Acetylcholine are also presumably involved Electrolyte imbalance Error in metabolism results in the transposition of sodium and potassium Biochemical theories remain controversial

 Neuroendocrine theories
Major Neuroendocrine axes of interest in mood disorders are the adrenal (hypersecretion of cortisol), thyroid, and growth hormone axes Other Neuroendocrine abnormalities include decreased nocturnal secretion of melatonin, decreased prolactin release to tryptophan administration, decreased levels of FSH and LH and decreased testosterone levels in men

Psychosocial theories
Psychoanalytic theories (Freud 1957)
Depression results due to loss of loved object and fixation in the oral sadistic phase of development Mania due to denial of depression (mirror image of depression) Faulty dynamics in the family Disturbed ego development gives way to strong Id (uncontrollable impulsive behavior)

MANAGEMENT OF MANIA
HOSPITALIZATION DRUG TREATMENT:
Antipsychotics
Inj: Haloperidol: 5-10mg till pt is sedated or maximum of 50 mg (rapid neuroleptization) and change to Tab: Haloperidol 1.5 10 mg 3 times a day OR Inj:Chlorpromazine 50-100 mg IM to start with followed by Tab:Chlorpromazine 100 200 mg 3 times a day & to be reduced gradually

Lithium: 900 -1200 mg/day Carbamazapine: 600 1800 mg/day Sodium valproate: 600- 2600 mg/day Other drugs:
Clonazepam (BZ) Calcium channel blockers

ECT PSYCHOSOCIAL TREATMENT

Cognitive therapy Supportive psychotherapy Group therapy Family therapy Behavior therapy

NURSING CARE
DIET: for loss of weight and dehydration DRUGS: OTHERS:
Supervision and observation Directions to maintain personal hygiene Emotional needs Maintain low level of stimuli in the patient s environment Remove all dangerous objects Maintain therapeutic environment

NURSING MANAGEMENT OF MANIA

High risk of violence; self-directed or directed to others related to manic excitement, delusional thinking and hallucinations
Pt will not harm self or others

Altered nutrition < body requirements related to refusal or inability to sit still long enough to eat, evidenced by wt loss, amenorrhea
Pt will not exhibit signs and symptoms of malnutrition

 Impaired social interaction related to egocentric & narcissistic behavior, evidenced by inability to develop satisfying relationships and manipulation of others for own desires
Pt will interact with others in an appropriate manner

Self-esteem disturbance related to unmet dependency needs, lack of positive feedbacks, unrealistic self expectations
Pt will have realistic expectations about self

Altered family process related to euphoric mood & grandiose ideas, manipulative behavior, refusal to accept responsibility for own actions
The family members will demonstrate coping ability in dealing with the pt

 Evaluation
Goals of care are achieved or not