Manic Episodes (DSM-IV-R)

DIAGNOSTIC CRITERIA FOR MANIC EPISODE

A Manic Episode is defined by a distinct period during which there is an abnormally and persistently elevated, expansive, and irritable mood.  This period of abnormal mood must last at least 1 week (or less if hospitalization is required).  The mood disturbance must be accompanied by at least three symptoms.

 

  1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week (or any duration if hospitalization is necessary).
  2. 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)
  3. The symptoms do not meet criteria for a Mixed Episode (characterized by the symptoms of both a Manic Episode and Major Depressive Episode)
  4. 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.
  5. 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).

ASSOCIATED FEATURES AND DISORDERS

Individuals with a Manic Episode frequently do not recognize that they are ill and resist efforts to be treated.  They may travel impulsively to other cities, losing contact with relatives and caretakers.  They may change their dress, makeup, or personal appearance to a more sexually suggestive or dramatically flamboyant style that is out of character for them.  They may engage in activities that have a disorganized or bizarre quality (e.g., distributing candy, money, or advice to passing strangers).  Gambling and antisocial behaviors may accompany the Manic Episode.  Ethical concerns may be disregarded every by those who are typically very conscientious.  The person may also be hostile and physically threatening to others.  Some individuals, especially those with psychotic features, may become physically assaultive or suicidal.  Adverse consequences of a Manic Episode (e.g., involuntary hospitalization, difficulties with the law, or serious financial difficulties) often result from poor judgement and hyperactivity.  When no longer in the Manic Episode, most individuals are regretful for behaviors engaged in during the Manic Episode.  Some individuals describe having a much sharper sense of smell, hearing, or vision.

 

Mood may shift rapidly to anger or depression.  Depressive symptoms may last moments, hours, or more rarely, days.  Not uncommonly, the depressive symptoms and manic symptoms occur simultaneously.  If the criteria for both a Major Depressive Episode and a Manic Episode are prominent every day for at least 1 week, the episode is considered a Mixed Episode.

 

ASSOCIATED LABORATORY FINDINGS

No laboratory findings that are diagnostic of a Manic Episode have been identified.  However, a variety of laboratory findings have been noted to be abnormal in groups of individuals with Manic Episodes compared with control subjects.  Laboratory findings in Manic Episodes include polysomnographic abnormalities and increased cortisol secretion.  There may be abnormalities involving the norepinephrine, serotonin, acetylcholine, dopamine, or gamma-amniobutyric acid neurotransmitter systems, as demonstrated by studies of neurotransmitter metabolites, receptor functioning, pharmacological provocation, and neuroendocrine function.

 

SPECIFIC CULTURE, AGE, AND GENDER FEATURES

Cultural considerations that were suggested for Major Depressive Episodes are also relevant to Manic Episodes.  Manic Episodes in adolescents are more likely to include psychotic features and my be associated with school truancy, antisocial behavior, school failure, or substance use.  A significant minority of adolescents appear to have a history of long-standing behavior problems that precede the onset of a frank Manic Episode.  It is unclear whether these problems represent a prolonged prodrome to Bipolar Disorder or an independent disorder.

 

COURSE

The mean age for onset for a first Manic Episode is the early 20s, but some cases start in the adolescence and others start after age 50 years.  Manic Episodes typically begin suddenly, with a rapid escalation of symptoms over a few days.  Frequently, Manic Episodes occur following psychosocial stressors.  The episodes usually last from a few weeks to several months and are briefer and end more abruptly than Major Depressive Episodes.  In many instances (50%-60%), a Major Depressive Episode immediately precedes or immediately follows a Manic Episode, with no intervening period of euthymia.  If the Manic Episode occurs in the postpartum period, there may be an increased risk for recurrence in subsequent postpartum periods and the specifier With Postpartum Onset is applicable.

 

DIFFERENTIAL DIAGNOSIS

A Manic Episode must be distinguished from a Mood Disorder Due to a General Medical Condition.  The appropriate diagnosis would be Mood Disorder Due to a General Medical Condition if the mood disturbance is judged to be the direct physiological consequence of a specific general medical condition.  This determination is based on the history, laboratory findings, or physical examination.  If it si judged that the manic symptoms are not the direct physiological consequence of the general medical condition, then the primary Mood Disorder is recorded.  A late onset of a first Manic Episode (e.g., after age 50 years) should alert the clinician to the possibility of an etiological general medical condition or substance.