Mania Research Paper

The current psychiatric nomenclature, DSM-IV (American Psychiatric Association 1994), has dropped the term ‘manic-depressive illness’ in favor of bipolar I and bipolar II mood disorders. However, the term ‘manic-depressive illness’ is perhaps more descriptive since mania is usually accompanied by some type of depressive or dysphoric state, and manic episodes are most frequently preceded or followed by depressive episodes.

Although there are descriptions of mania as early as the ancient Greeks, the modern concept of manicdepressive illness emanates from the work of Emil Kraepelin in the late nineteenth century. The excellent review of manic-depressive illness by Goodwin and Jamison (1990) relates the Greek sense of mania as being attributed to an excess of yellow bile. Early scholars involved in the description of mania included Hippocrates, Aristotle, and Soranus of Ephesus. The notion that mania followed depression was perhaps first developed by Aretaeus of Cappadocia in the second century AD (Adams 1856). It is described that Aretaeus identified a bipolar disorder, a unipolar manic disorder, and a paranoid psychosis which might now be called schizoaffective mania. Aretaeus’ descriptions of mania (as cited by Roccatagliata 1986) describe a period of depression followed by patients being gay, laughing, joking, singing, and dancing all day and all night. Assaultiveness during mania was described for the more serious forms and the notion of suspicion and paranoia was identified as part of mania by Aretaeus. Aretaeus apparently believed that mania originated in the heart. Galen of Pergamon, writing in the second century, discussed melancholia (depression) as a chronic and recurrent condition.

Other authors who have discussed the history of the evolvement of mania, such as Jackson (1986), relate that throughout the years mania and depression were considered two separate illnesses but having some close connection between them. These notions persisted into the nineteenth century. Falret (1854) described folie circularie, a circular form of mania and depression. This description is a forerunner of what we now consider a rapid-cycling form of bipolar disorder in which manic and depressive episodes occur multiple times throughout the year.

In contrast to severe mania, a mild state or what we now call hypomania was first defined by Mendel (1881). Others including Falret and Esquirol had also described mild mania. Kahlbaum (1882) described a mild form of mood shifts which is now considered cyclothymia, or a rather stable characteristic of some individuals to have rapidly alternating high and low mood changes.

Kraepelin (1921) in the late nineteenth century introduced the term ‘manic depressive’ and separated individuals with mood disorders from those with schizophrenia. The term ‘manic depressive’ as used by Kraepelin included what we now consider bipolar I disorder (which is mania with and without episodes of depression), bipolar II disorder (which is recurrent depression with preceding or following hypomania), and recurrent major depression (which is now considered unipolar disorder or recurrent major depressive disorder). A major contribution of Kraepelin regarding mania was to give this disorder a name which described the course of illness (manic depressive) as well as to separate this condition from other psychoses, particularly from what is now called schizophrenia.

The Kraepelin view of mania persisted in the nomenclature through about 1980 when there was a movement to change the classification of manicdepressive illness (which included both bipolar and nonbipolar forms) into bipolar and unipolar mood disorders. Prior to 1980 the ‘US–UK Study’ (Kendell et al. 1971) demonstrated that the difference in prevalence rates for schizophrenia between the USA and UK was less likely due to absolute prevalence rate differences than to differences in definition. In this landmark study patients were diagnosed by psychiatrists trained either in the UK or in the USA. Of 11 patients diagnosed as manic by the UK team only one was so diagnosed by the US psychiatrists. Interestingly, the psychoanalytic approach viewed mania as a defense against depression, and schizophrenia was broadly defined. As psychoanalysis took hold in the USA, there was a reduction in research interest in mania or bipolar disorder (in contrast to schizophrenia) as a specific disorder in comparison to Europe. Considering that US psychiatry had a broad notion of schizophrenia and mania was a ‘defense against depression,’ it is no wonder that patients who might have been manic were not so diagnosed by the US-trained psychiatrists. The use of lithium carbonate in psychiatry was an important step in the process to change diagnostic terminology in the USA. Lithium carbonate’s importance relates to its utility as a treatment for bipolar patients rather than for patients with schizophrenia. Thus it became important for psychiatrists in the USA, who heretofore had not diagnosed mania, to be able to classify those patients who might be lithium responsive. The change in diagnostic nomenclature in 1980 forced US clinicians to diagnose mania based on operational criteria for this condition. These operational criteria reflected the work of Clayton et al. (1965), who defined the symptom complex of patients with mania in such a way that reliability for symptoms could be ascertained. This led to a change in diagnostic style from a subjective to a more objective approach (DSM-II to DSM-III). This transition included proposals for symptom-based criteria for mental disorders (Feighner et al. 1972, Spitzer et al. 1978). This systembased approach has continued through DSM-III-R and DSM-IV (American Psychiatric Association 1994).

The other major change in diagnostic criteria for mania has been the acceptance of hypomania as a condition, resulting in the diagnosis of bipolar II disorder. Modern contributions for this area of research are from Dunner et al. (1976) and Akiskal (1981). Bipolar II disorder was included as a separate diagnostic entity in DSM-IV (Dunner 1993), based on clinical, familial, and treatment data separating such patients from bipolar I and unipolar patients. Additionally, the refinement of the concept of cyclothymic disorder as described by Kahlbaum (1882) has led to its inclusion into the DSM system (Howland and Thase 1993). Finally, the concept of a circular form of bipolar disorder resulted in the inclusion of a rapidcycling form of bipolar disorder in DSM-IV. This work emanated from the observations of Stancer et al. (1970) and Dunner and Fieve (1974), with subsequent studies identifying rapid-cycling patients as being somewhat treatment-resistant to lithium, more likely to be women than men, and having a diagnostic relationship to bipolar rather than unipolar disorder (Bauer et al. 1994).

1. The Symptoms of Mania and Hypomania

The classic symptoms of mania are change in mood state to elation or irritability accompanied by symptoms such as grandiosity, decreased need for sleep, racing thoughts, increase in activity, distractibility, impulsive behavior, and increase in energy. The syndrome for bipolar I disorder needs to be psychosocially disruptive and often results in hospitalization. If the patient is not hospitalized, the symptoms need to last at least one week. Psychotic symptoms may be present.

Hypomania has similar symptoms to mania. The condition needs to last at least four days. However, psychosocial disruption is not part of the hypomanic picture, which is usually a productive time. Psychotic symptoms are absent during hypomania. Patients with manic or hypomanic episodes usually experience depressive episodes just prior to or after the mania hypomania. Depressive episodes are defined as two weeks or longer periods of a grouping of symptoms: depressed mood, decreased interest in usual activities, sleep changes (insomnia or hypersomnia), psychomotor change (psychomotor retardation or agitation), appetite change (increase or decrease in appetite weight), loss of energy, difficulty with concentration, psychological symptoms such as guilt, and suicidal ideation.

2. Epidemiology

The population frequency of bipolar I disorder is approximately one percent, that is one percent of individuals in Western countries are likely to experience mania at some point in their life (Kessler et al. 1994). This disorder usually begins sometime after puberty and most individuals who manifest bipolar I disorder become ill by the age of 50. The gender ratio for bipolar I disorder reflects equal rates for men and women.

In contrast bipolar II disorder may be more difficult to diagnose and differentiate from unipolar (major) depression since hypomania is a productive state and often not recognized as ‘illness’ by the patient. The true population prevalence of bipolar II disorder is unknown, although it is generally thought to be somewhat more frequent than bipolar I disorder with perhaps 1–3 percent of the population experiencing lifetime episodes of depression and hypomania. The gender ratio likely reflects more women than men, similar to the ratio found in major depressive disorder, where a 2:1 female to male ratio is found. The age of onset of bipolar II disorder tends to be somewhat later than that for bipolar I disorder with earliest onset in puberty. However later onsets through the fifth and sixth decades are not uncommon.

3. Bipolar–Unipolar Dichotomy

Various proposals have been made regarding the separation of bipolar (depression with mania or hypomania) from unipolar (depression only) patients. The Kraepelin concept of manic depression included both patients with mania and depression, and those with depression only. The bipolar–unipolar concept originated with Leonhard et al. (1962), and was supported by research by Perris (1966) and Angst (1966). These studies showed higher familial rates of mania in relatives of bipolar as compared to relatives of unipolar patients. Further research by Dunner et al. (1976) supported the bipolar–unipolar concept and introduced bipolar II (patients with depression and hypomania) as a distinct subtype. Bipolar II has been included in the most recent diagnostic nomenclature (Dunner 1993).

4. Mixed Mania

Mixed mania refers to a manic condition where depressive symptoms and manic symptoms coexist. Patients with an admixture of manic and depressive symptoms are well described in the article by Baastrup and Schou (1967), and generally are lithium nonresponsive and may require treatment with moodstabilizing anticonvulsants. Mixed mania is also included in the correct nomenclature (DSM-IV), although it is less well researched than typical mania (McElroy et al. 1992).

5. Stage III Mania

The evolution of psychotic symptoms during mania was described by Carlson and Goodwin (1973). They studied a series of 20 patients and described a progression of symptoms and behavior from a mild prodome stage I through a more typical hypomania with grandiosity (stage II) to mania complicated by frank psychotic symptoms (stage III). The issue of diagnosis of such patients had much to do with the broad concept of schizophrenia in the USA at that time and the notion that anyone who exhibited psychotic symptoms was schizophrenic. Thus the idea that untreated manic patients might progress through phases to become psychotic lent some credence to the psychoanalytic notion of mania being a psychological defense against depression, and yet clearly differentiated this condition from chronic schizophrenia, in which affective symptoms were rare. The differential diagnosis, however, between schizoaffective disorder (which is now defined as chronic psychosis with superimposed manic or depressive symptoms) versus psychotic mania was at that time confusing.

6. Secondary Mania

The concept of secondary mania was developed by Krauthammer and Klerman (1978) to describe manic syndromes following or due to exposure to trauma of the nervous system, seizures, medications, drugs, or infectious diseases of the nervous system. This concept has been refined in DSM-IV and classified as ‘mania due to a general medical condition.’

7. Cyclothymic Disorder

The issue of cyclothymia as a disorder versus a personality or Axis II problem is also one that requires more research (Howland and Thase 1993). Indeed, it is difficult to find research on cyclothymic disorder, as patients with this rather stable condition rarely present for treatment. Patients diagnosed as cyclothymic experienced brief hypomanic periods (lasting fewer than four days) and brief mild depressive periods (lasting fewer than two weeks). Within a day, mood alterations from feeling high to feeling low are common. This mood pattern is persistent for two years or more.

8. Rapid Cycling

Rapid cycling is a type of bipolar I or a bipolar II disorder with episodes of mania, hypomania, mixed mania, or depression occurring at least four times a year. This condition was noted to be less responsive to the maintenance treatment effects of lithium carbonate, and thus its distinction as a separate type of bipolar I and bipolar II disorder highlights the difficulty in treatment of this condition for the clinician (Dunner and Fieve 1974). About 15 percent of bipolar I and bipolar II patients experience rapid cycling. The condition may itself be episodic with periods of rapid cycling followed by periods of less frequent mood cycles. Whereas the average frequency of episodes of mania or depression in bipolar I disorder is about four episodes in ten years (Winokur et al. 1969), a tenfold or higher frequency of episodes is found for rapidcycling patients. The gender ratio for rapid cyclers is such that increased rates of women are found to experience increases in frequency of episodes (Bauer et al. 1994). A greater percentage of patients with rapid cycling experience a history of thyroid difficulties than nonrapid-cycling bipolar patients. Treatment of the rapid-cycling condition may require use of multiple mood stabilizers, avoidance of antidepressant medication which may indeed induce cycling in some patients, and longer treatment trials than one might use for nonrapid-cycling patients.

9. Differentiation of Rapid Cycling, Mixed Mania, and Cyclothymic Disorder

Rapid cycling, mixed mania, and cyclothymic disorder are characterized by frequent fluctuations in mood from high to low. Mixed mania is a manic-like episode wherein there are both manic and depressive symptoms present at the same time. It is severe and disabling. Cyclothymic disorder is a rather stable mild condition with very frequent mood shifts from depression to hypomania. Rapid cycling has formed episodes of illness (hypomanic episodes of at least four days and depressive episodes of at least two weeks). In mixed mania and cyclothymic disorder there is often within-a-day cycling, such that the patient will experience rapid changes of high and low moods. Mixed mania is a briefer and a more severe state than one might experience with a patient who is cyclothymic, where the mood shifts are mild, not especially disruptive, and persistent for two years or more.

10. Euphoric s. Irritable Mania

Clinically, two types of mania may be encountered. In one the patient is jovial, elated, euphoric, and funny, and in the second the patient may be irritable, paranoid, and more threatening. However, in both conditions there are frequently mood alterations from depression to irritability to normal mood to elation. Perhaps the hallmark of the mood disorder in mania is its lability.

11. Interpersonal Behavior

Interpersonal effects of mania are described in a classic article by Janowsky et al. (1970), which discusses the effects of manic behavior on others. Often there is a need for discussion among the individuals involved with the treatment of the manic patient so that all have the same approach and are aware of the same information. If not, the manic patient is likely to create a sense of havoc among those trying to give treatment by pointing out discrepancies in the treatment plan.

12. Treatment

Treatment of acute mania has indeed been considerably advanced by the introduction of lithium carbonate. Although acute mania is also well treated with antipsychotic drugs these generally lack the long-term mood-stabilizing effects of lithium. More recently, several anticonvulsants have been shown to have longterm mood-stabilizing effects for bipolar I disorder and it is likely that some of the new generation antipsychotic drugs may also be of benefit in longterm stabilization of this illness.

In contrast, bipolar II disorder is usually viewed as recurrent depression and the hypomania as a time of productivity. Thus individuals with this condition are less likely to ask for treatment for the hypomanic phase, which they view as a productive time of their life. However the approach to treating bipolar II disorder is indeed to prevent the recurrence of hypomania, and by stabilizing the hypomania the tendency to recurrent depressions is also stabilized. It should be noted that the suicide rate in bipolar I and bipolar II patients is considerable, particularly during depressed phases, and that the behavior of bipolar I patients when manic may result in their being hospitalized or jailed because of events related to their hyperactivity, manic grandiosity, and at times grandiose delusions.

Sometimes individuals during a manic syndrome will develop the stage III noted by Carlson and Goodwin (1973) and the psychosis may be mood congruent (delusions consistent with the elation or grandiosity evidenced by the patient, such as a belief that one has special powers). On the other hand, the delusions may be mood incongruent and have little to do with the mood state of the patient (for example, a sense that television programs are shown in order to control their thoughts). The presence of psychosis during mania should lead one to combine treatment with mood stabilizers, antianxiety medication, sedatives, and antipsychotic medication.

13. Summary

The concept of mania has evolved throughout the centuries from a disorder seen as separate to a condition combined with other mood states (manicdepressive illness) to bipolar I and bipolar II disorders. Further changes in the nomenclature to characterize additional subtypes of bipolar I and bipolar II disorders (such as rapid cycling) have added to our ability to develop treatment patterns for specific patients.

Future research is likely to focus on issues related to patients whose mania is mixed, as they present more difficult treatment issues. Additional research is needed for patients whose mania is more likely to be secondary to a history of polysubstance abuse, medical causes, head trauma, or other brain diseases. Furthermore, since the medications which are currently available are not always effective, there needs to be further development of pharmacotherapy both for the treatment of acute mania as well as for the stabilization of depressive episodes in bipolar patients.

Bibliography:

1. Adams F (ed.) 1856 The Extant Works of Aretaeus, the Cappadocian. The Sydenham Society, London
2. Akiskal H S 1981 Subaffective disorders: Dysthymic, cyclothymic and bipolar II disorders in the ‘borderline’ realm. Psychiatric Clinics of North America 4: 25–46
3. American Psychiatric Association 1994 Diagnostic and Statistical Manual of Mental Disorders, 4th edn. (DSM-IV). American Psychiatric Association, Washington, DC
4. Angst J 1966 Zur Atiologie und Nosologie endogener depressiver Psychosen. Springer-Verlag, Berlin
5. Baastrup P C, Schou M 1967 Lithium as a prophylactic agent: Its effect against recurrent depression and manic-depressive psychosis. Archi es of General Psychiatry 16: 162–72
6. Bauer M S, Calabrese J, Dunner D L, Post R, Whybrow P C, Gyulai L, Tay L K et al. 1994 Multisite data reanalysis of the validity of rapid cycling as a course modifier for bipolar disorder in DSM-IV. American Journal of Psychiatry 151: 506–15
7. Carlson G A, Goodwin F K 1973 Stages of mania: Longitudinal analysis of manic episode. Archi es of General Psychiatry 28: 221–8
8. Clayton P J, Pitts Jr. F N, Winokur G 1965 Affective disorder: IV mania. Comprehensi e Psychiatry 6: 313–22
9. Dorland’s Illustrated Medical Dictionary, 28th edn. 1994 W. B. Saunders, Philadelphia, PA
10. Dunner D L 1993 A review of the diagnostic status of ‘Bipolar II’ for the DSM-IV work group on mood disorders. Depression 1: 2–10
11. Dunner D L, Fieve R R 1974 Clinical factors in lithiumcarbonate prophylaxis failure. Archi es of General Psychiatry 30: 229–33
12. Dunner D L, Gershon E S, Goodwin F K 1976 Heritable factors in severity of affective illness. Biological Psychiatry 11: 31–42
13. Falret J 1854 Memoire sur la folie cuculaire, forme de maladie mentale caracterisee par la reproduction successive et regulaire de l’etat maniaque, de l’etat melanchlogue, et d’un intervalle lucide plus ou moins prolonge. Bulletin de l’Academie de Medecine 19: 382–415
14. Feighner J P, Robins E, Guze S B, Woodruff R A, Winokur G, Munoz R 1972 Diagnostic criteria for use in psychiatric research. Archi es of General Psychiatry 26: 57–63
15. Goodwin F K, Jamison K R 1990 Manic-Depressi e Illness. Oxford University Press, New York
16. Howland R H, Thase N E 1993 A comprehensive review of cyclothymic disorder. Journal of Ner ous and Mental Disease 181: 485–93
17. Jackson S W 1986 Melancholia and Depression: From Hippocratic Times to Modern Times. Yale University Press, New Haven, CT
18. Janowsky D S, Leff M, Epstein R 1970 Playing the manic game: Interpersonal maneuvers of the acutely manic patient. Archi es of General Psychiatry 22: 252–61
19. Kahlbaum K L 1882 Uber cyclisches Irresein. Der Irrenfreund 10: 145–57
20. Kendell R E, Cooper J E, Gourlay A J, Copeland J R, Sharpe L, Gurland B J 1971 Diagnostic criteria of American and British psychiatrists. Archi es of General Psychiatry 25: 123–30
21. Kessler R C, McGonagle K A, Zhao S, Nelson C B, Hughes M, Eshelman S, Wittchen H U, Kendler K S 1994 Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the US: Results from the national comorbidity study. Archi es of General Psychiatry 51: 8–19
22. Kraepelin E 1921 Manic Depressi e Insanity and Paranoia [trans. Barclay R E, ed. Robertson G M]. Livingstone, Edinburgh, UK
23. Krauthammer C, Klerman G L 1978 Secondary mania: Manic syndromes associated with antecedent physical illness or drugs. Archi es of General Psychiatry 35: 1333–9
24. Leonhard K, Korf I, Schulz H 1962 Die Temperamente in den Familien der monopolaren und bipolaren phasischen Psychosen. Psychiatrie, Neurologie und Medizinische Psychologie 143: 416–34
25. McElroy S L, Keck Jr P E, Pope H G, Hudson J I, Faedda G l, Swann A C 1992 Clinical and research implications of the diagnosis of dysphoric or mixed mania or hypomania. American Journal of Psychiatry 149: 1633–44
26. Mendel E 1881 Die Manie. Urban and Schwazeberg, Vienna Perris C (ed.) 1966 A study of bipolar (manic-depressive) and unipolar recurrent depressive psychoses. Acta Psychiatrica Scandina ica 194, suppl.: 1–152
27. Roccatagliata G 1986 A History of Ancient Psychiatry. Greenwood Press, New York
28. Spitzer R L, Robins E, Endicott J 1978 Research Diagnostic Criteria (RDC) for a Selected Group of Functional Disorders, 3rd edn. New York State Psychiatric Institute of Biometric Research, New York
29. Stancer H C, Furlong F W, Godse D D 1970 A longitudinal investigation of lithium as a prophylactic agent for recurrent depression. Canadian Journal of Psychiatry–Re ue Canadienne De Psychiatrie 15: 29–40
30. Winokur G W, Clayton P J, Reich T 1969 Manic-depressive Illness. C. V. Mosby, St. Louis, MO