Introduction

Definition of mania

Mania is a mental health symptom characterised by a substantial elevation of mood and euphoria that lasts for a week or more.¹ This increase is rather abnormal and often unnoticeable by the person affected, however, family, friends, and other people around them are able to recognise this drastic change in behaviour. These mood changes are accompanied by feelings of grandiosity and excitement, as well as a tendency to make inappropriate, impulsive decisions and indulge recklessly in pleasurable activities such as gambling.^1,2 Someone with mania may also start to speak rapidly and think of multiple things and ideas at the same time. They also may become easily distracted and irritable¹.

Importance of accurate diagnosis

People with mania present with an array of symptoms that may render diagnosis tricky, as they are hallmarks of other medical conditions.

Mania can be confused for schizophrenia if the patient is experiencing delusions and hallucinations, especially grandiose delusions. It can also be confused with physiological conditions such as hyperthyroidism (abnormal increase in the activity of the thyroid glands) or the presence of tumours or masses in the brain.^1,3

Manic signs are also similar to those seen in patients under the influence of recreational drugs such as amphetamines and cocaine.¹

Proper assessment of the presenting symptoms and utilisation of diagnostic tools and tests allow practitioners to make an accurate diagnosis and provide patients with the right course of treatment and support to alleviate symptoms and prevent or reduce the occurrence of manic episodes.

Mania can be a medical emergency and require prompt admission into hospital, as the patient may be susceptible to harming themselves or others.

Overview of the assessment process

The assessment process usually starts by observing the symptoms upon admission into hospital or examination in an outpatient setting. A detailed account of all signs, their intensity, onset, duration and whether this is the first time they have been experienced or are recurring must all be taken into consideration. An investigation should also be made to establish whether the manic state has been caused by certain triggers or whether it was a result of some medications the patient was taking.

The assessment typically relies on the use of questionnaires filled out by the patient to determine whether what they are experiencing qualifies as mania or is maybe a sign of another condition. A full psychiatric assessment may be undertaken if other mental conditions are suggested.

If a physiologic illness is suspected, specific tests are carried out to confirm this. This could include testing thyroid hormones if hyperthyroidism is suspected or using imaging to detect the presence of any abnormal masses in the brain.

If illicit substances are thought to be the cause of their symptoms, a toxicology screen may be carried out to detect their presence and type in the blood or urine.

Diagnostic criteria

If being treated in the UK, patients will receive questionnaires to fill out when admitted to secondary care following a referral to a psychiatrist by their general practitioner.

Many questionnaires are available for use by specialists and are all developed based on the diagnostic criteria included in the Diagnostic and Statistical Manual of Mental Disorders V (DSM-5) and the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10).

Both of these resources are used worldwide and provide a foundation for assessing and diagnosing mental conditions.

DSM-5 criteria for manic episode

According to the DSM-5 system, a mania diagnosis is made if the patient meets the following criteria:⁴

• The symptoms of elation and irritability have been consistently present throughout a set period of time
• This period would have lasted for a week or more and is observed every day and for the most part of the day

A list of additional symptoms has been devised, of which at least three need to be present, or four if the patient is only irritable. These include symptoms of grandiosity, insomnia, talkativeness, distractibility, flight of ideas and excessive impulses

Differential diagnosis

A differential diagnosis aims to determine the exact presenting complaint associated with the symptoms at hand. Often, a medical history is not enough to deduce whether the patient is in a manic episode or is displaying symptoms of another medical condition.

This process will enable the clinician to exclude diagnoses of conditions such as hypomania, hyperthyroidism, substance-induced mania, and other psychiatric illnesses like schizophrenia.

The healthcare team will make use of different diagnostic tools, which may include comprehensive psychiatric evaluations, blood tests, toxicology screens, and imaging techniques such as magnetic resonance imaging (MRI).

Assessment tools

Structured clinical interviews

SCID (Structured Clinical Interview for DSM Disorders)

SCID was developed according to the criteria of the DSM-5 framework. It is used by clinicians to identify and diagnose mania and other psychiatric conditions.

MINI (Mini International Neuropsychiatric Interview)

M.I.N.I is a quick assessment tool that should not take longer than 15 minutes to complete. It was created as an alternative to traditional tools to allow quick and easy completion by the patient under the supervision of a trained professional.⁵

Self-report questionnaires

Young Mania Rating Scale (YMRS)

The young mania rating scale is a test undertaken by the patient where they report their symptoms throughout the last 48 hours. The test is completed under the supervision of a specialised healthcare professional and may take between 15 to 30 minutes to complete.⁶

The patient is evaluated on 11 items, four of which carry a twofold weight. The final score is used to assess manic symptoms from their first manifestation and their development.⁶

Mood Disorder Questionnaire (MDQ)

The Mood Disorder Questionnaire is another tool utilised by patients to assess their symptoms. It is a straightforward tool where the patient answers with “Yes” or “No” to a set of 13 questions, followed by a question which quantifies the impact of these symptoms on the patient’s daily life.⁷

Observation and behavioural assessment

If mania is suspected, the healthcare team will carry out detailed psychiatric assessment and the patient will be closely monitored, and their symptoms and behaviour constantly assessed.

Additional information 

Family and carers may be consulted when obtaining a medical history and a full account of the patient’s symptoms and their onset and intensity. As previously mentioned, the patient is often unaware of the changes in their mood and behaviour, but this is noticed by those around them.

Physical and laboratory assessments

Comprehensive medical history

The clinician will need to obtain a thorough medical history from either the patient or their carer. This history will encompass all medical conditions the patient has and any treatment received for them. It will also include other medication the patient is taking over the counter and any homoeopathic or herbal supplements that are being used. It also looks at general lifestyle in terms of diet and exercise, and the consumption of tobacco, alcohol or recreational drugs.

Physical examination

This includes conducting basic vital checks for heart rate, blood pressure, respiratory rate and temperature. Reflexes might also be checked to rule out other neurological disorders and the thyroid gland may be palpated to detect any swelling or abnormalities that might suggest hyperthyroidism.

Laboratory tests

In some cases, physical examination and medical history might be inconclusive. In this case, certain laboratory tests or imaging might be requested to confirm a diagnosis. These may include:

• Thyroid function tests: if hyperthyroidism is thought to be the cause of the symptoms, a blood test may be ordered to measure the levels of thyroid-stimulating hormone (TSH), free triiodothyronine (T3) or free thyroxine (T4). In hyperthyroidism, the tests will show a decrease in TSH accompanied by an increase in free T3 and T4⁸
• Drug screening: as discussed previously, exposure to drugs can lead to symptoms similar to those present in mania. The screening can be done by testing the blood, urine or hair follicles. The results will show the presence or absence of drugs, and if found, the type of hallucinogen that has been consumed by the patient
• Neuroimaging: an MRI or a CT scan may be ordered to look for and locate any tumours that may have developed in the brain. This is carried out as often a change in behaviour can be the result of such growths within the brain

Special considerations

Paediatric and adolescent mania

Children and adolescents suspected of being in a manic state require assessment and intensive monitoring by a specialist. In the UK, this is carried out following a referral to Child and Adolescent Mental Health Services (CAMHS), where experts in the area are able to observe their symptoms and advise on the best course of action.³

Manic symptoms in children and adolescents can also be the result of physical or sexual abuse. If this is the case, an investigation might be carried out to ensure the safety and well-being of the child.

Mania in the elderly

Despite its high prevalence, mania in the elderly is poorly documented and research is scarce in this population. Patients might have already suffered from mania in early years of life, or may be presenting with manic symptoms for the first time. Care should be exercised when making an assessment, and a diagnosis needs to take into account other comorbidities and any medication being used by the patient.⁹

Summary

Mania is a medical state of abnormally elevated mood and excitement that may present in similar ways to other mental and physiological conditions.

As with any presenting medical complaint, the key to optimal treatment and recovery is in obtaining an accurate diagnosis. This is done by eliminating the possibility of other diagnoses through the use of different diagnostic tools and approaches.

Once a diagnosis is made, continuous monitoring and follow-up is necessary to ensure the patient is responding to any prescribed treatment or intervention. Early detection and prompt responding to symptoms reduces the risk of relapse and self-harm which is common in patients with mania.