Manic episode (F30). F30 Manic episode Bipolar disorder and depression

• What is a Manic Episode?
• Treatment for a Manic Episode
• Preventing a Manic Episode
• Which doctors should you contact if you are having a manic episode?

What is a Manic Episode?

Manic episode is an affective disorder characterized by pathologically elevated mood levels and an increase in the volume and pace of physical and mental activity.

The patient's mood is elevated inappropriately to the circumstances and can vary from carefree gaiety to almost uncontrollable excitement. Elevated mood is accompanied by increased energy, leading to hyperactivity, excessive volume and speed of speech production, increased vital drives (appetite, sexual desire), and decreased need for sleep. Perceptual disturbances may occur. Normal social inhibition is lost, attention is not maintained, there is marked distractibility, inflated self-esteem, and over-optimistic ideas and ideas of grandeur are easily expressed. The patient has many plans, but none of them are fully realized. Criticism is reduced or absent. The patient loses the ability to critically assess his own problems; possible inappropriate actions With negative consequences for social status and material well-being, may commit extravagant and impractical acts, spend money thoughtlessly, or be aggressive, amorous, hypersexual, or playful in inappropriate circumstances.

During some manic episodes, the patient may be described as irritable and suspicious rather than elated. Mania with psychotic symptoms is experienced by 86% of patients with bipolar disorder during their lifetime. At the same time, increased self-esteem and ideas of superiority turn into delusions of grandeur, irritability and suspicion transform into delusions of persecution. In severe cases, there may be expansive-paraphrenic experiences of greatness or delusional ideas about noble origin. As a result of racing thoughts and verbal pressure, the patient’s speech often turns out to be incomprehensible to others.

Manic episodes are much less common than depression: according to various sources, their prevalence is 0.5-1%. Separately, it should be noted that a manic episode in cases where one or more affective episodes(depressive, manic or mixed) are diagnosed as part of bipolar affective disorder and are not considered independently.

Today, quite conventionally, there are three degrees of severity of manic disorders:

• Hypomania
• Mania without psychotic symptoms
• Mania with psychotic symptoms

Hypomania- this is a mild degree of mania. There is a constant mild uplift in mood (at least for several days), increased energy and activity, a sense of well-being and physical and mental productivity. Also often noted are increased sociability, talkativeness, excessive familiarity, increased sexual activity and a decreased need for sleep. However, they do not lead to serious disruptions in work or social rejection of patients. Instead of the usual euphoric sociability, irritability, increased self-esteem and rude behavior may be observed.

Concentration and attention may be disrupted, thereby reducing the ability to both work and relax. However, this condition does not prevent the emergence of new interests and vigorous activity or a moderate tendency to spend.

Mania without psychotic symptoms- this is a moderate degree of mania. The mood is elevated inappropriately to the circumstances and can vary from carefree gaiety to almost uncontrollable excitement. Elevated mood is accompanied by increased energy, leading to hyperactivity, speech pressure and a decreased need for sleep. Normal social inhibition is lost, attention is not maintained, there is marked distractibility, increased self-esteem, and over-optimistic ideas and ideas of greatness are easily expressed.

Perceptual disturbances may occur, such as experiencing a color as particularly bright (and usually beautiful), preoccupation with small details of a surface or texture, or subjective hyperacusis. The patient may take extravagant and impractical steps, spend money thoughtlessly, or may become aggressive, amorous, or playful in inappropriate circumstances. In some manic episodes, the mood is irritable and suspicious rather than elated. The first attack most often occurs at the age of 15-30 years, but can occur at any age from childhood to 70-80 years.

Mania with psychotic symptoms- this is a severe degree of mania. The clinical picture is consistent with a more severe form of mania without psychotic symptoms. Increased self-esteem and ideas of grandeur can develop into delusions, and irritability and suspicion can develop into persecutory delusions. In severe cases, pronounced delusional ideas of greatness or noble origin are noted. As a result of racing thoughts and speech pressure, the patient’s speech becomes incomprehensible. Heavy and prolonged physical activity and agitation can lead to aggression or violence. Neglect of food, drink and personal hygiene can lead to dangerous condition dehydration and neglect. Delusions and hallucinations can be classified as mood-congruent or mood-incongruent.

Manic episodes, if left untreated, last 3-6 months with a high likelihood of relapse (manic episodes recur in 45% of cases). Approximately 80-90% of patients with manic syndromes develop a depressive episode over time. With timely treatment, the prognosis is quite favorable: 15% of patients recover, 50-60% recover incompletely (numerous relapses with good adaptation in the intervals between episodes), in a third of patients there is a possibility of the disease becoming chronic with persistent social and labor maladjustment.

What triggers a manic episode?

The etiology of the disorder has not yet been fully elucidated. According to the majority of neurologists and psychiatrists, the most important role in the occurrence of the disease is played by genetic factors; this assumption is supported by the high frequency of the disorder in the families of patients, the increase in the probability of developing the disease with increasing degree of relationship, as well as the 75% level of probability of developing the disease in monozygotic twins. However, the provoking influence of changes cannot be excluded environment. Possible etiological factors include: metabolic disorders of biogenic amines (serotonin, norepinephrine, dopamine), neuroendocrine disorders, sleep disorders (reduced duration, frequent awakenings, sleep-wake rhythm disturbances), and even psychosocial factors.

Pathogenesis (What Happens?) During a Manic Episode

Symptoms of a Manic Episode

Criteria for a manic episode:

• inflated self-esteem, a sense of self-importance or grandiosity;
• decreased need for sleep;
• increased talkativeness, obsessiveness in conversation;
• racing thoughts, feeling of “flight of thought”;
• instability of attention;
• increased social, sexual activity, psychomotor excitability;
• involvement in risky transactions with securities, thoughtlessly large expenses, etc.

A manic episode may include delusions and hallucinations, including

To diagnose mania, at least three of these symptoms must be present, or four if one of the symptoms is irritability, and the episode must last for at least 2 weeks, but the diagnosis can be made for shorter periods if the symptoms are unusually severe and they come quickly.

Diagnosis of a Manic Episode

When diagnosing a manic episode, the main thing is clinical method. The main place in it belongs to questioning (clinical interview) and objective observation of the patient’s behavior. Through questioning, a subjective history is collected and clinical facts are identified that determine the patient’s mental state.

An objective history is collected by studying medical records, as well as from conversations with the patient’s relatives.

The purpose of collecting anamnesis is to obtain data about:

1. hereditary burden of mental illness;
2. the patient’s personality, characteristics of his development, family and social status, exogenous harm suffered, characteristics of response to various everyday situations, mental trauma;
3. characteristics of the patient's mental state.

When taking a history of a patient with a manic episode, attention should be paid to the presence of risk factors such as:

1. episodes of mood disorders in the past;
2. family history of affective disorders;
3. history of suicide attempts;
4. chronic somatic diseases;
5. stressful changes in life circumstances;
6. alcoholism or drug addiction.

Additional examination methods include clinical and biochemical blood tests (including glucose, ALT, AST, alkaline phosphatase; thymol test);

Treatment for a Manic Episode

Treatment for a manic state is usually inpatient; the length of hospital stay depends on the speed of symptom reduction (on average 2-3 months). Aftercare is possible in semi-inpatient or outpatient settings.

There are three relatively independent stages in the system of treatment measures:

• relief therapy aimed at treating current state;
• follow-up or stabilizing (maintenance) therapy aimed at preventing exacerbation of a previous condition;
• preventive therapy aimed at preventing relapse (repeated condition).

At the stage of relief therapy, the drugs of choice are lithium salts (lithium carbonate, lithium oxybate), carbamazepine, valproic acid salts (sodium valproate).

In case of sleep disturbance, sleeping pills (hypnotics) are added - nitrazepam, flunitrazepam, temazepam, etc.

In cases of severe psychomotor agitation, aggressiveness, and the presence of manic-delusional symptoms, antipsychotics are prescribed (usually haloperidol, which is administered parenterally if necessary), the dose of which is gradually reduced until complete withdrawal as the therapeutic effect is achieved. To quickly reduce psychomotor agitation, zuclopenthixol is used. The use of antipsychotics is necessary due to the fact that the effect of mood stabilizers appears only after 7-10 days of treatment. For motor agitation and sleep disorders, antipsychotics with a sedative effect (chlorpromazine, levomepromazine, thioridazine, chlorprothixene, etc.) are used.

If there is no effect in the first month of treatment, a transition to intensive therapy is necessary: ​​alternating high doses of incisive antipsychotics with sedatives, adding parenterally administered anxiolytics (phenazepam, lorazepam). In cases of resistant mania, combination therapy with lithium salts and carbamazepine, lithium salts and clonazepam, lithium salts and valproic acid salts is possible.

At the second stage, the use of lithium salts should continue for an average of 4-6 months to prevent exacerbation of the condition. Use lithium carbonate or its prolonged forms; plasma lithium concentration is maintained within 0.5-0.8 mmol/l. The issue of stopping lithium therapy is decided depending on the characteristics of the disease and the need for preventive therapy.

The minimum duration of maintenance therapy is 6 months after the onset of remission. When discontinuing therapy, it is considered advisable to slowly reduce the dose of the drug over at least 4 weeks.

Today, there are three degrees of severity of manic disorders:

Causes

It has not been possible to find out why this disorder occurs, at least to date. According to most psychiatrists and neurologists, genetic factors play a huge role in the occurrence of a manic episode.

But it is also possible that the environment, psychosocial factors, and neuroendocrine disorders can also influence.

Symptoms of a manic episode

How to identify a manic episode? Signs may be as follows:

• Increased self-esteem;
• A person practically does not need sleep;
• Talkativeness;
• Racing thoughts;
• Inattentiveness, easy distractibility;
• Social, sexual activity.

Diagnosis of the disease

Treatment for a manic episode begins with diagnosing the disorder. First of all, this is a clinical method, that is, interviewing the patient, observing behavior.

During communication not only with the patient, but also with relatives, the doctor tries to find out whether relatives had such disorders (that is, confirms or excludes a genetic factor). The doctor also finds out the patient’s personality, asks about the characteristics of his development, family and social status, and how he reacts to various stressful situations. Also important is the fact whether the patient had mental trauma.

If further research is needed to confirm or refute the diagnosis, then

Clinic. The contagiousness of a euphoric mood can sometimes lead an inexperienced clinician to an insufficient perception of the painfulness of the condition, which is more accurately perceived by people close to the patient. An irritable shade of affect often replaces the initial euphoric one during the episode and is especially evident when the patient’s ambitious plans fail. The dysphoric shade of manic affect can take on depressive features, in these cases the episode is usually called a mixed state. Frustration tolerance is reduced, reactions of anger and hostility easily appear. About 75% of patients behave in an aggressive or threatening manner. Orientation, as a rule, is not impaired, but consciousness of the disease is often absent. Increased libido may be accompanied by increased appetite.

Patients can be difficult for others to communicate with, especially in inpatient settings, due to their tendency to challenge the framework of generally accepted norms of behavior and the establishment of a treatment regimen, shift responsibility for their actions to others, take advantage of the weaknesses of others and set them against each other. A tendency to deception and deceit is common. They annoy others with their verbosity and do not like to be interrupted. The speech is replete with jokes, rhymes, puns, which are funny at first. In acute manic agitation, its similarity to acute catatonic excitation in schizophrenia is revealed: loosening of associations, jumping ideas, word salad, neologisms. There is also a common tendency to excessive alcoholism, partly as a means of self-medication, involvement in rampant gambling, phone calls, especially at long range and in the early morning hours, to unusual combinations of bright, extravagant outfits and jewelry. The impulsiveness of actions is combined with the conviction of their expediency.

Delusional symptoms are observed in 75% of patients; ideas of grandeur are considered consonant with the affect; fanciful (and not coinciding with the main affect) hallucinatory-paranoid experiences are less typical, but they do occur. In adolescents, manic episodes are often combined with the so-called. philosophical intoxication, multiple hypochondriacal complaints and antisocial behavior.

Diagnosis

Subtypes of a manic episode are distinguished depending on the severity of the condition and the presence or absence of psychotic symptoms. These conditions are essentially separate stages of the manic disorder continuum. The first stage corresponds to hypomania, which can develop into the second - severe mania, characterized by a greater quantitative intensity of psychomotor and affective disorders; qualitative differences relate to a greater representation of irritability in the general structure of affect, a greater tendency to explosive and aggressive behavior. The less commonly observed third stage is characterized by psychotic symptoms, making it difficult to distinguish from the pictures of any Florida psychosis, including schizophrenia and organic brain damage.

Hypomania (F30.0) is diagnosed based on the condition meeting the following criteria:
1) the mood is elevated or has a hint of irritability to a level that is clearly not characteristic of a premorbid patient for at least 4 days in a row;
2) in the clinical picture, at least 3 of the following signs are noted and disorganize daily activities -

• increased talkativeness,
• decreased concentration, distractibility,
• decreased need for sleep,
• increased libido,
• frivolous and irresponsible behavior, inappropriate purchases,
• increased sociability or excessive gullibility;

3) the episode does not meet the criteria for mania (F30.1,2), bipolar affective disorder (F31), depressive episode (F32), cyclothymia (F34.0) or anorexia nervosa (F50.0);

Mania without psychotic symptoms (F30.1) is diagnosed based on whether the condition meets the following criteria:
1) clearly unusual premorbid premorbid predominant elation, expansiveness or irritability, conspicuous to others and lasting at least 1 week;
2) in the clinical picture, at least 3 (4, if the affect is characterized only by irritability) of the following signs are noted, severely disorganizing daily activities -

• increased activity or motor restlessness,
• verbosity, speech flow,
• leap of ideas,
• loss of normal control social behavior, inappropriate actions,
• decreased need for sleep,
• inflated self-esteem or delusions of grandeur,
• distractibility or constant change of activities and plans,
• reckless or frivolous behavior, the risk of consequences of which is not correctly assessed,
• increased libido or tactless social behavior;

3) absence of delusions or hallucinations, although perception disturbances may be noted (hyperacusis, increased color intensity, etc.);
4) the episode does not meet the criteria for substance abuse (F1) or organic brain damage (F0).

Mania with psychotic symptoms (F30.2) is diagnosed based on the condition meeting the following criteria:

1. the episode corresponds to signs of mania without psychotic symptoms (F30.1), except 3;
2. the episode does not correspond to the signs of schizophrenia (F20.0 - 3) or manic type of schizoaffective disorder (F25.0);
3. The hallucinatory-delusional manifestations that arise often do not correspond to those described in schizophrenia (they are not absurd, culturally inadequate, the “voices” are not in the form of comments, where the patient is spoken of in the 3rd person);
4. the episode does not meet the criteria for substance abuse (F1) or organic brain damage (F0).

Differential diagnosis. Difficulties in differential diagnosis arise in the presence of mixed affect and in the assessment of behavioral abnormalities. It is necessary to differentiate manic states from a number of personality disorders (hyperthymic, cycloid, hysteroid types). There are well-known difficulties in differentiating a manic episode with psychotic symptoms from a Florida episode of schizophrenia. The following can help in diagnosing a manic state: the contagiousness and syntony of manic affect, data on the hereditary burden of MDP and typical manic episodes in the anamnesis, the absence of manifestation of schizophrenic symptoms simultaneously with manic ones, a combination of increased affect, rapid speech and hyperactivity, the rapid onset of manic manifestations. When examining a depressed patient with catatonic motor disorders, one should look for evidence of a history of affective pathology and a hereditary predisposition to MDP. Sometimes the clinician has no other choice but to simply wait for the further development of the disorder.

(abbr. bipolar disorder) is a mental illness in the group of so-called affective disorders. Affective disorders (associated with emotions, affects) are characterized by frequent mood swings - from depression to euphoria (mania) and vice versa. Episodes are cyclical and often have periods of remission. “Phases” can last from several weeks to two to three years, periods of remission from five to seven years, and in severe cases they may even be absent.

Women usually suffer more than men. This may be partly due to the fact that they are more likely to seek help and, accordingly, more women are diagnosed. According to statistics, as of 2016, approximately 40 million people suffer from bipolar disorder worldwide, with 55% being women and 45% being men.

How to recognize bipolar disorder?

Recognizing the symptoms of bipolar disorder is the first step to treating manic and depressive episodes.

Everyone experiences ups and downs in their lives, but for people with bipolar disorder, these mood ups and downs are dramatic and affect sleep, alertness, social functioning, judgment, habitual behavior, and the ability to think clearly.

People aged 25 to 44 years are most often affected, but the disease can also appear in adolescence and less commonly in children.

Symptoms of mania

During the period of mania, a person has a lot of energy, is in a good mood, regardless of whether there is a reason for it, has a very optimistic attitude and increased self-esteem, is confident that he can cope with all or many difficulties at the same time, thinks that he is very gifted, that has many abilities and skills, and often begins to take risks and participate in events for which he does not have the resources.

To detect a manic episode of bipolar disorder, 3 or more of the following symptoms must be present:

• Fast and chaotic speech
• Increased self-esteem or grandeur, feeling of euphoria
• High energy and being more active than usual
• Decreased need for sleep or trouble sleeping
• Irritability, hyperactivity, frequent aggression and anger, provocative and obsessive behavior
• Poor concentration and lack of common sense
• Risk taking (risky/reckless sexual behavior, spending money, etc.)

Unfortunately, the symptoms of bipolar disorder are often not recognized in time either by the patient’s relatives or by the patient himself. People in a manic episode may irritate their loved ones, but they attribute their behavior not to the illness, but to bad character traits.

During the period of mania, they are very prone to taking unnecessary risks, such as spontaneous family and child planning or taking out loans for large-scale purchases, reckless actions due to excessive self-confidence and much more.

Typically, patients do not notice changes in their behavior, do not seek medical help or refuse it because they consider it inappropriate. During this period, they experience euphoria and good health and do not understand the need for treatment. Episodes of mania can lead to rash and disastrous decisions for the future. This is why early recognition of symptoms and prompt treatment of the episode and the disease in general is important to prevent the next one.

Symptoms of a depressive episode

Depression is a state of low mood commonly found in people with bipolar disorder. A depressed person is unmotivated, has no desire to work or have fun, and lacks energy.

If you think you or a loved one has signs and symptoms of mania or depression, consult your doctor. It is possible that a patient with this condition is reluctant to seek help, unable to recognize the devastating impact of the disease on his life, especially if he is experiencing a euphoric episode. It is important to seek help to cope with emotional extremes.

How is bipolar disorder treated?

Drug treatment and psychotherapy are the most common treatments for this disease. They are very effective, especially if followed correctly and consistently. Bipolar disorder is relatively easy to recognize by psychiatrists. There are effective and safe medications to treat its episodes.

To some extent, additional beneficial effects of up/down deviations can be achieved through psychotherapy, more exercise, and dietary changes, but it is important to know that this condition occurs due to abnormal brain chemistry and drug therapy is necessary.

A personalized approach based on a pharmacogenetic test is especially helpful in choosing the right drug treatment. Pharmacogenetic testing can also provide information about the mechanisms of action of drugs in relation to each patient's genetic profile, allowing the best treatment for bipolar disorder to be selected, reducing the trial-and-error process.

Recognizing the symptoms of the disease, seeking qualified help, prescribing therapy based on individual biological characteristics, and following the prescribed treatment plan from a psychiatrist can all help stabilize the patient's condition and make a positive contribution to the patient's overall well-being and life satisfaction.

Publication date August 9, 2018Updated October 25, 2019

Definition of disease. Causes of the disease

Mania, also known as manic syndrome, is a state of abnormally elevated levels of arousal, affect, and energy, or “a state of increased general activation with heightened affective expression together with lability (instability) of affect.” Mania is often considered a mirror image: while depression is characterized by melancholy and psychomotor retardation, mania involves an elevated mood, which can be euphoric or irritable. As mania worsens, irritability may become more severe and lead to violence or anxiety.

Mania is a syndrome caused by several causes. Although the vast majority of cases occur in the context of manic disorder, the syndrome is a key component of other mental disorders (such as schizoaffective disorder). It can also be secondary to various general diseases (for example, multiple sclerosis). Mania can be caused by certain medications (for example, Prednisolone) or substance abuse (cocaine) and anabolic steroids.

Based on intensity, they distinguish between mild mania (hypomania) and insane mania, characterized by symptoms such as disorientation, psychosis, incoherent speech and catatonia (impaired motor, volitional, speech and behavioral spheres). Standardized instruments such as the Altman Self-Rating Mania Scale and the Young Mania Rating Scale can be used to measure the severity of manic episodes.

A person with mania does not always need medical help, since mania and hypomania have long been associated with creativity and artistic talent in people. Such people often maintain enough self-control to function normally in society. This state is even compared to creative upsurge. Often there is an erroneous perception of the behavior of a person with manic syndrome: it seems that he is under the influence of drugs.

If you notice similar symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!

Symptoms of manic disorder

A manic episode is defined in the Psychiatric Association's Diagnostic Manual as "a distinct period of abnormally and persistently elevated, incontinent, irritable mood, and an abnormal and persistent increase in activity or energy, lasting at least a week and almost the entire day." These mood symptoms are not caused by drugs, medications, or a medical condition (such as hyperthyroidism). They cause obvious difficulties in work or communication, may indicate the need for hospitalization to protect themselves and others, and may indicate that the person is suffering from psychosis.

The following symptoms indicate a manic episode:

Although the activities that a person does while in a manic state are not always negative, it is much more likely that the mania leads to negative consequences.

Classification system World Organization Health defines a manic episode as a temporary state in which a person's mood is higher than the situation requires, and which can range from a relaxed good mood to a barely controlled, excessively high mood, accompanied by hyperactivity, tachypsia, low need for sleep, decreased attention and increased distractibility. Often the confidence and self-esteem of people with mania are exaggerated. Behavior that becomes risky, stupid, or inappropriate (perhaps as a result of a loss of normal social boundaries).

Some people with manic disorder exhibit physical symptoms, such as sweating and weight loss. In full-blown mania, a person with frequent manic episodes will feel that nothing and no one is more important than himself, that the consequences of his actions will be minimal, so he should not restrain himself. The personality's hypomanic connections with the outside world remain intact, although the intensity of the mood increases. If hypomania is left untreated for a long time, “pure” (classical) mania can develop, and the person moves to this stage of the disease without even realizing it.

One of the characteristic symptoms of mania (and to a lesser extent hypomania) is acceleration of thinking and speech (tachypsychia). As a rule, the manic person is overly distracted by objectively unimportant stimuli. This contributes to absent-mindedness, the thoughts of a manic individual completely absorb him: the person cannot keep track of time and does not notice anything except his own stream of thoughts.

Manic states always correlate with the normal state of the suffering person. For example, a gifted person may, during a hypomanic stage, make seemingly “brilliant” decisions and be able to perform actions and formulate thoughts at a level far beyond his abilities. If a clinically depressed patient suddenly becomes overly energetic, cheerful, aggressive, or “happier,” then such a change should be understood as a clear sign of a manic state.

Other, less obvious elements of mania include delusions (usually grandiosity or persecution, depending on whether the prevailing mood is euphoric or irritable), hypersensitivity, hypervigilance, hypersexuality, hyperreligiosity, hyperactivity and impulsivity, compulsion to over-explain (usually accompanied by speech pressure), grandiose schemes and ideas, decreased need for sleep.

Also, people suffering from mania, during a manic episode, may take part in dubious business transactions, spend uneconomically cash, exhibit risky sexual activity, abuse drugs, engage in excessive gambling, tend to be reckless (hyperactive, “daredevil”), disorder social interaction(especially when meeting and communicating with strangers). This behavior can increase conflicts in personal relationships, lead to problems at work, and increase the risk of conflicts with others. law enforcement agencies. There is a high risk of impulsive behavior that is potentially dangerous to self and others.

Although "severely elevated mood" sounds quite pleasant and harmless, the experience of mania is ultimately often quite unpleasant and sometimes unsettling, if not frightening, for the affected person and those close to him: it promotes impulsive behavior, such as You may regret it later.

Mania can also often be complicated by the patient's lack of judgment and understanding regarding periods of exacerbation of characteristic conditions. Manic patients are often obsessive, impulsive, irritable, combative, and in most cases deny that anything is wrong with them. Stream of thoughts and misperceptions lead to frustration and decreased ability to communicate with others.

Pathogenesis of manic disorder

Various triggers of manic disorder are associated with the transition from depressive states. One common trigger for mania is antidepressant therapy. Dopaminergic drugs such as dopamine reuptake inhibitors and agonists may also increase the risk of developing hypomania.

Lifestyle triggers include irregular wake/sleep schedules and lack of sleep, as well as extremely emotional or stressful stimuli.

Mania may also be associated with strokes, especially brain lesions in the right hemisphere.

Deep brain stimulation of the subthalamic nucleus has been associated with mania, especially with electrodes placed in the ventromedial STN. The proposed mechanism involves an increase in excitatory input from the STN to the dopaminergic nuclei.

Mania can also be caused by physical injury or illness. This case of manic disorder is called secondary mania.

The mechanism underlying mania is unknown, but the neurocognitive profile of mania is highly consistent with dysfunction in the right prefrontal cortex, a common finding in neuroimaging studies. Various lines of evidence from post-mortem studies and proposed mechanisms of anti-manic agents point to abnormalities in GSK-3, dopamine, protein kinase C and inositol monophosphatase (IMPase).

A meta-analysis of neuroimaging studies demonstrates increased thalamic activity and bilateral decreased activation in the inferior frontal gyrus. Activity in the amygdala and other subcortical structures such as the ventral striatum (the site of motivational and reward processing) tends to be increased, although results are inconsistent and likely dependent on task characteristics.

Reduced functional connectivity between the ventral prefrontal cortex and the amygdala along with variable findings support the hypothesis of a general dysregulation of subcortical structures by the prefrontal cortex. Bias toward positively valenced stimuli and increased responsiveness in reward circuits may predispose to mania. And while mania is associated with damage to the right hemisphere, depression is usually associated with damage to the left hemisphere.

Manic episodes may be caused by dopamine receptor agonists. This, combined with a preliminary report of increased VMAT2 activity measured using radioligand binding PET scans, suggests a role for dopamine in mania. A decrease in cerebrospinal fluid levels of the serotonin metabolite 5-HIAA was also found in manic patients, which may be explained by impaired serotonergic regulation and dopaminergic hyperactivity.

Limited evidence suggests that mania is associated with the reward theory of behavior. Electrophysiological evidence supporting this comes from studies linking left frontal EEG activity to mania. The left prefrontal region on the EEG may be a reflection of behavioral activity when the system is activated. Neuroimaging evidence during acute mania is sparse, but one study reported increased activity in the orbitofrontal cortex to monetary reward and another study reported increased striatal activity.

Classification and stages of development of manic disorder

In ICD-10 there are several disorders for manic syndrome:

• organic manic disorder (F06.30);
• mania without psychotic symptoms (F30.1);
• mania with psychotic symptoms (F30.2);
• other manic episodes (F30.8);
• unspecified manic episode (F30.9);
• manic type of schizoaffective disorder (F25.0);
• manic affective disorder, current manic episode without psychotic symptoms (F31.1);
• manic affective disorder, current manic episode with psychotic symptoms (F31.2).

Mania can be divided into three stages. The first stage corresponds to hypomania, which is manifested by sociability and a feeling of euphoria. However, in the second (acute) and third (delusional) stages of mania, the patient may become extremely irritable, psychotic, or even delusional. When a person is simultaneously excitable and depressed, a mixed episode is observed.

In a mixed affective state, a person, although meeting the general criteria for a hypomanic or manic episode, experiences three or more simultaneous depressive symptoms. This has led to some speculation among physicians that mania and depression, rather than representing "true" polar opposites, are rather two independent axes on a unipolar-bipolar spectrum.

Mixed affective states, especially those with severe manic symptoms, increase the risk of suicide. Depression in itself is a risk factor, but when combined with increased energy and goal-directed activity, the patient is more likely to commit an act of violence in response to suicidal impulses.

Hypomania is a reduced state of mania that is less likely to impair function or reduce quality of life. It inherently improves productivity and creativity. In hypomania, a reduced need for sleep and goal-motivated behavior increases metabolism. While the elevated mood and energy levels associated with hypomania can be seen as a benefit, mania itself tends to have many undesirable consequences, including suicidal tendencies. Hypomania may indicate.

To diagnose manic disorder, one manic episode is sufficient in the absence of secondary causes (i.e., substance use disorder, pharmacological, general health).

Manic episodes are often complicated by delusions and/or hallucinations. If psychotic features persist longer than the manic episode (two weeks or more), a diagnosis of schizoaffective disorder is more likely.

Some diseases on the spectrum of obsessive-compulsive disorders and impulse control disorders are called "mania", namely kleptomania, pyromania and trichotillomania. However, no connection exists between mania or manic disorder with these disorders.

Hyperthyroidism can cause symptoms similar to mania, such as agitation, increased mood and energy, hyperactivity, sleep disturbances, and sometimes, especially in severe cases, psychosis.

Complications of manic disorder

If manic disorder is left untreated, it can lead to more serious problems that affect the sufferer's life. These include:

• drug and alcohol abuse;
• breakdown of social relations;
• poor performance at school or work;
• financial or legal difficulties;
• suicidal behavior.

Diagnosis of manic disorder

Before starting treatment for mania, it is necessary to conduct a thorough differential diagnosis to exclude secondary causes.

There are several other mental disorders with symptoms similar to manic disorder. These disorders include severe ADHD, as well as some personality disorders such as ADHD.

Although there are no biological tests that diagnose manic disorder, blood tests and/or imaging may be performed to rule out medical conditions with clinical manifestations similar to manic disorder.

Neurological diseases such as multiple sclerosis, complex partial seizures, strokes, brain tumors, Wilson's disease, traumatic brain injury, and complex Huntington's disease can mimic the features of manic disorder.

Electroencephalography (EEG) can be used to rule out neurological disorders such as epilepsy, and CT scan or MRI of the head can be used to exclude brain damage and endocrine system disorders, such as hypothyroidism, hyperthyroidism, as well as for differential diagnosis with connective tissue diseases (systemic lupus erythematosus).

Infectious causes of mania that may appear similar to bipolar mania include herpetic encephalitis, HIV, or neurosyphilis. Certain vitamin deficiencies, such as pellagra (niacin deficiency), vitamin B12 deficiency, folate deficiency, and Wernicke Korsakoff syndrome (thiamine deficiency), can also lead to mania.

Treatment of manic disorder

Family-centered therapy for manic disorder in adults and children begins with the assumption that negativity in family environment(often a product of the stress and burden of caring for an ill relative) is a risk factor for subsequent episodes of mania.

Therapy has three goals:

• increase the family's ability to recognize escalation of early subsyndromal symptoms;
• reduce family interactions characterized by high criticism and hostility;
• enhance the at-risk person's ability to cope with stress and adversity.

This is done through three treatment modules:

1. psychological education for children and families about the nature, causes, course and treatment of manic disorder, as well as self-management;
2. strengthening communication learning to reduce negative communication and achieve maximum protective influence of the family environment;
3. problem-solving skills to directly reduce the impact of specific conflicts in the family.

Psychological education begins with introducing the family to goals and expectations. Family members are provided with a self-care guide (Miklowitz & George, 2007), which outlines the main symptoms of mood disorders in children, risk factors, most effective treatments, and self-management tools. The purpose of the second session is to familiarize the family with the signs and symptoms of severe mood disorder, its subsyndromal and prodromal forms. This task is facilitated by a handout that distinguishes between “mood disorder symptoms” and “usual mood” in two columns. The handout structures a discussion of how an at-risk child's moods do and do not differ from what is normal for their age. The child is also encouraged to note changes in mood and sleep/wake rhythm on a daily basis using a mood chart.

Family-centered treatment is one of many possible ways early intervention. Other treatments may include interpersonal therapy to focus on managing social problems and regulating social and circadian rhythms, and individual or group cognitive behavioral therapy to teach adaptive thinking and emotional self-regulation skills.

Drug treatment Manic disorder includes the use of either mood stabilizers (valproate, lithium, or carbamazepine) or atypical antipsychotics (olanzapine, quetiapine, risperidone, or aripiprazole). Although hypomanic episodes may respond to a mood stabilizer alone, full-blown episodes are treated with an atypical antipsychotic (often in combination with a mood stabilizer, as they tend to provide the most rapid improvement).

Once the manic behavior has subsided, long-term treatment focuses on preventive treatment to try to stabilize the patient's mood, usually through a combination of pharmacotherapy and psychotherapy. The likelihood of relapse is very high for those who have experienced two or more episodes of mania or depression. While treating manic disorder is important to treat the symptoms of mania and depression: research shows that relying on medication alone is not the best effective method treatment. The drug is most effective in combination with psychotherapy, self-help, coping strategies and in a healthy way life.

Lithium is a classic mood stabilizer to prevent further manic symptoms. A systematic review found that long-term lithium treatment reduced the risk of manic relapse by 42%. Anticonvulsants such as valproate, oxcarbazepine, and carbamazepine are also used for prevention. Clonazepam (“Klonopin”) is also used. Sometimes atypical antipsychotics are used in combination with previously mentioned drugs, including olanzapine (Zyprexa), which helps treat hallucinations or delusions, Asenapine (label, Sycrest), aripiprazole (Abilify), risperidone, ziprasidone, and clozapine. which is often prescribed to people. who do not respond to lithium or anticonvulsants.

Verapamil, a calcium channel blocker, is useful in the treatment of hypomania and in cases where lithium and mood stabilizers are contraindicated or ineffective. Verapamil is effective for both short-term and long-term treatment.

Antidepressant monotherapy is not recommended for the treatment of depression in patients with manic disorders type I or II. The combination of antidepressants with mood stabilizers did not have the desired positive effect on such patients.

Forecast. Prevention

As stated earlier, the risk of manic disorder is genetically mediated and can often be observed as subsyndromal features of the disease. In addition, interpersonal and family stress associated with the development of symptoms (both stress caused by symptoms and uncontrollable stressors or adversities that interfere with the child's successful developmental adjustment) may interfere with prefrontally mediated mood regulation. In turn, poor emotional self-regulation may be associated with increased cycling and resistance to pharmacological interventions. Thus, preventative interventions (i.e., those administered before the first fully syndromic manic episode) that alleviate early symptoms, increase the ability to cope with dependent and independent stressors, and restore healthy prefrontal circuitry should reduce the likelihood of adverse disorder outcomes (Chang et al. 2006,). With these assumptions, the intervention planning researcher or clinician can intervene at the level of biological markers (eg, brain-derived growth factor), environmental stressors (eg, aversive family interactions), subsyndromal mood, or ADHD symptoms.

It can be argued that treatment of a child at risk should begin with psychotherapy and progress to pharmacotherapy only if the child continues to be unstable or worsens. Although psychotherapy requires more time and effort than psychopharmacology, it can be a precise, targeted intervention with lasting effects even after its completion (Vittengl, Clark, Dunn, & Jarrett, 2007).

Psychotherapy does not usually cause potentially harmful side effects. In contrast, medications such as the atypical antipsychotic olanzapine (which is often used as a mood stabilizer), while reducing conversion to psychosis among at-risk adolescents, may be associated with significant weight gain and “metabolic syndrome” (McGlashan et al. 2006 ).

The medications will likely have little effect on the intensity of environmental stressors and will not buffer the at-risk individual from stress once they stop taking them. In contrast, psychosocial interventions can reduce psychosocial vulnerabilities and improve the resilience and coping of those at risk. Involving the family in treatment can also help the caregiver recognize how his or her own vulnerabilities, such as an individual history of mood disorder, translate into hostile parent/offspring interactions that may contribute to offspring responsibility.

Despite important advances, relatively little is known about the actual constellation of risk and protective factors that most accurately predict the onset of manic disorder or weighing genetic, neurobiological, social, familial, or cultural factors at different stages of development. It can be argued that elucidating these developmental trajectories is a necessary precondition for fully effective preventive interventions, especially if therapeutic targets can be identified at different developmental stages. Studies examining the interaction of genetic, neurobiological and environmental factors, should be useful in identifying these intervention targets.

We have long known that differences in social environments can lead to differences in gene expression and variations in brain structure or function, and, recursively, variations in genetic vulnerability or brain function can lead to differential environmental selection. The puzzle is how best to examine the role of environmental variables while controlling for the role of genetic factors, and vice versa. Examining the role of the environment in married couples or identical twins may help control for the role of shared environmental factors and will allow examination of the role of nonshared familial or other environmental factors. For an example of antisocial behavior, Caspi et al. (2004) showed that among identical twin pairs, the twin to whom the mother expressed more emotional negativity and less warmth was at greater risk of developing antisocial behavior than the twin to whom the mother expressed less negativity and more warmth. Experimental designs such as these could usefully be applied to siblings or twin pairs of manic disorder to clarify how different stressors lead to differences in gene expression and likelihood of developing mood episodes.

Understanding these diverse developmental pathways will help us tailor our early intervention and prevention efforts, which may mean designing interventions differently for children with different prodromal presentations. For prodromal children with the highest genetic loads for mood disorders, early intervention with medications can have a profound impact on later outcomes. In contrast, youth for whom environmental contextual factors play a central role in the occurrence of episodes (e.g., girls adolescence with a history of sexual abuse and current marital conflict) may benefit most from interventions that focus on enhancing the protective effects of immediate social environment, with pharmacotherapy introduced only as a salvage strategy.

Finally, the results of research and preventive measures can shed light on the nature of genetic, biological, social and cultural mechanisms. Indeed, if early intervention trials show that changing family interactions reduces the risk of early-onset bipolar disorder, we will have evidence that family processes play a causal rather than a reactive role in some trajectories of manic disorder. In parallel, if treatment-related changes in neurobiological risk markers (such as amygdaloid volume) improve the trajectory of early mood symptoms or comorbidities, we can develop hypotheses for these biological risk markers. The next generation of research into the development of manic disorder must address these questions.