Mania diagnosis

Secunda SK, Katz MM, Koslow SH, et al Mania diagnosis, state measurement and prediction of treatment response. J Affect Disord 8 113-121, 1985 Seeman MV Neuroleptic prescription for men and women. Social Pharmacology 3[3) 219-236, 1989... 

Evans, D. L., M. J. Byerly, and R. A. Greer. 1995. Secondary mania diagnosis and treatment. Journal of Clinical Psychiatry 56 (Suppl)31-7. 

Crucial factors affecting overall cost are the responsiveness to medication (for example, less than 70% of patients are lithium responders ), adherence to recommended treatment, and adverse events resulting from medication. A particular hazard of lithium treatment is the risk of rapid re-emergence of mania, which occurs in up to 50% of patients if the dmg is abruptly discontinued (see Cookson, 1997). Disappointingly, it has not been found that the introduction of widespread treatment with lithium has been associated with a reduction in the number of patients admitted and discharged from hospital with a diagnosis of mania. In order to achieve the best result with the available... 

Bipolar I disorder affects men and women equally bipolar II seems to be more common in women. Rapid cycling and mixed mania occur more often in women. Individuals with bipolar disorder commonly have another psychiatric disease with 78% to 85% reporting another Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis during their lifetime. The most common comorbid conditions include anxiety, substance abuse, and eating disorders.2... 

The classic symptoms of depression are listed in Table 12.1, which is based on DSM-IV criteria. For a diagnosis of major depressive disorder, most of these symptoms must be present, including the first two (APA, 2000). These symptoms should be of sufficient intensity and chronic duration (at least 2 weeks) to cause clinically significant distress and impairment in social or economic functioning. However, they should not be a result of another psychiatric or somatic illness, nor of drug misuse or bereavement. For a diagnosis of mania, the symptoms are a mirror image of those for depression (Table... 

More controversial is the occurrence of antidepressant-induced mania or hypo-mania. DSM-IV specifically states that manic or hypomanic episodes triggered by antidepressant treatment should not count toward the diagnosis of BPAD. However, clinicians have traditionally viewed antidepressant-induced switching from depression into mania as an unmasking of a preexisting BPAD that had previously been unrecognized and undiagnosed. 

The diagnosis can be clarified by collecting a retrospective history both from the patient and from a collateral source, such as a friend or family member. A history of bipolar disorder will include episodes of illness that typically arise spontaneously, last for days or weeks, and often result in a decreased need for sleep during times of hypomania or mania. The periods of affective lability in the patient with a Cluster B personality generally do not arise in this spontaneous fashion but are instead triggered by a stressful life event. In addition, they seldom last as long as the typical... 

The diagnosis of mania is made on the basis of clinical history plus a mental state examination. Key features of mania include elevated, expansive or irritable mood accompanied by hyperactivity, pressure of speech, flight of ideas, grandiosity, hyposomnia and distractibility. Such episodes may alternate with severe depression, hence the term "bipolar illness", which is clinically similar to that seen in patients with "unipolar depression". In such cases, the mood can range from sadness to profound melancholia with feelings of guilt, anxiety, apprehension and suicidal ideation accompanied by anhedonia (lack of interest in work, food, sex, etc.). 

Encephalopathy - Impaired cognition confusion obtundation altered mental status auditory/visual hallucinations psychosis (delirium, paranoia) mood changes (eg, mania, agitation, combativeness) diffuse hypotonus hyperreflexia myoclonus tremor asterixis involuntary movements major motor seizures lethargy/stupor/coma diffuse weakness. Approximately one-third of patients with a diagnosis of encephalopathy may have had... 

More common are case series and open trials of mood stabilizers for acute mania (see Davanzo and McCracken, 2000 for review). These studies, some of which were done in the 1970s and 1980s with classical adolescent manic patients, showed promise for the use of lithium in the treatment of mania. In some early studies, response to lithium was a requirement for diagnosis, a circular criterion that would undoubtedly have increased the response rate. 

Biederman, J., Wozniak, J., Kiely, K., Ablon, S., Faraone, S., Mick, E., Mundy, E., and Kraus, I. (1995) CBCL Clinical Scales discriminate prepubertal children with structured-interview-derived diagnosis of mania from those with ADHD. / Am Acad Child Adolesc Psychiatry 34 133-140. 

Other factors associated with poor lithium response in mania include a history of prior lithium failure and a diagnosis of schizoaffective disorder. Bowden et al. [1994b] observed in a double-blind, placebo-controlled trial of patients with acute mania that those with a history of lithium response improved on lithium in this trial, whereas those with a history of prior lithium failure did not. Patients with a diagnosis of schizoaffective disorder may respond less well to lithium than patients with bipolar disorder, although this has not been extensively studied [Keck et al. 1994, for review]. 

Little is known about possible relations between psychiatric diagnosis and seizure threshold. A few reports have suggested that patients with mania may have lower seizure thresholds than patients with depression [Mukherjee... 

McElroy SL, Keck PE Jr, Pope HG Jr, et al Correlates of antimanic response to valproate. Psychopharmacol Bull 27 127-133, 1991b McElroy SL, Keck PE Jr, Pope HG Jr, et al Clinical and research implications of the diagnosis of dysphoric or mixed mania or hypomania. Am J Psychiatry 149 1633-1644, 1992... 

A history of episodes of mania or hypomania should suggest the diagnosis of bipolar disorder. Because antidepressants can precipitate... 

A limited body of evidence indicates that lithium helps atypical mania, schizoaffective disorder, or schizophreniform disorder, both as an acute treatment and for prevention of recurrence. There are younger patients who demonstrate both schizophrenic and manic features early in the course of their illness. When in doubt about the diagnosis, lithium may be preferable for an acute episode because, if successful, it will most likely be an effective prophylaxis as well. Clearly, some patients are so disturbed that the clinician cannot wait until lithium becomes fully effective, and an antipsychotic must be added, but often it can be discontinued after a brief period to determine whether lithium alone is sufficient. 

Although hypomanic and manic episodes are discussed comprehensively in Chapter 9, it is important to note that the disturbance in mania (and hypomania), as well as in depression, includes the same core symptoms, differing only in the direction of change. Complicating the diagnosis, unipolar patients may also present with classic melancholia or atypical (nonclassic) symptoms. The latter, in particular, can overlap considerably with hypomania. Similarly, bipolar patients in a depressive phase may demonstrate classic or nonclassic symptoms (Table 6-5). 

It is important to consider explanatory precipitants in a patient with no prior history of a mood disorder. Clearly, the diagnosis of bipolar mania should not be made if the syndrome can be explained by known organic factors, which vary widely and include the following ... 

Schizophrenia-related disorders, such as schizophreniform disorder, can closely mimic an acute exacerbation of mania. Attention to premorbid personal and family history may help differentiate them from mood disorders. A definitive diagnosis may not be possible, however, until the course of the illness is followed for a period of time. Clinical clues include the propensity of bipolar manics (in contrast to schizophrenics) to demonstrate pressured speech, flight of ideas, grandiosity, and overinclusive thinking. Hallucinations are less common than delusions in both mania and depression, with delusions normally taking on the qualities of expansivity, hyperreligiosity, or grandiosity. Delusions are also relatively less fixed than in schizophrenia. 

Davis JM, Noll KM, Sharma R. Differential diagnosis and treatment of mania. In Swann AC, ed. Mania new research and treatment. Washington, DC American Psychiatric Press, 1986 1-58. Mendlewicz J, Fieve RR, Rainer JD, et al. Manic-depressive illness a comparative study of patients with and without a family history. Br J Psychiatry 1972 120 523-530. 

Perhaps even more important in children is the issue of bipolar disorder. Mania and mixed mania have not only been greatly underdiagnosed in children in the past but also have been frequently misdiagnosed as attention deficit disorder and hyperactivity. Furthermore, bipolar disorder misdiagnosed as attention deficit disorder and treated with stimulants can produce the same chaos and rapid cycling state as antidepressants can in bipolar disorder. Thus, it is important to consider the diagnosis of bipolar disorder in children, especially those unresponsive or apparently worsened by stimulants and those who have a family member with bipolar disorder. These children may need their stimulants and antidepressants discontinued and treatment with mood stabilizers such as valproic acid or lithium initiated. 

Those disorders that require the presence of psychosis (Table 10—1) as a defining feature of the diagnosis include schizophrenia, substance-induced (i.e., drug-induced) psychotic disorder, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder, and psychotic disorder due to a general medical condition. Disorders that may or may not have psychotic symptoms (Table 10—2) as an associated feature include mania and depression as well as several cognitive disorders such as Alzheimer s dementia. 

Trials of lithium in patients with acute psychosis (and not just mania) showed that lithium was inferior for the treatment of severely overactive patients, presumably because of its toxicity, but comparable to neuroleptics for the treatment of less overactive patients, regardless of diagnosis (Braden et al. 1982 Johnstone et al. 1988). A trial conducted in the 1960 comparing opium and chlorpromazine in acute schizophrenic patients showed equivalent improvement over three weeks with both drugs (Abse, Dahlstrom, Tolley 1960). 

---