Mania, psychotic

Educate family members and the patient about the characteristics of the disorder(s) being treated, e.g., euphoric mania, mixed mania, psychotic mania, severe... 

Physicians use benzodiazepines to treat many disorders, including a number of anxiety disorders. These include acute anxiety, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. In addition, benzodiazepines can be used to treat agitation or anxiety that is caused by other psychiatric conditions such as acute mania, psychotic illness, depression, impulse control disorders, and catatonia or mutism. 

The beneficial effects of antipsychotic drugs are not limited to schizophrenia. They also are employed in disorders ranging from postsurgical delirium and amphetamine intoxication to paranoia, mania, psychotic depression, and the agitation of Alzheimer s dementia (although their efficacy in this disorder in not proven). They are especially useful in severe depression and possibly in other conditions marked by severe turmoil or agitation. 

Affective (mood) disorders are characterized by changes in mood. The most common manifestation is depression, arranging from mild to severe forms. Psychotic depression is accompanied by hallucinations and illusions. Mania is less common than depression. In bipolar affective disorder, depression alternates with mania. 

Electroconvulsive therapy (ECT) is the application of prescribed electrical impulses to the brain for the treatment of severe depression, mixed states, psychotic depression, and treatment-refractory mania in patients who are at high risk of suicide. It also may be used in pregnant women who cannot take carbamazepine, lithium, or divalproex. 

In clinical psychiatric terms, the affective disorders can be subdivided into unipolar and bipolar disorders. Unipolar depression is also known as psychotic depression, endogenous depression, idiopathic depression and major depressive disorder. Bipolar disorder is now recognised as being heterogeneous bipolar disorder I is equivalent to classical manic depressive psychosis, or manic depression, while bipolar disorder II is depression with hypomania (Dean, 2002). Unipolar mania is where periods of mania alternate with periods of more normal moods. Seasonal affective disorder (SAD) refers to depression with its onset most commonly in winter, followed by a gradual remission in spring. Some milder forms of severe depression, often those with an identifiable cause, may be referred to as reactive or neurotic depression. Secondary depression is associated with other illnesses, such as neuro-degenerative or cardiovascular diseases, and is relatively common. 

Exercise (regular aerobic and weight training at least three times a week) / The use of electroconvulsive therapy for severe mania or mixed episodes, psychotic depression, or rapid cycling is still considered the best... 

Use alone or in combination with other drugs (e.g., lithium, carbamaz-epine, a nti psychotics) for the acute treatment of mania and for maintenance treatment. 

Use in combination with other drugs (e.g, anti-psychotics, lithium, valproate) for the acute treatment of mania or mixed episodes. Use as a short-term adjunctive sedativehypnotic agent. Binds to the benzodiazepine site and augments the action of GABA/, by increasing the frequency of Cl" channel opening which causes hyperpolarization (a less excitable state) and inhibits neuronal firing. 

Lithium is effective for acute mania, but it may require 6 to 8 weeks to show antidepressant efficacy. It may be more effective for elated mania and less effective for mania with psychotic features, mixed episodes, rapid cycling, and when alcohol and drug abuse is present. Maintenance therapy is more effective in patients with fewer episodes, good functioning between episodes, and when there is a family history of good response to lithium. It produces a prophylactic response in up to two-thirds of patients and reduces suicide risk by eight- to 10-fold. 

Again, the character of the patient s prior episodes, premorbid functioning, and family history all are helpful. By definition, schizophrenia is marked by a 6-month decline in social and occupational functioning that is seldom seen in bipolar illness. In addition, the delusions and hallucinations of schizophrenia are present during periods of normal mood, whereas bipolar patients only experience psychotic symptoms in the context of severe mood disturbance (i.e., mania or depression). 

Brief Psychotic Disorder. This disorder occurs in the immediate aftermath of a markedly stressful event (or series of events). It is marked by emotional turmoil in conjunction with one or more psychotic symptoms such as delusions, hallucinations, disorganization, or catatonia. On presentation, a brief psychotic disorder can be difficult to distinguish from psychotic depression or mania. The presence of a precipitating stressor is not always helpful, because episodes of psychotic mood disorders (especially early in the course of illness) are also commonly triggered by stressful life events. Careful evaluation for symptoms of emerging depression or... 

Delirium. Delirium is an abrupt change in mental status often accompanied by agitation and seemingly psychotic symptoms that may resemble mania. Unlike mania, however, delirium is commonly characterized by a fluctuating level of consciousness and disorientation. The chief precipitants of delirium include infections, medications, and metabolic disturbances. Therefore, all patients who present in an acutely agitated state should undergo a comprehensive yet expeditious medical evaluation to rule out potential causes of delirium. This evaluation must include a thorough physical examination and a battery of laboratory tests. 

Mood Disorder with Psychotic Features. One subtype of major depression and many episodes of mania are associated with psychotic symptoms. Like schizophrenia, the most prominent psychotic symptoms of psychotic depression or mania are delusions and auditory hallucinations. Unless a longitudinal history is available, it is often difficult to distinguish schizophrenia from a psychotic mood disorder. 

Manic-depressive illness connotes a psychotic disorder of affect that occurs episodically without external cause. In endogenous depression (melancholia), mood is persistently low. Mania refers to the opposite condition (p. 234). Patients may oscillate between these two extremes with interludes of normal mood. Depending on the type of disorder, mood swings may alternate between the two directions (bipolar depression, cyclothymia) or occur in only one direction (unipolar depression). 

Bipolar mania (ora only) - For the treatment of acute manic or mixed episodes associated with bipolar disorder, with or without psychotic features. Schizophrenia - For the treatment of schizophrenia. 

Treatment with steroids may initially evoke euphoria. This reaction can be a consequence of the salutary effects of the steroids on the inflammatory process or a direct effect on the psyche. The expression of the unpredictable and often profound effects exerted by steroids on mental processes generally reflects the personality of the individual. Psychiatric side effects induced by glucocorticoids may include mania, depression, or mood disturbances. Restlessness and early-morning insomnia may be forerunners of severe psychotic reactions. In such situations, cessation of treatment might be considered, especially in patients with a history of personality disorders. In addition, patients may become psychically dependent on steroids as a result of their euphoric effect, and withdrawal of the treatment may precipitate an emotional crisis, with suicide or psychosis as a consequence. Patients with Cushing s syndrome may also exhibit mood changes, which are reversed by effective treatment of the hypercortisolism. 

Mania. Mania and hypomania can also occur in children and adolescents on SSRIs, and, again, it is not known if there is an added developmental risk (Ven-kataraman et al., 1992). In a fluoxetine treatment study for depression, 3 (of 48) patients developed manic symptoms, even after excluding patients with psychotic depression, bipolar symptoms, or a family history of bipolar disorder (Emslie et al., 1997). In a paroxetine treatment study for depression, 5 adolescents (of 93) were removed for emotional lability and 1 for eupho-ria/expansive mood (Keller et al., 2001). 

There are two studies of hospitalized children with mania or manic symptoms. The first, a controlled trial of lithium in 11 children (7 of whom were treated under double-blind, placebo-controlled conditions), found that 6 showed improvement over an 8-week period of hospitalization, but only 3 were well enough to be discharged on lithium. Long-standing concurrent ADHD complicated assessment of response (Carlson et al., 1992a), and the addition of methylphenidate was necessary to achieve an improvement in attention span and hyperactivity (Carlson et ah, 1992b). An open trial of lithium in 10 acutely manic/psychotic prepubertal children showed positive response in all (Varanka et ah, 1988). 

Carlson, G.A. (2000) Very early onset bipolar disorder. Does it Exist in Childhood In Rapoport, J, ed. Onset of Adult Psychopathology—Clinical and Research Advances. APPI Press, pp. 303-332. Carlson, G.A., Bromet, E.J., and Lavelle, J. (1999) Medication treatment in adolescents vs adults with psychotic mania. / Child Adolesc Psychopharmacol 9 221-231. 

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