Mania

Introduction

Mania is a state of abnormally elevated arousal, affect and energy level.

Mania is a far less common ED presentation than the other mood disorder, depression. However, a full manic syndrome is one of the most distinctive conditions in clinical practice and these patients often require admission.

 

The core symptoms include raised mood, increased enjoyment and interest and boundless energy. Inflated self-esteem and confidence can lead to a belief they are gifted or special and they are very hopeful about the future. Thoughts race and speech becomes pressured with a flight of ideas.

 

Sleep is severely disrupted and patients can exhibit reckless behaviours leading to risky sexual liaisons, gambling problems, and drug taking.

 

Poor judgement and lack of insight can cause severe disruption of relationships, employment and finances, and untreated can lead to high rates of debt, divorce, suicide, and violence.

Clinical Features

 

Features Associated with Acute Mania

  • Abnormally and persistently elevated or irritable mood and abnormal and persistent goal-directed behaviour or energy asctd with some combination of the below;

    • Inflated self-esteem or grandiosity

    • Decreased need for sleep

    • Rapid and pressured speech

    • Flight of ideas or subjectively feeling that their thoughts are racing

    • Reported or observed distractibility

    • Psychomotor or physical agitation or acceleration

    • Excessive involvement in activities that have a high potential for painful consequences (e.g. unrestrained buying sprees, sexual indiscretions, foolish business investments

  • Mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning

  • The episode is not attributable to the direct physiological effects of a substance (e.g.a drug of abuse, a medication, or other treatment) or another medical condition.

Features Associated with Organic Causes

  • Age > 40yrs with no past pscyh history.

  • Visual hallucinations

  • Disorientation with clouded consciousness

  • Recent memory loss

  • Abnormal vital signs

  • Focal neurological signs

  • Psychomotor retardation

Differential Diagnosis

 

Psychiatric Disorders

  • Bipolar Disorder

    • responsible for vast majority of manic syndrome presentations. But not all

  • Schizoaffective Disorder

  • Severe OCD

  • Severe anxiety

  • Certain personality disorders

Drugs

  • Illicit drug intoxication

    • e.g. Cocaine, MDMA, caffeine, amphetamines, PCP

  • Adverse effects of prescription drugs

    • e.g. steroids, levodopa, baclofen

  • Alcohol

    • wernicke’s encephalopathy, withdrawal

Organic Psychosis

  • Delerium secondary to any cause

    • infection, inflammation, electrolyte abnormalities, hypo/hyperthyroidism

  • Dementia

  • Frontal Lobe lesions/trauma

  • Post puerperal psychosis

 

Clinical Investigations

 

The single most important component required to make the diagnosis is taking a good personal history from the patient and collateral history from his or her family.

All patients who present to the ED with an apparent mental health crisis need to be assessed medically to out rule any causative or concurrent physical pathology. A full history and physical exam may be sufficient in some cases, particularly those who are presenting with a pattern of behaviour consistent with their previous psychiatric attendances. However, as this patient cohort are at high risk of having an underlying contributing disease process you should have a low threshold to perform some routine investigations.

All patients who present with a first presentation of acute mania or psychosis require investigations to screen for an organic cause.

 
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Bedside

  • Urine toxicology screen

    • may have some role if you suspect drugs may be contributing to presentation

  • BHCG in any woman of child bearing age

  • ECG

    • assess for underling arrhythmia

  • VBG

    • assess electrolytes, acidosis indicates psychomotor acceleration more likely to be organic or drug related

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Laboratory

  • FBC, CRP

    • elevated acute phase reactants in infection/inflammation

  • Renal Function

    • Severe uraemia can cause delerium

  • TFTs

  • Lumbar puncture

    • if concerned regarding CNS infection

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Radiology

  • CT Brain

    • neuro-imaging should be performed on all patients who present with psychosis or acute mania for the first time

  • Other imaging as clinically indicated

Emergency Management & Disposition

Safety and Initial Stabilisation

  • Manic patients are generally expansive, energetic and “on top of the world” but they may become distressed, hostile and irritable especially if they feel threatened.

  • It is imperative to ensure patient and staff safety at all times. This is further explored in Case 1 (link)

  • Medical stabilisation and attention to ABC as clinically indicated.

  • Mood stabilisers should be started at the discretion of the admitting psychiatrist as this can alter their assessment of the patient.

    • However in the acute setting an antipsychotic (e.g. olanzapine) or oral or IV benzodiazepine may be required

Risk Assessment

  • Assess if the patient is at risk of hurting themselves or others. Enquire about thoughts of suicide or self harm

  • Are they at risk of misadventure secondary to reckless behaviours and lack of insight

  • Determine if the patient may need to be forcibly detained under the Mental Health Act 2001 for emergency psychiatric evaluation.

    • This Act allows for involuntary admission of patients with mental disorders (includes mental illness, dementia, and intellectual disability) who are deemed a risk to themselves or others, or at risk of further deterioration of their condition if not admitted.

Medical Evaluation

  • Seek and treat organic medical conditions that might cause or contribute to abnormal behaviour or thought processes

  • Seek and treat any injuries that may have occurred as a result of abnormal behaviour

Psychiatric Consultation & Disposition

  • ED should seek emergency psychiatric consultation on all patients who presents with symptoms of mania that are not due to an underlying medical condition

  • Psychiatry to determine the formal mental health diagnosis and the requirement for admission to an acute mental health bed

References

  1. Stringer, S., Church, L., Davison, S., Lipsedge, M. 2009. Psychiatry P.R.N. 1st ed. Oxford: University Press.

  2. Wyatt, J., Illingworth, R., Graham, C., Hogg, K. 2018. Oxford Handbook of Emergency Medicine. 4th ed. Oxford: Oxford University Press.

  3. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). 5th Edition.

  4. Dailey MW. Mania. StatPearls Publishing LLC. Nov 2020

  5. Larkin G, Beautris A. Psychosocial Disorders. Section 24. Tintinall’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition

This blog was written by Dr James Morris and was last updated in January 2021

 Before you go have another look at the case to see if your answers have changed and if so how?