Mania in bipolar disorder – why is it dangerous and how it should be treated?

Bipolar affective disorder (BPAD) is a condition characterized by extreme mood swings and fluctuations in a person's degree of activity. This is a mental illness that, if left untreated, can destroy relationships with others, take a person out of society and even lead them into a suicidal state.

The diagnosis is most often made in patients aged 15-25 years old and extremely rarely at an earlier age. Sometimes the disease can start to manifest during the 30s-40s.

For the patients, depressive phases subjectively cause the most discomfort. And hypomania and mild mania can be perceived as a good thing because these phases are identified by good mood, the inflow of energy, and willingness to live a full life. But mania is not just a good mood it is a dangerous condition that can lead to severe injuries or rash acts that can ruin the patient’s or someone else’s life. In this article, we are explaining BAPD with special attention to mania identification and treatment.

Bipolar disorder in short

BPAD overview

It is crucial to begin therapy for BPAD as soon as the first symptoms become visible. The main signs are alternating phases of extreme euphoria or mania and depleting depression. Between two polar states, a person is in a normal emotional state and leads a normal life. But during phases, mood swings are far more debilitating and disabling than those experienced by most healthy people. Some individuals may have hallucinations and other symptoms similar to schizophrenia.

The manifestations of the disease are contingent on the personal features of each patient. In certain people, bipolar states alternate every few months; in others, each of the states can last for years. A person can also be in a mixed state - simultaneously feeling negative and feeling intense anxiety.

In a manic state, a person can behave in a risky, aggressive manner, feel omnipotent and overconfident. Their speech can be very fast and confusing. In this state, a person can waste money, abuse drugs or alcohol, and perform actions that are dangerous for themselves and others.

In a depressed state, a person has feelings of despair and hopelessness. They develop trouble sleeping, intense anxiety, unreasonable guilt, low concentration, fatigue, and lethargy. Physical symptoms sometimes appear, such as severe pain, weight loss or gain. In a critical situation, an individual may think about committing suicide.

The manifestations of BPAD can be controlled with correctly chosen and adjusted treatment. Specialists help such patients to correct their behavior and adequately perceive themselves and the surrounding reality through therapy. Also, special drugs about which you can read further in the article, help preventing phase alteration and mitigate their negative effects. As a result of treatment, the individual can work, study, and live a fulfilling life.

Manifestations and course of BPAD

A diagnosis of BPAD is made when at least two of any affective episodes during an individual's life were present. One of which must be manic or mixed. There are two subtypes of BPAD, which differ in the intensity of manic manifestations:

- BPAD type I consists of alternating depressive and manic (mixed) episodes;
- In BPAD type II, depressive phases alternate with phases of mild mania (hypomania).

To catch the disorder early, tests for BPAD type II should be made for all young patients suffering from depression and in patients of any age suffering from recurrent depression. If a patient with BPAD is misdiagnosed as simply depressed, they may receive treatment with antidepressants only which will only worsen their condition as antidepressants without a counterweight drug (mood stabilizers, antipsychotics) can induce mania.

Psychotic symptoms in the disorder can be observed both during a phase of mania and depression. Clinically, patients with BPAD experience many more depressive than manic phases.

There are two types of BPAD based on the phases’ alteration:

- Classic, remitting type: episode - remission - episode.
- Dual-phase or continuous phase is when there is no normal period between the polar phases of mania and depression.

There is also a separate group, a so-called fast-cyclic form characterized by a rapid phase change. It is diagnosed when a patient has had four or episodes alterations during the year. In extreme forms, phases can change within weeks or even days. Such severe forms are more common for women with BPAD type II, hypothyroidism, who use antidepressants for extended periods of time which is why it is crucial to make a correct diagnosis to avoid improper therapy that can only worsen the condition. Besides quick phase alterations, such patients usually develop the symptoms at an early age, suffer from more severe depressive phases, are often misdiagnosed, have an increased risk of suicide, poorer functioning, and a poorer response to lithium therapy.

Why is mania dangerous and must be treated?

Patients with BPAD often report that they feel incredibly energized and in an incredible mood when they are manic. Until they have received treatment, they do not understand why they need to get rid of such positive feelings and work with a specialist. Indeed, it would seem that if a person feels so well, why should they be deprived of this state?

First of all, it should be noted that if a patient had at least one episode of mania, there is a very high probability that they will reoccur and each episode will be more intense and posses a greater risk of self-damage or harming other people. Thus, patients and their families need to take preventive therapy after even one episode.

BPAD can be thought of as a pendulum that swings from side to side. In a neutral position, when the pendulum is in the middle, a person lives a normal life: goes to work or school, is happy and sad without extremes. If the pendulum is unbalanced, a depressive or pre-depressive state becomes one of its poles. In this state, a person feels bad, anxious, and sometimes does not want to live.

The other pole of the pendulum is the pre-manic or hypomanic state. If you do not consult a specialist in time, it can develop into manic. In this state, a person feels active and omnipotent, does not want to sleep, and does not feel tired. In a manic state, a person can squander money they do not own, run around the streets naked, not noticing how others are looking at them, involve in risky driving, and so on. A person may even decide that they can fly, jump from a great height and die. In BPAD, mania is at its worst. A person may have an erroneous, painful perception of reality.

In a state of mania, a person can commit murder or injure others. At this moment, the individual may imagine that the people around them are a threat, and they need to be stopped. Such a person is not responsible for their actions and needs treatment. It is advisable to have time to consult a specialist when the patient is still in a hypomanic state, i.e. has mild symptoms of mania to prevent the manic stage.

You can check your condition or the condition of your family member using our express test for episodes mania:

1. You have had a period in your life when your condition was different from usual and you had been:
-  In an unusually uplifted mood that it was visible to others or led you to trouble.
- Unusually irritable, could yell at someone, start a fight or a heated argument.
- Extraordinarily self-confident and felt like you can do anything and all will work out great.
- Sleeping less than usual and did not feel the need for extra sleep.
- More chatty than usual or your speech was faster.
- Having your thought all over the place;
- Easily distracted and it was hard for you to focus or continue the conversation.
- More vigorous and energetic than always.
- More outgoing or more than usual sought amusement/company, e.g., call your friends late at night.
- Having a much more intense sex drive than usual.
- Doing things that are uncommon for you or that others seen as excessive, stupid, or risky.
- Spending money in a way that caused trouble for you or your family.
2. If you answered YES to more than one of these questions, did several of these events occur simultaneously?
3. How big were your problems, which led to any of them - for instance, you were incapable of working, encountered family/relationship problems, financial or legal problems, got into conflicts or fights? Please circle only one answer:
- There were no problems;
- There were minor problems;
- There were moderate problems
- There were serious problems.

A positive test result (all three of the following criteria are met simultaneously):
Question 1 - 7 or more answers "yes" - plus.
Question 2 - the answer is yes – plus.
Question 3 - moderate or serious problems – plus.

Results:
- Three pluses mean that you have had an episode of mania and should certainly seek medical help.
- If you have two pluses, you are still highly advised to seek medical help to avoid further progression of the disease.
- In case of zero or one plus, observe your condition further and notice the mentioned manifestations, if they repeat or worsen – seek medical help.

Principles of BPAD therapy

Therapy of BPAD is divided into three main stages:

1. Emergency therapy – help in an acute condition - mania, depression, or a mixed episode until a normal mood is achieved. This stage is made at a hospital.
2. Stabilization of the results – the continuation of emergency help with the gradual lowering of the dosages of the medications for several months considering the average duration of manic (3-5 months) or depressive episode (6-9 months).
3. Maintenance therapy is the basis therapy made at home at the lowest effective dosage of drugs with established efficacy for phase change prevention.

The medicines used to BPAD can be divided into the following groups:

1. Mood stabilizers - lithium, valproate, carbamazepine, and others used in different dosages for acute conditions and anti-relapse therapy.
2. Traditional (typical) and atypical antipsychotics – Olanzapine, and others for stopping mania, psychosis, and agitation.
4. Antidepressants used for depressive phase:
- Selective serotonin reuptake inhibitors are the first-choice treatment. For instance, it can be Paroxetine or others; If this group is unsuitable for any cause, they can be replaced with:
- Selective norepinephrine reuptake inhibitors;
- Reversible monoamine oxidase inhibitors;
- Heterocyclic (HCA);
- Tricyclic (TCA).
5. Benzodiazepine tranquilizers - diazepam, lorazepam, clonazepam.

You can find medications for bipolar disorder at our online drugstore and buy them without a prescription to save on the cost per pill. But make sure to get diagnosed and follow the prescribed treatment plan to ensure that your condition improves and not worsens.

Post by: Christopher Ames, MD, pshychiatrist, Medibank, Sydney, Australia