ORGANUM
Hallmarks of mania:
Pressured speech
Elevated, expansive, or irritable mood
Impaired judgement
Manic patients are excited, talkative, sometimes amusing, and frequently hyperactive. Their speech is rapid and loud and challenging to interrupt; it is commonly referred to as pressured, appearing as if driven by some unknown urgency. Pressured speech is a hallmark of mania.
An elevated, expansive or irritable mood is the hallmark of a manic episode. The elevated mood is euphoric and often infectious and can even cause a countertransferential denial of illness by the inexperienced clinician. Although those with do not know the patient may not be able to recognise the unusual nature of the patient's mood, those who know the patient will recognise it as unusual. Alternatively the mood ay be irritable, especially when someone prevents a patient from some unrealistic plan. They also have a low frustration tolerance, which can lead to feelings of anger and hostility. Manic patients may be emotionally labile, switching from laughter or irritability to depression in minutes or hours. Patients often exhibit a change from euphoria early in the mood course to later irritability.
Manic patients describe rapid thoughts, as inferred from their speech. As the manic state increases, their speech contains puns, jokes, rhymes, or plays on words. They may seem clever and brilliant; genius like. Manic patients are often easily distracted, and their cognitive functioning in the manic state is unrestrained, with an accelerated flow of ideas. At a still higher activity level, associations become loosened, the ability to concentrate fades, and flight of ideas, clanging and neologisms (newly coined word) appear. In acute manic excitement, speech can be incoherent and indistinguishable from that of a person with schizophrenia.
The manic patients thought content includes themes of self-confidence and self-aggrandizement. At times, manic patients are grossly psychotic and disorganised and require physical restraints and the IM injection of sedating drugs.
Delusions occur in 75% of all manic patients. A delusion is a false, firmly believed belief. Mood-congruent manic delusions are often concerned with great wealth, extraordinary abilities, or power. Bizzare and mood-incongruent delusions and hallucinations also appear in mania.
Grossly, orientation and memory are intact, although some manic patients may be so euphoric that they answer questions incorrectly. Emil Kraepelin called the symptom delirious mania. We know much less about the cogniotive deficits associated with bipolar disorders than such chronic disorders like schizophrenia. However, there is some evidence to suggest they share some common deficits.
Impaired judgement is a hallmark of manic patients. They may break laws about credit cards, sexual activities, and finances and sometimes involve their families in financial ruin. Manic patient also have little insight into their disorder. Their disinhibition may result in other examples of poor judgement, such as making phone calls during inappropriate times of the day. Pathologic gambling, a tendency to disrobe in public places, wearing clothing and jewelry of bright colours in unusual or outlandish combinations and inattention to small details (e.g. forgetting to hang up the phone) are also symptomatic of the disorder. Patients act impulsively, and at the same time, with a sense of conviction and purposeness. They are sometimes preoccupied with religious, political, financial, sexual or persecutory ideas that can evolve into complex delusional systems. Occasionally, manic patients may become regressed and play with their urine and feces.
75% of all manic patients are assaultive or threatening at some time. Manic patients are at increased risk for suicide. However, the most significant risk seems to be when bipolar patients are depressed. Manic patients often drink alcohol excessively, perhaps in attempt to self-medicate.