MANIA
Definition
Mania is a psychiatric syndrome characterized by a distinct period of abnormally elevated,
expansive, or irritable mood accompanied by increased energy and activity, lasting at least one
week or requiring hospitalization.
The DSM-5 defines a manic episode as a distinct period of persistently elevated, expansive, or
irritable mood and abnormally increased goal-directed energy. This state must last for at least
one week (or require hospitalization) and cause significant impairment in social or occupational
functioning.
TYPES OF MANIA
Mania can present in different forms depending on the severity, duration, and presence of
psychotic symptoms.
1. Hypomania
Hypomania is a mild form of mania characterized by elevated mood and increased activity that
lasts for at least 4 consecutive days. Unlike mania, it does not cause severe impairment in social
or occupational functioning, does not require hospitalization, and is not accompanied by
psychotic features.
Clinical features:
Elevated or euphoric mood
Increased confidence
Reduced need for sleep
Increased talkativeness
Increased productivity
Enhanced creativity
Mild distractibility
2. Acute Mania
Acute mania is the classic and most severe form. Symptoms are intense, interfere with daily
functioning, and often require hospitalization.
Features:
Extreme excitement
Excessive talking
Aggression
Impulsivity
Grandiose delusions
Poor judgment
Hyperactivity
Insomnia
Reckless spending
Hypersexuality
3. Delirious Mania
This is a rare but life-threatening condition combining severe mania with delirium.
Features:
Severe agitation
Confusion
Disorientation
Hallucinations
Delusions
Fever
Dehydration
Exhaustion
It is a psychiatric emergency requiring immediate treatment.
4. Psychotic Mania
Psychotic mania is characterized by manic symptoms accompanied by psychotic features.
Psychotic symptoms include:
Grandiose delusions
Religious delusions
Delusions of special powers
Auditory hallucinations
Visual hallucinations (less common)
CAUSES OF MANIA
1. Genetic Factors
2. Biological Factors; These include: Neurotransmitter imbalance, Structural brain
abnormalities, Thyroid dysfunction, Hormonal disturbances, Circadian rhythm disruption
3. Psychological Factors; Stressful events may trigger manic episodes. Examples: Loss of
loved one, Divorce, Examination stress, Job loss, Marriage, Childbirth
4. Environmental Factors; such as Sleep deprivation, substance abuse
5. Medical Causes: Secondary mania may occur due to: Hyperthyroidism, Stroke, Brain tumors
Epilepsy, Multiple sclerosis, HIV infection, Head injury
CLINICAL FEATURES OF MANIA
Mood Disturbances
Euphoric mood
Elevated mood
Irritable mood
Labile emotions
Cognitive Symptoms
Inflated self-esteem
Grandiosity
Racing thoughts
Poor concentration
Distractibility
Poor judgment
Loud and rapid speech
Flight of ideas
Behavioral Symptoms
Increased activity
Restlessness
Hypersexuality
Excessive spending
Reckless driving
Gambling
Frequent business ideas
Increased social interaction
Physical Symptoms
Reduced need for sleep
Weight loss
Fatigue despite overactivity
Poor nutrition
Increased energy
DSM-5-TR DIAGNOSTIC CRITERIA FOR MANIA
A manic episode is diagnosed when there is a distinct period of abnormally elevated,
expansive, or irritable mood lasting at least 1 week (or any duration if hospitalization is
necessary), with increased energy or activity.
During this period, three or more of the following symptoms (or four if the mood is only
irritable) must be present:
Inflated self-esteem or grandiosity.
Decreased need for sleep.
More talkative than usual or pressure to keep talking.
Flight of ideas or racing thoughts.
Distractibility.
Increased goal-directed activity or psychomotor agitation.
Excessive involvement in risky activities.
The episode must:
Cause marked impairment in functioning,
Require hospitalization, or
Include psychotic features.
The episode should not be attributable to the effects of a substance or another medical
condition.
INVESTIGATIONS
There is no specific laboratory test to diagnose mania. Investigations are performed to exclude
medical causes and establish baseline health before treatment.
Laboratory Investigations
Full Blood Count (FBC)
Electrolytes, Urea, and Creatinine (E/U/Cr)
Liver Function Test (LFT)
Thyroid Function Test (TFT)
Fasting Blood Glucose
Lipid Profile
Pregnancy Test (where applicable)
Urinalysis
Urine Drug Screen
Blood Alcohol Level (if indicated)
Imaging: CT scan and MRI of the brain, used when neurological disease is suspected.
Psychological Assessment Tools
Young Mania Rating Scale (YMRS)
Mood Disorder Questionnaire (MDQ)
MANAGEMENT OF MANIA
The goals of treatment are to:
Ensure the safety of the patient and others.
Control acute manic symptoms.
Restore normal sleep and eating patterns.
Prevent complications.
Prevent relapse.
Improve psychosocial functioning and quality of life.
Pharmacological Management
A. Mood Stabilizers
These are the cornerstone of treatment.
Lithium
Effective for acute mania and relapse prevention.
Requires regular monitoring of serum lithium levels, kidney function, and thyroid function.
Sodium Valproate (Valproic Acid)
Particularly useful in acute mania and mixed episodes.
Avoid during pregnancy because of teratogenicity.
Carbamazepine
Alternative mood stabilizer when lithium or valproate is unsuitable.
Requires monitoring for blood dyscrasias and liver toxicity.
B. Antipsychotics
Used to rapidly control manic symptoms, especially when psychosis or severe agitation is
present.
Second-generation (atypical) antipsychotics include:
Olanzapine
Risperidone
Quetiapine
First-generation antipsychotics:
Haloperidol (commonly used in severe agitation)
C. Benzodiazepines
Useful for short-term management of agitation and insomnia. Examples:
Lorazepam
Clonazepam
Diazepam
They should generally be used for a short duration due to the risk of dependence.
Non-Pharmacological Treatment
Psychoeducation
Cognitive Behavioural Therapy (CBT)
Family therapy
Occupational therapy
Group therapy
Electroconvulsive Therapy (ECT) for severe or treatment-resistant mania, catatonia, or
when a rapid response is needed.
Nursing Management
1. Assessment
Assess mood and affect.
Assess risk of suicide or violence.
Assess nutritional status.
Monitor sleep pattern.
Assess medication adherence.
Monitor mental status.
2. Nursing Diagnoses
Risk for injury.
Disturbed thought processes.
Imbalanced nutrition: less than body requirements.
Disturbed sleep pattern.
Impaired social interaction.
Ineffective coping.
3. Nursing Interventions
Ensure a safe environment by removing dangerous objects.
Observe the patient closely.
Set firm, consistent limits on behavior.
Use calm, brief, and clear communication.
Reduce environmental stimulation.
Encourage frequent high-calorie finger foods and fluids.
Promote rest periods and sleep.
Administer medications as prescribed.
Monitor therapeutic drug levels (e.g., lithium).
Watch for medication side effects.
Reinforce reality gently; do not argue with delusions.
Educate the patient and family about relapse prevention and medication adherence.
Encourage follow-up appointments.
Prevention of mania
1. Primary Prevention:
Stress management
Healthy sleep habits
Avoid psychoactive substances
2. Secondary Prevention:
Early diagnosis
Prompt treatment
3. Tertiary Prevention:
Long-term medication adherence
Regular psychiatric follow-up
Relapse prevention plans
Patient and Family Education
Emphasize the importance of taking medications consistently.
Teach early warning signs of relapse, such as decreased need for sleep, increased
energy, irritability, or excessive spending.
Encourage regular clinic attendance.
Advise avoidance of alcohol and illicit drugs.
Encourage family involvement in treatment and support.
Case study
Mr. Musa Samuel, a 32-year-old married businessman, was brought to the psychiatric unit by
his wife and elder brother because of 10 days of increasingly unusual behavior.
According to his wife, he had become unusually cheerful and energetic. He woke up every day
at 2:00 a.m., claiming he did not need sleep because he had "too many important ideas."
Despite sleeping only 2–3 hours each night, he remained active throughout the day.
He began speaking continuously, often so rapidly that people could not interrupt him. During
conversations, he frequently changed from one topic to another before completing his thoughts.
Within one week, he spent over ₦6 million from the family's savings buying expensive cars,
electronics, and gifts for strangers. He also promised several people jobs in companies that he
did not own.
At home, he became unusually religious and claimed that God had chosen him to become the
next President of Nigeria. He insisted that he possessed supernatural powers and could heal
sick people.
His family noticed that he became easily irritated whenever anyone questioned his decisions.
On two occasions, he became physically aggressive after being advised to rest.
His appetite decreased significantly because he claimed eating was "a waste of valuable time."
He lost about 5 kg within two weeks.
He stopped taking his prescribed psychiatric medications eight months earlier because he
believed he had been permanently cured.
His wife reported that he had experienced a similar episode four years earlier and was admitted
to a psychiatric hospital, where he improved after treatment with lithium and an antipsychotic
medication.
There was no recent history of alcohol misuse or illicit drug use. There was also no history of
fever, head injury, seizures, or chronic medical illness.
ASSIGNMENT
1. Design a nursing care plan for the case study above
2. Read on the non-pharmacological management of mania
References
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental
Disorders (5th ed., text rev.; DSM-5-TR).
National Institute for Health and Care Excellence (NICE). (2023). Bipolar disorder:
Assessment and management (CG185).
Townsend, M. C., & Morgan, K. I. (2024). Psychiatric Mental Health Nursing: Concepts of
Care in Evidence-Based Practice (11th ed.).
Varcarolis, E. M. (2022). Essentials of Psychiatric Mental Health Nursing (4th ed.).