Mania
Background[1]
- See Bipolar disorder
- Manic episode defines Bipolar I disorder
- Do not need major depressive episode for Bipolar I diagnosis
- Hypomania is a feature of Bipolar II and cyclothymic disorders
- Psychiatric emergency - impaired judgement can make them dangerous to themselves and/or others
- 90% of those with a manic episode will have an additional mood episode within 5 years
Clinical Features[1]
Manic Episode
- Distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently goal directed activity or energy lasting at least 7 days and including 3 of the following (4 if mood is only irritable):
- Distractibility
- Inflated self-esteem or grandiosity
- Increased goal directed activity (can be social, work, or sexual in nature) or psychomotor agitation
- Decreased need for sleep
- Flight of ideas or racing thoughts
- More talkative than usual or pressured speech (rapid and uninterruptible)
- Excessive involvement in pleasurable activities that have high risk of negative consequences
- Symptoms must not be attributable to a substance or medical conditions
- Symptoms must cause clinically significant distress or social/occupational impairment
Hypomanic Episode
- Features as above except:
- Lasts at least 4 days
- No marked impairment in social/occupational function
- Does not need hospitalization
- No psychotic features
- Features as above except:
Differential Diagnosis
Psychiatric
- Mania (Bipolar I)
- With or without psychosis
- Schizophrenia spectrum of disorders
- Schizoaffective disorder, bipolar type
- ADHD
- Borderline personality disorder
Medical
- Delirium
- Hyperthyroidism
- Wilson disease
- Infectious
- Medication/Substance induced
- Cocaine/Amphetamines/Other Sympathomimetics
- Corticosteroids
- Dopamine/Levodopa
- Antidepressants
- Alcohol/benzodiazepine withdrawal
- Neurologic disorders
Evaluation
- Interview and physical for diagnostic criteria as above
- Collateral if available
- Assess for alternate medical causes based on situation
- Psychiatric consultation
Workup
ACEP Clinical Policies: Psychiatric Patient[2]
- Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing. (Level C Recommendation)
- Tailor medical workup based on individual clinical scenario
- Pregnancy test in reproductive age female
- TSH often reasonable if new mania
- Consider toxicologic workup if unclear med/substance history
- Consider Head CT if altered and no psychiatric history
- Consider LP if high concern for infectious CNS cause
- Consider lab evaluation for causes of delirium
Diagnosis
- Clinical - see clinical features
- Exclude organic causes as best as possible
ED Management
- Psychiatric evaluation - typically with admission
- Medications for agitation as needed - consider atypical antipsychotics
General Management
- Psychotherapy
- Supportive, family, group
- Pharmacotherapy[3]
- Lithium
- Long term use reduces suicide risk
- Lithium toxicity can be fatal
- Mood stabilizers
- Atypical antipsychotics
- Often as adjunct to mood stabilizer, less common monotherapy
- Lithium
- ECT
Disposition
- Mania usually necessitates admission
- Medical admit if underlying cause identified
- Hypomania may be able to be discharged with outpatient support
See Also
External Links
https://www.acep.org/patient-care/clinical-policies/Psychiatric-Patient
References
- ↑ 1.0 1.1 American Psychiatric Association. Diagnostic and statistical manual of mental disorders. American Psychiatric Association Publishing; 2022 Mar 18.
- ↑ Brown MD, Byyny R, Diercks DB, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Ingalsbe GS, Kaji A. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Annals of emergency medicine. 2017 Apr 1;69(4):480-98.
- ↑ Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY, USA: McGraw Hill Education; 2016.