Mania 111Box 11.2A summary of ICD-10∗criteria for a manic episode
There is a prominent episode of elevated, expansive or irritable mood that is
definitely abnormal for the individual concerned and sustained for at least 7
days (or requires hospitalisation). During the episode of altered mood, at least
three of the following symptoms need to have been present, leading to severe
interference with personal functioning in daily living. (If the abnormal mood is
irritable rather than elevated or expansive, then the minimum requirement is
four rather than three symptoms.)
1 Increased purposeful activity (getting more done) or psychomotor agitation.
2 More talkative.
3 Flight of ideas or a subjective sense of accelerated thought.
4 Loss of normal social inhibitions, resulting in behaviour that is inappropriate
to the circumstances.
5 Less need for sleep, for example, feeling alert and fully rested after just a few
hours sleep per day.
6 Exaggerated self-esteem or grandiosity.
7 Easily distracted by small or unimportant stimuli.
8 Reckless behaviour whose risks the individual does not recognise, for example,
spending sprees.
9 Marked sexual energy or sexual indiscretions.
The symptoms are not directly attributable to substance use (for example,
cocaine) or a medical illness (for example, hyperthyroidism).
Note:∗DSM-IV criteria are generally similar.The ICD-10 Classification of
Mental and Behavioural Disorders: Diagnostic Criteria for Research(World Health
Organization 1993).In addition, it is worth noting that some depressed individuals expe-
rience ‘rebound’ hypomanic symptoms when treated with antidepres-
sants. This alone is not enough to qualify for Bipolar II (since symptoms
are directly attributable to treatment). Individuals who experience an
antidepressant-induced rebound may be at increased risk for future bipolar
disorder.
A manic episode can potentially be accompanied by the full range of
psychotic symptoms described in Box 24.1. It is relatively easy to see that
grandiose delusions – involving special powers and high status – are con-
gruent with elevated mood and exaggerated self-esteem. It is a surprise,
however, to find that mania can also involve the hard-to-understand psy-
chotic symptoms that many psychiatrists link particularly to schizophrenia.
This is potentially a diagnostic trap: a psychotic adolescent with some
hard-to-understand hallucinations or delusions may be given a premature
diagnosis of schizophrenia that later needs to be changed to bipolar
disorder once it becomes clear that there are clear episodes of mania and
depression, with good recovery in between. It is worth adding, however,
that drawing a sharp distinction between schizophrenia and bipolar disor-
der may distort what is actually a continuum, both phenomenologically
and genetically.