Manic Episode The nosology of the various stages of a manic episode has changed over the decades. In cu rrent DSM-IV nomenclature, hypomanic episodes are separated from the more severe full manic episodes, which in turn are characterized as either mild, moderate, severe, or severe with psychotic features. Kraepelin, however, divided the “manic states” into four forms—hypomania, acute mani a, delusional mania, and delirious mania—and noted that his observation revealed “the occurrence of gradual transiti ons between all the various states.” In a similar vein, Carlson and Goodwin, in their elegant paper of 1973, divided a manic episode into “three stages”: hypomania, or stage I; acute mania, or stage II; and delirious mania, or stage III. As this “staging” of a manic episode is very useful from a descriptive and differential diagnostic point of view, it is used in this chapter. Thus, when the term “manic episode” is used it may refer to any one of the three stages of mani a: hypomania, acute mania, or delirious mania. Manic episodes are often preced ed by a prodrome, lasting from a few days to a few months, of mild and often transitory and indistinct manic symptoms. At times, however, no prodromal warning signs may occur, and the episode starts quite abruptly. When this occurs, patients often unaccountably wake up during the night full of energy and vigor—the so-called “manic alert.” The cardinal symptoms of mania are the following: heightened mood (either euphoric or irritable); flight of ideas and pressure of speech; and incr eased energy, decreased need for sleep, and hyperactivity. Th ese cardinal symptoms are most plainly evident in hypomania. In acute mania they exacerbate and may be joined by delusions and some fragmentation of behavior, and in delirious mania only tattered scraps of the cardinal symptoms may be present, otherwise being obscured by florid and often bizarre psychotic symptoms. Although all patients experience a hypomanic stage, and almost all progress to at least a touch of acute mania, only a minority finally are propelled into delirious mania. The rapidity with which patients pass from hypomania through acute mania and on to delirious mania varies from a week to a few days to as little as a few hours. Indeed, in such hyperacute onsets, the patient may have already passed through the hypomanic stage and the acute manic stage before he is brought to medical attention. The duration of an entire manic episode varies from the extremes of as little as a few days or less to many years, and rarely even to a decade or more. On the average, however, most first episodes of mania last from several weeks up to 3 months. In the natural course of events, symptoms tend to gradually subside; after they fade many patients feel guilty over what they did and perhaps are full of self-reproach. Most patients are able to recall what happened during hypomania and acute mania; however, memory is often spotty for the events of delir ious mania. With this brief general description of a manic episode in mind, what follows now is a more thorough discussion of each of the three stages of mania.
Posted on: Sun, 04 Aug 2013 12:10:59 +0000
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