Few years back, I was in Hyderabad. One morning, as I was about to open the morning newspaper with my tea, the doorbell rang. I was surprised to see after many years a far off relative of mine (paternal side cousin uncle) standing at my door with a suitcase. I took him inside. As soon as he entered, he sat on the couch and started talking to me very excitedly. I hadn’t even brushed till then. I asked him to sit for a while till I freshen up. He immediately switched on the TV and started watching it with full volume. After some time, I came back with two cups of tea and sat with him. Uncle took a sip and said “Tea is very good”. I smiled and said “staying alone, I have not learnt to cook many things.” He took out a small pouch from his pocket and offered me a “paan” which he had carried all the way from Odisha. I refused politely and said “I don’t take paan”. But he was not in a mood to listen. Putting one in his mouth and one in mine, he laughed out loud and said “I still remember, when you were a kid, you used to steal and eat my paan.” His behavior appeared a bit strange to me. I remembered, when I was a kid, at times he would get excited without any reason and behave like this. He was under treatment for the same. I thought, may be, he is again in the same excitation phase.

We sat talking about family and friends for a while. Suddenly he got up, opened his suitcase and started showing me the gifts that he had got for me. I was quite surprised to see an expensive shirts, a quite exclusive wrist watch, a tie, many packets of Odisha famous snacks etc. I said “That’s really nice of you uncle. But you are a retired person. Why did you do so much of expenditure?” He simply laughed out loud.

Next day, I saw he was busy talking to someone over phone for hours. He stayed with me for almost for a week. I noticed him doing a lot of unnecessary expenditure. He was talking for hours over phone, remaining excited most of time. He was also talking a lot with me till late nights. One day, I asked him “Don’t you feel sleepy?” He said “No I am not able to sleep at night. Daily I wake up around 3-4 O’clock and am not able to sleep after that.” I could know that he is suffering from mania. I counsel him and gave medicines.

Next day, while returning from station after dropping uncle, I got a call from my brother. I told him about uncle. My brother said “Do you remember Rahul, your school friend? I said “of course, what happened to him?” My brother said “he is behaving strangely now a day. Not doing any work and simply roaming around. Saying that, he would shift to Mumbai and become a film hero. He has many big contacts there and they would do anything for him. His parents are very worried. Their financial condition is not too good and this boy goes on doing a lot of unnecessary expenditure. He borrows money from others and goes to help other people. Doesn’t care a damn for his parents. Previously he used to be so shy. Now he talks a lot with girls. His parents say “he doesn’t sleep. Stays awake till late night and gets up early in the morning. His behavior is totally changed.” I said “I feel he is definitely suffering from mania. Ask his parents to consult a Psychiatrist and start treatment. He would definitely improve.”

Few months later, One night around 9 O’clock, I got a call from Rahul’s parents and uncle’s son. Rahul and uncle were now under regular treatment and had improved a lot. There was a smile of satisfaction on my face as I switched off the lights and went to bed.

Mania and Bipolar Disorder-FAQ

 1.How is mania recognized?

Manic states range in severity from milder hypomania to psychotic or delirious manic states. The mood in mania may be elated or euphoric, but as severity increases the mood is more likely to become irritable, labile, and dysphoric. Thoughts may race; as mania progresses, thinking becomes disorganized, expansive, and grandiose. Behavior increases from early physical hyperactivity, pressured speech, and decreased need for sleep to later manifestations of hypersexuality, increased impulsivity, and risk taking.

 2.What is bipolar disorder?

Bipolar disorder encompasses a heterogeneous group of disorders characterized by cyclical disturbances in mood, cognition, and behavior. The diagnosis requires a history of mania. Cyclothymia refers to patients with chronic mood swings that fluctuate between hypomania and minor but not major depression.

3.What is the epidemiology of bipolar disorder?

The lifetime risk for bipolar I disorder is 0.6–0.9% in industrialized nations, with no apparent gender differences; unipolar depression, however, is twice as common in women as it is in men.

Family studies find that if one parent has a major affective disorder the risk to the offspring is 25–30%, whereas if both parents have an affective disorder the risk to the offspring may be as high as 50–75%. Suicide is common in untreated bipolar disorder; 25–50% of patients attempt suicide at least once. Seasonal variations exist; depression is more common in the spring (March through May) and autumn (September through November), whereas mania is more common in the summer.

4.What is a “mixed state”?

A mixed state is diagnosed when the patient simultaneously meets criteria for mania and major depression. Mixed states are common, occurring in approximately 40% of manic patients.

5.What is the course of illness issues in bipolar disorder?

 For bipolar patients, the mean age of first impairment due to psychiatric symptoms is 17 to 19 years. The rate of cycling increases with each successive episode. The average free interval between the first and second episode is 5 years, but by the fourth episode cycles are occurring at least yearly. Although duration of episodes demonstrates inter-individual variability, the average untreated manic episode lasts 4 months and the average depressive episode 6–9 months. Manic episodes often begin abruptly over hours to days. Bipolar depressions usually take weeks to develop.

A history of chronicity, substance abuse, and mixed states is associated with poorer outcome.

6.Is there any relationship between stress and onset of affective episodes in bipolar disorder?

 Investigations suggest that stressors are statistically more likely to be associated with the onset of episodes early in the course of illness.

Interpersonal and work difficulties are common precipitants associated with mood destabilization. Sleep reduction may be a final common pathway that leads to mania in a variety of situations, including stress-induced sleep disruption, parturition, and travel. There also is a high rate of bipolarity in patients whose moods demonstrate seasonal variation.

7.what are the medical conditions that may cause, mimic, or exacerbate bipolar disorder?

 Drugs- Isoniazid, steroids, disulfram

Neurologic factors- Multiple sclerosis, closed head injury, CNS tumors, epilepsy, Huntington’s disease, cerebrovascular accident

Metabolic factors- Thyroid disorders, postoperative states, adrenal disorders, vitamin B12 deficiency, electrolyte abnormalities

Infection- AIDS dementia, neurosyphilis, influenza

8.What psychiatric conditions are commonly co-morbid with bipolar disorder?

Bipolar disorder is most likely to be associated with comorbid substance abuse or dependence.

Anxiety symptoms are also found more commonly in patients with bipolar disorder.

9.What are the medications used in the treatment of bipolar disorder?

Lithium, valproic acid and carbamazepine are considered by many clinicians to be the first-line drug in the treatment of mania and bipolar mood cycling. More recently,investigators and clinicians have looked at the use of lamotrigine, gabapentin, and topiramate for patients with bipolar disorder. The treatment of acute mania includes the use of antimanic drugs and, depending on the severity of illness, adjunctive agents such as sedative-hypnotics, benzodiazepines, and antipsychotic agents. The treatment for acute depression is complicated in bipolar patients by the need to minimize the use of antidepressant agents.

Preventive treatment with antibipolar agents usually is indicated, because bipolar disorder almost always is recurrent.