We think we know mania when we see it, but it is such a diverse group of symptoms that it has become established as “manic episodes” that are building blocks of diagnosis, rather than separate diagnoses. It functions primarily to separate Bipolar Disorder, formerly called manic depressive disorder from the other depressive conditions.
Mania has been described as the most heterogeneous mental health symptom there is, raising the question “When we say mania are we all talking about the same thing?” Are there types of mania that have different causes and indicate varying diseases?
Currently there are over 400 recognized disorders or conditions that might be the focus of treatment in the DSM-4. As you may have seen from previous posts many of these disorders have lots of subtypes that look differently in practice and may require different treatments.
Mania and Bipolar disorders are especially difficult because of their wide diversity of symptoms. For more on the DSM-4 and some to be DSM-5 descriptions see: What is mania? And What is hypomania?
Encarta Dictionary definitions of mania include
1. An excessive and intense interest or enthusiasm for something and 2. A psychiatric disorder characterized by excessive physical activity, rapidly changing ideas and impulsive behavior. The two uses of the word mania don’t have a lot in common.
Kraepelin, whose work has formed much of the foundation for modern efforts to divide up and diagnose illnesses, reported there were 6 types of mania. His distinctions seem to have been blended together into the one thing we now call Mania. But are all manias really the same?
Research has been less than helpful here as most researchers exclude a lot of people from their studies. If you exclude enough people for enough reasons the group left may look all alike. That does not mean the resulting study tells us anything about the various problems people with mania are undergoing.
One study (Haro et al., 2006) tells us that they found three vary different forms of mania. The most common form of mania they called “typical mania” and this group contained 60% of the people in the study. But the other 40% had symptoms that were so different that the authors separated them into two additional subtypes of mania.
Psychotic mania is not like “Typical mania.”
Psychotic symptoms sometimes end up in making mania for a bipolar diagnosis but psychotic episodes can occur in other illnesses such as schizophrenia. It is common for families to have members who have been diagnosed with bipolar disorders and other schizophrenia. Psychotic mania looks a lot like psychosis and bipolar at the same time but then we have another illness schizoaffective disorder to use for that also. This leaves the diagnosis of psychotic Bipolar in doubt. I have seen doctors record a diagnosis of schizophrenia – bipolar type.
Dual Mania is similar to other dual diagnoses
Dual Mania was described by Haro et al. as significantly different from other types of mania. Dual-diagnosis mania has been poorly recognized simply because most people who abuse substances are routinely excluded from research studies . Haro et al. report that this systematic exclusion of people with multiple problems leaves a huge gap in our understanding of mania and therefore Bipolar Disorder .
Dual Diagnosis client with mania spent significantly more days in the psychiatric hospital and had more suicide attempts. This is consistent with other studies that have shown people with Bipolar Two are at the highest risk for a suicide attempts and that people who abuse substances have higher risks also. Unfortunately acutely suicidal clients are also routinely excluded from studies of mania and Bipolar Disorders despite there being over represented in substance abuse treatment and acute psychiatric facilities.
Other characteristics of clients with “dual mania” included being male and younger than others with a mania episode. Dual mania resulted in higher disability levels. Dual mania was also more likely to cause job and relational problems.
Of those clients in the Haro et al study, 25% had a history of alcohol abuse. Of those with dual mania 40% had a history of marijuana use or abuse. So that means many dual mania clients had abused both.
In substance abuse treatment the pattern of alcohol and marijuana use coupled with job, relational and legal problems is so common as to be almost universal. Among those in treatment for methamphetamine abuse, manic and hypomanic symptoms are commonly reported even when the client is not using drugs. Episodes of manic or hypomanic symptoms are also commonly reported as triggers for substance abuse relapse.
Of those with long term mania and multiple hospitalizations the “aggressive type” all had histories of substance abuse (Soto, 2003.) This study did not specifically include a substance abuse type of mania but noted that among those with long term mania and a history of substance abuse those who had not used in the last 30 days were no different than those who had used or drank. The suggestion to me is that there is something different about those who experience mania and abuse substances. Mania predisposes people to abuse substances and both conditions need to be treated.
The continued exclusion of substance abusers and those who are suicidal results in research data that excludes those at highest risk and those who most use mental health services.
For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page . For information about my other writing work beyond this blog there is also a Facebook authors page, in its infancy, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com . Thanks to all who read this blog.
Comments on Mania, Bipolar co-occurring disorders and recovery and most anything mental health related are always welcomed.