in the last video we learned about depression in this video we're going to learn about the flip side of that coin which is known as mania mania is characterized by excessive elevations in mood and energy rather than dips down like in depression mania is the hallmark state of bipolar disorder a psychiatric condition that involves both manic highs and depressive lows like we did in the last video we will start by learning about how to diagnose mania before talking about its epidemiology prognosis and treatment we will then wrap up by learning about how mania and depression can present in a few distinct combinations like depression mania involves not only changes in mood but also other clinical features as well let's start with the mood side of things patients in a state of mania have an elevated mood and will generally describe their emotional state as great wonderful fantastic on top of the world or like a million bucks this begs an obvious question what exactly is so bad about somebody feeling so good with depression it makes sense why too much sadness is a problem but with mania it's less clear why too much happiness is a disorder the problem with mania is that just like in depression a patient's mood in mania is non-reactive making them incapable of experiencing emotions other than happiness to use an analogy it's not a problem if a car can go fast as long as it's capable of slowing down when it needs to however in mania it's like the brakes have been cut and the patient can't go any speed other than fast this was illustrated for me most dramatically when i was working with a patient who was hospitalized for mania during his hospitalization his mother was involved in a serious car accident who was on life support fighting for her survival when we told him he responded by smiling laughing and cracking jokes as his manic state did not allow him to feel the usual emotions that would accompany such news later when he was out of the manic episode he was absolutely horrified by how he had responded and he felt a deep shame over how he had reacted despite his actions not being entirely within his control at the time another problem with mania is that some patients will experience it not as euphoria but rather as irritability at its core mania is a sustained increase in energy while many patients will experience this in a positive way a sizable minority of patients will instead experience this energy as irritability or even hostility other patients will alternate between euphoria and irritability depending on the circumstances i liken this to the energy boosting effects of caffeine many people feel great after drinking some coffee but others just get cranky into beset finally mania is problematic because it is accompanied by other patterns that can lead to bad outcomes these additional signs and symptoms of mania are summarized in the mnemonic dig fast first the d stands for distractibility people in a state of mania are often highly distractible and have trouble staying on any one subject they may have difficulty finishing a conversation or even a single sentence as their tension is being quickly pulled in many different directions this makes it hard to interact with others or get much of anything done next the i is for impulsivity patients in a state of mania act without regards to consequences often in a way that involves pleasure-seeking activities accordingly they are known to engage in risky behaviors like drug use reckless driving unprotected sex and spending thousands of dollars at a time on unnecessary purchases patients can and do wreck their lives due to mania related impulsivity leading to lost jobs strained finances and ruined relationships the g is for grandiosity thought content in mania often involves a degree of self-importance and grandiosity people in a manic state can come to believe that they are a special or exalted figure like a king president ceo prophet or messiah and make plans accordingly like changing their name or insisting that others call them by their new title the f is for flight of ideas while grandiosity describes the thought content in mania flight of ideas describes the thought process in mania ideas fly through the mind so rapidly that it's difficult for anyone to keep track of the conversation if you're having difficulty keeping up with the thought process of a patient that you're interviewing this is highly suggestive of a manic episode the a is for activity more than any other sign or symptom an increase in energy and activity is a key hallmark of mania specifically the activity in mania is goal directed and involves working towards some kind of reward or outcome this increased busyness of people in a manic state is highly sensitive of mania analogous to anhedonia and depression and the dsm even changed its diagnostic criteria so that the absence of increased goal-directed activity effectively rules out the diagnosis goal-directed activity is important enough that i encourage you to make an acronym out of the word mania that stands for mood abnormalities and increased activity it's not just one or the other you need both next the s is for sleep decreased sleep is another key symptom of mania in contrast to depression which is most often characterized by an inability to get refreshing sleep sleep disturbance in mania is experienced as a decreased need for sleep it's not uncommon for people in a manic state to keep going for days or even weeks on only a couple hours of sleep per night and not even feel the slightest bit tired finally the t is for talkativeness people in a manic state are often exceptionally chatty they may talk a mile a minute and be difficult to interrupt or even walk around a room repeatedly striking at conversations with every person present and wanting to shake their hands this is described on a mental status exam as pressured speech and is a specific sign of mania in the dsm to be diagnosed with the manic episode you need to have elevated mood plus at least three of the seven dig fast symptoms one of which must be increased goal directed activity the threshold is increased to four out of the seven for patients who experience mania exclusively as irritability as irritability is less specific for mania than euphoria these changes must be present for one week or more just like you can think of two blue weeks in depression you can think of one fun week in mania and that's how you diagnose mania if mania is like driving a car with no brakes then it makes sense that this will inevitably end in a crash this is exactly what we see with mania as manic episodes are frequently followed by depressive episodes indeed the relationship between mania and depression is so well characterized that we refer to people who experience manic episodes as having bipolar disorder the depressive episodes seen in bipolar disorder are clinically indistinguishable from those seen in unipolar depression and patients will present with the same sigicapp signs and symptoms that we talked about in the last video however despite the similarities in presentation bipolar depression is likely a completely different disorder than unipolar depression and requires its own treatment considerations as we'll talk about shortly let's learn more about what happens with bipolar disorder across the lifespan including who gets it what they can expect to happen and what forms of treatment are effective bipolar disorder is a relatively rare syndrome affecting around one percent of the population compared to around 20 for unipolar depression compared to unipolar depression bipolar disorder also tends to begin earlier in life with onset in early adulthood at an average age of 21 years men and women are equally affected like unipolar depression functioning is often significantly impaired during an episode but preserved between episodes however people with bipolar disorder tend to spend more of their lives in a mood episode compared to people with unipolar depression in fact studies show that people with bipolar disorder spend as much as 50 percent of their lives in some form of abnormal mood with about a third being depression a tenth being a state of mild romantic symptoms known as hypomania and about five percent being spent cycling between episodes from this we can see that mania despite being the hallmark state of bipolar disorder is actually quite rare making up only around one percent of the lives of patients with bipolar disorder despite this rarity mania must be taken seriously given its potential for harm especially considering the high-risk behavior like reckless driving or drug abuse in which patients tend to engage during a manic episode in contrast to depression bipolar disorder is a highly recurrent syndrome while the risk of recurrence after a single depressive episode is only fifty percent the risk of another mood episode after a single manic episode is over ninety percent this means that many patients will need lifelong monitoring and treatment to ensure the best outcomes bipolar disorder also has an even higher mortality rate than unipolar depression mostly due to an elevated risk of suicide during depressive episodes up to one percent of all people with bipolar disorder will attempt suicide within a one year span a rate 60 times higher than the general population in addition people with bipolar disorder tend to use highly lethal means like guns more often leading to more deaths per suicide attempt untreated an episode of mania typically lasts around three to six months but with treatment a manic episode can be stopped within a matter of days or weeks hospitalization may be necessary for acute stabilization and to ensure safety given that mania is often experienced as an enjoyable state patients may be hesitant or unwilling to seek help so involving family and friends to help encourage treatment can be very effective unlike depression where treatment generally includes either therapy medications or both with bipolar disorder the standard of care is to almost always use medications with psychotherapy alone not being considered sufficient treatment even if it can help to improve outcomes when combined with drug treatment medications used to treat bipolar disorder are known as mood stabilizers the oldest known mood stabilizer is lithium which has been shown to be effective of both treating and preventing manic and depressive episodes lithium is also one of the few medications that has been proven to lower suicide risk in fact patients taking lithium are over 80 percent less likely to commit suicide while on the drug certain anticonvulsant medications that are often used to treat seizures can also act as mood stabilizers however these tend to treat either mania or depression not both valporic acid and carbamazepine are helpful for treating mania but do not treat depression while lamotrigine prevents depression but does nothing against mania drugs known as antipsychotics which most people tend to associate with psychotic disorders like schizophrenia are in fact quite effective at treating bipolar disorder as well in fact antipsychotics are actually faster at treating mania than conventional mood stabilizers and should be used as a first-line treatment in situations when urgent treatment is needed any antipsychotic can treat mania in contrast only a select few antipsychotics can treat bipolar depression with quatipine lorazodone olanzapine and kryprizine being the only four at this time given that depressive episodes are a big part of bipolar disorder you might be tempted to use antidepressants like ssris as well however this doesn't actually work as well as you would hope with studies showing that conventional antidepressants are often ineffective for treating bipolar depression and may actually be harmful by increasing the rate that a patient cycles between mania and depression that's not to say that they're never helpful for any patients but they should generally not be a first-line option like depression bipolar disorder is not a single condition but instead comes in a few varieties each of which carries important implications for prognosis and treatment let's talk about how mania and depression can combine in different ways to create distinct disorders first bipolar disorder type 1 is characterized by episodes of mania alternating with episodes of depression the presence of even a single manic episode qualifies the patient for a diagnosis of bipolar 1 regardless of how many depressive episodes they've had in contrast bipolar disorder type 2 is characterized by episodes of hypomania rather than mania hypomania is on the same spectrum as mania with elevated mood and increased goal direct activity being key features but importantly it doesn't get to the level where it becomes impairing in fact many people with bipolar 2 find hypomania to be a delightful state with improved mood and incredible productivity because it does not impair the patient's ability to function hypomania is not considered to be an inherently pathological state however the reason why bipolar 2 is a disorder is that patients with hypomania often if not always experience episodes of severe depression as well indeed despite the absence of full-blown manic episodes on the whole cases of bipolar 2 should not be seen as milder compared to bipolar 1. while their manic states are less pronounced people with bipolar 2 often have more frequent and severe depressive episodes leading to similar overall levels of functional impairment and higher rates of suicide you can remember this by thinking of the two in bipolar 2 as two lowercase l's standing for lower lows another related disorder is cyclothymia which in theory at least is a mild form of bipolar disorder where the patient has both hypomanic episodes that are not severe enough to meet criteria for a manic episode as well as periods of dysthymia that are not severe enough to meet criteria for a major depressive episode it is essentially bipolar disorder's version of dysthymia representing a more persistent but less severe version of the prototypical disorder as with dysthymia patients must have features of the disorder for two years in order to qualify for the diagnosis in actual clinical practice a diagnosis of cyclothymia is incredibly rare this is due to the fact that it's ultimately not that hard to meet criteria for a major depressive episode in which case the patient would instead be diagnosed with bipolar 2. someone who truly never reaches a full-blown state of either depression or mania may also be less likely to seek treatment compared with someone in a full depressive or manic episode for both of these reasons you will rarely if ever diagnose cyclothymia research on treatment is limited although it appears to be treated similarly to bipolar disorder with mood stabilizers and or antipsychotics let's recap the five mood disorders we've talked about in these past two videos when talking about these disorders it's worth pointing out that these are all mutually exclusive and any given patient can only have one of them at a time that's because each of these diagnoses is superseded by the one above it for example someone with a history of both depressive episodes in hypomanic episodes doesn't have both major depressive disorder and bipolar 2 they just have bipolar 2. if this same patient were to then go on to have a full-blown manic episode they would then convert to bipolar 1 disorder rather than having both keep this in mind to avoid adding on more diagnoses than are necessary one variant of mania that's worth talking about is a mixed state while classically depression and mania were considered to be mutually exclusive states our modern understanding is that it is not only possible for someone to have both depressive and manic symptoms at the same time but that is actually rather common this mixture of depressive and manic symptoms is known as a mixed state while it may seem paradoxical to be both manic and depressed at the same time it makes more sense when you consider that the core feature of mania is increased energy and goal-directed activity therefore a mixed state isn't someone who feels both happy and sad at the same time rather it's a combination of low mood including thoughts of guilt worthlessness hopelessness despair and suicide with increased goal-directed activity this combination makes mixed states a high risk state with a higher chance of reckless activity or suicide compared to either depression or mania alone diagnostically mixed states are considered to be equivalent to manic episodes so if a patient has even one mixed episode in their life their diagnosis would be bipolar one as with most bipolar disorders treatment of a mixed state involves mood stabilizers and or antipsychotics with antidepressants to be avoided as a final note it's worth pointing out that just as depression can present with psychotic features so too can bipolar disorder co-occur with psychosis this can occur during mania depression or a mixed state the frequency of psychotic symptoms and bipolar disorder is even more pronounced than in unipolar depression with more than half of all patients with bipolar disorder experiencing some degree of psychotic symptoms in their lifetime treatment often involves antipsychotics either on their own or combined with a mood stabilizer like lithium or an anticonvulsant hey congrats on finishing this video bipolar disorder is a tricky beast to learn about due to the many different mood states making for increased diagnostic complexity but hopefully this lecture simplified things what we covered in this video is just scratching the surface of bipolar disorder so consider checking out my book memorable psychiatry to learn more including a full discussion of the mechanisms at play as well as how to tell bipolar disorder apart from many other diagnoses all involving mood instability there are a bunch of practice questions as well to test your knowledge until then see you in the next video