Mania is a facet of type I bipolar disorder in which the mood state is abnormally heightened and accompanied by hyperactivity and a reduced need for sleep.

1. By- Isha Thapa Magar
Nursing Instructor

3. Introduction
• Mood disorders previously referred to as affective
disorders.
• Mood disorders encompass a large group of
disorders; characterized by pervasive
dysregulation of mood and psychomotor activity
and by related biorhythmic and cognitive
disturbances.
• Mood disorders are one of the most commonly
occurring psychiatric-mental health disorders.

4. • By the year 2020, mood disorders are
estimated to be the second most important
cause of disability worldwide.
• The prevalence rate of mood disorders is 1.5
percent, and it is uniform throughout the
world.

5. Definitions
• Mood disorder is a condition whereby the
prevailing emotional mood is distorted or
inappropriate to the specified circumstances.
• Affective disorders are group of disorders in
which fundamental disturbances or changes in
mood occur accomplished by overall change in
level of activity

6. • Mood disorder is a clinical condition in which
mood change is predominant and persistent,
associated with cognitive, psychomotor,
psycho-physiological and behavioral
difficulties; accomplished by a full or partial
manic or depressive syndrome, and
occurrence of such manifestations based on
client's mood.

7. Classification of Mood Disorder
According to the ICD-10, the mood disorders
are classified as follows:
F30-F39 :Mood Disorder
– F30 - Manic episodes
– F31 - Bipolar mood (affective) disorder
– F32 - Depressive mood (affective) disorder

8. – F33 - Recurrent depressive disorder
– F34 - Persistent mood disorder (including
cyclothymia and dysthymia)
– F38 - Other mood disorders (including mixed
affective episode and recurrent brief depressive
disorder)
– F39 - Unspecified mood disorders

9. Etiology
• The etiology of mood disorders is currently
unknown.
Biological Theories
A. Genetic Hypothesis
• Genetic factors are very important in
predisposing an individual to mood disorders.
• The lifetime risk for the first-degree relatives
of patients with mood disorder is 25% and of
normal controls is 7%.

10. • The lifetime risk for the children of one
parent with mood disorder is 27% and of both
parents with mood disorder is 74%.
• The concordance rate for monozygotic twins
is 65% and for dizygotic twins is 15%.

11. B. Biochemical theories.
• Increased amounts of norepinephrine,
serotonin and dopamine activity cause an
elevation in mood and the two phases of
bipolar disorder whereas decreased amounts
lead to depressed mood.
C. Neuroendocrine Disturbance
• Mood is also affected by the thyroid gland.
Approximately 5%-10% of clients with
abnormally low level of thyroid hormones
suffer form a chronic mood disorder.

12. • Clients with a mild, symptom-free form of
hypothyroidism are more vulnerable to
depressed mood than the average person.
• Abnormalities of neuroendocrine such as
decreased nocturnal secretion of melatonin,
decreased levels of prolactin, follicle-
stimulating hormone, testosterone , and
somatostation and sleep-stimulation of
growth hormone cause mood disorders in
clients.

13. Psychological theories
A. Psychoanalytic theory
• According to Freud depression results due to loss
of a 'loved object' and fixation in the oral sadistic
phase of development.
• In this model, mania is viewed as a denial of
depression.
B. Behavioural theory
• This theory of depression connects depressive
phenomena to the experience of uncontrollable
events. According to this model, depression is
conditioned by repeated losses in the past.

14. C. Cognitive theory
• According to this theory depression is due to
negative cognitions which includes:
- Negative expectations of the environment
- Negative expectations of the self
- Negative expectations of the future
• These cognitive distortions arise out of a
defect in cognitive development and cause of
the individual to feel inadequate, worthless
and rejected by others.

15. D. Sociological theory
• Stressful life events such as the loss of parent
or spouse, financial hardship, illness,
perceived or real failure, and midlife crisis etc
are factors contributing to the development of
a mood disorders.
• Certain populations of people including the
poor, single persons, or working mothers with
young children seem to be more susceptible
than others to mood disorders.

16. Manic Episode

17. Definition
• It is a psychotic medical condition in which
client manifests a clinical syndrome
characterized by extremely elevated mood,
energy, hyperactivity, unusual thought process
with flight of ideas and acceleration in
speaking process.

18. Incidence
• 0.6 – 1 per cent adults will have mania during
their life time.
• Onset is most common in late adolescence or
early adulthood.
• Incidence is more in
- Unmarried, separated or divorced cases
- Urban, upper socioeconomic groups

19. - Positive family history, monozygotic twins.
- Drug induced manic disturbance
- Male : Female ratio 1:1 (Bipolar disorder; males
tend to have manic episode first, cycling with
depressive episode; females tend to have
depressive episode first circle with mania later).

20. Clinical features
A. Elevated, Expansive or Irritable Mood
B. Psychomotor Activity Disorder
C. Goal Directed activities
D. Speech and thought disorder
E. Other Features

21. A. Elevated, Expansive or
Irritable Mood
The elevated mood in mania has four stages
depending on the severity of manic episode:
1. Euphoria ( mild elevation of mood):
• An increased sense of psychological well-being
and happiness, not in keeping with ongoing
events.
• This is usually seen in hypomania (Stage I).

22. 2. Elation (moderate elevation of mood):
• A feeling of confidence and enjoyment, along
with an increased psychomotor activity.
• Elation is classically seen in mania (Stage II).
3. Exaltation (severe elevation of mood):
• Intense elation with delusions of grandeur;
seen in severe mania (Stage III)

23. 4.Ecstasy (very severe elevation of mood):
• Intense sense of rapture or blissfulness;
typically seen in delirious or stuporous mania
(Stage IV)

24. B. Psychomotor activity disorder
• Increased psychomotor activity, ranging from
over activeness and restlessness to manic
excitement.
• The activity is usually goal-oriented and is
based on extend environmental cues

25. C. Speech and Thought Disorder
• More talkative than usual
• Flight of ideas: Thought racing in mind, rapid
shift from one topic to another.
• Pressure of speech: Speech is forceful, strong
and interruptive. Use playful language with
rhyming, joking an teasing and speak loudly.
• Delusion of grandiosity, persecution
• Distractibility

26. D. Goal-directed Activity
• Patient is unusually alert, trying to do many
things at one time.
• In hypomania, the ability to function becomes
much better and there is a marked increase in
productivity and creativity.
• In mania:
- Marked increase in activity with excessive
planning and, at times, execution of multiple
activities.

27. - Easily distractibility, there is often a decrease
in the functioning ability in later stages
- Marked increase in sociability even with
unknown people
- Person becomes impulsive and disinhibited,
with sexual indiscretions, and can later
become hypersexual.
- Poor judgment

28. • Usually dressed up in gaudy ( a showy
ornament) and flamboyant clothes bright
light, orange red colour), although in severe
mania there may be poor self care, dress is
often inappropriate (bright color that do not
match, excessive make up and jewelers, untidy
appearance).

29. - Involved in the high-risk activities such as
buying sprees, reckless driving, foolish
business investments, and distributing money
and/or personal articles to unknown persons.

30. E. Other Features
• Sleep is usually reduced (<3 hours) with a
decreased need for sleep.
• Appetite may be increased but later these is
usually decreased food intake due to marked
activity.
• Insight is absent, especially in severe mania.

31. • Psychotic features such as delusions,
hallucinations which are not understandable
in the context of mood disorder e.g. delusions
of control, may be present in some cases.

32. • Loss of normal inhibitions, resulting in
behavior that is inappropriate to the
circumstances.
• Behavior that is reckless and whose risks the
individual does not recognize, e.g. spending
sprees, foolish enterprises, reckless driving.
• Marked sexual energy
• The episode is not attributed to psychoactive
substance use or to any organic mental
disorder.

33. Classification of Mania
• F30 Manic episode
F30.0 Hypomania
F30.1 Mania without psychotic symptoms
F30.2 Mania with psychotic symptoms
F30.8 Other manic episodes
F30.9 Manic episode, unspecified

34. 1. Hypomania
• It is mild form of mania.
• Hypomania is not severe enough to cause
marked impairment in social or occupational
functioning or to require hospitalization and it
does not include psychotic features.

35. • Hypomania is a period of
- abnormality and persistently mild elevation of mood,
- increased energy and activity, and
- usually marked feelings of well being and
- both physical and mental efficiency lasting 4 days and
- including three or four of the additional symptoms
(e.g. Increased sociability, talkativeness, over
familiarity, increased sexual energy, and decreased
need for sleep are often present but not to the extent
that they lead to severe disruption of work or result in
social rejection but do not impair the person's ability
to function and there is no psychotic features
(delusions and hallucinations).

36. 2. Mania without psychotic symptoms
• In mania without psychotic symptoms, mood is
predominantly elevated, expensive, or irritable,
- accompanied by increased energy, resulting in over
activity, pressure of speech, a decreased need for
sleep, lost in social inhabitation,
- marked distractibility in addition Self esteem is
inflated, and
- definitively abnormal for the individual concerned for
at least 1 week leading to severe interference with
personal functioning of daily living without psychotic
symptoms.

37. 3. Mania with psychotic symptoms
• The episode meets the criteria for mania
without psychotic symptoms and hallucination
or delusions.
• The commonest examples are those with
grandiose, self referential, or persecutory
content.
• The episode is not attributable to
psychoactive substance use or to any organic
mental disorder.

38. Diagnosis

39. Proper history taking
Mental status examination (positive criteria or
mania)
ICD 10 Diagnostic Criteria of Hypomania,
Mania without and with psychotic symptoms

40. 1. Diagnostic criteria for Hypomania
(ICD 10 diagnostic criteria)
The mood is elevated or irritable to a degree that
is definitely abnormal for the individual
concerned and sustained for at least 4
consecutive days.
At least three of the following signs must be
present, leading some interference with personal
functioning in daily living.
– Increased activity or physical restlessness
– Increased talkativeness

41. – Distractibility or difficulty in concentration
– Decreased need for sleep
– Mild overspending of reckless or irresponsible
behavior
– Increased sexual energy
– Increased sociability or over familiarity.
– The episode does not meet the criteria for mania,
bipolar affective disorder, depressive episode,
cyclothymia, or anorexia nervosa.
– The episode is not attributable to psychoactive
substance use or to any organic mental disorder.

42. 2.
Diagnostic criteria for Mania without
psychotic Symptoms
Mood must be predominantly elevated,
expensive, or irritable, and definitively
abnormal for the individual concerned. The
mood change must be prominent and
sustained for at least 1 week.
At least three of the following signs must be
present, leading to severe interference with
personal functioning of daily living.

43. There are no hallucinations or delusion,
although perceptual disorders may occur.
The episode is not attributable to
psychoactive substance use or to any organic
mental disorder.
The mood disturbance is sufficient to cause
impairment at work or danger are present to
the patient or other.

44. 3.Diagnostic criteria for Mania with
psychotic symptoms
• The episode meets the criteria for mania
without psychotic symptoms and hallucination
or delusions.

45. Treatment

46. A. Pharmacotherapy
1. Lithium
– Lithium is the drug of choice for the treatment of
manic episode (acute phase ) as well as for
prevention of further episodes in bipolar mood
disorder.
– The usual therapeutic dose range is 900-1500 mg
of lithium carbonate per day.

47. Nursing Consideration
• Lithium treatment needs to be closely
monitored by repeated blood levels, as the
difference between the therapeutic and lethal
blood levels is not very wide (narrow
therapeutic index).
- Therapeutic blood lithium = 0.8-1.2 mEq/L
- Prophylactic blood lithium = 0.6 – 1.2 mEq/L
• A blood lithium level of > 2.0 mEq/L is often
associated with toxicity, while a level of more
than 2.5-3.0 mEq/L may be lethal.

48. 2. Antipsychotics
• Antipsychotics are an important adjunct in the
treatment of mood disorder.
• The commonly used drugs include
risperidone, olanzapine, quetiapine,
haloperidol, and aripraxole.

49. 3. Other Mood stabilizers
i. Sodium valproate
– For acute treatment of mania and prevention of
bipolar mood disorder.
– Particularly useful in those patients who are
refractory to lithium.
– The dose range is usually 1000-3000mg/day ( the
therapeutic blood levels are 50-125 mg/ml).
– It has a faster onset of action than lithium,
therefore, it can be used in acute treatment of
mania effectively.

50. ii. Carbamazepine
– For acute treatment of mania and prevention of
bipolar mood disorder.
– Particularly useful in those patients who are
refractory to lithium and valproate.
– The dose range of carbamazepine is 600-1600
mg/day ( the therapeutic blood levels are 4-12
mg/ml).

51. iii. Benzodiazepines
– Lorazepam (IV or orally) and clonazepam are used
for the treatment of manic episode alone rarely;
however, they been used more often as adjuvant
to antipsychotics.

52. B. ECT (electro-convulsive therapy)
• ECT can also be used for acute mania
excitement if it is not adequately responding
to antipsychotic and lithium.

53. C. Psychosocial treatment
• Cognitive Behavior Therapy
• Interpersonal Therapy
• Psychoanalytic Therapy
• Behaviour Therapy
• Group Therapy
• Family and Marital therapy

54. Nursing Management

55. Nursing Diagnosis
• Potential risk for injury related to extreme
hyperactivity and impulsive behavior, evidenced
by lack of control over purposeless and
potentially injurious movements.
• Potential risk for violence; self-directed or
directed at others related to manic excitement,
delusional thinking and hallucinations. Altered
nutrition, less than body requirements related to
refusal or inability to sit still long enough to eat,
evidenced by weight loss, amenorrhea.

56. • Impaired social interactions related to
egocentric and narcissistic behavior,
evidenced by inability to develop satisfying
relationships and manipulation of others for
own desires.
• Self-esteem disturbance related to unmet
dependency needs, lack of positive feedback,
unrealistic self-expectations.
• Altered family processes related to euphoric-
mood and grandiose ideas, manipulative
behavior, refusal to accept responsibility for
own actions.

57. Nursing Interventions
Encouraging taking medications.
– Explain to the client and his family members the
importance of medicine and contribution of
medication as per prescription and treatment plans,
effects or complications, if not consuming drugs, etc.
in an understanding , simple manner; it is a good to
convey the message in their own language.
– Administer the drugs according to doctors order and
monitor for side effects, record and report the drugs
administered, and if any side effects observed.

58. – Administer the drugs according to doctors order
and monitor for side effects, record and report the
drugs administered, and if any side effects
observed.
– While the client is on lithium prescription,
monitor the level of serum lithium levels
periodically, advice salt restrictions diet.
– Encourage the client to perform productive
activities
– Provide calm and quiet environment.

59. Prevent from injury
– Establish calm and quiet, non-productive or non-
stimulating environment.
– Keep sharp instruments away from the client.
– Provide supportive environment.
– Keep the client aside from stressful environment.
– Do not provoke or argue with the client or others
in the client's unit.
– Protect the client by engaging in useful activities.

60. – Divert the client's by engaging in useful activities.
– Divert the client's mind by asking him to
participate in calm activities like watching TV,
playing with children, reading spiritual materials
or interest of his own.
– Never allow violent patients stay together or
nearby place in same environment.
– Establish reliable, framed environment, set
priorities and goals for everyday activities.

61. – Educate the client the coping strategies and deep
relaxation techniques to overcome aggressive
feelings.
– Never leave client all alone, one person has to
accompany to observe and guide or assist the
patient to perform useful activities. Observe the
client's interaction and restrict him to involve in
group destructive activities.
– Keep the music volume low and dim light in
client's room.
– Avoid slippery floor to prevent accidents.

62. Prevent for violence resulting causing harm
himself or to others related to manic excitement
and perceptual disturbance.
– Provide peaceful, safe, environment, establish
and maintain low stimuli in client's unit.
– Monitor the client's behavior every 15 minutes
once and maintain process recording of it,
report if to appropriate health care
professional.
– Remove all hazardous material in client's unit.

63. – Motivate the client to verbalize his feelings openly,
thereby internal conflicts and hesitation will be
reduced.
– Encourage the client to perform deep breathing
exercises, medication and interested activities in a
desirable manner.
– Promote physical outlet for violent behavior.
– Accept the client's feelings, be with him, show
positive attitude, concern, and make him to
understand that nurses are their well wishers and
caretakers. Be brief, clear, direct speech in
conversation, make the client to ventilate the
emotions.

64. – Administer the drugs as per order and explain to
the client and his relatives its importance.
– Always some nursing staff should be ready to
handle the client in the time of need (violent
behavior or exciting if needed placement of
restraints may be necessary.
– If restraints are placed, gradually remove one by
one by observing his behavior.
– Maintain adequate distance with the violent client
and be ready to exit during violent behavior.

65. – Exhibit consistency behavior at all times.
– Never hurt inner feeling of the client, do not do any
unhealthy comparisons.
– Review the incident with client after he gained control
over his behavior.
– Restrict or limit the client's negative feeling or
activities.
– Define specified tasks, schedule it, orient and
reinforce the cleitn to perform his scheduled activities
without postponing , insist for implementation of
activities.
– Encourage the client to participate in group activities
and in small discussions.
– Provide minimum furniture.