One essential criterion for a diagnosis of bipolar I disorder is a past or present history of a manic episode. Manic episodes are characterized by a predominantly elevated, expansive, or irritable mood that presents as a prominent or persistent part of the illness. Manic patients classically have abundant resources of energy and engage in multiple activities and ventures. At baseline and between episodes, the bipolar manic patient may indeed function at a high level of productivity, particularly in areas requiring creative talent. In the initial stages of an episode—and sometimes in attenuated episodes—the ventures may appear genuinely creative and perhaps only mildly eccentric. In time, however, as the investment in these activities becomes excessive, the individual loses the capacity to behave with reasonable caution and judgment and to conform to social expectations and norms. When the mood elevation is of a milder nature, either in severity or in duration, and is unassociated with a marked impairment in function, an assessment of hypomania rather than mania is made, resulting in a bipolar II disorder rather than a bipolar I diagnosis. It is not known whether these disorders are distinct in their etiology or exist on a continuum. In many manic episodes, particularly in the initial stages, the predominant mood is euphoria, although dysphoric mania is not as rare a condition as previously thought. The mood is often accompanied by a sense of absolute conviction or certitude, usually involving a self-perceived talent or perception but occasionally centering around more metaphysical and cosmic matters. A newly discovered or dramatically enhanced interest in religious or sexual experiences is a common feature. The euphoria experienced by the manic patient has an infectious quality and may mislead some people—even close associates—into accepting types of behavior that otherwise might not be tolerated. Manic patients can be quite engaging, and their well-known proclivity for buying sprees and improvident business ventures is often accompanied, at least for a time, by a remarkable ability to obtain loans or gifts of money and encouragement from people whose judgment is usually better.
One of the primary early symptoms of a manic episode is a decreased need for sleep, so that in many cases the individual may not sleep for 3 or 4 days at a time. A “hunger” for social interchange may be manifested by frequent and inappropriate phone calls to distant acquaintances, particularly during late-night periods when social stimulation is minimal. Hypergraphia (excessive writing) and a fascination with music and playing musical instruments are frequently noted. Manic patients may also have a tendency to wear bright colors and unusual combinations of eccentric attire or may exhibit an attitude of carelessness about clothes or makeup. Public disrobing is also common.
Manic speech is characteristically rapid and discursive. Manic patients are difficult to interrupt and have difficulty not interrupting others who are speaking. The speech itself may involve rhyming, punning, and bizarre associations, but there are no pathognomonic elements. Manic patients are readily distractible and respond to both internal and external stimuli in a self-referential manner. Manic episodes that are more severe or that are observed later in the natural history of the disorder may be characterized by paranoia and irritability rather than euphoria and grandiosity. Anxiety and feelings of suspicion can cause the verbal output of such individuals to be markedly decreased, leading to erroneous diagnostic conclusions. Significant social aggression is rare, although acute mania and hypomania are common diagnoses in individuals with a history of psychiatric treatment who commit violent crimes. In some cases, severe depression may occur concomitantly with the manic state (“mixed state”) or in abrupt alternation with the manic state. Suicidal risk is significantly elevated over the base rate for bipolar disorders in such individuals. True delusions and auditory hallucinations may be present, giving rise to difficult problems of differential diagnosis. The content of the delusions or hallucinations is often consistent with the predominant mood (mood-congruent).
In severe cases, mania can present as a state of catatonia. In such cases, the individual appears “willfully” unresponsive, often assuming a fixed posture and appearing mute except for occasional shouts or guttural sounds. Less severe states may be characterized by primitive delusions, fecal smearing, and extremes of tearfulness and emotional lability.