Changes in mood

Manic episodes are characterised by an elated mood, described by some as ‘feeling high’. Elation can, of course, be a normal mood state, and in mania is distinguished from normal cheerfulness because it is persistent, out of context and may be extreme.

People experiencing manic episodes are often infectiously happy. However, their mood can be labile, and brief periods of sadness, fearfulness, anger or irritability are common, typically lasting less than a minute and being followed by a rapid return to elation. In some cases, elation does not occur and irritability and anger are the predominant emotions.

Biological functions

Energy is increased and can seem boundless. Sleep is reduced and typically the person affected doesn’t feel tired or in need of rest. Appetite may be increased but the person’s behaviour is often so frantic and disorganised that they end up eating less than usual. Increased energy and activity mean that weight loss may occur. Libido is usually increased.

Thinking

Thinking becomes faster and more expansive. An early sign of this is prolixity of speech, in which the person talks more than usual and covers in their conversation an uncharacteristically broad range of topics. As the episode progresses and thinking speeds up more, the person may begin to exhibit pressure of speech, talking more forcefully and faster than usual and being difficult to interrupt. During episodes of mania, speech often reflects an underlying thought disorder called ‘flight of ideas’, in which thoughts progress from one topic to another in a logical way, but so quickly that it can be difficult to follow the train of thought. Puns and rhymes may be used to connect thoughts.

People experiencing hypomania become sociable, optimistic and confident. Their life may seem more vivid and interesting. During episodes of mania, they can become grandiose, thinking they are superior to other people and capable of great things. Impaired judgement and disinhibition occur. Attention and concentration are impaired.

These changes in thinking are manifest in the person’s behaviour. They may be effusive, and wish to share their wonderful ideas with the world, but may also be self-important and pompous. A manic episode can be a time of great creativity, but often projects are started and not completed. Poor judgement can result in grandiose ideas being acted upon with disastrous consequences.

Psychotic symptoms

Psychotic symptoms in mania are typically mood congruent. The most common are grandiose delusions and are an extension of the optimism and confidence that occur when manic episodes are less severe. The person may believe that they have superhuman powers, are very important or wealthy, or have a special mission to achieve. Persecutory delusions are also common, with the belief that others are against them usually being related to the person’s sense of self-importance. Auditory hallucinations are unusual. If they do occur they are usually in the second person.

Depressive episodes

Bipolar depression presents in the same way as unipolar depressive episodes, the clinical features of which are described on pages 52–53. The only way to establish whether a depressive episode is part of a unipolar or bipolar disorder is to check for a history of manic episodes. There are, however, features of depressive episodes that can suggest the possibility of bipolar disorder – psychotic symptoms, severe agitation suggestive of a mixed affective state, atypical symptoms such as increased sleep and appetite, and poor response to antidepressant drugs are all suggestive of bipolar depression and should prompt a review of the case, to check whether a history of manic episodes has been missed.