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MAMATA COLLEGE OF NURSING KHAMMAM Date: Time: SUBJECT: CLINICAL SPECIALTY PSYCHIATRY- II TOPIC : MANIA GUIDE: MRS.

ASHA KUMARI ASST. PROFESSOR PRESENTED BY: UDAYA SREE.G M.Sc. (N) II YEAR SEMINAR ON MANIA INTRODUCTION Mania is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression. Mania is a criterion for certain psychiatric diagnoses. The word derives from the Greek "" (mania), "madness, frenzy". In addition to mood disorders, persons may exhibit manic behavior because of drug intoxication (notably stimulants, such as cocaine and methamphetamine), medication side effects (notably steroids and SSRIs), and malignancy. But mania is most often associated with bipolar disorder, where episodes of mania may alternate with episodes of major depression. Gelder, Mayou, and Geddes (2005) suggest that it is vital that mania be predicted in the early stages because otherwise the patient becomes reluctant to comply to the treatment. The criteria for bipolar disorder do not include depressive episodes, and the presence of mania in the absence of depressive episodes is sufficient for a diagnosis. DEFINITION It is a psychiatric 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. -K.P. Neeraja An alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition. -Mary C. Townsend

Mania is excitement manifested by mental and physical hyperactivity, disorganization of behavior, and elevation of mood. INCIDENCE AND EPIDEMIOLOGY 0.6- 1 percent adults will have mania during their life time Onset is most common in late adolescence and young adulthood Incidence is more in unmarried, separated or divorced cases Urban, upper socioeconomic groups Positive family history, monozygotic twins Drug induced manic disturbances Male, female ratio 1:1 (bipolar males tend to have manic episode first, females have depressive episode first)

CLASSIFICATION ACCORDING TO ICD-10 F30- manic episode F30.0 hypomania F30.1 - mania without psychotic symptoms F30.2 mania with psychotic symptoms F30.8 other manic episodes F 30.9 manic episode unspecified

TYPES I Acute mania Hypomania or mild to moderate mania Delirium mania or severe mania II Primary mania Secondary mania due to organic causes III Description of recent manic episodes Mania without psychotic symptoms Mania with psychotic symptoms

Unspecified manic episode Mania with catatonic features Mania with postpartum episode IV Mania Hypomania Mixed state or dysphoric mania ETIOLOGY Neurotransmitter and structural hypotheses Manic episodes are related to excessive levels of norepineprine and dopamine, an imbalance between cholinergic and noradrenergic systems or a deficiency in serotonin. Biologic findings suggest that lesions are more common in this population in areas of the brain such as the right hemisphere or bilateral sub cortical and periventricular gray matter. Genetic considerations Monozygotic (identical) twins have a higher rate of incidence than normal siblings and other close relatives. Siblings and close relatives have a higher incidence of manic and depressive illness than a general population, and cyclothymiacs characteristics are common among family members of bipolar patients. Psychodynamic theories Developmental theorists have hypothesized that faulty family dynamics during early life are responsible for manic behaviors in later life. Another psychodynamic hypothesis explains manic episodes as a defense against or denial of depression. Stressful life events. For examples bereavement Secondary mania can occur due to a variety of Neurological conditions, eg: multiple sclerosis, brain tumors, epilepsy, brain trauma Metabolic disorders Endocrinal disorders, eg: hyper-adreno-corticalism, hyperthyroidism Conditions which affects brain functioning Drug induced: corticosteroids, adrogenic steroids, l-dopa, anti-depressants, stimulants Co-morbid illnesses adversely affect the outlook for mania. Eg alcoholism and substance abuse

BIOLOGICAL MECHANISM The biological mechanism by which mania occurs is not yet known. One hypothesised cause of mania (among others), is that the amount of the neurotransmitter serotonin in the temporal lobe may be excessively high. Dopamine, norepinephrine, glutamate and gammaaminobutyric acid also appear to play important roles. Imaging studies have shown that the left amygdala is more active in women who are manic and the orbitofrontal cortex is less active. CLINICAL FEATURES An excess in behavioral activity, mood states, self esteem and confidence. Manic behavior seems to begin abruptly or over the space of few hours or few days. Mild mania or hypomania Episodes will be at least for five days, euphoria or expansive mood( stage-1) abnormal mood elevation, cheerful, extremely happy, elevated sence of psychological well being; happiness is not correlated with ongoing events, may tend to have more enthusiasm, emphasis on certain events (expensiveness). A sudden pleasant mood, lightening, positive energy, heightened feelings of well being with increased alertness and drive, sudden oscillation of moods, expansive sociability the individual is able to function well; inflated self esteem. Persistent and pervasive elated or irritable mood, thoughts and consistent behaviors, absence of psychotic symptoms. Confident on skills, abilities or strengths, thoughts Creative talents, most productive Total awareness easily gets ides, over flowing with new ideas; energetic, flight of ideas Coherent thoughts, feeling pressure from within the thought process which keeps him to talk or racing thoughts Immune to fear and doubts Talks to the strangers easily, offer solutions to problem, finds pleasure in small activities Sometimes hypo manic episodes can be dysphoric, irritable, ragful, may make poor choices and display little or no sympathy for others emotions Inflated self-esteem or grandiosity Decreased need for sleep or decreased sleep pattern, rapid eye movement is increased, but the client looks fresh Being more talkative than usual Easily distractible, attention deficit Increase in psychomotor agitation

Involvement in pleasurable activities that may have a high potential for negative psychosocial or physical consequences Mild or severe form of obsessional behavior Poor judgement relative to a particular situations judgement Partially controllable Mild to severe recklessness Involves in risky sexual activity Simply feels great Increased assertiveness, denies if anything goes wrong Delusion of grandiosity Uninhibited in approach Oracious eater Intellectual Inability to tolerate criticism, anger, aggressive, argumentative, more ambitious, poor interpersonal relationship among partners Bored with routines, lack of interest in specific topics Possesses humor and makes environment happy Oscillation in moods Extrovert, mischievous in behavior Mixed mood state/ dysphoric mania Pronounced symptoms of both depression and mania coexist or alternate during different periods of the day. Increased probability of suicide in mixed state, as they have the energy needed to commit suicide. Acute mania Euphoria, elation (stage-II) and exaltation of mood ( stage-III) Elation of mood- moderate elevation of mood, increased psychomotor activity, joyous excitement Exaltation of moods (stage-III); intense elevation of mood, grandeur delusions (affective tonality), frequent variations in moods Unselective enthusiasm for interacting with people and surrounding environment Extreme irritability may easily be evoked especially when the person is stopped from doing what he is intended to do, however, they may be unrealistic Inflated self- esteem Over activity/ increased activity, restlessness Obvious over talkativeness or pressured or rapid speech, used rhythmic, rhyming language, loudly speaks, difficulty to interrupt Socially embracing behavior, distress to family

Inflated self esteem or delusion of grandiosity, persecution, paranoid, delusion of control, reference, etc. may be seen Distractibility- easily attention will be drown to irrelevant stimuli Indiscretion Flight of ideas, rapidly shifting from one to another, making it hard for the others to understand Racing thoughts and perceptions leads to frastation- rapid thoughts that the patient finds it hard to keep up with them or express them Decreased need for sleep, sleep deprived psychosis only few hours of sleep is needed daily for the client to feel rested, do not look fatigued Humorous and teasing Frequently denies if anything is wrong with them Impulsively taking part in activities Potentially harmful to self and others Anger or rage, provocative, aggressive, intrusive demanding, revengeful Hypersensitivity Hyper sexual drive Hyper religious Increased stress in personal relationship, problems at work Increased goal directed activity, pursues with specific goals at work Fragmented and psychotic Excessive involvement in pleasurable activities with high potential for negative consequences Common problems Spending sprees, sexual indiscretion, increased substance abuse (cocaine tranquilizers), investing more money in unreasonable manner Distribute articles or money to unknown persons Excessively high overly good Unrealistic beliefs in ones abilities and powers Lacks judgement skills, impaired attention concentration, poor insight Denial tendency Children with mania are more prone destructive tantrums Neglects hygiene, disorganized dressing Impulsive, sociable Free suggestions Hallucinations may occur, but not common Sad, crying

Delirious mania Rarely it will occurs Client will be out of contact with external world Word salad; incoherent speech Client will be active without any aim or goal Perceptual problems i.e. hallucination, delusion, may be extreme Self care deficit, unable to concentrate Client may die as a result of physical exhaustion

TREATMENT Involuntary admission may be required until client stabilizes, to prevent harm to themselves or others. Tactful persuasion is necessary. Before beginning treatment for mania, careful differential diagnosis must be performed to rule out non-psychiatric causes. Acute mania in bipolar disorder is typically treated with mood stabilizers or antipsychotic medication. Note that these treatments need to be prescribed and monitored carefully to avoid harmful side-effects such as Neuroleptic malignant syndrome with the antipsychotic medications. It may be necessary to temporarily admit the patient involuntarily until the patient is stabilized. Antipsychotics and mood stabilizers help stabilize mood of those with mania or depression. They work by blocking the receptor for the neurotransmitter dopamine and allowing serotonin to still work, but in diminished capacity. Lithium is the classic mood stabilizer to prevent further manic and depressive episodes. Anticonvulsants such as Valproic acid, Oxcarbazepine and Carbamazepine are also used for prophylaxis. More recent drug solutions include lamotrigine, which is another anticonvulsant. Clonazepam (Rivotril, Ravotril or Rivatril) is also used. Sometimes atypical antipsychotics are used in combination with the previous mentioned medications as well, including Olanzapine (Zyprexa) which helps treat hallucinations or delusions, Aripiprazole (Abilify), Risperidone, Ziprasidone, and Clozapine which is often used for people who do not respond to lithium or anticonvulsants. Verapamil, a calcium-channel blocker, is useful in the treatment of hypomania and in those cases where lithium and mood stabilizers are contraindicated or ineffective. Verapamil is effective for both short-term and long-term treatment.

Electroconvulsive therapy If the client is not responding to antipsychotic medications or in early pregnancy to avoid the risk of birth defects due to drugs; ECT may be given Psychotherapies Marital therapy Behavioral therapy Family therapy Cognitive therapy certainly useful as adjunctive therapies.

NURSING MANAGEMENT Nursing assessment Obtain the general history of the client, both from the client (primary source) and from other reliable source. General demographic information Socio economic history Education Occupation Economy Marital history Family history Past medical history Present medical history

Nursing diagnosis High risk for injury related to extreme hyperactivity and impulsive behavior, evidenced by lack of control over purposeless and potentially injurious movements High risk for self violence, self directed or directed at others related to manic excitement, delusional thinking and hallucinations Imbalanced nutrition less than body requirements related to refusal or inability to sit still long enough to eat, evidenced by weight loss, amenorrhea Impaired social interaction related to egocentric and narcissistic behavior, evidenced by inability to develop satisfying relationships and manipulation of others for own desires

Disturbed thought process related to disorientation and decreased concentration evidenced by disruption of activities Self esteem disturbances related to unmet dependency needs, lack of positive feedback, unrealistic self expectations Disturbed family process related to euphoric mood and grandiose ideas, manipulative behavior, refusal to accept responsibility for own actions Ineffective coping skills related to poor impulse control evidenced by acting out behavior Non compliance to treatment carries an increased risk for relapsed Nursing intervention Establish calm and quiet, non-provocative or non stimulating environment Keep sharp instruments away from clients Provide supportive environment Keep the client aside from stressful environment Protect the client by engaging in useful activities Divert the client mind by asking him to participate in calm activities like watching TV, playing with children, regarding spiritual materials or interest of his own Never allow violent patients stay together or nearby place in the same environment Educate the client coping strategies and deep relaxation techniques to overcome aggressive feelings Never leave the client alone, one person should accompany to observe and guide Keep the music volume low, and dim light in clients room Avoid slippery floor to avoid accidents Monitor clients behavior every 15 min Administer drugs as per order and explain to the client and his relatives its importance. If restrains are placed gradually remove one by one by observing his behavior Maintain adequate distance with violent client and be ready to exit during violent behavior Never hurt inner feelings of the person, do not do any unhealthy comparisons Define specific tasks, schedule it, orient and reinforce the client to perform his scheduled activities without postponing, insist for implementation of activities in a desirable manner Provide minimum equipment or furniture

SUMMARY Mania is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression. Mania is a criterion for certain psychiatric diagnoses. The word derives from the Greek "" (mania), "madness, frenzy". In addition to mood disorders, persons may exhibit manic behavior because of drug intoxication (notably stimulants, such as cocaine and methamphetamine), medication side effects (notably steroids and SSRIs), and malignancy. BIBLIOGRAPHY KP. Neeraja. Essentials of mental health and psychiatric nursing, Volume-1 ; Jayapee brothers publication, 2008 Bimla Kapoor. Psychiatric nursing, Volume-2, Pearsons publications, 2005 Sreevani. Psychiatric nursing, Volume-1, Suresh Kumar publications 2004 Mary C. Townson. Psychiatric and mental health nursing, Jayapee brothers publications, 2009 Madhavi K. Essentials of mental health and psychiatric nursing for nurses, Vijams series publications, 2009 The ICD-10 classification of mental and behavioral disorders, WHO authorized print, India: no-47-49

MAMATA COLLEGE OF NURSING KHAMMAM Date: Time: SUBJECT: CLINICAL SPECIALTY PSYCHIATRY- II TOPIC : MANIA GUIDE: MRS.ASHA KUMARI ASST. PROFESSOR PRESENTED BY: UDAYA SREE.G M.Sc. (N) II YEAR MASTER PLAN ON MANIA I. II. III. IV. V. VI. VII. VIII. IX. X. XI. Introduction Definition Incidence Classification Risk factors Causes Stages Manifestations Treatment Nursing management Nursing interventions

XII. XIII.

Summary Bibliography