Mania: Signs, Causes, and Tips for Managing an Episode

One year after she started as an assistant professor in psychiatry at UCLA, Kay Redfield Jamison, now a respected expert in mood disorders and the author of Fires in the Dark: Healing the Unquiet Mind, entered an acutely manic stage that was part of the bipolar disorder she had lived with since she was 17.

Describing her condition, she wrote in The New York Times in May 2023: “My highs—during which new ideas, writing, and enthusiasm came easily; thoughts sped; and life was a euphoric and high-voltage thing—almost always ended in chaos and regret.”

Jamison is one of the approximately 2.8% of the US population living with bipolar disorder, formerly referred to as manic-depressive illness.

A manic episode is actually a small part of experiencing bipolar disorder, and may not happen at all, depending on what type of bipolar you have.

“The majority of people with bipolar disorder tend to live more in a state of depression,” according to Anna Costakis, MD, an assistant professor at the Zucker School of Medicine at Hofstra/Northwell department of psychiatry, and adult ambulatory psychiatry director at Zucker Hillside Hospital in Glen Oaks, NY. “When they move into a manic state, they initially feel good but it can deteriorate into a full-blown manic episode. In a worst-case scenario, they can even become psychotic with hallucinations or delusions.”

Dr. Costakis explains that when people are in an acute manic phase, “frontal lobe inhibition is reduced, leading people to believe they’re untouchable, and their behavior can get out of control. At its worst, the manic state can be indistinguishable from someone who is using a substance like cocaine.”

There are several types of bipolar disorder. People with bipolar 1 have had at least one manic episode in their lifetime lasting at least one week. A manic episode may have been preceded by a hypomanic or major depressive episode.

People with bipolar II disorder have had a hypomanic episode lasting at least four consecutive days along with depressive episodes. Hypomania is a less severe form of mania that is not serious enough to affect social or work/school functioning.

In cyclothymic disorder, there have been periods with milder hypomanic symptoms that have not met the criteria for a hypomanic episode, and periods with depressive symptoms not severe enough to meet the criteria for major depression.

Studies show that approximately 10% of people with bipolar have only a single manic episode in their lifetime. Frequency of episodes depends on the person’s natural course of the condition, as well as treatment and medication compliance and efficacy.

Most people swing on the bipolar continuum between mania and depression. You can also have mixed features, in which elements of both depression and mania are present.

Bipolar disorder not only affects mood but also can cause cognitive decline, similar to what we see in dementia, Dr. Costakis points out. The higher number of mood episodes a person has in their lifetime, the more likelihood there is that these episodes will be toxic to the brain and affect cognition.

“Our goal is for people to be in a euthymic (normal mood) state as much as possible,” she says.

According to the Cleveland Clinic, mania is a condition in which you have a period of abnormally elevated, extreme changes in your mood or emotions, energy level or activity level. This highly energized level of physical and mental activity and behavior must be a change from your usual self and be noticeable by others.

Symptoms of mania include:

• Decreased need for sleep

• Abnormally high level of activity or energy

• Feeling extremely happy, excited, or euphoric

• Inflated self-esteem

• More talkative than usual, pressured speech

• Racing thoughts (flight of ideas)

• Easily distracted

• Impulsive behavior that can lead to poor choices, such as buying sprees or reckless sex

If you have a bipolar predisposition or vulnerability, Dr. Costakis explains, several things can trigger a manic episode, including:

• Changes in sleep patterns

• Stress

• Seasonal changes

• Loss of a loved one

• Misuse of drugs or alcohol

• Certain types of medications

Hormonal changes such as those seen pre-menstrually, postpartum, or in the perimenopausal period can also precipitate a manic episode.

Treatment for bipolar disorder optimally includes a mix of psychotherapy and medications.

Mood stabilizers such as lithium, carbamazepine, and lamotrigine are the preferred medications. Standard SSRI antidepressants are generally not used since they can cause mania. In an acute manic episode, atypical antipsychotics may be used since they work more quickly than mood stabilizers.

Dr. Costakis points out the importance of staying on prescribed medications: “People often enjoy being hypomanic or manic, and feel the medicine robs them of the ‘highs’ and of their ability to be creative and productive, but it’s crucial to remember that eventually it takes a negative turn.”

To prevent manic episodes, it is important to maintain a stable sleep pattern and daily routine and to avoid overstimulation when possible. Alcohol and recreational drugs should be avoided.

When used in conjunction with medication, various types of therapy such as cognitive-behavioral (CBT), interpersonal and social rhythm therapy, and family therapy have proven to be helpful. Psychoeducation, in which you are taught about your condition along with strategies for relapse prevention, has been particularly useful in preventing manic episodes.

Avoiding excess stimulation, getting adequate sleep, and having your medication assessed or changed if necessary are all helpful in “calming the chaos within,” as Dr. Costakis calls it.

Practice relaxation techniques like deep breathing, or do a more physical relaxing activity, like yoga. Keep a journal (on paper or with a free app) of your mood so you can recognize changes and triggers.

Anger and rage can also be part of a manic episode. If you, or someone you love, is in a violent or threatening manic state, reach out quickly for help. Call 911 if physical danger is concern, call or text the National Suicide & Crisis Lifeline at 988, or text HOME to 741741 to reach the Crisis Text Line.