‘A 30 year old married man was brought by his work colleagues to see the psychiatrist. They were concerned about his behaviour over the past 2 weeks. Two days back he was asked to take leave from his work as an engineer, to get medical attention. This was after he behaved oddly at work, firing his boss and 2 colleagues, stating that he was taking charge of the office. His colleagues reported that this was quite out of character for him as he is normally a very non-confrontational person. He had returned from a period of annual leave back home 2 weeks ago. During the period of leave he was drinking excess alcohol on a daily basis and was spending a lot of money buying alcohol for his friends. After returning from his leave he had been talking about starting a new business. He was staying awake regularly till 3 or 4 AM, making several telephone calls to his friends and family back home. In the last week he had been getting very little sleep and had been very irritable towards his colleagues. Three days back he started saying that he had taken charge as the manager of the company and started promising promotions in the company for his friends. In the 2 weeks since his return to Doha, he accumulated QR 12,000 as traffic fines for speeding and crossing the red lights. He believed that this was not a major issue as he was going to make ‘big money’ very shortly. He felt that there was no need for him to see a psychiatrist as there was nothing wrong with him. He was angry at his friends and colleagues for bringing him to the psychiatric outpatient clinic.’ 

This young man is going through a manic episode. The main features of this condition are elevation of mood, increased activity and self important ideas. Some individuals suffering from this condition may be in a euphoric state with elation, infectious joviality, over confidence and over optimism. However, others may present with a dysphoric mood state leading to irritability and anger. The mood can often vary within the day and sometimes the high spirits could be interrupted by brief episodes of depression. You can often see changes in the person’s appearance, with a choice for bright colours in the clothes worn. In the more severe cases the person could look untidy and disheveled. There is over activity which may lead to a state of physical exhaustion. Activities are initiated, but remain unfinished, as the person gets distracted by new projects that seem exciting. There is a feeling of less need for sleep with an increase in activity during the normal sleep hours. Speech is rapid with an increase in the volume of information. The topics change in a tangential way, making it difficult for the listeners to follow the train of thought. During interaction with other people, the normal social manners are lost and there is a lack of care about the consequences of the person’s behaviour towards others. The sexual desire is increased along with disinhibition in the related behaviours. Some individuals may have an increase in appetite with little attention to the display of normal manners and courtesies. Expansive ideas could lead to the person giving over importance to their own thoughts and beliefs. Spending sprees are common with no regard for the cost or the consequences of the purchases. There is a high risk taking tendency leading to reckless behaviours and poor judgements. When untreated, the condition could progress in to a more severe form of mania, where the person could experience psychotic symptoms such as grandiose delusions (the person believing that he/she has extraordinary powers and special significance), or have hallucinations where there are experiences of voices talking to him/her about his/her special powers. 

The insight is invariably poor as the person often refuses to acknowledge the presence of an illness and does not believe that his/her grandiose plans and spending sprees should be restrained. In a severely ill state a manic person is very likely to deny the need for any form of treatment. Invariably there is externalization of the blame as the person feels that problems have been occurring entirely as a result of other people’s behavior towards him/her and other external factors. Frequently these individuals are brought for treatment by the family or friends. Whilst it is difficult to engage them in treatment, the response to treatment is often remarkable, with the expansive mental state settling down within a few days of commencing medication. On recovery the person starts regaining insight and starts to acknowledge the need for treatment. With effective relapse prevention work the precipitating factors for this illness can be minimized and a healthy mental state can be maintained for prolonged periods. 

Dr Aju Abraham Consultant Psychiatrist
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