Bipolar disorder type I is one of the most severe mood disorders, usually manifesting itself in the form of emotional swings between the extremes of mania and depression.

Both forms of clinical expression occur in a not necessarily alternating sequence (several depressive episodes occurring consecutively, for example), but with timely treatment they can be mediated by periods of stability.

On the other hand, mania is fundamental to understand this mental health problem . Therefore, it will occupy a central position in this article.

What is the manic phase of bipolar disorder?

Manic episodes are periods in which the person experiences an abnormally high mood , which manifests itself as a kind of overflow euphoria. Sometimes the symptom can acquire a hint of irritability, showing the sufferer a critical attitude towards others or towards himself, and reacting abruptly to circumstances in the environment that could make him feel upset.

Strictly speaking, it requires that the state of mind be prolonged for at least a week, and that it conditions (by its intensity) the ability to carry out daily responsibilities normally. In this sense it can compromise work or academic life, and even require a period of hospitalization with the aim of avoiding possible harm to oneself or others.

Mania is the most important symptom of bipolar disorder type I, as it is the only one required for diagnosis (prevalence is as high as 0.6% of the world population). Depression, therefore, need not be present (although it is the most common). Mania should not be confused with hypomania, which is a less disabling form, and which constitutes (together with the presence of depressive episodes) the mainstay of bipolar disorder type II (0.4% globally).

In the following we will detail the symptoms that are typical of the manic episodes in bipolar disorder , exemplifying each one of them to show their potential impact on the life of the person who suffers them and those around him.

1. Exaggerated self-esteem or grandiosity

One of the defining characteristics of mania is the inflammation in the perception that the person projects on himself, which experiences an expansion that exceeds all limits of reason. He can refer to himself by making use of attributes that suggest greatness or superiority, overstating to the extreme his personal qualities. The exaggeration of one’s own worth may be accompanied, moreover, by the devaluation of that of others .

This symptom acquires its maximum expression through the feeling of omnipotence, which harbours unrealistic beliefs about one’s own abilities and which can be associated with risky behaviour for life or physical integrity, as well as the wearing out of physical or material resources.

Another circumstance that can occur in this context is erotomania, a form of delirium characterized by feeling oneself the object of another person’s love, without any objective cause that could support such reasoning. Generally it is a figure of notable social transcendence, which serves to strengthen some beliefs of superiority on which the self-image is built. The symptom is more common in serious cases.

2. Decreased need for sleep

People who go through a manic phase can abruptly reduce the time they spend sleeping (limiting it to three hours a day or less), and even stay awake for entire nights. This is due to a pressing need to get involved in activities, and occasionally to the belief that sleep itself is an unnecessary waste of time.

The feeling of tiredness fades away, and the person devotes all his or her nightly hours to maintaining a hectic pace of purposeful activities, which are carried out erratically and excessively. Just as there is an inflexible commitment to certain types of tasks, these can be unexpectedly abandoned in favor of others that arouse unusual interest, which implies an incessant use of energy.

Under this state there is obvious physical and mental exhaustion, but the person does not seem to be aware of it. There are studies suggesting that such reduced need for sleep is one of the most predictive of manic episodes in people with bipolar disorder who were previously stable.

3. Taquilalia

Another characteristic of manic episodes is the substantial increase in speech latency , with much higher word production than is usual in the periods between episodes. Alterations may emerge such as de-arraying (speech without an apparent connecting thread), tangentiality (addressing issues irrelevant to the central theme being addressed) or distracted speech (changing the subject in response to stimuli in the environment that hog the attention).

In the most serious cases, an alteration of verbal communication known as “word salad” can break out, in which the content of the speech is devoid of any hint of intelligibility, and the interlocutor feels unable to appreciate its meaning or intention.

4. Thought acceleration

The acceleration of thought (tachypsique) is directly connected to the increase in the rhythm of verbal production . Both realities are firmly interconnected, so that the commitment to the integrity of mental contents will be translated into affected speech. This pressure of thought overflows the person’s capacity to translate it into operational terms for efficient use, observing what is known as a “flight of ideas”.

This flight of ideas entails an evident disorganization in the hierarchy of priorities of thought, so that the discourse with which a conversation was initiated (and which harboured a clear communicative intention) is interrupted by a cluster of secondary ideas that are chaotically superimposed on each other, and which end up being diluted in a frenzied flow of mental content that ends up in a raging ocean of unconnected words.

5. Distractibility

People living in a manic phase of bipolar disorder may have certain higher cognitive functions altered , in particular attention processes. Under normal circumstances they are able to maintain relevant selective attention, giving greater relevance to elements of the environment that are necessary for proper functioning based on contextual cues. Thus, the projection of the focus on what is dispensable or accessory for the occasion would be inhibited.

During the manic phases an alteration in this filtering process can be seen, so that the various environmental stimuli compete for the resources available to the person, making it difficult for the behaviour to be expressed in adaptive terms. For this reason, it is usually extremely difficult to maintain sustained vigilance over any one stimulus, oscillating attention from one point to another without it being able to find a clear reference.

6. Increased intentional activity

In the context of a manic episode there is usually a peculiar increase in the person’s general activity level . Thus, he or she can spend most of his or her time on any task that arouses his or her interest, getting involved in it in such a way that he or she does not seem to feel any fatigue despite the time that has elapsed. This may be accompanied by a very powerful feeling of being creative and constructive, inhibiting the rest of the responsibilities.

Sometimes this incessant flow of activity is resistant to the attempts of others to force their detention, in the face of concern about the possible consequences of over-exertion on the health of the person (who may be left up all night to do their chores). In these cases, there may be a response of open opposition to attempts at deterrence, accompanied by a certain irritability and perception of wrongdoing.

7. Impulsivity

Impulsivity is the difficulty to inhibit the impulse to emit a specific behaviour in the presence of a trigger stimulus (physical or cognitive), and that often also implies the impossibility to stop it at the moment it is underway. This symptom is one of the most descriptive in the manic episodes of bipolar disorder, and may also be one of the most damaging to personal and social life.

It is not uncommon, in the context of the manic phase of bipolar disorder, for individuals to make risky decisions whose consequences involve a profound drain on their financial or fiduciary resources, such as disproportionate investments in companies whose prognosis for success is poor or uncertain. This results in irreparable losses of personal or family assets, which increase the relational tension that could have been established in the intimate circle of people of trust.

Involvement in other types of risky activities, such as substance use or sexual behaviour without the use of appropriate prophylactic strategies, may generate new problems or even increase the intensity of the symptoms of mania (as would be the case with cocaine use, which acts as a dopamine agonist and increases the difficulties the person is experiencing).

Neurobiology of Bipolar Disorder

Many studies have found that acute episodes of depression and mania, which occur during the course of bipolar disorder, increase the deterioration in cognitive functions that accompanies this psychopathology over time. All this has shown the possibility that there may be structural and functional mechanisms in the central nervous system that are at the base of its particular clinical expression.

Regarding mania, empirical evidence has been found of a reduction in the total volume of the grey substance in the dorsolateral prefrontal cortex ; which contributes to functions such as attention, impulse inhibition or the ability to plan in the medium and long term. Similar findings have also been described in the lower frontal gyrus, which is involved in word formation processes (as it has close connections with the primary motor area).

On the other hand, alterations have been detected in the areas of the brain responsible for processing rewards, especially in the left cerebral hemisphere, which may be in a situation of hyperactivity. This fact, together with the aforementioned perturbation of the frontal cortical areas, could build the foundations of impulsivity and attentional difficulty of people with a bipolar disorder.

It is important for the person with bipolar disorder to seek specialized help, as the use of mood stabilizers is key to balancing the affects and facilitating an adequate quality of life. These drugs, however, require careful monitoring by the doctor due to their potential toxicity in case of inadequate consumption (which could require changes in the dose or even the search for alternative medicines).

Psychotherapy, on the other hand, also plays an important role. Here it can help the person to know better the illness he or she is suffering from, to detect in advance the appearance of acute episodes (whether depressive, manic or hypomanic), to manage subjective stress, to optimise family dynamics and to consolidate a lifestyle that leads to greater well-being.

Bibliographic references:

  • Abé, Ch., Ekman, C.J., Sellgren, C., Petrovic, P., Ingvar, M. and Landén, M. (2015). Manic episodes are related to changes in frontal cortex: a longitudinal neuroimaging study of bipolar disorder 1.

  • Rowland, T. and Marwaha, S. (2018). Epidemiology and Risk Factors for Bipolar Disorders. Therapeutic Advances in Psychopharmacology, 8(9), 251-269.

  • Satzer, D. and Bond, D.J. (2016). Mania secondary to focal brain injury: implications for understanding the functional neuroanatomy of bipolar disorder. Bipolar Disorders, 2016, 205-220.