Three key subdimensions of mania identified, validated

Mania, the defining feature of bipolar disorder, is not the monolithic entity it is portrayed to be in the DSM-5, but instead has at least three distinct "subdimensions" that distinguish it from other mental disorders, according to a report in the Journal of Affective Disorders.

Researchers who found the DSM-5 portrayal of mania to be "unidimensional" and "misleading" sought to establish a more nuanced characterization by using detailed clinical interviews of 422 psychiatric outpatients to identify the key features unique to mania. These patients, predominantly women with a mean age of 42 years, were currently receiving mental health treatment; 17% had a diagnosis of bipolar disorder and 6% were in a manic episode at the time of the interview, said Camilo J. Ruggero, Ph.D., of the department of psychology, University of North Texas, Denton, and his associates.

Using the Interview for Mood and Anxiety Symptoms; the Structured Clinical Interview for DSM-IV Axis I Disorders; the Inventory of Depression and Anxiety Symptoms, Expanded Version; the Global Assessment of Functioning; and the Sheehan Disability Scale, the investigators identified three subdimensions that consistently characterized mania and distinguished it from other disorders: euphoric activation, which reflected increased energy; hyperactive cognition, which reflected flight of ideas, pressured speech, and distractibility; and reckless overconfidence, which reflected extreme overconfidence and resulting poor judgment and recklessness. The latter subdimension is similar to grandiosity but not necessarily delusional. A fourth subdimension, irritability, also was characteristic of mania but was not as unique to it as were the other three, since it can also occur in depression and other disorders (J. Affect. Disord. 2014;161:8-15).

After creating an instrument to reflect these four subdimensions of mania, Dr. Ruggero and his associates validated their findings in clinical interviews with a separate study population: 306 student volunteers who had a history of mental health treatment, 31% of whom were currently in treatment. All four subdimensions were highly prevalent in patients who had mania but not in those with other disorders.

Identifying these key subdimensions could elucidate the etiology of bipolar disorder. And, instead of focusing on "the higher-order syndrome" of mania, highlighting these subdimensions might help resolve discrepancies in results from pathophysiologic studies, since different facets of mania might reflect different pathophysiological processes, the researchers noted.

"Moreover, assessing distinct types of symptoms has important clinical implications; not all subdimensions affect functioning equally." For example, in these two patient populations, euphoric activation had little impact on participants’ daily functioning, compared with other symptoms, the researchers added.

Dr. Ruggero and his associates cited several limitations. Neither psychotic nor depressive symptoms were included in their analyses. Also, a few of the patients were in a current manic episode at the time of the study. Despite those limitations, their study "provides important new findings about mania. Future work can use these dimensions ... to better discern the pathophysiology of bipolar disorder," they wrote.

This work was supported in part by the Feldstein Medical Foundation. Dr. Ruggero and his associates reported no conflicts of interest.

Mania, the defining feature of bipolar disorder, is not the monolithic entity it is portrayed to be in the DSM-5, but instead has at least three distinct "subdimensions" that distinguish it from other mental disorders, according to a report in the Journal of Affective Disorders.

Researchers who found the DSM-5 portrayal of mania to be "unidimensional" and "misleading" sought to establish a more nuanced characterization by using detailed clinical interviews of 422 psychiatric outpatients to identify the key features unique to mania. These patients, predominantly women with a mean age of 42 years, were currently receiving mental health treatment; 17% had a diagnosis of bipolar disorder and 6% were in a manic episode at the time of the interview, said Camilo J. Ruggero, Ph.D., of the department of psychology, University of North Texas, Denton, and his associates.

Using the Interview for Mood and Anxiety Symptoms; the Structured Clinical Interview for DSM-IV Axis I Disorders; the Inventory of Depression and Anxiety Symptoms, Expanded Version; the Global Assessment of Functioning; and the Sheehan Disability Scale, the investigators identified three subdimensions that consistently characterized mania and distinguished it from other disorders: euphoric activation, which reflected increased energy; hyperactive cognition, which reflected flight of ideas, pressured speech, and distractibility; and reckless overconfidence, which reflected extreme overconfidence and resulting poor judgment and recklessness. The latter subdimension is similar to grandiosity but not necessarily delusional. A fourth subdimension, irritability, also was characteristic of mania but was not as unique to it as were the other three, since it can also occur in depression and other disorders (J. Affect. Disord. 2014;161:8-15).

After creating an instrument to reflect these four subdimensions of mania, Dr. Ruggero and his associates validated their findings in clinical interviews with a separate study population: 306 student volunteers who had a history of mental health treatment, 31% of whom were currently in treatment. All four subdimensions were highly prevalent in patients who had mania but not in those with other disorders.

Identifying these key subdimensions could elucidate the etiology of bipolar disorder. And, instead of focusing on "the higher-order syndrome" of mania, highlighting these subdimensions might help resolve discrepancies in results from pathophysiologic studies, since different facets of mania might reflect different pathophysiological processes, the researchers noted.

"Moreover, assessing distinct types of symptoms has important clinical implications; not all subdimensions affect functioning equally." For example, in these two patient populations, euphoric activation had little impact on participants’ daily functioning, compared with other symptoms, the researchers added.

Dr. Ruggero and his associates cited several limitations. Neither psychotic nor depressive symptoms were included in their analyses. Also, a few of the patients were in a current manic episode at the time of the study. Despite those limitations, their study "provides important new findings about mania. Future work can use these dimensions ... to better discern the pathophysiology of bipolar disorder," they wrote.

This work was supported in part by the Feldstein Medical Foundation. Dr. Ruggero and his associates reported no conflicts of interest.

Mania, the defining feature of bipolar disorder, is not the monolithic entity it is portrayed to be in the DSM-5, but instead has at least three distinct "subdimensions" that distinguish it from other mental disorders, according to a report in the Journal of Affective Disorders.

Researchers who found the DSM-5 portrayal of mania to be "unidimensional" and "misleading" sought to establish a more nuanced characterization by using detailed clinical interviews of 422 psychiatric outpatients to identify the key features unique to mania. These patients, predominantly women with a mean age of 42 years, were currently receiving mental health treatment; 17% had a diagnosis of bipolar disorder and 6% were in a manic episode at the time of the interview, said Camilo J. Ruggero, Ph.D., of the department of psychology, University of North Texas, Denton, and his associates.

Using the Interview for Mood and Anxiety Symptoms; the Structured Clinical Interview for DSM-IV Axis I Disorders; the Inventory of Depression and Anxiety Symptoms, Expanded Version; the Global Assessment of Functioning; and the Sheehan Disability Scale, the investigators identified three subdimensions that consistently characterized mania and distinguished it from other disorders: euphoric activation, which reflected increased energy; hyperactive cognition, which reflected flight of ideas, pressured speech, and distractibility; and reckless overconfidence, which reflected extreme overconfidence and resulting poor judgment and recklessness. The latter subdimension is similar to grandiosity but not necessarily delusional. A fourth subdimension, irritability, also was characteristic of mania but was not as unique to it as were the other three, since it can also occur in depression and other disorders (J. Affect. Disord. 2014;161:8-15).

After creating an instrument to reflect these four subdimensions of mania, Dr. Ruggero and his associates validated their findings in clinical interviews with a separate study population: 306 student volunteers who had a history of mental health treatment, 31% of whom were currently in treatment. All four subdimensions were highly prevalent in patients who had mania but not in those with other disorders.

Identifying these key subdimensions could elucidate the etiology of bipolar disorder. And, instead of focusing on "the higher-order syndrome" of mania, highlighting these subdimensions might help resolve discrepancies in results from pathophysiologic studies, since different facets of mania might reflect different pathophysiological processes, the researchers noted.

"Moreover, assessing distinct types of symptoms has important clinical implications; not all subdimensions affect functioning equally." For example, in these two patient populations, euphoric activation had little impact on participants’ daily functioning, compared with other symptoms, the researchers added.

Dr. Ruggero and his associates cited several limitations. Neither psychotic nor depressive symptoms were included in their analyses. Also, a few of the patients were in a current manic episode at the time of the study. Despite those limitations, their study "provides important new findings about mania. Future work can use these dimensions ... to better discern the pathophysiology of bipolar disorder," they wrote.

This work was supported in part by the Feldstein Medical Foundation. Dr. Ruggero and his associates reported no conflicts of interest.