The Stages of Mania

A Longitudinal Analysis of the Manic Episode

Gabrielle A. Carlson, MD, and Frederick K. Goodwin, MD, Bethesda, Md

The progression of symptoms during an acute manic episode was nostically or prognostically from manic patients without
studied retrospectively in 20 bipolar manic-depressive patients such symptoms.
whose diagnosis was reconfirmed at follow-up. Three stages were
delineated, the most severe of which was manifested by bizarre be- Methods
havior, hallucinations, paranoia, and extreme dysphoria. Despite
symptoms that might have otherwise prompted a diagnosis of schiz- Prior to admission to either of two metabolic research units at
ophrenia, patients appeared clearly manic both earlier in the course the National Institute of Mental Health (NIMH), patients were
and later as the episode was resolving. screened for primary affective disorder by at least one psychia¬
The level of functioning was ascertained at follow-up and com- trist and a psychiatric social worker. Patients were referred by
pared statistically with the level of psychotic disorganization during private psychiatrists or mental health clinics, generally from the
the acute manic episode; no relationship was found. The advantages Washington, DC, area. The referral sources were aware of our
of using a longitudinal view of a psychotic episode as a diagnostic group's interest in affective illness and of the free inpatient treat¬
tool is discussed. ment available at NIMH. More specifically, referrals were stimu¬
lated by the availability of lithium carbonate through our pro¬
gram.
Twenty consecutively admitted patients were selected for this
In the course of longitudinal studies of manic-depres¬
sive illness during the past seven years we have study on the basis of having participated in an ongoing follow-up
reexamination of manic-depressive patients and having had at
frequently observed periods during the patient's manic least one complete manic episode during hospitalization. A com¬
episode when his symptoms appeared to be indistin¬ plete manic episode is one in which patients proceed from a de¬
guishable from those of acute schizophrenia. Because of pressed or normal mood state, thru mania, and returning to a de¬
the recent availability of lithium carbonate for the acute pressed or normal state while hospitalized, so that the entire
and prophylactic treatment of mania,1·2 the task of recog¬ course was observed. The manic episodes under study averaged
nizing this illness and differentiating it from schizophre¬ four weeks in duration. The total length of hospitalization (aver¬
nia has assumed renewed importance. aging four months) was longer than is usual for affective illness—a
We have attempted to investigate systematically the consequence of the fact that the research protocols involved long
course of the manic episode in 20 patients who by strict periods off medication. In addition, some patients were kept in the
diagnostic criteria were considered on admission to have hospital through more than one manic or depressive episode.
The diagnosis of bipolar affective disorder was based on a his¬
manic-depressive illness, who had a complete manic epi¬ tory of relatively good premorbid adjustment, a history of previ¬
sode at some time during hospitalization, and in whom the
ous episodes of mania and depression, no history of personality
diagnosis of manic-depressive illness was confirmed on deterioration, and symptoms compatible with the diagnosis of
follow-up. The date reviewed suggest that the occurrence mania or depression at the time of admission.3 Though not re¬
of "schizophrenic-like" symptoms during the manic epi¬ quired for the diagnosis, patients frequently had a family history
sode in some patients does not differentiate them diag- of affective disorder. Special care was taken to exclude patients
whose histories were suggestive of schizophrenia, particularly pa¬
Accepted for publication Oct 11, 1972. tients with any of Schneider's first-rank symptoms of schizophre¬
From the Section on Psychiatry, Laboratory of Clinical Science, National nia (experiences of alienation, thought insertion, thought with¬
Institute of Mental Health, Bethesda, Md.
Reprint requests to Clinical Research Unit, Section on Psychiatry, Labo- drawal, thought broadcasting, persistent feelings of influence,
ratory of Clinical Science, National Institute of Mental Health, 9000 Rock- complete auditory hallucinations, and delusional perceptions).4
ville Pike, Bethesda, Md 20014 (Dr. Goodwin). Hospital Study.—The manic episode was first identified by using

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 Table 1.—Excerpts From Daily Nursing Notes, Including Patient Verbalizations
Stage I Stage II Stage III
'Now I feel like talking" and does so, Hypersexual, bizarre (wearing 3 dresses Very frightened, talking and crying
increasing intrusiveness and irri¬ at a time), screaming, angry, delusion; constantly, pacing. "I'll never get
tability, flight of ideas, restless; in control but frightened that other out." "I have cat eyes. He crawls
"I'm not feeling so depressed." patients are against her; grandiose, around inside me and he can't stand
incessant talking. the light." Profane, hypersexual, un¬
cooperative. "Oh please let me die.
I can't take it anymore." "National
Institute of Hell."
'I'm going higher than a Georgia Pine. Pacing, manipulative, religious; says he Much pacing, grimacing, and bodily shak¬
I'm going to fly tonight. I could can't trust people; crude, hypersexual, ing; slaps self on arms; afraid of
kill you." assaultive; wants to be King Kong; dying. "They're going to cut out my
grimaced and postured as if anguished; heart." Afraid of being given TNT;
felt "life on the unit is designed to thought there was special meaning
test my tolerance." when his doctor pointed a finger at
him; running up and down hall making
animalistic noises.
Hyperactive, pressure of speech, sarcastic, Took bath in nightgown, yelling, crying, Throwing things, exposing herself, try¬
playful; "I'm having a ball." laughing, throwing food, threatening, ing to escape, parading around in
Talks of spending $3,000,000. combative. flimsy pajamas crying, "even God has
given up" and later, "I'm dying. The
radioactivity has made my hair
straight." Voided on the seclusion
room floor.
"I'm excited but I don't think I'm Talking about big plans for Christmas
worried about anything." Later, party; very loud, profane, almost
"You'd rather have me on top of the assaultive, slightly paranoid, very
table than under it wouldn't you?" inappropriate telephone use (calling
people to solicit money.)
Somewhat labile, good frame of mind, Hypersexual, hyperverbal, hyperactive,
very busy. suspicious; very angry, assaultive,
obscene; banging urinal on door; wanting
to use phone to buy stocks._

global mania ratings for each patient; these global ratings were responsibilities
obtained twice daily by consensus of the nursing research team. 3-Return to full-time work but in position of
This method of evaluation, originally designed to measure depres¬ lesser status
sion,5 has been revised to include a global mania item." The epi¬ 2-Employed irregularly or works around the home
sode was analyzed if the mania rating averaged at least 4 over 1—Sustained unemployment
three consecutive days (equivalent to a moderate degree of mania, Interpersonal and Family Relationships
ie, hypomania). 4—Patient and family satisfied
Additional corroboration of the manic nature of the episode was 3—Family less satisfied but tolerant
obtained from the psychiatrists' and nurses' written descriptions 2-Family dissatisfied but together
of the patient's affect, psychomotor activity, and cognitive state. 1—Family disruption due to illness
Using these daily written observations, we recorded the sequence Social Function
of symptoms from the beginning to the end of the episode, specifi¬ 4—Normal social function
cally following longitudinal changes in affect, behavior, and cogni¬ 3-Some social withdrawal
tion. Both the nurses who originally recorded the observations and 2—Moderate social withdrawal
we who reviewed the clinical data were blind to all research or 1-Complete social withdrawal
therapeutic medications given to these patients. Mental Status
Follow-Up Study.—Follow-up data described in detail elsewhere 4-Completely normal
(Carlson GA et al, unpublished data) were obtained independently 3-Very mild affective symptoms
through two-hour systematic interviews with the patient and 2—Obvious affective symptoms
most significant family member available (spouse, sibling, or par¬ 1—Symptoms requiring constant care
ent) without prior knowledge of the patient's course during hospi¬
talization. A 200-item questionnaire was used which focused on These points were totaled and the patients were ranked from
job status, changes in family and social relationships, mental best to worst functioning. These rankings and the rankings of the
status, further hospitalization, and the status of psychiatric treat¬ severity of the acute manic episode (as measured by the extent of
ment. The degree of return to premorbid level of function was as¬ progression towards psychotic disorganization) were compared
sessed by scoring each patient's job status, social function, and in¬ using Spearman's rank order correlation technique.
terpersonal relationships at the time of interview as compared to
those parameters before the first episode of manic-depressive ill¬
ness. The scoring method was the following: Results

Areas of Rated at Follow-Up Patients had an average age of onset of first episode at
Functioning
28 years with a mean of 4.4 manic episodes and 2.2 depres¬
Job Status sive episodes over an average of 12.3 years. These de¬
4—Return to the same or better job with same mographic data are summarized below:

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 15

12

1rr 9

"co
a>
co
e
3
Dysphoria ,,
IT tr
O- /

Mania

Hospital 93 95
Days

A little Brought too Hyperverbal, Still paranoid Quieter. Appropriate,

delusional, but cooperative,m°re organized, realistic,
pressured many clothes more
speech, from home, "has x-ray restless, overtalkative showing concern

vision," seductive, for

somewhat paranoid, hypersexual, still others
tangential, hyper-religious, talking with manipulative,
hyperactive, hyperverbal, dead father, still angry, depressed
happy pacing, panicked— makes telephone
numerous afraid he calls
telephone might
calls, blow
grandiose up, labile,
suspicious,
sexually preoccupied
occasionally disoriented
unable to complete a
thought, very angry
Fig 1.—Relationship between stages of a manic episode and daily behavior ratings (patient 69).

Demographic Data These demographic data are similar to those derived

Sex Men, 10 Women, 10 from other studies of manic-depressive patients,3 suggest¬
Age of onset Average 28 (range 17 to 57) ing that our patients are not atypical with respect to re¬
No. of episodes Average 6.6 (range 1 to 20)
1 to 3 episodes 8 patients
lapse frequency, duration of illness, and so forth.
4 to 6 episodes 4 patients
The patient's longitudinal course was divided into three
7 episodes 8 patients stages based mainly on the predominant mood: in stage 1
or more (including 2 patients euphoria predominated, in stage 2 anger and irritability
with frequent, severe, prevailed, while stage 3 was dominated by severe panic.
alternating manic and In all 20 patients the initial phase of the manic episode
depressive episodes) was characterized by increased psychomotor activity
Frequency of episodes which included increased initiation and rate of speech and
Mania—4.4 per patient increased physical activity. The accompanying mood was
Depression-2.2 per patient labile but euphoria predominated, although irritability be¬
Duration of illness came obvious when the patient's many demands were not
Average 12.3 years (range instantly satisfied.
3 to 31 years)
The cognitive state during the initial stage was charac¬
Family history of affective disorder (either parent, sibling
or both treated for or incapacitated by a depressive episode, terized by expansiveness, grandiosity, and overconfi-
manic episode, or both): 15 patients (75%) dence. Thoughts were coherent though sometimes tan¬
Depression immediately prior to index mania: 6 patients gential. Also frequently observed during this stage were
(30%) increased sexuality or sexual preoccupations, increased in-

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 Hospital 13
Days

Stage I Stage II Stage I

Talking and Sarcastic, angry, hyperactive, Pleasant, overly

laughing more, overly pleasant cheerful, slightly
more irritable, and cheerful, manipulative, hyperverbal, bought
seductive, carrying around many things,
said she was clothing, records, etc, carrying around
having ideas that "Happy Easter to you all, quince blossoms,
might get her into scratch, scratch," occasionally
trouble provocative, suspicious, irritable and
constant flow of chatter, sarcastic
grandiose, uncooperative

Fig 2.—Relationship between stages of a manic episode and daily behavior ratings (patient 15).

terest in religion, increased and inappropriate spending of was observed in six patients during this stage; and three
money, increased smoking, telephone use, and letter writ¬ patients also had ideas of reference. The diagnosis of
ing. Some of the patients were aware of the mood change schizophrenia, at least as described by Bleuler,7 was most
on some level and described the feeling of "going high," often entertained at this state. (Schizophrenia, according
having racing thoughts, and feeling like they were in an to Bleuler, was "characterized by a specific type of think¬
airplane. At this stage patients were not out of control. ing, feelings and relation to the external world," and in¬
The second or intermediate stage was also observed in cluded many nonspecific symptoms and a variable progno¬
all patients. During this period the pressure of speech and sis. We, however, are using the narrower concept of K.
psychomotor activity increased still further. Mood, al¬ Schneider,4 and none of his first-rank symptoms were ob¬
though euphoric at times, was now more prominently served in these patients at any time during their hospital¬
characterized by increasing dysphoria and depression. The ization.) Quotes from patients in each of the three stages
irritability observed initially had progressed to open hos¬ appear in Table 1.
tility and anger, and the accompanying behavior was fre¬ The clinical material on which the staging was based is
quently explosive and assaultive. Racing thoughts pro¬ illustrated in Fig 1 to 3 which present individual patient
gressed to a definite flight of ideas with increasing data showing the progressive changes in the nurses' rat¬
disorganization of the cognitive state. Preoccupations ings of mania, psychosis, and dysphoria (an average of the
that were present earlier became more intense with ear¬ ratings for depression and anxiety) along with clinical
lier paranoid and grandiose trends now apparent as frank vignettes and quotes. This material emphasizes the fol¬
delusions. lowing points: (1) the mania ratings rise first, followed
ß final stage was seen in 14 of 20 patients (70%) and closely by the psychosis ratings; (2) the dysphoria rating is
was characterized by a desperate, panic stricken, hopeless always fairly high, but as mania and psychosis increase so
state experienced by the patient as clearly dysphoric, ac¬ does dysphoria; (3) stage III, the most intense stage, is
companied by frenzied and frequently even more bizarre represented on the graph as a concatenation of the peaks
psychomotor activity. Thought processes that earlier had of mania, psychosis, and dysphoria not observed in stage
been only difficult to follow now became incoherent and a II patients.
definite loosening of associations was often described. De¬ While the sequence of symptom progression was re¬
lusions were bizarre and idiosyncratic; hallucinations were markably consistent, the rate of acceleration was variable.
present in six patients; disorientation to time and place Some patients progressed to stage III in hours, others

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 Ili¬

ce
CD
CO °
e Dysphoria, j-, XD-.

Mania V'
• '
Psychosis
-4—^^^ -!^-·"
Hospital Days 20

Stage I Stage Stage Stage II Stage

Distractable, More manic and No sleep, religious Coherent, tired, Labile, numerous
racing thoughts, hyperverbal, delusions, still paranoid, phone calls, feels
joking, intrusive, hyperactive, "hearing God" difficulty good, laughing and
happy, can't concentrate, impulsive, much fragmented, restless, concentrating, joking, hyperverbal,
impulsive, pressure of speech, confused, racing thoughts, irritable, changing
hyperverbal, still responding disruptive, loud, depressed, labile moods quickly,
singing to limits, racing more talkative, insightful
thoughts, paranoid, severely agitated, delusions and
grandiose, labile "Going downhill at hallucinations
190 MPH," singing
loudly, crying
Fig 3.—Relationship between stages of a manic episode and daily behavior ratings (patient 72).

took several days. All of the stage III patients, even the patients showed insight, recognizing themselves as hav¬
six most psychotic, passed through earlier stages where ing been ill and requiring help for their illness. Four pa¬
their symptoms were typically manic. In their decelera¬ tients who showed an abnormal mental status at the time
tion phase they again passed through stages in which they of follow-up had a mental status compatible with affec¬
appeared more typically manic. Delusions and hallucina¬ tive disorder, not schizophrenia. Those patients who ex¬
tions disappeared as mood returned to normal. Although hibited symptoms of stage III mania had no greater fre¬
treatment with antimanic agents hastened the return to a quency of relapse or abnormal mental status at the time
normal mood state, the disappearance of symptoms fol¬ of follow-up than did stage II manic patients.
lowed the same course in both spontaneously remitting
and treated patients. Comment
Hyperactivity, extreme verbosity, pressure of speech, We have presented longitudinal clinical data on the se¬
grandiosity, manipulativeness, and irritability, ie, the ma¬ quence of symptoms occurring during the manic episodes
nic symptoms most frequently reported in other studies,3 s of 20 patients admitted with the diagnosis of manic-de¬
were found in all patients. Table 2 shows the prevalance of pressive illness based on the criteria of Winokur et al.3
symptoms. Examples of some of the delusions, ideas of None of Schneider's4 first-rank symptoms of schizophrenia
reference, and bizarre behaviors are illustrated in the pa¬ was revealed by history or observed on admission. Six of
tients' quotes in Table 1. Examples of the hallucinations the patients, however, at the peak of their manic episodes
were "hearing the theme from Rawhide," "hearing the became grossly psychotic with disorganized thoughts, ex¬
hallelujah chorus from the Messiah," "seeing a box open tremely labile affect, delusions, hallucinations, and brief
with beautiful flowers emerge," "seeing a kaleidoscope of ideas of reference. Because of these symptoms the diag¬
colors running together," and "talking to my dead daugh¬ nosis of schizophrenia was sometimes entertained.
ter." Reference to schizophrenia-like psychotic symptoms oc¬
No significant relationship between the severity of the curring during manic episodes can be found in some of the
acute manic episode and the level of function to which the older literature."11 The current view as reflected in recent
patients returned during the follow-up period were shown textbooks of psychiatry is that mania is a syndrome in
by Spearman's rank order correlations technique. which euphoria predominates and behavior and pre¬
Follow-up data per se are discussed in detail elsewhere. occupations are really secondary to the prevailing mood.
However no patient at the time of discharge or follow-up For example, Arieti,12 Noyes and Kolb,13 and Freedman
showed signs of persistent delusions or hallucinations. All and Kaplan14 have briefly paraphrased Kraepelin's de-

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 Table 2.—Classical and "Atypical" Symptoms provide a longitudinal picture of the episodes he describes
in 20 Manic Patients under the three "types" and it is not clear whether the
acute "delusional" and the "delirious" descriptions apply
Patients Manifesting to separate populations or to different phases in the same
Symptoms Symptoms, %
Hyperactivity 100
patients as we have described here.
Extreme verbosity 100
Some studies which have attempted to relate the pres¬
ence of psychotic symptoms in mania to the clinical condi¬
Pressure of speech 100
Grandiosity 100
tion at follow-up are summarized in Table 3.
Manipulativeness 100 Rennie, in his follow-up from the predrug era,1" has de¬
Irritability 100 scribed some psychotic symptoms in his manic-depressive
Euphoria 90 patients. Although he does not say what percentage of
Mood lability 90 those having hallucinations or delusions were manic or de¬
Hypersexuality 80 pressed, he does give some examples of hallucinations, eg,
Flight of ideas 75 "see something white," "saw and heard God and the an¬
Delusions 75 gels," "saw trees glitter like gold," "saw dead father,"
Sexual (25) "heard voices say, they've got me now," "heard God's
Persecutory (65) voice," etc (hallucinations similar to those verbalized by
Passivity (20) our patients). He also described bizarre behavior which in¬
Religious (15) cluded grimacing, smearing, "fear with screaming of
Assaultiveness or
threatening behavior 75 being killed," posturing, spitting, wetting, soiling, refus¬
Distracti bi I ity 70 ing medication, hoarding, and mannerisms. He concluded
Loosened associations 70 that the depth of psychosis had no relation to the clinical
Fear of dying 70 status at follow-up since 76% of those recovered had been
Intrusiveness 60 "seriously psychotic."
Somatic complaints 55 Lundquist,11 in 1945, discussed the symptoms of con¬
Some depression 55 fusion and hallucinations occurring during the acute
Religiosity 50
phase of the first manic episode in relation to the outcome
Telephone abuse 45
of manic-depressive illness. He found that the duration of
Regressive behavior untreated manic episodes was shorter in patients with
(urinating or defecating
inappropriately; exposing confusion, while the duration of the episode did not seem
self) 45 to be related to the presence of hallucinations.
Symbolization or gesturing 40
Astrup et al,18 while not clarifying which of their pa¬
Hallucinations (auditory and tients had mania or depression as their predominant mood
visual) 40
Confused 35 at admission, felt that the presence of ideas of reference,
Ideas of reference 20 paranoia, passivity, or symbolism during the acute episode
was a poor prognostic sign because more patients with
those symptoms in their study had a chronic schizophrenic
scription of "delirious" mania10 but it is presented as a course. Again, the presence of hallucinations did not nec¬
variant of the normal clinical picture in mania, given little essarily correlate with outcome.
emphasis, and may consequently be rarely recognized. Langfeldt,19 on the other hand, found that some pa¬
Redlich and Freedman,15 and Slater and Roth16 emphasize tients diagnosed as schizophrenic because of Astrup's
that delusions are part of the grandiosity seen in mania. "poor prognostic" symptoms on their first admission, go
Only Henderson and Gillespie17 describe in some detail the on to have manic-depressive course. The clinical descrip¬
bizarre and frenetic picture possible in severe mania, but tions of both these populations sound very similar and one
they add that it is rarely seen. can only conclude that the presence of Astrup's "poor
Before somatic treatments were available, psychiatrists prognosis" symptoms is in no way pathognomonic or even
had the opportunity to observe the natural history of the diagnostic of schizophrenia.
manic episode and their clinical descriptions and reports Winokur et al,3 studying a population of manic patients
of the incidents of psychotic symptoms are of interest. very similar to ours, recorded the prevalence of symptoms
Kraepelin's9 description of three types of mania are per¬ in 100 directly observed manic episodes. In this study, and
haps the most thorough: acute mania, delusional mania, in an earlier one of 31 manies,8 they note that delusions
and delirious mania. His descriptions of these latter two (persecutory, passivity, sexual, religious, and depressive),
types bear clear similarities to the clinical picture de¬ hallucinations, posturing, and symbolism may occur in
scribed here. Thus in delusional mania, paranoid delusions mania even though these features are often considered
and hallucinations prevail, while in delirious mania hallu¬ symptoms of schizophrenia. Finally, Lipkin et al20 re¬
cinations are numerous and the mood changes from eu¬ ported three patients with paranoid delusions, bizarre be¬
phoria to "anxious, despairing thoughts of death," psy¬ havior, and excitement who were first diagnosed as schizo¬
chomotor activity is "senseless" and "raving," patients phrenia or paranoid state, but who later responded to
"pass their motions under them, smear everything, make lithium carbonate. In the brief case histories presented,
impulsive attempts at suicide, take off their clothes," and the authors record but do not emphasize the occurrence of
articulations are incoherent. Kraepelin, however, does not typical "manic" symptoms preceding the onset of a dis-

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 Table 3.—Psychotic Symptoms in Manic Patients,
Review of the Literature

% Patients
Perse¬ No
cutor Passivity No Ideas of Incoher- Symbol- Halluci- Halluci- Confu-
Follow-Up Studies Delusions Delusions Delusions Reference enee ism nations nations sion
NIMH (1972)
20 patients
with complete
manic episodes 65 15 25 20 70 40 40 60 35
Astrup (1959)18
96 manic-depressives
No. of manies not
specified
77 recovered 27 55 45
13 chronic schizophrenic 38 23 10 15 23 38 62 38
Winokur (1969)3
100 manic episodes in
61 patients 19 22 52 28 30 70
Clayton & Winokur (1965)"
31 patients 48 16 84 58
Rennle (1942)10
208 patients (66 manies) 24 52 22
Lundquist (1945)"
95 recovered manies 13 23

organized, agitated, paranoid psychotic state. lithium carbonate was observed in all the stage III pa¬
There are several possible explanations for our findings tients and in all but one of the stage II patients, a success
of a higher incidence of psychotic symptoms during mania rate comparable to that reported in the literature.1·22
than is generally emphasized in the literature. Our study, Do the data presented here suggest that these cases
in contrast to others, included only patients hospitalized should be classified as "schizo-affective" psychosis? The
with a complete manic episode rather than patients who meaning of this question awaits further clarification of
had already been manic for some time before hospitali¬ what constitutes this diagnostic category. Clayton et al23
zation. The inclusion of patients admitted to the research have presented evidence that the "schizo-affective" psy¬
unit when the episode was already beginning to subside choses can be reasonably considered variants of manic-de¬
would have increased the proportion of "nonpsychotic" to pressive illness. Our data are compatible with such a view,
"psychotic" patients. and we realize that others may choose to diagnose the pa¬
Furthermore, because of our interest in studying the tients discussed as schizo-affective.
natural phenomenonology of mania, drug treatment was We have, however, presented clinical and therapeutic
not instituted in the earlier phases as it would be in most reasons as well as historical precedents to support the con¬
other settings. Thus, the full clinical picture is more likely clusion that they are manic. Whether or not these patients
to unfold. This suggests one reason that the observations ultimately will become chronic schizophrenics also cannot
of Kraepelin,9 Lundquist,11 and Rennie1" from the predrug be assessed. The average duration of illness thus far is
era are in reasonable agreement with our data. Finally, only 14 years. In Astrup's "atypical" cases, chronic schizo¬
Mendlewicz et al21 have reported that in manic patients phrenia became obvious anywhere from one to 52 years
with a positive family history of affective disorder (ie, after onset of initial psychiatric symptoms.18 It seems that
similar to our patients), almost half had previously been a conclusive diagnosis cannot be made because of the
misdiagnosed as schizophrenic. They speculate that this is evidently long age of risk for the late-developing schizo¬
the result of a higher incidence of psychotic symptoms phrenias.
during mania and therefore the tendency to misdiagnose Although to our knowledge no one has systematically
schizophrenia in patients with more psychotic manias. examined the sequence, progression, and significance of
The course of the illness and response to medication in symptoms over the course of the entire manic episode it¬
these patients has been no different from those parame¬ self, there are several reports examining the onset and
ters in groups of manic patients reported in the litera¬ early phases of the episode. Bunney et al24 describe three
ture.1 All 20 patients eventually received lithium carbon¬ phases occurring in the first ten days following the switch
ate in a double-blind fashion and showed an antimanic into mania. They note the progression of behavior from
response; 40% of the most disturbed were treated simulta¬ euphoria, irritability, and hyperactivity to more psychotic
neously with phenothiazines for the acute episode. Despite behavior. Their emphasis is on the "switch process" itself,
continuation of the phenothiazines, manic episodes re¬ however, and the more psychotic symptoms were not high¬
curred when lithium carbonate was replaced by a placebo. lighted since they usually occur later in the course of the
Moreover, ultimate withdrawal of phenothiazines with illness.
lithium carbonate maintenance was accomplished without Both Cohen13 and Henderson and Gillespie17 have noted
return of symptoms. In addition, a prophylactic benefit of that delirious mania may follow earlier stages of mania or

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 begin acutely. We found even in those cases with a fairly The ability to distinguish mania from schizophrenia
abrupt onset of severe mania, the earlier stages were pres¬ during the acute psychotic episode has both practical and
ent even though transient. To recapitulate then, although theoretical importance. The therapeutic modalities for
the sequence of symptom appearance is rather consistent, both the treatment and prophylaxis of mania now in¬
the rate of progression of mania varies considerably in cludes lithium carbonate, a medication probably con-
different individuals. traindicated in schizophrenia.25 Furthermore, the lack of
This study has demonstrated that cross-sectional obser¬ clarity concerning proper diagnostic boundaries has often
vations are not always reliable in making a diagnosis, and clouded the interpretation of the psychobiological data in
that the presence during mania of symptoms sometimes affective illness. The use of longitudinal sequential analy¬
thought of as schizophrenic (eg, hallucinations, paranoid sis of changing symptom patterns, rather than simple
delusions, and ideas of reference) should not necessarily cross-sectional enumeration of symptoms, should result in
rule out the diagnosis of affective disorder. Finally, even increased diagnostic clarity.
when such symptoms are present they apparently do not
distinguish that population of patients from those without The nursing staff of 4-West contributed valuable behavioral observations
psychotic symptoms in terms of subsequent functioning. and ratings; Martin Matzen and Eloise Orr provided technical assistance.

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