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Clinical Manifestations of Mania in Patients With Bipolar I Disorder Based on

the Primary Symptoms in DSM-5

Article in Practice in Clinical Psychology · October 2017

DOI: 10.29252/nirp.jpcp.5.4.289

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 October 2017, Volume 5, Number 4

Research Paper: Clinical Manifestations of Mania in

Patients With Bipolar I Disorder Based on the Primary CrossMark

Symptoms in DSM-5

Zahra Mohammadi1, Abbas Pourshahbaz1*, Behrooz Dolatshahi¹, Marjan Poshtmashhadi¹

1. Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.

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Citation: Mohammadi, Z., Pourshahbaz, A., Dolatshahi, B., & Poshtmashhadi, M. (2017). Clinical Manifestations of Mania in Pa-
tients With Bipolar I Disorder Based on the Primary Symptoms in DSM-5. Journal of Practice in Clinical Psychology, 5(4), 289-296.
https://doi.org/10.29252/NIRP.JPCP.5.4.289
: : https://doi.org/10.29252/NIRP.JPCP.5.4.289

Article info: ABSTRACT

Received: 30 Mar. 2017
Accepted: 13 Jul. 2017 Objective: According to DSM-5, bipolar disorder is a condition in which the patient
experiences one or several manic episodes and sometimes major depressive episodes too. The
signs and symptoms of the disorders in DSM are generally influenced by cultural and ethnic
factors. Therefore, the present study was aimed at identifying the clinical manifestations of
mania in bipolar I disorder in Iranian population.
Methods: The present work is a cross-sectional study. The participants included 64 patients in
the manic phase of bipolar I disorder who were selected from the Razi psychiatric hospital and
the Taleghani Hospital, using a convenience sampling method. The study data were gathered
using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Young
Mania Rating Scale (YMRS).
Results: According to the findings, the most common signs and symptoms of mania in
hospitalized patients with bipolar I disorder included reduced need for sleep (89.1), poor insight
(87.5), elevated mood (85.9), talkativeness (79.7), and psychotic features (68.8). The major
symptoms of the patients according to DSM-5 criteria included reduced need for sleep (89.1),
talkativeness (79.7), and psychomotor agitation (40.6). According to t-test analysis, patients
with and without a history of mental disorders did not have significantly different mania scores.
The one-way analysis of variance (ANOVA) analysis indicated no significant difference in
mania scores based on the age of onset of the disorder, marital status (single, married, divorced,
or widow), education level, and number of hospitalizations. The chi-squared test revealed that
patients with a lower education level showed more aggressive behaviors.
Keywords: Conclusion: According to our results, since the response of a patient to a particular treatment
Bipolar disorder, Mania, is largely influenced by the symptoms of the disorder, clinicians should pay critical attention to
Clinical manifestations the most common signs and symptoms of any mania.

* Corresponding Author:
Abbas Pourshahbaz, PhD
Address: Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
Tel: +98 (939) 3391589
E-mail: [email protected]

289
October 2017, Volume 5, Number 4

1. Introduction with an older age of onset, and this makes the clinical
manifestations of their disorder even more severe (Carl-

A
ccording to Diagnostic and Statisti- son, Bromet, & Sievers, 2000; Schulze et al., 2002). In
cal Manual of Mental Disorders, Fifth addition, since their condition has started at an early
Edition (DSM-5), bipolar disorder is a age, these patients usually do not have much educa-
condition in which the patient experi- tional qualification. Bipolar I disorder is more common
ences one or several manic episodes, in single, divorced, or widowed individuals compared
and sometimes also major depressive to married people (Sadock & Sadock, 2011). Given the
episodes (Whitbourne & Halgin, 2014). differences in demographic variables and other cultural
The prevalence of bipolar I disorder is estimated to be be- factors, the most common symptoms of mania in bipolar
tween 0 and 0.6 percent (American Psychiatric Associa- I disorder in the US include increased psychomotor ac-
tion, 2013). This condition leads to a significant decrease tivity, racing thoughts, pressure of talking, and reduced
in job performance, which in turn results in a lower socio- need for sleep (Cassidy & Carroll, 2001), while in the
economic status for the patients, despite having a simi- UK, it includes talkativeness, psychomotor agitation,
lar level of education to that of their peers in the general and reduced need for sleep (Goodwin & Jamison, 2007).
population (American Psychiatric Association, 2013).
The socio-cultural issues in each society affect the clin-
Consequently, bipolar I disorder reduces the quality ical presentations of mental disorders; however, these is-
of life of the patients and imposes different costs on sues have not received enough attention in the universal
them, their families, and the society (Van der Voort et classifications like DSM. Given that the symptoms of
al., 2015; Sammarco, 2016). Mania is the major clinical manic episodes in bipolar I disorder are culture-bound,
manifestation of bipolar I disorder (Proudfoot, Doran, knowing their frequency in each society can lead to a
Manicavasagar, & Parker, 2011). In fact, patients in the more accurate diagnosis of bipolar I disorder. Therefore,
manic phase are diagnosed with bipolar I disorder, even the goal of the present study is to examine the clinical
when there are no depression episodes (American Psy- manifestation of a manic episode in Iranian patients with
chiatric Association, 2013). Patients’ experiences during bipolar I disorder.
mania are very complex (Goodwin & Jamison, 2007).
They may seem extremely sociable, talkative, vigilant, 2. Methods
witty, and over-confident. Their openness and high en-
ergy can lead to serious dysfunctions. They may have The present research work is a descriptive cross-section-
a severe false self-esteem and grandiose or even psy- al study. The statistical population included all patients
chotic thinking. In addition, they may experience racing with bipolar I disorder in the Razi psychiatric hospital
thoughts, become easily distracted, and need excessive and the Taleghani Hospital in 2016-2017. Among this
stimulation. Manic patients are very energetic. However, population, a total of 97 patients with bipolar I disorder
euphoria can suddenly change into severe irritability or were selected using a convenience sampling method, and
even aggression or hostility, especially if other people try were examined in terms of the inclusion and exclusion
to stop their unreasonable or grandiose plans (American criteria; 64 patients, who met the criteria, were included
Psychiatric Association, 2013). in the analysis. The inclusion criteria were as follows: di-
agnosed with bipolar disorder according to SCID-I, aged
Although DSM-5 includes diagnostic criteria for bi- between 18 to 65 years, and being able to understand the
polar I disorder, it must be noted that the severity and study questions. The exclusion criteria included severe
manifestations of bipolar symptoms are determined by mental retardation, severe physical disorders, and the un-
multiple factors, including environmental and biological willingness of patients to participate in the study. The fol-
ones (Lieberman, Massey, & Goodwin, 2010). Bipolar I lowing instruments were used to collect data:
disorder is equally common in men and women, but men
tend to have significantly more manic episodes as com- The Structured Clinical Interview for DSM-IV Axis I
pared to women (Sadock & Sadock, 2011); however, the Disorders (SCID-I): This is a semi-structured interview
age of onset of mania is higher in women, and two peak used to diagnose the major disorders of axis I, according
ages are particularly seen in women viz., early adulthood to DSM-IV criteria. SCID-I has two versions: A research
and midlife (Kroon et al., 2013). version (SCID-I-RV) and a clinical version (SCID-CV).
The research version includes the axis I disorders with
Patients having bipolar disorder with an earlier age of complete details and is very useful in studies that re-
onset suffer from more psychotic symptoms than those quire accurate details, whereas the clinical version only

290 Mohammadi, Z., et al. (2017). Clinical Manifestations of Mania in Patients With Bipolar I Disorder Based on the Primary Symptoms in DSM-5. JPCP, 5(4), 289-296.
 October 2017, Volume 5, Number 4

includes disorders commonly observed in clinics. Test- with a mean age of 47.50 (SD=13.57). 39.1% of the
retest reliability estimates of 0.40 (dysthymic disorder) participants were illiterate or had primary school educa-
and 0.84 (bipolar disorder) have been reported for the tion, 15.6% middle school education, 14.1% high school
SCID-I (Mohammadkhani, Jahani Tabesh, & Tamanaie- education, and 31% a high school diploma or college
far, 2013). In the present study, the SCID-CV was used. education. 39.1% of the participants were single, 37.5%
Demographic questionnaire: A researcher-made demo- married, and 23.4% divorced or widowed. 60.9% of the
graphic questionnaire was used to gather data on gender, participants had a family history of mental disorders.
age, educational level, marital status, age of onset of the In 23.4% of the participants, the first symptoms had
disorder, family history of mental disorders, and number emerged in the age range of 10-20 years, in 64.1% in the
of hospitalizations, if any. age range of 20-40 years, and in 12.5% in the age range
of 40-60 years. 23.4% of the participants had been hospi-
The Young Mania Rating Scale (YMRS): The YMRS talized only once, 21.9% twice, and the rest had three or
was developed by Young, Biggs, Ziegler and Meyer more, earlier hospitalization records. In overall, 76.6%
(1978) based on the descriptions provided for the main had more than one hospitalization records (Table 1).
symptoms of mania. It is aimed at assessing the sever-
ity of mania symptoms in patients with bipolar disorder, According to the data from the YMRS, the most com-
based on patients’ self-reports of their clinical condition mon signs and symptoms of mania in the patients with
and clinicians’ observations during clinical interviews. bipolar I disorder included reduced need for sleep (89.1),
Reliability of the scale has been reported to range from poor insight (87.5), elevated mood (85.9), talkative-
0.41 (appearance) to 0.85 (thought and language disor- ness (79.7), and psychotic features (68.8). In addition,
ders), an inter-rater reliability of 0.93 has been reported the main symptoms of mania according to DSM-5 cri-
for the total scale, and inter-rater reliability estimates teria included reduced need for sleep (89.1), talkative-
ranging from 0.66 (aggressive-destructive behavior) to ness (79.7), and psychomotor agitation (40.6) (Table 2).
0.95 (sleep) have been reported for its subscales (Young Among the mania symptoms, the categories of poor in-
et al., 1978). In Iran, Cronbach’s alphas of 0.72 and sight (1.89) and aggressive- destructive behaviors (0.20)
0.63, respectively in patient and clinical groups, and had the highest and lowest severity levels, respectively;
an inter-rater reliability of 0.96 have been reported for whereas, among the main symptoms of mania based on
the YMRS (Barekatain, Tavakoli, Molavi, Maroufi, & DSM-5 criteria, reduced need for sleep (2.39) and rac-
Salehi, 2007). In the present study, the reliability of the ing thoughts (0.25) had the highest and lowest sever-
YMRS was found to be 0.72. ity levels, respectively. According to the results of the
chi-squared test, there was no significant difference in
Firstly, patients diagnosed with bipolar I disorder by a clinical manifestations of mania based on demographic
psychiatrist were selected. Consequently, medical records characteristics; the only exception was that those with a
were reviewed to examine the inclusion and exclusion cri- lower education level showed more aggressive behav-
teria. Then, the SCID-I was conducted to confirm the diag- iors (Sig.=0.04).
nosis of mania in the patients. Subsequently, demographic
data were collected based on the information provided in According to the results of the independent samples
medical records and also by interrogating the patients. Fi- t-test, there was no significant difference in mania
nally, the YMRS was administered to examine the clinical scores between patients with or without a family his-
manifestations of manic episodes. Before completing the tory of mental disorders (Sig.=0.51). In addition, the
questionnaires, participants were informed about the study results of ANOVA indicated no significant difference in
objectives and were reassured that their personal informa- mania scores based on the age of onset of the disorder
tion remained confidential. In addition, participation in (Sig.=0.94), marital status (Sig.=0.63), education level
the study was completely voluntary, and participants were (Sig.=0.32), and number of hospitalizations (Sig.=0.88)
given the freedom to leave the study at any time. The study (Tables 3 and 4).
data were analyzed using independent samples t-test and
one-way analysis of variance (ANOVA). Analyses were 4. Discussion
performed using the SPSS software v.22.
The goal of the present study was to identify the clini-
3. Results cal manifestations of mania in patients with bipolar I
disorder, and to examine the differences in clinical mani-
Among the participants, 90.6% were women with a festations based on demographic characteristics. In ac-
mean age of 38.22 (SD=11.14), and 9.4% were men cordance with several previous reports, particularly Ken-

Mohammadi, Z., et al. (2017). Clinical Manifestations of Mania in Patients With Bipolar I Disorder Based on the Primary Symptoms in DSM-5. JPCP, 5(4), 289-296. 291
October 2017, Volume 5, Number 4

Table 1. Frequency distribution of demographic variables

Frequency Frequency (%)

Female 58 90.6
Gender
Male 6 9.4

Single 25 39.1

Marital status Married 24 37.5

Divorced and widowed 15 23.4

Illiterate or primary school education 25 39.1

Middle school education 10 15.6

Education level
High school education 9 14.1

High school diploma or college education 20 31.3

Having 39 60.9
Family history of mental
disorders
Not having 25 39.1

10-20 15 23.4
Age of onset of the disorder 20-40 41 64.1
40-60 8 12.5

Once 15 23.4

Number of hospitalizations Twice 14 21.9

Three times or more 35 54.7

Table 2. The most common signs and symptoms of mania according to the YMRS

Severity of Signs and Symptoms

Signs and Symptoms Frequency Frequency (%)
Mean SD
Reduced need for sleep* 57 89.1 2.39 1.03
Poor insight 56 87.5 2.84 1.25

Elevated mood 55 85.9 1.73 0.97

Talkativeness* 51 79.7 1.81 1.27

Psychotic features 44 68.8 0.68 0.46

Appearance 26 40.6 0.53 0.79

Psychomotor agitation* 26 40.6 0.98 1.29

Distraction* 25 39.1 0.39 0.49

Sexual desire* 24 37.5 0.57 0.86

Megalomania* 17 26.6 0.26 0.44

Racing thoughts* 16 25.0 0.25 0.43

Irritability 16 25.0 0.40 0.77

Aggressive-destructive behaviors 10 15.6 0.20 0.53
* Mania symptoms according to DSM criteria

292 Mohammadi, Z., et al. (2017). Clinical Manifestations of Mania in Patients With Bipolar I Disorder Based on the Primary Symptoms in DSM-5. JPCP, 5(4), 289-296.
 October 2017, Volume 5, Number 4

Table 3. Results of t-test for mania scores based on family history of mental disorders

Mean SD df P

With family history of mental disorders 17.51 3.64

62 0.51
Without family history of mental disorders 16.88 3.94

Table 4. Results of ANOVA for mania scores according to demographic variables

Variables Mean SD F P

Age of onset of the disorder 1.89 0.59 0.05 0.94

Marital status 1.84 0.78 0.45 0.63

Education level 2.37 1.29 1.18 0.32

Number of hospitalizations 3.31 0.83 0.12 0.88

nedy et al. (2005), Schwartzman et al. (2007), and Eid rate (Sadock & Sadock, 2015). In addition, 68.8% of the
et al. (2013), we observed that despite the higher rate patients in this study had an education qualifications be-
of manic episodes in men, more women had attended low high-school diploma, a finding in line with those of
the hospitals to seek treatment and this probably could Maede et al. (2011) and Olfson et al. (2016); this could
be attributed to the fact that in the manic phase, women be related to the onset of mania early in life, or unwill-
are significantly more likely than men to be hospitalized. ingness of patients with a high education level to seek
The study is also in line with the findings of Coryell, Fie- treatment due to social stigmas.
dorowicz, Leon, Endicott and Keller (2013), indicating
that the onset of mania commonly occurs at a young age. In the present study, the signs and symptoms of mania
in the hospitalized patients with bipolar disorder includ-
Keeping in view of the above findings, we infer that ed reduced need for sleep, poor insight, elevated mood,
those with a family history of mental disorders (In the talkativeness, and psychotic features, but based on DSM-
present study, it was found that 60.9% of the patients 5 criteria, the main symptoms of mania included reduced
with bipolar I disorder had a family history of mental need for sleep, talkativeness, and psychomotor agitation;
disorders) have experienced more manic and depressive however, megalomania, reduced need for sleep, and talk-
episodes in the past (In the present study, it was found ativeness were particularly the most common symptoms
that 76.6% of the patients had multiple hospitalizations in DSM-5. This can be attributed to different cultural
in the past), and have a younger age of onset that is re- backgrounds affecting the form and content of the symp-
lated to the genetic prediction hypothesis. Based on this toms of mental disorders. In a previous study by Akiskal
hypothesis, the severity of mental disorder is increased, et al. (1998) in France, megalomania, reduced need for
and the age of onset of mental disorder is decreased sleep, talkativeness, and racing thoughts; and in a study
across consecutive generations (Grabe, 2017). by Angst et al. (2011), talkativeness, reduced need for
sleep, and an increase in goal-directed behaviors, were
In the present study, we observed that majority of the respectively the most common symptoms of mania.
patients with bipolar I disorder were single or divorced;
this finding is consistent with those of Hu et al. (2017) Largely, these findings are consistent with the pres-
and Gignac, McGirr, Lam and Yatham (2015). The rea- ent study results. Furthermore, according to this study,
son why mania is more common in single or divorced we infer that although euphoria and elevated mood are
patients is that those with bipolar I disorder are less among the main characteristics of mania, it is not in fact
likely to get married, and those who are married have a euphoric condition. In overall, in contrast to a previous
dysfunctional marriages with a high possibility of ex- report by Yazla, İnanç, and Bilici (2012), no significant
tramarital affairs; therefore, they have a higher divorce difference was found between clinical manifestations of

Mohammadi, Z., et al. (2017). Clinical Manifestations of Mania in Patients With Bipolar I Disorder Based on the Primary Symptoms in DSM-5. JPCP, 5(4), 289-296. 293
October 2017, Volume 5, Number 4

mania based on demographic characteristics, except that sive episode: the BRIDGE study. Archives of General Psychiatry,
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those with a lower education showed more aggressive
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This paper is an outcome of the first author’s Master’s Goi, P. D., Mosqueiro, B. P., & Cunha, A. B. D. (2009). The im-
thesis work on clinical psychology from the University pact of marital status in hospitalized patients with bipolar
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Conflict of Interest Goodwin, F. K., & Jamison, K. R. (2007). Manic-depressive illness:

Bipolar disorders and recurrent depression (Vol. 1). Oxford: Ox-
ford University Press.
All authors certify that this manuscript has neither been
published in whole nor in part nor being considered for Grabe, H. J. (2017). Environment, genes, and mental health anticipa-
tion and medicine. Berlin: Springer.
publication elsewhere. The authors have no conflicts of
interest to declare. Hu, C., Torres, I. J., Qian, H., Wong, H., Halli, P., Dhanoa, T.,
et al. (2017). Trajectories of body mass index change in first
episode of mania: 3-year data from the Systematic Treat-
ment Optimization Program for Early Mania (STOP-EM).
Journal of Affective Disorders, 208(15), 291-297. doi: 10.1016/j.
jad.2016.08.048
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