Is chronic mania a distinct clinical entity?

Sir,

Sometimes, chronic mania poses a great diagnostic and management challenge in day to day clinical practice. Chronic mania is defined as presence of manic symptoms for more than two years without remission.[1] Clinician face difficulty in such patients in differential diagnosis from clinical conditions like cyclothymia, bipolar disorder (mixed), and borderline personality disorder.

Due to this overlapping of clinical manifestations, diagnosis of chronic mania is difficult to make in these patients. Here the authors present a case of a young woman with a persistent mood disorder.

A 35-year old female presented to our clinic with features of irritability, hostile feelings, marked reactivity, increased psychomotor activity with decreased sleep and appetite for the last 21 years. She had poor interpersonal relations with her close family members. Over trivial issues, she used to become irritable and suspicious and thus not allow her husband to go out of home. Patient developed dysphoric mood, delusions of infidelity, distortion of reality but had no perceptual disturbances. Her husband developed negative feelings against her and developed suicidal wishes. Her family members visited many medical practitioners and mental health professionals. She was given antipsychotics, ECTs, antidepressants, and anxiolytics but response with medications was variable. Her husband and family members were distressed with her clinical condition and her husband on one occasion left her home.

During their visit to our clinic, patient's detailed examination and investigations ruled out any organic etiology for the symptoms. There was no past or family history of any medical or psychiatric illness. She was primarily diagnosed as chronic mania and was subsequently started on lithium carbonate 800 mg/day and sodium valproate 1500 mg/day. She recovered well with treatment. She has been followed up in OPD for the last six months and has been maintained well on lithium carbonate 450 mg/day. Her other medication sodium valproate was tapered off and stopped over a period of two months after remission.

Renewed interest has been generated in clinical entity chronic mania in the last decade of third new millennium.[2-4] Even with current therapies a significant number of patients with persistent mood disorder particularly chronic mania have a poor outcome. This clinical entity of chronic mania deserves a better attention of health professionals. In the above case report, patient was prescribed many medications in the past but she did not improve. No mood stabilizer was prescribed in last so many years and patient was treated on the line of major depression, agitated depression, personality disorder. In the past, patient received a misdiagnosis and subsequent poor management of psychotic symptoms. More research work on persistent mood disorders especially chronic mania is suggested to better understand the phenomenology of this subgroup of patients.

In a recent European cohort study (EMBLEM), 15% of patients fulfilled criteria for chronic mania and this clinical entity was associated with lower severity of mania symptoms, less socially active and greater occupational impairment in such patients.[4] Khanna et al.,[5] found that in India chronic and recurrent manic pattern is more prevalent than the typical bipolarity. Our case highlights that primary persistent mood disorders like chronic mania can occur at young age and should be managed with mood stabilizers. It has a definite place as a separate clinical entity.