The manic state is in most ways the opposite of the depressed state, being characterized by a euphoric flight of ideas, motor and speech hyperactivity, and an increased appetite and sex urge. When such a state is fully developed, it qualifies as a psychosis. After a minimum of sleep, the patient awakes with enthusiasm and expectation. The manic individual appears to possess great drive and confidence yet lacks the ability to carry out plans. Often headstrong, impulsive, socially intrusive behavior is characteristic. Judgment may be so impaired that reckless investments are made; fortunes are spent in gambling or on extravagant shopping sprees. Setbacks do not perturb the patient, but rather act as goads to new activities. Euphoria and expansiveness sometimes bubble over into delusions of power and grandeur, which, in turn, may make the patient offensively aggressive. Up to a point, the patient’s mirth and good spirits may be contagious, and others may join in; however, if the patient is thwarted, the warmth and good humor can suddenly change to anger. Irritability rather than elation may become the prevailing mood. The threshold for paranoid thinking is low, which makes the patient sensitive and suspicious.
Personal neglect may reach the point of dishevelment and poor hygiene. In its most advanced form, a condition described as “delirious mania,” the patient becomes totally incoherent and altogether disorganized in behavior. (Such were the descriptions in some of the great literature of the 19th and early 20th centuries depicting the mania of neurosyphilis.) At this stage visual and auditory hallucinations and paranoid delusions may be rampant.
Hypomania describes a milder degree of the disorder but this term is also used loosely to depict behavior in a normally functioning individual who is unusually energetic and active. In this latter sense, hypomania is a personality trait found in many talented and productive persons and need not arouse concern unless it is excessive and out of character for the individual. As Belmaker noted, a number of highly creative individuals have had bipolar disorders, but full-blown mania is uniformly destructive of careers and personal relationships. Such individuals are actually more creative when treated with appropriate medications. Even though many authors, such as Thomas Mann in his character of Adrian Leverkühn in Doctor Faustus, romanticized a link between madness and creativity, the linkage in reality goes only so far.
First attacks of either depression or mania last an average of 6 months if untreated, although the duration varies greatly. With treatment, this can be reduced according to some trials by more than half in many patients. Although most attacks of bipolar disease subside in a matter of months, a significant number, remain chronically ill for long periods. According to Winokur and colleagues, 14 percent of their bipolar patients had not recovered after 2 years and 5 percent had not recovered after 5 years. Comparative figures for primary unipolar patients were 19 and 12 percent, respectively. The majority of depressed patients have one or more recurrences. Variables that are predictive of an unfavorable outcome are high degrees of anxiety, strongly positive family history of a similar psychiatric illness, and presence of depression-provoking circumstances (Hirschfeld et al). Perhaps most important is the duration of illness before treatment, that is, earlier treatment is generally associated with a more favorable prognosis.