although chronic mania has been described in psychiatry literature for a century now , it has not received the equivalent status as given to chronic depression by the current nosological systems .
one of the major limitations of this is the lack of systematic research on this entity . in this report , we present a case of chronic mania and discuss the clinical features of chronic mania reported in the literature , which are helpful in distinguishing chronic mania from acute mania .
mr a , 22-years - old , unemployed , and belonged to a nuclear family of lower socioeconomic status , presented with an insidious - onset illness of 5 years duration , with a continuous course , characterized by dysphoric mood , grandiose ability , grandiose associations , grandiose identity , poor self - care , wandering , abusiveness , assultativeness , and aggressive behavior .
the patient had been using cannabis off and on for a few days , but use of or abstinence from cannabis did not have much influence on the nature of psychopathology .
he also had a history of tobacco dependence syndrome since the age of 15 years . over the period of 3 years , he frequently absconded from home ; whenever found he would be in a disheveled state and when asked about his whereabouts , he would talk about his grandiose abilities , identity , and association and would say that he had been on his special mission of the army .
he was treated with some psychotropic medications after continuation of symptoms for a period of 3 years , with which family members perceived only 20% improvement in his psychopathology .
later , he was treated with tablets of olanzapine 20 mg / day , lithium 600 mg / day , and valproate 500 mg / day , and he showed a 25% improvement in his symptoms with the above combination .
he had been kept in seclusion for few months before being brought to our center .
early developmental history did not reveal any abnormality , and there was no history of hyperthymic traits .
there was no history suggestive of schneider 's first - rank symptoms , overfamiliarity , depressive features , head injury , and seizures . on examination ,
he was found to have dysphoric mood and he expressed grandiose delusions of being a general in the army and ability to control people at remote areas .
he also had secondary delusions that people are trying to harm him because of his special powers and abilities .
his cognitive functions were preserved , but he lacked insight into his illness . with the available information ,
his routine investigations and a computerized tomography scan of brain did not reveal any abnormality .
he was managed with a course of 12 electroconvulsive therapy treatments along with olanzapine 30 mg and benzodiazepines .
he showed only marginal improvement in his symptoms with the above combination . following this ,
he was shifted to tablets of haloperidol 15 mg / day along with lithium 1050 mg / day ( serum lithium level 0.7 meq / l ) . with this combination , over the period of 6 weeks , the patient showed improvement in his overall behavior , delusion of persecution subsided , but the grandiose delusions persisted .
his family was asked to shift the patient to a long - stay mental health facility .
however , his family decided to keep the patient at home . over the period of next 1 year
, he was continued on the combination of haloperidol 20 mg / day and lithium 1050 mg/ day , during which he did not take up any work and continued to harbor the grandiose delusions and had elevated mood .
however , he was better in the form of lack of abusiveness and running away behavior .
the current nosological systems define mania by a duration of 7 days , and epidemiological studies suggest that untreated mania usually remits within 6 months , though in some cases it may last longer .
classically , chronic mania has been defined as the presence of manic symptoms for more than 2 years without remission . however , in recent years , other researchers have used different definitions such as lack of improvement by at least two points from baseline on the clinical global impression - bipolar disorder mania scale at any observation during the 12 months after starting treatment for acute mania .
however in literature , chronic mania lasting for about 48 years has also been described .
studies that have evaluated patients with bipolar disorders have reported an incidence of 615% for chronic mania among all the patients with bipolar disorders . with regard to symptomatology and associated clinical features , one of the recent studies that compared patients of acute mania and chronic mania suggested that chronic course usually arises in the background of hyperthymic temperament and recurrent mania , with a deteriorative pattern .
furthermore , the authors reported that compared to patients with acute mania , patients with chronic mania have significantly a high rate of almost constant euphoria , grandiose delusions , and related delusions and relatively low rates of sleep disturbance , psychomotor agitation , and hypersexuality .
another study suggested that compared with treatment responders , patients who do not respond and run a chronic course have a lower severity of mania symptoms at baseline but a higher prevalence of delusions / hallucinations , have a shorter duration of current episode prior to start of the treatment , are less socially active , and have a higher occupational impairment .
however , despite the presence of clear diagnostic symptoms of mania , it is often difficult to diagnose a patient with chronic mania because of superimposed cyclothymic or hyperthymic temperament or overlap of symptoms between mania , schizophrenia , and schizoaffective disorders .
in general , it is suggested that the grandiosity in chronic mania is associated with an elevated mood , compared to schizophrenia , in which patients exhibit grandiosity associated with the flat effect . with regard to management
, it is generally suggested that chronicity denotes poor outcome ; however , reports contrary to this belief also exist .
the index case exhibited manic symptoms for 5 years prior to presentation to us , with minimum improvement with treatment .
he has been under our care of about 1.5 years , with no change in the core manic symptoms despite good treatment compliance .
this clinical picture fits with the clinical description of chronic mania and suggests that in rare patients , mania can run a chronic course . in recent times , there have been a few reports of chronic mania from various other centers in india , and this suggests that chronic mania does exist in clinic population and there is a need to study this clinical entity more meaningfully to understand its biological correlates and treatment outcome .
 chronic mania ( defined as the presence of manic symptoms for more than 2 years without remission ) poses significant problems in diagnosis and management . 
 generally it denotes poor outcome , though contrary reports are available . 
 we present a case of chronic mania and discuss the clinical features of chronic mania reported in the literature , which are useful in distinguishing chronic mania from acute mania . 
INTRODUCTION
CASE REPORT
DISCUSSION