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In comparison to most psychiatric interviews where open questions are preferred, you may need to use short, closed questions to keep the conversation on track. The mental state examination may give you more clues than the history for diagnosis.
Key Knowledge
What is Mania?
ICD-11 defines mania as an extreme mood state lasting at least a week (unless shortened by treatment) characterised by euphoria, irritability, expansiveness, increased activity / energy accompanied with rapid speech, flight of ideas, increased self-esteem / grandiosity, decreased sleep, distractibility, impulsive behaviour and mood lability.
A hypomanic episode has similar features but they are not severe enough to cause marked impairment in functioning and there are no psychotic symptoms.
Differential Diagnosis for Mania
1. Bipolar I disorder is defined by the presence of at least one manic episode
2. Schizoaffective disorder, when the diagnostic requirements of schizophrenia and a manic episode are met within the same episode of illness
3. Drug-induced psychosis e.g. stimulants (cocaine, amphetamines) and also steroids
4. Organic causes of psychosis e.g. encephalitis, lupus
Mental State Examination in Mania
Appearance & behaviour: may be in flamboyant dress, unable to sit still, easily distracted, sometimes intrusive/disinhibited
Speech: rapid, loud, difficult/uninterruptable (pressured speech)
Mood & Affect: ‘Euphoric’, ‘energised’, ‘on top of the world’, affect is expansive or labile, may be irritable
Thought content & form: may have grandiose delusions (special powers, excessive wealth) or preoccupations with projects or schemes. Thoughts likely racing with flight of ideas (rapidly shifting topic with loose connections)
Perceptual disturbance: hallucinations can occur
Cognition: easily distracted
Insight: often absent, reject need for help
Risk Assessment in Mania
As with every risk assessment, you must consider risk to self, to others and from others. There are some specific things you should consider in manic presentations often relating to increased impulsivity, recklessness and grandiose delusional beliefs:
● To self: self-neglect, exhaustion, financial risk (over-spending, gambling), sexual risk (unprotected sex, STIs, pregnancy), substance misuse, disruption to relationships, accidental injury/death, deliberate self-harm, suicide (in particular where there are mixed manic and depressive symptoms)
● To others: reckless driving, irritability/aggression/violence
● From others: sexual or financial exploitation
Communication Tips
● Maintain a calm, nonjudgmental tone and use short, clear, focused questions, e.g. “How would you describe how you feel in one word?”
● Avoid direct confrontation about grandiose or delusional beliefs as that will increase irritability.
Ensure you have phrases to move on e.g. “I can see this is important to you. We can come back to it later, but I just wanted to ask you…”
● Encourage the patient to sit and focus, but accept pacing if needed.
● Comment on what you see e.g. “It seems like you’ve got a lot of energy right now”.
CASC Practice Scenarios
Scenario 1: Mental State Examination
Candidate Instructions
You are working in the emergency department as part of the mental health liaison team. Ms Julia Evans, a 29-year-old marketing executive, has been brought in by her flatmate after three days of erratic behaviour and not sleeping.
Conduct a mental state examination.
Actor Instructions
You are Julia Evans, a 29-year-old woman. You are dressed in mismatched, flamboyant clothes, with bright lipstick and glitter on your face. You are pacing the room, talking rapidly and switching topics frequently. You believe you have discovered a “revolutionary” marketing idea that will make you famous worldwide, and you are frustrated that no one recognises your genius.
You have barely slept in the last week, saying you don’t need sleep because your mind is “on fire with ideas.” Your mood is “wonderful” and has been for the last 2 weeks. You have spent large sums on business courses and gadgets, even though you are already in debt. You do not have a high sex drive and have not had any sexual contacts in the past 2 weeks.
You feel extremely confident and energetic, but get irritable if people interrupt or question you. You are easily distracted e.g. you might stop mid-sentence to comment on someone’s clothes.
You deny hearing voices or seeing things others cannot. You do not think you are unwell and reject any suggestion you need help. You have no history of drug or alcohol use.
You live with a flatmate but have stopped seeing friends because “you don’t have time”.
You do not have thoughts of harming yourself or others, but admit to feeling annoyed when people don’t understand your ideas. You have not been in any physical altercations recently. You do not drive.
You do not have any past psychiatric history. You have no medical conditions. You are not on any medication. You drink alcohol socially (but none recently) and you do not take drugs.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
Systematically identify and describe components of the mental state examination e.g. appearance, behaviour, speech, e.g. “I have noticed you are talking very quickly, is that typical for you?” and probe for mood changes, abnormal thoughts and check insight
Include a targeted risk assessment including financial and sexual risk
Communication
A good candidate will:
Use short, focused questions and gently redirect tangential speech
Avoid confrontation
Example phrases:
“I’m sorry, I think what you are saying is very important but we are short on time, so I need to ask you…”
Scenario 2: Mental State Examination
Candidate Instructions:
You are the psychiatry registrar on-call. Mr Daniel Brooks, a 42-year-old secondary school teacher, has been brought in by police after being found wandering the streets at night, loudly proclaiming he was destined to “lead a new world order.” He is restless, argumentative, and has not slept for days.
Conduct a mental state examination.
Actor Instructions:
You are Daniel Brooks, a 42-year-old man. You appear dishevelled, with an unbuttoned shirt and mismatched shoes. You are pacing, fidgeting, and frequently interrupt the interviewer. Your speech is loud, pressured, and you jump from topic to topic, often making grand statements about your destiny and abilities. You are overfamiliar and will comment on the candidate’s appearance or ask if they would be willing to go out with you.
You insist you have been chosen for a special mission and that you possess unique insight into world affairs. You become irritable and dismissive if the candidate questions your beliefs, sometimes raising your voice or making sarcastic remarks. When asked about your mood, reply that it’s “great”.
You admit you haven’t slept more than a couple of hours in the past week, saying you don’t need sleep because you are “running on pure inspiration.” You are eating less because you’ve got to focus your time on the mission. You have been spending money on books, travel, and gifts for strangers because you have so much to give. Your sex drive is high and you have been engaging in unprotected sex which is unlike you.
You deny hallucinations but occasionally mention “signs” or “messages” in everyday events. You do not believe you are unwell and see no reason to be in hospital.
You use cannabis and stimulants such as cocaine and amphetamines. Lately, you acknowledge an increase in cocaine use, and claim it helps sharpen his mind and fuels your inspirational episodes. You also experiment with “research chemicals” or so-called “legal highs” purchased online, describing these as simply part of a creative process.
You live alone, and your relationships with friends have become strained because you feel they are jealous or trying to hold you back.
You deny suicidal or homicidal thoughts, but admit to feeling “invincible” and taking risks, such as running across busy roads.
Feedback for Scenario 2
Knowledge & Clinical Skills
A good candidate will:
Comment on appearance (dishevelled, mismatched), behaviour (restless, argumentative), speech (pressured, loud), thought form (tangential)
Ask about mood and thought content (grandiosity).
Explore insight
Assess risk (impulsive spending, self-neglect, sexual disinhibition, aggression, suicidality)
Communication
A good candidate will:
Remain calm and non-judgmental, even when Daniel is irritable
Validate Daniel’s experience without confrontation
Use brief, focused questions and redirect as needed
Example phrases:
“It sounds like you have a lot on your mind right now”
Authors/Reviewers
Dr Damir Rafi is a Psychiatry Speciality Registrar in forensics, currently working in London.
Dr Sarah Barber is a Psychiatry Registrar, currently taking time out of clinical work to complete a PhD in psychiatric epidemiology.
Dr Mohammad Lalji is a Psychiatry Specialty Registrar. He has previously worked as a medical education fellow in North London.
References and Resources
1 World Health Organization (2022). ICD-11: International classification of diseases (11th revision).
2 National Institute for Health and Care Excellence (NICE). (2024). Bipolar disorder: assessment and management. NICE guideline [CG185]. Retrieved from https://www.nice.org.uk/guidance/cg185
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
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