Case studies · Psychiatry · 10 November 2026

Acute manic episode case study

The case

Patient: A 28‑year‑old male, single, software engineer, presents to the emergency department accompanied by his sister.

Presenting complaint: “He has been “on fire” for the past 5 days.”

History of presenting illness:

• Onset: Abrupt, 5 days ago, after a weekend of heavy alcohol intake (≈ 6 standard drinks per night).
• Course: The patient reports feeling “extremely energetic”, needing only 3 hours of sleep per night, waking up at 3 a.m. and staying awake until late evening. He describes a “racing mind” with rapid, unrelated thoughts.
• Behaviour: He has been talking loudly, jumping from one topic to another, and has been unusually sociable, calling multiple ex‑girlfriends and sending numerous text messages. He purchased an expensive motorcycle impulsively and spent ₹ 2 lakh on a high‑end gaming console despite having no savings.
• Mood: Elevated, euphoric, “the best feeling ever”. He denies sadness, guilt, or hopelessness.
• Psychotic features: He reports that his colleagues are “admiring his brilliance” and that “the walls are whispering encouragement”. No visual hallucinations.
• Substance use: Daily alcohol (≈ 30 g ethanol) for the past 2 years; occasional cannabis (once a month). No nicotine. No recent medication changes.
• Past psychiatric history: None documented. No prior episodes of mood disturbance.
• Medical history: Unremarkable. No known chronic illnesses.
• Family history: Mother diagnosed with major depressive disorder; father died of myocardial infarction at 55 y. No known psychiatric illness in first‑degree relatives.

Examination:

Initial investigations (all performed within 2 h of presentation):

The investigations are essentially normal, ruling out metabolic, endocrine, or structural causes of mood elevation.

Questions

1. What is the most likely diagnosis?
2. Which clinical findings in the history and examination support this diagnosis, and why do they exclude other differentials?
3. List the essential investigations that must be performed to confirm the diagnosis and rule out mimics, and explain the rationale for each.
4. Outline the acute management plan, including pharmacological and non‑pharmacological interventions, with dosing recommendations.
5. Discuss potential complications of an acute manic episode and strategies for prevention and monitoring.

Answers

1. What is the most likely diagnosis?

Acute manic episode (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition – DSM‑5, 2022).

• The patient meets Criterion A for mania: a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting ≥ 1 day (here 5 days) with ≥ 3 (or ≥ 4 if mood is only irritable) characteristic symptoms (pressured speech, flight of ideas, decreased need for sleep, grandiosity, risky behaviour, distractibility).
• The symptoms cause marked impairment in social/occupational functioning (impulsive purchase, excessive texting, disrupted work).
• No evidence of a substance‑induced mood disorder (BAC low, urine screen negative for stimulants) and no medical condition that could better explain the presentation.

Thus, the case fulfills the DSM‑5 criteria for a Manic Episode.

2. Which clinical findings support this diagnosis and exclude other differentials?

Collectively, these findings point to a primary mood disorder (mania) rather than substance‑induced, medical, or primary psychotic conditions.

3. Essential investigations and rationale

All performed tests are within normal limits, strengthening the diagnosis of a primary manic episode.

4. Acute management plan

4.1 General principles

• Safety first: Assess risk of harm to self or others, protect valuables, and consider brief inpatient admission if there is significant impulsivity, psychosis, or inability to care for self.
• Rapid symptom control to prevent escalation, reduce distress, and enable functional recovery.

4.2 Pharmacological treatment

Typical regimen: Start lithium (or valproate) plus olanzapine. If agitation persists, add haloperidol or lorazepam. Adjust doses based on clinical response and serum levels.

4.3 Non‑pharmacological interventions

• Structured environment: Low‑stimulus room, regular meals, limited access to cash or credit cards.
• Psychoeducation: Explain illness to patient and family, emphasize medication adherence.
• Sleep hygiene: Encourage dark, quiet bedroom; limit daytime napping.
• Psychotherapy (post‑stabilisation): Cognitive‑behavioral therapy (CBT) for bipolar disorder, focusing on relapse prevention.

4.4 Discharge criteria (if inpatient)

• Mood stabilizer at therapeutic level for ≥ 3 days.
• No dangerous impulsivity or psychosis.
• Patient and family understand medication schedule and warning signs.

4.5 Follow‑up

• First outpatient visit within 1 week for lithium level, renal function, and symptom check.
• Long‑term maintenance: Continue mood stabilizer for at least 12 months after the first manic episode (NICE 2022).

5. Potential complications and prevention

Early identification of these complications and systematic monitoring reduce morbidity and improve long‑term prognosis.

Key learning points

• Acute mania is diagnosed when ≥ 1 day of abnormally elevated/irritable mood plus ≥ 3 characteristic symptoms cause functional impairment.
• Rule out medical and substance‑induced mimics with a basic metabolic panel, thyroid function, toxicology screen, and neuroimaging when indicated.
• Lithium remains the first‑line mood stabilizer for acute mania (APA 2023), but valproate or carbamazepine are acceptable alternatives, especially when lithium is contraindicated.
• Atypical antipsychotics (e.g., olanzapine, risperidone) are useful for rapid symptom control and for managing psychotic features.
• Safety assessment (risk of harm, impulsivity) dictates the need for inpatient care.
• Monitoring includes serum drug levels, renal/hepatic function, ECG, and metabolic parameters.
• Long‑term maintenance after a first manic episode should continue for at least 12 months to prevent relapse (NICE 2022).
• Psychoeducation and family involvement are essential to improve adherence and reduce recurrence.

Practice MCQs

1. A 30‑year‑old woman presents with a 3‑day history of elevated mood, decreased need for sleep, and grandiosity. Her labs are normal, and urine toxicology is negative. Which of the following is the most appropriate first‑line pharmacologic agent for acute management?

A. Fluoxetine
B. Lithium carbonate
C. Haloperidol
D. Carbamazepine

Answer: B — Lithium carbonate is the first‑line mood stabilizer for acute manic episodes according to the APA 2023 guideline. Fluoxetine is an antidepressant and may precipitate mania; haloperidol is reserved for severe agitation; carbamazepine is a second‑line option.

2. Which of the following clinical features would most strongly suggest a substance‑induced manic‑like state rather than primary bipolar mania?

A. Grandiosity and risky spending
B. Positive urine screen for amphetamines
C. Decreased need for sleep without fatigue
D. Pressured speech lasting > 5 days

Answer: B — A positive amphetamine screen indicates stimulant intoxication, a common cause of substance‑induced mood elevation. The other features are typical of primary mania.

3. During the first week of lithium therapy, the patient’s serum lithium level is 0.6 mmol/L and she continues to have significant agitation. According to NICE 2022, the next best step is:

A. Discontinue lithium and start valproate
B. Increase lithium dose to achieve 0.8–1.2 mmol/L
C. Add high‑dose olanzapine (20 mg) without changing lithium
D. Switch to lithium carbonate 300 mg once daily

Answer: B — The therapeutic range for acute mania is 0.8–1.2 mmol/L. The level of 0.6 mmol/L is sub‑therapeutic; the appropriate action is dose escalation while monitoring renal function and electrolytes.

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