What is mania?

Mania: Clinical Features and Diagnostic Criteria

Mania is a distinct psychiatric syndrome characterized by abnormally and persistently elevated, expansive, or irritable mood, accompanied by increased energy, decreased need for sleep, racing thoughts, and impaired judgment that represents a significant departure from baseline functioning and causes marked impairment. 1

Core Clinical Features of Mania

• Mood changes are the cardinal symptoms, including marked euphoria, grandiosity, and irritability 1
• Racing thoughts, increased psychomotor activity, and mood lability are characteristic associated symptoms 1
• Marked sleep disturbance is a hallmark sign, typically presenting as decreased need for sleep 1
• Paranoia, confusion, and/or florid psychosis may be present 1
• Symptoms represent a significant departure from baseline functioning and are evident across multiple settings 1

Diagnostic Criteria

• According to DSM criteria, mania requires distinct periods of abnormally and persistently elevated, expansive, or irritable mood with increased activity or energy 1
• The episode must last at least one week (or any duration if hospitalization is required) 1
• Manic symptoms must include at least three of the following (four if mood is only irritable):
  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual or pressure to keep talking
  • Flight of ideas or racing thoughts
  • Distractibility
  • Increase in goal-directed activity or psychomotor agitation
  • Excessive involvement in pleasurable activities with high potential for painful consequences 1, 2

Presentation Variations

• In adolescents, mania frequently presents with psychotic symptoms, markedly labile moods, and/or mixed manic and depressive features 1
• In younger children, changes in mood, energy levels, and behavior are often more labile and erratic rather than persistent 1
• Irritability, belligerence, and mixed manic-depressive features are more common than euphoria in juvenile presentations 1
• Manic grandiosity and irritability present as marked changes in mental and emotional state, rather than reactions to situations or temperamental traits 1

Differential Diagnosis

• Manic-like symptoms of irritability and emotional reactivity may be found in other conditions, including:
  • Disruptive behavior disorders
  • Posttraumatic stress disorder
  • Pervasive developmental disorders 1
• Organic causes of mania must be ruled out, including:
  • Neurological disorders
  • Toxic exposures
  • Metabolic conditions
  • Medication-induced mania (particularly corticosteroids, levodopa, antidepressants) 3, 4

Clinical Course

• Bipolar disorder with manic episodes is cyclical in nature 1
• Significant depressive symptoms may precede, occur conjointly (mixed episodes), or follow manic symptoms within the same episode 1
• The early course of bipolar disorder in adolescents appears to be more chronic and refractory to treatment than adult onset 1
• Mania in adults typically has onset between late adolescence and age 25, whereas onset after age 35 is more suggestive of organic causes 3

Clinical Pitfalls to Avoid

• Failing to distinguish between irritable mania and common anger problems, especially given high rates of comorbidity with disruptive behavior disorders 1
• Confusing manic symptoms with those of ADHD, which can appear similar but represent distinct conditions 1
• Not recognizing that acute psychosis in an adolescent may be the first presentation of mania 1
• Overlooking medication-induced mania, particularly in patients taking antidepressants, corticosteroids, or dopaminergic medications 4
• Applying adult diagnostic criteria to children without considering developmental context 1

Proper diagnosis requires careful assessment of symptom patterns, duration, associated features, and impact across multiple domains of functioning to distinguish true mania from other conditions with overlapping presentations.