Diagnostic Criteria for Mania According to DSM-5-TR
According to the DSM-5-TR, a manic episode is diagnosed when there is a distinct period of abnormally and persistently elevated, expansive, or irritable mood AND abnormally and persistently increased activity or energy lasting at least 7 days (or any duration if hospitalization is required). 1
Core Diagnostic Criteria
- A manic episode requires both mood change (elevated, expansive, or irritable mood) AND increased activity or energy as co-primary symptoms 2, 3
- The episode must last for at least 7 days, unless hospitalization is required 1
- The symptoms must represent a significant departure from the individual's baseline functioning 1
- The disturbance must be severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization 1
Associated Symptoms
During the period of mood disturbance and increased energy/activity, at least 3 of the following symptoms (or 4 if the mood is only irritable) must be present to a significant degree:
- Inflated self-esteem or grandiosity 1, 4
- Decreased need for sleep 5
- More talkative than usual or pressure to keep talking 5, 4
- Flight of ideas or subjective experience that thoughts are racing 5, 4
- Distractibility 5
- Increase in goal-directed activity or psychomotor agitation 5, 2
- Excessive involvement in activities with high potential for painful consequences 5
Diagnostic Considerations
- The symptoms must not be attributable to the physiological effects of a substance (e.g., drug of abuse, medication) or another medical condition 1, 6
- The episode must be severe enough to cause marked impairment in functioning, necessitate hospitalization, or include psychotic features 5
- The symptoms must not be better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other psychotic disorders 6
Clinical Pearls and Pitfalls
- The addition of "increased activity or energy" as a co-primary criterion in DSM-5-TR has reduced the number of patients diagnosed with manic episodes by approximately 34% compared to previous DSM criteria 2, 3
- Manic episodes in adolescents often present with psychosis and may be misdiagnosed as schizophrenia 1
- Irritability as the predominant mood requires 4 (rather than 3) additional symptoms for diagnosis 5
- Distinguishing between mania and hypomania is based on severity and functional impairment, not symptom type 5
- Manic symptoms precipitated by antidepressant treatment should be classified as substance-induced according to DSM criteria 1
Special Considerations
- In children and adolescents, mood can be irritable rather than elevated, but care must be taken to distinguish irritable mania from common anger problems or disruptive behavior disorders 1
- Hallmark manic symptoms in youth must be differentiated from symptoms of other common childhood disorders such as ADHD, conduct disorder, or normal developmental phenomena 1
- For children with suspected bipolar disorder who don't meet full criteria for mania, the diagnosis of Bipolar Disorder Not Otherwise Specified (NOS) may be appropriate 1