What are the symptoms and treatment options for mania and hypomania?

Symptoms of Mania and Hypomania

Mania and hypomania share the same core symptoms—abnormally elevated, expansive, or irritable mood with increased energy/activity—but differ primarily in severity and duration, with mania causing marked functional impairment and lasting at least 7 days, while hypomania causes observable but less severe changes lasting at least 4 days. 1, 2

Core Diagnostic Features

Mania

Increased energy/activity is the most important core feature of mania, even more so than mood changes. 3 The essential symptoms include:

• Abnormally and persistently elevated, expansive, or irritable mood lasting at least 7 days (or any duration if hospitalization required) 1
• Increased energy or goal-directed activity that represents a marked departure from baseline functioning 1, 3
• At least three additional symptoms (four if mood is only irritable): 1, 2
  • Inflated self-esteem or grandiosity 1
  • Decreased need for sleep 1, 2
  • More talkative than usual or pressured speech 1, 2
  • Racing thoughts or flight of ideas 1, 2
  • Distractibility 1
  • Increased goal-directed activity or psychomotor agitation 1, 2
  • Excessive involvement in pleasurable activities with high potential for painful consequences 1, 2

Typical manic symptoms also include pressure of speech, motor hyperactivity, poor judgment, aggressiveness, and possibly hostility. 2

Hypomania

Hypomania requires the same symptom criteria as mania but with critical differences: 4

• Duration of at least 4 days (though some evidence suggests briefer episodes may be clinically significant) 5, 4
• Observable change in functioning that does NOT cause marked impairment 4
• No psychotic features (psychosis defines mania) 4
• Often increases rather than impairs functioning, which helps distinguish it from mania 4

Atypical and High-Risk Presentations

Irritability as a Core Feature

Irritability and belligerence are more common than euphoria in hypomanic episodes, especially in younger individuals. 5 This is a critical diagnostic consideration:

• In recalled hypomania, irritable mood was present in 65.9% of cases while elevated mood was present in 81.4% 6
• Irritability alone lacks diagnostic specificity and must be accompanied by other manic features 7

Mixed Features

Mixed presentations with concurrent depressive and hypomanic symptoms are common, particularly in juvenile presentations and carry increased suicide risk. 5, 1 Key characteristics include:

• Depressed, manic, hypomanic, or severely anxious states occurring together 8
• Adolescents with mania frequently present with psychotic symptoms, markedly labile moods, and/or mixed manic-depressive features 1
• Mixed depression (depression with subthreshold hypomanic symptoms) occurs in 66.4% of bipolar II depressive episodes 6

Atypical Cycling Patterns

Ultrarapid and ultradian cycling represent atypical presentations not captured by standard diagnostic criteria: 5

• Ultrarapid cycling: brief, frequent episodes lasting hours to days 5
• Ultradian cycling: extremely rapid mood shifts occurring multiple times within a day 5
• Episodes lasting only minutes to hours should be classified as Bipolar Disorder NOS, as they don't meet minimum duration criteria 7

Age-Specific Presentations

Children and Adolescents

In younger children, mood, energy, and behavioral changes are often more labile and erratic rather than persistent. 1 Important developmental considerations include:

• Irritability, belligerence, and mixed features are more common than euphoria in juvenile presentations 5, 1
• Behavioral dyscontrol with explosive, erratic outbursts lasting minutes to hours 5
• Emotional lability with rapid mood shifts that don't meet duration criteria 5
• High rates of comorbid ADHD, disruptive behavior disorders, and anxiety disorders complicate the clinical picture 5
• Acute psychosis in an adolescent may be the first presentation of mania 1

Symptom Profiles Distinguishing Mania from Hypomania

Five symptoms correctly classify 82.8% of bipolar I (mania) versus 80.1% of bipolar II (hypomania) patients: 9

• Reckless activity 9
• Distractibility 9
• Psychomotor agitation 9
• Irritable mood 9
• Increased self-esteem 9

Bipolar I patients show higher prevalence of these five symptoms compared to bipolar II patients. 9

Critical Diagnostic Pitfalls to Avoid

Failing to distinguish irritable mania from common anger problems is a major diagnostic error, especially given high comorbidity rates with disruptive behavior disorders. 1

Confusing manic symptoms with ADHD is another common pitfall—both conditions can present with distractibility, increased activity, and talkativeness, but represent distinct disorders. 5, 1

Overlooking irritability as a core hypomanic feature by attributing it solely to personality, stress, or other psychiatric conditions leads to underdiagnosis. 5

Not recognizing that brief activated episodes may represent true mood elevation—chronic personality traits should not be confused with episodic mood changes. 7

Applying adult diagnostic criteria to children without considering developmental context results in misdiagnosis. 1

Treatment Implications

Acute Management of Mania

Lithium produces normalization of manic symptomatology within 1 to 3 weeks. 2 Evidence-based acute treatments include:

• Mood stabilizers: lithium and valproate 4, 10
• Second-generation antipsychotics: olanzapine (5-20 mg/day), quetiapine, risperidone, ziprasidone, aripiprazole 11, 12, 4, 10
• Combination therapy with atypical antipsychotics plus lithium or valproate for severe cases 10

Acute Management of Hypomania

Hypomania should be treated even if associated with overfunctioning, because depression often follows hypomania (the hypomania-depression cycle). 4 Treatment follows similar principles to mania management. 4

Mixed Mania/Hypomania

Aripiprazole, asenapine, carbamazepine, olanzapine, and ziprasidone show the strongest evidence for acute-phase treatment of mixed states. 10 Quetiapine and divalproex/valproate are also efficacious. 10

Maintenance Treatment

Lithium is supported by multiple controlled studies for preventing both depression and hypomania recurrences. 4 For maintenance:

• Olanzapine and quetiapine (alone or combined with lithium/divalproex) show strongest evidence 10
• Lamotrigine shows efficacy in delaying depression recurrences 4
• Lithium and lamotrigine may be beneficial given preventive effects on suicide and depressive relapse 10

Treatment Monitoring

Close monitoring for suicidality is essential, especially in the first months of treatment and following dosage adjustments, as SSRIs carry a boxed warning for suicidal thinking through age 24. 8 The pooled absolute rate for suicidal ideation is 1% with antidepressants versus 0.2% with placebo (NNH=143). 8

Monitor for behavioral activation/agitation (motor restlessness, insomnia, impulsiveness, disinhibited behavior), which is more common in younger children and anxiety disorders. 8 This typically occurs early in SSRI treatment and supports slow up-titration. 8

Distinguish behavioral activation from mania/hypomania: activation typically occurs in the first month and improves quickly with dose reduction, while mania may appear later and persist despite medication changes. 8