What is the definition of a manic episode according to the DSM-5?

DSM-5 Definition of a Manic Episode

According to DSM-5 criteria, a manic episode is best described as option B: a distinct period of persistently elevated, expansive, or irritable mood AND abnormally increased activity or energy, lasting at least one week and present most of the day nearly every day (or any duration if hospitalization is required). 1

Core Diagnostic Requirements

The DSM-5 introduced a critical change from DSM-IV by requiring both mood changes AND increased activity/energy as co-primary symptoms for diagnosing mania 1, 2:

• Mood component: Abnormally and persistently elevated, expansive, or irritable mood 1
• Energy/activity component: Abnormally and persistently increased activity or energy 1
• Duration: At least 7 consecutive days, present most of the day, nearly every day 1
• Exception to duration: Any duration if hospitalization is required 1

This dual requirement represents a fundamental shift—increased energy or activity is now considered a core symptom, not merely an associated feature 2.

Why the Other Options Are Incorrect

Option A (altered sense of reality and surroundings) describes dissociative symptoms or psychosis, not the primary definition of mania. While psychosis can occur during manic episodes, particularly in adolescents, it is not part of the core diagnostic criteria 1.

Option C (hypervigilance, concentration problems, exaggerated startle response) describes symptoms of post-traumatic stress disorder or anxiety disorders, not mania 1.

Option D (lasting at least four consecutive days) describes a hypomanic episode, not a manic episode. Hypomania requires only 4 days duration and causes less severe impairment without requiring hospitalization 3, 1.

Additional Diagnostic Requirements

Beyond the core criteria, the episode must include 1:

• At least 3 additional symptoms (or 4 if mood is only irritable) such as grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, increased goal-directed activity, or excessive involvement in risky activities 1
• Marked impairment in social or occupational functioning, or necessitate hospitalization, or include psychotic features 1
• Symptoms not attributable to substances or another medical condition 1

Clinical Impact of DSM-5 Changes

The addition of increased activity/energy as a mandatory criterion has significant practical implications 2:

• Research demonstrates this change reduces the prevalence of diagnosed manic and hypomanic episodes compared to DSM-IV criteria 2
• Among patients meeting DSM-IV criteria for mania, requiring the additional energy/activity criterion decreased the number qualifying for a manic episode diagnosis 2
• However, this change did not affect longitudinal clinical outcomes, suggesting it improves diagnostic specificity without missing clinically significant cases 2

Common Diagnostic Pitfalls

In children and adolescents, manic episodes present differently than in adults 3, 1:

• Irritability is more common than euphoria in youth 3, 1
• Mood changes may be more labile and erratic rather than persistently elevated 3
• High comorbidity with ADHD can complicate diagnosis—distinguish true mania from ADHD symptoms by the episodic nature and departure from baseline functioning 1
• Adolescents with manic episodes often present with psychosis and may be misdiagnosed as having schizophrenia 1

Duration matters critically: Brief mood elevations lasting hours to days, even if severe, do not meet criteria for mania unless hospitalization occurs 4, 1. These patterns may represent ultrarapid or ultradian cycling but require different diagnostic considerations 4.