How to Take a History of Mania or Hypomania
Core Approach: Focus on Overactivity First, Then Mood
When screening for mania or hypomania, prioritize asking about increased goal-directed activity and overactivity before probing mood changes, as this approach reduces false-negative diagnoses and better identifies bipolar disorder that is commonly misdiagnosed as unipolar depression. 1
Essential Stem Questions
Primary Screening Questions
- Ask about overactivity/increased goal-directed activity as your first question - this has stronger diagnostic utility than starting with mood elevation 1
- Probe for distinct periods of abnormally elevated, expansive, or irritable mood lasting at least 7 days (or any duration if hospitalization required) 2
- For hypomania, ask about periods lasting at least 4 days 3
- Inquire about abnormally increased energy levels during these periods 2
Critical Distinguishing Features
Assess whether symptoms represent a significant departure from baseline functioning across multiple settings, not just reactions to specific situations - this is the key distinction between true mania and situational anger or irritability. 3
Specific Symptoms to Probe (In Order of Diagnostic Importance)
Hallmark Symptoms (Present in All Historical Expert Descriptions)
- Decreased need for sleep - this is pathognomonic for mania in adults, though present in <50% of juvenile cases 4, 3
- Pressured speech and increased talkativeness 5
- Hyperactivity and increased motor activity 5
- Grandiosity or inflated self-esteem 2, 5
- New activities with painful consequences (reckless behavior) 5, 6
- Irritability 5
Additional Core DSM Symptoms
- Racing thoughts or flight of ideas 2
- Distractibility 6
- Excessive involvement in pleasurable activities with high potential for painful consequences 2
Clinically Important Features Often Missed by DSM Criteria
- Impulsivity 5
- Hypersexuality 5
- Mood lability with rapid extreme shifts 3, 5
- Altered moral standards 5
- Increased humor 5
- Hypergraphia 5
- Vigorous physical appearance 5
Age-Specific Considerations
In Adults
- Look for clear episode boundaries with cyclical nature 3
- Episodes represent distinct departure from baseline 3
- More classic presentation with euphoria predominating 3
In Adolescents
- Expect psychotic symptoms frequently - these are common and historically led to misdiagnosis as schizophrenia 4, 2
- Markedly labile moods are typical 3
- Mixed manic and depressive features occur commonly 3
- More chronic and refractory course than adult-onset 3
In Children
- Irritability, belligerence, and mixed features are more common than euphoria 3
- Mood changes are markedly labile and erratic rather than sustained 4
- High comorbidity with disruptive disorders creates diagnostic confusion 3
- Episodes may be ultrarapid (hours to days) or ultradian (minutes to hours, cycling daily) 4, 3
Characterizing Episode Patterns
Use a Life Chart Approach
Create a longitudinal timeline documenting the pattern, severity, duration, and treatment response of all mood episodes - this distinguishes episodic illness from chronic temperamental traits. 3
Specific Episode Types to Identify
- Manic episodes: ≥7 days duration (or any duration if hospitalized) 3, 2
- Hypomanic episodes: ≥4 days duration, milder elevation, no marked impairment or hospitalization 7, 3
- Mixed episodes: ≥7 days with simultaneous manic and depressive symptoms 3
- Rapid cycling: ≥4 mood episodes per year 3
- Ultrarapid cycling: 5-364 cycles per year 4, 3
- Ultradian cycling: >365 cycles per year (daily cycling) 4, 3
Critical Differential Diagnosis Questions
Distinguishing True Mania from Other Conditions
Ask whether euphoria or grandiosity are present - the presence of either strongly suggests bipolar disorder over major depression with agitation. 3
Key Differentiating Features
- Impairment across multiple settings (not isolated to one environment) indicates true mania versus situational reactions 3
- Psychomotor, sleep, and cognitive changes accompanying mood disturbance support mania 3
- Symptoms are marked changes in mental/emotional state, not reactions to situations 3
Rule Out Substance-Induced Mania
- Antidepressant-induced symptoms have the strongest evidence as triggers and should be classified as substance-induced 3, 2
- Ask about all medications, drugs of abuse, and medical conditions that could cause symptoms 2
Family History Assessment
Probe specifically for bipolar disorder in first-degree relatives - strong genetic loading increases likelihood of true bipolar disorder versus other explanations. 3
- Approximately 20% of youths with major depression develop mania by adulthood 3
- Family history of affective disorders is a key risk factor 3
Red Flags for Bipolar Risk in Depressed Patients
When taking history from someone presenting with depression, ask about:
- Rapid onset of depressive episodes 3
- Psychomotor retardation during depression 3
- Psychotic features during depression 3
- History of hypomania or mania after antidepressant treatment 3
- Premorbid anxiety and dysphoria 3
Common Pitfalls to Avoid
In Children and Adolescents
- Do not confuse chronic irritability and explosive outbursts with episodic mania - true mania shows distinct episodes, not stable baseline patterns of anger 4
- Distinguish manic symptoms from ADHD, conduct disorder, or normal development 2
- Recognize that only <50% of juvenile mania cases have sleep disturbance, unlike adults 4
In All Age Groups
- Do not rely solely on mood elevation - many patients present with irritability as the predominant mood 2
- Psychomotor agitation alone is present in 18% of major depressive disorder patients and does not indicate mania 6
- Dysphoric symptoms exist on a continuum rather than as a distinct subtype 8
Gender Considerations
- Early-onset cases (before age 13) are predominantly male 4
- Female gender may be associated with dysphoric presentations under certain definitions 8
Functional Impairment Assessment
Document marked impairment in social or occupational functioning, or need for hospitalization - this severity threshold is required for manic episodes. 2