What are the symptoms and treatment options for hypomania?

Symptoms of Hypomania

Core Diagnostic Features

Hypomania is characterized by abnormally and persistently elevated, expansive, or irritable mood accompanied by increased energy, decreased need for sleep, racing thoughts, and increased goal-directed activity, lasting at least 4 days according to DSM-IV criteria. 1

The cardinal symptoms include:

• Mood changes: Marked euphoria, grandiosity, and irritability are the hallmark mood symptoms 1
• Elevated or expansive mood: A distinct period of abnormally elevated mood that represents a clear departure from baseline functioning 2
• Irritable mood: Often more prominent than euphoria, especially in younger individuals and juvenile presentations 3

Behavioral and Cognitive Symptoms

The diagnosis requires at least three of the following symptoms (four if mood is only irritable):

• Inflated self-esteem or grandiosity: Exaggerated sense of confidence or abilities 2, 4
• Decreased need for sleep: Feeling rested after only a few hours of sleep, not just insomnia 1, 2, 4
• Increased talkativeness or pressure to keep talking: More talkative than usual with pressured speech 1, 2, 4
• Racing thoughts or flight of ideas: Subjective experience of thoughts racing through the mind 1, 2
• Distractibility: Attention easily drawn to irrelevant external stimuli 1, 2
• Increase in goal-directed activity: This is the most discriminating symptom, with the highest predictive value (OR=28.3) for distinguishing hypomania from other conditions 4, 5
• Psychomotor agitation: Observable increase in physical activity and restlessness 1, 2
• Excessive involvement in pleasurable activities with high potential for painful consequences: Risky behaviors such as spending sprees, sexual indiscretions, or foolish business investments 2, 5

Key Distinguishing Features from Mania

Hypomania differs from mania in several critical ways:

• Duration: Hypomania requires only 4 days versus 7 days for mania 1, 2
• Severity: Hypomania does not cause marked impairment in social or occupational functioning, whereas mania does 2
• Hospitalization: Hypomania does not require hospitalization, while mania may 2
• Psychotic features: Hypomania does not include psychotic symptoms, which define mania 2
• Functional impact: Hypomania often increases functioning rather than impairing it, making the distinction clearer 2

Atypical Presentations

Several atypical patterns warrant recognition:

• Irritability predominance: Irritability and belligerence are more common than euphoria, particularly in younger individuals 3
• Mixed features: Concurrent depressive and hypomanic symptoms are common, especially in juvenile presentations 3, 6
• Ultrarapid cycling: Brief, frequent episodes lasting hours to days rather than the typical 4+ days 3
• Emotional lability: Rapid mood shifts that may not meet full duration criteria 3
• Behavioral dyscontrol: Explosive and erratic outbursts lasting minutes to hours 3

Most Discriminating Symptoms

Research using tetrachoric factor analysis and prediction rules has identified the core symptoms with highest diagnostic accuracy:

• Increase in goal-directed activity (overactivity) is the single most powerful predictor (OR=14.9 as independent predictor, OR=28.3 in univariate analysis) 4, 5
• Elevated mood is the second most discriminating symptom (OR=7.5) 4, 5
• Increased talkativeness ranks third (OR=3.6) 5
• A prediction rule combining overactivity (weighted score=15) plus elevated mood (weighted score=7) plus talkativeness (weighted score=4) correctly classified 88-94% of hypomanic episodes 5

Critical Diagnostic Pitfalls to Avoid

• Confusing behavioral activation from SSRIs with hypomania: Behavioral activation typically occurs in the first month of treatment and improves quickly with dose reduction, whereas hypomania may appear later and persists despite medication changes, requiring active pharmacological intervention 7, 1
• Mistaking ADHD symptoms for hypomania: Both conditions share features of distractibility and overactivity, but hypomania represents a distinct departure from baseline functioning 1, 3
• Overlooking irritability as a core feature: Attributing irritability solely to personality, stress, or other conditions rather than recognizing it as a manifestation of hypomania 3
• Failing to distinguish irritable hypomania from common anger problems: This is particularly challenging given high rates of comorbidity with disruptive behavior disorders 1
• Applying adult criteria to children without developmental context: Juvenile presentations are often more chronic, irritable, and mixed compared to adult presentations 3

Treatment Considerations

While the question focuses on symptoms, understanding treatment implications helps contextualize the importance of accurate diagnosis:

• Hypomania responds to mood-stabilizing agents (lithium, valproate) and second-generation antipsychotics (olanzapine, quetiapine, risperidone, ziprasidone, aripiprazole) 2
• Hypomania should be treated even when associated with increased functioning, because depression often follows hypomania in the hypomania-depression cycle 2
• For mixed mania/hypomania, aripiprazole, asenapine, carbamazepine, olanzapine, and ziprasidone show the strongest evidence of efficacy 6