What are the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision) criteria for a manic episode in Bipolar disorder?

DSM-5-TR Criteria for Manic Episode in Bipolar Disorder

A manic episode requires 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), representing a significant departure from baseline functioning. 1

Core Criterion A Requirements

The DSM-5 introduced a critical change from DSM-IV by making increased activity or energy a mandatory co-primary symptom alongside mood changes 1, 2. This means:

• Both components must be present: abnormal mood (elevated, expansive, or irritable) AND increased energy/activity 1, 2
• This dual requirement reduces false positive diagnoses by approximately 34% compared to DSM-IV criteria that only required mood changes 3
• The addition of increased energy/activity as obligatory improves diagnostic specificity, as episodes meeting this stricter criterion are more severe and have stronger associations with other manic symptoms 2, 3

Duration Requirements

• Manic episodes: Must persist for at least 7 days, or any duration if hospitalization is required 1
• Hypomanic episodes: Must last at least 4 days with similar symptoms but less severe, without marked functional impairment or need for hospitalization 1

Associated Symptoms (Criterion B)

During the mood disturbance and increased energy/activity period, at least three additional symptoms must be present (four if mood is only irritable) 1:

• Decreased need for sleep without feeling tired
• Racing thoughts or flight of ideas
• Pressured speech or increased talkativeness
• Grandiosity or inflated self-esteem
• Distractibility
• Increased goal-directed activity or psychomotor agitation
• Excessive involvement in pleasurable activities with high potential for painful consequences (e.g., sexual indiscretions, foolish investments, spending sprees)

Functional Impairment and Severity

• The episode must cause marked impairment in social or occupational functioning, require hospitalization to prevent harm, or include psychotic features 1
• Symptoms cannot be attributable to physiological effects of substances or another medical condition 1

Special Considerations

Antidepressant-Induced Mania

A manic syndrome arising during antidepressant treatment that persists beyond the known physiological effects of that treatment qualifies as a true manic episode, not merely a substance-induced mood disorder 1, 4. This represents an important diagnostic clarification in DSM-5.

Mixed Features

• DSM-5 eliminated the separate category of "mixed episode" and introduced a "with mixed features" specifier 4
• This specifier applies when at least 3 symptoms of the opposite polarity are present during a manic episode (e.g., depressive symptoms during mania) 5, 4
• Common contrapolar symptoms during mania include: dysphoric mood, expressed beliefs of worthlessness, hopelessness, and suicidal ideation 4

Diagnostic Challenges and Clinical Pitfalls

Pediatric Presentations

Bipolar disorder in children and adolescents often presents atypically compared to adults 6, 1:

• More irritability rather than euphoria as the predominant mood 6, 1
• More rapid cycling and mixed states 1
• Mood changes may be more labile and erratic rather than persistent 1
• High rates of comorbidity with ADHD and disruptive behavior disorders complicate diagnosis 6

Critical distinction: Clinicians must differentiate irritable mania from commonplace anger problems, and grandiosity from normal childhood boasting or imaginary play 6. The American Academy of Child and Adolescent Psychiatry notes that hallmark manic symptoms like grandiosity, psychomotor agitation, and reckless behavior must be distinguished from hyperactivity, dangerous play, and youthful indiscretions 6.

Longitudinal Assessment

A longitudinal history is essential rather than relying solely on cross-sectional assessment 1. Consider:

• Changes in energy, activity, and sleep patterns in addition to mood symptoms 1
• Whether symptoms represent a significant departure from the individual's baseline functioning 1
• Pattern of illness over time, including frequency and duration of episodes

Rapid Cycling Patterns

• Rapid cycling: Four or more distinct mood episodes within 12 months, with each episode still meeting full duration criteria 7
• Ultrarapid cycling: Episodes lasting hours to days (but less than 4 days), with 5-364 cycles per year 7
• Ultradian cycling: Mood cycles occurring within the same day (minutes to hours), greater than 365 cycles per year 7

These patterns are course specifiers, not separate diagnoses 7.