Defining Manic vs Hypomanic Episodes
A manic episode requires at least 7 days of abnormally elevated, expansive, or irritable mood with increased energy/activity causing marked functional impairment or requiring hospitalization, while a hypomanic episode has identical symptoms but lasts only 4+ days, does not cause marked impairment, and never requires hospitalization. 1
Core Diagnostic Features
Manic Episode
- Duration: Minimum 7 days (or any duration if hospitalization is required) 2, 1
- Mood: Distinct period of abnormally and persistently elevated, expansive, or irritable mood 1
- Energy: Abnormally and persistently increased activity or energy (now a coprimary criterion in DSM-5) 1, 3
- Functional Impact: Causes marked impairment in social or occupational functioning, or requires hospitalization 1, 4
- Psychosis: May include psychotic features 1
Hypomanic Episode
- Duration: Minimum 4 days 1, 4
- Mood and Energy: Same symptom quality as mania (elevated, expansive, or irritable mood with increased activity/energy) 1, 4
- Functional Impact: Does NOT cause marked impairment in functioning and does NOT require hospitalization 1, 4
- Psychosis: Never includes psychotic features (presence of psychosis automatically makes it mania) 4
- Key Distinction: Hypomania often actually increases functioning, which helps distinguish it from mania 4
Required Associated Symptoms (Both Episode Types)
Both manic and hypomanic episodes require at least 3 of the following symptoms (4 if mood is only irritable): 1, 4
- 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
Critical Clinical Distinctions
The symptoms are identical between mania and hypomania—the difference lies entirely in severity, duration, and functional impact. 4
Severity Markers
- Mania: Severe enough to cause marked impairment or require hospitalization 1
- Hypomania: Observable change in functioning but not severe enough to cause marked impairment 4
Duration Threshold
- Episodes lasting less than 4 days do not meet criteria for hypomania, regardless of symptom severity 1
- Brief mood swings lasting minutes to hours are not hypomania 1
Common Diagnostic Pitfalls
Beware of misdiagnosing chronic irritability or mood lability as bipolar disorder. 1
- Symptoms must represent a distinct departure from baseline functioning, not chronic baseline irritability 1
- Mood changes that are purely reactive to stress or interpersonal conflict do not constitute hypomania 1
- Patients with borderline personality features are frequently misdiagnosed as having bipolar disorder 1
Use longitudinal assessment, not just cross-sectional evaluation. 1
- Document exact duration of activated states across multiple settings 1
- Verify decreased need for sleep during elevated mood states (not just insomnia) 1
- Confirm whether mood changes occur spontaneously or only in reaction to stressors 1
Special Considerations in Youth
Children and adolescents may present differently than adults, with more irritability, mixed states, and rapid cycling. 2, 1
- Juvenile mania may manifest as very rapid, brief, recurrent episodes lasting hours to a few days, or as chronic mania as baseline functioning 2
- Patterns in youth are often more labile and erratic rather than persistent 1
- High rates of comorbidity with ADHD and disruptive behavior disorders complicate diagnosis 1