What are the DSM‑5 criteria for diagnosing a manic episode?

DSM-5 Criteria for Manic Episode

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), plus at least three additional symptoms (four if mood is only irritable), causing marked impairment or necessitating hospitalization. 1, 2

Core Criterion A: Dual Requirements

The DSM-5 introduced a critical change from DSM-IV by requiring both mood change and increased activity/energy as co-primary symptoms 2:

• Mood component: Abnormally and persistently elevated, expansive, or irritable mood 1, 2
• Energy/activity component: Abnormally and persistently increased goal-directed activity or energy 1, 2
• Duration: At least 7 consecutive days, or any duration if hospitalization is required 1, 2

This dual requirement substantially reduces the number of episodes diagnosed as mania by approximately 34% compared to DSM-IV criteria, which only required mood changes 3. Research demonstrates the strongest association exists between mood elevation and increased energy/activity (OR 8.65) 3.

Required Additional Symptoms (Criterion B)

During the mood and energy disturbance, at least three of the following symptoms must be present (or four if the mood is only irritable) 1:

• Inflated self-esteem or grandiosity 2
• Decreased need for sleep without feeling tired 4, 1
• More talkative than usual or pressured speech 4, 1
• Racing thoughts or flight of ideas 4
• Distractibility 1
• Increased goal-directed activity (socially, at work/school, or sexually) 1
• Excessive involvement in pleasurable activities with high potential for painful consequences 1

Functional Impairment Requirement (Criterion C)

The disturbance must be severe enough to cause marked impairment in social or occupational functioning OR necessitate hospitalization to prevent harm to self or others OR include psychotic features 2. This distinguishes mania from hypomania, which by definition does not cause marked impairment 4, 1.

Exclusion Criteria (Criterion D)

The episode must not be attributable to the physiological effects of a substance (medication, drug of abuse) or another medical condition 2. However, antidepressant-induced manic symptoms meeting full criteria should be classified as substance-induced mania per DSM criteria 2.

Key Diagnostic Distinctions

Departure from Baseline Functioning

True mania represents a significant departure from baseline that is evident across multiple settings, not isolated reactions to situations 4:

• The mood change must be spontaneous, not merely reactive to stressors 4, 1
• Impairment occurs across different realms of life (home, work, social), not just one setting 4
• Associated psychomotor, sleep, and cognitive changes accompany the mood disturbance 4

Duration Thresholds

• Manic episode: ≥7 days (unless hospitalization required) 4, 1
• Hypomanic episode: ≥4 consecutive days 4, 1
• Episodes <4 days: Do not meet criteria; classify as Bipolar Disorder NOS 4, 1

Special Considerations in Children and Adolescents

Youth presentations differ substantially from adults 4, 1:

• Greater irritability rather than euphoria is more common 4, 2
• Mixed affective states and rapid cycling occur more frequently 4, 1
• Psychotic features are frequently present and may lead to misdiagnosis as schizophrenia 1, 2
• High comorbidity with ADHD and disruptive behavior disorders complicates diagnosis 4, 1

Critical Differential Diagnosis in Youth

Clinicians must distinguish irritable mania from chronic anger problems, ADHD, conduct disorder, and normal developmental phenomena 2:

• Chronic baseline irritability without distinct episodes departing from baseline does not constitute mania 1
• ADHD shows chronic overactivity without episodic nature or mood component 4
• Disruptive behavior disorders exhibit chronic irritability as baseline, not episodic departures 4

Structured Assessment Approach

Use a life-charting method to document the longitudinal course 4, 1:

• Map exact duration of activated states and sleep changes 4, 1
• Document functional impairment across multiple settings 4
• Identify cycling patterns and episode boundaries 4, 1
• Assess family psychiatric history, particularly for bipolar disorder 4

Key Clinical Questions

When evaluating suspected mania, systematically assess 4, 1:

• Are there distinct periods representing significant departure from baseline functioning?
• Is there decreased need for sleep during elevated mood states?
• Do mood changes occur spontaneously or only in reaction to stressors?
• Is impairment evident across multiple life domains?
• Are psychotic features present, and do they occur primarily during mood episodes?

Common Diagnostic Pitfalls

Avoid these frequent errors 1, 2:

• Diagnosing mania based on mood changes alone without increased activity/energy 2, 3
• Misinterpreting chronic irritability or emotional dysregulation as episodic mania 4, 1
• Confusing situational reactions with true manic episodes 4
• Misdiagnosing adolescent mania with psychosis as schizophrenia 1, 2
• Failing to document temporal separation between episodes 1

Clinical Impact of DSM-5 Changes

The addition of increased activity/energy as a co-primary criterion has significant implications 3, 5:

• Episodes diagnosed under DSM-5 criteria are likely more severe 3
• The stricter criteria may prevent overdiagnosis but risk underdiagnosing some hypomanic/manic episodes 3
• No differences in longitudinal clinical outcomes were observed between DSM-IV and DSM-5 diagnosed episodes 5