What are the DSM‑5 criteria that differentiate hypomania from mania?

DSM-5 Differentiation of Hypomania from Mania

The critical distinction between hypomania and mania in DSM-5 rests on three key factors: duration (≥4 days for hypomania versus ≥7 days for mania), severity of functional impairment (absent in hypomania, marked in mania), and hospitalization requirement (never needed for hypomania, may be required for mania). 1, 2, 3

Core Criterion A Requirements

Both hypomania and mania require the same foundational symptoms under DSM-5 Criterion A:

• Abnormally and persistently elevated, expansive, or irritable mood PLUS abnormally and persistently increased activity or energy 1, 2, 4
• This represents a critical change from DSM-IV, where increased energy/activity was optional—DSM-5 now mandates both mood change AND increased energy/activity as co-primary symptoms 4, 5, 6
• Research demonstrates this stricter criterion reduces the prevalence of diagnosed hypomanic/manic episodes by 34%, but episodes that do meet criteria tend to be more severe 5

Duration Thresholds

Hypomania:

• Must last at least 4 consecutive days 1, 3
• Episodes lasting less than 4 days do not meet hypomania criteria and should be classified as Bipolar Disorder Not Otherwise Specified (NOS) 1, 3

Mania:

• Must last at least 7 consecutive days 1, 2, 3
• Exception: Any duration qualifies if hospitalization is required 1, 2

Functional Impairment and Severity

Hypomania:

• Does not cause marked impairment in social or occupational functioning 1, 3
• Does not require hospitalization 1, 3
• Represents a noticeable change from baseline but remains manageable 1

Mania:

• Causes marked impairment in social or occupational functioning 2
• OR necessitates hospitalization to prevent harm to self or others 2
• OR includes psychotic features (which automatically qualifies as mania regardless of other factors) 2, 3

Psychotic Features

• The presence of psychotic symptoms (paranoia, hallucinations, delusions) automatically classifies the episode as mania, not hypomania 2, 3
• Psychotic features are common in adolescent manic presentations and frequently lead to misdiagnosis as schizophrenia 1, 2

Clinical Assessment Approach

When differentiating hypomania from mania, systematically evaluate:

Episode Duration:

• Document the exact number of consecutive days with sustained mood elevation/irritability AND increased energy/activity 1, 3
• Use a life-charting approach to map temporal patterns 1, 3

Sleep Changes:

• Both hypomania and mania feature decreased need for sleep without feeling tired 1, 3
• This is a hallmark sign distinguishing true mood episodes from other conditions 3

Functional Impact Across Settings:

• Assess whether the patient can maintain work/school performance, relationships, and daily responsibilities 1, 2
• True mania shows impairment across multiple domains, not isolated to one setting 3

Need for Intervention:

• Determine if hospitalization was required or considered 2
• Evaluate whether the patient posed danger to self or others 2

Presence of Psychosis:

• Screen for paranoia, confusion, hallucinations, or delusions 2, 3
• Any psychotic features during a mood episode indicate mania 2, 3

Common Diagnostic Pitfalls

• Irritability alone lacks specificity: Irritability is common across many psychiatric conditions and does not distinguish hypomania from mania—focus on the constellation of symptoms, duration, and impairment 1, 3
• Chronic baseline irritability is not hypomania: Episodes must represent a significant departure from baseline functioning, not temperamental traits 1, 3
• Antidepressant-induced symptoms: Manic or hypomanic symptoms precipitated by antidepressants should be classified as substance-induced per DSM-5 2, 3
• Pediatric presentations differ: Children and adolescents show more irritability, mixed states, and rapid cycling compared to adults, complicating the distinction 1, 3
• High comorbidity in youth: ADHD and disruptive behavior disorders frequently co-occur with bipolar disorder in children, requiring careful differentiation of chronic overactivity from episodic mood elevation 1, 3

Special Considerations in Children and Adolescents

• Youth often present with greater mood lability, mixed affective states, and rapid cycling that differ from classic adult presentations 1, 3
• Distinguish hallmark hypomanic/manic features from normative childhood behaviors such as boastful play, imaginative scenarios, typical overactivity, and age-appropriate risk-taking 3
• Adolescent mania frequently includes psychotic features and is often misdiagnosed as schizophrenia—confirm the episodic nature with clear periods of normal functioning between episodes 1, 2

Impact of DSM-5 Changes

• The addition of increased energy/activity as a mandatory co-primary symptom reduces the number of diagnosed hypomanic/manic episodes but identifies more severe cases 4, 5, 6
• Real-world smartphone-based daily assessments show that co-occurring elevated/irritable mood with increased activity occurs only 0.12% of the time for four consecutive days, compared to 24% for mood changes alone 7
• This stricter criterion may prevent overdiagnosis of bipolar disorder but risks underdiagnosing clinically significant hypomanic episodes 5, 6