What are the symptoms of mania?

Symptoms of Mania

Mania is diagnosed when a patient exhibits a distinct period of abnormally and persistently elevated, expansive, or irritable mood PLUS abnormally and persistently increased activity or energy lasting at least 7 days (or any duration if hospitalization is required), accompanied by at least three additional characteristic symptoms (four if mood is only irritable). 1

Core Diagnostic Features

The essential elements that must be present include:

• Mood disturbance: Elevated, expansive, or irritable mood that represents a clear departure from the person's baseline functioning 1
• Increased energy/activity: This is now a coprimary criterion alongside mood changes and must be present to diagnose mania 1, 2
• Duration: Symptoms must persist for at least 7 consecutive days, unless hospitalization is required (in which case any duration qualifies) 1, 3

Associated Symptoms (Need ≥3, or ≥4 if Mood is Only Irritable)

During the mood disturbance and increased energy period, the following symptoms must be present to a significant degree:

• Inflated self-esteem or grandiosity: Exaggerated sense of importance, abilities, or special powers 1, 3
• Decreased need for sleep: Feeling rested after only a few hours of sleep, which is a hallmark sign 3
• Increased talkativeness or pressured speech: Rapid, difficult-to-interrupt speech 4
• Racing thoughts or flight of ideas: Subjective experience of thoughts racing through the mind 4
• Distractibility: Attention easily drawn to irrelevant external stimuli 5
• Increased goal-directed activity: Heightened involvement in work, social, or sexual activities 1
• Psychomotor agitation: Observable restlessness and hyperactivity 3, 4
• Excessive involvement in pleasurable activities with high potential for painful consequences: Such as unrestrained buying sprees, sexual indiscretions, or foolish business investments 5

Severity and Functional Impact

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 be accompanied by psychotic features. 1 This severity criterion distinguishes mania from hypomania, where functioning may actually increase rather than decline. 5

Common Clinical Presentations

Mood Quality

• Euphoria: Marked elevation with excessive optimism and judgment impairment 3, 6
• Irritability: Belligerence and anger, particularly common in children and adolescents 3
• Mood lability: Rapid and extreme shifts between euphoria, irritability, and dysphoria 3

Psychotic Features

Psychotic symptoms are common and may include:

• Paranoia 3
• Confusion 3
• Florid psychosis with delusions or hallucinations 3
• Grandiose delusions that align with the elevated mood 3

Age-Specific Presentations

In Adults

• More classic presentation with clearer episode boundaries 3
• Cyclical nature with distinct episodes representing departure from baseline 3

In Adolescents

• Frequently associated with psychotic symptoms 3
• Markedly labile moods 3
• Mixed manic and depressive features 3
• More chronic and refractory to treatment than adult-onset cases 3
• Often misdiagnosed as schizophrenia when psychosis is present 1

In Children

• Irritability, belligerence, and mixed features more common than euphoria 3
• Markedly labile and erratic changes in mood, energy, and behavior 3
• High rates of comorbid disruptive disorders 3
• Very rapid, brief, recurrent episodes lasting hours to days, or chronic mania as baseline functioning 7

Critical Diagnostic Distinctions

The symptoms must represent a significant departure from the individual's baseline functioning and be evident across multiple settings, not isolated reactions to specific situations. 1, 3 This is crucial for distinguishing true mania from:

• Chronic temperamental traits 3
• Situational anger or irritability 1, 3
• ADHD (which shows chronic overactivity without episodic mood changes) 3
• Conduct disorder or oppositional defiant disorder 1
• Normal developmental phenomena in children 3

Exclusion Criteria

The symptoms must not be attributable to the physiological effects of a substance (e.g., drug of abuse, medication such as antidepressants) or another medical condition. 1 However, approximately 58% of individuals with bipolar disorder develop manic symptoms after antidepressant exposure, which should be classified as substance-induced mania per DSM criteria. 1, 8

Clinical Pearls

• Reduced need for sleep is a hallmark sign that helps distinguish mania from other conditions with increased activity 3
• The presence of euphoria or grandiosity strongly suggests bipolar disorder over other causes of irritability and agitation 3
• Hyperactivity, increased speech, and thought disorder appear as core features based on factorial analysis studies 9, 4
• Use a life chart to document the longitudinal course, including episode patterns, severity, and treatment response, to distinguish episodic illness from chronic traits 3