Symptoms of Mania
Mania is characterized by a distinct period of abnormally elevated, expansive, or irritable mood with increased energy/activity, decreased need for sleep, racing thoughts, pressured speech, grandiosity, and excessive involvement in pleasurable activities with high potential for harmful consequences. 1
Core Diagnostic Features
The essential symptoms that define a manic episode include:
- Increased energy/activity is the most important core feature of mania, showing the highest correlation with overall syndrome severity and representing a broader range of severity levels than mood changes alone 2
- Elevated, expansive, or irritable mood that is abnormally and persistently present 1
- Decreased need for sleep without feeling tired is a hallmark sign of mania 1, 3
These three symptoms—elevated/irritable mood, hyperactivity, and rapid/pressured speech—are the most diagnostically specific features, with patients requiring at least two of these three to establish a manic diagnosis 4
Additional Manic Symptoms
Beyond the core triad, manic episodes typically include:
- Racing thoughts and flight of ideas with rapid shifts between topics 1
- Pressured speech that is difficult to interrupt 1, 4
- Grandiosity with inflated self-esteem or unrealistic beliefs about one's abilities 1, 3
- Excessive involvement in pleasurable activities with high potential for painful consequences (e.g., spending sprees, sexual indiscretions, risky business investments) 1
- Psychomotor agitation with marked increases in goal-directed activity 5
Mood Quality and Presentation
The mood experience in mania can be heterogeneous:
- Marked euphoria is common, though not universal 3
- Irritability and belligerence may be prominent, especially in youth 3
- Mood lability with rapid and extreme mood shifts is characteristic 3
- The mood represents a significant departure from baseline functioning that is evident across different realms of life, not isolated to one setting 3
Psychotic Features
- Paranoia, confusion, and/or florid psychosis may be present during manic episodes 3
- Psychotic features are particularly common in adolescent presentations of bipolar disorder 6, 3
Duration and Episode Criteria
- A full manic episode must last at least 7 days, unless hospitalization is required 1, 6
- The symptoms must represent a clear departure from the individual's baseline functioning 1
- Episodes are spontaneous rather than merely reactive to situational stressors 3
Special Considerations in Youth
Manic presentations differ significantly in children and adolescents:
- Greater irritability rather than euphoria is more common 3
- Markedly labile moods with mixed manic and depressive features 3
- Changes in mood, energy, and behavior are often more erratic rather than persistent 1
- Rapid cycling patterns are more frequent than in adults 3
- Episodes may be extremely short-lived, lasting only hours to days, or present as a chronic baseline pattern 3
Common Pitfalls in Recognition
- Patients often do not feel ill or seek treatment during manic episodes, contributing to underdiagnosis 7
- Hypomania can be hidden by substance use disorders, making detection more difficult 7
- Irritability alone lacks diagnostic specificity and must be accompanied by other core features to distinguish mania from other psychiatric conditions 3
- Brief mood swings lasting minutes to hours do not meet criteria for mania, which requires sustained duration 1