DEFINITION

• Mania is a distinct period of abnormally elevated, expansive, or irritable mood and increased energy. Per the DSM-5-TR, this period must last at least one week (or any duration if hospitalization is necessary). This state must constitute a noticeable change from usual behavior and typically leads to marked impairment in social and/or occupational functioning.[1]
• The syndrome of mania is defined by a constellation of signs and symptoms, which may include:[2]
  • Decreased need for sleep
  • Hyperverbal speech or pressured speech (rapid speech that is difficult to interrupt)
  • Rapid thinking, racing thoughts, or flight of ideas
  • Distractibility and impulsivity
  • Increased goal-directed activity or psychomotor agitation (purposeless activity)
  • Abnormal engagement in risky activities (e.g. spending, gambling, promiscuity, etc.)
  • Inflated sense of self and increased sense of perceptual and intellectual acuity
  • Indefatigable, rash, intrusive, aggressive, and at times violent behavior
  • Delusions of grandeur and/or persecution, and religious and/or sexual preoccupations are often present.
  • Hallucinations may be present but are less common.
• Hypomania is less severe in the degree, type, and duration of mood, cognitive, and behavioral symptoms exhibited.
  
  • According to the DSM-5 TR, hypomania need only persist for the majority of the time over 4 consecutive days.[1]
  • Hypomania does not cause significant impairment, but the patient will be noticeably different than baseline.
  • If there is significant impairment, hospitalization, or psychotic symptoms (e.g. delusions or hallucinations), the episode is manic by definition.
• Volatility of affect is the rule rather than the exception in mania and hypomania.
  • Even when mood is predominantly expansive and euphoric, there is usually an irritable underpinning.
• Mixed States
  • Manic and hypomanic symptoms (e.g. increased energy) can coexist with depressive ones (e.g. dysphoria) in mixed states.
  • Most frequently observed are patients with predominantly depressed mood and poverty of thought who simultaneously manifest restlessness and dysphoric energy, or patients with depressed mood who also exhibit flight of ideas, distractibility, anxiety, and/or agitation.
  • Mixed states can be transitional states from one phase of illness to another (e.g. from mania to depression) or can be independent clinical states.
  • Mixed features are associated with poorer prognosis and place patients at particularly high risk for suicide.[1][3]