Core criteria
Distinct period of abnormally elevated/expansive or irritable mood AND increased energy/activity, plus ≥3 of DIGFAST (≥4 if mood only irritable): Distractibility, Indiscretion (risky pleasurable activity), Grandiosity, Flight of ideas, Activity increase, Sleep need decreased, Talkativeness/pressured speech.
The manic/hypomanic split (it changes management)
| Hypomania | Mania | |
|---|---|---|
| Duration | ≥4 days | ≥7 days (or any, if hospitalised) |
| Severity/impairment | Noticeable, not marked | Marked functional impairment |
| Psychosis | Absent | May be present |
| Hospitalisation | No | May be needed |
Rule: psychosis or the need for hospitalisation ⇒ the episode is manic, not hypomanic, regardless of duration.
The high‑yield discriminator
*Decreased need for sleep* ("3 hours, fully energetic") ≠ insomnia ("want to sleep, can't"). The former is a specific manic marker; the latter is non‑specific.
Safety and workup
Mania is a risk state: financial ruin, sexual risk, dangerous driving, aggression, psychosis, self‑neglect. Also exclude secondary mania — stimulants, steroids, dopaminergics, antidepressant‑induced switch, hyperthyroidism, CNS lesion — especially at atypical age or first presentation.
Pitfalls
- Recording "cheerful/happy" and missing the energy/activity criterion and the impairment.
- Missing an organic/substance cause of a first manic episode.
Pearls
- 🎯 The hallmark is pathological elevation/irritability + increased energy with impaired judgement, not euphoria.
- 🩺 Psychosis during the episode ⇒ manic (⇒ Bipolar I) — a single decision with large downstream consequences.
Next → Integrate the poles into the bipolar diagnosis and its treatment logic (Concept 19).