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Am I experiencing mania or hypomania? It’s a pretty common question among people with bipolar disorder. Part of the reason we care is that it’s the number one differentiating factor between diagnoses of bipolar I vs bipolar II. Another reason is that while hypomania has potential to wreak havoc, mania is downright dangerous to self and others.

The uncertainty in the distinction between the two is such that I’ll routinely use “hypo/mania” to describe an elevated mood state because I’m just not sure. As far as I know or anyone has told me, I’ve never been fully manic. I can think of situations that might be eligible for the label if I spilled the beans about specifics, though I’m not sure what that would accomplish.

But it can be hard to know where the line is drawn in terms of subjective experience. The DSM-IV-TR defines the two states with these criteria (differences in definitions are in bold):

Diagnostic Criteria for a Hypomanic Episode

  • A distinct period of persistently elevated, expansive or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.
  • During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
    1) inflated self-esteem or grandiosity
    2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
    3) more talkative than usual or pressure to keep talking
    4) flight of ideas or subjective experience that thoughts are racing
    5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
    6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation
    7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
  • The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
  • The disturbance in mood and the change in functioning are observable by others.

Diagnostic criteria for a Manic Episode

  • A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
  •  During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
    1) inflated self-esteem or grandiosity
    2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
    3) more talkative than usual or pressure to keep talking
    4) flight of ideas or subjective experience that thoughts are racing
    5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
    6) increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
    7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
  • The symptoms do not meet criteria for a Mixed Episode.
  • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

The updated DSM-V is proposing to change those definitions to these (differences from DSM-IV in bold):

Diagnostic Criteria for a Hypomanic Episode

  • A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day (or any duration if hospitalization is necessary).
  • During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree:
    1.  Inflated self-esteem or grandiosity
    2.  Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
    3.  More talkative than usual or pressure to keep talking
    4.  Flight of ideas or subjective experience that thoughts are racing
    5.  Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
    6.   Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
    7.   Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
  • The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
  • The disturbance in mood and the change in functioning are observable by others.
  • The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

Diagnostic criteria for a Manic Episode

  • A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
  • During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree, and represent a noticeable change from usual behavior:
    1.  Inflated self-esteem or grandiosity
    2.  Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
    3.  More talkative than usual or pressure to keep talking
    4.  Flight of ideas or subjective experience that thoughts are racing
    5.  Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
    6.  Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal directed activity)
    7.  Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
  • The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

There are some differences between the old and upcoming versions of the hallowed DSM, and the new version does clarify a little. There is a lot more detail in the hypomania definition, and the changes seem quite sensible to me. Some of the wordsmithing is a bit better too.

But can you really tell the difference between mania and hypomania from these definitions? Sure, there are guidelines according to episode duration, but as many bipolars can attest, hypomania can last just as long as mania.

There’s also the psychosis factor. Pretty straightforward there. Similarly, in the current DSM, mixed episodes (both manic and depressive symptoms at the same time) also qualify you for a bipolar I dx, but that’s been updated to an equal-opportunity symptom in the proposed revisions. I would hazard a guess that mixed states could look pretty different for bipolar I and II.

The bit about severity is actually the key variable to consider. But can you confidently make a call as to whether you’ve had marked impairment in social or occupational functioning? I still find it hard to know what where some of my experiences would fall on the spectrum of functional impairments. A lot of extreme symptomatic behavior was written off as just being those wild college days – which I supposed everyone had. And they did, but not the way I did.

So in cold clinical terms, these criteria may make plenty if sense. But for understanding your own experience, they don’t shed much light on things. You can glean a senses of it from examples, but in patient communities I’ve seen the very symptoms and behaviors that I’ve called hypomania labelled as mania. Is it sloppy use of terminology? Conflicting applications of the diagnostic criteria by different doctors? A difference in severity that does not come through in a post? I don’t know, but it adds to my confusion.

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