Hypomanic Episode

The hypomanic episode represents a milder form of mood elevation, characterized by symptoms similar to those of a manic episode, but of lesser intensity and without the severe social, occupational, or relational impairments that define the fully developed manic state.

A hypomanic episode is defined by the presence of a mood alteration lasting at least four consecutive days, for most of the day and nearly every day, perceived as abnormally elevated, expansive, or irritable. This mood change must be accompanied by at least three typical symptoms of manic excitement—or four if the mood is only irritable:

• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feeling rested after only a few hours of sleep)
• Marked and often uncontrollable talkativeness
• Flight of ideas or subjective experience of racing thoughts
• Marked distractibility, often triggered by irrelevant stimuli
• Increased goal-directed activity or psychomotor agitation
• Excessive involvement in potentially risky activities (exaggerated spending, reckless investments, imprudent sexual behavior)

These symptoms must be clearly noticeable to others, even though they do not cause significant impairment in social or occupational functioning. This distinguishes hypomanic episodes from manic ones, in which the symptoms severely disrupt daily life and often require hospitalization.

Another important distinction is that in a hypomanic episode, delusions and hallucinations are never present, and behaviors are not so severe as to require inpatient care. The mood, although elevated or irritable, remains within a somewhat "controlled" range, at least from the patient's own perspective.

In some cases, the patient may experience the hypomanic phase as particularly productive and positive, with increased creativity, sociability, and motivation. This perception can make it difficult to recognize hypomania as a pathological state, especially in individuals whose symptoms do not lead to overtly dysfunctional behaviors. However, over time, these episodes are often followed by severe depressive phases, allowing only retrospective reconstruction of the underlying mood disorder.

For these reasons, the hypomanic episode plays a key role in the diagnosis of bipolar disorder type II, in which major depressive episodes alternate with hypomanic episodes, without any full-blown manic phases.

It is also important to note that a diagnosis of hypomanic episode is not applicable if the symptoms are induced by the direct effects of a substance (medications, drugs, etc.) or a general medical condition (e.g., hyperthyroidism), nor if they meet the criteria for a mixed episode.

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Publishing. 2013.
2. Goodwin FK, Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression. Oxford University Press. 2007.
3. Bauer M et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of unipolar depressive disorders, Part 1: Update 2013 on the acute and continuation treatment of unipolar depressive disorders. World J Biol Psychiatry. 2013;14(5):334-385.
4. Akiskal HS. The bipolar spectrum: new concepts in classification and diagnosis. J Clin Psychiatry. 1996;57(Suppl 7):4–11.
5. Judd LL et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry. 2002;59(6):530–537.
6. Post RM et al. Recurrent affective disorders: patterns of illness and treatment strategies. J Clin Psychiatry. 1989;50(Suppl):5–13.
7. Yatham LN et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 Guidelines for the Management of Patients with Bipolar Disorder. Bipolar Disord. 2018;20(2):97-170.
8. Angst J, Gamma A, Benazzi F. Hypomania: a transcultural perspective. World Psychiatry. 2003;2(3):176–183.
9. Hirschfeld RM et al. Screening for bipolar disorder in the community. J Clin Psychiatry. 2003;64(1):53–59.
10. Malhi GS, Bell E, Bassett D et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2021;55(1):7-117.