The hypomanic episode represents an attenuated 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 consequences that characterize a fully manic presentation.
For a hypomanic episode to be diagnosed, the mood alteration must be present for at least four consecutive days, for most of the day and nearly every day, and must be experienced as abnormally elevated, expansive, or irritable. At least three typical symptoms of manic activation must accompany this alteration, or four if the mood is only irritable:
Inflated self-esteem or grandiosity
Reduced need for sleep (e.g., feeling rested after only a few hours of sleep)
Talkativeness marked, often difficult to control
Flight of ideas or a subjective sense that thoughts are racing
Distractibility marked, often due to irrelevant stimuli
Increased goal-directed activity or psychomotor agitation
Excessive involvement in potentially risky activities (excessive spending, reckless investments, or indiscreet sexual behavior)
These symptoms must be sufficiently pronounced to be clearly observable by others, while not causing significant impairment in social or occupational functioning. This distinguishes them from a manic episode, in which symptoms severely disrupt the patient’s daily life and often require hospitalization.
Another important distinction from a manic episode is that a hypomanic episode never includes delusions or hallucinations, nor does it involve behavior severe enough to require hospital containment. Although elevated or irritable, mood remains in some way “controlled,” at least from the individual’s perspective.
In some cases, the patient may experience the hypomanic phase as particularly productive and positive, with increased creativity, sociability, and motivation. This may make hypomania difficult to recognize as pathological, especially when symptoms do not cause clearly dysfunctional behavior. Over time, however, these states may be followed by depressive phases, often severe, allowing the full mood disorder to be reconstructed only retrospectively.
For these reasons, a hypomanic episode plays a central role in the diagnosis of bipolar II disorder, in which major depressive episodes alternate with hypomanic episodes without full manic phases.
Finally, the diagnosis of a hypomanic episode does not apply when symptoms are induced by the direct effects of a substance (medications, drugs, etc.) or a general medical condition (for example, hyperthyroidism), or when they meet the criteria for a
mixed episode.
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). American Psychiatric Publishing. 2013.
Goodwin FK, Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression. Oxford University Press. 2007.
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.
Akiskal HS. The bipolar spectrum: new concepts in classification and diagnosis. J Clin Psychiatry. 1996;57(Suppl 7):4–11.
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.
Post RM et al. Recurrent affective disorders: patterns of illness and treatment strategies. J Clin Psychiatry. 1989;50(Suppl):5–13.
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.
Angst J, Gamma A, Benazzi F. Hypomania: a transcultural perspective. World Psychiatry. 2003;2(3):176–183.
Hirschfeld RM et al. Screening for bipolar disorder in the community. J Clin Psychiatry. 2003;64(1):53–59.
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.
