persistently elevated, expansive, or irritable mood and persistently increased
activity or energy that is present for most of the day, nearly every day, for a period of at
least 1 week (or any duration if hospitalization is necessary), accompanied by at least three
additional symptoms from Criterion B. If the mood is irritable rather than elevated or expansive,
at least four Criterion B symptoms must be present.
Mood in a manic episode is often described as euphoric, excessively cheerful, high, or
“feeling on top of the world.” In some cases, the mood is of such a highly infectious quality
that it is easily recognized as excessive and may be characterized by unlimited and haphazard
enthusiasm for interpersonal, sexual, or occupational interactions. For example,
the individual may spontaneously start extensive conversations with strangers in public.
Often the predominant mood is irritable rather than elevated, particularly when the individual’s
wishes are denied or if the individual has been using substances. Rapid shifts in
mood over brief periods of time may occur and are referred to as lability (i.e., the alterna-tion among euphoria, dysphoria, and irritability). In children, happiness, silliness and
“goofiness” are normal in the context of special occasions; however, if these symptoms are
recurrent, inappropriate to the context, and beyond what is expected for the developmental
level of the child, they may meet Criterion A. If the happiness is unusual for a child (i.e.,
distinct from baseline), and the mood change occurs at the same time as symptoms that
meet Criterion B for mania, diagnostic certainty is increased; however, the mood change
must be accompanied by persistently increased activity or energy levels that are obvious
to those who know the child well.
During the manic episode, the individual may engage in multiple overlapping new
projects. The projects are often initiated with little knowledge of the topic, and nothing seems
out of the individual’s reach. The increased activity levels may manifest at unusual hours of
Inflated self-esteem is typically present, ranging from uncritical self-confidence to marked
grandiosity, and may reach delusional proportions (Criterion B1). Despite lack of any particular
experience or talent, the individual may embark on complex tasks such as writing a novel
or seeking publicity for some impractical invention. Grandiose delusions (e.g., of having a
special relationship to a famous person) are common. In children, overestimation of abilities
and belief that, for example, they are the best at a sport or the smartest in the class is normal;
however, when such beliefs are present despite clear evidence to the contrary or the child attempts
feats that are clearly dangerous and, most important, represent a change from the
child’s normal behavior, the grandiosity criterion should be considered satisfied.
One of the most common features is a decreased need for sleep (Criterion B2) and is
distinct from insomnia in which the individual wants to sleep or feels the need to sleep but
is unable. The individual may sleep little, if at all, or may awaken several hours earlier than
usual, feeling rested and full of energy. When the sleep disturbance is severe, the individual
may go for days without sleep, yet not feel tired. Often a decreased need for sleep heralds
the onset of a manic episode.
Speech can be rapid, pressured, loud, and difficult to interrupt (Criterion B3). Individuals
may talk continuously and without regard for others’ wishes to communicate, often
in an intrusive manner or without concern for the relevance of what is said. Speech is
sometimes characterized by jokes, puns, amusing irrelevancies, and theatricality, with
dramatic mannerisms, singing, and excessive gesturing. Loudness and forcefulness of
speech often become more important than what is conveyed. If the individual’s mood is
more irritable than expansive, speech may be marked by complaints, hostile comments, or
angry tirades, particularly if attempts are made to interrupt the individual. Both Criterion
A and Criterion B symptoms may be accompanied by symptoms of the opposite (i.e., depressive)
pole (see “with mixed features” specifier, pp. 149–150).
Often the individual’s thoughts race at a rate faster than they can be expressed through
speech (Criterion B4). Frequently there is flight of ideas evidenced by a nearly continuous flow
of accelerated speech, with abrupt shifts from one topic to another. When flight of ideas is severe,
speech may become disorganized, incoherent, and particularly distressful to the individual.
Sometimes thoughts are experienced as so crowded that it is very difficult to speak.
Distractibility (Criterion B5) is evidenced by an inability to censor immaterial external
stimuli (e.g., the interviewer’s attire, background noises or conversations, furnishings in
the room) and often prevents individuals experiencing mania from holding a rational conversation
or attending to instructions.
The increase in goal-directed activity often consists of excessive planning and participation
in multiple activities, including sexual, occupational, political, or religious activities.
Increased sexual drive, fantasies, and behavior are often present. Individuals in a manic
episode usually show increased sociability (e.g., renewing old acquaintances or calling or
contacting friends or even strangers), without regard to the intrusive, domineering, and
demanding nature of these interactions. They often display psychomotor agitation or restlessness
(i.e., purposeless activity) by pacing or by holding multiple conversations simultaneously. Some individuals write excessive letters, e-mails, text messages, and so forth, on
many different topics to friends, public figures, or the media.
The increased activity criterion can be difficult to ascertain in children; however, when
the child takes on many tasks simultaneously, starts devising elaborate and unrealistic
plans for projects, develops previously absent and developmentally inappropriate sexual
preoccupations (not accounted for by sexual abuse or exposure to sexually explicit material),
then Criterion B might be met based on clinical judgment. It is essential to determine
whether the behavior represents a change from the child’s baseline behavior; occurs most
of the day, nearly every day for the requisite time period; and occurs in temporal association
with other symptoms of mania.
The expansive mood, excessive optimism, grandiosity, and poor judgment often lead
to reckless involvement in activities such as spending sprees, giving away possessions,
reckless driving, foolish business investments, and sexual promiscuity that is unusual for
the individual, even though these activities are likely to have catastrophic consequences
(Criterion B7). The individual may purchase many unneeded items without the money to
pay for them and, in some cases, give them away. Sexual behavior may include infidelity
or indiscriminate sexual encounters with strangers, often disregarding the risk of sexually
transmitted diseases or interpersonal consequences.
The manic episode must result in marked impairment in social or occupational functioning
or require hospitalization to prevent harm to self or others (e.g., financial losses, illegal
activities, loss of employment, self-injurious behavior). By definition, the presence of
psychotic features during a manic episode also satisfies Criterion C.
Manic symptoms or syndromes that are attributable to the physiological effects of a
drug of abuse (e.g., in the context of cocaine or amphetamine intoxication), the side effects
of medications or treatments (e.g., steroids, L-dopa, antidepressants, stimulants), or another
medical condition do not count toward the diagnosis of bipolar I disorder. However,
a fully syndromal manic episode that arises during treatment (e.g., with medications, electroconvulsive
therapy, light therapy) or drug use and persists beyond the physiological effect
of the inducing agent (i.e., after a medication is fully out of the individual’s system or
the effects of electroconvulsive therapy would be expected to have dissipated completely)
is sufficient evidence for a manic episode diagnosis (Criterion D). Caution is indicated so
that one or two symptoms (particularly increased irritability, edginess, or agitation following
antidepressant use) are not taken as sufficient for diagnosis of a manic or hypomanic
episode, nor necessarily an indication of a bipolar disorder diathesis. It is necessary to
meet criteria for a manic episode to make a diagnosis of bipolar I disorder, but it is not required
to have hypomanic or major depressive episodes. However, they may precede or
follow a manic episode. Full descriptions of the diagnostic features of a hypomanic episode
may be found within the text for bipolar II disorder, and the features of a major depressive
episode are described within the text for major depressive disorder.