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Not everyone who becomes manic experiences the full-blown syndrome of a manic episode. Hypomanic individuals show an expansive, energized and sometimes elated mood, with rapid thinking and pressured speaking in evidence. At a minimum (for the label hypomania to be appropriately applied), this expanded mood state must persist for at least four straight days.

As is the case with manic episodes, hypomanic episodes are also characterized by the presence of characteristic symptoms. At least three of the following must be present (for at least four days) before the diagnosis of hypomanic episode is appropriate:

• an inflated or expansive and even grandiose (but not delusional; not completely out of touch with reality) sense of self
• reduced sleep needs compared to normal
• talks more than usual
• subjective sensation of racing thoughts (often called a “flight of ideas”)
• distraction or derailment of thought occurring significantly more often than normal
• an increase in goal-directed activity, or physical agitation
• a marked increase in participation in risky but pleasurable behavior (such as unprotected sex, gambling, unrestrained shopping, etc.)

You’ll notice that these are essentially the same criteria that are applied to manic episodes. What is suggested (and what is intended) by this duplication of criteria is that what separates a hypomanic episode from a manic episode is mostly the degree of intensity (or energy) present in the behaviors the manic person emits (and not in their variety). When the observed energy level is above average but still within normal limits, you have a hypomanic state on your hands. When the energy level goes off the normal scale entirely, you have a manic episode.

People experiencing a hypomanic state are not necessarily unrelentingly sunny in disposition; they may experience irritable mood states too, as is also the case with full manic episodes. However, whatever level of irritability may be present during a hypomanic episode is by definition nowhere near as severe as what might occur during a fully manic episode.

Since hypomania is less severe than mania, people experiencing a hypomanic episode may retain sound judgment and not engage in self-destructive behavior. In fact, their sharpened intellect and ability to function with little sleep contributes to hypomanic individuals’ increased productivity compared to non-manic people. This is to say, hypomania can create a distinct advantage in the workplace, because it helps people to be maximally productive and get more things done than their peers. This positive aspect of hypomania is often seen as a benefit by people who have bipolar disorder. Hypomanic individuals are likely to be creative risk-takers, who can bring creative ideas to fruition. Numerous historical and contemporary figures, including composer Ludwig van Beethoven, pioneering physicist Issac Newton, authors Charles Dickens and Edgar Allen Poe, artist Vincent van Gogh, statesmen Abraham Lincoln, Winston Churchill and Theodore Roosevelt, and media mogul Ted Turner have been documented to have experienced severe and debilitating recurrent mood swings. Some authors (e.g., John Gartner, MD [Hypomanic Edge] have even suggested that America’s unique entrepreneurial character and spectacular economic achievements achieved over the last century are due in large part to a high incidence of hypomania among American entrepreneurs. While we can neither confirm or discard this interesting speculation, we can say that there is more to hypomania than a simple business advantage. When you are hypomanic on a regular basis, you have a mild form of what can be a disabling illness. There is no guarantee that your hypomania will stay stable as hypomania. When left untreated, the underlying causes that produce hypomania can and do sometimes worsen until full manic episodes occur.

Although popular culture tends to equate mania with happiness and depression with sadness this isn’t really the best way to think about what is happening in bipolar disorder. Bipolar Disorder involves not so much a swing between happy and sad states, as it does a swing between high and low energy states. When in a high-energy state, people appear happy because they are motivated and excitable, whereas in a low energy state, people feel sad, and lack motivation and enthusiasm. As the energy level of a manic episode increases, the early happy mood tends to degenerate into a more agitated and psychotic state which may be experienced more as terrifying than happy, but which is nevertheless very energizing. Similarly, as a depressive mood state increases, people may go from merely feeling badly about themselves to literally not being able to leave their bed. Thus, the happy and sad moods that are thought to characterize mania and depression respectively are results of different energy states and not necessarily primary features of the disorder.

The high and low energy states characteristic of bipolar disordered moods are often thought of as places that exist upon a continuum of energy levels. Manic moods are characterized by high energy states, while depressive moods are characterized by low energy states. As bipolar moods shift from depressed to manic and back to depressed again, part of what is happening, according to this way of seeing things, is that there is a smooth shifting of the bipolar person’s energy state moving up and down the energy continuum. Each end of this energy continuum can be considered to be a pole, or end point (in the same way that the North and South Poles are the end points of the earth), hence the origin of the term “Bipolar” (meaning, involving movement between two poles).

Mania and Manic Episodes

Because high-energy manic states exist on a continuum, it is possible for someone to be a little manic or very manic. People who are very manic are said to be experiencing a manic episode. People who are only a little manic are said to be experiencing a Hypomanic Episode. The term ‘hypo’ means “under”, so the term “hypomanic” translates to “less than fully manic”.

There are defined criteria (in the DSM) that must be met in order to say that someone is experiencing a full manic episode. For example, manic episodes must be present for at least one week’s duration before they can be diagnosed (although they may last far longer than that). Up to several months duration are possible.

A variety of symptoms are possible during a manic episode. At least three of the following symptoms need to be present before the diagnosis can be made:

• an inflated, expansive, grandiose (and possibly delusional) sense of self
• reduced sleep needs compared to normal
• pressured speech (talking so fast the words don’t have time to get out the mouth)
• subjective sensation of racing thoughts (often called a “flight of ideas”)
• distraction or derailment of thought occurring significantly more often than normal
• an increase in goal-directed activity (purposeful behavior), or physical agitation
• a marked increase in participation in risky but pleasurable behavior (such as unprotected sex, gambling, unrestrained shopping, etc.)

Manic episodes typically do not come on all at once. Rather, there is a progression of manic symptoms that occurs over a period of time. During an early manic phase of a bipolar condition, a person may become highly energetic, have a million ideas, become very talkative, stay up all night, feel sexually and generally potent, and become very productive. As the manic episode progresses and gains in strength, manic individuals tend to lose their inhibitions and whatever judgment they might normally have, and pursue one or more ill-advised and risky, but immediately pleasurable courses of behavior. Severely manic people may become sexually promiscuous, for instance, leading their becoming pregnant (or impregnating someone else) or becoming infected with a sexually transmitted disease. They may spend impulsively on shopping, travel, gambling, or drugs, causing massive credit card debts, and leaving a trail of bounced checks and large cash withdrawals from the ATM in their wake. In their enthusiasm to socialize, manic people may chatter on and on about things that are inappropriate to share with strangers, (e.g. personal beliefs, sexual experiences, etc.) They may also display inappropriate anger, or agitation, and even lash out and become violent in some cases. For example, a manic individual in a bar might pick a fight with little provocation. In the most severe cases of mania, hallucinations, delusions, and outright psychosis occur, further complicating the situation. The inappropriate and out-of-control behavior characteristic of people experiencing a manic episode makes the costs associated with mania sometimes devastatingly high.

The American Psychiatric Association publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM), which describes the criteria necessary for the diagnosis of all mental disorders, including Major Depression. In the DSM, Major Depression appears as a member of the Depressive Disorders category, which also includes the Bipolar Disorders, Dysthymic Disorder, Cyclothymia and Depressive Disorder Not Otherwise Specified. These various mood disorders are all similar in that they all have something to do with disordered mood, and more specifically, with depressed mood. They are distinguished by the extent and severity of a person’s mood disturbance, and by the direction (up or down) of the moods involved.

Here is a key point: The mood disorder diagnoses are essentially defined as patterns of mood disturbances observed through time. Clinicians choose from among the various mood-related diagnoses on the basis of their observation of patients’ sequence of mood episodes. Most people with mood disorders will have (or have already had) a history of multiple mood episodes. Individual mood episodes last for several weeks or months and then give way to normal mood, or to another mood episode.

In order to fully understand how mood disorders are defined, you first have to understand the concept of mood episodes. There are four kinds of mood episodes described in the DSM: Major Depressive, Manic, Hypomanic, and Mixed. Major Depressive episodes are characterized by the classic symptoms described above. Manic episodes are characterized by a persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). In addition, three (or more) of the following symptoms must be present (four symptoms must be present if the person’s mood is only irritable):

• Inflated self-esteem or grandiosity
• Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
• More talkative than usual or pressure to keep talking
• Racing thoughts
• Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
• Increase in goal-directed activity (either socially, at work or school, or sexually) or feelings of agitation/restlessness
• Excessive involvement in risky activities (e.g., shopping sprees, sexual indiscretions, or foolish business investments)

Hypomanic episodes are a milder form of manic episodes. Both share the same list of symptoms described above. However, the DSM criteria for Hypomanic episodes state that the person’s mood disturbance occurs throughout at least 4 days (rather than 1 week as with a Manic Episode).

Mixed episodes are essentially a combination of manic and depressive episodes that become superimposed so that symptoms of both are present (at different times) during the same day. More specifically, the criteria are met both for a Manic Episode and for a Major Depressive Episode nearly every day during at least a 1-week period.

Major Depression is a distinct and separate condition from Bipolar Disorder and the other mood disorders. By definition, people diagnosed with Major Depression show only a history of one or more major depressive episodes. People with Major Depression never have a history of manic or mixed episodes, and neither do they show signs of hypomania. People with Major Depression also have relatively severe mood symptoms. People who show signs of depressive mood on a regular basis but who do not meet the formal criteria for a depressive mood episode cannot be diagnosed with Major Depression. Such individuals will instead tend to have some other mood diagnosis, such as Dysthymic Disorder.

In this article, we focus on the Unipolar forms of depression; namely Major Depressive Disorder, Dysthymic Disorder, and Depressive Disorder Not Otherwise Specified. The other mood disorders tend to be variations on the theme of bipolar disorder and are discussed in our Bipolar Disorders Topic Center. Throughout our discussion it is important to keep in mind that the term “depression” is not particularly specific. There are multiple kinds of depression; and the diagnosis of a particular disorder varies depending on the severity, duration, and persistence of symptoms.

Major Depression

The classic symptoms of Major Depression are described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)*, the widely accepted standard guidelines for psychiatric diagnoses. Symptoms associated with Major Depression cause clinically significant distress and impairment in social, occupational, or other areas of functioning.

Variations of Depression

Depressive symptoms can vary tremendously from one individual to the next. While one depressed person may experience feelings of sadness, hopelessness, and helplessness, another may feel angry, irritated, and discouraged.

• Depressive symptoms may also seem like a change in someone’s personality.
  • For example, a typical person might begin to lose his or her temper about things that normally would not be troubling to him or her.
• Depressive symptoms can also change across the course of the illness; someone who is initially withdrawn and sad can become highly frustrated and irritable as a result of decreased sleep and the inability to accomplish simple tasks or make decisions.

When Major Depression is severe, people may experience psychotic symptoms, such as hallucinations and delusions.

• Hallucinations are “phantom” sensations that appear to be real even though they are not caused by real things in the environment.
• Hallucinations may occur within any sensory realm (including sight, sound, taste, smell and touch), and can be very convincing (as well as disturbing) in their reality.
• The most common form of hallucination is auditory; involving hearing voices of people who are not actually present.

Delusions are very strongly held false beliefs that cause a person to misinterpret events and relationships.

• Delusions vary widely in their themes; they may be:
  • Persecutory (someone is spying on or following you).
  • Referential (a t.v. show or song lyrics contain special messages only for you).
  • Somatic (thinking that a body part has been altered or injured in some way).
  • Religious (false beliefs with religious or spiritual content).
  • Erotomanic (thinking that another person, usually someone of higher status, is in love with you).
  • Grandiose (thinking that you have special powers, talents, or that you are a famous person).

When someone is depressed and experiencing psychotic symptoms, the content of hallucinations and delusions is usually consistent with a depressed mood and focuses on themes of guilt, personal inadequacy, or disease.

• For instance, depressed people might truly believe that they are not able to perform their job or their parenting duties because they are inadequate (a feeling that may be reinforced by voices telling them that they are inadequate) and that everyone is snickering at them behind their back.
• A depressive episode that involves psychotic symptoms can be particularly problematic because a person can lose the ability to discriminate between real and imagined experiences.

Video: What is Depression?

Below is a TED Ed video by Helen M. Farrell on the symptoms of depression, its possible causes, and a few available treatment options.