Bipolar spectrum

One question decides most bipolar items: how long, and how bad? The difference between a manic and a hypomanic episode is measured in days and consequences, and that single line sorts clients into bipolar I versus bipolar II.

A manic episode is a distinct period of abnormally elevated, expansive, or irritable mood plus increased energy, lasting at least 7 days (or any duration if hospitalization is required). Symptoms are captured by DIG FAST: Distractibility, Irresponsibility/risky pleasure-seeking, Grandiosity, Flight of ideas, Activity increase, Sleep decreased (feeling rested on little sleep), Talkativeness/pressured speech. Mania causes marked impairment, may require hospitalization, or includes psychotic features.

A hypomanic episode has the same symptom list but lasts at least 4 consecutive days and is not severe enough to cause marked impairment, hospitalization, or psychosis. The change is observable by others but not disabling. That severity line is everything.

Now the categories. Bipolar I requires at least one manic episode — depression is common but not required. Bipolar II requires at least one hypomanic episode AND at least one major depressive episode, and never a full manic episode (one manic episode reclassifies the client as bipolar I). Cyclothymic disorder is the chronic low-grade version: numerous periods of hypomanic and depressive symptoms for at least 2 years (1 year in children/adolescents) that never meet full criteria for a hypomanic, manic, or major depressive episode, with symptoms present at least half the time and no symptom-free stretch beyond 2 months.

Clinical Pearl: Mania = 7 days or hospitalization with marked impairment/psychosis; hypomania = 4 days, no marked impairment. Bipolar I needs one manic episode (depression optional); bipolar II needs hypomania + MDD and never mania.