Mood episodes: manic, hypomanic, major depressive

Every mood diagnosis on the exam is assembled from three building blocks: the manic, hypomanic, and major depressive episode. If you can classify an episode, you can name the disorder.

Manic episode. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and persistently increased activity or energy, most of the day, nearly every day, lasting at least 1 week (or any duration if hospitalization is needed). Three or more of seven symptoms (four if mood is only irritable): inflated self-esteem or grandiosity, decreased need for sleep, pressured or increased talkativeness, flight of ideas or racing thoughts, distractibility, increased goal-directed activity or psychomotor agitation, and excessive involvement in risky activities (spending sprees, sexual indiscretions, reckless investments). The episode causes marked impairment, requires hospitalization, or includes psychotic features. Not due to a substance or medical condition — but a full manic episode that emerges during antidepressant treatment and persists beyond the drug's physiological effect counts.

Hypomanic episode. The same symptom set and counts, lasting at least 4 consecutive days. The change in functioning is unequivocal and observable by others, but not severe enough to cause marked impairment or hospitalization, and there are no psychotic features. If any of those occur, the episode is manic by definition.

Major depressive episode. Five or more of nine symptoms during the same 2-week period, with at least one being depressed mood or loss of interest or pleasure: depressed mood (irritable in youth), anhedonia, significant weight or appetite change, insomnia or hypersomnia, psychomotor agitation or retardation observable by others, fatigue, worthlessness or excessive guilt, poor concentration or indecisiveness, and recurrent thoughts of death, suicidal ideation, a plan, or an attempt. Clinically significant distress or impairment; not substance- or medically caused. After a significant loss, clinical judgment separates expected grief from a depressive episode.

Hinge differentials.

• Manic vs hypomanic: severity, not symptoms — marked impairment, hospitalization, or psychosis makes it manic.
• Hypomania vs a good mood: a hypomanic period is a clear change from baseline that others notice.
• Episode vs personality pattern: episodes are discrete multi-day periods; borderline mood shifts last hours and react to interpersonal events.
• Substance or medical causes: stimulants, steroids, and thyroid disease can mimic either pole.

On the NCMHCE. Classify each episode by duration and severity, then apply it: any manic episode → bipolar I; hypomanic plus depressive, never manic → bipolar II; depressive only → MDD. Always ask about past elevated periods before treating depression, gather collateral, screen suicide risk in every depressive or mixed presentation, and refer for medical and substance rule-outs.

Clinical Pearl: Manic = 1 week (or hospitalized); hypomanic = 4 days; depressive = 2 weeks with 5 of 9. In an elevated-mood episode, psychosis or hospitalization makes it manic.