Manic Episode: Symptoms, How Long It Lasts and Warning Signs

A manic episode is a distinct period of abnormally elevated, expansive or irritable mood combined with abnormally increased activity or energy, the core definition used in DSM-5^[7]. It is the defining feature of bipolar I disorder and one of the mood states of bipolar disorder more broadly^[2].

The American Psychiatric Association (APA) describes a manic episode as lasting at least one week, present most of the day on most days, with at least three changes in behavior that are clear to friends and family and severe enough to disrupt work, family or social life^[1]. NIMH adds that an episode shorter than 7 days still qualifies when symptoms are severe enough that hospital care is needed^[2].

Mania is not the same as an ordinary good mood. According to the APA, everyday mood changes typically last hours rather than days and do not come with extreme changes in behavior or functioning^[1]. Figures on how many U.S. adults have the condition are on the bipolar disorder statistics page.

NIMH lists these signs of a manic episode^[2]:

• Feeling very up, high or elated, or extremely irritable or touchy
• Feeling jumpy or wired, or being more active than usual
• Racing thoughts
• Decreased need for sleep
• Talking fast about a lot of different things (flight of ideas)
• Excessive appetite for food, drinking, sex or other pleasurable activities
• Feeling able to do many things at once without getting tired
• Feeling unusually important, talented or powerful (grandiosity)

The APA's list adds distractibility, faster speech, restlessness and risky or impulsive behavior such as reckless driving, spending sprees and sexual promiscuity^[1]. These behaviors must be a change from the person's usual behavior and clear to friends and family^[1].

Psychotic features

During severe manic episodes, some people experience disorganized thinking, false beliefs or hallucinations, which the APA calls psychotic features^[1]. NIMH notes that these symptoms tend to match the mood: someone in a manic episode may falsely believe they are famous or have special powers^[2].

Psychosis in mania is not rare. In the NIMH Collaborative Depression Study, 90 of 139 patients who entered during a manic episode (about 65%) had psychotic features, and their symptoms were rated as more severe at intake^[4]. NIMH warns that people with bipolar disorder and psychotic symptoms can be misdiagnosed with schizophrenia^[2].

Irritability and energy, not only euphoria

Mania does not always look happy. Both the APA and NIMH include extreme irritability as a core mood state of a manic episode^[1][2]. Since DSM-5, increased activity or energy is required alongside the mood change; in the STEP-BD sample, applying that requirement reduced the number of identified manic and hypomanic episodes by 48%^[7].

A hypomanic episode involves the same kinds of symptoms at lower intensity. The APA defines it as less severe manic symptoms lasting at least four days in a row rather than a week, without the major problems in daily functioning that mania commonly causes^[1].

The distinction decides the diagnosis. One manic episode is enough for bipolar I disorder, while bipolar II disorder requires at least one hypomanic episode and at least one major depressive episode^[1]. Recurrent hypomanic and depressive symptoms that never reach full episode criteria describe cyclothymic disorder^[2].

Mixed features

Some episodes combine manic and depressive symptoms at the same time. NIMH describes these as mixed episodes, and DSM-5 records them with a mixed features specifier^[2][7]. In STEP-BD, a large share of patients who no longer met the stricter DSM-5 mania criteria instead met criteria for a major depressive episode with mixed features^[7].

Mixed and cycling episodes tend to last longer than pure mania. In a follow-up of 219 people with bipolar I disorder lasting up to 25 years, recovery from a mixed major cycling episode was 67% less likely at any point than recovery from major depression, and one in four such episodes lasted more than 7 years^[8].

By definition, a manic episode lasts at least 7 days unless hospitalization is needed sooner^[2]. NIMH says mood episodes cause symptoms lasting a week or two, sometimes longer, present every day for most of the day^[2].

Long-term cohort data give a fuller picture. In the Collaborative Depression Study, which followed 219 people with bipolar I disorder for up to 25 years, the median duration of all bipolar I mood episodes was 13 weeks^[8]. A quarter of the 246 manic episodes observed ended within 4 weeks, and recovery from mania was 71% more likely at any given point than recovery from major depression^[8].

Severity at onset matters. Episodes that began with psychosis or severe impairment in the first week had about a 25% lower probability of recovery than episodes with a milder start^[8].

The McLean-Harvard First-Episode Mania Study followed 166 people for 2 to 4 years after their first hospitalization for a manic or mixed episode^[3]. Half reached syndromal recovery, meaning they no longer met diagnostic criteria, by 5.4 weeks, and 98% did so within 2 years^[3].

Manic episodes often build over days or weeks. A 2003 systematic review of 17 studies covering 1,191 people found that at least 80% of individuals with a mood disorder could identify one or more prodromal symptoms, the early changes that come before a full episode^[5].

Sleep disturbance was the most robust early sign of mania, with a median prevalence of 77% across studies^[5]. Manic prodromes averaged more than 20 days and ranged from 1 to 120 days^[5].

The same review found that early symptoms of mania were identified more often than early symptoms of depression^[5]. NIMH notes that a person in a milder elevated state may feel very good and productive, while family and friends are the ones who notice the change in mood and activity^[2].

No single cause has been identified, but several triggers are documented. The APA lists stress, sleep disruption, and drugs and alcohol as environmental factors that may trigger mood episodes in vulnerable people^[1].

Sleep loss

In a 2017 study of 3,140 people with bipolar disorder, 20% reported that sleep loss had triggered episodes of mania or hypomania^[9]. People with bipolar I were 2.81 times as likely as those with bipolar II to report this trigger, and women remained more likely than men after adjustment (odds ratio 1.30)^[9].

Antidepressants without a mood stabilizer

NIMH states that antidepressants are not used alone in bipolar disorder because they can trigger a manic episode or rapid cycling^[2]. In a Swedish registry study of 3,240 patients, the rate of mania in the 3 months after starting antidepressant monotherapy was 2.83 times the rate in an untreated period, while no increase was seen in patients also taking a mood stabilizer^[6].

NIMH notes that when subtle signs of bipolar disorder are missed and a first depressive episode is treated with an antidepressant alone, a manic episode may follow^[2]. That pattern is one reason screening and history matter, as covered in how bipolar disorder is diagnosed and how bipolar screening tests work.

Medical conditions and substances

Not every manic-looking state is bipolar disorder. NIMH notes that thyroid disease can cause similar symptoms and that some prescribed, recreational or illicit drugs can mimic or worsen mood symptoms, which is why evaluation usually starts with a physical exam and medical testing^[2].

Acute treatment centers on medication. NIMH lists mood stabilizers such as lithium or valproate and atypical antipsychotics as the most commonly prescribed types, and the APA notes that a manic episode commonly requires hospital care to ensure safety^[2][1].

In the Collaborative Depression Study, 181 of 246 manic episodes (74%) were treated with at least one mood stabilizer^[8]. What drug and therapy trials show is covered in bipolar therapy treatment.

Recovery from the episode is not the end of the course. Within 2 years of syndromal recovery in the McLean-Harvard study, 40% had a new episode, split evenly between mania (20%) and depression (20%), and 19% switched into a new phase, mainly depression, without recovering first^[3].

Depression usually occupies more of the illness than mania. A longitudinal study cited in the STEP-BD analysis found that people with bipolar I had depressive symptoms in 30.6% of weeks observed, versus 9.8% of weeks in manic or hypomanic states^[7].

NIMH describes bipolar disorder as usually requiring lifelong treatment and notes that, without adequate treatment, episodes often occur more frequently over time^[2]. People in immediate distress or thinking about hurting themselves can call or text the 988 Suicide & Crisis Lifeline at 988^[2].