Synopsis
Recognise pathological mood elevation through change in energy, activity, sleep, cognition and behaviour, distinguish mania from hypomania by consequence and severity, and identify medical, substance-related and safeguarding emergencies promptly.
- Mania or hypomania is an episodic change from baseline involving elevated, expansive or irritable mood together with increased energy or activity; happiness alone is not the syndrome.
- Reduced need for sleep means feeling rested after very little sleep, unlike insomnia in which the person wants sleep and feels tired or distressed by its absence.
- Look for pressured speech, racing or rapidly shifting thoughts, distractibility, inflated confidence, increased sociability or sexuality, goal-directed activity, spending and risk taking.
- Mania causes marked impairment, serious danger, hospital-level need or psychosis; hypomania is observable and uncharacteristic but lacks psychosis and does not cause that degree of disruption.
- In primary care, previous overactivity or disinhibition lasting four days or more during a depressive presentation should prompt consideration of specialist bipolar assessment.
- Perform a structured mental-state examination and document appearance, engagement, speech, mood, affect, thought form and content, perception, cognition, insight and judgement separately.
- Seek a longitudinal and collateral history, with consent where possible, because impaired insight and recall can conceal sleep loss, spending, sexual risk or functional change.
- Review medicines, prescribed steroids or dopaminergic drugs, stimulants, cannabis, alcohol and other substances and assess thyroid, neurological, infectious and metabolic explanations when indicated.
- Suspected mania, severe depression or danger to self or others requires urgent specialist mental-health referral; a screening questionnaire must not replace clinical assessment.
Key red flags
Current intent to die, dangerous driving, weapon access, escalating aggression or behaviour that exposes the person or others to immediate serious harm requires an emergency response.
Fever, autonomic instability, fluctuating attention, altered consciousness, new neurological signs or recent medicine or substance exposure suggests delirium, toxicity or neurological illness.
Several nights with almost no sleep, continuous activity, poor fluid intake or physical overexertion can lead to dehydration, rhabdomyolysis, collapse and rapidly worsening judgement.
Persecutory, grandiose or religious delusions, command hallucinations or marked thought disorganisation indicate severe illness and can make apparently purposeful behaviour unpredictable.
New activation, confusion or psychosis during pregnancy or soon after childbirth requires urgent specialist perinatal assessment because deterioration can be rapid.
Investigation priorities
Define onset, duration, baseline change, previous depression or activation, recovery, triggers and treatment effects.
Management branches
Marked activation is accompanied by psychosis, serious risk, exhaustion or major functional loss.
- Reduce stimulation, maintain personal space, address immediate physical needs and obtain trained help before confrontation escalates.
- Assess ABCDE, cognition, substances, medical mimics, suicide and harm scenarios and identify children or vulnerable adults needing protection.
- Arrange urgent psychiatric assessment and the least restrictive safe setting, documenting capacity, consent, legal basis and direct handover.