A manic episode is the diagnostic anchor of bipolar I disorder. DSM-5 requires at least one week (or any duration if hospitalization is required) of distinctly elevated, expansive, or irritable mood with increased goal-directed activity or energy, plus at least three additional symptoms (four if mood is only irritable).
The DIGFAST mnemonic captures the symptom cluster: Distractibility, Indiscretion (impulsive risky behaviors — spending, sexual, substance use), Grandiosity (inflated self-esteem, sometimes reaching delusional intensity), Flight of ideas (racing thoughts, often felt as a pressure of thought), Activity increased, Sleep decreased (decreased need for sleep — the patient functions on 2-3 hours), Talkativeness (pressured speech, often impossible to interrupt).
The neuroanatomical picture: hyperactive mesolimbic dopamine flooding the nucleus accumbens, reduced sleep architecture, prefrontal cortex initially overdriven but eventually overwhelmed. The patient feels powerful, capable, charged — and judgment becomes profoundly impaired. Reward salience expands; consequence weighting collapses.
The clinical urgency: suicide risk in mania is real (often through impulsive action rather than chronic ideation); risky behavior is constant (financial, sexual, substance use); psychosis can emerge (grandiose or persecutory delusions, sometimes auditory hallucinations); judgment about safety and treatment is impaired. Hospitalization is often required for severe manic episodes.
Treatment goals: stabilize mood and behavior, ensure safety, address sleep, screen for substance use, prevent escalation to psychosis. First-line: a mood stabilizer (lithium, valproate, carbamazepine) or second-generation antipsychotic (risperidone, olanzapine, quetiapine, aripiprazole, cariprazine — several have specific FDA indication for acute mania). For severe mania with agitation: combination therapy. Benzodiazepines for acute agitation as adjunct.
Critical clinical point: never start an antidepressant alone in a patient with bipolar history — antidepressant monotherapy can induce manic switch or rapid cycling. Always screen for bipolar disorder before initiating antidepressant therapy: prior episodes of elevated mood, decreased sleep need with energy, periods family said were "different," postpartum psychosis. The diagnostic move matters more than any specific drug choice.
After acute treatment, prophylaxis with a mood stabilizer indefinitely is standard — relapse is common if treatment is stopped. Lithium remains the best-evidence agent for long-term prevention of mania and reduction of suicide risk in bipolar disorder; it is underused due to monitoring requirements but remains the gold standard for many patients. Patient and family education about warning signs and adherence is essential.