• Users Online: 1519
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2019  |  Volume : 35  |  Issue : 2  |  Page : 137-141

Hypomania: A clinician's perspective

Avon and Wiltshire Mental Health Partnership NHS Trust, England

Date of Submission13-Jun-2018
Date of Decision24-Sep-2018
Date of Acceptance29-Oct-2018
Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Avneet Sharma
Avon and Wiltshire Mental Health Partnership NHS Trust, Civic Center, High Street, Kingswood Bristol, BS15 9TR
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_46_18

Rights and Permissions

Hypomania as a syndrome retains a central place in diagnosis of milder forms of bipolar illnesses, especially bipolar II. This article highlights some of the challenges that the clinicians are faced with and lists strategies that they could use while diagnosing hypomania and bipolar illnesses.

Keywords: Bipolar II, diagnosis, hypomania

How to cite this article:
Sharma A. Hypomania: A clinician's perspective. Indian J Soc Psychiatry 2019;35:137-41

How to cite this URL:
Sharma A. Hypomania: A clinician's perspective. Indian J Soc Psychiatry [serial online] 2019 [cited 2022 Jun 30];35:137-41. Available from: https://www.indjsp.org/text.asp?2019/35/2/137/261482

  Hypomania: the Clinical Importance Top

The demand and hence pressure on the clinicians for diagnosing hypomania and bipolar illness in their routine practice have been on the rise. There could be several factors behind this.

The current diagnostic systems have included the concept of bipolar being a spectrum illness – the categories of bipolar I and bipolar II are well described in the Diagnostic and Statistical Manual of Mental Disorder (DSM) 5,[1] the International Statistical Classification of Diseases (ICD)-10[2] does not draw this distinction though ICD-11 is likely to. DSM 5 has also included the category of recurrent depression with antidepressant-induced mania/hypomania. Although the clinical utility of bipolar spectrum is yet to be established and there is currently no indication whether treatment is necessary or effective, it is generally acknowledged that these patients present as suffering from depression and get diagnosed and treated as recurrent unipolar depression as opposed to bipolar depression.[3] There is a strong argument for treating bipolar depression not with antidepressants but in a rather specific way, for example, with mood stabilizers such as lithium, as it has better chances of preventing suicides and improving course of the bipolar illness. Experts indeed argue for a more frequent diagnosis of bipolar II on the basis that a milder condition is usually more frequent than a severe one[4] and that bipolar patients spend much more time in milder conditions.[5] There is some acceptance of the evidence that unipolar depression is reportedly the most frequent misdiagnosis in patients with bipolar disorder (BD), especially in BD Type II, because patients with this illness, by definition, never experience an episode of mania[6] and between 25% and 50% of people with recurrent depression may in fact be part of bipolar group of illnesses.[7] A recent study from the UK suggested that up to 21% of primary care patients with depression have in fact unrecognized BD.[8]

Mood instability is a common reason for referral to adult community mental health teams with up to 80% of patients reporting this symptom at assessment.[9] Many of us working in the field of general adult psychiatry in the NHS UK may have come across referrals for persons seeking an assessment for confirming the diagnosis of bipolar illness.[10] This trend could be looked as a form of help seeking and qualitative research has shown these patients to be looking for an explanation of their symptoms (rather than an outright diagnosis) and for consistent support.[11] There is however a worry that the spectrum definitions especially around what constitutes hypomania might subsume cases with non-BDs and “diagnosis creep” may lead practitioners to overdiagnose BD in marginal cases and the more diagnoses of BD will increase aggressive pharmacotherapy.[12]

Indeed, there is an ongoing debate about the inaccurate diagnosis of bipolar illness in clinical practice, and recent studies indicate that overdiagnosis of bipolar illness might already have become a bigger problem with the rate of over diagnosis likely to be threefold higher to that of underdiagnosis.[13] This may largely be a reflection of how the clinical practices have changed over a period of time especially while diagnosing hypomania both in clinical population and epidemiological studies. Evidence from two studies[3],[14] suggests that if a clinician diagnosed a patient with BD, the chance that the patient effectively met criteria for that diagnosis according to the structured clinical interview for DSM disorders (SCID)[15] was modest. In terms of the requirement to “do no harm,” the consequences of being falsely diagnosed with BDs tend to be more severe than those of being falsely diagnosed with major depressive disorder,[16] including the negative effects of unnecessary labeling, the risk of harm related to unnecessary treatments, and the misuse of health care resources, with important human and financial implications.[13]

There is a case for looking more closely for bipolar spectrum cases, especially of bipolar II type in clinical population which in simpler terms will largely boil down to accurately diagnosing hypomania.

  Why Diagnosing Hypomania Accurately Is not as Straightforward? Top

The challenge before the clinicians nowadays is to elicit the diagnostic symptoms of hypomania that too in retrospect in somebody who is presenting as depressed and try and differentiate it from other conditions such as borderline personality disorder (PD).

Establishing diagnosis in retrospect is challenging as depression is the most frequent clinical presentation of BD more so with bipolar II.[17] Furthermore, unipolar depression is more prevalent than BD: The lifetime prevalence of unipolar major depressive disorder is 16.2%, whereas the lifetime prevalence of bipolar spectrum disorders is 4.5%.[18] The clinical presentation of a patient with BD when depressed may not differ from that of a nonbipolar-depressed patient. Hypomanic symptoms also largely go undetected as these are often desirable and individuals are often unaware of these as problematic. Recalling information about the past is prone to bias more so especially when patients are depressed.[19] One will end up relying heavily on information provided by close relatives though that may not be available in all the cases.

There is some consistent evidence to indicate that psychomotor activation forms the core of hypomania and mania – it means rapidity of thoughts, feelings, and activities and this should be enough to differentiate hypomania from other disorders.[20] In actual practice, it is harder in retrospect, for example, to evaluate euphoria than overactivity[21] while the place of irritable mood as a primary symptom for hypomania has been questioned.[22] DSM 5 now requires the change in mood in hypomania to be accompanied also by persistently increased activity and energy as well as three other symptoms of hypomania (four if irritability only) over the same period. The inclusion of increased activity and energy as a defining symptom will also be included in ICD-11; this change is expected to prevent overdiagnosis of hypomania and bipolar II disorder.[23] Nevertheless, it might still be difficult for clinicians to make a decision about whether the elevated mood and increased activity levels might be within normal limits or warrant a diagnosis of hypomania.[24]

In both DSM 5 and ICD-10, the diagnosis of hypomanic episode requires symptoms of hypomania to last for at least 4 days, which was reduced from the 7 days required by earlier versions. Although the initial decision to agree to this cutoff was labeled as arbitrary, a multicenter study found 4-day duration criterion for hypomania to be best correlated with external validators.[21] Those who have hypomanic symptoms lasting between 1 and 3 days have been shifted from DSM 4 category of “BD not otherwise specified” in DSM 5 to major depressive episode with specifier of brief hypomanic episodes. It is expected that short-lived periods of hypomania though an indicator of bipolar illness may go undetected as these will be much harder to clinically distinguish from the rapid mood alterations seen, for example, in borderline PD or normal variants in temperament.

Differential diagnosis poses a major challenge as hypomanic symptoms are shared by many other disorders such as attention-deficit hyperactivity disorder (ADHD) or substance abuse; the issue, however, is not only of differential diagnosis but also that of comorbidity.[25]

ADHD can often be mistaken as BD due to features of irritability, rapid or impulsive speech, physical restlessness, impaired attention, and sometimes defiant or oppositional behavior. Symptoms such as grandiosity, decreased need for sleep, elated mood, flight of ideas, and hypersexuality have been suggested to be the hypomanic features that would differentiate BD II from ADHD.[26]

Substance misuse (with stimulants/cocaine) can induce hypomanic symptoms, and in clinical practice, this can be very hard to distinguish due to problems in judging what the “direct physiological consequence of a drug, medication, or somatic treatment” means.[27]

A common clinical dilemma nowadays is distinguishing between borderline PD and BD, especially bipolar II – the misdiagnosis has serious implications as both the disorders will have very different treatment approaches.

The challenge here is whether the clinician can identify the mood changes in these two conditions especially when the focus is on emotional instability or rapid and brief mood swings. Whereas anger or irritability may occur in hypomania, elevated bipolar states are more generally characterized by euphoria, grandiosity, and feeling creative with an individual coming across as consistently free from anxiety and worry while by contrast those with borderline PD manifest painful extremes of normally regulated emotions (principally anger, hostility, and sadness and anxiety).[28] At times, the only way to reduce the dilemma seems to be by considering the longitudinal and as well as broader cross-sectional features.[29] Imprecision in differentiating these two would reflect either diagnostic difficulty or true comorbidity.[30]

One strategy suggested to improve the detection of bipolar illnesses especially in patients presenting as depressed is to use screening questionnaires in addition to clinical interview as a two-stage assessment. Two of the self-report instruments that have been developed are the mood disorder questionnaire[31] and the HCL-32 checklist[32] to screen clinical and nonclinical samples for hypomania and bipolar illness. The instruments or the scales have not achieved widespread clinical usage, especially among professionals in the UK – there is some evidence to show that these tend to be better at ruling out diagnosis of BD while rather poor in ruling the diagnosis of BD in.[33] Similarly, the explosion of apps over recent years for monitoring and self-management of BDs appears to be an opportunity though a recent review[34] pointed out that most of the apps are being developed independently of research data and without reference to clinical guidelines.

  Strategies for Tackling the Issue of Accurate Diagnosis of Hypomania Top

Young and Macpherson[35] have asserted that the improved detection of bipolar illness rests on better ascertainment of history of hypomania.

[Table 1] lists strategies which have been used to accurately diagnose hypomania and Bipolar illness in patients presenting with depression. Some of these especially those based on risk factors do enjoy a certain level of recognition among clinicians, relying solely on these will be seen as working on clinical beliefs and expectations rather than on directly accessible signs and symptoms in arriving at a diagnosis. Also listed are the strategies which can be used to minimize the risk of overdiagnosis, for example, use of semi-structured interviews such as SCID for accurate diagnosis or using experienced clinicians, though none of these will be considered practical or possible given the constraints in busy clinical settings. Using screening questionnaire or using mood diaries in clinical practice has been found to be not useful especially in process of assessment.[33],[41]
Table 1: Improving diagnosis of hypomania in clinical settings

Click here to view

Sticking with criteria and focus on phenomenology though crucial might be hard as in routine practice while looking for bipolar illness clinicians appear to use an instinctive approach instead of strictly adhering to diagnostic criteria and tend to follow an additive model while making the diagnosis while relying not upon a specific criterion but on the total number of criteria.[24]

  Conclusion Top

Mood instability has a relatively high prevalence in the general population (estimated at 13.9%[42] and making a reliable diagnosis is important to inform current treatment decisions – it has been suspected that a broadening of the BD diagnostic category, leading to greater heterogeneity, might have led to the perceived reduction in effectiveness of lithium.[43] An accurate diagnosis of bipolar illnesses will also to contribute in developing future treatment options – for example, having patients with falsely diagnosed BDs in genome-wide association studies may cloud statistically significant associations with important implications about development of personalized treatment options.[44]

Clinicians may want to reflect whether and how their clinical practice in relation to diagnosis of hypomania and bipolar illness may have undergone change particularly in view of the popular concept of bipolar spectrum disorders and start asking the questions whether they have patients in their practice who are possibly bipolar but not diagnosed as such, or more importantly in my view whether they have patients who are being treated as bipolar but may not have bipolar at all.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, (DSM-V). 5th ed. Washington, DC: American Psychological Association; 2014.  Back to cited text no. 1
World Health Organization. ICD 10 International Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1994.  Back to cited text no. 2
Ghaemi SN, Boiman EE, Goodwin FK. Diagnosing bipolar disorder and the effect of antidepressants: A naturalistic study. J Clin Psychiatry 2000;61:804-8.  Back to cited text no. 3
Angst J. Bipolar disorders in DSM-5: Strengths, problems and perspectives. Int J Bipolar Disord 2013;1:12.  Back to cited text no. 4
Phillips ML, Kupfer DJ. Bipolar disorder diagnosis: Challenges and future directions. Lancet 2013;381:1663-71.  Back to cited text no. 5
Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: How far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry 2003;64:161-74.  Back to cited text no. 6
Angst J, Gamma A. Prevalence of bipolar disorders: Traditional and novel approaches. Clin Approaches Bipolar Disord 2002;1:10-4.  Back to cited text no. 7
Smith DJ, Griffiths E, Kelly M, Hood K, Craddock N, Simpson SA, et al. Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry 2011;199:49-56.  Back to cited text no. 8
Gilbert P, Allan S, Nicholls W, Olsen K. The assessment of psychological symptoms of patients referred to community mental health teams: Distress, chronicity and life interference. Clin Psychol Psychother 2005;12:10-27.  Back to cited text no. 9
Diana C, Lester S. I want to be bipolar, a new phenomenon. Psychiatrist 2010;34:103-5.  Back to cited text no. 10
Bilderbeck AC, Saunders KE, Price J, Goodwin GM. Psychiatric assessment of mood instability: Qualitative study of patient experience. Br J Psychiatry 2014;204:234-9.  Back to cited text no. 11
Youngstrom E, Van Meter A, Algorta GP. The bipolar spectrum: Myth or reality? Curr Psychiatry Rep 2010;12:479-89.  Back to cited text no. 12
Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? J Clin Psychiatry 2008;69:935-40.  Back to cited text no. 13
Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, Dalrymple K, Young D, et al. Overdiagnosis of bipolar disorder and disability payments. J Nerv Ment Dis 2010;198:452-4.  Back to cited text no. 14
Spitzer RL, Williams JB, Gibbon M, First MB, Arlington VA. User's Guide for the Structured Clinical Interview for DSM-III-R: SCID. US: American Psychiatric Association; 1990.  Back to cited text no. 15
Frances A, Jones KD. Bipolar disorder type II revisited. Bipolar Disord 2012;14:474-7.  Back to cited text no. 16
Judd LL, Akiskal HS, Schettler PJ, Coryell W, Endicott J, Maser JD, et al. Aprospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003;60:261-9.  Back to cited text no. 17
Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the national comorbidity survey replication. Arch Gen Psychiatry 2007;64:543-52.  Back to cited text no. 18
Andrews G, Anstey K, Brodaty H, Issakidis C, Luscombe G. Recall of depressive episode 25 years previously. Psychol Med 1999;29:787-91.  Back to cited text no. 19
Goodwin KF, Jamison RK. Manic Depressive Illness: Bipolar Disorder and Recurrent Depression. 2nd ed. Oxford University Press; 2007. p. 102-9.  Back to cited text no. 20
Angst J, Azorin JM, Bowden CL, Perugi G, Vieta E, Gamma A, et al. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: The BRIDGE study. Arch Gen Psychiatry 2011;68:791-8.  Back to cited text no. 21
Benazzi F. What is hypomania? Tetrachoric factor analysis and kernel estimation of DSM-IV hypomanic symptoms. J Clin Psychiatry 2009;70:1514-21.  Back to cited text no. 22
Severus E, Bauer M. Diagnosing bipolar disorders in DSM-5. Int J Bipolar Disord 2013;1:14.  Back to cited text no. 23
Wolkenstein L, Bruchmüller K, Schmid P, Meyer TD. Misdiagnosing bipolar disorder – Do clinicians show heuristic biases? J Affect Disord 2011;130:405-12.  Back to cited text no. 24
Ghouse AA, Sanches M, Zunta-Soares G, Swann AC, Soares JC. Overdiagnosis of bipolar disorder: A critical analysis of the literature. Scientific World Journal 2013;2013:297087.  Back to cited text no. 25
Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL, Delbello MP, et al. Diagnostic characteristics of 93 cases of a prepubertal and early adolescent bipolar disorder phenotype by gender, puberty and comorbid attention deficit hyperactivity disorder. J Child Adolesc Psychopharmacol 2000;10:157-64.  Back to cited text no. 26
Goldberg JF. Bipolar disorder with comorbid substance abuse: Diagnosis, prognosis, and treatment. J Psychiatr Pract 2001;7:109-22.  Back to cited text no. 27
Parker G. Is borderline personality disorder a mood disorder? Br J Psychiatry 2014;204:252-3.  Back to cited text no. 28
Bayes A, Parker G, Fletcher K. Clinical differentiation of bipolar II disorder from borderline personality disorder. Curr Opin Psychiatry 2014;27:14-20.  Back to cited text no. 29
Paris J, Gunderson J, Weinberg I. The interface between borderline personality disorder and bipolar spectrum disorders. Compr Psychiatry 2007;48:145-54.  Back to cited text no. 30
Hirschfeld RM, Williams JB, Spitzer RL, Calabrese JR, Flynn L, Keck PE Jr., et al. Development and validation of a screening instrument for bipolar spectrum disorder: The mood disorder questionnaire. Am J Psychiatry 2000;157:1873-5.  Back to cited text no. 31
Angst J, Adolfsson R, Benazzi F, Gamma A, Hantouche E, Meyer TD, et al. The HCL-32: Towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord 2005;88:217-33.  Back to cited text no. 32
Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, McGlinchey JB, Dalrymple K, et al. Performance of the mood disorders questionnaire in a psychiatric outpatient setting. Bipolar Disord 2009;11:759-65.  Back to cited text no. 33
Nicholas J, Larsen ME, Proudfoot J, Christensen H. Mobile apps for bipolar disorder: A systematic review of features and content quality. J Med Internet Res 2015;17:e198.  Back to cited text no. 34
Young AH, Macpherson H. Detection of bipolar disorder. Br J Psychiatry 2011;199:3-4.  Back to cited text no. 35
Vieta E. Overview of bipolar disorder. In: Bipolar Disorder in Clinical Practice. London, UK: Current Medicine Group; 2007. p. 1-6.  Back to cited text no. 36
Iordache I, Low NC. The overdiagnosis of bipolar disorder. J Psychiatry Neurosci 2010;35:E3-4.  Back to cited text no. 37
Manning JS. Tools to improve differential diagnosis of bipolar disorder in primary care. Prim Care Companion J Clin Psychiatry 2010;12:17-22.  Back to cited text no. 38
Simpson SG, McMahon FJ, McInnis MG, MacKinnon DF, Edwin D, Folstein SE, et al. Diagnostic reliability of bipolar II disorder. Arch Gen Psychiatry 2002;59:736-40.  Back to cited text no. 39
Dunner DL, Tay LK. Diagnostic reliability of the history of hypomania in bipolar II patients and patients with major depression. Compr Psychiatry 1993;34:303-7.  Back to cited text no. 40
Sharma A, Kumar J. Self diagnosing bipolar illness: Questions for clinicians. Psychiatrist 2015;39:51. [doi: 10.1192/pb. 39.1.51a].  Back to cited text no. 41
Marwaha S, Parsons N, Flanagan S, Broome M. The prevalence and clinical associations of mood instability in adults living in England: Results from the Adult Psychiatric Morbidity Survey 2007. Psychiatry Res 2013;205:262-8.  Back to cited text no. 42
Grof P. Has the effectiveness of lithium changed? Impact of the variety of lithium's effects. Neuropsychopharmacology 1998;19:183-8.  Back to cited text no. 43
Schulze TG. Genetic research into bipolar disorder: The need for a research framework that integrates sophisticated molecular biology and clinically informed phenotype characterization. Psychiatr Clin North Am 2010;33:67-82.  Back to cited text no. 44


  [Table 1]

This article has been cited by
1 Predictor Variables for Elevated Mood and Activity in Hypomania and Self-Actualization
Andrii Zaiets
Bulletin of Taras Shevchenko National University of Kyiv. Series “Psychology”. 2021; 1(13): 28
[Pubmed] | [DOI]
2 ??????????? ???’????????? ??????? ??????? ?????????? ?? ?????????: ??????????????? ??????????? ? ????????????? ??????’? PEXI
Andrii Zaiets
International Journal of Innovative Technologies in Social Science. 2021; (2(30))
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Hypomania: the C...
Why Diagnosing H...
Strategies for T...
Article Tables

 Article Access Statistics
    PDF Downloaded213    
    Comments [Add]    
    Cited by others 2    

Recommend this journal