A 29-year-old man comes to the physician with his wife because she has noticed a change in his behavior over the past 2 weeks. His wife reports that he is very distracted and irritable. His colleagues have voiced concerns that he has not been turning up for work regularly and behaves erratically when he does. Previously, her husband had been a reliable and reasonable person. The patient says that he feels “fantastic”; he only needs 4 hours of sleep each night and wakes up cheerful and full of energy each morning. He thinks that his wife is overreacting. The patient has been healthy except for a major depressive episode 5 years ago that was treated with paroxetine. He currently takes no medications. His pulse is 98/min, respirations are 12/min, and blood pressure is 128/62 mm Hg. Mental status examination shows frenzied speech and a flight of ideas. Which of the following is the strongest predisposing factor for this patient's condition?

Maternal obstetric complications

A 26-year-old female college student is brought back into the university clinic for acting uncharacteristically. The patient presented to the same clinic 6 weeks ago with complaints of depressed mood, insomnia, and weightloss. She had been feeling guilty for wasting her parent’s money by doing so poorly at the university. She felt drained for at least 2 weeks before presenting to the clinic for the first time. She was placed on an antidepressant and was improving but now presents with elevated mood. She is more talkative with a flight of ideas and is easily distractible. Which of the following statements is most likely true regarding this patient’s condition?

Her diagnosis of unipolar depression is incorrect.

The patient may have psychotic features.

The patient may have a history of mania.

Antidepressants are inappropriate.

Her new symptoms need to last at least 7 days.

An 11-year-old boy’s parents brought him to a psychologist upon referral from the boy’s school teacher. The boy frequently bullies his younger classmates despite having been punished several times for this. His mother also reported that a year prior, she received complaints that the boy shoplifted from local shops in his neighborhood. The boy frequently stays out at night despite strict instructions by his parents to return home by 10 PM. Detailed history reveals that apart from such behavior, he is usually not angry or irritable. Although his abnormal behavior continues despite warnings and punishments, he neither argues with his parents nor teachers and does not display verbal or physical aggression. Which of the following is the most likely diagnosis?

Attention-deficit/hyperactivity disorder, hyperactivity-impulsivity type

Disruptive mood dysregulation disorder

Intermittent explosive disorder

Manic episode criteria and features for USMLE Step 2 CK: High-Yield Psychiatry Lessons

DSM-5 Criteria - The Mania Checklist

A. Mood & Energy: A distinct period of abnormally and persistently elevated, expansive, or irritable mood, AND abnormally and persistently increased goal-directed activity or energy.
- Lasts at least 1 week and is present most of the day, nearly every day.
B. Symptom Threshold: During the mood disturbance, ≥3 of the following symptoms are present to a significant degree (≥4 if the mood is only irritable).
- 📌 DIGFAST Mnemonic:
  - Distractibility
  - Impulsivity / Indiscretion (excessive involvement in high-risk activities)
  - Grandiosity or inflated self-esteem
  - Flight of ideas or racing thoughts
  - Activity ↑ (goal-directed) or psychomotor agitation
  - Sleep ↓ (decreased need; e.g., feels rested after only 3 hours)
  - Talkativeness ↑ (pressured speech)
C. Severity: Causes marked impairment in social or occupational functioning, OR necessitates hospitalization to prevent harm, OR there are psychotic features.

⭐ A manic episode that emerges during antidepressant treatment (e.g., SSRI) and persists beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a Bipolar I diagnosis.

Clinical Features - The Manic Spectrum

Core Criteria: A distinct period of abnormally and persistently elevated, expansive, or irritable mood, with increased goal-directed activity or energy, lasting ≥ 1 week.
Requires ≥3 of the following symptoms (≥4 if mood is only irritable):
- 📌 DIG FAST Mnemonic:
- Distractibility
- Indiscretion/Impulsivity (high-risk behaviors)
- Grandiosity
- Flight of ideas / racing thoughts
- Activity ↑ (psychomotor agitation)
- Sleep need ↓
- Talkativeness (pressured speech)
Severity: The mood disturbance is severe enough to cause marked impairment in social or occupational functioning, to necessitate hospitalization, or there are psychotic features.

⭐ High-Yield: The presence of psychotic features (e.g., grandiose delusions, hallucinations) automatically makes an episode manic, not hypomanic.

Bipolar 1 vs. Bipolar 2 Comparison (Manic vs. Hypomanic)

Differential Diagnosis - Not Always Bipolar

First, rule out mimics: Always consider substances or other medical conditions as the underlying cause of manic symptoms before diagnosing a primary psychiatric disorder.

Key Distinctions:
- ADHD vs. Bipolar: ADHD is a lifelong, pervasive pattern of hyperactivity and inattention, whereas bipolar disorder presents as distinct mood episodes.
- Personality Disorder vs. Bipolar: BPD/NPD involves chronic, pervasive patterns of emotional dysregulation and grandiosity, not the clear episodic nature of bipolar mania.

⭐ For schizoaffective disorder, a key criterion is the presence of delusions or hallucinations for ≥2 weeks in the absence of a major mood episode during the illness lifetime. If psychosis only occurs with mania, it's Bipolar I.

High-Yield Points - ⚡ Biggest Takeaways

A manic episode requires an elevated or irritable mood plus increased energy lasting ≥1 week.

Look for ≥3 DIGFAST symptoms: Distractibility, Impulsivity, Grandiosity, Flight of ideas, Activity, Sleep (decreased need), Talkativeness.

The disturbance must cause marked functional impairment, necessitate hospitalization, or include psychotic features.

Unlike hypomania, which is shorter (≥4 days) and does not cause marked impairment.

Always rule out substance-induced or medical causes for the mood disturbance.

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Manic episode criteria and features