What is the approach to taking a history for bipolar disorder?

Comprehensive Approach to Taking a History for Bipolar Disorder

When taking a history for bipolar disorder, focus on identifying distinct periods of mood changes with associated sleep disturbances and psychomotor activation, as these are the core diagnostic features that distinguish bipolar disorder from other conditions. 1

Key Components of the Bipolar History Assessment

1. Screening for Mood Episodes

• Ask about distinct, spontaneous periods of:
  • Elevated, expansive, or irritable mood
  • Decreased need for sleep without feeling tired
  • Increased energy, activity, and goal-directed behavior
  • Racing thoughts or flight of ideas
  • Grandiosity or inflated self-esteem
  • Distractibility and poor concentration
  • Increased talkativeness or pressured speech
  • Excessive involvement in pleasurable activities with high potential for painful consequences

2. Duration and Pattern of Episodes

• Document duration of mood episodes (manic episodes require ≥7 days, hypomanic episodes ≥4 days) 1
• Assess for cycling patterns:
  • Rapid cycling (≥4 episodes per year)
  • Ultrarapid cycling (5-364 cycles per year)
  • Ultradian cycling (>365 cycles per year, multiple mood shifts within a day) 1
• Determine if episodes represent a significant departure from baseline functioning 1

3. Depressive Symptoms Assessment

• Depressive episodes dominate the longitudinal course of bipolar disorder and account disproportionately for morbidity and mortality 2
• Inquire about:
  • Depressed mood, anhedonia
  • Changes in appetite and weight
  • Sleep disturbances (particularly hypersomnia)
  • Psychomotor changes (especially retardation)
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Diminished concentration
  • Recurrent thoughts of death or suicide

4. Mixed Episodes and Symptom Presentation

• Assess for concurrent manic and depressive symptoms (mixed episodes) 1
• Document mood lability and emotional reactivity
• Note that irritability and belligerence are more common than euphoria, especially in children and adolescents 1

5. Age of Onset and Course of Illness

• Determine age at first mood symptoms (earlier age of onset suggests bipolar disorder) 3
• Document progression of symptoms over time
• Assess for shortening intervals between episodes, which may occur naturally in the illness course 4
• Note that the first presentation is often depression rather than mania 5

6. Family History

• Obtain detailed family history of mood disorders, especially bipolar disorder 3
• Document family history of suicide attempts or completions
• Ask about family history of substance use disorders

7. Previous Treatment Response

• History of antidepressant-induced switching to mania/hypomania (strongly suggests bipolar disorder) 3
• Response to previous mood stabilizers
• Side effects from previous medications
• Adherence to treatment regimens

8. Comorbidity Assessment

• Screen for substance use disorders (commonly comorbid)
• Assess for anxiety disorders
• Evaluate for ADHD symptoms (especially in children)
• Screen for medical conditions that may mimic or exacerbate mood symptoms

9. Functional Impact Assessment

• Document impact on:
  • Occupational/academic functioning
  • Interpersonal relationships
  • Self-care abilities
  • Financial decision-making

10. Risk Assessment

• Evaluate suicide risk (bipolar disorder has among the highest suicide rates of psychiatric disorders) 2
• Assess for risk-taking behaviors during manic episodes
• Document history of hospitalizations

Special Considerations

Children and Adolescents

• In younger patients, symptoms may present differently:
  • More irritability and mixed states than euphoria
  • More chronic presentation with rapid mood shifts
  • Higher rates of comorbid ADHD and disruptive behavior disorders 1
• Use DSM criteria including duration requirements when making diagnosis 1

Diagnostic Challenges

• Bipolar depression may be misdiagnosed as unipolar depression 3
• Features suggesting bipolar depression include:
  • Earlier age of onset
  • Family history of bipolar disorder
  • Psychotic features
  • Reverse neurovegetative symptoms (hypersomnia, increased appetite)
  • Poor response to antidepressants or antidepressant-induced mania 3

Collateral Information

• Whenever possible, obtain information from family members or close friends
• Patients may lack insight into manic symptoms or minimize their severity
• Family members often notice behavioral changes before the patient does

By systematically covering these areas in your history-taking, you can more accurately identify bipolar disorder and distinguish it from other conditions with overlapping symptoms, leading to appropriate treatment decisions and improved outcomes for patients.