How do you assess for Post-Traumatic Stress Disorder (PTSD) and Bipolar disorder?

Assessment of PTSD and Bipolar Disorder

PTSD Assessment

Begin by directly asking patients if anything scary or concerning has happened to them or their family, followed by open-ended questions to explore trauma exposure, as these questions are essential for identifying PTSD. 1

Core Diagnostic Requirements

PTSD diagnosis requires all of the following components present for more than one month with significant functional impairment 1:

• Trauma exposure through direct experience, witnessing trauma, learning about trauma to close others, or repeated exposure to traumatic details 1
• At least one intrusion symptom: recurrent memories, traumatic nightmares, flashbacks, or intense psychological distress to trauma reminders 1
• At least one avoidance symptom: avoiding trauma-related thoughts, feelings, or external reminders 1
• At least two negative cognition/mood alterations: inability to remember trauma aspects, persistent negative beliefs, distorted thoughts about cause/consequences, persistent negative emotional state, diminished interest, detachment from others, or inability to experience positive emotions 1
• At least two arousal/reactivity alterations: irritable behavior, reckless behavior, hypervigilance, exaggerated startle response, concentration problems, or sleep disturbance 1

Validated Screening Tools

• Use the PTSD Reaction Index Brief Form for known trauma exposures 1
• Use the Pediatric Traumatic Stress Screening Tool in primary care settings 1
• The Clinician-Administered PTSD Scale (CAPS) is the gold standard diagnostic interview, assessing frequency and intensity of 17 symptoms using structured questions and behaviorally anchored rating scales 2

Age-Specific Assessment Approaches

For children with trauma exposure, ask parents about 1:

• The child's understanding of the traumatic event
• Sleep problems and appetite changes
• Clinginess and behavioral regression
• Physical complaints without clear medical cause

For adolescents 1:

• Incorporate questions into the HEADSSS framework
• Ask specifically about new or increased substance use
• Assess for increased risk-taking behaviors

Critical Assessment Pitfalls

• Do not rely solely on observable behaviors when assessing for PTSD, as most symptoms are internal—you must ask directly about symptoms 1
• Screen children directly when age-appropriate, as parents and teachers often underestimate their distress 1
• Underdiagnosis is common because many patients do not voluntarily report symptoms, requiring direct screening 1

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Bipolar Disorder Assessment

Screen for bipolar disorder by asking about distinct, spontaneous periods of mood elevation with decreased need for sleep and psychomotor activation, while recognizing that irritability alone is non-specific and occurs across multiple diagnoses. 3, 4

Core Diagnostic Approach

• Follow DSM criteria strictly, including duration criteria: at least 4 days for hypomania or 7 days for mania 3, 4
• Assess for manic episodes characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood that represents a clear departure from baseline functioning 3
• Document whether symptoms are chronic or episodic—this is critical for differentiating bipolar disorder from conditions like DMDD (which presents with chronic, persistent irritability without distinct episodes) 3

Essential Screening Questions

Two simple initial screening questions are effective 4:

• Ask about periods of abnormally elevated, expansive, or euphoric mood clearly different from baseline
• Ask about periods of markedly increased goal-directed activity or physical restlessness

All positive screening results must trigger full diagnostic interviews using standard DSM criteria 4

Hallmark Features to Assess

Focus on these specific features that differentiate bipolar disorder 3, 4:

• Decreased need for sleep (not just insomnia, but feeling rested after minimal sleep)
• Distinct mood episodes with clear periods of elevation alternating with baseline or depressed mood
• Psychomotor activation during mood episodes
• Manic grandiosity and irritability presenting as marked changes in mental/emotional state, rather than reactions to situations or temperamental traits 3

Longitudinal Assessment Strategy

• Use a life chart to map the longitudinal course of symptoms, documenting when specific symptom clusters began, their duration, and any periods of remission 3, 4
• Organize clinical information to characterize patterns of episodes, severity, and treatment response 4
• Assess both current and past history of symptomatic presentation, treatment response, psychosocial stressors, and family psychiatric history 3

Critical Differential Diagnosis Considerations

Manic symptoms must be differentiated from other common disorders 3:

• ADHD: Bipolar presents with episodic changes versus chronic ADHD symptoms
• PTSD: PTSD-related irritability is typically reactive to trauma reminders, whereas manic irritability occurs spontaneously as part of a mood episode 3
• Disruptive behavior disorders: Look for the episodic nature and mood component in bipolar disorder

Essential Comorbidity Assessment

• Assess for suicidality, as bipolar patients have high rates of suicide attempts 3
• Evaluate psychosocial stressors 3
• Screen for medical problems that could mimic or exacerbate mood symptoms 3
• Assess family history of mood disorders, as this is a significant risk factor 4

Special Diagnostic Challenges

• Rule out substance-induced mood disorder by obtaining toxicology screening and assessing temporal relationship between substance use and mood symptoms 3
• Complete thorough medical evaluation including thyroid function tests, complete blood count, and comprehensive metabolic panel to exclude organic causes 3
• Consider cross-cultural issues that may influence symptom expression or interpretation 3

Diagnostic Caution

• The diagnostic validity of bipolar disorder in very young children (preschoolers) has not been established, requiring extreme caution in diagnosis 3
• Avoid relying solely on checklists to identify psychopathology—instead assess symptoms in perspective given family, school, peer, and other psychosocial factors 4

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Assessing Comorbid PTSD and Bipolar Disorder

When both conditions are suspected, recognize that PTSD is highly prevalent in bipolar disorder, affecting approximately 16% of bipolar patients—roughly double the general population rate. 5

Key Comorbidity Considerations

• Patients with bipolar disorder and comorbid PTSD have higher depressive symptoms and more conflicting appraisals than those without PTSD 6
• Comorbid PTSD is associated with accelerated illness progression in bipolar disorder, including lower age at onset of manic/hypomanic episodes, earlier initiation of illicit drug use, and higher number of manic/hypomanic episodes 7
• DSM-5 PTSD criteria may overdiagnose PTSD in bipolar patients due to mood symptom overlap—ICD-11 criteria show lower rates (31.8% vs 41%) but good concordance (Cohen's k = 0.643) 8

Assessment Strategy for Comorbidity

• Assess temporal relationships carefully: Determine whether mood symptoms preceded trauma exposure or emerged afterward 9
• Use structured interviews rather than relying solely on clinical impression, as clinicians may miss comorbid bipolar disorder in PTSD patients 9
• Recognize that combat veterans with PTSD may meet structured interview criteria for bipolar disorder (54.1% in one study) even when clinicians do not observe this clinically 9

Monitoring Approach for Unclear Cases

• Initiate close monitoring before making definitive diagnoses given the diagnostic complexity and treatment implications 3
• Track mood patterns, sleep changes, and functional impairment prospectively 3
• Reassess diagnosis periodically, as the clinical picture may evolve over time 3