What questions do I ask to elicit a past manic episode?

Screening Questions to Elicit a Past Manic Episode

Ask about distinct periods of abnormally elevated, expansive, or irritable mood lasting at least 7 days (or any duration if hospitalization was required), accompanied by persistently increased energy or activity that represented a marked change from their usual self. 1, 2

Essential Screening Questions

Core Mood and Energy Changes

• "Have you ever had a period lasting at least a week where you felt extremely happy, 'high,' or on top of the world—much more than your usual good mood?" 2, 3
• "Have you ever had a period where you felt extremely irritable or easily angered for at least a week, where this was very different from your normal self?" 1, 2
• "During that time, did you have much more energy than usual, feeling like you could go and go without getting tired?" 4 (Note: increased energy/activity is the core feature of mania and may be more informative than mood changes alone)

Sleep Disturbance (Pathognomonic Sign)

• "During that time, did you need much less sleep than usual but still felt rested or full of energy?" 1, 5 (This is a hallmark sign—reduced need for sleep, not just insomnia)
• "For example, did you sleep only 2-3 hours but wake up feeling great and ready to go?" 3

Associated Manic Symptoms

Ask if during that same period they experienced:

• Grandiosity: "Did you feel like you had special powers or abilities, or that you were extremely important or famous?" 2, 3
• Pressured speech: "Did people tell you that you were talking much more than usual or that they couldn't interrupt you?" 3
• Racing thoughts: "Did your thoughts race so fast that you couldn't keep up with them?" 3
• Increased goal-directed activity: "Were you much more active than usual—starting lots of projects, making big plans, or being unable to sit still?" 3
• Risky behavior: "Did you do things that were risky or that you wouldn't normally do, like spending lots of money, making impulsive business decisions, or engaging in risky sexual behavior?" 3

Functional Impairment and Hospitalization

• "Did this change in your mood and energy cause serious problems at work, school, or in your relationships?" 2
• "Were you ever hospitalized during this time because of your mood or behavior?" 2 (Any duration counts if hospitalization occurred)
• "Did you experience confusion, paranoia, or hear/see things that weren't there during this time?" 5 (Psychotic features are common, especially in adolescents/young adults)

Distinguishing True Mania from Situational Reactions

• "Was this a clear change from how you normally are, not just a reaction to a specific situation or good news?" 5
• "Did these symptoms occur across different areas of your life—at home, work, and with friends—not just in one setting?" 5
• "Did this happen even when there wasn't an obvious reason for feeling this way?" 5

Substance and Medication History

• "Were you taking any medications when this happened, especially antidepressants?" 6 (Antidepressant-induced mania is classified as substance-induced but indicates bipolar vulnerability)
• "Were you using any drugs or alcohol heavily during this time?" 1
• "Were you taking steroids or any other medications prescribed by a doctor?" 7

Critical Diagnostic Considerations

Use a Life Chart Approach

• Ask the patient to map out when these episodes occurred, how long they lasted, and what treatments they received. 1, 5 This longitudinal perspective improves diagnostic accuracy since acute presentations can be confused with other disorders.

Family History

• "Does anyone in your family have bipolar disorder, severe depression, or other mood problems?" 1, 5 Strong genetic loading increases the likelihood of true bipolar disorder.

Depression History

• "Have you also had periods of severe depression?" 5 Approximately 20% of youth with major depression develop manic episodes by adulthood, and most bipolar patients experience depressive episodes. 5, 6

Common Pitfalls to Avoid

• Don't confuse chronic irritability or anger outbursts with mania. 1, 5 True manic irritability represents a marked change in mental state, not temperamental traits or reactions to conflict.
• Don't rely solely on irritability and increased energy without other manic symptoms. 1 These occur in many conditions (ADHD, conduct disorder, PTSD, personality disorders).
• Distinguish reduced need for sleep from insomnia. 1 In mania, patients sleep less but feel rested and energized; in depression or anxiety, they want to sleep but cannot.
• Verify the episode lasted at least 7 days (or required hospitalization). 2 Shorter episodes may represent bipolar disorder NOS or other conditions. 1
• Confirm impairment across multiple settings. 1, 5 Context-dependent symptoms suggest other diagnoses like personality disorders or situational reactions.