Psychiatric Evaluation for Bipolar Disorder
Conduct a structured diagnostic interview focusing on distinct episodic mood changes with decreased sleep need and psychomotor activation, using DSM criteria requiring ≥7 days for mania or ≥4 days for hypomania, while systematically ruling out substance-induced presentations and medical causes. 1
Initial Screening Questions
Ask these specific questions to identify hallmark features:
"Have you had distinct periods—lasting at least several days—when you felt unusually happy, energetic, or irritable, clearly different from your normal self?" This targets the episodic nature that differentiates bipolar from chronic irritability. 1, 2
"During those times, did you need much less sleep than usual but still felt rested—like only 2-4 hours?" Decreased sleep need (not insomnia) is the single most discriminating feature. 1, 2
"Did you have racing thoughts, talk much more than usual, or feel like your mind was going too fast?" These capture the cognitive acceleration of mania. 1
"Did you have much more energy, take on multiple projects, or feel restless and unable to sit still?" This assesses psychomotor activation. 1, 2
"Did you do things that were risky or that you later regretted—like spending sprees, sexual indiscretions, or reckless driving?" This evaluates impulsivity during episodes. 3
Longitudinal Pattern Assessment
Create a life chart mapping the timeline of mood episodes. Document when specific symptom clusters began, their duration, and periods of normal functioning. This visual tool is essential for distinguishing episodic bipolar disorder from chronic conditions like ADHD or persistent irritability. 1, 2
Key temporal distinctions:
Episodic vs. chronic: Bipolar presents with distinct episodes separated by periods of baseline functioning, whereas ADHD and disruptive behavior disorders show chronic, persistent symptoms. 1
Duration requirements: Mania requires ≥7 days (or any duration if hospitalization needed); hypomania requires ≥4 days. Episodes lasting only hours to <4 days are classified as Bipolar NOS, not Bipolar I or II. 1, 3
Spontaneous vs. reactive: Manic irritability occurs spontaneously as part of a mood episode, whereas PTSD-related irritability is triggered by trauma reminders. 1
Critical Historical Information
Past Psychiatric History
Document the following systematically:
All prior psychiatric diagnoses (including incorrect ones) and psychiatric hospitalizations. 1
Response to past treatments, particularly noting any antidepressant-induced mood elevation or agitation—this strongly suggests underlying bipolar disorder, as approximately 20% of youths with major depression eventually develop manic episodes. 1, 3
Pattern of depressive episodes: Psychomotor retardation, hypersomnia, and psychotic features during depression increase suspicion for bipolar disorder. 1
Substance Use Assessment
Obtain detailed substance use history and consider toxicology screening to rule out substance-induced mood disorder. 1 Document:
- Current and past use of alcohol, marijuana, cocaine, hallucinogens, stimulants, and other substances
- Misuse of prescribed or over-the-counter medications
- Temporal relationship between substance use and mood symptoms 1
Manic episodes precipitated by antidepressants are characterized as substance-induced per DSM criteria. 1
Family Psychiatric History
First-degree relatives with bipolar disorder confer a 4-6 fold increased risk. Family history of mood disorders is a significant diagnostic clue. 1, 3
Medical Evaluation
Complete a comprehensive medical workup to exclude organic causes:
- Thyroid function tests (hyper/hypothyroidism can mimic mood episodes)
- Complete blood count
- Comprehensive metabolic panel
- Vital signs and neurologic examination 1, 2
Differential Diagnosis—Critical Distinctions
ADHD vs. Bipolar Disorder
- ADHD: Chronic, persistent symptoms from childhood without distinct episodes; no decreased sleep need
- Bipolar: Episodic mood changes with clear periods of elevation; decreased sleep need during episodes 1, 2
High comorbidity exists—many bipolar patients also have ADHD, requiring treatment of both conditions. 1
PTSD vs. Bipolar Disorder
- PTSD: Irritability is reactive to trauma reminders or environmental triggers
- Bipolar: Irritability occurs spontaneously as part of a mood episode 1
Borderline Personality Disorder vs. Bipolar Disorder
Both share emotional dysregulation, impulsivity, and affective instability. Key differentiators:
- Decreased sleep need is hallmark of bipolar mania; BPD has sleep problems related to emotional distress, not reduced sleep need
- Episode duration: Bipolar mood shifts last days to weeks; BPD mood shifts are typically hours
- Context: BPD mood changes are often triggered by interpersonal stressors 1
Do not overlook the possibility of both diagnoses coexisting. 1
Safety Assessment
Bipolar disorder has exceptionally high suicide rates—assess thoroughly at every visit. 1, 2 Document:
- Prior suicidal ideas, plans, and attempts (including aborted or interrupted attempts)
- Current suicidal ideation and intent
- Prior aggressive behaviors or homicidal ideation
- Current impulsivity 1
Comorbidity Screening
Systematically assess for conditions that commonly co-occur:
- Substance use disorders: Rates are particularly high in adolescents with bipolar disorder 1, 2
- Anxiety disorders 1, 2
- ADHD (present in majority of pediatric bipolar cases) 1
- Eating disorders 1
Special Considerations by Age
Children and Adolescents
Use identical DSM criteria as adults—duration requirements apply equally. 4, 1
Pediatric presentations differ: Irritability, belligerence, and mixed features are more common than euphoria; symptoms are often more labile and erratic. 1
Exercise extreme caution in children under age 6—diagnostic validity has not been established in this age group. Consider alternative explanations first (developmental disorders, psychosocial stressors, temperamental difficulties). 1, 3
Peak onset is 15-30 years, making adolescence a high-risk period. 1
Adolescent-Specific Features
- More chronic, rapid-cycling patterns than adults 1
- Frequently associated with psychotic symptoms and markedly labile moods 1
- High rates of comorbid conduct disorder and oppositional defiant disorder 1
Collateral Information
Obtain information from family members or other sources whenever possible. Patients often lack insight during manic episodes, and family members can describe behavioral changes and episodic patterns more objectively. 1
Diagnostic Pitfalls to Avoid
Do not diagnose based on irritability alone—it is non-specific across multiple psychiatric conditions. 1, 2
Avoid checklist-only approaches—prioritize longitudinal patterns and contextual information. 1, 2
Do not miss substance-induced presentations—always obtain toxicology screening when substance use is suspected. 1
Do not overlook medical causes—thyroid dysfunction, neurological conditions, and medications can mimic bipolar symptoms. 1
Monitoring and Reassessment
Schedule follow-up visits to observe symptom evolution over time. Prospectively track mood patterns, sleep changes, and functional impairment using the life chart. Reassess diagnosis periodically, as the clinical picture may evolve. 1, 2
Treatment Initiation After Diagnosis
Once bipolar disorder is confirmed:
For Bipolar I Disorder (Mania)
First-line pharmacotherapy includes lithium, valproate/divalproex, or atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine, ziprasidone). 3, 5 Combination therapy with a mood stabilizer plus an atypical antipsychotic shows superior efficacy compared to monotherapy. 2
For Bipolar II Disorder (Depression)
Quetiapine or lamotrigine are first-line treatments. Antidepressant monotherapy is contraindicated in bipolar depression—it may trigger manic episodes. 3, 6, 7
Baseline Monitoring Before Treatment
- For lithium: Complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium 2
- For atypical antipsychotics: Body mass index, waist circumference, blood pressure, fasting glucose, fasting lipid panel 4, 2