History and exam

Key diagnostic factors

common

history of major depressive episode(s)

A history of depression is common in bipolar disorder. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria for a major depressive episode include depressed mood or anhedonia, although irritability may be predominant in children and adolescents; changes in appetite, energy, concentration, and sleep; and psychomotor problems, excessive guilt, hopelessness, and suicidal ideation.[4]

≥7 days of elated, expansive, or irritable mood and persistently increased activity/energy different from patient's usual self (mania)

Elated and/or expansive mood can be elicited from older children and teens; it is inferred in younger children, although the validity of inference is difficult to establish. It is easier when the mood change represents a difference in behavior. Becoming overly angry very quickly is a symptom that is not specific to mania, but when it occurs within a manic episode, it is compelling. The person becomes enraged with minimal provocation. The behavior is most important when it represents a change in function.[80]

Increased activity or energy is abnormal and persistent and should be concurrent with mood change. Children or teens take on many different activities that they may or may not be able to accomplish; they might feel very energetic about doing so.

There may be changes in scholastic, social, sexual, or leisure involvement, or in activity level associated with work, family, friends, new projects, interests, or activities (e.g., telephone calls, letter-writing).[80]

inflated self-esteem or grandiosity

Symptom should be concurrent with mood change. Children should have a cognitive and language age of at least 7 years in order to be able to accurately determine their abilities. This is important in deciding whether their self-esteem is pathologically elevated or within developmental norms.[80]

decreased need for sleep

Symptom should be concurrent with mood change. There may be a change in how much sleep the child needs to feel rested. The behavior of the child while they are not asleep should be recorded. If there is a true decreased need for sleep, the child will not be tired the next day.

pressure of speech

Symptom should be concurrent with mood change. The child may talk very rapidly, and cannot be stopped. Pressure of speech does not occur just because the child is momentarily excited about a particular event or topic.[80]

subjective experience that thoughts are racing

Symptom should be concurrent with mood change. Children may describe this symptom as "too many thoughts".

distractibility

Symptom should be concurrent with mood change. Children or teens may realize they have trouble sustaining attention. They may become easily distracted, and not return to the task in hand.

excessive involvement in pleasurable activities that have a high potential for painful consequences

Symptom should be concurrent with mood change. In young people, new-onset drug experimentation, dangerous internet use, and theft of credit cards to buy things may occur.[80]

impairment in functioning

Symptom should be concurrent with mood change. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR), marked impairment in functioning or hospitalization occurs with manic episodes, whereas in hypomania, marked impairment does not occur, but the disturbance in mood and the change in functioning are observable by others.

Other diagnostic factors

common

adolescence and young adulthood

The most common age of onset is adolescence or young adulthood, although onset can occur at any age. There is most consensus on the diagnosis of mania in children older than 10 years of age.[18][89]

flight of ideas

Symptom should be concurrent with mood change. This sign can be described as statements jumping from topic to topic without explanation. In severe cases, the child is incoherent. The speed of associations will be rapid, and there will be an inability to complete ideas and sustain attention in a goal-directed manner. Ongoing pragmatic language problems must be excluded.[80]

Risk factors

strong

family history of bipolar disorder

The risk is 5 to 8 times higher in offspring who have a first-degree relative with bipolar I disorder compared with those with no family history.[61][62][63][64]

history of depression

In one cohort study 2.21% of children admitted to hospital with depression converted to a diagnosis of bipolar disorder within 4 years.[65] Female sex and psychotic depression increased the risk of conversion from unipolar depression to bipolar disorder.[65] A large community study reported that adolescents and young adults who had major depression with ADHD comorbidity had an increased incidence of subsequent bipolar disorder (18.9%) compared with those without ADHD (11.2%).[66]

physical and/or sexual abuse

Patients with bipolar disorder have significantly higher rates of sexual and physical abuse histories than comparison groups.[17][67][68][69] Abuse appears to be related to increased severity of symptoms, substance use, greater comorbidity, suicidality, and a worse family environment.[70]

poor sleep

Poor sleep quality significantly increased the risk for the subsequent development of bipolar disorder in a large community cohort of young adolescents and young adults.[71]

neurodevelopmental abnormalities

A population study reported a substantially increased risk of bipolar disorder in young people with autism spectrum disorders.[72]

Neurodevelopmental abnormalities have also been reported to be antecedents in a subgroup of high-risk children (i.e., offspring of parents with bipolar disorder).[73]

weak

lack of maternal warmth/expressed emotion (duration)

The level of maternal warmth/expressed emotion is associated with duration of illness.[34][74] However, it is nonspecific.

life events

Life events are established risk factors for the onset of mood disorder but less so in recurrent episodes. Some evidence suggests that psychological features (passive coping and harm-avoidant temperament) contribute to the risk of an episode occurring, and have a moderating effect on the association between life events and mood episodes.[75]

increased sociability and verbal functioning

A twin registry study has reported that supra-normal levels of sociability and verbal functioning may be associated with liability for bipolar disorder.[76]

persistent affective symptoms (transition to bipolar disorder)

Adolescents with any persistent affective symptoms are at increased risk of later bipolar disorder, and this risk is greater with an increasing number of symptoms.[77] However, the predictive value of this signal is weak.[78][79]

male sex (when ADHD is comorbid)

Where ADHD is a comorbidity, male sex is more common; otherwise, bipolar disorder is equally distributed between sexes.[80]

high intellectual performance

There is some evidence to suggest that exceptional intellectual ability is a risk factor for later bipolar disorder in adolescent boys.[81]

family conflict

Adolescent mania symptoms improve more rapidly in low-conflict than in high-conflict families, and a reduction in parent-reported conflict predicts a decrease in manic symptoms in these adolescents.[82]

symptoms of inattention

According to a literature review, symptoms of inattention may be part of a mixed clinical presentation during the early stages of evolving bipolar disorder in high-risk children (i.e., offspring of parents with bipolar disorder).[73]

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