There is not a mental disorder that generates more consternation when it comes to diagnostic assuredness than bipolar disorder, particularly on an initial evaluation. We clinicians are forever searching for better screening questions to more quickly hone in on a diagnosis, and of course, bipolar is no exception. But we shouldn’t act in haste simply to be more expeditious. I often emphasize when I’m training less experienced clinicians that just as Rome wasn’t built in a day, nailing down a diagnosis after a single session just isn’t realistic. This applies to experienced practitioners as well, and is particularly relevant to diagnosing bipolar disorder because of its complexity and symptom presentations which mimic other mood disturbances.
So here are the 3 best questions, in my estimation, to get you started:
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“Has there been a time when you can remember having boundless energy for getting things done, whereby you needed little sleep and where you’ve felt really up and high in such a way that other people commented on it and said they thought you were acting strange or different?” This question points best to a consideration of mania which characteristically is linked to an increase in goal-directed activity, marked by an inability to slow down, ease off and relax. - This second question is the “polar” opposite of the first one. “Has there been a time when you’ve felt so sad, down and withdrawn that you isolated yourself in such a way that people noticed your absence and commented on it?”
The tricky part about these first two questions is what position the client is in at the initial evaluation. If the individual presents in a manic state, this may remain prolonged, be on the cusp of running its course or the harbinger of a switch to a depressive state soon to come; vice versa if the client presents in a depressed fashion, and all but impossible to establish a bipolar diagnosis on an initial evaluation if the client presents in a state of “pseudo” normalcy. For the first appointment then, having a family member who is close to the client and who has consistent contact with him or her is critical to dissecting questions 1 and 2. Look for validation in the form of a head nod or an outright verbal “yes” or “no.”
- This third question goes directly to history, again begging the presence of a close family member to confirm, deny or shake the family tree when it comes to bipolar. “Is there anyone as far back as you can remember who has been hospitalized or treated for what turned out to be bipolar disorder or treated for ongoing odd behavior that involved marked and distinct mood swings?”
If you get affirmative responses to these questions, you’re off and running when considering a bipolar diagnosis. The next step in subsequent visits would be to set up a more structured interview for determining whether the client is predominately manic, or predominately depressed using DSM-5 criteria as a guide.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.