Both authors are affiliated with The George Washington University School of Medicine, Department of Child and Adolescent Psychiatry, Children’s National Medical Center, Washington, DC. Angelica L. Kloos, DO, is Assistant Professor of Pediatrics. Adelaide S. Robb, MD, is Associate Professor of Psychiatry and Pediatrics.
Dr. Kloos has disclosed no relevant financial relationships. Dr. Robb has disclosed the following relevant financial relationships: grant support — NICHD; Supernus, GlaxoSmithKline; Merck/Schering Plough; Johnson & Johnson; grant advisory board — Forest; advisory board and speakers’ bureau — McNeil Pediatrics; royalties — Epocrates; advisory board and speakers’ bureau — Eli Lilly; grant, advisory board, speakers’ bureau — Bristol-Myers Squibb; grant and advisory board — Otsuka America; and consultant — Lundbeck, Shinogi.
Address correspondence to: Adelaide Robb, MD, via email: firstname.lastname@example.org.
One of the most controversial diagnoses in child and adolescent psychiatry is bipolar disorder.1 Early psychiatrists such as Kraeplin recognized that bipolar disorder could occur in prepubertal children, although at low rates of 0.3% to 0.5%.2 As the psychiatric establishment from the 1920s to the 1970s embraced Anna Freud’s view of psychosocial development, practitioners believed that children did not have the ego development to show signs and symptoms of bipolar disorder, thus it was rarely diagnosed.3 In the 1970s, the advent of biological psychiatry changed treatment paradigms for adults with bipolar disorder, and psychiatrists once again began to consider the bipolar diagnosis in children and adolescents. In the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnostic criteria for bipolar disorder included information about the presentation of this affective disorder in children and adolescents, which was continued in DSM-IV-TR.4,5
Data from large epidemiologic and genetic studies showed that 20% to 40% of bipolar adults had childhood onset of symptoms, and that bipolar disorder runs in families with up to 40% to 70% being inherited.6,7 In a large epidemiologic study of youth 14 to 18 years of age, up to 1% met diagnostic criteria for bipolar disorder.8 Other studies have shown that the incidence rate of childhood bipolar disorder diagnoses has risen rapidly in the last 2 decades from 0.6% to 13% depending on definitions.1,9
The first National Institute of Mental Health (NIMH) trials on pediatric bipolar disorder were in the 1990s and 2000s; registration trials of various psychopharmacologic agents began in the early 2000s with atypical antipsychotic agents and antiepileptic mood stabilizers.10 More recently, NIMH has looked beyond epidemiology to treatment with monotherapy, comparisons of antimanic agents, family-focused psychotherapy, genetics, and neuroimaging. All these trials have been done to further understand the phenomenology, diagnosis, and treatment of pediatric bipolar disorder. However, before one can study children with this disorder in a research trial, or before one can treat a patient in the office for pediatric bipolar disorder, one has to make an accurate symptom-based diagnosis.
Presenting Signs and Symptoms
Cardinal vs. Non-Specific Symptoms
One of the ways to distinguish bipolar disorder from other more common childhood psychiatric disorders is to focus on the cardinal symptoms of bipolar disorder rather than more generic symptoms of mental illness (see Sidebar 1). In a large trial of youth with bipolar disorder and attention-deficit/ hyperactivity disorder (ADHD), Geller and colleagues examined the symptoms that differentiated bipolar disorder from ADHD.11 What the group noted is that the five primary bipolar symptoms — elation, grandiosity, flight of ideas/racing thoughts, decreased need for sleep, and hypersexuality — are mania-specific and do not overlap with ADHD. Four other symptoms are not present any more frequently in bipolar youth than in those with ADHD, including irritability, hyperactivity, accelerated speech, and distractibility.11
“A” was a 5-year-old boy brought in by his parents for evaluation of pediatric bipolar disorder with irritable and silly moods for the last 4 months. He had the worst case of terrible 2’s and 3’s ever seen by his experienced pediatrician and veteran pre-K teacher. He was admitted for safety as he had left the home at 2 a.m. because he wanted to go to an amusement park and ride the Ferris wheel. In the hospital, he tried to recreate the Sistine Chapel drawings on the ceiling of the quiet room, because he was a talented artist. Family history was significant for BPI in maternal uncle, grandfather. and great aunt. Mother had BPII, and father had MDD.School Age
“B” was an 11-year-old girl who had been treated for a depressive episode characterized by low mood, crying, weight loss, and worries she was going to die because she was a bad girl and God was angry with her. She had been treated with cognitive behavioral therapy and recovered after 6 months of treatment back to her usual self. At the start of the next school year, she began staying up late, she started giggling over everything, she was in trouble with teachers at school for talking out of turn, and she started wearing garish makeup and tube tops to school. She told the principal he was stupid and needed to be fired and thought she was ready to win a Grammy for her singing career. Family history was significant only for alcohol abuse in paternal grandfather.Adolescent
“C” was a 17-year-old boy who had been treated for an episode of major depression in the fall. He had successful resolution of his symptoms with an SSRI and tapered off the medication over winter break. He had stopped doing his homework and was failing most of his classes. Despite his bad grades, he was not worried because school was “optional” and his teachers all loved him because he was “charismatic.” Once his mother was asleep, he would sneak out, take the car and either drive to his girlfriend’s house for a liaison, go to a strip club for entertainment, or go out partying with his friends. His therapist and mother were both worried about the dramatic change in his behavior. On the unit, he told staff he was able to drive without a license, because he had played driving video games and he was certain to be a lawyer and a professional football player the day after he graduated from high school despite never playing any sports inside or outside of school. Family history was significant for major depression in mother and a completed suicide in his paternal great grandfather.
For each child whose chief complaint is mood swings, the clinician must evaluate the mood in the context of the child’s normal development and pre-existing behavior and mood (Sidebar 2, see page 482). While children commonly experience happiness, children with bipolar disorder have levels of good mood beyond the normal excitement over summer vacation or a trip to the amusement park. Children with euphoric moods can burst out laughing for no reason, and may be labile, alternating “goofy” moods with dysphoria and agitation.
Sidebar 2.Cardinal Symptoms (BPD)
Nonspecific Symptoms (BPD and ADHD)
- Flight of ideas/racing thoughts
- Decreased need for sleep
- Pressured speech
Adolescents are more likely to have euphoria and elation with paranoid and grandiose delusions and hallucinations. These must be viewed in the context of a child’s developmental and chronological age to differentiate developmentally appropriate imagination and fantasy from pathological symptoms. Since bipolar episodes in many children and adolescents are often missed early, patients tend to present for clinical help later, when they are more likely to experience delusions and hallucinations. They may also act as if they are above the law and beyond consequences, wondering why they should be in trouble for taking what they want and acting on their own desires.
Irritability and Rage
Some physicians believe that irritability and rage are the two symptoms pathognomonic for pediatric bipolar disorder. However, irritability is a nonspecific symptom similar to aggression that is seen in a variety of childhood psychiatric disorders. Other illnesses that can present with irritability symptoms include ADHD and other disruptive behavior disorders (conduct disorder, and oppositional defiant disorders), anxiety disorders, major depression, substance-use disorders, psychotic disorders, and personality disorders.12 NIMH’s internal research division further describes irritability as an essential component in severe mood dysregulation (SMD) and the newly proposed DSM-5 temper dysregulation disorder with dysphoria (TDDD). In these two disorders of temperament, irritability is a key component of the diagnostic criteria, usually combined with a sad or angry mood. When a clinician has a patient with marked irritability, before deciding upon the bipolar diagnosis, the clinician must clarify what other symptoms can be identified and focus on the presence of cardinal symptoms.13
Rages, dramatic rapid discharges of angry — sometimes violent — affect, are another symptom that leads many children to acquire the diagnosis of bipolar disorder without meeting full diagnostic criteria.14 In a study of rages, Carlson and colleagues examined the actual diagnosis of patients admitted to the hospital with a symptom of rage.14 Of 130 children admitted to an inpatient psychiatric unit, 55% had rages. Bipolar disorder was the admitting diagnosis in 35% of those with rages and 15% of those without rages. After a thorough diagnostic evaluation and consensus discussion, bipolar disorder was determined to be the diagnosis in only 9% of those with rages and 6% of those without rages. In 93% of those who had a rage in the hospital, the most common discharge diagnoses of these children were ADHD, conduct disorder, and/or oppositional defiant disorder (ODD). Among children with rages, 82% had an ADHD diagnosis at discharge compared with 9% with a bipolar diagnosis at discharge. This study shows that out-of-control behaviors are much more likely to be due to disruptive behavioral disorders, not bipolar disorder.14
Chronicity, Episodes, and Cycling
Another area of confusion in the field centers on the duration of symptoms and chronicity. While youth must have at least 1 week of symptoms to meet the key duration symptom for bipolar mania, many children in studies have a much longer duration of symptoms than a month.4,5 In the recent TEAM (Treatment of Early Age Mania) study, the average age of onset was age 5.3 years with an average duration of manic symptoms of 5 years.15 In extensive studies of several cohorts of children with bipolar disorder and ADHD, Geller and colleagues described the difference between episodes and cycles.16 Geller and colleagues define a cycle as a mood switch occurring daily or every few days during an episode. The researchers define an episode as the duration from onset to offset of a period at least 2 weeks in length, during which only one mood state exists, or duration of a period of ultrarapid or ultradian cycling. Rapid cycling5 is four or more cycles a year, ultrarapid is more than five cycles per year and ultradian is daily cycling. If a child does not have a history of discrete episodes of substantial days duration of altered mood state, the diagnosis of bipolar disorder should be in doubt.17,18
Theoretically, while a child with bipolar disorder in New Jersey should still be classified as having bipolar disorder in New Zealand, based on the similarities in diagnostic criteria, the estimated prevalence rate of bipolar disorder varies. Traditionally, the commonly presented lifetime prevalence rate in adolescence is stated to be 1%.8 However, perhaps with a trend toward broadening diagnostic considerations, the prevalence of diagnosed pediatric bipolar disorder increased nearly 40-fold from 1994 to 2003.19 Carlson and Kashani demonstrated this in their epidemiologic study of 14- to 16-year-old adolescents.20 They found the estimated lifetime prevalence of mania in this group to be 0.6% when strict criteria were applied. However, rates rose to 13% when a variety of duration and severity criteria were used. While in adults bipolar disorder may affect males and females equally, prepubertal boys tend to experience more bipolar symptoms before age 13.1
Adults with bipolar disorder often report that their initial episode was depression, with 20% to 40% of these adults reporting onset of symptoms before 18 years of age.16 Most research indicates that children with bipolar disorder will experience a chronic course with recurrent symptomatic episodes continuing into adulthood.21
Longitudinal Course of Symptoms
One of the most important issues in the diagnosis and treatment of psychiatric disorders in children and adolescents is the continuity of the disorder over the course of development. The belief is that diagnosing and treating a mood disorder early in childhood will prevent the psychiatric morbidity and mortality seen in adults with bipolar disorder. Adult-onset bipolar disorder is associated with 2.6 to 7.5 years of symptoms before being appropriately diagnosed and treated; people with juvenile-onset bipolar disorder often wait 12 to 17 years before diagnosis and treatment.6
Several longitudinal studies have followed children with pediatric bipolar disorder. One study prospectively followed a group of youth with ADHD for 6 years to determine the rate of switching to bipolar disorder.22 They found that, at 6 years, the risk rate was 29%. Risk factors that predisposed the switch included a father with recurrent major depression, no use of stimulants, and more impaired Clinical Global Assessment Scale (CGAS) at intake.
A separate study examined a 4-year course of youth with bipolar disorder.23 In this Course and Outcome of Bipolar Youth (COBY) study of 413 bipolar youth aged 7 to 17 years, the findings revealed at 2.5 years after intake, 82% had recovered, but 63% of the children and teens later relapsed. At the end of the 4-year follow-up, children originally diagnosed with bipolar disorder had experienced at least one further bipolar episode (usually one of depression).
A third study followed boys and girls with ADHD for 10 years, tracking the development of bipolar disorder in those ADHD youth; in girls approximately 7% had bipolar disorder at 10 years and in boys, the rates of bipolar disorder were just 14% at 10 years.24,25 A fourth study from the NIMH intramural program examined 84 children diagnosed with SMD and 93 children with classic “narrow criteria” bipolar disorder and followed them prospectively for up to 3 years for the rate of bipolar episodes.18 At 2 years, only one of the SMD youth had converted to bipolar spectrum disorder, while the risk for another bipolar episode was 50 times higher in the classic bipolar disorder youth. These four studies confirm that classic bipolar disorder presenting in youth is continuous with adult bipolar disorder, while those with less definitive childhood bipolar symptoms are rarely diagnosed with bipolar as adults.
Research of family, twin, and adoption studies have supported a four- to sixfold increased risk of developing bipolar disorder in first-degree relatives of affected individuals.1 A sample of 192 children in the COBY study found 38%26 had a first-degree relative with a history of mania, suggesting a strong family loading. Regarding SMD, the relationship between childhood SMD and adult bipolar disorder is not as convincing. In a pilot study comparing the diagnoses of parents of SMD and bipolar children,27 33% of parents of youth with bipolar disorder met criteria for bipolar disorder, which was similar to the COBY results. However, only 3% of parents of children with SMD met criteria for bipolar disorder, suggesting the possibility of separate diagnoses and genetic causes.9
Differentiation from Disruptive Behavior Disorders
ADHD and the other disruptive behavioral disorders are the most common pediatric psychiatry disorders that can overlap with bipolar disorder (Table, see page 484). The disruptive behavioral disorders often present with the nonspecific symptoms seen in common with BPD, including irritability, hyperactivity, distractibility, and pressured speech. In BPD, it is the affective symptoms of elation and grandiosity accompanied by neurovegetative symptoms of decreased need for sleep that help clarify the differential. In addition, ADHD has a much earlier onset, with chronic symptoms rather than the later onset and episodic symptoms seen in BPD. The ADHD child acts without thinking before landing in trouble, while the bipolar child knows the action is wrong but does not care about breaking the rules.
Table. Comparative Criteria Between BPD, ADHD, MDD, and SMD11,12,18,20
Differentiation from MDD and Anxiety
Major depression is the more common affective disorder seen in both children and teenagers occurring in up to 5% of high school students. Of youth with depression, 20% to 40% will eventually develop bipolar disorder.20 When evaluating a child with depression for the type of mood disorder, it is crucial to ask about family history of bipolar disorder and any symptoms suggestive of an underlying manic diathesis such as grandiosity, decreased need for sleep, and euphoria. Irritability can be seen in both bipolar and major depression in children and teenagers, and does not serve to clarify the diagnosis.12 In addition, some children with unipolar depression can describe mood swings alternating between feeling miserable and normal. Those with depression will have appetite changes, insomnia, loss of interest and pleasure in activities, and lack of desire to interact with friends. Depressed youth frequently have low self-esteem rather than the exaggerated sense of worth seen in manic individuals.17,20
Anxiety disorders may also have signs of agitation, hyperactivity, irritability, and poor concentration.28 However, the primary affective state is anxiety, and worry is a predominant feature. At other times very anxious youth may have “racing thoughts” that tend to be ruminative worries. They may even speak quickly, especially when worried or faced with their fears. Patients with anxiety caused by confronting their fears can rage and become aggressive.28
Differentiation from SMD
Children and adolescents with SMD experience the extreme irritability sometimes seen in bipolar disorder. However, the major difference is that SMD children and adolescents experience chronic irritability without distinct mood episodes.9 Both youth with SMD, and those experiencing a manic episode experience symptoms of hyperarousal (increased rate of speech, flight of ideas). However, the difference between the two relies on chronicity of symptoms versus distinct mood episodes. In addition, symptoms such as decreased need for sleep, increase in goal-directed activities, and grandiosity are not included in diagnostic criteria for SMD.9
Differentiation from Medical Illness
Medical illnesses can frequently overlap with signs and symptoms of bipolar disorder. Endocrine disorders (thyroid, Cushing’s, etc); neurologic disorders (seizures, migraines, strokes); autoimmune disorders (lupus, multiple sclerosis); infections (Lyme, syphilis); and other systemic disorders (porphyria) should be considered. A routine workup for bipolar disorder should include hematologic testing, chemistry, and thyroid testing. Further work-up including EEG and MRI scans should be done based on history, signs, symptoms, and the physical examination.
Differentiation from Substance Abuse and Medication-Induced Bipolar Disorder
Up to 32% of children with bipolar disorder have a comorbid substance abuse.1 In addition, the use of certain illicit substances, including hallucinogens, amphetamines, cocaine, and even marijuana, can produce symptoms of mania. Medications used at standard, FDA-approved doses in children can also induce or mimic manic symptoms and behaviors, including ketamine, steroids, beta-agonists, and prescription stimulants. Some children may have idiosyncratic reactions leading to manic symptoms while on antidepressants, some antiepileptic drugs (felbamate and levetiracetam), and other drug classes. Having a “manic-like” reaction to a medication, such as an selective serotonin reuptake inhibitor, does not mean that a child has bipolar disorder.29
The rapid rise in the diagnosis of bipolar disorder in children unfortunately has not been accompanied by adequate consistency and accuracy. Clinicians should not pin the diagnosis of bipolar disorder on a single symptom of irritability, rages, or mood swings. Astute clinicians should weigh the presenting signs and symptoms with special attention to the cardinal bipolar symptoms of elation, grandiosity, flight of ideas/racing thoughts, decreased need for sleep, and hypersexuality.11 These symptoms should be put in the context of medical history, previous psychiatric treatment, and family history to rule out other items on the differential diagnosis and arrive at an accurate, evidence-based diagnosis of bipolar disorder.19 More accurate identification of bipolar versus other diagnoses with similar presentations in children will ensure patients can receive the most appropriate treatment.
- McClellan J, Kowatch R, Findling RL, et al. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psych. 2007;46(1):107–125. doi:10.1097/01.chi.0000242240.69678.c4 [CrossRef]
- Kraepelin E. Manic Depressive Insanity and Paranoia. London: E & S Livingstone; 1921.
- Noam GG, Young CH, Jilnina J. Social cognition, psychological symptoms, and mental health: The model, evidence, and contribution of ego development. In: Cicchetti and Cohen. Developmental Psychopathology. 2nd ed. Hoboken, NJ: John Wiley and Sons; 2006: 750–794.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: 1994.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington, DC: 2000.
- Leverich GS, Post RM, Keck PE. The poor prognosis of pediatric onset bipolar disorder. J Pediatr. 2007;150:485–490. doi:10.1016/j.jpeds.2006.10.070 [CrossRef]
- Chang K, Steiner H, Ketter T. Studies of offspring of parents with bipolar disorder. Am J Med Genet C Semin Med Genet. 2003;123C(1):26–35. doi:10.1002/ajmg.c.20011 [CrossRef]
- Lewinsohn PM, Klein DN, Seeley JR. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. J Am Acad Child and Adolesc Psych. 1995; 34(4):454–463. doi:10.1097/00004583-199504000-00012 [CrossRef]
- Baroni A, Lunsford JR, Luckenbaugh DA, Towbin KE, Leibenluft E. Practitioner review: the assessment of bipolar disorder in children and adolescents. J Child Psychol Psychiatry. 2009;50(3):203–215. doi:10.1111/j.1469-7610.2008.01953.x [CrossRef]
- www.clinicaltrials.gov. Accessed Sept. 9, 2011.
- Geller B, Zimmerman B, Williams M, et al. DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls. J Child Adolesc Psychopharm. 2002;12(1):11–25. doi:10.1089/10445460252943533 [CrossRef]
- Stringaris A. Irritability in children and adolescents: a challenge for DSM-V. Eur Child Adolesc Psychiatry. 2011;20(2):61–66. doi:10.1007/s00787-010-0150-4 [CrossRef]
- Robb AS. Pharmacotherapy for Aggression in Children and Adolescents. Psychiatr Ann. 2010; 40(4):231–236. doi:10.3928/00485713-20100330-10 [CrossRef]
- Carlson GA, Potegal M, Margulies D, et al. Rages — what are they and who has them?J Child Adolesc Psychopharm. 2009;19(3):281–288. doi:10.1089/cap.2008.0108 [CrossRef]
- Robb A. NIMH psychopharmacology trials: How the results inform practice. Presented at: APA Annual Meeting. . May, 2011. ; Honolulu, HI. .
- Tillman R, Geller B. Definitions of rapid, ultrarapid, and ultradian cycling and of episode duration in pediatric and adult bipolar disorders: A proposal to distinguish episodes from cycles. J Child Adolesc Psychopharm. 2003;13(3):267–271. doi:10.1089/104454603322572598 [CrossRef]
- McClellan J, Werry J. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child and Adolesc Psych. 1997;36(supp):157S–176S. doi:10.1097/00004583-199710001-00010 [CrossRef]
- Stringaris A, Baroni A, Haimm C, et al. Pediatric bipolar disorder versus severe mood dysregulation: Risk for manic episodes on follow-up. J Am Acad Child Adolesc Psychiatry. 2010; 49(4):397–405.
- Moreno C, Laje G, Blanco C, et al. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64(9):1032–1039. doi:10.1001/archpsyc.64.9.1032 [CrossRef]
- Carlson GA, Kashani JH. Phenomenology of major depression from childhood through adulthood: Analysis of three studies. Am J Psych. 1988;145(10):1222–1225.
- Luby JL, Navasaria N. Pediatric bipolar disorder: Evidence for prodromal states and early markers. J Child Psychology and Psychiatry. 2010; 51(4): 459–471. doi:10.1111/j.1469-7610.2010.02210.x [CrossRef]
- Tillman R, Geller B. Controlled study of switching from attention-deficit /hyperactivity disorder to a prepubertal and early adolescent bipolar I disorder phenotype during 6-year prospective follow-up: Rate, risk, and predictors. Development and Psychopathology. 2006; 18(4):1037–1053. doi:10.1017/S0954579406060512 [CrossRef]
- Birmaher B, Axelson D, Goldstein B, et al. Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: The course and outcome of Bipolar Youth (COBY) study. Am J Psych. 2009; 166(7):795–804. doi:10.1176/appi.ajp.2009.08101569 [CrossRef]
- Biederman J, Petty CR, Monuteaux MC, et al. Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. Am J Psychiatry. 2010;167(4):409–417. doi:10.1176/appi.ajp.2009.09050736 [CrossRef]
- Biederman J, Petty CR, et al. How persistent is ADHD? A controlled 10-year follow-up study of boys with ADHD. Psychiatry Research. 2010;177(3):299–304. doi:10.1016/j.psychres.2009.12.010 [CrossRef]
- Rende R, Birmaher B, Axelson D, et al. Childhood-onset bipolar disorder: Evidence for increased familial loading of psychiatric illness. J Am Acad Child Adolesc Psych. 2007;46(2):197–204. doi:10.1097/01.chi.0000246069.85577.9e [CrossRef]
- Brotman MA, Kassem K, Resiing MM, et al. Parental diagnoses of youth with narrow phenotype bipolar disorder or severe mood dysregulation. Am J Psych. 2007;164(8):1238–1241. doi:10.1176/appi.ajp.2007.06101619 [CrossRef]
- Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin N Am. 2009; 32(3):483–52. doi:10.1016/j.psc.2009.06.002 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Available at: www.dsm-5.org. Accessed Sept. 20, 2011.
Comparative Criteria Between BPD, ADHD, MDD, and SMD11,12,18,20
|Duration||At least 1 week.||Years.||At least 2 weeks.||Months to years.|
|Onset||Any age, rare< 10 years old.||< 7 years old.||Any age, rare< 10 years old.||< 12 years old.|
|Sleep||Decreased need for sleep.||Trouble initiating sleep, then OK.||Insomnia, initial and terminal, middle less common.||Insomnia.|
|Fatigue in morning||None, ready to go.||May be a little tired in beginning.||Exhausted, even with full night sleep.||May be if sleep is impaired.|
|Energy||Boundless; rarely sits or becomes fatigued.||Hyper, but says has regular energy.||Usually tired/exhausted but may have psychomotor agitation.||Psychomotor agitation may be present.|
|Appetite/weight||May be increased or decreased.||Normal may decrease with stimulants.||Usually loss of appetite but may increase.||No characteristic change in weight.|
|Interest/pleasure||Lots of interest and pleasure.||Flits from activity to activity, but rarely finishes anything.||Not interested in most activities, usually just TV and video games.||Can be easily distracted in activities and is often not satisfied.|
|Sex drive||Increased.||No change.||Decreased.||No change.|
|Friendships||Increased to the point of being overly familiar.||No change but peers may avoid due to unpredictable behavior.||Loss of friendships, turns down activities when friends call.||Often has difficulties making and keeping friends due to displayed irritability and emotional reactivity.|
|Speech pattern||Rapid at times, hard to interrupt.||Talks too much out of turn but not rapid or pressured.||Slow, with increased latency.||Pressured speech and intrusiveness may be present.|
|Racing thoughts/flight of ideas||Frequent.||Distracted easily but no racing thoughts.||Thoughts tend to be slow, but may have ruminations with repetitive thoughts and worries.||Often present as sign of hyperarousal.|
|Appearance||Outlandish overdone in makeup and dress; others may ignore hygiene.||Normal, may be messy.||Poor hygiene, may wear dirty clothing and be disheveled.||No significant change in appearance.|
|Concentration and memory||Poor; dashes through homework, or thinks homework is stupid and does not need to do it.||Poor; dashes through homework.||Poor; may take longer to finish work.||Can be easily distracted.|
|Family history||38% BPI disorder.23||10% to 35% ADHD.||15% to 45% MDD.28||2.7% BP.9|