56 Psychiatric Clinical Skills
exploring a patient’s interest in activities in her world, you
Key Point:
You will need to remain flexible in your interviewing style
when trying to establish the history of presenting illness with
an acutely manic patient.
Before trying to elicit lists of symptoms, try to explore
what the patient has been experiencing in the recent past.
Once you do start to obtain specific symptoms, for exam-
ple, depressive symptoms in Case Example 2, you need to
place these symptoms in the individual context of the per-
son’s life. It may help to imagine you are constructing a nar-
rative of her recent circumstances. If you try to do this, you
will gain the richness of detail and the context in which to
place her mood symptoms. Remember that each person’s
symptoms, despite her characteristic patterns and clusters,
manifest in a uniquely individual and interesting way,
according to the person’s individual life circumstances.
Focus on the story, instead of simply obtaining a symptom
or diagnostic criteria list.
Key Point:
Try to create a narrative of the person’s history of presenting
illness. Remain flexible and contextualize the symptoms to
the individual.
Eliciting Mood Symptoms
Once you have elicited the patient’s story of the recent
period of “unwellness” or “feeling markedly different
than usual” (this value-free description may be more
palatable to a euphoric manic patient), and you under-
stand the context for these difficulties, you need to flesh
out the specific mood symptoms the patient has experi-
enced recently.
Inquiring About Depressive Symptoms
In Case Example 2, Laura describes her mood recently
as “bleak and flat.” Try to elicit the patient’s recent mood
state by capturing her experience in her own words. Try to
avoid asking leading questions, such as, “Have you been
feeling depressed recently?” If the patient is having diffi-
culty with the more open-ended questions, then you can
provide options such as sad, depressed, or calm.
Remember that patients may not describe their mood as
“depressed” but may indeed be depressed.
In Case Example 2, you inquire further and find out that
Laura enjoys very little in her day, including her time spent
with her children, which before she started feeling
depressed would have given her much pleasure. When
need to understand her “outside world”; don’t ask a ques-
tion about interest in daily activities without understanding
the person at baseline. Appropriate open-ended questions
may be: “What do you usually enjoy doing? What do you
do for fun in your week? What activities do you look for-
ward to?” In Case Example 2, for example, Laura can tell
you that normally she loves to be with her young children,
and now that has significantly changed.
Key Point:
When exploring a patient’s interest in daily activities, you
need to understand her “outside world”; that is, don’t ask a
question about her interest in daily activities without
understanding her at baseline. Only then can you interpret
whether her mood is affecting her baseline level of
functioning.
In depressed states sleep is often disturbed, and it is also
important to explore in detail how sleep is affected. We ask
the patient, “How many hours do you sleep each night? Do
you have difficulty falling asleep, staying asleep, or waking
up in the morning? Is your sleep restful, or has it changed
in quality?” In depressive episodes, increased need for
sleep is a characteristic of a depression with atypical fea-
tures and is more common in bipolar illness. This detailed
qualifying and quantifying of sleep disturbance has impli-
cations for treatment because different medications are
shown to be more effective in patients with atypical depres-
sion. In addition, a depressed patient with melancholic
features will often endorse early morning awakening, and
this, too, will help characterize the nature of the patient’s
depressive symptoms.
Always establish whether there has been a significant
change in a person’s appetite in either direction. A patient
may endorse eating three good meals each day but describe
a lack of enjoyment while eating, with little interest in food.
You should also remember to inquire about fluctuations in
body weight.
In Case Example 2, Laura endorses significant cognitive
changes, including difficulty concentrating, feeling con-
fused, ruminating about her life with an inability to focus
on her children’s needs, and feeling inadequate and useless
each day. Overall, she feels slowed down both mentally and
physically and constantly feels guilty for her “inadequacy”
as a wife and mother.
Inquiring About Manic/Hypomanic Symptoms
Manic or hypomanic symptoms fall into three major
groups: (1) mood, (2) behavior changes, and (3) cognition
and perception.
 Assessment of Patients with Bipolar Disorder
Mood
Here, one should inquire in an open-ended manner
about how the patient is feeling during the assessment; that
is, “How would you describe your mood today and over the
past few weeks?” Try to limit the patient to how he has
been feeling recently, in order to ascertain his current
mood status. Patients will not usually volunteer that they
feel “manic” or “hypomanic” because these are technical
terms. In fact, these terms should be avoided during the
assessment because they can be misleading. It is important
to elicit the patient’s subjective feeling of elevated mood
without leading the patient in a directive manner. For
example, in Case Example 1, if one had asked Jack a few
weeks before his presentation in the emergency depart-
ment about how he was feeling and how he would describe
his mood, he may have spontaneously described a feeling of
“self-confidence” or “euphoria,” “feeling exalted” or “the
best I’ve ever felt.” These descriptions would give you an
individualized sense that his mood is elevated. Interviewers
often equate elevated mood with mania or hypomania, but
one must remember that one needs to demonstrate addi-
tional disturbance of behavior and cognition/perception to
be considered manic/hypomanic. During the interview
with Jack in the emergency department, he may describe
his mood as “great,” but you would observe his striking irri-
tability in his interactions with you during the interview. It
is important to be attuned to the underlying irritability,
which is common in manic patients. The mood elevation
that is expressed is often fluctuating and volatile. If one
persists in interviewing a manic patient for more than a few
minutes, it is likely that the irritability, anger, and fear will
be revealed. Patients who are manic will often demonstrate
extreme lability of mood, with rapid shifts from unre-
strained euphoria to weeping and irritability.
Behavior
A decreased need for sleep is a hallmark feature of mania
and can often help distinguish manic or hypomanic symp-
toms from “simply having a good time.” In addition, a
“decreased need for sleep” is probably the most useful and
reliable criterion for mania. You have to persist with ques-
tions about sleep and not accept a quantification of
“enough.” Sometimes manic patients will either overesti-
mate their sleep or provide a socially desirable normative
response like, “Oh, about 6 or 7 hours.” You should then
ask, “What’s the least amount of sleep you’ve gotten away
with in the last 2 weeks? How have you felt the next day?
Have you had any nights where you haven’t slept at all?”
This may help unmask previously covert manic sleepless-
ness and elevated energy. In Case Example 1, Jack had
been sleeping 2 to 3 hours each night over a period of more
than a week. This lack of sleep, in conjunction with his
behavioral agitation, increased energy, and other symp-
57
toms of mania, helps establish a diagnosis of an acute manic
episode. Patients often endorse feeling “really happy, and
more outgoing and confident” for a period of days to weeks.
It is important to establish whether there was sleep distur-
bance as well as the other symptoms of mania/hypomania
concurrently, as this will help distinguish mania from a nor-
mal elevation in mood state. There is a low sensitivity for
eliciting previous hypomanic episodes from the patient,
and, subsequently, they are often missed in clinical inter-
views.
Patients with mania are very often impulsive and disin-
hibited in their behavior. The challenge is to elicit the
information from the patient in a way that does not seem
artificial or judgmental. An opening question to avoid
using would be: “Have you noticed that you are more
impulsive or behaving differently than usual?” Manic
patients have little insight into the recent change in their
behavior, and it is often through interviews of family and
friends that the full extent of behavioral change becomes
clear. In Case Example 1, Jack was brought into the emer-
gency department by police who observed his behavioral
disinhibition. He reportedly tried to destroy a public mon-
ument. It would be important to explore with Jack the rea-
sons for this act and to try and understand whether there
was an impulsive aspect to this behavior. Increased impul-
sivity is a hallmark feature of behavioral change in manic
patients. Collateral information is often vital in determining
the severity of recent bizarre and inappropriate behaviors.
In Case Example 1, Jack is accompanied by his mother,
who may be able to provide vital information regarding his
potential to endanger himself or others. Jack’s mother
adds that he was recently found running down the street
naked and that he had left a lit cigarette on the table and
had almost caused a fire. In addition, when the police
found him attacking the public monument, he resisted
their help and began to engage in a physical fight with
three policemen. These accounts of aggressive, disinhib-
ited, and socially inappropriate behaviors provide one with
essential information about the patient’s safety and
the risk of the patient harming himself or other people
around him.
In addition to the obviously bizarre and uncontrolled
behavioral change in manic patients, patients with hypoma-
nia or emerging behavioral change may present with
smaller and subtler changes in behavior. It is important to
try to understand the baseline or normal functioning of the
patient. For example, someone who would normally be
considered a cautious person may demonstrate initial
changes in behavior that are subtle and small, for example,
attending late parties or deciding to take a vacation without
any planning. These small changes in behavior often pre-
cede more obvious, dramatic, and bizarre behavioral dis-
turbances.
58 Psychiatric Clinical Skills
Mania is often accompanied by reported increased
spending. As one patient described in an interview, “When I
am high, I couldn’t worry about money if I tried. So I don’t.
The money will come from somewhere; I am entitled and
God will provide.” In Case Example 3, Victoria regrets hav-
ing charged $2000 to her credit card in the past week.
Patients often describe the need to spend money as so
great and overpowering, that the purchases occur with a
great sense of urgency and importance, as if “nothing can stop
it happening.” One patient reported spending thousands of
dollars on costume jewelry, unnecessary furniture, and four
identical sweaters in a half-hour time period. She reported
feeling out of control during this time. The patient’s subjec-
tive feeling while spending the money is important, as the
objective amount in dollars can be misleading.
Behavioral changes in manic patients often occur around
changes in sexual behavior and attitude. Manic patients
may first report an increased feeling of self-confidence,
feeling less shy, finding that the right words and gestures
seem obvious and the power to captivate others is felt to be
certain. One patient reported that her sense of sensuality
was pervasive, and the desire to seduce and be seduced was
irresistible. Often an acutely manic patient’s overt behavior
during the assessment can be sexually provocative, provid-
ing one with objective evidence of heightened sexuality.
However, patients may not volunteer the information, and
it is important to ask about feelings of sexuality and sexual
interest during an initial assessment. This can be done in a
contextualized, natural manner when inquiring about
recent relationships, whether the patient has a partner/
spouse. In addition, collateral information from the
patient’s partner often provides one with this information.
Cognition/Perception
Patients in a milder hypomanic state often describe
increased creativity, a profusion of ideas, and an ease and
flow of their ideas, which facilitates artistic expression.
Many artists who have experienced mania, including Robert
Schumann and Virginia Woolf, described this heightened
creativity and productivity while their thought form was still
intact.4 However, the surplus of thoughts and ideas
increases as mania progresses, and as the interviewer you
should be observing keenly when the person’s conversation
jumps from one topic to another. In a patient with disorder
of thought form, incoherence predominates; patients will
describe their thoughts as racing at great speed, as well as
thoughts feeling disjointed and feeling overall very dis-
tractible. In addition, you should listen to the quality, speed,
volume, and intensity of their speech because in mania,
speech is often louder and more pressured, rapid, and
urgent than normal. In an interview with a manic patient
with thought disturbance, it is often difficult to direct the
questions or to feel like you have any control over the inter-
view. It is best to perform an active mental status examina-
tion, noting the patient’s disordered cognition, and if possi-
ble, remembering specific examples of the patient’s thought
process, with rapid shifts of topic and “flight of ideas” that
are pathognomonic for mania. The interviewer’s questions
should be kept closed ended, simple, and clear, so as to
allow the disorganized patient to focus on a finite answer.
Finally, in the case of the patient with mania and psychosis,
thoughts and perceptions become fragmented and
ultimately often psychotic and separated from reality. In
Case Example 1, Jack believes that he “controls the entire
city.” This is a grandiose delusion that is a common delusion
endorsed by manic patients. The way to uncover such a
belief is not easily done through formulaic questions, for
example, “Do you have any special powers?” Rather, by
allowing the patient to describe his recent activities and
behavior, you will be able to explore with the patient his
underlying belief and understand more accurately how he
views the world. For example, in Case Example 1, by
exploring the recent event where Jack was found to be dam-
aging state property, one could uncover that indeed Jack
believed that he was leader of the city and that he had the
authority to do this, as well as to govern the people of the
city. Patients with mania and grandiose delusions often
describe an inner compulsion to act (often in a dangerous
manner) as a means of contributing to society. They often
describe a great moral imperative that involves finding
faults in society that they believe need to be corrected.
Perceptual abnormalities experienced in patients with
mania are often described by the person as beginning with
a mildly increased awareness of objects that ultimately
leads to a chaotic disarray of the senses. Patients describe
visual, auditory, tactile, and olfactory experiences that are all
heightened, with “every external detail of the world becom-
ing more etched in consciousness.” In your discussion with
manic patients, you should ask them about altered experi-
ences involving the senses. Patients often describe an over-
all heightened sensory awareness, colors appearing
brighter, words sounding like music, and the feeling that the
different senses of vision, hearing, taste, and feeling are
merging to form one combined experience. Furthermore,
one can inquire about any religious experiences the manic
patient may have had, as mania often involves mystical and
pronounced religious experiences.
COMPONENTS OF THE ASSESSMENT
(HPI AND PAST PSYCHIATRIC HISTORY) KEY
TO INTERVIEWING PATIENTS WITH
BIPOLAR DISORDER
It is important to consider the course of illness, family his-
tory, and treatment response in addition to phenomenology