Getting a clinical history is an important part of the bipolar diagnosis in children and adolescents.

No laboratory study can be used to confirm the diagnosis of bipolar disorder. Therefore, gathering the history of present and past disturbances of mood, behavior, and thought is critical to properly diagnose a psychiatric condition such as bipolar disorder. Unlike other areas of medicine, in which the clinician often relies on laboratory or imaging studies to identify or characterize a disorder, mental health professionals rely almost exclusively on descriptive symptom clusters to diagnose mental disorders. As a consequence, the history is an essential part of the patient examination.

• The appropriate first step in evaluating a person for a psychiatric disorder is to ensure that no other medical condition is causing the mood or thought disturbance. Thus, the evaluation of the patient is best started by obtaining their oral history of current and past medical and behavioral symptoms and treatments. To further clarify the problem, gathering additional information from family and friends always is urged for a person experiencing an altered mood or behavioral state.
• After interviewing the patient, performing a physical examination, and gathering more information from family, friends, and perhaps other physicians to whom the patient is known, the problem may be classified as being primarily caused by a physical health problem or by a mental health problem.
  • While obtaining the history, the physician must explore the possibilities that substance abuse or dependence, trauma to the brain in the present or past, and/or seizure disorders may be contributing to or causing the current symptoms of illness.
  • Similarly, central nervous system (CNS) insults, such as encephalopathy or medication-induced mood changes (ie, steroid-induced mania), must be considered. Delirium is one of the most important medical conditions to exclude early in persons presenting with altered mental states or acute disturbances of mood and conduct.
  • Perhaps more relevant to youth is the evaluation of substance abuse patterns because acute drug intoxication states may mimic bipolar disorder.
• If the physical examination does not reveal a medical condition contributing to the patient's mental state, a thorough mental health evaluation is appropriate. Through observation and interviewing, mental health professionals may learn of mood, behavioral, cognitive, or judgment and reasoning abnormalities.
• The mental status examination (MSE) is the essential component of a mental health evaluation. This examination goes beyond the mini-mental status examination (eg, Folstein Mini-Mental State Examination to screen for dementia) often used in emergency departments. Rather, the MSE assesses general appearance and demeanor, speech, movement, and interpersonal relatedness of the patient with the examiner and others.
  • Mood and cognitive abilities (eg, orientation to circumstance; attentiveness; immediate-, short-, and long-term modes of memory) are assessed in the MSE.
  • Some of the most important components of the MSE are those addressing issues of safety of individuals and members of a community. Thus, suicidal and homicidal issues are explored.
  • Similarly, screens for the more subtle forms of psychosis, such as paranoid or delusional states, in addition to screens for overt psychosis, such as observing the patient responding to unseen others or other non-reality-based internal stimuli, are explored.
  • Lastly, insight into the patient's mental and physical states, the current circumstances of medical or mental health care, and the patient's ability to use age-appropriate judgments are assessed and integrated into the evaluation of the global mental state of the patient at that moment.
• Because bipolar disorder may cause a transient but marked impairment of judgment, insight, and recall, multiple sources of information are crucial to understand a particular patient. Thus, other family members, friends, teachers, caregivers, or other physicians or mental health care workers may be interviewed to clarify the full clinical picture.
• Nonetheless, the patient's subjective experience is essential in the evaluation and treatment processes, and the establishment of a therapeutic alliance and trust early in the assessment is vital to obtaining an accurate and useful history from the patient.
• Knowledge of the family's psychiatric history is another essential part of the patient's history because bipolar disorder has genetic transmission and familial patterns. A genogram may be developed to further describe a particular patient's risk of bipolar disorder based on familial and genetic attributes within the family system.

Physical:

• The physical examination must include a general neurologic examination, including examination of cranial nerves, muscular bulk, and tone and deep tendon reflexes.
• Cardiovascular, pulmonary, and abdominal examinations are also essential because abnormal pulmonary functioning or poor vascular perfusion of the brain may cause abnormal mood, behavior, or cognition.
• If these examinations do not reveal a medical condition contributory to the current mental state, a mental health evaluation should be sought