Commonly Reported Prodromal Symptoms of BD

Patients with bipolar disorder commonly experience subthreshold symptoms, which increase during a prodrome and are also associated with significant functional decline.7 They are summarized in Table 1.

Table 1: Commonly Reported Prodromal Symptoms of Bipolar Disorder

Subthreshold Manic Symptoms


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Subthreshold Depressive Symptoms

Other Prodromal Symptoms

· Elevated/irritable mood (>6 hours/day)

· Racing thoughts

· Rapid speech

· Increased energy

· Reckless/dangerous behavior

· Depressed mood (>6 hours/day)

· Anhedonia

· Self-harm

· Suicidal thoughts

· Mood swings

· Sleep disturbances

· Anxiety

· Functional decline

· Decreased concentration

· Social isolation

· Appetite changes

· Hearing voices

Recognizing an Incipient Prodrome

It is important to be alert to signs of incipient prodrome both before a formal diagnosis of bipolar disorder and when there is an already established diagnosis. Early personality or temperamental traits (e.g., childhood irritability or dyscontrol) may be predictors of later development of bipolar disorder,6 gradually increasing in number, frequency, and severity before the first manic episode. These should be monitored closely. Beyond the classic hypomanic symptoms described above, each individual may have his or her own unique set of idiosyncratic warning signs.8  It can be helpful for patients to create a “relapse profile” consisting of potential triggers, early warning signs, and prevention strategies.9

Staging and Screening Instruments

Although clinical screening tools have been designed to screen for full disorder, they may be potentially useful as an adjunct to clinical assessment in early-stage bipolar disorder.6 Tools include the Hypomania Checklist-32, which helps discriminate between bipolar disorder and major depressive disorder (MDD),10 the Mood Disorder Questionnaire (MDQ),11 and the Bipolar Spectrum Diagnostic Scale (BSDS).12