Patients reveal early signs that the DSM criteria miss
STUDY: Beekman RAL et al, J Affect Disord 2026
STUDY TYPE: Qualitative study
FUNDING: Independent
Background
Detecting mania early depends on knowing each patient’s warning signs. DSM criteria and mania rating scales came from what clinicians observe, and this study looks at what patients feel first.
The Study
- 383 adults with bipolar disorder (77% bipolar I) at a Dutch specialty clinic.
- Each had written a crisis plan with relatives and a psychiatric nurse, listing signs from early to very severe mania.
- Psychiatrists sorted the 6,510 signs into categories.
Results
Changes in behavior were the most common early signs (seen in 22%):
- Working longer hours
- Starting projects
- Spending
- Singing or dancing.
Many of early signs fell outside the DSM criteria:
- Anxiety, with shaking, stomach tension, or diarrhea
- Suspiciousness
- Taking song lyrics personally
- Distorted sense of time
- Heightened sensitivity to colors and sounds
- Cleaning and making lists to stay in control
- Forgetfulness and trouble organizing the day
Some signs ran opposite to the textbook, such as slowed thinking, fatigue, and social withdrawal.
Many of the signs were interior changes, only observable to the patient (39-46%), but insight limited detection. Most patients said they didn’t notice the early changes when they were happening.
Practice Implications
- Early mania is personal, and some signs look like anxiety or depression.
- Learn more: Jim Phelps and I collected 126 unique symptoms of mania in Bipolar, Not So Much (print or audio).
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
