Table 8

Features that may help distinguish between primary bipolar and psychotic disorders and those secondary to substance use341–343 345 508

	Primary disorder	Secondary to substance use
History	Possible past history of episodes and family history of disorder and no report of substance use	Use may be acknowledged with sensitive enquiry and corroborative reports (eg, from family, friends, etc)
Clinical features	Symptoms may be similar Longitudinal course is more likely to be of episodes lasting weeks or more	Symptoms may be similar Episodes may self-limit after a few days Irritability and aggression are more common Sub-syndromal presentations are more likely than full syndromes Close temporal relationship to use Association with high dose and multiple substance use
Physical exam	Signs of increased arousal may be present (eg, increased pulse and/or blood pressure)	The following signs may be present: AAS use – acne, needle marks, female hirsutism, jaundice, gynaecomastia (men), breast atrophy (women), testicular atrophy or prostatic hypertrophy (men), clitoromegaly (women) Stimulant use – increased arousal, dilated pupils, tics Cannabinoid use – characteristic smell, conjunctival injection, drowsy, slowed responses, impaired short term memory