Table 8

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

Primary disorderSecondary to substance use
HistoryPossible past history of episodes and family history of disorder and no report of substance useUse 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 examSigns 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

  • AAS, anabolic–androgenic steroid.