What can we learn from patients about early warning signs of (hypo)mania?

To improve self-management in bipolar disorders (BD), it is essential to refine the characterisation of early warning signs (EWS) of (hypo)mania from patients' perspective. In crisis plans, patients describe EWS based on their personal experience, including signs that are primarily internally noticeable.

Investigate how patients describe EWS of (hypo)mania, by qualitative analysis of their crisis plans.

EWS and later signs of (hypo)mania from crisis plans were extracted and analysed through qualitative directed content analysis. The crisis plans were created by adult patients from a specialised outpatient clinic for BD, with support of relatives and a trained nurse as part of standard care.

Crisis plans of 383 patients, containing 6510 signs of (hypo)mania, were coded into the following ten main categories: emotions, thought process, self-reflection, thought content, cognitive functioning, physical signs, sleep, behaviour, communication process, and communication reciprocity. Patients reported a broad spectrum of EWS, including signs that do not overlap with BD classification criteria such as suspiciousness, changed sense of time, increased sensibility to stimuli and control-seeking behaviour. They also reflected on changed insight in EWS during early (hypo)mania. Internally noticeable signs were most pronounced in later phases of (hypo)mania.

Crisis plans are cocreated by patients, their relatives and mental healthcare professionals, as partly reflected by the use of medical language in the wording of the signs.

EWS of (hypo)mania constitute a broad spectrum of signs, many of which are internally noticeable and not captured by BD classification criteria.