Fit and exclusions
Start with the deciding signal, then test chronology, competing explanations, and the effect on diagnostic wording.
- Opposite-pole symptoms are observable, recurrent, and tied to the current episode.
- Activation includes features such as elevated drive, reduced need for sleep, or accelerated thought and speech.
- The pattern changes the assessment of bipolarity and antidepressant-related risk.
- The only cross-over features are irritability, distractibility, insomnia, or nonspecific agitation.
- Activation is better explained by substances, medication, trauma arousal, ADHD, or another condition.
- Map symptoms to the predominant episode
- Ask about reduced need for sleep, not insomnia alone
- Review medication and substance timing
- “I am depressed but my thoughts are racing”
- “I barely sleep and still feel driven”
- “I feel sped up and hopeless”
Treat as a cross-polar signal: reassess medication strategy, activation risk, and longitudinal bipolar history.