Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Early-onset psychosis and bipolar disorder
Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Behavioural crisis may conceal immediate medical or psychiatric danger
Command hallucinations, suicidal or violent intent, severe agitation, catatonia, rapidly fluctuating consciousness, delirium, intoxication, neurological signs or an inability to eat, drink or maintain basic safety requires urgent assessment rather than a routine diagnostic pathway.
Action: Secure a low-stimulation safe setting, assess ABCDE and glucose, obtain urgent senior paediatric, emergency and mental-health input, treat suspected intoxication or medical illness, and use the least restrictive lawful response. Do not leave the young person or family to manage an immediate risk while awaiting outpatient CAMHS or early-intervention review.
Overview
Recognise possible psychosis and episodic mania in children and adolescents, exclude medical and substance-related causes, secure timely specialist assessment, and deliver developmentally appropriate family-inclusive treatment with safe physical monitoring.
Psychosis describes impaired reality testing rather than a single diagnosis. Ask the young person to describe what happened in their own words: whether a voice seems internal or external, occurs while falling asleep, gives commands, can be resisted, and changes behaviour; how fixed an unusual belief is; and whether speech, self-care, education or relationships have changed. Children may use imaginative language, while autistic communication, intrusive thoughts, dissociation, bereavement and trauma re-experiencing can be misread as psychosis. Seek collateral history without treating carers as automatically more accurate.
Establish the timeline. Abrupt onset over hours or days, fluctuation, fever, seizure, head injury, new medicine or substance exposure shifts priority towards urgent medical causes. A more gradual prodrome may include withdrawal, falling attainment, sleep reversal, suspiciousness and reduced self-care, but these features remain non-specific. Examine mental state, cognition, hydration and neurology, assess suicide, violence, vulnerability and safeguarding, and ask directly about cannabis, stimulants, hallucinogens, steroids, prescribed medicines and over-the-counter products in a private, non-punitive manner.
Practice
Two practice questions
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Question 1 of 2
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PsychiatryOriginal SBA
Attenuated psychotic symptoms
A 15-year-old reports occasional indistinct whispers and increasing suspiciousness for two weeks, remains partly doubtful about them, and has no acute medical red flags. What is the best next step?
Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE separates possible from sustained psychosis. Transient or attenuated experiences still need referral without delay to a specialist CAMHS or early-intervention service because formulation and follow-up require expertise. If clear psychotic symptoms have continued for four weeks or longer, make an urgent referral. An early-intervention team that accepts the young person's age can provide the pathway; otherwise CAMHS should retain responsibility. Referral should not be delayed while every physical test is completed, although acute medical red flags demand parallel hospital assessment.
For attenuated symptoms, monitor change and function and offer evidence-based treatment for any established anxiety, depression, substance misuse or emerging emotional difficulty. NICE specifically advises against antipsychotic medication for symptoms below the diagnostic threshold or solely to prevent psychosis. This protects young people from metabolic, endocrine, neurological and subjective adverse effects without proven preventive benefit. Explain uncertainty honestly, give a route for rapid reassessment, and avoid labels that make ordinary developmental experiences appear inevitably progressive.
A first episode requires a comprehensive multidisciplinary assessment spanning psychiatric symptoms, physical health, prescribed and non-prescribed drugs, developmental and educational history, trauma, relationships, accommodation, culture, communication and caring responsibilities. NICE recommends oral antipsychotic medication alongside family intervention and individual CBT. Choice is collaborative with the young person and parents or carers where appropriate, comparing expected symptom benefit with weight, metabolic, prolactin, cardiovascular, movement and sedation effects rather than assuming a class effect.
Record baseline physical and neurological measures before starting an antipsychotic wherever the emergency permits: height and weight on age-adjusted charts, waist and hip circumferences, pulse, blood pressure, fasting glucose or HbA1c, lipid profile, prolactin, movement disorder assessment, nutrition, activity and relevant sexual or pubertal effects. An ECG is indicated when the product information requires it, cardiovascular examination or history is concerning, there is a family history of sudden cardiac death or prolonged QT, or the young person is being admitted as an inpatient. Monitor closely during titration and record why benefit outweighs harm.
Bipolar disorder is episodic. In younger patients, chronic irritability, emotional dysregulation, ADHD, autism, trauma and sleep deprivation are much more common explanations than mania. NICE advises that suspected bipolar disorder in those under fourteen is referred to specialist CAMHS, while those aged fourteen or over should be referred to a specialist CAMHS team or age-appropriate early-intervention service with bipolar expertise. Diagnosis should follow intensive prospective longitudinal monitoring by a clinician trained in bipolar disorder in children and young people.
For a diagnosis of mania in young people, NICE requires euphoria on most days and for most of the day for at least seven days, with corresponding episodic change and other manic features. Irritability is not itself a core criterion, although it can accompany mania. Do not diagnose bipolar disorder solely because a depressed young person has a family history; follow the child or adolescent over time and treat the current depression according to the relevant pathway. Always examine sleep need, energy, speech, activity, grandiosity, judgement and episodicity separately from situational distress.
Treatment of established bipolar mania is specialist. NICE identifies aripiprazole as an option for moderate to severe manic episodes in those aged thirteen and over, within the specialist pathway and after the relevant technology-appraisal discussion; this is not a justification for unsupervised primary-care initiation. Psychological, family, educational and relapse work remains essential. Review the continuing need for acute antipsychotic treatment, because NICE advises not routinely continuing it for longer than twelve weeks in children and young people unless a specialist review supports the plan.
Recovery planning should address meaning and function, not only positive symptoms. Agree early warning signs, sleep protection, substance reduction, school adjustments, family communication, physical-health goals and who to contact. Discuss confidentiality while inviting family involvement, offer developmentally appropriate written information, and prepare transitions before service age boundaries. Reassess diagnosis when the course, treatment response or neurological picture does not fit; uncertainty is safer than prematurely fixing a lifelong label.
Key points
Possible psychosis includes hallucinations, delusional ideas, thought interference, disorganisation or functional decline, but developmental imagination, trauma phenomena, sleep transitions, substances and neurological illness can resemble it.
NICE advises referral without delay to CAMHS or an early-intervention service when a child or young person has transient or attenuated psychotic symptoms or other experiences suggestive of possible psychosis.
Sustained psychotic symptoms lasting four weeks or more warrant urgent specialist referral; do not wait for further deterioration or a complete primary-care diagnostic work-up.
Do not offer an antipsychotic merely for attenuated symptoms or to reduce future psychosis risk; offer indicated treatment for anxiety, depression, substance misuse or emerging personality difficulties while specialists monitor change.
For first-episode psychosis, NICE recommends oral antipsychotic medication together with family intervention and individual CBT, chosen collaboratively after discussing likely benefits and adverse effects.
Before antipsychotic treatment, record weight, height, waist and hip circumferences, pulse, blood pressure, fasting glucose or HbA1c, lipids, prolactin, movement findings, nutrition and activity; obtain ECG when NICE indications apply.
Aetiology
01
Neurodevelopmental vulnerability
Heritable and developmental differences interact with maturation, stress and environment to increase risk without determining an inevitable illness course.
02
Affective susceptibility
Familial and individual mood vulnerability can produce episodic mania or depression, but family history alone never establishes a diagnosis.
03
Substance and medicine exposure
Cannabis, stimulants, hallucinogens, steroids and some prescribed medicines can precipitate, amplify or imitate psychotic and manic syndromes.
04
Trauma and social adversity
Abuse, discrimination, isolation, sleep disruption and severe stress may shape unusual experiences, distress, mistrust and routes into care.
Pathophysiology
1
Salience and reality testing
Altered assignment of significance to perceptions and thoughts can make coincidences, internal speech or ambiguous cues feel externally meaningful.
2
Network developmental change
Maturing cognitive, emotional and social brain networks influence symptom form, insight and the age at which syndromes become recognisable.
3
Mood activation cycle
Reduced sleep need, reward sensitivity and escalating goal-directed activity can reinforce arousal, judgement impairment and manic behavioural risk.
4
Stress and sleep interaction
Stress physiology, circadian disruption and sleep loss can worsen perceptual anomalies, emotional regulation and vulnerability to relapse.
Clinical features and red flags
Positive psychotic experience
Hallucinations, delusional conviction or passivity experiences become clinically significant through persistence, distress, impaired reality testing and behavioural consequence.
Disorganisation and decline
Incoherent communication, markedly disorganised behaviour, lost self-care or falling educational and social function can accompany an emerging psychotic disorder.
Possible psychosis state
Transient or attenuated experiences remain diagnostically uncertain but justify specialist assessment without delay and an explicit deterioration plan.
Episodic mania
A distinct period of elevated or euphoric mood, reduced need for sleep, increased activity, pressured speech, grandiosity and risky behaviour suggests mania.
Organic warning pattern
Fluctuation, cognitive change, fever, seizure, focal signs, abnormal movements or autonomic disturbance argues against assuming a primary psychiatric illness.
Red flags requiring action
New confusion, fluctuating attention, fever, seizure, focal neurology, severe headache, movement disorder, autonomic instability or abrupt cognitive decline suggests an organic syndrome requiring urgent medical investigation.
Command experiences, persecutory beliefs linked to action, weapons access, suicidal intent, severe self-neglect, dehydration, food refusal or inability to protect a dependent child requires same-day safety planning and escalation.
Investigations
01Developmental psychiatric interviewFirst step
Why
Define phenomenology, conviction, context, duration, mood linkage, functional change and the young person's explanation.
Interpretation and limitations
A symptom word is not a diagnosis; developmental stage, culture, sleep and trauma alter its meaning.
02Collateral and longitudinal record
Why
Compare baseline development, school function, sleep, behaviour and episodes across family, education and health sources.
Interpretation and limitations
Consistent episodic change supports formulation, while disagreement identifies context or uncertainty rather than proving deception.
03Physical and neurological assessment
Why
Identify delirium, intoxication, seizure, infection, endocrine disease, head injury or abnormal movement needing medical care.
Interpretation and limitations
Target blood, urine, imaging, EEG or specialist tests to the history and examination instead of ordering an indiscriminate panel.
04Substance and medicine assessment
Why
Establish cannabis, stimulant, hallucinogen, steroid, prescribed and non-prescribed exposure with timing and consent-aware testing.
Interpretation and limitations
A positive result may contribute without explaining the whole syndrome; a negative test has substance and timing limits.
Differential diagnosis
01
Developmental and neurodivergent experience
Imaginative play, autistic language, sensory phenomena and ADHD dysregulation may look unusual without representing impaired reality testing.
02
Trauma and dissociation
Flashbacks, internal voices, depersonalisation and threat-based interpretations can resemble psychosis and may sometimes coexist with it.
03
Substance or medicine effect
Timing of cannabis, stimulant, hallucinogen, steroid or prescribed-drug exposure may explain acute psychosis, agitation or mood elevation.
04
Delirium or neurological disease
Encephalitis, epilepsy, infection, endocrine disorder, head injury and metabolic illness require urgent consideration when physical signs appear.
05
Unipolar or chronic dysregulation
Depression, anxiety, ADHD and persistent irritability lack the distinct sustained euphoric episodes required for paediatric mania.
Additional chapter-specific clues
Trauma or developmental mimic
Intrusions, dissociation, imaginative play, sensory phenomena, literal language and obsessive thoughts require careful phenomenology before they are called psychosis.
Management
01Possible psychosisRefer without delay and preserve uncertaintyFirst stepTransient, attenuated or otherwise suggestive psychotic experiences occur without an immediate medical emergency.+
2Refer without delay to specialist CAMHS or an age-appropriate early-intervention service and provide a named urgent-return route.
3Treat established coexisting anxiety, depression or substance misuse, but do not use antipsychotic medication simply to prevent psychosis.
02First episodeCombine specialist biological and psychological careSustained psychotic symptoms or a specialist-confirmed first episode requires active treatment.+
1Complete comprehensive multidisciplinary and physical assessment, involving family while respecting the young person's confidentiality and preferences.
Complications
01
Suicide and accidental harm
Despair, command experiences, impaired judgement, impulsivity and grandiose risk-taking can create immediate fatal danger during either syndrome.
02
Developmental disruption
Untreated illness can interrupt education, relationships, identity formation, physical health and the acquisition of independent living skills.
03
Treatment-related physical harm
Antipsychotics may cause weight, metabolic, prolactin, cardiovascular, sedation and movement effects that are especially consequential during growth.
04
Stigma and diagnostic foreclosure
Premature labels can narrow expectations, obscure trauma or neurodevelopment and deter young people from seeking future help.
05
Family and service rupture
Crisis, secrecy, conflicting explanations and poorly planned age transitions can fracture support and increase relapse or disengagement.
Monitoring and follow-up
Track psychotic and mood symptoms alongside sleep, self-care, education, relationships and the young person's own recovery priorities.
Ask directly and repeatedly about suicide, command experiences, violence, exploitation, substance exposure and ability to eat, drink and remain safe.
During antipsychotic treatment, record weight weekly for the first six weeks and again at twelve weeks, then continue age-adjusted monitoring at the NICE intervals.
Review benefit, adherence, subjective effects and movement regularly, and repeat height, waist circumference, pulse, blood pressure, glucose or HbA1c, lipids and prolactin at the NICE intervals or sooner when indicated.
Chart manic episodes prospectively, distinguishing reduced need for sleep from insomnia and sustained euphoria from brief reactive excitement.
Review family understanding, school support, substance reduction, crisis contacts, physical activity and transition ownership at every major care change.
Special situations
Phenomenology before labels
Asking how an experience occurs and changes behaviour is more informative than recording the word hallucination without context.
Attenuated is not trivial
Diagnostic uncertainty calls for prompt specialist assessment and follow-up, not either preventive antipsychotic treatment or casual dismissal.
Irritability is non-specific
Chronic anger or dysregulation alone does not satisfy NICE's paediatric mania requirements and has many developmental alternatives.
Treatment is a package
First-episode care combines medication, family intervention and individual CBT rather than making tablets the only active component.
Physical monitoring protects choice
Growth, metabolic, prolactin and movement data allow early harm reduction and a more honest collaborative medication decision.
Common pitfalls
01
Calling imaginative play, intrusive thoughts, autistic communication or trauma re-experiencing psychosis without careful developmental phenomenology.
02
Waiting four weeks before referring attenuated or transient possible psychosis, when NICE says referral should occur without delay.
03
Prescribing an antipsychotic solely to prevent psychosis in a young person with below-threshold experiences.
04
Diagnosing bipolar disorder from irritability, brief mood shifts, antidepressant activation or depression plus family history alone.
05
Starting an antipsychotic without baseline growth, metabolic, prolactin, movement and cardiovascular assessment when the situation permits.
06
Explaining every acute behavioural change as psychiatric and missing intoxication, delirium, seizure, encephalitis or safeguarding danger.
07
Excluding family automatically or disclosing everything automatically instead of making a reasoned consent and confidentiality plan.
Clinical stateAwaiting review
JurisdictionUnited Kingdom
A bipolar diagnosis in young people requires specialist, prospective longitudinal assessment; episodic euphoria must be present for most of the day on most days for at least seven days when diagnosing mania.
Irritability alone is not a core diagnostic criterion for paediatric bipolar disorder, and depression plus a family history does not establish bipolar disorder.
Assess development, neurodivergence, trauma, culture, school, family, sleep and substances before attributing unusual communication or behaviour to psychosis or bipolar disorder.
Marked agitation, little or no sleep, disinhibition, grandiose risk-taking or psychotic behaviour may represent mania, intoxication or another acute state and should not be managed by telephone reassurance alone.
Catatonic immobility, mutism, posturing, excitement or autonomic change is a medical and psychiatric emergency; antipsychotic treatment should not be improvised before expert review.
Abuse, exploitation, trafficking, online coercion, substance supply or frightening experiences within the home may generate or shape symptoms and require a private safeguarding assessment.
05
Antipsychotic baseline screen
Why
Record growth, cardiovascular, metabolic, prolactin, movement, nutrition and activity measures before treatment.
Interpretation and limitations
Baseline values guide choice and reveal change; use age-adjusted charts and repeat measures during titration.
06Prospective mood chart
Why
Record sleep need, mood quality, energy, speech, activity, psychosis and function across time and settings.
Interpretation and limitations
Distinct episodes with sustained euphoria support bipolar assessment more than chronic irritability or retrospective impression alone.
2Offer oral antipsychotic treatment together with individual CBT and family intervention, choosing medication collaboratively after baseline monitoring.
3Review symptoms, function, adherence, subjective experience, movement, prolactin, growth and metabolic effects and revise diagnosis when the course is atypical.
03Possible bipolar disorderUse specialist longitudinal diagnosisEpisodic elevated mood, reduced sleep need and behavioural change raise concern for mania or bipolar disorder.+
1EscalationEscalate acute danger or medical uncertainty, then refer under-fourteens to specialist CAMHS and older adolescents to a service with bipolar expertise.
2Monitor prospectively for sustained euphoria, episodicity and associated manic features while evaluating ADHD, autism, trauma, substances and sleep.
3Use specialist NICE treatment only after formulation, include family and relapse work, and review whether acute antipsychotic treatment remains necessary beyond twelve weeks.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
NICE TA292 recommends aripiprazole as one licensed specialist option for moderate to severe manic episodes in adolescents aged 13 years and older; diagnosis and treatment remain within the age-appropriate bipolar specialist pathway.
Aripiprazole for a bipolar I manic episode in an adolescent
For an adolescent aged 13 years or older with a moderate to severe bipolar I manic episode, give 2 mg orally once daily for 2 days using the 1 mg/mL oral solution, then 5 mg once daily for 2 days, then the recommended 10 mg once daily. Use for the minimum period needed for symptom control and no longer than 12 weeks. Doses above 10 mg daily are exceptional, require close monitoring and must not exceed 30 mg daily.
Younger patients have higher adverse-effect risk. Discuss and monitor akathisia and other extrapyramidal effects, somnolence, fatigue, weight and metabolic change, cardiovascular status, impulse-control symptoms and CYP2D6 or CYP3A4 interactions. Higher doses have no demonstrated enhanced efficacy in this population and cause substantially more adverse effects.