Diagnosing mental health conditions is challenging. Unlike physical health conditions such as diabetes or hypertension, there is no vital sign, lab marker or imaging study to differentiate a mood from an anxiety disorder. The mental health provider relies on sound clinical judgment derived from a thorough history and mental status exam (MSE).
This difficulty is evident in efforts to differentiate Bipolar Disorder from Generalized Anxiety Disorder (GAD). An exacerbation in anxiety symptoms may mimic a hypomanic or manic episode. There is an overlap in symptoms such as sleep disturbances, concentration deficits, irritability, racing thoughts, and increased speech rate.
It is critical for the mental health provider to identify key differences between Bipolar Disorder and GAD. A diagnostic error can have devastating consequences for the patient. For example, if a mental health provider mistakes a hypomanic episode for an exacerbation in GAD and prescribes a selective serotonin reuptake inhibitor (SSRI), a manic episode may ensue.
First of all, the sleep disturbances differ between a hypomanic/manic episode and GAD. An individual will report a decreased need for sleep during a hypomanic/manic episode. On the other hand, a person with GAD is dissatisfied with the quality and quantity of his or her sleep. They find such disturbances disruptive to their functioning.
There are also differences in energy. During a hypomanic/manic episode, a patient may report increased energy or feeling euphoric despite a lack of sleep. I have also had patients tell me that they are more creative during such periods. They may even like the boost in energy and creativity that occurs during a hypomanic episode. Unfortunately, their level of functioning deteriorates as the episode worsens.
On the other hand, a person with GAD may complain of fatigue. They may experience difficulties getting out of bed and starting their day. They may also nap in the afternoon or drink excessive caffeine to cope with the fatigue. They are not likely to report creativity. Rather, concentration deficits can make it difficult to complete a task at hand.
Furthermore, a careful MSE will reveal differences in thought content and process. GAD is characterized by worry thoughts. A highly anxious individual tends to worry about hypothetical “what if” scenarios and anticipate negative outcomes. They tend to engage in catastrophic, worst-case scenario thinking. They may also express ambivalence as they struggle coping with opposing feelings or choosing between different options.
This differs from the increase in goal-oriented thinking that is observed during a hypomanic/manic episode. Such episodes are characterized by high motivation to complete tasks (1). Unfortunately, the bar of expectations is often set at unrealistic levels. For example, I recall an older gentleman in the middle of a manic episode who was determined to become a pilot and travel the world despite having vision problems.
Moreover, a thorough history will reveal differences in behavior. Patients may present as hyperactive or impulsive during a hypomanic/manic episode. They may engage in risky behavior with a potential for negative consequences. Examples include unrestrained spending sprees, foolish business investments or disinhibited sexual behaviors.
On the other hand, highly anxious individuals tend to be risk averse. They avoid taking action in an effort to mitigate uncertainty and risk (2). This may occur because they overestimate the risk of a negative outcome if they pursue a particular action. As a result, they may procrastinate and fail to meet deadlines.
Unfortunately, they also tend to underestimate the risk of avoidance behavior. For example, I have had patients avoid opening their mail because of the fear of being confronted with a bill. However, they underestimate the risk of not paying their bills such as accumulating debt which only exacerbates their problems.
Finally, Bipolar Disorder and GAD exhibit a different clinical course. A manic/hypomanic episode tends to be time limited. If left untreated, a first episode of mania may last an average of two to four months. Major Depressive episodes tend to be more prevalent and last longer during the course of Bipolar Disorder. Without treatment, episodes tend to become more frequent and last longer as time passes (3).
On the other hand, GAD follows a chronic course with low rates of remission and moderate rates of relapse/recurrence following remission. This chronic pattern may last up to 20 years (4).
1. Johnson, Sheri. Mania and dysregulation in goal pursuit: A review. Clinical Psychology Review. 2005 Feb; 25(2):214-262
2. Charpentier CJ et al. Enhanced Risk Aversion, But Not Loss Aversion, in Unmedicated Pathological Anxiety. Biological Psychiatry. 2017 Jun 15;81(12):1014-1022
3. Bipolar Disorder (Manic Depressive Illness or Manic Depression). Harvard Health Publishing Harvard Medical School. March 2019. Web. February 8, 2020.
4. Keller MB. The long-term clinical course of generalized anxiety disorder. Journal Clin Psychiatry. 2002;63 Suppl 8:11-6
Dimitrios Tsatiris, M.D. is a practicing Board Certified psychiatrist and Fellow of the American Psychiatric Association.He completed his psychiatry residency training at University Hospitals Case Medical Center as Chief Resident and more extensive training at the Cleveland Psychoanalytic Center. He specializes in the treatment of anxiety disorders and teaches resident psychiatrists and supervises therapists. To read more of his thoughts, follow him on Twitter @DrDimitriosMD