Cases That Test Your Skills

Is it anxiety, depression, or bipolar disorder?

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DSM-IV-TR1 divides bipolar disorder into three categories:

  • type I, in which the patient has had at least one manic episode with or without major depression
  • type II, characterized by one or more major depressive episodes and at least one hypomanic episode
  • cyclothymia, which is defined as fluctuation between hypomanic and minor depressive episodes.

Much is said about how underdiagnosis of bipolar disorder8 delays or prevents proper therapy with mood stabilizers, leading to suboptimal symptom resolution. As with Ms. R, however, an incorrect bipolar disorder diagnosis can be just as harmful. Three years of unnecessary and ineffective treatment worsened her anxiety and depressive symptoms and quality of life.

A comprehensive clinical interview supplemented with insights from family and friends can minimize the risk of misdiagnosis when patients present with symptoms that suggest bipolar disorder, depression, or GAD.

Differentiating between the following clinical features can also help you reach a diagnosis:

Sleep/energy level. Mania/hypomania is characterized by decreased need for sleep; patients often feel energetic even after 2 to 4 hours of sleep. Both depression and GAD diminish energy level, although mood is more depressed in depression. Patients with GAD have trouble falling asleep, while those with depression awaken early or have hypersomnia.

Behavior. Patients in the manic phase of bipolar disorder engage in risky, pleasurable activities with high potential for painful consequences. This drastic behavior change is not seen in depression or GAD (Table 2).

Table 2

Differentiating symptoms common to GAD, major depression, and mania

SymptomGADMajor depressionMania
ConcentrationDifficulty concentrating (mind goes blank)Diminished ability to concentrate or think (indecisiveness)Easily distracted (difficulty focusing on one task)
EnergyTires easilyConstant fatigue or loss of energySubjective feeling of increased energy
MoodCan be irritableIrritable, though more depressedEuphoric or extremely irritable
BehaviorSeems more keyed upMore withdrawnIncrease in risky behavior with potential for painful consequences
SleepDisturbed (mostly difficulty going to sleep)Disturbed (hypersomnia or insomnia, more likely terminal insomnia)Decreased need for sleep (energetic after sleeping 2 to 4 hours)

Related resources

Drug brand names

  • Bupropion • Wellbutrin
  • Buspirone • BuSpar
  • Escitalopram • Lexapro
  • Fluoxetine • Prozac
  • Gabapentin • Neurontin
  • Quetiapine • Seroquel
  • Valproic acid • Depakene
  • Venlafaxine • Effexor


Dr. Williams is a speaker for Wyeth.

Dr. Singh reports no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

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