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Generalized Anxiety Disorder and Bipolar II

Here are the official criteria for GAD (I've reorganized them a bit; you'll see why in a moment). :

It is very clear that some people who are experiencing anxiety, who often have been diagnosed with GAD, respond to the "mood stabilizers" we use for bipolar disorder.^Freeman   Could they have a form of bipolar II?

Sometimes the answer to this question doesn't matter as much as just trying to find a treatment that works!  But, if you're going to try to figure out the diagnosis part first, then we should compare the symptoms of these two conditions.  A routine list of BPII symptoms would not look like GAD.  However, anxiety clearly is part of bipolar disorder (for a full discussion, see the essay on Anxiety and Bipolar Disorder).  

Let me show you how I came to regard GAD and BPII as so closely related.  As you may have read in the section of this website on Diagnosis of BPII,  two symptoms that seem to best identify people who are going to respond to these medications, are, in my experience: 

• profound insomnia; and 
• difficulty concentrating. 

These are two of the GAD symptoms.  I’ve put them in brackets in the right column below.  In that column you'll also find a list of the symptoms of bipolar II using the broad criteria offered by Dr. Akiskal (head of the mood disorders clinic at UC San Diego).  Among bipolar experts, his views are probably the most extreme in terms of the breadth of bipolar disorder.  Therefore be aware that the table below represents a fairly extreme viewpoint.  You'll find relatively few psychiatrists who think these conditions overlap this much.   However, even with a big grain of salt, this is still a pretty impressive overlap: 

Generalized Anxiety Disorder (DSM-IV) Bipolar II (Akiskal + Phelps) Cognitive worry difficulty concentrating Energy keyed up, on edge restlessness, tension easily fatigued difficulty falling/staying asleep Mood irritability Cognitive free floating anxiety [difficulty concentrating] Energy motor agitation restlessness extreme fatigue [profound insomnia] Mood dysphoria, irritability

When you look at these virtually identical lists, I hope it makes sense to you than anyone with GAD symptoms who has not responded well to antidepressants should consider a trial of mood stabilizers. Remember, not everyone will respond. Raised hopes carry risk of dashed hopes later, so be cautious and wait for the "proof in the pudding".  Bipolar II is not a condition one would want to have.

It should also make sense to you that even if you have GAD, you might want to use some caution starting up on an antidepressant.  As you may have read elsewhere on this website, antidepressants are known to bring on manic symptoms in patients with bipolar disorder, to cause rapid cycling and mixed states, and perhaps even worsen the course of bipolar disorder.  This has led to substantial controversy within psychiatry on how cautious to be with antidepressants.  Click for more on this controversy. 

However, evidence has accumulated recently that antidepressants can improve GAD symptoms substantially.  Several of the newer antidepressants have received FDA approval for this, although several older antidepressants like imipramine have been known for years to be effective in GAD.   Therefore, you'll hear antidepressants offered as one of the primary means of treatment of GAD.

There is a cognitive-behavioral therapy approach to GAD that has been shown to be effective^Erickson, but not as dramatically effective as the CBT approach for panic.  However, it's nice to know that there's a therapy approach to use instead of or in addition to antidepressants -- if you can find a therapist with plenty of experience in CBT who knows how to apply it to GAD.  That might be a smart starting place if you end up, after reading this, wondering if it's safe to take an antidepressant for your GAD-like symptoms.