Anxiety can intensify mood symptoms, but treating both conditions together can support greater stability and daily functioning.
Key Takeaways
- Anxiety disorders are common with bipolar disorder, and many people experience both.
- Treating anxiety alongside bipolar disorder can help reduce mood shifts and support greater stability.
- CBT and emotional regulation therapy can help with worry, rumination, and physical anxiety symptoms.
- Some anxiety treatments may increase the risk of mania, so they should be carefully monitored; sudden symptoms like a racing heart or shortness of breath should also be checked by a healthcare professional.
For Lakshmi B. of North Carolina, anxiety begins with a single thought that swirls repeatedly in her mind. Sometimes, the obsessive thinking is joined by physical symptoms: a stomachache, nausea, a headache that feels like a vise screwing down.
“The anxiety is there all the time,” says Lakshmi, who prefers not to use her real name in the story. “Anxiety and bipolar are my Siamese twins.”
Lakshmi was diagnosed with bipolar 1 at age 19, but for decades she had difficulty finding a psychiatrist “willing to address or acknowledge her anxiety,” she says. She has finally found some relief through cognitive behavioral therapy and antianxiety medication, which she uses on an as-needed basis when her anxiety symptoms become crippling.
These tools have been life-changing, she explains: “I have better relationships, I’m functioning much better, I have less rumination.”
Importantly, Lakshmi finds that easing her anxiety has also reduced the impact of her bipolar.
“My mood swings are less intense, mostly, and their duration has also decreased,” she reports, adding: “It is a work-in-progress. I’m taking it one day at a time, moment-by-moment sometimes.”
Why Treating Both Conditions Together Matters
Addressing anxiety is critical because unrecognized or untreated anxiety disorders can diminish your quality of life. This happens not only because of the wretchedness of anxiety symptoms themselves, but also because people often start to avoid situations and activities that might trigger them.
That instinct toward self-isolation can compound the depressive tendency toward social withdrawal — just one of the ways anxiety and depression (bipolar and unipolar) tend to feed into each other. Not only do a number of symptoms overlap, but increasing anxiety may foreshadow an oncoming depressive episode. (For those with bipolar 1 disorder, the same is often true with mania.)
The High Rate of Bipolar and Anxiety Co-Occurrence
On top of that, when anxiety and bipolar occur together, evidence suggests the course of bipolar will be worse, with more — and more severe — mood episodes. That’s especially alarming because at least one in three individuals with bipolar will also have at least one anxiety disorder. (Some researchers put that figure as high as two-thirds.)
An older large-scale analysis, found that individuals with bipolar have a three-fold risk of having anxiety compared with the general population.
“The common co-occurrence of, and the hazards associated with, anxiety and bipolar, are very well documented,” says psychiatrist Roger McIntyre, MD, FRCPC, a professor of psychiatry and pharmacology at the University of Toronto and founding director of the Brain and Cognition Discovery Foundation.
Furthermore, Dr. McIntyre notes, “when we look at comorbidity with bipolar disorder, anxiety [disorders] are the most common disorders that affect people who live with bipolar.”
Improving Anxiety Screenings in Bipolar Care
As with any dual diagnosis, addressing co-existing bipolar and anxiety with medications and therapeutic guidance targeted to the individual conditions leads to better outcomes than treating just one. As Lakshmi found, however, it’s not always easy for someone living with bipolar to have their anxiety recognized.
Back in 2006, McIntyre was lead author on an analysis called “Anxiety Disorders and Bipolar Disorder: A Review,” and published in Bipolar Disorders. It called for “prioritizing the identification and management of anxiety symptomatology in the bipolar population.”
Although that call has been echoed by other researchers in the years since, there are still no formal guidelines requiring clinicians to assess individuals who have bipolar disorder for anxiety. Yet, McIntyre says there has been encouraging progress over the years:
- When the latest update to the Diagnostic and Statistical Manual of Mental Disorders (known as DSM-5) came out in 2013, a specifier for “anxious distress” was added to the diagnostic options for both manic and depressive episodes of bipolar.
- The Florida Best Practice Psychotherapeutic Medication Guidelines for Adults with Major Depressive Disorder, a manual informally adopted by practitioners across the country as a reference for treatment protocols, includes a section on bipolar written by McIntyre. In it, he draws attention to what he calls “the four As” of bipolar disorder: anxiety, agitation, anger, and attentional problems.
- More clinics and healthcare systems are routinely administering depression and anxiety questionnaires as part of standard care. But, he adds, “we have no way of knowing how many clinicians [in private practice] are doing this.”
All of that is moot for many people whose anxiety symptoms emerge well before definitive markers of bipolar disorder (such as a manic episode).
“It’s very common for someone to be diagnosed with bipolar in their twenties and thirties, and you find out in their chart or taking their history that they had panic disorder or generalized anxiety disorder,” McIntyre adds.
How a Bipolar Diagnosis and Treatment Finally Helped Lifelong Anxiety
Shanna H. of Richmond, Kentucky, was only 11 years old when her mother took her to the doctor for anxiety.
“I’ve had anxiety ever since,” says Shanna. “I developed coping mechanisms at an early age.”
One was making art. Another was being outdoors — “playing in the woods and the streams. I’d be gone from sunlight to dark. It had a calming effect on me,” she recalls.
As an adult, Shanna spent the years raising her three daughters in a near-constant state of worry about unlikely events — the girls would be kidnapped, a car would crash into the house, or a sniffle signaled a dire illness.
She took medication for anxiety and for the bouts of immobilizing depression she experienced, but nothing really improved. She tried a few years of therapy, also with moderate results. Along with anxious thoughts, she began to have “spontaneous attacks” of physical symptoms such as tremors, nausea, and crying episodes.
Treatment for Bipolar Disorder and Anxiety
Finally, in 2018, Shanna made an emergency appointment with her therapist. The therapist floated the idea that Shanna might have bipolar 2 disorder, which was then confirmed by a psychiatrist.
Life has been much better now that she’s being treated for bipolar rather than a depressive disorder. For panic attacks, she has a beta-blocker she takes as needed. It interferes with the stress hormone that fuels symptoms such as a racing heart.
Lifestyle Strategies That Support Stability
Shanna has also returned to the pursuits that calmed her as a child, in the form of gardening and watercolor painting.
“My mood stabilizer has made an incredible difference, as well as the return to the creative aspect of my personality,” she reflects. “I never could have imagined that would make such a big impact.”
Medication Considerations and Risks
Medications used to treat bipolar don’t necessarily help with anxiety, notes clinical psychologist Sarah Sperry, PhD, who is associate director of the Heinz C. Prechter Bipolar Research Program at the University of Michigan and an assistant professor in the university’s psychiatry department.
Meanwhile, medications for anxiety aren’t part of the usual pharmacotherapy for bipolar. In fact, the various classes of antidepressants commonly prescribed for anxiety can be problematic for individuals with bipolar due to concerns about inducing mania, Dr. Sperry notes.
Therapy Options for Bipolar Anxiety
But skills learned in psychotherapy can be useful for both conditions. Sperry will use cognitive behavioral therapy (CBT) and psychoeducation to help people identify triggers and signs of both anxiety and bipolar. She also teaches exercises to counteract anxiety’s physical manifestations, including deep breathing, grounding meditation, body scan meditation, and progressive muscle relaxation.
Another approach, known as emotional regulation therapy, teaches anxious individuals how to step back from overwhelming emotions and self-calm through mindfulness and other strategies.
It was co-developed by two psychologists: Douglas Mennin, PhD, a professor of clinical psychology at Columbia University, and David Fresco, PhD, co-director of Michigan Mindfulness Laboratory, a center based at the University of Michigan that focuses on meditative techniques as an adjunct intervention for mood and anxiety disorders.
The evidence-based therapy is targeted at those who are “stuck in their heads,” says Dr. Mennin — trapped in a cycle of rumination, worry, and self-criticism.
In addition, techniques such as imagery, exposure therapy, and role-playing aim at reducing avoidance behaviors (staying away from situations that provoke anxiety).
“The idea is to look at how people respond in the difficult moments that arise for them and how to get better at managing them,” Mennin says.
“Often people with bipolar disorder have generalized anxiety and worry, and this may drive them further into different types of elevated mood and lability [emotional shifts],” he adds. “We help people slow down and make better choices.”
Physical Symptoms: When Anxiety Takes Over the Body
Billy K., a construction worker from Brunswick, Georgia, has learned all too well how his tendency toward catastrophic thinking can upset his balance.
Realizing his utility bill is due before his next paycheck comes in can easily tip him into overwhelming worry, he explains — even though rationally, he understands there are options like calling the company to arrange an extension.
When he goes into an anxiety spiral, Bill says, “I have to take time and talk myself out of it.”
His panic attacks often seem to have no trigger. “I can be stable on my [bipolar] medications and the anxiety just comes,” explains Billy, whose bipolar 1 was diagnosed in 2017. “Sometimes I might not feel anxiety for weeks at a time, and sometimes it happens every couple of days.”
For example, he describes waiting peacefully on his front porch for his ride to work when everything suddenly goes haywire: heart palpitations, profuse sweating, damp palms, and nausea. Sometimes he’ll actually vomit.
“It’s terrible. It just takes over my body. Even though I know in my mind it’s okay, my body reacts just like I’m getting chased by a grizzly bear,” he explains.
When either of his disorders act up, he’s grateful to have an understanding boss. He also has a good support system in his counselor and friends from his weekly men’s group.
Billy didn’t clue into his anxiety issues until he committed to sobriety in 2018. Before that, he says, he used alcohol to smother anxious feelings. He now regularly takes an antianxiety medication along with his mood stabilizer. It helps, he says, but it’s not a complete cure.
When panic breaks through, he turns to techniques he’s learned in counseling: counting to 10, breathing exercises, rubbing his earlobes.
Deconstructing his irrational thinking — a foundation of CBT — has been an especially powerful tool against rumination. He also credits simply knowing more about how having bipolar and anxiety disorders relates to how he thinks and acts.
He can step back from an angry reaction and remind himself it’s his brain affected by bipolar at work. He can wait out a panic attack because he understands it’s a kink in his body’s stress response.
Yes, he’ll be grappling with his twin conditions for life — “but it’s not as serious as it used to be before I understood what it was.”
The Role of Underlying Trauma in Bipolar and Anxiety Disorders
While research has established that people with co-existing bipolar and anxiety disorders tend to have a poorer course of bipolar, it’s still unclear why.
“Nothing in the symptomology of anxiety itself is linked to a bad course of bipolar,” says McIntyre.
One possibility, he says, is that a history of trauma is associated with a worse course of bipolar, and past trauma is also a known trigger for anxiety disorders. Thus, underlying trauma creates correlation (a mutual relationship) rather than causation (one is responsible for the other).
Another possibility is that bipolar affects multiple regions of the brain, and anxiety also affects multiple regions of the brain, so altogether there are more areas of the brain involved than in either condition individually.
For example, both bipolar and anxiety can create cognitive difficulties, and “if you have two problems affecting cognition it’s worse than one problem,” McIntyre notes.
Diagnosing Specific Anxiety Disorders Alongside Bipolar
Recognizing anxious symptoms and anxiety disorders alongside bipolar can be a challenge. For one, a number of symptoms overlap between the two conditions.
Obsessive thoughts and insomnia characterize manic episodes, but they can also be part and parcel of anxiety. Catastrophic thinking — anticipating the worst possible outcome — links to both depressive and anxious states.
If anxious symptoms show up only during a mood episode, a specifier for “anxious distress” can be added to the original bipolar diagnosis.
Experiencing continued anxiety when otherwise well makes diagnosis of a generalized anxiety disorder more clear-cut. Panic attacks, social anxiety, and phobias (irrational fears of something specific) merit their own diagnoses.
The following descriptions are from the National Institute of Mental Health (NIMH):
- Generalized Anxiety Disorder (GAD) is a persistent feeling of anxiety or dread. Symptoms include restlessness, difficulty concentrating, irritability, excessive worrying, fatigue, sleep problems, and physical reactions such as headaches, stomachaches, muscle aches, and unexplained pain.
- Panic Disorder is characterized as sudden bursts of extreme fear that occur although there is no real danger or trigger. Symptoms include feelings of impending doom, a pounding or racing heart, sweating, trembling, chest pain, and feeling you can’t catch your breath.
- Social Anxiety Disorder is a deep fear of being watched and judged by others, which can ultimately lead to avoiding social situations. A number of symptoms overlap with panic attacks: a pounding or racing heart, stomachaches, sweating, and trembling. Blushing and reluctance to meet other people’s eyes may also occur.
- Phobia-Related Disorder is an intense fear or aversion to a specific object or situation, typically out of proportion to any actual danger. Common phobias include being out in public, flying, receiving injections, and various members of the animal kingdom (dogs, spiders, snakes, and so on). People with a phobia experience intense anxiety when encountering the feared object or situation, worry about encountering the feared object or situation, and actively avoid the feared object or situation.
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Printed as “Side-by-side Solutions,” Fall 2022
