Bipolar Disorder & Anxiety: Connections, Symptoms, & Treatment Options

What’s the Connection Between Anxiety & Bipolar Disorder?

Many people with a bipolar diagnosis are met with extreme bouts of anxiety to the extent of having a diagnosable anxiety disorder as a comorbid condition.¹ Lifetime rates of diagnosable bipolar and anxiety disorders as comorbid conditions are relatively high, with research indicating rates of around 40-50%.²

For individuals diagnosed with bipolar disorder, anxiety may prove challenging. A key feature of a bipolar diagnosis is the vehement effectual shift from low lows to high highs and back again. Though the frequency and severity of bipolar disorder cycles can differ, the experience is an unpleasant one regardless. These swings may significantly impair personal well-being, interpersonal relationships, and daily functioning.¹

A literature review published in the World Journal of Psychiatry in 2019 reported the following lifetime rates for adults with bipolar disorder having another specific condition:²

• Panic disorder (17% to 22%)
• GAD (13% to 20%)
• Social phobia (20%)
• PTSD (11% to 17%)
• Social anxiety disorder (13%)
• OCD (10% to 13%)
• Specific phobias (11%)
• Agoraphobia (8%)

Among children/adolescents the mean prevalence statistics are as follows:²

• GAD (25%)
• Separation anxiety disorder (22%)
• OCD (17%)
• Social phobia (15%)

How Do Bipolar & Anxiety Affect Each Other?

One of the most challenging symptoms associated with bipolar disorder is emotional lability, more commonly known as “mood swings.” Though mood swings may be predictable over time, there are many occasions in which they are not. Being unsure of how one will function individually or socially in front of others is often met with worry, increasing anxiety incidents. Understanding this connection requires some insight into the physiological processes that lead both disorders to affect each other.

Bipolar disorder affects the thinner cortical gray matter in the frontal, temporal, and parietal regions of both brain hemispheres and the hippocampus, with the most considerable effect seen in blank areas, such as:^{3, 4, 5}

• The left pars opercularis (related to speech)
• The left fusiform gyrus (allows us to recognize facial features in objects)
• The left rostral middle frontal cortex (related to emotional regulation and working memory)

Given the significant impact of bipolar disorder on the brain, it makes sense that those impacts may also lead to anxiety.

Can Bipolar Disorder Cause Anxiety?

While it is unclear whether an anxiety disorder can lead to a bipolar disorder, there is a clear connection for bipolar disorder leading to anxiety.^{2, 3, 4, 7}

Some risk factors that might increase the likelihood of someone with bipolar disorder developing an anxiety disorder include: ⁸

• Genetic predisposition
• Chronic and elevated stress
• Experiencing substantial loss
• Substance abuse

The following are some of the most common anxiety disorders linked to bipolar disorder with anxiety:⁹

• Panic disorder: This condition is marked by unexpected and intense fear (panic attacks) that occur with consistency. Many may struggle to differentiate an intense panic attack vs. a heart attack and may feel they are about to die from a panic attack.
• Generalized Anxiety Disorder (GAD): This condition is marked by a continued state of excessive worry. GAD is the most diagnosed comorbid anxiety condition with bipolar disorder.
• Social Anxiety Disorder (SAD): Individuals experience excessive worry about social situations. They may find attending social events or even the mere thought of doing so overwhelming.
• Specific Phobias: This condition is met with an intense, often extremely exaggerated fear of a particular trigger (person, place, idea or thing). Some conditions are associated with real-life threats, such as heights (acrophobia), while others are not, such as being near stuffed animals (pediophobia).

Can Anxiety Cause Bipolar Disorder?

Though anxiety and bipolar disorder have a relatively high rate of comorbidity (approximately 50%), it is difficult to say with certainty that anxiety causes bipolar disorder.² There are noted cases in clinical practice where individuals diagnosed with an anxiety disorder develop bipolar disorder many years later; however, the connection is unclear.⁶

Instead, it is seemingly more appropriate to consider how bipolar disorder causes anxiety. Given the potentially severe symptoms associated with a bipolar diagnosis, struggles with anxiety serve to complicate the condition further.

Symptoms of Bipolar Disorder & Anxiety

There are several overlapping symptoms that are shared between bipolar disorder and anxiety disorders. In combination, particularly with a comorbid diagnosis, the two serve to reinforce and intensify their symptoms beyond the independent severity of a single condition alone.

In clinical practice, there are instances where bipolar disorder may be initially misdiagnosed as anxiety or major depressive disorder. This is especially true for those who may have experienced a manic or hypomanic episode but failed to report it. In other cases, mania has yet to be experienced. Missing this during diagnosis may lead to compromised treatment and continued confusion for the patient.

If you or someone you love believes that the condition may be a bipolar diagnosis, it is essential to share this information with the mental health professional. The more information the therapist has, the better.

Bipolar disorder may create worsening anxiety symptoms such as:

• Anxiety tremors
• Dizziness
• Excessive worrying
• Restlessness
• Muscle tension
• Emotional lability
• Irritability
• Negative self-talk
• Rumination of negative thoughts
• Depression

Anxiety disorders may create worsening bipolar symptoms such as:⁷

• Increased cycling of episodes, becoming rapid cycling bipolar disorder
• Increased mood episodes (i.e., depression & mania)
• Greater risk of substance use disorders
• Pressured speech
• Lack of engagement with supportive networks
• The presence of nervous breakdowns, worrying, or fearful avoidance behaviors
• Significant problems with sleep (i.e., insomnia)
• Persistent anxiety even when not in a manic state
• Lacking response to initial treatment, possibly forming treatment-resistant depression
• Increased sensitivity to initial side effects of medication, and sometimes a longer time timeframe to find the right medication combination and dosing.

Though this list is not all-inclusive, the above-mentioned are some of the more commonly impacted symptoms of a dual diagnosis.

15 Ways to Manage Bipolar Disorder & Anxiety

The harsh reality is that comorbid disorders come with increased impairments to daily life and often require additional coping mechanisms. Speaking to a professional is always a recommended course of action. Especially with a condition such as bipolar disorder, it is highly likely that psychiatric medication is required as part of treatment since it is a neurological impairment. Still, there are many ways people can improve how they feel on their own and learn how to calm anxiety (especially when combined with a formal treatment regimen).

Here are 15 healthy coping mechanisms and self-care tips for anxiety and bipolar disorder:

1. Maintaining a healthy diet
2. Developing a support network
3. Seeking Treatment
4. Practicing meditation for anxiety
5. Implementing mindfulness for anxiety
6. Using mantras to calm anxiety
7. Engaging in group therapy & support groups
8. Exercise for mental health, such as walking meditation
9. Journaling your thoughts and feelings
10. Reading or writing
11. Accessing the benefits of music therapy by either playing, listening, or singing
12. Taking deep breaths and finding your favorite breathwork techniques
13. Guided imagery/visualization
14. Progressive muscle relaxation
15. Having a light moment by playing a game, watching a show, etc.

When it comes to effective coping skills, the key is finding what works for you. There is no one-size-fits-all approach to this. If one strategy does not work, continue moving on to the next one. As ones that work are found, hold onto them, and use them when and as often as necessary. These truly can make a difference when symptoms intensify.

When to Talk to Your Doctor About Bipolar Disorder & Anxiety Symptoms

It is highly recommended that if you or a loved one are experiencing debilitating symptoms specific to mental health, especially bipolar symptoms, speak with a mental health professional as soon as possible. Like physiological health problems, many mental health problems are pervasive and become more invasive and debilitating without intervention. Bipolar and anxiety disorders are two such conditions.

Some signs and symptoms someone should monitor before approaching their doctor about potential bipolar disorder/anxiety include but are not limited to:

• Increased mood swings
• Manic, hypomanic, and/or depressive episodes
• Increased irritability
• Sleeplessness
• Excessive worry
• Jumbled thoughts/confusion
• Significant others saying you are acting differently
• Feeling as though life is becoming out of control
• Risk-taking behaviors
• Substance abuse
• Feelings of helplessness/hopelessness
• Homicidal or suicidal ideation or attempts
• Bottling up negative emotions, especially due to a belief that others will not understand

This list is by no means all-inclusive but does indicate a potential problem, especially if multiple symptoms are present with increased severity. For those already diagnosed with bipolar disorder or an anxiety disorder, be sure to communicate these changes with your doctor as well. The more informed your provider is, the greater likelihood of an accurate diagnosis and desired treatment outcomes.

How Co-Occurring Anxiety & Bipolar Disorder Are Treated

Most anxiety conditions are curable over time with intentional and consistent effort. Bipolar disorder, on the other hand, currently has no known cure. Fortunately, both conditions are treatable. Numerous people who engage in treatment have found relief from their symptoms and lead healthy, happy lives.

Therapy

Many forms of therapy used for bipolar disorder work for an anxiety disorder and vice versa. The critical difference, however, is that bipolar disorder typically requires medication for stabilization. Some anxiety disorders warrant medication as well, but many do not. Accordingly, this is a conversation to have with your doctor. Fortunately, psychotherapy has been met with promising outcomes.

Some more successful forms of therapy include:¹⁰

• Cognitive behavioral therapy for anxiety
• Cognitive behavioral therapy for bipolar disorder
• Mindfulness-based CBT
• Interpersonal therapy
• Relaxation therapy

Said approaches may be used alone or in an integrated fashion. Depending on the severity of the condition, individuals may attend a less invasive outpatient therapy or an intensive outpatient (IOP) and residential (inpatient) treatment which is a more invasive setting.

For additional assistance with finding a provider, please see our ways to find the right therapist page and/or refer to an online therapist directory.

Medication

Again, it is highly likely that a bipolar diagnosis requires medication. Medication prescribed does vary widely, and it may take some time before any differences are experienced. When positive differences are experienced, this is an indication that the medication is working. At this point, and every other throughout the process, it is imperative to take medication as prescribed.

Stopping medication abruptly or only taking medication when it feels necessary will impair brain chemistry and functioning, which heightens undesirable symptoms. If, after a period, the medication seems not to be working, it is imperative to have this discussion with the prescribing physician before stopping your medication.

Commonly recommended medications for comorbid bipolar and anxiety disorders include:¹⁰

• First line: gabapentin, quetiapine
• Second line: divalproex sodium, lamotrigine, serotonergic antidepressants,* olanzapine, olanzapine-fluoxetine* combination
• Third line: lithium, risperidone, aripiprazole, pregabalin, medium or long-acting benzodiazepines**

*These medications carry a black box warning, the most serious kind of warning from the FDA for risk of suicidal thoughts and behaviors in certain people. You should talk with your doctor about these risks before starting this medication.

**This medication has black box warnings, the most serious kind of warnings from the FDA for abuse or misuse, risk of physical dependence, and risk of serious side effects, including death when combined with an opioid.

If you are wondering how to get anxiety medication or bipolar medications there are many great online psychiatry organizations that can give you the support you need.

Final Thoughts

The truth is that dealing with anxiety disorder and bipolar disorder is challenging. Left untreated, either condition alone can prove debilitating. They may feel like the final straw that breaks the camel’s back. What you’re dealing with is unique to you, but you’re not alone. Talking to a professional, or even reaching out to a trusted friend or family member, is a great way to start feeling better. Everything begins with taking the first step. If you are reading this article right now, you are already on your way to recovery. It is about following through with what you need to be healthy. Remember, you are worth it.