PTSD & Bipolar: Understanding the Connection

What Is PTSD?

Post-traumatic stress disorder (PTSD) is a psychiatric condition that can develop when someone is exposed to real or perceived harm or death. PTSD is characterized by constant re-experiencing of the traumatic event through intrusive thoughts or images, negative emotional states, physiological hyperarousal, and avoidance of trauma triggers.³ Symptoms of PTSD must persist longer than one month for a formal diagnosis.

PTSD occurs in 5-10% of the population.⁴ Risk factors include stressful childhood events, pre-existing mental health disorders, lower education, lower socioeconomic status, lack of social support, and being a woman.⁴ PTSD is twice as common in women as it is in men.⁴ PTSD can severely affect one’s quality of life, as it is linked to disability, substance use, legal problems, suicide attempts, and dementia.³

Common symptoms of PTSD include:

• Intrusive flashbacks about trauma
• Nightmares or night terrors about the trauma
• Persistent fear, anger, or shame
• Feeling detached from others
• Self-destructive behaviors
• Dissociative episodes
• Negative beliefs about oneself, such as “I am bad”
• Negative beliefs about others, such as “The world is dangerous”
• Hyperarousal, such as a racing heart and exaggerated startle response
• Avoidance of triggers to the stressful event
• Feelings of hopelessness
• Suicidal ideation or attempts

What Is Bipolar Disorder?

Bipolar disorder (BD) is a psychiatric condition characterized by severe shifts in mood. BD is one of the top ten disabling conditions worldwide, with a prevalence rate of 2.4%.⁵ The ups in bipolar disorder are called hypomania or mania, while the downs are called depression. BD appears to develop pretty equally across sex and ethnicity.⁵

There are two main types of bipolar called Type I and Type II. Type I can be distinguished from Type II bipolar by the presence of more severe symptoms, such as mania rather than hypomania, a less severe form. Potential causes of bipolar include childhood abuse or neglect.⁵ Risk factors for the development of BD include stressful life events like childbirth, unemployment, divorce, early parental loss, or disability.⁵

Common depressive symptoms of bipolar include:

• Significant fluctuations in weight
• Change in sleeping patterns
• Sad mood for most of the day
• Little experience of joy or pleasure
• Feeling revved up or slowed down
• Feelings of guilt or worthlessness for no apparent reason
• Inability to concentrate
• Crying spells

Common manic symptoms of bipolar include:

• Overly inflated self-esteem
• Increase in risky behaviors such as gambling
• Feeling little need for sleep
• Talking faster and more than usual
• Flights of ideas, frequent changing of topics
• Feeling more interested in sex or taking more sexual partners than usual
• High distractibility
• Feeling and acting more social than typical
• Going on spending sprees
• Becoming interested in hobbies one is not usually interested in

How Are PTSD & Bipolar Disorder Connected?

Trauma is the primary connection between PTSD and bipolar disorder, as it can result in PTSD and is also a common risk factor for developing BD.⁹ One study found exposure to domestic violence, parental neglect, parental substance abuse, and sexual assault are associated with developing both disorders.⁷ Other shared risk factors include high neuroticism, lower social support, and lower socioeconomic status.⁹

Researchers have also found an overlap of genetic risk in PTSD and bipolar spectrum disorders, meaning that they may have shared pathways for development.⁶ Although experts are unsure of the exact brain patterns behind bipolar PTSD, many studies have been conducted on the disorders separately. For example, undue stress can trigger different biological systems to “talk” with one another and trigger bipolar symptoms in those genetically predisposed.⁸

Can Trauma Cause Bipolar Disorder?

No research indicates that trauma itself can cause bipolar disorder. Experts agree that exposure to trauma is one of the risk factors for the development of BD.⁹ If you are genetically predisposed to bipolar disorder, a stressful event like trauma can cause bipolar to develop or symptoms to exacerbate in those already diagnosed.⁹

How Common Is It to Have Both Bipolar & PTSD?

Bipolar and PTSD commonly occur together, although experts are unsure of exactly why this happens. Some studies indicate the rate of PTSD in bipolar populations is double that of the general population.⁹Rates of PTSD among those with bipolar range from 4-40%.¹ Rates of bipolar among those with PTSD range from 6-55%.¹

PTSD Vs. Bipolar Disorder Symptoms

A key difference between bipolar and PTSD is the presence of one traumatic event. Someone with PTSD will report a traumatic event after which their symptoms began, whereas someone with bipolar generally tends to seek services during a depressive episode. Trauma-related symptoms that indicate PTSD include flashbacks, nightmares, and avoidance of people, places, or situations related to the event.

Sometimes, a person with bipolar who seeks services during a depressive episode will report some symptoms of previous manic episodes that have caused distress, such as spending sprees, extra-marital relationships, or foolish business ventures. Other times, it may take some time for a provider to see these symptoms, as people with bipolar can either have positive associations with mania, like having more energy, or experience dissociation during these episodes.

Similarities Between PTSD & Bipolar Symptoms

Someone with both bipolar and PTSD may experience rapid mood cycling, increased mood instability, less satisfaction with life, and increased suicide attempts. In both disorders, irritable or angry outbursts, episodes of self-destructiveness, and negative shifts in relationships with others are also common.

Challenges of Diagnosing PTSD Vs. Bipolar Disorder

Some of the symptoms of bipolar and PTSD overlap, which can make differentiating between disorders difficult. Overlapping symptoms that can complicate diagnosis include hopelessness, suicidal ideation and attempts, mood swings, and sleep disturbances.

Someone with bipolar but not PTSD may seek services during a depressive episode, whereas during manic episodes, they are less likely to seek services. This can provide another challenge in diagnosing bipolar versus PTSD because bipolar depression can resemble some of the negative cognitions found in PTSD. Additionally, bipolar mania can share features of PTSD like irritability outbursts, self-destructive behavior, and sleep disturbances.

Can PTSD Be Misdiagnosed as Bipolar Disorder?

Sometimes, symptoms of PTSD and depressive episodes in bipolar can look similar, leading to misdiagnosis of PTSD as bipolar. Feelings of worthlessness, negative beliefs about self and others, loss of pleasure, fatigue, and depressed mood are some symptoms of bipolar depression that can resemble PTSD. Some symptoms of PTSD can also overlap with manic episode symptoms, such as increased irritability, outbursts, dissociation, lack of sleep, and self-destructive behaviors.

The key difference will be that someone with PTSD reports a stressful life event related to their symptoms. For example, they may report wanting to sleep but difficulty sleeping due to flashbacks of the event. In contrast, someone in bipolar mania might report not feeling the need to sleep for days.

Impact of Having Both PTSD & Bipolar Disorder

Someone with PTSD bipolar or bipolar PTSD experiences more frequent and intense symptoms than someone with one disorder. Someone with PTSD and bipolar also tends to have lower chances of recovery, worse treatment outcomes, rapid cycling of moods, increased risk of suicide attempts, and a lower quality of life.¹⁰ These symptoms often impact the ability to secure stable relationships, jobs, housing, and healthcare.

The failure to correctly diagnose both conditions can lead to poorer treatment outcomes since symptoms are not being addressed properly.¹¹ Early intervention is important for the best treatment outcomes.

Treatment for PTSD & Bipolar Disorder

Experts recommend a trauma-informed psychological assessment to differentiate if one or both disorders are occurring.¹¹ If trauma is present, a provider may decide to use trauma-informed therapy to address PTSD symptoms. The initial step to bipolar PTSD treatment is generally mood stabilization through the use of medication. Mood stabilization helps provide the person with an emotional buffer before beginning trauma-specific therapy.

Treatment for PTSD and bipolar disorder can involve:

Medication for PTSD & Bipolar Disorder

Research is lacking on evidence-based medication treatments for comorbid bipolar and PTSD.² Medication for bipolar generally includes mood stabilizers, antipsychotics, or certain seizure medications. Standard medication for PTSD generally includes SSRIs, which can exacerbate manic symptoms in individuals diagnosed with bipolar.²

Experts agree that mood stabilization should be the primary goal when treating either condition. Typically, a mood stabilizer or antipsychotic might be initially prescribed, and if symptoms do not improve, then an antidepressant may be added. Psychopharmacological treatment of both conditions can be tricky. Therefore, psychotherapy is the most conservative treatment option for comorbid PTSD and bipolar.²

Therapy for PTSD & Bipolar Disorder

Research is still ongoing into exactly how therapy approaches can be adapted for bipolar and PTSD occurring together. Currently, experts indicate that once mood stabilization occurs, psychotherapy utilized for bipolar or PTSD separate diagnosis can be used for treatment. Since research is ongoing in this area, we may see changes in recommended treatment approaches as more studies come out about comorbid bipolar and PTSD.

Effective treatment options for someone with PTSD and bipolar disorder include:

• Cognitive behavioral therapy (CBT): CBT for PTSD focuses on challenging negative thought patterns associated with trauma-related symptoms, helping the person experience healthy shifts in mood and behavior. CBT for bipolar disorder includes helping the person recognize how their distorted thinking patterns may exacerbate some of their bipolar mood shifts and how to stabilize some of their thinking and behaviors.
• Eye-movement desensitization and reprocessing (EMDR): Preliminary evidence suggests EMDR can be a helpful trauma-targeted approach for individuals with bipolar PTSD, especially when other therapies have failed.¹² EMDR focuses on using bilateral stimulation strategies to help an individual re-process a traumatic event, helping reduce how stressed they become by triggers.
• Stress inoculation training: Since stress can cause or exacerbate symptoms of either PTSD or bipolar, stress inoculation training can teach strategies for stress reduction. Through training, individuals learn how to better respond to symptoms of stress in the body through strategies like deep breathing, relaxation, and changing self-talk.
• Motivational interviewing (MI): Motivational interviewing can be a helpful person-centered approach to helping someone with bipolar and PTSD who has ambivalence around treatment. MI is a gentle way of helping someone explore how symptoms impact their life and the pros and cons of engaging in treatment.
• Family-based therapies: Family-based therapies can be indicated when the root of someone’s bipolar PTSD symptoms comes from dysfunctional communication patterns in the family. Family-based therapy can help when all family members are committed to change and, if indicated, have their own individual therapists and medication plans to provide stabilization outside of sessions.

When to Seek Professional Support

If symptoms like unpredictable mood shifts, flashbacks, or negative thoughts about yourself are getting in the way of fulfilling personal and professional obligations, it may be time to seek treatment. This online therapist directory or online therapy platform can help you search for a therapist familiar with trauma and mood episodes. Online psychiatrist options can help with medication management of bipolar and PTSD symptoms.

Especially if you are experiencing frequent thoughts about death or dying, professional support can help you figure out the best course of treatment. Suicidal thoughts are an indicator that symptoms have been going on for a while, and professionals can help you decide on a course of treatment to help you gain control of your life again. PTSD can also meet the criteria for a disability if it substantially limits one or more major life activities and some people receive disability benefits for their PTSD diagnosis.

How to Cope With PTSD & Bipolar Disorder

Heightened stress can exacerbate symptoms of both bipolar and PTSD. Educating yourself on symptoms of bipolar and PTSD and tracking your own personal warning signs can help you prevent episodes from worsening. Building routines that minimize stressors, strengthening support systems, and following outlined treatment plans can help stabilize symptoms. Finally, developing good self-compassion practices can help challenge negative cognitions of bipolar PTSD.

Here are seven ways to cope with PTSD and bipolar disorder:

1. Implement Lifestyle Modifications

Since stress can exaggerate symptoms of bipolar and PTSD, making lifestyle changes can help mitigate stressors. Having a routine at work and home is a simple way to help build stability into your day. Making time for movement and eating foods that feel good in your body can promote positive mood shifts that help with feelings of worthlessness and low motivation.

Reducing the amount of stimulation and change you deal with can help with symptoms like hypervigilance. Stress-reduction techniques like diaphragmatic breathing or guided imagery meditation can help relax the body and calm the mind, alleviating symptoms like emotional dysregulation and irritability.

2. Build a Support System

Having a strong support system can positively impact treatment. Strengthening family and friend relationships can give you an outlet outside of treatment to process emotions and engage in healthy distractions. Sometimes, in-person or online support groups for bipolar and PTSD can provide additional support by helping build connections with others who have similar experiences.

3. Follow the Treatment Plan

Developing a routine around treatment can help you achieve the best outcomes possible for recovery. Strategies like maintaining a therapy and psychiatry schedule, reporting new symptoms to your treatment team, and keeping a mood log can assist with the maintenance of your condition. Taking medications at the correct times helps avoid fluctuations in the bloodstream, so make sure to use reminders if you struggle to remember a schedule.

4. Identify & Monitor Triggers

Monitoring your triggers for mood episodes, sleep disturbances, or negative thoughts can help you recognize what people, places, and situations exacerbate your condition. Once you recognize triggers, you can plan with your treatment team to either engage in exposure-based therapies or minimize the amount of triggers you experience. After you begin addressing your triggers, you can monitor how the coping mechanisms work and report back to your therapist with any obstacles.

5. Educate Yourself

Your treatment team may provide psychoeducation on typical signs and symptoms of your bipolar and PTSD. It can be helpful to ask about other verified resources for information on the conditions. You can also purchase books about bipolar disorder or books about PTSD. Understanding more about how symptoms can present can help you plan how you want to cope.

6. Develop Good Practices for Sleep Hygiene

Sleep disturbances are common in both bipolar and PTSD.¹ Developing a nighttime routine can help prepare the body and brain for sleep. Practicing good sleep hygiene, like limiting distractions before bedtime, sleeping in a cool and dark space, and limiting caffeine intake, can promote better rest. Since better sleep is connected to better emotion regulation, good sleep hygiene is an important part of bipolar PTSD treatment.

7. Engage in Self-Compassion Practices

Having bipolar and PTSD likely means you struggle with negative self-talk. These negative thoughts can include self-blame, guilt, and even shame. Self-compassion practices like developing gentle self-responses to negative behaviors can help you cope with unintended mood shifts and self-destructive episodes.

Self-compassion practices like writing letters to yourself or repeating positive affirmations can help with processing past experiences and committing to engaging in treatment to move forward. Letter-writing is an intervention best done with the care of a therapist or counselor.