Understanding How Bipolar Disorder And Anxiety Can Overlap

“Comorbid” is a term that refers to any two or more health conditions that present in the same individual simultaneously. Understanding comorbidity can be an important factor in making sure that a person receives the right care if they’re experiencing multiple mental health conditions at once. Two types of conditions that occur together fairly commonly are bipolar disorder and anxiety disorders. Below, we’ll provide a brief overview of both types of disorders along with what you need to know about when they are comorbid with each other.

What is bipolar disorder?

Bipolar disorder is a category of mental health conditions that cause an individual to alternate between states or “episodes” that are characterized by manic symptoms, depressive symptoms, or a mixture of both. Symptoms of these two types of episodes can impact a person’s judgment, sleep patterns, energy levels, and capacity to think clearly and focus. 

Note that there are a few different types of bipolar disorder according to symptom severity. Bipolar I disorder is characterized by the most severe symptoms, which can include psychotic episodes and may sometimes require hospitalization for stabilization. Bipolar II disorder is characterized by less severe symptoms, and cyclothymic disorder is characterized by less severe symptoms that include hypomanic rather than manic states. 

According to the diagnostic criteria outlined in the DSM-5, a manic episode will typically manifest as three or more of the following symptoms all or most of the day, every day, for at least a week. A hypomanic episode will typically manifest as three or more of the following symptoms all or most of the day, every day, for at least four days:

• An inflated sense of self-esteem
• Racing thoughts
• Being easily distracted
• A decreased need for sleep
• Talking more than usual
• Increased goal-directed activity

In contrast, a depressive episode is usually characterized by at least five of the following symptoms experienced during a two-week period, which correspond with symptoms of major depressive disorder: 

• A depressed mood (feelings of sadness, emptiness, hopelessness)
• Significant weight gain or loss
• Significant changes in sleep patterns
• Restlessness or slowness
• Trouble concentrating
• Fatigue
• Feelings of worthlessness or guilt
• Thoughts of suicide

Bipolar disorder can occur alongside several other mental health conditions—aside from anxiety disorders—including post-traumatic stress disorder, substance use disorder, and conduct disorders. Obsessive-compulsive disorder (OCD) can also develop as a comorbid condition. OCD symptoms often arise during depressive phases. Comorbid OCD and bipolar disorder can cause longer mood episodes, reduced medication adherence, and decreased treatment responsiveness. 

What is an anxiety disorder?

It’s normal for people to experience occasional feelings of worry, concern, or anxiety from time to time, especially in the face of a stressful or uncertain situation. However, when these feelings are persistent, debilitating, and/or interfere with an individual’s daily functioning, they may signify an anxiety disorder. 

The American Psychiatric Association estimates that 30% of adults will experience an anxiety disorder at some point in their lives. There are various types, from generalized anxiety disorder (GAD) and social anxiety disorder (also called social phobia) to panic disorder and specific phobias. While each will present with its own unique set of symptoms, anxiety disorders in general often manifest as:

• Physical symptoms such as sweating, trembling, headaches, stomach aches, a racing heart rate, hyperventilation or other breathing problems, muscle tension, chest pain, neck pain or other unidentified pain without an apparent cause, and fatigue 
• Behavioral symptoms such as actively avoiding people or places that may cause anxiety, and significant changes to eating and sleeping habits
• Psychological symptoms such as mood swings, “brain fog” or the mind going blank, trouble concentrating, disorientation, irritability, a persistent and overwhelming sense of impending doom or constant danger, extreme nervousness that doesn’t go away, and difficulty controlling worry

In addition to co-occurring bipolar disorder, individuals with anxiety disorders have a greater risk of living with depressive disorders and substance use disorder than the general population. Post-traumatic stress disorder is another potential co-existing mental health condition.  

The relationship between these disorders

While bipolar disorder and anxiety disorders are separate mental health conditions, they frequently occur together in the same individual.

There are several other types of anxiety linked to bipolar disorder, though, including social anxiety disorder, generalized anxiety disorder, and agoraphobia. Comorbid anxiety and bipolar disorder can cause additional adverse effects and influence treatments. Another study suggests that at least half of those with bipolar disorder are likely to develop a comorbid anxiety disorder at some point in their lifetime. 

Being aware of the fact that these two conditions are often comorbid can be important for three key reasons. First, symptoms of one condition may complicate symptoms of the other, and understanding how the two might coexist in the same individual can inform both the diagnosis and treatment processes. Second, the treatment of one may interfere with the treatment of the other, so being aware of the comorbidity can allow a provider to adjust their recommendations as needed for maximum effectiveness.  

Third, according to an article published in the World Journal of Psychiatry, the comorbidity of anxiety and bipolar disorders is associated with substantial increases in the burden that symptoms place on the affected person. This can include a higher risk of psychosis, earlier onset of psychiatric symptoms, longer periods of untreated illness, decreased response to treatment, impaired quality of life, and an increased risk of substance or alcohol use disorders and suicidal thoughts and behaviors. 

Treatment options 

For people with bipolar disorder, the recommended treatment is usually a combination of medication and psychotherapy—typically interpersonal and social rhythm therapy or cognitive behavioral therapy. Patients with bipolar disorder may be prescribed a mood stabilizer, antipsychotic medication, or antidepressant, depending on their symptoms. According to a systematic review conducted by the International Society for Bipolar Disorders, the mood stabilizer lithium may be particularly effective in preventing recurrence. 

Psychotherapy

For people with anxiety disorders, the recommended treatment is usually psychotherapy—typically cognitive behavioral therapy (sometimes styled as cognitive behavior therapy), which may or may not be advised in tandem with medication. Psychotherapeutic treatment of anxiety disorders can take several forms, including individual, group, or family therapy. A proper diagnosis of both conditions is crucial for effective treatment because the medications frequently prescribed for each can negatively interact with each other.

Medication

As an article in The Mental Health Clinician journal states, serotonergic antidepressants are typically used to treat anxiety disorders. However, these pharmacological anxiety treatments can increase the risks of a manic switch and potentially destabilize mood in an individual with comorbid bipolar disorder. That’s why individuals who have comorbid bipolar disorder and an anxiety disorder will typically be placed on mood stabilizer therapy first before any medications are added to their treatment plan. 

Benzodiazepines, which are often used for short-term treatment of severe anxiety symptoms, are typically avoided as well for people with an anxiety disorder and bipolar disorder. These medications can exacerbate manic symptoms and lead to addiction and substance misuse. 

Self-care

Self-care strategies can also help individuals with co-occurring anxiety and bipolar disorder alleviate their symptoms. Maintaining a balanced diet, exercising regularly, and getting plenty of high-quality sleep can boost mood and reduce symptoms of both conditions. Additionally, utilizing relaxation techniques like deep breathing exercises and progressive muscle relaxation can alleviate stress that is connected to anxiety and bipolar disorder. 

Seeking the support of a therapist

Since some form of medication is typically required to effectively treat bipolar disorder, it’s usually recommended that you meet with a psychiatrist for evaluation if you’re experiencing symptoms. They may recommend that you also meet with a therapist to help you learn how to challenge and shift distorted thoughts and develop healthy coping mechanisms, which can be helpful for symptoms of an anxiety disorder as well. A therapist can also provide you with a safe space to express and process your feelings if you’re experiencing distress after having received a new mental health diagnosis.

For some people, meeting with a therapist in person is uncomfortable, intimidating, or inconvenient. Those who would prefer to connect with a qualified provider from the comfort of home can explore online therapy options. With an online therapy platform like BetterHelp, you can get matched with a licensed therapist whom you can meet with via phone, video call, and/or in-app messaging to address the challenges you may be facing. Research suggests that there’s no difference in effectiveness between online and in-person methods, so most people can feel confident in selecting whichever one works best for them.