5 Types of Anxious Bipolar Disorder

In 1967, the pioneering psychiatrist Aubrey Lewis set out to find the meaning of “anxiety.” He concluded that the word was overused, poorly defined, but unlikely to go away anytime soon.¹ Little has changed since then. Over 90% of patients with bipolar disorder struggle with anxiety at some point in their lives, and yet anxiety is not even a symptom of the disorder. To treat it, we first need to get to the cause, and in these slides I’ll highlight 5 ways that anxiety can present as part of bipolar disorder.²

Anxiety is higher in mixed states than in pure episodes of mania or depression, whether in the form of free-floating anxious symptoms or as comorbid anxiety disorders. The patient in a mixed state is tense, restless, and agitated. Their mind races with every kind of worry, conjuring scenes of gruesome accidents, traumatic assaults, and other worst-case-scenarios. They complain of an inner tension “like I’m being ripped apart from the inside.” While most anxiety makes people avoid danger, this mixed-state anxiety has a fearless, impulsive edge, driving the patient toward substance abuse, self-harm, or even suicide to relieve it.³

Rumination is problem-solving gone awry, where the mind grapples with unanswerable questions like “Why can’t I do anything right?”, “What do people really think of me?”, and “What is it all worth?” The stream of negative thoughts creates a haze of anxiety, but the underlying cause is the mental habit of rumination. Rumination is as common in mania as it is in depression, and it often persists after a mood episode resolves.⁸ It is treatable with psychotherapy, and addressing it reduces the risk of future depressions.⁹

Anxiety is common to all disorders but specific to none. Even anxiety disorders are defined not so much by anxiety but by avoidance or intolerance of anxiety. However, for patients who suffer from anxiety it is often the symptom that bothers them the most. To recognize this important but diagnostically ambiguous symptom, DSM-5 created the “anxious distress” specifier for many disorders, including bipolar disorder.¹⁰

“Anxious distress” is a nonspecific specifier; a conflation of 2 synonymous words, 1 of which (distress) is already imbedded in the DSM criteria. It should not be confused with specific forms of anxiety, such as panic attacks, phobias, or obsessions, and it does not necessarily respond to medications for those disorders.

Though it does not point the way toward a specific diagnosis or treatment, anxious distress is a useful marker of severity.

Distress improves when we treat the underlying cause. In bipolar disorder, that could be mania, depression, a mixed state, insomnia, a comorbidity, or a major life stressor. Anxiolytics are not always the best option. If the distress is associated with suicidal thoughts, lithium may be the best choice, as this medication has antisuicidal effects that are independent of its mood benefits. Regardless of the treatment, patients with anxious distress require more care and attention because their high anxiety and low frustration tolerance places them at risk for adverse medication effects, treatment drop-out, and suicide.