In what 5 ways can anxiety present in bipolar disorder?
Over 90% of patients with bipolar disorder struggle with anxiety. Here are 5 ways that it can present.
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
In bipolar disorder, anxiety often results from manic rather than depressive symptoms. Mania is restless, impatient, and anxious for action. Bipolar depression, in contrast, is marked by inertia and low energy. That may explain why researchers at Massachusetts General Hospital found higher levels of anxiety sensitivity during mania and hypomania than bipolar depression.4 Anxiety sensitivity is a measure of how fearful someone is of anxiety sensations. It is a risk factor for panic disorder, which frequently comingles with bipolar disorder.
The practical lesson here is that antidepressants may be even more dangerous in bipolar anxiety than they are in bipolar depression. Though FDA approved for anxiety disorders, these medications can worsen a manic state.
Anxiety disorders tend to congregate in the family trees of patients with bipolar disorder, suggesting a genetic association between the 2 disorders. Environment also contributes to this anxiety. Rates of trauma and childhood adversity are 2-3 times higher in patients with bipolar disorder than in the general population.5,6
Anxiety disorders require a different approach when they co-occur with bipolar disorder. Antidepressants can cause mania, mixed states, and rapid cycling, but cognitive behavioral therapy is both safe and effective for comorbid anxiety disorders. In the large STEP-BD trial, anxiety was the strongest predictor of response to psychotherapy in bipolar disorder.7
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.
1. Lewis A. Problems presented by the ambiguous word "anxiety" as used in psychopathology. Isr Ann Psychiatr Relat Discip. 1967;5(2):105-21.
2. Rakofsky JJ, Dunlop BW. Treating nonspecific anxiety and anxiety disorders in patients with bipolar disorder: a review. J Clin Psychiatry. 2011;72(1):81-90.
3. Sani G, Vöhringer PA, Barroilhet SA, Koukopoulos AE, Ghaemi SN. The Koukopoulos Mixed Depression Rating Scale (KMDRS): An International Mood Network (IMN) validation study of a new mixed mood rating scale. J Affect Disord.2018;232:9-16.
4. Simon NM, Otto MW, Fischmann D, et al. Panic disorder and bipolar disorder: anxiety sensitivity as a potential mediator of panic during manic states. J Affect Disord. 2005;87(1):101-105.
5. Palmier-Claus JE, Berry K, Bucci S, Mansell W, Varese F. Relationship between childhood adversity and bipolar affective disorder: systematic review and meta-analysis. Br J Psychiatry. 2016;209(6):454-459.
6. Neria Y, Olfson M, Gameroff MJ, et al. Trauma exposure and posttraumatic stress disorder among primary care patients with bipolar spectrum disorder. Bipolar Disord. 2008;10(4):503-510.
7. Deckersbach T, Peters AT, Sylvia L, et al. Do comorbid anxiety disorders moderate the effects of psychotherapy for bipolar disorder? Results from STEP-BD. Am J Psychiatry. 2014;171(2):178-186.
8. Silveira Éde M Jr, Kauer-Sant'Anna M. Rumination in bipolar disorder: a systematic review. Braz J Psychiatry.2015;37(3):256-263.
9. Topper M, Emmelkamp PM, Watkins E, Ehring T. Prevention of anxiety disorders and depression by targeting excessive worry and rumination in adolescents and young adults: A randomized controlled trial. Behav Res Ther. 2017;90:123-136.
10. Tundo A, Musetti L, de Filippis R, et al. Is there a relationship between depression with anxious distress DSM-5 specifier and bipolarity? A multicenter cohort study on patients with unipolar, bipolar I and II disorders. J Affect Disord.2019;245:819-826.