Adding an anxiety diagnosis to bipolar can feel like bad news — but it’s a key step toward real relief.

Dave M. has been through the unshakable weight of depression and the reckless risk-taking of mania. But he says the sudden panic of Anxiety is worst of all. It’s been a constant in his life as far back as high school, when he remembers freezing in place at the chalkboard in algebra, unable to write the answer to an equation as sweat beaded up.

Rebecca R. was diagnosed with Bipolar at age 21, but her persistent worrying began a decade earlier. Among other things, she was afraid her single mother couldn’t afford rent and food — to the point that the youngster spent the allowance her father gave her on milk and eggs. Rebecca’s internalized anxieties translated to sleepless nights, painful stomach aches, and bowel problems.

Alan R. not only couldn’t open his mouth around girls in middle school, but his social phobia made him so panicky he’d have to leave. “I felt like I was crawling out of my skin,” he recalls. He turned to street drugs in high school, which he says made everything worse. After two decades in treatment, discovering that he has bipolar as well as an anxiety disorder made a real dent in his symptoms.

Anxiety Disorder and Bipolar Are Often Co-Companions

A research review published in the World Journal of Psychiatry in 2019 indicates that at least half of people with bipolar disorder also have an anxiety disorder. Often the anxiety strikes first, suggesting that it could be a risk factor for developing bipolar, says Regina Sala, MD, PhD, a psychiatrist based in London.

Dr. Sala says symptoms characteristic of anxiety include constant worrying, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and trouble sleeping. There is overlap between anxiety and bipolar symptoms, but anxiety symptoms that persist outside of times of depression and mania/hypomania point to an anxiety disorder.

Co-existing anxiety tends to make the course of bipolar disorder worse — meaning more depression, mania/hypomania episodes, according to Sala’s research. That’s why getting the right diagnosis and treatment early is important.

Michael Otto, PhD, director of the Translational Research Program at Boston University’s Center for Anxiety and Related Disorders and co-author of Living with Bipolar Disorder: A Guide for Individuals and Families, says it’s not clear whether people with both conditions have more severe bipolar symptoms because of the ongoing burden of anxiety or because the co-occurring disorders are actually a subtype of bipolar that has a worse course.

Living With Both Disorders

Knowing that twin diagnoses tend to mean a tougher road might actually help people work harder to improve their mental health, says Alan, who has founded several peer support groups outside New Haven, Connecticut.

After decades of therapy, he says, “I consider myself a coach for the mentally ill.”

Alan was treated for generalized anxiety disorder and depression long before anyone recognized his agitation, irritability, and anger as signs of bipolar. Looking at old family videos, he hears how critical he was with his children. He’s still embarrassed by a road-rage incident that erupted from somewhere beyond his rational mind.

Over the years, he says, his anxiety, depression, and hypomanic agitation shifted places, so that typically one would be worse while the others were milder.

“I would wake up very anxious, irritable. Or I’d wake up in a good mood. Or I’d want to stay in bed all day,” he says.

He reached a crisis point while going through a divorce at age 43. His anxiety exploded, leaving him unable to work full days at his thriving physical therapy business. Higher doses of antianxiety medication proved counterproductive, however. At that point, his depression diagnosis was changed to bipolar disorder and a more appropriate mix of medications reduced his symptoms.

A New Focus on the Interaction of Anxiety and Bipolar

Part of the challenge for diagnosis and treatment is that anxiety and bipolar interact in various ways which differ from individual to individual.

For example, says Dr. Otto, anxiety often causes people to avoid certain situations and experiences, which makes life more stressful and paves the way for depressive symptoms.

“Likewise, depression affects anxiety by coloring experiences, making interactions and events feel more difficult and more dangerous,” Otto points out.

Anxiety has such an influence on how a person with bipolar disorder responds to treatment that assessing anxiety is likely to become a standard part of care for bipolar. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, added “anxious distress specifier” to the chapter on bipolar and related disorders. The specifier is meant to identify people who have symptoms of anxiety that don’t fall under the diagnostic criteria for bipolar disorder.

“It’s a tremendous step forward,” says Ayal Schaffer, MD, head of the Mood & Anxiety Disorders Program at Sunnybrook Health Sciences Centre in Toronto and an associate professor of psychiatry at the University of Toronto.

“Historically, symptoms of depression or mania would be the exclusive focus for managing bipolar disorder, with anxiety not receiving the required attention.”

Dr. Schaffer was lead author for a paper on treating patients with both a mood disorder and an anxiety disorder, published in the Annals of Clinical Psychiatry. On the individual’s side, he says, “People tend to link anxiety to their life experiences rather than think of it potentially as part of their illness.” 

But according to research published in The Mental Health Clinician, not only is anxiety the most prevalent comorbid diagnosis among individuals with bipolar, but it also “can significantly impact the severity of bipolar symptoms, increase the risk of suicidality, and decrease psychosocial functioning and quality of life.” 

Rebecca of Edmonton, Alberta, uses an automotive image to explain how closely her conditions are connected.

Bipolar is like the car she has been given to drive, “and if I maintain it, it works efficiently,” she says. “But on the road to life, there are still potholes. I’ll get a flat tire, or I’ll forget to put gas in, or my alignment will be off.”

Anxiety is the important steering wheel: “If I don’t hold on, it’s going to drift.”

She has learned that spiraling anxiety immediately affects her sleep, complexion, eating habits and other physical factors. Those red flags signal that her mood is beginning to make a bipolar shift in either direction.

The good news, she says: “I’m still the one driving the car. I’m not just the passenger in life.”

Treating Both Disorders

Rebecca was diagnosed with depression at 18 after roommates pointed out her moodiness and self-isolation, then with bipolar after a manic episode three years later. A psychiatrist she saw cast doubt on the bipolar diagnosis, however, and she muddled along with intermittent therapy and antidepressants.

Anxiety symptoms — racing heart, hyperventilating, feeling like the walls were closing in — were explained away as linked to temporary stresses.

She sank to a new low in her early thirties, devastated because her husband wanted to end their marriage. Hospitalized for delusions, she got a definitive diagnosis of bipolar plus a separate anxiety diagnosis.

At first, the double whammy made her feel as if she would never get better. But with different medication, “in under six weeks, I was a brand-new person,” she says.

Once her symptoms were under control, coping ideas she had heard previously in therapy began to make sense. She rebuilt her life and became a medical secretary.

The right diagnoses were also critical to better mental health for Dave, who lives in Oregon. But he didn’t even seek help for 25 years, despite symptoms that began in his late teens.

Panic attacks struck unpredictably, even when a barber cutting his hair tried making small talk. His ringing phone, signaling the need to talk to someone, would make him so nervous he couldn’t answer it. Dave’s sudden, sweating anxiety also disrupted college classes, job interviews, and social occasions.

He didn’t have a name for the distressing feelings: “It was constant, but it was just part of me,” he says.

Dave now believes his untreated anxiety triggered his first depressive episode at age 17, when he sat listlessly in his back yard for hours. Yet during episodes of boundless energy, he opened a bakery, bought a half-dozen Subway franchises, and ran for political office. He never knew if he’d wake up as an outgoing guy who joked around and made things happen, or a withdrawn, fearful or hopeless shell of himself.

He finally got help at age 43. After days curled on the couch, speaking in monotones, he let his wife take him to the hospital. He was diagnosed with depression and prescribed medications that made the down times less deep.

Years later, when he read a magazine article about mania, he recognized his fast-talking times when he took big business risks and-felt invincible. “I thought, ‘This sounds like me,” he recalls.

Dave shared the information with his doctor, received a bipolar diagnosis and appropriate treatment, and saw his manic moods become less extreme. But when he was finally diagnosed with generalized anxiety disorder as well and his medication changed accordingly, the new treatment provided huge relief and “changed my life,” he says.

The man who wouldn’t answer his phone began to share his story as a mental health speaker with the National Alliance on Mental Illness in Clackamas County, Oregon, where he began working. “There is hope. You can come out the other side,” Dave adds.

*   *   *   *   *

Fast Facts About Anxiety

• Research indicates that more than half of people with bipolar disorder also have an anxiety disorder.
• Anxiety and bipolar symptoms overlap, but anxiety symptoms that persist when depression and mania/hypomania are in remission point to an anxiety disorder.
• Co-existing anxiety tends to make the course of bipolar disorder worse, so getting accurate diagnoses early is of utmost importance.
• Anxiety has such an influence on how a person with bipolar disorder responds to treatment that assessing anxiety symptoms is likely to become a standard part of care for bipolar.

Anxiety Coping Mechanisms

Just as the symptoms of bipolar and anxiety overlap, so do coping techniques such as adequate sleep, plenty of physical activity, and learning to reshape negative patterns of thought and behavior. Schaffer notes that cutting back on caffeine, often recommended for people with bipolar, seems to play an important role in defanging anxiety.

To cope with constant worrying: Mindfulness techniques can help to quiet racing thoughts. Dave says taking time daily to sit and meditate is critical to managing his anxiety.

Rebecca also recommends having a mindfulness practice — and she deploys an arsenal of more proactive tools as well.

When she’s plagued by persistent worries, she lists steps to resolve the problem that’s obsessing her. She tells herself: “There you are. That’s my worry again. I’m not going to listen to you today.” If the issue still bothers her days later, she’ll talk with her psychologist.

To cope with self-limiting behavior: When anxiety leads to avoiding social interactions and other fear-provoking situations, sometimes doing the very thing you’re afraid of is the best response.

In the Depression and Bipolar Support Alliance groups he leads, Alan gives out homework to counter isolation, such as, “Call a friend you haven’t seen in six months.”

Schaffer recommends a similar approach: “If you’re getting more isolated because of your anxiety, ask a friend or family member to help get you out of your home. Plan at least one activity each day in which you speak to another person, ideally in the morning. Email or text doesn’t count!”

Some other tips:

• Take baby steps toward changing behavior. After Rebecca’s hospitalization, she says, “I started small: ‘I’m going to brush my teeth today.’ ‘I’m going to get up before 1.’” Early in her recovery, she got out into the world by volunteering at a Métis association and other organizations.
• Learn your limitations and when to ask for help. When Rebecca starts to feel swamped by emotions, she knows she needs to schedule a vacation day or call a friend to meet for dinner.
• Look for the humor in life. Dave mines his anxiety and bipolar in a stand-up routine he performs as part of a comedy group of people with mood disorders.
• Become your own advocate to get the best possible care. “Treatment providers are not created equally, and recent research makes clear that seeking out a good therapist can have powerful effects beyond a mood stabilizer in treating bipolar depression and helping prevent relapses,” says Otto.

Types of Anxiety Disorders

According to the National Institute of Mental Health, there are several types of anxiety disorders. These are the symptoms of three of the most common. 

Generalized Anxiety Disorder 

• worrying very much about everyday things
• knowing you worry much more than you should
• having trouble controlling the constant worries
• not being able to relax
• having trouble concentrating
• being easily startled
• having trouble falling asleep or staying asleep
• feeling tired all the time 
• having a hard time swallowing 
• trembling or twitching
• having to go to the bathroom a lot
• being irritable
• sweating a lot, 
• feeling light-headed or out of breath
• having headaches, muscle aches, stomach aches or unexplained pains.

Phobias 

• strong, irrational fear of something that poses little or no actual danger 
• being anxious and extremely self-conscious in everyday social situations — such as eating or drinking in front of people — are signs of a social phobia. 
• People with phobias try to avoid what they’re afraid of, such as heights, public places, water or flying; if they can’t, they may experience panic, fear, rapid heartbeat, shortness of breath, trembling, and a strong desire to get away.

Panic disorder 

• is indicated by sudden and repeated attacks of fear that last for several minutes or longer. These panic attacks bring a fear of disaster or of losing control even when there’s no real danger. A person may also have a pounding or racing heart, breathing problems, weakness or dizziness, tingly or numb hands, chest pain, stomach pain, or feel hot or a cold chill. Panic attacks can occur at any time.

Editorial Sources and Fact-Checking

Spoorthy M, Chakrabarti S, Grover S. Comorbidity of Bipolar and Anxiety Disorders: An Overview of Trends in Research. World Journal of Psychiatry. January 2019. 

Highlights of Changes From DSM-IV-TR to DSM-5 [PDF]. American Psychiatric Association. 

Schaffer A, McIntosh D, Goldstein B, et al. The CANMAT Task Force Recommendations for the Management of Patients With Mood Disorders and Comorbid Anxiety Disorders. Annals of Clinical Psychiatry. February 2012. 

Ott C. Treatment of Anxiety Disorders in Patients With Comorbid Bipolar Disorder. The Mental Health Clinician. November 2018. 

Anxiety Disorders. National Institute of Mental Health. April 2023.

UPDATED: Originally printed as “The Tension Tango,” Fall 2012

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