Most people feel anxious at times and have their ups and downs. It is natural for a mood to change or anxiety level to rise when a stressful or difficult event occurs. But some people experience feelings of anxiety or depression or suffer mood swings that are so severe and overwhelming that they interfere with personal relationships, job responsibilities, and daily functioning. These people may be suffering from an anxiety disorder, bipolar disorder, or both.

It is not uncommon for someone with an anxiety disorder to also suffer from bipolar disorder. Many people with bipolar disorder will suffer from at least one anxiety disorder at some point in their lives. The good news is that the disorders are treatable separately and together. Read on to find out more.

Anxiety Disorders
Anxiety disorders are a unique group of illnesses marked by persistent, excessive and irrational anxiety. These disorders include generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder, posttraumatic stress disorder (PTSD), social anxiety disorder, and specific phobias. Find out more about anxiety disorders.

Bipolar Disorder
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy, and ability to function. The mood episodes associated with the disorder persist from days to weeks or longer, and can be dramatic, with periods of being overly high and/or irritable to periods of persistent sadness and hopelessness. Severe changes in behavior go along with the mood changes. These periods of highs and lows, called episodes of mania and depression, can be distinct episodes often recurring over time, or they may occur together in a so-called mixed state. Often people with bipolar disorder experience periods of normal mood in between mood episodes.

A manic episode is diagnosed if an elevated mood occurs with three or more primary symptoms most of the day, nearly every day, for at least one week. With an irritable mood, four additional symptoms must be present for a diagnosis.
Signs and symptoms of a manic episode can include the following:

• Increased energy, activity, and restlessness
• Excessively high, overly good, euphoric mood
• Extreme irritability
• Racing thoughts and talking very fast, jumping from one idea to another
• Distractibility, inability to concentrate well
• Little sleep needed
• Unrealistic beliefs in one's abilities and powers
• Poor judgment
• Spending sprees
• A lasting period of behavior that is different from usual
• Increased sexual drive
• Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
• Provocative, intrusive, or aggressive behavior
• Denial that anything is wrong

A depressive episode is diagnosed if five or more primary depressive symptoms last most of the day, nearly every day, for a period of two weeks or longer.
Signs and symptoms of a depressive episode can include the following:

• Lasting sad or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in activities once enjoyed, including sex
• Decreased energy, a feeling of fatigue or of being "slowed down"
• Difficulty concentrating, remembering, making decisions
• Restlessness or irritability
• Sleeping too much, or having trouble sleeping
• Change in appetite or unintended weight loss or gain
• Thoughts of death or suicide, or suicide attempts

It can be helpful to think of bipolar disorder as a spectrum of moods. At one end is severe depression, above which is moderate depression, and then mild low mood, which may be called the blues when it is short-lived and dysthymia when it is chronic. Next is normal or balanced mood, then hypomania (mild mania that may feel good and be relatively brief and less severe), and then severe mania, which can include hallucinations, delusions, or other symptoms of psychosis.

Some people may experience symptoms of mania and depression together in what is called a mixed bipolar state. Symptoms often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad hopeless mood even while feeling extremely energized.

Read more about bipolar disorder in adults and in children and teens.

Co-Occurring Anxiety Disorder and Bipolar Disorder
According to Naomi M. Simon, MD, Associate Director of the Center for Anxiety and Traumatic Stress Disorders at Massachusetts General Hospital and Assistant Professor in psychiatry at Harvard Medical School, making a diagnosis of an anxiety disorder plus bipolar disorder can be confusing, and it is best to seek help from a mental health professional. But, Dr. Simon says, a few clues may suggest the presence of both an anxiety disorder and bipolar disorder:

1. The presence of panic attacks, significant anxiety, nervousness, worry, or fearful avoidance of activities in addition to periods of depression and mania or hypomania.
2. The development of symptoms as a child or young adult, which people with both disorders are more likely to report.
3. Significant problems with sleep and persistent anxiety even when not in a manic state, and lack of response to initial treatment.
4. Increased sensitivity to initial side effects of medication, and sometimes a longer time frame for finding the right medication combination and dosing.

Suffering from an anxiety disorder and bipolar disorder has been associated with decreased functioning and quality of life and an increased likelihood of substance abuse and suicide attempts. Insomnia, a common anxiety disorder symptom, is a significant trigger for manic episodes.

The Course of Bipolar Disorder
Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third find that some linger. A small percentage experience chronic unremitting symptoms despite treatment.

Bipolar I disorder is the classic form of the illness, which involves recurrent episodes of mania and depression. People with bipolar II disorder never develop severe mania; instead they experience episodes of hypomania that alternate with depression. When four or more episodes of illness occur within a twelve-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.

Most people with bipolar disorder can lead healthy and productive lives when the illness is properly treated. Without treatment, however, the disorder tends to worsen. Over time a person may suffer more frequent and more severe manic and depressive episodes than when the illness first appeared.

Some people with bipolar disorder become suicidal. Risk for suicide appears to be greater earlier in the course of the illness. A person with bipolar disorder, or anyone thinking about committing suicide, needs immediate attention from a mental health professional or a physician.

Treatment Options
To achieve wellness, it is essential that people receive treatment for a co-occurring anxiety disorder and bipolar disorder. Treatment for both, however, is more complex than treatment for one. Carefully consider all treatment options with your doctor or mental health provider: medication, therapy, or a combination. With proper treatment, anxiety disorders and bipolar disorder can be overcome.

Medications
When treating a co-occurring anxiety and bipolar disorder with medication, most doctors first prescribe a mood stabilizer to address the bipolar disorder. Starting an antidepressant (a common medication approach for anxiety disorders) before mood stabilization is achieved may worsen the bipolar disorder symptoms. However, an antidepressant can trigger manic episodes, even while taking a mood stabilizer. For this reason, doctors sometimes avoid prescribing antidepressants or prescribe them at a low dose for patients with co-occurring disorders, and they monitor carefully any patients who are taking a mood stabilizer and an antidepressant.

Because benzodiazepines (a class of drugs often used to treat anxiety disorders) do not appear to have negative effects on bipolar disorder, they may be used for anxiety in patients with co-occurring bipolar disorder. However, they may cause side effects, including physical dependence and tolerance (a need for more medication over time), and there is some risk of abuse among people suffering from bipolar disorder, particularly those who have experienced alcohol or substance abuse. People may need to try a few different combinations to find the most effective medications.

Types of Therapy
People with bipolar disorder should receive medication for mood stabilization. But therapy also plays an important role. Using cognitive-behavioral therapy (CBT) or another evidence-based psychotherapy instead of medication for an anxiety disorder addresses concerns about side effects from taking mood stabilizers with anti-anxiety medications. Below are forms of therapy with varying levels of research evidence for anxiety disorders:

Cognitive-Behavioral Therapy. Many therapists use cognitive and behavior therapies, often referred to as CBT, which is a short-term form of psychotherapy. The patient is actively involved in his or her own recovery, has a sense of control, and learns skills that are useful throughout life. CBT focuses on identifying, understanding, and modifying thinking and behavior patterns. When a person changes thinking and behavior, emotional changes usually follow. Because CBT teaches skills for handling anxiety, people who learn and practice the skills can use them when needed.

Cognitive Therapy. The goal of cognitive therapy is to identify, challenge, and change unwanted, unproductive thoughts, feelings and behaviors. A person learns to separate unrealistic thoughts and feelings from realistic ones. As with behavior therapy, the person is actively involved in his or her own recovery.

Behavior Therapy. The goal of behavior therapy is to modify and gain control over unwanted behavior. A person learns to cope with difficult situations, often through controlled exposure to them.

Family Therapy. This form of therapy uses strategies to reduce the level of distress within a family that may either contribute to an ill person’s symptoms or result from them.

Relaxation Techniques. These techniques may help people develop the ability to cope more effectively with the stresses that contribute to anxiety and mood, as well as with any associated physical symptoms. Breathing re-training, progressive muscle relaxation, and exercise are among the techniques.

Interpersonal and Social Rhythm Therapy. Effective for bipolar disorder, this treatment program stresses maintaining a regular schedule of daily activities and stability in personal relationships. Patients record the timing of their activities, moods, and levels of social stimulation. As treatment progresses, they work to keep stable social rhythms (when to sleep, exercise, eat, etc.), anticipate events that could disrupt rhythms, and develop plans for continued mood and social rhythm stability.

Finding a Therapist
ADAA provides a searchable listing of mental health providers who specialize in treating anxiety disorders: Find a therapist in your area. Consider asking the following questions during your initial consultation:

• What training and experience do you have in treating anxiety disorders and bipolar disorder?
• What is your basic approach to treatment?
• Do you recommend treating the anxiety first or the bipolar disorder?
• How do you manage treatment if I am seeing another doctor/therapist for treatment as well?
• Can you prescribe medication or refer me to someone who can?
• How long is the course of treatment?
• How frequent are treatment sessions and how long do they last?
• Do you include family members in therapy?
• Will it be possible to reach you after hours in the event of an emergency or crisis?
• What is your fee schedule, and do you have a sliding scale for varying financial circumstances?
• What kinds of health insurance do you accept?

More Steps to Reduce Anxiety and Regulate Mood
Join a support group. Support groups can be an invaluable resource for recovery and empowerment. Usually facilitated by a consumer, layperson, or survivor, they involve people with similar needs or experiences. Search the ADAA website for local support groups for anxiety disorders. Learn about other self-help groups at the Depression and Bipolar Support Alliance (DBSA) website.

• Exercise regularly. Exercise can have a beneficial effect on anxiety, bipolar disorder, and depression because chemicals released during exercise have a stabilizing effect on mood. Set a goal of 30 minutes of activity three to five times a week: Jog, walk, bike, or dance. Discover more about exercise as a part of therapy.
• Get a good night’s sleep. Sleep deprivation is never beneficial. As noted above, insomnia can be a trigger for manic episodes. Learn more about anxiety and sleep disorders. Take these tips from the National Sleep Foundation to get a good night’s sleep.
• Avoid alcohol and drugs. Alcohol and drugs that have not been prescribed can aggravate anxiety, trigger panic attacks, and worsen episodes of mood disorders. Find out more about anxiety disorders and alcohol abuse.

Helping Loved Ones
The support of family and friends is important to the recovery process for anyone diagnosed with co-occurring anxiety and bipolar disorders. Taking these steps can help a loved one:

• Learn about the disorders.
• Recognize and praise small accomplishments.
• Modify expectations during stressful periods.
• Measure progress on the basis of individual improvement, not against some absolute standard.
• Be flexible and try to maintain a normal routine.
• Keep track of symptoms. Loved ones may notice a change in behavior or symptoms before the person suffering from them does, and treatment modification based on these changes may help stave off a severe episode.
• Provide ongoing encouragement during the treatment process, and help your loved ones consistently take their medication and keep therapy appointments, particularly when they are not feeling well. Be aware that it may take awhile to find the best individual treatment plan.
• Make a clear plan for emergency situations should symptoms become severe or hospitalization become necessary.
• Keep in mind that the recovery process is stressful for family and friends. Try to build a support network of relatives, friends, and therapists, if necessary.

Children With Co-Occurring Anxiety and Bipolar Disorders
Many children with bipolar disorder also suffer from at least one co-occurring anxiety disorder. The age of onset for an anxiety disorder often precedes the age of onset for bipolar disorder. The co-occurrence of an anxiety disorder with bipolar disorder can worsen the symptoms and course of each disorder, so it’s essential that both are treated. Sometimes severe mood episodes, extreme irritability, and other pronounced symptoms of bipolar disorder mask underlying obsessive thoughts, compulsions, worries, or other anxiety symptoms. It’s recommended that children with bipolar disorder are also assessed for an anxiety disorder.

Helping Your Child
Consult a mental health provider or physician as soon as possible if your child exhibits symptoms of an anxiety or bipolar disorder. Find out more information about helping your child, including suggestions to find the right mental health professional.  The Child & Adolescent Bipolar Foundation (CABF) website provides information about finding a therapist.

NOTE: This information is not intended to provide a diagnosis or specific clinical advice to individuals about their psychiatric condition, nor to the family members or friends of individuals with psychiatric conditions. Anyone seeking to rule out or establish a diagnosis or anyone seeking immediate help for a psychiatric condition should contact a mental health professional.

Resources

Child & Adolescent Bipolar Foundation

Depression and Bipolar Support Alliance

Mental Health America

National Alliance on Mental Illness