Peanut Butter & Jelly, Barbie & Ken, Bipolar Disorder & Anxiety

Okay, so you’re a purist when it comes to your bipolar diagnosis. Doggone it, if a symptom isn’t listed in the good ‘ole DSM-IV-TR, then it just can’t be a part of the equation – even if you’re experiencing that very impossibility.

With that “in-mind,” let’s chat anxiety. Go ahead – grab a DSM and take a look at the seven things that make for a manic or hypomanic episode (of which 3.62 have to occur over 3.98 days, causing a 49.2% compromise in functioning). You won’t find anxiety.

By the way, you won’t find anxiety in the criteria for a major depressive episode either.

Hmmm – well that means anxiety can’t be a tree in the bipolar landscape. Ah, but not true, oh pure one.

The man in the image is Dr. Jim Phelps, a Corvalis, OR psychiatrist. I was introduced to his work several years ago when I read his book, Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder. His website,, is a must-visit for anyone involved with a mood disorder. Not only are his insights creative and fresh, his writing style is fun and engaging.

What you’re about to digest (hopefully) is a re-chew of Dr. Phelps’ cabbage.

Anxiety, as either a symptom of bipolarity or a comorbid (separate/co-existing) diagnosis, absolutely must be considered and assessed because of the huge treatment implications. Now, if anxiety is a symptom of bipolarity, it could likely improve as the mood issues are stabilized. But if it’s presenting comorbidly, it’ll require its own treatment regimen.

And that has the potential to complicate matters because if it comes down to having to use medicine to treat the anxiety, an antidepressant is the likely candidate. Unfortunately, the use of an antidepressant in the absence of mood-stabilizing medicines can push one into a highly elevated mood very quickly.

Externally, anxiety as a symptom of bipolarity may present in behaviors such as pacing, leg-pumping, and running one’s fingers through their hair. Internally, it may present as a sense of great discomfort in one’s own skin, racing or disorganized thoughts, feelings of a pending explosion inside, or inattention.

To make matters so much worse, when you apply a layer(s) of anxiety on top of a more recognized symptom of bipolarity – say, irritability – life can become yet more unpleasant, damned quickly. And it’s at this point some very icky – even life threatening – coping mechanisms and behaviors may occur. Finally, if a major depressive episode log is tossed on the fire, things can spin very horribly out-of-control.

So, yes – anxiety disorders and bipolarity are very frequently comorbid situations. But deciding whether it’s an issue of co-existence or symptomatology is always a tough call. And that’s because they can so closely resemble each other. For example, generalized anxiety disorder looks very much like bipolar II. It can be a comorbid diagnosis, yet its symptoms frequently hit the highway as one’s mood is stabilized. So it takes on the face of a symptom. Very dicey stuff.

Well, we can speculate on matters of inclusion or independence ‘til the cows come home. But, according to Dr. Phelps, from a treatment standpoint here’s the bottom-line…

  • Always treat bipolarity first.
  • If anxiety symptoms continue after mood has been stabilized, treat them.
  • Opt for psychotherapy first in addressing the anxiety piece.
  • Should therapy not work well, consider an antidepressant – but only if a mood-stabilizing med has been introduced.

So there it is – the bipolarity/anxiety dance. And it can involve a whole lot of fancy footwork as both fight to lead.

What are your experiences with bipolarity and anxiety? We’d love to have your thoughts in a comment. Won’t you?