Anxiety: A Core Feature of Bipolar?

Patient Expert

If you have been following this blog, you know that I've been immersed in the first draft of a book on bipolar. Part of the exercise involves looking at old material through new eyes. Predictably - or, rather, unpredictably - new realizations pop out. My most recent one involves anxiety.

Both my first book, Living Well with Depression and Bipolar Disorder, and my website,, devote considerable space to anxiety and its link to stress, and how all this feeds into our moods. The DSM-5 of 2013 expressly recognized this in the form of a new subtype for both depression and (hypo)mania - "with anxious distress."

Basically, whether manicky or depressed, we're keyed up and on edge, burdened by worry, barely able to hold it together.

In his classic Manic-Depressive Insanity of 1921, the pioneering diagnostician Emil Kraepelin described "depressive or anxious mania" and "excited depression." Freudian psychiatrists saw "neurosis" as driven by anxiety, which in turn fed into mood.

The first modern DSM - the DSM-III of 1980 - however, separated out anxiety from mood, as if the two conditions were unrelated. Yes, you could have both going on at once, but only as part of two distinct illnesses arriving on your doorstep. The technical term is "comorbid."

According to the 2007 National Comorbidity Survey Replication, three in every four individuals with bipolar also experience anxiety. Do you see an aha moment developing here? Here's what I have to say in my draft:

The numbers make a compelling case that we need to think of anxiety as a core bipolar feature, one that merits the same status and respect as depression and hypomania and mania.

I also add that it would be foolish to disregard less severe forms of anxiety. Just a little anxiety - and who doesn't get a little anxious? - may have a major impact on our moods. There is an impressive body of research that validates this. Give the DSM credit for finally getting with the program.

The DSM-5 lists a number of different types of anxiety, including generalized, social, phobias, and panic. In a nutshell, our irrational fears and worries have a way of kicking off panic or a sense of helplessness. Typically, we cope by resorting to no end of maladaptive behaviors.

Another wrinkle to this conversation is that for some of us, mild anxiety may form a natural part of our personality - fidgety types, the high-strung. If this describes you, aiming for calm equipose all the time may be overshooting the mark. Not all anxiety is bad.

But all of us do need to worry about anxiety running away from us. The most obvious way to head it off at the pass is by managing our stress. This will work a lot of the time, but not always. Life, too often, takes us by surprise.

Nevertheless, you will thank yourself for all those times you succeed.

We also need to work on building good lifestyle routines, whatever works for you - walks, yoga, quiet times. In addition, cognitive behavioral therapy will help you build a good coping toolkit.

For those in-case-of-emergency-break-glass situations, you may want to have anti-anxiety medication on hand. In general, these are prescribed on an "as needed" basis.

In a pinch, our breath is our best friend. The stress response initiates shallow breathing, which essentially pours oil on the fire of fight-or-flight. Thus, if you spot flashing blue lights in your rearview mirror, now would be a good time to concentrate on deeper breathing.

Essentially, long slow out-breaths kick in the relaxation response. (See The Breath - Bipolar's Number One Killer App.)

To close "

Anxiety will certainly complicate the course of your bipolar, but you are not helpless. Give the condition the respect it deserves. Regard it as a core part of your illness. Do your research, pick up your own coping tricks, develop new habits. Forgive yourself when anxiety runs away from you, pat yourself on the back with each small success. Take heart, live well "