Bipolar Anxiety: How Anxiety Shows Up in Bipolar Disorder (and What to Do About It)

Living with bipolar disorder is often described as navigating a world of extremes—the soaring highs of mania and the crushing lows of depression. However, for a significant majority of patients, there is a third, often invisible passenger on this journey: bipolar anxiety.

While the diagnostic criteria for bipolar disorder focus heavily on mood swings, clinical reality tells a different story. Anxiety isn’t just an “add-on” or a separate problem for many; it is woven into the very fabric of their mood episodes. Whether it manifests as a frantic restlessness during a manic phase or a paralyzing dread during a depressive slump, bipolar disorder with feeling anxiety is one of the most challenging aspects of the condition to treat and manage.

In this comprehensive guide, we will explore the intersection of these two emotional powerhouses, how to distinguish between them, and the evidence-based strategies used to bring the nervous system back into balance.

What Is Bipolar Anxiety?

To understand bipolar anxiety, we must first look at how it differs from a standalone anxiety disorder. In plain English, bipolar anxiety refers to intense feelings of tension, apprehension, or physical nervousness that occur specifically within the context of bipolar disorder.

It is rarely a separate, static diagnosis. Instead, clinicians often view it through two lenses:

1. A Comorbidity: Having both Bipolar Disorder and a separate Anxiety Disorder (like GAD or Panic Disorder) simultaneously.
2. A Specifier: The DSM-5 uses the term “with Anxious Distress” to describe a mood episode that is permeated by high levels of anxiety.

Unlike general anxiety, which may be constant, bipolar anxiety depression or manic-anxiety often fluctuates in tandem with mood shifts. It isn’t just “worrying about things”; it is a physiological state of high arousal where the brain’s “alarm system” is stuck in the ‘on’ position while the mood is already unstable.

Is Anxiety Common in Bipolar Disorder?

If you struggle with bipolar disorder with feeling anxiety, you are far from alone. In fact, you are in the majority. Research indicates that up to 50% to 70% of people with bipolar disorder will experience a lifetime comorbid anxiety disorder.

Why Anxiety Matters in Bipolar Disorder

Anxiety is not a “benign” addition to manic depression and anxiety. Statistically, when anxiety is present, the clinical course of bipolar disorder becomes more complex:

• Longer Episodes: Mood episodes tend to last longer when anxiety is high.
• Reduced Treatment Response: Traditional mood stabilizers may take longer to work.
• Higher Suicide Risk: Intense anxiety creates a sense of “mental agitation” that can increase the risk of self-harm.
• Increased Substance Use: Many individuals attempt to “self-medicate” the physical vibration of anxiety with alcohol or sedatives.

Understanding that anxiety is a core part of your bipolar experience—rather than a separate personal failing—is the first step toward finding a medication and therapy plan that actually works.

What Is “Anxious Distress” in Bipolar Disorder? (DSM-5 Explained)

In 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced a specific “Anxious Distress Specifier.” This was a landmark change for patients with bipolar 1 with anxious distress or bipolar 2 with anxious distress.

The Criteria for Anxious Distress

To meet this specifier, an individual must experience at least two of the following symptoms during a majority of days during a mood episode:

1. Feeling keyed up or on edge.
2. Feeling unusually restless.
3. Difficulty concentrating because of worry.
4. Fear that something awful might happen.
5. Feeling that the individual might lose control of themselves.

Why This Specifier Is Often Missed

Because BPD is so “loud” (mania and depression are very dramatic), clinicians sometimes overlook the “background noise” of anxiety. However, identifying anxious distress is vital because it often signals that a patient may not respond well to antidepressants alone and might require a more robust mood-stabilizing approach.

Bipolar 1 vs. Bipolar 2 With Anxiety

While anxiety is prevalent in both types, the patterns of bipolar 2 depression and anxiety often differ from those seen in Bipolar 1.

What Is the Difference Between Bipolar 1 and 2?

• Bipolar 1: Characterized by at least one full manic episode (often requiring hospitalization). Anxiety here often manifests as agitated mania, where the “high” is not euphoric, but rather a terrifying, high-energy panic.
• Bipolar 2: Characterized by hypomania and severe major depression. In bipolar 2, anxiety is frequently the “engine” behind the depression. Patients may not feel “sad” so much as they feel “paralyzed by dread.”

Suicide Risk Differences

Interestingly, some studies suggest that suicide risk is actually higher in Bipolar 2 with anxious distress than in Bipolar 1. This is because the “energy” of anxiety combined with the “hopelessness” of depression creates a dangerous state where an individual has the motivation to act on self-destructive thoughts.

What Does Bipolar Anxiety Feel Like?

If you ask ten different people, “What is bipolar anxiety like?”, you will get ten different answers, but they generally fall into three categories:

1. Internal Restlessness

This isn’t just “fidgeting.” It is a sensation that your blood is made of caffeine or that your nerves are being touched by a live wire. You may feel like you need to “jump out of your skin” but have nowhere to go.

2. Racing Thoughts

Unlike the “creative” racing thoughts of pure mania, bipolar anxiety thoughts are “repetitive loops.” You may obsess over a minor social interaction or a perceived future catastrophe, unable to break the cycle.

3. Physical Anxiety Symptoms

The body takes the brunt of bipolar anxiety. Common physical signs include:

• Tightness in the chest or a “heavy” feeling on the lungs.
• Gastrointestinal distress (the “knot” in the stomach).
• Chronic muscle tension, particularly in the jaw, neck, and shoulders.
• Shortness of breath or hyperventilation during mood shifts.

Does Mania Increase Anxiety?

A common misconception is that mania is always “happy” or “euphoric.” So, does mania increase anxiety? Absolutely.

In clinical terms, this is often referred to as a Mixed Episode or “Mixed Features.” When the high energy of mania meets the negative affect of anxiety, it creates “Dysphoric Mania.”

The Experience of Agitated Mania

In this state, you are manic—you aren’t sleeping, your thoughts are fast, and you are impulsive—but you aren’t having fun. Instead, you are terrified. You are “vibrating” with energy but convinced that something is wrong. This is perhaps the most dangerous state in bipolar disorder because the impulsivity of mania is driven by the panic of anxiety.

Am I Manic or Anxious? How to Tell the Difference

Because both mania and anxiety involve high energy and racing thoughts, it can be difficult to distinguish between the two. Understanding the difference between anxiety and bipolar mania is crucial for proper medication adjustment.

Mania vs. Anxiety Comparison Table

If you are “fast” and “fearful,” you are likely experiencing bipolar anxiety. If you are “fast” and “invincible,” you are likely experiencing pure mania.

Bipolar Anxiety vs. Depression and Anxiety Disorders

Distinguishing between bipolar vs. depression and anxiety is one of the most difficult tasks in modern psychiatry. Because most people with bipolar disorder seek help during a “down” phase, they are frequently misdiagnosed with Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD).

The Danger of Misdiagnosis

When diagnosing anxiety and depression, a clinician must look for the “hidden” history of hypomania. If a person with bipolar disorder is treated for depression and anxiety diagnosis with standard antidepressants (SSRIs) alone, it can trigger a manic switch or increase “rapid cycling.” In these cases, the anxiety doesn’t go away—it becomes “electrified,” turning into an agitated, mixed state.

How Bipolar Anxiety Differs from GAD

In GAD, the anxiety is often about life circumstances (money, health, work). In bipolar anxiety depression, the anxiety often feels “biological”—it arrives without a specific trigger, like a weather system moving through the brain.

Bipolar Anxiety and Panic Attacks

For many, the intersection of bipolar panic attacks is where the disorder becomes most debilitating. Panic attacks can occur during any phase of bipolar disorder, but they are most common during depressive or mixed episodes.

• Panic During Mood Episodes: If you are already in a state of “anxious distress,” your threshold for a panic attack is much lower. A minor stressor can send you into a full-blown physical “meltdown.”
• Trauma Overlap: There is a high correlation between Bipolar Disorder and PTSD. If a panic attack is triggered by a traumatic memory, it can destabilize the underlying mood episode, making the “come down” from the panic much longer.
• Comorbid Panic Disorder: If panic attacks occur frequently and independently of mood episodes, a psychiatrist may diagnose a separate Panic Disorder alongside the bipolar diagnosis.

Best Bipolar Medication for Anxiety (Evidence-Based Overview)

When it comes to best bipolar medication for anxiety, the philosophy is “stability first.” You cannot effectively treat anxiety in a bipolar brain if the underlying mood is still “swinging.”

Important Framing: The Anti-Antidepressant Paradox

For most anxiety disorders, SSRIs (like Prozac or Zoloft) are the first choice. However, in anxiety and bipolar medication management, antidepressants are used very cautiously. Without a mood stabilizer, an antidepressant can make bipolar anxiety significantly worse by adding “fuel” to the manic fire.

What is the Best Anxiety Medication for Bipolar Disorder?

Finding the best anxiety medication for bipolar requires a balancing act: calming the anxiety without “pulling” the person into depression or “pushing” them into mania.

1. Mood Stabilizers

• Lithium: The gold standard for preventing mania, it has moderate anti-anxiety effects for some, though it primarily stabilizes the “floor and ceiling” of the mood.
• Valproate (Depakote): Often effective for “agitated” states and mixed episodes where anxiety is high.
• Lamotrigine (Lamictal): Particularly effective for bipolar 2 depression and anxiety. It has a unique ability to lift the “weight” of depressive dread without causing mania.

2. Atypical Antipsychotics

• Quetiapine (Seroquel): Frequently prescribed specifically for bipolar disorder with feeling anxiety. At certain doses, it is highly sedating and can “quiet” the racing, anxious brain.
• Lurasidone (Latuda): Primarily used for bipolar depression; it helps clear the “fog” of anxiety that often accompanies a depressive low.

3. Medications Used Cautiously

• SSRIs/SNRIs: Only used when a mood stabilizer is already “on board” to prevent a manic switch.
• Benzodiazepines (e.g., Xanax, Ativan): Useful for short-term “rescue” during a panic attack, but used with caution due to the risk of dependence and their tendency to cause “rebound anxiety” in bipolar patients.

Treating Anxiety in Bipolar Disorder: Full Treatment Plan

A treating anxiety in bipolar disorder plan must be “multi-modal.” Medication provides the biological foundation, but psychotherapy provides the “manual” for living.

Psychotherapy

• CBT Adapted for Bipolar: Traditional Cognitive Behavioral Therapy is modified to help patients recognize “mood triggers” versus “anxiety triggers.”
• Dialectical Behavior Therapy (DBT): Excellent for “distress tolerance.” It teaches you how to survive an anxiety spike without making impulsive manic decisions.
• Psychoeducation: Learning the “mechanics” of your brain reduces the “fear of the fear.”

Lifestyle & Adjunctive Strategies

• Sleep Regulation: Sleep is the “anchor” of the bipolar brain. Anxiety often destroys sleep, which then triggers mania. Using strict “sleep hygiene” is a medical necessity, not just a suggestion.
• Exercise: Helpful for burning off the “agitated energy” of bipolar anxiety, but must be timed correctly to avoid over-stimulation.

Non-Medication Support for Bipolar Anxiety

While not replacements for medical care, adjunctive strategies can lower the “baseline” of your anxiety.

• Meditation for Depression and Anxiety: For bipolar patients, “mindfulness” should be practiced carefully. Sometimes, sitting in silence with racing thoughts can be triggering. Guided, “grounding” meditations that focus on the body are often safer.
• Acupuncture and Depression Anxiety: Some patients find that acupuncture helps lower cortisol levels and reduces the “physical vibration” of bipolar anxiety.
• Dark Therapy: Some evidence suggests that spending time in total darkness (or using blue-light blocking glasses) can help calm the brain’s “manic-anxiety” center by regulating melatonin production.

Online and Professional Help for Bipolar Anxiety

Navigating the complexities of bipolar anxiety often requires a team approach. Because this condition involves both biological mood shifts and psychological distress, a combination of professional roles is usually necessary.

Psychiatry vs. Therapy Roles

• Psychiatrist: Your psychiatrist is the “medical architect.” Their role is to manage anxiety and bipolar medication, ensuring your mood stabilizers are at therapeutic levels before addressing anxiety symptoms. If you are looking for a psychiatrist depression anxiety specialist, ensure they have specific experience with bipolar spectrum disorders.
• Anxiety Depression Therapist: A therapist helps you deconstruct the “thought loops” that fuel your anxiety. When searching for an anxiety depression therapist near me, look for someone trained in CBT-Ib (CBT for Bipolar) or DBT.

Telehealth and Urgent Care

The rise of online help for anxiety and depression has made support more accessible. Telehealth platforms can be excellent for consistent therapy; however, if you are experiencing “agitated mania” or severe “anxious distress” where you feel you might lose control, an in-person psychiatric evaluation at an urgent care or hospital is the safest route.

Chronic Depression, Anxiety, and Bipolar Disorder

For some, the struggle isn’t episodic—it feels permanent. Chronic depression and anxiety are frequently the “baseline” for individuals with Bipolar 2.

The Problem of Treatment Resistance

If you have been treated for “chronic depression” for years without success, it may be because the underlying bipolar nature of the illness hasn’t been addressed. Bipolar anxiety depression requires a different chemical approach than standard clinical depression. Once the “cycling” is stopped with mood stabilizers, the “chronic” nature of the anxiety often begins to lift.

How Bipolar Anxiety Is Diagnosed

Diagnosing anxiety and depression within the bipolar spectrum requires a “longitudinal” view—looking at your history over years, not just weeks.

The Clinical Interview

A professional depression and anxiety diagnosis for a bipolar patient involves:

• Mood History: Mapping out periods of high energy vs. low energy.
• Family History: Bipolar disorder has a strong genetic link.
• The “Antidepressant Test”: Reviewing if SSRIs ever made you feel “wired,” “jittery,” or caused you to stay up all night.

Axis I Disorders: Where Bipolar and Anxiety Fit

In the historical “Multi-axial” system of psychiatry, users often ask, “What disorders are in Axis 1?” Under this older framework, Axis I was reserved for “clinical disorders,” which included both Bipolar Disorder and Anxiety Disorders. While the current DSM-5 has moved away from this “axis” system to a more integrated approach, the concept remains helpful for understanding that BPD and anxiety are clinical conditions—they are biological illnesses, not personality traits or character flaws.

When to Take a Bipolar or Anxiety Self-Test

If you are seeing signs of bipolar disorder, you might wonder “When should I take a self-test?” ### Could You Have Bipolar Disorder? Key Symptoms to Watch For:

• Periods of high energy where you didn’t need sleep.
• Anxiety that feels “electrical” or “buzzy” rather than just “worried.”
• A history of antidepressants “not working” or making you feel worse.

A Note on Screening: A self-test is a conversation starter, not a diagnosis. Use it to gather your thoughts before seeing a professional.

FAQs About Bipolar Anxiety

What is bipolar anxiety like?

It is often a physical, high-energy state of dread. It feels like “racing thoughts” that are focused on fear rather than creativity.

Am I manic or anxious?

If you feel “invincible” and don’t need sleep, it’s likely mania. If you feel “terrified,” restless, and can’t sleep despite being tired, it’s likely bipolar anxiety.

What is the best anxiety medication for bipolar?

Usually, a combination of a mood stabilizer (like Lithium or Lamotrigine) and a calming atypical antipsychotic (like Quetiapine).

Key Takeaways: Managing Anxiety in Bipolar Disorder Safely

1. Anxiety is a Bipolar Symptom: In many cases, the anxiety is part of the mood episode, not a separate disorder.
2. Stability First: Treat the “bipolar” before the “anxiety.” Calm the mood swings to give the anxiety a chance to settle.
3. Avoid Antidepressant-Only Treatment: Without a stabilizer, these can turn anxiety into dangerous agitation.
4. You Are Not Your Symptoms: The “fear that something awful will happen” is a chemical signal, not a prophecy.

Emergency Support: If your anxiety has reached a point where you feel you might lose control, please text or call 988 (in the US and Canada) or visit your nearest emergency room.

Authoritative References & Clinical Resources

1. National Institute of Mental Health (NIMH): Bipolar Disorder 
2. American Psychiatric Association (APA): What Are Bipolar Disorders? 
3. The International Society for Bipolar Disorders (ISBD) 
4. Mayo Clinic: Bipolar Disorder Symptoms & Causes 
5. Journal of Clinical Psychiatry: Anxiety Comorbidity in Bipolar Disorder