updated 2/2019

Yes, anxiety can be “bipolar”

This is not even controversial, if you accept that agitation can feel like “anxiety”.  People with agitation often describe their discomfort as “anxiety” – including to themselves. 

Agitation is a core symptom of “mixed states”. You don’t even have to have bipolar disorder to have a mixed state. Huh? Yep, time to learn more… 

What are mixed states?

“Bipolar” is the wrong description. A person can have depression and manic symptoms (including very subtle ones) at the same time. This is called a mixed state.

The mood spectrum concept found all over this site helps explain variations of depression that are “a little bipolar” (e.g. see the Diagnosis page). That same spectrum concept helps explain the many variations of mixed states, as implied by this graph:

Mixed states combine manic and depressive symptoms many ways
How many mood specialists view mixed states

Hold on, this is controversial. The DSM version of “mixed states” only allows certain manic symptoms to count toward mixed-ness. Insomnia, irritability, and distractibility for example, are excluded. Most mood specialists I’ve read think this is wrong (e.g. Ghaemi). Considerable research suggests the excluded symptoms are among the most important ones (e.g. Angst).

Why do mixed states matter?

  1. They’re common
  2. They can easily be confused for anxiety
  3. Antidepressants can cause them
  4. Antidepressants can make them worse
  5. They can occur in plain old depression too, not just “bipolar”

What do they feel like?

Here’s a comparison of mixed state symptoms and hypomania (if you’ve not learned about hypomania yet, go to the Diagnosis page ). This list was prepared by my colleague and co-author, Dr. Chris Aiken. Thanks much!

A comparison of mixed state symptoms and hypomania
Compare mixed symptoms versus hypomania

These are the various symptoms. But they often don’t just sit there, they shift, sometimes quickly. The result is a weird, changing mood/energy state ranging from purely depressed to highly over-energized (often in very negative ways). For a graphic view of this weird shifting, see the Mixed States as Waves page).

Treatment

This a very long story. A short version: follow the same principles as I’ve laid out for bipolar disorder in general (see the Treatment page). Maximize non-medication approaches; add mood stabilizers until cycling stops, or in this case, until mixed symptoms gradually fade away; and watch out for antidepressants.

The difference here is that antidepressants are even more clearly associated with mixed states than with rapid cycling. So while treatment guidelines for mixed states generally suggest adding medications like lurasidone or olanzapine or ziprasidone, my strong preference is to begin by gradually tapering the antidepressant (which is so commonly already there). Of course if symptoms are severe, “gradual” is not the right approach. The bigger guns may be needed, for a while.

Gradual can mean anything from a few months to much longer, so this is a very long process. You’ll need to be convinced it’s really necessary. For many people that means trying many other approaches first. See the Antidepressant Taper page for much more on that process.

More on anxiety and bipolar

This is a very complicated relationship, these two things. For more (perhaps too much? decide when you get there…) see my specific page on this.