With this comorbidity, the patients are consistently anxious, maintaining high levels of anxiety regardless of precipitants. They often worry excessively about areas of life including occupation, family relationships, finances, parenting, sexual relationships, medications, medication side effects, and potential lack of response to treatment, to name a few. Although environmental precipitants may make the anxiety worse, these patients are anxious and worried even in the absence of negative life precipitants.

Elevated mood patients may have isolated rare panic attacks or have frequent debilitating episodes, constituting a panic disorder diagnosis. In some patients, the panic attacks are limited to the elevated mood state. For others, attacks are seemingly unrelated to any specific mood state occurring spontaneously
in response to trigger behaviors or phobias such as flying, public speaking, highway driving, heights, closed spaces or fear of being alone. Patients with bipolar disorder may experience panic attacks as a side effect to the initiation of antidepressant medication. When this occurs, other hypomanic symptoms usually accompany the onset of panic attacks. These can include difficulty sleeping, a heightened level of mental and behavioral arousal, physical hyperactivity, and racing thoughts. On occasion, the new onset or worsening of panic attacks in a patient who has otherwise been diagnosed as having a unipolar depression may herald the necessity for a reevaluation and possible re-diagnosis to the bipolar spectrum. When such a patient has not been placed on a mood stabilizer and the antidepressant has been begun alone, the initiation of a mood stabilizer may eliminate or markedly decrease any anxious and panicky symptoms. In general, the antidepressant doses are simultaneously lowered and when possible, discontinued.

Elevated mood patients whose anxiety occurs in the context of obsessive thoughts or compulsive rituals may display significant anxiety when unable to complete mental or behavioral compulsions. Obsessiveness may be unrelated to mood states becoming more intense, however, unless there is satisfactory completion of prescribed rituals. Considerably increased agitation can be anticipated if such rituals are interrupted or left uncompleted.

It would be highly unusual for a patient with elevated mood to display symptoms of social anxiety during hypomania. In fact, elevated mood patients tend to be overly social to the point of being intrusive. It is possible, however, that in the depressed phase of a bipolar condition, patients may become socially reclusive and anxious about appearing in groups or attending social functions. Since most bipolar patients present for treatment in the depressed rather than the elevated mood phase, it is possible that these patients may present with depressed mood and symptoms of social anxiety. Such patients often describe distinct periods when social anxiety disappears and they are comfortable in groups, crowds, or situations of social scrutiny. This history of marked “on/off” social anxiety can often be a key sign to the diagnostician that a bipolar condition may be comorbid with what appears to be a social anxiety disorder.

The trauma associated with PTSD can occur either prior to the emergence of bipolar symptoms or after bipolar symptoms reveal themselves. A variety of studies have looked at the comorbidity of PTSD and bipolar I disorder and found an incidence of between 9% and 18% of youth with bipolar I disorder having comorbid PTSD (7,8,9). There are a variety of potential causes for this overlap. With genetic loading, children with bipolar disorder are born in significantly higher frequency to couples where
one or both parents have bipolar disorder. Such parents with bipolar disorder have an increased risk of angry, rageful or out-of-control behavior that may result in physical, emotional, and/or sexual trauma to their children. Likewise, parents with bipolar disorder have significantly increased incidence of alcohol and other substance abuse that further contributes to lack of impulse control and poor parenting, resulting in traumatic experiences for their children. These children, therefore, may be genetically vulnerable to bipolar disorder and have a high incidence of abuse leading to PTSD. These connections were borne out in a study with a primary aim to determine the relationship between trauma and attention-deficit hyperactivity disorder (ADHD), but yielded interesting information about PTSD and bipolar disorder (10). Two hundred and sixty children and adolescents with and without ADHD were studied in longitudinal fashion over 4 years. It was noted that 27% of youth with ADHD who were exposed to trauma had significantly higher baseline rates of bipolar disorder when compared to those with ADHD who were not exposed to trauma (9%). The investigators found that early bipolar disorder in children with ADHD is the most significant predictor for subsequent trauma and concluded that early bipolar disorder is an important antecedent for trauma rather than a consequent result of trauma.

In adults, it is not surprising then that comorbid PTSD and bipolar disorder are also common (11). In addition to PTSD resulting from childhood trauma described above, persons with elevated mood are also more likely to engage in impulsive, reckless, and dangerous behaviors with minimal regard for the consequences. Such risky behavior may lead to fights, provocations, sexual assaults, and accidents—all of which could result in PTSD. Military combatants with subsyndromal cyclothymia or bipolar II disorder might not only be more sensitive to the aftereffects of conflict but might also volunteer impulsively for dangerous missions, leading to postcombat PTSD.

As in social anxiety disorder, separation anxiety disorder in children may precede a diagnosis of a bipolar condition (12,13). Such children demonstrate recurrent, excessive worry and distress at being separated from home or people to whom they are most attached. These children are totally reluctant or refuse to attend school, are fearful about being alone, and are unable to sleep without a parent nearby. Recurrent nightmares or physical symptoms such as nausea, vomiting, stomach aches, or headaches are common when separation is anticipated or actually occurs.