he likelihood that patients with hypomania will present for clinical care in the depressed state has been discussed in Chapter 4
. This section now elaborates on another diagnostic confound, the relationship between anxiety and hypomania. A number of studies (1
) report the high prevalence of anxiety in bipolar disorder. Although many psychiatric conditions are comorbid with bipolar disorder, 95.5% of the national comorbidity survey patients with bipolar I disorder met the criteria for three or more additional psychiatric disorders. Of these comorbid disorders, anxiety disorders were the most common. Boylan et al. (2
) demonstrated that over half the number of patients with bipolar disorder had at least one comorbid anxiety disorder and a third of those patients had multiple anxiety disorders. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) found that half the number of the patients studied showed a lifetime comorbid anxiety disorder. The comorbidity was higher for patients with bipolar II than bipolar I disorder. Anxiety has multiple negative effects on the outcome and treatment response of individuals with bipolar disorder. The presence of anxiety in bipolar illness is associated with an earlier age of onset, decreased response to treatment, increased use of substances, decreased quality of life, and increased rates of suicide (6
Anxiety and elevated mood diagnosis
Patients may present with overactivated, agitated, or anxious symptoms intermingled with mood symptoms or may present with symptoms of anxiety alone. The challenge for the clinician is to discern the cause of the activated or anxious state, one of which may be hypomania. There are, however, a number of other conditions—both psychiatric and medical—which can co-occur with hypomania. These comorbid conditions can challenge the most seasoned clinician because anxiety and overactivation may be intrinsic parts of the elevated mood syndrome or be a separate comorbid condition.
Patients with elevated mood may present as agitated, anxious, and overactive and complain of anxiety. However, this is not universally true. Many hypomanic individuals, while overactive and hyperenergetic, neither subjectively feel anxious nor necessarily present an anxious appearance to the clinician. They may appear energized, busy, and productive, and have perceived themselves as nonanxious, mentally sharp, and “clicking on all eight cylinders”. The course of treatment may be quite different for anxiety that is an intrinsic part of an elevated mood state, and anxiety that is referable to another condition. An accurate diagnosis, therefore, for anxiety is critical. Consider the causes of anxiety listed in Table 10.1
Anxiety, as perceived by the patient and described to the clinician, may present in a variety of ways. The patient may describe feelings of mental nervousness or agitation, being emotionally “out of control,” feeling mentally speeded or pressured, being unable to slow down, and having difficulty falling or staying asleep. Anxiety may present as panic attacks, internal restlessness, fidgeting/pacing, physical shakiness, or tremor. When hypomania is associated with anxiety, these symptoms rarely occur in isolation and are usually accompanied by one or more of the following:
Increased speed of thought
Lack of need to sleep
Impulsive and/or dangerous behavior
Displays of unusual energy
Feelings of exceptional well-being
TABLE 10.1 Anxiety and elevated mood
When present with elevated mood, anxiety may be
an intrinsic element of the hypomanic state
a symptom of a primary anxiety disorder or another psychiatric condition other than hypomania
a side effect of OTC or prescription medication
a symptom of a medical condition
Another cue to anxiety being part of hypomania is that the anxiety is episodic, rather than continuous, being punctuated by long periods without anxious symptoms. Anxiety, when due to hypomania, often presents a constellation of symptoms including those listed in the preceding text that recur periodically and predictably. Normal mood and energy, or even periods of anergia and nonproductivity may be present episodically, and during these times, the patient does not complain of anxiety. When antidepressants have been used to treat depression and the symptoms of hypomania and anxiety are in temporal correlation to the use of these antidepressants, there is a distinct possibility that the anxiety is a symptom of a hypomanic syndrome precipitated by antidepressant use.
Anxiety comorbid with elevated mood
As has been noted, patients with bipolar disorder or hypomania may have a variety of comorbid diagnosable anxiety disorders and, in some cases exhibit symptoms of more than one anxiety disorder. These are shown in Table 10.2
Generalized anxiety disorder.
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.
Panic attacks and panic disorder.
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.
TABLE 10.2 Conditions that may be comorbid with hypomania
Generalized anxiety disorder
Social anxiety disorder
Post-traumatic stress disorder
Separation anxiety disorder (in children)
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.
Social anxiety disorder.
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.
Post-traumatic stress disorder (PTSD).
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
). 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.
Separation anxiety disorder (in children).
As in social anxiety disorder, separation anxiety disorder in children may precede a diagnosis of a bipolar condition (12
). 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.
Other anxiety connections
Anxiety or behaviors that are confused with anxiety may be part of other mental health conditions. Individuals with an affective mixed state,
example, may have considerable anxiety and agitation as part of their mixture of affective symptoms. Anxiety may also be intermingled with depression,
anergia, crying spells, hypersomnia, and hyperphagia when the patient is in the depressed phase of a bipolar illness.
Although anxiety is not a regular feature of attention-deficit disorder, behaviors referable to attention deficits may confound even experienced clinicians. Pacing, fidgeting, and inability to sit still that are seen in children or adults may be mistakenly identified as bipolar-driven anxiety symptoms as opposed to ADHD-related behaviors. These can include problems sustaining attention, inability with following instructions, difficulty in organizing tasks, and easy distractibility. A cue to differentiating ADHD from anxious elevated mood is that ADHD is a continuous lifelong condition. ADHD presents itself from very early in childhood and into adult life, and is present in virtually all situations requiring concentration and attention. Anxiety associated with bipolar disorder is often episodic and punctuated by periods of anxiety-free euthymia or depressed mood. The presence of grandiosity and hypersexuality also mediates against the likelihood of an ADHD diagnosis and points more predictably to a bipolar diagnosis.
Mental anxiety and physical agitation may occur as a side effect of prescription medications,
over-the-counter (OTC) medications, and commonly available substances. Any of the prescription medications listed in Table 10.3
can produce physical and mental agitation. The clinician should inquire about the use of these medications as part of a diagnostic assessment of anxiety
and elevated mood. Similarly, OTC medications, especially those containing caffeine such as APCs (aspirin, phenacetin, caffeine) as well as other combination products such as NoDoz or appetite reduction pills, can produce anxiety as a side effect. Caffeine ingested in coffee, tea, colas, and other caffeinated beverages may likewise produce significant anxiety in the mooddisordered patient. Lastly, alcohol tends to calm anxiety for most bipolar patients; however, particularly after heavy use, the physiologic rebound and withdrawal symptoms may cause significant anxiety.
TABLE 10.3 Medications that can precipitate anxiety
Xanthines such as theophylline
TABLE 10.4 Medical conditions associated with anxiety
Chronic obstructive pulmonary disease (COPD)
In addition to medications, patients with elevated mood may have anxiety caused by independent medical conditions. When anxiety is present and associated with other physiologic complaints, a thorough physical examination and laboratory evaluation should be completed. Medical conditions associated with anxiety are listed in Table 10.4
Specific anxiety questions in bipolar mood disorder
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