Childhood Anxiety May Precede Adolescent Bipolar Disorder

The relationship between anxiety disorders and bipolar disorder is well established in peer-reviewed scientific journals that publish articles on child, adolescent, and adult mental health.

Research shows that in most cases of co-morbid – a.k.a dual diagnosis – anxiety disorders and bipolar disorders, an anxiety disorder appears first, during childhood or early adolescence. Bipolar disorder most often appears second, typically during late adolescence or early adulthood. This aligns with the commonly accepted age of onset for both disorders. The typical age of onset for early anxiety is between 5 and 15 years old, and the typical age of onset of early bipolar disorder is 15-19 years old.

This can create problems in the long-term outlook and treatment success for adolescents with either disorder, since the symptom of one can mask symptoms of the other. A child diagnosed with early anxiety disorder may not receive additional screenings for bipolar disorder. A teen diagnosed with bipolar disorder may not receive additional screenings for anxiety disorder. This means that in some cases – when an adolescent reaches an age where both disorders may be present – they may participate in therapy and treatment focused on one disorder and not the other. And, in some of those cases, they receive treatment for the wrong disorder. An treatment mismatch can exacerbate the symptoms of the disorder they do have.

In addition, when an adolescent develops both an anxiety disorder and bipolar disorder, a treatment plan that focuses on a single disorder may not help either disorder. Instead, it may exacerbate the symptoms of both.

Anxiety Disorders and Bipolar Disorder in Adolescents

We need to clarify something about the relationship between these two disorders, which explains why almost all the research available on the co-occurrence of anxiety disorders and bipolar disorder focuses on the affect of anxiety on the course of bipolar disorder, rather than the effect of bipolar disorder on the course an anxiety disorder.

The reason is simple. While anxiety disorders can be disruptive, debilitating, and cause significant problems and distress over the lifetime of a person with an anxiety disorder, they do not – in most cases – result in the same magnitude of distress, disruption, and difficulty caused by bipolar disorder over the lifetime of a person diagnosed with bipolar disorder.

While the following statement is somewhat reductive and needs to be understood in context, it’s not false. Bipolar disorder, on balance, is a more serious disorder than anxiety. That’s why it’s important for parents of teens diagnosed with early anxiety to watch for signs of early onset bipolar disorder and encourage their teen’s therapist and treatment to watch for signs of early bipolar disorder during treatment for an anxiety disorder.

Therefore, although this article is one in our series on anxiety and anxiety disorders in adolescence, most of the data we present comes from studies that examine the presence of anxiety disorders in adolescents with bipolar disorder, rather studies on the presence of bipolar disorder in adolescents with anxiety. The reason is the same as the one we describe above: the one supersedes the other in both symptom complication and treatment complexity.

In other words, when a teen with early onset anxiety develops bipolar disorder, bipolar disorder becomes the primary disorder of concern – and treatment revolves around resolving the underlying causes and symptoms of bipolar disorder, rather than the anxiety disorder.

Anxiety Disorders and Bipolar Disorder in Teens: Facts and Figures

However, evidence indicates that it’s critical to address both – not one or the other – to ensure the best possible treatment outcome for an adolescent with both anxiety and bipolar disorder. To understand the scope of the problem of treating comorbid anxiety and bipolar disorder, let’s take a look at the most comprehensive publication to date on the phenomenon of comorbid bipolar disorder and anxiety disorder.

A meta-analysis published in 2019 called “Comorbidity of Bipolar and Anxiety Disorders: An Overview of Trends in Research” examined data from 103 studies that contained information collected from more than 50,000 children, adolescents, and adults with anxiety and bipolar disorder. We’ll start with the prevalence statistics, then present the complications that arise when a teen with bipolar disorder also has an anxiety disorder, as identified by the research team.

Here’s what they found.

Among children and adolescents with bipolar disorder:

• 50% reported the presence of an anxiety disorder
• 25% reported general anxiety disorder (GAD)
• 22% reported separation anxiety disorder
• 17% reported obsessive-compulsive disorder (OCD)
• 15% reported social phobia

Now let’s look at the complications caused by the presence of an anxiety disorder on the course of bipolar disorder. As a reminder, because of its size and scope, this study was large enough to make broad generalizations on the relationship between these two disorders.

Here’s what they found.

Among individuals with bipolar disorder, the presence of an anxiety disorder correlated strongly with the following six negative outcomes:

1. Increased presence of disruptive symptoms. Disruption included increased:

• Overall psychological distress
• Irritability
• Severity of acute manic and depressive episodes
• Frequency of manic and depressive symptoms

2. Increased duration of mood episodes. Increases included:

• Longer manic episodes
• Longer depressive episodes
• Higher rates of repeated manic and depressive episodes

3. Decreased rates of remission and recovery. These included:

• Longer time to remission
• Decreased likelihood of achieving complete remission/recovery
• Increased persistence of milder symptoms
• Decreased length of remission
• Increased risk of early relapse or recurrence
• Increased risk of psychiatric hospitalization

4. Impaired overall wellbeing. This included:

• Greater functional impairment
• Decreased quality of life

5. Decreased overall treatment response. This included:

• Delayed diagnosis
• Delayed treatment initiation
• Attenuated treatment progress
• Increase in severe negative reactions to medication
• Increased non-adherence with treatment, i.e. not following or completing treatment plan
• Increased non-mental health related use of healthcare services
• Higher overall cost associated with treatment and care

6. Elevated risk of suicide. In people with BD and anxiety:

• Suicide risk doubled
• Increased suicide risk was related to:
  • Increased overall severity caused by comorbidity
  • Higher rate of depressive symptoms
  • Increased rate substance use disorder
  • Increased rate of personality disorders
  • Higher levels of impulsivity
  • Higher levels of neuroticism

There are several top-line takeaways from this information for parents.

First, any child or teen diagnosed with an anxiety disorder needs constant monitoring for signs of early onset bipolar disorder. Second, accurate diagnosis is critical: everything above indicates a quick assessment and diagnosis for one or the other disorder is inadequate. A full assessment that covers all possible diagnoses can reduce significant problems after treatment begins. Third, when a clinician determines the presence of both bipolar disorder and an anxiety disorder, the treatment plan must account for this. As evidence indicates, “Comorbid disorders may worsen the course of each individual disorder.”

Finally, creating a workable treatment plan for bipolar disorder + an anxiety disorder may take time, and involve a period of trial and error, because of the complex and mutually reinforcing symptoms related to bipolar disorder and anxiety disorders.

That leads us to the final topic we’ll cover in this article: treatment for co-occurring anxiety and bipolar disorder.

Medication, Therapy, and Treatment Adherence

In the paper “Treatment of Anxiety Disorders in Patients with Comorbid Bipolar Disorder,” researchers indicate that “The goals of treatment for patients with comorbid anxiety and BD are remission of symptoms and a return to baseline functioning.” To that end, mood stabilization for bipolar disorder is typically the first goal of treatment. This means that a teen in treatment for comorbid anxiety/BD needs to find balance and mitigate the effects of the up and down, cyclic nature of contrasting manic and depressive phases of bipolar disorder. Once they achieve workable balance, treatment for anxiety can begin.

However, since the primary approach to mood stabilization for BD is medication, and a secondary – but important – approach to anxiety treatment is also medication, problems related to the interaction of medications for BD and anxiety often occur. In fact, medications for one can exacerbate the symptoms of the other. Therefore, researchers conclude:

“There is limited clinical evidence for appropriate use of medications that are effective specifically for these comorbidities, leading clinicians to attempt to treat each disorder separately based upon treatment guidelines…It is important to…advocate for the use of psychotherapy and cognitive behavioral therapy (CBT) as complementary treatment options.”

We encourage parents of teens with anxiety and bipolar disorder to seek treatment from experts in adolescent mental health with extensive experience in the following:

• Adolescent mental health. Yes, that’s repetitive, but it’s very, very, important.
• Adolescent anxiety
• Adolescent bipolar disorder
• Comorbid bipolar disorder/anxiety in adolescents
• Any and all possible medications that may be indicated for BD and anxiety, including the potential negative interactions between medication for BD and medication for anxiety
• Tailoring mental health treatment plans to the unique needs of the adolescent population, specifically those with complex comorbidities

That’s a lot for parents to think about, but it’s important to understand that the right treatment at the right time administered by the right people can save both time and energy – and can keep teens in treatment longer, which has a significant effect on positive treatment outcomes. It can also help a teen get back to living life on their own terms sooner, rather than later. That’s the ultimate goal for all teens in treatment for any mental health disorder.

Finding Help: Resources

If you’re seeking treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.