Expert: Ivan Goldberg, M.D. - 11/22/2003

Question
Hi,
Have you seen people with anxiety/panic disorder "move up" to Bipolar disorder? Can the depression that occurs with the anxiety disorder grow to a point where it becomes something else?Have you seen these disorders exhibit even more irritation and turmoil when combined with religious conflict (obsession with God/Biblical Word/guilt/demons etc)? If so, is psychotherapy effective in relieving the symptoms? Can anything really be "healed" when it comes to this? Thanks for any information.
JRiley

Answer
Hi . . .

It is not unusual for anxiety to precede the onset of bipolar disorder. See the abstract below.

Best regards . . .

Ivan
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Journal of Affective Disorders.
2001 Dec;67(1-3):199-206.  
The temporal relationship between anxiety disorders and (hypo)mania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder.

Perugi G, Akiskal HS, Toni C, Simonini E, Gemignani A.

Institute of Psychiatry, University of Pisa, Via Roma 67, 56100 Pisa, Italy. g.perugi@psico.med.unipi.it

BACKGROUND: The relationship between anxiety and depressive disorders has been conventionally limited to unipolar depression. Recent studies from both clinical and epidemiologic samples have revealed intriguing associations between anxiety and bipolar (mainly bipolar II) disorders. The present report examines the temporal sequence of hypomania to panic (PD), obsessive-compulsive (OCD) and social phobic (SP) disorders. METHODS: Specialty-trained clinicians retrospectively evaluated the foregoing relationships in 63 patients meeting the DSM-III-R diagnosis for PD, OCD and SP with lifetime comorbidity with bipolar disorders (87% bipolar II). Structured interviews were used. RESULTS: In nearly all cases, SP chronologically preceded hypomanic episodes and disappeared when the latter episodes supervened. By contrast, PD and OCD symptomatology, even when preceding hypomanic episodes, often persisted during such episodes; more provocatively, nearly a third of all onsets of panic attacks were during hypomania. LIMITATIONS: Assessing temporal relationships between hypomania and specific anxiety disorders on a retrospective basis is, at best, of unknown reliability. The related difficulty of ascertaining the extent to which past antidepressant treatment of anxiety disorders could explain the anxiety-bipolar II comorbidity represents another major limitation. CONCLUSIONS: Different temporal relationships characterized the occurrence of hypomania in individual anxiety disorder subtypes. Some anxiety disorders (notably SP, and to some extent OCD) seem to lie on a broad affective continuum of inhibitory restraint vs. disinhibited hypomania. By contrast, and more tentatively, PD in the context of bipolar disorder, might be a reflection of a dysphoric manic or mixed hypomanic symptomatology. The foregoing suggestions do not even begin to exhaust the realm of possibilities. The pattern of complex relationships among these disorders would certainly require better designed prospective observations.