Key Takeaways
- Racing thoughts, poor sleep, restlessness and irritability appear in both anxiety and bipolar disorder, but they feel different and follow different time patterns.
- Anxious thoughts circle around worry; in hypomania or mania, thoughts speed up and leap between ideas, often with high energy and little need for sleep.
- The two often occur together: one meta-analysis found that about 43% of people with bipolar disorder have had an anxiety disorder.
- Antidepressants commonly used for anxiety are not used alone in bipolar disorder, because they can trigger mania or rapid cycling.
- Anxiety that does not respond to usual treatment is a reason to look for an unrecognized mood pattern.
Anxiety and bipolar disorder share several symptoms that can make them hard to tell apart: racing thoughts, trouble sleeping, restlessness and a short fuse. The difference usually shows in the details. Anxiety tends to be persistent and centered on worry or fear, and lack of sleep leaves you drained. In hypomania or mania, the mind speeds up with ideas rather than worries, and you may sleep little but feel energized. Many people live with both. Telling them apart matters because some common anxiety treatments need extra care when bipolar disorder is present.
Why they are easy to mix up
Both conditions can bring a busy mind, poor sleep, physical tension, irritability and trouble concentrating. People also tend to seek help for whatever feels worst at the moment, and for many that is anxiety or depression, not a high-energy stretch that felt good. When nobody asks about the highs, a bipolar pattern can sit underneath years of anxiety treatment.
There is also a formal overlap. DSM-5 added a "with anxious distress" specifier that can apply to mood episodes in bipolar disorder, recognizing how often anxiety comes along with them.
Racing thoughts: worry or speed?
The phrase "racing thoughts" describes two different experiences:
- Anxious racing thoughts loop around threats: what might go wrong, what someone meant, whether you locked the door. They feel unwanted and tiring, and they tend to replay the same few concerns.
- Hypomanic or manic racing thoughts jump from idea to idea, often with excitement, plans or a sense of insight. Speech may speed up to keep pace, and others may find you hard to follow or interrupt.
Some people experience a blend: agitation and racing thoughts with a dark or desperate mood. That combination can signal a mood episode with mixed features, which carries its own risks. Our page on mixed features in bipolar disorder explains what to watch for.
Sleep tells a lot
NIMH lists trouble falling or staying asleep, along with fatigue, among the symptoms of generalized anxiety disorder (GAD). Anxious insomnia usually means lying awake wanting to sleep, then paying for it the next day.
In hypomania and mania, the need for sleep itself drops. A person may sleep three or four hours and get up full of energy, sometimes for several nights in a row. That pattern is one of the clearest signs of a possible bipolar episode and a common early warning of relapse. Our page on sleep and bipolar disorder goes into how to track it.
The time pattern
Anxiety disorders tend to be persistent or tied to particular situations. NIMH describes GAD as difficulty controlling worry on most days for at least six months, and notes that a panic attack can last from a few minutes to an hour or sometimes longer. Social anxiety flares in social situations; phobias around specific triggers.
Bipolar disorder runs in episodes: hypomania for at least four days, mania for a week or more, depression for two weeks or more, with periods of more usual mood in between. If your anxiety rises and falls in distinct stretches that also involve changes in energy, sleep and confidence, that is worth raising with a clinician.
| Anxiety disorder | Hypomania or mania | |
|---|---|---|
| Thought content | Worry, threat, what-ifs | Ideas, plans, excitement or irritation |
| Sleep | Can’t sleep, then exhausted | Needs less sleep, still energetic |
| Energy | Tense but drained | Increased, driven |
| Timing | Persistent or situational; panic attacks last minutes to an hour | Episodes lasting days to weeks |
| Self-view | Doubtful, on edge | Can become unusually confident |
Panic attacks and mood episodes
A panic attack and the start of a mood episode can both feel like losing control, which is part of why people wonder which one they are having. NIMH describes panic attacks as sudden surges of fear with a pounding heart, sweating, trembling, shortness of breath, dizziness or chest pain, lasting from a few minutes to an hour or sometimes longer. Afterward, the body settles, even if worry about the next attack remains.
A mood episode does not pass in an hour. Hypomania or mania builds over days and is defined by sustained changes in energy, sleep, speech and behavior. Panic attacks can happen during a bipolar depressive or mixed episode, and panic disorder is the most common anxiety disorder found alongside bipolar disorder in the meta-analysis cited below, so the two can coexist. Chest pain or trouble breathing should always be checked medically first, especially the first time.
When you have both
Having both is common, not unusual. A 2015 meta-analysis of 52 studies found that 42.7% of people with bipolar disorder had a lifetime anxiety disorder, including panic disorder (16.8%), GAD (14.4%), social anxiety disorder (13.3%), PTSD (10.8%) and OCD (10.7%). In the World Mental Health Survey across 11 countries, three-quarters of people with bipolar disorder met criteria for at least one other condition, most often an anxiety disorder.
Anxiety matters for safety, too. Research pooled by an international bipolar task force lists co-occurring anxiety among the factors linked to suicide attempts in bipolar disorder. If you are having thoughts of suicide, call or text 988, or chat at 988lifeline.org; in an emergency, call 911.
Treating anxiety when bipolar disorder is present
For anxiety on its own, NIMH notes that cognitive behavioral therapy (CBT) and SSRI or SNRI antidepressants are commonly used. In bipolar disorder, that second option needs care. NIMH states that antidepressants are not used alone in bipolar disorder because they can trigger mania or rapid cycling, and an international task force advised that in bipolar I they be prescribed only alongside mood-stabilizing medication. Our page on antidepressants in bipolar disorder covers that evidence.
In practice, the usual approach is to stabilize mood first, since anxiety often eases when mood does, and then address what remains. The VA/DoD guideline suggests CBT for anxiety that persists once bipolar disorder is in remission. Other supports include regular sleep and daily routines and avoiding alcohol and drugs, which NIMH advises for people with bipolar disorder. Medication decisions belong with your prescriber; do not start, stop or switch an antidepressant on your own.
If anxiety has not improved despite several treatments, an unrecognized mood pattern is one possibility to check. Our article on anxiety that does not respond to medication looks at that and other reasons.
At Willow & Stone
The 90-minute evaluation with Dr. Stacey Forbes, a board-certified psychiatric-mental health nurse practitioner, looks at anxiety and mood together, including past responses to antidepressants. Read about bipolar disorder treatment at Willow & Stone, or explore the bipolar disorder guide for more on symptoms and care.
Common Questions
Can anxiety be mistaken for bipolar disorder?
Yes. Racing thoughts, insomnia, restlessness and irritability occur in both. Anxiety usually centers on worry and leaves you tired, while hypomania or mania brings speeding ideas, high energy and less need for sleep in episodes lasting days. A careful history of how symptoms come and go separates them.
Is it common to have anxiety with bipolar disorder?
Very. A meta-analysis of 52 studies found that about 43% of people with bipolar disorder have had an anxiety disorder in their lifetime, most often panic disorder, generalized anxiety or social anxiety. DSM-5 even includes an "anxious distress" specifier for mood episodes.
Are racing thoughts anxiety or bipolar disorder?
It depends on what they feel like. Anxious thoughts loop around worries and feel unwanted. In hypomania or mania, thoughts jump rapidly between ideas, often with excitement, fast speech and little need for sleep, and the change lasts days. Racing thoughts with a dark mood can signal mixed features.
Can SSRIs trigger mania?
In people with bipolar disorder, yes. NIMH notes antidepressants used alone can trigger mania or rapid cycling, which is why they are not used alone in bipolar disorder and why antidepressant labels tell prescribers to screen for bipolar disorder first. Talk with your prescriber before making any change.
Can bipolar disorder cause panic attacks?
Panic attacks can occur during bipolar episodes, especially depressive or mixed ones, and panic disorder is common in people with bipolar disorder: about 17% in one large meta-analysis. A panic attack lasts minutes to about an hour, while a mood episode lasts days or weeks.
What helps anxiety in bipolar disorder?
Stabilizing mood is usually the first step, because anxiety often improves with it. CBT is suggested for anxiety that remains once mood is stable, alongside steady sleep, daily routines and avoiding alcohol and drugs. Any medication change should be planned with your prescriber.
Part of our bipolar disorder guide
Sources & Further Reading
- Nabavi B, Mitchell AJ, Nutt D. Lifetime prevalence of anxiety disorders in bipolar disorder: meta-analysis. EBioMedicine 2015
- Merikangas KR et al. Prevalence and correlates of bipolar spectrum disorder in the World Mental Health Survey Initiative, 2011
- NIMH: Generalized Anxiety Disorder (revised 2025)
- NIMH: Panic Disorder: When Fear Overwhelms (revised 2025)
- NIMH: Bipolar Disorder (NIH Pub. 25-MH-8088, revised 2025)
- Pacchiarotti I et al. ISBD task force report on antidepressant use in bipolar disorders. Am J Psychiatry 2013
- VA/DoD Clinical Practice Guideline for the Management of Bipolar Disorder (2023)
This article is general education, not a diagnosis or advice for your situation. Do not start, stop, or change a medication without talking to the clinician who prescribes it; stopping a mood stabilizer suddenly can trigger relapse.
If you need help right now
Willow & Stone is an outpatient practice and is not an emergency service. If you or someone you care about is in immediate danger, call 911.
For urgent mental health support at any hour, call or text 988 to reach the Suicide & Crisis Lifeline, or text HOME to 741741 for the Crisis Text Line. Both are free, confidential, and available 24/7 nationwide.
Dr. Stacey Forbes, DNP, APRN, PMHNP-BC
Board-certified Psychiatric-Mental Health Nurse Practitioner and founder of Willow & Stone Integrative Mental Health. Nearly two decades of clinical experience; integrative, root-cause psychiatry in person in Arlington and by telehealth. Licensed in Texas, New Mexico, Florida, Alaska, Arizona, Colorado & Washington.
About Dr. Forbes →