Comorbid anxiety disorders are common in people with bipolar disorder. Generalised anxiety disorder is characterised by continuous and excessive worrying for six months or more. Specific phobias are characterised by anxiety provoked by a feared object or situation, resulting in avoidance. Social phobia is anxiety provoked by social or performance situations. Agoraphobia is anxiety about situations where escape may be difficult or where help might not be available. Panic disorder is characterised by a panic attack, which is a distinct episode where a person experiences sudden apprehension and fearfulness, and may experience shortness of breath, palpitations, chest pain or feeling of choking.

What is the evidence regarding anxiety disorders in people with bipolar disorder?

Moderate quality evidence found the lifetime prevalence of anxiety disorders in children, adolescents, and adults with bipolar disorder is around 45%, and the prevalence in adults in the euthymic phase is around 35%. These rates are significantly higher than in people without bipolar disorder.

The most common anxiety disorders in adults were generalised and social anxiety disorders, agoraphobia, specific phobias, and panic disorders. The most common anxiety disorders in children were generalised and separation anxiety disorders. The most common anxiety disorders in adolescents were panic disorder and social phobia.

Moderate to low quality evidence found cognitive behavioural therapy is effective for improving symptoms of anxiety in people with bipolar disorder.

Please also see the related topics on comorbid post-traumatic stress disorder and obsessive compulsive disorder, which are no longer considered anxiety disorders in the DSM-5.

October 2021

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Pending enough primary studies, we invite reviews on this topic to be conducted. Alternatively we will endeavour to conduct our own review to fill this gap in the Library.

October 2021

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ADHD is a behavioural disorder characterised by inattention, hyperactivity, and impulsivity. The estimated prevalence in children under 18 years in the general population is around 5%. It is more prevalent in males than in females. ADHD can persist into adulthood with an estimated prevalence of 2.5% of ADHD in the adult general population. The DSM-5 requires that ADHD in adults began in childhood, with inattentive or hyperactive-impulsive symptoms needing to be present before age 12.

What is the evidence for rates of attention deficit hyperactivity disorder (ADHD) in people with bipolar disorder?

Moderate to high quality evidence finds around 17% of adults with bipolar disorder also have ADHD. Prevalence of ADHD was higher in small than in large studies and was higher in studies from Western Asia (Turkey and Iran) than in studies from America or Europe.

Conversely, around 8% of adults with ADHD also have bipolar disorder. Prevalence of bipolar disorder was higher in studies using the DSM than the ICD to diagnose bipolar disorder, and in studies from America than in studies from Europe or Taiwan. Age of bipolar disorder onset occurred earlier in those with ADHD than in those without ADHD.

Moderate quality evidence finds around 10% of children and youth with ADHD go on to develop bipolar disorder. This represents a large increase in the risk of bipolar disorder in children and youth with ADHD when compared to children and youth without any psychiatric disorder.

Moderate quality evidence finds a small increased risk of ADHD in people with bipolar disorder compared to people with major depression, and a medium-sized increased risk of ADHD in people with any mood disorder compared to people without any mood disorder. Prevalence of ADHD ranged from 17% in adults with bipolar disorder, to 43% in adolescents with bipolar disorder, to 73% in children with bipolar disorder.

October 2021

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Eating disorders include anorexia nervosa, which involves a lack of maintaining normal weight, usually less than 85% of the expected weight, and an intense fear of gaining weight. Bulimia nervosa involves the presence of binge eating followed by compensatory behaviours to prevent weight gain, while binge eating disorder does not involve compensatory behaviour.

What is the evidence for eating disorders?

Moderate quality evidence finds the prevalence of any eating disorder in people with bipolar disorder is around 13%. The prevalence of binge eating disorder is around 12.5%, bulimia nervosa is around 7%, and anorexia nervosa is around 2.5%. Overall, prevalence rates of eating disorders were highest in females with bipolar disorder, and in people with bipolar II disorder.

October 2021

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Impulsivity-related disorders include intermittent explosive disorder characterised by uncontrolled fits of extreme anger and violence, pyromania characterised by irresistible urges to light fires, kleptomania characterised by irresistible urges to steal, and conduct disorder characterised by repetitive and persistent behaviours that violate societal rules and the basic rights of other people. Related disorders include; trichotillomania characterised by uncontrollable hair twisting and pulling, skin-picking disorder, pathological gambling, compulsive sexual behaviour and exhibitionism, compulsive buying, internet addiction, video or computer game addiction, food addiction, work addiction, tanning addiction and physical exercise addiction.

What is the evidence for impulsivity-related disorders?

Moderate to low quality evidence finds more harmful behavioural addictions in people with bipolar disorder than controls without the disorder.

Moderate quality evidence finds the prevalence of bipolar disorder in people with problem gambling is around 9%. Risk factors for problem gambling in people with bipolar disorder include suicidal ideation or attempt, history of rapid cycling, and younger age at illness onset.

October 2021

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Obsessive-compulsive disorder (OCD) can occur in people with bipolar disorder. It involves persistent and intrusive thoughts (obsessions) and repetitive actions (compulsions). The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) defines obsessions as recurrent and persistent thoughts, urges, or impulses that are experienced as intrusive and unwanted, with associated anxiety or distress. The individual attempts to suppress these obsessions by performing a compulsion; repetitive behaviours (e.g., hand washing, ordering, checking) or thoughts (e.g., praying, counting, repeating words). The obsessions or compulsions are time-consuming and can cause significant impairment in social, occupational, or other areas of functioning. Related disorders include hoarding disorder, excoriation disorder (skin-picking), body dysmorphic disorder (obsessive focus on a perceived flaw in appearance) and trichotillomania (hair-pulling).

What is the evidence for OCD in people with bipolar disorder?

Moderate quality evidence suggests the lifetime prevalence of obsessive-compulsive disorder in people with bipolar disorder is around 11% compared to 2.5% in the general population. This represents a large increased risk of obsessive-compulsive disorder in people with bipolar disorder.

The lifetime prevalence of obsessive-compulsive disorder in children and adolescents with bipolar disorder is around 17%, with adolescents showing higher rates of obsessive-compulsive disorder than children.

The current prevalence rate is also around 11% in people with bipolar disorder compared to 1.6% in the general population. The current prevalence rate during euthymia in people with bipolar disorder is around 7%.

The antipsychotic aripiprazole plus mood stabilisers may be effective therapy for obsessive-compulsive symptoms during manic episodes. The glutamate modulators topiramate or memantine plus mood-stabilisers may also relieve obsessive-compulsive symptoms during manic episodes.

October 2021

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Personality disorders are enduring patterns of behaviours, thoughts and feelings that deviate from social norms. Many people exhibit these behaviours, thoughts or feelings occasionally, but deviations that persist across situations and cause significant distress and impairment are considered disorders.

There are a number of different personality disorders. These include; antisocial personality disorder (disregard for the rights of others); schizoid personality disorder (detachment of social interactions and limited emotional expression); schizotypal personality disorder (discomfort of close relationships, cognitive distortions and eccentric behaviour); paranoid personality disorder (distrust and suspiciousness of others); borderline personality disorder (self-harming, difficulty relating to others); histrionic personality disorder (patterns of attention-seeking behaviour and emotions); narcissistic personality disorder (disregard of others, inflated self-image); avoidant personality disorder (feelings of inadequacy, social inhibition); dependent personality disorder (extreme psychological dependence on others); obsessive-compulsive personality disorder (excessive control, orderliness); and personality disorder not otherwise specified (mixed symptoms).

What is the evidence for comorbid personality disorders?

Moderate to high quality evidence suggests around 42% of people with bipolar disorder have a personality disorder. The most common include obsessive-compulsive, borderline, paranoid and histrionic. There is a medium-sized increased risk of personality disorders in people with an early age of onset of bipolar disorder (<18yrs) compared to people with a later onset of bipolar disorder.

October 2021

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The prevalence of pervasive developmental disorders in the general population is around 0.5%. They are a group of conditions that are characterised by abnormal development in social interactions, communication, behavioural flexibility and repetitive patterns of behaviour and activities. These are core features of autism and are usually apparent by the age of 2 to 4 years. Autism involves impaired socialisation, poor communication and behavioural inflexibility, whereas Asperger’s syndrome involves an absence of an intellectual disability. Pervasive developmental disorder not otherwise specified shares the socialisation symptoms of autism but allows for atypical presentations.

What is the evidence for comorbid pervasive developmental disorders in bipolar disorder?

Moderate to low quality evidence suggests that the co-occurrence of autism spectrum and bipolar disorders is between 7% and 19%.

October 2021

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The Diagnostic and Statistical Manual of Mental Disorders’ (DSM-5) criteria for a diagnosis of post-traumatic stress disorder (PTSD) includes having been exposed to a trauma via direct means (e.g. threats, experience, or witnessing), or indirect means (e.g. learning that a relative or close friend has been exposed to a trauma).

For a diagnosis of PTSD, symptoms must last for more than one month and create distress and functioning impairment such as an inability to work, go to school, or socialise. Symptoms include persistently re-experiencing the traumatic event via intrusive thoughts, nightmares, or flashbacks. These can be brought on with exposure to traumatic reminders and are associated with emotional distress. As a result, avoidance of trauma-related stimuli occurs. There is often an inability to recall key features of the trauma.

Other symptoms include negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect, decreased interest in activities, feelings of isolation, irritability or aggression, risky or destructive behaviour, hypervigilance, heightened startle reaction, and difficulty concentrating and sleeping.

What is the evidence on PTSD in people with bipolar disorder?

Moderate quality evidence find the lifetime prevalence of PTSD in people with bipolar I or bipolar II disorder is around 17%. This represents a medium-sized increased risk of PTSD when compared to people without bipolar disorder.

Moderate to low quality evidence suggests cognitive behavioural therapy may be effective for improving PTSD symptoms in people with bipolar disorder.

October 2021

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Somatic symptoms are medically unexplained bodily sensations or basic physical dysfunctions such as appetite, digestion, or sleep dysfunction. They may be localised to a particular bodily region, or generalised, as in the case of excessive fatigue or loss of energy. Symptoms are not intentionally produced or feigned. For a diagnosis of somatic symptom disorder, the extent to which a person’s feelings, thoughts, and behaviours about their somatic symptoms must be distressing, excessive, or disproportionate, and persist for more than six months.

What is the evidence for somatic symptoms in people with bipolar disorder?

Moderate quality evidence finds a small, increased risk of more somatic symptoms in people with bipolar disorder compared to general population rates. People with depression report similar rates of somatic symptoms as people with bipolar disorder.

October 2021

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