Bipolar disorder (BD) is a complex mood disorder defined by extreme shifts in mood, energy, and activity levels, cycling between periods of intense high (mania or hypomania) and severe low (depression). A panic attack (PA) is a sudden, brief episode of intense fear that triggers severe physical reactions without real danger or apparent cause. These episodes are characterized by symptoms like a racing heart, chest pain, dizziness, and a terrifying feeling of losing control or impending doom. While BD does not directly cause PAs, research indicates the two conditions frequently coexist, suggesting a profound interaction and shared biological vulnerabilities. The mood shifts inherent to bipolar disorder can act as powerful triggers for anxiety and panic.
Understanding Co-Occurrence
While bipolar disorder does not typically cause panic disorder in a simple linear fashion, the two conditions are diagnosed together (comorbid) at rates significantly higher than expected. The lifetime prevalence of panic disorder in individuals with BD ranges from approximately 15% to 21%, which is 10 to 20 times greater than the rate observed in the general population. This diagnostic overlap presents a challenge for medical professionals, as the symptoms of both conditions can sometimes mimic one another. For instance, the physical agitation and racing heart during a manic or hypomanic episode can be mistaken for the acute physiological symptoms of a panic attack. Having both conditions often leads to a more severe course of illness, including greater functional impairment and higher rates of substance use, and is associated with unstable forms of bipolar illness, such as rapid-cycling or mixed states.
Shared Underlying Vulnerabilities
The significant link between bipolar disorder and panic disorder suggests they share common biological and genetic roots. Both disorders involve abnormalities in similar brain structures, particularly the amygdala and related limbic system areas. The amygdala is involved in emotional processing and threat detection, and its dysregulation contributes to deficits in emotional conditioning observed in both mood and panic episodes.
Neurochemically, shared dysregulation in monoamine neurotransmitters is frequently observed, including altered activity in serotonin and norepinephrine systems. For example, increased noradrenergic activity is implicated in both the onset of panic attacks and the switch into a manic state. A common genetic vulnerability also exists, with specific polymorphisms in the serotonin transporter (SERT) gene associated with both conditions.
The body’s stress response system, known as the hypothalamic-pituitary-adrenal (HPA) axis, also shows hyperactivity in both conditions. Abnormally high cortisol levels, a measure of HPA axis hyperactivity, have been linked to bipolar disorder and an increased risk for panic attacks. These overlapping factors suggest some individuals possess a foundational susceptibility that makes them prone to developing both conditions simultaneously.
Bipolar Phases as Panic Triggers
Beyond the shared biology, the extreme psychological and physical states inherent to bipolar mood phases can directly precipitate episodes of panic.
Manic and Hypomanic States
During a manic or hypomanic episode, symptoms like racing thoughts, extreme agitation, and intense bursts of energy can overwhelm the nervous system. This internal state of hyperarousal generates anxiety and dread that can quickly escalate into a full-blown panic attack. The lack of sleep that often accompanies mania is also a powerful physiological stressor that increases the body’s susceptibility to anxiety and panic.
Depressive and Mixed States
Conversely, the depressive phase of bipolar disorder also creates conditions that predispose an individual to panic. Periods of intense hopelessness and worry, combined with heightened sensitivity to internal physical sensations, can easily trigger a fear response. An individual in a depressive state may interpret a normal physical symptom, such as a heart palpitation, as a sign of imminent collapse, initiating a panic cascade. Panic attacks are particularly common during depressed or mixed states.
Integrated Treatment Approaches
When bipolar disorder and panic disorder co-occur, treatment must be integrated, as addressing only one condition often leads to poor outcomes for the other. The initial focus is typically on stabilizing the underlying mood disorder, which involves using mood stabilizers as the foundation of pharmacotherapy. Achieving mood stability often reduces the frequency and intensity of the manic and depressive episodes that act as panic triggers.
Careful consideration must be given to medication selection, since certain medications frequently used for anxiety, such as specific antidepressants, carry the risk of triggering a manic episode in a susceptible individual. Therefore, any anti-anxiety treatment must be balanced within the context of the overall mood stabilization plan. Psychotherapeutic approaches, such as Cognitive Behavioral Therapy (CBT), are highly effective for managing panic symptoms by helping individuals restructure their thought patterns and reduce fear of physical sensations. Therapies like Interpersonal and Social Rhythm Therapy (IPSRT) can also be beneficial by helping patients establish stable routines, which is crucial for regulating both mood and anxiety in bipolar disorder.