How you manage your anxiety is crucial to managing your mood.

by John McManamy


EMIL KRAEPELIN in his classic 1921 Manic-Depressive Insanity had this to say about what he called "excited depression":

It is here a case of patients who display, on the one hand, extraordinary poverty of thought but, on the other hand, great restlessness. ... Mood is anxious, despondent, lachrymose, irritable, occasionally mixed with a certain self-irony. ...

And here he is expounding on "depressive or anxious mania":

A morbid state arises, which is composed of flight of ideas, excitement, and anxiety. The patients are distractible, absent-minded, enter into whatever goes on round them, take themselves up with everything ...

Nearly a century later, - in 2013 - the DSM added to mania, hypomania , and depression this specifier: “With anxious distress.” This same specifier also appears with mania and depression.

You know the feeling. You’re keyed up, on edge, burdened by worry, barely holding it together. Imagine yourself outside your car with a ticking nuclear bomb in the trunk with your keys locked inside—that sort of describes it.

The likely connecting link is stress. Think of the amygdala—that tiny part of the brain which kicks off fight or flight—launching a plate of spaghetti against the wall. In this context, some of what sticks is mania/hypomania, some of it anxiety. Keep in mind that our brains are not organized according to DSM categories.

Hagop Akiskal sees anxiety occupying the same spectrum as depression and mania, from temperament (think of people with “nervous” dispositions) to illness. He is supported by a ton of his own and other people’s research, plus no end of population studies. The most definitive one, part of the National Comorbidity Survey Replication from 2007 in which he took part, reveals that three in every four individuals with bipolar also experience a form of full-blown anxiety.

The numbers make a compelling case that we need to think of anxiety as a core bipolar feature, one that merits the same status and respect as depression and hypomania and mania. Conventional psychiatry views anxiety as a separate group of disorders that may be “comorbid” (ie co-occurring) with bipolar.

For our own well-being, though, we need to keep in mind that our neural circuits don’t necessarily make these distinctions, and that when our minds start running away from us a lot of things are going on, sometimes at once, sometimes in sequences.

In addition, unlike conventional psychiatry, our brains don’t simply dismiss less severe forms of anxiety. All of us experience a little bit of anxiety, and just this little bit (the technical term is “subsyndromal”) is enough to massively complicate the course of our illness—in effect turn our “pure” states into mixed ones and perhaps kickstart our mood episodes.



The DSM-5 lists a number of different types of anxiety—including generalized, social, phobias, and panic—but let’s not worry about diagnostic fine points. Basically, our irrational fears and worries have a way of kicking off panic or a sense of helplessness. Typically, we cope by adopting “avoidant” and other socially unuseful behaviors.

So, let’s say you have a fear of driving that leads you to not renew your license. Decades pass. Suddenly, you realize you need to get back behind the wheel. Your road test is today. Panic sets in. You feel your brain running away from you, a brain predisposed to depression and hypomania.

Lights, camera, action …

In 1976, I moved to New Zealand with my fiancée. Her uncle was at the airport to pick us up. I hopped in the passenger side of the car. In New Zealand the passenger side comes equipped with steering wheel and pedals and control panel. There is only a glove box on the driver’s side.

I never recovered from the incident.

New Zealanders drive on the left side of the road, and they refused to make an exception for me. Most of them displayed a total lack of understanding when I entered roundabouts on the side to which I was accustomed. Plus, speed limit signs were posted in kilograms, kilobytes, whatever.

Soon, my wife was doing all the driving. I didn’t bother to apply for a New Zealand license. I allowed my two North American licenses to expire. It’s not like cars are important, anyway.

Eleven years in New Zealand, five in Australia. By the time I returned to the States, I had lost the will to get back behind the wheel.

Years passed ...

Then, in late 2006, I moved to rural Southern California. If I wanted to buy groceries or do my banking or fill a prescription, I needed to drive 12 miles to the nearest town. Oops, I don’t drive.

A month went by. I purchased an old beater, but it sat in the front of the house for 18 months. Finally, I willed myself to do the work and obtain my California learner’s permit. I got behind the wheel for the first time in decades. Nothing came back. I’d completely lost my driving reflexes. The road persisted in moving to where the car didn’t want to be.

Then came the day of my road test. Compounding my usual worries was the fact that I had just met a lovely woman who lived 40 miles away. I NEEDED to pass this test.




The inspector asks me to turn on my left signal. I turn on my right signal. It's all downhill from there. FAIL! Now I’m depressed. I'm a loser, an idiot. The woman I just met is going to dump me for sure. We work it out. She will help me. I book another appointment.

Two weeks later, I call her in a panic. I’ve just discovered DMV videos on YouTube. More than a hundred of them. Ten top reasons drivers fail the test. Something about forgetting that Burma is now called Myanmar. Automatic fail.

I’m never going to pass this test!

Moment of truth. I’ve willed my heart down to 300 beats a minute. Turn left, the inspector instructs.

What did he mean by that? I wonder.

He's scribbling in his clipboard. One turn and already I've given him something to write about! I'm doomed!

I see a city bus stopping. Am I supposed to stop for the bus? I turn to the inspector for an answer. Nothing. I feel extreme panic overtaking me. I freeze like a deer in the headlights.

I don’t know what to do. My brain completely fails me. I really don’t know what to do. I’m about to bring the car to a complete stop on a busy thoroughfare. FAIL! I know it. I just know it.



Somehow I manage to get the car back to the DMV and park it without running over any pedestrians. The inspector tells me I have a tendency to overthink and panic. Duh! He tells me I've passed. I PASSED! I refrain from hugging him.

History lesson: Howard Hughes was an aviation pioneer, movie producer, inventor, entrepreneur, and ladies’ man. But, in the prime of life, he became reduced to nothing at the prospect of simply going out the door. He couldn’t do it. He never overcame it.

The prospect of driving was one of those things that reduced me to nothing. Of all the things I’ve been through in my life, getting back behind the wheel was by far the most terrifying. I also regard it as one of my greatest achievements.

If nothing else, facing down your fears has a way of turning you into your own hero, even if others only shake their heads.

Inevitably, it’s our manias and depressions that bring us to the attention of psychiatry. Anxiety, though, may be the major impediment to getting our lives back on track.

Walk into any bipolar support group and you will hear people talking of how depression and mania effectively masked their anxiety. They had no idea it was there.

They found out soon enough. You can well appreciate the frustration. You set goals and just about reach them, and then—when no one’s looking—our trickster god moves the goal posts.

It’s even worse than that. Via the stress connection, anxiety can trigger mania, hypomania, and depression. And the presence of anxiety makes the mood episode much more difficult to contend with. In the context of mania and hypomania, imagine our thoughts running away from us. Now imagine that runaway thinking having to do with meeting a project deadline or an impending meeting with the boss.

Now imagine losing sleep over it. There is absolutely no upside to this scenario.

July 8, 2016


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