PTSD vs Bipolar

What is PTSD?

Post-traumatic stress disorder, or PTSD, is a potentially debilitating trauma-based disorder. Though PTSD is most commonly associated with veterans of the armed forces who have been in combat, it’s also common among people who have experienced trauma like assault, natural disasters, and acts of terrorism.

PTSD has many symptoms, including intrusive memories, avoidance of anything associated with the trauma, self-blame, and an exaggerated startle response. These symptoms can last for months, years, or sometimes for the remainder of a person’s life. Complicating matters is that some people with PTSD have a comorbid condition, such as a substance abuse disorder.

What is bipolar disorder?

Bipolar disorder is a severe mood disorder characterized by an unstable mood that cycles between mania and depression. There are two main types of bipolar disorder – bipolar 1 and bipolar 2. Full mania is only experienced by people with bipolar 1, while those with bipolar 2 experience a state called hypomania. When someone with bipolar disorder is in a manic phase, they exhibit symptoms like delusions, participating in risky behaviors, and having seemingly untapped energy.

But, when a person with bipolar disorder is in a depressive phase, they exhibit typical symptoms of depression: withdrawal from activities, changes in sleep patterns, and feelings of hopelessness. The cycle between mania and depression typically lasts several days to more than a week. However, some people have a type of bipolar called cyclothymic disorder, which involves rapid mood changes, though the severity of the changes is less extreme.

PTSD vs Bipolar Disorder: Symptoms

As noted above, bipolar and PTSD have some similar symptoms. However, PTSD and bipolar also have distinct characteristics that enable clinicians to differentiate between the two. Below is an overview of the similarities and differences in symptomatology.

PTSD vs Bipolar: Symptom Similarities

Perhaps the most salient similarity between bipolar and PTSD is the presence of depressive symptoms. Patients with either disorder can experience the following:^[1][2]

• Social withdrawal and withdrawal from enjoyable activities
• Changes in sleep patterns, such as difficulty falling asleep or staying asleep; some patients experience the opposite and sleep for long periods
• General lack of energy
• Difficulty concentrating
• Inability to remember things

In severe cases, both PTSD and bipolar patients may have suicidal ideation or engage in self-harm.

PTSD vs Bipolar: Symptom Differences

PTSD and bipolar disorder can be more easily differentiated because of significant symptom differences.

Emotional dysregulation is common with PTSD. However, extreme swings between mania and depression are not present as they are in bipolar disorder. Likewise, the flight of ideas, grandiosity, and extreme talkativeness that commonly occur with manic phases of bipolar disorder typically do not occur with PTSD.^[3]

Another significant difference between the symptoms of these disorders is that PTSD patients experience intrusive dreams, flashbacks, and extreme psychological distress in the face of traumatic memories. In contrast, bipolar disorder doesn’t include these symptoms. Moreover, PTSD patients are prone to hypervigilance, an inability to experience positive emotions, and persistent negative beliefs about the world. These symptoms are not usually associated with bipolar disorder.^[3]

A quick examination of the diagnostic criteria for these disorders further differentiates between their symptoms. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines the following criteria for diagnosing PTSD:^[4]

• Exposure to the threat of death or actual death, injury, or sexual violence.
• Intrusive symptoms such as distressing memories, distressing dreams, or dissociative reactions, prolonged psychological distress when exposed to aspects of the trauma, or physiological reactions to aspects of the trauma
• Persistent avoidance of stimuli related to the event, such as efforts to avoid memories, thoughts or feelings of the event, and avoidance of people, objects, situations, and other external reminders of the event.
• Negative alterations in thoughts and mood associated with the event, such as:
  • Inability to remember parts of the event
  • Exaggerative negative beliefs about oneself, other people, and the world
  • Distorted thoughts about the cause of the trauma or consequences of the trauma that lead to self-blame or blaming others
  • Persistent negative emotional state
  • Less interest in once enjoyable activities
  • Distance from others and feelings of detachment
  • Reduced ability to experience positive emotions
• Alterations in arousal and reactivity, including:
  • Irritability and angry outbursts
  • Self-destructive or reckless behavior
  • Hypervigilance
  • Exaggerated startle response
  • Difficult concentrating
  • Sleep disturbances

The DSM-5 criteria for bipolar 1 disorder are markedly different:^[5]

• At least one manic episode has occurred and meets the following criteria:
  • Lasts one week or more, or any length of time if mania results in hospitalization
  • During the manic episode, at least three of the following are observed:
    • Exaggerated self-esteem or grandiosity
    • Less need for sleep
    • Talking quickly or more than usual
    • Racing thoughts
    • Distractibility
    • Increased goal-directed activities
    • Engagement in high-risk activities
  • The mood disturbance causes impairment in social or occupational functioning, hospitalization, or there are psychotic traits
  • Substance use and medical causes are ruled out as potential causes of the behavior
• At least one major depressive episode has occurred and meets the following criteria:
  • Five or more of the following symptoms during the same two-week period:
    • Depressed mood
    • Decreased interest in activities
    • Significant weight change or changes in appetite
    • Sleep disturbances such as insomnia or hypersomnia
    • Nonsensical movements
    • Fatigue or loss of energy
    • Excessive or inappropriate guilt or feelings of worthlessness
    • Indecisiveness or inability to concentrate
    • Recurrent thoughts of death, suicidal ideation, specific plans to commit suicide, or a suicide attempt
  • Symptoms cause significant distress or impairment of social, occupational, and other important areas of functioning
  • Substance use and medical causes are ruled out as potential causes of the behavior

Note that bipolar 2 disorder has different diagnostic criteria than bipolar 1 and involves having at least one hypomanic and one major depressive episode but no manic episodes. In any case, the DSM lays out the differences between these disorders, which makes a proper diagnosis more likely.

PTSD vs Bipolar Disorder: Causes

One of the most significant differences between these disorders is their etiology.

As noted earlier, PTSD is directly related to experiencing trauma. Common traumas that might trigger the development of PTSD include:^[6]

• A serious car accident
• The death of a loved one
• Emotional, physical, or sexual abuse
• War, torture, and other intense conflicts
• The loss of a baby
• Natural or manmade disasters

And while childhood trauma might be a risk factor for the development of bipolar disorder in some patients,^[7] it’s likely caused by many factors, including genetics, brain structure, and brain function.^[8]

However, research indicates that stress might serve as a trigger for a bipolar episode and PTSD.^[9] And while stress differs from trauma, traumatic events can be stressful.

For example, the death of a loved one is stressful and traumatic. On the one hand, the trauma of such an event could trigger PTSD. On the other hand, the stress associated with such an event could lead someone with a genetic predisposition for bipolar disorder to experience symptoms.

Bipolar and PTSD share other risk factors that could lead to the development of one or both disorders. These include:^[9][10]

• A severe physical illness
• Abuse
• Extreme fear
• Compounding stressors (e.g., money problems, a relationship ending, difficulties at work)

Again, these are complex mental health issues with no specific known cause. While some people might experience extreme trauma, they might not develop PTSD. Likewise, not everyone with the biological markers associated with bipolar disorder will develop the condition.

PTSD vs Bipolar Disorder: Treatment

Bipolar and PTSD are severe mental health conditions. However, many highly effective treatments exist, including various therapies and medications.

Both PTSD and bipolar can be treated with cognitive-behavioral therapy (CBT), a type of talk therapy that hones in on maladaptive thinking patterns and relearning those patterns to affect different outcomes. CBT is a front-line treatment for PTSD.^[11] It is also effective for treating depressive symptoms in bipolar patients.^[12]

This is the only mainstream treatment option shared between these disorders. There are far more treatment options specific to each condition.

For example, PTSD is often treated with:^[11]

• Cognitive processing therapy (CPT) is a subtype of CBT that focuses on challenging maladaptive beliefs regarding trauma.
• Cognitive therapy is a more general cognitive based therapy that can help to modify negative memories and assessments of the trauma while interrupting negative thoughts and behaviors that impact daily life.
• Exposure therapies, like prolonged exposure, are a type of CBT that instruct patients to face trauma-related fears, feelings, and situations gradually. Eye movement desensitization and reprocessing (EMDR) is another type of exposure therapy that asks patients to face and process the trauma while simultaneously experiencing bilateral stimulation, which aims to reprogram how the trauma is stored in the brain, thereby reducing symptoms.^[13]
• Medications, particularly selective serotonin reuptake inhibitors (SSRIs) like sertraline, paroxetine, fluoxetine, and venlafaxine, are often prescribed to help patients manage their PTSD symptoms.

Bipolar disorder is often treated with the following:

• Family therapy focuses on family relationships and encourages family members to work together toward improving mental health and functioning.^[12]
• Psychotherapy, especially when it focuses on stress management, self-care, and identifying the onset patterns of manic and depressive states.^[14]
• Medications, especially lithium, are highly effective for stabilizing mood and reducing extreme mania and depression. Anticonvulsants like valproic acid and carbamazepine are used to treat mania, while lamotrigine can reduce the frequency of bipolar episodes. Second-generation antipsychotics like quetiapine and symbyax (a combination of fluoxetine and olanzapine) can also help manage the symptoms of bipolar depression.^[14]

Again, though the bulk of treatments for these disorders are different, they offer effective ways of minimizing symptoms and improving day-to-day life for people with one or both disorders.

Can you have PTSD and Bipolar disorder at the same time?

PTSD and bipolar can occur together. Research suggests that anywhere from 4 percent to 40 percent of people with bipolar also have PTSD. The incidence of bipolar among people with PTSD is even higher, ranging from 5 percent to 55 percent.^[15]

Interestingly, bipolar with PTSD is more likely among women. Likewise, bipolar with PTSD is more common among patients with bipolar 1 disorder than bipolar 2 disorder.^[15]