Anxiety in Depression and Bipolar Disorder
How you manage your anxiety is crucial to managing your mood.
Anxiety and Mood. 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 ...
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Unbelievably, the DSM-IV is silent on both anxious depression and anxious mania. The DSM-5, due out in 2013, would change this somewhat, with the new diagnosis of "mixed/anxiety depression," but nearly a century after Kraepelin, the people who should know better can't bring themselves to acknowledge the obvious in mania.
About 60 percent of those with major depression and 40 percent of those with bipolar also contend with full-blown anxiety, but the issue goes far deeper, as all it takes is one or two anxiety symptoms to make your depressions and manias much more difficult to contend with.
The technical term is "subsyndromal comorbidity," and for years researchers such as Herman Van Praag and Anthanasious Koukopolous have been arguing that psychiatry needs to get with the program. Two studies by Ellen Frank PhD et al of the University of Pittsburgh found that depressed or bipolar patients with co-occurring panic symptoms experienced significant delays in their weeks to remission. These patients also had higher levels of residual impairment.
We need to think beyond the DSM symptom list, Dr Frank advised a symposium at the 2004 American Psychiatric Association's annual meeting. "The DSM has made us less sensitive to our clinical intuition."
That is putting it mildly.
The Biology of Anxiety and Depression
Both anxiety and depression share the same stress pathways. In an article in the Sept 2003 Scientific American, Robert Sapolsky PhD of Stanford writes on how the fight or flight response underpins both anxiety and depression:
The primate stress response, Dr Sapolsky begins, can be set in motion by the mere anticipation of an event, and when we erroneously believe a stressor is about to happen we "have entered the realm of neurosis, anxiety, and paranoia." The amygdala in the brain receives input on a conscious level from the cortex and unconsciously from specialized parts of the brain. In response to a perceived threat, the amygdala sets off a chain of events that results in the hormone CRF signaling the brain stem, which activates the sympathetic nervous system. In response, the adrenal glands produce adrenaline (epinephrine) and through a different pathway cortisol, both which prepare the body for fight or flight.
In addition, the amygdala sends information back to the frontal cortex and to sensory cortices, which accounts for emotionally-influenced decision-making and vivid sensations, respectively. In addition, the amygdala is involved in memory. Paradoxically, stress can strengthen the ability of the amygdala to form implicit or preconscious memories while inhibiting the hippocampus' ability to form explicit or conscious memories. The individual may thus experience a fight or flight response to a voice in a crowd without knowing why, being unable to link the sound of that voice to the similar-sounding voice of a past assailant, resulting in "free-floating" anxiety.
Meanwhile, cortisol activates a brain region called the locus coeruleus, which sends norepinephrine to communicate back to the amygdala, thus initiating the stress response all over again and resulting in a destructive feedback cycle.
The torpor of depression may appear to be the opposite of anxiety, but like anxiety can be related to stress. Moreover, depression is not a passive state. According to Dr Sapolsky, "the dread is active, twitching, energy-consuming, distracting, exhausting - but internalized. A classic conception of depression is that it represents aggression turned inward ..."
Dr Sapolsky asks us to imagine a rat trained to press a lever to avoid a mild shock. The anticipation of mastery might activate pleasurable dopamine release to the frontal cortex. If the lever is disconnected, however, so that pressing it no longer prevents shocks, the rat will frantically press the lever repeatedly, attempting to gain control.
This, says Dr Sapolsky, is the essence of anxiety, characterized mainly by adrenaline and norepinephrine secretion and to a lesser extent by cortisol production. As the shocks continue and the rat finds its attempts at coping useless, a transition occurs where cortisol dominates and key neurotransmitters are depleted.
In the words of Dr Sapolsky: "It has learned to be helpless, passive and involuted. If anxiety is a crackling, menacing brushfire, depression is a suffocating heavy blanket thrown on top of it."
Anxiety Gets Personal
Kevin, describes how this deadly combination of mood and anxiety ruined his life:
It felt like being caught in a huge wave, unable to get my footing any longer, unable to understand which way to the surface, and just helplessly and hopelessly thrown about, powerless to do anything about the hostile world that was coming down around me. I stayed curled up in the corner of a couch, unable to answer the phone or the doorbell. Everything that came in the mail scared me, so I wouldn't open it for several days at a time. I did not leave the house and did not want to see anyone. I didn't care any longer about the way I looked.
He goes on:
Every time I have a couple of decent days back to back, I hope that this is the beginning of my recovery. Then something negative confronts me and I get a panic attack and head for the Xanax. I go right down the tubes to hopelessness and constant depression and anxiety. There, even good things are heavily veiled in grey. No shower, no shaving, no energy, no hope. Just scared and remembering back to my childhood diagnosis of "Born Wrong."
In 2008, after not driving for 30 years, I booked a road test, only to discover to my horror that my old skills did not come back "like riding a bicycle." As I describe it in my blog on HealthCentral:
My anxiety levels are through the roof. I have just met a wonderful woman who lives [40 miles away] in San Diego. I NEED 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! I feel lower than a snake's belly. 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 for August.
Two weeks later, I call her in a panic. I have 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!
Yesterday. I’ve willed my heart down to merely 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! The test ends. 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 the inspector.
Okay, Let's Overthink This
People with depression have a tendency to ruminate, inevitably on dark thoughts, even when not depressed. Those with bipolar tend to have racing thoughts, even when not manic. Thinking is good, but we often think too much. We fret, we get excited, we get overloaded. The reactive parts of our brain respond by hitting the panic button. Now, ironically, our thinking - our rational thinking, anyway - is off-line. The primitive fight-or-flight parts of our brain are in charge. Of all things, we often find our neurons in a state of gridlock. We are stuck, frozen, like a deer caught in the headlights.
Like a guy who hasn't driven in 30 years in a drivers test.
It's a two-way street, then: Manage your emotions to manage your thinking. Manage your thinking to manage your emotions. Your anxiety may be an indicator of a mood episode about to happen. Your mood may be an indicator of a panic attack about to engulf you.
Either way, you need to catch your thoughts and emotions as they occur, when they are capable of being managed, before they overtake you. Mindfulness is the key. Once you have identified an incipient runaway thought or emotion, you can take immediate action, such as stopping to smell the roses, thinking things through, or popping an anti-anxiety med. Mindfulness takes years to master and is hardly fool-proof, but even a slight proficiency that produces modest results is a giant leap forward.
Continue to The Mood and Anxiety Connection ....
This article replaces an earlier article, May 18, 2011
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