Anxiety + Depression Effective Treatment of the Big Two Co
Occurring Disorders
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Introduction
CO-OCCURRING ANXIETY and depression are not always obvious—
even to a seasoned therapist. It has happened to me more than once: I see a
client for anxiety and decide a psychiatric consult regarding medication is
in order. The client comes back with a diagnosis of depression and, of
course, a prescription for medication to treat the depression but no mention
of the anxiety I thought was the problem. Now there are two professionals
with two views of the same symptoms. Who is right? I suspect that, most of
the time, we both are. Herein lies the challenge: It’s hard enough to treat
these disorders when they exist on their own, and it gets even harder when
they present together.
The biggest challenge is being able to spot both problems. Typically one
symptom picture dominates, at least in the description we obtain from
clients. But think about some of the obvious ways these two disorders
interact:
• A person who is depressed and very low on energy may not have the
mental “oomph” to fight constant anxious rumination, and the anxiety
will make depression worse.
• When acute anxiety is unremitting and uncontrolled, it can make any
person depressed and exhausted.
• A high-energy client who complains of constant worry may not
recognize how the depressive feelings of pessimism and inadequacy
are leading to the worry about failing or making mistakes. Symptom
management of worry will be less effective if the depression isn’t also
treated.
• A quiet, shy client who has become socially anxious may become
depressed as the social anxiety leads to avoidance of activities that
might have interested him or her. The depression makes it harder to
have motivation to overcome social fear and reengage with others.
Even when you can see that both disorders are present, how do you know
where to start in therapy?
As a clinician specializing in anxiety and depression, and with more
than 30 years of experience, I have seen the challenges that these two co-
occurring (comorbid) conditions produce. They appear together so often
that we need to ask some questions:
• How common is this comorbidity and why does it exist?
• How can I be sure my client is showing signs of both anxiety and
depression? What indications of comorbidity should I look for?
• Is there a way to identify when one disorder is more prominent than
the other? If so, do I treat one first and then the other? If not, should I
view them as the same clinical problem, and treat both in tandem?
• How will one disorder affect treatment response when I work with the
other?
Consider the following case:
Pat sought help for what she said was overwhelming anxiety. She
reported that she constantly fretted about her health and her husband’s
health. (Neither was sick, but they could be!) She worried about
whether she had offended someone, berated herself for having been so
stupid as to buy a house in a neighborhood with so many noisy children,
and was concerned that she would be fired for working too slowly,
despite the fact that her boss had never voiced such a complaint. She
worried about whether she would lose her friends because she worried
so much.
What were hard to see, and what Pat did not recognize either, were the
common themes of loss and failure underlying her anxiety. In fact, she had
strong feelings of worthlessness and hopelessness about the future
(symptoms of depression) that had to be addressed if she was to feel less
anxious. In this way, the depression Pat did not identify would interfere
with letting go of worry, and it needed to be addressed to successfully
diminish her anxiety.
Conversely, sometimes an underlying anxiety fuels depression. This was
the case with Mark.
Mark told me he didn’t know how much longer he could pretend to
be working before the others in his office caught on. He said that he
tried to work but couldn’t concentrate and felt sluggish and
unmotivated. At the end of the day he went straight home to lie on the
couch all evening. Mark presented as depressed. But a fuller picture
developed when I began asking him about how he had functioned
previously. Mark reported that he had always been a worrier, and he so
annoyed his wife with requests for reassurance that she finally left him,
not wanting to be married to such a “clingy” man and feel so
responsible for his wellbeing. The anxiety that had plagued Mark
eventually turned into depression, partly as a result of the losses he had
suffered and partly because of his inability to handle anxiety. Mark had
never had a particularly positive outlook on life, but the persistent,
nagging doubt and anxiety completely squashed any natural optimism
he might have had otherwise.
These kinds of clients walk into your clinical office every week. This
book describes the most frequently seen combinations of anxiety and
depression and explains how these two disorders affect each other as the
client moves through the process of therapy.
Although the methods I use to help clients manage and eliminate
symptoms are grounded in solid clinical research and supported in the
literature on how therapies work, the interplay I describe is based on my
own extensive experience with clients who suffer from depression and
anxiety. I will address questions I frequently hear from therapists when I
teach seminars. For example:
“I have a client whom I thought had generalized anxiety—lots of
worry, strong physical agitation. But I see her as having no joy or
optimism. I thought that would clear up as she managed her worry
better, but I don’t see it getting any better. Is it possible she is
depressed?”
My answer: “Most definitely!” In this book, I will describe how that
kind of depression can masquerade as acute anxiety and discuss how it
undermines the client’s attempts to manage anxiety. Treatment methods
must interweave depression management with anxiety treatment; if they
don’t, the client will become depressed about lack of progress, too.
“I’m treating a 50-year-old man who says he has been depressed
since his wife died. He seems to have dealt with his grief, but he still has
no zest for life, and he is wondering what the future will hold. He
doesn’t know how to connect with neighbors and has no friendships
outside of talking to people at work. Could he possibly be anxious about
meeting new people or going into social situations without his wife?
Could I be missing social anxiety?”
Yes, of course. Life experiences such as the death of a loved one do not
always result in depression, but they can when the circumstances of a
person’s life are dramatically altered and the person does not have the skills
to cope with it. A socially anxious (or panicky) person may come to rely on
a family member and never see the anxiety as an impediment until life
forces him or her to function alone.
“Is there any way to definitively rule out anxiety or depression?”
That is a question that has to be answered equivocally. Although there
are assessment tools that effectively measure the degree of anxiety or
depression, like the Beck or Hamilton scales so popular in research studies,
the symptoms on these scales are not mutually exclusive: A person can have
high scores on scales for both anxiety and depression. Ideas about how to
parse what disorder is dominant and how each affects the other are the meat
of this book.
“Are these disorders one and the same, with varying dominant
symptoms?”
We might end up deciding that is the case at some point in the future,
but I suspect it’s an issue of underlying neurobiology intersecting with life
experience to push the client toward depression or anxiety. In my clinical
practice, I spend a fair amount of time looking for signs of biology of
depression or anxiety that preexisted the life situation that catapulted the
client into anxiety or depression, and I’ve found that certain life
circumstances, like trauma, often push clients toward anxiety whereas other
circumstances, like significant losses, push clients more toward depression.
“Isn’t it necessary to get at underlying causes before you can
effectively treat the anxiety or depression regardless of which seems
dominant?”
For many reasons, which I will outline in different cases, symptom
treatment can be effective and often leads clients to recognize that there is
some underlying cause of their symptoms, such as growing up with an
abusive parent or addicted family member. When clients have effective
treatment for the symptoms of anxiety or depression, they are equipped
with skills to manage the anxiety-provoking aspects of treatment for
underlying issues. They are also more ready for the emotional challenges of
dealing with the underlying causes.
“When the diagnosis becomes clear, how do I decide what treatment
protocol to choose?”
I want to take some time with this answer. All of us who do
psychotherapy already know that anxiety and depression are the most
common complaints people bring to therapy. We spend time studying how
to treat them, but there is no single place to get a manual for treating
comorbid disorders. My intent with this book is to help you figure out
where to start and where you might go as you progress with clients who
present with co-occurring anxiety and depression. Let’s examine the
treatment protocol issue.
Due to the incredible rates of comorbidity, it seems prudent to operate
as if these two disorders are facets of the same underlying neurochemical or
brain-function problem. But it is the complex interplay of nature, nurture,
and life experience that leads people to have different symptoms. Similarly,
the course of treatment relies on the interplay among the client’s history,
response to interventions, and impact of symptoms on the course of
treatment. The art of therapy lies in the therapist’s ability to move with the
client.
Despite the trend in the U.S. toward treating first with medication,
psychotherapy is where clients with comorbid depression and anxiety
belong. Although pharmaceutical interventions may be beneficial during the
initial stages of therapy when clients may suffer from low energy and poor
concentration that affect therapy compliance, research studies repeatedly
demonstrate that cognitive-behavioral therapies are superior in the long run
to psychopharmacology (Siddique, Chung, Brown, & Miranda, 2012; Wiles
et al., 2013). In fact, the efficacy of psychotherapy for most clients is so
strong that the American Psychological Association recently began a
campaign using both video and print ads to urge people with mental health
issues to try psychotherapy as the first-line treatment.
The considerable overlap between anxiety and depression suggests that
we would do well to regard these disorders as one syndrome and treat it
using a symptom-management approach. Farchione and colleagues (2012)
argued effectively for what she called a “transdiagnostic approach” to
treatment, noting that most manuals offer treatment approaches focused on
one diagnosis, which forces clinicians to treat one disorder at a time.
Farchione’s research supports the effectiveness of inclusive styles of
therapy such as cognitive restructuring, identifying and changing ineffective
behaviors or maladaptive coping strategies, preventing avoidance, and
exposure with response prevention. Various additional models of therapy,
such as cognitive therapy, acceptance and commitment therapy (which uses
mindfulness-based treatment), and exposure therapies lead the list of
approaches to the symptoms.
Transdiagnostic treatment has been around for many years and has been
known by different names, such as “multimodal” and “eclectic” therapy.
This pragmatic approach to psychotherapy not only has been acknowledged
as commonly practiced but also has been supported as valid (Lazarus, 1981;
Palmer & Woolfe, 2000). For example, interventions for panic disorder
have grown over the years to include a combination of psychoeducation,
diaphragmatic breathing, and progressive muscle relaxation to decrease the
probability of panic attacks occurring, along with cognitive interventions to
change catastrophic interpretations of physical sensations and the meaning
ascribed to the sensations. Other methods include interoceptive exposure to
feared bodily sensations (e.g., dizziness, rapid heart rate) through spinning
or exercise, and exposure to places that the individual has avoided for fear
of having a panic attack. A similar set of treatment models is utilized for
social anxiety.
Cognitive-behavioral therapy (CBT) works well when applied to
symptoms of anxiety or depression, as it does not identify an underlying
cause before treatment ensues. The broad range of CBT methods typically
includes self-monitoring of depression or anxiety-provoking cues to
identify and change maladaptive responses to them, metacognitive therapy
to change thinking about symptoms, lifestyle changes, and identifying and
correcting cognitive errors. CBT is widely recognized as effective for all
age groups.
What about the underlying causes? When do you treat those? In my
experience, effective symptom management is the key to subsequently
identifying the underlying psychological causes that might drive these
disorders. Those root causes can then be treated with appropriate
psychotherapies. For example, with symptoms under control, a person who
became anxious as a consequence of childhood experiences with an
addicted parent can continue therapy to address that history and develop
better ways of dealing with experiences that cause the depression or anxiety
to reemerge.
In this book I will explain why anxiety disorders and depression are so
often seen together. I will describe the brain structure and function that
underlie comorbidity and discuss the hallmarks of each disorder. I will look
at ideas for treatment protocols in the different presentations of co-
occurring anxiety and depression. As always, in referring to clients
throughout the book, confidentiality rules: All are amalgams of several
people and do not describe any one individual.
ANXIETY +
DEPRESSION
CHAPTER 1
WHERE TO START?
THE SIMILARITY between symptoms of anxiety and depression presents
a serious clinical challenge. The case of Mary Jane was a classic example.
Mary Jane persistently worried about the recurrence of her cancer,
despite getting good reports from her physician. She felt like worry was
ruining her life. It kept her awake at night, and it drove her to
overschedule her days, with constant participation in community and
family affairs. But no matter how busy she was, she continued to
experience a constant undertow of worry about dying, and no amount of
reasoning would resolve it. She sought therapy to help her stop
worrying and be able to enjoy all her activity.
When I began asking about her history, however, a more
complicated picture emerged. Mary Jane ruefully admitted that she had
some anger problems: She got frustrated with people she saw as being
“slow” or “dense” and she had trouble not showing that she was
irritated, which she constantly seemed to be. She knew she yelled too
much. Closer questioning also revealed another side to her activity
level. Mary Jane laughingly stated that if she stopped moving, she
would never start again, and that would be a disaster because she was
the only one in her family who really got things done. Yes, her husband
was employed, but that was where his contributions ended. She needed
to supplement their income with her job and she was the one who drove
the children to school and appointments, cleaned the house, and
planned family events from birthday parties to vacations. She then joked
that it might be easier to just give up trying to be happy altogether.
These revelations, offered in a lighthearted tone, were serious
indications of the depression that was at the heart of Mary Jane’s
ruminating about dying. Her belief that worry was preventing her happiness
was probably correct but not complete. She was feeling neither joy nor
interest in life. She was busy due to obligations and her well-defined sense
of duty, but she seemed more to be warding off hopelessness than seeking
delight.
To me, Mary Jane’s diagnostic picture was clouded by the presence of
both anxiety and depressive symptoms: She was a busy worrier who was
mostly depressed. Treatment for her would have to address both as well.
Mary Jane’s case is a good example of how anxiety and depression can
overlap. It is likely, in fact, that the high rate of co-occurrence is partly due
to overlapping symptoms (Zbozinek et al., 2012). For example, people who
endorse worry on a survey or in an interview also endorse the ruminative
quality of depressive thinking. Examples of overlapping symptomatology
include:
• Preoccupation or worry (topics vary—in depression, rumination is
more likely about hopelessness or helplessness; in anxiety it is more
apprehensive)
• Physical agitation
• Fatigue
• Sleep problems
• Irritability
• Loss of pleasure (notable as symptom of depression, but also
prevalent in generalized anxiety disorder)
It is also well known that these disorders affect each other in reciprocal
fashion:
• Anxiety precedes depression most often, as the weight of anxiety is
depressing, but there is probably also a neurochemical reason for
anxiety to come first, rooted in the impact of stress, which is a
hallmark cause of anxiety.
• Suffering a panic attack while seriously depressed can lead to
impulsive, ill-considered attempts to end life due to the press of
terrifying feelings at a time when one is not feeling optimistic and
resourceful. People suffering panic tend toward catastrophic
explanations of life events and as a result their emotional regulation
suffers. When they are also depressed, they do not readily see a way
out of their suffering.
• People with social anxiety disorder tend to be passive, low on the
scale of enthusiasm and energy, and are often shy and withdrawn.
They are not necessarily depressed initially, but their isolation
contributes to developing depression. In addition, their innate feeling
of being socially incompetent and their lack of involvement in social
activities make it tough to shake off depression when it occurs. Once
depressed, they are less likely to push themselves toward more social
experiences.
DISTINGUISHING BETWEEN ANXIETY AND
DEPRESSION
Although the symptoms of anxiety and depression can be similar, there are
certain features that can help a clinician decide which problem may be
dominant. Table 1.1 shows what I listen for in an interview when I’m trying
to parse the two.
TABLE 1.1 Side-by-side comparison of anxiety and depression symptoms.
ANXIETY DEPRESSION
Worry is relieved by resolving the particular Worry is more like constant fretting over
situation, but anxiety returns after a brief themes of worthlessness and inadequacy—
relief. static conditions that do not change.
Attitude is positive but includes “if only” Attitude is negative, and typically has
thinking about what would resolve the hopeless or helpless themes that the
problem once and for all. problem cannot be resolved.
Energy may be high or low depending on Energy is usually low, except in the highly
the type of anxiety. Social anxiety often active person who is becoming burned out.
includes passivity and low energy; panic Then depression will emerge even if it did
and generalized anxiety often involve high not preexist the burnout.
energy.
Sense of personal control may be excellent While in a state of depression even people
with generalized anxiety disorder clients, but who have an internal locus of control feel
external locus of control is common with unable to exercise it due to feelings of
panic and social anxiety. inadequacy and worthlessness.
Irritability is not constant. It results from Irritability is persistent—like the person’s
tension and small things may cause temperament is sour.
behavior eruptions.
Attention is disrupted by preoccupation with Attention is disrupted by low mental energy
worries. to hold focus.
Negativity isn’t constant—it comes and goes Negativity is persistent. Life is not seen as
with the perception of threat of danger being good or as likely to work out well.
(problems, losses, rejections, etc.). Life is People may see others, but not themselves,
not seen as being bad, but one’s as having a good life.
experiences are.
Persistent high anxiety can overwhelm A depressed person with high anxiety will
coping skills, leading people to be feel overwhelmed and have trouble
preoccupied with a “sick to the stomach” functioning in work and home life. The
feeling, and to begin making mistakes in anxiety might not be diagnosed as the
work and home life. This condition leads to problem when depression is evident, but it
depression, which might appear to be will hinder recovery.
primary.
Performance at work is often high but Signs of impairment often show up at home
anxiety is experienced at home. before they do at work.
Sleep problems are typically restlessness Sleep problems tend to be early-morning
and problems quieting the mind to fall awakening or not feeling restored despite
asleep. Worry dreams make sleep less sleeping enough hours.
restorative.
ASSESSING ANXIETY AND DEPRESSION
In assessing where to start, I look first at three issues:
• Physical health
• Readiness to change
• Mental energy
Physical Health
Physical health is unquestionably the first thing to look at. I’ve found that
it’s most often an issue with extremely revved-up clients and with low-
energy clients.
Revved-Up Clients
Revved-up clients have high energy and display physical agitation. They
are jittery and tense. Their mental process is also fast and jumpy. Their
words spill over each other in a way that makes you think they are trying to
tell you two things at once. Their communication does not have the racing,
flight-of-ideas quality you may hear in mania, but you will get a sense that
they are rushing to get it all out fast so that you can get busy treating them.
I often refer to revved-up clients as having “TMA” (too much activity).
They tend to have a busy lifestyle or a very busy mental life, and when
anxiety crests, they may move from one activity to another as is seen in
attention deficit disorder (ADD). For example, one woman told me how she
would find herself stopping in the middle of writing a check so that she
could phone her sister to ask a question and then change a load of laundry
and, returning to the check, find the dollar amount half written. The
distinguishing feature here is that the anxious person without ADD
remembers what he or she was doing!
When treating revved-up clients, it is important to rule out physical
causes other than neurochemistry (see Chapter 2). Ask about and consider
medical evaluation for:
• USE OF STIMULANT MEDICATIONS. Many drugs (such as
asthma medication) have side effects that raise levels of adrenalin and
norepinephrine. Make sure clients are responding appropriately to
medications with this profile.
• FEMALE HORMONE LEVELS. Women who have suffered
premenstrual distress seem to be especially sensitive to normal shifts
in levels of hormones. This can lead to an overreactive stress response
and create anxiety or depression. That same woman is likely to have
trouble during other life hormonal transitions. During perimenopause,
for example, she may resemble revved-up clients, describing a
“jumping out of my skin” feeling of easy irritability and physical
agitation. At menopause, more depression may ensue.
• CONSUMPTION OF CAFFEINATED BEVERAGES AND
ALCOHOL. Caffeinated beverages, especially “energy” drinks, can
produce symptoms that look like anxiety. Ironically, alcohol, which is
more often thought of as a calming agent, can be another cause of
overarousal. People who binge on alcohol may experience intense
physical agitation the following day from the body’s normal process
of detoxifying.
• LACK OF SLEEP. Emotions and physical reactions can become
unstable with fatigue, and whereas one person may be exhausted,
another can become agitated. Lack of sleep may be caused by any
number of physical problems, such as pain or sleep apnea, to name
just a couple.
Low-Energy Clients
Low-energy clients slouch in the chair as they tell you with minimal
verbiage about their issues. Slow talking or less talking and long thinking
are often initial signs of low energy. (Of course, these behaviors may also
indicate introversion or hesitance to share information, but when they are
coupled with other signs of low energy, you can be reasonably sure you’re
dealing with a low-energy client.) These clients radiate lethargy and you
may find working with them tiring. Even when they are quite pleasant, you
may feel a sense of helplessness in effectively treating their symptoms.
Low-energy people can be real worriers. Their anxiety may in fact
dominate over depression, but genuine lethargy is a typical indicator of
depression. As one of my clients described, “It is only when my anxiety
about being fired skyrockets that I have enough mental oomph to overcome
my lack of energy to do the work.”
There are several physical issues to consider here:
• SLEEP. Is your client getting adequate rest? Waking up refreshed? If
the answers to either of those questions is no, then evaluation of sleep
is in order. The American Academy of Sleep Medicine website (in the
resource list) can be a good starting point for developing a list of
questions about sleep habits and sleep environment. Often simple
interventions, such as no “screen time” for an hour before sleep, no
work email after dinner, or sleeping in a dark room without the
television on can make a world of difference. But you may well need
to request a sleep study for sleep apnea, even in children.
• HORMONES. Low testosterone, which can affect women as well as
men, is a common cause of low energy (as well as low libido). The
physician doing the physical evaluation should be knowledgeable
about hormones and their effects on mood and energy. Many of my
clients seek advice from physicians trained in integrative medicine or
from naturopaths when they suspect problems stem from hormonal
imbalances and deficits.
• MEDICATIONS. Many medications, especially
psychopharmacological drugs, are culprits for low energy; the list is
too long to include here. A physician must be consulted.
• LOW VITAMIN LEVELS. Vitamin D deficiency tends to present as
fatigue or depression; vitamin B deficiency can look like anxiety.
Other low vitamin levels may have an impact as well. This is an easy
problem to fix. For a time, large doses of vitamins prescribed or
administered by injection by a physician may be necessary, and
subsequent daily vitamins may be added to the diet. Also be aware
that aging clients are more likely than younger clients to have
adequate nutrition but malabsorption of vitamins, so physical issues
like their level of intrinsic factor should be investigated.
• ANOTHER ISSUE RELATED TO AGING IS THE INCREASING
LIKELIHOOD OF DISEASE PROCESSES. Anemia, low blood
pressure, heart disorders, and many other causes of low energy should
be investigated. This reinforces the need for careful physical
examinations of clients.
• HIDDEN ALLERGIES. This issue is often harder to spot. The
reserves of the low-energy client may be depleted during times of year
when airborne allergens are prevalent. Food allergies can also produce
symptoms of fatigue. One interesting possible indicator of food
allergy is craving for foods or eating one primary food. A client who
had significant fatigue issues told me the only beverage she drank was
milk, and she drank a lot of it—at least six glasses a day. It turned out
she had a latent food allergy to dairy that contributed to her fatigue
and general feeling of malaise.
• NUTRITION. Even without vitamin deficiencies or food allergies,
nutrition is often an issue for clients. Are they getting the right
nutrients to build healthy, energetic brains and bodies? Check out the
Reading & Resources section for books on eating right if you do not
have a working knowledge of general nutrition.
Readiness to Change
Your clients’ readiness to make changes in their lives depends on several
factors. They must not only want to change but also see the problem for
what it is and have the skills to move forward. Clinicians can learn a lot
from questioning clients about how they perceive their problem to affect
them, how they understand its origins, and what they have already tried to
make things better.
Motivational interviewing is a style of therapy that has operationalized
the process of questioning to help identify the client’s stage of readiness to
change. It also identifies the needs of each stage to promote change. Many
clinicians understand and use this style in a less structured, intuitive way,
even if they have not studied it. (See the Reading & Resources for more
information about this style of working.) It is a remarkably helpful style for
working with people with addictions, especially if they are not currently
motivated to change their addictive behaviors. It is also very helpful with
anxiety and depression, when clients often clearly need skills but may need
some groundwork on motivation first.
When it comes to anxiety and depression, most people are motivated to
feel better, but not every client enters treatment of his or her own volition.
Often family members urge these clients to seek help, especially if panic or
social anxieties cause stress for the family, as might happen if clients are
reluctant to drive or go out socially without a companion. We start our
inquiry into the client’s condition by asking some version of the question
“Why now?” When we hear that clients are there because someone sent
them to get “fixed,” we need to ask this question somewhat differently. We
want to find out who wants them to change and what others say about their
symptoms. Then we need to look for any personal motivation the client has
to make a change.
I see this motivation issue most often with young adults who are
socially anxious. They get sent to therapy by parents who want them to do
better in college or find a better job, but these young people do not share
that motivation except in a general way. They may not view their anxiety as
the problem yet, instead identifying the problem as being outside of
themselves—the university’s classes are too large, for example, or the job
market is too tight.
I’ve also seen the issue come up when one partner in a relationship
wants the other to be less anxious, less depressed, more confident, and so
on. The situation is especially challenging when clients firmly believe their
problems would not be an issue if some external circumstance would
change. They think their anxiety or depression would disappear if their
partner would earn more money, stop being so angry, be more helpful, stop
nagging, and so on—or if they themselves could just get a better job, feel
physically better, move to a better house or neighborhood, and the like.
Most people will not put effort into psychotherapy if they believe the rest of
the world causes their problems.
Clients who are ready for change show an understanding that some (or
most) of their problems in life are caused by their anxiety or depression and
it is up to them to change that, even if they have no idea how to begin. They
