Often, patients come to my office complaining of anxiety, and the more I listen to them, the more I realize they are in the middle of a full-blown depression, with anxiety and sadness as the major symptoms. The fear of bad things happening dominates the mental land-scape. Someone may fear going crazy. She may fear being left. She may fear bad things happening to her or to her family. She may fear being unable to provide for her family in the future. She may fear an inability to function and to sustain a life for herself. Or she may fear experiencing an unbearable psychic pain.
It is important to explain depression, briefly. Commonly spanning at least a two-week period, depression includes feeling low sex drive, decreased interest in life, increased rumination or sense of guilt, low energy, low mood, deep feelings of the blues, sadness, inability to rally, poor concentration ability, low appetite, de-creased food intake, feelings of paralysis or heaviness, contemplation of suicide, and/or a basic listless quality.
Life may simply no longer feel worthwhile or worth living. It is not surprising that one of the most common elements of depression is anxiety. There are many ways to think about this relationship, and much thought has been given to this clinically. Often, a loss or a sad event takes place, either real or perceived. This injury, in turn, triggers the depressive feelings. Not attaining one’s desired status can leave one feeling less than ideal; this loss of ideal opens the floodgates of depression.
Anxiety stemming from depression can mushroom into the panic of hopelessness, which, in turn, can lead to frenetic behavioral attempts to manage the anxiety with impulsive decisions. At the time, these desperate attempts seem to provide relief, but longitudinally, they can trigger further distress. For example, a patient who is acutely anxious about future terrorist attacks may decide to pack the family apartment, leave her spouse, and move the family to a rural setting. Once she relocated and thought the distress was confined to the urban landscape, this patient’s untreated depression might manifest further anxious symptoms.
Now she may believe that the water supply of the town will be contaminated or preoccupy herself with rural terrorist attacks. This impulsive streak might make a doc-tor suspect bipolar illness (manic depression); however, often action-prone plans stem from the anxiety fueled by an untreated depression. Anxiety is a major piece of the larger clinical picture so common today. Now, in as much panic as before, the patient is isolated and with-out the social and community resources familiar from years in her former neighborhood. You can see how the cycle worsens without treatment.
I have thought of this particular anxiety as reflecting a question within the self. Will the individual be able to return to an ideal sense of self? Anxiety serves as the substrate of this preoccupation. The internal anxiety, after a patient has been fired, might be, “will I be able to work and maintain a job at the level I did before?” This initial worry can spring into anxiety over survival. This metamorphosis creates a vulnerable state, which,if not mended, can reinforce further depression. It is not surprising that as one’s depression gets treated, anxiety invariably lessens.
Rick’s comments:
It’s not always easy to tell, even about oneself, where one symptom ends and another symptom begins. At least I don’t find it easy and I doubt that I’m alone in this. I tend to think of my depressive tendencies as involving lethargy, sadness, a lack of enjoyment in life and a sense of being very alone and disinterested. Anxiety, for me, is more of a jittery feeling—more alive than the depressive ones, more active— yet not in a comfortable way. Maybe it makes sense to say that my depression is more like pain, my anxiety more like an itch, and my OCD like an attempt to scratch that itch.