When Anxiety Butts Heads With Mood

I just finished rewriting my old mcmanweb article on anxiety and mood, which I expanded into two articles: Anxiety in Depression and Bipolar, and The Mood and Anxiety Connection. Below are three snippets from the two articles, thoughtfully stitched together for your reading pleasure ...

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 ...

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.

Mixed Depression/Anxiety

Filed under "Depressive Disorders" is the proposed DSM-5 diagnosis of "mixed depression/anxiety." This involves "three or four of the symptoms of major depression" (a straight depression diagnosis requires at least five symptoms). One of the symptoms must include depressed mood or loss of pleasure. The depressive symptoms must be accompanied by "anxious distress."

The draft DSM-5 defines anxious distress as "having two or more of the following symptoms: irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen."

In essence, the DSM-5 is part-way to acknowledging that anxiety can be both an illness and a symptom of another illness. Depression, psychosis, sleep, and eating and other conditions already share this dual status. Indeed, in this particular area, the DSM-5 harkens back to the pre-modern DSM-I of 1952 and DSM-II of 1968, which viewed much of mental illness as the result of an underlying emotional disturbance called "neurosis." (More serious was "psychosis.")

According to the DSM-II, "anxiety is the chief characteristic of the neuroses." In a manner of speaking, anxiety both drove neurosis and could be one of its main symptoms, along with depression. Back in those days, symptoms were viewed as maladaptive responses to one's surroundings.

In other words, anxiety and depression and mania and even schizophrenia were seen as failures in our ability to cope. As naive as this may appear today, there is considerable merit in the old view that anxiety is inevitably to be found at the scene of the crime in almost any mental illness, whether as the principal or the accessory. Mix despair with anxiety and we're immobilized, unable to pick up the phone. Change it to a racing mind and we're yelling into that same phone, freaked out over some slight disturbance.

In one sense, the world is way too close and immediate, on the other too far and disconnected. One day we're treading water surrounded by thrashing ravenous crocodiles. The next we're Major Toms, a million miles from nowhere, cut off from humanity.

Mixed Mania/Anxiety

The DSM-IV does not recognize this state, and neither would the DSM-5. From a clinical level, mixed mania/anxiety would probably be impossible to diagnose, so why bother? But on a personal level, we need to acknowledge reality. It's easy, really. Simply imagine a state of irrational worry combined with failure to control one's impulses. Thus, you may find yourself fretting about your situation at work. Fairly normal. What's not normal is storming into the boss' office and quitting your job, with no other job lined up. This happened to me. It wrecked my life, but I'm grateful I ONLY quit my job. In the frame of mind I was in, I could have done something much worse.

An additional twist: Walk into any support group, and you will hear participants discussing their "mood triggers." Excessive worry, for instance, may cause you to lose sleep, which makes you a sitting duck for mania. Or it may set off depression, which later sets up mania. Keep in mind, depression and mania never operate in isolation. We are talking about a constant two-step, in this case with an additional dance partner.

My Driver’s Test Mood-Anxiety Hell

From a blog I did 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.

Is the Psychiatry of 1952 More Relevant to Our Recovery Than the Psychiatry of 2010?

From my keynote I gave to the DBSA Kansas State conference in Kansas in late April ...

Let’s turn to another researcher I heard speak in San Francisco.

This is a guy called Robert Sapolsky of Stanford. And he has dedicated his life to studying stress. So, Dr Sapolsky asks us to imagine a rat who has been trained to press a lever to avoid a mild shock.

Now, as he describes it:

The anticipation of mastery might induce a flood of dopamine to the frontal cortex and trigger pleasure. 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.

In human terms, I would describe it this way. Imagine waiting for a hot date to show up. The anticipation of a great night ahead triggers pleasure. But then the date doesn’t turn up on time. Pleasure changes to anxiety. And then it looks like the date will not turn up at all. So, to return to the rat, the real rat, not the no good bastard:

The shocks continue. The rat finds its attempts at coping useless. The rat basically gives up. Key neurotransmitters are depleted while stress hormones increase. In the words of Dr Sapolsky: The rat “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."

That's a pretty good description, right? Says quite a lot about what we go through.

So, here you are. You’re all dressed up with nowhere to go. In the space of an hour or two, you have gone from pleasure to anxiety to depression.

Is this normal? Yeh, of course it is. The front end and the back end of the brain are working exactly as they should be. Yes, the result sucks, but if we have any kind of feelings at all, depressed is the state we’re supposed to be in.

Now, in a resilient brain, we will bounce back. Life may suck, but we cope, life goes on.

But suppose our brains are vulnerable. Say we don’t bounce back. Say we start thinking we’re worthless. Say we start over-ruminating. We lie in bed all day. And say this goes on for four months.

I’m going to finish up in a bit, but I want to throw another one at you here. I’m sure you’re aware that earlier this year the DSM-5 Task Force came out with a draft. Are people aware of that? Okay, good.

To keep it short: The DSM is due for an update in 2003. And this is the diagnostic Bible - okay? - put out by the American Psychiatric Association. No - 2013. Is that the same as two thousand - I don't know. I'm one of these guys who doesn't know if three-fifths is more than half or less than half.

Anyway, the DSM-IV is the current edition, which came out in 1994, and that's based on the DSM-III Revised which came out in 1987, which in turn is based on the DSM-III which came out in 1980, with hardly any changes all the way along. And guess what? The DSM-5 of 2013 is going to continue that tradition of making sweet F-all changes. So, basically, we're going to come out with a document that's going to set the tone for psychiatry for the next 20 years based on the DSM-III of 1980 and its ridiculously - stupid - criteria for depression.

Anyway, while I was doing my research, I dug out the old DSM-I from 1952 and the DSM-II from 1968. Basically, these are much the same and they're supposed to represent ancient history, you know, before psychiatry got modern, stuck in 1980 Ground Hog Day forever. Much of the DSM I and II had to do with this Freudian artifact called “neurosis.”

Well, guess what? According to these ancient DSMs, depression was a form of neurosis. Okay, fine. And guess what drove neurosis? Anxiety!

That’s not all. These ancient DSMs tried to break down mental illness two ways: That which they saw as biology-based - which they didn't have a clue about -  and that which was the result of a maladaptive response to stress.

So. Freeze-frame. Stress-anxiety-depression. Does that sound very close to the language Dr Sapolsky was using? Is the psychiatry of 1952 more relevant to our recovery than the psychiatry of 2010?

Well, in one sense, yes. The psychiatry back then was interested in looking under the hood, but they lacked the means. No brain scans. No gene tests. The best they could do was speculate about neurosis.

The old psychiatry also had no idea that stress was related to biology. They thought that just about all mental illness was a product of the mind as distinct from the brain. Nevertheless they knew that true recovery involved digging below the surface, deep into the mind. The catch was the only tool at their disposal - psychoanalysis - really didn’t work for most people. And it really didn't get patients all that much better.

Well these days, we know a lot more about recovery. There are a lot of tools available to us. We know a lot of them have very good success rates, and we heard a lot about that this morning.

After lunch, I will be giving another talk. I’m looking forward to concentrating more on recovery tools. And you will also hear more speakers talk about recovery. But what I want to emphasize here is:

Recovery starts with knowledge. It helps knowing that we have vulnerable brains. That the back and front ends of our brains don’t always act the way they should. That they don’t always talk to each other the way they should. That we have a tendency to over-react. That we also have a tendency to both over-think and under-think.

Not only that, our brains are slow in resetting to normal.

What this means is - instead of coping with life, life becomes a struggle.

Do we have some kind of consensus on this? We're on the same page with this? Because - you know - you really get this wisdom going to DBSA support groups and also NAMI groups. And other groups. There's a lot of patient and family wisdom there.

Mental illness is simple, really. We get overwhelmed, overloaded. Too much of one thing, too much of everything. Too much thought, too much emotion, too much sensory input. Too much of nothing, even. Think of a fire in your brain or of being trapped deep underground, unable to breathe. There is no way the brain can respond rationally.

The brain copes, instead, by flipping out or shutting down.

But this doesn’t mean we have to give up. It only means we have to work harder and smarter.

So - know thyself. Look under the hood. Check out what’s really happening inside. Take nothing for granted. Question everything.

So here we are, on our journey, somewhere in the Land of Oz, looking to return home, to Kansas ...