[This is the fourth post in a series on anxiety and depression. See Part 3 here.]
A reader's comment on the third post in this series has led me to rework the post that I had planned for today. In essence, I was asked if I thought that all persons with anxiety were using that as a defense or screen against depression. The short answer to that is: No, not at all.
In fact, I am not at all certain how often anxiety is a screen over depression. I do not know of any statistical studies of this phenomenon. My thoughts on this matter come from on my own clinical observations.
I have a confession to make. Sometimes it takes repeated exposure and then being slapped in the face with it before I recognize the importance of an issue.
What happened was that a cluster of these cases occurred over the span of a few months. I did not have a good explanation of it for the patients or myself. This process of anxiety followed by depression was not new to me. Right now, off the top of my head, I can think of at least a dozen times that I have seen anxiety lead to depression. Its previous occurrences, though, were sporadic. At those times, I shelved the process as an unimportant anomaly. Not until the cases came in a group did I start to look for common threads and a decent explanation.
To repeat myself, I do not think that anxiety necessarily covers over depression nor that anxiety must lead to depression. That has not been my clinical experience at all.
My sense is that anxiety guards against depression in a limited number of cases. It seems to happen mostly to people with long-standing anxiety problems. These persons are in difficult life situations. In addition, they have difficulty separating anxiety-generated worries from objective concerns and thoughts. Further, it also appears that due to either other factors or the anxiety itself, there is a damaged self-esteem.
However, it also can happen abruptly. Imagine, for instance, a person who unexpectedly finds some evidence that his/her spouse is having an affair. This could lead to anxiety and doubt. On a level not quite conscious, the person could choose to remain anxious and doubtful rather than openly talk to the spouse about their suspicions. If the spouse confessed to the affair, it would be too depressing and painful for that particular person to bear. The anxiety is seen as the lesser of two painful situations. Recall that in anxiety some hope remains. In depression, hope is no longer present.
Allow me to start with the treatment of a "pure" anxiety disorder. This will show the types of anxiety cases that are not engaged in a defense against depression or some life event. Let us assume that the person obtained a thorough psychological evaluation. There is no suggestion of an underlying depression. The person expresses confusion about why they are anxious since there are no major stresses in her/his life. There is no history of trauma or substance abuse. Recent medical examinations found the person to be in good physical health. Anxiety or panic is the only clinically significant finding.
In such a case, I would proceed straight to cognitive-behavioral treatment. Any thoughts of anxiety shielding a depression are aside unless new clinical evidence called for their return.
In these instances, the following is the treatment that I have found most often to be helpful.
Before going further, let me emphasize that this does not substitute in any fashion for treatment or diagnosis by a professional.
There are five cornerstones in my approach. Each is critical in the reduction of anxiety, although some are harder to achieve than others.
1. Good sleep habits. To keep this post brief, allow me to suggest a page from the University of Maryland Medical Center. That will help explain the basics of good sleep hygiene.
2. Good diet. Caffeine, sugar, missed meals, highly processed foods are all gasoline to the fires of anxiety. While not exactly a food group, at least for most folks, alcohol and other intoxicants as well as nicotine can also ignite anxiety. For more details on good eating habits, you can go to MentalHelp.net's article "A Healthy Diet." It's hard to overemphasize how much of a role diet plays.
3. Light exercise. This means nothing more than a 20-minute walk around the block. Any kind of physical activity that involves your whole body will do the trick. However, it does not include competitive sports and similar events where there are goals and high expectations.
There is a way to cheat on this if you absolutely cannot fit 20 minutes of light exercise into your day. But I have found that it is not as effective as exercise on a regular basis. For the sake of brevity in this post, I'll direct you to another post on MentalHelp.net: "Progressive Muscle Relaxation for Stress Reduction" by Mills, Reiss and Dombeck. There you will find detailed instruction and explanation of this stress relief practice.
4. Fun. This simple activity is often the most difficult for people to be able to do. Whatever you consider fun, schedule it into your week. Fun is an antidote to the buildup of stress and anxiety.
5. Get out of the house and socialize, do things with your friends and family. Yes, even if you don't feel like it or think that you won't enjoy yourself or worry that you'll spoil everything because of your anxieties.
If those are the cornerstones, then the ground upon which they rest is air. Or, to be more specific, it's a type of breathing. For a host of physiological reasons, breathing is an essential element in both the kindling process of anxiety as well as in reducing anxiety.
Breathing by using your diaphragm is the simplest and most effective anxiety reduction technique that I know (excluding medications). The main problem with this method is that it is so easy, most people don't think it can be effective.
There is another post by Mills, Reiss and Dombeck, entitled "Methods of Stress Reduction" that explains how to breathe in this fashion. You'll find the instructions near the bottom of the page.
If you prefer a visual instruction, a YouTube video demonstrates the process. The video is from the Center for Hindu Studies and is called "Diaphragmatic Breathing."
Once you learn how to do it, you can breathe this way everywhere you go and no one can tell. It does not need to be as formal as in the video. With practice, you can breathe with your diaphragm while walking up the stairs or sitting in a chair at dinner. It works best as a preventative measure and is only minimally effective if you wait until a panic attack to use it. So breathe with your belly regularly and often for best results.
Once these are accomplished, the cognitive aspect of the treatment comes into play. Here I listen for distortions, generalizations and other effects anxiety upon the thought process. We can then look at those assumptions and objectively assess them.
The following is a typical anxiety-ridden statement. "Whenever I try something new, I make a mess of it." This can be challenged gently. I might ask if there really have been no successes ever in the person's life. There has to be one in there somewhere and I build on it. That patient's sentence is also loaded with anticipatory anxiety. One believes that "a mess" will be the result. To get past the dreadful anticipation, a mess is made sooner rather than later. It then helps to discuss ways to recognize when you're setting yourself up for failure through anticipatory anxiety and how to substitute in thoughts that are more constructive. These and other strategies improve the thought processes and minimize anxiety.
In a thumbnail, that summarizes my initial treatment plan for dyed-in-the-wool anxiety disorders. I also offer to refer the person to a psychiatrist to see if medications can also be of assistance. Most of the cases that I treat fall into this category. The anxiety disorder stands by itself. Here, anxiety does not cover or shield a depressive disorder or a painful life circumstance that is being avoided.
I hope that this post has clarified that my focus in this series is on a limited sub-set of anxiety disorders. In the next post, I plan to look at the treatment of persons who do have anxiety standing guard against depression and painful life events.