I never wore flip flops out of the house until recently. Previously, I always wore laced-up shoes or running shoes. I had a motive: Caution. Preparedness. Readiness. If there were a fire somewhere, I could escape with shoes on. If I were mugged, I could run or show off my Ninja skills. Shoes work. No one fears a guy with naked toes. 

I have absolutely no reason to worry, yet I do. I have been a worrier most of my life. Worrying is pointless. I know that. Still, I worry. Sometimes I worry about worrying. I always thought worrying prepared me for all of life’s blight - broken legs, divorces, bug bites, poorly made liverwurst sandwiches, weak coffee.

I have prepared for most everything, yet none of these things have come to pass, except the weak coffee, which wasn’t such a blight after all. As for liverwurst, you can’t ruin it. It is what it is. Live with it.

None of these bad things I have worried about all these years have occurred. That’s not to say they won’t happen, but whatever worry I invested in contemplating these scenarios didn’t seem wasted until recently.

I don’t mean to make light of worry. There are people with clinical-level worry. This is a condition Freud noticed in 1894 as a generalized, but personalized anxiety. Worry is such an elusive condition psychiatric experts considered it as a catch-all designation until 1980 or so when worry became a distinctive diagnostic category. Nowadays, worry is categorized as generalized anxiety disorder, defined roughly as worry that last three months or more. The word worry may yet make its way into the next DSM. So, there is nothing humorous about worry.

Of course, worry is immaterial unless it impacts one’s life. And it has its upside. Successful people don’t become successful without the motivation of worry. Worry also guards you against stepping into a lion’s den. Worry has its place.

I admit I consume news the way Stephen King consumes bodies. I see the crime, the poverty, the wars, the bad stuff. I often need a break to stop worrying.

Unfortunately, I have found that when I stop worrying about the world spinning off its axis, I transfer the worry to another handy topic. Which radiated creatures lurk under our streets? Did I pay enough taxes in 1998? Did I or did I not return the sweater to Linda what’s-her-face after that incident in high school? Why did Mrs. Gross hate me so in fourth grade? You would think someone with a name like that would go out of their way to be friendlier.

I have been told that this general worry, this darkness may have ethnic origins. My Irish ancestry, in other words, may carry with it the whimsy of a light-hearted spirit, wit, a literary or oratory zeal balanced by the dark baggage of a brooding soul. With one, you get the other. Could be, yet one does not have to live with that dark baggage.

Of late I’ve realized that ruminating about the same thing over and over is like tossing gasoline onto the barbecue mid-cook — everything gets blown out of proportion.

I imagine most of us worry from time to time, some more than others. When it goes into overdrive, into rumination and begins to affect quality of life, it’s probably time to visit with someone or actively begin looking at the worry from a different point of view, as I have. According to E. Joseph Cossman, a marketing specialist and an entrepreneur, here’s one way:

If you want to test your memory, try to recall what you were worrying about one year ago today.

That is great advice. I usually say this thing I’m worried about won’t matter in 100 years, but giving it only one year seems much more reasonable. How about six months from now, next week? How about tomorrow?

Even our own Thomas Jefferson offered insight:                                                        

How much pain they have cost us, the evils which have never happened.

Some of us probably worry much like Gone with the Wind’s Scarlett O’Hara, who said: “Oh, I can’t think about this now! I’ll go crazy if I do! I’ll think about it tomorrow.” But she can’t wait, and continues to worry about bringing her lover Rhett Butler back into her life after he’s already hit the road. She needn’t worry. He’s gone, man. Gone. Her rumination over unrequited love is wasted time, pointless. She should have saved her strength. She should have done what nonchalant modern women do these days when some guy dumps them — get a quart of ice cream and dig in.

If ice cream doesn’t do it for you, there’s psychotherapy and medication. Worry is something all of us do, but it shouldn’t take over your life. I no longer allow it to take over mine. I have my reasons.

I understand the Mayans have foretold the end of the world this December. These are the sorts of foreboding some people can’t just blow off. But I have. I’m not worried about the world ending. Why should I? Even if I leave the house in flip flops, I still have a darn good pair of shoes, laces and all. And I’ve already put in a lifetime of training.

Armageddon?

Bring it on!

In my last post, “Why can’t we just be neurotic?” I complained about problems applying the Diagnostic and Statistical Manual of Mental Disorders¹ (DSM) to patients who suffer with a combination of severe depression and intense anxiety. That is, sometimes we are forced to diagnose depression over anxiety when patients have both. Where do we put the anxiety? In the quest for precision, the diagnostic manual has pulled apart problems that belong together.

This post has two aims: first, to tangle and disentangle anxiety and depression; and second, to underscore the importance of appreciating the role of anxiety in depression.

Putting anxiety and depression in perspective

In my previous post, I emphasized the comingling of anxiety and depression. But readers should be aware that the image of simultaneous disorders oversimplifies; we need a developmental perspective. Anxiety and depression occur in episodes over the lifetime; either one is equally likely to precede the other.² Moreover, the occurrence of one is likely to increase the likelihood of the subsequent occurrence of the other.^{2, 3} Anxiety begets depression, and depression begets anxiety. Thus we see a cascade of episodes: as time goes on, an individual who has a lifetime history of either disorder is increasingly likely to have a history of the other.⁴

Back to the comingling problem. The diagnostic system forces us to put symptoms into boxes and to decide which box offers the best fit. But the contents seem to spill over from one box to another.

Psychologists come to the rescue. We are less keen on chopping up nature into categories and more inclined to measure everything in degrees—not “intelligent” versus “unintelligent” but rather a full range of IQ scores. So it is with anxiety and depression: We have innumerable scales to measure each in fine degrees. And when we do so, we find a high degree of overlap (i.e., statistical correlation). The more depressed you are, the more anxious you also are likely to be, and vice versa.

Using scales to measure different facets of depression and anxiety

By fancy statistical methods such as factor analysis, psychologists can use multi-item scales measuring different facets of depression and anxiety in degrees to sort out what goes together and what does not. Such studies consistently reveal what has been called a “tripartite” model of emotional disorders,⁵ and, more recently, a “quadripartite” model.⁶ The tripartite model is enough to fill our hands for now. This model includes three relatively distinct factors, each of which is measured in degrees:

1. aspects of anxiety that are separable from depression;
2. aspects of depression that are separable from anxiety; and
3. a great deal of overlapping experience.

The separable aspects of anxiety relate to physiological hyperarousal (e.g., racing heart, dizziness, shortness of breath and sweating); these anxiety symptoms are rooted in fear.⁷ The separable aspects of depression relate to a lack of capacity for positive emotional experience, such as interest, pleasure and excitement.⁸

As psychologist Paul Meehl⁹ presciently put it in the Bulletin of the Menninger Clinic decades before the role of neurotransmitters in reward circuits was fully appreciated, depression entails a lack of cerebral joy juice. Meehl’s phrase parallels William Styron’s characterization of his depression as dank joylessness in his poignant memoir, Darkness Visible.¹⁰

It’s the third factor that interests me: the overlap between anxiety and depression. Here we can welcome vagueness back in. This factor has been variously named: negative emotionality, distress, dysphoria, neuroticism (the one I miss) and anxious misery⁶ (now my favorite).

Treatment development & the DSM

This conspicuous overlap between anxiety and depression relates to another major problem in the field of psychotherapy. Clinical researchers have put enormous energy into developing disorder-specific treatments aligned with the diagnostic manual, resulting in separate treatments for anxiety and depression. Thus we have a proliferation of “empirically supported treatments”—indeed, we have so many of these treatments that therapists cannot possibly learn them all, or even a significant subset of them.¹¹

Accordingly, there is a counter move toward “integrative” treatments, which are consistent with the overlap among ostensibly separable disorders. Keenly aware of the overlap between anxiety and depression, David Barlow has proposed a Unified Protocol for the treatment of “emotional disorders” based on cognitive-behavioral treatments.^{12, 13} Being content with even more vagueness, I have argued for a return to “Plain Old Therapy” (POT).^14-16

DSM-V

Frustration with the diagnostic manual is widely shared by mental health professionals, psychiatrists and psychologists alike. I do not want to appear dismissive of the manual; research on its categories has moved understanding and treatment forward dramatically—ironically, in part by revealing the problems with the categories, a process that leads to continual refinement.

The overlap between depression and anxiety that has flummoxed me is a case in point. A workgroup devoted to sorting out this problem in the next iteration of the manual, DSM-V,¹⁷ has contributed to considerable refinement in our understanding that promises to lead to helpful revisions.¹⁸ The current proposal for DSM-V includes mixed anxiety-depressive disorder as a bona fide diagnosis, now listed under depressive disorders rather than anxiety disorders NOS. Yet this mixed disorder will be applied only to patients who do not meet full criteria for major depression.

Thinking more like psychologists, the workgroup is considering another straightforward proposal: including a rating of severity of anxiety for persons with major depression. Apart from a categorical diagnosis, this additional assessment of anxiety severity is important, because severe anxiety intermingled with depression can prolong the course of the depressive episode, create greater disability, contribute to physical health problems and increase the risk of suicide.¹⁷

Hence this last proposal is perfect: this patient suffers from major depression and also is very very anxious. Neurotic indeed, with plenty of good company on this planet.

References

1. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.

2. Kessler RC, Gruber M, Hettema JM, Hwang I, Sampson N, Yonkers KA. Major depression and generalized anxiety disorder in the National Comorbidity Survey follow-up survey. In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:139-170.

3. Fergusson DM, Horwood LJ. Generalized anxiety disorder and major depression: Common and reciprocal causes. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:179-189.

4. Goldberg D. The relationship between generalized anxiety disorder and major depressive episode. In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:355-361.

5. Goldberg D. Psychometric aspects of anxiety and depression. In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:109-123.

6. Watson D. Differentiating the mood and anxiety disorders: A quadripartite model. Annual Review of Clinical Psychology. 2009;5:221-247.

7. Andrews G, Charney DS, Sirovatka PJ, Reiger DA, eds. Stress-induced and fear circuitry disorders: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2009.

8. Watson D. Mood and temperament. New York: Guilford; 2000.

9. Meehl PE. Hedonic capacity: Some conjectures. Bulletin of the Menninger Clinic. 1975;39:295-307.

10. Styron W. Darkness visible. New York: Random House; 1990.

11. Chambless DL, Ollendick TH. Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology. 2001;52(685-716).

12. Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotional disorders. Behavior Therapy. 2004;35:205-230.

13. Wiliamoska ZA, Thompson-Hollands J, Fairholme CP, Ellard KK, Farchione TJ, Barlow DH. Conceptual background, development, and preliminary data from the unified protocol for transdiagnostic  treatment of emotional disorders. Depression and Anxiety. 2010;27:882-890.

14. Allen JG. Is psychotherapy going to POT? SayNoToStigma.com. Houston, TX: The Menninger Clinic; July 21, 2010.

15. Allen JG. Can we grow more potent POT? SayNoToStigma.com. Houston, TX: The Menninger Clinic; August 9, 2010.

16. Allen JG. Preserving hope. Bulletin of the Menninger Clinic. 2011;75:185-204.

17. www.DSM5.org.

18. Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010.

I miss neurosis. It’s long gone from the official manual for psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders, now in its fourth iteration, DSM-IV.¹ Unfortunately, taking neurosis out of the manual has not eradicated it from the human condition. I can attest to that fact from personal experience, and I’ve had many occasions to observe it in others.

The concept of neurosis was too tied to psychoanalysis, and the diagnosticians deliberately aspired to divorce diagnoses from any particular psychological theory. More germane to this blog post, however, the concept of neurosis was too vague. The diagnosticians properly strived to make psychiatric diagnoses as precise as possible. Precision fosters agreement. It’s important for patients that diagnosticians agree on their condition, and it’s important for researchers that different research projects are all studying patients with disorder x defined in the same way. We have enough disagreement in research results as it is, without having even more due to the fact that different studies are conducted with dissimilar groups of patients ostensibly with the same disorder. Here’s an irony: The quest for precision has backfired when it comes to eliminating neurosis. The diagnostic manual has separated problems that belong together. We need more vagueness.

Diagnostic interviews

At The Menninger Clinic, the research department routinely administers the Structured Clinical Interviews for DSM-IV Disorders^{2, 3} to all patients. The systematic and thorough nature of these interviews aids the clinical process. We do not use research interviews to make final diagnoses—that’s up to the treating psychiatrist, as it should be. Rather, the results of the interviews inform the treating psychiatrist’s diagnosis, along with much other information about the patient. Yet doing these diagnostic interviews, while endeavoring to hew to precise rules, has us occasionally aspiring to do something akin to figuring out how many angels can dance on the head of a pin. One such challenge pertains to neurosis.

Depression + anxiety

Here’s what drives me nuts. Our most common diagnosis at The Clinic is major depressive disorder (MDD). Extensive research attests to two facts. First, in combination with genetic vulnerability and a history of stress exposure, episodes of major depression commonly are triggered by stressful life events and difficulties.^{4, 5} Second, although the depressed person may appear inactive and placid, this appearance is misleading; depression is a high-stress state, as evidenced by patterns of brain activity associated with stress⁶ and elevated stress hormones.⁷ Hence many patients who are in the midst of depressive episodes also are anxious. Yet, despite their conspicuous anxiety, by precise criteria many of these patients with major depression do not qualify for a diagnosis of a specific anxiety disorder, such as generalized anxiety disorder (GAD), obsessive-compulsive disorder, social phobia or posttraumatic stress disorder. We can resort to what we sometimes derogate as a “wastebasket” diagnosis, anxiety disorder not otherwise specified (NOS). But this seems like a cop-out and isn’t very satisfying—vagueness indeed!

Depression trumps anxiety

This paragraph you are about to read (or quit reading) will give you a taste of the complexities in diagnosing psychiatric disorders. Here’s our trap: One basis for diagnosing anxiety disorder NOS is the presence of a mixed anxiety-depressive disorder.¹ This highly appealing option seems to get us off the hook. But there’s a catch: We cannot make this diagnosis when the patient’s symptoms meet the criteria for a specific mood disorder or a specific anxiety disorder. So, if they have major depression, we can’t diagnose mixed anxiety-depressive disorder. Moreover, patients with MDD cannot also be diagnosed with GAD—even if they meet the criteria—if their anxiety is confined to the time frame of the depressive episode. Depression trumps anxiety, for reasons that are unclear.⁸

To complicate matters even further, the time frames for diagnosing MDD and GAD differ: two weeks of symptoms are required for MDD and six months for GAD, a problem that confounds research on their overlap.^{8, 9} Furthermore, it seems arbitrarily to put mixed anxiety-depressive disorder into the anxiety disorder group rather than the mood disorder group. Moreover, while tucked into anxiety disorder NOS, the mixed anxiety-depressive disorder also is relegated to an appendix of the diagnostic manual, “Criteria Sets and Axes Provided for Further Study.” It’s unofficial.

One of several books about depression and trauma by Dr. Allen.

Here’s the analogue to how many angels can dance on the head of a pin: How much more anxious must a patient with major depression be beyond the ordinarily highly anxious depressed person to qualify for an additional diagnosis of anxiety disorder NOS which, technically, we shouldn’t be using anyway? Sometimes I feel like throwing away the book! I’ll point to a way out of these traps in a subsequent post, “Anxious Misery.” 

References 

1. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.

2. First MB, Spitzer RL, Gibbon M, Williams JBW. User’s guide for the Structured Clinical Interview for DSM-IV Axis I disorders: Clinician version, SCID-I. Washington, DC: American Psychiatric Press; 1997.

3. First MB, gibbon M, Spitzer RL, Williams JBW, Benjamin LS. User’s guide for the Structured Clinical Interview for DSM-IV Axis II personality disorders: SCID-II. Washington, DC: American Psychiatric Press; 1997.

4. Brown GW, Harris TO. Social origins of depression: A study of psychiatric disorder in women. New York: Free Press; 1978.

5. Hammen C. “Stress and depression.” Annual Review of Clinical Psychology. 2005;1:293-319.

6. Drevets WC. “Prefrontal cortical-amygdalar metabolism in major depression.” Annals of the New York Academy of Sciences. 1999;877:614-637.

7. Nemeroff CB. “Psychopharmacology of affective disorders in the 21st century.” Biological Psychiatry. 1998;44:517-525.

8. Goodyer IM. “Episodes and disorders of general anxiety and depression.” In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:257-269.

9. Moffitt TE, Caspi A, Harrington H, et al. “Generalized anxiety disorder and depression: Childhood risk factors in a borth cohort followed to age 32 years.” In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:217-239.

Everyone worries. Doing so can be useful, such as by motivating you to finish a project. It can also help you anticipate and prepare for an upcoming event.

But fretting constantly over unlikely problems is not healthy.

Severe worry is a severe problem. Called generalized anxiety disorder (GAD), the illness is characterized by six months or more of chronic, exaggerated worry and tension that is unfounded or much more severe than the normal anxiety most people experience, according to the National Institute of Mental Health.

“People with this disorder usually expect the worst; they worry excessively about money, health, family or work, even when there are no signs of trouble,” the NIMH reports. “They are unable to relax and often suffer from insomnia. Many people with GAD also have physical symptoms, such as fatigue, trembling, muscle tension, headaches, irritability or hot flashes.”

About 2.8 percent of the adult U.S. population ages 18 to 54 – about four million Americans – has GAD during the course of a given year. GAD most often strikes people in childhood or adolescence, but can begin in adulthood, too.

People who are anxious tend to overestimate the extent of the threat that worries them. John Hart, a licensed clinical professional counselor trained in the application of psychotherapy techniques, said his treatment might begin with showing a patient a more realistic outcome. A patient fearful a loved one will die in an accident, for example, might lead Mr. Hart to suggest that dying in an automobile crash is a relatively rare event, an observation that establishes a more realistic baseline from which he could launch his therapy in a clear direction.

Additionally, he said he might explore the ramifications of a potential death. How would it affect the patient? What steps would the patient take in light of such a death? Outlining all the worries in a therapeutic approach called cognitive behavior therapy lessens their grip.

“If you’re prepared to solve the problem, you’re less anxious about it. The patient can solve a problem that doesn’t exist yet,” Mr. Hart said.

For people who worry but do not require clinical treatment, there is hope, too. You can keep worry under control and make it work for you by working through the worry. Here are three ways to accomplish that:

Write about it.

Jot down every possible scenario. Then rank them in order of likelihood and discard the bottom third. Plan how you would handle the rest. Thinking through a problem this way gives you perspective.

Work it out.

Doing something physical helps release tension. A vigorous housecleaning or a long walk can take the edge off. It will also give you a sense of  accomplishment, beneficial exercise and help you feel up to handling the problem.

Talk it through.

Talking about your worries can help you discover their causes. You may also learn that others have the same fears and concerns.