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.

Author and guest blogger Julie Hersh

When I entered the Wellness Expo, my feet dragged. My sixth sense hinted my talk wasn’t right for the people gathered. A couple practiced yoga on the green grass. Each member of a trio swung a large swath of white fabric with a ball at its end – oversized slingshots without targets. Signs offered psychic readings. Not the crowd for my version of wellness, which includes medication and a controversial procedure called ECT (electroconvulsive therapy).

For the most part, I was wrong. I rattled off my Struck by Living Top Six, my personal list for wellness. I never offer my list as a solution for someone else, but merely an inspiration for others to create their own formula for staying well. I opened for questions. One woman asked how she could personally help her depressed spouse. I’ve heard that question in almost every one of the 75 talks I’ve given, no matter what the audience. Others followed. Then the skeptic barked his question from the back of the room:

“Dr. X says that you can solve all problems with depression by food intake and taking natural supplements.”

The corny dog and funnel cake I’d just eaten at the Texas State Fair tightened in my stomach. I agreed with this man, to a point. Unfortunately, because of people like this man, medical intuitive Carolyn Myss and a long list of other spiritual healers who insisted that if I were spiritually whole I would not need medication, I went off medication in 2005. In 2007, I relapsed into suicidal ideation. I did ECT and recovered. Now I take my little dose of Wellbutrin every morning without hesitation.

Right before I went under the anesthesia for ECT in 2007, the anesthesiologist asked me why I was back in the psych ward after a six-year reprieve. “I went off medication in 2005,” I began. He shook his head. He began the cliché for which we all know the answer: “If I had a nickel for every time….”

Why is this? Why do people go off medication for mental illness even when the side effects of medication are minimal to nonexistent? Why do some people, like the man in the back row, feel compelled to advise someone to drop psychiatric medication for the wonder of natural supplements? What is natural anyway? I’ve never seen fish oil tablets grow on trees.

Don’t get me wrong, I take fish oil and a high dosage of Vitamin D. I exercise and firmly believe these things allow me to maintain my health and possibly reduce the amount of medication I need. However, I don’t think I’ve ever heard someone pressuring a diabetic to drop insulin in favor of a “natural” supplement. The difference lies in the perception of mental illness as a deadly disease. If the man in the back row understood that more than 33,000 U.S. citizens take their lives on an annual basis, he might not be so generous with his lightly-researched advice.

The man was insistent. He presented his arguments with religious fervor. He’s not the first person to try to “save” me from medication. But here’s the rub: ECT saved my life, but if at all possible I want to avoid the procedure in the future. Due to first-hand experience, I happen to know my body better than he does. All the supplements in the world can’t change that.

I walked out of the conference to see a man seated with his bare feet in a yellow bucket filled with water. A woman with wild hair seated across from him held his hands, stared into his eyes and whispered with intensity. The tarot cards turned with my exit. The irony struck. In an environment so open to the supernatural, why is it so hard to accept a man-made pill might help a life?

Editor’s note: guest blogger Julie Hersh is president of the board of directors of the Dallas Children’s Theater and an active supporter of the Suicide and Crisis Center, CONTACT, Mental Health America, Empower African Children and other non-profits. Julie’s Struck By Living blog is featured on the Psychology Today website. She is also the author of Struck By Living: From Depression to Hope.

The field of psychotherapy suffers from acronymania: a proliferating plague of acronyms. Your psychotherapy brand will not be taken seriously if you don’t have a good acronym for it, preferably three letters, although you can get by with four or two. A short list: CBT, DBT, TFP, DIT, CPP, TPP, SIT, ERP, IPT, PCT, CFP, EFT, MBT, RLX, EMDR, ADEP and PE. Ideally, your therapy will qualify as an EBT or EST (evidence-based or empirically-supported treatment), that is, a treatment of experimentally-proven effectiveness that comes with a manual instructing the therapist on how it’s to be conducted.

More acronyms, please

Of course, we also have acronyms for psychiatric conditions: MDD, OCD, PTSD, BPD and so on. The crowning glory is having an EST for a particular condition: CBT for MDD, ERP for OCD, PE for PTSD and MBT for BPD (translation: cognitive-behavior therapy for major depressive disorder, exposure and response prevention for obsessive-compulsive disorder, prolonged exposure for posttraumatic stress disorder and mentalization-based treatment for borderline personality disorder, respectively).

We are truly blessed that clinician-researchers have developed all these ESTs for various psychiatric disorders. We need these specialized treatments for specific disorders and symptoms. Yet there are two problems with this state of affairs. First, to be fully competent in treating a range of psychiatric disorders, the therapist would need to learn 150+ treatment manuals—a daunting task. Second, many patients who seek treatment have a number of different disorders and problems at the same time (e.g., depression, anxiety, alcohol abuse, an eating disorder and personality disturbance).

Do we send such patients to several psychotherapists, as we might send patients to several medical specialists? Does the same psychotherapist administer several treatments sequentially, one after the other, or even concurrently?

Common factors

The problem I am addressing is not unique to psychiatry or even general medicine. We live in a world of increasing specialization such that individuals can hardly even keep up with the knowledge in their own field of endeavor. In the field of psychotherapy, there has been, in response to ever-increasing specialization, a countervailing movement for decades: the emphasis on “common factors” that account for the effectiveness of the therapy, regardless of the therapist’s specific technique or the brand name of the therapy. There is solid research support for this focus on common factors: it is extremely difficult to demonstrate that any good type of therapy is more effective than any other.

For example, we know that a positive therapeutic alliance—a trusting relationship in which the patient and therapist are working together toward common goals—is a major contributor to the effectiveness of therapy. Another important common factor is the therapist’s empathy. Recently, we have been advocating another common factor based on attachment theory and research: mentalizing, that is, an open-minded or mindful attentiveness to mental states such as thoughts, feelings and needs in oneself and others. It is a truism that psychotherapy requires interest in what is going on in the mind—and a meeting of minds. We use our colleague, Peter Fonagy’s, phrase for this process: holding mind in mind. We describe the ubiquitous role of mentalizing in relationships—including psychotherapy relationships—in our book, Mentalizing in Clinical Practice.

New psychotherapy brand

I am more concerned with common factors than specific techniques; I aspire to mentalize and help my patients to do so with me; and, not denying my competitive response to social pressure, I feel a need for a catchy acronym.

Hence, after more than four decades of practicing psychotherapy, I have decided on my own brand of psychotherapy: POT, Plain Old Therapy.

A patient once asked me at the beginning of our first session, “What kind of therapy do you practice? Talk Therapy?” I replied, “Yes, Talk Therapy, that’s what I do.” But I like POT better than TT.

To the extent that psychotherapists are returning to a common core of effective elements, the psychotherapy field might be going to POT. For many patients whose symptoms are multifaceted and rooted in problems with self and others, POT is in order. I acknowledge that POT is not optimal for treating patients with specific disorders for which effective specialized treatments are available. But even these specialized treatments, well delivered, must be laced with POT.

In his popular book, A Secure Base, John Bowlby, the psychiatrist and psychoanalyst who pioneered attachment theory, stated that the psychotherapist’s role is

“to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.”

In a trauma education group, I once remarked, “the mind can be a scary place.” A young woman in the group spontaneously replied, “Yes—and you wouldn’t want to go in there alone!” She thus epitomized Bowlby, and I have never heard such a trenchant characterization of psychotherapy since. This is POT, as I endeavor to practice it.

Coping with Depression, one of many books written by Jon G. Allen, PhD

I have found two basic ideas to be helpful in understanding depression: stress pileup and catch-22. We know that episodes of major depression are preceded by stressful events, and these events have two main themes: loss and failure. Loss of a key relationship through death, divorce or a break-up is a common precipitant of depression. A feeling of failure could be associated with not meeting your aspirations or others’ expectations at work or in school—or with relationship problems that also involve loss.

Often, depression is preceded by a cascading pileup of stress: problems at work lead to overuse of alcohol, which further impairs work performance; drinking to cope leads to marital conflict, which further fuels alcohol use; marital conflict is stressful for children, who then have more difficulty in school—such scenarios are innumerable.

All the things you must do to recover from depression are made difficult by the symptoms of depression.

Being vulnerable

Although depression is commonly preceded by stress, many people manage a pileup of stress without becoming depressed. Why do some and not others succumb? One reason is genetic vulnerability to becoming depressed in the face of stress. In addition, general medical conditions and physical ill health can contribute to depression.

Yet another reason for vulnerability: a history of stress pileup over a person’s lifetime. Childhood trauma, such as loss, abuse and neglect—combined with genetic vulnerability—can contribute to risk for depression in adulthood. Stress and episodes of depression in adolescence also add to risk for later depression. And, as in the example given earlier, substance abuse is a catalyst for depression: if you’re headed into depression, substance abuse can speed up the process and hinder recovery.

Depression’s impact

Depression notoriously saps energy and impairs concentration and complex problem-solving ability. Thus, heading into depression, you are liable to struggle harder to stay afloat, for example, in managing demanding jobs and household responsibilities, including caring for children or aging parents. Effort increases while energy decreases. At some point, you run out of energy entirely and “crash” into severe depression. It’s as if your mind wants to keep going but your body declares, “I quit.” At the extreme, you can become bedridden.

Adding insult to injury and contributing further to the pileup is the fact that many people feel ashamed of being depressed and withdraw from relationships as a result. Because social isolation is a major contributor to depression, more stress pileup ensues. Another potential blow: the prospect of stigma can interfere with seeking professional help.

The catch-22

Paradoxically, the process of recovering from depression also is stressful in that it’s extremely challenging. I attribute this to a catch-22: all the things you must do to recover from depression are made difficult by the symptoms of depression: you should sleep well, eat well, be active, engage in pleasurable activities, think realistically, stay engaged with persons who can provide support and maintain hope.

Now consider the symptoms of depression: insomnia, poor appetite, lethargy, diminished capacity for pleasure, negative thinking, social withdrawal and hopelessness. Recovery is the norm, but the catch-22s often make this process of recovery slow—several months to recover fully from an episode of major depression is not unusual. (I talk a lot about the catch-22s of depression in my book Coping with Depression in case you’re interested in learning more about them.)

Tips on recovery

Here are some key points for recovering from depression and preventing further episodes:

1. See if you can find a way to get out of the maelstrom of stress pileup to take stock of your situation, respecting the power of the stresses without minimizing them. Psychotherapy can be helpful in such stock-taking; sometimes patients need the asylum provided by hospitalization to get the needed respite and distance from the stressful situation.
2. At least in the short run, do everything humanly possible to minimize stress. This is not easy: you can’t give up your children or quit your job and go to the Bahamas. Yet you might find ways to cut back some. Saying “no” is not easy but can be helpful. Ditto for seeking help.
3. Take stress seriously and develop methods of coping more effectively. In his masterful book, The End of Stress as We Know It, stress researcher Bruce McEwen asserted that everything we know about managing stress our grandmothers could have told us. But now we have the scientific evidence to back up grandmother’s wisdom. Sleep, diet, exercise, relaxation, pleasurable activities—these are the mainstays of stress management. Yet we must be mindful of the catch-22s.
4. Be patient with yourself regarding any difficulty you may experience in recovering from depression. Patients who have recovered refer to the “baby steps” that got them there. Catch-22: being patient with yourself can be difficult because depression spawns self-criticism.
5. Make every effort to stay connected: the mere presence of another person can ameliorate stress, and the presence of a trusted companion with whom you have an emotional bond is the most potent antidote to stress known to man (and to many other mammals).
6. A caution: It is little wonder that depressed persons seek potent chemical solutions. Alcohol, for example, relieves anxiety and produces pleasure—all too temporarily. In the long run, as stated earlier, substance abuse catalyzes and prolongs episodes of depression. The worst time to drink or do drugs is when you are doing so to manage psychiatric symptoms of any sort.

There is one major basis for hope: the vast majority of depressed persons recover, albeit slowly. And to drive home the importance of others in a person’s recovery,  I conclude with this anecdote: when I made the point in an educational group that it is difficult but not impossible to recover from depression, a patient rightly protested: “Doc, I can tell you that it was impossible for me to recover on my own.”

You’ve heard about them in the news, maybe seen them in an airport or sat next to one of them on a flight. You maybe a family member, neighbor, co-worker or friend with one of them. Who are they? They are our nation’s warriors, the men and women in our Armed Forces, individuals who make extraordinary sacrifices for our national interests.

Many of us do not think about them as often as we probably should because they usually stay under our radar, quietly doing their jobs efficiently and expertly. After they are discharged from the military, some of them will need help adjusting to civilian life—and yes, some of them will suffer posttraumatic reactions that will require mental health care.

Posttraumatic stress disorder (PTSD) is, arguably, the most commonly recognized form of emotional problem following military stress. The disorder, formally recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM) since 1980, is characterized by a constellation of anxiety-based symptoms that include:

• trauma-related nightmares
• recurrent thoughts
• “flashbacks,”
• sleep-disturbance
• anger management difficulties
• avoidance of feelings and activities
• social isolation
• hypervigilance
• exaggerated startle response to loud noises or sudden movements

The disorder is also associated with interpersonal difficulties, including problems with intimacy, marital and family relationships and workplace relationships. PTSD as we define it is a serious psychiatric disorder that can have dramatic and devastating consequences.

What Can We Do?

Don’t stigmatize or judge:  Be compassionate; understand that some people returning from war may have emotional difficulties or problems readjusting to life as a civilian. In addition to PTSD, other emotional problems such as depression, anxiety, substance abuse and marital problems may also be troubling for some. In fact, depression and interpersonal difficulties are probably more common than PTSD after deployment. The Department of Defense and the Department of Veterans Affairs offer a range of mental health services and benefits to help our warriors overcome these problems. There are also other private and community services available. If you know a veteran or a member of our Armed Forces who may be struggling to adapt to civilian life after overseas deployment, encourage them to seek professional counsel—because PTSD and depression are treatable conditions!

Don’t assume or stereotype:  It’s also wise not to make assumptions or rely on stereotypes about how an individual will or should respond to life post-deployment. Remember, the large majority of veterans adapt quite well to life after their combat service is over. Furthermore, of those veterans who do appear to be having difficulties, very few of them will fit the stereotype depicted so often in Hollywood movies. In his fine book Stolen Valor, B.G. “Jug” Burkett, himself a Vietnam veteran, reviewed the actual data related to many of the most common myths of the “dysfunctional Vietnam veteran” of stereotype and found that they were just that—myths.

Consider these lessons from a previous era:  In his book Band of Brothers, about E Company of the 506th Regiment of the 101st Airborne, a highly decorated combat unit that fought in the Normandy Invasion, Operation Market Garden and Bastogne and took nearly 150% casualties over the last year of World War II, historian Stephen Ambrose wrote of their post-war lives:

They accepted a hand-up in the G. I. Bill, but they never took a handout. They made their own way.  A few of them became rich, a few became powerful, almost all of them built their houses and did their jobs and raised their families and lived good lives, taking full advantage of the freedom they had helped to preserve….

There are many ways to support the men and women who have served overseas in our nation’s Armed Forces. I urge each of us to stop and think about what we can do personally for the returning veteran in our families, our churches and synagogues, our schools, and our neighborhoods. When you encounter one of them, perhaps the most important thing you can do is to welcome them home—and thank them for their service!

I’ve adopted the term biomania to refer to what I see as excessive enthusiasm for an exclusively biological approach to understanding and treating psychiatric disorders. As a psychologist who practices psychotherapy, I share enthusiasm for neurobiological understanding, and I am grateful for effective biological treatments that help patients make good use of psychotherapy. I am hopeful that neurobiological research will contribute to the development of increasingly effective uses of psychiatric medications as well as novel biological treatments. Moreover, I believe we can help ameliorate stigma associated with mental illness through recognition that, like other medical conditions, psychiatric disorders have a biological basis. My objection relates to an exclusive emphasis on biology that leaves the person out of the picture.

Notoriously, decades ago psychiatrist Thomas Szasz went too far in the opposite direction from biomania, as captured in the title of his 1974 book The Myth of Mental Illness, in which he proclaimed that psychiatry deals with problems in living, not illnesses. As decades of neurobiological research amply demonstrates, psychiatric disorders are physical illnesses: many have a genetic basis, and neuroimaging research shows alterations in brain functioning associated with these illnesses.

Problems in living

I think Szasz was obviously wrong in failing to acknowledge psychiatric illness, but he was right in drawing attention to problems in living. Let me use major depression—a well defined, common, and serious psychiatric disorder—to illustrate my point. Major depression is a state of high physiological stress, and functional neuroimaging studies typically show high emotional arousal in conjunction with impairment in the prefrontal cortex, an “executive” area of the brain that is active in planning and organizing activity, thus pivotal in complex problem solving.

Seriously depressed persons have no doubt that they are ill, and they are not surprised to learn that their brain is not functioning optimally. In his brilliant memoir Darkness Visible, author William Styron noted how depression resulted from an “aberrant biochemical process.” Here is how he experienced the altered biochemistry:

“With all of this upheaval in the brain tissues, the alternate drenching and deprivation, it is no wonder that the mind begins to feel aggrieved, stricken, and the muddied thought processes register the distress of an organ in convulsion.”

He concluded, “It is a storm indeed, but a storm of murk.”

Stress pileup

What is the basis of these adverse brain changes? We know that episodes of depression stem from a combination of genetic vulnerability and psychological stress. I have used the idea of “stress pileup” to characterize the psychological stress that builds up over a person’s lifetime. Not uncommonly, an interaction of genetic risk with childhood adversity such as loss and trauma sets the stage for adulthood stress to trigger a depressive episode. Often enough, stressful events that can trigger episodes are completely beyond the individual’s control: death of a loved one, natural disasters, general medical illnesses, accidents. Yet much of the time, the stress that contributes to depression is partly self-generated: overwork, perfectionism and the self-criticism that goes with it and—most prominently—interpersonal conflicts. These latter sources of stress can be viewed as problems in living; they are psychological and interpersonal.

I remember one day in a patient education group explaining the stress pileup view of depression and going through a cascade of psychological and interpersonal stressors that can ensue over time. A patient piped up and said, “But my doctor says I have a chemical-imbalance depression.” I replied that all depression is biochemical. The question is: What causes these biochemical changes (and alterations in patterns of brain activity)? An important part of the answer is psychological stress. The stress pileup view and chemical imbalance view are complementary, not mutually exclusive.

In need of something more

The field of mental health needs neuroscientists who are biomanics, that is, passionately excited about researching the biology of psychiatric disorders. But there is a danger of clinicians and patients becoming biomanics, as biomania can be associated with an exclusive focus on biological treatments. Many patients become demoralized after trying multiple medications and combinations with limited benefit; they need something more. Szasz was half-right: to the extent that stress plays a role in the development, perpetuation and recurrence of psychiatric disorders, we must pay attention to problems in living—that is, problems in thinking, feeling, behaving and relating. No doubt, effective psychiatric medication can help enormously with problems in living that stem from psychiatric disorders. But we also know that many forms of psychotherapy are highly effective in treating psychiatric disorders insofar as they directly address problems in living and promote new learning. Hence psychotherapy and medication can complement each other, and research suggests that combining the two is most effective for severe depression.

Psychology and biology are thoroughly intertwined. We know that the quality of early relationships influences brain development; moreover, the quality of the patient-therapist relationship plays a central role in the effectiveness of psychotherapy. Furthermore, psychotherapy, like medication, has been shown to affect patterns of brain functioning. Yet we still have much to learn about all these matters, and we can count on biomanics along with psychotherapy researchers to bring continuing progress in our efforts to treat more than the illness, namely, the person who is ill.