Have you ever made a wish that came true? Or considered Fate or Providence to be at play when someone or something entered your life at an opportune time? What about dreaming about an event that intriguingly played out in real life? Have you ever mourned the passing of a loved one, only to inexplicably feel their presence?

Most people probably identify with such experiences, and many would assign value or meaning to them—perhaps identifying them as divine intervention, believing in the gift of clairvoyance or feeling a special connection with the spiritual realm. Such experiences can impact an individual’s life by providing reassurance, guidance or a stronger sense of spirituality.

Is it possible that people’s stories about miracles or spiritual encounters are merely symptomatic expressions of something more ominous—a psychiatric illness perhaps? From a diagnostic viewpoint, such experiences may be labeled “magical thinking,” “delusional” or “psychotic.” Could they be chalked up to a diagnostic label? And how do clinicians have the authority to make this determination—especially as they interpret such experiences through their own spiritual (or agnostic) lens?

A matter of perspective

The issue of spirituality versus psychopathology seems to be a matter of perspective. Overvalued ideas about one’s spiritual belief system can be interpreted by others as symptoms of a personality disorder or psychosis. How do we differentiate between healthy spirituality and psychopathology? The Diagnostic and Statistical Manual of Mental Disorders (DSM) offers some guidance, defining delusional beliefs as beliefs “not ordinarily accepted by other members of the person’s culture or subculture.” However, with ever-increasing spiritual sects, it can be difficult for the clinician to know what beliefs might be shared. Additionally, the DSM references the level of impairment, context of behavior or belief and symptoms that may be substance-induced. Thus, isolated experiences that are not part of a broad pattern of disturbance should not be diagnosed.

At times a patient’s spiritual beliefs can interfere (from the clinician’s perspective) with their ability to function in a social, occupational or academic setting. These cases can be challenging to filter through the diagnostic decision tree, especially when it seems as though no one can know for sure the extent of truth to any unusual experience.

For example, I met with a patient who had a strong sense that he was “different” from others; he believed he had lived many past lives and had a special connection with the world that most people he encountered could never understand. He described countless “messages from the universe” directing him in his everyday activities. 

From a diagnostic perspective his descriptions bordered on quirky if not impairing. He became quite concerned with physical symptoms, such as feeling like his body was being taken over by an unexplained force, which doctors could not explain. He continually found hidden meanings in TV commercials or friends’ comments that most would consider ordinary experiences. Although he was able to function for the most part independently, he maintained an outlook on the world that made it difficult for him to relate to others and ultimately caused rifts in his relationships.    

SCID platform

The topic of unusual events, or what some define as paranormal or supernatural phenomena, is not typically at the forefront of most clinical discussions between patients and clinicians, in part because they are not of primary concern for patients seeking treatment. However, in my role conducting the Structured Clinical Interview for the DSM Disorders (SCID), I have a platform for discussing them.

In the psychotic symptoms module is a question about unusual religious experiences. Inevitably, patients pause before asking, “What do you mean by unusual?” At this point a dialogue ensues regarding a patient’s personal experience with the supernatural (however they choose to define it) and their interpretation of this experience. The question “Have you ever had visions or seen things others couldn’t see?” sometimes elicits responses about encounters with apparitions of deceased loved ones or patients hearing their name being called or seeing menacing, dark entities. 

In the schizotypal personality disorder module are questions about experiences with the supernatural, unseen forces and unusual perceptional experiences. Interestingly, many patients will disclose personal experiences, such as encountering an animal they believe is the spirit of a deceased relative or describing an ability to predict events that others cannot. Some patients report being guided by entities not of this world—or being protected from near fatal situations by inexplicable forces. Such experiences, while unexplainable, may have a profound impact on their outlook for the future or their belief in forces that transcend our worldly knowledge. 

I am always struck by patients’ initial hesitancy in sharing these extraordinary events; however, I understand discussing them during a diagnostic interview can seem more stigmatizing than normalizing. I find interesting patients’ insistence on presenting their story with the disclaimer,

“This probably means I’m crazy, but….”

It seems as though there is a tendency in the mental health field to dismiss such occurrences as not only strange but indicative of psychiatric illness, implied, in part, by the fact that such questions even exist in the SCID. At times patients decline further elaboration because their experience is deeply personal and meaningful and fear a diagnostic label or quizzical reaction would be demeaning. 

James vs. Freud

The topic of supernatural experiences is nothing new in psychology. In fact, psychologist and philosopher William James wrote about an enormous range of spiritual experiences in The Varieties of Religious Experience: A Study in Human Nature. James believed in an unseen reality and that mystical experiences contributed to a more fulfilling life. Rather than categorizing them as pathological, James sought to include spirituality as a healthy component of psychological functioning. James recounts examples of patients’ mystical encounters in which they felt connected to a higher power through events that ranged from auditory experiences of God talking to them to inexplicable physical energies. 

In contrast to James, Sigmund Freud tended to pathologize religion and religious experiences. In The Future of an Illusion, he depicted religion as a manmade illusion created in an attempt to control human instincts (cannibalism, incest and desire to hurt or kill one another). Freud, an outspoken atheist, likened religious practices to neurosis, claiming that humankind had an obsessive need for protection which could only be achieved through a relationship with a father figure (God). Unlike James, Freud viewed spiritual beliefs and experiences as illusions, in part because they lacked scientific explanation. The opposing viewpoints of James and Freud reflect the significant divergence in clinical perception regarding spiritual experiences that persists to this day. 

So is it psychotic or on the fringe of psychosis to believe in a spiritual connection with a deceased loved one? Should you be diagnosed with schizotypal personality disorder if you believe that ordinary things in your life are meant to give you a special message? The answer is a resounding…it depends. Schizotypal personality disorder is diagnosed not on the basis of isolated experiences or quirky beliefs, but rather on a cluster of problematic traits. Psychotic disorders are diagnosed on the basis of a major break with reality and significant impairment in functioning. It is unlikely that science will ever be able to make an absolute distinction between what is symptomatic of psychopathology and what is merely an aspect of diverse human experience. This illustrates the significant influence of cultural considerations on diagnoses and demonstrates that diagnoses cannot be reduced to a science. Ultimately, we must rely on human judgment, which makes my work all the more intriguing.

Returning military deserve the best mental healthcare available.

With the war in Iraq over, our troops are returning home to their families and communities and attempting to re-integrate themselves into civilian life. It is not an easy task, especially for the increasing number of military with posttraumatic stress disorder (PTSD), traumatic brain injury and combat-related depression.

Many appear to be fine physically, but inside, their brains suffer the marks of war. Returning military with PTSD or combat-related depression find themselves quick to anger and at the mercy of their unpredictable moods, or lacking the energy or will to go about daily life. Those with mild to moderate traumatic brain injury, which often goes undiagnosed, may be at a loss for what’s wrong with them. They can’t concentrate or do the tasks required at work or at home. They just know something isn’t right.

Joining Forces

In January, as president of the American Psychiatric Association, I joined leaders of several national healthcare organizations along with the Departments of Defense and Veterans Affairs at the White House launch of Joining Forces, an effort organized by First Lady Michelle Obama and Dr. Jill Biden to help returning military, particularly those with posttraumatic stress disorder, posttraumatic brain injury (TBI) and combat-related depression. Joining Forces has a three-part goal:

1. educate the public about PTSD, TBI and combat-related depression;
2. improve access to healthcare when needed; and
3. help returning servicemen and servicewomen find meaningful employment when they leave the military.

The stigma of mental illness and the culture of the military dissuade many members of the military from seeking the psychiatric help they so desperately need. An estimated 50 percent of returning military don’t get it. Access to quality psychiatric care for former military in the civilian world is also a challenge. I am proud to join our nation’s leaders, military and medical establishment to change that.

Joining Forces comes along at a crucial time for our country and military. Over the next four years, more than one million servicemen and women will be leaving the military—at one of the toughest economic periods in our country’s history. Many of our military are returning home with brain injuries because, thanks to amazing advances in medical technology, our troops are surviving their injuries in greater numbers instead of dying from them. For example, it used to take hours for those wounded in combat to go from the field to the operating room table. Now it takes an average of only 22 minutes—dramatically increasing survival rates for our troops.

While we are doing a vastly better job treating the bodies of our military, we have a long way to go in treating their minds.

On the home front

We are making progress on this front here at Menninger, following a long tradition of taking care of the military patient. In particular, Pam Greene, PhD, RN, a former member of the military and our senior vice president and chief nursing officer, has been actively training mental health professionals on suicide prevention in military veteran populations. Suicide is a tremendous problem for the military; in fact, statistics released in December identified 260 potential suicides in 2011.

But there is hope. Treatment for PTSD, TBI and combat depression does work and can help returning members of our military manage their conditions and live full lives. It is our job as mental health professionals to continue efforts to reduce stigma and other factors that block access to care. For their service and sacrifice, our military men and women deserve nothing less than our full attention, respect and the best mental healthcare available.

Can the future of psychotherapy be found in an iPad?

As I read Dr. Allen’s recent blog post “What’s Next? Psychotherapy by iPad?,” I had a few thoughts. I was reminded of the seemingly natural gradiosity that we humans possess in believing that there are certain behaviors that only we can do, or that we do best. I recall reading When Elephants Weep: The Emotional Lives of Animals and having that same thought: Is it not grandiose to believe that, as a species, we have the corner on the market of complex emotional worlds? As an avowed middle-aged geek, I was also reminded of Data from Star Trek: The Next Generation and his quest to be human. In one episode, the wise Captain Picard mused that perhaps humans ought to aspire to be more like Data.

Attachment and machines

In all seriousness, I think one question that begs to be answered is whether or not computers can simulate mentalization. I have a pleasant memory of the old computer program ELIZA that was created in the 1960s and programmed to give Rogerian-type responses to “clients” who chatted with it. Many people found ELIZA to “feel” strikingly human and some reported feeling helped by “her.” A more modern version of ELIZA can be found in MindMentor, a computer-programmed “chat therapy” developed by a pair of Dutch psychologists. According to one survey, 47 percent of individuals who used the program reported that they had been helped by it. Did they feel heard? Did the program mentalize them? Is it possible to attach to a computer in the same way that persons attach to other non humans such as family pets?

Though I realize I am straying away from the topic of mentalization and attachment, as Dr. Allen alluded to in his post, there are other, non-human modes of treating people out there. There are CBT sites, for example, that purport to help people with depression and OCD. Also, as he mentioned, thousands (millions?) of self-help books exists that presumably have helped individuals in their recovery. Did the individuals reading these books feel “heard” or “understood” when they turned the pages? Did the books “speak” to them?

In the future

The most recent Monitor on Psychology, a publication of the American Psychological Association, just arrive in my inbox, and on the front page, it says “Beyond one-on-one psychotherapy.” In Dr Allen’s post, he rightfully mentioned recent thinking by psychologists that we need to try to reach more clients. We ought to be able to provide services in many modalities, and to people who are geographically, financially and mobility challenged. It seems to me that ongoing debate and study regarding alternative delivery methods is inevitable. It’s conceivable to me that, in the future, I might pull out my smartphone and utilize an “app” that helps me think about an interpersonal problem I might be having. Will I feel “attached” to my smartphone? Well, I already am. (Just a little textual cue so that you might better mentalize me and the playful spirit with which this post was submitted.)

So here we are wrapping up 2011. If you believe the TV commercials, movies and all the rest, celebrating the New Year is the best party of the year, one that everyone wants to attend. But surely not everyone can always be in the frame of mind for a party on December 31. I wondered about those who have to cope with a mental illness and those who care for someone with a mental illness. Surely it can’t be easy for them.

So I posed some questions about this to some Menninger clinicians, and thought I’d share their answers with you. Here they are:

What advice would you give someone currently struggling with a mental illness to help them through New Year’s Eve celebrations?

Thomas E. Ellis, PsyD, ABPP: Keep in mind that most New Year’s resolutions are a waste of time and good intentions, because they are too darned hard and doomed to fail. But here’s one worth considering: To spend a little time each day cultivating kindness and compassion toward yourself. Remember the reverse golden rule: Treat yourself as you would hope to treat others. There are lots of ways of doing this, from meditation that focuses on self-nurturing thoughts to engaging in acts of kindness toward yourself. When was the last time you treated yourself to a funny movie?

Elizabeth C. Cantini, MSN, RN, Professionals in Crisis Program:

1. Sometimes a smaller group with warm and close friends can be safer and more rewarding to bring in the New Year. 
2. Try not to get caught up in the hype and mindset of partying with everyone looking so happy and fulfilled. Everyone has challenges and difficulties to face in life.
3. Celebrating New Years can be fun and meaningful with sparkling grape juice and other beverages without ETOH (regardless of what commercials advertise).
4. Fun can be within reach while maintaining good judgment and discretion.
5. Remember to regulate emotions before, during and after New Year’s.
6. Role play before being around friends if social anxiety is an issue.
7. Keep in mind that everyone needs friendship and affirmation.
8. It is a myth that everyone has to stay up until midnight!
9. Call, contact or visit someone less fortunate.
10. It’s fun to talk about everyone’s goals and New Year’s resolutions.

Dee Henderson, MSN, RN-BC, Comprehensive Psychiatric and Stabilization Program:

For those struggling with a mental illness, some coping strategies for the New Year’s holiday include:

• Stay close to friends or family that understand.
• Take medications as prescribed.
• Get adequate sleep.
• Relax by listening to favorite music or doing other activities that relax you.
• Make realistic resolutions.
• Allow yourself to grieve losses of this year.
• Don’t dwell on the negative.
• Be gentle with yourself.

 Chris B. Webb, CPRP, MT-BC, Rehabilitation Services:

• Refer to your wellness and recovery plan if you have one. If you don’t have one, start one.
• Spend New Year’s Eve with supportive friends and family.
• Spend New Year’s Eve at a place of worship.
• Attend small parties if you are triggered by crowds and loud music/noise.
• Ask how they would like to spend New Year’s Eve that will allow them to enjoy themselves without feeling overwhelmed or triggered.

Frances Fisher, CPRP, MT-BC, Rehabilitation Services: Someone living with a mental illness may view not view the coming of the New Year as a new beginning but rather as just more of the same old struggle. Life is not filled with possibilities; only the hopeless feeling of impossibilities and limitations. These feelings may be exacerbated on a day that is exclusively devoted to the celebration of ringing in this New Year. To this person who is struggling, I would say: Step back from the hype of New Year’s Eve and consider that EVERY day is a new day whether it feels like it or not. Know that recovery from mental illness is real and a possibility for your life.

What advice would you give someone with a friend or family member who has a mental illness to help them through New Year’s Eve?

Chris B. Webb, CPRP, MT-BC:

• Ask them how they would like to celebrate it.
• Ask how they would like to be supported.
• Host a healthy and supportive NYE party with soft drinks, play games, share highlights of the past year or best and worst of the last year and expectations of the New Year.

 Dee Henderson, MSN, RN-BC:

For families trying to support a loved one with a mental illness at New Year’s, some strategies include:

• Reach out to those who are alone or vulnerable.
• Encourage honesty in how they are feeling.
• Let them know you truly care about them.
• Support ways of celebrating that are low-key.
• Don’t compare this holiday with previous ones.
• Focus on the positives.
• Allow them to process feelings with you.

‘Tis the season for giving and getting.

For many in the military, this “season” has been 10 years in the making. Now that the war in Iraq is officially over, the wishes of many loved ones across the country are coming true with the return of thousands of our brave warriors.

While their return will no doubt be joyful, our veterans face an uncertain future. Perhaps, if they remain in the military, they’ll be redeloyed to Afghanistan. If they return to civilian life, they face the prospect of searching for a good job in a bad economy. Either way, many will find themselves facing the challenge of mental health issues like depression, substance abuse or posttraumatic stress disorder (PTSD).

If that’s not enough, there’s also the challenge of combating the stigma of mental illness. According to the Department of Veterans Affairs, research indicates 10-18 percent of veterans are likely to have PTSD following their return home. While many will receive care at VA medical centers for physical care, many won’t seek treatment for mental health problems. The VA offers plenty of reasons why, including the fear of being seen as weak or of being treated differently. Stigma is the new enemy.

That’s why I was so happy to see this video clip of John Oldham, MD, MS, the president of the American Psychiatric Association and the chief of staff at The Menninger Clinic, talking about some opportunities for giving that the APA has in this battle.

(From American Psychiatric on Vimeo)

There’s lots more we can give to help these veterans–Santa, hint hint–and I hope that the coming years will prove that the mental health community has served these men and women as well as they’ve served us.

Current trends in the delivery of mental healthcare bring this question to the fore. We have long known that psychotherapy is a limited resource, plainly inadequate to meet mental health needs. This limitation is true not only of individual psychotherapy but also of all forms of psychotherapy combined: individual, group, couples and family. Not only is the distribution of mental health services grossly uneven geographically, the pervasive limitations of resources have also become more glaring in the context of healthcare debates and global economic woes.

New service delivery mechanisms

Thus, not without justification, Alan Kazdin and Stacey Blase argue that we must develop and disseminate a far broader array of non-psychotherapeutic interventions, even if the magnitude of their effectiveness is more limited than psychotherapy. Small effects with wide reach are better than no effects, given the unmet needs for mental health services. Joining a venerable chorus, these authors also advocate greater emphasis on prevention as well as the benefits of early intervention.

Yet, as a committed practitioner of Plain Old Therapy, I’m jarred by their advocacy of impersonal interventions now made possible by burgeoning new technologies. Telephone therapy is not new, and enhancing it with video seems eminently sensible; this expansion of service delivery can greatly enhance the likelihood of developing therapeutic relationships. How much is lost (or gained?) in video versus face-to-face interactions is an empirical question. But, as Kazdin and Blase review, we now have an expanding array of web-based interventions and smart-phone applications, for example, to monitor mood and promote coping skills, which are derivatives of cognitive-behavioral therapies.

Key limitation of technology

I find persuasive Kazdin and Blase’s basic point that we need to expand the reach of mental health services and that any form of help we can provide—even if modest in its effectiveness—is all to the good. Moreover, as these authors state, new technologies can serve well as adjuncts to psychotherapy. Books have done so for decades.

Although we don’t seem to be able to live without them, computers don’t mentalize—hold mind in mind. For that, we need parents, friends, romantic relationships and—especially when things have gone wrong to the point that these ordinary relationships cannot adequately provide needed help and support—psychotherapists.

Reference

Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6, 21-37.

'Tis the season

This time of year creates different reactions in people. Most of us are blessed to have family and friends with whom to share the holidays, and are able to celebrate all the things for which we are thankful. It is a joyful time: We travel to be with people we miss and share traditions of food, song, decorations, lights, games and warm interactions. To most of us, it is a festival for the senses and a time we look forward to every year.

Unfortunately, not all people will feel that way. Some are alone, depressed, fearful and in need. For them, the holidays bring thoughts of what their lives lack, which can make their emotional distress worse. Travel challenges can trigger panic disorders and destabilize bipolar disorders. Eating disorders can be triggered by holiday foods and the pressure to indulge in them. Alcohol is free-flowing in some settings, and those challenged with addiction have additional pressure with which to contend. People may feel forced to be with individuals they may avoid the rest of the year, and old issues can arise, increasing the stress. Expectations run high, and disillusionment fuels conflicts. Even under the best of circumstances, the holidays are stressful, and stress can precipitate underlying depression and anxiety.

Some surveys indicate that not only do many people suffer from depression during the holidays, some experience distress to the extent that they cannot partake in the season’s activities at all, increasing their sense of isolation and exacerbating existing mental illness. At worst, the depression is severe enough to generate feelings of hopelessness and thoughts of suicide.

The positive news is that support from loved ones and treatment by mental healthcare professionals can help individuals cope with depression, anxiety and other mental illnesses, both during the holidays and when the regular routine resumes.

As you count your blessings this holiday season, consider giving to non-profit organizations that support those with mental health issues in gratitude for the health your family enjoys or maybe the help these organizations provide for someone you care about. 

Have a safe, happy and blessed holiday season!

Editor’s note: Many wonderful non-profits treat individuals with mental illness, do research into the nature of mental illlness and help families cope with the effects of mental illness. These organizations work at the national, regional and local levels to alleviate suffering and offer hope. Many, including The Menninger Clinic and The Gathering Place, Menninger’s psychosocial clubhouse, send out year-end appeals. Others, including the National Alliance on Mental Illness and Mental Health America, urge their web visitors to support their work. To find other mental health non-profits in need of your support this holiday season, a quick Google search will lead you to them. 

Demonstrators from the Occupy Wall Street movement

It has been more than a month since the demonstrations in New York began, and protests have spread to cities across the country. Occupy Wall Street started as a movement about economic inequality in the country, with the demonstrators’ common refrain, “We are the 99 percent,” referring to the gap between the top one percent, who control about 40 percent of the United States’ wealth, and the rest of the population. The movement speaks of themes of unemployment, inadequate health insurance and the quest for a living wage.

The Occupy Wall Street group has seemed to tap into a common frustration and despair among Americans. According to Mental Health America, nearly half of Americans are stressed by finances, and 32 percent of Americans also report employment issues as a source of stress. And as anxiety levels increase, other mental health indicators are impacted, including depression and sleep disturbances.

Lessons to be learned

So what can the movement teach us?

First, it’s important to underscore what the National Alliance on Mental Illness makes clear:

“Mental illnesses can affect persons of any age, race, religion, or income. Mental illnesses are not the result of personal weakness, lack of character or poor upbringing.”

However, according to The Equality Trust (an independent, evidence-based campaign located in the United Kingdom), the bigger the gap between a nation’s rich and poor populations, the greater is the dysfunction in that nation’s society. Utilizing mental health studies culled from the World Health Organization, it appears that different societies have very different levels of mental illness. In some countries only five or 10 percent of the adult population have suffered from any mental illness in the past year, but in the U.S., more than 25 percent have. Mental illness is much more common in more unequal countries, not to mention in richer countries as well.

What the Occupy Wall Street movement serves to teach us, regardless of our stance on the intentions of the group, is that there is power in being part of a group process, and there is power in learning how to speak about our experiences.

Strength in numbers

In a sense, the therapeutic value in announcing something which has been stigmatized, such as your mental illness or lack of wealth, is akin to exposure therapy. As a society not accustomed to sharing privileged information such as our bank account or personal narratives, being a part of a movement which asks you to do just that can be a way to face and control fears that are not often addressed.

Being a part of a group with a shared goal can be a powerful experience. The commonality of the members of the Occupy Wall Street contingent can be seen through the sea of signs announcing their discontent or shared experiences of poverty and disenfranchisement. Similarly, being a part of a group in a mental health setting can bring up feelings of peer support and a greater sense of normalcy. Many people feel as though they are struggling with solitary experience, and it can be cathartic to realize that you are not the only one grappling with a particular issue. Group psychotherapy serves to create a container for people, as they begin to shed their feelings of isolation. The same could be said for political rallies and movements.

Perhaps one of the reasons why the Occupy Wall Street movement has continued is that people no longer feel so alone. Members of the movement have seen a unity that bonds them together. Might the same be said for people fighting the stigma of mental health?

More and more, people are clamoring to speak up about their struggles with poverty and the inextricable links to depression and anxiety. The shame of sharing continues to be alleviated, as evidenced by the growing movement. Even if you are not marching in the streets yourself, it’s hard to deny the importance of bearing witness to people finding freedom in speaking their truth.

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.