What is anxious depression?
There's anxiety and there's depression
and they're both separate disorders.
But what about when you have both?
That's what I'm talking about today.
I'm Dr. Tracy Marks a psychiatrist
and I make mental health education videos.
This topic is based on a viewer question
from Madhusudan, sorry if I mispronounced that.
Anxiety and depression often come together
and there's different ways that they can look.
Sometimes anxiety spawns depression where you start off
with something like obsessive compulsive disorder,
where you have these overwhelming thoughts
that you can't get out of your head or rituals
that you can't stop doing
or you may have generalized anxiety disorder
where you're gripped with worry and fear.
Some people's anxiety can be so bad
that they wake up every morning and throw up
or you can feel like
there's this heavy weight pressing on you all day.
And some people feel like their throat
is closing all day long
and this is a horrible way to feel
especially when there's not a clear reason to feel anxious.
You can start to think what's wrong with me,
why can't I feel normal and feeling like this
for weeks or months on end
can make some people sink into a depression.
In this case, you would have two disorders,
the original anxiety disorder and then a depression
that's one scenario.
Another scenario is when your primary problem is depression
having no joy, feeling hopeless,
hardly having the energy to do anything.
Instead of feeling a heavy weight on your chest all day,
you feel tears just behind your eyes all day,
ready to stream at the slightest provocation.
In fact, you'd probably do need to go off
and cry from time to time
but it's not one of those nice cleansing cries
where you feel like you purged pent up emotions.
It's crying on top of pain
and the tears don't release anything.
You still hurt even after you've cried.
This is what your depression might look like
if you had pure depression
but many times people have anxiety symptoms mixed
in with their depression.
The anxiety doesn't really rise to the level
of a full disorder like panic disorder
or generalized anxiety disorder.
But its presence is enough to make the quality
of the depression different.
The term for this is depression with anxious distress.
Anxious distress is what we call a core specifier.
It gives more specific information
about how your depression looks and behaves.
Here's the criteria for the specifier
and this is from the Diagnostic and Statistical Manual
of mental disorders 5th edition.
Anxious distress is defined as the presence
of at least two of the following symptoms
during the majority of days of a major depressive episode
or persistent depressive disorder, dysthymia.
Let me jump in here.
This is saying that this specifier applies
to either depression or this re-imagined entity
called persistent depressive disorder,
formerly called dysthmic disorder
which is a chronic lower level of depression
that hangs around for at least two years.
So you need to have these.
Feeling keyed up or tense,
feeling unusually restless,
difficulty concentrating because of worry,
fear that something awful may happen,
feeling that you may lose control of yourself.
Every time I hear it reference to losing control,
I think of the Android and the original Alien movie
when it was discovered that he wasn't real
and he started malfunctioning.
This is not what it looks like to lose control.
You may fear that this is what you'll be doing
but that fear is part of the anxiety,
imagining extreme behaviors
but losing control can be as subtle
as not being able to stop yourself
from doing something destructive like quitting your job.
Two of these symptoms put you in the mild level
of anxious distress.
Three symptoms is moderate and four to five
is moderate to severe and four to five with motor agitation
is considered severe.
What is motor agitation?
Motor just refers to your body movements
and agitation is increased physical activity.
It could take the form of pacing or leg shaking,
it's usually movement that doesn't have any real purpose.
So it could be incessant throat clearing or pin clicking.
Scientists have seen differences in the brains
and blood work of people with anxious depression
compared to non- anxious depression.
The brain imaging shows thinning of the gray matter
in parts of the brain.
The gray matter represents densely packed nerve cells
and looks great on a scan.
This is also called cortical thickness.
One of the references in the description uses this term.
Why does all of this matter?
Because anxious depression tends to be harder to treat
than depression without the anxiety mixed in.
In my experience, this is where people fall
into the treatment resistant category.
Treatment resistance is usually used when someone fails
to get better from one or two antidepressants,
also people with anxious depression
are more likely to have a negative experience
with antidepressants like having your anxiety ramp up
when you first start medication
or even feeling more depressed when you first start
the antidepressant.
And when this happens, it could be very discouraging.
I talk about that in a video I did on
why antidepressants make you feel worse.
So should we just all pack up and go home?
No, all is not lost
and if you know ahead of time
that starting medication can make you feel worse first,
then you can be prepared for the long haul
with trying different agents.
Also, this means that
you will probably require more than one antidepressant
to get and stay better.
Uncomplicated depression responds well to one antidepressant
and often this can be treated by your primary care doctor.
And you may not need to see a psychiatrist
but anxious depression that does not respond
to a single medication, usually requires a psychiatrist
to look at other options.
Some of which are off-label meaning that they're used
for their drugs that we use outside
of their approved purposes.
For anxious depression in addition to the antidepressant,
we will use anti-psychotic medications
like aripiprazol or brexpiprazole.
Sometimes we add on an anticonvulsant
like Lamotrigine or Gabapentin.
Of course, psychotherapy in combination with medication
is more helpful than medication alone.
So the moral of this story is if you have depression
with anxious distress,
be prepared that you may need more than one medication
to treat your condition
and you may have to try a few before you get one
that works well with the least amount of side effects.
Thanks for watching, see you next time.