Mood

Anxiety in Depression and Bipolar Disorder

How you manage your anxiety is crucial to managing your mood.

So bound up is anxiety to mood that it may be more convenient to think of each as part of the same illness. Herman Van Praag of the Maastricht University in an article in Neuropsychopharmacology and Biological Psychiatry proposed there be a new subtype of depression called anxiety/aggression-driven depression. According to the US National Comorbidity Survey published in 1996, 58 percent of those with major depression also suffer from anxiety.

One’s anxiety, however, need not be full-blown to sabotage recovery. The technical term is "subsyndromal comorbidity," which applies in this context to a mood disorder and under-the-radar anxiety. Two studies by Ellen Frank PhD et al of the University of Pittsburgh found that depressed or bipolar patients with co-occurring panic symptoms experienced significant delays in their weeks to remission. These patients also had higher levels of residual impairment.

Forty-two percent of patients with bipolar disorder have co-occurring DSM anxiety, according to a 2001 study by McElroy et al. This breaks down to 20 percent of patients with panic, 16 percent with social phobia, six percent generalized anxiety disorder, seven percent PTSD, and nine percent OCD. High anxious bipolar patients have more suicide attempts, more alcohol use, less response to lithium, and longer time to remission.

STEP-BD data from the first 1,000 bipolar patients in an NIMH ongoing study found 34 percent had a co-occurring anxiety disorder. The data showed that "use of comorbidity specific pharmacotherapy ... was limited, suggesting that comorbid conditions in patients with bipolar disorder may be undertreated." Earlier, after the data from the first 500 patients was in, Gary Sachs MD of Harvard and principal investigator of the NIMH-funded STEP-BD, at the 2003 Fifth International Conference on Bipolar Disorder, suggested that anxiety could actually be a manifestation of the illness.

We need to think beyond the DSM symptom list, Dr Frank advised at the 2004 American Psychiatric Association's annual meeting. "The DSM has made us less sensitive to our clinical intuition."

The Biology of Anxiety and Depression

Both anxiety and depression share the same stress pathway. In an article in the Sept 2003 Scientific American, Robert Sapolsky PhD of Stanford writes on how the fight or flight response underpins both anxiety and depression:

The primate stress response, Dr Sapolsky begins, can be set in motion by the mere anticipation of an event, and when we erroneously believe a stressor is about to happen we "have entered the realm of neurosis, anxiety, and paranoia." The amygdala in the brain receives input on a conscious level from the cortex and unconsciously from specialized parts of the brain. In response to a perceived threat, the amygdala sets off a chain of events that results in the hormone CRF signaling the brain stem, which activates the sympathetic nervous system. In response, the adrenal glands produce adrenaline (epinephrine) and through a different pathway cortisol, both which prepare the body for fight or flight.

In addition, the amygdala sends information back to the frontal cortex and to sensory cortices, which accounts for emotionally-influenced decision-making and vivid sensations, respectively. In addition, the amygdala is involved in memory. Paradoxically, stress can strengthen the ability of the amygdala to form implicit or preconscious memories while inhibiting the hippocampus’ ability to form explicit or conscious memories. The individual may thus experience a fight or flight response to a voice in a crowd without knowing why, being unable to link the sound of that voice to the similar-sounding voice of a past assailant, resulting in "free-floating" anxiety.

Meanwhile, cortisol activates a brain region called the locus coeruleus, which sends norepinephrine to communicate back to the amygdala, thus initiating the stress response all over again and resulting in a destructive feedback cycle.

The torpor of depression may appear to be the opposite of anxiety, but like anxiety can be related to stress. Moreover, depression is not a passive state. According to Dr Sapolsky, "the dread is active, twitching, energy-consuming, distracting, exhausting - but internalized. A classic conception of depression is that it represents aggression turned inward ..."

Dr Sapolsky asks us to imagine a rat trained to press a lever to avoid a mild shock. The anticipation of mastery might activate pleasurable dopamine release to the frontal cortex. If the lever is disconnected, however, so that pressing it no longer prevents shocks, the rat will frantically press the lever repeatedly, attempting to gain control. This, says Dr Sapolsky, is the essence of anxiety, characterized mainly by adrenaline and norepinephrine secretion and to a lesser extent by cortisol production. As the shocks continue and the rat finds its attempts at coping useless, a transition occurs where cortisol dominates and key neurotransmitters are depleted. In the words of Dr Sapolsky: "It has learned to be helpless, passive and involuted. If anxiety is a crackling, menacing brushfire, depression is a suffocating heavy blanket thrown on top of it."

Anxiety Gets Personal

With anxiety a virtual trip wire for a mood episode (including mania), successful management of the former is vital to the outcome of the latter. Elsewhere on this web, Kevin describes how this deadly combination ruined his life:

"When major depression finally swept over me, it felt like being caught in a huge wave, unable to get my footing any longer, unable to understand which way to the surface, and just helplessly and hopelessly thrown about, powerless to do anything about the hostile world that was coming down around me. I stayed curled up in the corner of a couch, unable to answer the phone or the doorbell. Everything that came in the mail scared me, so I wouldn't open it for several days at a time. I did not leave the house and did not want to see anyone. I didn't care any longer about the way I looked. For the past 20 years I had been a stockbroker. Now the market was going down, I was already just a whisper away from death and clients were leaving in droves. My financial ruin has only made matters harder for me to recover. I have a lien against my house now by the IRS, a default judgment for $50,000 and more to come. Every time I have a couple of decent days back to back, I hope that this is the beginning of my recovery. Then something negative confronts me and I get a panic attack and head for the Xanax. I go right down the tubes to hopelessness and constant depression and anxiety. There, even good things are heavily veiled in grey. No shower, no shaving, no energy, no hope. Just scared and remembering back to my childhood diagnosis of 'Born Wrong.'"

Anxiety Types and Symptoms

Anxiety is the most common form of mental illness, with an estimated 19 million Americans suffering from one form or another of the illness over the course of a lifetime. The DSM-IV classifies anxiety as follows:

Panic Disorder - According to the Anxiety Disorders Association of America (ADAA), "people with panic disorder suffer severe attacks of panic - which may make them feel like they are having a heart attack or are going crazy - for no apparent reason." Symptoms may include: palpitations, sweating, trembling, shortness of breath or a smothering feeling; a feeling of choking, chest pain or discomfort; nausea or abdominal discomfort, dizziness or lightheadedness; a sense of things being unreal, depersonalization; a fear of losing control or "going crazy", a fear of dying; tingling sensations, chills or hot flushes.

Twenty percent of those with bipolar disorder, 10 percent of people with unipolar depression, and just 0.8 percent of the general population experience panic attacks. Genetic researcher Dean MacKinnon MD of Johns Hopkins refers to the link as "the manic panic connection."

Generalized Anxiety Disorder (GAD) - GAD is characterized by excessive, unrealistic worry lasting six months or more. Because it is not as dramatic as a panic attack, GAD can cause a lot of damage going unrecognized and untreated.

Agoraphobia - fear of being placed in situations from which escape might be difficult or impossible - may coincide with panic attack.

Social Anxiety Disorder or Social Phobia - According to the ADAA: "Social Phobia is characterized by an intense fear of situations, usually social or performance situations, where embarrassment may occur. Individuals with the disorder are acutely aware of the physical signs of their anxiety and fear that others will notice, judge them, and think poorly of them. This fear often results in extreme anxiety in anticipation of an activity, a panic attack when faced with an activity, or in the avoidance of an activity altogether. Adults usually recognize that their fears are unfounded or excessive, but suffer them nonetheless."

Specific Phobia - (eg unreasonable fear of heights).

Obsessive Compulsive Disorder (OCD) - In the words of the ADAA, OCD is characterized by "persistent, recurring thoughts (obsessions) that reflect exaggerated anxiety or fears," which may include rituals such as excessive hand-washing. According to the Epidemiological Catchment Area Survery, 21 percent of those with bipolar disorder and 12.2 percent of those with unipolar depression have experienced OCD over their lives.

Post Traumatic Stress Disorder (PTSD) - The DSM-IV states that PTSD involves a person witnessing, experiencing, or being confronted with an event involving injury or a threat to his or her life or to that of another individual, and that the person’s response involved intense fear, helplessness, or horror. Those with PTSD typically relive the event in the form of recurring recollections, dreams, acting as if the event were recurring, and intense psychological and/or physical distress to internal or external cues - so much so that patients attempt to avoid situations associated with the trauma, may have difficulty recalling an important aspect of the trauma, become emotionally numb, and/or have lowered expectations of the quality of their own lives. Patients also may have difficulty falling asleep, may feel irritable or angry, have difficulty concentrating, be hyper-vigilant, and have an exaggerated startle response.

Anxiety Talking Therapy Treatment

When researchers had a second look at the data at a depression study of women on different treatments, to their surprise they discovered more than half had either lost their parents before age 15, experienced childhood physical and/or sexual abuse, and/or endured neglect, leading the study’s authors to note, "these findings alone highlight the remarkably high prevalence rate of early life trauma in patients with chronic forms of major depression."

They also discovered that the women had a much higher rate of response to talking therapy than antidepressants. The type of talking therapy was of short duration, designed to help people cope rather encourage them to root out and confront their traumas and fears. The three main types of talking therapy aimed at coping with everyday situations include cognitive therapy, behavioral therapy, and interpersonal therapy.

Longer term therapy that gets inside a patient's head may only be appropriate after a patient is first stabilized from his or her mood disorder and not likely to decompensate should the therapy go wrong.

According to an article on Harvard’s Intelihealth: "There is some evidence that people who receive counseling and supportive therapy immediately after a trauma have a lower risk of developing PTSD than those who don't."

A feature article in the New York Times Magazine by Lauren Slater, author of Prozac Diary, challenges that assumption, making a strong case for keeping trauma repressed, contrary to an industry of therapy built on prizing loose bad experiences from survivors. As early as 1952, a study found that psychotherapy in general healed no more than the passage of time, and observations coming out of 9/11 indicate that many survivors actually got worse in the hands of their therapists. The article cites an Israeli study of 116 heart attack victims, which found those who repressed the occurrence "fared better in the long run." After seven months, the "repressors" experienced only seven percent PTSD compared to 19 percent among those who sought to "lift the lid."

Researchers hypothesize that repressors may perceive the magnitude of events differently, say "where you see a downpour, they see a drizzle." Another theory is that repressors are good at turning attention away from the disaster, or else believing - rightly or wrongly - that they can cope. According to Kansas City psychologist Richard Gist, who has assisted survivors of disasters but is questioning the worth of his efforts: "For all we know, the repressors are actually the normal ones who effectively cope with the many tragedies life presents. Why are we not more fascinated with these displays of resilience and grace? Why are we only fascinated with frailty?"

Treatment for PTSD is long-term, reports Intelihealth, which includes antidepressants, benzodiazepines such as Ativan and Valium, and Buspar. Patients also learn anxiety management, which includes relaxation training, breathing training, and thought stopping (learning to halt distressing thoughts by thinking, "Stop," then performing a distracting action such as snapping the wrist with a rubber band). Other therapies include cognitive therapy (more on this later), exposure therapy (controlled re-exposure to people, situations, and objects that trigger memories of the traumatic event, play therapy (for children), and education, supportive counseling, and family therapy.

According to Intelihealth, about 30 percent of PTSD patients recover completely while another 40 percent show only mild symptoms. These percentages may increase, they say, now that antidepressants have been found efficacious.

Anxiety Medications Treatment

Many of the same treatments for depression work well for the different types of anxiety, including cognitive therapy and other talking therapies that focus on coping skills, as well as meds. Right lifestyle choices such as diet, exercise, and sleep are also critical, yoga and meditation can be especially useful, and natural treatments such as supplements are also an option.

The ADAA offers the following guide for meds:

Neurontin, for SAD, thought to affect the neurotransmitter GABA, takes at least two weeks to act, is sedating.
Buspar, for GAD, less sedating than benzodiazepines, works slowly.
Benzodiazepines (includes Ativan, Klonopin, Librium, Valium, and Xanax), for GAD, SAD, panic disorder, enhances GABA function, fast acting, potentially habit forming, can cause drowsiness.
Beta Blockers (Inderal, Tenomin), for SAD, reduces ability to produce adrenaline, fast acting, should not be used for those with a wide variety of medical conditions, such as diabetes and heart conditions.
MAOIs (Selegiline, Marplan, Nardil, Parnate, for panic disorder, SAD, PTSD, blocks an enzyme from breaking down serotonin and norepinephrine, takes at least two weeks start kicking in, strict dietary restrictions.
SSRIs (Prozac, Paxil, etc), for panic disorder, OCD SAD, GAD.
Tricyclic antidepressants, for panic disorder and PTSD, Anafranil for OCD.
Other antidepressants (Desyrel, Effexor, Serzone), for panic disorder, OCD, SAD, GAD.

At the 2004 APA meeting, Lori Davis MD of the Tuscaloosa VA Medical Center summarized the data we have on meds and talking therapy for treating bipolar and anxiety:

Lithium: BP mania ++, BP depression +, PTSD +
Anticonvulsants: BP mania ++. BP depression ++, Panic ++, OCD +, Social phobia ++
Atypical antipsychotics: BP mania ++, BP depression ++, OCD +/-, PTSD +/-
SSRIs: BP Depression +, Panic ++, OCD ++, PTSD ++, Generalized anxiety disorder (GAD) ++, Social phobia ++
Benzodiazepines: BP mania +/-, Panic ++, OCD +, PTSD +/-, GAD ++, Social phobia ++
Buspar: PTSD +, GAD ++
Cognitive behavioral therapy (CBT)/Behavioral/Exposure: BP depression +, Panic ++, OCD ++, PTSD ++, GAD ++, Social phobia ++

Proposed treatment strategies, Dr Davis said, include:

Concurrent bipolar and panic: Anticonvulsant (Depakote) with SSRI and perhaps CBT.
Concurrent bipolar and OCD: Mood stabilizer with SSRI and perhaps CBT.
Concurrent bipolar and PTSD: Anticonvulsant (Lamictal or Depakote), perhaps with an antipsychotic, perhaps an SSRI, and perhaps CBT.
Concurrent bipolar and social phobia: Mood stabilizer and perhaps Neurontin and/or SSRI and/or CBT.
Concurrent bipolar and GAD: Mood stabilizer and perhaps Buspar or SSRI and perhaps CBT.

Conclusion

Please do not assume that you JUST have depression or bipolar disorder. Those incidental fears and behavioral quirks and unexplained physical symptoms of yours may warrant further consideration by your psychiatrist or therapist. Hold back nothing. The difference between successful treatment of your mood disorder and failure may depend on how well you identify and manage your anxiety.

Updated June 19, 2004, reviewed Feb 10, 2008

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Our very lives depend on how we manage stress.

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