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Section 5
Core Dimensions of Anxiety and Depression

Question 5 | Test | Table of Contents | Anxiety CEU Courses
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In the last section, we discussed four conditions and how they are connected with panic disorder. These four conditions were inner ear disorders; menstruation and pregnancy; mitral valve prolapse; and enzyme impairment.

Many times, I have found that clients with panic or anxiety disorder seem to also suffer from some form of depression. The first trouble we have in this finding, however, is the question of which is the primary disorder? 

In this section, we will examine depression co-occurring with anxiety disorder. We will examine primary depression; primary anxiety disorder; and the combination of both primary depression and anxiety disorder.

♦ #1 Primary Depression
The first aspect we will discuss is when depression is the primary disorder. Clients who have primary depression may exhibit symptoms of an anxiety disorder. They may display an inability to sit still, constant pacing, hand wringing, picking at clothing or fingers, lip biting, and anguished facial features. This depressive state may increase one’s anxiety about everyday occurrences. Also, the client may be unable to make up his or her mind about trivial matters.

In conjunction with these anxious symptoms, clients also manifest the tell-tale signs of depression. Some may sleep for long hours during the day. Many experience weight gain, listlessness, hopelessness, or the urge to cry at inappropriate times. Maxine was a client of mine who had originally been referred to me as an anxiety disorder client. She had reported grinding her teeth and feeling restless. However, her anxiety did not meet the criteria for an anxiety disorder.

Instead, many of her other symptoms such as her overeating seemed to affect her daily life more than her anxiety.  I asked Maxine how she had been feeling lately and Maxine stated, "Actually, not so good. I just went through a terrible divorce, so I feel like a wreck.  I don’t feel like getting out of bed in the morning. But then I feel restless by staying in bed.  All I want to do is watch Maury and eat sugary stuff.  This isn’t like me at all.  I used to feel great about myself.  Now, since there’s no one there that I need to look good for, I’ve stopped trying." 

As you can clearly see, Maxine fit the diagnosis for depression not anxiety disorder.

♦ #2 Primary Anxiety Disorder
The second aspect of co-occurring depression and anxiety disorder is when the anxiety disorder is the primary disorder. When a client suffers from a primary anxiety disorder, depression may be a result of the first condition. Many times, if anxiety lasts too long, a client may become easily depressed and hopeless about a situation if they feel they cannot control it.

Usually, I have found that clients whose anxiety disorder occurs primarily tend to have less intense depressive symptoms than those whose depression occurs primarily. Denise was an anxiety disorder client of mine who had reported feelings of depression. Denise stated, "When my sister was sick for a long while in the hospital, I was feeling almost as sick with anxiety. I kept expecting that call with the doctor on the other end saying, ‘We couldn’t do anything for her.’ Even though I knew the cancer was in remission, I had this overwhelming feeling something awful was going to happen.  This went on for about three months, and after a while, all I felt like doing was lying in bed and crying." 

As you can see, as a result of her anxiety, Denise had developed depression. I explained to Denise that these feelings of listlessness were a symptom of her anxiety.  Her body had been so overwhelmed by worry that it was starting to shut down emotionally. 

♦ Technique:  Best Case Scenario
To help Denise get through her depressive state and ease her anxiety, I asked her to write out "A Best Case Scenario."  For this technique, I asked Denise to think about the best possible outcome to this situation and write it out on a scrap of paper.

Denise wrote, "Beth will come home from the hospital, smiling and energized. In a few days, we will be able to take walks again and have our chats over coffee or lemonade, depending on the season. Her cancer won’t come back for a long time, and even if it does, the doctors will treat it once again and she will beat it once again."

I asked Denise to put this scenario in a place she could easily see it. Denise framed it and put it on her bedside table. Whenever Denise felt like staying in bed, she would look over to see her Best Case Scenario and her anxiety would be somewhat eased.  Think of your "Denise."  Could he or she benefit from a "Best Case Scenario"?

♦ #3 Both Primary Depression and Anxiety Disorder
In addition to primary depression and primary anxiety disorder, the third aspect we will discuss is when both anxiety and depression occur primarily. As you know, when this occurs, a differential diagnosis must be done. To do this, I examine the client’s own medical history, that of his or her family which we discussed earlier on in the section, and the sequence of the symptoms, to perhaps discover if one may trigger the other.

To obtain a differential diagnosis, I must ascertain a client’s mental health. To do so, I use the following list of criteria when interviewing a client for one of the first introductory sessions:

  1. General appearance, manner, and attitude.  Clients with panic disorder may appear calm during interview.
  2. Consciousness, including orientation as to time, place, and person.
  3. Apperception-perception as modified by one’s own emotions, memories, and biases.
  4. Affectivity and mood.  Fear and apprehension suggest anxiety.
  5. Conation and motor aspects of behavior.
  6. Associations and stream of thought.
  7. Thoughts of life and mental trends including delusions (false beliefs). (I might suggest asking about phobias, obsessions, compulsions, and excessive fears or bodily preoccupation.)
  8. Perception, including auditory and visual hallucinations.
  9. Memory, both recent and remote.  Retention and recall—digit span is impaired in extremely anxious clients.
  10. Function of information.  Intellectual function is intact in clients with anxiety disorders.
  11. Judgment.  The ability to compare facts or ideas, to understand their relations and to draw correct conclusions from them.
  12. Insight, the extent to which a client is aware that he or she is ill.  Anxiety clients are often unwilling to accept an emotional explanation for their physical condition.

Using these criteria, I map out a line of questioning that will adapt for each client. 

In this section, we discussed depression co-occurring with anxiety disorder. We went over primary depression; primary anxiety disorder; and when both depression and anxiety disorder are primary.

In the next section, we will examine three types of phobias which result in anxiety. The three types we will examine are simple phobias; blood-injury phobias; and illness phobias.

- Kim, Y., M.D., Lee, S., M.D., Choi, T., M.D., Suh, S., M.D., Kim, B., M.D., Kim, C., Ph.D., . . . Yook, K., M.D.1. (2009). Effectiveness of mindfulness-based cognitive therapy as an adjuvant to pharmacotherapy in patients with panic disorder or generalized anxiety disorder. Depression & Anxiety, 26(7), 601-606. doi:10.1002/da.20552

Peer-Reviewed Journal Article References:
Allan, N. P., Albanese, B. J., Judah, M. R., Gooch, C. V., & Schmidt, N. B. (2020). A multimethod investigation of the impact of attentional control on a brief intervention for anxiety and depression. Journal of Consulting and Clinical Psychology, 88(3), 212–225.

Conway, C. C., Zinbarg, R. E., Mineka, S., & Craske, M. G. (2017). Core dimensions of anxiety and depression change independently during adolescence. Journal of Abnormal Psychology, 126(2), 160–172.

Niileksela, C. R., Ghosh, A., & Janis, R. A. (2020). Dynamic changes in generalized anxiety and depression during counseling. Journal of Counseling Psychology. Advance online publication.

What are three aspects of a co-occurring anxiety disorder and depression? To select and enter your answer go to Test.

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