Yesterday, in a brief article Anxiety vs. Depression at Psychology Today, psychiatrist Fredric Neuman tried to explain why psychiatrists often prescribe antidepressant medication even if the patient indicates that her main problem is anxiety or panic attacks rather than depression.
He states that major depression can often have not a kind of sad feeling as its predominant symptom, but rather anxiety. According to him, when there are also other well-known symptoms such as interrupted sleep, loss of appetite and loss of sexual interest, this specific combination of symptoms can be clear enough for the psychiatrist to diagnose a case as depression: even when the patient would label herself primarily as suffering from waves of anxiety, not from depression.
I suppose he may be right – but only, of course, in those cases where (a) this anxiety or panic does indeed come together with other main symptoms of depression, and (b) where this occurs not incidentally but frequently, throughout most days over an extended period.
Brief as it is, Neuman’s interesting article leaves several important questions unanswered. Here are the two questions that came to my mind immediately:
1. Many people experience anxiety or sudden panic attacks once in while or even frequently. By itself, this may not necessarily be abnormal or an indication of illness; it can for example be caused by actual worries, or by a temporarily overactive self-protection mechanism. Can we be sure that psychiatrists will not jump too easily to the conclusion that such anxiety indicates an underlying depression?
In other words, can we be sure that psychiatrists will not too easily prescribe antidepressant medication – with sometimes far-reaching and undesirable side effects – even in simple cases where in fact it might be better to just address this anxiety by itself?
2. Neuman does define “depression” but did not really define “anxiety”. So this raises the question what degree of anxiety a psychiatrist should consider bad enough to justify the prescription of antidepressant medication. I suppose this applies to anxiety that is so intense that the patient cannot function normally in daily life anymore. But will it also apply to intermittent feelings of anxiety that the patient merely finds unpleasant or disturbing? Where exactly do we draw the border line between serious anxiety and fairly “normal” anxiety?
In other words, can we be sure that psychiatrists will not too easily prescribe antidepressant medication even in simple cases where in fact it might be better to explain to the patient that sometimes anxiety (just like grief) is not a kind of aberration but a natural feeling that we should accept as one of the many facets of life?
Neuman is a qualified anxiety expert (at the Anxiety & Phobia Center of White Plains Hospital) so I hope he will soon give us a follow-up article with a little more of his views on anxiety in relation to depression.
• tip: In my own perhaps too simple view, the best short-term way to counter a frightening, paralyzing, irrational attack of anxiety is this.
Seek out someone else who at that moment can be more rational than you. Do not yet start a talk about possible causes of your anxiety: for this will often just not work in your present panicky state. Instead, together with this other person try to do something, some kind of simple distracting activity.
• footnote: At the bottom of Neuman’s Psychology Today article is also a link to his personal blog, but due to a typo it will send you to an error page. Here is a link that works.
For some of us, depression comes with fear. A deeply-rooted, vague, undefined, continuous, horrifying feeling of fear. Your psychiatrist will probably label this as “depression-related anxiety”, but in fact it can be much worse than this bland term suggests.
To take a closer look at this fear, first I want to take you for a walk in the woods. I like hiking through the forest – although sometimes I’m too lazy or too depressed to actually go out for that healthy walk. But a track in the woods offers so much to see and hear and smell and feel. An unexpected flower or mushroom, a bird tweeting high up, a sudden ray of light through the leaves, a shrub with a penetrating better-not-touch-me smell, a glimpse of was-that-a-squirrel? and the soft bouncy crunch of twigs and dead leaves under your feet. In comparison, a walk through open fields can seem more dull and monotonous.
We share this primordial, direct, instinctive mechanism of fear with most animals. On a basic level, we may say that it is not just us feeling such instinctive fear: in many cases, it is produced by a residual Ape that is still living on, deep down in the secret cellars of our brain.
The very worst kind of such depression-related fears is when, without fully realizing what it is that makes you so afraid, it actually is yourself you’re so afraid of. When in fact you’re afraid of a Sabre-Toothed Depression Tiger that roams through your own thoughts, wanting to end it all, wanting to kill you. In other words, when it is the threat of your own suicidal, self-destructive feelings that again and again fuels the flames of your fear.
“Hi! You know, I’m getting used to these interviews! You really do a wonderful job telling people about my work here! Now first of all, do you remember that last time, I introduced you to our therapeutic concept of NUMB meals? Those unidentifiable meals where patients won’t get any clue about what it actually is they’re trying to eat? Well in the meantime, with full support of our management and marketing divisions, I’ve been able to develop NUMB into a regular product, complete with registered trademark. We’re already selling the concept to more hospitals than you’d care to know. It’s a tremendous success and I’m very, very proud to have a share in it. I refined and streamlined the whole thing, too: we can now use the very same basic recipe every time – for daily variation, we only need to mix a few color additives that give those same foodballs a slightly different look every day. Simply super. You really should give it a try; maybe later on I can still serve you the meal that you missed last time?”
“What you see here is the room of a patient who arrived only a couple of days ago, so she’s still in the process of building her own informal environment. But as you see, she has already managed to leave quite a personal touch. And by doing so, she’s gradually re-discovering her own valuable identity: re-establishing the lost core of her own individual personality, so to speak. All by herself! Starting from nothing at all! Every time I see them achieve something like this, I’m deeply moved, I can tell you. Now you wonder why there’s hardly any furniture in here? That’s simply because she hasn’t had time yet to explore our Furniture Repository.”
“Our patients are invited to go through the stack and borrow whatever they think would fit in their room, anything that can help them feel at home. Furnishing their own hospital room is of course also a stimulating, challenging activity in itself. And there’s more! If you want to shlep a heavy soggy armchair to your room, of course you need to ask some other patients for help, so it’s a great social stimulus as well! Once again, in fact we all benefit here: for from a budgetary point of view… But let me stress that as always, therapeutic considerations come first. Now let’s walk on to the lavatory arraignments, shall we?”
“Same story here: I hope you’re not going to find this a bit, um, Dull… ha-ha. Again that familiar homely atmosphere where we offer as much activities as possible to the patients themselves. Toilets, wash basins, shower cabins, it’s all there for the patients, so we leave it to them to discover they still should regain some kind of responsibility of their own. Beginning to understand that cleaning themselves also means cleaning things themselves. Feeling just a tiny bit responsible again is one of the many small stepping stones of the long staircase up towards recovery. Absolutely. Works in wonderful ways. Yes you noticed? We also let them wash and dry their own clothes if they need to. All by hand, naturally: repeating some simple physical activity is just another great stepping stone in our therapeutic trajectory.”
“Ah yes. The people who are afraid of mice. I can tell you, for those patients who couple their depression or other psychical problems with some kind of phobia, our Mice Project works in even more positive ways. Due to the number of mice in our wards, a confrontation with them simply cannot be avoided. So after the initial phase of sheer panic or feeling afraid and repelled, this in fact confronts such patients with the actual roots of their irrational fears or repugnance. Because they cannot stay clear of the mice, in due course they are forced to come to terms with them – and thus, to re-orientate themselves and at the very least begin to accept and control their panic and fear. And the long-term exposure to our mice will gradually teach them that all their fears are actually unnecessary and unfounded.”
Can you remember moments of intense alienation? Moments when nothing around you made sense anymore? Maybe you can even remember a moment when your best friend, in the same room, who a moment ago sat talking to you, briefly looked like a pink jellyfish with huge alien eyes and a strange flapping beak making weird hoarse sounds.
Unfortunately a broken “fuzziness shield” is difficult to repair. Once a more realistic death awareness has become part of our own usual mindset, it is almost impossible to undo. So maybe we should stop trying to fool ourselves by recreating some surrogate “fuzziness shield”. Maybe instead we should take our death awareness for what it is, but try to give that unpleasant condition a new and refreshing twist.
But it does make some difference on another level. Looking at your lifespan from the customary habitual perspective of years tends to obscure the value, the uniqueness, the once-in-a-lifetime preciousness of each individual day. When you look at your lifespan from the fresh and unusual perspective of days, this suddenly can make you realize better how your days are ticking away one-by-one: how every single one of all those numbered days is unique and precious in its own right. How each new day has its own unique number that will never return, so you will have to make the best of that unique day.
May 18, 1048 –
