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Treating Post-Holiday Let-Down & Depression
Depression continuing education psychology CEUs

Section 16
Linking Anxiety and Depression

CEU Question 16 | CEU Test | Table of Contents | Depression
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs

It is not surprising that some people who experience anxiety attacks become depressed. When we begin to feel our world closing in around us, when we are unable to face situations that previously caused us no anxiety, when we experience physical symptoms that seem to have no clear cause, then self-doubt, discouragement, and sadness are understandable side effects.

Many people who experience panic also complain of symptoms related to depression: a low energy level, feelings of hopelessness, low self-esteem, crying spells, irritability, difficulty concentrating, lack of interest in normal activities, a decrease in sexual desire, difficulty with sleep, and fluctuations in weight.

The relationship between panic disorder and depression has been well established through numerous controlled studies. At the same time, this research indicates that panic disorder (and agoraphobia) and depression are distinct and separate problems which happen to coexist within the same individual. A large majority of patients with panic disorder or agoraphobia have had episodes of serious depression. One study found that half the panic disorder and agoraphobia patients entering treatment with a history of depression had experienced at least one major depressive period prior to developing panic disorder or separate from periods of panic. In other words, depression doesn't develop simply in reaction to prolonged struggles with panic. And your depression can lift even though a problem with panic continues.

For the person suffering from panic, the most important issue regarding depression is the way it complicates and slows the recovery process. Consider for a moment the thoughts of an anxious person who experiences panic attacks. He looks to a specific future event and worries, "Can I handle it?" He considers the possibility of failure and says, "It's possible I'll fail." He desires to take some action but says, "I'm too afraid." The panic-prone person wishes to actively engage his world, but is doubtful he can manage specific tasks. As panic lingers in a person's life, his outlook and his self-evaluation may take on depressive qualities. The person who is primarily anxious will look to the future with uncertainty. He is not sure how difficult his future tasks will be; he doesn't know whether or not he will perform up to par or if he will be able to control the situation. He doubtfully questions the future.

If he begins to adopt a more depressed attitude, this uncertainty is transformed into fatalistic expectations. He looks to a specific future event and says, "I won't be able to handle it." He considers the possibility of failure and says, "I'll fail." The internal struggle, between wishing to take action and feeling too afraid, shifts. Instead of doubting the future he becomes more certain of what will happen: "I will not succeed." An even more self-destructive attitude may arise:
"I don't really care that much."

These negative predictions and lack of drive are supported by a pervasive sense of personal worthlessness, as though he is missing the essential traits to be a complete, competent human being. Instead of thinking, "I'm not prepared for that job," or "I doubt I can enter that building," he begins to think, "I'm inadequate. I don't have what it takes. I don't fit in." As he looks to his past, he finds justification for this feeling. "Things are no different than they've ever been. Nothing has ever made that much difference. My limitations are unchangeable."

Helping someone face panic when he or she has adopted a depressed attitude is a difficult task, for obvious reasons: If I believe that I am basically inadequate, that nothing ever really changes in my life, that tomorrow will be about the same as yesterday, then why should I bother considering alternatives to my present state of affairs? Through my eyes, there seems to be no point.

If you are feeling this kind of depression, you must confront and shift your entrenched attitude in order to face the challenges presented by panic. Through some means, you must move your attitude from a position of certainty ("Nothing is going to change things") to one of uncertainty. Even an anxious attitude ("I don't know whether or not I can manage this") is an improvement. In fact, this is the position I want and expect my clients to take as they begin facing panic. It is not necessary to embrace some false sense of confidence and assurance, because uncertainty is a major component of adult life. By saying "I'm not sure," you are opening your mind up to the possibility of change ("Maybe I won't handle this particular challenge, and maybe I will.")

There are two ways to begin changing this depressive attitude. The first is to directly wrestle with your negative beliefs: to listen to how you state those beliefs in your mind, to learn how those statements influence your actions, and then to explore other possible attitudes which might support your goals.

The second way is to begin to change your activities even before you change your attitude. Try some specific, small activities, without needing to believe they will help you. Change your patterns of behavior during the day, alter your routine, do some things that you imagine someone else might consider "good for you." There is no requirement that you engage in these new activities with the belief that they will help you. At first, just do them. Don't predict how you are "supposed" to feel during or after them-that will usually be a setup to prove, once again, that "nothing will change." Simply change your patterns as a way of giving yourself experiences that might challenge your beliefs in a small way.

Let me illustrate the purpose of this process by describing its use with another kind of problem. in my practice as a clinical psychologist I specialize in the treatment of anxiety disorders and also in the management of chronic pain syndromes. Years ago I worked as a therapist at the Boston Pain Center, a medical in-patient unit for chronic pain patients. The facility is designed to help those who have tried every known medical treatment and yet remain in significant physical discomfort because of a physical injury or illness.

The chronic pain patient and the person suffering from panic disorder share the predominance of depression. Consider the patient who enters the treatment unit with chronic low-back pain. He describes himself as "vegetating in front of the 'boob-tube' all day for the past five years." He perceives himself as useless, since he hasn't been able to work in five years and his wife supports the family. He can't even mow the lawn or take out the garbage because of his back pain, much less figure out how to return to productive, paid employment. And "all of the doctors have given up hope" on him, so how could the future be anything else but just like the past, or worse?

The in-patient program takes him out of the normal routine of his home and provides a broad range of activities which are designed to challenge this attitude. He lives for four to six weeks among twenty other patients with similar pain problems. He is required to rise first thing in the morning, make his own bed, eat in a group dining room, attend four support/therapy group meetings a week plus medical sessions, community meetings, and special outings. To manage his physical pain he attends individual and group physical therapy sessions, receives massages and ice massages, hot packs, ice packs, and whirlpools. He is taught biofeedback and relaxation techniques. His pain medications are slowly diminished and eventually discontinued, as he learns alternative ways to successfully manage his pain.

This is the typical design of a "therapeutic community," where the medical staff and patients work together to find the best treatment for each individual. We don't expect every approach to work for every patient. Instead, we provide as many options as possible in order to discover which combination will be most effective.

But one of the first things that must change is the patient's attitude, since a depressive outlook can prevent any learning. How does that attitude shift? Most frequently it changes because the patient begins to have experiences that don't fit into his negative expectations.

For instance, a low-back pain patient may complain of an inability to stand or sit for more than twenty or thirty minutes at a time (he then must lie down to relieve his discomfort). By altering his pattern of activities, the therapeutic community offers him a chance to have new experiences which change his belief. On day five of the program he discovers that he just sat through an hour-and-a-half group therapy session without having to stand or lie down. Then he remembers that this is the third time in two days that he has sat for over one hour. It is this kind of awareness that can lead him to say, "Maybe I can do something to help myself. Maybe things can change."

This is usually the turning point for patients on the Pain Unit. Once they decide that change is possible, they tend to look at any new treatment with a ray of hope. They stop being so certain of failure and begin thinking of their options. Trying each new technique now involves curiosity. "How might I benefit from learning biofeedback?" "I wonder what results I'll get if! do these physical therapy exercises every day for a couple of months?"

If you are suffering from depression, this is the kind of curiosity you must strive for. Part II of this book will suggest a number of new techniques and activities for you to practice. It will also directly address your depressive attitude, giving you alternative ways of thinking about yourself and your future. As you proceed, keep in mind the need to confront your negative view. For a while you may have to try the suggestions even though your mind is saying, "What's the use?" Above all, you must take action. No matter how low you feel, some part of you believes that you can help yourself. Even if it is a small ember of hope deep within you, let that supportive self give you the gift of curiosity.
- Wilson, Reid, Don't Panic: Taking Control of Anxiety Attacks, Harper & Row Publishers: New York, 1986.

Depression Management Tool Kit

- The John D. & Catherine T. MacArthur Foundatin's Intiative on Depression & Primary Care and 3CM, LLC. (2004). Depression Management Tool Kit.


Personal Reflection Exercise #4
The preceding section contained information about linking anxiety and depression. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 16
What are two ways to begin changing depressive attitudes? Record the letter of the correct answer the CEU Test.

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