Anxiety depression

In connection with the introduction of ICD-10, based on the DSM-IV classification, into medical practice in almost all countries, depressive and anxiety disorders were artificially separated, thus anxious depression, as a nosology, ceased to exist.

At the same time, the same treatment methods are suggested for the treatment of both: among medications - some modern antidepressants [for example, selective serotonin reuptake inhibitors (SSRIs)], among non-pharmacological methods - cognitive-behavioral therapy.

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Anxiety depression or anxiety and depressive disorders?

The difficulties in understanding the boundaries and relationships between anxiety disorders and depression are largely due to the uncertainty of the distinctions between:

• anxiety as a characterological feature;
• anxiety as a psychophysiological mechanism of adequate adaptive (in the biological sense) response to changes in the situation and external stimuli;
• pathological anxiety that disorganizes behavior.

In the future, the boundaries between normal and pathological anxiety may be verified by neuroimaging or other instrumental methods [for example, by the intensity of metabolic and neurotrophic (neurodegenerative) processes in certain subcortical structures]. At present, there is not even a generally accepted opinion about the normal or pathological level of corticotropic hormones in clinically and psychodiagnostically recorded anxiety.

The concept of comorbidity provides a formal basis for identifying anxiety disorder as a discrete pathological entity, especially in cases where anxiety as an expressive and mobile phenomenon pushes other symptoms of a complex affective syndrome into the background. In recent decades, psychological mechanisms of anxiety have increasingly been recognized as primary and are increasingly rarely associated with autonomic disorders. The latter are usually considered as sensations and "somatic complaints" rather than as regular mechanisms with a fairly well-studied neurophysiological regulation, or more precisely, dysregulation.

Descriptive characteristics of anxiety, on the contrary, are repeatedly reproduced in various articles and manuals, although it is difficult to discern anything fundamentally new in them. Innovations concern the allocation of some relatively independent categories, for example, social phobia (the independence of which is questionable); giving the symptom of agoraphobia (literally - "fear of squares") the status of a syndrome with polymorphic symptoms. It is also worth mentioning the replacement of traditional concepts of anxiety-vegetative crises with predominantly sympathoadrenal or vagus-insular manifestations with the concept of panic disorders, with a shift in emphasis in understanding their nature to almost exclusively psychological mechanisms, which creates difficulties in diagnosis and treatment.

Convincing data from clinical and biological studies in favor of differentiating between depressive and anxiety disorders, as well as attempts to find such data, belong to a relatively recent past rather than the present. We are talking about a series of works using the so-called dexamethasone test or the thyrotropin-releasing factor test. In domestic Psychiatry, the original diazepam test has become famous. Unfortunately, these traditions have been interrupted and the differentiation of depression and anxiety is based primarily on psychometric methods, which seems insufficient for solving not only pathogenetic, but also utilitarian diagnostic problems. Of course, common questionnaires and special scales remain a very useful tool, primarily for monitoring therapy.

Operational diagnostics accepted in modern research allows us to differentiate depressive and anxiety disorders as discrete conditions, as well as to establish their comorbidity as independent variables. Meanwhile, classical psychopathology assumes close and diverse connections between hypothymic affects of melancholy and anxiety, as well as partial apathy and anxiety in the general continuum of affective spectrum disorders. The artificiality of the distinctions between anxiety and depressive disorders accepted today is recognized by both Russian researchers and foreign authors. Anxiety may also be present in the structure of mixed affective disorders.

Dynamic observation, including not only in a hospital but also in the conditions of a psychiatrist's (psychotherapist's) office in the primary health care network, allows us to state the rarity of independent existence of anxiety disorders: in the absence of timely and adequate therapeutic actions, they in a significant proportion of cases tend to transform into depressive states. In this case, several stages of the latter can be distinguished: specific anxious fears or reactions to obvious stimuli turn into free-floating anxiety, where its objects are already more or less random and multiple, then - into an objectless anxiety, breaking away from the object. In turn, an objectless ("unaccountable") anxiety is related to depressive melancholy due to phenomenologically and pathogenetically close manifestations of the vitalization of hypothymic affect. The most significant sign of the transformation of anxiety disorders into related depressive disorders can be the loss of reactivity as a connection with external conditions and influences of psychological and biological levels.

The emotional component (excitement, internal anxiety, tension, anxious exaltation) does not exhaust the content of anxiety, as well as other types of depressive affect.

Vegetative components in anxiety are usually even more pronounced than in melancholy depression: it is important to establish trends, a certain shift in vegetative reactions from multidirectional to stable sympathicotonic ones.

Among sensory disturbances, hyperesthesia is more characteristic of anxious depression than of other depressive disorders. However, dynamic tendencies with the fading of the brightness of the sensory tone of perception indicate that the condition belongs to affective disorders with the probability of the formation of characteristic depressive symptoms.

Movement disorders usually consist of a complex combination of signs of agitation and increasingly noticeable - as depression develops - inhibition with a decrease in movements, a reduction in their tempo, amplitude, etc.

Conative functions suffer to a lesser extent in anxiety disorders than in simple depressions. A volitional effort is usually able to control behavior and suppress anxious anxiety by switching attention. Motivation for activity remains relatively intact before the development of severe anxious depression.

Cognitive impairments depend on the severity of anxiety disorders and the degree to which they are similar to typical depressions. Anxiety, even within the framework of ordinary anxiety reactions, causes in many people disturbances in concentration, temporary mild disorganization of thinking and, accordingly, the coherence of speech. In this regard, anxious depression is characterized by more severe impairments of executive cognitive functions than in simple depression, and the signs of inhibition are expressed not so much as unevenness in the flow of associations, frequent switching of attention.

Ideation disorders are fundamentally the same as in depression in general, but in anxious depressions, a tendency to form hypochondriacal ideas is assumed and is more acceptable (as an anxious transformation of ideas of worthlessness and self-accusation into assumptions about the condemning assessment of the actions, appearance and behavior of this patient by others). Systemic cognitive functions in such a condition as anxious depression can suffer to a greater extent than in simple depressions: criticism is even less accessible and stable, requires constant external "supportive correction" with apparent responsiveness and availability to contact. Of course, we are not talking about a comparison with melancholic depression, where affective tension, detachment from the environment, narrowing of the content of consciousness by depressive experiences (including anxious expectation) does not allow us to talk about the preservation of criticism. Melancholic depression, according to the modality of the dominant affect, can be either melancholy or anxious (with vital “unaccountable” anxiety) or melancholy-anxious.

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