Anxiety Depression

In connection with the introduction of medical practice in almost all countries ICD-10, based on the classification of DSM-IV, depressive and anxiety disorders have been artificially divided, so anxious depression as nosology has ceased to exist.

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

[1], [2], [3], [4], [5], [6]

Anxiety Depression or Anxiety and Depression?

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 psycho-physiological mechanism of an adequate adaptive (in the biological sense) response to changes in the situation and external stimuli;
• pathological anxiety, disorganizing behavior.

In the future, the boundaries between normal and pathological anxiety can be verified by neuroimaging or other instrumental methods [for example, in the intensity of metabolic and neurotrophic (neurodegenerative) processes in certain subcortical structures]. Currently, 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 isolating an 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, the psychological mechanisms of anxiety are increasingly recognized as primary and increasingly correlated with vegetative disorders. The latter are usually considered as sensations and "somatic complaints," and not as regular mechanisms with a sufficiently well-studied neurophysiological regulation, or more precisely, disregulation.

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

Convincing data of clinical and biological research in favor of distinguishing between depressive and anxiety disorders, as well as attempts to find such data belong to a relatively recent past, rather than the present. This is a series of works using the so-called dexamethasone test or a test with a tyrotropin releasing factor. In the native psychiatry, the original diazepam test became known. Unfortunately, these traditions are interrupted and the differentiation of depression and anxiety is based primarily on psychometric techniques, 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 controlling therapy.

Operational diagnosis, accepted in modern studies, allows us to distinguish between depressive and anxiety disorders as discrete states, as well as to establish their comorbidity as independent variables. Meanwhile, classical psychopathology presupposes a close and multifaceted connection of hypotensive affects of longing and anxiety, as well as partial apathy and anxiety in the general continuum of affective spectrum disorders. The artificiality of delineation of anxious and depressive disorders, accepted for today, is recognized by both Russian researchers and foreign authors. Anxiety can also be present in the structure of mixed affective disorders.

Dynamic observation, including not only in the hospital, but also in the conditions of the psychiatrist's office in the primary medical network, makes it possible to ascertain the rarity of the independent existence of anxiety disorders: in the absence of timely and adequate therapeutic actions, they tend to transform into depressive states. In this case, several stages of the latter can be singled out: specific anxious fears or reactions to obvious incentives turn into a free-floating anxiety, where its objects are more or less accidental and plural, then to an objectless anxiety, detached from the object. In turn, non-objective ("unconscious") anxiety is related to depressive melancholy at the expense of phenomenologically and pathogenetically close manifestations of the vitalization of hypotensive 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 the effects of psychological and biological levels.

The emotional component (excitement, inner anxiety, tension, anxious exaltation) by no means exhausts the content of anxiety, as well as other types of depressive affect.

Vegetative components in case of anxiety are usually even more pronounced than with depressing depression: it is important to establish trends, a certain shift in vegetative reactions from differently directed to resistant sympathicotonic ones.

Among sensory disorders, hyperesthesia is more common in anxious depression than in other depressive disorders. However, dynamic trends with the diminishing brightness of the sensory tone of perception indicate that the condition belongs to affective disorders with the probability of forming a characteristic depressive symptomatology.

Motor disorders usually constitute a complex combination of signs of excitement and increasingly noticeable - as depression develops - inhibition with impoverishment of movements, a reduction in their tempo, amplitude, etc.

Conative functions in anxiety disorders suffer less than in simple depression. A strong-willed effort is usually available to control behavior and suppress disturbing anxiety by switching attention. Motivation of activity before the development of expressed anxious depression remains relatively safe.

Cognitive impairment depends on the severity of anxiety disorders and the degree of their convergence with typical depressions. Anxiety, even in the context of everyday anxiety reactions, in many people causes a violation of concentration, temporary light disorganization of thinking and, accordingly, the harmony of speech. In this regard, anxiety depression is characterized by more severe impairment of executive cognitive functions than with simple depression, while signs of inhibition are not so much expressed, as are the unevenness of the flow of associations, frequent switching of attention.

Ideator disorders are basically the same as with depression in general, but with anxious depression it is supposed and more likely that a propensity to form hypochondriacal ideas, as well as ideas of condemnation (as an alarming transformation of ideas of inferiority and self-blame on the assumption of condemning the assessment of actions, appearance and behavior of this patient surrounding). Systemic cognitive functions in such a state as anxiety depression may suffer more than with simple depression: criticism is even less accessible and stable, requires constant external "supportive correction" with apparent responsiveness and accessibility to the contact. Of course, we are not talking about a comparison with melancholic depression, where affective tension, detachment from the surrounding, narrowing of the content of consciousness by depressive feelings (including anxious anticipation) does not allow talking about the preservation of criticism. Melancholic depression in the modality of the dominant affect can be both dreary and disturbing (with vital "reckless" anxiety) or melancholy-anxious.

[7], [8], [9], [10], [11]