Margaret Wehrenberg - Anxiety + Depression: Effective Treatment of the Big Two Co-Occurring Disorders

Copyright 2014 by Margaret Wehrenberg

All rights reserved

First Edition

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The Library of Congress has cataloged the printed edition as follows:

Wehrenberg, Margaret.

Anxiety + depression : effective treatment of the big two

co-occurring disorders / Margaret Wehrenberg. First edition.

pages cm

A Norton professional book.

Includes bibliographical references and index.

ISBN 978-0-393-70873-8 (hardcover)

1. AnxietyTreatment. 2. Depression, MentalTreatment.

3. Comorbidity. I. Title. II. Title: Anxiety and depression.

RC531.W424 2014

616.85'22dc23

2013049976

ISBN 978-0-393-70975-9 (e-book)

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For the many people
with whom Ive been privileged
to work over these many years.

GETTING A book into print is never a solo task, and I am very appreciative of those people who helped me along the way on this one. First, I am deeply grateful to Andrea Dawson, my editor, who encouraged me to write about my experiences with clients who suffer anxiety and depression. She was a central force in the conceptualization of this work and also in the structure of the book. I would not have managed it without her excellent advice and appropriately-timed nudging. My copy editor, Casey Ruble, is another whose work to polish my words was necessary and is unparalleled. She has an uncanny knack of writing in my voice so that whatever she adds to flow of the manuscript comes out as if my inner better writer produced it.

I also get by with a little help from my friends. When I am in the throes of writing, I dont give them the attention they deserve and still they offer so much support. Cathy Lessmann is my wonderful local voice of cheer, ready to offer me dinner, and a reminder to get outside. Shannon Burns makes space for me both literally and emotionally, and Susan Palo Cherwien expands my knowledge as she shares her own, and she never fails to make me feel valued. There are many (everyone should blessed) who add such pleasure and positivity to my life that I can continue to work with my clients with joy and energy.

CO-OCCURRING ANXIETY and depression are not always obviouseven to a seasoned therapist. It has happened to me more than once: I see a client for anxiety and decide a psychiatric consult regarding medication is in order. The client comes back with a diagnosis of depression and, of course, a prescription for medication to treat the depression but no mention of the anxiety I thought was the problem. Now there are two professionals with two views of the same symptoms. Who is right? I suspect that, most of the time, we both are. Herein lies the challenge: Its hard enough to treat these disorders when they exist on their own, and it gets even harder when they present together.

The biggest challenge is being able to spot both problems. Typically one symptom picture dominates, at least in the description we obtain from clients. But think about some of the obvious ways these two disorders interact:

A person who is depressed and very low on energy may not have the mental oomph to fight constant anxious rumination, and the anxiety will make depression worse.

When acute anxiety is unremitting and uncontrolled, it can make any person depressed and exhausted.

A high-energy client who complains of constant worry may not recognize how the depressive feelings of pessimism and inadequacy are leading to the worry about failing or making mistakes. Symptom management of worry will be less effective if the depression isnt also treated.

A quiet, shy client who has become socially anxious may become depressed as the social anxiety leads to avoidance of activities that might have interested him or her. The depression makes it harder to have motivation to overcome social fear and reengage with others.

Even when you can see that both disorders are present, how do you know where to start in therapy?

As a clinician specializing in anxiety and depression, and with more than 30 years of experience, I have seen the challenges that these two co-occurring (comorbid) conditions produce. They appear together so often that we need to ask some questions:

How common is this comorbidity and why does it exist?

How can I be sure my client is showing signs of both anxiety and depression? What indications of comorbidity should I look for?

Is there a way to identify when one disorder is more prominent than the other? If so, do I treat one first and then the other? If not, should I view them as the same clinical problem, and treat both in tandem?

How will one disorder affect treatment response when I work with the other?

Consider the following case:

Pat sought help for what she said was overwhelming anxiety. She reported that she constantly fretted about her health and her husbands health. (Neither was sick, but they could be!) She worried about whether she had offended someone, berated herself for having been so stupid as to buy a house in a neighborhood with so many noisy children, and was concerned that she would be fired for working too slowly, despite the fact that her boss had never voiced such a complaint. She worried about whether she would lose her friends because she worried so much.

What were hard to see, and what Pat did not recognize either, were the common themes of loss and failure underlying her anxiety. In fact, she had strong feelings of worthlessness and hopelessness about the future (symptoms of depression) that had to be addressed if she was to feel less anxious. In this way, the depression Pat did not identify would interfere with letting go of worry, and it needed to be addressed to successfully diminish her anxiety.

Conversely, sometimes an underlying anxiety fuels depression. This was the case with Mark.

Mark told me he didnt know how much longer he could pretend to be working before the others in his office caught on. He said that he tried to work but couldnt concentrate and felt sluggish and unmotivated. At the end of the day he went straight home to lie on the couch all evening. Mark presented as depressed. But a fuller picture developed when I began asking him about how he had functioned previously. Mark reported that he had always been a worrier, and he so annoyed his wife with requests for reassurance that she finally left him, not wanting to be married to such a clingy man and feel so responsible for his wellbeing. The anxiety that had plagued Mark eventually turned into depression, partly as a result of the losses he had suffered and partly because of his inability to handle anxiety. Mark had never had a particularly positive outlook on life, but the persistent, nagging doubt and anxiety completely squashed any natural optimism he might have had otherwise.

These kinds of clients walk into your clinical office every week. This book describes the most frequently seen combinations of anxiety and depression and explains how these two disorders affect each other as the client moves through the process of therapy.