Anxiety and Depressive Disorder in Adults

Depression

Depression affects a significant portion of the population. It is estimated that 7-12% of men and 20-25% of women will have a major depressive episode at some point in their life.

Depressive disorders consist of a variety of symptoms in the areas of mood, thinking, behaviors and physical reactions. Mood related symptoms include sadness, irritability, depression and anger. Many depressed people are also anxious and nervous. When we are depressed our thinking is characterized by negative thoughts about ourselves (self criticism), negative thoughts about the future and negative interpretations/ thinking about ongoing events in our lives. When we are depressed our beliefs are characterized by negativity as well. For example, we may believe:

“I’m a failure”
“I’m no good”
“I’m unlovable”

The behavioral symptoms of depression include withdrawal, avoidance of other people, and not doing activities that in the past gave us a sense of pleasure or mastery.

The physical symptoms of depression include tiredness, fatigue and insomnia. Additionally, depression is associated with an alteration in brain chemistry.

These four areas (mood, thinking, behavior and physical functioning) of our functioning interact and affect each other. When there is a change or alteration in any one of these areas the other three areas change in response. For example, changes in brain chemistry (anti-depressant medication) may lead to changes in mood, thinking and behavior. Similarly, enduring changes in thinking create enduring changes in mood and behavior. Finally, changes in behavior result in changes in thinking, brain chemistry and mood.

Cognitive therapy is a form of psychotherapy that has been demonstrated to be very effective in the treatment of depression. Cognitive is a fancy word that refers to thoughts or beliefs. Cognitive therapy is an active, structured, directive form of therapy that focuses on the thoughts, beliefs and behaviors that accompany depressive disorders. In cognitive therapy, clients learn to identify, evaluate and change the thoughts, beliefs and behaviors that accompany depression. This usually leads to a significant reduction in depression symptoms – often in a brief period of time.

Learning to consistently think in newer and more adaptive ways can lead to less frequent and severe symptoms of depression. Many people report that this process leads to greater amounts of meaning, satisfaction and happiness in their lives.

Research consistently shows that 70 to 80 percent of people with depression improve with cognitive therapy. Additionally, patients receiving cognitive therapy or cognitive therapy along with anti depressant medications have a lower relapse rate (reoccurrence of the depression) than patients that are treated with anti depressant medications alone.

Depression Fact Sheet

How Psychotherapy Helps People Recover From Depression

According to the National Institute of Mental Health, an estimated 18.8 million adult Americans suffer from depression during any one-year period. Many do not even recognize that they have a condition that can be treated very effectively. This question-and-answer fact sheet discusses depression with a focus on how psychotherapy can help a depressed person recover.

How does depression differ from occasional sadness?

Everyone feels sad or “blue” on occasion. Most people grieve over upsetting life experiences such as a major illness, loss of a job, a death in the family, or a divorce. These feelings of grief tend to become less intense on their own as time goes on.

Depression occurs when feelings of extreme sadness or despair last for at least two weeks or longer and when they interfere with activities of daily living such as working or even eating and sleeping. Depressed individuals tend to feel helpless and hopeless and to blame themselves for having these feelings. Some may have thoughts of death or suicide.

People who are depressed may become overwhelmed and exhausted and stop participating in certain everyday activities altogether. They may withdraw from family and friends.

What causes depression?

Changes in the body’s chemistry influence mood and thought processes, and biological factors contribute to some cases of depression. In addition, chronic and serious illnesses such as heart disease or cancer may be accompanied by depression. For many individuals, however, depression signals first and foremost that certain mental and emotional aspects of life are out of balance.

Significant transitions and major life stressors such as the death of a loved one or the loss of a job can help bring about depression. Other more subtle factors that lead to a loss of identity or self-esteem may also contribute. The causes of depression are not always immediately apparent, so the disorder requires careful evaluation and diagnosis by a trained mental health care professional.

Sometimes the circumstances involved in depression are ones over which an individual has little or no control. At other times, however, depression occurs when people are unable to see that they actually have choices and can bring about change in their lives.

Can depression be treated successfully?

Absolutely. Depression is highly treatable when an individual receives competent care. Psychologists are among the licensed and highly trained mental health providers with years of experience studying depression and helping patients recover from it.

There is still some stigma, or reluctance, associated with seeking help for emotional and mental problems, including depression. Unfortunately, feelings of depression often are viewed as a sign of weakness rather than as a signal that something is out of balance. The fact is that people with depression can not simply “snap out of it” and feel better spontaneously.

Persons with depression who do not seek help suffer needlessly. Unexpressed feelings and concerns accompanied by a sense of isolation can worsen a depression. The importance of obtaining quality professional health care can not be overemphasized.

How does psychotherapy help people recover from depression?

There are several approaches to psychotherapy – including cognitive-behavioral, interpersonal, psycho-dynamic and other kinds of “talk therapy” – that help depressed individuals recover. Psychotherapy offers people the opportunity to identify the factors that contribute to their depression and to deal effectively with the psychological, behavioral, interpersonal and situational causes.

Skilled therapists such as licensed psychologists can work with depressed individuals to

• Pinpoint the life problems that contribute to their depression, and help them understand which aspects of those problems they may be able to solve or improve. A trained therapist can help depressed patients identify options for the future and set realistic goals that enable these individuals to enhance their mental and emotional well-being. Therapists also help individuals identify how they have successfully dealt with similar feelings, if they have been depressed in the past.
• Identify negative or distorted thinking patterns that contribute to feelings of hopelessness and helplessness that accompany depression. For example, depressed individuals may tend to over generalize, that is, to think of circumstances in terms of “always” or “never.” They may also take events personally. A trained and competent therapist can help nurture a more positive outlook on life.
• Explore other learned thoughts and behaviors that create problems and contribute to depression. For example, therapists can help depressed individuals understand and improve patterns of interacting with other people that contribute to their depression.
• Help people regain a sense of control and pleasure in life. Psychotherapy helps people see choices as well as gradually incorporate enjoyable, fulfilling activities back into their lives. Having one episode of depression greatly increases the risk of having another episode. There is some evidence that ongoing psychotherapy may lessen the chance of future episodes or reduce their intensity. Through therapy, people can learn skills to avoid unnecessary suffering from later bouts of depression.

In what other ways do therapists help depressed individuals and their loved ones?

The support and involvement of family and friends can play a crucial role in helping someone who is depressed. Individuals in the “support system” can help by encouraging a depressed loved one to stick with treatment and to practice the coping techniques and problem-solving skills he or she is learning through psychotherapy.

Living with a depressed person can be very difficult and stressful for family members and friends. The pain of watching a loved one suffer from depression can bring about feelings of helplessness and loss. Family or marital therapy may be beneficial in bringing together all the individuals affected by depression and helping them learn effective ways to cope together. This type of psychotherapy can also provide a good opportunity for individuals who have never experienced depression themselves to learn more about it and to identify constructive ways of supporting a loved one who is suffering from depression.

Are medications useful for treating depression?

Medications can be very helpful for reducing the symptoms of depression in some people, particularly for cases of moderate to severe depression. Some health care providers treating depression may favor using a combination of psychotherapy and medications. Given the side effects, any use of medication requires close monitoring by the physician who prescribes the drugs.

Some depressed individuals may prefer psychotherapy to the use of medications, especially if their depression is not severe. By conducting a thorough assessment, a licensed and trained mental health professional can help make recommendations about an effective course of treatment for an individual’s depression.

Depression can seriously impair a person’s ability to function in everyday situations. But the prospects for recovery for depressed individuals who seek appropriate professional care are very good. By working with qualified and experienced therapists, those suffering from depression can help regain control of their lives.

This Depression Fact Sheet was reprinted with permission from The American Psychological Association.

© 2004 American Psychological Association.

Generalized Anxiety Disorder

Generalized Anxiety Disorder is:

A. Excessive anxiety and worry, occurring more days than not, for at least six months, about a number of events or activities, such as work or school performance;

B. Difficulty controlling the worry;

C. The anxiety and worry are associated with three or more of the following symptoms:

1. Restlessness or feeling on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)

D. The focus of the anxiety is not confined to worry about a panic attack, being embarrassed in public (social phobia), or being contaminated (Obsessive-Compulsive Disorder).

E. Anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning

(Adapted from DSM-IV-TR-Revised)

In addition to the above symptoms, people with Generalized Anxiety Disorder may experience the following:

• numbness or tingling sensations in their finger tips, toes or on the top of their head
• feeling warm or hot
• wobbliness
• difficulties relaxing
• thinking that something terrible is about to happen
• feeling dizzy or lightheaded
• heart palpitations
• feeling unsteady
• feeling scared
• trembling
• fears of losing control
• difficulties breathing
• sweating not due to the heat

Thoughts (cognitions) associated with anxiety often begin with “what if…?” The thoughts associated with anxiety are often:

• catastrophic expectations of the future, and
• the sense that something terrible or bad is going to happen

Anxiety is associated with thoughts that involve:

• threat
• danger
• personal vulnerability

Five percent of the population is likely to have Generalized Anxiety Disorder at some point in their life, and one percent of the population is likely to have Generalized Anxiety Disorder at some time in the course of any given 12-month period of time.

Anxiety is a “fight or flight” response and occurs as a result of the perception of danger, threat or vulnerability. Cognitive therapy teaches people to identify, evaluate and perhaps alter thoughts and beliefs that may be contributing to the anxiety they are experiencing. Additionally, Generalized Anxiety Disorder responds well to relaxation training, which can include progressive muscle relaxation, breathing exercises, and relaxing imagery. A component of treatment involves exposure to events or internal experiences that may be creating anxiety. Antidepressant medication or antianxiety medications may also be helpful in addressing Generalized Anxiety Disorders.

Without treatment, Generalized Anxiety Disorder can be chronic and persistent. Cognitive therapy, relaxation training and behavioral therapy have demonstrated in research studies to be very powerful and effective in the treatment of Generalized Anxiety Disorder. Cognitive Behavioral Therapy can be helpful in reducing symptoms and achieving a sense of safety, security and control.

Panic Disorder

Panic Disorder is the experience of panic attacks followed by ongoing concern and worry about having another panic attack and/or worry about the possible consequences of a panic attack.  There may be avoidant behaviors associated with, and secondary to, the panic attacks.  Panic attacks consist of:

1. Heart palpitations or racing heart
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or a smothering sensation
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, lightheaded or faint
9. Feelings of unreality or being detached from oneself
10. Fear of losing control or going crazy
11. Fear of dying
12. Numbness or tingling sensation
13. Chills or hot flushes (DSM IV-TR-Revised)

One to two percent of the population is likely to have a Panic Disorder at some point in their life.  Often associated with a panic attack is a catastrophic misinterpretation of a physical sensation.  For example, in response to a rapid heartbeat, a person with panic disorder may think:

• “I’m having a heart attack.”

In response to a feeling of dizziness, a person with Panic Disorder may conclude:

• “I’m having a stroke.”

These catastrophic misinterpretations further create anxiety which exacerbates the physical sensation and strengthens the catastrophic misinterpretation.  The thoughts most often associated with panic include:

• “I’m having a heart attack,”
• “I’m having a stroke,”
• “I’m out of control,”
• “I’m going to die.”

In the past panic disorder has been thought of as a condition that was chronic or only treated with psychiatric medication. In the last 20-30 years new, highly effective cbt treatments for panic disorder have been developed, tested, and refined. The newest cbt treatments are not only effective in a relatively brief period of time but research has demonstrated a low relapse rate.  Most people with panic disorder get better and stay better after cbt treatment. Panic disorder has the best prognosis of any problem a person can come to a psychologist with and can generally be treated in 12-20 sessions.

Psychotherapy consists of relaxation exercises and patients learning to identify, evaluate and alter the thoughts that are associated with their panic attacks.  This is often combined with systematically approaching situations that are being avoided because of fear of having a panic attack.

Obsessive Compulsive Disorder

Obsessive-Compulsive Disorder is likely to affect 2% of the population at some point in their life. The disorder is equally common in males and females.

Obsessions are:

1. Recurrent or persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress;
2. The thoughts, impulses, or images are not simply excessive worries about real life problems;
3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action;
4. The person recognizes that the obsessive thought, impulses, or images are a product of his or her own mind.

Compulsions are:

1. Repetitive behaviors (for example, hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly;
2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
3. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.
4. The obsessions or compulsions cause marked distress, are time consuming (take more than one hour a day) or significantly interfere with a person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

Adapted from the Diagnostic and Statistical Manual of Mental Disorders – IV-TR.

Obsessions are distressing and persistent thoughts that are associated with anxiety. Obsessive thoughts frequently have a theme of contamination (germs or dirt), or doubts over something that was said or done. Obsessive thoughts may have a religious theme or ideas of feeling unacceptable or immoral. Many people have obsessive thoughts that have to do with perfection, order or preciseness.

Compulsions, on the other hand, are behaviors or actions that are designed to reduce the anxiety associated with the obsessive thought. Compulsive behaviors are repetitive actions (behaviors) that are also designed to prevent a dreaded consequence from occurring. Compulsive behaviors include repetitive washing or cleaning, showering or doing some other activity in a particular order, checking, double-checking and triple-checking, etc., repeating phrases or thoughts or redoing actions. Compulsive behaviors frequently result in a reduction of anxiety and a temporary sense of feeling good. The most common compulsive behaviors are washing and checking.

Treatment of Obsessive Compulsive Disorder

The behavioral treatment of Obsessive-Compulsive Disorder consists of two components – exposure and response prevention. Exposure involves systematic, gradual contact or exposure to events in which the obsessive thoughts and -compulsive behaviors are likely to occur. For example, a person with a fear of contamination from germs might decide that it could be helpful to gradually come in contact with germs via petting a dog or a cat. This could be combined with the response prevention component of the treatment which is to not engage in the usual compulsive activity which, in this example, may be hand washing. Variations on response prevention include response delay or response restriction. Response delay means delaying immediately washing the hands for longer and longer periods of time. Response restriction, means limiting the amount of time that the hands are washed. One of the purposes of the exposure and response prevention is to see if the fear or anxiety diminishes with time and without the compulsive behavior. For most people with OCD, this a difficult and scary proposition, as their anxiety initially increases; however, many people report surprise and relief when they discover that their anxiety dissipates and disappears with time.

The cognitive component of treating OCD involves assessing and understanding the result of the exposure and response prevention exercises described above. For example, how does one make sense of the fact that no disease was contracted despite touching the dog or cat, and not washing for a significant period of time? Does this new experience cause one to rethink their assumptions about their vulnerability and the purpose of their compulsive behaviors? The cognitive therapy component of treating OCD is also designed to teach people new thinking methods and strategies that can help them identify and alter the interpretations that they have of their obsessions.

Treatment of OCD also involves learning, practicing and implementing anxiety management strategies including progressive muscle relaxation, mental imagery or deep breathing. Becoming proficient in these relaxation strategies can make it easier to approach feared and anxiety producing situations.

Cognitive behavioral therapy has shown to be effective in the treatment of Obsessive-Compulsive Disorders. Exposure and response prevention is classified by the American Psychological Association Division 12 Task Force on Promotion and Dissemination of Psychological Procedures as a well established, empirically supported treatment for OCD.

Social Anxiety

Social anxiety is painful and anguishing. It can interfere with social functioning, relationships and career. Social anxiety is characterized by:

• Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
• Exposure to the feared situation almost always provokes anxiety or panic.
• The person recognizes that the fear is excessive or unreasonable.
• The feared social or performance situation are avoided or endured with intense anxiety or distress
• The avoidance, anxious anticipation, or distress significantly interferes with the person’s normal routine, occupation or social functioning.

Social anxiety is a very prevalent psychological problem. Studies have found that approximately 40% of adults consider themselves shy to the point that it creates problems in their lives. 7 – 13% of people meet criteria for having social phobia.

Social anxiety consists of certain behaviors, thoughts, and physical reactions, combined with fear, anxiety or panic.

Thinking and Social Anxiety

When in a social situation (or thinking about going into a social; situation) people with social anxiety have thoughts (cognitions) that have to do with worry about being judged, scrutinized or looked at closely. Particular thoughts may include:

• “They will think negatively of me”
• “They will see that I’m nervous”
• “They will see that I’m blushing”
• “I won’t know what to say”
• “I’ll sound stupid”
• “They won’t like me
• “They will understand how incompetent I really am”

These thoughts have the theme of a social danger or threat and are often accompanied by avoidance of situations where one might be judged. Avoidance is the behavior most often associated with social anxiety. Most people would not willingly or easily put themselves in a situation where they believe they will be judged negatively.

Physical Reactions and Social Anxiety

The Physical reactions or symptoms associated with social anxiety are:

• Rapid Heart Beat
• Breathing Changes
• Sweating
• Blushing
• Dizziness

These physical reactions are a “fight or flight” response. Millions of years of evolution have created a finely tuned response to perceived danger. In this situation the body is preparing to deal with the perceived social danger or threat. Sometimes these physical responses actually improve our performance. At other times the physical response is so overwhelming that it interferes with doing our best.

Moods and Social Anxiety

The mood associated with social anxiety is fear or panic. When people with social anxiety go into a social situation or think about going into a social situation they often are overwhelmed with fear or panic which can intensify as the social situation approaches.

Importantly, these four areas (thoughts, moods, behaviors and physical functioning) operate in tandem. We don’t know for sure, and it may not matter, which of these areas occurs first or causes the social anxiety. What we do know is that there is a reciprocal interaction between these areas. Changes in any one of the areas (thoughts, moods, behaviors, physical functioning) will result in changes in the other three areas.

Cognitive Behavioral Therapy of Social Anxiety

Cognitive-Behavior Therapy (CBT) is an active, structured goal directed form of psychotherapy that targets thoughts (cognitions) and behaviors (avoidance) associated with social anxiety. In the context of a warm and trusting therapy relationship CBT helps clients look at difficult and painful experiences. In understanding these experiences clients can learn new skills, methods and strategies that may enable them to overcome their social anxiety. CBT can help people identify and alter the thoughts and behaviors associated with social anxiety.

The goal of CBT for social anxiety is often increased social interaction with minimal anxiety. Successful treatment may result in the ability to interact in any group or social situation without anxiety and with little or no concern about being evaluated or judged. Successful treatment may result in the elimination of avoidance behaviors.

In CBT of social anxiety disorder clients learn to identify, evaluate and change the automatic thoughts associated with their anxiety. For many people this results in a reduction of their anxiety and a greater sense of comfort in group and social settings.

The behavioral component of CBT for social anxiety disorder includes overcoming the avoidance associated with the anxiety. This can be done gradually and systematically. Overcoming avoided situations begins by creating a list of all situations in which the anxiety is likely to occur. This may include situations that you participate in with anxiety, situations you avoid or situations that you feel anxious just thinking about. After the list is developed each item is given a value of how anxiety producing it is. The item on the list that creates the most anxiety is given a value of 100 while the item at the bottom of the list is given a value of 1. Every other item on the list is given a value somewhere in between 1 and 100.

Utilizing the cognitive therapy and anxiety management skills that have been previously developed the client then begins the process of gradually approaching and exposing oneself to increasingly difficult (anxiety producing) situations. In these situations, in a systematic way, clients learn to manage, control, minimize or accept their anxiety. Often, the new thinking and anxiety management skills become more developed and powerful as the client works their way up the list of feared situations. This process continues until the most difficult situations can be experienced with a lack of or minimal amount of anxiety and a sense of comfort and confidence.

Social anxiety disorder is very treatable. Psychotherapy research studies have shown that CBT is a highly effective treatment for anxiety disorders in general and social anxiety in particular. The beneficial results are often achieved in 20 CBT sessions or less and appear to be durable in that the results are usually maintained even after the discontinuation of treatment.