“We often meet our destiny on the road we take to avoid it”.
(Jean de La Fontaine)
Anxiety often comes hand-in-hand with depression; this is a known fact in psychiatry. We say it’s a comorbidity. And it is not surprising that most antidepressants are also powerful drugs against anxiety, especially the ones following the paths of serotonin. I’d like to elaborate more on this.
Anxiety has something to do with the future; it’s roughly either the fear of future or the fear of death (which is also in the future). Depression deals mostly with stuff that happened in the past: regrets, guilt, sadness caused by things we cannot change or we have little power to change. So Anxiety (Fear) and Depression (Sadness) are rather distinct emotions or psychiatric conditions, and it should be easy to separate them. More, it is important to decide between the 2 conditions because the psychotherapeutic approach is different. Anxiety and fear are best managed with cognitive-behavioral therapy (CBT), while depression is best managed with psychodynamic (psychoanalytical) therapies or with the new CBT variant of Schema Therapy. Anxiety is rather superficial, often seen as “easy” pathology (compared to other psychiatric disorders), and CBT often solves the problem in a couple of sessions. Anxiety also deals a lot with imagination, with fantasizing about disasters in the future. Depression is profound, can be a terrible disorder, sometimes ending in suicide attempts, takes a lot longer to manage with psychotherapy, and often deals with existential problems like the loss of various things or persons. I always see depression as something very serious, and the emotional impact on me (the transfer I perceive from the patient) has a distinct quality that is hard to express in words. Often, depression can’t be seen at all clinically, especially in highly intelligent people who can hide very well the symptoms of inner void and tend to be rather philosophical.
Both anxiety and depression can get very somatic – that is, can cause physical symptoms. A lot of people forget – and a lot of physicians too – but we do have a body, and everything that is not okay in our minds will eventually have an impact on our physical health. Often, there is a differential diagnosis problem between depression with somatic features, somatic problems caused by constant anxiety, somatoform or conversive disorders, psychosomatic disorders and plain hysteria or borderline personality disorder. The psy-originated physical symptoms can go in all directions and can mimic almost every “real” disease, and understanding the context is the key to good diagnosis and, consequently, good management. Often, at this stage of investigating the psychological background, we sometimes ask ourselves, as psychiatrists, if what we have in front of us is really depression or pure anxiety. Because anxiety can disguise itself in depression…
Let’s say a person has to face a challenge in life. Below you’ll see a Pixar video called Piper, where a bird has to face the big waves of the ocean in order to feed itself. Being a bird that was raised in a secure and loving environment, it finds the courage to face the challenge and eventually finds a creative out-of-the-box solution to its problem. In the human society however, secure and loving relationships tend to be the exception. So the person, too often, can’t find the courage to get out of its nest and fight. Fear quickly leads to dependence, especially when the parents are also not well and accept the powerlessness of their children instead of pushing them towards independence. The situation deepens in time and the process of “getting out in the big world” is aborted. Symbiotic families are frequent in the psy practice, and there is always that excuse from the parents that “I’m doing this because I love my kid“.
The fear that is blocking a human being needs, with the passing of time, reasons to exist. There is always the possibility that someone says: “Hey kid, you’re now grown up, get out and fight!” So there is need for an excuse, a justification. If too much anxiety leads to physical problems – say diarrhea or stomachaches or shortness of breath – there is a good excuse not to do that thing that causes anxiety. There is a benefit. After some time however, and heavy treatments for the physical symptoms, there is need for something more, more convincing. What about “depression“? Sounds great! Another benefit! Depression is the perfect excuse for not doing anything, for risking nothing, for avoiding the responsibility to fight what one is afraid of. “I’m depressive, for God’s sake! I’m ill! Leave me alone! I can’t do that!” Depression becomes what is called a defense mechanism; it protects the person from dealing with its fear. It has all the symptoms necessary to diagnose the depressive disorder – lack of energy, sadness, lack of sleep, poor concentration, memory loss, episodes of really low mood and crying, guilt and suicidal thoughts – and everything is in place for heavy antidepressant treatment and, why not, handicap and social aid for the “disabled” patient. And all this can happen if the doctor is blindly following the psychiatric guidelines, not thinking about the family circumstance, and not thinking about the fact that depression can very well be a defensive mechanism and a pretext for avoiding everything in life.
Defensive depression can go on for years without being noticed. Heavy treatments will only bring more arguments that the situation is bad and the depression does not go away. Combined with personality vulnerabilities, this will potentially become a reason to say that life (and that person) is a failure.
We may take a lot of steps to avoid fear. We may do everything possible to avoid dealing with anxiety but, in the end, we must confront it. There is no other choice. With or without (medical/psychological/professional) help, we must get out. Nobody can do this in our name and in our place. No matter how much we avoid facing our fears, no matter how many years we lose, we always come back to the same situation, just like that lesson that is not learned and it presents itself over and over again until it’s fully learned. At the time when we accept the challenge, we might find out that our well-known depression has vanished. When there aren’t any available excuses, when we begin to look foolish in our own eyes, we become aware that there is no other way but to go straight through our fear, just like the little bird in the video, who goes straight through the big scary wave.
You may ask what makes someone go through the big scary wave… Some people go through their fears because they are… afraid. They are afraid that they are wasting their lives, so their fear of not living is bigger than the fear of getting out of their nasty situation. This is healing through fear. There is another group of people who can’t use this particular mechanism, so they go through their fears because they are disgusted (of themselves or their situation). But healing through disgust is another story…