Neurotic or anxious depression
When unprepared people hear the word “depression,” at the call of books and television stereotypes, the brain draws a heavy-handed person who is so dreary at heart that his only occupation is to “prepare for suicide.” However, in addition to falling under the classic manifestations of depression – endogenous and psychogenic – there are such different manifestations as masked (hidden) and chronic depression. This article is about another atypical in its manifestations, but nevertheless often encountered pathology – anxious depression.
It would seem that the diagnosis of depression should exclude anxiety, but in our case it’s just the opposite. Since it’s neurotic depression, i.e., caused by excessive psychological trauma or chronic stress, the classical depressive symptoms, more typical for endogenous depression, give way to anxious and doubtful signs of exogenous – having the cause outside – nature.
Sad and gloomy thoughts about the future, turn into pessimism, irascibility and anger; slowing down of movements and thinking turn into vague anxiety, feeling of impending disaster, imminent and terrible collapse of any undertakings; suicidal tendencies appear only as an extremely dangerous flash on the height of these expectations, and the decline of self-esteem goes into the background and requires painstaking medical work for detection.
People suffering from neurotic depression constantly expect a bad end and wait for negative news either from the outside or from within themselves, recognizing in every bodily sensation the signs of formidable diseases, sometimes even unknown to modern science, and therefore “not recognized” by conventional methods.
Anxiety-depressive disorder (another synonym) necessarily includes both symptoms of the depressive and anxiety-phobic registers, and only a qualified psychiatrist is able to make a competent differential diagnosis with other depressions, phobias and diseases of the neurotic circle.
The accession of somatized symptoms, hypochondria and obsessions makes this depression sometimes elusive. However, the astheno-depressive syndrome is always detected: it is the asthenization and exhaustion of the nervous system that is the weak point where the disease strikes. It must be said that this is not a so-called “fashionable diagnosis”: under the name “depressive neurosis” this disease has been known to psychiatrists since the second half of the last century.
Causes of anxious depression
The main cause of this astheno-depressive state is the rapid depletion of mental defense mechanisms. It is because of the constitutional features of the personality and psychotraumatic situations, and stresses – both acute and chronic – begin to form the disease already in childhood.
Deprivation of parental (especially maternal) affection, mushra, childhood in an incomplete family, child suppression, bullying in children’s company can form the basis for the disease, and even develop into a mixed anxiety and depressive disorder already in children.
Treatment of neurotic depression
When depressive neurosis is diagnosed, treatment usually does not require hospitalization; the exception is when the patient is in danger to himself/herself and/or others.
In not severe cases, non-pharmacological methods of treatment may be sufficient. First of all, all efforts are made to eliminate the psychologically traumatic situation, the chronic stressor and its consequences on the patient’s psyche and health. Considering the hypersensitivity and vulnerability of such patients, it is sometimes necessary to begin with the correction of objective physical defects and disadvantages of the person, but in any case, without competently chosen and performed psychotherapy, the long-term effect will not be achieved.
Treatment of depressive neurosis in children is worth special mention. Since clinical manifestations in childhood are different (we talk about clinical equivalents of depression) and are characterized by aggression towards peers and adults as a defensive reaction of the imaginative personality of its objective and subjective features (scoliosis, wearing glasses, poor academic performance, lack of intelligence), being suspected, the diagnosis is made only after an in-depth examination, including an experimental and psychological study, EEG, completion of questionnaires on depression, repeated medical conversations. However, from the moment of confirmation of the diagnosis, there are no fundamental differences in the further management of adult and young patients.
Choosing how to treat anxiety depression, the psychiatrist, if he considers drug therapy to be necessary, turns first of all to the wide range of modern antidepressants of various mechanisms of action available today, but predominantly sedative. Sometimes tranquilizers are used to relieve symptoms of anxiety, intrusive thoughts and actions. Although anxiety depression is considered prognostically so well treated that it usually does not require a combination of medications, in severe cases, the use of multiple antidepressants or an antidepressant and a normotimer (mood stabilizer) is considered justified and even necessary.
It is difficult to overestimate the help with depression and neurosis of a qualified therapist in working with the patient and his family. Concurrently with psychopharmacotherapy is work on self-acceptance, hard work aimed at seeing yourself as a person worthy of love and respect from others and, most importantly, from yourself. The patient learns to avoid unpleasant situations, to move away from the constant expectation of bad news and events. The increase in self-esteem opens up possibilities for managing one’s micro- and macroenvironment, building a harmonious environment. And cognitive psychotherapy helps to find pathological thought chains and reasoning in order not only to disavow them, but also to prevent the occurrence of such thoughts in the future.
Anxiety Depression Disorder – Symptoms and Treatment
What is anxiety-depressive disorder? We’ll discuss the causes, diagnosis and treatment methods in an article by Dr. Fedotov Ilya Andreevich, a psychiatrist with 13 years of experience.
The article by Dr. Fedotov Ilya Andreevich was written by literary editor Margarita Tikhonova, scientific editor Sergey Fedosov, and editor-in-chief Lada Rodchanina
Definition of the disease. Causes of the disease
Anxiety-depression disorder is a condition in which a person has symptoms of both anxiety and depression at the same time, but separately they are not so pronounced as to clearly define the disorder. Its danger is that it can end in suicide.
A summary of the article is in the video:
Often the severity of patients with anxiety-depressive disorder is underestimated, as they more resemble somatic patients with complaints of shortness of breath, palpitations, abdominal or chest pain. Depressive symptoms are erased, which makes it difficult to diagnose the disorder.
Currently, anxiety-depressive disorder is a provisional diagnosis, and patients are seen by psychiatrists and psychotherapists  . However, in the near future, with the approval of ICD-11 (International Classification of Diseases), it is planned to distinguish anxiety-depressive disorder as an independent diagnostic category  .
Anxiety and depression are the two most common human reactions to stress. They are combined in 23-87% of cases . According to the WHO (World Health Organization), more than 300 million people suffer from these disorders worldwide . Every year, the initial diagnosis of these disorders in Russia is decreasing. This is largely due to insufficient detection and low turnover of the population to psychologists and psychotherapists.
Anxiety-depressive disorder occurs at any age. Its course is less favorable than that of anxiety and depression separately.
Women suffer from this disorder more frequently. This is due to the frequent variability of the hormonal background at different periods of life – menstruation, pregnancy, menopause. However, there are trigger (provoking) factors that contribute to the disorder equally in both sexes.
Genetic predisposition is one of the most important causes of the development of anxiety-depressive disorder. Children whose parents suffered from this pathology are more likely to suffer from the same disorder.
Anxiety and depression are not always associated with psychologically traumatic events, but prolonged stress may contribute to the onset of the disorder .
Thus, the reasons for the development of the disorder can be internal (heredity, violation of the hormonal background and balance of neurotransmitters in the brain), and external (death of a loved one, job loss, etc.).
If you notice similar symptoms, consult your doctor. Don’t self-medicate – it is dangerous for your health!
Symptoms of anxiety-depressive disorder
The anxiety that occurs with this disorder is unfounded. It is not limited to any particular situation and is not directly related to stress. Its clinical symptoms and symptoms of depression are subtle. They are relatively uniform, with at least a few autonomic symptoms: tachycardia and bradycardia, chills, abdominal pain, shortness of breath, sweating, tremors, headaches and dizziness, stool and urinary disorders, muscle tension and pain    .
The DSM-V (Diagnostic Manual of Mental Disorders) defines anxiety-depressive disorder as a chronic or recurrent mood disorder in which features of dysphoria (morbidly depressed mood) and at least four of the following symptoms are present for a month or more 
- Difficulty concentrating;
- sleep disturbances (trouble falling asleep, feeling sleepy during the day, restless sleep that does not bring rest)
- feelings of weakness or loss of energy;
- a tendency to worry too much;
- expectation that something bad will happen;
- hopelessness (deep pessimism in the view of the future);
- low self-esteem, self-deprecation.
Significant clinical distress (excessive tension) and/or impairment in social, occupational, or other important areas of life may also be observed in anxiety-depressive disorder (12) .
Specific clinical symptoms of the disorder are quite rare. Often non-specific polysystemic autonomic disorders – tachycardia, hyperventilation syndrome (problems with breathing control, feeling of lack of air against the background of increasing anxiety), functional dyspepsia (digestive disorders not related to internal organs diseases), etc. – come to the fore. They significantly complicate the diagnosis of illness and increase the turnover of such people to doctors who treat somatic (bodily) illnesses.
In a detailed interview, people with anxiety-depressive disorder complain of decreased mood, apathy and anxiety. Some patients state that they are “fed up with everything,” “have no energy,” even though they are quite vigorous and verbose about their problems .
Without identifying somatic pathology, general practitioners, as a rule, diagnose “neurocirculatory dystonia” (or vegetative vascular dystonia) and as a result prescribe the wrong treatment. Only 1/3 of patients with anxiety-depressive disorder reach doctors-psychiatrists and psychotherapists.
The pathogenesis of anxiety-depressive disorder
The mechanism of anxiety-depressive disorder is not yet fully understood. There are many theories and scientific assumptions about the origin of this disease.
The most developed is the monoamine hypothesis. It is associated with a violation of the production of monoamine neurotransmitters (serotonin, dopamine and noradrenaline) in the brain. This assumption by scientists is confirmed by the effectiveness of treating anxiety-depressive disorder with drugs such as SSRIs – selective serotonin reuptake inhibitors . However, it remains a mystery as to exactly what causes contribute to the emergence of disturbances in mediator systems.
Some scientists consider affective syndromes (disorders of the disorder), which are inherited, to be the basis of the pathogenesis of anxiety-depressive disorder. The results of genetic studies confirm that anxiety and depression have a joint neurochemical mechanism of development – insufficiency of brain systems that produce serotonin (excitatory and inhibitory mediator). For example, it was found that in patients with anxiety disorders and depression and their siblings (siblings) the disease is associated with the expression of the serotonin transporter gene  . Short alleles (variants) of this gene contribute to decreased serotonin reuptake, increased levels of neuroticism (expressed in anxiety, restlessness, emotional instability) and inherited vulnerability to stressful influences. High levels of glucocorticoids (adrenal hormones) under chronic stress have also been shown to alter the expression of 5-HT1A receptors (serotonin receptor subtypes) in the hippocampus, which does not occur with antidepressants, especially SSRIs  .
Other popular hypotheses are:
- The theory of neuroinflammation (autoimmune inflammation in nervous tissue underlies the process)  ;
- the theory of the relationship between gut microbiota disorder and neurometabolic processes in the brain  ;
- cognitive model  .
Classification and developmental stages of anxiety-depressive disorder
There is no independent classification for anxiety-depressive disorder. According to ICD-10, it belongs to the group of stress-related neurotic disorders and somatic disorders. Self-reported depressive and anxiety disorders are classified as mood disorders (1).
In isolated anxiety or depression, patients present with only isolated symptoms of these affective disorders, whereas in mixed anxiety-depressive disorders, they are combined.
Signs of an anxiety disorder include:
- feelings of panic and fear;
- trouble sleeping;
- chills and sweating;
- tingling sensations in the hands and feet;
- shortness of breath;
- rapid pulse;
- muscle tension;
- nausea, dizziness, etc.
Signs of depressive disorder include:
- persistent lowering of mood;
- despondency, a sense of hopelessness;
- Increased fatigue after the usual stresses;
- Loss of interest in things that used to bring pleasure;
- concentration problems;
- low self-esteem;
- feeling of guilt;
- presentation of the future in a negative light, etc.
There are three stages of anxiety-depressive disorder:
- Stage one : increased sensitivity, irritability, minor anxiety, rapid fatigue, insomnia.
- Second stage (psychosomatic): somatic manifestations (muscle pain, abdominal pain, chest pain, sexual dysfunction, dizziness, palpitations, etc.), increasing anxiety.
- Stage 3 – Manifestations of the previous two stages intensify, anxiety continues to grow, self-esteem drops, apathy and a lowered mood appear.
Complications of Anxiety Depression Disorder
Lack of timely treatment can worsen the course of the disease and lead to mental and somatic ailments: the emergence and increase the duration of panic attacks (up to 40-60 minutes), sociophobia, hypertension and other cardiovascular disease, as well as gastrointestinal disease.
Household and professional skills and family relationships suffer. The quality of life of patients decreases considerably: they have less life space, they get less pleasure from achievements, and their motivation for development and creative self-expression decreases.
Without treatment, anxiety-depressive disorder can end in suicide  .
Diagnosis of Anxiety Depression Disorder
The criteria for diagnosing an anxiety-depressive disorder are less clear-cut than other anxiety disorders. They are based more on the principle of exclusion. Only a psychiatrist can make the diagnosis.
To diagnose anxiety-depressive disorder, standard test methods are used:
- Zung’s scale and Beck Depression Questionnaire – identify the presence and severity of a depressive state;
- Hamilton Scale and Montgomery-Asberg Scale, to determine the degree of depression.
The clinical picture is assessed by the following signs:
- Anxiety and depressive symptoms existing equally and combined with several autonomic symptoms;
- a mood disorder of at least one month;
- reaction to stress, not adequate to the situation (when the person and his/her relatives are not threatened by anything, he/she is not a participant in hostilities);
- symptoms are not related to somatic (bodily) illnesses, i.e. the symptoms of the disorder are primary.
Laboratory diagnostics – general blood and urine tests, blood chemistry and hormonal tests – are performed to detect possible signs of deterioration of the patient’s condition, as well as to rule out somatic diseases, inflammatory, immunological and hormonal abnormalities.
Sometimes they turn to instrumental methods of examination:
- Electroneuromyography (EMNG) – in complaints of muscle pain to assess the condition of peripheral nerves and muscle function;
- Electroencephalography (EEG) – to rule out epilepsy, which has some similar symptoms;
- MRI of the brain – to rule out organic causes of the disease and study blood flow in the brain area;
- Ultrasound and X-rays – to rule out somatic diseases;
- electrocardiography (ECG) – when complaining of shortness of breath or a pressing feeling inside the chest to rule out cardiovascular disorders  .
It is important to distinguish anxiety-depressive disorder from separate anxiety and depressive illnesses:
- Depressive episode – more pronounced symptoms of depression;
- generalized anxiety disorder – more pronounced symptoms of anxiety; – pronounced somatic disorders; – recurrent manic episodes and depression;
- mental and behavioral disorders caused by the use of alcohol or taking drugs.
It should be remembered that people suffering from anxiety-depressive disorder, in contrast to independent disorders, have a stronger decrease in the quality of daily life, more pronounced psychosomatic manifestations and a higher risk of suicidal tendencies  .
Treatment of Anxiety Depression Disorder
Anxiety-depressive disorder is well treated in its early stages. With the right therapy, results are noticeable in as little as 1-2 weeks.
The effectiveness of treatment depends to a large extent on the patient’s desire and willingness to understand the cause of his illness and improve the situation. An important criterion for successful therapy is the patient’s trusting relationship with the doctor (compliance) and the willingness to follow all of the specialist’s recommendations.
Treatment must be complex. It includes psychotherapy, medications and physical therapy.
Psychotherapy is an effective method of treating anxiety and depression, especially in its early stages. The doctor chooses the method of work with the patient individually. There are quite a few options. These include:
- Cognitive-behavioral psychotherapy – work aimed at managing thoughts and behavior;
- Gestalt therapy – increasing awareness, i.e. own responsibility for one’s life;
- Hypnosis – work with personality problems through immersion into a state of heightened focus and suggestibility;
- Family psychotherapy – work with the patient and his or her family members;
- auto-training – control of the mental state through self-hypnosis.
The doctor together with the patient makes a plan of life correction, daily regime, sleep, work and rest, teaches relaxation techniques .
This method of treatment consists of taking tranquilizers, antidepressants, beta-adrenoblockers.
Tranquilizers are prescribed under strict indications to reduce anxiety, fear, and normalize sleep. They successfully cope with panic attacks and somatic disorders, stabilize the autonomic nervous system, have an anticonvulsant effect, and relax muscles.
Since in anxiety-depressive disorder there is an imbalance of neurotransmitters (serotonin, noradrenaline and GABA), benzodiazepine tranquilizers – phenazepam, elzepam, seduxen, elenium – are most often used in treatment. They are prescribed as short-term courses, up to 2-4 weeks, because they can lead to drug dependence and withdrawal syndrome (worsen the condition after discontinuation).
Currently, a new generation of tranquilizers (non-benzodiazepine) – blockers of histamine H1-receptors (for example, hydroxyzine) – has been widely introduced into therapeutic practice. Such drugs do not impair cognitive functions, act quickly, and do not lead to the development of dependence and withdrawal syndrome.
Antidepressants are prescribed in most cases with tranquilizers, because the effect of antidepressants is cumulative (you have to wait up to two weeks to start), while tranquilizers start working after 15 minutes. Antidepressants help relieve anxiety, vegetative disorders, increase pain threshold (used for pain symptoms), relieve symptoms of depression: mood, sleep, appetite improve, apathy and melancholy go away. They do not cause an addiction. They are chosen strictly on an individual basis.
- SSRIs – fluoxetine, paroxetine, escitalopram, citalopram, sertraline, fluvoxamine;
- tricyclic antidepressants – amitriptyline;
- Dual-action antidepressants – venlafaxine, duloxetine .
The drugs of choice for the first-line treatment of anxiety-depressive disorder are SSRIs together with benzodiazepine tranquilizers. Tricyclic antidepressants and non-benzodiazepine tranquilizers are second-line drugs .
Beta-adrenoblockers suppress autonomic symptoms: tachycardia, blood pressure spikes, arrhythmias, sweating, weakness, tremors.
Usually propranolol, atenolol, metoprolol are used . It is important to evaluate the interaction of these drugs with antidepressants, as many combinations are undesirable.
Sometimes low-potency neuroleptics (antipsychotics) may be prescribed in small doses, such as thioridazine or sulpiride. However, after taking them, the patient may experience weakness, a drop in blood pressure, a decrease in libido (libido), weight gain, galactorrhea (breast milk secretion), and menstrual disorders . Therefore, caution should be exercised.
Widely used methods of physical therapy include therapeutic massage, self-massage, electromassage and electrosleep. These treatments relax, soothe, reduce tension, and normalize sleep.
If the disorder is detected in time and the correct treatment is prescribed, the prognosis is quite favorable. The duration of the illness is of fundamental importance, since with a prolonged course without therapy, the condition may become chronic. It is connected with the fixation of neurotic reactions (first of all, avoidance) which impose an imprint on the entire personality (it was formerly called the neurotic development of the personality).