Types of Anxiety and Mood
One of the most complicated questions we face working with people who have experienced depression or mood swings has to do with the relationship between mood and anxiety. One way of trying to bring a little bit of clarity to this discussion is by considering the different types of anxiety.
In this post we will try to define the important types of anxiety and their relationship to mood states. We will also consider some of the more complicated distinctions by talking about what “agitation” and “racing thoughts” are like in energized (hypomanic or manic) mood states and finally what “agitation” can be like in a “pure” depression.
Types of Anxiety
At the risk of much oversimplifying a complicated topic, we think about anxiety in the following ways:
- Anxiety related to a traumatic event.
- Sudden overwhelming anxiety that feels as though you are going to die or go crazy.
- Worrying about many different things over a fairly long period of time.
- Worrying about one thing over and over.
- Fear that perhaps all is not as it seems, that perhaps people cannot be trusted.
Many people with mood disorders have experienced a traumatic event, which, as defined by the diagnostic manual for psychiatry, means “direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.”
Common examples in our experience are a sexual assault, being mugged, being attacked by a spouse.
Traumatic events seem to create the conditions for mood instability, and addressing them and their consequences in treatment is important for good recovery.
There are specific treatments for PTSD: both pharmacological and psychotherapeutic.
For many people with both PTSD and a mood disorder true mood stability depends on treating both conditions… This is more true if the trauma occurred in adulthood. The treatment of bipolar and early childhood PTSD is often more complex.
Sudden Extreme Anxiety
The most common form of this type of anxiety is a “panic attack”. Again, the diagnostic manual defines a panic attack as:
“intense fear or discomfort in the absence of real danger that is accompanied by many of the following physical or thought symptoms. Symptoms can include: palpitations, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, dizziness or lightheadedness, feeling that suddenly things aren’t real or feeling disconnected from your self, fear of losing control or “going crazy,” fear of dying, funny tingling sensations in the body, and chills or hot flushes. The attack has a sudden onset and builds to a peak rapidly (usually in 10 minutes or less) and is often accompanied by a sense of imminent danger or impending doom and an urge to escape.”
Panic attacks can occur along with many other conditions and isolated panic attacks may not mean all that much. Repeated panic attacks suggest that there may be a specific biological predisposition to panic and suggests that treatment should include CBT or exposure therapy and perhaps pharmacologic treatments of panic disorder.
Ongoing Worry about Many Things
This kind of worry, called “Generalized Anxiety” in the diagnosis manual, is very common among those with mood disorders, and is often the first “symptom” to develop, often beginning in childhood.
Here again is a description:
“The person finds it difficult to keep worrisome thoughts from interfering with attention to tasks at hand and has difficulty stopping the worry. Adults with Generalized Anxiety Disorder often worry about everyday, routine life circumstances such as possible job responsibilities, finances, the health of family members, misfortune to their children, or minor matters (such as household chores, car repairs, or being late for appointments). Children with Generalized Anxiety Disorder tend to worry excessively about their competence or the quality of their performance.”
Cognitive behavioral therapy and certain medications may be helpful.
This kind of generalized anxiety can have several different relationships to mood symptoms. Some people find that their anxiety levels alternate with depressive symptoms. In other words, when they get anxious they have increased energy and are coming out of depression, and as they get depressed their anxiety goes away as they enter an apathetic and unmotivated state. Other people find that anxiety and depression co-occur, as they get more depressed they feel more anxious.
Because the relationship between this kind of anxiety and mood symptoms is so variable, mood charting is especially important.
Finally, some people tend to worry over and over again about specific worries. There are many types of worries, but the key to this type of worry is that the worry is intrusive and disturbing and is difficult to control. It may be about:
- Cleanliness, germs
- Neatness, order
- Forgetting to lock a door or turn off an electrical appliance
- Being overweight
- Or many other types of things.
This type of worry seems to be particularly responsive to a specific type of psychotherapy: behavioral therapy, and a particular type of medication: agents that enhance serotonin in the brain.
These fears, that somehow everything is not as it should be, or that people around one can’t be trusted, are often very difficult to discuss with anyone. However, recognizing them and discussing them with a therapist or psychiatrist is extremely important since they may not respond much, or at all, to typical treatment.
Agitation and Racing Thoughts in Energized States
Often when someone is in an energized state there is a sense of “agitation” or needing to move as well as the experience that thoughts are “racing” or difficult to keep up with. Both of these experiences can happen with anxiety. Also, energized states that are associated with agitation are often not at all pleasant (not the happy state that people associate with being “manic”). In fact, despite the increased energy, they are often experienced as depressed states. The key to identifying this type of agitation is:
- Getting a lot done, or needing less sleep
- The racing thoughts are not about one thing, and they are not about familiar “worries”, they still have the quality of novelty that accompanies more typical hypomania.
Agitation in Depression
There is considerable controversy about agitated depression. Some people feel it doesn’t exist. Certainly it is very difficult to distinguish from anxiety and depression. In fact, the “agitation” and “racing thought” in this kind of depression is similar to the “recurrent anxiety” described above. It tends to be about one or more worries that recur over and over again. And if there is physical activity, it also tends to be repetitive: pacing up and down, wringing hands, etcetera.