Anxiety-Depressive Disorder: Understanding Interconnections and Symptoms
In anxiety-depressive disorder (ICD-10 — code F41.2, ICD-11 — code 6A73), symptoms of both anxiety and depression are present simultaneously, but neither reaches the quantitative threshold necessary for an independent diagnosis. This condition is considered subpsychotic, situated between psychotic and neurotic disorders. The symptoms can vary. In some cases, the motor component dominates (restlessness, agitation), while in others, the emotional component (anhedonia, low mood) is more pronounced, and autonomic symptoms may be minimal or absent.
Anxiety-depressive disorder is a combination of anxiety and depression symptoms that interact and sometimes mask each other. The primary challenge is that, in one case, anxiety predominates, in another, depression takes the lead, and at times, they are so intertwined that distinguishing one from the other becomes difficult.
In younger patients, anxiety is more likely to prevail. In middle age, depression starts to dominate. In old age, anxiety symptoms can re-emerge as the primary issue. This shift is associated with age-related changes in the brain’s biochemical processes.
Anxiety disorders often act as a precursor to depression. Initially, a patient experiences generalized anxiety, which over time becomes less tied to specific events. Gradually, against the backdrop of this anxiety, depressive symptoms emerge: anhedonia, reduced motivation, weight loss, and insomnia.
Anxiety-depressive disorder carries a higher risk of relapses and suicides compared to isolated anxiety or depressive conditions. This is explained by the fact that anxiety activates the patient, providing energy to act on suicidal thoughts, whereas in pure depression, the individual may be too apathetic to take any action.
Key Differences Between Anxiety and Depression
Anxiety and depression have fundamentally different emotional foundations. In depression, the core issue is loss: the person feels they have lost something permanently—joy in life, success, love, or even their sense of self. In anxiety, the foundation is a threat to the future, meaning the fear that something bad might happen.
These conditions also differ in terms of thought patterns. In depression, the internal questions often include: “Why did this happen to me?” or “Why is everything going wrong?” In contrast, in anxiety, dominant thoughts include: “What if something terrible happens?” or “What will happen next?”
Depression more often leads to psychomotor slowing—reduced speed of movement and speech activity. Anxiety, on the other hand, causes agitation, motor restlessness, nervousness, a wandering gaze, and chaotic speech.
However, these differences are not always obvious. For instance, in cases of severe anxiety, a person may withdraw, stay at home, and avoid contact with others. This can be mistakenly interpreted as depression.
In depression, physical activity can improve the condition because it increases the levels of catecholamines (norepinephrine and adrenaline), which are deficient in depression. In anxiety, the situation is the opposite: physical activity can worsen the condition due to an excessive release of catecholamines, which are already elevated in anxious individuals. This difference can be used as a diagnostic tool. If physical activity provides relief, it is likely the patient suffers from depression. If the condition worsens, it indicates an anxiety disorder.
In depression, appetite is usually reduced. The patient eats little, gets full quickly, loses interest in food, and portion sizes decrease. Eating stops being a source of pleasure and becomes a necessity, while taste preferences fade. In anxiety, by contrast, appetite often increases. Patients may “eat away” their anxiety to compensate for internal discomfort. However, there are exceptions: in some individuals, anxiety can also reduce appetite, particularly when it is accompanied by strong autonomic symptoms such as nausea or stomach cramps.
Depression often leads to early awakenings, with the person waking up at 4-5 a.m. and being unable to go back to sleep. Sometimes depression is accompanied by excessive sleepiness and prolonged total sleep duration. Anxiety, in contrast, makes it difficult to fall asleep. Patients may toss and turn in bed, thinking over various frightening future scenarios.
In depression, the main problem is difficulty recalling information. The patient may remember details but find it hard to retrieve them. In anxiety, on the other hand, there are difficulties in retaining new information because attention jumps from one object to another.
Depression is not accompanied by true asthenia. The patient may lack motivation to act, but if asked to perform a physical task (such as lifting a bucket of water), they can do it. Anxiety, however, is always associated with muscle tension and, consequently, true asthenia. Constant internal tension depletes the body, and the patient may genuinely feel physically weak.
Depression is characterized by anhedonia—the inability to experience pleasure. Anhedonia can be either predictive (the person believes they will be unable to feel pleasure) or actual (even when engaging in enjoyable activities, they do not feel joy). Anxiety, on the other hand, lowers the emotional baseline but not to the extent of completely blocking joy. However, due to constant tension, positive emotions are suppressed or diminished.
Differential Diagnosis
It is important to distinguish anxiety-depressive disorder from the coexistence of two separate disorders – depression and anxiety. If comorbidity is present (e.g., depression and generalized anxiety disorder), the symptoms of both conditions will be sufficient to warrant separate diagnoses.
It is also crucial to consider that generalized anxiety disorder carries an increased risk of progressing to major depressive disorder, whereas the reverse transition is extremely rare.
The Challenge of Balance in Treatment
One of the key challenges in treating this disorder is selecting medications that are effective antidepressants without exacerbating anxiety. The problem lies in the fact that many antidepressants have an activating component, which is beneficial for overcoming apathy and motivational deficits but can worsen anxiety symptoms.
Medications with a pronounced activating effect (e.g., fluoxetine) can quickly increase the patient’s energy levels and stimulate activity. However, this can lead to heightened anxiety, especially in the first few weeks of treatment before the full antidepressant effect takes hold. Therefore, such medications should either be combined with anti-anxiety agents at the initial stage or their use should be limited when the anxiety component predominates.
On the other hand, excessive focus on eliminating the anxiety component (e.g., through the use of strong sedatives or tranquilizers) can result in untreated depressive symptoms. The patient may experience reduced anxiety, but their anhedonia, lack of motivation, and sense of hopelessness may persist, leading to an overall deterioration of their condition.
To achieve balance, it is essential to select medications that have a clear antidepressant effect without intensifying anxiety. Some medications have a milder effect on anxiety symptoms and can simultaneously address both components of the disorder.
Key Medications
Escitalopram. One of the most selective serotonin reuptake inhibitors, known for its good tolerance and strong anti-anxiety effect. Escitalopram is often prescribed to patients with a dominant anxiety component and moderate depression, as it helps reduce anxiety without the risk of significant stimulation.
Venlafaxine. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI). However, its mechanism of action strongly depends on the dosage:
- In low doses (up to 75 mg per day), it primarily acts as an SSRI, inhibiting serotonin reuptake and providing a strong anti-anxiety effect.
- In high doses (above 150 mg per day), it begins to stimulate the noradrenergic system, which may exacerbate anxiety, especially in sensitive patients.
For this reason, venlafaxine is more commonly prescribed in low or moderate doses for anxiety-depressive disorders to avoid excessive norepinephrine activation and worsening anxiety symptoms.
Mirtazapine. A tetracyclic antidepressant with strong sedative and sleep-inducing properties. It blocks alpha-2 adrenergic receptors, leading to increased release of serotonin and norepinephrine. Its key feature is the blockade of 5HT2 and 5HT3 receptors, which allows it to:
- Reduce the risk of increased anxiety.
- Prevent nausea and gastrointestinal side effects.
Mirtazapine is particularly effective in patients with anxiety-depressive disorder accompanied by sleep and appetite disturbances.
Buspirone. A specific anti-anxiety agent that can be used as an adjunct to antidepressants in cases of severe anxiety. Buspirone does not have sedative or activating effects, which helps avoid exacerbation of depression during its use. It is indicated for generalized anxiety or when enhancing the anti-anxiety component of treatment is necessary without the risk of depressive complications.
Psychotherapy for Anxiety-Depressive Disorder
In addition to classic psychotherapy approaches (cognitive-behavioral therapy, Gestalt therapy, systemic therapy, etc.), alternative methods are gaining popularity due to their effectiveness, such as solution-focused therapy and solution-focused hypnotherapy:
Solution-Focused Therapy (SFT). This is a short-term psychotherapy method that focuses on the patient’s resources and finding solutions to current problems rather than a detailed analysis of the causes of the disorder. In SFT, the therapist helps the patient identify and enhance their internal resources and find concrete steps toward improvement. The main elements of the therapy include:
- Formulating positive goals: not “stop worrying,” but “learn how to manage situations.”
- Identifying successful strategies from the past and applying them in the present.
- Supporting small steps toward improvement.
SFT is effective in treating anxiety-depressive disorder because it helps quickly reduce the severity of anxiety symptoms and gives the patient a sense of control over their condition.
Solution-Focused Hypnotherapy. Hypnotherapy is a powerful tool for working with the patient’s subconscious, allowing them to bypass conscious barriers and develop more positive attitudes. Solution-focused hypnotherapy differs in that its goal is not to analyze past trauma but to achieve specific improvements in the present. The main elements include:
- Implanting positive behavioral scenarios into the subconscious.
- Strengthening self-confidence and reducing internal tension.
- Alleviating physical symptoms of anxiety (muscle tension, rapid heartbeat) through deep relaxation.
Hypnotherapy helps patients calm down quickly, improve sleep, and regulate negative stress responses.
Conclusion
Anxiety-depressive disorder is a complex and multifaceted condition that requires a comprehensive treatment approach. Understanding the differences between anxiety and depression not only aids in accurate diagnosis but also helps tailor the treatment strategy to address both components of the disorder.
Anxiety-depressive disorder requires a combination of pharmacotherapy and psychotherapy. The success of treatment depends on the individualized selection of medications that can simultaneously target depressive and anxiety symptoms, along with the use of psychotherapeutic methods that support the patient in coping with chronic stress and emotional overload.
Life’s challenges — such as work-related stress, health problems, or adapting to a new country — often lead to anxiety disorders. In such moments, it’s especially important to talk to a specialist who not only understands your problem but also speaks your language.
At the Plexus center in Warsaw, you’ll find a psychiatrist who speaks Polish and Russian, who will listen to you and help you find a solution tailored to your situation. Don’t postpone taking care of your well-being.