Anxiety disorders and mood disorders are common. They affect people of all ages and walks of life. When someone suffers from anxiety and mood disorders at the same time, they’re diagnosed with comorbid anxiety and depression.
Four common questions about co-occurring anxiety and depression are:
- How often do they co-occur?
- Why do they co-occur?
- What’s the prognosis?
- What’s the treatment?
In general, comorbid conditions of all types are common.
One study found that about 50% of American adults with any psychiatric diagnosis have 2 or more disorders.
Co-occurring anxiety and depression are even more common than that.
Both conditions co-occur more often than the lifetime rates of either depression (16.6%) or anxiety (28.8%) alone. More specifically, about 60% of people with depression have comorbid anxiety, and 60% of people with anxiety have comorbid depression.
A natural next question is why anxiety and depression commonly co-occur.
Researchers do not know what puts someone at risk for comorbid anxiety and depression, compared with either condition by itself.
Theories range from biological explanations to situational life events. Another possibility is overlapping symptoms, such as insomnia, link the two disorders.
Some experts suggest that having one of the disorders is a risk factor for having the other.
Identifying causes for the co-occurrence is difficult. One reason for this is the different types of anxiety and depression.
For example, Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD) are highly comorbid. They also share four symptoms:
- Trouble sleeping
- Difficulty concentrating
- Being easily fatigued
MDD and GAD are considered to have to similar genetic factors.
MDD and other anxiety disorders, such as Panic Disorder, are not considered to be linked genetically. They are less often comorbid.
Gender may be another risk factor. Females have a higher rate of each condition than males. And a higher rate of comorbid anxiety and depression too. (This could also be due to bias toward diagnosing women more often than men with the disorders.)
Age is yet another factor. Onset for anxiety disorders is much earlier than for mood disorders (11 years old vs age 30 years of age). Whether this affects comorbidity is unknown.
What is the prognosis for comorbid anxiety and depression?
Another version of this question is how comorbidity affects treatment outcome.
Remember that when anxiety and depression co-occur, they’re usually harder to treat. Why? Because the symptoms tend to be more persistent and intense when combined.
The prognosis for people with comorbid anxiety and depressive disorders is poorer than that for either disorder alone.
The more intense symptoms include increased risk of suicidality, more chronic symptoms, and more everyday impairment.
So, people with depression and anxiety have a worse response than people with depression or anxiety alone. Their illness tends to be more chronic.
So how do you treat the conditions when they co-occur?
Unfortunately there is no single best treatment.
Experts even disagree whether to treat one condition first and then the other (aka sequential treatment). Or, to treat both at the same time (aka simultaneous treatment).
Further, clinicians can recognize one mental illness relatively easily. But, it’s much harder to recognize comorbid illnesses. And to distinguish comorbid conditions from conditions such as Bipolar disorder or Substance Use disorder.
However, it is not all gloom and doom!
Medication-wise, selective serotonin reuptake inhibitors (SSRIs) are the treatment of choice in treating depression and comorbid anxiety disorders.
In general, the SSRIs and the Selective Norepinephrine Reuptake Inhibitor (SNRI) venlafaxine are first-line medications used in the treatment of both anxiety and depression.
Examples of SSRIs include sertraline, fluoxetine, citalopram, fluvoxamine, paroxetine. They’re preferred due to their treatment effectiveness.
One downside to SSRIs is they can intensify anxiety among already anxious patients. Clinicians thus tend to start patients at a low dose and then increase the dose over the first few weeks of treatment.
The most common psychotherapy approach is cognitive behavioral therapy, or CBT for short.
CBT is a here-and-now, solutions-oriented approach. It’s based on the idea that thoughts, feelings, and perceptions influence behavior. One of the cool things about CBT is that it is an effective treatment for either disorder. And for both when they occur at the same time.
With comorbidity, treatment providers have to make sure both disorders are being treated. For example, antidepressants may help a person’s mood, but not their anxiety. A next step may be to add CBT. Or to change the medication.
There’s still a lot to learn about recognizing and treating conditions that present at the same time. Especially in the case of anxiety and depression.
While treatment has more challenges when dealing with comorbidity, success is possible.
I am a clinical psychologist in private practice. In my experience, the majority of adolescents and adults who present for treatment have comorbid conditions, including anxiety and depression.
Highly Sensitive People are born with a genetic trait called sensory processing sensitivity. Basically, that means they have a super responsive nervous system. As a result, a Highly Sensitive Person (HSP) is, typically, shall we say, well acquainted with anxiety.
Let’s define anxiety, talk more about HSPs, and then discuss the overlap.
What is anxiety?
Anxiety is a combination of fear and stress. It is a normal, common emotion.
Think of anxiety as a form of worry, uneasiness, and/or nervousness.
Our ancestors’ anxiety helped them to fight off danger, such as animals, and to run for safety.
Anxiety helped to keep them alive by activating the fight-or-flight mechanism. The same mechanism is still in place today in our brain. It prepares us for action and orients us for safety’s sake.
Without the safety mechanism of anxiety, humans would not have survived.
These days, fight-or-flight activation can easily be a ‘false alarm’. No longer are there lions or their equivalent chasing you. The threat in the present is more benign, like having a first date or arriving late to an appointment. Much less is usually at stake than being attacked by a ferocious beast. But, our nervous system doesn’t distinguish.
So, all of us — Highly Sensitive People and people without the trait– can actually thank anxiety for the evolution of our species.
Something else important to know about anxiety is that it manifests in your mind AND body.
Anxiety shows up in the form of thoughts, feelings, and physical sensations – whether you’re a Highly Sensitive Person or not.
Let’s take the ferocious beast example to illustrate how anxiety manifests.
A large, scary, growling animal is coming toward you. You think something like, “Oh s**t! He is going to eat/hurt/maul me.”! You feel fear. Your body goes into fight or more likely flight mode. Your heart rate and pulse increase, preparing your body to RUN like the wind!
Anxiety is helpful. It protects you, Highly Sensitive or not, from danger.
Let’s use a first date example to illustrate how anxiety can be not-so-helpful.
You’re scheduled to meet a blind date at a busy, crowded Starbucks. You arrive early. Immediately, you start to think about the miserable blind dates you’ve had, the zit on your chin, and the stain on your shirt. You feel awkward, nervous, and overwhelmed. Your body is sweating, and your heart is beating louder than a drum.
Your blind date approaches you, and he looks older than he does in his profile photos. You feel extremely anxious, you bolt for the bathroom (flight, as in fight-or-flight), and stay there. After awhile, you leave the bathroom, hoping he will be long gone.
In this case, the anxiety was not as helpful.
This blind date example illustrates how a Highly Sensitive Person’s nervous system might respond to a similar type of scenario. (A person without the High Sensitivity trait is less likely to respond as…. strongly.)
What is a Highly Sensitive Person (HSP)?
An HSP is someone born with a trait that has four key features, summarized by the acronym, “DOES“.
- D stands for Depth of Processing:
Highly Sensitive People process things deeply. They reflect more often and intensely. Especially on their own internal workings, relationships, and decision making. They make connections in their mind that other people respond to by saying they never thought of it that way.
- O stands for Over-arousal/Overstimulation:
The five senses of a Highly Sensitive Person respond intensely and easily. Certain smells, sounds, or textures are overwhelming – sometimes in good ways and sometimes not.
Crowds, bright lights, and loud noises can also be overwhelming – usually in the negative sense of the word. They can activate the same ‘fight or flight’ response we spoke of at the beginning of this article. As a result, they’re likely among the first in certain environments to feel overstimulated. (Hi, Starbucks example.)
- E stands for Emotion responsivity and Empathy:
Highly Sensitive People feel emotions intensely. They also worry about the health and welfare of vulnerable people and animals. When they see a flower that reminds them of a loved one, for example, they become sentimental.
Sometimes HSPs’ empathy is so strong that they can feel others’ emotions – even when the people themselves do not feel the emotions.
- S stands for sensory sensitivity:
HSPs notice details and nuance. The moment-to-moment changes of a setting sun, a subtle shift in facial expression, or the sound of the wind as it picks up speed are all things HSPs naturally notice. Their senses are highly attuned, and their experience of life is very rich.
HSPs are anxiety prone because they process thoughts and feelings deeply. Because of how deeply they experience the world, they’re more easily and quickly overstimulated. (Hello, Starbucks example.)
Overstimulation and anxiety feel similar in the body.
In the Starbucks blind date example, the HSP felt anxious relatively soon. She arrived early, giving herself time to (over)think and judge herself and her appearance. The crowded and loud setting frayed her nerves. It was tooooo much. She also likely felt others’ emotions and the dynamics within the coffee shop. She probably felt nearly depleted and taxed before her date even arrived.
The E, emotionality, also put the HSP at risk for anxiety. What if he didn’t like her? What if she spilled her coffee? Who was going to pay for whom? (Can you say AWKWARD?!)
The S, sensory responses, are anther way HSPs are inclined to feel overwhelmed. Their response to loud sounds, such as sirens, is more intense because of their hardwiring. So is the tendency to feel overwhelmed and ill-at-ease in a crowd. Or not to like bright lights, rambunctious scenes, or other social situations with people they don’t know.
Consider how easily and naturally the HSP felt overwhelmed and anxious at Starbucks. So many emotions to process, factors to consider, and ideas to evaluate…
You can see how things (e.g. sounds, situations, dynamics) that may seem benign or neutral are anything but for an HSP.
Living with the High Sensitivity trait means there are a lot of ‘extra’s’ in life. At times that can mean life feels extra stressful. As an HSP, you may feel extra anxiety, sooner than someone without the trait. But that is ok!
It just means you have extra incentive – aka ‘good’ obligation — for your own self care.
Know yourself. Be curious about the way “DOES” shows up for you.
Anxiety does not have to be a bad thing. Especially when you know why you are feeling it. And, how to live your life in a way that optimizes your unique attunement and experience of the world.
I am a private practice psychologist who works with women and men interested in learning how to use their HS as a gift and how to find the humor when it is not.
The world benefits from what HSPs have to offer.
If you have anxiety or depression, you may wonder if a support group would be helpful to you. First step? Consider the pros and cons of participating in anxiety and depression support groups.
Being part of a support group provides an opportunity to be with people with similar concerns.
To be in the presence of others who talk about their challenges can feel like a breath of fresh air. Especially because mental health challenges can be isolating.
In a support group, you’re likely to understand one another. And also recognize that not everyone is exactly the same. The main focus is on sharing experiences without focusing on the negative feelings of depression or anxiety.
Problem solving, sharing, and empowering each another can feel incredibly supportive. And really help to improve your symptoms of anxiety and depression.
In a group environment, members generate ideas for themselves and each other. The group setting is a safe place to practice skills that you can then more confidently practice in your every day life.
Many benefits of participating in a support group for anxiety or depression make it an appealing option. And well worth the effort.
For example, being in a support group may help you feel less isolated in your depression and anxiety. Recognizing that other people feel similarly to you can be such a relief. That you really are not alone.
The guidelines of the group are important and should be clearly stated from the very beginning. Basics include confidentiality, expectations (e.g.re being on time; missing sessions; safety protocols; outside of group contact), and participation. Even having an agreement or contract for all group members to sign, agreeing to the group rules, may be helpful.
The “what’s said in this room stays in this room” guideline is especially essential in order for people in the group to feel safe.
And to really be able to utilize the group fully. You want to be confident that what you are sharing in the group does not find its way outside of the group.
Expectations are also important to state at the beginning. Such things as attendance and participation. And whether group members need to be in individual therapy alongside the group therapy.
There can be disadvantages too in support groups for anxiety or depression. Especially if the group is not run well. For example, poor boundaries in the group may cause members not to feel safe. Or if there is a victim vibe, “poor me” atmosphere. Another challenge may be handling other people’s emotions.
Ideally, group members feel lighter, less burdened, more connected to others and to themselves after a group session.
So, if you want to feel less alone, and challenge yourself to go outside your comfort zone, consider an anxiety or depression support group. As is true for nearly everything in life, there is no guarantee participating in a group will help. But an open mind and a well run group may be an ideal addition to individual therapy.
I am a Boston area licensed psychologist, specializing in working with men and women who know they could be deriving more – pleasure, meaning, and purpose – in their lives.
Disordered eating is so common that it’s hard to identify and define. It’s just accepted as “normal”.
Kind of like fish not knowing they’re wet. It’s just how they live.
We’re born with all of the knowledge we need in order to eat well. But over time, the knowledge goes offline. Especially with our cultural obsession with thinness as our backdrop. And the tendency to categorize food as “good” or “bad”. As if food has a moral quality.
What is normal eating anyway? To define DISordered eating, we first need to know what ordered (“normal”) eating is.
Ellyn Satter, a registered dietician and family therapist, has an often cited definition. (She has lots of street cred as an internationally recognized expert on eating.)
She says normal eating is….
- “… eating until you are satisfied.
- Being able to choose food you enjoy and eat it and truly get enough of it – not just stop eating because you think you should.
- Giving some thought to your food selection so you get nutritious food, but not being so wary and restrictive that you miss out on enjoyable food.
- Giving yourself permission to eat sometimes because you are happy, sad or bored, or just because it feels good.
- Mostly three meals a day, or four or five, or it can occasionally be choosing to munch along the way.
- Leaving some cookies on the plate because you know you can have some again tomorrow, or it is eating more now because they taste so wonderful.
- Overeating at times, feeling stuffed and uncomfortable. And it can be undereating at times and wishing you had more.
- Trusting your body to make up for your mistakes in eating. Normal eating takes up some of your time and attention, but keeps its place as only one important area of your life.
In short, normal eating is flexible. It varies in response to your hunger, your schedule, your proximity to food and your feelings.”
Is it even possible to have a “normal” relationship with food these days?
My thoughts: “YES, but…”
“Normal eating” remains quite the oxymoron in our culture. As if the two words don’t belong together, side by side. And that an understanding of how the two words could possibly be a real thing is hard to believe. A common response is something like, “nondieting and normal eating may work for other people, but not for me. I could never do that.”
Indeed, nondieting (“ordered” rather than disordered eating) may seem like a radical act. To actually tune back into your own body’s natural signals. Not an easy thing to do – the signals have been derailed. Diet Culture’s rules of should’s and shouldn’ts have overridden your body’s inherent wisdom. BUT, you CAN reclaim that wisdom. Actually, to do so is your birthright.
Defining disordered eating is also difficult because there’s no specific criteria. In order to address a problem, defining it is helpful in order to know what it even is. And to understand why it is a problem in the first place.
The main reason disordered eating is hard to identify and define is because it is more the norm than not in our weight obsessed, diet oriented culture.
Consider the fact that disordered eating, Eating Disorders, and dieting are more common than normal eating. That’s disturbing.
So what are the signs and symptoms of disordered eating, and how do you distinguish it from Eating Disorders or dieting?
Signs of Disordered Eating:
Disordered eating takes a variety of forms. Examples include limiting intake to a certain number of calories or macros; eating only certain foods and avoiding others for weight related reasons; bingeing, purging, restricting, and/or fasting.
The mindset and behaviors that drive disordered eating can be hard to distinguish from cultural definitions of normal eating. And to distinguish from an Eating Disorder All of these behaviors are concerning. In time they can easily morph into a full blown Eating Disorder.
Disordered eating often has additional features, including:
- Self-worth based on body weight and size
- Body dissatisfaction
- Exercise to compensate for eating
- Preoccupation with food, weight
- Compulsive use of scale to check body weight
- Fad dieting
- A rigid approach to eating, such as only eating certain foods, inflexible meal times, refusal to eat in restaurants or outside of one’s own home
There are also lots of side effects of disordered eating.
- Decreased ability to focus because thoughts about food, body, and exercise get in the way.
- Social activities are affected, especially if they involve eating in a restaurant. Or eating foods that aren’t part of the plan.
- Using disordered eating rules to cope with stress.
- Anxiety due to food, weight, exercise.
Treating Disordered Eating
Disordered eating impacts physical and psychological health and puts people at risk for a host of problems. And it takes away from quality of life. Big time.
The relationship we have with our bodies is complex. So is how we nourish ourselves.
Fortunately, it is never to late to improve your relationship with food or your body. And there is no better time than right now.
As a psychologist, I’m biased in favor of psychotherapy. At least to support you as you start on the path of improving your relationship with food and your body. Finding like minded people also helps. There are communities to join online for example that may empower you.
Psychotherapy is helpful because it provides an opportunity to understand complex relationships with food and body. Also, therapy helps people move toward body acceptance. In addition, a nutritionist who specializes in eating disorders and adopts a non-diet approach to food and exercise can also be a good resource. Particularly with respect to increasing attention to the body’s natural hunger/fullness cues.
Reclaim your natural default of Intuitive Eating. Eat unconditionally. In whatever way pleases your body. Food is meant to be a source of pleasure. Denying yourself of it does not make you virtuous. Fueling and nourishing yourself well provides a sense of freedom, energy, and limitlessness.
Consider being your own unique fish, and surround yourself with others who share your vision.
I am a psychologist with a passion! My strong belief is that we all deserve the freedom to derive pleasure from food and be comfortable in our own skin, regardless of our body’s size or shape. Join me in this revolution.
If you’re married to a Highly Sensitive Person (HSP), you’re a lucky spouse.
Why? Because your partner is one of the universe’s deep feelers and thinkers. And “noticers” of subtleties.
Maybe her uniqueness attracted you. Or her deep reflections, appreciation of nature, and delight in delicious food. Regardless, there are unique things to recognize about your spouse if you’re married to a Highly Sensitive Person.
First, keep in mind that all Highly Sensitive People are not exactly the same. Any one description isn’t a “one size fits all”.
So what is High Sensitivity (HS)? It’s a trait, present at birth, in about 15% of the population. As much as eye color is a trait you’re born with, so is High Sensitivity.
HSPs have a unique hard wiring. Their nervous system is highly attuned and ultra responsive.
Some people consider the trait a Super Power. It certainly can be!
By the way, half of Highly Sensitive People are male. Men with the HS trait often have a history of being bullied or teased as kids. Throughout life, they’re likely to keep their high sensitivity on the downlow. Makes sense!
After all, sensitivity in our culture is deemed natural for women and not so much for men.
Certain challenges are somewhat predictable when you’re married to a Highly Sensitive Person– whether two HSPs or an HSP with a non-HSP. Many advantages are also available if you understand the HS temperament. The ideas below are primarily referencing a marriage with an HSP wife and non HSP husband.
Here are nine things to recognize about your spouse if you’re married to a Highly Sensitive Person:1. Intensity:
From sights, to sounds, to emotions, Highly Sensitive People experience life more intensely. Why? Because their nervous system is genetically designed that way. As a result, HSPs experience positive events VERY positively (and negative events more negatively than someone without the trait).
The enhanced intensity means she derives extra delight from sensory pleasures.
Sunrises and sunsets, the smell of the ocean, the sensual feel of velvet. Ahhhhh! And her turbo charged nervous system can be highly responsive when aroused.
Being married to a Highly Sensitive Person means you too can experience natural pleasures in life more easily, often, and fully.
HSPs are more easily overwhelmed by external events and may therefore at times feel broken. This is due to the combination of their nervous system’s makeup and cultural messaging.
Experiencing life more intensely and being judged for something that’s just inherent in who they are can create of a lot of wounding.
This is very important to be aware of if you’re married to a Highly Sensitive Person.
Unfortunately, cultural values of dominance and overt power have led many HSPs to incorrectly believe they’re flawed, that something’s wrong with them. (In contrast, in Japan, where cultural values are different from those in this culture, HSPs are held in high regard.)
Especially if you’re married to a Highly Sensitive Person, knowing this about her is important. You know she’s not damaged or a weird-o. (And, anyway, sometimes, weird is a compliment. No clone concerns there!)
Encourage your Highly Sensitive spouse to express her quirkiness and nerdiness. And laugh alongside her at her puns and sense of humor.
At times HSPs are mislabeled as “shy,” “fearful,” “introverted” or “timid.” In reality, being an HSP means she engages in close relationships on a deep level. And she experiences the world in a very acute way. Life is filled with a lot of “extra’s”. At different times she is an Old Soul, and other times a Late Bloomer.
Approximately 30% of HSPs are extroverted. They thrive on social activity and become energized in exciting social situations. Extroverted HSPs walk a thin line though between getting the social interaction they crave without entering into overwhelm.
4. Words matter:
HSPs process words, thoughts, and content deeply.
Case in point: Among others, Ralph Waldo Emerson, Celine Dion, Mozart, and ee cummings are HSPs.
If you’re married to a Highly Sensitive Person, your particular expressions of love are super important to her. She’s likely the type to save cards, notes, emails, and texts in which you profess your love.
Tone and posture matter do too:
Be mindful of your tone of voice and body language. If you’re married to a Highly Sensitive Person, you already know that she has a ‘sixth sense’; that she may intuitively seem to know how you feel.
She will recognize when what you say and how you say it aren’t aligned.
5. Conflict avoidance:
HSPs tend not to do well with conflict. Actually, most prefer to avoid it.
As the non HSP spouse, you’re probably more adept at arguing and comfortable dealing with things head-on.
Your HSP spouse is more likely to withdraw from, rather than address, a conflict.
If you’re married to a Highly Sensitive Person, you already know that at times she prefers her own company- i.e. to spend time alone. This may especially be true after an intense discussion. And may be a necessity rather than a preference.
Don’t take this personally. Having time to regroup means her nervous system is back to baseline. She’ll feel more content afterward. And have a longer fuse.
Ideally, you two generally communicate with each other in a way that doesn’t create or escalate to conflict. Let’s be realistic, though: Conflict is inevitable in relationships. Discover methods (at times other than in the heat of the moment) to minimize conflict. After all, you are on the same team! Consider using humor, writing, or even “time-outs”.
6. Tendency toward Overwhelm
All of us have an optimal level of stimulation and arousal. A zone where we’re neither bored nor overwhelmed.
HSPs have a more narrow window of optimal stimulation. Therefore, your HS spouse tends not to enjoy crowds, noisy restaurants, or a lot of commotion. These kinds of settings become overwhelming, sometimes immediately. (If your spouse is an extraverted HSP, she enjoys social environments but can suddenly become too overwhelmed to stay.)
Her threshold for overwhelm is probably lower than yours.
Remember, she naturally takes in a ton of stimuli. As a result, some alone or quiet time is needed for her nervous system to recalibrate.
Maybe, for example, she needs to retreat to a quiet, dimly lit, comfortable place such as the bedroom, to recharge. If you’re married to a Highly Sensitive Person, expect that she will need down time in her daily life.
7. Social activity parameters
Reiterating the propensity for overwhelm is important. Even if redundant.
Your Highly Sensitive spouse is unlikely to enjoy large gatherings, such as sporting events. Or loud social get-togethers, like a tail gating party. And forget about small talk at parties. No thank you. These forms of stimulation frazzle her nervous system.
When she has had enough, she has had ENOUGH. Time to go! Not “oh one more drink.” or “In five minutes.” This isn’t personal. It is her biology.
8. Decision making
Because of the depth of processing, HSPs may take longer to make decisions.
They consider pros and cons, all possible outcomes, and risk-to-reward ratios before coming to a final decision.
If you’re married to a Highly Sensitive Person, you’ll learn to be patient if you’re not already. Keep in mind that what may appear to be indecision is in fact just her way of processing the options.
9. Contagion Effect
If you are married to a Highly Sensitive Person, you’ll discover an increase in your creativity, kindness, and warmth. Your HSP spouse is likely to bring out the best in you, especially if you’re familiar with the trait.
You may become more inclined to notice subtleties and nuance after spending time together. And to be aware of other people’s goodness in a way that you hadn’t been before.
If you’re married to a Highly Sensitive Person, understanding your spouse empowers you both to create a glorious, thriving relationship. One in which both of you feel known, loved and safe. Where you’re comfortable being your true selves. You understand one another, respect each other’s wiring, and communicate well.
As with any marriage, finding the balance between what you need and what your spouse needs is key.
No marriage is perfect. If you’re married to a Highly Sensitive Person, you’re in for a lifetime of sensory pleasures, a deep sense of connection, and a meaningful life together.
I am a private practice psychologist who enjoys helping Highly Sensitive People access their superpowers with confidence and ease. I tend to have a pun or two to share along the way. #canthelpit