Stress, Anxiety and Depression

I feel very passionate that this is an area in medicine.  Stress, Anxiety and Depression exhibit significant health disruptions and only superficial energy is spent educating and managing these conditions. My goal in this blog post is to lay the groundwork on the general principles for how to approach this very difficult topic.  Would this even be a true Medical Blog if it didn’t have any disclaimers?  I will not be addressing mental health conditions such as Schizophrenia, Schizoaffective Disorder, Bipolar or Personality Disorders. This blog also does not directly address genetic predispositions that follow a family’s lineage.  Now that we have that taken care of, let’s get started!

Feeling stressed, along with having anxious or depressed feelings are experiences common to all people.  This is both a blessing and a curse when having discussions about these topics. The blessing is that these conditions are relatable, and the terminology is familiar such as, “feelings of irritability, feeling as if your mind is very distractible, feeling lethargic with no motivation for the day”.  The curse is that “everyone is an expert” in this area, but I want to make it clear that feeling stressed, anxious or depressed is very different from clinical Anxiety or Depression.   As a result, friends and/or family will say things like, “Well you know, I was feeling pretty stressed last year, and I didn’t go to see a doctor about it……”. This creates a real barrier to further education, treatment and compliance with therapy.  The other real hurdle for this area in medicine is the lack of objectivity.  In almost every other area of medicine there is a lab, imaging or some test that tells you where you are compared to the normal set of standards.   There is not a lab, image or other test that will objectively tell you the level of depression or anxiety you are experiencing.   This particular hurdle has led to a significant stigma within our society when discussing mental health.  The automatic conclusion is that “I’m crazy” or that “something is wrong with my ability to handle stress” or “I must have a lack of inner fortitude”.  Another contributing factor to this stigma is that mental health is primarily about thoughts and feelings which are very subjectively influenced by what is going on around you in your environment.  Sometimes, even within the midst of significant Anxiety or Depression, you will have days that aren’t so bad and make you feel as if you should be able to get through this on your own without asking for help.   What follows is a general outline of what is going on inside you and will give you a frame of reference to work from when discussing Stress, Anxiety and Depression.

Let’s start the conversation with the function of the human brain.  The brain is a biologic processing computer that contains about 100 billion neurons with about 1 quadrillion synapses weighing in at about 5 lbs.  Anytime you try to compare the human brain with our man-made silicon-based computers, you are going to run into problems – they don’t work the same way, and they don’t do the same jobs.  However, it’s quite safe to say that the brain’s processing speed is mind boggling and yet both your brain and the silicon-based systems run on electricity.  But the amount of electricity required by your brain is orders of magnitude less than the electricity needed for our computers. Why?  Well, the answer has to do with chemicals called neurotransmitters. We are up to discovering about 100 different transmitters that have effects on the brain and continue finding more, however there are seven neuropeptides that do the vast majority of the work.  They are made by the brain and stay in the brain.  These chemicals take electrical impulses that last for only a nano-second and continue the effects for up to seconds.  This ability to couple electrical impulses with chemical transmission makes our brains far more efficient than any silicon-based system.  These neuropeptides are the basis for connecting stress with anxiety and depression.  These chemicals are made in the brain when the brain is in a rested state. Normally we go through a period of stress (preparing for a big test, mourning the loss of a loved one, etc) that during this time, production of the neurotransmitters drops as the brain is prioritizing other functions above neurotransmitter production.  Despite this, we maintain high cognitive efficiency by operating off of our built up reserve of these neurotransmitters. However, when the period of stress passes and we have rest, the production goes back up and we replenish our supply of neurotransmitters.  This is referred to as the “normal stress response” and there may very well be feelings of anxiety or depression during this time, however the feelings resolve when the time has passed.  The problem is if the “stressor” that is causing a drop in neurotransmitter production does not pass quickly, eventually your neurotransmitter levels drop below a threshold where the brain now cannot operate efficiently.   This causes several symptoms to develop:  

1.  Increased irritability.  Normally you may be a calm or even a laid-back individual, but you find yourself doings things like yelling at the dog which are out of character for you.

2.  Difficulty falling asleep.  Specifically, you have difficulty in getting your mind to turn off for going to bed.  You are exhausted, but when you lay down, your brain keeps running and thinking about a million different random things.  Eventually, you fall asleep but you notice your sleep is not only shorter than normal but the time you did sleep is not restful.

3.  Difficulty maintaining concentration.  When you are trying to complete a task, it’s as if you now have “Attention Deficit Disorder”, and your thoughts go off in random directions along with you being very distractible.

4.  Appetite fluctuations.  In general, your appetite will drop but then you have these terrible cravings where you snack on things at random times.  Usually what you are craving is not healthy either.

It’s at this point, depending on which of the neurotransmitters are the lowest, symptoms of either depression or anxiety begin developing and sometimes a person will have feelings of both at the same time.  The medical diagnosis at this point would be Adjustment Disorder (with anxiety, with depression or both).  This state has the potential to now perpetuate itself indefinitely, it no longer needs significant outside stressors to keep the brain from making adequate levels of neurotransmitters, the symptoms now create their OWN stress. For example, the increased irritability causes you to get in arguments with your loved ones both with increased frequency and with increased intensity – this strains your relationships resulting in increased stress.  Difficulty falling asleep leads to inadequate amounts of sleep and even sleep deprivation which is a direct stressor on the body.  Difficulty maintaining concentration means that your task performance efficiency plummets and this can cause significant stresses at work and/or home. The appetite fluctuations mean that you are not fueling your body appropriately which stresses the body.  All of these contribute to a chronically stressed condition which prevents the brain from making the appropriate levels of neurotransmitters and the chronically low neurotransmitters perpetuates an inefficiently operating brain.    

One of the primary stressors that leads to this perpetuation of symptoms is a history of faulty storing of difficult or stressful memories.  As we’ve discussed, the brain is a biological computer that responds to inputs and calculates responses.  However, the brain is also the housing to your mind, will and emotions.  One of its primary tasks is in the processing of information and then storing it away into your memory.  Yet when this information is not easy to process, such as having very negative emotions attached to it, the brain needs to exert a lot of energy in processing that information.  If the brain’s processing capacity has already been lowered due to low neurotransmitter levels you simply cannot process the difficult information fully and this leads to a log jam within the brain, eventually causing even further processing dysfunctions.  The way I have described this to my patients in the past is to think of purchasing a brand-new personal computer (PC).  Imagine it being one where you splurged and spent $6,000 on getting the very best. It has a huge amount of memory, large RAM and great processing capacity.  You decide that because it’s so great and powerful that you will store all your files, movies and pictures from your previous computer to the desktop. That way they will all be neatly displayed for you the moment you start up your computer.  Almost immediately after setting it up this way you start noticing that simple programs are not operating well.  You are seeing the “circle of death” waiting for the program to open or respond.  You are now so frustrated because of the amount of money you spent on this computer that now can’t even handle simple programs efficiently.  What happened?  Well it wasn’t that there was too much information being stored for the computer.  The problem was the location of the stored information.  Saving all the information on the desktop overloaded the RAM and the overall function of the computer suffered as a result.  The human brain has a similar setup with the Hippocampus and Amygdala handling short term processing.  If a situation/memory is complex and tied up with negative emotions it takes a lot of energy and processing capacity to sort through it, untangle it and store it in long term memory.  If your brain’s processing capacity has already been compromised, you often end up repressing the memory for better daily function, instead of properly processing the information.  This strategy works “OK” in the short term.  However, this leads to the short term memory centers becoming overloaded and developing dysfunctional ways of handling stress which continue to exacerbate the problem over time.

This brings up two questions:  1.  What is the “cure” for this?  2.  How does medication therapy fit into this?

Anxiety and Depression are complicated manifestations of the brain, as a result of having low neurotransmitters and faulty thinking processes.  In this Blog, again I am trying to take something quite complex and simplify it down to level that you get a sense of the “overall” perspective of the problem. One of the risks to doing this is to take something that may be very disruptive and complicated in someone’s life and paint a picture that the solution is easy and very straightforward. There is nothing easy or from a day to day perspective straightforward about these conditions, however the method of healing and “curing” the condition is fairly simple.  The answer is that you need to be able to talk out the memories in full to someone you trust.  There is something about speech, that enacts the full processing capacity of your brain onto that one problem.  This allows the brain to begin processing the memory and placing it in a more appropriate location in the brain.  This frees up space in the short term memory centers and allows for a more efficient conscious thinking of the brain.  Well, if the “cure” is so simple then why do these issues build up and become lifelong?   Several factors play into this.  One is that the memories are highly tied into emotions.  In our culture showing emotions, especially negative ones is looked down upon and seen as a personal weakness.  Second the negative emotions that are stirred up can be very disruptive, not just for the moments of talking about them but can destabilize daily function for weeks.  Third, frequently people develop crutches/coping mechanisms such as drinking, smoking, shopping, intensive exercising or even illicit drugs.  So instead of talking it all through they end up relying even more on their coping mechanism.

This is where I discuss the possibility of starting a medication to help.  There are two things I immediately identify when about to start a medication.  One is, once the medication has brought stability, who is your trusted individual (Pastor, Counselor, Physician, Spouse, Sister, etc) that you are going to engage with in talking out the difficult memories?  Two, is once we gain stability with the medication – we will have built in an exit strategy for getting off the medication.  I generally find that one year of stable management with a medication is the right amount of time to begin weaning off the medication.  You see, the whole purpose of the medication is provide stability so that you can talk out your memories, feelings, emotions without days to weeks of destabilization.  The medication can also provide stability and improved function during that time in order to reduce the other stressors in your life. Medications are not a “one size fits all” approach at all and require close follow up, careful monitoring and good compliance in taking them regularly.  Medications are also not for every case, sometimes patients seek help when they still have enough “neurotransmitter reserve” to be able to talk things out without destabilizing themselves.  New coping strategies can be taught and implemented that manage the stressors without the need for medications.  I explain to my patients that medications for anxiety and/or depression can be thought of as a splint or cast.  They provide stability while the brain is recovering and are to be taken away once it has recovered.  But like a cast, there has to be compliance in the management.  If a cast is taken off by the patient early because “my leg doesn’t hurt anymore” they are not likely to have a good healing.  Often times, patients will stop a medication on their own because “I feel fine now and I don’t need these crazy pills”.  Well, unfortunately as I mentioned earlier, there is a strong stigma about seeking help for anxiety/depression.  Every human being has experienced some level of these emotions and are therefore “experts” on the subject, saying something like “Well I was feeling depressed last year for a time, but I didn’t need to go on medications.”  The truth is that we cannot measure a person’s neurotransmitter levels from their bloodwork, remember that the primary neurotransmitters are hormones made by the brain that stay in the brain.  But if you went to that same person and told them that your Thyroid levels were low and you started taking a medication for low Thyroid, there wouldn’t be any question to that or stigma.  The process is exactly the same, however one has a lab result print out to show and the other does not.

I know that this has been a long blog post.  This is not an easy topic to summarize.  Anxiety is so disruptive, causing physical sensations that can be very unsettling and only increase your anxiety, making you feel like you cannot accomplish goals and tasks in your life.  Depression leaves you with no energy and a narrowing of perspective to where all you can see around you is the looming problems and troubles.  You cannot see all the good, beauty and love that truly is around you and robs you of that joy.  This is an area of medicine that I am very passionate about because it is often overlooked compared to the amount of impact it has on the quality of a patient’s life.  I approach this topic from a very holistic perspective and that often means taking account of the quality food you are eating, the amount of water you drink daily and engaging in exercise regularly.  However, once you have been “underwater” for some time, your ability to wait on these helpful changes in your life becomes very limited.  You’re literally going “day by day”.  If that’s you, don’t hesitate to seek help from someone you trust.