Carlo Lorenzo Cazzullo
Institute of Clinical Psychiatry, School of Medicine, University of Milan, 20122 Milan, Italy
The topic of this meeting is indeed a very interesting one, because an open question —the nature of the relationship between anxiety and depression—is debated. Anxiety and depression are the two basic emotions in man. They are part of human experience all along the course of life and are diffused everywhere without any anthropological, cultural, social, or geographical limitation. Anxiety and depression are part of intrapersonal and interpersonal psychology as well as everyone’s psychopathology; they are frequently mixed, or the one strictly follows the other. Some situations of distress or disease can arise within this dynamic relationship, and quite often each is considered separately. As a consequence of this artificial separation, effects of drug treatment, as well as unexpected reactions of psychotherapy, are observed (e.g., autoaggressive impulses or seclusive behavior). The characteristics of fundamental experience of being-in-the-world make anxiety and depression basic elements of the human psychobiological apparatus (as a structure and as a function). As emotions, they are placed at a point where psychology and physiology meet, and their respective virtualities pass reciprocally from one to the other. Sherrington made this observation many years ago, and Pavlov’s school later asserted it. Anxiety and depression have well-defined neurophysiological equivalents in some basic functions of CNS (neurotransmitters) and in the organs strictly dependent on it (cardiovascular, respiratory apparatus, etc.). Because of their psychobiological duplicity they appear to be suitable for biological research and pharmacological treatment. However, their expressions are absolutely unique. Anxiety has a particular position because it presents through various aspects; it is an emotion that seems capable of changing human behavior in a defined, sudden, and progressive way. Since it is one of the most diffused human phe nomena, it is considered by many clinicians as a basic element for understanding all mental diseases. It is well known that Freud maintained that anxiety is the crucial point of neuroses where it provokes the first defense mechanism. It is true, indeed, that anxiety is also present in all those psychic disorders that show a change in reality process, that is, psychoses, especially schizophrenia. Therefore it is difficult to talk about pure anxiety or pure depression. Anxiety is represented by an abnormal increase of emotional-physiological tension; it appears when the subject perceives a stimulus as a threat to, a danger to, or an attack on his or her own personal unity or a part of it considered as essential to him- or herself. The stimulus, or the stress, endangers more than physical integrity—a deeper and more intimate quality, that is, the meaning of his or her personality. Psychopathologically we can follow the various steps of this stormy path. At first the subject reacts with a state of alert and uneasiness, then a condition of uncertainty sets in, which is dominated by the perplexity of finding proper tools to counteract the stressor agents. Afterwards, a feeling of the inadequacy of his or her own defense capacities penetrates, and anxiety becomes invasive. When the subject no longer feels, but really believes that he or she is inadequate, vis-a-vis the stressful situation, hopeless, helpless, and self-depreciating, then anxiety is shading into depression. The relationship between anxiety and depression as symptoms can be examined from three points of view: the first refers to a unitary model, the second to a multiple model, and the third to a combined model. The unitary model is substantially supported also by the combined model, which defines the syndrome as anxious depression. The conceptualization of the unitary model considers the two disorders as represented by a continuum. They can also be conceived as two symptomatic stages of affective disorders with the ratio of anxiety/depression symptoms varying over time so that the diagnosis depends on when, in the course of the illness, the observation is made. Change in diagnosis, especially from anxiety to depression, often occurs, with a frequency of about 25%. Many authors have reported that the presence of depressive symptoms in anxious patients ranges from 40% to 65% (3,6). The basic feature is always a feeling of bereavement or a fear of losing a part of self, or a feeling of total loss of self. Anxiety is bound to the fear of loss, which refers to threatening characteristics of the stimulus, whereas depression is bound to the awareness of loss. Threat or danger is always experienced as a reduction of one’s own autonomy. Anxiety, alone or mixed with depression, is always present in every disease since every disease represents a loss and a reduction of freedom. Sometimes these feelings are preceded by or appear together with feelings of guilt, manifesting as phobias, or as ideas of guilt and injury toward others, taking on the features of obsessions. This consideration explains why anxiety has an ambiguous character because: (a) it includes somatic and psychic symptoms, and (b) it ends in a fight-or-flight situation when facing stress. Because of its ambiguous character, I believe we cannot separate anxiety from depression when considered as symptoms, and since it is very difficult to separate them, there are some doubts that panic attacks may be separated as such. Panic attacks manifest as a consequence of the weakness of personality, which is unable to organize any defense; therefore they have the basic features of depression. This kind of observation is reported by some authors (6,8) as varying between 60% and 30%. In London in 1962, part of the program of a WPA Symposium was devoted to the treatment of anxiety and depression. On that occasion W. Sargant reported that anxious patients had responded favorably to antidepressants. In the past, tricyclic antidepressants, such as amitriptyline, have been recommended because of their so-called amphoteric activity. At the present time, interest is focused instead on anxiolytics, with properties similar to those of alprazolam, which is believed to affect both symptoms. Another group of research findings deals with the course and outcome of the syndrome. It is well known that chronic anxiety states tend in the long run to acquire predominant depressive features (1,7). According to Lesse, the paradigm stress—anxiety—depression is usually observed; more rarely, stress produces an acute or subacute severely depressive state without anxiety, or with the kind of reaction that English doctors call grief. The sequence is different in early infancy. The child often wavers between the two phenomena, anxiety and depression. Both are part of the maturation process so that they can occur also as an evolutionary mechanism and can reach deeper and less organized stages than in the adult (2). These findings on anxiety and depression in childhood have been confirmed through psychodynamic interpretations and behavioral studies as well through pharmacological approach (2). In fact, the child suffering from anxiety gains more from treatment with antidepressants than from anxiolytics. Anxiety as well as depression are not only simple emotional phenomena but complex experiences in which affects, thoughts, and motor behavior are all involved. Lazarus has clearly illustrated the so-called "coping process," the meaning of which is that no kind of emotion can exist unless bound to an idea and to a motoric paradigm. This fact was later demonstrated by Papakostopulos at the Burden Institute through research on movement-related brain macropoten-
tial (4). The cognitive wave of Grey Walter is in fact almost completely disrupted in the anxious patient following two subsequent stimulations, whereas almost no changes are observed in normal subjects. Thus, anxiety is taking active part in any cognitive process. Depression reveals the same pattern, but latency time is quite enhanced. Moreover, we can say that anxiety has a more vigorous motor expression because it is acted "out"; depression is more concerned with internal activity, it is experienced more inside the self. Motor behavior, being a part of the whole behavior, is therefore charged by the ambiguity of these emotional phenomena. Finally, pharmacological research and neuroanatomical and neurophysiolog-ical studies in animals and humans suggest that certain parts of the brain mediate the anxiolytic action of benzodiazepine drugs. These regions include potentially large areas that comprise the amygdala, the ventromedial hypothalamus, the mamillary bodies, the anterior thalamus, and the frontal cortex. PET findings seem to support the hypothesis of greater right hemispheric involvement in high anxiety stress (5). The associative function of these four main structures, frontal neocortex, hippocampus, amygdala, hypothalamus, was recently elucidated in Moscow by Pavel Simonov within the frame of the need-information theory of emotions. The experimental data showed that these four brain structures play a major role in the estimation of signals coming from the environment and in the choice of the subject’s reaction. Their function is strictly interconnected, as is their anatomical component. Since all emotions, hence depression as well as anxiety, are involved, they proceed from the same biochemical background. Therefore we should take into account the possible role of various neuroreceptors in modulating the waving and progressive dynamics of defense mechanisms, in which anxiety is strictly connected with depression and usually represents the first step of a process in which depression constitutes the later stage.