Depression and anxiety combined (Mental Health pros wanted)

boozysassmouth said:

MA in Forensic Psych

First thing, when is this set? You were just saying Korea for a while, which no longer exists, but then you say South Korea. Are you refering to North Korea as just Korea, or is this set before the war? That will drastically change what psychological information is available at the time.

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You're describing a lot of symptoms there. I can pick out pieces of anxiety disorders, but not a specific one from what you've written. I would want to know if she is afraid of having more panic attacks and if this has reduced her ability to function in anyway. I would also want to know if her fear of social situations rise to the point of being irrational, and if they do, if she's aware of that. Look into panic disorder and social phobia.

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As for the depression and psychotic break. You can have depression that's so severe that it's accompanied by psychotic symptoms (hallucinations or delusions, generally).
But it sounds like you're describing nothing more than severe depression. If it were catatonia (which is a psychotic symptom), she's be completely unreachable and either immovable or actually pose-able, as in you move her arms an she says in that pose for hours.

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Just being curled in a ball and voluntarily shutting the world out, is just deep depression. Layman would probably call it a nervous breakdown, but that term doesn't exist, psychologically speaking. She could eventually become psychotic, especially if her depression continues to get worse, but I don't think based on what you said, she got to that point. Psychosis is very severe.

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In terms of her depression, I'd want to know how many depressive episodes she's had (you need at least one to qualify as having major depressive disorder), how long they've lasted, what treatment she's been given in the past and what has worked and what hasn't, and if she's ever been hospitalized. Most of that applies to the anxiety symptoms as well.

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As for treatment, drugs would be antidepressants and anxiolytics. Antidepressants come in three classes: Tricyclics, MAOIs, and SSRIs. SSRIs are the newest, and probably have the fewest side effects (sorry, can't remember), so they'd probably try those first. The only anxiolytics I remember are benzodiazepines, but I think they use some antidepressants now as well.

As for therapies, there's different schools of thought for treating depression. If it was severe, they'd definitely try drugs. Extremely severe cases in which people don't respond to drugs, they may try ECT (electroconvulsive therapy), as this has show some success with these types of cases. It's not the barbaric procedure that you're thinking, the technique is much improved. There are a lot of talk therapies that can be tried, and these would depend on the doctor treating her, and what's been successful in the past.

For the anxiety, aside from meds, it would depend on her disorder. If she can't be diagnosed with a specific anxiety disorder, then it may just be a talk therapy similar to what she'd get for depression, rather than a specific anxiety disorder therapy (like exposure therapy).

Also remember that only psychiatrists can prescribe meds, and from what I understand they aren't usually as well versed in non-drug treatments as psychologists. Though it isn't uncommon to find psychologists and psychiatrists in practice together.

The other thing I should add is that this is American psychology. I don't know anything about North or South Korean psychology.

My memory for treatments is not so good, so someone else please comment and add/correct!

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archetypewriting said:

Me: PsyD in clinical psychology, with particular expertise in mood disorders

First, I'm totally on board with everything boozysassmouth has told you, so you're lucky to be getting such good help from her.

One piece of advice I typically give writers is to pick one or two disorders max. More than that and you have a complicated clinical picture. And you have to portray that complicated clinical picture accurately, which can be tough to do, especially consistently throughout a novel. Also, people with complicated mixes of disorders are much harder to help, because they're buried under the weight of so many problems.

Typically it's not just the disorder that's causing the problem, either. It's the snowball effect -- just two examples: the impact on friends, including the ability to get social support; and work, including the ability to earn money and stay employed. Someone with severe depression and severe social anxiety might even be on disability. People with one (or especially both) of these disorders cost employers billions of dollars a year in missed days.

Depression and anxiety are often treated similarly, both in terms of medications and in terms of therapy. If you add psychosis, though, you've got a whole new can of worms.

I think, like boozy said, that you actually meant a "nervous breakdown" rather than a "psychotic break." What's a nervous breakdown? Also as boozy said, it's not a clinical term. Whenever people brought that term up in therapy, I had them explain what they mean. To some people it means they exploded in anger. To some it means they got so emotionally exhausted or stressed out that they stopped being able to get out of bed and face the day. Some mean they started crying and couldn't stop for a long time. It's fine to use the term in your novel...just not by the therapist!



Chronic low-grade to moderate depression may be dysthymia. There don't tend to be ups and downs with dysthymia, and the person is supposed to have had it for 2 years to be diagnosed with it.

Severe depression is a major depressive disorder, and it tends to wax and wane some. People will occasionally go up to "normal" and then plunge back down into the depression.

Someone with a "double depression" (colloquialism, not an official diagnosis) has both. They are down in the abyss of major depression, but when they come up, they only come up as far as dysthymia, and then go back down.



Social anxiety is different from other anxiety disorders. Social anxiety is like a phobia, and would require exposure-based treatments and some cognitive therapy. By contrast, if you meant something like generalized anxiety disorder (constant anxiety with no apparent cause), cognitive therapy still makes sense, but exposure therapy doesn't. (What would you expose someone who's afraid of nothing they can identify to?)



Dissociation is not typical of depression or anxiety, and it's (arguably) not so much of a coping mechanism as an escape. Dissociation means you wall off an experience or a part of yourself, either very mildly (you're paying attention to your phone conversation rather than to where you're going and you accidentally find yourself heading towards work) or very severely (for example, with a fugue, where someone develops autobiographical amnesia for some event or information and travels away from home, sometimes unconsciously making up a new identity along the way).

With that having been said, someone who has extremely painful bouts of depression or who's having panic attacks may depersonalize or derealize, which are forms of dissociation. Depersonalization means you disconnect from yourself and feel like you're not entirely real; derealization means you disconnect and feel like the world's not entirely real. This is the time-slows-down-and-everything-feels-surreal thing and is common with car accidents and other traumas. In someone with unbearable depression, the person may just sort of walk around disconnected, apathetic, and numb. In someone with anxiety, the dissociation tends to happen during panic attacks.



Yes, anxiety disorders and depression are often comorbid. Again, cognitive treatments are usually very effective. (If you want something to look up, try Rational Emotive Behavioral Therapy.) Other theoretical approaches could also be relevant based on why the character has the disorders she has (e.g. Interpersonal Therapy, IPT).

I could spend pages explaining what cognitive therapy looks like. I always hesitate to direct people to The Writer's Guide to Psychology, just because it's a personal plug, but it also seems silly not to direct you someplace where I've already spent many pages explaining in extreme detail how all of this would look in therapy, including exactly how a therapist would interact with and theorize about someone who has these problems, as well as how things like Rational Emotive Behavioral Therapy work and which meds you'd use. (There's also very detailed inside information on ECT in there. Most docs who do ECT won't talk to people who don't also do ECT, but I found a back door.)



You'd start with SSRIs, which include things like Prozac, Zoloft, Lexapro, Celexa, etc. and/or possibly (for a severe depression) an SNRI, which would be Cymbalta or Effexor. The SSRIs also are effective with anxiety disorders, because dep. and anx. impact the same neurotransmitters (brain chemicals).

I don't know what you mean by "used against her," but if someone starts these meds and then goes cold turkey on them, she can have a nasty "discontinuation syndrome." In other words, she goes into withdrawal. Cymbalta and Effexor withdrawal in particular can make someone look and feel like they're coming off a much heavier-duty drug. Withdrawal also usually includes relapse into the depression.

Typically the psychiatrist weans you off of an SSRI over time, but Effexor and Cymbalta can be troublesome even when you take that approach.

For anxiety, you could also add something like Buspar or benzodiazepines (Valium, Xanax), though you have to be really careful with benzos because they're enormously addictive. Also, if you are dealing with social anxiety, benzos in particular can interfere with treatment.

In addition to the cognitive therapy (eg REBT) I mentioned above, a therapist may work with someone with social anxiety on social skills, first individually and then in a group.

I started out recommending you pick one or two disorders. I think the major depression and social anxiety hang together just fine, but I'd personally hesitate to throw in the wrenches of dissociation or psychosis. Definitely not both. That feels like a lot to manage to ME in a story, and I've seen very complicated disorder combinations in the therapy room. If you needed something else, I'd add intermittent suicidality.

Hope most of that makes sense and that some of it is helpful!

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Severe depression is a major depressive disorder, and it tends to wax and wane some. People will occasionally go up to "normal" and then plunge back down into the depression.

With that having been said, someone who has extremely painful bouts of depression or who's having panic attacks may depersonalize or derealize, which are forms of dissociation. Depersonalization means you disconnect from yourself and feel like you're not entirely real; derealization means you disconnect and feel like the world's not entirely real. This is the time-slows-down-and-everything-feels-surreal thing and is common with car accidents and other traumas. In someone with unbearable depression, the person may just sort of walk around disconnected, apathetic, and numb. In someone with anxiety, the dissociation tends to happen during panic attacks.

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