The dynamics of anxious depression

We all know the feeling: tired but wired. Too exhausted to sleep. Seeming to have too much energy and yet not enough to do anything but stay in bed. Some even seek out the euphoric twin of this state: Red Bull and cola, anyone? A 90s supermodel perhaps best expressed it in her desire, apparently, to ingest a beverage that would simultaneously "wake her up" and "mess her up," out of which the now ubiquitous espresso martini was born.

But not many would decide to chase the "evil twin" of this state. The evil twin has a few names in the clinical literature: agitated depression, depression with anxious distress, mixed anxiety and depression. Among these different diagnostic labels, the experience is shared: the mind is both racing and stuck, the body restless yet leaden, the spirit both desperate for relief and too exhausted to seek it.

In this article, I'll attempt to explain what it means to live with the accelerator and the brake pressed down at once and how psychotherapy can help to understand and address this state.

Making sense of anxious depression

To understand anxious depression, its internal workings can be broken down into three areas: conflict, defences against feeling, and relational patterns:

Conflict

Unconscious conflict between two different feelings, impulses, or wishes is at the heart of anxious depression. When someone feels angry and wants to argue back, but is also afraid of the consequences, because they have learned that arguing back in this context is socially unacceptable, this creates a conflict within the mind.

When this seemingly unacceptable feeling of anger and desire to fight or argue back starts to surface, this generates anxiety in the body, and physiological signs like muscular tension, increased heart rate, and blurred vision can manifest. However, the anxiety itself isn't the main problem; it's the signal that there is a conflict in the mind between one part of the mind that has an impulse or desire to do X and another part of the mind that, for whatever reason, thinks doing X is not acceptable.

This signal is the "accelerator." It's like a smoke detector in your mind that, when it goes off, can create the overwhelming sensation of having too many tabs open all at once, and leave you feeling flooded with a sense of urgency to do something. The smoke alarm, however, is not foolproof. Sometimes it goes off when there is real smoke, and sometimes it goes off when it detects aerosol or vape mist.

Defences against feeling

When this conflict creates such intolerable anxiety, the mind hits the depressive "brake." One's internal saboteur, or inner critic, launches an attack, flooding your sense of self with feelings of inadequacy, helplessness, and hopelessness. In its own uncompromising way, it has understood the task at hand: silence the unbearable conflict at all costs. There may even be a perverse, masochistic part of you that is secretly grateful; the saboteur has done its job, and the original, seemingly irreconcilable conflict is annihilated, along with anxiety.

The defence of slamming the brakes on, however, is precarious and unsustainable. This state of being forced into submission by a crushing and punishing part of you can feel so confusing and scary that it triggers a fresh wave of anxious sensations. In the thick of anxious depression, this is when people can start to feel trapped in their own mind, as a part of it presses the depressive brake every time the conflict, and thereby anxiety, emerges. However, the conflict remains unresolved, and the symptoms persist. The painful paradox is that the defence becomes a new source of distress.

Relational patterns

The way that individuals navigate their internal conflict is usually understood as having its origins in our formative, early relationships. For example, a parent who is angry and volatile some of the time, and then loving and caring at others, becomes seen by you as both a source of nurture and comfort, but also of threat and harm. This creates the template for the "accelerator and brake" dynamic in adult relationships, because part of you is trying to move towards someone for care and nurture, and another part is trying to pull away to avoid imagined threat.

These are the echoes of earlier relationships in current ones, because a part of our minds doesn't know the difference between past and present, and we haven't developed the resources to orient ourselves to the present and discern whether what is happening now just feels like an earlier relationship, or is the same as one.

Implications for therapy

In psychodynamic therapy, you will be helped to identify how the ways in which parts of your mind have learned to hit the accelerator and brake have their genesis in formative relationships, and continue to play out in your current relationships. This playing out includes both how you relate to yourself, others, and also the therapist. Their task is to help you identify ingrained patterns of relating as they happen.

Instead of reacting in the same way others might, a therapist will carefully observe these patterns and describe them back to you. They might notice that you make a joke whenever you describe a painful emotional experience and they may say something like, “I noticed that just as we were feeling something difficult, you made a joke, and maybe part of the reason for doing that was to protect me, in the same sort of way you felt you had to protect your parents because they were focused on your brother’s difficulties.”

The purpose of this approach is to strengthen your own observing self. This is the part of you that can see your own patterns clearly. This insight is what creates the freedom to make different choices and relate to other people in new ways.

Psychotherapy involves tracing these emotional and relational patterns as they appear across different areas of your life. For example, you might talk about a resentment towards a friend who often talks about themselves and doesn’t seem interested in you. This may trigger a memory of a parent who confided in you about things you were too young to really know about. At the time, because you were under their care, you may have felt that adopting the confidante role was necessary to manage your anxiety, and refusing to adopt this role would have caused understandable anxiety. 

When you think of refusing to adopt this confidante role with your friend, unfortunately, a part of your mind can’t actually tell the difference between the past and present. This part of your mind then feels as though the consequences of refusing to adopt the confidante role are real, and that you won’t get your survival needs met. This triggers anxiety.

Through psychotherapy, you can then begin to notice when this is happening, and then orient yourself to the present by noticing what is actually happening right now. You may then notice a pattern that contains echoes of early relationships in it. Contextualising patterns in this way reduces shame and also helps strengthen your observing self's ability to notice the difference between past and present. 

In psychotherapy, you can begin to understand the pushing and paralysing nature of anxious depression. This can feel incredibly freeing, as you begin to notice windows of opportunity to act and relate to others and yourself differently. When those changes occur, you may start to notice improvements in how you feel simply as a result of these new ways of relating. This will likely cause others to relate to you in new ways. By strengthening your observing self, both the accelerator and brake become more something that you actively choose, rather than distressing and dampening forces that you find yourself at the mercy of.

Sources:

• Individual Psychotherapy and the Science of Psychodynamics (1995) by David H. Malan
• A Clinician’s Guide to Understanding and Using Psychoanalysis in Practice (2022) by Paul Terry