Anxious worrying is one of several personality styles identified as a risk factor to developing a depressive disorder. The other personality styles, which have been described in previous articles are:
– Social avoidant
– Personal reserve
– Sensitivity to rejection.
Not all of them are considered to be risk factors for depression.
People with high levels of anxious worrying in their personality style are more likely to have a parent who suffers from anxiety, more likely to have demonstrated traits of behavioural inhibition and school refusal as a youngster, more likely to have DSM-IV Cluster C personality traits (such as rejection sensitivity, irritability and self-criticism) and score highly on measures of neuroticism, trait anxiety and worrying. In comparison to other presentations of non-melancholic depression, they are more likely to have developed the depressive disorder at an earlier age and suffer more frequent and lengthier depressive episodes. We suggest a strong genetic component to the anxious worrying personality style which, together with the irritable style, is underpinned by a temperament characterized by high levels of autonomic arousal. Such characteristics increase the risk to depression and, when challenged by a life stressor, amplify those anxiety features and shape the phenotypic picture of ‘anxious depression’. People who have this type of personality style are more likely to report that they have ‘always been a worrier’. They may be able to relate several incidents in their lives where periods of unchecked worry dominated their thinking for days on end. Anxious worriers are possibly more likely to report somatic symptoms such as muscle tension, headaches and gastrointestinal problems. Over time, they possibly would have developed a number of strategies to help them cope with their high levels of anxiety, some of which may only be effective in the short-term. Some people with predominant features of this personality style may actively seek reassurance while others may withdraw from their friends and family members and stew over their problems.
On interview, anxious worriers are more likely to report:
– That they have ‘Always been a worrier’
– Several periods in their lives where they have worried or stewed over problems for hours or days at a time
– Somatic symptoms of anxiety such as muscle tension, headaches and gastrointestinal problems
– Possible history of prior strategies to help curb their anxiety and worries.
Cognitive and Behavioural Characteristics of the Anxious Worrier
The key feature of this personality style is the cognitive aspect of long-standing worry which worsens when depressed. Worry may focus on any aspect of their lifestyle or on current problems. Many with this personality style will describe periods of hours or days of worry. Underpinning these worries is usually a set of dysfunctional cognitive structures which serve to drive the content of their current concerns. Some of these dysfunctional cognitive schemas are:
– The world is a dangerous and unpredictable place
– No matter how hard I plan, things always go wrong
– It’s a disaster when things don’t go to plan
– If I worry about something enough a solution may be forthcoming
Without the necessary psychological tools, it is unlikely that these cognitive structures would have been actively challenged. New experiences of worry will tend to reinforce such entrenched beliefs rather than help to dispute their validity.
At a behavioural level, the anxious worrier is likely to stew over their problems and withdraw into themselves. People with features of this personality style may continue to interact with others at a superficial level while ruminating about their problems. If worries are unchecked their lifestyles may become somewhat limited to those areas that cause them the most worry. When depressed, the anxious worrier is likely to find themselves overwhelmed by anxiety and worry. Seeking reassurance from others can help alleviate some of the worries. In the long-term however this is largely inadequate as a coping strategy especially when others are unavailable or unintentionally reinforce the content of their worry. Some may have discovered that strategies that help to alleviate the anxiety, such as exercise or meditation, may also curb their level of worry. Others may have tried several ways to distract themselves from their worries. However, when the distraction is removed, worries usually return. A history of self-medicating with alcohol and/or benzodiazepines may be found among those with features of this personality style.
Behavioural strategies to reduce worry may include:
– Seeking reassurance from friends and family
– Using anxiety reduction strategies such as exercise and meditation
– Using distraction to cope with worries
– Alcohol and benzodiazepine use to curb anxiety and worry
Origins of the Anxious Worrier Personality Style
While there are many theories about the origins of personality, these may be roughly grouped into those that essentially espouse developmental factors (eg. delayed or retarded stages of development) and others that rely on early parenting, learning and possible exposure to traumatic experiences. This type of personality style seems to be related to heightened levels of autonomic arousal and people with features of this personality style also return high scores on questionnaires assessing the personality construct ‘neuroticism’ which, in turn, is thought to have a genetic/ physiological basis. Non-melancholic depression characterised by high levels of anxiety may result when individuals with personality styles of anxious worrying are challenged by salient stressors.
Possible Associations of Anxious Worrying with Personality Styles and Other Disorders
As mentioned in previous articles, the key personality styles identified by the our research into non-melancholic depression reflect dimensional constructs. Individual patients may present with a combination of several personality attributes which contribute to the overall presentation of their non-melancholic depressive episode. We have found that in a sample of community volunteers responding to a web-based survey, anxious worrying as a personality style was found to be highly correlated with the other personality styles of rejection sensitivity, irritability and self-criticism. In clinical practice, this has implications for the development of management plans which need to accommodate influences of such personality styles in short- and long-term outcomes.
An anxious worrying personality style can be associated with generalized anxiety disorder if depression is not the primary diagnosis. Research is required to examine this possible association and, if so, whether it is mediated by high levels of autonomic arousal. Another possible association is with a diagnosis of adjustment disorder, especially where there may be a mixture of anxiety and depressive symptoms. It is also possible that anxious worrying may be associated with high levels of alcohol and benzodiazepine use. However, this has yet to be formally investigated.
A detailed psychiatric history is necessary to rule out the possibility of a melancholic (or psychotic) depression. In melancholic depression, worries tend to focus on guilt and importuning (wondering ‘what will become of me’). It should be noted that diagnosing melancholic and psychotic depression is also based on a number of other key characteristics which have already been discussed in previous articles. Patients with personality styles characterized by high levels of anxious worrying as compared with other personality features are possibly more likely to seek help when depressed. However, by the time they do present for treatment they are likely to feel overwhelmed by and ineffective in their day-to-day activities. Once engaged in therapy, they are more likely to complete the course and to be compliant with homework tasks. It is possible and, at times, desirable to treat so-affected individuals in small groups within a supportive structured therapy format where they can discuss and challenge irrational or unrealistic catastrophic worries to other group participants. Strategies that target the reduction of high levels of autonomic arousal, challenge catastrophic thoughts and break the spiral of dysfunctional thinking are particularly effective.
The Role of Medication and Alternative Treatments
Patients presenting with a non-melancholic depression and an anxious worrying personality style tend to achieve considerable benefit from the SSRIs. These mute the worrying and emotional dysregulation, allowing distance from perceived problems. Patients commonly report that the problems remain but they feel that, with an SSRI, they are coping much better with their concerns. The SSRIs have the capacity to normalise worry. However, too high a dose can make patients feel numbed and not “worried enough”. Some such patients will need to stay on SSRIs for extended periods, others benefit from receiving such medicine for a period sufficient to re-set their own “rheostat”, while others benefit from a second phase of more focused non-medication therapy and no longer need medication.
While many natural and alternative treatments may be of assistance to most expression of non-melancholic depression, specific types of such treatments may have differing efficacy across varying personality styles. Alternative treatments may be divided into three categories listed below.
Lifestyle factors that may help the anxious worrier include:
– Exercise and dance or movement therapies
– Meditation or yoga
– Relaxation training.
Non-prescription alternative medications that may be helpful include:
– St John’s Wort
Dietary changes can also help to alleviate high levels of anxiety. These may include:
– Reducing caffeine intake
– Reducing sugar consumption
– Modifying problem drinking (if applicable)
The anxious worrying personality style is one of the most common patterns found in non-melancholic depression.