Off the top of my head, I would say that they are both effects with the common origin of insecure attachment, with related reliance on an inadequate auto-regulation (rather than co-regulation) strategies for affect management. You can "teach" self-regulation (e.g. CBT) with a therapist but it doesn't tend to generalize to the marital attachment relationship. IMO the best alternative is to go straight to the marital relationship - see Stan Tatkin - Psychobiological Approach to Couples Therapy. A marital pair who can co-regulate will have a much more robust capacity to manage anxiety in all of their other relationships

And the reason that the skill set taught within CBT doesn't generalize is that the learning with CBT is at the level of the higher brain function while the anxiety operates at the level of the limbic system. When this is "in charge" the higher brain functions are "off-line". The marital dysfunction is based on the triggering of maladaptive attachment strategies neurologically developed and wired prior to 18 months that aren't going to be changed by CBT! From this perspective, OCD/GAD are evidence of early threat that exceeded the capacity of the person's self/autoregulation strategies in the absence of the option to use the ' other" to down-regulate, leaving the person in an endless loop of desperate maintenance of a status quo approach to "at least it isn't getting worse"

Though my knowledge is more theoretically based, the research that I covered with regards to GAD/OCD indicates that evidence is purely correlational, and that it would be like asking, which came first the chicken or the egg? If I had to speculate GAD/OCD, which start developing due to a trigger, which causes the occurrence of dysfunctional belief systems, which are maintained by dysfunctional cognitive processing take long periods of time to develop. One can contribute to the other, dependent on the context of the patient. Mental disorders, such as GAD develop based on the interaction between self schemas/belief structures , attentional systems, memory systems and naturally executive functions such as the development of strategies, and the resultant plans, monitoring and control thereof. In brief, therapy would require a two pronged approach, I would agree with the idea of treating both. The marital partner of the person concerned perhaps could be taught coping strategies and become an integral part of the treatment system (which they are in any event if one considers it from an ecosystemic perspective). However as we all know that could be fairly difficult as they may also be playing a role in maintaining the mental disorder. This would need to be investigated. In support of the effects of therapy on pathways of the brain I have added additional information. However there is no convergence of evidence and must be considered in the light of other evidene. Extrapolation can be tempting but dangerous. A pivotal finding discussed by the National Institute of Mental Health (NIMH) (2005) which is mentioned here very briefly, is that PET was used on N=17 patients who were unmedicated patients with Depression, and compared against depressed patients who were on paroxetine (Paxil). Those who were not medicated received CBT of between 15-20 sessions. The findings of the study were that CBT “increased blood flow and metabolic activity in the Hippocampus and Dorsal Cingulate....and decreased activity throughout the Frontal Cortex" (2005, pp 18-19). This is a significant finding as brain areas that were linked to thinking, possibly perseverative cognitions and meta cognitive processes were reduced whilst brain areas linked to memory, attention and motivation were increased in activity. Though it is attractive to use this as a strategic part of the argument for the effectiveness of CBT and theories relating to Cognitive processes, other factors could have played a role, and further research needs to duplicate and verify this finding. The other aspect of this study was the finding that the Pharmacotherapy drug Paxil decreased blood flow in the lower regions of the brain and increased activity within the Frontal cortex regions. This provides a possible preliminary explanation of why combined CBT and Pharmacotherapy drugs may be the most effective combination in reducing the prevalence and severity of emotional disorders, in this case Depression. In regards to therapy, Dr Adrian Wells and colleagues have had success in treating patients with GAD and OCD, using metacognitive therapy, which targets dysfunctional cognitive processing across many levels. Meta-cognitive therapy in conjunction with Attentional Training techniques can be successful. You can find detailed information on Meta-cognitive therapy on their website: http://www.mct-institute.com/metacognitive-therapy.html. CBT, or therapy in general creates metabolic changes within the brain that appear to influence the activation of the central nervous system. From a therapeutic viewpoint based on my theoretical leanings towards Cognitive/ Cognitive Behavioural and Meta Cognitive Therapy in conjunction with an ecosystemic epistomology, I would treat both the Disorder and the marital distress.

Hey Cheryl: a very detailed and complete answer. My concern has to do with many years of CBT work with clients whose ability to activate/maintain/generalize their CBT strategies evaporates when they move outside the level of arousal above which their HPA axis is dominant. From a clinical perspective, the troubles associated with such periods is usually why they are siting in my office. The research around state-dependent learning is relevant here I think. I don't know the neurological work done with measuring brain function/blood flow/electrical activity and CBT. Do any of the findings mentioned above hold when the subject is in high levels of arousal?

Thank you for your response Bob it is much appreciated. Unfortunately the information provided on this research is not detailed enough in their report to ascertain the levels of arousal, nor do they specifiy the type of Cognitive/Cognitive Behavioural approach used per se. The report due to its nature cannot provide the level of detail and the research document was not available to me online. I can find further information on these studies and come back to you on them, so that you can access them. I do know though that in Meta Cognitive Therapy (I do not work for them or have any other link, other than I am using their theory and work, particularly Cognitive Attentional Syndrome, for the basis of a PhD) , there is a reduction of these high levels of arousal, as with practice and the development of new automaticized cognitions, panic attacks, GAD and OCD seem to be reduced over time as dysfunctional cognitive processes are slowly replaced by new ones which according to the studies mentioned in the previous post reduce activation of physical systems. However, I have not found any information specifying if therapeutic techniques work at the time of high states of arousal...BUT I do hypothesize that utilising a switching approach, whereby the attentional system is diverted during high states of arousal may contribute to a reduction in their intensity. The attentional training technique is a therapy and homework exercise that can be undertaken and provides training which can be habitual in the long term, which may assist during a high state of arousal, but I have no evidence to support my hypothesis. I give the example of a child who is very upset and if their attention is brought to another object which is of interest to them (alternative trigger), the switching of attention assists in reducing their level of upset, and when they are slightly calmer, they are able to cope better with the initial upset. Based on cognitive processes, this may disrupt dysfunctional processes, allowing the patient to entertain more functional plans and strategies, whilst desensitizing them to the ever growing list of triggers that seem to feed back into their monitoring of threatening situations (perceived or real). If one has, over time developed automatic processes for attention switching (based on the adoption of new strategies, monitoring for dysfunctional content and using that as a trigger for switching, and thereby executing a new plan), one is able to have a certain level of control over emotional states ( as soldiers for instance, are trained to do). Though I have done many assessments, and counselling I do not have your high level of experience, so my comments may be erroneous for your specific clientele, and for your level of experience. Thank you for taking the time to explain the problem, I will attempt to assist with further information if you would like some more.

very much appreciate the dialogue. Although very much interested in in what can be hypothesized, demonstrated, and replicated within an empirical approach, my primary interest these days is at the complementary end of the clinical learning dynamic, the level of n=1, what seems to work for the client, especially in real time. I prefer CBT and related cognitive perspectives but simply haven't had the success my clients desire [could be my skill limitation :-)] with such approaches. The report often is: ' Bob, it is driving me nuts, I know exactly what I should do and yet I do exactly the same thing I always do...I must be 'self-destructive', 'unmotivated', 'have an addictive personality', 'bad', stupid' etc. My belief is that these are the cognitive explanatory attempts for something that happens through threat appraisal based within the limbic system and which occurs long before the slower processes of the neo-cortex can " have a certain level of control over emotional states".

As with couples, these days I would rather work directly with the parent-child dyad to improve the ability of the parent to emotionally down-regulate their child. This external regulation of the child keeps them below their limbic system threshold and therefore allows the acquisition of cognitively driven self-regulation strategies. I believe this is the natural extension of the original process of the attachment-driven exquisite co-creation of the child nervous systems. My guess is that this is also the fastest and most effective way to take advantage what we know of neuroplasticity to embed new affective capacities in the child

Thank you so much Bob, what you are saying makes perfect sense to me and I doubt it would be skill limitation, therapy unfortunately, no matter the type of therapy is not an exact science that produces successful results in every case. There have been some advances in the area of research with regards to neuroplasticity, which does exist in adults, but not as much as there is in children. I hope that you are able to find an innovative approach to the issue. I appreciate your learned input and it has raised some questions for me to consider with regards to treatment, which I will look into, when working on treatment resistent Depression. Your experience has been invaluable in providing insight, though that was not the original intention of this post. Thank you for conversing me!

No amount of cognitive research or brain scanning is going to resolve this question. A genetically-informed developmental approach, preferably a longitudinal cohort is needed. The fact that anxiety disorders but not marital distress occur in children should give a clue as to which came first. Without specifically checking the literature, I suspect both are due to some personality factor, neuroticism for example. This and similar underlying personality constructs are influenced by genes and environmental factors specific to a child, not by the family-wide environmental factors that would be expected from a century of developmental psychology.

Anthony, I quite agree with you! No disorder such as OCD or GAD appears out of the blue, it begins early on. There is a genetic susceptibility, neurotransmitter issues,etc , ie., in ADHD DAT 4 is implicated. This, in combination with an environmental trigger (macro system) results in the development over time of a disorder such as GAD. My discussion was based more on a Cognitive/ therapeutic approach, and I am glad that you mentioned the genetic basis etc. In considering GAD, with regards to an ecosystemic approach, often as the anxiety becomes more free floating, any environmental factor can become a focus of anxiety. What I mean by ecosystemic approach is that one needs to consider internal micro levels, which encompasses physiological, emotive, cognitive etc processes and macro systems would be factors such as family, school, work etc, when conducting a therapeutic assessment (aside from the history of the patient and when the vulnerability was triggered). I apologize for not explaining that aspect in a bit more detail.

...and would any of that "genetic susceptibility" matter or would any of those "neurotransmitter issues" develop if the child is contained within and experiences the neurological growth associated with parenting by parents who themselves were parented by securely attached primary caregivers... The quality of this care litertally ceartes the child's mind and capacity for emotional state management (read anxiety disorder). Until we do the research that identifies cohorts of "genetically susceptible" and "neurotransmitter impaired" subjects controlled for environmental variance (eg parenting experiences)... we will continue in this debate around nature-nurture, something that I first danced with in the 1970s

Three good reasons why genetic susceptibility matters. First, in science knowledge is always better than ignorance. Second, it is only behavior genetic studies that tell us which types of environmental factors matter. Thus parenting experiences or secure attachment are irrelevant to explaining the large individual differences between siblings or even fraternal twins. It is the more idiosyncratic child-specific factors that matter. Third, in the past a vast amount of distress was caused to parents by blaming them for disorders in their children, falsely as it turns out.

Don't you hate it when you stumble across ignorance!

Genetic Susceptibility or Epigenetics? See: http://www.newscientist.com/article/dn23299-women-abused-as-children-likelier-to-bear-autistic-child.html

It shows how science can go wrong..

By ignorance, I mean relying on intrinsically unreliable secondary sources like the New Scientist above, rather than referring to the primary source, in this case JAMA Psychiatry March 2013. Here is the last paragraph from this original article

"Maternal abuse was strongly associated with almost every perinatal risk factor we examined, and adjustment for abuse attenuated the associations of several perinatal risk factors with autism in children. If maternal abuse increases the risk for autism in offspring through mechanisms not mediated by perinatal risk factors or if maternal abuse is an indicator of genetic risk for autism in children, studies examining perinatal risk factors may find statistical associations with autism even if the factors have no causal role in the origin of autism. If maternal childhood abuse is associated with autism in offspring primarily through shared genetics, mental disorders that specifically increase the risk for child abuse perpetration may overlap genetically with those that increase risk for autism in children. Future work should further investigate causal mechanisms by which maternal child abuse may be associated with autism in offspring."

Obviously, to resolve the ambiguity stated above, future studies need to be genetically informed. Note there is no mention here of epigenetics, though it was mentioned as a possibility earlier in the paper. Nevertheless, the long abstract in NS chose to mention epigenetics, but not genetics. Can someone please explain why genetics cannot be mentioned in polite society, but epigenetics can?

Given that this thread started with a therapy question, let's be ridiculously over-simplistic about it. People don't come to therapy to be told that the best explanation for your "problem" is that you have a genetic defect, marker, susceptibility etc. As fascinated and cognizant as I am about the genetics of this on-going nature-nurture debate and our rapidly growing ability to identify the genetic correlations,what is the value to the client in defining something from the perspective of unfixable genetics in a therapy context (you are depressed because you have "bad" genetics...so best leave my office???, any genetically informed therapist knows the variance "explained" by genetics is essentially irrelevant in a therapy context ). And the simple answer to the question of why "epigenetics" is so fascinating for therapists is because the environmental correlates may be preventable and therefore "TREATABLE"!

One of the main values of RG is that one can look behind the everyday exigencies of therapists for example, and ask more fundamental questions as to which environmental varibles are important and which are not. Genetic studies are uniquely able to do this, and have had surprising results, especially in developmental psychology. Phenylketonuria is due to a simple genetic deficiency, and working this through, led to a simple and effective environmental fix, removing phenylalanine from the diet. If my grandson were taken to a psychologist with developmental delay, I would be delighted to be told he had PKU.

I suppose it varies, but my view would be that they interact with one another. Few things in life are only one way. If one takes a history and find that this was an anxious person prior to the couple relationship that is different perhaps than finding the anxiety related elements are more phobic-like in nature and focused strictly on the relationship. It would also depend on one's theoretical framework to some extent how one might view or approach these issues. In the more systemic theoretical orientations they would be treated simultaneously with anxiety perhaps being addressed using other modality techniques (e.g., CBT, etc) within the systemic frame.

@Bob - I agree. The Zeitgeist today is sending the meta-message (if not stronger) that everything about the human relates to our being a bio-mechanical machine. Issues are related to the function of the machine and there is nothing more to us/it than this. The information we garner from various sources like neuro and genetics certainly inform, but often it appears to me we confuse correlation with causation and descriptions of function for cause.

There is actually some interesting research on a CBT couples therapy for PTSD that suggests that treating the anxiety disorder results in improvements in marital distress, mediated by the changes in PTSD. Candace Monson has done some very interesting research in this area.

I would focus less on "which came first" and more on how these phenomena are woven together.

I know that as a researcher, you want answers, but I myself often go back to the advice of Rilke to his poet friend:

"…I would like to beg you dear Sir, as well as I can, to have patience with everything unresolved in your heart and to try to love the questions themselves as if they were locked rooms or books written in a very foreign language. Don’t search for the answers, which could not be given to you now, because you would not be able to live them. And the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer."

Rainer Maria Rilke, 1903

in Letters to a Young Poet

Excessive anxiety is a feature of depression, disappearing with the others when an adequate treatment is performed.

The real cause of marital distress is the associated signs of depression and not anxiety by itself.

Irritability, procrastination, negativism, low sexueal function etc. are the true causes. A good treatment can lead to the disappearance of these disfunctions and, sometimes, to a re-marriage!

Regardless of original cause there seems to be a cyclic effect where one drives the other.... looking beyond this at basic human function, us a chemical beings these three conditions (listed below) may well explain the bulk of the populations who suffer from both anxiety and depression. All three conditions can only be exasperated by epigenetic/environmental issues such as heavy metals, poor diets, infections, addictions, parasites and chemical exposures.

Undermethylation: This condition is innate & is characterized by low levels of serotonin, dopamine, and norepinephrine, high whole blood histamine and elevated absolute basophils. This population has a high incidence of seasonal allergies, OCD tendencies, perfectionism, high libido, sparse body hair, and several other characteristics. They usually respond well to methionine, SAMe, calcium, magnesium, omega-3 essential oils (DHA & EPA), B-6, inositol, and vitamins A, C, and E. They should avoid supplements containing folic acid. In severe cases involving psychosis, the dominant symptom is usually delusional thinking rather than hallucinations. They tend to speak very little & may sit motionless for extended periods. They may appear outwardly calm, but suffer from extreme internal anxiety.

Overmethylation: This condition is the biochemical opposite of undermethylation. It is characterized by elevated levels of serotonin, dopamine, and norepinephrine, low whole blood histamine, and low absolute basophils. This population is characterized by the following typical symptoms: Absence of seasonal, inhalent allergies, but a multitude of chemical or food sensitivities, high anxiety which is evident to all, low libido, obsessions but not compulsions, tendency for paranoia and auditory hallucinations, underachievement as a child, heavy body hair, hyperactivity, "nervous" legs, and grandiosity. They usually respond well to folic acid, B-12, niacinamide, DMAE, choline, manganese, zinc, omega-3 essential oils (DHA and EPA) and vitamins C and E, but should avoid supplements of methionine, SAMe, inositol, TMG and DMG.

Pyrrole Disorder: This condition, also called pyroluria, is a genetic stress disorder associated with severe mood swings, high anxiety, and depression. The biochemical signature of this disorder includes elevated urine kryptopyrroles, a double deficiency of zinc and B-6, and low levels of arachidonic acid. Pyrolurics are devastated by stresses including physical injury, emotional trauma, illness, sleep deprivation, etc. Symptoms include sensitivity to light and loud noises, tendency to skip breakfast, dry skin, abnormal fat distribution, rage episodes, little or no dream recall, reading disorders, underachievement, histrionic behaviors, and severe anxiety. They usually respond quickly to supplements of zinc, B-6, Primrose Oil, and augmenting nutrients.

Theoritical considerations are very interresting of a speculative point of view. However, we can presently offer the patients a precise diagnosis and an efficient treatment, avoiding the rupture of the family.

http://bmaroy.free.fr/depressionF&E

I join the english version of the abstract of my book in french "La dépression et son traitement : aspects méconnus" L'Harmattan Paris 2011