Shame, Anxiety and Depression: When They Occur Together – A

Psychodynamic and Pluralistic Perspective

Anxiety and depression frequently occur together. In my work

as a psychotherapist and counsellor in Central London, I often meet clients who

arrive describing symptoms of anxiety — racing thoughts, restlessness, tension,

overthinking — alongside the heavy stillness of depression: low mood, fatigue,

self-criticism, and a loss of meaning.

This co-occurrence is common. Anxiety and depression are not

opposites. They are often deeply intertwined emotional experiences, each

shaping and reinforcing the other. Understanding how they operate together —

rather than treating them as separate diagnoses — can be an important step in

therapy.

In my practice in Angel (N1), Holborn (WC1), Marylebone

(W1G), and online across the UK, I approach anxiety and depression through a

predominantly psychodynamic lens, while working pluralistically and

integratively. This means I draw on different therapeutic approaches where

helpful, but I remain attentive to emotional depth, relational patterns, and

unconscious processes.

Why Anxiety and Depression Often Co-Exist

From a psychodynamic perspective, anxiety and depression can

represent different expressions of underlying emotional conflict.

Anxiety may reflect unprocessed fear, internal pressure, or

unresolved relational dynamics. It can feel like the mind is constantly

scanning for threat — even when no obvious danger is present. Depression, by

contrast, may emerge when emotional energy collapses inward. It can feel like

withdrawal, numbness, or a turning of anger and disappointment against the

self.

Often, the anxious part of a person is trying to prevent

something — conflict, rejection, failure, loss. When that vigilance becomes

exhausting or feels futile, depression can follow. The nervous system cannot

remain in a constant state of hyper-arousal indefinitely. At times, it shifts

into shutdown.

In therapy, we do not simply reduce symptoms; we become

curious about what those symptoms are communicating.

The Role of Attachment in Anxiety and Depression

When anxiety and depression occur together, attachment

patterns are frequently part of the picture.

Attachment theory helps us understand how early relational

experiences shape our internal sense of safety, worth, and connection. While

the term attachment disorder is often used clinically in childhood

contexts, in adult psychotherapy we are usually exploring attachment

difficulties or insecure attachment patterns that may contribute to anxiety and

depression.

In my counselling and psychotherapy practice in London, I

often see how attachment dynamics underpin emotional distress. A person with an

anxious attachment style may experience chronic relational anxiety — fearing

abandonment, over-interpreting cues, feeling hyper-alert to shifts in tone or

distance. Over time, this hypervigilance can contribute to exhaustion and

depressive withdrawal.

Similarly, someone with avoidant attachment patterns may

suppress emotional needs, struggle with vulnerability, or detach under stress.

This can manifest outwardly as independence, but internally it may coexist with

loneliness and depressive numbness.

In more complex cases — particularly where there has been

early trauma, neglect, or inconsistent caregiving — attachment disruption may

sit at the core of both anxiety and depression. The nervous system may

oscillate between hyper-arousal (anxiety) and collapse (depression), reflecting

early relational instability.

Attachment Disorder, Developmental Trauma, and Emotional

Regulation

Although formal attachment disorders such as Reactive

Attachment Disorder are diagnosed in childhood, the legacy of early attachment

trauma often persists into adulthood.

Adults who have experienced early relational neglect,

unpredictability, or emotional unavailability may develop:

• 
  
• 
  
• Chronic
• anxiety in relationships
• 
  
• 
  
• Deep-seated
• shame and self-criticism
• 
  
• 
  
• Fear
• of closeness alongside fear of abandonment
• 
  
• 
  
• Emotional
• dysregulation
• 
  
• 
  
• Difficulty
• trusting others
• 
  
• 
  
• Persistent
• depressive states linked to feelings of worthlessness
• 
  

In psychodynamic therapy, we explore how these patterns were

once adaptive. A child who learned that emotional expression led to rejection

may become hyper-vigilant or emotionally withdrawn as a means of survival.

These strategies made sense at the time. However, in adult life, they can

contribute to anxiety, depression, and relational distress.

Attachment-based anxiety often involves a fear of being left.

Attachment-related depression may involve a conviction that one is

fundamentally unlovable. These internal working models are rarely conscious,

yet they shape adult relationships profoundly.

Anxiety, Depression and the Internalised Relationship

From a psychodynamic perspective, early attachment

relationships become internalised. The voices of caregivers — whether critical,

distant, intrusive, or inconsistent — often become part of the internal world.

This is frequently visible in the co-occurrence of anxiety

and depression.

An internal

critical voice may generate anxiety:

“You must not fail.”

“You must not upset anyone.”

“You are not good enough.”

When these

demands feel impossible to meet, depression may follow:

“What is the point?”

“I always get it wrong.”

“There is something fundamentally wrong with me.”

In therapy, we begin to identify and differentiate these

internalised dynamics. The anxious part may be attempting to maintain

connection or prevent rejection. The depressive part may represent despair at

never feeling secure or accepted.

Understanding these internalised attachment dynamics is often

central to meaningful change.

Anxiety and Depression in the Therapy Room

When someone presents with both anxiety and depression, the

therapeutic work often involves holding two emotional states simultaneously:

• 
  
• 
  
• The
• part that feels agitated, restless, or afraid
• 
  
• 
  
• The
• part that feels flat, defeated, or hopeless
• 
  

A pluralistic approach allows us to respond flexibly to both.

For example, in moments of acute anxiety, grounding

techniques, breathing work, or elements of cognitive therapy may help regulate

the nervous system. When the emotional intensity reduces, deeper exploration

becomes possible.

However, I remain interested in what the anxiety is

protecting against. Is there unspoken anger? Fear of abandonment? Shame rooted

in attachment trauma?

Similarly, when working with depression, it is important not

to rush towards activation. Depression often carries meaning. It may reflect

unresolved grief, relational loss, or long-standing attachment wounds.

In psychodynamic counselling and psychotherapy in London, we

explore these layers gradually, allowing insight and emotional integration to

unfold over time.

Working Pluralistically with Attachment, Anxiety and

Depression

Although my primary orientation is psychodynamic, I work

pluralistically. This means we consider together what feels helpful.

For some clients, exploring attachment history is central.

For others, immediate coping strategies are necessary alongside deeper work.

Some benefit from understanding attachment styles intellectually; others need

relational experience in the therapy room to shift longstanding patterns.

The therapeutic relationship becomes a secure base. Within

that space, anxious expectations can be explored safely. Depressive withdrawal

can be met with steadiness rather than rejection. Over time, new relational

experiences can soften rigid internal models.

Pluralistic therapy allows space for:

• 
  
• 
  
• Attachment-informed
• reflection
• 
  
• 
  
• Emotional
• regulation work
• 
  
• 
  
• Cognitive
• understanding
• 
  
• 
  
• Exploration
• of unconscious patterns
• 
  
• 
  
• Attention
• to present-day relational difficulties
• 
  

It is not about choosing one model over another. It is about

using what serves the individual while maintaining psychodynamic depth.

Anxiety, Depression and Professional Life in London

In high-pressure professional environments — common in

Central London — attachment patterns often intersect with workplace stress.

An anxiously attached individual may overwork to secure

approval. An avoidant individual may detach emotionally until burnout occurs.

Perfectionism, imposter syndrome, and chronic self-doubt can be understood

through an attachment lens.

Over time, this dynamic can contribute to both anxiety and

depression, particularly when self-worth is tied to performance.

Therapy offers a space separate from performance — a place

where one does not need to achieve in order to be valued.

Anxiety and Depression Therapy in Central London and Online

If you are experiencing co-occurring anxiety and depression —

whether linked to attachment difficulties, relationship patterns, trauma, or

life stress — therapy can help make sense of these experiences.

In my counselling and psychotherapy practice in Angel (N1),

Holborn (WC1), Marylebone (W1G), and online across the UK, I offer a

reflective, integrative approach grounded in psychodynamic understanding.

Therapy is not about eliminating all anxiety or sadness. It

is about developing a more compassionate and coherent relationship with your

internal world.

Over time, this can lead to:

• 
  
• 
  
• Greater
• emotional stability
• 
  
• 
  
• Reduced
• self-criticism
• 
  
• 
  
• Improved
• relational security
• 
  
• 
  
• Increased
• resilience
• 
  
• 
  
• A
• deeper sense of self-understanding
• 
  

Taking the First Step

Beginning therapy when you feel anxious or depressed can feel

daunting, particularly if attachment history has made trust difficult.

If you are considering anxiety and depression therapy in

London or online counselling in the UK, you are welcome to get in touch. The

first session offers space to explore what you are experiencing and whether

working together feels right.

Anxiety and depression are not signs of weakness. They are

often meaningful responses to relational history, life stress, and emotional

overwhelm. With careful attention, a pluralistic framework, and psychodynamic

depth, therapy can support lasting change.