In my last post, “Why can’t we just be neurotic?” I complained about problems applying the Diagnostic and Statistical Manual of Mental Disorders1 (DSM) to patients who suffer with a combination of severe depression and intense anxiety. That is, sometimes we are forced to diagnose depression over anxiety when patients have both. Where do we put the anxiety? In the quest for precision, the diagnostic manual has pulled apart problems that belong together.
This post has two aims: first, to tangle and disentangle anxiety and depression; and second, to underscore the importance of appreciating the role of anxiety in depression.
Putting anxiety and depression in perspective
In my previous post, I emphasized the comingling of anxiety and depression. But readers should be aware that the image of simultaneous disorders oversimplifies; we need a developmental perspective. Anxiety and depression occur in episodes over the lifetime; either one is equally likely to precede the other.2 Moreover, the occurrence of one is likely to increase the likelihood of the subsequent occurrence of the other.2, 3 Anxiety begets depression, and depression begets anxiety. Thus we see a cascade of episodes: as time goes on, an individual who has a lifetime history of either disorder is increasingly likely to have a history of the other.4
Back to the comingling problem. The diagnostic system forces us to put symptoms into boxes and to decide which box offers the best fit. But the contents seem to spill over from one box to another.
Psychologists come to the rescue. We are less keen on chopping up nature into categories and more inclined to measure everything in degrees—not “intelligent” versus “unintelligent” but rather a full range of IQ scores. So it is with anxiety and depression: We have innumerable scales to measure each in fine degrees. And when we do so, we find a high degree of overlap (i.e., statistical correlation). The more depressed you are, the more anxious you also are likely to be, and vice versa.
Using scales to measure different facets of depression and anxiety
By fancy statistical methods such as factor analysis, psychologists can use multi-item scales measuring different facets of depression and anxiety in degrees to sort out what goes together and what does not. Such studies consistently reveal what has been called a “tripartite” model of emotional disorders,5 and, more recently, a “quadripartite” model.6 The tripartite model is enough to fill our hands for now. This model includes three relatively distinct factors, each of which is measured in degrees:
- aspects of anxiety that are separable from depression;
- aspects of depression that are separable from anxiety; and
- a great deal of overlapping experience.
The separable aspects of anxiety relate to physiological hyperarousal (e.g., racing heart, dizziness, shortness of breath and sweating); these anxiety symptoms are rooted in fear.7 The separable aspects of depression relate to a lack of capacity for positive emotional experience, such as interest, pleasure and excitement.8
As psychologist Paul Meehl9 presciently put it in the Bulletin of the Menninger Clinic decades before the role of neurotransmitters in reward circuits was fully appreciated, depression entails a lack of cerebral joy juice. Meehl’s phrase parallels William Styron’s characterization of his depression as dank joylessness in his poignant memoir, Darkness Visible.10
It’s the third factor that interests me: the overlap between anxiety and depression. Here we can welcome vagueness back in. This factor has been variously named: negative emotionality, distress, dysphoria, neuroticism (the one I miss) and anxious misery6 (now my favorite).
Treatment development & the DSM
This conspicuous overlap between anxiety and depression relates to another major problem in the field of psychotherapy. Clinical researchers have put enormous energy into developing disorder-specific treatments aligned with the diagnostic manual, resulting in separate treatments for anxiety and depression. Thus we have a proliferation of “empirically supported treatments”—indeed, we have so many of these treatments that therapists cannot possibly learn them all, or even a significant subset of them.11
Accordingly, there is a counter move toward “integrative” treatments, which are consistent with the overlap among ostensibly separable disorders. Keenly aware of the overlap between anxiety and depression, David Barlow has proposed a Unified Protocol for the treatment of “emotional disorders” based on cognitive-behavioral treatments.12, 13 Being content with even more vagueness, I have argued for a return to “Plain Old Therapy” (POT).14-16
Frustration with the diagnostic manual is widely shared by mental health professionals, psychiatrists and psychologists alike. I do not want to appear dismissive of the manual; research on its categories has moved understanding and treatment forward dramatically—ironically, in part by revealing the problems with the categories, a process that leads to continual refinement.
The overlap between depression and anxiety that has flummoxed me is a case in point. A workgroup devoted to sorting out this problem in the next iteration of the manual, DSM-V,17 has contributed to considerable refinement in our understanding that promises to lead to helpful revisions.18 The current proposal for DSM-V includes mixed anxiety-depressive disorder as a bona fide diagnosis, now listed under depressive disorders rather than anxiety disorders NOS. Yet this mixed disorder will be applied only to patients who do not meet full criteria for major depression.
Thinking more like psychologists, the workgroup is considering another straightforward proposal: including a rating of severity of anxiety for persons with major depression. Apart from a categorical diagnosis, this additional assessment of anxiety severity is important, because severe anxiety intermingled with depression can prolong the course of the depressive episode, create greater disability, contribute to physical health problems and increase the risk of suicide.17
Hence this last proposal is perfect: this patient suffers from major depression and also is very very anxious. Neurotic indeed, with plenty of good company on this planet.
1. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.
2. Kessler RC, Gruber M, Hettema JM, Hwang I, Sampson N, Yonkers KA. Major depression and generalized anxiety disorder in the National Comorbidity Survey follow-up survey. In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:139-170.
3. Fergusson DM, Horwood LJ. Generalized anxiety disorder and major depression: Common and reciprocal causes. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:179-189.
4. Goldberg D. The relationship between generalized anxiety disorder and major depressive episode. In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:355-361.
5. Goldberg D. Psychometric aspects of anxiety and depression. In: Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010:109-123.
6. Watson D. Differentiating the mood and anxiety disorders: A quadripartite model. Annual Review of Clinical Psychology. 2009;5:221-247.
7. Andrews G, Charney DS, Sirovatka PJ, Reiger DA, eds. Stress-induced and fear circuitry disorders: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2009.
8. Watson D. Mood and temperament. New York: Guilford; 2000.
9. Meehl PE. Hedonic capacity: Some conjectures. Bulletin of the Menninger Clinic. 1975;39:295-307.
10. Styron W. Darkness visible. New York: Random House; 1990.
11. Chambless DL, Ollendick TH. Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology. 2001;52(685-716).
12. Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotional disorders. Behavior Therapy. 2004;35:205-230.
13. Wiliamoska ZA, Thompson-Hollands J, Fairholme CP, Ellard KK, Farchione TJ, Barlow DH. Conceptual background, development, and preliminary data from the unified protocol for transdiagnostic treatment of emotional disorders. Depression and Anxiety. 2010;27:882-890.
14. Allen JG. Is psychotherapy going to POT? SayNoToStigma.com. Houston, TX: The Menninger Clinic; July 21, 2010.
15. Allen JG. Can we grow more potent POT? SayNoToStigma.com. Houston, TX: The Menninger Clinic; August 9, 2010.
16. Allen JG. Preserving hope. Bulletin of the Menninger Clinic. 2011;75:185-204.
18. Goldberg D, Kendler KS, Sirovatka PJ, Regier DA, eds. Diagnostic issues in depression and generalized anxiety disorder: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing; 2010.