I miss neurosis. It’s long gone from the official manual for psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders, now in its fourth iteration, DSM-IV.1 Unfortunately, taking neurosis out of the manual has not eradicated it from the human condition. I can attest to that fact from personal experience, and I’ve had many occasions to observe it in others.
The concept of neurosis was too tied to psychoanalysis, and the diagnosticians deliberately aspired to divorce diagnoses from any particular psychological theory. More germane to this blog post, however, the concept of neurosis was too vague. The diagnosticians properly strived to make psychiatric diagnoses as precise as possible. Precision fosters agreement. It’s important for patients that diagnosticians agree on their condition, and it’s important for researchers that different research projects are all studying patients with disorder x defined in the same way. We have enough disagreement in research results as it is, without having even more due to the fact that different studies are conducted with dissimilar groups of patients ostensibly with the same disorder. Here’s an irony: The quest for precision has backfired when it comes to eliminating neurosis. The diagnostic manual has separated problems that belong together. We need more vagueness.
At The Menninger Clinic, the research department routinely administers the Structured Clinical Interviews for DSM-IV Disorders2, 3 to all patients. The systematic and thorough nature of these interviews aids the clinical process. We do not use research interviews to make final diagnoses—that’s up to the treating psychiatrist, as it should be. Rather, the results of the interviews inform the treating psychiatrist’s diagnosis, along with much other information about the patient. Yet doing these diagnostic interviews, while endeavoring to hew to precise rules, has us occasionally aspiring to do something akin to figuring out how many angels can dance on the head of a pin. One such challenge pertains to neurosis.
Depression + anxiety
Here’s what drives me nuts. Our most common diagnosis at The Clinic is major depressive disorder (MDD). Extensive research attests to two facts. First, in combination with genetic vulnerability and a history of stress exposure, episodes of major depression commonly are triggered by stressful life events and difficulties.4, 5 Second, although the depressed person may appear inactive and placid, this appearance is misleading; depression is a high-stress state, as evidenced by patterns of brain activity associated with stress6 and elevated stress hormones.7 Hence many patients who are in the midst of depressive episodes also are anxious. Yet, despite their conspicuous anxiety, by precise criteria many of these patients with major depression do not qualify for a diagnosis of a specific anxiety disorder, such as generalized anxiety disorder (GAD), obsessive-compulsive disorder, social phobia or posttraumatic stress disorder. We can resort to what we sometimes derogate as a “wastebasket” diagnosis, anxiety disorder not otherwise specified (NOS). But this seems like a cop-out and isn’t very satisfying—vagueness indeed!
Depression trumps anxiety
This paragraph you are about to read (or quit reading) will give you a taste of the complexities in diagnosing psychiatric disorders. Here’s our trap: One basis for diagnosing anxiety disorder NOS is the presence of a mixed anxiety-depressive disorder.1 This highly appealing option seems to get us off the hook. But there’s a catch: We cannot make this diagnosis when the patient’s symptoms meet the criteria for a specific mood disorder or a specific anxiety disorder. So, if they have major depression, we can’t diagnose mixed anxiety-depressive disorder. Moreover, patients with MDD cannot also be diagnosed with GAD—even if they meet the criteria—if their anxiety is confined to the time frame of the depressive episode. Depression trumps anxiety, for reasons that are unclear.8
To complicate matters even further, the time frames for diagnosing MDD and GAD differ: two weeks of symptoms are required for MDD and six months for GAD, a problem that confounds research on their overlap.8, 9 Furthermore, it seems arbitrarily to put mixed anxiety-depressive disorder into the anxiety disorder group rather than the mood disorder group. Moreover, while tucked into anxiety disorder NOS, the mixed anxiety-depressive disorder also is relegated to an appendix of the diagnostic manual, “Criteria Sets and Axes Provided for Further Study.” It’s unofficial.
Here’s the analogue to how many angels can dance on the head of a pin: How much more anxious must a patient with major depression be beyond the ordinarily highly anxious depressed person to qualify for an additional diagnosis of anxiety disorder NOS which, technically, we shouldn’t be using anyway? Sometimes I feel like throwing away the book! I’ll point to a way out of these traps in a subsequent post, “Anxious Misery.”
1. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.
2. First MB, Spitzer RL, Gibbon M, Williams JBW. User’s guide for the Structured Clinical Interview for DSM-IV Axis I disorders: Clinician version, SCID-I. Washington, DC: American Psychiatric Press; 1997.
3. First MB, gibbon M, Spitzer RL, Williams JBW, Benjamin LS. User’s guide for the Structured Clinical Interview for DSM-IV Axis II personality disorders: SCID-II. Washington, DC: American Psychiatric Press; 1997.
4. Brown GW, Harris TO. Social origins of depression: A study of psychiatric disorder in women. New York: Free Press; 1978.
5. Hammen C. “Stress and depression.” Annual Review of Clinical Psychology. 2005;1:293-319.
6. Drevets WC. “Prefrontal cortical-amygdalar metabolism in major depression.” Annals of the New York Academy of Sciences. 1999;877:614-637.
7. Nemeroff CB. “Psychopharmacology of affective disorders in the 21st century.” Biological Psychiatry. 1998;44:517-525.
8. Goodyer IM. “Episodes and disorders of general 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; 2010:257-269.
9. Moffitt TE, Caspi A, Harrington H, et al. “Generalized anxiety disorder and depression: Childhood risk factors in a borth cohort followed to age 32 years.” 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; 2010:217-239.