There’s a new diagnosis in the DSM-5 called anxious distress. But is this truly a new diagnosis, or just another way of defining depression? This month, we spoke with Mark Zimmerman, MD, a clinician and leading researcher on the topic of anxious distress, to get some answers.
TCPR: We’ve been learning about a new understanding or new diagnosis of combined anxiety and depression, which the DSM-5 is calling anxious distress. Can you give us your take?
Dr. Zimmerman: Well, it’s a new specifier. Is it a new diagnosis? That’s something that research is being done on right now. To what degree does it agree with other ways of defining anxious depression? Details on that are just beginning to emerge. We just published a paper looking at the concordance between the DSM anxious distress specifier and the Hamilton Depression Scale (HAM-D) anxiety somatization factor, and that approach toward identifying anxious distress (Zimmerman M et al, J Nerv Ment Dis 2018;206(2):152–154). We found that, while they’re significantly related, the degree of co-occurrence between the two is rather modest, if not poor. But the research into this is just beginning.
TCPR: Can you tell us more about depression with anxious distress? How do you diagnose it exactly, and what are the criteria?
Dr. Zimmerman: There are five criteria: feeling keyed up or tense, feeling unusually restless, impaired concentration, feeling that something awful will happen, and feeling that you might lose control. Regarding the concentration item, it’s not just the major depressive disorder (MDD) criterion of impaired concentration; rather, the individual is supposed to attribute it to being anxious or worrying.
TCPR: How are those symptoms related to the typical anxiety disorders or the discrete anxiety disorders? It sounds like they are similar to generalized anxiety.
Dr. Zimmerman: Absolutely; they are similar. Several of them are diagnostic criteria for generalized anxiety disorder. However, only two-thirds of the individuals who meet the anxious distress specifier are also diagnosed with generalized anxiety disorder, and one-third of the individuals who are not diagnosed with the anxious distress specifier are diagnosed with generalized anxiety disorder. So, it’s not completely concordant. The other anxiety disorder that it seems related to is panic disorder—that fear of losing control.
TCPR: So, how is this new specifier helpful for practicing psychiatrists?
Dr. Zimmerman: I think its potential importance is in simplifying the assessment of anxiety. Rather than having to go through and assess all of the anxiety disorders, it would be much simpler to assess the five anxious distress criteria. There are a number of studies that show how comorbidity gets missed and is not diagnosed in routine clinical practice. We published one study that looked specifically at the issue of recognizing anxiety disorders in depressed patients and found that all anxiety disorders are under-recognized (Zimmerman M and Chelminski I, J Psychiatr Res 2003;37(4):325–333). Social phobia, by the way, is the most frequently underdiagnosed and under-recognized anxiety disorder—we learned that by comparing the frequency of diagnoses based on unstructured clinical interviews with diagnoses based on semi-structured interviews. So, in routine clinical practice, comorbid disorders get missed. Considering that, what may be most helpful with this specifier is that it is more clinically useful than assessing all the anxiety disorders.
TCPR: Based on the five criteria you mentioned earlier, can you talk about how we would then assess whether patients are suffering from anxious distress?
Dr. Zimmerman: I’d start by assessing their mood state, and I would establish the negative mood states of depression—you know, the sadness, as well as establishing the presence or absence of anxiety and whether they tend to worry about things. I’d inquire about their ability to focus and concentrate, and if they say concentrating is an issue, then I’d ask them what they attribute that to, and to what degree they have problems concentrating. Is it because their mind is on the things that they are anxious about? So, I think it would be relatively straightforward like that.