Proposed Diagnostic Criteria for Mixed Anxiety Depression

The patient has three or four of the symptoms of major depression (which must include depressed mood and/or anhedonia), and they are accompanied by anxious distress. The symptoms must have lasted at least 2 weeks, and no other DSM diagnosis of anxiety or depression must be present, and they are both occuring at the same time.

Anxious distress is defined as having two or more of the following symptoms: irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen.

Proposal for a DSM-5 Diagnosis of “Mixed Anxiety Depression”

This diagnosis has been in the Appendix of DSM-IV, and is in the ICD-10. It has not previously been defined precisely. (The ICD definition states that symptoms of both anxiety and depression are both present, but neither set of symptoms, considered separately is sufficient to justify a diagnosis).

The advantages of this proposal are that it ensures that symptoms of both disorders are indeed present and distressing (cf DSM-IV), and the ambiguity of the ICD-10 criteria are also avoided.

Where the criteria came from

The anxious distress symptoms came partly from the Promis anxiety scale ¹, and partly from the GAD-7 ² . Some of the items from the Promis were difficult to translate into other languages (Chinese, Italian) and thus a GAD-7 item replaced them. It was necessary to modify the wording of the Promis itemJustification for the diagnosis

Fifty eight percent of depressed probands displayed anxiety symptoms that met DSM-III criteria for agoraphobia, panic disorder, or generalized anxiety disorder. In two thirds of these, the anxious symptoms were associated with depressive episodes ³. There is much convergent evidence that anxious symptoms during a depressive episode are associated with a longer time in episode ^{4 - 7}.  Depressives who are co-morbid with anxiety have a higher suicide risk than depression on its own ^{8 – 11}. At one year follow-up in primary care settings, half the case of MADD have progressed to symptomatic status for MDD, GAD pr MDD + GAD, the other half have remitted ¹². This remission rate is closeley comparable to that for GAD and MDD, but higher than that for co-morbid GAD and MDD. In psychiatric out-patient settings, the diagnosis was relatively stable, but disabling and half were also suffered from chronic physical health problems ^{13, 14}. In the DSM-IV field trials it was found that affective symptoms that did not meet definitional thresholds for DSM-III-R axis I disorders were at least as common as patients with several of the already established anxiety and mood disorders in each of the seven sites, and their disorders were associated with significant distress or impairment ¹⁵. In the UK National Surveys of psychiatric morbidity 8.8% of the population was found to satisfy ICD-10 criteria, for MADD, to be compared with only 7.7% satisfying diagnostic criteria for MDD, GAD or a combination. The impact of MADD on health related QOL was similar to that for anxiety disorders, and greater than for the non-cases. Twelve percent of those with MADD reported lifetime suicide attempts. MADD accounted for 20% of all disability days in the UK, and about half of all those due to a common mental disorder ¹⁶. Finally, a taxometric analysis found that each taxometric procedure (MAXCOV, MAMBAC) identified a taxon with a prevalence of 13% +/- 2%, and found that the taxon was predictive of the development of mood and anxiety disorders over a 14-month longitudinal follow-up ¹⁷. The validity of the concept rests upon  shared genetic risk factors for anxiety and depression ¹⁸, on the high co-morbidity between GAD and MDD ¹⁹,  and on a shared temperamental factors, negative affect for both of them ²⁰.

Behavioral Severity Dimensions: Anxiety

Rationale: There is mounting evidence that co-morbid anxiety and possibly the severity of anxiety symptoms may have a major influence on the treatment outcome of mood disorders, in terms of treatment response and a high risk of suicide and suicide attempts. While co-morbid anxiety disorders diagnosis may be made, they do not capture all of the co-morbid anxiety because of the asymmetry of criteria (e.g. two weeks of criteria symptoms for major depression and 6 months of criteria symptoms for Generalized Anxiety Disorder. Anxiety occurring as a component of a Mood disorder is not captured). Also the severity of the anxiety is not captured by a co-morbid diagnosis. The addition of an anxiety severity dimension may increase clinical awareness and increase the focus of treatment on the severity of co-morbid anxiety as a part of treatment planning, and possibly to the development of more effective treatments for co-morbid anxiety in the mood disorders and perhaps other disorders.

At present, the Mood Workgroup is considering a simple method by which a clinician is able to rate anxiety severity on a single dimension, useful for both mixed anxiety depression and major depression accompanied by anxiety:

Anxious Distress- defined as 3 or more of the above anxious symptoms. 

4. Severely anxious with motor agitation

Behavioral Dimensions: Anxiety ( continued option #2 )

Mixed Anxiety Depression is currently listed in Appendix B of DSM-IV: “Criteria Sets and Axes for Further Study.”  The work group is proposing that this disorder be moved from the Appendix to a free-standing diagnosis in DSM-5.