Mixed anxiety-depressive disorder

A typical example of diagnostic splintering provides the group of mood disorders. One reads about major depression, minor depression, double depression, dysthymia, unipolar and bipolar depression, depressive personality, depression not otherwise specified, brief recurrent depression, subsyndromal symptomatic depression, mixed anxiety depression disorder, seasonal depression, and adjustment disorder with depressive mood. 

Comorbid anxiety and depressive features are common in clinical practice, and DSM-IV has included mixed anxiety-depression in its appendix of conditions needing nosological refinement. The presence of comorbid anxiety has prognostic implications. For example, prospective studies of patients with depression have found that the co-occurrence of panic attacks was correlated with a poor outcome (Coryell et al. 1988 van Valkenburg et al. 1984). Some evidence suggests that such patients do better with MAOls. Likewise, patients with depression and obsessive-compulsive disorder may be more resistant to treatment, even with SSRls (Hollander et al. 1991)... 

The anxiolytic activity of several compounds in some, but not all, animal models of anxiety in fact suggests that different receptor subtypes may modulate different types of anxiety as discussed below. It would not be surprising if the specific serotonin links to disorders of anxiety also differ among the various disorders of anxiety such as generalized anxiety versus obsessive-compulsive disorder versus panic disorder versus social phobia versus mixed anxiety depression. Such studies are in progress, and much further research is necessary to clarify the potential links between subtypes of anxiety and subtypes of serotonin receptors. 

Beta-adrenoceptor antagonists, particularly propranolol, have been shown to be effective for anxiety symptoms particularly in situational anxiety and GAD. Buspirone, an azaspirodecanedione, is an agonist at 5-HTlA receptors and seems to have anxiolytic effects, though it is less potent than the BDZs and the effects take up to three weeks to become evident. There is high first pass metabolism and a considerable proportion of the effect is due to a metabolite (1-PP). The principal adverse effects of buspirone are nausea, gastrointestinal upset and headache. Antidepressant drugs, both the older tricyclic antidepressants and the newer drugs, have been demonstrated to have anxiolytic effects in mixed anxiety-depressive patients, GAD and panic disorder. 

FIGURE 8-1. Anxiety and depression can be combined in a wide variety of syndromes. Generalized anxiety disorder (GAD) can overlap with major depressive disorder (MDD) to form mixed anxiety depression (MAD). Subsyndromal anxiety overlapping with subsyndromal depression to form subsyn-dromal mixed anxiety depression, sometimes also called anxious dysthymia. Major depressive disorder can also overlap with subsyndromal symptoms of anxiety to create anxious depression GAD can also overlap with symptoms of depression such as dysthymia to create GAD with depressive features. Thus, a spectrum of symptoms and disorders is possible, ranging from pure anxiety without depression, to various mixtures of each in varying intensities, to pure depression without anxiety. 

FIGURE 8—6. Subsyndromal mixed anxiety depression (MAD) may be an unstable psychological state, characterized by vulnerability under stress to decompensation to more severe psychiatric disorders, such as generalized anxiety disorder (GAD), full-syndrome MAD, or major depressive disorder (MDD). 

F43.2 Adjustment disorders. 20 Brief depressive reaction. 21 Prolonged depressive reaction. 22 Mixed anxiety and depressive reaction. 23 With predominant disturbance of other emotions. 24 With predominant disturbance of conduct. 25 With mixed disturbance of emotions and conduct. 28 With other specified predominant symptoms... 

The usually accepted prevalences for generalized anxiety disorder (GAD) are around 1.6% for current, 3.1% for 1 year and 5.1% lifetime (Roy-Byrne, 1996). The condition is twice as common in women as in men (Pigott, 1999). A small minority (10%) have GAD alone, and about the same proportion suffer from mixed anxiety and depression. Morbidity is high. About a half of those with uncomplicated GAD seek professional help, but two-thirds of those with comorbid GAD do so. Up to a half take medication at some point. The condition may coexist with other anxiety disorders such as phobias, with affective disorders, or with medical conditions such as unexplained chest pain and irritable bowel syndrome. 

In this chapter we reviewed taxometric studies in domains of psychopathology that only recently attracted the attention of taxometricians eating disorders, depression, anxiety, personality disorder, and issues surrounding comorbidity. In all these areas the findings are mixed, and it is impossible to offer a verdict about the taxonic status of any of these forms of psychopathol-... 

Depression, generalized anxiety disorder (GAD) PO 10 mg/day Uniabeied Uses Mixed anxiefy and depressive disorder Contraindications Usewifhin 14 days of MAOIs... 

Whereas such data exist for MDD and the various anxiety-related disorders, such data do not exist for the proposed mixed anxiety and depression category. 

Bipolar affective (manic-depressive) disorder occurs in 1-3% of the adult population. It may begin in childhood, but most cases are first diagnosed in the third and fourth decades of life. The key symptoms of bipolar disorder in the manic phase are excitement, hyperactivity, impulsivity, disinhibition, aggression, diminished need for sleep, psychotic symptoms in some (but not all) patients, and cognitive impairment. Depression in bipolar patients is phenomenologically similar to that of major depression, with the key features being depressed mood, diurnal variation, sleep disturbance, anxiety, and sometimes, psychotic symptoms. Mixed manic and depressive symptoms are also seen. Patients with bipolar disorder are at high risk for suicide. 

Mood symptoms of depression are associated with many conditions in addition to major depressive disorder, including mood and anxiety symptoms in schizophrenia, schizoaffective disorder, bipolar manic/depressed/mixed/rapid cycling states, organic mood disorders, psychotic depression, childhood and adolescent mood disorders, treatment-resistant mood disorders, and many more (see Chapter 10, Fig. 10-6). Atypical antipsychotics are enjoying expanded use for the treatment of symptoms of depression and anxiety in schizophrenia that are troublesome but not severe enough to reach the diagnostic threshold for a major depressive episode or anxiety disorder in these cases the antipsychotics are used not only to reduce such symptoms but hopefully also to reduce suicide rates, which are so high in schizophrenia (Fig. 11 — 53). Atypical antipsychotics may also be useful adjunctive treatments to anti-... 

The mood and anxiety disorders in their various permutations constitute a major source of personal suffering and impaired ability to engage in productive Avork and interpersonal relationships. Between 5 and 9% of women and between 2 and 3% of men meet the diagnostic criteria for major depression at any time 10-25% of all women suffer major depression sometime in their lives, while 5-10% of men will develop major depressive disorder (American Psychiatric Association, 1994). The anxiety disorders obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), panic disorder, and generalized anxiety disorder (GAD) show lifetime prevalence rates of approximately 2.5%, 7%, 2.5%, and 5% respectively. Between 3 and 13% of individuals in community samples are regarded to meet the diagnostic criteria for social phobia. Mood and anxiety disorders are common comorbidities (American Psychiatric Association, 1994) and the most common antidepressant medications including the serotonin reuptake inhibitors, the mixed serotonin-catecholamine reuptake inhibitors, the tricyclic antidepressants, and the monoamine oxidase inhibitors, are all effective treatments for anxiety and panic attacks. 

In general, anxiety disorders are a group of heterogeneous illnesses that develop before age 30 and are more common in women, individuals with social issues, and those with a family history of anxiety and depression. Patients often develop another anxiety disorder, major depression, or substance abuse. The clinical picture of mixed anxiety and depression is much more common than an isolated anxiety disorder. ... 

The drug exerts its therapentie aetion to eombat various types of anxiety disorders viz., generalized anxiety disorders, panie attaeks, phobie disorders, obsessive-compulsive disorder, post-tranmatic stress disorder, and mixed anxiety and depressive disorders. Perhaps the drug acts as a atypical antisychotic agent by virtue of its reduced tendency to produce the extrapyramidal effects. 

A 22-year-old man who had had ADHD since the age of 8 years took methylphenidate, and had an adequate response for 14 years (52). However, his symptoms worsened and he switched from methylphenidate to mixed amfetamine salts 20 mg bd. A month later he continued to have difficulty in focusing on tasks, and the dosage was eventually increased to 45 mg tds over several weeks, with symptomatic improvement. However, 5 days later, he awoke feeling nauseated and agitated and had choreiform movements of his face, trunk, and limbs. He had also taken escitalopram 10 mg/day for anxiety and depression for 2 months before any changes in his ADHD medications. He was treated with intravenous diphenhydramine, lora-zepam, and diazepam without improvement in the chorea. Amfetamine was withdrawn and 3 days later his chorea abated. He restarted methylphenidate and the movement disorders did not recur. 

Favorable tolerability profile leading to off-label uses for many indications other than schizophrenia (e.g., acute bipolar mania bipolar II disorder, including hypomanic, mixed, rapid cycling, and depressed phases treatment-resistant depression anxiety disorders)... 

Currently, the benzodiazepines and the SSRIs are the most commonly employed pharmacotherapies for common clinical anxiety disorders see Chapter 16). Benzodiazepines sometimes are given to patients presenting with anxiety mixed with symptoms of depression, although their efficacy in altering the core features of severe major depression has not been demonstrated. 

Although psychogenic erectile dysfunction was historically considered to be the most common cause, mixed disorders are most common. Psychogenic erectile dysfunction can be caused by performance anxiety, strained interpersonal relationships, lack of sexual arousability, and overt psychiatric disorders such as depression and schizophrenia. Several studies have confirmed the strong relationship between depression and sexual dysfunction (Araujo et al. 1998 Shabsigh et al. 1998). 

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