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Anxious Distress: A New DSM Diagnosis
Mark Zimmerman, MD
Director of the Partial Hospital Program and Adult Outpatient Psychiatry at Rhode Island Hospital
Dr. Zimmerman has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.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.
TCPR: How prevalent is impaired concentration?
Dr. Zimmerman: Impaired concentration is one of the more frequent signs of MDD. Obviously, low mood is the most frequent, but impaired concentration is up there. In our research, we found that three-quarters of individuals within a major depressive episode reported experiencing impaired concentration due to worry (Zimmerman M et al, J Nerv Men Dis 2006; 194(3):158–163).
TCPR: Can you tell us how you assess for the criterion of feeling keyed up?
Dr. Zimmerman: We follow the typical approach used in semi-structured interviews, and that is to ask direct questions. So, we would ask, “Have there been times when you’ve felt keyed up or tense?” And then, because we are interested in rating severity, we would ask, “How often did you feel this way?” and, “How strong was the feeling?”
TCPR: What would you ask the patient to assess the criterion of feeling unusually restless?
Dr. Zimmerman: In that case, we would ask, “Have you felt restless? Is it hard to sit still?” And if it’s not observed in the interview, we would inquire whether while at home the person often gets up just to walk around due to feeling so restless.
TCPR: And how about the fear that something awful might happen?
Dr. Zimmerman: We straightforwardly ask the patient, “Have you had a sense that something terrible might happen?” We then follow up and inquire, “Can you tell me anything in particular about that?”
TCPR: Finally, what should we ask to determine loss of control? What do you say to a patient who asks, “What do you mean by losing control?”
Dr. Zimmerman: What I ask is, “Have you felt like you were not going to be able to control your behavior and just lose it? Do you feel like you’re having a nervous breakdown? Do you feel like you can’t control your emotions?”
TCPR: To arrive at a diagnosis of anxious distress, do patients need to meet all 5 criteria?
Dr. Zimmerman: No, only 2 of the 5, which is why I suspect all studies have found that somewhere between 55% and 75% of individuals meet the criteria for anxious distress. In fact, in a recent JAMA Psychiatry issue, there is a report from the NESARC study of MDD in the community. This is the first community sample of individuals who were diagnosed with depression, and a little bit more than 70% of those in a major depressive episode met the anxious distress specifier (Hasin DS et al, JAMA Psychiatry 2018;10.1001.4602).
TCPR: So, anxious distress is a pretty prevalent thing, and my guess is that it will be diagnosed even more by psychiatrists going forward. Considering that, let’s talk about treatment. What are your thoughts here, and what is the literature telling us about medications?
Dr. Zimmerman: Efficacy cuts across a lot of different medications. And obviously, all these meta-analyses and pooled analyses indicate that the medication under study was effective for the anxious depressed patient. It’s important to point out that some of these trials could contain biases (Wang SM et al, Expert Rev Clin Pharmacol 2018;11(1):15–25). But there are a lot of medications to choose from, and there are reports on the effectiveness of vortioxetine, venlafaxine, imipramine, and mirtazapine, in addition to a report on quetiapine (Thase ME et al, Depress Anxiety 2012;29(7):574–586). There’s a lot of research touting the efficacy of SNRIs, SSRIs, and the newer generation of antidepressants.
TCPR: Was there any other interesting research you came across relating to medications?
Dr. Zimmerman: Yes. There was a study comparing bupropion and SSRIs, and they looked at the HAM-D anxiety somatization factor and found that SSRIs were better than bupropion. I don’t think clinicians are all that enthusiastic about prescribing bupropion to highly anxious depressed individuals, so this study confirmed that clinical intuition (Papakostas GI et al, J Clin Psychiatry 2008;69(8):1287–1292). We also published a paper back in 2004 looking at what factors influenced antidepressant choice. Anxiety was the most common factor that influenced clinicians prescribing, and clinicians clearly were disinclined to prescribe bupropion when anxiety was a determining factor in choosing a medication (Zimmerman M et al, Am J Psychiatry 2004;161(7):1285–1290).
TCPR: What about some treatment alternatives to psychopharmacology? What’s your view on psychotherapy for treating anxiety and depression?
Dr. Zimmerman: I’ll often start by either doing therapy myself or referring patients to other therapists. It’s only when the anxiety is overwhelming, more incapacitating, that I’m more willing to add a medication. But when the anxiety is uncomfortable and the individual is engaging in a lot of avoidance behavior, I’ll use therapy to try and overcome that tendency to avoid. And I don’t necessarily mean avoidance in the extreme phobic sense, but just avoiding things that are uncomfortable. I’ll talk to patients about how life is often uncomfortable, but they can’t run away from it. I tell them that it’s more a matter of learning how to manage it. Rather than avoiding it, what skills can be taught to help cope with it? Mainly, they are just avoiding dealing with the usual things in life—they need to pay the bills and the mail is piling up, for example. When they are avoiding dealing with the reality of the situation, of course they are just digging a deeper hole for themselves.
TCPR: Are there any final thoughts on the subject that you’d like to leave us with?
Dr. Zimmerman: I’m happy we touched on the psychotherapeutic aspect of this—I think that’s important. It’s not just about prescribing medication or picking another medication. In fact, with a number of individuals, when they come in to our partial hospital program, I begin a negotiation with them and say, “Let’s not start medication now. Let’s wait a couple of days. Let’s see how beneficial therapy can be and then we can reevaluate. I don’t want to deprive you of the opportunity of learning that you’re able to feel better without making any changes in medication.”
TCPR: Thank you for your time, Dr. Zimmerman.
General PsychiatryTCPR: 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.
TCPR: How prevalent is impaired concentration?
Dr. Zimmerman: Impaired concentration is one of the more frequent signs of MDD. Obviously, low mood is the most frequent, but impaired concentration is up there. In our research, we found that three-quarters of individuals within a major depressive episode reported experiencing impaired concentration due to worry (Zimmerman M et al, J Nerv Men Dis 2006; 194(3):158–163).
TCPR: Can you tell us how you assess for the criterion of feeling keyed up?
Dr. Zimmerman: We follow the typical approach used in semi-structured interviews, and that is to ask direct questions. So, we would ask, “Have there been times when you’ve felt keyed up or tense?” And then, because we are interested in rating severity, we would ask, “How often did you feel this way?” and, “How strong was the feeling?”
TCPR: What would you ask the patient to assess the criterion of feeling unusually restless?
Dr. Zimmerman: In that case, we would ask, “Have you felt restless? Is it hard to sit still?” And if it’s not observed in the interview, we would inquire whether while at home the person often gets up just to walk around due to feeling so restless.
TCPR: And how about the fear that something awful might happen?
Dr. Zimmerman: We straightforwardly ask the patient, “Have you had a sense that something terrible might happen?” We then follow up and inquire, “Can you tell me anything in particular about that?”
TCPR: Finally, what should we ask to determine loss of control? What do you say to a patient who asks, “What do you mean by losing control?”
Dr. Zimmerman: What I ask is, “Have you felt like you were not going to be able to control your behavior and just lose it? Do you feel like you’re having a nervous breakdown? Do you feel like you can’t control your emotions?”
TCPR: To arrive at a diagnosis of anxious distress, do patients need to meet all 5 criteria?
Dr. Zimmerman: No, only 2 of the 5, which is why I suspect all studies have found that somewhere between 55% and 75% of individuals meet the criteria for anxious distress. In fact, in a recent JAMA Psychiatry issue, there is a report from the NESARC study of MDD in the community. This is the first community sample of individuals who were diagnosed with depression, and a little bit more than 70% of those in a major depressive episode met the anxious distress specifier (Hasin DS et al, JAMA Psychiatry 2018;10.1001.4602).
TCPR: So, anxious distress is a pretty prevalent thing, and my guess is that it will be diagnosed even more by psychiatrists going forward. Considering that, let’s talk about treatment. What are your thoughts here, and what is the literature telling us about medications?
Dr. Zimmerman: Efficacy cuts across a lot of different medications. And obviously, all these meta-analyses and pooled analyses indicate that the medication under study was effective for the anxious depressed patient. It’s important to point out that some of these trials could contain biases (Wang SM et al, Expert Rev Clin Pharmacol 2018;11(1):15–25). But there are a lot of medications to choose from, and there are reports on the effectiveness of vortioxetine, venlafaxine, imipramine, and mirtazapine, in addition to a report on quetiapine (Thase ME et al, Depress Anxiety 2012;29(7):574–586). There’s a lot of research touting the efficacy of SNRIs, SSRIs, and the newer generation of antidepressants.
TCPR: Was there any other interesting research you came across relating to medications?
Dr. Zimmerman: Yes. There was a study comparing bupropion and SSRIs, and they looked at the HAM-D anxiety somatization factor and found that SSRIs were better than bupropion. I don’t think clinicians are all that enthusiastic about prescribing bupropion to highly anxious depressed individuals, so this study confirmed that clinical intuition (Papakostas GI et al, J Clin Psychiatry 2008;69(8):1287–1292). We also published a paper back in 2004 looking at what factors influenced antidepressant choice. Anxiety was the most common factor that influenced clinicians prescribing, and clinicians clearly were disinclined to prescribe bupropion when anxiety was a determining factor in choosing a medication (Zimmerman M et al, Am J Psychiatry 2004;161(7):1285–1290).
TCPR: What about some treatment alternatives to psychopharmacology? What’s your view on psychotherapy for treating anxiety and depression?
Dr. Zimmerman: I’ll often start by either doing therapy myself or referring patients to other therapists. It’s only when the anxiety is overwhelming, more incapacitating, that I’m more willing to add a medication. But when the anxiety is uncomfortable and the individual is engaging in a lot of avoidance behavior, I’ll use therapy to try and overcome that tendency to avoid. And I don’t necessarily mean avoidance in the extreme phobic sense, but just avoiding things that are uncomfortable. I’ll talk to patients about how life is often uncomfortable, but they can’t run away from it. I tell them that it’s more a matter of learning how to manage it. Rather than avoiding it, what skills can be taught to help cope with it? Mainly, they are just avoiding dealing with the usual things in life—they need to pay the bills and the mail is piling up, for example. When they are avoiding dealing with the reality of the situation, of course they are just digging a deeper hole for themselves.
TCPR: Are there any final thoughts on the subject that you’d like to leave us with?
Dr. Zimmerman: I’m happy we touched on the psychotherapeutic aspect of this—I think that’s important. It’s not just about prescribing medication or picking another medication. In fact, with a number of individuals, when they come in to our partial hospital program, I begin a negotiation with them and say, “Let’s not start medication now. Let’s wait a couple of days. Let’s see how beneficial therapy can be and then we can reevaluate. I don’t want to deprive you of the opportunity of learning that you’re able to feel better without making any changes in medication.”
TCPR: Thank you for your time, Dr. Zimmerman.
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