Mixed anxious-depressive disorder: definition, causes and treatment

Mixed anxious-depressive disorder has aroused great controversy in its conception and has not been included in all existing diagnostic classifications. It is not that its existence is not recognized, but sometimes it has been considered that it is either a depressive disorder with secondary anxious characteristics and not a single disorder.

In mixed anxious-depressive disorder Symptoms of anxiety and depression are present, but none of them clearly predominates nor is it of sufficient intensity to justify a separate diagnosis.

This disorder is manifested by a mixture of comparatively mild symptoms that are seen frequently in primary care, its prevalence being even higher in the general population.

The combination of depressive and anxiety symptoms causes a significant deterioration in the functioning of the affected person. However, opponents of this diagnosis have argued that its availability discourages clinicians from taking the time necessary to take a complete psychiatric history. A story that in turn allows us to differentiate true depressive disorders from anxiety disorders.

When is mixed anxiety-depressive disorder diagnosed?

To make the diagnosis it requires the presence of anxiety symptoms and low intensity depression. In addition, there must be some vegetative symptoms such as tremors, palpitations, dry mouth and a feeling of gastric discomfort.

However, general practitioner sensitivity for mixed anxiety-depressive disorder syndrome is low. Therefore, it is possible that this lack of recognition solely reflects the lack of an appropriate diagnostic label for these patients.

Depression and anxiety: common and differential aspects

It is well known by specialists that Anxiety and depression share several symptoms that rarely occur completely separately.. That is why specialists have focused on identifying what aspects they have in common and where they diverge.

Below, we show what they share and how they differ.

Points in common:

High negative affect. In both disorders there is a lot of emotional pain, irritability, feelings of guilt and low mood.Low self-esteem. In both anxiety and depression, the person has low self-esteem that generates great helplessness and they believe that they are not capable of coping with life.

Differences:

Anhedonia or lack of energy. This trait is more characteristic of depression and does not appear in people with pure anxiety.The hyperarousal It is more typical of anxiety. People who suffer from it usually experience overexcitement because they anticipate things that are to come or have to be done, even if this overexcitement is of no use to them. In a person with depression, energy levels decrease, therefore, there is no hyperactivation.

These are some common and differential aspects of both disorders, but What happens when both appear at the same time?

Symptoms of mixed anxiety-depressive disorder

The clinical manifestations of this condition combine symptoms of anxiety disorders and depressive disorders. Besides, Symptoms of hyperactivity of the autonomic nervous system, such as gastrointestinal discomfort, are commonand contribute to the fact that these patients are frequently treated in medical outpatient clinics.

DSM-IV Research Criteria for Mixed Anxious-Depressive Disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM) proposes a series of criteria to make the diagnosis of this disorder. On the other hand, as we have already mentioned, it is done solely for research purposes. Let’s see them:

The essential characteristic of this disorder is a persistent or recurrent dysphoric mood that lasts at least 1 month. This mood is accompanied by additional symptoms of identical duration, including at least four of the following:

Difficulties with concentration or memory, sleep disorders, fatigue or lack of energy.Marked irritability.Recurrent and intense worry.Easy crying, hopelessness or pessimism about the future and low self-esteem or feelings of worthlessness.Hypervigilance, anticipation of danger.

These symptoms cause significant clinical distress or impairment in social, occupational, or other important areas of the person’s functioning. On the other hand, mixed anxiety-depressive disorder should be ruled out when the symptoms are due to the direct physiological effects of a substance or a medical illness, or if at some point the individual has met the diagnostic criteria for major depressive disorder, dysthymic disorder. , panic disorder or generalized anxiety disorder.

Nor should the diagnosis be established if the criteria for any other anxiety or mood disorder are met at the same time, even if they are in partial remission.

It is also necessary that the symptomatic condition cannot be better explained by the presence of another mental disorder. Most of the initial information on this entity has been collected in primary care centers, where the disorder appears to be more common; It is probably also more prevalent among outpatients.

Diagnostic criteria for mixed anxious-depressive disorder, according to the ICD-10

For its part, the tenth edition of the International Classification of Diseases (ICD-10) does recognize mixed anxiety-depressive disorder as a diagnostic category.

In this case, Mixed anxiety-depression disorder is diagnosed when symptoms of both anxiety and depression exist, but neither of them are severe enough to make an individual diagnosis.

Therefore, if symptoms of anxiety and depression occur together, and are severe enough to justify separate diagnoses, both should be recorded and, therefore, this category should not be used.

In this case, The clinical manifestations are the same as those previously presented by the DSM-IV.

What is the incidence of mixed anxiety-depressive disorder?

The coexistence of major depressive disorder and panic disorder is very common. Two-thirds of patients with depressive symptoms have clear symptoms of anxiety. One third may meet the diagnostic criteria for panic disorder.

Some researchers have reported that 20% to 90% of all patients with panic disorders have episodes of major depressive disorder. These data suggest that the coexistence of depressive and anxiety symptoms is very common.

However, formal epidemiological data for mixed anxiety-depressive disorder are not available at this time. In this sense, some researchers have estimated that The prevalence of this disorder in the general population is 10% and in primary care it reaches 50%. More conservative estimates suggest a prevalence of 1% in the general population.

Why does this disorder occur?

Four experimental lines suggest that anxiety and depressive symptoms are linked to identified causes.

First of all, several researchers have found Similar neuroendocrine causes in depressive and anxiety disorders. These include flattening the cortisol response to adrenocorticotropic hormone; flattening of the growth hormone response to clonidine; and flattening of thyroid-stimulating hormone and prolactin responses to thyrotropin-releasing hormone.

Second, several researchers have presented data that identifies hyperactivity of the noradrenergic system as a relevant factor in the origin of depressive and anxiety disorders of some patients.

Specifically, these studies have found that depressed and panic disorder patients who were actively experiencing a panic attack present elevated concentrations of the norepinephrine metabolite MHPG in urine, plasma, or cerebrospinal fluid.

As with other anxiety and depressive disorders, Serotonin and GABA may also be associated with the origin of mixed anxiety-depressive disorder.

In third place, Many studies have found that serotonergic drugs, such as fluoxetine and clomipramine, are useful in the treatment both depressive disorders and anxiety disorders.

Finally, several family studies have presented data indicating that Anxiety and depressive symptoms are genetically linked, at least in some families.

Course and forecast

Based on current clinical information it appears that at baseline, patients may be equally likely to have predominantly anxiety symptoms or predominantly depressive symptoms, or a proportional mix of these.

During the course of the disease, anxiety and depressive symptoms would alternate in their predominance. The prognosis is not yet known.although separately depressive and anxious disorders tend to become chronic without adequate psychological treatment.

Treatment of mixed anxiety-depressive disorder

As there are no adequate studies comparing treatment modalities for mixed anxiety-depressive disorders, clinicians tend to provide appropriate treatment based on symptom presentation, severity, and prior experience with different treatment modalities.

Psychotherapeutic approaches can be time-limited, such as cognitive or behavioral therapiesalthough some clinicians use a less structured psychotherapeutic approach, such as insight psychotherapy.

Pharmacotherapy

Pharmacological treatment of mixed anxiety-depressive disorders is scheduled with anxiolytics, antidepressants, or both. Among anxiolytics, some data indicate that the use of triazolobenzodiazepines (for example, alprazolam) could be indicated, due to their effectiveness in the treatment of depression associated with anxiety.

Substances that affect the 5-HT receptor, such as buspirone, may also be indicated. Among antidepressants, serotonergics (for example, fluoxetine) can be very effective in the treatment of mixed anxiety-depressive disorder.

Psychological treatment

Anyway, The treatment of choice for this type of pathology is cognitive-behavioral psychotherapy.. On the one hand, it is about the patient being able to first reduce her level of physiological activation. This is achieved through breathing techniques (e.g. diaphragmatic breathing) and relaxation techniques (progressive muscle relaxation, autogenic training, mindfulness, etc.).

In second place, it is necessary for the patient to improve his mood. This can be achieved in different ways. The…