It’s no secret that Anxiety conditions and Depression co-occur. In fact, most researchers agree they co-occur at least 60% of the time. They’re so interrelated that most antidepressants are also often effective for anxiety; both conditions are highly associated with decreased serotonin. With these facts in mind, it’s no surprise that some people, when they experience an MDD episode, there is an onset of some specific anxiety that is congruent to the depression.

The presentation:

Depressed patients with anxious distress are not only down and out. They’re tormented by an inner restlessness and anticipating worst-case scenarios that compound the negative thinking already present from the depression. Unfortunately, it seems like anxious distress is more common than meets the eye. Researchers like Zimmerman et al. (2018) have noted that, in a sample of 260 people with MDD, 75% met criteria for the specifier; this was after controlling for co-occurring anxiety disorders. Imagine the compounded misery of the poor patient!

Consider the case of Liz:

Liz, a 26-year-old part-time college student, was no stranger to anxiety. She struggled with Social Anxiety Disorder (SAD) throughout her teens and 20’s. It made it tough for her to get through college, but she was gaining on it. Nonetheless, like many suffering from SAD, Liz was prone to Major Depressive episodes. For Liz, the episodes would come on when she began dwelling on how stalled her life was from SAD. So many peers were in careers and had a family already. She wondered if she’d ever make it. Liz made an appointment with Dr. H, her long-term psychologist, because the depression felt different this time. “Doc, I’ve dealt with being depressed, I’ve dealt with getting through socially anxious situations, but I’m not handling well whatever is happening to me this time,” she said on the voicemail to Dr. H. At her appointment, Dr. H noticed Liz not only going to that dark place again, but she also appeared to have a tense jaw and was prone to hand wringing; she looked very uneasy on top of being depressed. Liz confessed that the past couple of weeks she’s increasingly dreading that she will never get out from under this psychological roller coaster. “I’m so stuck!” she lamented, noting she worries about the depression never ending and being alone forever. “It seems so futile, I may as well give up,” Liz mumbled through tears.

Courtesy of page 184 in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the criteria for With Anxious Distress are:

  • Poor concentration due to worry
  • Feeling tense
  • Restlessness
  • The feeling something bad will happen
  • The feeling of losing control.

Symptoms must be present more days than not during the Major Depressive episode. Two symptoms= mild, three= moderate, 4 or 5=severe.

Critical thinking about what qualifies as an Anxious Distress specifier:

Though Liz experienced an anxiety disorder at baseline, Social Anxiety, it does not make the fact she experiences an anxiety disorder and a depressive episode together as “with anxious distress.” These would be considered independent, co-occurring diagnoses. The anxiety symptoms that arise with the Major Depressive episode were a direct consequence of her mood; “owned by the depression,” if you will, and therefore meet the criteria for With Anxious Distress specifier. Interested readers are directed to Yang et al. (2014) who explores this matter in detail.

You may be asking yourself, “What about if the person develops panic attacks from being so overwhelmed by the depression?” Remember, as noted in our post from July 8, Panic is “special” in that any condition can have a “with panic” specifier. Though uncomfortable, panic is often sporadic and fleeting, while the symptoms of With Anxious Distress must be specially noted because they are chronic and gnawing, adding torment to the person’s condition, creating a dangerous cocktail of psychopathology. Imagine suffering the low feeling of serious depression, coupled with a feeling you can’t gain control, worrying it will never end and being physically tense. This is quite a problem in that, as seen with Liz, the depression is encouraging the anxiety, and the anxiety is encouraging intensifying depression.

Treatment implications:

This additional insult of anxiety on the MDD episode can induce so much havoc that Barlow and Durand (2015) note, “The presence of anxiety [in depressive episodes] makes a more severe condition, makes suicidal thoughts and completed suicide more likely, and predicts a poorer outcome.”

Research is not clear if Anxious Distress tends to be a trend in every episode for people prone it, or if it may vary. Regardless, given the gravity of the matter, clinicians must be vigilant to the possibility of arising Anxious Distress amid their patients’ depression, and evaluate accordingly. Patients may not be as forth-coming and obvious as Liz. Perhaps it is more of an inner tension they are experiencing and the patient assumes worrying their life will never get on track is just part of being depressed. Directly asking depressed patients if they’ve developed muscle tension, worry, and feeling they’re losing control takes mere minutes and can have big clinical pay-offs. Assuaging the anxiety will help in managing the MDD.

Clinical considerations if Anxious Distress is suspected:

  1. Suicide prevention: keeping in mind that suicidality is more prevalent with anxious distress, evaluating for risk is even more important.
  2. Being sure to consult with the person’s prescriber that you are noticing Anxious Distress. They should be aware because some medications could exacerbate the anxiety and there is always the possibility the anxiety will not get reported or noticed in the prescriber’s office.
  3. Evaluating for if the person’s lifestyle may be exacerbating the anxious distress. Namely, are they caffeine junkies, eat a lot of junk food/sugar, and get no exercise? It’s no surprise that caffeine and sugar can make things worse. Exercising, if they are capable, can help “burn off” some anxiety; it can also provide further structure and occupation rather than being 100% stuck inside their mind. The old saying is particularly true for sufferers of depression and anxiety: “idle mind=-devil’s playground.” The positive effects of exercise on anxiety and depression are well-documented. If the person does not already exercise, of course suggest they consult their doctor before initiating a regimen.

Once beginning to stabilize, the job a therapist is to not only help the episode to continue to remit, but continue to evaluate for any return of the Anxious Distress. In the long run, prevention is the best option. If we know a patient is prone to Anxious Distress, it of utmost importance to have a plan in place to immediately return to treatment if they or friends/loved ones recognize the onset of a depressive episode. Keeping the depression at bay likely will help keep the Anxious Distress away.

Stay tuned for tomorrow’s tour of what is perhaps the “darkest flavor” of Major Depressive Disorder: Melancholic Features.


Barlow, D.H. and Durand, V.M. (2015). Abnormal psychology: an integrative approach. Cengage.

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

Yang, M.J., Kim, B.N., Lee, E.H., Lee, D., Yu, B.H., Jeon, H.J., & Kim, J.H. (2014). Diagnostic utility of worry and rumination: a comparison between generalized anxiety disorder and major depressive disorder. Psychiatry and Clinical Neurosciences (68), 712720 doi:10.1111/pcn.12193

Zimmerman, M., Martin, J., McGonigal, P., Harris, L., Kerr, S., Balling, C., Keifer, R., Stanton, K., & Dalrymple, K. (2018). Validity of the dsm-5 anxious distress specifier for major depressive disorder. Depression and Anxiety (36), 1, 31-38.