Current Issues in Anxiety and Depression: Comorbid, Mixed, and Subthreshold Disorders.

Abstract

Recent attention has been given to the high frequency of coexisting anxiety and depressive symptoms that has served to challenge the more traditional view that these two disorders are typically discrete syndromes. Furthermore, research suggests that less severe states of anxiety and depression continue to be overlooked, despite their capacity to produce significant psychosocial impairment. Given the implications for diagnostic and treatment outcome, psychologists need to be aware of the epidemiology, clinical presentations, and treatment strategies surrounding comorbid and subthreshold anxiety and depression. We review the literature, present issues related to these syndromes, and discuss the implications for diagnostic and clinical activities. RAFAEL A. RIVAS-VAZQUEZ received his PsyD in clinical psychology from Nova Southeastern University and completed his predoctoral internship at Harvard Medical School/Massachusetts General Hospital. He received his postdoctoral MS in clinical psychopharmacology from Nova Southeastern University in 2001. He is currently adjunct faculty in psychology at University of Miami. His research interests include psychopharmacology, depression, Alzheimer's disease, and cross-cultural assessment and treatment issues. DALIA SAFFA-BILLER received her PsyD in clinical psychology from Nova Southeastern University in 1997 and completed her predoctoral internship at Citrus Health Network, Inc., Hialeah, FL. She is the director at the Weston Center for Psychological Services in Weston, FL. Her research interests include parenting and custody issues. IVONNE RUIZ received her PsyD in clinical psychology from Nova Southeastern University in 2000 and completed her predoctoral internship at Citrus Health Network, Inc. She is the clinical coordinator of the School and Community Based Clinical Services at Citrus Health Network. Her research interests include pervasive developmental disorder and childhood assessment and treatment. MARK A. BLAIS received his PsyD in clinical psychology from Nova Southeastern University in 1990. He is the associate chief of psychology at Massachusetts General Hospital and is associate professor at Harvard Medical School. His research interests include psychological assessment, psychotherapy outcome, and personality disorders. ANA RIVAS-VAZQUEZ received her PhD from the University of Miami in 1969 and her postdoctoral MS in clinical psychopharmacology from Nova Southeastern University in 2001. She was board certified in clinical psychology in 1988. She

The Impact of DSM-IV Symptom and Clinical Significance Criteria on the Prevalence Estimates of Subthreshold and Threshold Anxiety in the Older Adult Population

“…[12][13][14] However, the use of this criterion with older adults may conversely increase the number of false-negative cases, since they are usually less active and less likely to perceive themselves as disabled than younger adults. 15 In addition, because older adults are more likely to somatize their distress and to report less emotional disturbances, 8,[16][17][18] the symptom criteria may be harder to satisfy in this population.…”

“…[12][13][14] However, the use of this criterion with older adults may conversely increase the number of false-negative cases, since they are usually less active and less likely to perceive themselves as disabled than younger adults. 15 In addition, because older adults are more likely to somatize their distress and to report less emotional disturbances, 8,[16][17][18] the symptom criteria may be harder to satisfy in this population.Knowing that the symptom and the clinical significance criteria may pose problems in the older adult population, the aim of the current study was to answer the following questions: (a) how these criteria affect the prevalence estimates of anxiety problems in this population and (b) do these criteria identify a group of older adults presenting a more severe condition needing psychiatric help? To answer these questions, respondents with a full anxiety disorder were compared with respondents presenting different patterns of subthreshold anxiety on their sociodemographic, health, and health behavior characteristics.…”

“…9-11 Subthreshold anxiety usually refers to a condition where individuals do not meet the full symptom criteria (i.e., the number of symptoms required for a formal diagnosis is not reached) and/or do not report significant impairment or distress in functioning (i.e., the clinical significance criterion is not met). [6][7][8] Despite its relevance in older adults, manifestations of subthreshold anxiety are nevertheless not considered as disorders according to the DSM-IV, particularly when the clinical significance criterion is not met. The rationale behind the introduction of the clinical significance criterion was to help identify a group of people presenting a more severe condition needing psychiatric help.…”

Cognitive Vulnerability–Stress Model of Depression During Adolescence: Investigating Depressive Symptom Specificity in a Multi-Wave Prospective Study

“…Second, this study did not investigate clinical levels of anxiety, depression, or externalizing problems through structured diagnostic interviews, so it is unclear whether the present findings of affective symptom specificity will generalize to more severe levels of psychopathology. Most research suggests that anxiety, depression, and externalizing problems can be represented and conceptualized best as dimensional continua, rather than discrete categories (e.g., Fergusson et al 2005;Osgood et al 2002;Rivas-Vazquez et al 2004;Vollebergh et al 2001), so it is most likely that the etiological factors that contribute to subclinical levels of psychopathology may also predict clinical levels as well (c.f., Gotlib et al 1995). Use of structured diagnostic interviews in future research can address this issue.…”

Subthreshold depression based on functional impairment better defined by symptom severity than by number of DSM-IV symptoms

“…As the authors of the DSM-IV point out, in reality this distinction between disorder and normality is not so clear-cut (APA, 1994). Categorical thresholds may not adequately capture clinically significant states (Rivas-Vazquez et al, 2004). To illustrate, major depressive disorder (MDD) is among the most impairing disorders in the world (Lépine, 2001), but impairment is not limited to full blown MDD alone.…”