Anxiety and Mania in Depression - Some Key DSM-5 Changes You Need to Know

Patient Expert

If you happened to have been depressed in May, then you went to sleep one evening with DSM-IV depression and woke up with DSM-5 depression. What changed? Absolutely nothing, well sort of absolutely nothing.

The DSM, as you may be aware, is psychiatry's diagnostic bible, issued by the American Psychiatric Association. As opposed to physical illnesses, mental illnesses are defined according to symptoms rather than cause. The symptom checklist debuted with the DSM-III in 1980. For depression, this took the form of ticking off at least five of nine symptoms. By 1987, these symptoms were virtually cast in stone. No one was about to change them. No one did.

But if you look closely at the fine print, under a heading called "specifiers," the DSM-5 includes a couple of additions that may be very significant to your condition.

Anxious Distress

Anxiety and depression are very much related. In certain situations, anxiety or panic may give way to depression. Likewise, dwelling on depressive thoughts may make one anxious. Sixty percent of those with depression also experience full-blown anxiety, but why quibble with counting symptoms? Just a little bit of anxiety may be all it takes to turn your depression into something that makes you a quivering nervous wreck.

In addition to five of nine depression symptoms, for an "anxious distress" specifier the DSM-5 mandates at least two of the following five symptoms:

  • Feeling keyed up or tense.
  • Feeling unusually restless.
  • Difficulty concentrating because of worry.
  • Feeling that something awful may happen.
  • Feeling that the individual may lose control of himself or herself.

These symptoms overlap somewhat with the symptom checklist for major depression, but we get a strong sense of someone who is worrying him or herself sick.

Just what you need, right? Going to sleep one evening with plain old depression and waking up the next morning with depression "with anxious distress." But wait - if you're anxious, even in a distressed way, it means your brain is putting up a fight. You have not yet given up hope. (Pure depression - as I see it - is the loss of hope.)

So, perhaps by resolving the anxious worry the depression itself, over time, will resolve. Or, to phrase it negatively, not resolving the anxious worry may invite depression back in.

With Mixed Features

The addition of "mixed features" acknowledges that many people - perhaps most - do not experience "pure" depressions. Typically, there is other stuff going on, including the intrusion of some mania symptoms. Way back in 1921, the pioneering diagnostician Emil Kraepelin wrote about "excited depression" and other related states. Think of full-blown depression with a little bit of mania.

These are your states where you feel as if you are crawling out of your skin, where you want to grab the world by the neck and wring it. "Agitated depression" is one way to describe it. The DSM-5 mandates - along with five of nine depression symptoms - at least three mania symptoms.

Here, of course, is where the trouble begins. One more mania symptom and your mixed depression morphs into "mania with depressive features." A full-blown (hypo)mania episode only requires four of seven symptoms. And once we crossed this arbitrary threshold into (hypo)mania, according to the DSM, the diagnosis is bipolar - no ifs, ands, or buts.

One symptom - just one - separating depression from bipolar. Does this sound absurd to you? Wait, it gets worse. When in doubt, clinicians tend to default to the depression diagnosis and prescribe an antidepressant, which may be the last thing someone experiencing mania symptoms needs to be taking.

In other words - in the interest of first do no harm - maybe we should consider treating these mixed mania depressions as if they were a form of bipolar. If nothing else, both patient and clinician need to be on their guard. In another piece, I took the DSM-5 to task for its inexcusable lack of diagnostic clarity. But, finally, after all these years, we do have the acknowledgment of bipolarity in depression.

Wrapping It Up

If you are living with depression, chances are you are living with complications attached to the condition. The two obvious ones are anxiety and mania. "Just a little bit" may be enough to change the entire nature of the beast and how you treat it. The reality has always been the same. The DSM just made it official.

Further reading: Agitated vs Vegetative Depressions