Anxiety in Depressive

Disorders

H. Kuhs In this psychopathological study, the subjective experience of anxiety was investigated in depressive patients by means of a semistructured interview. Both International Classification of Diseases-9 (ICD-9) diagnostic criteria (melancholia or neurotic depression; N = 160 or 93, respectively) and the DSM-III classification system (major depressive episode with or without “melancholia”; N = 63 or 153, respectively) were applied. Anxiety can be identified in virtually all patients examined. In contrast, the themes of anxiety are subject to substantial differences. There is a statistically significant correlation between the extent of anxiety and the severity of depression by the Hamilton Depression Scale (Ham-D). However, a distinction between anxiety and depression is possible in the majority of cases if the contents of anxiety are taken into account. Copyright 0 1991 by W.B. Saunders Company

T

HE SIGNIFICANCE of anxiety in depressive disorders is undisputed. Hamilton’ found anxiety in 97% to 98% of melancholic patients, and Kim* in 97% (mental anxiety) and 98% (physical anxiety), respectively, of his depressive patients. Operational recording of anxiety is nevertheless subject to greater difficulties than providing evidence of other “objectively” ascertainable symptoms (e.g., loss of weight). Therefore, it is not surprising that the results of multivariate statistical studies are contradictory. Some investigators3.4 found anxiety to be characteristic of endogenous depression (melancholia); according to others5 anxiety is characteristic of nonmelancholic (neurotic) depressive states. Other investigators point out that the mere existence of anxiety without any further qualitative characterization cannot be used for differentiating subtypes of depressive disorders, since anxiety is found just as frequently among various types of depressive patients.“8 Therefore, anxiety is not applied at all to the symptomatological characterization of depressive disorders in more recent classification systems.‘-” One important question concerns the differentiation of anxiety and depression.‘2-‘4However, the frequent occurrence of anxiety in depressive patients makes it difficult to distinguish between anxiety and depression at a symptomatogical and syndromatological leve1.15%16 No satisfactory discrimination between the two psychopathological phenomena can be obtained with standardized self-rating scales.17,‘8The results’y22oare no more encouraging when clinical assessments (Hamilton Anxiety Scale, Ham-A*$ Hamilton Depression Scale, Ham-D**) are used. Data of multivariate statistical studies on the differentiation of anxiety and depression are also difficult to interpret. For example, factor analysis shows that some aspects of anxiety are closely linked with depression, while others preclude each other.“3 The psychopathological study reported here attempts to record anxiety in depressive disorders on as broad an empirical basis as possible. Not only the From the Department of Psychiatry University of Miinster, Miinster, Germany. Address reprint requests to Privatdozent Hubert Kuhs, M.D., Department of Psychiatry, University of Miinster, Albert-Schweitzer-Strasse II, 4400 Miinster, Germany. Copyright 0 1991 by V? B. Saunders Company 0010-440X/91/3203-0002$03.00/0 Comprehensive

Psychiatry, Vol. 32, No. 3 (May/June),

1991: pp 217-228

217

218

H. KUHS

extent of anxiety-and even less its mere presence or absence-is to be investigated, but its thematic characteristics. Furthermore, as anxiety is most likely to be revealed in the patient’s subjective experience, the study is to focus on self-report data.24 The main issues covered by the study are (1) How frequent is the symptom “anxiety” in depressive disorders? (2) How frequently do the various themes of anxiety occur in depressive patients classified according to both International Classification of Diseases-9 (ICD-9) and DSM-III? (3) What contribution do the themes of anxiety make toward differentiating depressive disorders? (4) What relationship exists between anxiety and depression? METHOD The study covered 160 melancholic and 93 neurotic depressive inpatients consecutively admitted to the Department of Psychiatry from March 1985 to June 1987. The diagnosis was made in accordance with ICD-9 criteria” by two psychiatrists not involved in the study and working independently of each other. The patients were classified simultaneously according to DSM-III: 63 patients met DSM-III criteria for a major depressive episode (MDE) with melancholia compared with 153 MDE patients without melancholia. Allocation of the patients to the compared classification systems is delineated in Table 1. The degree of conformity is low: only 61 (=38.1%) of the patients classified as ICD-9 melancholies met DSM-III criteria for a MDE with melancholia. Seventy-eight (83.8%) of the neurotic depressive patients, but only 75 (46.9%) of the melancholic patients fulfilled the criteria for an MDE (without melancholia). Severity of depression was determined, using the Ham-D. Baseline data are shown in Table 2. Subgroups were formed in addition, matched for severity of depression, age, and gender.‘6 The baseline data for the ICD-9 subsamples are melancholia: N = 75; Ham-D score, 20.5 f 3.6; age, 45.1 f 9.9 years; male/female, 32/43; neurotic depression: N = 42; Ham-D score, 20.2 2 4.2; age, 44.6 2 10.7 years; male/female, 18124.The corresponding data for the adjusted DSM-III subgroups are MDE: N = 88; Ham-D score, 22.9 f 3.2; age, 48.2 ? 14.2 years; male/female, 33/55; MDE with melancholia: N = 40; Ham-D, score, 22.6 f 3.7; age, 48.9 f 13.3 years; male/female, 15/25. The experience of anxiety was examined, using a semistructured clinical interview:4,*6 at the onset of hospitalization, i.e., before clinical remission. As a generally comprehensible definition of anxiety, the rater first suggests to the patient, with reference to Schulte *‘: “Anxiety is an unpleasant, agonizing feeling that occurs when one is confronted with the threatening and the unknown and feels that one is at their mercy.” The patient is then asked to speak in as much detail as possible about feelings of anxiety during the current depressive episode. If the fundamental affect is not unequivocally apparent from the patient’s descriptions or if his statements are contradictory, the rater asks the patient whether his experience can be described as anxiety according to the above-stated definition. The decision on this is made by the patient as a matter of principle. The rater then asks about further symptoms of anxiety. The themes of anxiety dealt with in the interview are listed in Table 3. The interviewer was blind to the patients’ diagnoses. Immediately after the interview, the written records of the patients’ statements were allocated to the above-stated themes of anxiety. Finally, data were coded to permit computerized evaluation.26

Table 1. Comparison

of ED-9

and DSM-III Classification

Systems in 253 Depressive Patients

Melancholia (N = 160)

ICD-S/DSM-III

No MDE MDE without melancholia/without mood-congruent features MDE with melancholia MDE with mood-congruent psychotic features

Neurotic Depression (N = 93)

1

13

75 61 23

78 2 0

psychotic

ANXIETY

IN DEPRESSIVE

219

DISORDERS

Table 2a. Baseline Data of Melancholic (N = 160) and Neurotic Depressive (N = 93) Patients According to ICD-9

N Sex (M:F) Age (vr) Severity of depression (Ham-D)

Melancholia

Neurotic Depression

160 66:94 51.9 k 14.8 23.7 f 5.4

93 40:53 36.0 ” 12.4* 18.8 -t 4.8*

Data on objectivity, split half reliability and validity of the interview (particularly with regard to conformity with the Self-Rating Anxiety Scale, SAS”), have been published elsewhere.24 In that report, semistructured and standardized assessments of anxiety are also compared under methodological aspects. Subsequent to the interview, the patient filled in the above-stated SAL’* The following statistical evaluation methods were used: Fisher exact probability test, I test for group differences, Pearson’s correlation coefficient (r), and linear discriminant function analysis according to Mahalanobis.

RESULTS Prevalence of Anxiety in Depressive Disorders

Only six (3.2%) of the melancholic patients denied the presence of anxiety. Among neurotic depressive patients, anxiety occurred without exception. A breakdown according to DSM-III criteria shows that six MDE patients (four without and two with melancholia) did not suffer from anxiety according to the interview. Frequencies of the Various Themes of Anxiety

These are listed in Table 4. Anxiety occum’ng more frequent& in melancholic than in nonmelancholic patients according to both classification systems. “Anxiety about everything” (so-called

everyday anxiety) was found more often both in melancholic compared with neurotic depressive patients (ICD-9) and in MDE patients with melancholia compared with MDE patients without melancholia. One patient’s statement may illustrate this anxiety about the thousand details of everyday life: “I’m afraid of just everything. . . . Always afraid of something. When I stop being afraid of one thing, I start being afraid of the next.” Of the “classic” themes of meIancholic anxiety, guilt-related anxiety occurred more frequently (NS) in melancholic patients (according to both ICD-9 and DSM-III criteria) than in nonmelancholic patients, whereas the presence of Table 2b. Baseline Data of Patients With MDE (N = 153) and of MDE Patients With Melancholia (N = 63); According to DSM-III

N Sex (M:F) Age (vr) Severity of depression (Ham-D) “P < ,001.

MDE

MDE With Melancholia

153 63:90 42.9 2 15.5 20.5 f 4.6

63 26:36 53.3 2 14.5* 24.9 + 4.9,

220

H. KUHS

Table 3. Semistructured

Clinical Interview-Themes

of Anxiety

1. Guilt-related anxiety 2. Poverty-related anxiety 3. Hypochondriasis-related anxiety 4. Anxiety about mental illness 5. Anxiety about dying Anxiety about death Anxiety about suicide 6. Failure-related anxiety (anxiety about the future the patients feel responsible for) Future-oriented anxiety (anxiety about future events beyond the responsibility of the patient) Anxiety about impending disaster 7. So-called everyday anxiety (“anxiety about everything” in the routine everyday life) 8. Anxiety in the context of derealization/depersonalization Metaphysical anxiety 9. Anxiety about losing a partner Anxiety about being alone 10. Anxiety in the context of suspicion 11. Anxiety in the context of obsession/compulsion 12. Situational and object-related anxiety (phobia) 13. Unfathomable anxiety 14. Physical expressions of anxiety 15. Anxiety about attachment Anxiety about loss of control (anxiety about losing control of one’s feelings)

hypochondriasis-related anxiety did not contribute to discriminating between the compared diagnostic groups. Anxiety occurrkg more frequently in nonmelancholic than in melancholic patients according to both classification systems. This anxiety group is composed of

failure-related anxiety, situational anxiety (phobia), and anxiety about being alone/having to live alone. In contrast to everyday anxiety, failure-related anxiety does not refer to the immediate, but to the more distant future, not to the routine of everyday life, but to tasks and stress in the patient’s sphere of responsibility and influence. It has to be conceded that everyday anxiety and failure-related anxiety cannot be unequivocally separated on a terminological basis. Transitional forms are feasible. However, most patients were capable of distinguishing between these two themes of anxiety. If the patients’ statements could not be allocated unequivocally to one of the two issues of anxiety, both forms were recorded. However, this procedure did not result in higher than random coincidence between the stated themes of anxiety in any of the compared samples. Anxiety concerning concrete external and thus unequivocally definable situations (phobia) relates first and foremost to public places (agoraphobia) and the use of transport facilities. Each of these statements was made by more than 20% of the neurotic depressive and MDE patients suffering from situational anxiety. Anxiety contributing to discrimination between melancholic and nonmelancholic patients classified according to ZCD-9 only. A variety of themes of anxiety have a

significantly higher incidence rate among neurotic depressive than among melancholic patients, while differences in frequencies are less marked within the DSM-III depressive groups. This applies in particular to anxiety about losing a partner, anxiety in the context of suspicion, anxiety about attachment, anxiety about loss of control, and poverty-related anxiety. Physical anxiety too, which in

ANXIETY

IN DEPRESSIVE

221

DISORDERS

Table 4. Anxiety in Depressive Patients ICD-9 Melancholia (N = 160)

1. Guilt-related anxiety 2. Poverty-related anxiety 3. Hypochondriasis-related anxiety 4. Anxiety about mental illness 5. Anxiety about dying Anxiety about death Anxiety about suicide 6. Failure-related anxiety Future-oriented anxiety Anxiety about impending disaster 7. Everyday anxiety 8. Anxiety in the context of derealizationldepersonalization Metaphysical anxiety 9. Anxiety about losing a partner Anxiety about being alone 10. Anxiety in the context of suspicion Il. Anxiety in the context of obsession/compulsion 12. Situational anxiety Object-related anxiety 13. Unfathomable anxiety 14. Physical expression of anxiety 15. Anxiety about attachment Anxiety about loss of control Fishertest:

DSM-III

Neurotic Depression (N = 93)

MDE With Melancholia (N = 63)

MDE (N = 153)

N

%

N

%

N

%

N

%

59 48

36.9 30.0

24 13

25.9 14.0t

24 15

38.1 23.8

38 30

24.8 19.6

53 106 10 21 56 79 I3

33.1 66.2 6.3 13.1 35.0 49.4 8.1

31 57 10 13 44 58 12

33.3 61.3 10.8 14.0 47.3 82.4* 12.9

19 41 5 I2 23 28 4

30.2 65.1 7.9 19.0 36.5 44.4 6.3

50 103 11 19 69 95 16

32.7 67.3 7.2 12.4 45.1 62.1* 10.5

6 90

3.8 56.3

1;

7.5 20.4t

2 40

3.2 63.5

IO 58

6.5 37.9t

26 14

16.2 6.7

10 7

10.8 7.5

I3 3

20.6 4.8

18 10

11.8 6.5

22 9

13.7

36 22

38.7t 23.7t

10 2

15.9 3.2

41 27

26.8 17.6t

41

25.6

41

44.It

16

25.4

50

32.7

: 0 40

31 5:6 0 25.0

2; 2 I8

0 29.0t 2.2 19.4

2 2 0 20

3.2 3.2 0 31.7

3 29 I 32

2.0 19.0t 0.7 20.9

135 0

84.4 0

87 II

93.5* 11.8t

58 0

92.1 0

133 8

86.9 5.2

2

I.2

IO

lO.fH

I

I.6

8

5.2

5.6

*P < .05; tP < .OI.

any case represents by far the most frequent subjective experience of anxiety, is even more marked among neurotic patients (ICD-9) than the other diagnostic groups. Arwkty not contributing to discrimination between melancholic and nonmelancholic patients according to either classijkation system. Anxiety in depressive patients-regardless of the classification system applied-is directed most frequently toward mental illness. Anxiety with a theme relating to death and dying, in contrast, is conspicuously rare. Anxiety related to events beyond the sphere of influence and responsibility of the patient (“anxiety about the future” and anxiety about impending disaster) is distinctly less frequent in all depressive diagnostic groups than failure-related anxiety (see above). Similarly, anxiety in the context of feelings of derealization/depersonalization and metaphysical anxiety with religious contents are expressed by only a minority of depressive patients. Among depressive patients, anxiety in the context of obsessive-compulsive symptomatol-

222

H. KUHS

ogy and anxiety directed toward an external object are extremely rare (compare situational anxiety). Finally, unfathomable anxiety (without any definable contents), expressed by 20% to 30% of patients, occupies an intermediate position between frequent and rare forms of anxiety regardless of the classification system applied. Do the Themes ofAnxiety Contribute To Discriminating Depressive Disorders?

Based on the themes of anxiety, discriminant function analysis permits differentiation between various depressive subtypes at a satisfactory level. This applies in particular to patients classified according to ICD-9: 130 of the melancholic (specificity, 81.3%) and 72 of the neurotic depressive patients (sensitivity, 77.4%), i.e., 79.8% of all patients examined, could be classified correctly according to the subjective experience of anxiety as expressed in the interview. In contrast, discriminant function analysis permitted a correct diagnostic assignment in only 46 (73.0%) of the MDE patients with melancholia and 108 (70.6%) of the MDE patients without melancholia (diagnostic selectivity, 71.3%). As ICD-9 melancholia covers not only nondelusional, but also delusional depression, data evaluation was taken one stage further to gather MDE patients with melancholia (N = 63) and with mood-congruent psychotic features (N = 23) into one group (N = 86) and to compare this newly formed patient group with the 153 MDE patients. Among MDE patients with melancholia and mood-congruent psychotic features, correct diagnostic allocation can be made in 73.3% (N = 63) by means of the interview, compared with 73.2% (N = 112) in the MDE patient group (diagnostic selectivity, 73.2%). The most important contribution to discrimination of depressive patients is made in both classification systems by everyday anxiety and situational anxiety (phobia), as is illustrated by their nearly identical though opposing weighted scores (Table 5a and b). Another noteworthy finding is that five of the six themes of anxiety most suitable for diagnostic allocation to neurotic depression or to MDE without melancholia concur in both classification systems. Apart from situational anxiety, these are anxiety about losing a partner, anxiety about being alone, and anxiety about attachment and loss of control. In Fig 1, the sum of weighted scores for the different themes of anxiety is plotted for each of the melancholic and neurotic-depressive patients. No bimodal anxiety distribution pattern is to be found. In other words, no categorical distinction is possible between the different depressive patient groups. This applies to MDE patients with and without melancholia as well (not illustrated). Relationship Between Anxiety and Depression

There is a statistically significant correlation between the number of anxiety themes expressed by each patient and the severity of depression (Ham-D score) (melancholic patients, r = .39, P < .OOl; neurotic depressive patients, r = .49, P < 0.001; MDE patients, r = .32, P < .OOl; MDE patients with melancholia, r = .32, P < .Ol). A similar correlation between extent of anxiety and severity of depression can be found comparing the overall SAS and Ham-D scores (melancholic patients, r = .46, P < .OOl; neurotic depressive patients, r = .46, P < .OOl;

ANXIETY

IN DEPRESSIVE

Table 5a. Discriminant

DISORDERS

223

Function Analysis-Melancholic and Neurotic Depressive Patients (According to ICD-9; N = 253)

Everyday anxiety Poverty-related anxiety Guilt-related anxiety Anxiety in the context of derealization Unfathomable anxiety Anxiety about mental illness Metaphysical anxiety Hypochondriasis-related anxiety Anxiety about death Future-related anxiety Anxiety about dying Anxiety about impending disaster Anxiety about suicide Failure-related anxiety Physical anxiety Anxiety in the context of suspicion Anxiety about loss of control Anxiety about being alone Anxiety about attachment Anxiety about losing a partner Situational anxiety (phobia)

Weighted

Scores

-0.45592 -0.22495 -0.16613 -0.09322 -0.07950 -0.06127 -0.02616

Melancholic patients

0.00261 0.01478 0.09487 0.09890 0.10140 0.14987 0.15524 0.16679 0.23733 0.27044 0.33689 0.35685 0.36608 0.41822

Neurotic depressive patients

MDE patients, r = .44, P < .OOl). No significant correlation could be determined between the Ham-D and SAS scores of MDE patients with melancholia. Thus, the severity of depression has considerable influence on the extent of anxiety. However, the marked differences in severity of depression (together with age and gender) between the depressive patient groups (Table 2) give rise to the Table 5b. Discriminant

Function Analysis-Patients (According to DSM-III;

Everyday anxiety Guilt-related anxiety Unfathomable anxiety Anxiety in the context of derealization Anxiety about dying Physical anxiety Poverty-related anxiety Anxiety about death Anxiety about mental illness Hypochondriasis-related anxiety Metaphysical anxiety Future-oriented anxiety Anxiety in the context of suspicion Anxiety about suicide Anxiety about loss of control Anxiety about losing a partner Anxiety about attachment Failure-related anxiety Anxiety about being alone Situational anxiety (phobia)

With MDE and MDE With Melancholia N = 216) Weighted

Scores

-0.45296 -0.25074 -0.21858 -0.21829 -0.16266 -0.13795 -0.08877 -0.02445

MDE with melancholia

0.04075 0.04635 0.06397 0.12173 0.13586 0.14935 0.15672 0.22199 0.23920 0.30954 0.37079 0.39408

MDE

224

H. KUHS number of patients

20

10

sum of weighted J.8

-2

melancholic

patients

neurotic-depressive

patients

Fig 1. Discriminant function analysis: melancholic (0) versus neurotic depressive patients (B) (according to ICD-9).

following question: Do the themes of anxiety continue to contribute to discrimination between different depressive subtypes when subgroups matched for severity of depression, age, and gender are compared? The frequencies of some selected themes of anxiety after eliminating the influence of the stated variables are shown in Table 6. So-called everyday anxiety is still indicative of the presence of ICD-9 melancholia, but loses discriminative value when DSM-III criteria are applied. Table 9. Anxiety in Depressive Patients Matched for Severity of Depression, Age, and Gender (Selection) DSM-III

KID-9 Melancholia (N = 75)

Guilt-related anxiety Poverty-related anxiety Hypochondriasis-related anxiety Failure-related anxiety Everyday anxiety Anxiety about losing a partner Anxiety about being alone Anxiety in the context of suspicion Situational anxiety (phobia) Fisher test: P < .05; tP < .Ol.

Neurotic Depression (N = 42)

MDE With Melancholia (N = 40)

MDE (N = 88)

N

%

N

%

N

%

N

%

21 18 13 41 38 13 5

28.0 24.0 17.3 54.7 50.7 17.3 6.7

9 9 16 24 11 12 5

21.4 21.4 38.1” 57.1 26.2t 28.6 11.9

16 7 7 15 22 9 2

40.0 17.5 17.5 37.5 55.0 22.5 5.0

21 19 37 54 44 17 11

23.9 21.6 42.0t 61.4* 50.0 19.3 12.5

19 5

25.3 6.7

14 12

33.3 28.6t

12 2

30.0 5.0

12 18

30.0 20.5*

ANXIETY

IN DEPRESSIVE

225

DISORDERS

The reverse is true of failure-related anxiety, which continues to contribute to discriminating between MDE patients with and without melancholia, although not to discriminating ICD-9 depressive subtypes. After eliminating the influence of severity of depression, age, and gender in patients classified according to ICD-9 and DSM-III, the frequencies of the themes of anxiety are changed in the same direction: the discriminating value of anxiety about losing a partner, anxiety about being alone, and anxiety in the context of suspicion recedes. Hypochondriacal anxiety now proves characteristic of nonmelancholic depressive states (neurotic depression and MDE without melancholia). In contrast, situational anxiety is asserted as outstandingly characteristic of depressive neurosis and of MDE without melancholia. Overall, the themes of anxiety lose none of their diagnostic selectivity by means of discriminant function analysis. Correct classification is still possible (specificity, 83.7%; sensitivity, 73.8%) in 79.5% of melancholic/neurotic depressive patients (compared with 79.8% in the initial sample). When classification is based on DSM-III criteria, the proportion of correctly allocated patients remains approximately the same (74.2% as compared with 71.3% in the total sample; specificity, 80.0%; sensitivity, 71.6%). DISCUSSION

A comparison between ICD-9 and DSM-III classification systems shows that, while neurotic depressive patients fulfil DSM-III criteria for an MDE with melancholia only in exceptional cases, only 38.1% of melancholic patients do so too. For the narrow DSM-III criteria for melancholia, this implies inversely that virtually all-61 of 63 (96.8%)-MDE patients with melancholia simultaneously meet ICD criteria for melancholia. In a study by Maier et a1.,29too, only 48% of ICD-9 endogenous depressive patients met criteria of an MDE with melancholia, whereas only 12% of the nonmelancholic patient group fulfilled DSM-III melancholia criteria. As is the case with the RDC diagnostic category “major depressive disorder,” 9MDE without melancholia covers patients with the clinical diagnosis of melancholic and of neurotic (endogenous and nonendogenous) depression.30 In accordance with other investigators,31.3’ our findings indicate that melancholic patients are older and suffer from more severe depression than nonmelancholic patient groups, no matter which criteria are applied. Only a minority of depressive patients did not suffer from anxiety according to the interview. This finding conforms with the results published by Hamilton’ and Kim,’ while P61dinger33 and Wolfersdorf34 ascertained anxiety in 74% or 62%, respectively, of their depressive patients. Regardless of the classification system applied, “anxiety about everything” is most characteristic of melancholic as opposed to nonmelancholic depression. This so-called everyday anxiety corresponds most closely to the pantophobia referred to by Kraepelin.35 Because of its interchangeable contents, this so-called everyday anxiety appears to be adjacent to unfathomable anxiety in which no theme of anxiety can be defined any more.36 On the other hand, failure-related anxiety, i.e., anxiety concerning future tasks in the patient’s sphere of responsibility, is found more frequently in nonmelan-

226

H. KUHS

cholic than in melancholic states of depression (according to both ICD-9 and DSM-III). Obviously, in at least part of melancholic patients, anxiety is derived from their mere existence here and now (“everyday anxiety”), so that the more distant future is completely closed off. Situational anxiety (phobia) also proves to be atypical of melancholic depression according to the two classification systems compared. The melancholic patients’ self-reports indicate that the anxiogenic situation merely reflects their own illness-dependent inability. A variety of themes of anxiety are far more pronounced in ICD-9 neurotic depressives compared with melancholic patients than in MDE patients without melancholia compared with MDE patients with melancholia. Matussek and Luks37 found that endogenous and nonendogenous depressive patients can be clearly differentiated by the themes of their thoughts. According to these investigators, the nonendogenous depressive patients could be characterized in particular by an ambivalent emotional relationship to their environment, especially to their partners. The considerable symptomatological differences between melancholia and neurotic depression (according to ICD-9) also explain why proposals for redefinition of “neurotic depression” contain a number of descriptivepsychopathological criteria.38-41 Finally, we found a number of themes of anxiety to be equally characteristic of depressive patients, regardless of their diagnostic allocation. The infrequent occurrence of “anxiety about the future” and anxiety about impending disaster (in comparison with failure-related anxiety) indicates a common feature of depressive disorders: both melancholic and nonmelancholic depressive patients experience future-oriented anxiety with a content unequivocally beyond their sphere of influence far less frequently than anxiety based on their own failure. In other words, the depressive patient feels responsible-and thus potentially guilty-for what happens in the future. Unfathomableness was regarded in the earlier psychopathological literature as characteristic of melancholic anxiety, but is obviously too much a general and fundamental characteristic of anxiety to be helpful in discriminating different subtypes of depression.36 The “classic” themes of melancholic anxiety-guilt, poverty, and hypochondriasis-are no more frequent in melancholic than in nonmelancholic patients. From a psychopathological viewpoint, the stated themes were emphasized in melancholic anxiety.42 However, this does not concern melancholia as a whole, but only delusional depression, in which anxiety becomes evident in a particularly impressive psychotic form. Based on ICD-9 criteria, melancholic and neurotic depressive states can be differentiated in four of five cases by means of discriminant function analysis when applying the interview. The diagnostic selectivity of the DSM-III classification system is lower in this respect. From the standpoint of ICD-9, this is mainly due to the fact that MDE patients without melancholia represent a heterogenous group with a substantial proportion of both endogenous and nonendogenous depressive patients. Nevertheless, on the basis of discriminant function analysis, the following applies equally to both classification systems: In line with the unimodal anxiety distribution pattern (Fig l), anxiety is represented as a continuum between the poles of melancholic and nonmelancholic anxiety. However, the majority of investigators succeeded in identifying a melancholic nucleus of patients with a restricted number of symptoms apart from other heterogenous depressive groups.h.43 In our study, among patients classified as melancholic by

ANXIETY

IN DEPRESSIVE

227

DISORDERS

both ICD-9 and DSM-III, significant weighted scores (< -0.30) could be determined only for so-called everyday anxiety (Table 5a and 5b). In contrast, several themes of anxiety indicate the presence of nonmelanchohc depression. Among ICD-9 neurotic depressive patients there were four, and among MDE patients without melancholia three themes of anxiety with correspondingly high weighted scores (> 0.30). There is a significant correlation between the severity of anxiety and depression. In other words, the severity of anxiety and depression increases and decreases in parallel. Taking the correlation coefficient as a measure, the relationship between the number of themes of anxiety expressed in the interview and the severity of depression (Ham-D) proves to be just as close as is the case when two standardized anxiety and depression scales (SAS, Ham-D) are compared.” However, there is no justification for concluding from the significant correlation between anxiety and depression that these phenomena are interchangeable or even identical. Our findings rather show that even if patient groups matched for severity of depression are compared, anxiety differs considerably between melancholic and nonmelancholic patients (according to both classification systems). Meaningful statements on the relationship between depression and anxiety can only be made if the thematic characteristics, i.e., qualitative aspects, of anxiety are taken into account. REFERENCES 1. Hamilton M: Frequency of symptoms in melancholia (depressive illness). Br .I Psychiatry 154:201-206,1989 2. Kim KI: Clinical study of primary depressive symptoms. Part III: Symptom pattern of the Korean depressive. Neuropsychiatry 16:46-52,1979 3. Rosenthal SH, Gudeman JE: The endogenous depressive pattern: An empirical investigation. Arch Gen Psychiatry 16:241-249, 1967 4. Hordern A: Depressive States, a Pharmacotherapeutic Study. Springfield, IL, Thomas, 1965 5. Carney MWP, Roth M, Garside RF: The diagnosis of depressive syndromes and the prediction of ECT response. Br J Psychiatry 111:659-674, 1965 6. Nelson JC, Chamey DS: The symptoms of major depressive illness. Am J Psychiatry 138:1-13.1981 7. Kendell RE: The classification of depressive illnesses. Maudsley Monograph no. 18, London, England, Oxford University, 1968 8. Feinberg M, Carroll BJ: Separation of subtypes of depression using discriminant analysis. I. Separation of unipolar endogenous depression from non-endogenous depression. Br J Psychiatry 140:384-391, 1982 9. Research Diagnostic Criteria (RDC) for a Selected Group of Functional Disorders (ed 3). New York State Psychiatric Institute, Biometrics Research, 1977 10. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3) (DSM-III). Washington, DC, APA, 1980 11. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3, revised). Washington, DC, APA, 1989 12. Angst J, Dobler-Mikola A: The Zurich study. VI. A continuum from depression to anxiety disorders? Eur Arch Psychiatr Neurol Sci 235:179-186. 1985 13. Kendler KS, Heath AC, Martin NG, et al: Symptoms of anxiety and symptoms of depression. Same genes, different environments? Arch Gen Psychiatry 44:451-457, 1987 14. Riskind JH, Beck AT, Berchick RJ, et al: Reliability of DSM-III diagnoses for major depression and generalized anxiety disorder using the Structured Clinical Interview for DSM-III. Arch Gen Psychiatry 44:817-820,1987 15. Klerman GL: Anxiety and depression, in Burrows GD, Davies B (eds): Handbook of Studies of Anxiety. Amsterdam, The Netherlands, Elsevier Biomedical. 1980, pp 145164 16. Wetzler S, Katz MM: Problems with the differentiation of anxiety and depression. J Psychiatr Res 2311-12, 1989

228

H. KUHS

17. Mendels .I, Weinstein N, Cochrane C: The relationship between depression and anxiety. Arch Gen Psychiatry 27:649-653,1972 18. Derogatis RR, Lipman RS, Covi L, et al: Factorial invariance of symptom dimensions in anxious and depressive neuroses. Arch Gen Psychiatry 27:659-665,1972 19. Maier W, Philipp M, Benkert 0: Die Bedeutung der kdrperbezogenen Angst fur die Differenzierung zwischen Angst und Depression, in Goetze P (ed): Leitsymptom Angst. Berlin, Germany, Springer-Verlag, 1984, pp 88-102 20. Philipp M, Maier W, Buller R, et al: Angst und Depression: Erfassung korperlicher und psychischer Aspekte mittels der Hamilton-Skalen, in Hippius H, Ackenheil M, Engel RR (eds): Angst-Leitsymptom psychiatrischer Erkrankungen. Berlin, Germany, Springer-Verlag, 1988, pp 51-59 21. Hamilton M: The assessment of anxiety states by rating. Br J Med Psycho1 3250-55, 1959 22. Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 23:56-62,196O 23. Moller HJ, Zerssen von D: Diagnostik von Depression und Angst mit standardisierten Beurteilungsverfahren, in Helmchen H, Linden M (eds): Die Differenzierung von Angst und Depression. Berlin, Germany, Springer-Verlag, 1986, pp 15-31 24. Kuhs H: Der pathische Aspekt in der psychopathologischen Forschung. Eine Methode der Erfassung von Angst bei melancholischen Patienten. (The subjective aspect in psychopathological research. A method of recording anxiety in melancholic patients.) Nervenarzt 61:402-407,199O 25. World Health Organization: International Classification of Diseases (9th revision; ICD-9). Geneva, Switzerland, WHO, 1978, pp 177-213 26. Kuhs H: Angst und Depression. Psychopathologische Untersuchungen des Angsterlebens melancholischer und neurotischer Kranker. (Anxiety and depression. A psychopathological investigation on the subjective experience of anxiety in melancholic and neurotic patients). Monographien aus dem Gesamtgebiete der Psychiatric, Band 59. Berlin, Germany, Springer-Verlag, 1990, pp 48-59 27. Schulte W: Angstsyndrome. Monatsschrift irztliche Fortbildung 11586-589, 1961 28. Zung WWK: The measurement of affects: Depression and anxiety. Mod Probl Pharmacopsychiatry 7:170-188,1974 29. Maier W, Philipp M, Buller R: Compatibility between ICD-9 and DSM-III classification of endogenous depression (melancholia). Pharmacopsychiatry 1958-61, 1986 30. Carroll BJ, Feinberg M, Greden JF, et al: Diagnosis of endogenous depression. Comparison of clinical, research and neuroendocrine criteria. J Affect Disord 2:177-194,198O 31. Davidson JRT, Turnball C, Strickland R, et al: Comparative diagnostic criteria for melancholia and endogenous depression. Arch Gen Psychiatry 41:506-511, 1984 32. Zimmerman M, Coryell W, Pfohl B, et al: The validity of four definitions of endogenous depression. Arch Gen Psychiatty 43:234-244, 1986 33. Pdldinger W: Psychiatrische Aspekte der Angst, in Kielholz P (ed): Angst. Das arztliche Gesprlch, ~0115. Frankfurt, Germany, pmi-L, Verlag, 1971, pp 32-53 34. Wolfersdorf M: Die Angst des depressiv Kranken-Ein klinische Betrachtung, in Faust V (ed): Angst-Furcht-Panik. Stuttgart, Germany, Hippokrates-Verlag, 1986, pp 111-127 35. Kraepelin E: Psychiatric (ed 2). Leipzig, Germany, Verlag, 1887, pp 229-236 36. Kuhs H: Zur Gegenstandslosigkeit melancholischer Angst. (Unfathomableness in melancholic anxiety.) Z Klin Psycho1 Psychopath01 Psychother 38:342-351, 1990 37. Matussek P, Luks 0: Themes of endogenous and nonendogenous depressions. Psychiatry Res 5:235-242,198l 38. Matussek P, Soldner M, Nagel D: Neurotic depression results of cluster analyses. J Nerv Ment Dis 170:588-597.1982 39. Winokur G: The validity of neurotic-reactive depression. Arch Gen Psychiatry 421116-1122, 1985 40. Zimmerman M, Coryell W, Pfohl B, et al: An American validation study of the Newcastle Diagnostic Scale. II. Relationship with clinical, demographic, familial and psychosocial features. Br J Psychiatry 150526-532, 1987 41. Bronisch T, Klerman GL: The current status of neurotic depression as a diagnostic category. Psychiatry Dev 4:245-275,1989 42. Schneider K: Die Aufdeckung des Daseins durch die cyclothyme Depression. Nervenarzt 21:193-194, 1950 43. Matussek P, Soldner M, Nagel D: Identification of the endogenous depressive syndrome based on the symptoms and the characteristics of the course. Br J Psychiatry 138:361-372, 1981