Current Medical Diagnosis & Treatment in Psychiatry

COMORBIDITY

Current Concepts in AnxietyAug 01, 06

An extremely confusing area is the intricate relationship between the anxieties and the depressions. I emphasize the plural since it seems clear that there are multiple discrete anxiety disorders as well as several different depressed states, which coexist in multiple combinations. This is often referred to as comorbidity, but since these so-called comorbidities are so common, that the symptomatic mix is actually due to the evolution of complex syndromes seems likely. If that were true, one would expect that the relatives of “comorbid” patients would be more likely to have symptomatically mixed conditions than simple anxious or depressive states. The literature is contradictory and the question remains unresolved (Mannuzza et al., 1994/5).

Again, phenocopies blur attempts to delineate genetically homogeneous, complex, classes.

That anxiety disorders often precede depressive disorders and respond to (some) antidepressants seems to support the idea that they are often a type of masked depression, but this is contradicted by the regularly poor results of ECT in anxious patients (although not in agitated depressions). Further, social phobia and the frequently comorbid atypical depression are both MAO inhibitor responsive, but only slightly tricyclic responsive. This gets even more confusing with regard to therapeutic mechanism, given the recent reports of the utility of SSRIs in social phobia. In general, pharmacological dissection fosters useful syndromal distinctions but pharmacological amalgamation is not helpful. Studies that incorporate the range of both syndromes and their complications are needed.

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