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What Is Major Depression With Anxious Distress?

Part 3: Identifying and understanding major depression subtypes

Key points

  • Anxious distress is not the same as having an anxiety disorder along with major depressive disorder.
  • Physical tension, feeling something bad will happen or you'll lose control, are signs of anxious distress in a major depressive episode.
  • Anxious distress within depression is believed to elevate suicidal thinking and activity.

It's no secret that anxiety conditions and depression co-occur. In fact, most researchers agree they co-occur at least 60 percent 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 a Major Depressive Disorder (MDD) episode, there is an onset of some specific anxiety that is congruent to the depression.

Gert Altmann/Pixabay
Source: Gert Altmann/Pixabay

The presentation:

MDD patients with Anxious Distress are not only down and out. They're tormented by 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 percent met the criteria for the specifier; this was after controlling for co-occurring anxiety disorders. Imagine the compounded misery of patients, like Liz:

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 was tough for her to get through college, but she was gaining on it. Nonetheless, like many suffering from SAD, Liz was prone to MDD. For Liz, the episodes would come on when she began dwelling on how stalled her life was from SAD. Many peers were already in careers and had a family, and 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. In her voicemail to Dr. H, she said, "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."

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 was 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 (which must be present more days than not during the current Major Depressive episode) are:

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

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 experienced an anxiety disorder and a depressive episode together as "with anxious distress." These would be considered independent, co-occurring diagnoses. The anxiety symptoms that arose with the MDD 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 in detail.

You may be asking yourself, "What about if the person develops panic attacks from being so overwhelmed by the depression?" Panic is "special" in that any condition can have a "with panic" specifier. Just because someone experiences a panic attack or occasional attacks, also doesn't mean they have Panic Disorder.

There must also be significant fear of future attacks and or maladaptive behaviors to try to keep future attacks at bay, like avoiding exercise and sex because the exertion can lead to feelings that are reminiscent of panic symptoms and there is fear it may evolve into an attack. Of course, someone may have MDD and Panic Disorder if full criteria for the latter are also met. Readers are directed to page 214 of the DSM-5 for more information on this nuance.

Though uncomfortable, panic is often sporadic and fleeting, while the symptoms of With Anxious Distress must be specifically noted because they are chronic and gnawing, adding torment to the person's condition. Imagine suffering the low feeling of serious depression, coupled with a feeling that you can't gain control, feeling physically tense, and worrying it will never end. This is quite a problem in that, as seen with Liz, the depression encourages the anxiety, and that added anxiety encourages 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 to 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' MDD episodes, and evaluate accordingly. Patients may not be as forthcoming 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 begun to develop muscle tension, worry, and feeling they're losing control takes mere minutes and can have big clinical payoffs. Assuaging the anxiety will help in managing the MDD.

Source: Cottonbro/Pexels

Clinical considerations if Anxious Distress is suspected:

  • Suicide prevention: Suicide attempts may be more prevalent with anxious distress, evaluating for risk is even more important.
  • Be sure to consult with the person's prescriber if you are concerned about 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.
  • Evaluate if the person's lifestyle may be exacerbating the anxious distress. Namely, are they caffeine consumers, eat a lot of junk food or 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 percent 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 of 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 is of utmost importance to have a plan in place to immediately return to treatment if they or friends and loved ones recognize the onset of a depressive episode. Keeping the MDD at bay likely will help keep the Anxious Distress away.

Stay tuned for the next post on Monday, October 11, for a tour of Melancholic Features, perhaps the "darkest flavor" of Major Depressive Disorder.


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), 712–720 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.

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