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Anxiety Disorders



Anxiety is a common symptom of depression, and depression is often associated with anxiety. In fact, approximately 42% of people with depression reported symptoms of worry, psychic anxiety and somatic anxiety of at least moderate severity in a 1983 survey (Fawcett and Kravitz, 1983). Atypical depression – characterised by depression with significant anxiety, hyperphagia, hypersomnia, reverse diurnal variation and extreme reaction sensitivity – is particularly associated with anxiety in depression. 

The efficacy of the selective serotonin reuptake inhibitors (SSRIs) in the treatment of both mood and anxiety disorders clearly demonstrates an overlap between the two. Furthermore, a recent epidemiological study by the World Health Organization on the association between anxiety and depression (Sartorius et al, 1996) confirmed the association between the two disorders. Anxiety symptoms were more pronounced in the elderly and in patients with concomitant medical disease.

Another authority (Liebowitz, 1993) confirms the co-occurrence of the two disorders and recommends that anxiety symptoms should be taken into account when assessing the most appropriate antidepressant agent for treating someone with depression, to optimise treatment outcome and recovery rate. People with depression who have high anxiety levels take significantly longer to recover, have a higher rate of multiple drug treatments, a higher incidence of suicide and more frequent episodes of depression than people with depression who have no symptoms of anxiety (Joffe, 1993; Angst, 1997).

The precise relationship between depression and anxiety disorders is still to be fully established. Anxiety is not a requirement for the diagnosis of major depression (DSM-IV, 1994; ICD-10, 1992), and mood and anxiety disorders are recognised as distinctly separate diseases. However, the question of a continuum has never been completely abandoned and a group of ‘in-between’ patients, with symptoms of both anxiety and depression, has been described (Angst, 1997).

Bipolar Disorders

The Stanley Foundation Bipolar Network reports a high percentage of concomitant psychiatric conditions with bipolar disorder. Panic disorder, social phobia, post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and impulse control disorders (e.g. pathologic gambling, kleptomania) often present concurrently with bipolar disorder (NIMH, 2000; Suppes et al, 2000). The National Institute of Mental Health (NIMH) recently reported an especially high incidence of PTSD and OCD in people with bipolar disorder, with 43% of people with bipolar disorder exhibiting symptoms of PTSD.


Severe anxiety may be a risk factor for suicide (Fawcett and Kravitz, 1983; Fawcett, 1997). Studies have reported that a significant number of people who committed suicide were diagnosed as having an anxiety disorder (Allebeck, 1988) and a significantly increased suicide rate is seen in people with panic disorder (Coryell, 1988).

A study in Finland investigating the role of anxiety as a comorbid diagnosis found that over a period of 1 year, 17% of people who committed suicide were diagnosed retrospectively as having depression with a comorbid anxiety disorder, and 6% had bipolar disorder with a comorbid anxiety disorder (Isometsä, 1994). In a prospective study by Fawcett et al. (1990), also investigating the comorbidity of anxiety and suicide, the role of the anxiety symptoms in suicide was clarified. Fawcett et al concluded that suicidal ideation, a history of past suicide attempts and the severity of hopelessness did not correlate significantly with suicide, whereas the severity of psychic anxiety and the presence of panic attacks did show a significant correlation with suicide. Further studies by this team confirmed the important role of severe psychic anxiety 1 week before suicide (Fawcett, 1997).

It is known that serotonin dysfunction has a role in both suicide and anxiety. Furthermore, a number of biological markers, such as markers of the hypothalamo–pituitary–adrenal axis and serotonin function, appear to be associated with both anxiety and suicide risk in depression. Dysfunction in the hypothalamo–pituitary–adrenal axis and the serotonin system may be associated with states of overwhelming anxiety-agitation and decisive treatment to correct the dysfunction seems to resolve this crisis and allow successful resolution of the episode. 

However, little attention is given to the role of anxiety in suicide in clinical practice and the potential for suicide is often not considered when planning treatment regimens for people with anxiety disorders.


Last updated: 20.12.2011





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