اضطراب خصلتی و اثر دوز بالای دیازپام واحد در افسردگی تک قطبی

In this cross-sectional study we explored in 101 depressive in-patients (DSM III-R) the association between level of trait anxiety and variables that have been investigated previously to discern primary and secondary depression, respectively. Besides, we explored the influence of trait anxiety level on difference in treatment response to either imipramine or mirtazapine. Trait anxiety was measured interviewing a close relative of the patient using a questionnaire related to aspects of psychic anxiety and to aspects of somatic anxiety. The interviewer focussed on fluctuating anxiety symptoms without persistent mood disturbance during the patient's normal lifelong functioning before developing a depressed mood. We found no relation between trait anxiety level and treatment response to either imipramine or mirtazapine. The most important finding of this study is the significant differential response to the diazepam test: depressive patients with high trait anxiety showed, predominantly, a disappearance of depressive symptoms without sedation and depressive patients with low trait anxiety showed, predominantly, sedation without disappearance of depressive symptoms. The opposite response to the diazepam test in patients with a different history of trait anxiety in spite of similar depressive symptomatology suggests differences in underlying pathophysiologic mechanisms.

Patients with a history of anxiety often develop depression later in their life. This applies to anxiety disorders (Clancy et al., 1978, Dealy et al., 1981, Schatzberg et al., 1990 and Moras and Barlow, 1992) proper as well as to chronic anxiety symptoms not fulfilling the diagnostic criteria for anxiety disorder. Van Valkenburg et al. (1983) e.g. found differences between depressive patients with chronic lifelong nervousness preceding the onset of depression (anxiety as a trait, without having a diagnosable preceding anxiety disorder) and patients without this premorbid nervousness. The concept of depression secondary to chronic anxiety may be related to the “psychasthenia” concept of Janet (Jelgersma, 1939): in addition to patients with melancholia (primary depression) he observed patients who had a lifelong vulnerability, a trait, to develop various complaints such as phobias, compulsions, doubt, shame, fear for the future, depersonalisation and fatigue. A related concept was proposed by Akiskal (1998): “Generalised anxious temperament” (GAT) with lifelong high trait anxiety which fluctuates in reaction to stress and which can escalate to a full-blown generalised anxiety disorder. According to Akiskal, Generalised anxiety disorder (GAD) is in continuum with GAT. Generalised anxiety temperament may predispose to and is often associated with depression. The view of generalised anxiety being a personality trait which can exacerbate into an anxiety disorder and which predisposes to depression is in line with the evidence from longitudinal studies that chronic anxiety disorders are not infrequently accompanied by secondary depression, whereas chronic depression is rarely associated with a secondary anxiety disorder (Cloninger et al., 1981). Nuller et al. (1982) reported that the reaction to the diazepam test distinguished primary depressions from depressions secondary to anxiety and predicted a good response to treatment with an antidepressant or to treatment with a benzodiazepine, respectively. We performed a cross-sectional study in depressed patients exploring clinical, personality and biological variables, which could give more insight into the differences between patients with a low level of trait anxiety and patients with a high level of trait anxiety. In imitation of the trait anxiety concepts of Van Valkenburg et al. (1983), Janet (Jelgersma, 1939) and Akiskal (1998) we defined trait anxiety as a lifelong disposition to develop (too) easily various symptoms of psychic and somatic anxiety in reaction to stressful circumstances which fluctuate in time and which sometimes can escalate to a full-blown anxiety disorder.