Department of Social Psychiatry, University of Limburg, 6200 MD Maastricht, The Netherlands



Over the last 20 years a rich and growing literature has appeared on anxiety and depression. From a selected review one may draw the simple conclusion that there are many anxiety patients who present with concurrent depressive symptoms and that there are many depressive patients who present with con­current symptoms of anxiety. Some studies (2) report as high as a 86% past or concurrent incidence of depression in a sample of agoraphobic-panic disordered patients. This co-occurrence of symptoms in clinical (15) and normal populations (13) is not merely of academic interest, for those individuals with mixed disorders seemingly suffer greater morbidity and poorer psychosocial outcome (28,30). Regardless then of the nosological debate begun by Carney et al. (3) and Gurney et al. (14) over whether a unitary or multidimensional theory about depression and anxiety describes the data best, the simple fact remains that the group that shares both characteristics is of great clinical significance. A series of new studies (21,25, and others in this volume) have further suggested that there are three disorders: pure anxiety, pure depression, and a mixed variant. These may be clinically and statistically defined. One of the goals of this volume is to determine if it is possible to unravel these clinical processes. A recent review by Stavrakaki and Vargo (28) criticizes the designs and results of current studies and questions our capacity to make distinctions between the three disorders on semantic, methodological, statistical, and interpretative grounds. The studies that they reviewed are suspect primarily because they have led to a high mis-classification rate. We are thus left with the conundrum of having discovered an important clinical entity while lacking a good method for defining it. This article argues that the problem may be created by the cross-sectional depression and anxiety assessment methods that we employ (Mullaney, this vol­ ume). We therefore suggest exploring alternative assessments as well as other sources of information about the disorder. For example, we may look to different developmental phases (Akiskal, this volume), the natural history of the illness Process (Cassano, this volume), and the use of new assessment techniques. One such new method is Experience Sampling (ES). ES supplements traditional cross-sectional assessment methods by providing daily life descriptions and self-reports of mental states gathered within the context in which they occur. In this paper, the ES technique is applied to anxiety patients with significant depression. Before describing the method and its results in detail, the following general comments are in order. The point of departure for this research is that nomothet-ically or group-derived categories are not as useful as we would like them to be for the planning of treatment and understanding of mental disorder. In the words of Klerman, "diagnosis is insufficient for treatment" (20). Investigations at the ideographic or person level are therefore more appropriate for elucidating treatment approaches, particularly when complex or chronic disorders are the focus of concern. To do this in a scientifically valid way, supplemental and refined measurement techniques are required. The following general suggestions are offered: (a) We should measure clinical phenomena in more detail and with greater frequency, paying particular attention to what happens within the day and from day to day. (b) We should, in spite of problems with self-report methods, use them more often. Self-report methods allow data to be gathered more fre­quently and in real time and context. These methods help alleviate the problems of the unreliable retrospective reporting of symptoms and increase the ecological validity of the findings. General findings of ambulatory randomly repeated self-report studies that interrupt the subject’s flow of experience with a signal to fill out self-reports are that: (a) illness symptoms vary over time and over the course of the day; (b) the actual incidence of symptoms or illness state is low when compared with as­sumptions based on classical one-time measuring instruments; and (c) as a con­sequence of these two findings, symptom variability and low frequency of oc­currence, it is possible to describe disorders as they are experienced in defined times, places, and situations. The description further demonstrates form and pattern. The research described here illustrates how temporal and contextual factors play a role in anxiety patients with significant depression and stresses the clinical relevance of these findings.

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