Masked Depression: Profile and Severity of Symptoms and Impulsivity in Patients with Generalized Anxiety Disorder

  • Ana Fresán
  • Rebeca Robles-García
  • Thelma Beatriz González-Castro
  • Sherezada Pool-García
  • Carlos Alfonso Tovilla-ZárateEmail author
  • Yazmín Hernández-Díaz
  • Isela Esther Juárez-Rojop
  • María Lilia López-Narváez
Original Article


Major depressive disorder may remain underdiagnosed as it can be hidden behind somatic complaints or behavioral problems such as impulsivity, making other symptoms difficult to be recognized. The aim of the study was to determine the presence of depression in a sample of patients first-time diagnosed with generalized anxiety disorder that do not refer symptoms related to depression and to compare anxiety symptoms profile and impulsivity features between depressed and non-depressed patients. A total of 86 patients with DSM-IV diagnosis of GAD were recruited from the outpatient psychiatric services of the General Hospital of Comalcalco, Tabasco. Anxiety symptom severity and impulsivity were assessed with previously validated instruments. Depression was rated with the Hamilton Depression Rating Scale and the sample was categorized in depressed and non-depressed patients. More than half of the patients (54.7%) were identified as clinically depressed. These patients reported more severe anxiety symptomatology and more impulsivity than non-depressed patients; depressed patients also reported more somatic symptoms (e.g., gastrointestinal and hypochondriasis) which patients might identify as anxiety symptoms. In Latin-America, it is very common to use somatic symptoms as idioms of expression of emotional distress. Therefore, in patients with GAD with high levels of somatic complaints and impulsivity, depression should be evaluated.


Comorbidity Somatic symptoms Generalized anxiety disorder Major depression Hamilton Depression Rating Scale 



The authors wish to thank for all the participants for their contribution, and the “Universidad Juárez Autónoma de Tabasco” and the “Hospital General de Comalcalco” personnel for their invaluable work for the logistics of the project.

Compliance with Ethical Standards

All procedures of the present study were in accordance with ethical standards of the Helsinki Declaration (World Medical Association 2013). The Ethics Review Board of the General Hospital of Comalcalco where patients were recruited and the University of Tabasco (UJAT-DAMC), Mexico approved the study. After receiving a comprehensive explanation of the nature and aims of the study, all patients enrolled gave their written informed consent to take part voluntarily in the study.

Conflict of Interest

The authors declare that they have no conflict of interest.

Informed Consent

All procedure followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.


  1. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (Fourth ed.). Washington, DC: American Psychiatric Association.Google Scholar
  2. Apiquian, R., Fresán, A., & Nicolini, H. (2000). Evaluation of the Psychopathology: Rating Scales in Spanish. Mexico: JGH Editors.Google Scholar
  3. Baxter, A., Scott, K., Vos, T., & Whiteford, H. (2013). Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychological Medicine, 43, 897–910.CrossRefGoogle Scholar
  4. Berenzon, S., Lara, M., Robles, R., & Medina-Mora, M. (2013). Depresión: estado del conocimiento y la necesidad de políticas públicas y planes de acción en México. Salud Pública de México, 55, 74–80.CrossRefGoogle Scholar
  5. Berlanga, C., Canetti, A., Chávez, E., De la Fuente, J. R., del Carmen Lara, M., León, C., . . . Sepúlveda, J. (1991). Tratamiento farmacologico de las crisis de angustia. Reporte comparativo de la eficacia y seguridad del alprazolam y la imipramina en un estudio controlado. Salud Mental, 14(1), 1–5.Google Scholar
  6. Berlanga, C., Cortés, J., & Bauer, J. (1992). Adaptación y validación de la Escala de Depresión de Carroll en español. Salud Mental, 15(4), 36–40.Google Scholar
  7. Carter, R., Wittchen, H., Pfister, H., & Kessler, R. (2001). One-year prevalence of subthreshold and threshold DSM-IV generalized anxiety disorder in a nationally representative sample. Depression and Anxiety, 13, 78–88.CrossRefGoogle Scholar
  8. Chachamovich, E., Stefanello, S., Botega, N., & Turecki, G. (2009). Which are the recent clinical findings regarding the association between depression and suicide? Rev Bras Psiquiatr. 2009; 31, S18–25. Revista Brasileira de Psiquiatria, 31, S18–25.Google Scholar
  9. Desjarlais, R. (1996). World mental health. Problems and priorities in low-income countries. Oxford: Oxford University Press.Google Scholar
  10. Escobar, J. (1987). Cross-cultural aspects of the somatization trait. Hospital and Community Psychiatry, 38, 174–180.Google Scholar
  11. Fried, E., van Borkulo, C., Cramer, A., Boschloo, L., Schoevers, R., & Borsboom, D. (2017). Mental disorders as networks of problems: a review of recent insights. Social Psychiatry and Psychiatric Epidemiology, 52, 1–10.CrossRefGoogle Scholar
  12. Goldberg, D., Reed, G., Robles, R., Bobes, J., Iglesias, C., Fortes, S., . . . Saxena, S. (2016). Multiple somatic symptoms in primary care: a field study for ICD-11 PHC, WHO’s revised classification of mental disorders in primary care settings. Journal of Psychosomatic Research, 91, 48–54.CrossRefGoogle Scholar
  13. Hamilton, M. (1967). Development of a rating scale for primary depressive illness. British Journal of Social and Clinical Psychology, 6, 278–296.CrossRefGoogle Scholar
  14. Hamilton, M. (1969). Diagnosis and rating of anxiety. British Journal of Psychiatry, 3, 76–79.Google Scholar
  15. Hofmeijer-Sevink, M., Batelaan, N., van Megen, H., Penninx, B., Cath, D., van den Hout, M., & van Balkom, A. (2012). Clinical relevance of comorbidity in anxiety disorders: a report from the Netherlands Study of Depression and Anxiety (NESDA). Journal of Affective Disorders, 137, 106–112.CrossRefGoogle Scholar
  16. Isaac, M., Janca, A., Burke, K., Costa e Silva, J., Acuda, S., Altamura, A., . . . Tacchini, G. (1995). Medically unexplained somatic symptoms in different cultures. A preliminary report from phase I of the World Health Organization international study of somatoform disorders. Psychotherapy and Psychosomatics, 64, 88–93.Google Scholar
  17. Jakuszkowiak-Wojten, K., Landowski, J., Wiglusz, M., & Cubała, W. (2015). Impulsivity in anxiety disorders. A critical review. Psychiatria Danubina, 27, S452–S455.Google Scholar
  18. Kessler, R., Aguilar-Gaxiola, S., Alonso, J., Chatterji, S., Lee, S., Ormel, J., et al. (2009). The global burden of mental disorders: an update from the WHO World Mental Health (WMH) Surveys. Epidemiologia e Psichiatria Sociale, 18, 23–33.CrossRefGoogle Scholar
  19. Kirmayer, J., & Young, A. (1998). Culture and somatization: clinical, epidemiological, and ethnographic perspectives. Psychosomatic Medicine, 60, 420–430.CrossRefGoogle Scholar
  20. Lobo, A., Chamorro, L., Luque, A., Dal-Ré, R., Badia, X., Baró, E., & Psicométricas, G. d. V. e. E. d. E. (2002). Validación de las versiones en español de la Montgomery-Asberg Depression Rating Scale y la Hamilton Anxiety Rating Scale para la evaluación de la depresión y de la ansiedad. Medicina clinica, 118(13), 493–499.CrossRefGoogle Scholar
  21. Miodek, A., Szemraj, P., Kocur, J., & Rys, A. (2007). Masked depression--history and present days. Polski Merkuriusz Lekarski, 23, 78–80.Google Scholar
  22. Moeller, F., Barratt, E., Dougherty, D., Schmitz, J., & Swann, A. (2001). Psychiatric aspects of impulsivity. American Journal of Psychiatry, 158, 1783–1793.CrossRefGoogle Scholar
  23. Muñoz, R., McBride, M., Brnabic, A., López, C., Hetem, L., Secin, R., & Dueñas, H. (2005). Major depressive disorder in Latin America: the relationship between depression severity, painful somatic symptoms, and quality of life. Journal of Affective Disorders, 86, 93–98.CrossRefGoogle Scholar
  24. Nicolini, H., Villarreal, G., & Ortega Soto, H. A. (1988). Alteraciones en la memoria de pacientes con crisis de angustia, y efecto del tratamiento farmacológico con alprazolam e imipramina. Salud ment, 11(4), 11–14.Google Scholar
  25. Nock, M., Hwang, I., Sampson, N., & Kessler, R. (2010). Mental disorders, comorbidity and suicidal behavior: results from the National Comorbidity Survey Replication. Molecular Psychiatry, 15, 868–876.CrossRefGoogle Scholar
  26. Páez, F., Jiménez, A., López, A., Ariza, J. P. R., Soto, H. O., & Nicolini, H. (1996). Estudio de validez de la traducción al castellano de la Escala de Impulsividad de Plutchik. Salud Mental, 19(Supl 3), 10–12.Google Scholar
  27. Plutchik, R., & Van Praag, H. (1989). The measurement of suicidality, aggressivity and impulsivity. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 13(Suppl), S23–S34.CrossRefGoogle Scholar
  28. Rickels, K., & Rynn, M. (2001). Overview and clinical presentation of generalized anxiety disorder. The Psychiatric Clinics of North America, 24, 1–17.CrossRefGoogle Scholar
  29. Vytal, K., Arkin, N., Overstreet, C., Lieberman, L., & Grillon, C. (2016). Induced-anxiety differentially disrupts working memory in generalized anxiety disorder. BMC Psychiatry, 16, 62. Scholar
  30. Wittchen, H., Kessler, R., Pfister, H., Höfler, M., & Lieb, R. (2000). Why do people with anxiety disorders become depressed? A prospective-longitudinal community study. Acta Psychiatrica Scandinavica, 102, S14–S23.CrossRefGoogle Scholar
  31. World Medical Association. (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA, 310, 2191.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Ana Fresán
    • 1
  • Rebeca Robles-García
    • 1
  • Thelma Beatriz González-Castro
    • 2
  • Sherezada Pool-García
    • 3
  • Carlos Alfonso Tovilla-Zárate
    • 4
    Email author
  • Yazmín Hernández-Díaz
    • 2
  • Isela Esther Juárez-Rojop
    • 5
  • María Lilia López-Narváez
    • 6
  1. 1.Subdirección de Investigaciones ClínicasInstituto Nacional de Psiquiatría Ramón de la Fuente MuñízMexico CityMexico
  2. 2.División Académica Multidisciplinaria de Jalpa de MéndezUniversidad Juárez Autónoma de TabascoJalpa de MéndezMexico
  3. 3.Secretaría de SaludHospital General de ComalcalcoComalcalcoMexico
  4. 4.División Académica Multidisciplinaria de ComalcalcoUniversidad Juárez Autónoma de TabascoComalcalcoMexico
  5. 5.División Académica de Ciencias de la SaludUniversidad Juárez Autónoma de TabascoVillahermosaMexico
  6. 6.Secretaría de SaludHospital General de YajalónYajalónMexico

Personalised recommendations