With mood disorders, a single episode of depression is experienced by 6% of the U.S. adult population (aged 18 to 64) in their lifetime, whereas recurrent depression occurs among 15% of adults (aged 18 to 64) in the U.S. in their lifetime. Combined, about 21% of the U.S. adult population—or one in five individuals aged 18 to 64—will experience either a single or multiple episodes of depression in their lifetime (Kessler et al., 2012). According to more recent data, from 2013 to 2016, about 8% of U.S. adults (aged 20 or over) reported experiencing symptoms of depression over a 14-day period (Brody et al., 2018).

For anxiety disorders, 13% of the U.S. adult population (aged 18 to 64) will suffer from social anxiety in their lifetime, along with 5% and 6%, respectively, for panic disorder and generalized anxiety disorder (Kessler et al., 2012). More recently, survey data collected in 2019 revealed that about 16% of U.S. adults (aged 18 or over) reported anxiety symptoms over a 14-day period (Terlizzi & Villarroel, 2020).

With PTSD, now considered a trauma-related disorder in the DSM-5, almost one in ten adults (aged 18 to 64) will meet diagnostic criteria at some point in their lifetime (Kessler et al., 2012). As revealed by more recent survey data collected in 2017, about 7% of U.S. adults (aged 18 to 70) met International Classification of Diseases, 11th Revision (ICD-11), criteria for either PTSD or complex PTSD, based on self-reported symptoms over the previous month (Cloitre et al., 2019).

For relationship distress, in a recent survey among U.K. adults, roughly one in ten who were married or living with a partner stated they at least occasionally thought about divorce or separation or had regrets about originally entering into the relationship (Sserwanja & Marjoribanks, 2016). What is more, in a recent survey among U.S. adults, only about one in two who were married or living with a partner stated the relationship was going “very well” (Pew Research Center, 2019). In a follow-up survey, about one in ten U.S. adults who were married or cohabitating with a partner reported “their relationship [was] going not too or not at all well” (Barroso, 2021).

With regard to specific symptoms, an episode of depression is characterized by a depressed or low mood that occurs over at least a two-week period (APA, 2013). This depressed mood can be reported by the client as hopelessness, extreme sadness, or a feeling of emptiness or noticed by friends, family, or a mental health professional via direct observation (e.g., crying spells) (APA, 2013). In addition to low mood, anhedonia—a loss of interest in activities that used to be pleasurable to the client—may be present (APA, 2013). Along with one or both of the above symptoms, at least several others among a longer list of symptoms need to be present to warrant a diagnosis of major depressive disorder (MDD), including weight loss or gain, trouble sleeping, a disruption in psychomotor functioning, diminished energy, extreme guilt or recurrent feelings of worthlessness, trouble concentrating or focusing, and suicidal thoughts (APA, 2013). Finally, the aforementioned symptoms need to lead to a struggle or inability to carry out day-to-day functioning in one or more major life domains, including work or interpersonal relationships (APA, 2013).

In terms of anxiety disorders, common general symptoms include an intense or overwhelming fear that is linked to some sort of present danger, anxiety that is associated with a perceived future catastrophe or threat, and behavioral problems that emanate from recurrent fear or anxiety (APA, 2013). Stated more succinctly, fear is rooted in the present moment, often associated with a fight-or-flight response within the sympathetic nervous system to prepare for immediate action in response to a current threat, whereas anxiety involves symptoms such as worry and tension when anticipating or predicting a future doomsday scenario that may or may not come true (APA, 2013). When considering a current or future danger, anxiety disorders differ from normal reactions to these real or imagined events in that the experience is usually excessive, with clients overreacting to day-to-day stressors by way of avoidance behaviors (APA, 2013).

Amid the most common anxiety disorders, social phobia involves excessive fear or anxiety linked to social interactions, with clients likely preoccupied with being negatively judged, evaluated, or rejected by others (APA, 2013). Along with these recurrent concerns, clients may believe they will display some sort of embarrassing behavior in a social context; thus, a range of interpersonal events and encounters are avoided so as to eliminate the likelihood of rejection, embarrassment, and, ultimately, anxiety (APA, 2013). Of course, given that the anxiety is excessive, it impairs day-to-day functioning (APA, 2013).

Panic disorder, on the other hand, includes episodes of extreme fear, often surprising to the individual and fairly regular in terms of frequency or occurrence (APA, 2013). Within these distinct instances of panic, a range of symptoms may be experienced, including excessive sweating, a sudden increase in heartbeat, thoughts about dying or losing control, and extreme shaking (APA, 2013). To receive a diagnosis of panic disorder, clients must experience an ongoing preoccupation with additional episodes, worrying that an unexpected attack will occur in the future, along with avoidance behaviors, in an attempt to ward off subsequent symptoms of panic (APA, 2013).

As one more anxiety disorder to consider, generalized anxiety involves recurrent worry, with clients struggling to ameliorate the experience of catastrophic predictions about a range of topics (APA, 2013). In addition to the central theme of worry, generalized anxiety consists of at least three more symptoms, such as decreased energy, trouble focusing or concentrating, irritable mood, difficulty sleeping, and an “on edge” feeling because of worry (APA, 2013). Similar to the aforementioned disorders, generalized anxiety impairs day-to-day functioning in one or more life areas, including work and interpersonal relationships (APA, 2013).

Concerning trauma-related disorders, PTSD involves being exposed to a serious, violent, life-threatening situation, followed by a variety of symptoms in response to the event (APA, 2013). More specifically, PTSD symptoms may include intrusive, distressing memories, dreams, flashbacks, or reactions to reminders about the traumatic event, the avoidance of internal and external reminders about the traumatic event, impaired thoughts (e.g., cognitive distortions) and feelings (e.g., extreme anger) about the traumatic event, and hyperarousal after the traumatic event (e.g., hypervigilance). Consistent with depressive and anxiety disorders, PTSD impairs daily living in relational, occupational, or other major areas of functioning (APA, 2013).

Turning to the “Relationship Distress with Spouse or Intimate Partner” V code in the “Other Conditions That May Be a Focus of Clinical Attention” section of the DSM-5 (APA, 2013), this designation is used when “the major focus of the clinical contact is to address the quality of the intimate (spouse or partner) relationship or when the quality of that relationship is affecting the course, prognosis, or treatment of a mental or other medical disorder” (p. 716). To warrant this V code assignment, the reported relational distress commonly impairs cognitive (e.g., recurrent negative evaluations of a partner’s behavior), affective (e.g., recurrent anger directed toward a partner), or behavioral (e.g., recurrent withdrawal from a partner during conflict) functioning (APA, 2013).

Unfortunately, major depressive disorder commonly co-occurs with social phobia, panic disorder, generalized anxiety disorder, and PTSD, referred to as comorbidity (APA, 2013). Also, relationship quality is negatively associated with depressive, anxiety, and trauma-related symptoms (McShall & Johnson, 2015), with relationship distress commonly impacting the “course, prognosis, or treatment” of many diagnoses, including depressive, anxiety, and trauma-related disorders (APA, 2013, p. 716). As an example, among a recent national sample in the Netherlands, 67% of individuals with a depressive disorder also had an anxiety disorder, with this rate increasing to 75% when considering the lifetime prevalence of anxiety disorders (Lamers et al., 2011). On the other hand, 63% of those with an anxiety disorder also had a diagnosis of depression, with this percentage rising to 81% when taking into consideration depression over their lifetime (Lamers et al., 2011). As another example, when studying PTSD and depressive symptoms among a clinical sample of adults who recently experienced a traumatic event, researchers concluded that “the bulk of psychopathology in the aftermath of trauma is best conceptualized as a general traumatic stress factor” (O’Donnell et al., 2004, p. 1395), not independent diagnoses. From a theoretical perspective, this type of overlap between depression, anxiety, and PTSD may be due to each disorder occurring as a different, isolated psychiatric disorder, interaction between the disorders, or the disorders being experienced along a continuum that is anchored to the same underlying neurobiology (Hranov, 2007). What is more, because of the likelihood of impaired social functioning with depressive, anxiety, and trauma-related disorders, relationship distress with a spouse or intimate partner may often occur in the midst of these DSM-5 diagnoses. Ultimately, relational distress can either exacerbate (with a bidirectional relationship) or emanate from these diagnoses.

Interestingly, many psychological problems, conditions, and disorders, including those previously mentioned, have in common attempts to avoid psychological pain, utilizing unhelpful strategies in an effort to eliminate the ensuing distress. For example, MDD typically involves social withdrawal, whereas panic disorder with agoraphobia includes isolation so as to seemingly avoid another panic attack in public. What is more, social anxiety involves an ongoing struggle with interacting with others, avoiding social events based on a fear of being embarrassed or scrutinized, whereas PTSD includes the avoidance of trauma-related stimuli, whether internal or external. Finally, intimate partners struggling with relational problems may withdraw as a short-term strategy to avoid relationship distress, which may lead to long-term problems with satisfaction, intimacy, commitment, longevity, and so forth.

Thus, frequently embedded within these diagnoses and V codes is a struggle with avoiding unpleasant inner (e.g., thoughts, feelings, sensations, memories), as well as corresponding outer (e.g., challenging situations, relational problems), experiences, given the possibility of additional psychological pain when faced with unrelenting environmental demands. In addition to the avoidance that is inherent within many of these psychological problems, conditions, and disorders, society often utilizes a range of strategies to reduce, eliminate, avoid, or distract from an array of psychological challenges, which often do not work in the long run.