Mohammed T. Abou-Saleh

NOSOLOGY AND CLASSIFICATION OF NEUROTIC DISORDERS 539Table 97.2Classification of neurotic disordersSpecial Considerations in Geriatric PatientsICD-10DSM-IVF40 Phobic disorderAnxiety disorders40.0 Agoraphobia.00 Without panic disorder.01 With panic disorder300.21 Panic disorder withagoraphobia300.01 Panic disorder40.1 Social phobias without agoraphobia40.2 Specific (isolated) phobias 300.22 Agoraphobia withoutF41 Other anxiety disordershistory of panic disorder41.0 Panic disorder 300.29 Specific phobia41.1 Generalized anxiety disorder 300.23 Social phobia41.2 Mixed anxiety and 300.3 Obsessive-compulsivedepressive disorderdisorderF42 Obsessive-compulsive disorder 309.89 Post-traumatic stress42.0 Predominantly obsessional disorderthoughts 308.3 Acute stress disorder42.1 Predominantly compulsive 300.02 Generalized anxietyactsdisorderF43 Reaction to severe stress andadjustment disordersSomatoform disorders300.81 Somatization disorder43.0 Acute stress reaction 300.11 Conversion disorder43.1 Post-traumatic stress 307 Pain disorderdisorder 300.7 Hypochondriasis43.2 Adjustment disorder 300.7 Body dysmorphic disorder.20 Brief depressive Dissociative disordersreaction300.12 Dissociative amnesia.21 Prolonged depressive 300.13 Dissociative fuguereaction300.14 Dissociative identity.22 With predominant disorderdisturbance of other 300.6 Depersonalizationemotionsdisorder.23 With predominant Adjustment disorderdisturbance of conduct 309.0 With depressed mood.24 With mixed 309.24 With anxietydisturbance of 309.40 With mixed disturbancesemotions and conduct of emotions and conductF44 Dissociative and conversion 309.28 With mixed anxiety anddisorderdepressed mood44.0 Psychogenic amnesia 309.3 With disturbance of44.1 Psychogenic fugue conduct44.2 Psychogenic stupor44.3 Trance and possession states44.4 Psychogenic movementdisorders44.5 Psychogenic convulsions44.6 Psychogenic anaesthesia andsensory lossF45 Somatoform disorders45.0 Multiple somatizationdisorder45.1 Undifferentiatedsomatoform disorder45.2 Hypochondriacal syndrome45.3 Psychogenic autonomicdysfunction45.4 Psychogenic painF48 Other neurotic disorders48.0 Neurasthenia48.1 Depersonalization–derealization syndromedisorders have been ruled out. Depersonalization–derealizationsyndrome is a rare disorder in which the patient feels that his/herown mental activity, body or surroundings are changed in qualityso as to be unreal or remote. This phenomenon is more commonlyobserved as a feature of depression, phobias, obsessive-compulsivedisorder and some psychoses.Anxiety, both as a symptom and as a disorder, is common amongthe elderly, but not remarkably more or less so than at other ages.The nature of worry and its clinical manifestations, however,change with increasing age. The intricate relationships amongpsychosocial stress, physical illness, depression and anxiety in latelife make the recognition, diagnosis and classification of neuroticdisorders in the elderly quite complex 14–16 .The clinician can usually compare the fears and concerns of ayounger patient against those of his/her own peers and arrive at acredible assessment of whether or not the anxieties are pathological.The aged, however have different fears; they worry aboutphysical illness, crime, institutionalization, financial disaster,senility and physical dependency. It is often hard for the youngerphysician to determine whether the subjective interpretation ofevents, or the anticipation of future events, is in the realm ofclinical anxiety or constitutes adaptive concern. Anxiety resultsfrom feelings of vulnerability, and the elderly are truly vulnerablein many ways. It is no easy task to diagnose agoraphobia in an 80-year-old person whose fear of crime in her neighborhood mayexceed its statistical likelihood. The clinician walks a fine linebetween pathologizing a healthy response and failing to recognizeneurotic dysfunction 14 .Physical illnesses with psychiatric manifestations increase inprevalence with age, as does the need to take medications withemotional or behavioral side effects. Emphysema, for example,may produce features indistinguishable from those of panicdisorder. Hyperthyroidism is commonly accompanied by symptomsresembling those of generalized anxiety disorder. Further,the guiding symptom profiles for the underlying disorders may beabsent or muted in the aging person. ‘‘Silent myocardialinfarction’’ and afebrile pneumonia are fairly common. Finally,the elderly consume significantly more medication than doyounger people and exhibit psychiatric side effects at lowerdoses and serum levels. Bronchodilators may produce thesymptoms of many anxiety states; recommended doses of overthe-countermedications for sleep or colds may induce presentationsresembling dissociative states 16 .As could be expected, the diagnosis of somatoform disordersand hypochondriasis is particularly complicated in the elderly.Somatic complaints are common. To some extent, the somaticpresentation of emotional disorders is a sociocultural cohortphenomenon. The generation of people over 70 in the 2000s, forexample, grew up in the 1940s and earlier. At that time, wordssuch as ‘‘depression’’ and ‘‘anxiety’’ were not commonplace partsof everyday conversation. Emotional introspection was notculturally normative. Thus, the older person who complainstoday of having ‘‘butterflies in my stomach’’ may be aware of thephysical concomitants of anxiety, but not of the emotional stateunderlying it. The clinician must ‘‘translate’’ somatically-phrasedcomplaints to help determine the affective condition.Furthermore, the increase in prevalence of almost all physicalillnesses with age confounds the determination of pathologicalperception and behavior, necessary for making diagnoses ofsomatoform disorders. Both DSM-IV and ICD-10 leave room fora subjective judgment of whether the presence of physicalsymptoms is sufficient to explain the intensity of the patient’sresponse. There are no objective grounds for deciding when acomplaint of abdominal pain constitutes a somatoform disorderin a person with concurrent emphysema, arthritis and congestiveheart failure 14,17 .While the delineation of the diagnosis and treatment of posttraumaticstress disorder (PTSD) followed the societal impact ofreturning Vietnam War veterans, the syndrome is not uncommonin older individuals. The trauma may have been a different war(World War II or Korea), a natural disaster, or a personal event