Mohammed T. Abou-Saleh

546 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYassistance 9 . This is especially true for financial help. One’s socialnetwork is typically made up of persons in similar economiccircumstances, whose financial resources may already be limited.There is evidence that most older people value independence andprefer to resolve problems by themselves, rather than dependupon others 27 . Systematic evidence for the impact of specificcoping strategies on psychiatric morbidity is presently lacking.The number and variety of possible coping responses, togetherwith the fact that assessments of appropriate coping behavior mayvary across situations and social groups, has made research in thisarea difficult 20 .Social SupportSocial support refers to a number of different aspects of socialrelations and includes: (a) social network: the size, stability, andstructure of an individual’s network of friends, relatives, andacquaintances; (b) social interaction: the presence and quantity ofinteraction with network members as well as organizationalparticipation; (c) instrumental support: services and assistanceprovided by family and friends; and (d) perceived support:subjective satisfaction with one’s social relationships and availabilityof support.Two alternative models have guided most empirical studies ofthe relationship between social support and depression. With the‘‘stress-buffering’’ model, a statistical interaction is hypothesized.The protective effect of support is expected to be at its maximumunder conditions of stress and weaker when stress is absent 28,29 .Given the presence of a potentially stressful event or experience,social support is thought to influence the degree to which thesituation is appraised as threatening, and an individual’s capacityto cope. The impact of stress on depression will therefore bestrongest among those lacking adequate support. In the absenceof stress, the availability of support is of less importance, and therelationship between support and depression is expected to beweaker. With the ‘‘main effect’’ model of stress, support anddepression, high levels of social support are hypothesized topromote mental health at all levels of stress. From thisperspective, the effects of stress and support are not interactive—theeffect of each does not depend upon the level of theother 30,31 .Reviewers report that the protective effect of support ondepression varies across its different dimensions in the generalpopulation and among older persons 8,9,20,21 . Perceived support ismost strongly and consistently protective for depression. Thereis also longitudinal evidence that the primary causal influence isfrom perceived support to depression, rather than the reverse.Findings for the protective effect of network size have beenmostly negative. Amount of social interaction is associated withdepression in several studies, but not with the onset ofdepression in longitudinal research. Received support canincrease, as well as reduce, the risk of depression 9,12 . Krauseet al. 9 reason that the receipt of assistance may reflect a failedattempt to solve a problem on one’s own, and may beaccompanied by hostility and resentment from those providingassistance. Reviewers are also in agreement that most (but notall) studies report a stress-by-support interaction consistent withthe stress-buffering models 11,20 . Positive findings for stressbuffering are most often present for perceived support, andrecent findings suggest that anticipated support—the belief thatothers stand ready and able to help if called upon—is especiallycritical, as it promotes effective coping and confidence that aproblem can be solved 9,13 .According to Kahn and Antonucci’s convoy metaphor forsocial support 32 , the size and composition of one’s social networkchanges over the life course as individuals enter and leave avariety of social roles (e.g. spouse, parent, employee). Socialnetworks change composition later in life in response to changesin one’s health and employment, and to impairment and deathamong one’s age peers 20 . For example, retirement can providetime to expand the scope of one’s social participation, and evenpoor health, which limits some relationships, may enhance othersas one’s support network is mobilized to provide assistance 33 .Findings are mixed regarding whether there is a net decrease innetwork size and frequency of contact in old age, allowingdifferent reviewers to draw different conclusions. However, thereis general agreement that aging is not a time of social isolation,and that most older people have a significant number ofrelationships 20,33 . Studies of changes in social network andinteraction after age 65 report considerable change, characterizedby widely varying patterns of gains and losses rather than a trendtoward isolation 33 . While it is unclear how these specific changesaffect the psychological health of older adults, the notion that oldage is a time of psychologically debilitating isolation is clearly notsupported.STRESS, COPING, SOCIAL SUPPORT AND THENEUROTIC DISORDERSThe proposition that stress, support and coping may affectneurosis is consistent with existing theories that suggest thatsymptoms of anxiety and panic disorders represent a dysfunctionalresponse to potentially stressful environmental events 10 .While anxiety is adaptive in the face of potentially threateningor unpleasant events, the anxiety disorders are characterized byunjustifiably intense and morbid anxiety and panic 2 . Endler’smultidimensional interaction model of anxiety includes situationalfactors (stressors) and individual characteristics whichinteract to produce anxiety symptoms and disorder 34 . Relevantindividual characteristics include ‘‘trait anxiety’’—a predispositionto react to stressors generally, or to particular stressors,with dysfunctionally high and persistent levels of anxiety.Individual traits also include differentially effective copingstyles and behaviors. One’s appraisal and use of availableresources, such as social support, is incorporated as part ofcoping.There is also reason to expect differences in how stress andsupport might relate to anxiety as opposed to depression. Theanxiety disorders, which include agoraphobia (with and withoutpanic attack), social and simple phobia, panic disorder, generalizedanxiety disorder and obsessive–compulsive disorder (OCD),are considerably more complex and diverse than the subtypes ofdepression. This has led reviewers to call for research thatconsiders these subcategories separately in examining the effectsof stress, support, coping and other risk factors 34,35 . The ‘‘multidimensional’’aspect of Endler’s model refers to the propositionthat trait anxiety may be stressor-specific. Environmental dangermight trigger anxiety only among those predisposed on this trait,while a symptomatic response to a job interview might be limitedto those differently predisposed. The implication—that the effectof a stressor on anxiety would be greatly attenuated unless it isestimated separately for those with the corresponding traitanxiety—adds considerable complexity to the stress-supportmodel. A related hypothesis—that stressors dealing with loss (ofhealth, finances or social support) might result in sadness anddepression, while stressors involving danger (severe future threatbut not necessarily loss) might trigger anxiety—further complicatesthe picture 36 .Reviewers agree that most studies report a positive associationbetween various stressors and one or another measure ofanxiety 34,35,37 . Investigators report both transient and long-termsymptoms of anxiety and depression following exposure to