Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0100Clinical Features of Anxiety DisordersErin L. Cassidy 1,2 , Pamela J. Swales 2 and Javaid I. Sheikh 1,21 Stanford University School of Medicine, Stanford, CA, USA, and2Veterans Affairs, Palo Alto Health Care System, CA, USAThe subjective sense of trepidation or dread about some futureevent that can motivate one person to stay at work late tocomplete an important project, can send another to the hospitalwith the belief that he/she is going into cardiac arrest. As a normalhuman emotion, anxiety has adaptive value in helping one preparefor, and possibly avoid, deleterious events. This emotion,however, can manifest pathologically if it becomes excessive,inappropriate or maladaptive. Such morbid or clinically significantanxiety can range from excessive worry about mundaneconcerns to experiencing intense episodes of fear (panic attacks)for no apparent reason. Clinically significant anxiety is usuallymanifested by a variety of cognitive, behavioral and physiologicalsymptoms. Table 100.1 lists some examples of these multidimensionalfeatures. When assessing such symptoms, theclinician will query the patient with regards to the duration,intensity and course to determine whether the cluster of symptomsmeet criteria for any of the specific anxiety disorders.Over the last two decades, researchers have made great stridesin furthering the understanding of the phenomenology, comorbidityand clinical course of anxiety disorders in the generalpopulation 1–4 . However, research with the geriatric population islagging, forcing clinicians to use knowledge gained from studiesthat more commonly study a younger age group. In addition toutilizing these empirical studies, those treating the anxious elderlymust rely mostly on their own observations and anecdotalinformation, in addition to the ‘‘youth-biased’’ literature base 5 .Some have expressed concern that the diagnosis of anxiety statesmay be particularly difficult in the elderly because of the frequentco-morbidity of depression or medical illness 6–7 . In addition,concerns are being raised regarding the Diagnostic and StatisticalManual of Mental Disorders, 4th edn (DSM-IV) of the AmericanPsychiatric Association 8 . The DSM criteria for the anxietydisorders may not always allow for the correct identification ofthe anxiety-disordered elderly because many older adults display atendency to deny cognitive symptomatology and instead somatizetheir distress 9 . Despite these limitations, analyses of the EpidemiologicCatchment Area (ECA) data (using the DSM-III-Rcriteria) indicate that anxiety disorders can be diagnosedsuccessfully. Finally, the risk of developing an anxiety disorderdoes not fade in late life. For example, in a large sample of the65+ age group, individuals experienced a rather high 6 monthprevalence of 19.7% for all anxiety disorders 10 .This chapter presents the clinical features of various anxietydisorders based on the criteria set out in the DSM-IV. A list of theDSM-IV anxiety disorders appears in Table 100.2. Differentialpresentations and unique features of the anxiety disorders in theelderly will be discussed where appropriate.PANIC DISORDER WITH/WITHOUTAGORAPHOBIA (PD/PDA)Panic attacks are acute and discrete episodes of intense anxietythat result as a reaction to some perceived threat (emotional,environmental, etc.). The term ‘‘panic attack’’ is used when anindividual experiences an intense and acute reaction to an internalor external cue, lasting between a few minutes and a half an hour.The physiological symptoms can include trembling, acceleratedheart rate, sweating, shortness of breath, chest pain, dizziness,nausea and the sense that one is somehow detached from one’ssurroundings 11 . For example, an individual might have beentrapped in a crowd of people entering an underground subwaysystem, and will describe feeling ‘‘sick to their stomach’’ whenentering one. Another individual might even report high levels ofacute anxiety at the mere sight of the stairs leading to the subway.A clinically significant degree of panic symptoms are documentedafter a review of the patient’s history, revealing recurrent andunpredictable panic attacks that precede at least 1 month spentwith anticipated worry over possible recurrence.Diagnostically, one needs also to consider whether there is thepresence of agoraphobia in relation to the panic attacks.Agoraphobia involves the persistent fear of being in a situationthat results in a panic attack. Individuals suffering fromagoraphobia will commonly stay inside their house all day longto ensure the avoidance of the feared situation. Some of thecommon examples of frightening situations include being caughtin traffic on a bridge or freeway. When comparing young andolder adults with panic disorder (PD), one of the factors that canaffect the clinical presentation appears to be the age of onset.Phenomenologically, it appears that late-onset PD (LOPD, onsetof PD at or after age 55) patients report fewer panic symptoms,less avoidance, and score lower on somatization measures than doearly-onset PD (EOPD, onset of PD prior to age 55) patients.AGORAPHOBIA WITHOUT HISTORY OF PANICDISORDER (AWOPD)The literature is scant regarding this relatively rare disorder. Itsdistinguishing feature from Panic Disorder with Agoraphobia is afear of being in public places or situations from which escapemight be difficult, even though there is the absence of a history ofpanic attacks. There is a possibility that, although these patientsmay not experience full-blown panic attacks, they might sufferfrom milder ones with only one or two symptoms (limitedsymptom attacks). It is thus possible that some of these patientsPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd