Mohammed T. Abou-Saleh

552 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYTable 100.1Multidimensional symptoms of anxietyCognitive Behavioral PhysiologicalNervousness Hyperkinesis Muscle tensionApprehension Repetitive motor acts Chest tightnessWorry Avoidance (e.g. certain places) PalpitationsFearfulness Pressured speech HyperventilationIrritability Increased startle response ParesthesiasDistractibility Lightheadedness LightheadednessSweatingSweatingUrinary frequencyUrinary frequencyare presenting with a variant of panic disorder. Multicenterstudies suggest that AWOPD, GAD and Social Phobia arecommonly co-morbid. Moreover, in general, AWOPD presentswith worse global functioning than PD or PDA 12 . This syndromehas not been studied in the elderly.SOCIAL PHOBIA (SOCIAL ANXIETY DISORDER)Social Anxiety Disorder (SAD) is defined by a persistent fear inone or more social situations marked by fears of performance,excessive scrutiny or of acting in a way that will be embarrassingor bring shame. Frequently, the fear is that of trembling, blushingor sweating profusely in social situations. Other commonconcerns are of saying something stupid or ‘‘babbling or talkingfunny’’. Common examples include fears of public speaking,avoidance of dating, parties or other social gatherings. Socialphobics typically experience marked anticipatory anxiety if theyattempt to enter the phobic situation. SAD is associated withonset in early life—typically manifesting in adolescence. The twodistinct subtypes, generalized and non-generalized, trigger differenttypes of symptoms, course of illness, pathophysiology andresponse to treatment 13 . Although systematic studies of thisdisorder in the elderly are lacking, epidemiological data 11 indicatethat it is chronic and persistent in old age. Common manifestationsin old age include the inability to eat food in the presence ofstrangers and, especially in men, being unable to urinate in publiclavatories. It is unlikely that an older adult will seek professionalhelp with these complaints as primary. Although systematicstudies of social phobia in older patients are lacking, our clinicalexperience suggests that eating or writing in public can beexceedingly difficult in older social phobics, exacerbated by theuse of dentures or the presence of tremors. It is not uncommon toencounter social phobics who present with symptoms of panicdisorder. Evidence suggests that this disorder is quite commonlyco-morbid with panic disorder 14 .SPECIFIC PHOBIA (FORMERLY SIMPLE PHOBIA)The distinguishing feature of this disorder is a marked andpersistent fear of a specific object or situation (other than a fearof experiencing a panic attack or a fear of social situations).Typically, the patient experiences immediate and intense distresson encountering the phobic stimulus, and recognizes that the fearis excessive and/or unreasonable. Further, the avoidance oranxious anticipation of encountering the phobic stimulus mustinterfere with the person’s daily routine, occupational functioningor social life, or the individual is markedly distressed abouthaving the phobia. The level of anxiety or fear usually varies as afunction of both the degree of proximity to the phobic stimuliand the degree to which escape is limited. Examples of commonphobias include fear of animals (dogs, snakes, insects, etc.),closed spaces (claustrophobia), flying or heights. There isTable 100.2DSM-IV anxiety disordersPanic disorder without agoraphobia (PD)Panic disorder with agoraphobia (PDA)Agoraphobia without history of panic disorder (AWOPD)Social phobia (social anxiety disorder, SAD)Specific phobia (formerly simple phobia)Obsessive-compulsive disorder (OCD)Acute stress disorder (ASD)Post-traumatic stress disorder (PTSD)Generalized anxiety disorder (GAD)Anxiety disorder not otherwise specified (ADNOS)Anxiety disorder due to a general medical conditionSubstance-induced anxiety disorderfrequent co-occurrence of Specific Phobia with PD and PDA.In the elderly, especially in urban settings, fear of crime seems tobe particularly prevalent in the elderly population (although theyare the least likely to be victimized). UK researcher Lindesay 15looked at elderly phobics and matched them for age and sex tocase controls without history of phobic disorders, and found thatin the elderly phobic disorders are associated with considerablyhigher psychiatric and medical morbidity. It also appears that,despite higher rates of contact among the phobic elderly withgeneral practitioners compared to controls, only 1 in 60 of thephobic elderly in this study was receiving psychiatric help. Ingeneral, systematic studies of specific phobias are lacking in theolder population.OBSESSIVE-COMPULSIVE DISORDERObsessive-compulsive disorder (OCD) involves persistent patternsof thoughts, obsessions and behaviors, compulsions that areperformed in an effort to decrease the anxiety experienced as aresult of the thoughts. Obsessions are thoughts or ideas that cometo a person’s mind, frequently during the process of completing aspecific task, or that occur during a particular type of situation.For example, sufferers may find themselves washing their handsrepeatedly, for hours at a time, as a result of shaking a stranger’shand. The unwanted thought is that they may have exposedthemselves to a serious disease. The act of washing in this exampleis what is referred to as a compulsion. OCD is a disorder that ischronic and often disabling for the individual 16 . Depression andother symptoms of anxiety often accompany the symptoms ofOCD.POST-TRAUMATIC STRESS DISORDER (PTSD)The distinctive feature of post-traumatic stress disorder (PTSD) isthat the individual has experienced, either witnessed or was avictim of, a traumatic event to which they reacted with feelings offear and helplessness. Examples of such events include those thatinvolve actual or threatened death or serious injury, or otherthreat to one’s integrity, or witnessing an event that involves deathor serious injury of another, or hearing about death or seriousinjury to a family member or close associate. In addition, theindividual’s accompanying response must have involved extremefear, helplessness or horror. Other essential features include anumber of symptoms that cluster into three categories: (a)persistent re-experiencing of the traumatic event; (b) persistentavoidance of stimuli associated with the traumatic event and anumbing of general responsiveness; and (c) persistent symptomsof increased arousal. Symptoms of re-experiencing includedistressing dreams of the event, and intense physical and/orpsychological distress at exposure to internal or external cues that