Anxiety

A panic attack is defined as a sudden intense feeling of fear associated with physical symptoms such as chest pain, shortness of breath, dizziness, shaking, feeling hot or cold, sweating, and nausea—in short, the symptoms caused by adrenaline release in a fight-or-flight response. A typical panic attack lasts about ten minutes. Panic disorder is diagnosed in people who have recurrent unexpected panic attacks along with persistent fear of these attacks or fear of what they mean or what they might cause. While this disorder is believed to be relatively rare in the elderly population, it may be that the disorder is difficult to diagnose because elderly individuals and their doctors attribute such physical symptoms to cardiac, respiratory, or other medical conditions. This misattribution has been illustrated earlier in this entry with other types of anxiety disorders as well.

Social phobia, also called social anxiety disorder, is a common disorder that typically begins early in life and usually lasts in some form throughout the life span; not surprisingly, it is seen in elderly persons, with about 1 percent suffering from the disorder. Its main feature is a fear of being criticized or humiliated while being observed or scrutinized by others. Its most common form is stage fright, or public-speaking phobia, but in the more severe cases, fear of eating, talking, or even being seen in public can paralyze individuals. Typically, elderly persons will have lived with this disorder for their entire lifetime and have adapted; that is, they have avoided feared situations (such as speaking in public) for so long that they view their lives as unaffected.

Specific phobias are the most common anxiety disorders: they are an intense, irrational fear of some situation. Common examples are acrophobia: fear of high places; and claustrophobia: fear of enclosed places. While considered less severe than other disorders, they can sometimes be quite disabling (e.g., the acrophobic who quits his job in a high-rise building). Similar to social phobia, elderly persons with specific phobias will probably have had these conditions for their entire life and have changed their lifestyle to avoid the feared situation or object.

Post-traumatic stress disorder (PTSD) is a type of response to an event that threatens or causes serious physical harm or even death, while also causing feelings of horror and/or helplessness. For example, being mugged or raped, or being shot at in battle can cause PTSD. It is diagnosed if the individual reexperiences the trauma in the form of nightmares, visions, or flashbacks, and if he or she exhibits chronic avoidance behavior and hyperarousability. The prevalence of this disorder is unknown in older adults. While it is common in such groups as combat veterans, it can also occur after serious medical events such as stroke and heart attack. In younger adults, PTSD tends to be chronic, lasting decades, and it is typically only partly responsive to medication (serotonin reuptake inhibitors). The course and response to treatment of this disorder in elderly persons is unknown, but as the combat veterans from the Korean and Vietnam wars grow older, much more will need to be known about this disorder as it presents in older adults.

Many older adults have problems with anxiety at some point in their life but do not have symptoms that meet the criteria for one (or more) of the above-described disorders. This is partly because the disorders described above were validated in younger age groups; thus, they may not describe the underlying disorder of many elderly persons suffering from symptomatic anxiety. As research in the field of geriatric psychiatry increases, anxiety disorders unique to older adults may be discovered. In any event, an older adult who suffers from anxiety should not be dismissed simply because their symptoms do not share features with the disorders described above.

The case examples presented here show some typical features of anxiety disorders as they present in older adults: they are common, though less so than younger adults, and they are not simply a "normal" reaction to aging or medical events. Further, they tend to be chronic and lead to much distress and disability, especially in combination with disabling chronic medical conditions such as stroke.

The problems with recognition and treatment of anxiety disorders in later life are twofold. First, there is the difficulty recognizing the disorder in an individual who may have lived with anxiety their entire life and view it as normal, or who may misattribute anxiety symptoms to medical problems common in this age group. Second, treatment options are for the most part unproven in older populations, due to the lack of controlled clinical trials for elderly persons with anxiety disorders. On the other hand, it is known that elderly people with depression respond to medication and psychotherapy just like their younger counterparts, and it is likely that this will be true for anxiety disorders as well. In the future, understanding of the presentation and treatment of anxiety disorders in the elderly will improve if there is better education of the public about these disorders and more treatment research to assure that potential treatments can find their place with elderly populations, just as in younger adults.