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Sucht und Angststörungen im Alter: Grundlagen und Interventionen in Beratung und Therapie
Abstract
Sucht und Angststörungen treten bei älteren Erwachsenen häufig gemeinsam auf. Vor dem Hintergrund der körperlich-biologischen, psychologischen und sozialen Aspekte des Alterns erwächst der Bedarf einer spezifischen Betrachtungsweise dieser Komorbidität. Insbesondere hinsichtlich Grundlagen und Interventionen im Kontext von Beratung und Therapie besteht diesbezüglich ein großer und angesichts der demografischen Entwicklung auch wachsender Bedarf. Daher werden in diesem Kapitel zunächst die Charakteristika der Komorbidität von Sucht und Angststörungen im Alter aufgezeigt und anhand eines Fallbeispiels in dieses Thema eingeführt. Nachdem in den vorangegangenen Kapiteln bereits die spezifischen Charakteristika von Abhängigkeitserkrankungen im Alter dargestellt wurden, werden in diesem Kapitel insbesondere Phänomenologie und Prävalenz von Angsterkrankungen im Alter beschrieben und Anhaltspunkte für die Beratung und psychotherapeutische Behandlung bei entsprechenden Krankheitsbildern aufgezeigt.
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In recent years, behavior therapists have made a deliberate effort to expand their horizons to include underserved populations. The application of behavioral and cognitive behavioral procedures to anxiety disorders in the elderly represents one such beginning effort. In this review, we will present an overview of available literature concerning the psychopathology, assessment, and behavioral treatment of the anxiety disorders in later life. As will be noted, research is beginning to elucidate specific features and treatment of anxiety in the elderly, although the majority of this attention has been directed at Generalized Anxiety Disorder, specific phobias, and non-clinical anxiety complaints. Areas for future research are highlighted throughout this review, in the hopes of stimulating increased attention in these areas.
Disadvantaged older medical outpatients (
N = 197; ages 55–92) completed the Beck Anxiety Inventory (BAI). The instrument demonstrated high internal consistency and no significant differences by sex or race, suggesting that it is appropriate to use with diverse populations. Total BAI score correlated negatively with age. Confirmatory factor analysis revealed a good fit to a 4-factor model consisting of cognitive, autonomic, neuromotor, and panic symptoms. Although scores on the BAI and 2 widely used depression scales were significantly correlated, factor analysis distinguished BAI and depression scale items, suggesting that the instruments measure distinct constructs. These findings suggest that the BAI could serve as a valuable screening test for anxiety symptoms among primary care patients who are older and have low income. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The development of a 21-item self-report inventory for measuring the severity of anxiety in psychiatric populations is described. The initial item pool of 86 items was drawn from three preexisting scales: the Anxiety Checklist, the Physician’s Desk Reference Checklist, and the Situational Anxiety Checklist. A series of analyses was used to reduce the item pool. The resulting Beck Anxiety Inventory (BAI) is a 21-item scale that showed high internal consistency (α = .92) and test—retest reliability over 1 week, r (81) = .75. The BAI discriminated anxious diagnostic groups (panic disorder, generalized anxiety disorder, etc.) from nonanxious diagnostic groups (major depression, dysthymic disorder, etc). In addition, the BAI was moderately correlated with the revised Hamilton Anxiety Rating Scale, r (150) = .51, and was only mildly correlated with the revised Hamilton Depression Rating Scale, r (153) = .25.
Comorbid anxiety is common in depressive disorders in both middle and late life, and it affects response to antidepressant treatment.
To examine whether anxiety symptoms predict acute and maintenance (2 years) treatment response in late-life depression.
Data were drawn from a randomised double-blind study of pharmacotherapy and interpersonal psychotherapy for patients age 70 years and over with major depression. Anxiety symptoms were measured using the Brief Symptom Inventory. Survival analysis tested the effect of pre-treatment anxiety on response and recurrence.
Patients with greater pretreatment anxiety took longer to respond to treatment and had higher rates of recurrence. Actuarial recurrence rates were 29% (pharmacotherapy, lower anxiety), 58% (pharmacotherapy, higher anxiety), 54% (placebo, lower anxiety) and 81% (placebo, higher anxiety).
Improved identification and management of anxiety in late-life depression are needed to achieve response and stabilise recovery.
The purpose of this study was to examine the comorbidity of and communality of risk factors associated with major depressive disorder and anxiety disorders in later life.
A random age- and sex-stratified community-based sample (N=3,056) of the elderly (age 55-85 years) in the Netherlands was studied. A two-stage screening design was used, with the Center for Epidemiologic Studies Depression Scale as a screening instrument and the National Institute of Mental Health Diagnostic Interview Schedule as a criterion instrument. Risk factors were measured with well-validated instruments and represented a broad range of vulnerability and stress-related factors associated with anxiety and depression. Multivariate analyses examined risk factors associated with pure major depressive disorder, pure anxiety disorders, and comorbid conditions.
Comorbidity was highly prevalent: 47.5% of those with major depressive disorder also met criteria for anxiety disorders, whereas 26.1% of those with anxiety disorders also met criteria for major depressive disorder. While the only variables associated with pure major depressive disorder were younger age and external locus of control, risk factors representing a wide range of both vulnerability and stress were associated with pure anxiety disorders. External locus of control was the only common factor. The group with anxiety disorders plus major depressive disorder had a distinct risk factor profile and may represent those with a more severe disorder.
Although high levels of comorbidity between major depressive disorder and anxiety disorders were found, comparing risk factors associated with pure major depressive disorder and pure anxiety disorders revealed more differences than similarities. Anxiety disorders in later life merit separate study.
Cognitive behavior therapy (CBT) can be effective for late-life generalized anxiety disorder (GAD), but only pilot studies have been conducted in primary care, where older adults most often seek treatment.
To examine effects of CBT relative to enhanced usual care (EUC) in older adults with GAD in primary care.
Randomized clinical trial recruiting 134 older adults (mean age, 66.9 years) from March 2004 to August 2006 in 2 primary care settings. Treatment was provided for 3 months; assessments were conducted at baseline, posttreatment (3 months), and over 12 months of follow-up, with assessments at 6, 9, 12, and 15 months.
Cognitive behavior therapy (n = 70) conducted in the primary care clinics. Treatment included education and awareness, motivational interviewing, relaxation training, cognitive therapy, exposure, problem-solving skills training, and behavioral sleep management. Patients assigned to receive EUC (n = 64) received biweekly telephone calls to ensure patient safety and provide minimal support.
Primary outcomes included worry severity (Penn State Worry Questionnaire) and GAD severity (GAD Severity Scale). Secondary outcomes included anxiety ratings (Hamilton Anxiety Rating Scale, Beck Anxiety Inventory), coexistent depressive symptoms (Beck Depression Inventory II), and physical/mental health quality of life (12-Item Short Form Health Survey).
Cognitive behavior therapy compared with EUC significantly improved worry severity (45.6 [95% confidence interval {CI}, 43.4-47.8] vs 54.4 [95% CI, 51.4-57.3], respectively; P < .001), depressive symptoms (10.2 [95% CI, 8.5-11.9] vs 12.8 [95% CI, 10.5-15.1], P = .02), and general mental health (49.6 [95% CI, 47.4-51.8] vs 45.3 [95% CI, 42.6-47.9], P = .008). There was no difference in GAD severity in patients receiving CBT vs those receiving EUC (8.6 [95% CI, 7.7-9.5] vs 9.9 [95% CI, 8.7-11.1], P = .19). In intention-to-treat analyses, response rates defined according to worry severity were higher following CBT compared with EUC at 3 months (40.0% [28/70] vs 21.9% [14/64], P = .02).
Compared with EUC, CBT resulted in greater improvement in worry severity, depressive symptoms, and general mental health for older patients with GAD in primary care. However, a measure of GAD severity did not indicate greater improvement with CBT.
clinicaltrials.gov Identifier: NCT00308724.
Given the public health significance of late-life depression and anxiety, and the limited capacity of treatment, there is an urgent need to develop effective strategies to prevent these disorders.
To determine the effectiveness of an indicated stepped-care prevention program for depression and anxiety disorders in the elderly.
Randomized controlled trial with recruitment between October 1, 2004, and October 1, 2005.
Thirty-three primary care practices in the northwestern part of the Netherlands.
A total of 170 consenting individuals, 75 years and older, with subthreshold symptom levels of depression or anxiety who did not meet the full diagnostic criteria for the disorders.
Participants were randomly assigned to a preventive stepped-care program (n = 86) or to usual care (n = 84). Stepped-care participants sequentially received a watchful waiting approach, cognitive behavior therapy-based bibliotherapy, cognitive behavior therapy-based problem-solving treatment, and referral to primary care for medication, if required.
The cumulative incidence of DSM-IV major depressive disorder or anxiety disorder after 12 months as measured using the Mini International Neuropsychiatric Interview.
The intervention halved the 12-month incidence of depressive and anxiety disorders, from 0.24 (20 of 84) in the usual care group to 0.12 (10 of 86) in the stepped-care group (relative risk, 0.49; 95% confidence interval, 0.24 to 0.98).
Indicated stepped-care prevention of depression and anxiety in elderly individuals is effective in reducing the risk of onset of these disorders and is valuable as seen from the public health perspective.
Nondirective (ND), applied relaxation (AR), and cognitive behavioral (CBT) therapies for generalized anxiety disorder (GAD) were compared. The latter 2 conditions were generally equivalent in outcome but superior to ND at postassessment. The 3 conditions did not differ on several process measures, and ND created the greatest depth of emotional processing. Follow-up results indicated losses in gains in ND, maintained gains in the other 2 conditions, especially CBT, and highest endstate functioning for CBT. AR and CBT thus contain active ingredients in the treatment of GAD; support exists for further development of imagery exposure methods or cognitive therapy because of their likely role in promoting maintenance of change with this disorder. Expectancy for improvement was also associated with outcome, suggesting the need for further research on this construct for understanding the nature of GAD and its amelioration.
Point prevalence of specific fears and phobias was determined in 704 respondents of 1000 randomly selected adults aged 18-70 yr. A phobia for lightning, enclosed spaces, darkness, flying, heights, spiders, snakes, injections, dentists and/or injuries was defined if subjects reported a fear that was out of conscious control, interfered with life and lead to the avoidance of the feared object [American Psychiatric Association, 1994. Diagnostic and statistical manual of mental disorders (4th edn). Washington, DC: American Psychiatric Press.] Fear intensity was assessed using visual analogue scales. A factor analysis generally supported the classification of fears and phobias into: (1) situational phobias (lightning, enclosed spaces, darkness, flying and heights); (2) animal phobias (spiders and snakes); and (3) mutilation phobias (injections, dentists, injuries). Total point prevalence of any specific phobia was 19.9% (26.5% for females and 12.4% for males). In total, 21.2% women and 10.9% men met criterias for any single specific phobia. Multiple phobias was reported by 5.4% of the females and 1.5% of the males. Animal phobia had a prevalence of 12.1% in women and 3.3% in men. Point prevalence of situational phobia was 17.4% in women and 8.5% in men. For mutilation phobia no gender difference was observed, being presented in 3.2% of the women and 2.7% of the men. Women as compared to men gave higher fear ratings for all objects and situations. Inanimate object fears and phobias were more common in older than younger individuals. Animal fears were more intense in younger than in older individuals. Fear of flying increased and fear of injections decreased as a function of age in women but not in men. Thus, specific fears and phobias are heterogeneous with respect to sex and age distribution.
Written by renowned therapists, this Workbook includes all the information patients need to learn the appropriate skills to combat anxiety and worry. For use in conjunction with supervised therapy, this online guide helps patients become an active participant in treatment. It includes user-friendly devices to help overcome excessive worry, such as self-assessment quizzes, homework exercises, and case studies of individuals experiencing the same issues. It also includes interactive forms to help monitor progress throughout treatment.
Investigations of the duration of combat‐related posttraumatic stress symptoms have focused mainly on survivors of World War II and the Vietnam War, with little attention to surviving veterans of World War I. The authors describe a case in which posttraumatic stress symptoms persisted for 75 years in a World War I combat veteran and increased in frequency toward the end of his life accompanied by advancing dementia and hospitalization. The case illustrates that posttraumatic stress symptoms may be lifelong and exacerbated by various consequences of aging, even if they are not disabling.
• Using symptom checklists administered on a large scale by survey interviewers in the 1979 National Survey of Psychotherapeutic Drug Use, we developed a method for classifying survey respondents by syndromes. These syndromes had symptoms and other characteristics consistent with their DSM-III diagnostic counterparts and showed one-year prevalence rates in accord with available epidemiologic data: Major Depression, 5.1%; Agoraphobia-Panic, 1.2%; Other Phobia, 2.3%; and Generalized Anxiety, 6.4%. However, the anxietyrelated syndromes occurred less frequently than clinical lore might suggest. The data showed a very low rate of antidepressant use and a higher rate of antianxiety agent use among Major Depressives (11% and 23%) and Agoraphobics (8% and 55%). Also noteworthy were the infrequent use of antianxiety agents among respondents with Generalized Anxiety (27%) and the low frequency of both antianxiety (19%) and antidepressant (3%) drug use among persons with high distress who did not qualify for any syndrome. These findings suggest that the majority of persons with serious psychiatric disorders still do not receive treatment or the most appropriate treatment.
Older adults are the fastest growing segment of the population. With these changing demographics, mental health professionals will be seeing more older clients. Additionally, older adults are an underserved population in that most older adults in need of mental health services do not receive treatment. Thus, it is essential that treatments for mental and behavioral health problems are empirically supported with older adults and that mental health professionals are aware of the special needs of older adult populations. Acceptance and Commitment Therapy (ACT) is an emerging approach to the treatment of distress. The purpose of this article is to provide a rationale for using ACT with older adults based on gerontological theory and research. We also review research on ACT-related processes in later life. We present a case example of an older man with depression and anxiety whom we treated with ACT. Finally, we describe treatment recommendations and important adaptations that need to be considered when using ACT with older adults and discuss important areas for future research.
anxiety disorders are the most commonly reported psychiatric disorders in recent community-based epidemiologic surveys / there have been few studies, however, of the epidemiology of the anxiety disorders across the life cycle
to explore the epidemiology of the anxiety disorders among older adults, we take advantage of the Piedmont Health Survey, part of the Epidemiologic Catchment Area Project / individuals in mid life (45 to 64) were compared with late life distribution across demographic factors of the anxiety disorders, with special attention to generalized anxiety
the Piedmont Health Survey / results of the survey
the results reported suggest that older adults do suffer relatively frequent generalized anxiety, compared with other psychiatric syndromes, though the prevalence is lower than for the middle-aged group (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The authors reviewed clinic records of 20 WWII veterans referred for evaluation of posttraumatic stress disorder (PTSD). Twelve patients qualified for a diagnosis of PTSD, and eight reported several symptoms of PTSD. The most frequent symptoms were insomnia (80%), nightmares (75%), and irritability (65%). Fourteen veterans had an exacerbation of symptoms occurring with life stresses, including retirement, deteriorating health, or death of a loved one. The authors conclude that elderly WWII combat veterans should be monitored for changes in PTSD symptoms when significant stressful life events occur.
Copyright (C) 1994 American Association for Geriatric Psychiatry
We assessed a consecutive series of 398 patients with probable Alzheimer's disease (AD) for the presence of Generalized Anxiety Disorder (GAD) using a standardized neuropsychiatric evaluation. Five percent of patients showed GAD during the 4 weeks preceding the psychiatric evaluation. AD patients with GAD showed significantly higher scores of depression, irritability, overt aggression, mania, and pathological crying than AD patients without GAD. The most severe symptoms of anxiety were those of tension, fears, insomnia, and physical complaints. Depression and Anxiety 7:166–170, 1998. © 1998 Wiley-Liss, Inc.
This community study of the anxiety disorders in people aged 65 and over finds a relatively high prevalence of anxiety disorders (15%), with phobic disorders being the most prevalent subclassification (12%). While generalized anxiety was usually seen with other psychiatric syndromes, phobic disorder was usually observed in the absence of either depression or anxiety. These results suggest that while generalized anxiety should be placed below depression in a diagnostic hierarchy, phobic disorder does not fit with this diagnostic model.
To study the prevalence and risk factors of anxiety disorders in the older (55-85) population of The Netherlands.
The Longitudinal Aging Study Amsterdam (LASA) is based on a random sample of 3107 older adults, stratified for age and sex, which was drawn from the community registries of 11 municipalities in three regions in The Netherlands. Anxiety disorders were diagnosed using the Diagnostic Interview Schedule in a two-stage screening design. The risk factors under study comprise vulnerability, stress and network-related variables. Both bivariate and multivariate statistical methods were used to evaluate the risk factors.
The overall prevalence of anxiety disorders was estimated at 10.2%. Generalized anxiety disorder was the most common disorder (7.3%), followed by phobic disorders (3.1%). Both panic disorder (1.0%) and obsessive compulsive disorder (0.6%) were rare. These figures are roughly similar to previous findings. Ageing itself did not have any impact on the prevalence in both bivariate and multivariate analyses. The impact of other factors did not change much with age. Vulnerability factors (female sex, lower levels of education, having suffered extreme experiences during World War II and external locus of control) appeared to dominate, while stresses commonly experienced by older people (recent losses in the family and chronic physical illness) also played a part. Of the network-related variables, only a smaller size of the network was associated with anxiety disorders.
Anxiety disorders are common in later life. The risk factors support using a vulnerability-stress model to conceptualize anxiety disorders. Although the prevalence of risk factors changes dramatically with age, their impact is not age-dependent. The risk factors indicate which groups of older people are at a high risk for anxiety disorders and in whom active screening and treatment may be warranted.
Background: Alcohol problems co‐occur with anxiety disorders at a rate that far exceeds chance (“comorbidity”). One view suggests that risk for developing a comorbid alcohol use disorder is increased when alcohol is used routinely to cope with anxiety symptoms (“self‐medication”). Indicating that this view is overly broad, however, the literature suggests that only a subgroup of anxiety‐disordered individuals tend to drink to manage their symptoms. Therefore, we set out to identify psychological characteristics that might mark those for whom drinking to cope with anxiety is most likely. Our survey of the literature identified several possibilities, including anxiety‐related personality traits (anxiety sensitivity, self‐consciousness and Trait Anxiety); higher‐order personality dimensions (Harm Avoidance, Reward Dependence, and Novelty Seeking); and, finally, alcohol outcome expectancies (specifically, those related to tension‐reducing effects from alcohol).
Methods: In a sample of nonproblem drinkers with panic disorder, we regressed predictor variables on several alcohol use measures, including drinking aimed at the control of anxiety symptoms (“self‐medication”).
Results: Although each variable related positively to a self‐medicating style of drinking, expectancies for tension reduction from alcohol use accounted for about twice as much variance as did the other predictors. With simultaneous entry in a step‐wise regression analysis, only tension‐reduction alcohol outcome expectancies and the Harm Avoidance personality dimension were retained as significant predictors.
Conclusions: Findings suggest that development of a self‐medicating style of drinking among individuals with panic disorder is predicated, in part, on specific psychological characteristics of the individual. Alcohol outcome expectancies emerged as the single most important predictor of drinking behavior in this anxiety‐disordered sample.
To present findings on the prevalence, correlates, and psychiatric comorbidity of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition posttraumatic stress disorder (PTSD) and partial PTSD in a nationally representative sample of U.S. older adults.
Face-to-face interviews with 9,463 adults age 60 years and older in the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions.
Sociodemographic correlates; worst stressful experiences; comorbid lifetime mood, anxiety, substance use, and personality disorders; psychosocial functioning; and suicide attempts.
Lifetime prevalences ± standard errors of PTSD and partial PTSD were 4.5% ± 0.25 and 5.5% ± 0.27, respectively. Rates were higher in women (5.7% ± 0.37 and 6.5% ± 0.39) than in men (3.1% ± 0.31 and 4.3% ± 0.37). Older adults with PTSD most frequently identified unexpected death of someone close, serious illness or injury to someone close, and their own serious or life-threatening illness as their worst stressful events. Older adults exposed to trauma but without full or partial PTSD and respondents with partial PTSD most often identified unexpected death of someone close, serious illness or injury to someone close, and indirect experience of 9/11 as their worst events. PTSD was associated with elevated odds of lifetime mood, anxiety, drug use, and borderline and narcissistic personality disorders and decreased psychosocial functioning. Partial PTSD was associated with elevated odds of mood, anxiety, and narcissistic and schizotypal personality disorders and poorer psychosocial functioning relative to older adults exposed to trauma but without full or partial PTSD.
PTSD among older adults in the United States is slightly more prevalent than previously reported and is associated with considerable psychiatric comorbidity and psychosocial dysfunction. Partial PTSD is associated with significant psychiatric comorbidity, particularly with mood and other anxiety disorders.
Corticotropin-releasing factor (CRF) and CRF-related neuropeptides have an important role in the central nervous system to mediate behavioral responses to stressors. CRF receptor antagonists are very effective in reversing stress-induced suppression and activation in behavior. An additional CRF-like neuropeptide, urocortin, has been identified in the brain and has a high affinity for the CRF-2 receptor in addition to the CRF-1 receptor. Urocortin has many of the effects of CRF but also is significantly more potent than CRF in decreasing feeding in both meal-deprived and free-feeding rats. In mouse genetic models, mice over-expressing CRF show anxiogenic-like responses compared to wild-type mice, and mice lacking the CRF-1 receptor showed an anxiolytic-like behavioral profile compared to wild-type mice. Results to date have led to the hypothesis that CRF-1 receptors may mediate CRF-like neuropeptide effects on behavioral responses to stressors, but CRF-2 receptors may mediate the suppression of feeding produced by CRF-like neuropeptides. Brain sites for the behavioral effects of CRF include the locus coeruleus (LC), paraventricular nucleus (PVN) of the hypothalamus, the bed nucleus of the stria terminalis (BNST), and the central nucleus of the amygdala. CRF may also be activated during acute withdrawal from all major drugs of abuse, and recent data suggest that CRF may contribute to the dependence and vulnerability to relapse associated with chronic administration of drugs of abuse. These data suggest that CRF systems in the brain have a unique role in mediating behavioral responses to diverse stressors. These systems may be particularly important in situations were an organism must mobilize not only the pituitary adrenal system, but also the central nervous system in response to environmental challenge. Clearly, dysfunction in such a fundamental brain-activating system may be the key to a variety of pathophysiological conditions involving abnormal responses to stressors such as anxiety disorders, affective disorders, and anorexia nervosa.
In order to assess how many general practice patients take benzodiazepines for long periods, a cross-sectional audit of clinical practice was conducted. During a 3-day census period, 26 general practitioners in the area of Bergamo, Italy, entered into the study every patient who was taking benzodiazepines. The prevalence of use of this class of drugs was 14.0% (CI 12.5-15.7), while the prevalence of daily use for 12 months or more was 4.7% (CI 3.8-5.8). Finally, the prevalence of very long-term use of benzodiazepines, i.e. those taking these drugs for more than 10 years, was 0.65% (CI 0.34-1.14). Compared to non-long-term users, long-term users were older (OR 2.38, CI 1.39-4.08) and had a lower level of education (OR 2.40, CI 1.04-5.54). In addition, insomnia was associated with long-term use of this class of drugs (OR 1.82, CI 1.02-3.24). These findings provide evidence that the long-term use of benzodiazepines is an important issue in everyday general practice and that this calls for precise management tactics.
As the initiation and acceleration of alcohol use commonly occurs during adolescence, the etiological basis for this phenomenon is of critical importance. Using the diathesis-stress model as a framework, this review will evaluate the emerging evidence implicating the limbic-hypothalamic-pituitary-adrenal (LHPA) axis in the development of alcohol use disorder (AUD).
Searches were conducted of the PubMed/Medline, PsycInfo, PsycBooks, Cochrane and ISI Web of Science databases, using a specified set of search terms.
Genetic liabilities, antenatal stress/anxiety or exposure to addictive substances, exposure to maltreatment or other traumatic events in childhood and psychiatric illness in childhood/adolescence can all increase the risk, or diathesis, for AUD. Greater LHPA dysfunction may serve as a marker for higher diathesis levels in youth. When exposed to stressors in adolescence, high-risk youth (or those with greater LHPA dysfunction) may use alcohol and/or other substances to cope with stressors and, in turn, become more vulnerable to AUD.
Evidence suggests that LHPA dysfunction and stress play an important role in the development of AUD. Genetic liabilities, antenatal insults, maltreatment, and psychiatric illness appear to increase LHPA dysfunction, raising risk for AUD. Further research is needed to clarify the complex interplay among adverse developmental experiences, LHPA dysfunction, and the development of AUD in adolescents.
Alcohol dependence (AD) is more likely to occur among individuals with rather than without an anxiety disorder. Self-medication theory (SMT) holds that drinking behavior is negatively reinforced when alcohol temporarily reduces anxiety and that the resulting escalation of drinking increases the risk for AD. We set out to empirically scrutinize SMT using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) dataset. We found that only a minority (about 20%) of anxiety disordered individuals endorsed drinking to control anxiety symptoms. This minority drank more alcohol, had a higher cross-sectional rate of AD, and was at higher risk for developing new AD over four years compared to anxiety disordered non-self-medicators and individuals with no anxiety disorder. Consistent with SMT, increased prospective risk for AD among self-medicators is partially mediated by an increased level of alcohol use. Understanding the processes that promote and inhibit self-medication should be a priority for anxiety disorder researchers.
Objectives:
Compulsive hoarding is a debilitating, chronic disorder, yet we know little about its onset, clinical features, or course throughout the life span. Hoarding symptoms often come to clinical attention when patients are in late life, and case reports of elderly hoarders abound. Yet no prior study has examined whether elderly compulsive hoarders have early or late onset of hoarding symptoms, whether their hoarding symptoms are idiopathic or secondary to other conditions, or whether their symptoms are similar to compulsive hoarding symptoms seen in younger and middle-aged populations. The objectives of this study were to determine the onset and illustrate the course and clinical features of late life compulsive hoarding, including psychiatric and medical comorbidities.
Methods:
Participants were 18 older adults (> or =60) with clinically significant compulsive hoarding. They were assessed using structured interviews, including the Mini International Neuropsychiatric Interview (MINI), Structured Clinical Interview for DSM-IV (SCID I), Yale-Brown Obsessive Compulsive Scale (YBOCS), and UCLA Hoarding Severity Scale (UHSS). Self-report Measures Included the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Sheehan Disability Scale (SDS), and Savings Inventory-Revised (SI-R). Psychosocial and medical histories were also obtained. To determine age at onset, participants were asked to rate their hoarding symptoms and describe major life events that occurred during each decade of their lives.
Results:
Results show that (1) onset of compulsive hoarding symptoms was initially reported as being in mid-life but actually found to be in childhood or adolescence. No subjects reported late onset compulsive hoarding. (2) Compulsive hoarding severity increased with each decade of life. (3) Comorbid mood and anxiety disorders were common, but only 16% of patients met criteria for OCD if hoarding symptoms were not counted toward the diagnosis. (4) The vast majority of patients had never received treatment for hoarding. (5) Older adults with compulsive hoarding were usually socially impaired and living alone.
Conclusions:
Compulsive hoarding is a progressive and chronic condition that begins early in life. Left untreated, its severity increases with age. Compulsive hoarding should be considered a distinct clinical syndrome, separate from OCD. Unfortunately, compulsive hoarding is largely unrecognized and untreated in older adults.
The purpose of this study was to determine OCD prevalence among older adults living in the community and to examine its correlates. Data were drawn from a large population survey using a representative sample of older adults aged 65 years and over (N=2798). The 12-month prevalence rate of OCD was 1.5%. Results showed that older adults with OCD were more likely to be men compared to those having another anxiety disorder or a mood disorder. They were also more afflicted with difficulties in social functioning than respondents presenting another anxiety disorder. In spite of social disabilities, respondents with OCD had the lowest rate of health services use among those reporting anxiety or mood disorders. It is suggested that older adults with OCD did not feel the need to seek treatment because they perceived their physical and mental health more positively than others and because they were surrounded by supportive peers.
To describe the burden of Generalized Anxiety Disorder (GAD), a common anxiety disorder in older adults.
Cross-sectional.
Late-life depression and anxiety research clinic in Pittsburgh, PA.
One hundred sixty-four older adults with GAD and 42 healthy comparison participants with no lifetime history of psychiatric disorder were recruited from primary care and mental health settings as well as advertisements.
Participants were evaluated with the Late Life Function and Disability Index to assess disability, the MOS 36-Item Short Form Survey Instrument to assess health-related quality of life (HRQOL), and the Cornell Service Index to assess healthcare utilization.
Older adults with GAD were more disabled, had worse HRQOL, and had greater healthcare utilization, than nonanxious comparison participants, even in the absence of psychiatric comorbidity. After controlling for medical burden and depressive symptoms, higher severity of anxiety symptoms was associated with greater disability and poorer HRQOL in several domains. The greatest decrements in HRQOL and function were observed in measures assessing role functioning, including social function.
This study, the largest ever of GAD in older adults, provides evidence of the significant burden of this disorder in late life. Given the high prevalence and chronicity of GAD in the elderly, these data provide a public health imperative for finding and implementing effective management strategies for this typically undiagnosed and untreated disorder.
To investigate the distribution of age at onset of generalized anxiety disorder (GAD) as well as the possible differences in demographic and psychosocial risk factors, the comorbidities of other psychiatric disorders, health status, and healthcare utilization in respondents suffering from early onset GAD (<50 years) and late-onset GAD (> or =50 years) in adults aged 55 or above.
Cross-sectional observational study.
The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (2001-2002), a national representative survey of the noninstitutionalized U.S. household population.
The 439 respondents aged 55 or above who participated in the NESARC and were found to have lifetime GAD.
The Alcohol Use Disorder and Associated Disabilities Interview Schedule--DSM-IV version was used to assess psychiatric disorders, and the Medical Outcomes study 12-item Short Form questionnaire was included.
The distribution of age at onset appeared normally distributed for respondents with current or lifetime GAD. Among respondents with lifetime GAD, early-onset cases tended to be younger with a higher education level and to have a significantly higher prevalence of panic disorder (current and lifetime), lifetime social phobia, current bipolar I disorder, lifetime alcohol abuse or dependence, or lifetime nicotine dependence than late-onset cases. In addition, respondents presenting with late-onset GAD were more likely to report hypertension and poor health-related quality of life than those with early-onset GAD.
About half of the older adult respondents with GAD reported a late onset and, among those with lifetime GAD, late-onset GAD was distinguished from early-onset GAD by a more frequent association with the presence of hypertension and a poorer health-related quality of life.
Obsessions or compulsions that cause personal distress or social dysfunction affect about 1% of men and 2% of women. About half of people with obsessive compulsive disorder (OCD) have an episodic course, whereas the other half have continuous problems. Up to half of people show improvement of symptoms over time. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of initial treatments for obsessive compulsive disorder in adults? What are the best forms of maintenance treatment for obsessive compulsive disorder in adults? What are the effects of treatments for obsessive compulsive disorder in adults who have not responded to initial treatment with serotonin reuptake inhibitors? We searched: Medline, Embase, The Cochrane Library and other important databases up to July 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 55 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: addition of antipsychotics to serotonin reuptake inhibitors; behavioural therapy alone or with serotonin reuptake inhibitors; cognitive therapy or cognitive behavioural therapy (alone or with serotonin reuptake inhibitors); electroconvulsive therapy; serotonin reuptake inhibitors (citalopram, clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline); and optimum duration of maintenance treatment.
This study aims to investigate the following: 1) the association of social anxiety disorder with childhood parental loss and recent stressful life events; 2) the coexistence of social anxiety disorder and major depressive disorders (MDD); and 3) the impact of social anxiety disorder on medical conditions, obesity, health service utilization, and health-related quality of life.
Cross-sectional observational study.
The National Epidemiologic Survey on Alcohol and Related Conditions (2001-2002), a national representative survey of the U.S. noninstitutionalized household population.
13,420 respondents aged 55 and above.
Social anxiety disorder was assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV). Demographic characteristics, psychosocial risk factors, psychiatric disorders, health-related quality of life, obesity, medical conditions, and health service utilization were measured.
The current and lifetime prevalence rates of specific phobia were found to be 1.83% and 3.50%, respectively. Multivariate analyses revealed that social anxiety disorder was more common among the younger age groups and those who reported stressful life events. In addition, MDD, specific phobia, and personality disorder were significantly related to social anxiety disorder. Lastly, after adjusting for other psychiatric comorbidities, the association of social anxiety disorder with health-related quality of life, medical condition, and health care service utilization became insignificant.
The correlation between social anxiety disorder and MDD raises further questions about the nature of social anxiety disorder among older adults, but this study does not support the notion that this disorder has a strong impact on the quality of life in old age independent of other psychiatric comorbidities.
This study aims to investigate: 1) the association of specific phobia with childhood parental loss and recent stressful life events; 2) the coexistence of specific phobia and major depressive disorders (MDDs); and 3) the impact of specific phobia on medical conditions, obesity, health service utilization, and health-related quality of life.
Cross-sectional observational study.
The National Epidemiologic Survey on Alcohol and Related Conditions (2001-2002), a national representative survey of the noninstitutionized U.S. household population.
The 8,205 respondents aged 65 and above.
Specific phobia was assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition version. Demographic characteristics, psychosocial risk factors, psychiatric disorders, health-related quality of life, obesity, medical conditions, and health service utilization were measured.
The current and lifetime prevalence of specific phobia were 4.51% and 6.05%, respectively. Multivariate analyses revealed that specific phobia was more common among younger age groups, women, and those who reported stressful life events but less common among foreign-born individuals. In addition, MDD was significantly related to lifetime specific phobia. Specific phobia was also significantly related to a lower health-related quality of life and two medical conditions.
Our prevalence rates of specific phobia in the elderly are at the lower end of the ranges identified in the previous studies. The correlation between specific phobia and MDD raises further questions about the nature of specific phobia in the elderly. This study supports the notion that specific phobia has a strong impact on the quality of life in old age.
To examine the prevalence of social phobia, and how the different Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic components of social phobia influence prevalence rates, among a population sample aged 70 years and older.
A general population sample was investigated in 2000-2001 with semistructured psychiatric examinations, including the Comprehensive Psychopathological Rating Scale, the Mini International Neuropsychiatric Interview, the Global Assessment of Functioning (GAF) scale, and the Mini Mental State Examination.
General population Participants: Randomized sample of 914 nondemented elderly, response rate 68%. The sample was stratified into two age groups: 70-year olds (N = 338 women and 224 men) and aged 78 and above (N = 352 women).
Social phobia according to DSM-IV requiring: a) fearing social situations, b) experiencing the fear as unreasonable or excessive, c) avoiding feared social situations or enduring them with intense anxiety or distress, and d) that this causes social consequences.
The 1-month prevalence of social phobia was 1.9% (N = 17), an additional 1.6% (N = 15) fulfilled criteria a, c, and d, but not b. Thus, 3.5% had "social phobia" that caused social consequences. This was related to lower GAF-score and concurrent depression,panic attacks, and agoraphobia. Almost one fourth (N = 220) of the total sample feared social situations. This was more common in 70-year-old women compared with 70-year-old men (29.9% versus 20.5%), and to women aged 78-92 years (21.0%).
Our results indicate that DSM-IV criteria exclude a large group of individuals with social phobia. It could be discussed whether DSM-IV criteria should be revised to also encompass these individuals.
Sixty confirmed cases of phobic disorder identified in an urban elderly community sample were compared with 60 controls matched pairwise for age and sex. Cases reported higher rates of specific and non-specific neurotic symptoms, and all were assigned to a diagnostic CATEGO class, compared with seven of the controls. A past history of chronic psychiatric disorder other than phobia was commoner in the cases. Most cases had more than one fear; agoraphobic main fears were predominantly of late onset and associated with moderate to severe social impairment, whereas specific main fears were associated with early onset and minimal social impairment. The onset of agoraphobic fears in old age was attributed by most cases to an episode of physical illness or other traumatic event. Increased rates of palpitations, dyspnoea, giddiness and tinnitus not attributable to anxiety were identified in the cases. Cases did not differ from the controls in socio-economic status, or in the number or quality of current intimate confiding relationships, but they reported higher rates than controls of parental loss before the age of 18 years. Cases reported higher rates of contact with general practitioners, but only one was in contact with psychiatric services at the time of interview. Cases also reported receiving more help in personal care from family members.
A sample of 890 people aged 65 years and over living at home in the Lewisham and North Southwark Health District was interviewed using a structured schedule containing CARE organic brain syndrome and depression scales, and items dealing with anxiety symptoms. Total prevalence rates were 4.6% for cognitive impairment, 13.5% for depression, 3.7% for generalised anxiety, and 10.0% for phobic disorders. Cognitive impairment increased exponentially with age, and was associated with lower occupational class. There was no significant association between occupational class and depression, generalised anxiety, or phobic disorder in this sample. Cognitive impairment, depression and agoraphobia were associated with significantly higher levels of dependency in the tasks of daily living.
The natural history of chronic PTSD was observed by reviewing the veteran's medical records, which had been commenced at enlistment, prior to active service. The masking of intrusive symptoms in mid-life was usual. A terminal phase of symptomatic reactivation in older age may occur. The indelibility of the memory of fear is demonstrated by these veterans.
The reticence to retell the trauma story remains a major obstacle in the study of the mental health sequelae of warfare. War-related psychiatric disorder in the elderly male is easily missed. Direct questioning regarding military service is advisable. The ineffectiveness of the management strategies offered to World War II PTSD sufferers is clearly apparent.
Forty-five World War II veterans reporting recent reactivation of chronic posttraumatic stress disorder (PTSD) symptoms were clinically assessed in order to determine war pension disability. In the course of these examinations, factors implicated in the exacerbation of their re-experiencing and arousal symptoms were recorded. The most prominent of these factors was that of physical ill health. Retirement, loneliness, comorbid psychiatric illness, anniversaries, service reunions, and alcohol and psychotropic medication usage were other factors.
Several studies have suggested an increased risk of fatal coronary heart disease (CHD) among patients with panic disorder, phobic anxiety, and other anxiety disorders. We prospectively examined this association in the Normative Aging Study.
An anxiety symptoms scale was constructed out of five items from the Cornell Medical Index, which was administered to the cohort at baseline. During 32 years of follow-up, we observed 402 cases of incident coronary heart disease (137 cases of nonfatal myocardial infarction, 134 cases of angina pectoris, and 131 cases of fatal CHD: made up of 26 cases of sudden cardiac death and 105 cases of nonsudden death). A nested case-control design (involving 1869 control subjects who remained free of diagnosed CHD) was used to assess the association between anxiety and risk of CHD. Compared with men reporting no symptoms of anxiety, men reporting two or more anxiety symptoms had elevated risks of fatal CHD (age-adjusted odds ratio [OR] = 3.20, 95% confidence interval [CI]: 1.27 to 8.09), and sudden death (age-adjusted OR = 5.73, 95% CI: 1.26 to 26.1). The multivariate OR after adjusting for a range of potential confounding variables was 1.94 (95% CI: 0.70-5.41) for fatal CHD and 4.46 (95% CI: 0.92-21.6) for sudden death. No excess risks were found for nonfatal myocardial infarction or angina.
These data suggest an association between anxiety and fatal coronary heart disease, in particular, sudden cardiac death.
Nationally representative general population data are presented on the current, 12-month, and lifetime prevalence of DSM-III-R generalized anxiety disorder (GAD) as well as on risk factors, comorbidity, and related impairments.
The data are from the National Comorbidity Survey, a large general population survey of persons aged 15 to 54 years in the noninstitutionalized civilian population of the United States. DSM-III-R GAD was assessed by lay interviewers using a revised version of the Composite International Diagnostic Interview.
Generalized anxiety disorder was found to be a relatively rare current disorder with a current prevalence of 1.6% but was found to be a more frequent lifetime disorder affecting 5.1% of the US population aged 15 to 45 years. Generalized anxiety disorder was twice as common among women as among men. Multivariate logistic regression analysis showed that being older than 24 years, separated, widowed, divorced, unemployed, and a homemaker are significant correlates of GAD. Consistent with studies in treatment samples, we found that GAD was frequently associated with a wide spectrum of other mental disorders, with a lifetime comorbidity among 90.4% of the people who had a history of GAD.
Contrary to the traditional view that GAD is a mild disorder, we found that the majority of people with GAD, whether they were comorbid or not, reported substantial interference with their life, a high degree of professional help seeking, and a high use of medication because of their GAD symptoms. Although lifetime GAD is highly comorbid, the proportion of current GAD that is not accompanied by any other current diagnosis is high enough to indicate that GAD should be considered an independent disorder rather than exclusively a residual or prodrome of other disorders.
The Alcohol Use Disorders Identification Test (AUDIT) has been developed from a six-country WHO collaborative project as a screening instrument for hazardous and harmful alcohol consumption. It is a 10-item questionnaire which covers the domains of alcohol consumption, drinking behaviour, and alcohol-related problems. Questions were selected from a 150-item assessment schedule (which was administered to 1888 persons attending representative primary health care facilities) on the basis of their representativeness for these conceptual domains and their perceived usefulness for intervention. Responses to each question are scored from 0 to 4, giving a maximum possible score of 40. Among those diagnosed as having hazardous or harmful alcohol use, 92% had an AUDIT score of 8 or more, and 94% of those with non-hazardous consumption had a score of less than 8. AUDIT provides a simple method of early detection of hazardous and harmful alcohol use in primary health care settings and is the first instrument of its type to be derived on the basis of a cross-national study.
Despite the prevalence of Generalized Anxiety Disorder (GAD) in older adults, little is known about psychopathological features of excessive worry in the elderly. This investigation compared 44 GAD patients (mean age 67.6), diagnosed using structured interview, with a matched sample free of psychiatric disorders on self-report and clinician measures. Results indicated that GAD in the elderly is associated with elevated anxiety, worry, social fears, and depression. Using self-report measures alone, near-perfect classification of Ss into groups was achieved with four measures (PSWQ, WS-Soc, FQ-Soc, and BDI). Using clinician ratings, near-perfect classification was achieved with Hamilton anxiety ratings. Comparison of GAD patients whose symptoms began in childhood vs middle adulthood revealed few differences on these dimensions. Results are discussed in light of features of GAD in the elderly, highlighting implications for further study.
There has been no systematic study of the clinical features of obsessive-compulsive disorder (OCD) in elderly patients. This study describes the symptoms and characteristics of OCD among 32 outpatients age 60 or older and 601 younger patients meeting DSM-III-R criteria and given the Yale-Brown Obsessive-Compulsive Scale (YBOCS), NIMH scale, and a 41-item symptom questionnaire. Elderly patients had a later age at onset compared with younger patients. No differences were found in severity of symptoms on the YBOCS. Elderly patients had fewer concerns about symmetry, need to know, and counting rituals. Handwashing and fear of having sinned were more common. There were few differences in clinical features of OCD among the elderly patients compared with younger OCD patients.
Post-traumatic stress disorder (PTSD) may present many years after the original trauma. Case studies of two elderly patients are described. Both had experienced life-threatening combat situations and witnessed intense suffering during the Second World War. Marked distress was triggered by the media commemorating the fiftieth anniversary of the end of the war. PTSD patients often avoid talking of their traumatic experiences because of associated distress. Without taking a military and trauma history from elderly patients the diagnosis is likely to be missed.
Recently, it has been suggested that situational specific phobias (e.g., phobias of driving, flying, enclosed places) are more closely related to agoraphobia than are other specific phobia types. The present study investigated this hypothesis by examining heterogeneity among the four main DSM-IV specific phobia types, particularly with respect to variables believed to be associated with agoraphobia. Using interviews and behavioral testing, 60 patients with specific phobias of animals, heights, blood/injections, or driving were compared with respect to etiology, age of onset, physiological response, predictability of panic attacks, and focus of apprehension. Fifteen patients suffering from panic disorder with agoraphobia served as a comparison group for some measures. Relative to the other specific phobias, driving phobias were most strongly associated with a later age of onset, similar to that of individuals with agoraphobia. Height phobias were also associated with a late age of onset as well as a more internal focus of apprehension, relative to other groups. Finally, individuals in the blood/injection phobia group reported a more internal focus of apprehension than those in other groups and were the only group to report a history of fainting in the phobic situation. Overall, the results did not support the hypothesis that situational phobias are a variant of agoraphobia. In fact, on several of the variables for which groups did differ, individuals with height phobias (a phobia from the natural environment type) showed a pattern most similar to individuals with agoraphobia. The implications of these results for the classification of specific phobias are discussed.