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ANXIETY DISORDERS
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OBJECTIVES
Know and understand:
• The classification of anxiety disorders
• How to assess anxiety disorders
• Which anxiety disorders are commonly
comorbid with each other or with depression,
dementia, or other medical disorders
• Principles of the pharmacologic and
psychologic management of anxiety disorders
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TO P I C S C O V E R E D
• Classes of Anxiety Disorders
 Panic Disorder
 Phobic Disorders
 Obsessive-Compulsive Disorder
 Posttraumatic Stress Disorder
 Generalized Anxiety Disorder
• Comorbidity
• Pharmacologic Management
• Psychologic Management
CLASSES OF ANXIETY DISORDERS
(1 of 2)
• Panic disorder with and without agoraphobia
• Panic disorder with agoraphobia
• Agoraphobia without history of panic disorder
• Specific phobias
 Animal type
 Natural environment type
 Blood-injection-injury type
 Situational type
 Other type
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CLASSES OF ANXIETY DISORDERS
(2 of 2)
• Social phobia
• Obsessive-compulsive disorder
• Posttraumatic stress disorder
• Acute stress disorder
• Generalized anxiety disorder
• Anxiety disorder due to a general medical
condition
• Substance-induced anxiety disorder
• Anxiety disorder not otherwise specified
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ASSESSMENT OF
ANXIETY DISORDERS
• Determine the:
 Course and nature of symptoms
 Nature of the patient’s mental status
 Level of external support
• Supplemental rating scales aid in comparing
a patient’s level of difficulties with that of
others and in assessing difficulties over time
• Laboratory tests
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A S S E S S M E N T D I F F I C U LT I E S
• Medical comorbidity
• Difficulty in differentiating anxiety from
depression
• Falsely high scores on anxiety rating scales
due to cardiac and respiratory problems
• Tendency of older patients to resist
psychiatric evaluation
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PA N I C D I S O R D E R
• Panic attack:
 Acute, discrete episode of intense anxiety
 Lasts between a few minutes and a half hour
• Symptoms may include:
 Trembling, dizziness, sweating, nausea
 Accelerated heart rate, chest pain, shortness of breath
 Sense of detachment from surroundings
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D I A G N O S I S O F PA N I C D I S O R D E R
• Recurrent and unpredictable panic attacks
• Have occurred for at least 1 month
• Patient spends time in worried anticipation of
possible recurrence
• Onset after age 55:
 Fewer panic symptoms
 Less avoidance
 Lower score on somatization measures
 Less likely to persist into old age
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SPECIFIC PHOBIA
• Involves a distinct trigger, such as a specific person,
animal, place, object, event, or situation that results in
symptoms of anxiety
• Commonly, the patient’s anxiety level increases
instantly when the feared trigger is encountered
• Patient is able to identify this fear as unrealistic and
unsupported, even though the cognitive and
physiologic responses persist
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SOCIAL PHOBIA
• Fear of reactions that are inept or embarrassing in
social situations, such as:
 Trembling
 Blushing
 Sweating profusely
• Feared situations include:





Giving public speeches
Going on dates
Urinating in public restrooms (especially older men)
Eating in public (in older persons)
Socializing with others at a function or party
OBSESSIVE-COMPULSIVE
DISORDER
• Obsessions: persistent thoughts or ideas that come to
mind, commonly while completing a specific task or in
a particular situation
• Compulsions: behaviors performed in an effort to
decrease the anxiety experienced as a result of the
obsessions
• Chronic and often disabling
• New onset in late life is unlikely
 More commonly associated with a depressive
syndrome or early dementia
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P O S T T R A U M AT I C S T R E S S
DISORDER
• Common symptoms:
 Re-experiencing of the traumatic event
 Avoidance of associated stimuli
 Hyperarousal (eg, difficulty falling or staying asleep,
hypervigilance, exaggerated startle response)
• Diagnosis requires:
 Having experienced, either as a witness or a victim, a significantly
traumatic event, with feelings of fear and helplessness
 Presence of symptoms for 1 month and clinically significant
distress or functional impairment
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GENERALIZED ANXIETY DISORDER
• Distinctive symptoms:





Feeling easily tired
Muscle tension
Trouble sleeping through the night
Difficulty concentrating on a task
Feeling irritable or on edge
• Diagnosis requires:
 Presence of symptoms for at least 6 months
 Sense that one cannot control the anxiety
 More than one stressor
DEPRESSION WITH
MARKED ANXIETY
• Anxiety is a prominent symptom of depression
in many older adults
• Expression of anxiety may be more culturally
acceptable in older adults than expression of
depression
• In patients with complaints of anxiety, evaluate
for a major depressive disorder
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ANXIETY AND
MEDICAL DISORDERS
• Medical illnesses that commonly accompany an
anxiety disorder include:
 Cardiovascular illnesses
 Pulmonary disorders
 Drug side effects or interactions
 Hyperthyroidism
• Thorough assessment, including a clinical
history, is imperative before treatment begins
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PHARMACOLOGIC MANAGEMENT
(1 of 2)
Disorder
First-line treatments
Second-line treatments
Panic disorder with or
without agoraphobia
SSRIs, SNRIs, CBT
Benzodiazepines
Social phobia,
generalized
SSRIs plus CBT
Benzodiazepines
Social phobia, specific
β-blockersOL plus CBT
Buspirone
Specific phobia
CBT or benzodiazepines
β-blockers
Obsessive-compulsive
disorder
SSRIs, SNRIs, CBT
Clomipramine
OL = off label
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PHARMACOLOGIC MANAGEMENT
(2 of 2)
Disorder
First-line treatments
Second-line treatments
Posttraumatic stress
disorder
SSRIs or SNRIs
CBT
Generalized anxiety
disorder
SNRIs, SSRIs, CBT
Benzodiazepines
Anxiety and medical
disorders
Identify and treat
underlying cause, use
SSRIs or SNRIs in
primary anxiety disorder
Benzodiazepines
Depression with severe
anxiety
SSRIs, SNRIs, CBT
Buspirone,
benzodiazepines
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ANTIDEPRESSANTS
Given their relatively favorable side-effect profile,
SSRIs are the drugs of choice for:
•
•
•
•
•
Panic disorder
Obsessive-compulsive disorder
Generalized anxiety disorder
Posttraumatic stress disorder in younger patients
Depression with severe anxiety
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BENZODIAZEPINES
• Choose a short-acting agent without active
metabolites (eg, lorazepam or oxazepam)
• Limit use to <6 months
• Long-term use is fraught with multiple
complications:
 Motor incoordination and falls
 Cognitive impairment
 Depression
 Potential for abuse and dependence
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BUSPIRONE
• Studies suggest efficacy in treating
generalized anxiety disorder treatment, but
clinical experience is less positive
• Appears to be safer than benzodiazepines for
patients taking several other medications or
needing treatment for longer periods
• Clinical response is delayed for ~4 weeks, so
concomitant use of short-term benzodiazepine
may be useful for some patients
D R U G S T H AT A R E
NOT RECOMMENDED
• Antihistamines: Sometimes used for mild anxiety
 There are few data demonstrating efficacy
 Anticholinergic effects can cause serious
problems
• Second-generation antipsychotics: Not
appropriate choices for treatment of a
nonpsychotic older adult with an anxiety disorder
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PSYCHOLOGIC MANAGEMENT
• Often adequate alone
• Typically includes a combination of cognitive
and behavioral approaches:
 Relaxation training (music, visual imagery,
aromatherapy, instruction in relaxation
techniques)
 Cognitive restructuring
 Exposure (for panic disorder and obsessivecompulsive disorder)
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S U M M A RY
• Late-life anxiety is often comorbid with other problems,
such as cognitive decline and depression
• Comorbid medical problems that commonly lead to
anxiety include cardiovascular and pulmonary
disorders
• SSRIs are often used as first-line treatment for anxiety
in late life
• Nonpharmacologic therapies may be helpful,
particularly for generalized anxiety and anxiety
secondary to medical conditions
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QUESTION 1 (1 of 2)
Which of the following is the most prominent
concern when an SSRI is prescribed for an
older adult with an anxiety disorder or anxious
depression?
A. The patient may become suicidal.
B. The patient may stop treatment prematurely
because of adverse effects.
C. Bone loss may accelerate.
D. The SSRI may cause hyponatremia.
E. The SSRI may not work.
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QUESTION 1 (2 of 2)
Which of the following is the most prominent
concern when an SSRI is prescribed for an
older adult with an anxiety disorder or anxious
depression?
A. The patient may become suicidal.
B. The patient may stop treatment prematurely
because of adverse effects.
C. Bone loss may accelerate.
D. The SSRI may cause hyponatremia.
E. The SSRI may not work.
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CASE 1 (1 of 3)
A 70-year-old woman comes to the office for the first time
in several years because she has recently begun to feel
anxious.
She describes nervousness and vague somatic
symptoms, and she worries about the nature of these
symptoms. The symptoms wax and wane throughout the
day and are bothersome.
She reports no problems with memory or other cognitive
functions, and she is not depressed.
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CASE 1 (2 of 3)
Which one of the following is most likely to be
excluded from the differential diagnosis?
A. Cardiopulmonary disorder
B. Anxiogenic medication
C. Withdrawal from sedative–hypnotic agent
D. Prodrome for dementia or other neurodegenerative
illness
E. New-onset panic or obsessive-compulsive disorder
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CASE 1 (3 of 3)
Which one of the following is most likely to be
excluded from the differential diagnosis?
A. Cardiopulmonary disorder
B. Anxiogenic medication
C. Withdrawal from sedative–hypnotic agent
D. Prodrome for dementia or other neurodegenerative
illness
E. New-onset panic or obsessive-compulsive disorder
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CASE 2 (1 of 4)
• A 65-year-old man comes to the office because he has
recurrent anxiety attacks. He describes episodes of
intense fear and anxiety that last from 30 minutes to
several hours; the episodes are accompanied by
physical and autonomic symptoms.
• He has no other psychiatric symptoms, does not drink,
and has no history of alcohol or drug abuse. History
includes hypertension, osteoarthritis, and urinary
retention related to prostatic hyperplasia.
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CASE 2 (2 of 4)
• He received a diagnosis of panic disorder as an adult
and was prescribed diazepam, but he has not taken
the medication for the past 20 years. He is interested
in restarting treatment with diazepam.
• Physical examination and laboratory evaluation
(thyrotropin, CBC, metabolic profile) indicate nothing
likely to cause new-onset panic attacks.
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CASE 2 (3 of 4)
Which of the following is the most appropriate
treatment?
A. A benzodiazepine plus an SSRI
B. A benzodiazepine plus cognitive-behavioral therapy
C. A benzodiazepine plus nortriptyline
D. An SSRI plus cognitive-behavioral therapy
E. Mirtazapine plus an SSRI
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CASE 2 (4 of 4)
Which of the following is the most appropriate
treatment?
A. A benzodiazepine plus an SSRI
B. A benzodiazepine plus cognitive-behavioral therapy
C. A benzodiazepine plus nortriptyline
D. An SSRI plus cognitive-behavioral therapy
E. Mirtazapine plus an SSRI
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GRS8 Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Author:
Judith Neugroschl, MD
GRS8 Question Author:
Eric Lenze, MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society