Anxiety Disorders and Other Neuroses

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9 Anxiety disorders and otherneuroses

Jam es Lindesay

Classification Epidemiology Aetiology Specific neurotic disordersManagement Conclusion

N eurotic disorders are relatively neglected in the elderly. H ow ever, thereis accu m ulating evidence that these co nditions are clinically im portan t

in term s of their prevalence, the distress they cause, the cost to servicesand the poten tial for treatm en t and prevention (Lindesay, 1995). A t allages, neurotic disorders com plicate and aggravate other psychiatric an dphysical disorders, and doctors should be able to recognise and m anagethese co nditions.

Classification

The concept of neurosisis going through troubled tim es. It w as originallycoined in the 18th cen tury to describe a category o f disorders of theperipheral nervous system (Knoff, 1970). A s the cen tral an d psychologicalorigin of m any of these conditions cam e to be recognised , the m eaningof the term w as revised an d review ed . In the 20th cen tury, it has usuallybeen applied to em otional and behavioural disorders arising from theim pact of stress factors on particularities of character. In recent years, thisconcept has been challenged by the grow th of biological psych iatry.R esearchers have dissected out specific conditions from the body o f

neurosis, on the basis of particular physiological characteristics, responsesto drugs, genetic heritability and even neuropathology. In the U S, thetrium ph of biology is com plete, and w ords such as neurosisand neuroticno longer form an y part of D SM IV nosology (A m erican Psych iatricA ssociation, 1994). IC D 10 (W orld H ealth O rganization, 1992) has alsorejected the traditional division betw een neuroses an d psychoses. Instead,it has placed m an y of the co nditions previously associated w ith theneuroses in the group neurotic, stress-related and som atoform disorders(Box 9.1).

The u nifying concept of neurosis is not, how ever, obsolete. A dvan cesin m ed ical understan ding com e from lum ping, as w ell as splitting clinicalphen om ena. The b iological evidence for discrete d isorders needs to beinterpreted in the ligh t of clinical and epidem iological evidence that w ithin


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135Anxiety disorders and other neuroses

ind ividuals, and over tim e, there is considerab le com orb id ity andinterch an gability b etw een these disorders. Tyrer (1985) has argued thatlabelling episodes of illness purely in term s of current sym ptom atologyis m isleading, and that such cases are better understood, both clinicallyand nosologically, as a general neurotic syndrom e w ith a prolonged courseand varying presentations over tim e. This is m ost apparen t in co m m unityand prim ary care populations, w here d im en sions of dep ression an d

anxiety underlie the m an ifest psychological sym ptom s in both youngerand older adults (G oldberg et al , 1987; M ackinnon et al , 1994). The unitarym odel of neu rotic d isorders is also supported by eviden ce from geneticstudies w hich suggest that it is not specific disorders that are inherited,so m uch as a general predisposing trait of neuroticism (Kendler et al ,1987; A ndrew s et al , 1990). In the elderly, w here chronicity and m ultiplepathology are the norm , the concept of a general neurotic syndrom e is usefulin m aking sense of changing clinical pictures, in understanding the causesand outcom e of neurotic presentations and in guiding their treatm ent.

Epidemiology

The prevalence rates of neurotic d isorders in the elderly depend on thepopulation studied . They are uncom m on prim ary diagnoses in hospitalpopulations, and w hile there is a steady accum ulation of ch ronic casesin prim ary care settings, there is a d ecline, w ith age, in the rate of new

consultations. A s w ith yo unger adults, the highest rates of neuroticdisorders, particularly anxiety, are found in the com m unity. To som e extentthe d iscrepancy b etw een clinical and com m unity populations is due toa proportion of the com m unity cases being m ild and non-problem atic.

Box 9.1 Summary of ICD10 classification of neurotic,stress-related and somatoform disorders (World Health

Organization, 1992)

AgoraphobiaSocial phobiasSpecific (isolated) phobiasPanic disorderGeneralised anxiety disorderObsessivecompulsive disorderPost-traumatic stress disorderAdjustment disordersDissociative disordersSomatisation disorders


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H ow ever, there are clinically significant cases of neurotic disorder thateither do not presen t to the health services or are not identified or treated(M acdonald, 1986; Thom pson et al , 1988; Lindesay, 1991).

Tab le 9.1 sum m arises prevalen ce rates for specific D SM III disorders inco m m unity sam ples of the o ver 65-year-o lds, rep orted b y the U SEpidem iologic C atchm ent A rea (EC A ) study. Studies have tended to reportdifferent rates, due m ainly to differences in the operation of hierarchicalrules for diagnosis and in the level of severity required for caseness. Inm ost neurotic disorders there is a fall in prevalence w ith age, in bothgenders, bu t the d ifferen ces are not large co m pared w ith clin icalpopulations. A t all ages, prevalence rates for neurotic disorders are high erin w om en than in m en , but this differen ce is least pronounced in theelderly. C om m unity studies of neurotic disorders in the elderly confirmthat the m ajority of cases are long-standing, w ith onset in young adulthoodand m iddle age. H ow ever, a sign ifican t m inority has an onset after theage of 65 years (Bergm an n, 1972; Lindesay, 1991).

Aetiology

Physical illness

Epidem iological studies of co m m unity populations provide the leastbiased inform ation about factors associated w ith neurotic d isorder in theelderly (Box 9.3). A s noted above, there is at all ages extensive com orbiditybetw een specific neu rotic d isorders an d depression (Boyd et al , 1984;W eissm an & M erikangas, 1986). In the co m m unity elderly, neu roticd isorders are also associated w ith increased m ortality and physical

Table 9.1 Epidemiologic Catchment Area study: prevalence of neurotic disorders in the elderly (%)

M ale Fem ale Total

One-year preval ence (Robins & Regier, 1991) Phobic disorder 4.9 7.8 Panic disorder 0.04 0.08 G en eralised anxiety 2.2O bsessive com pulsive disorder 0.8 0.9 1.7

One-month prevalence (Regier et al, 1988) Phobic disorder 2.9 6.1 4.8Panic disorder 0.0 0.2 0.1O bsessive com pulsive disorder 0.7 0.9 0.8Som atisation disorder 0.0 0.2 0.1D ysthym ia 1.0 2.3 1.8


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m orb id ity, notab ly card iovascu lar, respiratory and gastro in testinalcom plaints (K ay & B ergm ann, 1966; Bergm ann, 1972; Lindesay, 1990).The relationship betw een physical and psychiatric d isorders in the elderlyis even m ore m arked in clin ical populations, an d em phasises theim portance o f careful history taking and physical exam ination, particularlyin late-onset cases.

To som e exten t, this association betw een neurotic and physical disorderm ay b e d ue to increased bodily co ncern leading to presen tation w ithphysical, rather than psychological com plaints; or to som atic an xietysym ptom s being w rongly attributed , by patien t and doctor, to physicalillness. H ow ever, m an y im portan t physical disorders m ay present w ithneu rotic sym ptom s, particu larly anxiety, an d should be suspected if: thepatient is m ale; there is no history of neurotic disorder; nothing in thepatient s circum stan ces accounts for the episode. B ox 9.2 sets out som eof the physical conditions that m ay p resent as neurotic disorder in thisage group. Fo r m ost elderly people an episode of physical illness, w ithits associated investigations and treatm ents, is a threatening and frighteningexperience. In vu lnerable individuals this m ay result in persistent neuroticdisturban ce, such as phobic w ithdraw al and generalised anxiety, as w ellas m ore tran sien t ad justm en t reactions.

Psychosocial factors

Psychosocial factors are im portant in the aetiology of neurotic d isorders inthe elderly, particularly at the sym ptom level, w here high scores are associated

Box 9.2 Physical causes of neurotic symptoms in theelderly (adapted from Pitt, 1995)

Cardiovascular: myocardial infarction, cardiac arrhythmias,orthostatic hypotension, mitral valve prolapse

Respiratory: pneumonia, pulmonary embolism, emphysema,asthma, left-ventricular failure, hypoxia, chronic obstructiveairways disease, bronchial carcinoma

Endocrine and metabolic: hypo- and hyperthyroidism, hypo-and hypercalcaemia, Cushing s disease, carcinoid syndrome,hypoglycaemia, insulinoma, phaeochromocytoma, hyper-kalaemia, hypokalaemia, hypothermia

Neurological: head injury, cerebral tumour, dementia, delirium,epilepsy, migraine, cerebral lupus erythematosus, demye-linating disease, vestibular disturbance, subarachnoidhaemorrhage, central nervous system infections

Dietary and drug related: caffeine, vitamin deficiencies, anaemia,sympathomimetics, dopamine agonists, corticosteroids,withdrawal syndromes, akathisia, digoxin toxicity, fluoxetine


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w ith low socio-econom ic status (H im m elfarb & M urrell, 1984; K ennedy et al ,1989). Studies of estab lished cases of neurotic disorders have not found asubstantive relationship w ith socio-econom ic indicators, such as occupationalclass or household tenure (Lindesay, 1991). H ow ever, generalised anxietyw as associated w ith low household incom e in the ECA study.

A dverse life events can provoke the onset of som e psychiatric d isordersin vu lnerable individuals; it is the m eaning o f the event for the individualthat is im portant, rather than the severity. Loss events generally lead todep ression, w hile threaten ing even ts m ay lead to anxiety (Brow n et al ,1987; B row n , 1993). A ge-related exp eriences such as retirem en t,bereavem en t an d institutionalisation m ay cau se acu te p sychologicaldisturban ce, but they do not appear to be a m ajor cause o f persisten tdisorders in the elderly.

In com m on w ith younger ad ults, early experience, such as paren talloss, m ay be im portan t in determ ining personal vulnerab ility to neu roticd isorder (Zah ner & M urphy, 1989; Lindesay, 1991). Perhaps, earlyexp eriences such as these lead to the d evelopm ent of particular cogn itivehabits and personality traits, w hich render the individual vu lnerable todeveloping neurotic d isorders in response to challenging experien ceslater in life (see C hapter 11). A ccording to A ndrew s et al (1990) it is thelack o f m astery over self and en vironm en t, and an inab ility to m ake useof effective coping strategies, that results in neurotic sym ptom atology.U nlike late-life d epression, phob ic d isorders in the elderly are not

associated w ith absen ce of confiding relationships (Lindesay, 1991);indeed, in som e cases, the presence of close relationships m ay m aintainphobic avoidance.

Biological factors

There has been very little research into possible biological factors involvedin the developm en t of neu rotic disorders in old age (Philpot, 1995).C om puterised tom ography studies of elderly depressed patien ts have

found that the m ilder, m ore neurotic cases, an d those w ith higher an xietyscores, tend to have norm al scans. Studies of patients w ith post-strokeanxiety d isorders suggest that the distribution of lesions is different fromthat seen in post-stroke depression, but there is no consistent location.Functional neu roim aging w ith younger patien ts w ith an xiety disorders isbeginning to iden tify chan ges in regional cereb ral blood flow associatedw ith the p rovocation of sym ptom s, and w ith treatm en t.

There is no association betw een neurotic d isorders an d dem en tia insurveys of co m m unity populations, but clinical studies have found

significant levels of anxiety in patients w ith dem entia, particularly thosein the early stages (W an ds et al , 1990; B allard et al , 1996). This anxietym ay b e associated w ith depression, psychotic sym ptom s or w ith theim plications of the d em entia and its im pact on social functioning.


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Specific neurotic disorders

Phobic disorderThe irrational fears reported by elderly people are sim ilar to those inyounger age groups: anim als, heigh ts, public transport, go ing out of doors,an d so on (Lindesay, 1991). U nfortunately, m uch is m ad e o f thereasonab leness of som e of these fears in the elderly, particularly thosew ho live in run-dow n areas of inner cities, and clinically im portant fearsm ay be dism issed as rational. In fact, the eviden ce from fear of crim esurveys indicates that an individual s perception of vu lnerability isdeterm ined principally by factors such as physical disability and the

availability of social support (Fattah & Sacco, 1989). It is these, ratherthan age, that should be taken into co nsideration w hen judging thereasonableness, or otherw ise, of fears.

Long-standing disorder

These are usually specific in nature, and associated w ith little in the w ayof distress or social im pairm ent. These individuals have organised theirlives so that they d o not need to confront their fears, and it is only

occasionally that the onset of old age m akes such a co nfrontationunavoidable; for exam ple, a need le phobic m ay have to contend w ith theonset of insulin-dependen t diab etes or an ago raphobic m ay need to shopafter the death of their spouse.

Late-onset di sor der

These are o ften agoraphobic in nature and associated w ith clinicallysignificant levels of distress and disab ility. They usually develop follow ing

a traum atic event such as an ep isode of physical illness, a fall or a m ugging.The resu ltin g im pairm en t usually p ersists long after the physicalconsequences of the event have resolved. U nfortunately, the psychologicaleffects of traum atic physical health events in old age are still poorly

Box 9.3 Factors associated with neuroses in the elderly

Physical illness notably cardiovascular, respiratory andgastrointestinal complaints

Low incomeAdverse life eventsEarly adverse experiences such as parental lossOther psychiatric illness, including dementia


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appreciated, w ith the result that the statutory services and the fam ily m ayunw ittingly collude w ith phobic avoidance by p roviding w ell-m eaningbut m isguided dom iciliary sup port. V ery few elderly peo ple w ith disab lingphobic disorders receive an y appropriate treatm ent for their problem(Lindesay, 1991).

Panic disorder

Panic attacks and panic disorder are rare in ep idem iological studies ofelderly co m m unity populations (Tab le 9.1), although cross-sectionalsurveys m ay underestim ate the true rates. The eviden ce from case reports,and non-psychiatric patien t an d volunteer sam ples, suggests that panicin old age is less com m on than in early adulthood, is m ore com m on inw om en and w idow s and is sym ptom atically less severe than in early-

onset cases (Sheikh et al , 1991). Elderly panic patients tend not to presentto psych iatric services, but the prom inen t physical sym ptom s m ay resultin their b eing referred in stead to card io logists, neu ro logists an dgastroenterologists. In one study of cardiology patients w ith chest painan d no co ronary artery disease, one-third of those aged over 65 years m etdiagn ostic criteria for panic disorder (Beitm an et al , 1991).

Generalised anxiety disorder

O ne result of the recogn ition of specific anxiety d isorders, such as phobicdisorders and panic disorder, by the new psychiatric classifications hasbeen the relative eclipse of the concept of generalised anxiety as adiagnostic entity. Indeed in IC D 10, generalised an xiety d isorder m ayonly be d iagnosed in the absence of any other m ood disorder. Th e currentunpopularity of generalised anxiety is probably due in part to the lackof specific treatm ents (Tyrer, 1985), and in part to the current em phasison the o rganic as opposed to psychosocial causes of anxiety disorders(B lazer et al , 1991). In particular, the role of chronic stress in theaetiology o f co nditions such as generalised anxiety has been neglectedin recent years.

C oncern has been expressed that the d iagnosis of generalised an xietydisorder m ay b e inappropriately applied to elderly people b ecause oftheir vu lnerability and physical frailty (Sham oian, 1991). In fact, theepidem iological evidence indicates that only a sm all percen tage of theelderly p opulation m eet diagn ostic criteria for this disorder (Copeland et al , 1987 a,b ; Lindesay et al , 1989; B lazer et al , 1991; M an ela et al , 1996).

W hatever the nosological status of generalised anxiety, the conditionap pears to be associated w ith an increased use of both physical andm ental health services (Blazer et al , 1991). If service use is regarded asa criterion of clinical im portan ce then generalised anxiety rem ains a usefulconcept, particularly at the prim ary care level.


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Neurotic depression

A lthough IC D 10 has retained the concept of neu rotic disorders (B ox9.1), no depressive condition appears in this group. A s a diagn osticcategory, neurotic depression has alw ays been unsatisfactory; the criteria

are vague, and it is defined m ore b y the absence of psychotic sym ptom sthan by the p resence of anything specific. N evertheless, as Sn aith (1991)points out, consideration of aspects of depression is integral to theunderstanding o f m any neurotic disorders because:

(a) C onditions such as phobic disorder, generalised an xiety d isorder,agoraphobia, obsessive com pulsive d isorder (O CD ) and som atisationare o ften accom panied by depressive sym ptom s, and these o ftencom e to dom inate the clinical picture over tim e, particularly if the

neu rotic sym ptom s are severe an d d isab ling. This dep ressiveelem ent of the clinical picture m ay w ell require treatm ent in itsow n right.

(b) A t all ages, the m ost com m on psychiatric d isorder seen in prim arycare settings is a m ild to m oderate m ixture of dep ressive an d an xietysym ptom s, arising in response to a specific stressor, often in thecontext of particular m aladaptive personality traits.

(c) D ep ression in the elderly som etim es presents w ith ap paren tlyn eu ro tic b eh avio u r, su ch as hyp o ch o n d riasis, an o rex ia,im p o rtu n in g an d scream in g, th at can m islead th e u n w arydiagn ostician.

Obsessive compulsive disorder

O f all the specific neurotic disorders O C D is the m ost persistent and stablediagnosis. It has a ch ronic, fluctuating course (R asm ussen & Tsuan g, 1986),and the clinical features of O C D in elderly patients are sim ilar to thoseseen in younger ad ults. A lthough a proportion of patien ts w ith O C D alsodevelop sign ifican t depressive sym ptom s, other eviden ce suggests thatO C D is a d istinct disorder involving the orbitofrontal cortex, basal ganglia,substan tia nigra and ven trolateral pallidum (M ontgom ery, 1980; G oodm anet al , 1989; Insel, 1992).

W hile the o nset of O C D in old age is rare (Bajulaiye & A ddonizio,1992), a m inority of cases present late, and m any elderly patients w ithlong-standing disorders have never been ad equately treated (Jenike, 1989).Therefore, it is im portant that all elderly p atien ts receive thoroughevaluation an d treatm en t w hen they com e to the notice of services.Th e d evelo pm en t o f o b session al o rd erlin ess an d p reo ccu patio nw ith ro u tin es m ay p resage th e o n set o f d em en tia. O b sessio n alsym ptom s m ay appear at any age follow ing head injury or cereb raltum our.


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Somatoform disorders

Somatisation

The som atisation of psychological distress usually starts in early adult life,and once established, has a chronic, fluctuating course show ing littleim provem ent w ith age (Pribor et al , 1994). Som atising patients are skilledat seeking m edical treatm ent and avoiding psychiatrists, and it is notunco m m on for these individuals to presen t to psychiatric services for thefirst tim e in old age. They com e w ith a very extensive history of com plaints,referrals and investigations; are usually d epressed and anxious; and theclinical picture is often com plicated by the p resence o f true p hysicalillness. They are the epitom e of the heartsink patient, and a significantchallenge to all invo lved in their care.

Hypochondriasis

In contrast to som atisation, hyp ochondriacal patients usually restrictphysical com plaints to one o r tw o body organs or system s. Typically theyare preoccupied w ith the possibility of serious physical illness and theird em an d is for in vestigation rather than trea tm en t (W orld H ealthO rganization, 1992). In the elderly, prim ary hypochondriasis is usuallylong-standing; hypochondriacal preoccupations that present for the firsttim e in late life are m ore likely to be a seco ndary m an ifestation ofdepression or an xiety.

Malingering

M alingering is an abnorm al illness behaviour that has yet to be d ign ifiedas a d isorder by any psychiatric n osology. It is largely unresearched andthere are no form al diagnostic criteria; nevertheless, it is w ell recognisedand disapproved of by doctors w ho tend to ignore o r dism iss w hat liesbehind it. D octors and other carers find m alingering p articularly irritating

because the m alingerer is clearly p hysically ill, or disabled, and yet thecom plain ts and crises, such as breath lessness, falls or episodes ofinco ntinen ce, are tim ed to cause distress an d inco nven ien ce to thoseresponsible for their care. It is im portant to understand w hat is beingco m m unicated by such beh aviour, such as distress, an ger, fear ordepression. Failure to address this can result in rejection by carers, andinstitutionalisation, w ith subseq uent escalation in the p atient s distressan d disruptive behaviour.

Dissociative disorders

Elderly patients occasionally m anifest w hat appear to be h ystericaldysm nesias and conversion reactions to stressful experiences, and it is


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im portan t to know w hat these rep resent. A s a rule the appearance ofsuch sym ptom s in late life is due to organic disease, or the release ofhysterical tendencies in vu lnerable personalities, by cerebral pathologyor functional psychiatric disorder. A s Bergm an n (1978) said, It is bestto assert dogm atically that prim ary hysterical illness does not begin in oldage .

Management

Psychological

A lthough the behavioural an d co gnitive approaches to psych ologicaltreatm ent are theoretically d istinct, in practice m ost interventions invo lveelem en ts of both. Cognitive behavioural therap y is of proven effectivenessin the treatm en t of conditions such as phobias and O C D , in youngeradults (M arks, 1978). C ase reports and sm all series indicate that they arejust as effective in the elderly (Len g, 1985; W oods & B ritton, 1985; W oods,1995). A nxiety m anagem ent training, involving instruction, relaxation andother control techniques (M cC arthy et al , 1991) is an im portan t approachto anxiety sym ptom s in the elderly, w hich can be applied in a w ide rangeof settings to both groups and individuals. Further research is needed toestablish w hich strategies are m ost effective in this age group; w hile theprinciples of cognitive behavioural therap y are the sam e at all ages, thegoals and techniques m ay need to be m odified to m ake allow ance forphysical disabilities (see C hapter 17).

Physical

D espite the effectiveness of behavioural, training and cognitive strategiesin the m an agem en t of neu rotic d isorders, m ost elderly patien ts w ith theseconditions are treated w ith drugs. So m etim es this is appropriate; forexam ple, if d ep ression is a p ro m in en t fea tu re th en a co urse o f

an tidep ressan t treatm en t should alw ays be considered . H ow ever, thepharm acotherap y o f neu rotic d isorders is often m erely an easy andconvenient m eans of avoiding a m ore detailed and painstaking assessm entof the patient s sym ptom s and circum stances.

The greatest problem s w ith inappropriate and excessive d rug treatm en tof neurotic disorders in the elderly have occurred in association w ithbenzodiazepines. In spite o f the fact that there h ave been relatively fewform al controlled trials of benzodiazepine treatm ent in elderly patients,old people are the largest consum ers of this class of drugs, particularly

as hypnotics. B ecau se o f the altered han dling o f drugs by the body w ithincreasing age, som e benzod iazepines and their m etab olites accum ulatesubstantially in som e elderly p atients, w ith the result that apparentlyth erap eu tic d o ses can even tu ally cau se p ersisten t d ro w sin ess,


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incontinence, delirium and falls (Evans & Jarvis, 1972; Fancourt &C astled en, 1986). O ther problem s in the elderly include increased centralnervous system sensitivity to the effect of the drug, the presence of physicalillness (particularly respiratory disease), interactions w ith other drugs andalcohol, an d non-com pliance (Salzm an, 1991). A t all ages, long-termb en zod iazepine u se can result in physical dep en den ce, co gn itiveim pairm en t and paradoxical excitem en t. In view of all these problem s,benzodiazep ine p rescription in the elderly should be restricted to shortco urses of short-acting com pounds w ithout active m etab olites, such asoxazepam . A s a ru le, long-term b en zod iazep ine u sers shou ld b eencouraged to w ithdraw from their m edication, particularly if they havecontinuing neurotic sym ptom s (see C hap ter 11).

There is eviden ce that som e o f the n ew generation of anxiolytics andantidepressants are m ore effective in providing relief in neurotic disordersw ithout unacceptable side-effects. B uspirone is an azap irone anxiolyticdrug w hose pharm acokinetics, safety and efficacy in the elderly, are sim ilarto those in younger ad ults (Robinson et al , 1988). It is w ell tolerated bythis age group, and it appears that short-term use is not associated w ithreb ound, dep enden ce or m isuse (Lader, 1991). U nlike other an xiolyticsit takes tw o to three w eeks to have an effect, so it is not useful in them an agem en t of acute anxiety states. N eurolep tic drugs have only a lim itedrole in the m an agem en t of an xiety becau se of the risk of d isab lingextrapyram idal side-effects. A ntihistam ine d rugs such as hydroxyzine have

a history of use as anxiolytics in elderly patients, and they m ay b e usefulw hen respiratory depressan t drugs are contraindicated.

Conclusion

N eurotic d isorders are m ore com m on in the elderly than generally realised .Faced w ith the u rgen t dem an ds of dem en tia and dep ression , it isunderstandab le that som e hard-pressed old age psych iatric services m ightregard the treatm ent of neurotic disorders as a relatively low priority.W hile it is true that services should aim to have a lim ited role in the long-term m an agem en t of these conditions, they should nevertheless beproficient in their assessm en t an d acu te treatm ent, an d be able to ad viseprim ary care team s, physician s an d others responsible for the continuingcare of these patien ts, in ap propriate m an agem en t strategies.

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Anxiety Disorders and Other Neuroses