Mohammed T. Abou-Saleh

556 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYspaces, darkness, flying, heights); (b) animal phobias (spiders,snakes); (c) blood-injury (injections, dentists, blood, injuries). Ananalysis of Epidemiological Catchment Area data suggests thatthe onset of social phobia is associated with female gender, loweducation and never having been married 26,27 . It is difficult tocharacterize the longitudinal course of simple phobias, principallydue to the multiplicity of specific causal stimuli. In addition,individuals with one specific phobia may develop additionalphobias or other psychopathology at some point in the course oftheir affliction.Exposure and related desensitization techniques are thepsychosocial treatments of choice for all variants of specificphobias and promise significant improvement 28 . These strategiesalso promise effective biobehavioral interventions for olderindividuals.POST-TRAUMATIC STRESS DISORDER (PTSD)This condition is commonly characterized by an acute-on-chroniccourse of multiple symptoms (e.g. emotional numbing, hyperarousal,hypervigilance, nightmares, avoidance behaviors) after atraumatic event. Most studies suggest that women are not atgreater risk for traumatic exposure, but are more likely to developPTSD when exposed to trauma, especially if experienced prior toage 15 years 29,30 . Intensity of the physiological response to theoriginal trauma seems to be the most significant predictor of arelatively poor long-term outcome 31 (see also comments regardingacute stress disorder). Dissociative phenomena, sensation-seeking/high-risk behavior, emotional constriction, and drug and alcoholabuse also seem to indicate poor prognosis; in addition, on-goinglife stressors may slow the recovery process 31 . PTSD is frequentlyaccompanied by obsessive–compulsive disorder, phobias, dissociativedisorder, generalized anxiety disorder, panic disorder,depression and substance use disorders 13 . In addition, a number ofsomatic symptoms such as headaches, chronic pain, irritablebowel syndrome and fatigue, are commonly co-morbid.There is accumulating evidence that pharmacotherapy iseffective for the treatment of PTSD. For example, the selectiveserotonin reuptake inhibitors have demonstrated significantbroad-spectrum effects in all the PTSD symptom clusters. Theymay be considered as first-line (preferred) pharmacologicalagents 32 . Other medications that may also be considered, arenefazodone, the tricyclic antidepressants and the monoamineoxidase inhibitors. Psychotherapy can be considered as either analternative or an additive treatment to medications. Numerouspsychotherapeutic techniques can help alleviate symptoms. Theseinclude cognitive–behavioral therapy, prolonged exposure, supportive–psychodynamictherapy and stress inoculation training 33 .Symptoms of the disorder are similar across age groups—reexperiencingthe trauma, avoidance and hyperarousal—and thereis no current evidence that aging affects the development ofpresentation of PTSD in older individuals. Elderly individuals donot appear any more predisposed to develop PTSD than doyounger persons 34 . It is not uncommon for individuals who haveexperienced trauma (e.g. combat) to experience an exacerbation ofPTSD, or for post-traumatic disorder to be reactivated, duringlater life 35,36 . As with other anxiety disorders, pharmacologicaland biobehavioral interventions found effective with youngerpopulations can be incorporated into treatment for older adults.GENERALIZED ANXIETY DISORDER (GAD)GAD typically has an early onset with an acute-on-chronic courseand is associated with increased utilization of medical and mentalhealth services and increased consumption of psychotropicmedications 37 . The presence of a co-morbid diagnosis is associatedwith a worsened prognosis and reduced remission rates comparedwith those patients with GAD alone 38,39 . Women with GAD aremore likely to develop co-morbid conditions (e.g. depression) andthe presence of such co-morbidity may reduce the likelihood ofremission 40 .Treatments for GAD include both pharmacological andpsychological interventions. Efficacy has been reported withbuspirone, the benzodiazepines, the SSRIs and venlafaxine 41,42,43 .Cognitive–behavioral therapy (CBT) can be quite effective for thisdisorder in the short term 44 . Additionally, the benefits of CBTappear to be maintained at long-term follow-up and thus mayprovide a long-term and cost-effective intervention for GAD 45 .ANXIETY DISORDER DUE TO A MEDICALCONDITIONThis syndrome may be more common in the elderly due to morefrequent medical illness. Prognosis depends on the nature andcourse of the underlying medical condition and its management.ACUTE STRESS DISORDERAcute stress disorder describes post-traumatic stress reactions thatdevelop in the first month following a traumatic event. A reviewof the empirical literature on psychological reactions to traumasuggests that dissociative, intrusive, avoidance and arousalsymptoms have often been identified across different kinds oftraumatic events 46 . Of those individuals who experience trauma, aminority develops acute stress disorder. However, the literaturesuggests that a substantial majority of those who meet criteria forthis disorder subsequently meet the criteria for ASD 47 . Symptomswith strong predictive power for the later development of PTSDinclude dissociation, re-experiencing, avoidance, acute numbing,and motor restlessness 48,49 . Therefore, in terms of prognosis, it isimportant to identify this pattern of reactions and to provideappropriate interventions to minimize their degree and duration.SUBSTANCE-INDUCED ANXIETY DISORDERA clinical picture of prominent anxiety, panic attacks, obsessionsor compulsions characterizes this disorder. There must beevidence that medication use or substance intoxication or withdrawalare etiologically related to the symptoms. Symptoms mustbe clearly in excess of those customarily associated with thesubstance and these must cause clinically significant distress orimpairment that warrants independent clinical attention. Once thesubstance is discontinued, the anxiety symptoms will usually remitwithin days to several weeks 13 . Symptom resolution is dependentupon the half-life of the substance, the presence of a withdrawalsyndrome and other factors such as general health, medical comorbiditiesand any psychiatric co-morbidities. For these reasonsand the factor of aging, prognosis in the elderly may be moreprotracted.CONCLUSIONIn summary, it appears that anxiety disorders are characterized bya chronic course, with symptomatology becoming worse duringperiods of physical and emotional stress. Both pharmacologicaland psychotherapeutic approaches seem to be effective in theacute or short term. Definitive literature about the longer-termeffects of treatments on the natural course of these disorders is still