Anxiety disorders

Research has only recently begun to address the nature and treatment of anxiety in later life. Prevalence rates suggest that anxiety disorders occur more than twice as frequently as depression among older adults, with the highest rates reported for generalized anxiety disorder and phobias. However, relatively little is known about the psychopathology and treatment of these and other anxiety disorders. In this review, recent clinical advances in this area are summarized. Particular attention is given to the prevalence and nature of late-life anxiety and its overlap with related conditions, psychometric properties of assessment tools for evaluating anxiety in older adults, and treatment outcome literature in both pharmacological and psychosocial domains. Directions for future research are provided throughout and summarized in a final section with the goal of stimulating additional empirical work in the area.     

Depression and anxiety among Asian American elders: a review of the literature

Depression and anxiety are often reported to be the most common psychological disorders among older adults in the United States. As the population of older Asian American adults steadily increases, mental health practitioners will need to be apprised of the etiological, diagnostic, and treatment issues in working with this population. This article reviews the existing literature on depression and anxiety among older Asian American adults. Little empirical research has been conducted, and more research on the mental health status and needs of older Asian American adults is needed. In addition, improved recruitment of Asian Americans into the health-care professions as well as improved clinical and research training in an increasingly diverse society are imperative to addressing the lack of attention to the mental health needs of older Asian American adults.     

The impact of co-occurring mood and anxiety disorders among substance-abusing youth

BACKGROUND: Co-occurring mood and anxiety disorders are highly prevalent amongst substance-using young adolescents, and have been associated with a range of adverse outcomes. Few studies however have examined the impact of affective disorders in samples of older adolescents and young adults attending youth drug treatment services. METHODS: One hundred young people (mean age 19.4 years) were recruited from two youth drug treatment services in Melbourne, Australia. A structured interview and questionnaires assessing drug use, psychopathology, risk-taking behaviours and quality of life were administered at a mutually convenient location. RESULTS: Fifty percent of the sample met criteria for at least one current mental health disorder. Excluding individuals with a current psychotic illness (n=3), 49% met criteria for a current mood or anxiety disorder, with 68% reporting a lifetime history. There were high rates of current Major Depressive Disorder (MDD; 27%) and Post-traumatic Stress Disorder (PTSD; 26%) within the sample. Participants with these disorders were more likely to have a higher number of comorbid disorders, report more substance-related problems and a poorer quality of life. LIMITATIONS: Cross-sectional design, lack of biological assays. CONCLUSIONS: In older adolescence and emerging adulthood, young drug users with comorbid affective disorders have greater mental health and substance use morbidity than those with substance use problems alone. These findings have important clinical implications for the management and rehabilitation of young people with substance use disorders.     

Psychophysiological arousal in older adults: a critical review.

In spite of the relatively high prevalence rates of anxiety disorders (AD) and related symptoms, very little is known about the experience, presentation, and assessment of anxiety in later life. Because the physiology of the autonomic nervous system changes with age, an enhanced understanding of how these developmental changes affect the somatic-physiological response patterns to anxiety-evoking stimuli among older adults may help explain whether we can generalize current assessment and treatment practices and procedures for AD from younger to older adults. In this paper, we describe and critically evaluate studies that have employed psychophysiological recording of autonomic arousal to anxiety-arousing or stressful stimuli among samples of younger and older adults. The conclusions one can draw from the review are quite limited by both the paucity of relevant literature and the methodological limitations of the published studies.     

The prevalence of anxiety in older adults: methodological issues and a review of the literature

BACKGROUND: Despite the relative neglect of anxiety in older adults, the growing literature on its prevalence suggests that anxiety is highly prevalent and associated with considerable distress and morbidity in this age group. This review provides a comprehensive overview of this literature and discusses some unresolved controversies in the field. METHODS: A systematic search of articles published from 1980-2007 was performed. Articles were included for review if they reported the prevalence of anxiety symptoms, anxiety disorder or specified anxiety disorders in adults aged >60 in either community or clinical settings. RESULTS: The prevalence of anxiety in community samples ranges from 1.2% to 15%, and in clinical settings from 1% to 28%. The prevalence of anxiety symptoms is much higher, ranging from 15% to 52.3% in community samples, and 15% to 56% in clinical samples. These discrepancies are partly attributable to the conceptual and methodological inconsistencies that characterise this literature. Generalised Anxiety Disorder is the commonest anxiety disorder in older adults. LIMITATIONS: The methodologies used in the studies are so variable as to make comparisons difficult. CONCLUSIONS: Although anxiety disorder, particularly Generalised Anxiety Disorder is common, issues in relation to comorbidity and the nature of anxiety in old age remain unresolved. This hampers the design of intervention programmes, and highlights the need for further research with a primary focus on anxiety.     

Fat Matters: Understanding the Role of Adipose Tissue in Health in HIV Infection

More than one-third of adults in the USA are obese and obesity-related disease accounts for some of the leading causes of preventable death. Mid-life obesity may be a strong predictor of physical function impairment later in life regardless of body mass index (BMI) in older age, highlighting the benefits of obesity prevention on health throughout the lifespan. Adipose tissue disturbances including lipodystrophy and obesity are prevalent in the setting of treated and untreated HIV infection. This article will review current knowledge on fat disturbances in HIV-infected persons, including therapeutic options and future directions.     

Consequences of anxiety in older persons: its effect on disability, well-being and use of health services.

BACKGROUND: Although anxiety is quite prevalent in late life, its impact on disability, well-being, and health care utilization of older persons has not been studied. Older persons are a highly relevant age group for studying the consequences of anxiety, since their increasing numbers put an extra strain on already limited health care resources. METHODS: Data of a large community-based random probability sample (N = 659) of older subjects (55-85 year) in the Netherlands were used to select three groups: subjects with a diagnosed anxiety disorder, subjects with merely anxiety symptoms and a reference group without anxiety. These groups were compared with regard to their functioning, subjective well-being, and use of health care services, while controlling for potentially confounding variables. RESULTS: Anxiety was associated with increased disability and diminished well-being. Older persons with a diagnosed anxiety disorder were equally affected in their functioning as those with merely anxiety symptoms. Although use of health services was increased in anxiety sufferers, their use of appropriate care was generally low. CONCLUSIONS: Anxiety has a clear negative impact on the functioning and well-being of older subjects. The similarity of participants with an anxiety disorder and those having merely anxiety symptoms regarding quality of life variables and health care use was quite striking. Finally, in spite of its grave consequences for the quality of life, appropriate care for anxiety is seldom received. Efforts to improve recognition, disseminate effective treatments in primary care, and referring to specialized care may have positive effects on the management of anxiety in late life.     

Predictors of unsuccessful magnetic resonance imaging scanning in older generalized anxiety disorder patients and controls

A thorough understanding of the neurobiology of late life anxiety is likely to depend on the use of brain imaging techniques such as magnetic resonance imaging (MRI). Generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders in older adults, and is thus a focus for neurobiological studies using MRI. This study tested 1–3 weeks predictors of unsuccessful scan outcomes (i.e., scan trials in which the participant moved excessively or prematurely terminated the scan) in older adults with GAD (n = 39) and age- and sex-matched nonanxious controls (n = 21). It was hypothesized that successful completion of a prior MRI scan, clinical status (GAD versus control), and scores on the Anxiety Sensitivity Index (ASI; Peterson et al. 1986), a measure tapping psychological aspects of medical interventions, would predict scan outcome when current diagnoses of claustrophobia were controlled. In logistic regression analyses, unsuccessful scan outcome was predicted by prior MRI completion and ASI Mental Concerns subscale scores, but not clinical status. This model correctly classified 91% of successful and 71% of unsuccessful scans. An alternative model that included a single ASI item rather than Mental Concerns subscale scores showed similar performance, and a model including categorical anxiety sensitivity groups was also effective but slightly less accurate. Implications for improving the success rates of MRI with older adults are discussed.     

The Changing Face of Dating Anxiety: Issues in Assessment With Special Populations

As a precursor to numerous psychological difficulties, dating anxiety is an important area of research that has been largely neglected, with existing research providing few answers concerning how this construct may present at different developmental stages of the life span, or across special interest groups. This article describes what factors may be important to consider when examining dating anxiety in adolescents, gay/lesbian/bisexual populations, ethnic minorities, older adults, and by addressing gender. Further research is necessary to address how social anxiety differs from dating anxiety, how these two constructs are similar and different across groups and throughout the life span, and how more developmentally sensitive measures of dating anxiety may be developed.     

Attachment and emotion experience in later life: the view from emotions theory

Despite the large volume of research on attachment over the past three decades based on work with children and young adults, there has been scant attention to later life. As such, Bowlby's claim that attachment theory has implications for the entire lifespan remains relatively untested. In this paper we present exploratory data documenting the relations between attachment and emotion in older adults. A sample of 1118 community-dwelling adults ranging in age from 65 to 86 years completed measures of attachment and Izard's (1972) Differential Emotions Scale. Consistent with a developmental-functionalist theory of emotions, different dimensions of attachment were associated with different emotion profiles, even when background variables were controlled. Attachment security was associated with less guilt, contempt, and shame, and with greater joy, sadness interest, fear and anger. Dismissingness, in contrast, was associated with greater interest and with less joy, shame, and fear. Finally, fearful avoidance was associated with greater joy, disgust, shame and anxiety. Taken together, our data suggest that the later life relations between emotion and attachment are similar to those documented in younger samples, although there appear to be some important developmental differences. The data are interpreted in the context of developmental-functionalist theories of emotions and implications for how emotions function within attachment systems and moderate social relations across the lifespan are discussed.     

Insomnia and health problems in Canadians

STUDY OBJECTIVES: The objective of this study was to determine the prevalence of, and to identify the relative contribution of selected factors associated with insomnia in the Canadian population age 15 and older. DESIGN: Weighted analysis of cross-sectional data from the Canadian General Social Survey, Cycle 6, 1991. Prevalence estimates were calculated for the total and age-specific Canadian population age 15 and older. Multiple logistic regression techniques were employed to study the contribution of an array of sociodemographic, lifestyle, stress, and physical health factors to the experience of insomnia. SETTING: N/A PARTICIPANTS: A representative sample of the Canadian household population age 15+ (n=11,924). INTERVENTIONS: N/A MEASUREMENTS AND RESULTS: Twenty-four percent of the Canadian population age 15+ report insomnia. The following factors were associated with insomnia in multivariate logistic regression: female gender, being widowed or single, low education, low income, not being in the labor force, ever having smoked, life stress, specific chronic physical health problems (circulatory, digestive and respiratory disease, migraine, allergy and rheumatic disorders), pain, activity limitation and health dissatisfaction. Age was not significantly associated with insomnia. CONCLUSIONS: Insomnia was highly prevalent among the non-institutionalized Canadian population age 15 and older. A very stressful life, severe pain and dissatisfaction with one's health demonstrated the highest odds ratios associated with insomnia. Increasing age per se and lifestyle factors were not significantly associated with insomnia.     

Attachment and emotion experience in later life: The view from emotions theory

Despite the large volume of research on attachment over the past three decades based on work with children and young adults, there has been scant attention to later life. As such, Bowlby's claim that attachment theory has implications for the entire lifespan remains relatively untested. In this paper we present exploratory data documenting the relations between attachment and emotion in older adults. A sample of 1118 community-dwelling adults ranging in age from 65 to 86 years completed measures of attachment and Izard's (1972) Differential Emotions Scale. Consistent with a developmental-functionalist theory of emotions, different dimensions of attachment were associated with different emotion profiles, even when background variables were controlled. Attachment security was associated with less guilt, contempt, and shame, and with greater joy, sadness interest, fear and anger. Dismissingness, in contrast, was associated with greater interest and with less joy, shame, and fear. Finally, fearful avoidance was associated with greater joy, disgust, shame and anxiety. Taken together, our data suggest that the later life relations between emotion and attachment are similar to those documented in younger samples, although there appear to be some important developmental differences. The data are interpreted in the context of developmental-functionalist theories of emotions and implications for how emotions function within attachment systems and moderate social relations across the lifespan are discussed.     

A review on cognitive impairments in depressive and anxiety disorders with a focus on young adults

BACKGROUND: There is growing evidence for cognitive dysfunction in depressive and anxiety disorders. Nevertheless, the neuropsychological profile of young adult patients has not received much systematic investigation. The following paper reviews the existing literature on cognitive impairments in depressive and anxiety disorders particularly among young adults. Additionally, the focus of young adult age group and the effect of confounding variables on study results are discussed. METHODS: Electronic database searches were conducted to identify research articles focusing on cognitive impairments in depressive or anxiety disorders among young adults published in English during years 1990-2006. RESULTS: Cognitive impairments are common in young adults with major depression and anxiety disorders, although their nature remains partly unclear. Accordingly, executive dysfunction is evident in major depression, but other more specific deficits appear to depend essentially on disorder characteristics. The profile of cognitive dysfunction seems to depend on anxiety disorder subtype, but at least obsessive-compulsive disorder is associated with deficits in executive functioning and visual memory. The conflicting results may be explained by heterogeneity within study participants, such as illness status, comorbid mental disorders, and medication, and other methodological issues, including inadequate matching of study groups and varying testing procedures. LIMITATIONS: The study is a comprehensive review, but not a formal meta-analysis, due to methodological heterogeneity. CONCLUSIONS: Cognitive impairments are common in major depression and anxiety disorders. However, more research is needed to confirm and widen these findings, and to expand the knowledge into clinical practice. Controlling of confounding variables in future studies is highly recommended.     

Non-pharmacological strategies to delay cognitive decline

Non-pharmacological preventive strategies to delay cognitive decline have become the focus of recent research. This review aims to discuss evidence supporting the use of physical and cognitive activity to reduce the risk of cognitive decline and dementia in later life. Both strategies are associated with better cognitive health in older adults. This positive effect seems stronger for middle-aged and older adults with normal cognition and less clear when cognitive impairment is present. Physical and cognitive activities have been linked to indirect and direct biological factors affecting brain health. Future research will need to explore details about type, intensity, duration and combination of interventions. An important aim is standardization between studies, as well as evidence of improved clinical outcomes and cost-effectiveness. Identifying strategies that succeed at sustaining improved lifestyle is necessary, and the use of modern technology could play a crucial role in this regard. In the meantime advice on physical and cognitive activities should be included when health advice is given to middle-aged and older adults.     

Prevalence of somatoform disorders and medically unexplained symptoms in old age populations in comparison with younger age groups: A systematic review

ObjectiveTo review current knowledge regarding the prevalence of somatization problems in later life by level of caseness (somatoform disorders and medically unexplained symptoms, MUS) and to compare these rates with those in middle-aged and younger age groups.MethodA systematic search of the literature published from 1966 onwards was conducted in the Pubmed and EMBASE databases.ResultsOverall 8 articles, describing a total of 7 cohorts, provided data of at least one prevalence rate for somatoform disorders or MUS for the middle-aged (50–65 years) or older age (≥65 years) group. Prevalence rates for somatoform disorders in the general population range from 11 to 21% in younger, 10 to 20% in the middle-aged, and 1.5 to 13% in the older age groups. Prevalence rates for MUS show wider ranges, of respectively 1.6–70%, 2.4–87%, and 4.6–18%, in the younger, middle, and older age groups, which could be explained by the use of different instruments as well as lack of consensus in defining MUS.ConclusionSomatoform disorders and MUS are common in later life, although the available data suggest that prevalence rates decline after the age of 65 years. More systematic research with special focus on the older population is needed to understand this age-related decline in prevalence rates.     

Fear and Missing Out: Youth Anxiety and Functional Outcomes

Anxiety disorders are prevalent and associated with functional impairments. Outcome research has focused on symptom reduction, rather than positive factors such as life satisfaction and improved functioning. We review the impact of youth anxiety disorders and elevated anxiety symptoms on academic, occupational, family, social, and legal functioning. Emphasis is placed on the degree to which developmental trajectories differ for youth with and without anxiety disorders. In some areas, psychopathology generally, rather than anxiety specifically, is associated with functional impairment. Other studies support youth anxiety as a unique predictor of functional impairment. In particular, social anxiety is associated with impairments in social functioning throughout development. The short‐ and long‐term impacts of anxiety treatment in youth are discussed. Last, research directions are suggested.     

Mental health problems and psychopathology in infancy and early childhood. An epidemiological study

The thesis includes seven published papers and an overview concerning the epidemiological aspects of mental health problems and psychopathology in children aged 0-3 years. The research behind the thesis focuses at psychopathology in the first years of life. The aim has been to investigate phenomenology, prevalence, risk factors and predictors, in order to contribute to the knowledge about early developmental psychopathology, and improve the scientific foundation for identification and treatment of mental illness of infants and toddlers, and optimize the foundation for prevention of psychiatric illness in early life. The Copenhagen Child Cohort CCC 2000 was established with inclusion of 6090 children born in year 2000. The cohort was described at baseline with data from Danish National registers and prospective data on mental health and development collected by health nurses at home visits. At 1? years of age a subpopulation was thoroughly investigated regarding child psychiatric illness, in a random sample prevalence study and a case-control study nested in cohort, with cases being children of health nurse concern in the first ten months of living. Mental health disorders were identified in 18% of 1? year-old children from the general population. The prevalence and distribution of main diagnostic categories correspond to results from studies of older children. Disorders of neurodevelopment (mental retardation, disorders of psychological development and ADHD) were associated with pre- and perinatal biological risks and predictors were deviant language development and impaired communication, recorded by health nurses in the first ten months of life. The findings correspond to results from studies of older children and adolescents and point to an earlier emergence of neurodevelopmental psychopathology than has been described hitherto. Risk factors of emotional, behavioural and eating and sleeping disorders were psycho-social adversities in parents, and parent-child relationship disturbances seem to be the key mediator in the risk mechanisms. Risk factors of relationship disorders at child age 1.5 years can be identified before the birth of the child, and predictors can be identified by health nurses from birth to 10 months. In the general child health surveillance between birth and ten months, community health nurses are able to identify risk factors and predictors of child mental disorders at 1.5 years, and by a global and unspecific screen, health nurses identify one fourth of children diagnosed with a mental disorders at age 1? year. The incidence of mental health disorders including mental retardation diagnosed at hospital in the first three years of life was 2%. Sex differences known from studies of older children were demonstrated in children referred to hospitals, with neurodevelopment disorders more often diagnosed in boys, and eating disorders more frequent in girls. CONCLUSIONS: For the first time it is shown in a general population study, that children as young as 1.5 years may suffer from mental illness as older children do. Risk factors and predictors of mental illness can be identified in the first ten months of life, and the association of risks found in studies of older children seem to operate already from birth. The results point to the potentials of mental health screening and intervention in the existing child health surveillance. PERSPECTIVES: The current longitudinal study of CCC 2000 in preschool and school age will expand the present findings and further elucidate the significance of the first years of life regarding child mental health. Future research in this area should include the study of measures to screen and intervene towards mental health problems in infancy within the general child health surveillance.     

Morbidity of DSM-IV Axis I disorders in patients with noncardiac chest pain: Psychiatric morbidity linked with increased pain and health care utilization

The present study examined current and lifetime psychiatric morbidity, chest pain, and health care utilization in 229 patients with noncardiac chest pain (NCCP), angina-like pain in the absence of cardiac etiology. Diagnostic interview findings based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) revealed a psychiatrically heterogeneous sample of whom 44% had a current Axis I psychiatric disorder. A total of 41% were diagnosed with a current anxiety disorder, and 13% were diagnosed with a mood disorder. Overall, 75% of patients had an Axis I clinical or subclinical disorder. Lifetime diagnoses of anxiety (55%) and mood disorders (44%) were also prevalent, including major depressive disorder (41%), social phobia (25%), and panic disorder (22%). Patients with an Axis I disorder reported more frequent and more painful chest pain compared with those without an Axis I disorder. Presence of an Axis I disorder was associated with increased life interference and health care utilization. Findings reveal that varied DSM-IV Axis I psychiatric disorders are prevalent among patients with NCCP, and this psychiatric morbidity is associated with a less favorable NCCP presentation. Implications for early identification of psychiatric disorders are discussed.     

Childhood attention deficit/hyperactivity disorder in adults with anxiety disorders.

BACKGROUND: Previous research has reported co-morbidity between attention deficit hyperactivity disorder (ADHD) and anxiety disorders. Interpretation of these findings is complicated by symptom overlap in the clinical presentation of the disorders. We estimate the prevalence of ADHD in both the current and childhood histories of adults with anxiety disorders, while taking symptom overlap into account. We also evaluate the utility of the Wender Utah Rating Scale (WURS) for retrospective reporting of ADHD. METHODS: Consecutive admissions (N = 149) to an anxiety disorders clinic were given a diagnostic and psychometric assessment. The WURS was administered to obtain a retrospective diagnosis of childhood ADHD. Twenty-nine of the 35 people surpassing the cut-off score on the WURS were given a structured interview of adult ADHD symptoms. RESULTS: The WURS contains many 'internalizing' items that may inflate retrospective accounts of ADHD. After taking this into account, there is still a significantly higher prevalence of ADHD in the retrospective reports of adults with anxiety disorders (15%) than would be expected by chance (4%). Furthermore, of those who meet retrospective criteria for ADHD, 45% (13 of 29) continue to meet diagnostic criteria for ADHD as adults. CONCLUSIONS: The WURS may require considerable revision for use with clinical populations. In spite of these difficulties with retrospective assessment, available evidence indicates that ADHD is more prevalent in the histories of anxiety disordered patients than would be expected from base rates.     

SAME‐SEX PARTNERSHIPS AND THE HEALTH OF OLDER ADULTS

While extensive research has examined associations between marriage, cohabitation, and the health of heterosexual adults, it remains unclear whether similar patterns of health are associated with same‐sex partnerships for lesbian, gay, and bisexual (LGB) older adults. This article examines whether having a same‐sex partner is associated with general self‐reported health and depressive symptoms for LGB older adults. Based on survey data collected from LGB adults 50 years of age and older, having a same‐sex partner was associated with better self‐reported health and fewer depressive symptoms when compared with single LGB older adults, controlling for gender, age, education, income, sexuality, and relationship duration. Relationship duration did not significantly impact the association between partnership status and health. In light of recent public debates and changes in policies regarding same‐sex partnerships, more socially integrated relationship statuses appear to play a role in better health for LGB older adults.