A few weeks ago I sat through a series of very nice presentations on geriatric mental health by a series of distinguished Geropsychologists and scholars at the VA Palo Alto Healthcare system and elsewhere. Wanted to highlight this, of course, because last week I groused about the dearth of quality CEs in and for Geropsychologists out there. Occasionally good CE experiences do happen to me!
Anyways, one particular presentation that stood out in my mind was one by psychologist Julie Wetherell, professor “in residence” at the Department of Psychiatry at UCSD. Dr. Wetherell has carved out a niche for herself doing research on chronic pain and germane to the current discussion, geriatric anxiety disorders and cognitive behavioral therapy, or CBT.
CBT, of course, is one of several schools of thought in psychotherapy (e.g., as contrasted with psychodynamic, humanistic, and family systems schools of thought). CBT has many features that distinguishes it from other schools of thought. It tends to be focused on the here-and-now, tends to be specific and problem-focused, and tends to emphasize hypothesis-testing and active experimentation and use of ‘homework assignments’ as part of the work. Therapeutic dialogue often takes the form of ‘Socratic questioning’ in CBT, often with the aim of helping patients to find more accurate ways of viewing and interacting with the world.
In the case of CBT, it’s been found to be an approach that works exceptionally well with older adults in the case of major depression, as has been found time and time again. It also works exceptionally well with middle aged and younger adults with depression and anxiety disorders.
Curiously, and this is where Dr. Wetherell’s presentation got interesting for me – CBT does not seem to work particularly well for older adults with anxiety disorders, particularly as regards the entity of generalized anxiety disorder.
Briefly on different anxiety disorders. Generally clinicians tend to split anxiety disorders into a few different categories. It’s worth mentioning that the introduction of the new edition of the Diagnostic and Statistical Manual of Mental Disorders has changed things up somewhat (e.g., the DSM-V), for example, post-traumatic stress disorder, or PTSD is not longer considered an anxiety disorder anymore and now is in a category of it’s own. However, generally anxiety disorders are still broadly categorizable into three groups, at least as I see them. First, there’s panic attacks, or Panic Disorder. This particular disorder is not-uncommonly seen in emergency rooms, and is frequently misdiagnosed as heart attacks or other medical disorders. The sufferer complains of all sorts of bodily symptoms such as sweating, shaking, pressure in the chest, racing thoughts, dizziness, etc., and is fearful that the symptoms are harbingers of serious health consequences or death. Panic disorder is frequently treated with anxiolytics and/or antidepressants, and psychotherapy.
Another category of anxiety disorder is phobias – the most classic one of which is fear of snakes (e.g., Indiana Jones). These phobias can take many forms, fear of heights, fear of open spaces (agoraphobia), fear of public speaking, et cetera. In this case, the treatment of choice is a specific form of psychotherapy called exposure and response prevention, or ERP.
Finally, there is Generalized Anxiety Disorder, or GAD. This is the classic “free floating anxiety,” where the patient reports being worried and anxious about, well, just about everything, and it seems disproportionate to anything being worried about. The treatment of choice for GAD, at least for younger adults, is CBT, as we mentioned, and as a second-line treatment, antidepressant treatment (typically with SSRIs).
The mystery is that according to published research out there, unlike with treatments for depression, CBT does not seem to work for older adults with GAD (which seems to be the most common anxiety disorder in older adults). So, if you’re working with an older adult with an anxiety disorder, and particularly if GAD is noted, the responsible advice to give them is to make use of an antidepressant like paroxetine or citalopram, and supplement with relaxation techniques (which, although isn’t psychotherapy per se, can be effective as a supportive therapy).
The older adult you’re working with may understandably protest – many are not keen on taking yet another pill. So what do you do? While I would certainly be sympathetic (given how so many older adults are probably tired of taking pills), given the state of current understanding as regards treatment for GAD and anxiety disorders in older adults, I would make sure the older adult in question is informed that there are significant risks to refusing what is in this case the first-line treatment for older adult GAD. I would then offer this older adult CBT and relaxation techniques, and do my very darndest.
The real question is, why does it seem like older adult GAD and anxiety disorders seem to be qualitatively different entities than in their younger adult and middle-aged counterparts? No one’s quite sure yet. I’ll let you know if anyone finds out.