Anxiety Disorders
Updated January 29, 2024
What this section covers:
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Generalized anxiety disorder
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Panic disorder
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Specific phobia and agoraphobia
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Social anxiety disorder (social phobia)
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Substance or medication-induced anxiety disorder
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Anxiety disorder due to another medical condition
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Key points
Although each of the anxiety disorders and syndromes listed above has distinguishing characteristics, what they have in common is that most people with anxiety have a good response to psychotherapy or medication, or a combination of the two. Cognitive-behavioral therapy has had great success in helping people change their thinking and reaction to stressors. Useful medications include drugs labeled as antidepressants, short courses of anti-anxiety drugs, and beta blockers. In addition to these prescribed treatments, validated self-help strategies can work to reduce anxious feelings. These include stress reduction techniques, meditation, mindfulness training, aerobic exercise, avoidance of stimulants such as caffeine, and participation in support groups.
Generalized anxiety disorder (GAD)
This disorder is characterized by persistent, excessive worry associated with restlessness, easy fatigue, difficulty concentrating,
irritability, muscle tension, and/or sleep disturbance. Physical symptoms of headache, stomachache, muscle soreness, and change in appetite may be seen. When symptoms last more than six months, a diagnosis of GAD can be made.
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The diagnosis and treatment of GAD first requires information about what your loved one is
anxious about. It may be that you find that he or she is worried about not having a place to live or enough food to eat. Sometimes, when these issues are settled, the anxiety resolves. This is situational anxiety. But if the anxious feelings just shift to other issues, you’ll need to have a longer conversation about what might be driving it.
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Your own primary care clinician can make a referral to a psychotherapist who can work with you or your loved one to create an overall treatment plan and provide information about non-drug options such as individual or group therapy. An exercise program may be recommended, as exercise is well known to reduce generalized anxiety. In addition, software programs available on the Internet, such as Calm, Headspace, and FearTools - Anxiety Aid may be very helpful for elders who are a little more tech-savvy, but these programs are not free.
Drugs marketed as antidepressants that work on the serotonin system can be helpful for generalized anxiety, even when depression is not present. The serotonin-selective reuptake inhibitors (SSRIs) are often the first choice for this indication. These include drugs such as citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft), to name a few. Other medications (e.g., buspirone and trazodone) could also be prescribed, and these are preferred by some patients.
Drugs that would generally be avoided for GAD are the benzodiazepines (Valium-like drugs). These drugs do quell anxiety, but their addictive potential is so great and side effects so troublesome that their use is confined to very specific indications. In general, drug treatment is continued for about one year before taper and discontinuation is attempted. Some patients do require lifelong medication for GAD.
Panic Disorder
This condition involves recurrent, unexpected panic attacks. These attacks are so frightening that between attacks, there is persistent worry about having another attack, and the individual may change his or her behavior to avoid this. For example, a person might stop exercising because a previous attack occurred while playing pickle ball. Elders who have had a panic attack often end up in the ER to rule out a heart attack. If heart attack is ruled out, do not make the mistake of ending the evaluation there! It isn’t all in their head!
What is a panic attack?
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An abrupt surge of intense fear or discomfort that reaches a peak in minutes, during which four or more of the following symptoms occur:
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Palpitations, pounding heart, or acceleration in heart rate.
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Sweating
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Trembling or shaking
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Sensations of shortness of breath or smothering
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Feelings of choking
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Chest pain or discomfort
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Nausea or abdominal distress
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Feeling dizzy, unsteady, light-headed, or faint
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Chills or heat sensations
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Paresthesias (numbness or tingling sensations)
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Feelings of unreality or being detached from oneself
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Fear of losing control or “going crazy”
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Fear of dying
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Although panic attacks can be predicted in certain stress-inducing situations, at least some attacks that come “out of the blue” are required for the diagnosis of panic disorder. Attacks can occur upon waking from sleep.
An attack with fewer than 4 symptoms is called a limited symptom attack, and these may be more common in elders. Panic disorder usually begins in adolescence or young adulthood, and in some cases persists into old age, although likely in a less severe form. Lower prevalence and reduced severity in old age may represent a dampening of the sympathetic ("fight or flight") system.
Panic disorder often occurs along with other anxiety disorders (e.g., GAD, agoraphobia), depression, and possibly mild alcohol use disorder. Certain medications (e.g., stimulants) have the potential to cause or worsen panic attacks. In addition, there is a possible association of panic disorder with medical conditions such as mitral valve prolapse and thyroid disease, so the first step in treatment is to exclude medical possibilities.
The gold standard of treatment for panic disorder is cognitive-behavioral therapy (CBT), often used in combination with medication. CBT is a well-accepted and effective mode of treatment for elderly patients. Several CBT programs are available, and can be found on the Internet. One highly regarded program is Mastery of Your Anxiety and Panic: Workbook (5th ed) by Michelle G. Craske and David H. Barlow, Oxford University Press, Inc. 2022. This program can be used with or without the guidance of a therapist.
For elders, the medication most used for panic disorder is an SSRI antidepressant. The potential to induce panic when an SSRI is started imposes limits on the starting dose and rate of titration. The SSRI is initiated at 25 to 50% of the usual starting dose, and the dose is increased slowly. These tiny doses may require the use of liquid preparations. Clinicians should be familiar with the protocol for further dose titration and switching drugs, if indicated. In some cases, a low dose of a benzodiazepine may be needed temporarily. Alprazolam (Xanax) taken as needed or lorazepam (Ativan) given on a schedule for a brief period are drugs of choice. Alprazolam taken as needed can be a good choice because many patients find that keeping it in a pocket or purse works as “insurance,” so they never need to take a dose.
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When panic symptoms have been in remission for 6-12 months, an attempt can be made to slowly taper and discontinue medication. Patients who have progressed with CBT often do very well with this taper. Others may see symptoms return, so medication is reinstated, and a taper attempted later. Some patients do require lifelong drug treatment for panic disorder.
Specific phobia and agoraphobia
Phobias are extreme fears or aversions to specific objects or situations. Common examples include fear of heights, flying, and enclosed spaces. The feared situations provoke a response every time they are encountered, resulting in significant distress or impairment in social, occupational, and other areas of functioning. A common strategy that people use for dealing with a phobia is complete avoidance of the feared object, often resulting in a restriction of activities.
Examples of Phobias
Flying (aerophobia)
Heights (acrophobia)
Storms (e.g., astraphobia-thunderstorms)
Water (aquaphobia)
Animals (zoophobia)
Blood-injection-injury
Falling (basophobia or basiphobia)
Choking (phagophobia)
Enclosed places (claustrophobia)
Open spaces (agoraphobia)
More than 500 phobias have been identified, some common and some rare and quite specific. The box shows some examples. Common fears among elders include fear of falling, fear of choking, and blood-injection-injury phobia (blood, needles). In most individuals with phobia, more than one phobia is present. ​
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As a rule, phobias begin in childhood, but it is possible for a phobia to arise at any age, particularly if there has been a traumatic event, such as a mugging or a choking episode. Phobias may accompany medical problems such as heart disease, lung disease, and Parkinson’s disease. There is some genetic component to phobias like animal phobias, but the link is not strong.
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When the object of the phobia is encountered, a part of the brain called the amygdala makes a threat assessment and judges the object to be more threatening than it really is. This causes the nervous system to kick into overdrive – the fight or flight response – with sometimes massive release of the activating brain chemical norepinephrine. In blood-injection-injury phobia, blood pressure can rise initially, but this is followed by a substantial blood pressure drop, such that fainting can result.
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Many patients with phobias also exhibit symptoms of depression and anxiety. When phobias go untreated, it is the avoidance behaviors that prove most problematic. The fear of falling, for example, may result in reduced mobility and deconditioning. The fear of choking may result in weight loss and undernutrition. Blood-injection-injury phobias are well known to discourage those affected from receiving needed medical care.
Agoraphobia is a special case of phobia involving multiple situations: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, and being outside the home alone. The feared situations are avoided because escape might be difficult, or help might not be available if panic symptoms were to develop. In severe cases, the individual becomes totally homebound. Demoralization, depression, and abuse of alcohol and sedative medications often ensue.
It may be true that most phobias never come to clinical attention because they are managed by simple avoidance. When that strategy falls apart because of consequences discussed above, several types of treatment can be used. The two most common are cognitive-behavioral therapy (CBT) and systematic desensitization. The latter involves a series of stepped exercises that the patient performs under the supervision of a therapist (virtual or in-person) to demonstrate that the feared stimulus is not really all that dangerous, and can be managed without significant anxiety. CBT addresses the patient’s ideas underlying the fears. In general, pharmacologic treatments are little used for phobias, except for complex cases involving co-occurring problems such as depression.
Social anxiety disorder (social phobia)
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This disorder involves intense fear or anxiety about social situations in which the individual may be subject to scrutiny. The social situation could be formal (e.g., giving a speech) or informal (meeting new people at a party or having a conversation), or could just involve being observed while eating or drinking in public. As with other phobias, the ideas underlying the fear have to do with potential humiliation, embarrassment, or rejection. Among elders, the anxiety may center on hearing loss or visual impairment, concern about appearance (e.g., tremor in one with Parkinson’s disease), incontinence, or cognitive impairment.
The consequences of social anxiety disorder may be disabling, particularly if the individual decides to opt out of social life. Moreover, restriction of social interaction represents a risk factor for the development of cognitive impairment.
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Cognitive-behavioral therapy can be used as the sole treatment for social anxiety disorder. If medications are used, drugs of choice include SSRI antidepressants (e.g., escitalopram, citalopram, sertraline) and venlafaxine (Effexor).
Substance or medication-induced anxiety disorder
Anxiety that results from alcohol or drug use or from prescribed medications most often takes the form of panic attacks and/or non-specific anxiety. The anxiety develops during or soon after intoxication, withdrawal, or even exposure to a drug. A list of drugs implicated is shown in the box. Once the drug is discontinued, the anxiety usually resolves within days to several weeks, depending on how long the drug remains in the body.
Drugs that cause anxiety
Alcohol
Caffeine (also in some pain pills)
Cannabis
Prednisone and other steroids
Asthma medications
Thyroid medications
Opioids (narcotics)
Sedative-hypnotics (sleeping pills)
Anxiolytics (Valium-like drugs)
Amphetamines and Ritalin
Phenytoin (Dilantin)
Anxiety due to another medical condition
Anxiety due to another medical condition also primarily takes the form of panic attacks, but may simply be a mix of less florid anxiety symptoms.
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There is a short list of medical conditions known to cause anxiety, as listed in the box below. It is important to note that the medical condition is present before the anxiety. Treatment of the medical condition helps to reduce or eliminate the anxiety.
Medical conditions that cause anxiety
Hyperthyroidism
Pheochromocytoma
Hypoglycemia (low blood sugar)
Hyperadrenocortisolism
Congestive heart failure
Pulmonary embolism
Atrial fibrillation
COPD
Parkinson’s disease
Asthma
Pneumonia
Vitamin B12 deficiency
Porphyria
Seizure disorder
Vestibular dysfunction
Encephalitis
Key Points
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Anxiety disorders can greatly reduce the quality of life for elderly people, mostly because of self-limitation of activities to avoid anxiety-provoking situations.
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These conditions are treatable with psychotherapy and medication, often used in combination.
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In general, benzodiazepines (Valium-like drugs) should be avoided in elders for anything but very short-term use. Valium itself should not be used in seniors.
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Self-help strategies that include exercise, stress reduction techniques, meditation, mindfulness training, and participation in support groups are of significant benefit.
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Certain medical conditions and medications can cause anxiety, and this fact should be considered in any treatment plan.