Anxiety disorders are among the most prevalent and understudied mental health problems in late life. Specific phobia, social anxiety disorder, and generalized anxiety disorder are the most prevalent anxiety disorders in older adults among the 11 disorders identified by the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). Anxiety disorders lead to significant functional burdens and interface with physical health problems and cognitive impairment, concerns frequently experienced in adults over age 65. Additional contextual factors should be considered when assessing and treating late-life anxiety, including the effects of polypharmacy, other mental health conditions, role changes, and societal attitudes toward aging. The relationship between anxiety and physical health problems in older adults can be causal or contextual, and can involve poorer estimates of subjective health and lower ratings of functioning. These factors present unique challenges to the detection, conceptualization, and treatment of late-life anxiety, including the tendency for older adults to focus on somatic symptoms and the potential for long-term behaviors that can mask distress such as substance use. Researchers are increasingly incorporating a gerodiversity framework to understand the contributions of cultural, individual, and other group differences that may affect the presentation of anxiety symptoms and disorders. Older adults in general are less likely to be treated for anxiety disorders, and intersecting individual and group differences likely further affect how anxiety disorders are perceived by healthcare providers. Cognitive behavioral therapy and its variants have the most empirical support for treatment. Newer evidence lends support to acceptance and commitment therapy and problem-solving therapy, which tend to address some of the contextual factors that may be important in treatment.
Jonathan S. Gooblar and Sherry A. Beaudreau
Despite high rates of mental illnesses, older adults face multiple barriers in accessing mental health care. Primary care clinics, and home- and community-based senior-serving agencies are settings where older adults routinely receive medical care and social services. Therefore, integration of mental health care with existing service delivery systems can improve access to mental health services and reduce the unmet mental health needs of seniors. Evidence suggests that with innovative components mental health provided in collaboration with primary care providers with or without co-location within primary care clinics can improve depression and anxiety. Home-based models for depression care are also effective, but more research is needed in examining home-based approaches in late-life anxiety treatment. It is noteworthy that integrative models are particularly helpful in expanding the reach in underserved communities: elders from minority and low-income backgrounds and homebound seniors.
DeMond M. Grant and Evan J. White
Cognitive control is the ability to direct attention and cognitive resources toward achieving one’s goals. However, research indicates that anxiety biases multiple cognitive processes, including cognitive control. This occurs in part because anxiety leads to excessive processing of threatening stimuli at the expense of ongoing activities. This enhanced processing of threat interferes with several cognitive processes, which includes how individuals view and respond to their environment. Specifically, research indicates that anxious individuals devote their attention toward threat when considering both early, automatic processes and later, sustained attention. In addition, anxiety has negative effects on working memory, which involves the ability to hold and manipulate information in one’s consciousness. Anxiety has been found to decrease the resources necessary for effective working memory performance, as well as increase the likelihood of negative information entering working memory. Finally, anxiety is characterized by focusing excessive attention on mistakes, and there is also a reduction in the cognitive control resources necessary to correct behavior. Enhancing our knowledge of how anxiety affects cognitive control has broad implications for understanding the development of anxiety disorders, as well as emerging treatments for these conditions.
Simona C. Kaplan, Michaela B. Swee, and Richard G. Heimberg
Social anxiety disorder (SAD) is characterized by fear of being negatively evaluated by others in social situations. Multiple psychological interventions have been developed to treat SAD. The most widely studied of these interventions stem from cognitive-behavioral, acceptance-based, interpersonal, and psychodynamic conceptualizations of SAD. In cognitive-behavioral therapy (CBT), patients learn to identify and question maladaptive thoughts and engage in exposures to feared situations to test the accuracy of biased beliefs. Mindfulness and acceptance-based approaches to treating SAD focus on mindful awareness and acceptance of distressing internal experiences (i.e., psychological and physiological symptoms) with the ultimate goal of behavior change and living a meaningful life based on identified values. Interpersonal psychotherapy links SAD to interpersonal problem areas and aims to reduce symptoms by targeting interpersonal difficulties. Psychodynamic psychotherapy for SAD focuses on identifying unresolved conflicts that lead to SAD symptoms, fostering insight and expressiveness, and forming a secure helping alliance. Generally, CBT is the most well-studied of the psychological treatments for SAD, and research demonstrates greater reductions in social anxiety than pill placebo and waitlist controls. Results from randomized controlled trials (RCTs) suggest that mindfulness—and acceptance-based therapies may be as efficacious as CBT, although the body of research remains small; four of five RCTs comparing these approaches to CBT found no differences. RCTs comparing CBT to IPT suggest that CBT is the more efficacious treatment. Two RCTs comparing CBT to psychodynamic psychotherapy suggest that psychodynamic psychotherapy may have efficacy similar to CBT, but that it takes longer to achieve similar outcomes. RCTs examining CBT and pharmacotherapy suggest that the medications phenelzine and clonazepam are as efficacious as CBT for treating SAD and are faster acting, but that patients receiving these medications may be more likely to relapse after treatment is discontinued than patients who received CBT. Research generally does not indicate added benefit of combining psychotherapy with pharmacotherapy above each monotherapy alone, although this body of research is quite variable. Effectiveness studies indicate that CBT is equally effective in community clinics and controlled research trials, but studies of this nature are lacking for other psychological approaches.
Christopher M. Bader and Scott B. Martin
As a field of study, sport psychology is relatively young, gaining its formalized start in the United States in the 1920s. Then and now, the practice of sport psychology is concerned with the recognition of psychological factors that influence performance and ensuring that individuals and teams can perform at an optimal level. In the past 30 years, sport psychologists have made their way into intercollegiate athletics departments providing mental health and performance enhancement services to intercollegiate student-athletes. The differentiation between mental health practice and performance enhancement practice is still a source of some confusion for individuals tasked with hiring sport psychology professionals. Additionally, many traditionally trained practitioners (in both mental health and performance enhancement) are unaware of the dynamics of an intercollegiate athletic department. The interplay of the practitioner and those departmental dynamics can greatly influence the efficacy of the practitioner.
Quincy J. J. Wong, Alison L. Calear, and Helen Christensen
Internet-based cognitive behavioral therapy (ICBT) is the provision of cognitive behavioral therapy (CBT) using the Internet as a platform for delivery. The advantage of ICBT is its ability to overcome barriers to treatment associated with traditional face-to-face CBT, such as poor access, remote locations, stigmas around help-seeking, the wish to handle the problem alone, the preference for anonymity, and costs (time and financial). A large number of randomized controlled trials (RCTs) have tested the acceptability, efficacy, and cost-effectiveness of ICBT for anxiety disorders, mood disorders, and associated suicidality. A meta-review was conducted by searching PsycINFO and PubMed for previous systematic reviews and meta-analyses of ICBT programs for anxiety, depression, and suicidality in children, adolescents, and adults. The results of the meta-review indicated that ICBT is effective in the treatment and prevention of mental health problems in adults and the treatment of these problems in youth. Issues of adherence and privacy have been raised. However, the major challenge for ICBT is implementation and uptake in the “real world.” The challenge is to find the best methods to embed, deliver, and implement ICBT routinely in complex health and education environments.
Nadeeka N. Dissanayaka
Progressive neurological disorders are incurable disorders with gradual deterioration and impacting patients for life. Two common progressive neurological disorders found in late life are Parkinson’s disease (PD) and motor neuron disease (MND). Psychological complications such as depression and anxiety are prevalent in people living with PD and MND, yet they are underdiagnosed and poorly treated. PD is classified a Movement Disorder and predominantly characterized by motor symptoms such as tremor, bradykinesia, gait problems and postural instability; however, neuropsychiatric complications such as anxiety and depression are common and contribute poorly to quality of life, even more so than motor disability. The average prevalence of depression in PD suggest 35% and anxiety in PD reports 31%. Depression and anxiety often coexist. Symptoms of depression and anxiety overlap with symptoms of PD, making it difficult to recognize. In PD, daily fluctuations in anxiety and mood disturbances are observed with clear synchronized relationships to wearing off of PD medication in some individuals. Such unique characteristics must be addressed when treating PD depression and anxiety. There is an increase in the evidence base for psychotherapeutic approaches such as cognitive behavior therapy to treat depression and anxiety in PD. Motor neuron disease (MND) is classified a neuromuscular disease and is characterized by progressive degeneration of upper and lower motor neurons is the primary characteristic of MND. The most common form of MND is Amyotrophic lateral sclerosis (ALS) and the terms ALS and MND are simultaneously used in the literature. Given the short life expectancy (average 4 years), rapid deterioration, paralysis, nonmotor dysfunctions, and resulting incapacity, psychological factors clearly play a major role in MND. Depression and suicide are common psychological concerns in persons with MND. While there is an ALS-specific instrument to assess depression, evaluation of anxiety is poorly studied; although emerging studies suggesting that anxiety is highly prevalent in MND. Unfortunately, there is no substantial evidence-base for the treatment of anxiety and depression in MND. Caregivers play a major role in the management of progressive neurological diseases. Therefore, evaluating caregiver burden and caregiver psychological health are essential to improve quality of care provided to the patient, as well as to improve quality of life for carers. In progressive neurological diseases, caregiving is often provided by family members and spouses, with professional care at advanced disease. Psychological interventions for PD carers addressing unique characteristics of PD and care needs is required. Heterogeneous clinical features, rapid functional decline, and short trajectory of MND suggest a multidisciplinary framework of carer services including psychological interventions to mitigate MND. A Supportive Care Needs Framework has been recently proposed encompassing practical, informational, social, psychological, physical, emotional, and spiritual needs of both MND patients and carers.