Clinical Geriatrics

Case Presentation

Ms. M is a 45-year-old divorced woman who makes an appointment for her 78-year-old mother with a psychiatrist. On the day of the appointment, Ms. M arrives alone, asking to meet with the psychiatrist. Ms. M appears distressed and worried. She explains that her mother, Mrs. S, has not left her apartment in the past four years. Ms. M has arranged for food to be delivered and has hired a housekeeper who performs cleaning and laundry tasks. She has tried numerous times to take her mother out, but Mrs. S refuses.

Ms. M describes her mother as an “anxious person” who always had difficulty going places far from their apartment. She reports that the severity of her current problem became apparent when Mrs. S refused to travel to another state to visit her first grandchild six years ago. Mrs. S has stopped seeing doctors and, while she talks to friends and family on the telephone, has almost no visitors. Ms. M reports that her mother appears calm but refuses to even discuss going outside. She calls her mother during the session and asks permission to discuss her problem with the psychiatrist. Mrs. S is polite and agrees to have her daughter provide her entire history. Mrs. S also adds that she plans on staying home and thanks both her daughter and the psychiatrist for their concern.

Ms. M is eager to provide history, even when counseled that she may need to focus more on her own life. Ms. M tells the psychiatrist that her mother is a widow who has three grown children. Following the death of her husband seven years ago, Mrs. S started staying inside her apartment for increasing periods of time. Ms. M reports that as a child she would often see her mother hyperventilate and appear very nervous when they attended family gatherings. She describes her father as a very demanding person who would simply insist that her mother go out, even carrying her down the stairs if she refused to leave.

Ms. M denies seeing any physical abuse but remembers that her mother often became acutely distressed, with periods of hyperventilating and complaining that she was unable to breathe. She and her sister often accompanied their mother to the family doctor, who told them that it was “nerves.” Ms. M reports that her mother never had any psychiatric evaluation or treatment, but she knows that she clearly has some type of anxiety or panic disorder. Ms. M asks the psychiatrist to prescribe some medication that will help her mother, and she becomes angry when told that her mother must be evaluated in person and undergo at least some basic medical tests. Ms. M leaves the office, telling the psychiatrist that the session was just a waste of time.

Discussion

Agoraphobia is a clinical term that refers to a persistent and pathologic fear of public places.1 Patients with agoraphobia frequently also have panic disorder and develop agoraphobia in response to the panic attacks that occur suddenly and spontaneously, causing significant anticipatory anxiety.