Anxiety in Palliative Care: Causes and Diagnosis #186

Abstract

Background

Anxiety is a state of apprehension and fear resulting from the perception of a current or future threat to oneself. The term is used both to describe a symptom and a variety of psychiatric disorders in which anxiety is a salient symptom. This Fast Fact will discuss the causes and evaluation of anxiety.

Prevalence

Anxiety is a common symptom in those facing life-threatening illnesses. At least 25% of patients with cancer and 50% of patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) experience significant anxiety. At least 3% of patients with advanced cancer and 10% of COPD inpatients meet DSM criteria for Generalized Anxiety Disorder (see below).

Etiologies

• Anxiety may be present as part of one of several psychiatric disorders (see below).

• Anxiety is often a prominent component of acute or chronic pain, dyspnea, nausea, or cardiac arrhythmias.

• Adverse drug effects: corticosteroids, psychostimulants, and some antidepressants.

• Drug withdrawal: alcohol, opioids, benzodiazepines, nicotine, clonidine, antidepressants, and corticosteroids.

• Metabolic causes: hyperthyroidism and syndromes of adrenergic or serotonergic excess.

• Existential and psychosocial concerns about dying, disability, loss, legacy, family, finances, and religion/spirituality.

Psychiatric Disorders with Anxiety as a Prominent Symptom

• Generalized anxiety disorder is a psychiatric disorder characterized by pervasive and excessive anxiety and worry about a number of events or activities (such as work or school performance), occurring more days than not for at least 6 months. The anxiety and worry are associated with at least 3 of the following 6 symptoms: restlessness, easy fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.

• Panic disorder is characterized by recurrent panic attacks. See Fast Fact #145 for its evaluation and management.

• Adjustment disorder occurs within 3 months of a major stressor, and causes marked distress and functional impairment. Usually it is characterized by a depressed mood but anxiety can also be its most prominent affective component.

• Acute or post-traumatic stress disorders (PTSDs) occur after an emotionally traumatic life event and are characterized by anxiousness and arousal, as well as by numbness, flashbacks, intrusive thoughts, and avoidance of stimuli that remind the patient of the trauma.

• Phobias are marked, persistent fears brought about by specific situations or objects.

Evaluation

• Complete a thorough history and physical examination, in particular ask about:

○ Prior episodes or anxiety, depression, PTSD, alcohol, and drug use.

○ Prior and current treatment by a mental health professional.

○ Presence of specific trigger situations or thoughts leading to anxiety.

○ Presence of apprehension, dread, insomnia, and hypervigilance; as well as physical symptoms such as diaphoresis, dyspnea, muscle tension, and tremulousness.

• Seek help from a professional familiar with the psychiatric disorders when anxiety is a prominent and functionally impairing part of a patient's symptoms.

• Symptoms that can be confused with anxiety are agitated delirium (see Fast Facts #160) and akathisia, an unpleasant sense of motor restlessness from dopamine-blocking medications such as antipsychotics and some antiemetics.

• Formal screening tools exist, but there is no consensus on the benefit of their routine use. Commonly used tools which evaluate for anxiety as a symptom include the Edmonton Symptom Assessment Scale, the Memorial Symptom Assessment Scale, and the Hospital Anxiety and Depression Scale.

References

Block

. Psychological issues in end-of-life care. J Palliat Med, 2006; 9:751–772.

Mikkelsen

, Middelboe

, Pisinger

, Stage

. Anxiety and depression in patients with chronic obstructive pulmonary disease (COPD). A review. Nordic J Psychiatry, 2004; 58:65–70.

Friedmann

et al Thomas

, Liu

, Morton

, Chapa

, Gottlieb

Sudden Cardiac Death in Heart Failure Trial Investigators: Relationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortality. Am Heart J, 2006; 152:940.

Tremblay

, Breitbart

. Psychiatric dimensions of palliative care. Neurol Clin., 2001; 19:949–967.

Bjelland

, Dahl

, Haug

, Neckelmann

. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res, 2002; 52:69–77.

Bruera

, Kuehn

, Miller

, Selmser

, Macmillan

. The Edmonton Symptom Assessment System (ESAS): A simple method of the assessment of palliative care patients. J Palliat Care, 1991; 7:6–9.

Portenoy

, Thaler

, Kornblith

, Thaler

, Kornblith

, Lepore

, Friedlander-Klar

, Kiyasu

, Sobel

, Coyle

, Kemeny

, Norton

et al. The Memorial Symptom Assessment Scale: An instrument for the evaluation of symptom prevalence, characteristics and distress. Eur J Cancer, 1994; 30A:1326–1336.