ANXIETY

Important points in the history include:

•  Drugs

•  Any new symptoms

•  Specific fears or phobias

•  Patient’s knowledge of disease

•  Previous experience of cancer or illness

•  Previous personality

•  Previous crises (“How did you cope?”)

•  Relationships (“Who do you rely on?”)

•  Pattern of anxiety (“When?”, “Where?” – not "Why?")

•  Sleep (dreams, nightmares, insomnia)

•  Behavior (attention-seeking, panic)

•  Views of family members

Drugs such as albuterol and aminophylline can cause shakiness. Anti-cholinergics can cause palpitations. Metoclopramide and haloperidol can make some people feel restless. High dose steroids occasionally cause excitation. It may be necessary to exclude thyrotoxicosis, which can mimic anxiety, by measuring serum thyroxine levels. 

Long term users of benzodiazepines may take high doses (diazepam 40mg to 60mg per day, for example) with no drowsiness, but they may suffer severe anxiety if the dose is reduced.

If can be helpful to try to classify the anxiety:

1. Chronic

2. Specific fears

3. Adjustment reaction (non-specific anxiety)

4. Separation

5. Excessive denial

1. Chronic anxiety – in severe anxiety states important questions are: What was the patient’s previous personality? Is there a history of chronic anxiety? Does the patient have a particular phobia about illness?

2. Specific fears – Anxieties due to specific worries can almost always be relieved. They may relate to the family (“How will they cope without me?”), to financial concerns or to spiritual matters. It is useful to ask a general question (“Are you a worrier?” or “Are you a sensitive person?”) to broach the subject. Asking “What is the thing you are most worried about?” often enables a patient to analyze and reality-test fears, and so reduces anxiety.

3. Adjustment reactions are transient episodes of anxiety or depression that are normal features of adapting to life changes, and to a different role and future. Patients (like bereaved family members) should be supported emotionally and practically as they grieve for what is lost. Most patients cope with losses and fears one step at a time. Anxiety is minimized by maintaining the patient’s morale and self respect in a secure and loving atmosphere where communication is encouraged. (see Adjustment Reaction)

4. Separation anxiety – Many patients feel worse in unfamiliar surroundings, and when separated from their family and friends. Separation anxiety is the first emotion we experience in life, and it is easily re-awakened. Frightened people need physical contact to reassure them. Feelings of insecurity and anxiety may only resolve with contact from a family member, lover or trusted friend.

5. Excessive denial – Denial, used intermittently, is a normal way of coping with overwhelming difficulties as a person learns to adjust. Used excessively, however, denial usually increases anxiety. The terminally ill patient who denies excessively has usually coped with previous crises by denial (presenting very late with the symptoms of cancer, for example), and is in effect saying “I am frightened, and I feel I cannot cope.” That patient never benefits from the self-confidence which comes from facing problems and working through grief. (see Denial)

Complete denial often results in increasing anxiety, which is also denied, and thus may manifest itself as symptoms (nausea, tremor), nightmares, insomnia, or very demanding behavior. Attention-seeking is usually due to anxieties that resolve if the patient is given sympathetic attention and time. Asking about nightmares in detail (without attempting interpretation) is a very useful way of allowing a patient to express fear, and can help the patient to discuss how he normally copes with fears.

Denial of severe anxiety can occasionally mimic confusion as the patient withdraws from an intolerable reality.

Patients who have previously coped with anxieties by being busy and competent can find terminal illness intolerable and may (very rarely) develop hysterical conversion symptoms like becoming mute or feigning coma.

The anxiety of denial is reduced by improving the patient’s acceptance of his illness and situation. Any deterioration in physical condition tends to increase anxiety, and is the time to give the patient plenty of opportunity to ask questions and express fears. Avoid forcing information on patients about matters they clearly do not wish to discuss. They usually deny the conversation and just feel more anxious.

Management options:

•  Counseling

•  Relaxation therapy

•  Visualization

•  Cognitive methods

•  Drug therapy

Allowing the patient time to ask questions and express fears, and supporting the patient with skilled and sympathetic personal attention remains the management option of choice. Carers must learn the extent and limits of their abilities in counseling and, when necessary, seek consultation with specially trained psycho-social professionals.

Relaxation therapy is very useful for almost all patients. Features of anxiety such as dyspnea and palpitations can make the patients fear that the disease has advanced. This can escalate into hyperventilation and panic. Relaxation practiced regularly can abort panic attacks. (see Relaxation) 

Visualization (usually practiced 2 times a day) can help patients set boundaries to the amount of time spent worrying about their disease, and can reduce anxiety by giving them a feeling of control. (see Visualization)

Cognitive methods focus on the thoughts that are associated with feelings of anxiety. In pathological anxiety the patient tends to overestimate a feared event (in terms of both probability and severity), and to underestimate coping resources (in self and others). By changing habitual modes of thought or behavior an individual can reduce his own distress. Automatic thoughts can be interrupted by distraction or positive thinking, or by positive self-statements.

It can be helpful to ask the patient to keep a log of mood, thoughts and activity as they occur during the day and night. These patterns can then be reviewed by the patient and carers (in cooperation with a psychologist or other psycho-social professional), restoring a feeling of control and providing a basis for behavioral and social modification.

A beta blocker (such as propanolol 20mg to 40mg 4 times a day) can be useful if there are physical manifestations of anxiety such as sweating, palpitations or tremor.

If anxiolytics are required diazepam 10mg at bedtime is effective. Lorazepam 0.5mg to 2mg every 3 to 6 hours is less cumulative.

Haloperidol 1.5mg to 5mg 1 to 3 times a day can be helpful if benzodiazepines are ineffective or cause drowsiness, or if there is an element of paranoia or severe agitation. On doses above 3mg 2 times a day, tremor and rigidity can occur. This is drug induced Parkinsonism, and can be partially controlled by oral procyclidine 2.5mg to 5mg 3 times a day (slightly sedating) or orphenadrine 50mg to 100mg 3 times a day (slightly stimulating). Chlorpromazine 10mg to 25mg 3 times a day is a useful alternative if sedation is also required.

A tricyclic anti-depressant may be necessary for patients with agitated depression.

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.