How Are Anxiety and Fear Best Treated in Patients With Serious Illness and in Those Facing the End of Life?

Defining Anxiety and Fear

Anxiety and fear are at the same time very similar but different states. Fear is an “unpleasant emotional response caused by the anticipation of danger” and encourages persons to avoid a threat. In contrast, anxiety is “prompted by generalized, nonspecific threats to the ‘self,’ motivating hypervigilance and the retention of proximity to the perceived threat.” Steimer describes the difference as follows: “anxiety is a generalized response to an unknown threat or internal conflict, whereas fear is focused on known external danger.”

The evolutionary function of both anxiety and fear was to warn of danger or the need to cope with a stressor. In palliative care settings, the spectrum ranges from fear regarding the dying process in relation to progressive and/or life-threatening illness (e.g., fear from pain, fatigue, etc.) to death anxiety with respect to the unforeseeable. Death anxiety has also been conceptualized as one of four ultimate concerns in existential philosophy/psychotherapy which cannot simply be talked about or explained away; they must be rediscovered, felt, and lived through.”

Pathological anxiety is an excessive response to external stress and/or a response to an unidentified internal stress which is often persistent rather than transient and leads to impaired coping behaviors, such as avoidance or withdrawal. The symptoms of pathological anxiety are physical (autonomic arousal with resultant tachycardia, tachypnea, diaphoresis, diarrhea, dizziness), emotional (edginess, terror, feelings of impending doom), behavioral (avoidance, compulsions, psychomotor agitation), and cognitive (worry, apprehension, fear, dread, uncertainty, obsession). In some instances, these symptoms lead to various forms of anxiety-related diagnosable disorders.

Prevalence of Anxiety Disorders

Anxiety disorders are the most common psychiatric disorders in the general population, with up to 33% of the U.S. population suffering from an anxiety disorder at some point in their lifetime. Often, no previous history of diagnosed anxiety disorder exists, and it appears that only a small percentage of people have any symptoms of anxiety prior to cancer diagnosis or treatment.

The prevalence of anxiety near the end of life is high: 70% of advanced cancer patients report moderate to severe anxiety, and up to 25% of patients meet criteria for formal anxiety disorders. Diagnoses are varied, with common disorders and risk factors listed in Table 26.1 .

Types of Anxiety Disorders

Several types of anxiety disorders exist. The most common anxiety disorders in a hospice or palliative care setting include adjustment disorder with anxious features, panic disorder, posttraumatic stress disorder, and generalized anxiety disorder.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a generalized anxiety disorder is a state of excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). People suffering with generalized anxiety are often described as worriers by their friends and families.

A panic attack is the sudden onset of intense terror, apprehension, fearfulness, or a feeling of impending doom, usually occurring with symptoms such as shortness of breath, palpitations, chest discomfort, a sense of choking, and fear of “going crazy” or losing control, often unexpected, “out of the blue,” without an apparent trigger or cue. Panic attacks are discrete in nature and time-course, usually lasting 15 to 20 minutes. A panic disorder is diagnosed when multiple panic attacks occur or fear of another attack significantly reduces psychosocial functioning.

An adjustment disorder is a psychological response to an identifiable stressor that results in the development of clinically significant emotional or behavioral symptoms but does not qualify for a diagnosis of an anxiety disorder. Many people with serious medical illness may have trouble psychologically adjusting to their diagnosis, prognosis, or treatment regimens, producing symptoms of anxiety that do not rise to the level of a diagnosable anxiety disorder, yet need attention and possibly intervention.

Some patients may develop hyperarousal associated with their diagnosis or treatments and have symptoms, or even meet the criteria, for a diagnosis of posttraumatic stress disorder (PTSD) ; that is, they reexperience a traumatic event with symptoms of increased arousal, nightmares, intrusive memories, reexperience of events, hypervigilance, and avoidance of reminders of the traumatic event.

Anxiety disorders bring about significant consequences for patients receiving palliative care, both in their experience of symptoms and in their medical care. Anxious patients also report less trust in physicians, impaired interactions in care discussions, more doubt about treatments, and poorer physical performance status. Often it is difficult to differentiate anxiety from other psychiatric disorders, such as depression or medical symptoms from their disease or its treatments. Common symptoms in depression, such as loss of appetite, decreased libido, irritability, isolation, and insomnia, may also be part of anxiety states. Other physical symptoms associated with illnesses are common in anxiety, including palpitations, dyspnea, hyperventilation, gastrointestinal distress, sweating, headaches, muscle tension, lightheadedness or dizziness, and fatigue.

Diagnosing Anxiety

Anxiety is often undiagnosed or underdiagnosed. Recogni­zing anxiety can be particularly difficult, as patients often have a complex mix of physical, psychological, and psychiatric issues. In patients with advanced, life-threatening ­illness and symptoms of anxiety, distress may be related to uncertainty regarding physical, psychological, social, spiritual, practical, end-of-life, and loss issues. Further, fears of uncontrolled symptoms or dependency are sometimes accompanied by a heightened interest in hastened death (see Chapter 27 ). For these patients, anxiety frequently presents with somatic symptoms that overshadow psychological and cognitive etiologies and manifestations. While many palliative care and hospice teams are adept at helping to navigate the differences in each of these anxiety-related diagnoses, a psychiatrist can be instrumental in helping the interdisciplinary team understand patients’ symptoms and their etiologies, and can also help diagnose and treat any underlying anxiety disorders.

Assessing for Anxiety

Interdisciplinary team members can help facilitate these important assessments, and a detailed history and appropriate physical exam/laboratory investigation is the gold standard of an anxiety assessment. Soliciting input from the patient, their family, and their friends can be invaluable. Such inquiry takes time, so learning to ask salient questions that lead to an accurate assessment of the patient’s circumstances and clinical picture is key. Some clinicians may utilize screening tools, such as the Hospital Anxiety and Depression Scale (HADS), which is the most widely studied instrument; the Edmonton Symptom Assessment Scale (ESAS); the Profile of Mood States; or the Generalized Anxiety Disorder Screener (GAD–7). In most cases physicians rely on targeted interview questions and skilled interdisciplinary team members, for example social workers, to glean important patient information.

Table 26.2 offers questions that are designed to guide conversations and can aid clinicians in assessing anxiety as well as other related clinical areas. Each question corresponds to an element of care; when these questions are asked in a comforting environment, they may lead to vital information about other domains as well.

For patients screening positive for anxiety, normal fears and worries must be distinguished from pathological anxiety. A more in-depth clinical interview should follow, with review of DSM-5 diagnostic criteria of anxiety and other psychiatric disorders (DSM-5 ), and referral to a mental health expert if diagnostic clarity is needed. Importantly, a primary anxiety disorder should not be diagnosed until somatic causes of anxiety are excluded (see Table 26.1 ).