Background for Fast Fact #186    Anxiety is a state of apprehension and fear resulting from the perception of a current or future threat to oneself.  The term is used 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 commonly reported in those facing life-threatening illnesses and yet clinicians frequently miss the diagnosis or symptom and report, mismanage the symptom, and report significant training gaps in the management of anxiety.  At least 25% and cancer patients and 50% of CHF and COPD patients experience significant anxiety.  At least 3% of patients with advanced cancer and 10% of COPD inpatients meet DSM criteria for generalized anxiety disorder (GAD) (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, prognostic awareness, disability, loss, legacy, family, finances, and religion/spirituality.  

Psychiatric disorders with anxiety as a prominent symptom 

• Generalized anxiety disorder (GAD) 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 (see Fast Fact #398) 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 which remind the patient of the trauma.
• Phobias are marked, persistent fears brought about by specific situations or objects.

Evaluation   Anxiety as a symptom and as a disorder can be treatable with the use of non-pharmacologic therapy (often employed by mental health professionals) and/or pharmacotherapy.  See Fast Fact #145, Fast Fact #211, Fast Fact #309, Fast Fact #465, Fast Fact #466 for more on the treatment of anxiety. Therefore, it is important that all clinicians who care for patients with serious illness garner skills in evaluating for anxiety.  

• Complete a thorough history and physical exam, 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 (e.g., primary care clinician, psychologist, psychiatrist, social worker) familiar with anxiety and how it 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 #1 and Fast Fact #60), and akathisia, an unpleasant sense of motor restlessness from dopamine-blocking medications such as antipsychotics and some antiemetics.
• Many medical conditions can cause symptoms mimicking anxiety — hyperthyroidism, autoimmune diseases, cardiac conditions, intoxication, hypercalcemia, adrenal insufficiency, etc. Perform a medical work-up that is appropriate to the goals of care and prognosis when anxiety presents as a new symptom.
• 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, the Hospice and Palliative Care Evaluation (HOPE) Symptom and Problem Checklist, and the Hospital Anxiety and Depression Scale.

References 

1. Block SD. Psychological issues in end-of-life care. J Palliat Med. 2006; 9:751-772.
2. Atkin N, Vickerstaff V, Candy B.  ‘Worried to death’: the assessment and management of anxiety in patients with advanced life-limiting disease, a national survey of palliative medicine physicians. BMC Palliative Care 2017; 16.
3. Mikkelsen RL, et al. Anxiety and depression in patients with chronic obstructive pulmonary disease (COPD). A review. Nordic J Psychiatry. 2004; 58:65-70.
4. Friedmann E, et al. Relationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortality. Am Heart J. 2006; 11:152.
5. Tremblay A and Breitbart W.  Psychiatric dimensions of palliative care. Neurol Clin. 2001; 19(4):949-67.
6. Emanuel LL, Solomon S, Chochinov HM, et al.  Death anxiety and correlates in cancer patients receiving palliative care. Journal of Palliative Medicine 2023; 26(2):235-243.
7. Bjelland I, et al. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002; 52(2):69-77.
8. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K. The Edmonton Symptom Assessment System (ESAS): a simple method of the assessment of palliative care patients. J Palliat Care. 1991; 7:6-9.
9. Portenoy RK, Thaler HT, Kornblith AB, et al. The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress. Eur J Cancer. 1994; 30A(9):1326-36.
10. Hofmann S, Hess S, Klein C, et al.  Patients in palliative care – development of a predictive model for anxiety using routine data. PLoS one 2017; 12(8):e0179415. 

Version History:  Originally published August 2007.  Version copy-edited in May 2009; then again July 2015; then again February 2025.
Conflicts of Interest: None to report.