#186

Anxiety in Palliative Care – Causes and Diagnosis

  • Joseph Stoklosa
  • Kevin Patterson MD
  • Drew A Rosielle MD
  • Robert Arnold MD

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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 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.  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 (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 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  

  • Complete a thorough history and physical exam, 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 #1,60) 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

  1. Block SD. Psychological issues in end-of-life care. J Palliat Med. 2006; 9:751-772.
  2. Mikkelsen RL, et al. Anxiety and depression in patients with chronic obstructive pulmonary disease (COPD). A review. Nordic J Psychiatry. 2004; 58:65-70.
  3. Friedmann E, et al. Relationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortality. Am Heart J. 2006; 11:152.
  4. Tremblay A and Breitbart W.  Psychiatric dimensions of palliative care. Neurol Clin. 2001; 19(4):949-67.
  5. 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.
  6. 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.
  7. 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.

Version History:  Originally published August 2007.  Version copy-edited in May 2009; then again July 2015.