FAST FACT AND CONCEPT #186: Anxiety in Palliative Care - Causes and Diagnosis

Authors: Joseph Stoklosa, Kevin Patterson MD, Drew Rosielle MD, and Robert Arnold MD

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; a future Fast Fact will address treatment.

Prevalence - Anxiety is a common symptom 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 effect: 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

1. 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.

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

3. 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.

4. 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 Journal of Psychiatry. 2004;58:65-70.
3. Friedmann E, et al. Relationship of depression, anxiety, and social isolation to chronic heart failure outpatient mortality. American Heart Journal. 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. Journal of Palliative Care. 1991;7:6-9.
7. Portenoy RK, Thaler HT, Kornblith AB, Lepore JM, Friedlander-Klar H, Kiyasu E, Sobel K, Coyle N, Kemeny N, Norton L, 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.

Fast Facts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For comments/questions write to: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu.

Copyright/Referencing Information : Users are free to download and distribute Fast Facts for educational purposes only. Stoklosa J, Patterson K, Rosielle D, Arnold R. Fast Fact and Concept #186. Anxiety in Palliative Care – Causes and Diagnosis. August 2007. End-of-Life/Palliative Education Resource Center ( www.eperc.mcw.edu).

Disclaimer: Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Purpose: Self-Study Guide, Teaching

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Non pain symptoms & syndromes; psychiatric disorders

Specific Disease and Organ System Category(s): Psychiatric Disorders