Anxiety

Definition

Appropriate assessment to identify cause and severity of symptoms

Assessment to identify cause and severity

Cause of anxiety in Palliative Care

Explanation to the patient and family

Correct reversible factors

Non-pharmacological intervention

Pharmacological intervention

Antidepressants for anxiety

Anti-psychotics for anxiety

At all stages consider referral to specialist care

Definition 

Anxiety is defined as a feeling of apprehension and fear characterized by physical symptoms such as palpitations, sweating, and feelings of stress. 

It is normal to be anxious in certain circumstances, especially in the Palliative Care setting. The spectrum of anxiety ranges from “normal” anxiety through to persistent and severe anxiety. Anxiety becomes a problem when its duration and severity exceed normal expectations and it interferes with normal functioning. Anxiety may be acute or chronic. 

Anxiety is common in the terminally ill for a variety of reasons such as the fear of uncontrolled symptoms, fear of dying or being left alone to die. 

Appropriate assessment to identify cause and severity of symptoms 

Symptoms of anxiety 

Core features 

• Persistently tense and unable to relax 
• Worry 
• More than normal mood variation 
• Cannot distract self 

Key symptoms 

• Poor concentration 
• Indecisiveness 
• Insomnia 
• Irritability 
• Sweating, tremor, nausea 
• Panic attacks 

Assessment to identify cause and severity 

• Is it severe? 
• Is it long-standing? 
• Is it alcohol withdrawal? 
• Is it situational? 
• Is it related to a specific fear? 
• Are the family anxious? 

Causes of anxiety in Palliative Care 

Explanation to the patient and family 

It is normal to feel anxious when faced with the realities of serious illness. Anxiety can be exhausting and is not helpful in managing the problems faced. It helps to know the facts of the illness so that we are not anxious about imagined things and to talk through our anxieties. Distraction and relaxation also help to control anxiety. If anxiety is severe and interferes with your activities, your doctor can prescribe medication to reduce the feeling of anxiety. 

Correct reversible factors 

Management involves assessing the patient for any reversible factors, such as pain or unfounded worries. Stimulant drugs, excessive alcohol or withdrawal of drugs or alcohol may exacerbate anxiety and need to be monitored. 

Non-pharmacological intervention 

It is necessary to provide the time and opportunity for patients to express their worries and concerns, and for these concerns to be addressed, honestly and clearly. Relaxation techniques and various complementary therapies may help, as may the controlled safe atmosphere of a hospice with professional carers. Professional counselling is a key intervention in management of anxiety. 

It is important for all members of the palliative care team to be aware of the “infectious” nature of anxiety, and for the team to avoid being driven to management extremes because of the anxiety of the patient, or their family. 

Anxiety can also be a problem for the palliative care team itself, particularly where individual team members feel unsupported in their work and are confronted with stressful situations for which they perceive their options to be very limited. No team is immune from anxiety and strategies need to be devised to provide ongoing support for team members, where such issues can be talked over and dealt with more concertedly where necessary. 

Psychological methods for managing anxiety and/or pain 

• Distraction 
• Behavioural therapy 
• Creative activity 
• Cognitive therapy 
• Art therapy 
• Imagery 
• Relaxation 
• Music therapy 
• Biofeedback 
• Psychodynamic therapies 
• Hypnosis

Pharmacological intervention 

Benzodiazepines - These very useful drugs have received a bad press because of their addictive potential. They are traditionally divided between compounds which have more sedating effects and those which have more anxiolytic actions. However, there is considerable overlap on the anxiety/sedating spectrum. 

They are useful to break the anxiety cycle, to restore sleep and to reduce the suffering of the situation where a patient feels they are “losing control”. They are not a substitute for taking the time to allow a patient to discuss their fears and anxieties. 

Antidepressants for anxiety 

Tricyclic antidepressants, such as amitriptyline, may be useful as anxiolytics, often in “sub-antidepressant” dosages. Selective Serotonin Re-uptake Inhibitor (SSRI) antidepressants, such as paroxetine and citalopram, are more expensive alternatives, but have fewer reported side-effects. Care must be taken to avoid enervating SSRIs, such as fluoxetine, which can initially increase anxiety. 

Anti-psychotics for anxiety 

At all stages consider referral to specialist care 

Complex anxiety states with depression and psychosis may be more suitably treated with neuroleptics. The help of a psychiatric team may be needed.