Overview of anxiety in palliative care
- Scott A Irwin, MD, PhD
Scott A Irwin, MD, PhD
- Associate Professor of Psychiatry
- Director, Supportive Care Services
- Samuel Oschin Comprehensive Cancer Institute
- Cedars-Sinai Medical Center
- Jeremy M Hirst, MD, PhD, FAPM, FAPA
Jeremy M Hirst, MD, PhD, FAPM, FAPA
- Professor of Psychiatry and Behavioral Neurosciences
- Associate Director, Palliative Care Psychiatry
- University of UC San Diego Health
- Director of Psychiatry & Psychosocial Services; Patient & Family Support Services
- University of California San Diego, Moores Cancer Center
- Section Editor
- Susan D Block, MD
Susan D Block, MD
- Editor-in-Chief — Palliative Care
- Section Editor — Psychosocial Issues
- Professor of Psychiatry
- Harvard Medical School
- Deputy Editors
- Diane MF Savarese, MD
Diane MF Savarese, MD
- Senior Deputy Editor — UpToDate
- Deputy Editor — Oncology and Palliative Care
- Clinical Instructor of Medicine
- Harvard Medical School
- Richard Hermann, MD
Richard Hermann, MD
- Deputy Editor — Psychiatry
- Associate Professor
- Tufts University School of Medicine
For most patients in palliative care, symptoms of anxiety are normal and are expected consequences given the uncertainties of living with serious illness and the possibility of approaching death. Anxiety is generally described as a feeling of helplessness or fear, often related to a sense of losing control that frequently accompanies life with illness, as well as being generated by death-related factors. A patient’s distress may also be related to physical, psychological, social, spiritual, practical, end of life, and loss issues [1,2]. They express fears about what their death will look and feel like and what events will lead up to it. They frequently voice concerns about religious beliefs, spiritual issues, existential matters, or how to achieve a good death. Some people with anxiety may require intervention and some may not. Often reassurance, presence, addressing their concerns directly, and controlling symptoms is all that is needed.
While many patients with serious illness have worries, fears, and apprehensions, they do not usually rise to the level of an anxiety disorder. That is, anxiety disorders should not be assumed to be an inevitable part of serious illness . However, for other patients symptoms of anxiety can be severely debilitating and require intensive treatment. At the most extreme, out of control anxiety can sometimes lead to a heightened interest in a hastened death .
The detrimental impact of untreated, persistent anxiety was demonstrated in one multicenter study of over 600 patients with advanced cancer that evaluated associations between anxiety disorders and multiple endpoints, including physician-patient relationships . Patients with anxiety disorders had less trust in their clinicians compared to those without anxiety. In addition, patients with anxiety reported being:
●Less comfortable asking questions about their health
●Less likely to understand the clinical information
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- CLINICAL MANIFESTATIONS
- DIFFERENTIAL DIAGNOSIS
- Adjustment disorder with anxious features
- Generalized anxiety disorder
- Panic disorder
- Posttraumatic stress disorder
- TREATMENT APPROACH
- Complementary therapies
- Lifestyle factors
- - Benzodiazepines
- Choice of agent and dosing
- Side effects
- - Selective serotonin reuptake inhibitors
- Alternative agents
- Choosing an antidepressant agent
- - Combination therapy
- Alternative agents
- Indications for referral to a mental health specialist
- SUMMARY AND RECOMMENDATIONS