Anxiety in medical patients

Classification of abnormal anxiety

Abnormal anxiety can be classified according to its clinical features. In standardised diagnostic systems there are four main patterns of abnormal anxiety.

Anxious adjustment disorder—Anxiety is closely linked in time to the onset of a stressor.

Generalised anxiety disorder—Anxiety is more pervasive and persistent, occurring in many different settings.

Panic disorder—Anxiety comes in waves or attacks and is often associatedwith panicky thoughts (catastrophic thoughts) of impending disaster and can lead to repeated emergency medical presentations.

Phobic anxiety—Anxiety is provoked by exposure to a specific feared object or situation. Medically related phobic stimuli include blood, hospitals, needles, doctors and (especially) dentists, and painful or unpleasant procedures.

Additionally, anxiety often presents in association with depression. Mixed anxiety and depressive disorders are much more common than anxiety disorders alone. Treatment for the depression may resolve the anxiety. Anxiety can also be the presenting feature of other psychiatric illnesses common in physically ill people, such as delirium or drug and alcohol misuse.

Role of non-specialists

Treating anxiety is part of the management of most medical conditions. It can lead to direct improvement of symptoms or improve patient compliance. It is important to intervene if a positive diagnosis of anxiety is made. Without treatment, anxiety is associated with increased disability, increased use of health service resources, and impaired quality of life.

Involving a mental health professional is not always possible for anxious patients, particularly those in general hospital settings. The range of available services is often limited, and not all patients are prepared to accept referral. Since many patients have to be managed without recourse to psychiatric services, treating anxiety should be considered a core skill for all doctors.

Giving informationis often the first step in helping anxious patients, so much so that it has been said that knowledge is reassurance. While information must be tailored to the wishes of the individual, many patients want more information than they are given. Such a simple step as showing people where they are to be cared for can reduce anxiety.

Effective communicationis central to information giving, with evidence that anxiety is associated with poor communication. Training doctors to use open questions, discuss psychological issues, and summarise—and to avoid reassurance, “advice mode,” and leading questions—has been shown to lead to greater disclosure and enduring change in patients with psychological problems.

Reassuranceis one of the most widely practised clinical skills. Doctors often need to tell patients that their symptoms are not due to occult disease. Simple reassurance, however, may be ineffective for anxious patients; their anxiety may be reduced initially by the consultation, but it rapidly returns. Several theoretical models of this problem have been suggested, based on the patterns of thinking (“cognitions”) of people who are difficult to reassure.

Characteristic features of health anxiety (using the example of asthma)

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Preparation for unpleasant procedures can remove the additional burden of facing the unknown. It may also allow planning of short term tactics for dealing with anxiety provoking circumstances. Anxious patients are highly vigilant and overaware of threatening stimuli. They often use “quick fix” techniques based on avoidance of threat to reduce anxiety; such strategies are generally maladaptive and result in increasing disability. In some medical situations, however, such avoidance may not be a bad thing if the threat is temporary. A similar effect is seen with use of benzodiazepine to provide temporary relief from anxiety symptoms that will not recur because the stressor is not persistent.

Behavioural treatments are among the most effective treatments for anxiety disorders. Many patients restrict their activities in response to anxiety, which often has the effect of increasing both the level of anxiety and the degree of disability in the longer term. The principle of treatment is that controlled exposure to the anxiety producing stimulus will eventually lead to diminution in symptoms. Although specific behavioural treatments will normally be conducted by specialists, other clinicians should be aware of the basic principles. It is important to encourage and help patients to maintain their normal activities as much as possible, even if this causes temporary increases in anxiety.

Drug treatments—Several drugs can be used to treat anxiety, each with its own advantages and disadvantages. Long term benzodiazepine dependence and misuse are considered by many to be a problem in medical practice. Although the evidence for this is conflicting, the use of benzodiazepines may be reserved for the short term treatment of anxiety and for emergencies.

Drug withdrawal—Dependence on other substances, particularly analgesics and alcohol, occurs fairly frequently in the context of anxiety. This often results from self medication for anxiety. In this situation withdrawal from the existing “treatment” will be an important part of the anxiety management programme.

Role of specialist treatment in brief psychological therapies

Clinical studies indicate that psychological interventions for anxiety can be effective both in general psychiatric settings and for physically ill patients. The most popular, and those with the best evidence to support them, are based on the principles of behaviour, cognitive behaviour, or interpersonal therapy.

In behaviour and cognitive behaviour therapies the main aim is to help patients identify and challenge unhelpful ways of thinking about and coping with physical symptoms and their meaning, about themselves, and about how they should live their lives. In interpersonal therapies the main focus is on relationships with family members and friends—how such relationships are affected by illness and how they influence patients' current emotional state. Patients need to know that such therapies may be both brief and practical. Fewer than six sessions may be enough, concentrating on symptoms or the immediate problems associated with them and learning new ways of dealing with problems. In only a minority of cases is more extended therapy needed, usually when anxiety is longer standing and only partially due to associated physical disease.