Adjustment Disorder
Panic Disorder
Phobias
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Generalized Anxiety Disorder
Anxiety Disorder Caused by Other General Medical Conditions

Patients who have the following symptoms may be experiencing a specific anxiety disorder that was present before they became ill with cancer and that recurs because of the stress of the diagnosis and treatment: intense fear, the inability to absorb information, or the inability to cooperate with medical procedures. Somatic symptoms include shortness of breath, sweating, lightheadedness, and palpitations. Patients with cancer can present with the following anxiety disorders: adjustment disorder, panic disorder, phobias, obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, or anxiety disorder that is caused by other general medical conditions. These patients are generally distressed about their symptoms and are usually compliant with behavioral and psychopharmacologic intervention.[1]

Adjustment disorder is diagnosed in patients who experience maladaptive behaviors and/or moods in response to an identified stressor. The maladaptive behaviors or moods include severe nervousness, worry, jitteriness, and impairment in normal functioning, such as the inability to work, attend school, or interact with others. These symptoms are in excess of normal reactions to cancer and occur within 6 months of the stressor event; however, this determination can be complicated in the patient with cancer, where the stressor is ongoing. Patients diagnosed with an adjustment disorder generally do not have a history of other psychiatric disorders. Patients with other chronic disorders, however, are likely to have had adjustment problems earlier in life that will recur in the cancer setting. Adjustment disorder is prevalent among cancer patients, particularly at critical times such as at diagnostic work-up, diagnosis, or relapse. Most patients with adjustment disorder respond to reassurance, relaxation techniques, low doses of short-acting benzodiazepines, and patient support and education programs.[2,3] (Refer to the PDQ Summary on Normal Adjustment and the Adjustment Disorders for more information.)

In panic disorder, intense anxiety is the predominant symptom. Severe somatic symptoms can also be present. These include shortness of breath, dizziness, palpitations, trembling, diaphoresis, nausea, tingling sensations, or fears of going crazy. Attacks or discrete periods of intense discomfort can last for several minutes or for hours. Patients with panic attacks often present with symptoms that can be difficult to differentiate from other medical disorders, though a known history of panic disorder can help clarify the diagnosis. Panic disorder in patients with cancer is most often managed with benzodiazepines and antidepressant medications.[1]

Phobias are persistent fears or avoidance of a circumscribed object or situation. People with phobias usually experience intense anxiety and avoid potentially frightening situations. Phobias are experienced by cancer patients in a number of ways, such as fear of witnessing blood or tissue injury (also known as needle phobia) or claustrophobia (for example, during a magnetic resonance imaging scan). Phobias can complicate medical procedures and can result in the refusal of necessary medical intervention or tests.[1]

Obsessive-compulsive disorder is characterized by persistent thoughts, ideas, or images (obsessions) and by repetitive, purposeful, and intentional behaviors (compulsions) that a person performs to manage his or her intense distress. To qualify as obsessive-compulsive disorder, the obsessive thoughts and compulsive behaviors must be time-consuming and sufficiently distracting to interfere with the person’s ability to function in employment, academic, or social situations. Patients with cancer who have a history of obsessive-compulsive disorder may engage in compulsive behaviors such as hand washing, checking, or counting to such an extent that they cannot comply with treatment. For such patients, normal worry about the cancer diagnosis and prognosis can develop into full obsessive-compulsive symptoms and be severely disabling. Obsessive-compulsive disorder is most often managed with serotonergic antidepressant medications (selective serotonin reuptake inhibitors and clomipramine) and cognitive-behavioral psychotherapy. This disorder is rare in cancer patients who do not have a premorbid history.

Posttraumatic stress disorder is diagnosed when a person re-experiences a traumatic event with intrusive distressing recollections, dreams, flashbacks, or hallucinations. Though definitions of a traumatic event have been focused on those outside the range of normal human experiences (e.g., military combat, torture, and natural disasters), the diagnosis of a life-threatening illness now meets criteria for a traumatic stressor.[4] Additionally, the experience of hospitalization and/or some painful treatment may also reactivate traumatic memories. Cancer patients who have posttraumatic stress disorder can become very anxious before surgery, chemotherapy, painful medical procedures, or dressing changes. Anxiolytic medications given in preparation for treatment can foster adjustment and reduce distress. No specific medications, however, have been consistently demonstrated to be the most effective or have been studied in other populations of patients with posttraumatic stress disorders; psychotherapy remains the treatment of choice. (Refer to the Posttreatment Considerations section and refer to the PDQ summary on Post-Traumatic Stress Disorder for more information.)

Generalized anxiety disorder is characterized by ongoing, unrealistic, and excessive anxiety and worry about two or more life circumstances. Some examples are patients’ fears that no one will care for them even though they have adequate and willing social support and the fear of exhausting their finances even though adequate insurance and financial coverage is available. Frequently a generalized anxiety disorder is preceded by a major depressive episode. A generalized anxiety disorder is characterized by motor tension (restlessness, muscle tension, and being easily fatigued), autonomic hyperactivity (shortness of breath, heart palpitations, sweating, and dizziness), or vigilance in scanning (feeling keyed-up and on-edge, irritability, and having exaggerated startle responses).

Causes of anxiety in cancer patients may include other medical factors such as uncontrolled pain, abnormal metabolic states (e.g., hypercalcemia or hypoglycemia), and hormone-producing tumors. Patients in severe pain are anxious and agitated, and anxiety can potentiate pain. To adequately manage pain, the patient’s anxiety must be treated.[6,7]

Acute onset of anxiety may be a precursor of a change in metabolic state or of another impending medical event such as myocardial infarction, infection, or pneumonia. Sepsis and electrolyte abnormalities can also cause anxiety symptoms. Sudden anxiety with chest pain or respiratory distress may suggest a pulmonary embolism. Patients who are hypoxic can experience anxiety; they may be fearful that they are suffocating.

Many drugs can precipitate anxiety in persons who are ill. For example, corticosteroids can produce motor restlessness, agitation, and mania as well as depression and thoughts of suicide. Bronchodilators and B-adrenergic receptor stimulants used for chronic respiratory conditions can cause anxiety, irritability, and tremulousness. Akathisia, motor restlessness accompanied by subjective feelings of distress, is a side effect of neuroleptic drugs, which are commonly used for control of emesis. Withdrawal from opioids, benzodiazepines, barbiturates, nicotine, and alcohol can result in anxiety, agitation, and behaviors that may be problematic for the patient who is in active treatment.

Certain tumor sites can produce symptoms that resemble anxiety disorders. Pheochromocytomas and pituitary microadenomas can present as episodes of panic and anxiety.[8] Nonhormone-secreting pancreatic cancers can cause anxiety symptoms. Primary lung tumors and lung metastases can often cause shortness of breath, which can lead to anxiety.

References

1. Razavi D, Stiefel F: Common psychiatric disorders in cancer patients. I. Adjustment disorders and depressive disorders. Support Care Cancer 2 (4): 223-32, 1994.  [PUBMED Abstract]
   
   
2. Forester B, Kornfeld DS, Fleiss JL, et al.: Group psychotherapy during radiotherapy: effects on emotional and physical distress. Am J Psychiatry 150 (11): 1700-6, 1993.  [PUBMED Abstract]
   
   
3. Jevne RF: Looking back to look ahead: a retrospective study of referrals to a cancer counseling service. Int J Adv Couns 13 (1): 61-72, 1990. 
   
   
4. American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association, 1994. 
   
   
5. Massie MJ: Anxiety, panic, and phobias. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 300-9. 
   
   
6. Velikova G, Selby PJ, Snaith PR, et al.: The relationship of cancer pain to anxiety. Psychother Psychosom 63 (3-4): 181-4, 1995.  [PUBMED Abstract]
   
   
7. Glover J, Dibble SL, Dodd MJ, et al.: Mood states of oncology outpatients: does pain make a difference? J Pain Symptom Manage 10 (2): 120-8, 1995.  [PUBMED Abstract]
   
   
8. Wilcox JA: Pituitary microadenoma presenting as panic attacks. Br J Psychiatry 158: 426-7, 1991.  [PUBMED Abstract]
   
   

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