Psychotherapy
Although antidepressants alone are effective in the treatment of depression, they are often synergistic with psychotherapy. Talk therapy may provide patients with basic support and encouragement during cancer treatment. Cognitive-behavioral therapy may help them tackle fundamental misperceptions about themselves and their disease and to develop new coping skills.

Anxiety

Like depression, “anxiety” refers to both a subjective emotion and a constellation of signs and symptoms that can be of physical or psychological origin.

Especially in seriously ill patients, subjective anxiety may be the first sign of a serious or catastrophic physiologic derangement (ie, sepsis or pulmonary embolus). It is also common at disease milestones, especially at initial diagnosis, time of recurrence, and progression to the terminal phase. In patients whose disease is stable or in remission, anxiety frequently occurs in conjunction with routine reevaluation.

Signs and symptoms/diagnosis

Psychological symptoms Patients with anxiety typically report worry, irritability, insomnia, and even depression, as there is considerable overlap between the two syndromes. They may appear hypervigilant or emotionally labile, crying unexpectedly or growing suddenly enraged. Typically, their thought processes are ruminative.

If anxiety proceeds to panic, patients may report time-limited feelings of impending doom, suffocation, or annihilation. Occasionally, distress is so intense that patients experience suicidal thoughts.

Physical symptoms A variety of somatic symptoms can be associated with anxiety. Cardiovascular signs and symptoms include palpitations and tachycardia, as well as subjective chest tightness or even pain. Respiratory symptoms include dyspnea, hyperventilation, and, as a result, light-headedness and dizziness. GI symptoms are common and include difficulty swallowing, abdominal cramping, nausea, diarrhea, and constipation. Patients may become diaphoretic. Preexisting pain may be aggravated.

Etiology

Psychological causes
Generalized anxiety disorder, panic disorder, and specific phobias (ie, to blood, needles, and even hospitals) are relatively common in the general population. Affected individuals are at risk for exacerbations of their anxiety disorders in the setting of cancer treatment. The stress associated with a cancer diagnosis can also trigger the onset of an anxiety disorder in a patient without a pre-morbid psychiatric diagnosis.

Cancer patients fear pain, suffering, disfigurement, and even death. Their concerns frequently center on loss of control or independence, strained finances, and family dynamics. Unpleasant procedures or medications can trigger anxiety, and this response can become conditioned, as in the case of anticipatory nausea. Even patients in the surveillance stage of treatment may find themselves suffering with considerable anxiety. In the absence of active treatment, these individuals become ruminative and fearful as they “wait for the other shoe to drop.” Anxiety of this type often peaks in anticipation of follow-up appointments.

Disease and treatment-related causes
Life-threatening causes of anxiety include hypoxia (secondary to pulmonary edema, pulmonary embolus, or sepsis). Other possible medical etiologies include severe anemia, electrolyte disturbances, endocrine disorders such as hyperthyroidism, hypercalcemia, and hyperadrenalism, pain syndromes, and the presence of hormone-secreting neoplasms, such as pheochromocytomas.

Cancer-related medications can also cause or exacerbate anxiety. Frequent offending agents include corticosteroids, which can trigger nervousness, agitation, and even frank mania, and antiemetics, including promethazine(Drug information on promethazine), and metoclopramide(Drug information on metoclopramide), which can produce akathisia, a subjective sense of restlessness. Other medications such as anticholinergics (ie, benztropine [Cogentin]), opioids, and benzodiazepines can produce paradoxical reactions including anxiety states. These paradoxical reactions occur more frequently in geriatric and in CNS-impaired populations. Finally, drug toxicity (ie, from immunosuppressants, bronchodilators, or psychostimulants) and drug withdrawal states (ie, from opioids, benzodiazepines, and alcohol(Drug information on alcohol)) can also trigger significant anxiety.

Management

Initial approaches to anxious patients vary with the severity of the symptom and the medical status of the patient. In all cases, medical underpinnings for anxiety should be considered and corrected when possible.

Psychotherapy
Talk therapy for anxious patients is universally appropriate. This intervention can take several forms. Supportive psychotherapy may enable an anxious patient to ventilate emotion in a safe setting. Cognitive-behavioral therapy may aid a patient in developing new coping skills through relaxation therapy, guided imagery training, or through a careful review of the patient’s core beliefs and the behaviors that help to trigger the emotion.