Anxiety in the Medical Patient

Anxiety and vulnerability to medical illness
Whether anxiety disorders are associated with increased morbidity and mortality remains an intensely investigated question. An earlier study showed higher mortality in patients with anxiety disorders. ⁸ More recent data have linked anxiety to an increased risk for mortality in cardiac patients. In men with coronary artery disease, phobic and panic-like anxiety predicted 3 times the risk for fatal coronary heart disease (CHD) at a 7-year follow-up compared with no anxiety. ⁹ In the Normative Aging Study, ¹⁰ which also included only men, higher levels of anxiety were associated with almost double the risk for fatal CHD.

The cause of the increased mortality in these large-scale community studies appears to have been related to sudden cardiac death rather than myocardial infarction. In women who were homemakers, anxiety symptoms were associated with increased rates of myocardial infarction and coronary-related death over a 20-year period. ¹¹ In a more recent study, women who had increased anxiety had a higher mortality rate than otherwise healthy women. ¹²

Longitudinal data from a huge community-based sample of older men and women in the Netherlands with a 7.5- year follow-up revealed that in men, adjusted mortality risk was 1.78 in those who had anxiety disorders diagnosed at baseline. ¹³ In this study, no significant association with mortality was found in women. The interesting sex differences are not well understood at present.

Nonetheless, it is important to note that an anxious mood, regardless of its primary cause, can produce extensive effects throughout the body. The neurophysiology of anxiety involves not only an increase in sympathetic activity but also activation of the hypothalamic- pituitary-adrenal axis. The amygdala, locus caeruleus, and their connecting neurons trigger the sympathetic discharge of epinephrine(Drug information on epinephrine) and norepinephrine(Drug information on norepinephrine) from the adrenal medulla and activate the hypothalamus and pituitary to increase adrenocorticotropic hormone (ACTH), prolactin, and human growth hormone. With the increase in ACTH, the adrenal cortex releases cortisol, inhibiting insulin and raising blood glucose. While these changes are not always clinically apparent, the possibilities for physiological abnormalities are numerous.

Possible mechanisms for higher mortality rates in patients with increased anxiety levels or, more generically, in patients with increased stress and life changes, include excessive sympathetic activation, neuroendocrine activation, platelet activation, and alterations in immune function. ¹⁴ Anxiety can enhance the production of pro- inflammatory cytokines, such as IL-6, which may predispose patients to increased health risks. In addition, anxiety-induced changes in health-related behaviors, such as smoking or dietary indiscretion, may influence patients' health outcomes.

Implications for management of anxiety in the medical patient
There are 5 practical implications in assessing and managing anxiety in the medically ill.

First, it is important to make the appropriate diagnosis and assessment. Although most anxiety states are overt, some are relatively hidden, such as social anxiety and obsessive-compulsive disorder. Clinicians need to ask patients directly about the presence of phobias, avoidance behavior, and compulsive rituals. This is especially important for patients with pulmonary and cardiac disease, who are more likely to have anxiety disorders, as well as patients with poorly explained somatic complaints. The assessment should differentiate anxiety disorders from adjustment disorders with anxiety. In many situations, anxiety may be adaptive and not excessive to the point of impairing a patient's coping capacity.

Second, as a general rule, anxiety often arises in situations in which people feel a lack of control. That may be particularly true in medical environments that are unfamiliar and frightening. Education and explanation about what the patient can expect tend to reduce anxiety. For many, the most effective preparation is geared to the patient's likely actual experience. Furthermore, one can alleviate anxiety by giving the patient as much control as possible, for example, by allowing a patient to take a break or to signal that a procedure has become overwhelming.

Third, simple acknowledgment of the patient's anxiety in an empathic way may help reduce it. One of the renowned psychiatric educators, the late Dr Elvin Semrad, summarized the essence of psychotherapy as helping a patient acknowledge, bear, and then put into perspective painful affects.

Fourth, judicious use of medications helps alleviate anxiety. Benzodiazepines are fast-acting, relatively safe, and effective, especially in acute situations. The exceptions to this include delirium and a history of substance abuse. The SSRIs and venlafaxine are particularly useful for patients with clear anxiety disorders, especially if there is evidence of comorbid depression. Among the SSRIs, sertraline(Drug information on sertraline) and citalopram(Drug information on citalopram) are often preferred because of their relatively smaller effect on P-450, an advantage for many medical patients who may be taking multiple medications.

Fifth, patients with anxiety disorders should be treated actively for their psychiatric condition. As already noted, comorbid psychiatric conditions are likely to exacerbate the course of many medical disorders. Most patients should also receive cognitive-behavioral therapy, which many studies have shown to be effective and underused in the treatment of anxiety disorders.