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Clinical features, screening, and diagnosis of anxiety disorders in patients with cancer

Clinical features, screening, and diagnosis of anxiety disorders in patients with cancer
Authors:
Jacynthe Rivest, MD
Jon Levenson, MD
Section Editors:
Jonathan M Silver, MD
Susan D Block, MD
Deputy Editor:
David Solomon, MD
Literature review current through: Jun 2022. | This topic last updated: May 16, 2022.

INTRODUCTION — Anxiety disorders such as agoraphobia, panic attacks, and specific phobia appear to be more common in patients with cancer than the general population. Recognizing anxiety symptoms and disorders is important because treatment can mitigate their negative impact on quality of life [1].

This topic reviews the epidemiology, clinical features, screening, and diagnosis of anxiety disorders in patients with cancer. The clinical features and diagnosis of other psychiatric disorders in cancer patients are discussed separately, as are the clinical features and diagnosis of anxiety disorders in palliative care and the management of anxiety disorders in cancer patients. (See "Clinical features and diagnosis of psychiatric disorders in patients with cancer: Overview" and "Overview of anxiety in palliative care" and "Management of psychiatric disorders in patients with cancer", section on 'Anxiety'.)

OVERVIEW — Anxiety is a common response to the threat posed by cancer, as patients anticipate or experience pain, worry about becoming dependent and disabled, cope with the uncertainty of recurrence, and face their mortality [2]. Anxiety tends to fluctuate in association with medical events and communication that occur during the course of illness. For most patients, anxiety can also be a normal reaction after the diagnosis of cancer is received; anxiety is usually transient and can motivate adherence to treatment [1]. Anxiety can also be a neuropsychiatric manifestation of a malignancy, a somatic response to medical complications (eg, dyspnea), or can be induced by medications such as corticosteroids or chemotherapy.

However, in a minority of patients with cancer, anxiety symptoms may constitute a recurrent or new anxiety disorder [1]. Anxiety disorders are characterized by excessive fear and anxiety that result in somatic symptoms or behavioral disturbances such as avoidance, which can interfere with treatment [1-3]. Specific disorders include:

Agoraphobia

Generalized anxiety disorder

Social anxiety disorder

Specific phobias

Panic disorder

Other specified anxiety disorder

The subsections below discuss the epidemiology, clinical features, screening, and diagnosis of anxiety disorders that are specific to patients with cancer. Separate topics discuss the clinical manifestations, assessment, and diagnosis of anxiety disorders in the general population.

EPIDEMIOLOGY

Prevalence — The point prevalence of anxiety disorders in patients with cancer is approximately 10 percent:

In a meta-analysis of 16 studies in which patients with cancer (number of patients not reported) were interviewed, the estimated point prevalence of anxiety disorders was 10 percent [4]. However, heterogeneity across studies was high.

A subsequent study of patients with cancer who were interviewed (n >2000) found that anxiety disorders were present in 11 percent [5].

Compared with the general population, the prevalence of [6,7]:

Agoraphobia in cancer patients is three to seven times greater

Panic attacks in cancer patients is two times greater

Specific phobia in cancer patients is three times greater

The prevalence of anxiety symptoms that do not meet criteria for diagnosis of an anxiety disorder appears to be quite common. A study of patients in treatment for cancer (n >8000) who completed a self-report survey found that clinically significant anxiety symptoms were present in 24 percent [8].

Clinically significant anxiety symptoms and anxiety disorders are also observed in cancer survivors. (See "Overview of psychosocial issues in the adult cancer survivor", section on 'Anxiety'.)

Risk factors — The risk of developing anxiety disorders following a diagnosis of cancer is elevated in patients with a prior history of anxiety disorders, as the experience of being afflicted by cancer may reactivate a subclinical anxiety disorder or precipitate a relapse [1]. As an example, a study of women with breast cancer (n = 247) found that the odds of developing generalized anxiety disorder were 16 times greater in patients with a prior history of the disorder than women with no previous history [9].

Other factors that may cause or contribute to anxiety symptoms or disorders include comorbid depression and insomnia, as well as factors stemming from cancer disease (eg, brain metastases, hypercalcemia, hypoxia, paraneoplastic syndromes, and thromboembolic disease) and cancer treatment (eg, glucocorticoid steroids) [1].

CLINICAL FEATURES — A common feature of anxiety disorders is that they cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. This distress and impairment can help distinguish an anxiety disorder from normal anxiety.

Although many clinical features of anxiety disorders are similar in patients with cancer and in the general population of patients with anxiety disorders, features that are particularly salient in cancer patients include the following [1,2]:

Agoraphobia can prevent patients from leaving their homes and traveling to the clinic or hospital.

Generalized anxiety disorder – Excessive worry about cancer may lead patients to either repeatedly call clinicians to ask about test results or to avoid information about prognosis. In addition, patients may have difficulties with deciding upon a course of treatment and with focusing upon noncancer related tasks.  

Panic disorder – Somatic symptoms of panic disorder such as dyspnea or tachycardia may cause patients to stop exercising, which can lead to physical deconditioning. Patients may also avoid unfamiliar situations, which may interfere with changes in treatment.

Specific phobias to blood, injection, injury, and vomiting can interfere with procedures, and anticipation of procedures may lead to panic attacks. In addition, claustrophobia may lead to difficulty tolerating magnetic resonance imaging or radiation therapy.  

Social anxiety disorder may lead patients to avoid discussing personal issues with clinicians due to fear of embarrassment; patients may also avoid situations in which they are the center of attention.

As in the general population of patients with anxiety disorders, anxiety disorders often occur in conjunction with depressive symptoms [10]. As an example, a study of patients in treatment for cancer (n >8000) who completed a self-report survey found that clinically significant symptoms of anxiety plus depression were present in 12 percent [8].

General information about the clinical features of specific anxiety disorders is discussed in separate topics.

SCREENING — Anxiety disorders are common in both the general population [11] and the cancer population; thus, we suggest that clinicians screen all patients with cancer for anxiety disorders, including generalized anxiety disorder, with the self-report, seven-item Generalized Anxiety Disorder (GAD-7) scale (table 1). Screening should be implemented with services in place to ensure follow-up for diagnosis and treatment, and should occur when the initial diagnosis of cancer is made and periodically thereafter as clinically indicated, especially with changes in cancer or treatment status (eg, posttreatment, recurrence, or progression), as well as transition to palliative care. Patients who screen positive (total score ≥5) should be interviewed to diagnose generalized anxiety disorder. This approach is consistent with guidelines from the American Society of Clinical Oncology, which are based upon practice guidelines from the Pan-Canadian Guideline on Screening, Assessment and Care of Psychosocial Distress (Depression, Anxiety) in Adults with Cancer [12]. The rationale for screening is that anxiety disorders are serious, prevalent, under-recognized, and treatable, and that standardized, valid screening tools are available. However, there are no high-quality studies that demonstrate routine screening of all cancer patients specifically for generalized anxiety disorder improves outcomes.

A reasonable alternative to the GAD-7 is the 14-item, self-report Hospital Anxiety and Depression Scale [12]. This widely used scale includes a seven-item subscale that assesses anxiety symptoms.

Several instruments with fewer than five questions are available to screen for anxiety and are appealing because of their brevity (eg, the single-item, self-report Distress Thermometer, or simply asking “How anxious have you felt this week?”); however, they perform poorly. As an example, a pooled analysis of results from four studies (n >2200 patients with cancer) found that these short instruments performed poorly in detecting possible cases of clinically significant anxiety; the pooled sensitivity was 77 percent and positive predictive value was 55 percent [13]. The instruments were somewhat better at excluding cases of possible major depression, with a specificity of 57 percent and negative predictive value of 80 percent.

ASSESSMENT AND DIAGNOSIS — The assessment for and diagnosis of anxiety disorders in patients with cancer are the same as those used in other patient populations. However, somatic symptoms of cancer and side effects of anticancer drugs such as corticosteroids can overlap with symptoms of anxiety disorders [1]. As an example, dyspnea or tachycardia may be a symptom stemming from cancer (eg, lung cancer) that requires a medical evaluation, or may be a symptom of panic disorder.

Separate topics discuss assessment and diagnosis of specific anxiety disorders in the general population:

(See "Agoraphobia in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis".)

(See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)

(See "Social anxiety disorder in adults: Epidemiology, clinical manifestations, and diagnosis".)

(See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis".)

(See "Panic disorder in adults: Epidemiology, clinical manifestations, and diagnosis".)

In addition, diagnosis of anxiety disorders in the context of palliative care is discussed separately. (See "Overview of anxiety in palliative care", section on 'Diagnosis'.)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

(See "Patient education: Generalized anxiety disorder (The Basics)".)

(See "Patient education: Panic disorder (The Basics)".)

(See "Patient education: Social anxiety disorder (The Basics)".)

SUMMARY

Anxiety is a common response to the threat posed by cancer and waxes and wanes for most patients. Although anxiety is often a normal reaction to cancer, anxiety can represent a psychiatric disorder that is characterized by intense fear and anxiety, which result in behavioral disturbances that can benefit from treatment. Specific anxiety disorders include agoraphobia, generalized anxiety disorder, social anxiety disorder, specific phobias, and panic disorder. Anxiety can also be a neuropsychiatric manifestation of a malignancy, a somatic response to medical complications (eg, dyspnea), or can be induced by medication (such as corticosteroids or chemotherapy). (See 'Overview' above.)

The point prevalence of anxiety disorders in patients with cancer is approximately 10 percent, and prominent anxiety symptoms that do not meet criteria for diagnosis of an anxiety disorder, but nevertheless require clinical attention, appear to be even more common. The risk of developing an anxiety disorder following a diagnosis of cancer is especially elevated in patients with a prior history of an anxiety disorder. (See 'Epidemiology' above.)

Clinical features of anxiety disorders that are particularly salient in cancer patients include the following:

Agoraphobia can prevent patients from leaving their homes and travelling to the clinic or hospital.

Generalized anxiety disorder – Excessive worry about cancer may lead patients to either repeatedly call clinicians to ask about test results or to avoid information about prognosis.

Panic disorder – Somatic symptoms of panic disorder such as dyspnea or tachycardia may cause patients to stop exercising, which can lead to physical deconditioning.

Specific phobias to blood, injection, injury, and vomiting can interfere with diagnostic and treatment-related procedures.

Social anxiety disorder may lead patients to avoid discussing personal issues with clinicians due to fear of embarrassment.

(See 'Clinical features' above.)

Clinicians are encouraged to screen all patients with cancer for anxiety disorders with the self-report, seven-item Generalized Anxiety Disorder scale (table 1). Screening should be implemented with services in place to ensure follow-up for diagnosis and treatment, and should occur when the initial diagnosis of cancer is made and periodically thereafter as clinically indicated. (See 'Screening' above.)

The assessment for and diagnosis of anxiety disorders in patients with cancer are the same as those used in other patient populations. (See 'Assessment and diagnosis' above.)

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