Supportive Care Clinic
What is anxiety?
Anxiety is a normal physiological state that involves our bodies, minds, emotions, and actions. Even though we are all familiar with the feelings of worry, fear, uneasiness, and nervousness that can accompany anxiety, feeling anxious is often very unpleasant and disruptive to our daily lives. Because anxiety is something we can experience in response to uncertainty and potential threats, a certain amount of anxiety is a common feature of the distress associated with cancer.
Anxiety can be composed of worries (the “what-if” thoughts we all have), of emotions (feelings of fear, panic, distress), of body sensations (racing heartbeat, feeling hot or cold, breathing faster), and behaviors (avoiding certain situations, habitual patterns of muscle tension). In a sense our nervous systems are “wired” for survival, as illustrated by the reflexive “flight or fight response” – the urge we feel to run or to defend ourselves when faced with real or imagined dangers. Unlike many threats that may be brief or time-limited, dealing with cancer and its uncertainties can be a longer-term process, which in turn can create chronic stress and lead to chronic anxiety.
Why is it important to keep anxiety under control?
Under certain conditions, normal anxiety can become problematic. Anxiety may bother a person so much that they can’t sleep, can’t eat, and can’t concentrate; they may avoid activities or people. Problems like these, if they go on for more than a week or two, can be disruptive to coping effectively.
A big problem with anxiety is that one natural response is often avoidance, which makes sense for some dangers. After all, when faced with a bear in the woods, your best option may be to RUN! However, the anxiety associated with cancer is rarely made better by avoidance. People may avoid chemotherapy because they fear nausea or needles; they may skip MRI appointments because they get anxious in enclosed places; or they may avoid their doctor and skip follow-up appointments because they feel anxious when they see their doctor or the clinic. Unfortunately, avoiding these things will not help the person’s cancer, and may cause more problems in the long run.
Similarly, people may avoid making plans for the future, like completing advanced directives or making out a will, because thinking about mortality makes them anxious. The anxiety and the avoidance are both understandable – most people would feel and react the same way -- but avoiding those tasks isn’t helpful and could even increase anxiety later.
What can help?
There are many strategies that can help with anxiety.
For worry and general tension:
- First, pay attention to any symptoms you are having. Are you feeling anxious the entire day? Certain times of the day? Are you more or less anxious when you are engaged in distracting tasks? Do certain things set your worry off? Simply monitoring your patterns of anxiety can lead to the discovery of important triggers and patterns, which can then be addressed.
For instance, Bob discovered that his feelings of tension and worry were not a problem at work or when he was talking with his wife and children. However, when he was by himself while driving to and from work, and after his family went to bed, he sometimes became distressed. In an effort to manage these symptoms, Bob decided to listen to books-on-tape while driving; he also listened to a relaxation tape at night to help him fall asleep. He found these changes to be helpful in distracting him from his worry.
- Second, pay attention to what you might be avoiding or putting off and consider how you might address these tasks. You may want to break down larger, more complex tasks into much smaller segments or steps . Give yourself credit for each step you accomplish. Just keep moving forward.
- Third, keep in mind that avoiding worrisome thoughts is usually not helpful. For instance, when we asked Bob about his worry, he told us that he was trying very hard NOT to worry in an effort to stay calm and avoid distressing his family. Unfortunately, his conscious attempt to NOT worry was having the opposite effect -- it kept the worrisome thoughts activated in his mind far longer than necessary.
To see for yourself, try the following exercise: For the next 60 seconds, DO NOT think of a white bear.
What did you find? Most people find that, because they are reminding themselves over and over NOT to think about the white bear, it becomes almost impossible to think about anything else. The same thing happened to Bob. His mind had a constant stream going: “Don’t think about the cancer, don’t think about the hospital, don’t worry about a recurrence…” He was constantly thinking about the very things he was trying to avoid.
We suggested that Bob try something different. We asked him to do two things:
1. Keep a “Worry Diary”, where he wrote down the worries he was having, and
2. Schedule fifteen to twenty minutes daily SPECIFICALLY to do nothing else but worry.
Scheduling time to worry is helpful for a couple reasons. First, it gives you permission to worry, within certain boundaries where it’s less distracting and disruptive. Bob found that he was in fact unable to worry for a full 20 minutes, even though when he was suppressing his worry it seemed to be with him all the time. Second, it allows you to hold worries for later (if, for example, you catch yourself worrying during a work meeting, you can jot the worry down and tell yourself you’ll get to it later, so you can focus on the meeting instead).
- Fourth, try some relaxation exercises. It is physiologically nearly impossible to be relaxed in body and anxious in mind at the same time, so relaxing your muscles (via breathing exercises, or tightening and relaxing various muscle groups) directs your mind away from anxious thoughts. There are many good relaxation tapes and exercises available (see below for recommended books and tapes).
- Fifth, if you feel anxious more often than not and it goes on for more than a couple weeks, ask your doctor what he or she recommends. There are a variety of effective treatments for generalized anxiety (see below).
For specific anxiety disorders:
The above are all helpful for people with general worry and tension. Sometimes, however, people develop more serious and disruptive anxiety problems. For instance, some people become so anxious that they have significant difficulty being around other people; they may avoid social gatherings, isolate themselves at home, and have trouble doing their jobs. These people may have a condition called Social Anxiety Disorder. Alternatively, a person may have powerful anxiety attacks which seemingly come out of the blue, causing the person to avoid places where these attacks might be triggered. This person may have a condition called Panic Disorder. Other anxiety disorders include Specific Phobias (of things like flying, animals or insects, enclosed spaces, needles or blood); Obsessive Compulsive Disorder (having very disruptive repetitive thoughts and/or behaviors); or Post-Traumatic Stress Disorder, which can be caused by experiencing a life threatening or terrifying event and is characterized by unpleasant, intrusive thoughts and memories, flashbacks, and excessive arousal.
All of these conditions contain elements that most people have experienced. Most of us, for example, have an aversion to certain bugs, or feel anxious when asked to speak in public. However, when a person’s daily life is seriously affected because of avoiding the feared object or activity on a regular basis, the problem is defined as an anxiety disorder.
These conditions may have existed before cancer, may be aggravated by the cancer experience, or may begin after cancer is diagnosed or treated. If you think you may have symptoms of one of these anxiety disorders, you should ask your treatment provider for an assessment or a referral for an assessment. Treatment for these anxiety disorders can be provided by a mental health professional; simply trying to talk yourself out of an anxiety disorder is like trying to talk yourself out of a heart or stomach problem.
What are some common treatments for anxiety?
The optimal approaches for anxiety disorders are 1) cognitive-behavioral therapy (CBT), and 2) medication. Both treatments, either alone or together, can be equally as effective.
This form of psychotherapy, used by members of the Vanderbilt Psychological Oncology Team, examines what people are thinking, feeling, and doing that may keep them feeling anxious and avoiding activities.
For example, after her chemo treatments were finished, Susan started having panic attacks once or twice a week. She would not go to any grocery store in town because she had had panic attacks in all of them. She had been to the emergency room twice with panic attacks, thinking each time that she was having a heart attack. However, the ER doctors and her own physician were sure that her attacks were anxiety-related, rather than related to heart problems. When we talked to Susan, she discovered that she followed a pattern: She would be stressed, perhaps because of work or an argument with her son. Her breathing would get faster, which is a natural body response to stress, but Susan didn’t notice that she was having this response until she felt a tightness in her chest (which was actually a byproduct of her rapid shallow breathing). Susan had heard that the kind of chemo she had received could cause heart damage, so she interpreted the chest tightness as a sign that she was having heart problems. Since heart problems are dangerous and scary, she would forget all the information her doctors had told her about her heart being fine, get even more anxious, have even more symptoms, and find herself having a panic attack. Once this pattern was identified, Susan was asked to test out some of her beliefs about the chest tightness, such as: a) it was dangerous and, b) it was a sign of heart problems. Susan was asked to go the stores she had avoided, to check out her assumptions that the stores were indeed dangerous places. Susan was asked to pay attention to physical symptoms and with the use of various techniques to understand what increased or decreased them. The goals of treatment were to have her TEST OUT HER BELIEFS and STOP AVOIDING. Susan soon realized that she could actually bring on the symptoms intentionally, and when she realized that, they became much less scary. She still had tightness in her chest periodically, because she still experienced stress from time to time, but she no longer interpreted it as a heart attack sign; eventually it would go away. She could go to any grocery store she wanted.
There are several groups of medications used to control anxiety. Until recently, the benzodiazepines were the primary medications for anxiety. These days, antidepressants -- particularly serotonin reuptake inhibitors (SRIs) -- are used as the first-line treatment for anxiety, because they are effective and have fewer side effects than other anti-anxiety drugs. You should not give up if one drug treatment fails; another may prove to be effective, even a drug of a similar type.
The following is just an overview. If you have more questions, please ask your doctor.
- Group 1: Benzodiazepines
- The benzodiazepines include Xanax, Valium, Ativan, Klonopin, Versed, and many others. These are powerful medicines which can reduce anxious feelings quickly, and can be taken as needed. However, because of the quick reduction in distress, these medicines can be addictive. You may become used to the medicine, so you have to take more to get the same effect, and then become reliant on the medicines so that you are having trouble getting through your days without them.
- If you have been taking any of these medicines regularly, DO NOT STOP COLD TURKEY! You must taper off these medicines gradually. Make sure you speak to you doctor before changing your dose of any of these medicines.
- Group 2: Serotonin Reuptake Inhibitors
- These medicines include Zoloft, Prozac, Paxil, Effexor, and Luvox. These were initially used as antidepressants, but are effective in reducing anxiety as well. These medicines do not have an immediate effect; they must be taken regularly, and over the course of weeks they start to have an effect on the brain chemicals involved in anxiety and fear. Because they don’t have an immediate punch, these medicines are not addictive in the way that alcohol or benzodiazepines are. However, your body can still become used to them, so you should again ALWAYS TAPER them, and always talk to your doctor before changing your dose.
- Group 3: Others
- Other medicines for anxiety include BuSpar, Trazedone, some of the older antidepressants like Elavil. These medicines can be effective, but some of them have problematic side effects (like oversedation or dry mouth). The same warnings about taper and telling your doctor before you change your dose apply to these medicines.