assessment and management of anxiety in palliative care ... · one of the most prevalent...
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Scott A. Irwin, MD, PhD Director Supportive Care Services Professor of Psychiatry and Behavioral Neurosciences
Samuel Oschin Comprehensive Cancer Institute Department of Psychiatry and Behavioral Neurosciences
[email protected] © 2016
Assessment and Management of Anxiety in Palliative Care Patients
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Key Points . . .
What anxiety is
How anxiety is assessed
How anxiety is managed
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What is Anxiety?
Expected, NORMAL, transient response to stress
May help with warning of danger or coping with the stress
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What is Pathologic Anxiety?
Excessive response to external stress
Response to an unknown internal stimulus
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Characteristics of Pathologic Anxiety
Autonomy: No recognizable trigger
Intensity: Exceeds ability to cope with stress
Duration: Persistent (instead of transient)
Behavior: Impaired coping, disabling behaviors Avoidance Withdrawal
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Symptoms of Pathologic Anxiety
Physical: Autonomic arousal Tachycardia, tachypnea, diaphoresis,
diarrhea, dizziness
Affective: Edginess, terror, impending doom
Behavioral: Avoidance, compulsions, psychomotor agitation
Cognitive: Worry, apprehension, obsessions, fears, dread
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Sue . . .
46 year-old married Caucasian female
Breast cancer diagnosed 3 years prior
Since her prognosis of 6 months or less: Increasingly worried about her husband
Inability to get good sleep
Inability to focus on anything other than “getting everything in order for him”
Thinking of this gets her “heart racing”
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. . . Sue
What characteristics and symptoms of anxiety did Sue display? Intensity: Exceeds ability to cope with stress
Duration: Persistent (instead of transient)
Behavior: Impaired coping, disabling behaviors
Physical: Autonomic arousal
Affective: Edginess, terror, impending doom
Cognitive: Worry, apprehension, obsessions, fears, dread
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Prevalence One of the most prevalent psychiatric disorders in
the general population
Up to 25% of US population lifetime
Up to 21% of cancer patients / 70 % with sx
Often no previous history of anxiety
Greatly increased risk if 1st degree relative with an anxiety disorder
Often un- or under-diagnosed
Many cancer patients develop PTSD symptoms
Research on cultural differences lacking, but little evidence of differences
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Course . . .
Significant impairment in physical and psychosocial functioning
Significant decrease in quality of life
Increased : ETOH use
Marital problems
Work related problems
Suicide
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. . . Course
Patients will improve with treatment
Few achieve full or sustained remission Maintenance therapy important and
necessary
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Assessment
Detailed history
Screening questions: Do you worry a lot? Are you often fearful? Do you feel anxious, nervous, or on edge?
Tools: Hospital Anxiety and Depression Scale Profile of Mood States
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Anxiety Disorders
Adjustment Disorder
Panic Disorder
Post-traumatic Stress Disorder
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Social Phobia
Specific Phobia
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Adjustment Disorder with Anxious Features
Reaction to a stressor within 3 months of onset of stressor
Lasts < 6 months after cessation of stressor
Distress is in excess of what is expected
Marked impairment in functioning
Diagnostic and Statistical Manual of Mental Disorders. 4th text revision ed. Washington, DC: American Psychiatric Association; 2000
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Panic Sudden onset of intense terror, apprehension,
fearfulness, or feeling of impending doom
Comes out of no where in unexpected situations, lasting 15 – 30 minutes
Usually occurring with autonomic symptoms Shortness of breath, sense of choking Heart racing or palpitations, chest pain Shaking, sweating, hot flashes Dizziness, tingling Fear of going crazy, losing control, death
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Post-Traumatic Stress Disorder
Traumatic event Diagnosis of an advanced, life-threatening illness
Nightmares
Intrusive memories
Re-experiencing
Avoidance
Hyper-arousal
Hyper-vigilance
Diagnostic and Statistical Manual of Mental Disorders. 4th text revision ed. Washington, DC: American Psychiatric Association; 2000
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Generalized Anxiety Disorder
State of constant, excessive, pervasive anxiety or worry
Lasting ≥ 6 months
Impacting day-to-day activities
Diagnostic and Statistical Manual of Mental Disorders. 4th text revision ed. Washington, DC: American Psychiatric Association; 2000
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Sue . . .
46 year-old married Caucasian female
Breast cancer diagnosed 3 years prior
Since her prognosis of 6 months or less: Increasingly worried about her husband
Inability to get good sleep
Inability to focus on anything other than “getting everything in order for him”
Thinking of this gets her “heart racing”
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. . . Sue
What anxiety disorder does Sue have? Adjustment Disorder with Anxious Features
Reaction to a stressor within 3 months of onset of stressor
Distress is in excess of what is expected
Marked impairment in functioning
Does not meet criteria for another anxiety disorder
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Differential Diagnosis . . .
Organic vs. Primary Anxiety Disorder Think organic if: Onset of symptoms after age 35
Lack of personal or family history of anxiety
Poor response to anxiolytics
Differentiate from other Psychiatric Disorders Depression, psychosis
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. . . Differential Diagnosis
Neurological: Seizures Stroke Pain
Endocrine: Hyperthyroidism Hyperparathyroidism Hyperadrenalism
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. . . Differential Diagnosis
Drug Induced: Caffeine Cocaine Amphetamine Theophylline Corticosteroids Thyroid hormone Antipsychotics (akathisia) SSRIs (akathisia)
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. . . Differential Diagnosis
Drug withdrawal: Alcohol
Sedative-hypnotics
Narcotics
Nicotine
Toxic-metabolic abnormalities: Acidosis
Hyperthermia
Electrolyte imbalances
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. . . Differential Diagnosis
Hypoxia (Cerebral Anoxia) Respiratory COPD Respiratory Distress Pulmonary Embolism
Cardiovascular Arrhythmias Angina CHF Anemia MI
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Management
Supportive counseling
Relaxation techniques
Pharmacotherapy
Combinations are best
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Supportive counseling
Weave into routine care Include family when possible
Improve understanding of situation
Educate about modifiable factors
Create a different perspective
Identify strengths, coping strategies
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Relax . . .
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Complimentary therapies Guided imagery
Muscle relaxation
Hypnosis
Meditation
Massage
Aromatherapy
Healing Touch
Energy therapy
Biofeedback
Exercise (if possible)
Bright light exposure
Avoid caffeine, alcohol
Treat insomnia
Payne DK, Massie MJ. Anxiety in palliative care. In: Breitbart W, ed. Handbook of Psychiatry in Palliative Medicine. New York, NY: Oxford University Press; 2000:435 Carter C, Holloway R, Schwenk TL. Patient Care. November 15,1994:36–52.
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Acute Anxiety in the Medically Well
Benzodiazepines – ideal for short term management, may play a role long term Anxiolytics, muscle relaxants, amnestics Contraindicated in elderly/medically ill (amnesia, delirium, falls)
Choose based on half-life ( t½ ) Almost never more than one at a time Taper slowly to avoid withdrawal
Triozzi PL, Goldstein D, Laszlo J. Contributions of benzodiazepines to cancer therapy. Cancer Invest. 1988;6(1):103-111
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Chronic Anxiety in the Medically Well
SSRIs (e.g. paroxetine, sertraline, escitalopram) Latency 2–4 weeks
Well tolerated
Once-daily dosing
Start with lower doses in anxiety or advanced illness (can cause anxiety)
Titrate to therapeutic dose Often higher than needed for depression
Check for medication interactions
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Alternatives/1st Line in the Medically ill
Gabapentin (100 mg q1hr)
Trazodone (25-50 mg q1hr)
Buspirone
Valproate/other anticonvulsants
Opioids?
Atypical antipsychotics? Schatzberg AF, Cole JO, DeBattista C. Manual of Clinical Psychopharmacology. 4th ed. Washington, D.C: American Psychiatric Pub.; 2003.
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. . . Sue
How do you want to treat Sue’s anxiety? Complimentary Therapies
Counseling/Psychotherapy
+/- Trazodone for sleep
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. . . Key Points
What anxiety is
How anxiety is assessed
How anxiety is managed