• Anxiety out of proportion to the level of threat
• Persistence or deterioration without intervention (>3 weeks)
• Symptoms that are unacceptable regardless of the level of threat, including
  Recurrent panic attacks
    Severe physical symptoms
  Abnormal beliefs such as thoughts of sudden death

• Disruption of usual or desirable functioning.

Unfortunately, there are few studies of the natural course of anxiety in physically ill patients, so it can be difficult to judge the distinction between normal and abnormal anxiety. In particular, some of the criteria used can be difficult to apply when a patient is experiencing a real threat of disease. A more reliable basis for diagnosing morbid anxiety is often that it causes unacceptable and disruptive problems in its own right.

Abnormal anxiety can present with various typical symptoms and signs, which include

• Autonomic overactivity
• Behaviours such as restlessness and reassurance seeking
• Changes in thinking, including intrusive catastrophic thoughts, worry, and poor concentration
• Physical symptoms such as muscle tension or fatigue.

Classification of abnormal anxiety
Abnormal anxiety can be classified according to its clinical features. In standardised diagnostic systems there are four main patterns of abnormal anxiety.

Anxious adjustment disorderAnxiety is closely linked in time to the onset of a stressor.

Generalised anxiety disorderAnxiety is more pervasive and persistent, occurring in many different settings.

Panic disorderAnxiety comes in waves or attacks and is often associated with panicky thoughts (catastrophic thoughts) of impending disaster and can lead to repeated emergency medical presentations.

Phobic anxietyAnxiety is provoked by exposure to a specific feared object or situation. Medically related phobic stimuli include blood, hospitals, needles, doctors and (especially) dentists, and painful or unpleasant procedures.

Additionally, anxiety often presents in association with depression. Mixed anxiety and depressive disorders are much more common than anxiety disorders alone. Treatment for the depression may resolve the anxiety. Anxiety can also be the presenting feature of other psychiatric illnesses common in physically ill people, such as delirium or drug and alcohol misuse.

	Detecting anxiety and panic

Top What is anxiety? Detecting anxiety and panic Treatment of anxiety and...

Who is at risk?Certain groups are more vulnerable to anxiety disorders: younger people, women, those with social problems, and those with previous psychiatric problems. However, such associations are less consistent in the setting of life threatening illness, perhaps because susceptibility to anxiety becomes less important as the stressor becomes more severe. Pathological anxiety is commoner among patients with a chronic medical condition than in those without.

View larger version (24K): [in this window] [in a new window]   Common physical problems that may be caused by anxiety

Excluding physical causesThere are many presentations with physical complaints whose aetiology may be due to anxiety. Equally, several physical illnesses can cause anxiety or similar symptoms. When such disorders cannot be reliably distinguished from anxiety by clinical examination they need to be excluded through appropriate investigation. A firm diagnosis of anxiety should therefore be made only when a positive diagnosis can be supported by the presence of a typical syndrome and after appropriate investigation.

Use of screening questionnairesScreening, with self completed questionnaires, has been widely used to improve detection of psychiatric morbidity, including anxiety. Such questionnaires are acceptable to patients and can be amenable to computerised automation in the clinic. The hospital anxiety and depression scale, the general health questionnaire, and many quality of life instruments include anxiety items. No one questionnaire has been consistently shown to be preferable to another.

Iatrogenic anxietyAnxiety symptoms can be caused by poor communication (see first two articles in this series) and by prescribed drugs. Well known causes include corticosteroids,  adrenoceptor agonists, and metoclopramide, but doctors should remember that many less commonly used drugs can cause psychiatric syndromes.

	Treatment of anxiety and panic

Top What is anxiety? Detecting anxiety and panic Treatment of anxiety and...

Role of non-specialists
Treating anxiety is part of the management of most medical conditions. It can lead to direct improvement of symptoms or improve patient compliance. It is important to intervene if a positive diagnosis of anxiety is made. Without treatment, anxiety is associated with increased disability, increased use of health service resources, and impaired quality of life.

Involving a mental health professional is not always possible for anxious patients, particularly those in general hospital settings. The range of available services is often limited, and not all patients are prepared to accept referral. Since many patients have to be managed without recourse to psychiatric services, treating anxiety should be considered a core skill for all doctors.

Giving information is often the first step in helping anxious patients, so much so that it has been said that knowledge is reassurance. While information must be tailored to the wishes of the individual, many patients want more information than they are given. Such a simple step as showing people where they are to be cared for can reduce anxiety.

Effective communication is central to information giving, with evidence that anxiety is associated with poor communication. Training doctors to use open questions, discuss psychological issues, and summariseand to avoid reassurance, "advice mode," and leading questionshas been shown to lead to greater disclosure and enduring change in patients with psychological problems.

Reassurance is one of the most widely practised clinical skills. Doctors often need to tell patients that their symptoms are not due to occult disease. Simple reassurance, however, may be ineffective for anxious patients; their anxiety may be reduced initially by the consultation, but it rapidly returns. Several theoretical models of this problem have been suggested, based on the patterns of thinking ("cognitions") of people who are difficult to reassure.

View larger version (26K): [in this window] [in a new window]   Characteristic features of health anxiety (using the example of asthma)

Preparation for unpleasant procedures can remove the additional burden of facing the unknown. It may also allow planning of short term tactics for dealing with anxiety provoking circumstances. Anxious patients are highly vigilant and overaware of threatening stimuli. They often use "quick fix" techniques based on avoidance of threat to reduce anxiety; such strategies are generally maladaptive and result in increasing disability. In some medical situations, however, such avoidance may not be a bad thing if the threat is temporary. A similar effect is seen with use of benzodiazepine to provide temporary relief from anxiety symptoms that will not recur because the stressor is not persistent.

Behavioural treatments are among the most effective treatments for anxiety disorders. Many patients restrict their activities in response to anxiety, which often has the effect of increasing both the level of anxiety and the degree of disability in the longer term. The principle of treatment is that controlled exposure to the anxiety producing stimulus will eventually lead to diminution in symptoms. Although specific behavioural treatments will normally be conducted by specialists, other clinicians should be aware of the basic principles. It is important to encourage and help patients to maintain their normal activities as much as possible, even if this causes temporary increases in anxiety.

Drug treatmentsSeveral drugs can be used to treat anxiety, each with its own advantages and disadvantages. Long term benzodiazepine dependence and misuse are considered by many to be a problem in medical practice. Although the evidence for this is conflicting, the use of benzodiazepines may be reserved for the short term treatment of anxiety and for emergencies.

Drug withdrawalDependence on other substances, particularly analgesics and alcohol, occurs fairly frequently in the context of anxiety. This often results from self medication for anxiety. In this situation withdrawal from the existing "treatment" will be an important part of the anxiety management programme.

Role of specialist treatment in brief psychological therapies
Clinical studies indicate that psychological interventions for anxiety can be effective both in general psychiatric settings and for physically ill patients. The most popular, and those with the best evidence to support them, are based on the principles of behaviour, cognitive behaviour, or interpersonal therapy.

In behaviour and cognitive behaviour therapies the main aim is to help patients identify and challenge unhelpful ways of thinking about and coping with physical symptoms and their meaning, about themselves, and about how they should live their lives. In interpersonal therapies the main focus is on relationships with family members and friendshow such relationships are affected by illness and how they influence patients' current emotional state. Patients need to know that such therapies may be both brief and practical. Fewer than six sessions may be enough, concentrating on symptoms or the immediate problems associated with them and learning new ways of dealing with problems. In only a minority of cases is more extended therapy needed, usually when anxiety is longer standing and only partially due to associated physical disease.

	Footnotes

Allan House is professor of liaison psychiatry at the Academic Unit of Psychiatry and Behavioural Sciences, School of Medicine, University of Leeds. Dan Stark is specialist registrar in medical oncology at the Academic Unit of Oncology, St James's University Hospital, Leeds

The ABC of psychological medicine is edited by Richard Mayou, professor of psychiatry, University of Oxford; Michael Sharpe, reader in psychological medicine, University of Edinburgh; and Alan Carson, consultant neuropsychiatrist, NHS Lothian, and honorary senior lecturer, University of Edinburgh. The series will be published as a book in winter 2002.

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