QUICK LESSON ABOUT. Anxiety, Health-Related. Description/Etiology. Facts and Figures

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1 QUICK LESSON ABOUT ICD ICD-10 F41.1 Author Jessica Therivel, LMSW-IPR Cinahl Information Systems, Glendale, CA Anxiety, Health-Related Description/Etiology Anxiety is caused by the negative anticipation of a threat or an event that has not yet happened. It may manifest in both physical and psychological ways. Anxiety can contribute to physical health conditions and illnesses, and result from them; the anxiety and the physical illness may negatively affect one another in a feedback loop. Some clients may meet the diagnostic criteria detailed in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), for anxiety due to another medical condition disorder. This does not mean that the client has a chronic or terminal illness and feels anxiety as a result of diagnosis or coping with that illness (that is, the client develops anxiety secondary to the illness). Instead, for anxiety due to a medical condition to be diagnosed, the client must have a medical condition that manifests anxiety as a physiological symptom (e.g., hyperthyroidism, congestive heart failure, asthma, B12 deficiency). No matter the cause of the anxiety, it needs to be treated with appropriate interventions that acknowledge the presence of a medical illness. Clients with health issues who are experiencing anxiety may or may not meet the DSM-5 criteria for a diagnosis of panic disorder, generalized anxiety disorder, or phobic disorder, all of which can occur in persons with chronic illness. Yet they may still be experiencing anxiety that is disrupting their activities of daily living, causing distress, and having a negative effect on their health-related quality of life (HRQoL); this level of anxiety should be addressed and treated. Certain chronic physical illnesses (e.g., heart disease, chronic respiratory disease, asthma, diabetes, gastrointestinal illnesses), or illnesses such as cancer, frequently cause anxiety in clients, and can make the disease worse, make the disease and its symptoms more difficult to treat, and increase morbidity and mortality. Treatment for health-related anxiety may include evaluation, psychotherapy, psychopharmacology with anti-anxiety medications, relaxation therapy, and education on wellness. Rather than attempting to find the source of health-related anxiety, clinicians should seek to improve client functioning, reduce unhealthy client behaviors, decrease the anxiety and stress level associated with chronic health conditions, and significantly reduce any symptoms of anxiety. Facts and Figures It is estimated that in 30% of individuals with anxiety disorders, the disorder is unrecognized (Harvard University, 2018). Among cancer patients studied, 15% to 23% experienced general anxiety, but with disease progression the number increased to 69% (Evans et al., 2005; Australian Cancer Network, 2004). Researchers reported that women with the highest levels of phobic anxiety were 59% more likely to have a cardiac event and the event was 31% more likely to be fatal when compared to women with the lowest levels of anxiety (Harvard University, 2018). Men and women who had the comorbidity of heart disease and an anxiety disorder were twice as likely to have a heart attack as heart disease patients without any anxiety disorder diagnosis (Harvard University, 2008). A study of post-stroke men and women found that 37% had generalized anxiety, and that stroke related fatigue was significantly associated to generalized anxiety, health-related anxiety, and stroke specific anxiety (Gallagan et a., 2016). July 27, 2018 Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright 2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

2 Risk Factors Women are at a significantly higher risk for symptoms of anxiety and diagnosis of an anxiety disorder. Clients who are obese are at a higher risk for health-relatedanxiety due to their higher risk for health problems. Clients who have cancer, heart disease, lung disease, or diabetes are at an increased risk for anxiety symptoms. Stress that is severe and persistent can cause anxiety and lead to unhealthy behaviors that increase the risk for chronic health conditions. Clients in highly stressful social or work environments thus face an increased risk of physical health conditions and illnesses. Signs and Symptoms/Clinical Presentation Psychological: panic attacks, feelings of fear and anxiousness, worry across multiple domains, irritability, trouble concentrating, fear of losing control, fear of dying Behavioral: forgetfulness, sleep disturbances, appetite disturbances, avoidance behaviors Physical: restlessness, nervousness, muscle tension, sweating, nausea, diarrhea, dizziness, shortness of breath, accelerated heart rate, headaches, irritable bowel, numbness or tingling Social: withdrawal from social supports, difficulties at work, school, or with interpersonal relationships Social Work Assessment Client History Assess client by taking a complete biopsychosocialspiritual history in order to explore all potential symptoms of anxiety and any physical health issues Assess and explore social and family functioning and measure available social supports Assess for suicidal ideation Assess client for substance or alcohol use disorders, which often co-occur with anxiety Relevant Diagnostic Assessments and Screening Tools Evaluate client to see if DSM-5 diagnostic criteria for any specific anxiety disorders is met Use appropriate screening tools for assessment of anxiety specific to medical illness, such as the Cardiac Anxiety Questionnaire (CAQ) Use appropriate screening tools to measure HRQoL related to specific illnesses, such as the Functional Assessment of Cancer Therapy General (FACT-G) Beck Anxiety Inventory to assess the severity of client-reportedanxiety Generalized Anxiety Disorder 7-Item Scale (GAD-7) Laboratory and Diagnostic Tests of Interest to the Social Worker Check for any available screens for alcohol or substance use If anxiety due to a general medical condition is suspected, request laboratory tests or medical examination to confirm the presence of the medical condition that is inducing the anxiety Social Work Treatment Summary Some clients may benefit from pharmacotherapy alone, but the majority will benefit most from behavioral, psychological, and psychoeducational interventions that may also include pharmacotherapy. Cognitive-behavioral therapy (CBT) and psychodynamic therapy are the most commonly used psychological interventions for clients with health-related anxiety. CBT helps clients target the thoughts that are causing anxiety and work on changing behaviors in situations that are causing anxiety. Psychodynamic therapy focuses on the roots of the emotional conflicts or traumas that might be contributing to the anxiety. A client s self-concept can be affected by illness, developmental stage, and stress. The social worker should consider the client s self-concept (e.g., identity, body image, self-esteem, and role performance) when designing therapeutic interventions. Clients also benefit from stress-management programs that reduce overall stress while promoting a healthier lifestyle. Examples include yoga, exercise programs, diets, relaxation training, and meditation. Mindfulness-based stress-reduction interventions are also used to reduce anxiety related to medical illnesses. Social workers should be aware of their own cultural values, beliefs, and biases, and develop specialized knowledge about the histories, traditions, and values of their clients. Social workers should adopt treatment methodologies that reflect their knowledge of the cultural diversity of the communities in which they practice.. Problem Goal Intervention

3 Diagnosis of cancer or other terminal illness and increased signs and symptoms of anxiety Decreased anxiety symptoms and increased ability to engage in treatment plan for medical condition Screen client for depression and anxiety. If present, include (with client s permission) oncologist or other specialist and primary care physician to address any mental health needs as disease treatment plan is developed. Utilize CBT, psychodynamic therapy, or address self-concept as appropriate. Refer client to disease support group that matches his or her age and diagnosis to help reduce isolation and feelings of worry and anxiety. Address areas of functioning that are causing anxiety for client (e.g., financial worries, worries about missing work, interpersonal issues and fears)

4 Diagnosis of a chronic medical illness with anxiety and stress resulting from the diagnosis and symptoms of illness Decreased symptoms of anxiety and increased acceptance of and adjustment to medical illness; positive engagement in treatment for medical condition Encourage client to have a realistic but positive approach to the illness. Enhance client s resilience by encouraging connections with family, friends, and social supports that will provide assistance and support. Help the client to develop realistic goals instead of focusing on the unachievable. Teach problem-solving skills to improve client s selfefficacy. Utilize CBT to identify and avoid cognitions that are causing anxiety and change behaviors in anxietyprovoking situations. Assist client with stress reduction by examining areas of stress and finding more effective ways to cope. Utilize psychodynamic therapy as needed to examine any deeprooted emotional conflicts or traumas that are contributing to anxiety symptoms. Teach or refer for relaxation therapy techniques to reduce somatic and emotional symptoms of anxiety. Work with client on identifying wellness approaches that may reduce anxiety and physical symptoms (e.g., diet, exercise program, sleep study). Applicable Laws and Regulations There are no specific laws or regulations related to anxiety and health-related issues Each country has its own standards for cultural competency and diversity in social work practice. Social workers must be aware of the standards of practice set forth by their governing body (e.g., National Association of Social Workers in the United States, British Association of Social Workers in England) and practice accordingly Social workers should practice with awareness of, and adherence to, the social work principles of respect for human rights and human dignity, social justice, and professional conduct as described in the International Federation of Social Workers (IFSW) Statement of Ethical Principles Available Services and Resources Online or community support resources for the client s particular health need (e.g., cardiac rehabilitation, cancer support groups, diabetic education/support) may help reduce anxiety the client is feeling about the illness

5 The Anxiety and Depression Association of America, offers support and resources for clients and professionals The National Alliance on Mental Illness (NAMI) provides online community support for anxiety, Anxiety BC lists resources for all of Canada at Food for Thought Anxiety may need to be considered a risk factor with pulmonary diseases, not just a comorbidity Poor mental health will reduce adherence to care plans for physical illnesses; individuals with mental health problems may be reluctant to come to primary care for treatment of their physical illnesses Participants in a study of health-related anxiety associated with escalation of online searches for health information (e.g., continuing a search, finding information about a symptom that linked it to a serious illness) had increases in anxiety post-search. Increases were recorded for participants who had pre-search baselines of low and high anxiety (Singh & Brown, 2016) Red Flags Any client who wishes to pursue a wellness strategy for improved stress management (e.g., yoga, diet changes) needs to have medical clearance from his or her physician Physicians who ignore the mind-body connection between anxiety and physical illness may underdiagnose anxiety in their patients Discharge Planning Educate client and family on connection between anxiety and health-relatedissues Ensure that client s physician is aware of client s anxiety, if client clears the release of that information Refer client and/or family to community support and support groups that are relevant for the client s health problem Provide referral information for online support and resources on anxiety to provide additional strategies References 1. American Psychiatric Association. (2013). Anxiety disorders. In Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (5th ed., pp ). Arlington, VA: Author. 2. Australian Cancer Network. (2004). Clinical practice guidelines for the prevention, diagnosis, and management of lung cancer. Sydney: Australian Cancer Network, Cancer Council of Australia. 3. British Association of Social Workers (BASW). (2012). The code of ethics for social work: Statement of principles. Retrieved June 22, 2015, from 4. Daniels, R., Grendell, R., & Wilkins, F. (2010). Nursing fundamentals: Caring and clinical decision making (2nd ed.). Clifton Park, NY: Delmar Cengage Learning. 5. Deimling, G. T., Brown, S. P., Albitz, C., Burant, C. J., & Mallick, N. (2017). The relative importance of cancer-related and general health worries and distress among older adult, long-term cancer survivors. Psycho-Oncology, 26, Evans, D. L., Charney, D. S., Lewis, L., Golden, R. N., Gorman, J. M., Krishnan, K. R. R,... Valvo, W. J. (2005). Mood disorders in the medically ill: Scientific review and recommendations. Biological Psychiatry, 58(3), Galligan, N. G., Hevey, D., Coen, R. F., & Harbision, J. A. (2016). Clarifying the associations between anxiety, depression and fatigue following stroke. Journal of Health Psychology, 21(12), Harvard Women s Health Watch. (2018, May). Anxiety and physical illness. Harvard Health Publishing. Retrieved May 12, 2018, from 9. Hedman, E., Ljotsson, B., Axelsson, E., Lekander, M., Karshikoff, B., & Axelsson, J. (2016). Health anxiety in a disease-avoidance framework: Investigation of anxiety, disgust, and disease perception in response to sickness cues. Journal of Abnormal Psychology, 125(7), Humble, M. N., & Slater, G. Y. (2011). Cancer does not phase us: Exploring anxiety levels in rural oncology patients. Journal of Human Behavior in the Social Environment, 21(6), International Federation of Social Workers. (2012). Statement of ethical principles. Retrieved June 22, 2015, from Kim, S., & Lee, J. H. (2016). Time course of attention bias of health-related information in individuals with health anxiety. Journal of Health Psychology, 21(8), Kirkwood, G., Rampes, H., Tuffrey, V., Richardson, J., & Pilkington, K. (2005). Yoga for anxiety: A systematic review of the research evidence. British Journal of Sports Medicine, 39(12), doi: /bjsm Muschalla, B., Glatz, J., & Linden, M. (2014). Heart-related anxieties in relation to general anxiety and severity of illness in cardiology patients. Psychology, Health, & Medicine, 19(1), doi: / National Association of Social Workers. (2015). Standards and indicators for cultural competence in social work practice. Retrieved May 12, 2018, from Singh, K., & Brown, R. J. (2016). From headache to tumor: An examination of health anxiety, health-related Internet use and query escalation. Journal of Health Psychology, 21(9), Smith, B., Metzker, K., Waite, R., & Gerrity, P. (2015). Short-form mindfulness-based stress reduction reduces anxiety and improves health-related quality of life in an inner-city population. Holistic Nursing Practice, 29(2), doi: /hnp

6 18. Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10),