Anxiety is, in many ways, a normal and appropriate response to a diagnosis of cancer. The words "you have cancer" release a torrent of concerns about your future, the treatment ahead, your uncertain future, and your life and that of your family.

Anxiety has been defined as a reaction to a threat, and cancer is a very serious threat to a person's well-being and life itself. A person's initial response of anxiety and fear is part of a coping mechanism common to most of us: recognize the threat and react to the implications of that threat. Then, as time passes, we move forward into coping with the threat. For some people, the intensity level of anxiety about cancer may not subside, and it becomes the dominant emotion of life. If your anxiety is great, and continuing, it can interfere with your quality of life, and your ability to make sound decisions and interact with others in your life.

Generally, anxiety is classified in two ways:

• Acute anxiety, lasting for a relatively short period of time, is characterized by an array of physical symptoms including rapid heartbeat, elevated blood pressure, chest pain, shortness of breath, feelings of suffocation, sweating or chills, dizziness, trembling, and nausea. Sometimes this is called a "panic attack" because the obvious physical stress of the person enduring such an attack resembles the symptoms of panic.
  
  A note of caution: if you or someone you know complains of chest pain, shortness of breath and other similar symptoms without direct cause, such as anxiety, don't hesitate to get emergency help. These symptoms can also be the warning signs of a heart attack.
  
  
• Chronic anxiety is marked by symptoms that linger on, sometimes for weeks or longer, including excessive, constant worrying, tension, insomnia, irritability, fatigue, difficulty concentrating and inability to make decisions.

Causes of Anxiety

The causes of anxiety in the face of a cancer diagnosis include:

• A very intense and/or prolonged emotional and physical response to the diagnosis, including worry and fear about dying, the process of dying (pain and suffering), the treatments ahead, medical procedures, loss of control, loss of intimacy, bodily disfigurement, fear of isolation and abandonment, and more.
  
  
• Some medications can cause anxiety in patients, including:
  
  
  • Corticosteroids. These can stimulate hyperactivity, inability to concentrate, a feeling of being out of control and other symptoms. Corticosteroids include prednisone (Deltasone) and dexamethasone (Decadron), and are used to treat inflammation and swelling as well as certain cancers. Consequently, these medications are commonly used as part of cancer treatment. While most people can take corticosteroids safely, on occasion they can trigger sudden, severe anxiety, which can be frightening to patients and their caregivers.
    
    
  • Bronchodilators. As inhalers or in tablet form, bronchodilators can trigger intense nervousness and agitation.
    
    
  • Antihistamines can also cause oversensitivity, irritability and nervousness. Antihistamines are medications often used to combat allergies
    
    
• Some medical conditions appear to make severe anxiety more likely:
  
  
  • Cancer metastases (spread of the cancer) to a patient's central nervous system
    
    
  • Lung cancer
    
    
  • Any condition requiring prolonged treatment with corticosteroids
    
    
• Some emotional experiences and conditions are seen as predecessors to anxiety, including:
  
  
  • Ongoing difficulty in communicating well with other people
    
    
  • Being socially isolated, without close friends and family
    
    
  • Negative personal experiences with other illnesses in the past, including past cancer treatment

Symptoms

The American Cancer Society lists these physical and emotional symptoms of cancer-related anxiety:

• Expression of anxiety
• Denial of obvious tension or anxiety
• Uncontrolled worry
• Difficulty solving problems and concentrating
• Muscle tension
• Trembling, shaking, other signs of restlessness
• Shortness of breath
• Racing heart
• Sweating
• Dry mouth
• Angry outbursts
• Irritability

What is unspoken here, but felt and seen by people with serious anxiety and those close to them is that extreme anxiety appears to almost possess the person experiencing it. The rest of the world fades away, and your mind is caught up in what feels like an endlessly-repeating cycle of fear and worry, fear and worry, with no way to interrupt the spinning. You feel you cannot control your thoughts, and your body responds to this extreme tension, tightening and constricting the lungs, muscles and stomach. Extreme anxiety is a prison of fear for body, mind and spirit.

Diagnosis & Treatment

Helping Yourself
In some cases of anxiety, it may be possible for you to find some acceptable and successful ways to cope with your anxiety. Patients and health care providers suggest trying these coping mechanisms:

• Get it out. Seek ways to release tension. Some ideas include having a good cry, pounding a pillow, and talking with someone close to you about your fears.
  
  
• Let it go. Practice relaxation techniques. These can include listening to relaxation tapes, deep breathing, imagery/visualization, yoga, massage and meditation. Please visit the Alternative and Complementary Medicine section of the NCCS Resource Guide for a list of organizations, Websites and publications with more information about these approaches.
  
  
• Redirect energy. Exercise — even a little — can help bring calm as it dissolves unwanted tension. Walking is an inexpensive and reliable approach, and doesn't require expensive equipment or a lot of time. You might consider exercise routines like Tai Chi and yoga, as well. Before starting an exercise routine, check with your health care team.
  
  
• Give and accept help. Support groups can prove very helpful to some people. Being with people who understand your situation because of their own life experiences can be comforting and informational. If possible, participate in a support group managed by a trained facilitator (often a social worker, counselor or nurse). There are also successful groups led by skilled, trained peer counselors.
  
  
  • If you don't choose to physically attend a support group, consider online support communities, often focused on specific cancers and related conditions. See the NCCS Resource Guide for more information.
    
    
  • See the section on Finding Support for more information.
  
  
• Write it down. Journaling — keeping a daily or frequent, private written record of your life and experiences with cancer — reduces anxiety for some people. Your journal is a private place where you are free to express your thoughts and emotions, without the interruption or judgment of others. See the Writing to Heal Website to learn more and for information on how to get started.

Beyond Self Help
When anxiety is almost constant, or if you are experiencing panic attacks (acute anxiety), your quality of life is undermined. Now is the time for more support than self-help can provide.

Begin by talking with your health care team about your ongoing anxiety and ask for their assistance in a thorough assessment of your condition and for recommendations for additional support and treatment. Some cancer facilities have individuals on staff called psycho-oncologists, psychologists who have a special interest and training in patient psychological responses to cancer. Psycho-oncologists are experts in the psychological aspects of cancer. A person like this would be an excellent resource in evaluating and treating your emotional adjustment, including your anxiety. Other cancer facilities may work with psychiatrists, psychologists, social workers and counselors experienced in cancer management — and they, too, are good referrals for you to consider.

Assessment
This is a time for honesty and candor. When meeting with the individual who will help you make treatment choices for your anxiety, it is critical to speak openly about your feelings and symptoms. This health care professional will be seeking information to help her or him make recommendations about counseling and medication that will be tailored just for you — so the more forthcoming you are about your symptoms, the more the recommendations you are given are likely to work.

Next Steps
Your psychological counselor may recommend a variety of approaches to treating your anxiety, including:

• Counseling sessions
• Relaxation exercises
• Medication

In the course of counseling, you may participate in a variety of what are called "behavioral interventions" — techniques health care professionals use, such as hypnotherapy, relaxation techniques, guided imagery training and distraction therapy. All of this will have your anxiety and the relief of it at the base, as the counselor works to help you find ways to regain control of your fears — and your life. Please visit the Alternative and Complementary Medicine section of the NCCS Resources Guide for a list of organizations, Websites and publications with more information about these techniques.

Medications, if needed, should be tailored to your situation, taking into account your cancer treatment and other medical conditions. Medications frequently used to treat anxiety include anxiolytics and antidepressants, either alone or in combination for a period of time. They are quite safe when taken as directed.

• Anxiolytics include benzodiazepine medications that work in short-, intermediate- and long-lasting formulations. Your health care provider will choose a medication suited to your needs. Some frequently-prescribed medications include:
  
  
  • Alprazolam (Xanax)
  • Buspirone (BuSpar)
  • Chlordiazepoxide (Librium)
  • Clonazepam (Klonopin)
  • Diazepam (Valium)
  • Lorzaepam (Ativan)
  • Temazepam (Restoril)
  • Triazolam (Halcion)
    
    
• Antidepressant medications include:
  
  
  • Selective Serotonin Reuptake Inhibitors (SSRIs). Serotonin is a neurotransmitter in the blood that affects mood; more serotonin usually means less depression. These drugs, and others that also act to reduce the dissipation of serotonin from the body, work to keep serotonin in your blood. Some of the most-prescribed are:
    
    
    • Fluoxetine (Prozac)
    • Paroxetine (Paxil)
    • Sertraline (Zoloft)
  
  
• Serotonin Norepinephrine Reuptake Inhibitors (SNRIs). These medications boost levels of norepinephrine as well as serotonin. The medication in this category often prescribed is venlafaxine (Effexor).
  
  
• Seratonin Antagonist Reuptake Inhibitors (SARIs). Yet another formulation that acts on serotonin to increase amounts in the body:
  
  
  • Nefazodone (Serzone)
  • Trazodone (Desyrel)
    
    
• Tricyclic Antidepressants. These medications and others like them have been around for many years:
  
  
  • Amitriptyline (Elavil)
  • Imipramine (Tofranil)
  • Nortriptyline (Pamelor)
    
    
• Norepinephrine Dopamine Reuptake Inhibitor (NDRI). The one medication in this category used for cancer patients is bupropion (Wellbutrin).
  
  
• Noradrenergic Specific Serotonergic Antidepressant (NaSSAs). The medication in this category used with cancer patients is mirtazapine (Remeron).

Questions to Ask Your Health Care Provider

1. How can I recognize the symptoms of anxiety?
   
   
2. How will you determine if I have anxiety and need help?
   
   
3. What help is available to me to treat my anxiety? Who will oversee my care?
   
   
4. Will treating anxiety interfere with my cancer treatment?
   
   
5. I have been feeling pretty upset and nervous for the last few days. Does this mean I am experiencing anxiety?
   
   
6. If I have anxiety that needs treatment, how long is it likely to last?
   
   
7. Is my kind of cancer or my treatment likely to cause anxiety?
   
   
8. Are the medications prescribed to me likely to cause anxiety?
   
   
9. The medication given to me for anxiety hasn't changed much for me for more than a week. I don't feel better. Is it time to try something else?
   
   
10. I have been very upset and sad that my cancer has recurred, but I figured these feelings were normal for the situation. Is it possible I have anxiety that should be treated?
    
    
11. Can you refer me to a social worker or other reliable source of information about support groups?

Resources.