Anxiety Management

Definition and Diagnosis

Anxiety disorders are characterized by symptoms that cause clinically significant distress or impairment in functioning, and must be differentiated from other medical conditions, such as unrelieved pain, fatigue, infection, or electrolyte imbalance, and substance-induced causes, including caffeine, alcohol withdrawal, or medication side effects 1, 2, 3
A diagnosis of Generalized Anxiety Disorder requires symptoms to persist for at least 6 months, include excessive anxiety and worry that is difficult to control, be accompanied by at least 3 of 6 physical or cognitive symptoms, and cause clinically significant distress or impairment in functioning 2
Symptoms of anxiety disorders may present differently across age groups and cultures, with some individuals experiencing predominantly somatic symptoms rather than psychological ones 1, 4

The Hospital Anxiety and Depression Scale (HADS), the Screen for Child Anxiety Related Emotional Disorders (SCARED), and the Spence Children's Anxiety Scale (SCAS) are tools used to assess anxiety, with a HADS score ≥8 indicating possible anxiety disorder 1, 3
The Generalized Anxiety Disorder-7 (GAD-7) scale can be used to assess anxiety severity, with higher GAD-7 scores (15-21) often associated with more severe symptoms 3

Autonomic nervous system activation symptoms include trembling or shaking, sweating, tachycardia, tachypnea, sweaty palms, hyperventilation, and chest pain 3
Musculoskeletal symptoms include muscle tension and stiffness, muscular cramps and twitching, fatigue and tiredness, and weakness 2, 3
Cognitive symptoms include excessive anxiety and worry about multiple events/activities, difficulty controlling worry, difficulty concentrating or mind going blank, memory impairment, and cognitive disorder/confusion 2, 3
Emotional symptoms include irritability, feeling on edge, feeling keyed up or restless, fear and apprehension, emotional distress, and decreased interest in activities 2, 3
Sleep disturbances include difficulty falling asleep, difficulty staying asleep, restless and unsatisfying sleep, and insomnia 2, 3
Behavioral changes include avoidance behaviors, restlessness or feeling keyed up, impaired coordination, and decreased functioning in social, occupational, or other important areas 2, 3

Family history of anxiety disorders, comorbid psychiatric disorders, history of alcohol or substance use/abuse, and presence of other chronic illnesses are all potential risk factors for anxiety disorders 3
Thoughts of self-harm or suicide, severe agitation, confusion or psychosis, and inability to care for basic needs are all potential indicators of severe anxiety or other underlying conditions 3

The American Society of Clinical Oncology recommends benzodiazepines for short-term relief of moderate to severe anxiety with significant distress, but notes that they should be time-limited due to the risk of dependence 3
The American Society of Clinical Oncology recommends SSRIs or SNRIs as first-line medications for long-term management of anxiety disorders, with the highest level of evidence, and notes that they require 4-8 weeks for full therapeutic effect 3

The European Society of Cardiology recommends providing oxygen therapy if oxygen saturation is <90% 5

The American Society of Clinical Oncology recommends referring patients for cognitive behavioral therapy (CBT), which has the highest level of evidence for anxiety disorders 3
Psychoeducation about the nature of derealization as a symptom of anxiety rather than a sign of "going crazy" is important for reducing catastrophic interpretations, as recommended by the American Psychiatric Association 2

The American Society of Clinical Oncology recommends scheduling follow-up within 2-4 weeks to assess treatment response, and considering altering treatment approach after 8 weeks if symptoms persist despite good compliance 3
The American Society of Clinical Oncology notes that depression occurs in 50-60% of patients with anxiety disorders, and recommends monitoring for comorbidities 3