To these are added many anxieties about loss which could result from illness; loss of physical integrity, social support, economic security, and finally the fear of loss of one's self.

Recent studies in general practice have shown that the amount of anxiety is increasing (H. Riebeling). Anxiety patients are often ones with a relatively unclear symptomatology. The classical neurotic anxieties which present as cardiac neurosis or cancer phobia seem rather less frequent.

Engelhardt et al. have analyzed how often anxieties appear in hospital patients. The interviewer categorized the anxious reaction of in-patients of a department of internal medicine according to the scale of "composed", "anxious" or "very anxious". Patients were found to be composed who knew that they had benign disease, and could therefore expect a mild effect. Patients who had successfully fought against unpleasant and threatening symptoms of disease, were also found in this category. "Anxious" reactions were defined as those of patients who were afraid of threatening effects of their disease, but could cope with the fear. "Great anxiety" was supposed to be present in patients who felt that their very existence was threatened, or in whom the illness led to a great amount of free-floating anxiety. The study showed that only 1 in 5 (21%) of the patients had reached an acceptance of their illness. About half of the patients (47%) showed anxious behaviour, and more than a quarter (30%) were suffering from great anxiety, related to despair or fear of death. In surgical patients an even more unfavourable picture was found by Duff and Hollingshead (1968): 10% showed minor anxieties, 30% moderate anxiety and 60% severe anxiety. Modern medicine also induces anxiety due its anonymity. This can be seen in the architecture of its clinics, hospitals and practices, in the design of the apparatus, and also in the activity which takes place. Modern medicine is hardly able to give a feeling of security. Although the illness is treated, the patient is not cared for. "Inhospitably" is becoming the trademark of hospitals, clinics and practices.

Stress-producing factors in the hospital which can provoke anxiety in patients (from K. Engelhardt et al.)

It is not necessarily the reaction of the patient to his disease, the hospital or the staff that are looking after him, which initiates the anxiety shown in this situation. It can be the expression of an unconscious conflict, the origin of which lies in the past and for which the illness is only the releasing factor. In these circumstances, the anxious reaction seems exaggerated and inappropriate. It can be very difficult to assess how serious this anxiety is in these patients, as defense mechanisms control how much of this anxiety is revealed. Typical forms of defense are displacement, denial, regression, rationalization and projection. This certainly does not apply only to neurotics, but can also be seen in otherwise "normal" patients (see chapter on discussions with terminally ill and dying patients ).

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History shows that various cultures and ages have experienced and worked through anxiety in different ways. The phenomenon of dread and anxiety were already present in the ancient Greek culture. These were bound up with certain situations and behaviour patterns along with means of resolution, and could be seen as: "Part of ethics in the frame of a world thought to be ordered by cosmic forces" (L. Beyer). The universal anxiety which is much more difficult to grasp, appeared later in Hellenism and even later in Christianity. Kierkegaard, Heidegger, Sartre and Jaspers considered anxiety a central key of their philosophies. Anxiety is taken to be a part of human nature; as a basic force of human existence. It is a basic phenomenon of human emotion. The dichotomy between anxiety (indefinite, lack of resistance, anonymous, unmotivated) and fear (definite, reaction to a particular threat or threatening situation, appropriate motivation) was initiated by Kierkegaard. People fear a certain object but can become anxious about nothing.

Anxiety about dying and death is coming to have a particular weight in our era. The thesis of man being unable to imagine personal death is gaining in importance in modern thinking. Meyer postulates that this inability to imagine one's own death will be one of the major problems of future generations. Increasing consumption, as the most important form of "having", will not succeed as compensation. Consumption is two-pronged; on one hand it decreases anxiety, as what is consumed cannot be taken away, but it also encourages the consumption of more and more, as consumption of one thing soon stops being satisfying. The modern consumer society can be identified with the slogan: "I am what I have, and what I consume" (E. Fromm).

It is exceedingly difficult for the modern Westerner to give up his tendency to possess. Deeply-seated anxiety and the feeling of loss of all sense of security would result. The phenomenon of orientation towards possessions (in contrast to the form of existence of being) as the source of many anxieties, is described by Fromm as follows: "Who am I, if I am what I have, and then lose what I have? Nothing more than a beaten, broken, pitiful person, a witness to a false way of life. As I can lose what I have, I am constantly worried that it will be lost. I fear this loss, business changes, revolutions, illness, death; I am anxious about loving, anxious faced with freedom, anxious about growing and changing and when confronted with the unknown. So I live with constant worries, and suffer from chronic hypochondria, not only with regard to disease but also every loss which could affect me..."

In a certain sense, anxiety is a fashionable symptom and this probably has accentuated the general potential for anxiety of this present age. V. Faust asks: "Are there not signs that we need anxiety, that we even seek it out as soon as we start to notice natural triggers for anxiety are missing? Do we not have a secret yearning for the weird hook - flirting with anxiety?" And Alewyn (1971) writes: "In this epoch of anxiety, many are a long way off avoiding anxiety, and rejoicing in freedom from it. On the contrary, it seems as if anxiety is found to be an unavoidable necessity: the desire for anxiety seen as flirting with it..."

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Day to day anxiety describes general conditions, which everybody knows from his own experience. They can be anticipated, are realistic, dependent on things, situations, dangers, thoughts or superstitions which release anxieties during the course of daily life (worries about illness, loneliness, darkness, people, the future or death). This is not easy to separate from neurotic anxiety, as the differences can not be quantified, and it is not always possible to discover a deeply-embedded conflict as its source. People now tend towards a somatization of their anxiety, probably as diseases of the organs have a greater "prestige value" than psychological disorders.

Freud introduced the term free-floating anxiety. This is described by von Baeyer (1971) as: "Readiness, floating backwards and forwards between normality and illness; to expect something awful to occur at any moment; to worry oneself with scrupulous anguish, a general anxiety that is independent of triggering situations and always finds - or invents - its object."

Phobic anxieties are relatively circumscribed anxieties arising from certain neuroses. The most well-known are those of cancer, collapse, blushing, or claustrophobia. Phobic anxieties can be focussed on the body, and manifest, for example, as cardiac neurosis.

Psychotic anxiety, typically seen in patients with schizophrenia or manic-depressive illnesses, counts among the most severe anxiety conditions. There is anxiety in the face of something dreadful and intangible, or strange, indescribable, incomprehensible anxieties in a sort of apocalyptic setting. Anxiety disorders form a major part of endogenous depressive symptoms.

Anxiety about understandable physical effects can be seen for example in alcoholics, or in those in the transitional period in intensive care wards. The patients are disorientated in time and space, confused and beset with intense anxieties, which may lead to enormous aggressivity.

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Illness itself is accompanied by many anxieties. One of major responsibilities of the doctor and his team has therefore to be not to fuel these anxieties by adding avoidable concerns. If one is able to feel how a patient feels who is admitted for the first time into hospital, one will immediately realize what are some of the grounds for anxiety. The initial anxiety will probably appear during the transportation accompanied by whailing sirens. In the hospital, the patient meets anonymous strangers, whose functions are not obvious. Perhaps he is referred to name (but perhaps not), or his name is mispronounced. Whatever is opening around him is taking place in a strange language, which is also abbreviated. He realizes very quickly that he is at the lower end of the hospital hierarchy. Investigations are carried out on him (some of which are stressful and others painful) the reasons for which are difficult to sort out. Lots of question concern him, for which he receives minimal or tangential answers. He finds himself regarded as an object, and has to fit in with the strict hospital routine. He sleeps in the same room as others, total strangers, and experiences their illnesses and even death.

Various chapters of this book will deal more with anxiety, the defenses of the patient and the ways that the doctor can attack it in different situations (i.e. discussions before and during stressful procedures, discussions with "difficult" patients, discussions in intensive medicine, discussions with terminally ill and dying patients).

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It is particularly important to use anxiety-inducing language as little as possible. R.S. Blacher and H.L. Levine have shown in their fine review (The Language of the Heart), how much anxiety can be induced just by terminology used if the heart is affected. The term "cardiac abnormality" often induces the picture of terminal cardiac failure. "Heart block" suggests that the blood can no longer circulate. Most lay people presume that "atrial fibrillation" means completely uncoordinated heart muscle action, and "split heart sound" can awaken dramatic pictures of torn heart muscles. A patient who hears something of a "hole in the heart" probably imagines blood leaking from this vital organ into all body cavities. Abbreviations are especially prone to release uncertainty and misunderstandings. The situation is also very difficult to follow if a doctor, instead of talking to him, speaks about him to others, or even to other patients.

The patient will certainly react with anxiety if he is not allowed to ask, if his questions remain unanswered, or if the information is evaded, and if he meets resistance to communication on all sides.

Studies have proven that it is poor communication which is more stressful than technical apparatus on the intensive ward. This is the reason why there should be flexibility with regard to visiting times and involvement of the relatives in the care of these patients. Benzer describes, how during the course of the development of the Vienna model of "psychological care of seriously ill patients" in 1977, it was possible to help a 17-year old, paralyzed from the neck downwards in a diving accident. In spite of maximal technical assistance, including an automatic writing system, doctors and nursing staff were helpless and did not know what to do, experiencing strong feelings of passive impotence. The most positive effect was achieved by the organization of visits from the parents. Although they could not come regularly, they could be summoned when the patient was particularly weak, even at night. It was only then that the patient could be brought into a state largely free of anxiety.

Whatever increases the external or internal isolation of the patient and whatever gives him the feeling that he is an object, induces anxiety and should therefore be avoided wherever possible. It is not possible to use modern medicine without a tremendous involvement of technical equipment. Anxiety about "the medical apparatus" is extensive and is made worse where there are strict legal requirements for technical explanations. An explanatory discussion and an introductory sympathetic preparatory discussion before stressful diagnostic and therapeutic procedures can be a major counterbalance to this widely distributed source of anxiety. Non-verbal signals (smiling, touching, stroking, skin-contact) are simple, and in principle always available and certainly effective tools for protecting against anxiety. Genuine cheerfulness and touches of humour can also reduce anxiety. Jokes however can cut in two directions, as they always have a "butt", which should never ever be the patient. An open attitude, presence, empathy and the ability to know what the person is going through, are the best conditions in medical practice which induce the least anxiety.

Finally the doctor should attempt to face his own anxieties, and to think about them. It is not infrequent that the anxiety of the patient is in fact that of the doctor.

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The behaviour is more likely to reveal the presence of anxiety than words themselves. Refusal to undergo diagnostic or therapeutic procedures is much more likely to be due to emotional (anxious) considerations than to rational reasoning. This is more likely to arise if there has been insufficient explanation, and an insufficient ability to motivate. Many problems of compliance are grounded in anxiety (i.e. fear of side-effects or addiction). The "difficult" patient is a typical example with background (and frequently unrecognized) anxiety, as is the patient "addicted" to illness, who suffers from neglection and separation anxiety, or the "driver" who tries to compensate for his feelings of inadequacy. Other masks of anxiety can be dependence on alcohol or medication (tranquilizers). The first thought on being faced with a patient who appears unapproachable by empathy, irrational, obstreperous, "difficult to handle" or refuses treatment, should be to wonder if his behaviour is not due to unspoken or unconscious anxiety.

The next step has to be a differentiation of the anxiety. Are these anxieties more like fears and should they be regarded as "normal" anxiety? Is the anxiety caused by organic changes? Does the anxiety go back to misunderstandings? Are they a result of the illness, the behaviour of the doctor or others? Is neurotic or psychotic anxiety present? Is the anxiety a sign of depression? Assistance in the differential diagnosis can be obtained from the flow diagram (F. Strian).

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[IMAGE]
Diagnostic flow diagram for the differential diagnosis of the anxiety syndromes (F. Strian)

The desire to eliminate anxiety completely should not be the major objective of discussion. Firstly this would be a fictitious objective for the majority of discussions aimed at overcoming anxiety. Next, a certain level of "background anxiety" is an effective defence mechanism in many situations, for example before operations. Studies have shown that patients who showed hardly any anxiety before an operation, had a poorer post-operative course than those who showed "normal" pre-operative anxiety. The most effective objective of such a discussion is to offer help so that the patient can find his own way of coping with his anxieties, in order that he is master of his anxiety, rather than being ruled by it.

It can be particularly difficult to recognize anxiety in terminally ill and dying patients. Often it can only be recognized by signs of defense mechanisms. Here the doctor is more often confronted with the whole range of defense mechanisms such as denial, rationalization, avoidance, projection etc, rather than admission of the underlying anxiety. As the defense mechanisms constitute a certain degree of control and in fact subject anxiety, they should only be regarded as a sign of anxiety and not destroyed. Certainly complete control of anxiety is usually impossible, so that the part of it which is left over (the uncontrolled free-floating anxiety) should be included in the treatment plan.

The severe anxiety of the depressive patient should of course be discussed, but cannot be overcome by conversation itself as it requires effective antidepressive medication to resolve it. Neurotic, and especially psychotic, anxieties usually need psychiatric treatment.

Ultimate anxieties troubling a person as disease brings him inextricably nearer death are perhaps only subdued by the assurance that a "New World" really does exist, "in which I can really be myself, with no anxiety..." (H. Küng). 

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