Discussions to alleviate anxiety
Sources of anxiety
Modern medicine is a nearly
inexhaustible source of anxieties:
|If one thinks
about human existence, more
|explanation is required
to show why people
|are usually not anxious,
than to reason why
|they are anxious occasionally.
induced by the gigantic technical potentialities;
result from lack of discussion or misunderstanding of language;
of anxiety present in modern hospitals;
are passed on to the patient from the staff working in an impersonal
and hectic climate;
||Fear of cancer
and concerns about intensive medicine;
||Fear of the loss
of self in a "mill" or "apparatus" which can not be influenced;
by previous medical experiences;
reflect the doctor's own anxiety;
by the media;
anxiety (loss of what one has or is).
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
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.
in the hospital which can provoke anxiety in patients (from K. Engelhardt
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.
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 ).
History of anxiety
The patient's anxieties cannot
be separated from the currents of contemporary history. The term "Age of
anxiety" is certainly a simplifying slogan. It is naturally very difficult
to obtain precise figures about the prevalence of anxiety, but those available
suggest between 10 and 40% of a healthy population are affected (V. Faust).
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
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..."
Forms of anxiety
The way in which anxiety is
depends on the position from which one approaches it (psychology, philosophy,
psychopathology, theology). Faust defines it from a physician's point of
view as: "An unpleasant emotional condition, usually with physiological
signs, arising from a feeling of threat, which can be either objective
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
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.
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.
There are three major approaches
for dealing with anxiety in medicinal practice:
anxieties, rather than releasing them.
and differentiate the various sorts of anxieties.
anxieties and demolish them.
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.
Of course it would be an illusion
to think that it would be possible to introduce the concept of medicine
free of anxiety. Even with the best will in the world, it is probably not
possible to create relationships between patient, doctor and team which
are completely free of anxiety. In fact it is more important to consider
whether a certain amount of "natural anxiety" is required for better adaptation
to certain situations. jams showed that a moderate degree of pre-operative
anxiety resulted in the best-possible adaptation post-operatively. More
recent investigations (Matthews and Ridgeway, 1981) have also showed that
patients with severe pre-operative concerns had, on average, more postoperative
difficulties than those with "healthy" pre-operative anxiety. One of the
most important objectives to keep in mind in medical treatment is that
of reducing its potential for creating anxiety. Only the person
who is free from overwhelming anxiety is able to be open to his illness,
to understand it, to co-operate and to rediscover his own identity.
inducing anxiety by the use of comprehensible and clear language
|2. Avoid anonymity (name
|3. Do not make the patient
into an object or isolate him
|4. Remove barriers to
|5. Recognize one's own
anxieties, and think about them
|II. Recognize and differentiate
between various anxieties
|1. Recognize the "masks
2. Differentiation of various
|- "difficult" behaviour
|- problems with compliance
|- defense mechanisms (denial,
rationalization, avoidance etc.)
|- abuse of alcohol and medications
|- "normal" anxiety?
|- anxiety due to organic
|- neurotic anxiety?
|- psychotic anxiety?
|III. Demolish anxiety
|1. Accept anxiety
|2. Allow discussion about
anxiety (no speeches!)
|3. Explain anxiety
|4. Work through anxieties
to their conclusions
|6. Do not disturb defense
|7. Employ all verbal and
non-verbal means of communication
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
Prevention of anxiety
The best way to avoid creating
anxiety in the patient is that everything that is said to him, and everything
that happens to him is understandable, whenever possible without
misunderstandings. The first step is to reduce anonymity in
general practices, out-patients and hospitals; doctors and members of the
team should introduce themselves by name and function. The patient should
be referred to as often as possible by his (correct) name. Help with
orientation in time and space should be available, especially for old
people. It is most important that there is one person who he knows is responsible
for him amongst the doctors or nursing staff. Everything that he is going
to undergo should be explained in general terms. The simplest rules
are broken many times a day: the pen of the ECG, the ultrasound picture
or the computer screen is looked at rather than the patient. It
is amazing how grateful in-patients are when greeted by a doctor
or nurse who is not one of their treatment team.
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.
Recognition and differentiation
Even though modern medical practice
bristles with all sorts of anxieties, it is rare for these to be mentioned
Anxiety is still seen as shameful or an oddity. It is often much easier
for a patient to describe the physical symptoms which are associated
with this anxiety, than to say directly "I am anxious". It is precisely
the unpleasant symptoms which appear at night (cramps, breathlessness or
tachycardia) which are the physical expression of anxiety conditions. Usually
the physical symptom is at the forefront. Ask guardedly during the further
course of the discussion if these symptoms could be due to anxiety. If
anxiety was present at the same time as the symptom, this question will
often elicit a positive answer. It should also be ascertained what really
happened first in the episode: anxiety or the physical symptoms.
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
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).
The acceptance of
anxieties and their demolition
It is of paramount importance
to accept the patient with all his anxieties. To overlook, push
to one side or to play down anxieties leads to a vicious circle resulting
in a further increase in the anxiety. The patient has to know that he is
to have anxiety, and that his anxiety is not the same as weakness, denial
or shame. It is therefore necessary to mention this anxiety carefully but
openly. Mentioning the anxiety allows the patient to see that his
doctor has registered its presence and is prepared to go into it, and that
he need not maintain the additional concern about keeping it to himself.
There is usually not much point in trying to "talk him out" of his anxieties
("You really don't need to worry"). It may just be helpful to talk about
the sorts of anxieties that patient might have by means of metacommunication.
effective step is to explain the development of anxiety, and to
assure him that, under the circumstances, his anxieties are understandable
and appropriate ("I can completely understand, that you could be anxious
when you think about this..."). It is also useful to allow anxieties and
concerns to be thought through to a conclusion rather than blocking
them prematurely. The facets of anxiety which can be verbalized
can be managed much more rationally than those that are still submerged
or repressed. It is particularly important to use all
non-verbal means of communication in situations which are embued
with severe anxiety or barriers to communication (intensive wards).
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
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
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).
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
of this page: http://www.linus-geisler.de/dp/dp13_anxiety.html