Treatment of Anxiety in Patients With Chronic Disease

This post was co-authored by Rebecca Lewinson.

When you’re feeling anxious, it can feel like alarm bells are constantly going off in your head. Your worries are amplified and constant, you might feel tightness or discomfort in your chest or stomach, or you might feel irritable or have trouble sleeping. This is extremely common for patients with chronic disease, and worries often center around the disease itself or how the disease will impact their life expectancy, quality of life, or relationships. Fortunately, there are effective and safe treatments that work.

As we discussed in Part 1 of this post, the first step is to have a diagnostic assessment so that your healthcare professional can determine the specifics of your anxiety disorder. For those with mild symptoms, their provider might recommend implementing strategies such as coping skills, mindfulness, or relaxation exercises into their daily life, exercising regularly, and/or identifying people or resources to which the person can turn if they are feeling overwhelmed. Regardless of severity level, incorporating these methods into your life has been shown to reduce anxiety.

Anxiety can be debilitating and persistently severe for many people with chronic disease, necessitating treatment. Two “first-line” treatments are available, psychotherapy and medication; both are backed by years of research evidence of their effectiveness and safety, thus minimizing your suffering. The treatment you choose should be based on your own preferences and informed by knowledge about available coverage you have for therapy and/or medications and often wait times to access therapy.

Psychotherapy

Although there are many forms of psychotherapy, we will focus on two modalities that have been extensively researched and established as effective for anxiety in many chronic disease populations. Be sure to find a mental healthcare professional who has training in anxiety and in working with people who have a chronic disease. Also, your relationship with your therapist is extremely important; If you feel uncomfortable or don’t have a good rapport with your therapist, try a different one if you can.

Cognitive-behavioral therapy (CBT) is the “gold-standard” treatment for anxiety. CBT focuses on how thoughts, emotions, and behaviors are interconnected. It teaches you how to modify your thinking (e.g., “I will never be able to lead a fulfilling life again” re-framed to “If I go to cardiac rehabilitation, I can regain my function”). CBT also teaches you to recognize behavioral patterns, like if you avoid situations that make you feel tight in your chest, such as going for follow-up tests, which are needed to ensure optimal treatment, so you live longer. Recognizing such patterns that fuel your anxiety allows you to cope better and function.

CBT also often includes the incorporation of relaxation exercises, such as progressive muscle relaxation. CBT typically involves eight to 12 one-hour sessions and some homework between sessions that will help you solidify the skills discussed in therapy. Some patients choose to continue therapy longer depending on coverage/affordability and progress. Patients can also return to therapy for a few “booster” sessions later on if their life situation warrants it.

For some, CBT may also include exposure therapy, which involves having you face your fears repeatedly step-wise or graded, starting from a relaxed state. These exposures may be imaginal (e.g., imagining a worst-case scenario), in-vivo (e.g., exposure to a situation in real life), or interoceptive (e.g., repeated exposure to a bodily sensation). The type of exposure used will depend on the patient, who collaborates with their therapist to determine the most appropriate exposures, and where to start.

Some people may feel that CBT is not the right fit for them. In those cases, many people with chronic diseases might benefit from acceptance and commitment therapy (ACT). ACT aims to help you flexibly navigate your life with a chronic disease by accepting it and the associated feelings, being mindful, and acting in ways that move you toward what you value. This can involve, for example, engaging in exercise to manage your chronic disease, even though it may be unpleasant at first; This is because it aligns with your overall value of physically and mentally healthy living, so you are around to see your grandchildren pass life milestones.

Both CBT and ACT are available in-person and online, and sometimes group-based treatment is available with shorter waiting times. Research has shown similar outcomes for these formats, so you can determine which format is the best fit for you.

Anti-Anxiety Medication

Benzodiazepines (e.g., lorazepam, diazepam) are short-acting anti-anxiety medications. They can be addictive, and their use can cause injury in the short term as well as cognitive issues in the long term.

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A better approach to start with is an antidepressant because many of them also reduce anxiety symptoms. The main classes are selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). SNRIs are newer, so there is a bit less safety data on these medications in patients with chronic disease, but data appear favorable, so speak with your doctor about what would be best for you.

SSRIs and SNRIs both work to increase the brain chemical serotonin in the brain, positively influencing mood and sleep. SNRIs also work to increase norepinephrine in the brain, which is involved in helping our body reduce stress responses, the basis of our body’s reaction to anxiety. SSRIs and SNRIs take four to six weeks to take effect, and so often, people will combine the start of their medication with the coping and behavioral strategies discussed above to alleviate their anxiety in the short term; there are online programs and self-help books that can help with implementation.

Whichever medication you and your healthcare provider choose, you will likely start on a relatively small dose. It will be slowly increased over a few months until you are taking a sufficient dose to reduce your anxiety. Your doctor will have regular follow-up appointments with you to see how your body is responding to the medication and how you are feeling. It is good practice that your anxiety is re-measured by the same questionnaire you filled out at the time of your diagnosis to see how your score has changed.

It is important to talk to your healthcare provider if you are experiencing any side effects or if you are thinking of stopping your medication; SSRIs and SNRIs should not be stopped suddenly or your anxiety will rebound. The length of time required on these medications differs from person to person; talk with your doctor about what is right for you once you feel your anxiety is well-managed.

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Final Thoughts

We all must experience the unpleasant emotion of anxiety, and having a chronic disease naturally causes some anxiety. At moderate levels, this anxiety motivates us to follow our doctor’s advice to manage our condition, improving our quality and quantity of life. When anxiety is too high, chronic disease patients may avoid seeking care and managing their condition, therefore it is important anxiety is identified and treated.

Psychotherapy and medication are effective where anxiety is severe, but for all anxiety, coping skills, mindfulness, following a healthy lifestyle (e.g., diet, sleep, exercise, avoidance of substances) and relaxation techniques should be used. It may also be helpful to seek out outpatient chronic disease management programs (e.g., cardiac rehabilitation), where a multidisciplinary team will support you to understand your mental well-being and apply these various approaches to your life over the long term.

Anxiety symptoms and uncomplicated anxiety disorders can often be managed by your primary care provider. But if your anxiety is not getting better, and your chronic disease is complicating matters as it often does, your primary care provider will hopefully engage a regulated mental healthcare provider to support your treatment. You can work collaboratively with your chronic disease specialist, mental health care, and primary care provider to optimize your physical and mental well-being.