Anxiety is an experience of diffuse apprehension or uneasiness, often accompanied by feelings of uncertainty and helplessness and activation of the autonomic nervous system (Carpenito, 2000). In nursing diagnosis terminology, the source of anxiety is either nonspecific or unknown, contrasting with fear, which occurs when the source of the uneasiness is known (Carpenito, 2000). Since these two nursing diagnoses overlap in terms of defining characteristics and appropriate interventions, the term anxiety is used here to describe a symptom associated with apprehension and uneasiness. Everyone feels anxious at times, especially when facing new situations, and particularly when facing a new medical diagnosis of an advanced, progressive disease. Anxiety may be mild, moderate, severe, or extreme. Although mild anxiety can be beneficial, leading people to seek appropriate information and support, increased or sustained anxiety can be detrimental both physiologically and psychologically (Shoemaker, 2005).

Studies of prevalence rates of anxiety are difficult to interpret since the term is neither defined nor measured consistently. Mild to moderate anxiety is common and expected when facing the physical, psychosocial, emotional, and spiritual issues associated with cancer and terminal illnesses (Breitbart, Chochinov, & Passik, 2004; Dinoff & Shuster, 2005; Noyes, Holt, & Massie, 1998; Vachon, 2004). Family caregivers of patients with advanced, progressive illnesses also experience anxiety and at higher levels than the general population (Grov, Dahl, Moum et al., 2005). Most people possess the necessary coping skills to manage lower levels of anxiety. However, in those with borderline coping skills, mild anxiety may progress to severe anxiety. Thus, even mild anxiety, although expected, must be assessed and addressed. Contrary to some beliefs, a high level of anxiety is not inevitable during the terminal phase of illness and should not be expected or tolerated (Breitbart, Chochinov, & Passik, 2004).

Anxiety disorders are syndromes characterized by anxiety that is beyond the norm in intensity, duration, or behavioral manifestations (Noyes, et al., 1998). There are several DSM-IV anxiety disorder diagnoses, including acute stress disorder, anxiety disorder due to general medical condition, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobias, and posttraumatic stress disorder (American Psychiatric Association, 1994). Anxiety disorders affect approximately 19 million Americans, or about 6% of the general population (National Institute of Mental Health, 2001). The incidence of anxiety disorders is higher in patients with cancer and those at the end of life than the general population. Studies examining the prevalence of pathological anxiety in patients with early to advanced stages of various cancer diagnoses show a range from 1% to 44% (Noyes et al., 1998). In addition, Olfson, Shea, Feder et al. (2000) reported that 14.8% of patients seeking primary care in an urban general medicine practice met the criteria for generalized anxiety. So, it appears appropriate to conclude that the prevalence of anxiety is higher in people seeking medical attention than the general, healthy population. Psychiatric disorders, including anxiety, often are unrecognized and untreated in the terminally ill, as a result of several factors (Academy of Psychosomatic Medicine, 1999):

Patients with higher anxiety scores are more likely to request a hastened death and less likely to have a peaceful death (Georges, Onwuteaka-Philipsen, van der Heide et al, 2005; Mystakidou, Rosenfeld, Parpa et al., 2005). This emphasizes the importance of assessing and aggressively managing, Rosenfeld, Parpa anxiety in the palliative care setting.

Anxiety has many causes—physical, psychosocial, emotional, and spiritual. Anxiety can be a manifestation of a medical problem (e.g., hypoxia) or a symptom of physical discomfort (e.g., dyspnea, pain, nausea). Many practitioners have observed that physical discomfort is often perceived as being worse in the presence of anxiety, creating a snowball effect of a symptom, anxiety, worsening of symptom, and worsening of anxiety.

Anxiety is sometimes a side effect of medications or a symptom of medication or substance withdrawal. Patients with cognitive dysfunction, such as those with Alzheimer’s disease or delirium, commonly exhibit anxiety or agitation. Indeed, anxiety can also be an early sign of delirium, so it must be assessed carefully (Caracini, Martini, & Simonetti, 2004).

A host of psychological or emotional concerns may lead to anxiety. Concerns or fears about control of symptoms, addiction to medicines, self-concept and role changes, the dying process, and unresolved family or financial issues are examples of potential issues that may contribute to anxiety in both patients and caregivers. And certainly, anxiety may be a symptom of spiritual distress. Box 17-1 illustrates the wide-ranging causes of anxiety.