fear and anxiety in palliative care - hospice · anxiety • ‘psychic inflammation’ (activates...
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Fear and Anxiety in Palliative Care
Sandy Macleod
University of Canterbury
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Anxiety & Fear
• Differing clinical states with different managements.
• ‘Anxiety’ used loosely in modern psychiatry – failure to differentiate from fright & fear.
• In palliative care disorders of fear are universal and disorders of anxiety common.
• No modern clinical literature on fear
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Anxiety Fear
• 38year old, single woman
• 3 (young) children
• Carcinoma of breast –3 year history, skeletal metastases
• Concerns/worries –recurrences, treatment options, opioid medications, childrens’ welfare and future care, finances……….
• 53 year old male
• SCC oropharynx (2 year history)
• Surgery, chemotherapy, RT
• Malignant wound
• Inspiratory stridor
• Terrified of suffocation, bleeding, pain, losing control, falling asleep, dying
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Fear
Spinoza (1632-1677)
fear is cognitive
Pascal (1623-1662)
fear is
emotional
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Anxiety• Roman ‘anxietas’ – a
lasting state of fear
• Benjamin Rush (1746-1813) –reasonable (death, surgery) and unreasonable (ghosts,
dark, insects) objects of fear
• Baron v. Feuchtersleben(1806-1849) – rational and irrational fears
• Kierkegaard (1813-1855)
‘angst’ (anxiety)
• Freud -‘anxiety neurosis’ 1895
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Human Responses to Threat / Danger
• Fright
• Fear
• Anxiety
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FrightStimulus Reaction Symptoms
sudden
unexpected
sensory
pre-emotional
innate reflex
startle pattern
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FrightDisorder of Fright Management
•Hyperkplexias
•?Acute Stress Disorder
•PTSD
•Prevention and avoidance
•Prophylactic intoxication
(alcohol, opioids, BDZs)
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FearStimulus Reaction Symptoms
Specific object of
threat
•innate
•learned (derived, not
primal)
•Differentiated
physiological,
behavioural &
cognitive.
• Rational.
“one has fear”
•Emotional &
physiological
arousal.
•Behavioural
reactions.
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Anxiety
Stimulus Reaction Symptoms
• Non-specific
• Objectless
• Threat to existence,
‘self’, ‘fear of
nothingness’
• Maximal at birth
and death
• Undifferentiated
emotional, catastrophic
reaction.
• Irrational.
• ‘one is anxious’
• ‘dissolution of self’
• Psychological –
worry, tension
……panic
• Physiological –
tachycardia,
sweating,
tremor……
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Fear is a universal emotion for the dying
Darwin’s fearful man
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Fear-Evoking SituationsInnate
• Pain
• Being alone
• Physical proximity
• Bleeding
• Novel places
• Confined spaces
• Strange things
• Bitter/nasty food
• Being stared at
• Unpleasant odours
• Loud sound
Acquired / Learned
• Dying
• Death
• Being buried alive
• Needles• Hospitals/doctors/ ? nurses
• Flying
• ……..
All (except perhaps flying)
are fears experienced in palliative care
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Physiological Fear Responses
• dry mouth
• ‘butterflies’
• palpitations
• hyperventilation
• dizziness
• tremor
• sweating
• urinary urgency
• …..
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Cognitive / Psychological Fear Responses
• worry
• apprehension
• dread
• tension
• catastrophic thoughts
• derealisation
• slowed thinking
• ……
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Behavioural Fear Responses
• “Fight” – aggressive defense
• “Flight” – withdrawal, avoidance
• “Freeze, Submission” - immobility, appeasement
• “Tend-and-befriend” - affiliation with others
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Fear of Premature Burial (Buried Alive)
• Traditionally relatives diagnosed death
• Peaked mid 19th
Century
• Rx medicalisation of death and death certification
Bondeson, Buried Alive, Norton: 2001
Edgar Allan Poe, The Premature Burial
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Thanatophobia (‘Death Anxiety’)
• Fear (phobia) of death, of being dead
• Innately human
• Peaked mid 19th century
• By-product of ‘dechristianization’, the loss Christian
dogma about heaven and the emergence of
secular rationalism
Philippe Ariés, The Hour of Our Death, 1981
Becker, The Denial of Death. 1973
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The Fear of Dying
“I do not believe that any man fears to be dead, but
only the stroke of death”.
Francis Bacon (1561-1626)
• A modern phenomenon in the elderly
• Enhanced by modern medicine’s focus on curing
and saving life (quantity, not quality, of life)
• Encouraged by medicine’s ability to artificially
support life
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Fear of Cancer Recurrence (FRC)
• Prevalence 26-56% of cancer survivors (Thewes 2012)
• ? Fear or Anxiety of cancer progression
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Fear v. Anxiety
Fear
• Reactive to explicit
threatening stimulus
• Brief duration
• Present focused
• Reality-based
• Adaptive/maladaptive
Anxiety
• Prompted by generalised,
non-specific cues
• Intrapsychic
• Long – lasting
• Future focused • Adaptive/maladaptive
Lang, J Aff Dis 2000
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Evolutionary Functions
Anxiety
• ‘Psychic inflammation’(activates coping ,mastery,
and psychological repair)
= acute pain
• In danger, anxiety and panic don’t occur = stress analgesia
• If chronic or panic (severe, abrupt anxiety),
maladaptive (avoidance,
non-compliance, denial,
cognitive paralysis …..) = chronic pain
Fear
• Behaviours enhances
safety (not always)
• Forewarns and
encourages
preparation
• If chronic, maladaptive= PTSD-like syndromes
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Suffering: the anxiety of palliative care ?
“A state of severe distress, that is subjective and unique to the individual, arising from the perception of threat to one’s integrity as a biologic, social, or psychological being”
Cassell, 1982
Prevalence of suffering (distress)
in advanced cancer: 50%Wilson, Cochinov 2007
Prevalence of anxiety in medical settings 15-20%, general population 6-13%
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Causes of Anxiety / Panic in Palliative Care
• Trait
• State / Situational / Precipitants: impending procedure, disease relapse, Rx withdrawal, physician abandonment, impending death, loss of control and autonomy…
• Disease:
Psychiatric: Delirium, GAD, Major Depression, PTSD…
Organic: pain, corticosteroids, bronchodilators, alcohol/hypnotic withdrawal, akathisia, cerebral irritation, impending catastrophic event (PE)…..
• Multifactorial (trait + situation + disease)
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Fear at the End of Life
• ? Universal
• 8.5% ‘non-peaceful’ deaths (Lichter & Hunt, 1990)
• Most (in hospice care) have ‘easeful’ (Warnock) deaths
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Management of Fear
• Behavioural Therapy (not cognitive)
avoidance of fearful stimuli
distraction
desensitisation
flooding
• Medication (prophylactic):
intoxication (alcohol, benzodiazepines)
physiological blockade (β-blockers)
• Psycho-philosophical
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Fear and Cognitive Therapy
If fear is an innate, pre-verbal, pre-
emotional, reflex response to a
recognisable danger is cognitive therapy likely to be therapeutic ?
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Psycho-philosophical Management of Fear
Achieving Fearlessness
• Manipulations of Hope
• ‘Teaching’ Courage
• The Acquisition of Bravery
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Baruch de Spinoza (1632-1677)
• Defined fear in juxtaposition to hope
• “Fear cannot be without hope, nor hope without fear”
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Fear is an ‘uncertain pain’ arising from the idea that
something we hate may befall us.
Hope is an ‘uncertain pleasure’ arising from the idea that a
good we wish will come to pass.
Spinoza
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Manipulation of Hope:
The Provision of Certainty
• Emotional Palliation
empathic support
reassurance
protective emotional custody (‘holding’)
• Exploitation of innocent / naïve / unrealistic hopes
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Innocent / Naïve Hope and Fearlessness
Five Year Relative Survival
2%6%8%
13%15%
22%34%
36%43%
45%48%
52%61%
68%76%
79%83%
90%3%
6%7%
12%13%
24%38%
45%45%46%
51%61%
67%71%
78%84%
95%
PancreasLung
OesophagusStomach
BrainMultiple myeloma
OvaryLeukaemia
KidneyColon
RectumNHL
BladderCervixUterusBreast
Hodgkin's lymphomaMelanomaPancreas
LungOesophagus
StomachBrain
Multiple myelomaLeukaemia
KidneyRectum
ColonNHL
ProstateLarynx
BladderMelanoma
Hodgkin's lymphomaTestis
Wo
men
Me
n
Five-year relative survival
10-50% survival:
29% of cases diagnosed
More than 50% survival:
38% of cases diagnosed
less than 10% survival:
More than 50% survival:
50% of cases diagnosed
10-50% survival:
27% of cases diagnosed
less than 10% survival:
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Unrealistic Hope and Fearlessness
Ten Year Survival Trends
PancreasLung
OesophagusStomach
Brain
OvaryLeukaemia
Kidney
Colon
Prostate
Bladder
Larynx (males)Cervix
UterusBreast (females)Hodgkin's lymphomaMelanoma
Testis
All cancers
Myeloma
0
10
20
30
40
50
60
70
80
90
100
1971-72(1)
1980-81(1)
1990-91(1)
2007 (2)
Pe
rce
nta
ge
su
rviv
al
Period of diagnosis37
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Courage and Fearlessness
• Courage (f.L ‘cor’ heart): the ability to do something that frightens one (OED)
• Courage is the willpower to overcome “the dread malady of fear” – Lord Moran, 1945
• “Death Talk” - the intent of education, instruction, advice, and anticipatory discussions of death is to foster courage
• ? effectiveness
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The Limitations of Teaching Courage
• Tolstoy : “Can this be death ?” asks the mortally
wounded Prince Andrew in War and Peace
• Wittgenstein : “Death is not an event in life: we do
not live to experience death”
• Freud: “In the unconscious every one of us is
convinced of his immortality”
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Bravery and Fearlessness
Brave: endure or face unpleasant conditions or
behaviour without showing fear (OED)
• The innately brave
rare
unable to be predicted
• Acquired bravery
not uncommon in the dying
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“[Lovat] was beheaded yesterday, and died extremely
well, without passion, affectation, buffoonery or timidity:
his behaviour was natural and intrepid”
Horace Walpole (1717-1797)
Intrepidness: A state of fearlessness, firmness of mind in the presence of danger,
boldness, bravery (OED). From Latin, in + trepidus (alarm)
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Lord Lovat(Simon Fraser)
(1667-1747)
Last man to be beheaded in
England. 20 died watching
his execution.
Personal Hx: violent feuding,
opportunism, deception,
rape.
Jacobite.
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Fearlessness and the Surrender of Hope
No future = No hope = No Fear
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No Hope
v.
Hopeless
• No hope – appreciating the present and past for
there is no future, affect neutral, survival mode
(affiliation with others), certainty (Spinoza’s
uncertainty is removed)
• Hopeless – concerned about the future (anxiety
symptom), distressed affect
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Management of Acute Anxiety / Panic
• Psychological (emotional palliation): reassurance,
explanation, distraction, relaxation, empathy,
therapeutic touch ……
• Pharmacological anxiolytics : benzodiazepines, β-
blockers, buspirone, barbiturates, opioids
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Management of Chronic Anxiety
• Psychotherapy (CBT, psychoanalytical ….)
+/-
• Pharmacotherapy (SSRIs / TCAs ….)
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Management of ‘Anxiety’ Disorders in
Palliative Care
• disorders of fright – avoid the stimulus
• disorders of fear – behavioural therapies, prophylactic intoxicating medications, psycho-philosophical Rx
• disorders of anxiety – psychotherapy +/-psycho-active medication
Thankyou
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