When Chronic Disease Overlaps with Anxiety

This post was co-authored with Rebecca Lewinson.

For a large portion of the population, chronic disease is a reality, impacting their emotional, physical and financial well-being. Coping with a chronic disease is difficult, however, it can be even harder when someone is also experiencing anxiety. Anxiety is a future-oriented negative emotional state resulting from perceptions of threat, characterized by a perceived inability to predict, control, or obtain desired results in upcoming situations. Symptoms include excessive apprehension, restlessness, being easily fatigued, muscle tension, hyper-arousal, and difficulty falling or staying asleep.

Anxiety serves a purpose for all of us. Anxious feelings, while uncomfortable, tell us that there is something in the future that could harm us, and hence motivates us to act. Think of anxiety as a set of alarm bells; if there is a fire, we want those alarm bells to go off.

For most of us, this anxious feeling passes when whatever thing or situation we are nervous about passes. For others though, the alarm bells keep going off, even when there is no fire, danger, or anything that requires us to be quick-thinking, fast-acting, or to make a big decision. When that happens, it can become all-encompassing, impacting social or occupational functioning, thus crossing the line to be considered an anxiety disorder. For more than two weeks at least, their thoughts are plagued by frequent, uncontrollable worries, they might almost always feel tense, and/or they may also feel irritable or exhausted a good portion of the time.

This experience becomes complicated when someone also has a chronic disease. The worries, emotions, or physical sensations they have are often based on the reality of their symptoms. For example, if a patient has recently had a heart attack, the chest tightness that people often experience with anxiety might be assumed to be an issue with their heart. Or the shortness of breath experienced by those with a lung condition could be conflated with anxiety. Cancer patients going for imaging tests of tumors would naturally feel anxiety given the uncontrollable situation. Moreover, anxious thoughts, such as “What if I die from my disease?” can be a real possibility.

Given the complex relationship between anxiety and chronic disease, if you suspect your anxiety is excessive, you could take a validated online screening survey. If you score in the elevated range, it is important that a diagnostic interview be conducted, preferably by a healthcare provider who specializes in mental health and chronic disease. You may be asked to fill out a questionnaire about your history and symptoms, and have an interview about the context around your symptoms as well as your chronic disease.

There are several different anxiety diagnoses with which you may be diagnosed, such as generalized anxiety disorder, or even post-traumatic stress disorder if the onset of your chronic condition was indeed traumatic, as can happen with sudden cardiac arrest or stroke. The clinician will also assess for other conditions that tend to cluster with anxiety that would need to be addressed for you to have a successful outcome, such as substance use disorders. Indeed, many patients have been suffering untreated for many years and turn to substances to reduce anxiety, ultimately developing an addiction.

How anxiety and chronic disease are related

Anxiety disorders are the most common mental health condition, with around 7 percent of people in the general population suffering from one at some point in their life. Yet, they are even more common among those with a chronic disease, reaching 26 percent of patients with coronary artery disease and 48 percent in patients with cancer. This is important, given that those who have a chronic disease and anxiety have a lower quality of life, experience delays in receiving anxiety treatment (if they access it all), and are more likely to be hospitalized and even die, compared to those with a chronic disease alone.

While most anxiety disorders will begin in adolescence or young adulthood, it is also common to develop symptoms or have a recurrence of anxiety upon diagnosis with a chronic disease, or even after dealing with that chronic disease for some time. Co-occurrence of chronic disease and anxiety is also more likely in lower socioeconomic populations.

There are several mechanisms that link anxiety to chronic disease. For example, certain forms of anxiety are related to heart rhythm issues. More broadly, there are physiological mechanisms, such as a heightened stress response, which leads to increased circulating cortisol. This has been shown to have negative health effects. Research is emerging on inflammatory and metabolic links.

Those with a chronic disease who also experience anxiety are also more likely to engage in less healthy lifestyles, exacerbating risk factors, including eating an unhealthy diet, using tobacco or alcohol to regulate mood, and being physically inactive. Indeed, some chronic disease patients have “anxiety sensitivity,” believing that the feeling of arousal associated with exercise, such as their heart pounding, has harmful consequences, when in fact exercise is ameliorative for both anxiety and chronic disease.

Identifying anxiety in patients with chronic disease

Sadly, anxiety can be erroneously perceived by healthcare providers as a “normal” response for patients with chronic disease, and benign. It is true that everyone experiences some anxiety, and at moderate levels, it can motivate a chronic disease patient to seek and follow treatment. But for many, anxiety disorders go unrecognized. This can result in delayed diagnosis, treatment, reduced quality of life, and exacerbation of chronic disease progression. This is unfortunate given the many safe and effective treatment options available for anxiety disorders. These will be discussed in part two of this post.

In the meantime, if you or someone you know are experiencing symptoms of anxiety, it might be warranted to make an appointment with your primary care provider to discuss your concerns, and potentially arrange a diagnostic interview.

Rebecca Lewinson is a Ph.D. student in clinical psychology at York University, Toronto.