Clinical Review ABC of psychological medicine

Anxiety in medical patients

BMJ 2002; 325 doi: http://dx.doi.org/10.1136/bmj.325.7357.207 (Published 27 July 2002) Cite this as: BMJ 2002;325:207
  1. Allan House,
  2. Dan Stark

    Doctors often consider anxiety to be a normal response to physical illness. Yet, anxiety afflicts only a minority of patients and tends not to be prolonged. Any severe or persistent anxious response to physical illness merits further assessment.

    William Cullen (1710-90) coined the term neurosis (though the term as he used it bears little resemblance to modern concepts of anxiety disorders)

    What is anxiety?

    Anxiety is a universal and generally adaptive response to a threat, but in certain circumstances it can become maladaptive. Characteristics that distinguish abnormal from adaptive anxiety include

    • Anxiety out of proportion to the level of threat

    • Persistence or deterioration without intervention (> 3 weeks)

    • Symptoms that are unacceptable regardless of the level of threat, including

    Recurrent panic attacks

    Severe physical symptoms

    Abnormal believes such as thoughts of sudden death

    • Disruption of usual or desirable functioning

    View this table:

    Somatic and psychological symptoms of anxiety disorders

    • Anxiety out of proportion to the level of threat

    • Persistence or deterioration without intervention (>3 weeks)

    • Symptoms that are unacceptable regardless of the level of threat,including

    Recurrent panic attacks

    Severe physical symptoms

    Abnormal beliefs such as thoughts of sudden death

    • Disruption of usual or desirable functioning.

    Unfortunately, there are few studies of the natural course of anxiety in physically ill patients, so it can be difficult to judge the distinction between normal and abnormal anxiety. In particular, some of the criteria used can be difficult to apply when a patient is experiencing a real threat of disease. A more reliable basis for diagnosing morbid anxiety is often that it causes unacceptable and disruptive problems in its own right.

    Distinguishing features of anxiety disorders

    Anxious adjustment disorder

    Prevalence in general population—Not known

    Cardinal features

    Onset of symptoms within 1 month of an identifiable stressor

    No specific situation or response

    Generalised anxiety disorder

    Prevalence in general population—31 cases/1000 adults

    Cardinal features

    Period of 6 months with prominent tension, …

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