Adjustment to Cancer: Anxiety and Distress (PDQ®)
- Anxiety is fear, dread, and uneasiness caused by stress.
- Distress is emotional, mental, social, or spiritual suffering. Patients who are distressed may have a range of feelings from vulnerability and sadness to depression, anxiety, panic, and isolation.
Patients may have anxiety while being screened for a possible cancer, waiting for the results of tests for cancer, receiving a cancer diagnosis, being treated for cancer, or worrying that cancer will recur (come back). It may cause patients to miss check-ups or delay treatment. Anxiety may increase pain, affect sleep, and cause nausea and vomiting. Even mild anxiety can affect the quality of life of patients with cancer and their families and may need to be treated.
Some patients living with cancer have a low level of distress and others have higher levels of distress. The level of distress ranges from being able to adjust to living with cancer to having a serious mental health problem, such as major depression. However, most patients with cancer do not have signs or symptoms of any specific mental health problem. This summary describes the less severe levels of distress in patients living with cancer, including:
- Normal adjustment—A condition in which a person makes changes in his or her life to manage a stressful event such as a cancer diagnosis. In normal adjustment, a person learns to cope well with emotional distress and solve problems related to cancer.
- Psychological and social distress—A condition in which a person has some trouble making changes in their life to manage a stressful event such as a cancer diagnosis. Help from a professional to learn new coping skills may be needed.
- Adjustment disorder—A condition in which a person has a lot of trouble making changes in his or her life to manage a stressful event such as a cancer diagnosis. Symptoms such as depression, anxiety, or other emotional, social, or behavioral problems occur and worsen the person's quality of life. Medicine and help from a professional to make these changes may be needed.
- Anxiety disorder—A condition in which a person has a lot of anxiety from a stressful event such as a cancer diagnosis. The anxiety affects his or her ability to manage their emotions, social relationships, and work life. Medicine and help from a professional to manage the anxiety may be needed.
This summary is about adjustment to cancer, anxiety, and distress in adults with cancer.
See the following PDQ summaries for information on these mental health problems:
Living with a diagnosis of cancer involves many life adjustments. Normal adjustment involves learning to cope with emotional distress and solve problems caused by having cancer. Patients with cancer do not make these adjustments all at once, but over a period of time as their disease and treatment change. Patients may need to make adjustments when they:
- Learn the diagnosis.
- Are being treated for cancer.
- Finish treatment.
- Learn that the cancer is in remission.
- Learn that the cancer has come back.
- Become a cancer survivor.
Patients find it easier to adjust if they can carry on with their usual routines and work, keep doing activities that matter to them, and cope with the stress in their lives.
Coping is the use of thoughts and behaviors to adjust to life situations. The way people cope is usually linked to their personality traits (such as whether they usually expect the best or worst, or are shy or outgoing).
Coping methods include the use of thoughts and behaviors in special situations. For example, changing a daily routine or work schedule to manage the side effects of cancer treatment is a coping method. Using coping methods can help a patient deal with certain problems, emotional distress, and cancer in his or her daily life.
Patients who adjust well are usually very involved in coping with cancer. They also continue to find meaning and importance in their lives. Patients who do not adjust well may withdraw from relationships or situations and feel hopeless. Studies are being done to find out how different types of coping methods affect the quality of life for cancer survivors.
Distress can occur when patients feel they are unable to manage or control changes caused by cancer. Patients with the same diagnosis or treatment can have very different levels of distress. Patients have less distress when they feel the demands of the diagnosis and treatment are low or the amount of support they get is high. For example, a health care professional can help the patient adjust to the side effects of chemotherapy by giving medicine for nausea.
The following factors affect how a patient copes with the stress of cancer:
- The type of cancer, cancer stage, and chance of recovery.
- Whether the patient is newly diagnosed, being treated, in remission, or having a recurrence.
- The patient's age.
- Whether the patient is able to get treatment.
- How well the patient usually copes with stress.
- The number of stressful life events the patient has had in the last year, such as starting a new job or moving.
- Whether the patient gets support from friends and family.
- Social pressures caused by other people's beliefs and fears about cancer.
The coping skills needed will change at important points in time. These include the following:
The process of adjusting to cancer begins before learning the diagnosis. Patients may feel worried and afraid when they have unexplained symptoms or are having tests done to find out if they have cancer.
A diagnosis of cancer can cause expected and normal emotional distress. Some patients may not believe it and ask, "Are you sure you have the right test results?" They may feel numb or in shock, or as if "This can't be happening to me". Many patients wonder, "Could I die from this?"
Many patients feel they are not able to think clearly and may not understand or remember important information that the doctor gives them about the diagnosis and treatment options. Patients should have a way to go over this information later. It helps to have someone with them at appointments, bring a tape recorder, or make a second appointment to ask the doctor questions and go over the treatment plan. See Talking with the Health Care Team in the PDQ summary on Communication in Cancer Care for more information.
As patients accept the diagnosis, they begin to feel symptoms of distress, including:
- Loss of appetite.
- Trouble sleeping.
- Not being able to focus.
- Trouble with the activities of daily life.
- Not being able to stop thinking about cancer or death.
When patients receive and understand information about cancer and their treatment options, they may begin to feel more hopeful. Over time, by using ways to cope that have worked in the past and learning new ways to cope, patients usually adjust to having cancer. Extra professional help to deal with problems such as fatigue, trouble sleeping, and depression can be helpful during this time.
As patients go through treatment for cancer, they develop coping strategies to adjust to the stress of treatment. Patients may have anxiety or fears about:
- Procedures that may be painful.
- Side effects such as hair loss, nausea and vomiting, fatigue, or pain.
- Changes to daily routines at work or home.
Patients usually adjust well when they can compare short-term discomfort to long-term benefit (for example living longer) and decide, "It's worth it". Questions that patients may ask during treatment include, "Will I survive this?"; "Will they be able to remove all the cancer?"; or "What side effects will I have?". Finding ways to cope with problems caused by cancer such as feeling tired, getting to and from treatment, and changes in work schedule is helpful.
Finishing cancer treatment can cause mixed feelings. It may be a time of celebration and relief that treatment has ended. But it may also be a time of worry that the cancer could come back. Many patients are glad that treatment has ended but feel increased anxiety as they see their doctors less often. Other concerns include returning to work and family life and being very worried about any change in their health.
During remission, patients may become stressed before follow-up medical appointments because they worry that the cancer has come back. Waiting for test results can be very stressful.
Patients who are able to express both positive and negative emotions are more likely to adjust well. Patients are more able to cope with the emotional stress of finishing treatment and being in remission when they:
- Are honest about their emotions.
- Are aware of their own feelings and are able to share them with others.
- Are able to accept their feelings without thinking of them as right or wrong or good or bad and are willing to work through their emotions.
- Have support from others who are willing to listen and accept their feelings.
Sometimes cancer comes back and does not get better with treatment. The treatment plan then changes from one that is meant to cure the cancer to one that gives comfort and relieves symptoms. This may cause great anxiety for the patient. The patient may feel shock and be unable to believe it at first. This may be followed by a period of distress such as depression, trouble focusing, and being unable to stop thinking about death. Signs of normal adjustment include:
- Times of sadness and crying.
- Feelings of anger at God or other higher power.
- Times of pulling away from others and wanting to be alone.
- Thoughts of giving up.
Patients slowly adjust to the return of cancer. They stop expecting to be cured of cancer and begin a different kind of healing. This healing is a process of becoming whole again by changing one's life in many ways when faced with the possibility of death. It is very important that patients keep up hope while they adjust to the return of cancer. Some patients keep up hope through their spirituality or religious beliefs. (See the PDQ summary on Spirituality in Cancer Care for more information.)
Patients adjust to finishing cancer treatment and being long-term cancer survivors over many years. As treatments for cancer have gotten better, cancer has become a chronic disease for some patients. Some common problems reported by cancer survivors as they face the future include:
- Feeling anxious that the cancer will come back.
- Feeling a loss of control.
- Reminders of chemotherapy (such as smells or sights) that cause anxiety and nausea.
- Symptoms of post-traumatic stress, such as being unable to stop thinking about cancer or its treatment or feeling separate from others and alone.
- Concerns about body image and sexuality.
Most patients adjust well and some even say that surviving cancer has given them a greater appreciation of life, helped them understand what is most important in their life, and stronger spiritual or religious beliefs.
Some patients may have more trouble adjusting because of medical problems, fewer friends and family members to give support, money problems, or mental health problems not related to the cancer.
Psychological and Social Distress
Almost all patients living with cancer have feelings of distress. Feelings of distress range from sadness and fears to more serious problems such as depression, panic, feeling uncertain about spiritual beliefs, or feeling alone or separate from friends and family.
Patients who are in distress during any phase of cancer need treatment and support for their distress. Patients are more likely to need to be checked and treated for distress during the following periods:
- Soon after diagnosis.
- At the start of treatment.
- At the end of treatment.
- From time to time after finishing treatment and during remission.
- If the cancer comes back.
- If the goal of treatment changes from curing or controlling cancer to palliative therapy to relieve symptoms and improve quality of life.
Patients who are having trouble coping with cancer may find it helpful to talk with a professional about their concerns and worries. These specialists include:
- Mental health professionals, including psychologists and psychiatrists.
- Social workers.
- Palliative care specialists.
- Religious counselors.
Studies have shown that patients who are having trouble adjusting to cancer are helped by treatments that give them emotional and social support, including:
- Relaxation training.
- Counseling or talk therapy.
- Cancer education sessions.
- Social support in a group setting.
These types of treatment may be combined in different ways for one or more sessions. Studies have shown that patients with cancer who receive such therapies receive benefits compared to those who do not receive these therapies. Benefits include having lower levels of depression, anxiety, and disease- and treatment-related symptoms, as well as feeling more optimistic. Patients who have the most distress seem to get the most help from these therapies. However, patients who received these therapies did not live longer than those who did not receive them.
An adjustment disorder occurs when the patient's reaction to a stressful event:
- Is more severe than the expected amount of distress.
- Affects relationships or causes problems at home or work.
- Includes symptoms of depression and anxiety or other emotional, social, or behavioral problems.
An adjustment disorder usually begins within three months of a stressful event and lasts no longer than six months after the event is over. Some patients may develop a chronic adjustment disorder because they have many causes of distress, one right after another.
An adjustment disorder may become a more serious mental disorder such as major depression. This is more common in children and adolescents than in adults. (See the PDQ summary on Pediatric Supportive Care for more information.)
Individual (one-to-one) and group counseling have been shown to help cancer patients with adjustment disorders. Counseling may include treatment that focuses on the patient's thoughts, feelings, and behaviors. The following are methods that may help patients cope:
- Relaxation training.
- Mental imagery exercises.
- Plan for events that may happen in the future.
- Change beliefs that are not true.
- Thought stopping.
- Positive thoughts.
Counseling should be tried before medicine. Some patients are not helped by counseling or develop a more severe mental health problem, such as severe anxiety or depression. These patients may be helped by an antianxiety or antidepressant medicine along with counseling. (See the PDQ summary on Depression for more information.)
Studies show that almost half of all patients with cancer say they feel some anxiety and about one-fourth of all patients with cancer say they feel a great deal of anxiety. Patients living with cancer find that they feel more or less anxiety at different times. A patient may become more anxious as cancer spreads or treatment becomes more intense.
For some patients feelings of anxiety may become overwhelming and affect cancer treatment. This is especially true for patients who had periods of intense anxiety before their cancer diagnosis. Most patients who did not have an anxiety condition before their cancer diagnosis will not develop an anxiety disorder related to the cancer.
Patients are more likely to have anxiety disorders during cancer treatment if they have any of the following:
- A history of an anxiety disorder.
- A history of physical or emotional trauma.
- Anxiety at the time of diagnosis.
- Few family members or friends to give them emotional support.
- Pain that is not controlled well.
- Cancer that is not getting better with treatment.
- Trouble taking care of their personal needs such as bathing or eating.
It may be hard to tell the difference between normal fears related to cancer and abnormally severe fears that can be described as an anxiety disorder. The diagnosis is based on how symptoms of anxiety affect the patient's quality of life, what kinds of symptoms have developed since the cancer diagnosis or treatment, when the symptoms occur, and how long they last.
Anxiety disorders cause serious symptoms that affect day-to-day life, including:
- Feeling worried all the time.
- Not being able to focus.
- Not being able to "turn off thoughts" most of the time.
- Trouble sleeping most nights.
- Frequent crying spells.
- Feeling afraid most of the time.
- Having symptoms such as fast heart beat, dry mouth, shaky hands, restlessness, or feeling on edge.
- Anxiety that is not relieved by the usual ways to lessen anxiety such as distraction by staying busy.
In addition to anxiety caused by a cancer diagnosis, the following may cause anxiety in patients with cancer:
- Pain: Patients whose pain is not well controlled with medicine feel anxious, and anxiety can increase pain.
- Other medical problems: Anxiety may be a warning sign of a change in metabolism (such as low blood sugar), a heart attack, severe infection, pneumonia, or a blood clot in the lung. Sepsis and electrolyte imbalances can also cause anxiety.
- Certain types of tumors: Certain hormone-releasing tumors can cause symptoms of anxiety and panic attacks. Tumors that have spread to the brain and spinal cord and tumors in the lungs can cause other health problems with symptoms of anxiety.
- Taking certain drugs: Certain types of drugs, including corticosteroids, thyroxine, bronchodilators, and antihistamines, can cause restlessness, agitation, or anxiety.
- Withdrawing from habit-forming drugs: Withdrawal from alcohol, nicotine, opioids, or antidepressant medicine can cause agitation or anxiety.
Anxiety from these causes is usually managed by treating the cause itself.
When patients who had an anxiety disorder in the past are diagnosed with cancer, then the anxiety disorder may come back. These patients may feel extreme fear, be unable to remember information given to them by caregivers, or be unable to follow through with medical tests and procedures. They may have symptoms including:
- Shortness of breath.
- Feeling faint.
- Fast heart beat.
Phobias are fears about a situation or an object that lasts over time. People with phobias usually feel intense anxiety and avoid the situation or object they are afraid of. For example, patients with a phobia of small spaces may avoid having tests in small spaces, such as magnetic resonance imaging (MRI) scans.
Phobias may make it hard for patients to follow through with tests and procedures or treatment. Phobias are treated by professionals and include different kinds of therapy.
Patients with panic disorder feel sudden intense anxiety, known as panic attacks. Symptoms of panic disorder include the following:
- Shortness of breath.
- Feeling dizzy.
- Fast heart beat.
- Heavy sweating.
- Feeling sick to the stomach.
- Tingling of the skin.
- Being afraid they are having a heart attack.
- Being afraid they are "going crazy".
A panic attack may last for several minutes or longer. There may be feelings of discomfort afterwards that last for several hours. Panic attacks are treated with medicine and talk therapy.
Obsessive-compulsive disorder is rare in patients with cancer who did not have the disorder before being diagnosed with cancer.
Obsessive-compulsive disorder is diagnosed when a person uses persistent (obsessive) thoughts, ideas, or images and compulsions (repetitive behaviors) to manage feelings of distress. The obsessions and compulsions affect the person's ability to work, go to school, or be in social situations. Examples of compulsions include frequent hand washing or constantly checking to make sure a door is locked. Patients with obsessive-compulsive disorder may be unable to follow through with cancer treatment because of these thoughts and behaviors. Obsessive-compulsive disorder is treated with medicine and individual (one-to-one) counseling.
See the PDQ summary on Post-traumatic Stress Disorder for information about this condition.
Patients with generalized anxiety disorder may feel extreme and constant anxiety or worry. For example, patients with supportive family and friends may fear that no one will care for them. Patients may worry that they cannot pay for their treatment, even though they have enough money and insurance.
A person who has generalized anxiety may feel irritable, restless, or dizzy, have tense muscles, shortness of breath, fast heart beat, sweating, or get tired quickly. Generalized anxiety disorder sometimes develops after a patient has been very depressed.
There are different types of treatment for patients with anxiety disorders, including methods to manage stress. Ways to manage stress include the following:
- Deal with the problem directly.
- See the situation as a problem to solve or a challenge.
- Get all of the information and support needed to solve the problem.
- Break big problems or events into smaller problems or tasks.
- Be flexible. Take situations as they come.
Patients with anxiety disorders need information and support to understand their cancer and treatment choices. Psychological treatments for anxiety can also be helpful. These include:
- Individual (one-to-one) counseling.
- Couple and family counseling.
- Crisis counseling.
- Group therapy.
- Self-help groups.
Other treatments used to lessen the symptoms of anxiety include:
Using different methods together may be helpful for some patients. (See the Psychological and Social Distress section of this summary for more information.)
If counseling is not available, antianxiety medicines may be used. These medicines relieve symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness. They may relieve daytime distress and reduce insomnia. These medicines may be used alone or combined with other therapies.
Although some patients are afraid they may become addicted to antianxiety medicines, this is not a common problem in cancer patients. Enough medicine is given to relieve symptoms and then the dose is slowly lowered as symptoms begin to get better.
Studies show that antidepressants are useful in treating anxiety disorders. Children and teenagers being treated with antidepressants have an increased risk of suicidal thinking and behavior and must be watched closely. (See the Treatment section of the PDQ summary on Depression for more information.)