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S3 guideline on palliative medicine, part 4/4

S3 guideline for palliative medicine, overview of recommendations

anxiety

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OL palliative medicine recommendation 16.1 (consensus-based): In patients with incurable cancer, the presence of anxiety should be actively and regularly checked, since a treatment indication results from the burden of symptoms and the suffering that the patient experiences.
An anamnesis of possible previous psychiatric illnesses should be taken upon admission.
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OL palliative medicine recommendation 16.2 (evidence-based): A validated and standardized screening instrument can be used to detect anxiety in patients with incurable cancer.
Recommendation grade 0, Level of Evidence 3, Sources: Luckett et al. 2011[1]; Plummer et al. 2016[2], Vodermaier et al. 2009[3], Ziegler et al.[4]

OL palliative medicine recommendation 16.3 (consensus-based): If symptoms of anxiety are present in patients with incurable cancer, an in-depth exploration should be carried out with regard to the anxiety content and intensity as well as the need for treatment.
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OL palliative medicine recommendation 16.4 (consensus-based): In the case of patients with incurable cancer, possible anxiety-related and anxiety-inducing burdens on relatives should also be recorded.
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OL palliative medicine recommendation 16.5 (consensus-based): In patients with incurable cancer, for whom self-disclosure is not possible, the level of fear should be recorded using non-verbal body signals and by a multi-professional team.
The perception and assessment of the relatives should also be included.
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Differential diagnosis

OL palliative medicine recommendation 16.6 (consensus-based): In patients with incurable cancer, anxiety in palliative situations should be differentiated from panic disorders, phobias, generalized anxiety disorders, adjustment disorders and post-traumatic stress disorders.
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Attitudes and general non-drug interventions

OL palliative medicine recommendation 16.7 (consensus-based): All professional groups who are involved in the treatment and support of patients with incurable cancer should support the patient empathetically and take them seriously and be sensitized to signs of fear.
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OL palliative medicine recommendation 16.8 (consensus-based): All those involved in the treatment and accompaniment should be supportive and trust-strengthening in their relationship with their choice of words and attitude towards patients with an incurable disease.
Unnecessary verbal and non-verbal communication that induces or intensifies fear should be avoided.
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OL palliative medicine recommendation 16.9 (consensus-based): In the presence of uncontrolled symptoms, e.g. pain, shortness of breath, nausea or acute states of confusion such as delirium that cause impairing anxiety, these symptoms should be treated first or at the same time.
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OL palliative medicine recommendation 16.10 (consensus-based): The people involved in the treatment of a patient with incurable cancer and anxiety should consult a psychiatric / psychotherapeutic expert
- if, after using all of the team’s own human resources, there are uncertainties in diagnosis and treatment planning with fear
- if there is a complex psychiatric history or a complex syndrome clinically
- in case of acute danger to oneself or others
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OL palliative medicine recommendation 16.11 (consensus-based): In patients with incurable cancer and an anxiety disorder that meets the criteria of ICD-10, it should be checked to what extent applicable psychiatric-psychotherapeutic guidelines (S3 guideline treatment of anxiety disorders) can be proceeded.
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Specific non-drug procedures

OL palliative medicine recommendation 16.12 (consensus-based): In patients with incurable cancer and anxiety, non-drug treatment should be used in the event of stress and / or impairment due to anxiety.
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OL palliative medicine recommendation 16.13 (evidence-based): Psychological / psychotherapeutic methods can be used for the specific, non-drug treatment of patients with incurable cancer and anxiety.
Recommendation grade 0, Level of Evidence 1+, Source: Fulton et al. 2018[5], Grossman et al. 2018[6], Wang et al. 2017[7]

OL palliative medicine recommendation 16.14 (consensus-based): Social work, spiritual and non-verbal methods can be used for the specific, non-drug treatment of patients with incurable cancer and anxiety.
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Medical therapy

OL palliative medicine recommendation 16.15 (consensus-based): To treat anxiety, patients with incurable cancer should be offered drug therapy with anxiolytic drugs:
- if non-drug measures are not possible
- to enable non-drug treatment
- if, according to the patient, the previous treatment has not led to a sufficient reduction in symptoms
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OL palliative medicine recommendation 16.16 (evidence-based): For the treatment of acute anxiety symptoms in patients with incurable cancer, short-acting benzodiazepines with a rapid onset of action should be used.
The dose and length of treatment should be based on the severity of symptoms reported by the patient and result in symptom relief that is satisfactory for the patient.
Recommendation grade B, level of evidence 4, sources: S3 guideline on anxiety disorders[8]

OL palliative medicine recommendation 16.17 (evidence-based): If benzodiazepines are insufficiently effective or intolerant in patients with incurable cancer, the indication for antidepressants, antipsychotics or other drugs with anxiolytic efficacy should be examined.
Recommendation grade B, Level of Evidence 1-, Sources: Nübling et al. 2012[9], Stockler et al. 2007[10]

OL palliative medicine recommendation 16.18 (evidence-based): Acute panic attacks in patients with incurable cancer should be treated with short-acting benzodiazepines.
It should be proceeded in stages: First, the acute symptom relief takes place with short-acting benzodiazepines. If this occurs repeatedly, the indication for long-term treatment with antidepressants, antipsychotics or other drugs with anxiolytic efficacy should be checked.
Recommendation grade A, level of evidence 4, sources: S3 guideline on anxiety disorders[8]

OL palliative medicine recommendation 16.19 (evidence-based): In patients with incurable cancer and currently recurring anxiety or panic states and a history of an ICD-10-relevant anxiety disorder, pharmacological treatment should be prescribed that was previously clinically effective.
Recommendation grade B, level of evidence 4, sources: S3 guideline on anxiety disorders[8]

environment

OL palliative medicine recommendation 16.20 (consensus-based): Since relatives can also develop stressful fears, they should be offered helpful measures to prevent or reduce fears as part of palliative medical treatment.
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OL palliative medicine recommendation 16.21 (consensus-based): In the case of children who are relatives of patients with incurable cancer and who experience fears, particular attention should be paid to age-appropriate and development-appropriate support and assistance should be provided that is appropriate to their respective age.
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OL palliative medicine recommendation 16.22 (consensus-based): Fear among those involved in the treatment and support of patients with incurable cancer should also be given the opportunity to reflect.
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introduction

Working group leader: Vjera Holthoff-Detto, Urs Münch

In addition to depression, anxiety is one of the most common psychological stressors experienced by patients with incurable cancer. Fears can differ in their appearance depending on their content, form and characteristics. The ICD, like the DSM, knows various anxiety disorders such as agoraphobia, panic disorder, special phobias, generalized anxiety disorder, anxiety and depression mixed. Described in a separate chapter, but inseparably linked to anxiety from the cause of the disorder and also subsumed under the heading of anxiety in the Canadian guidelines for cancer patients[11], are post-traumatic stress disorder and acute stress reaction.

Anxiety disorders that meet the ICD-10 criteria have an 11.5% chance of developing cancer in patients with disease progression[12]. However, fears, which are referred to in the specialist literature as subsyndromal anxiety disorders and specific fears, occur much more frequently[13][14] and experienced by those affected as stressful. Subsyndromal anxiety subsumes anxiety syndromes that do not fully meet the current ICD or DSM criteria for diagnosing an anxiety disorder and are therefore not classified as anxiety disorders (panic disorder / agoraphobia, generalized anxiety disorder, social or specific phobia)[15]. Specific fears are fears that are triggered by the illness situation with all its accompanying symptoms. As a rule, they are understandable and appropriate fears in view of the respective illness situation. The prevalence rate of these two fear groups is given as up to 48%[13]. It is assumed that these disorders and stresses occur more frequently in patients with incurable cancer, but there are currently no reliable figures on this[14]. In the case of anxiety disorders, subsyndromal anxiety and specific fears, the treatment indication and treatment planning result from the suffering caused by the burden of symptoms that the patient experiences.

Fears and anxiety disorders (subsyndromal or ICD-10-relevant) require (if possible and / or desired) in relation to the population of patients with incurable cancer, an in-depth exploration through psychological and psychopathological findings (see Introduction and OL palliative medicine - Section 16.2: Acquisition). Risk factors for the occurrence of (subsyndromal) anxiety disorders and specific fears in patients with incurable cancers include affective disorders and a history of anxiety disorders, unfavorable communication with the treatment team, lack of social support, inadequate symptom control (e.g. pain, shortness of breath), long-lasting Treatment phases, surgical interventions, treatment side effects and negative effects of progressive disease[11][16].

The causes of the specific fears are manifold[11]. They can be caused by actual or feared symptoms and functional restrictions such as shortness of breath, pain or loss of mobility. They can relate to planned or performed therapies, but also to possible ailments as a result of insufficient supply and insufficient support, side effects of the disease (e.g. in the case of CNS tumors) or therapies (e.g. whole-brain radiation) or side effects of symptoms associated with the disease (e.g. shortness of breath). The awareness or becoming aware of the imminent end of life can trigger fear and insecurity. The fear can be directed towards different aspects (fear of the dying process, fear of being dead, fear of loss of control, fear of the progression of the disease, fear triggered by insecurity about caring for relatives, fear as an expression of an existential crisis of meaning). In addition, fear can also be the result of poor communication or a lack of information on the part of the person concerned. The latter is favored by insufficient education and information about the disease, the possible course of the disease and available therapy and support options[17]. In a family context, fear can also be a fear of the future in relation to loved ones and leave them alone or expose them to a great deal of stress from their own illness. Patients with incurable cancer usually experience a healthy reaction in their fear that is appropriate to the existential nature of their situation. A systematic description of the fears of patients with incurable, advanced cancer is described in OL-Palliative Medicine Section 16.3: Differential Diagnosis.

For the treatment of anxiety disorders according to ICD or DSM criteria, reference may be made to the S3 guideline for the treatment of anxiety disorders[8]. Taking into account the individual situation, anxiety disorders should be diagnosed and guideline-based psychiatric-psychotherapeutic treatment initiated[8][18]. If these anxiety disorders occur in patients with incurable cancer, it is important to work with the patient and consulted experts (specialist in psychiatry and psychotherapy, specialist in psychosomatic medicine, psychotherapist) to develop a therapy strategy, taking into account the expected remaining life span and the to coordinate the patient's state of health[11][14] (see also OL palliative medicine section 16.3: Differential diagnosis and OL palliative medicine section 16.4: Attitudes and general non-drug measures).

In contrast to the anxiety disorders classified according to ICD-10, the subsyndromal fears as well as the specific fears of palliative patients as “healthy” but associated with great suffering are referred to below as fear or as fear in palliative situations. To date, there are no guidelines for these forms of anxiety in patients with incurable cancer.

Capture

OL palliative medicine recommendation 16.1 (consensus-based): In patients with incurable cancer, the presence of anxiety should be actively and regularly checked, since an indication for treatment results from the burden of symptoms and the suffering that the patient experiences.
An anamnesis of possible previous psychiatric illnesses should be taken upon admission.
EK

OL palliative medicine recommendation 16.2 (evidence-based): A validated and standardized screening instrument can be used to detect anxiety in patients with incurable cancer.
Recommendation grade 0, Level of Evidence 3, Sources: Luckett et al. 2011[1]; Plummer et al. 2016[2], Vodermaier et al. 2009[3], Ziegler et al.[4]

OL palliative medicine recommendation 16.3 (consensus-based): If symptoms of anxiety are present in patients with incurable cancer, an in-depth exploration should be carried out with regard to the anxiety content and intensity as well as the need for treatment.
EK

OL palliative medicine recommendation 16.4 (consensus-based): In the case of patients with incurable cancer, possible anxiety-related and anxiety-inducing burdens on relatives should also be recorded.
EK

OL palliative medicine recommendation 16.5 (consensus-based): In patients with incurable cancer, for whom self-disclosure is not possible, the level of fear should be recorded using non-verbal body signals and by a multi-professional team.
The perception and assessment of the relatives should also be included.
EK

background

For this chapter, a systematic literature search was carried out on the question of the validity, reliability, sensitivity and specificity of instruments for the screening of anxiety. The corresponding recommendation is evidence-based. The remaining recommendations are based on the expert opinion of the guideline group.

The word "fear" is used in German for different things[19]:

  • Fear: Emotional reaction to an acute or expected specific danger in the form of increased heartbeat, shallow breathing, tremors, sweat and dry mouth
  • Anxiety: Indefinite expectation that something bad could happen
  • Panic (anxiety attack): Exaggerated fear reaction that is not limited to a specific situation or special circumstances and therefore cannot be foreseen
  • Uncertainty: Cautious, hesitant, tentative, reticent behavior in an unknown situation
  • Anxiety: Describes a personality trait; chronic insecurity, tension, anxiety
  • Concern: Worrying about someone or something relates to the future and is more likely to be associated with thoughtfulness and depressed mood than with a fearful reaction; the (negative) outcome of a situation is anticipated

In all its various facets, fear is a source of possible stress, which can also be expressed in the intensity of other symptoms such as shortness of breath, sleep disorders or pain. Brooding can be another form of fear expression. Depression and severe distress can also be the result of persistent fear and subjectively experienced fainting.

For treatment teams, the following clues can be indications of the existence of distressing anxiety in patients and their relatives:

Clues as an indication of the existence of stressful anxiety, adapted from Howell et al.[20]

Feelings of restlessness or agitation, irritability

fear

Physical symptoms such as dry mouth, palpitations, excessive sweating, abdominal pain, headache, diarrhea

sleep disorders

fatigue

Difficulty concentrating

Muscle tension

Shortness of breath

An early systematic query / recording and documentation of fear and its (subjective) stress is the basis for the offer of support and for the possibility of alleviating and treating fears[13]. Fears are to be recorded repeatedly and regularly in terms of their occurrence, their severity and in relation to their possible stress in the course of treatment and disease, since fears and the associated stresses can change in the course of the disease (depending on dynamics that are determined by individual factors, disease progression, Develop the treatment / care setting and the associated consequences for the patient and their relatives). This requires appropriate documentation and must be included in the multi-professional case discussion. Possibilities for recording are self-testimony of the patient and / or external anamnesis. It is important that the self-disclosure is as low-threshold as possible and that it meets the criteria of standardized screening procedures (see paragraph below). In the case of patients, this assessment of fears, possible other psychological symptoms or previous disorders should be part of the basic palliative care assessment. As an alternative to screening, there is the possibility of a clinical finding by a psychologist / psychotherapist / doctor. This possibility should also be offered to relatives, since fears of patients and relatives are mutually dependent and can represent a burden for the entire system[21][22].

If necessary, at the beginning, but in any case during the course, an external medical history must also be taken, e.g. with relatives or team members who work close to the patient. Even with active recording, the patient does not always state all relevant fears in the self-assessment. A third-party anamnesis is also a helpful addition to self-disclosure for recording anxiety-relevant anamnestic data.

The evidence on the use of screening instruments for anxiety is based on four systematic reviews that were identified in the course of the systematic research. Three reviews examine instruments for distress, anxiety and / or depression in oncological patients[1][3][4]. Among the very short instruments (“ultra-short”), Vodermaier et al. Identify two instruments that specifically ask about anxiety: the multi-symptom ESAS (Edmonton Symptom Assessment Scale) with a question about anxiety and the one-question screening ("Are you anxious"). These were examined in three studies with a palliative or mixed (oncological and palliative) population[3]. In one study, the fear question showed insufficient specificity (0.52) (reliability: no information; sensitivity: 0.78). In two studies, the ESAS showed a sensitivity of 0.86 and 0.90, a specificity of 0.56 and 0.76 (reliability: no information)[3]. A frequently studied tool in the general oncological population is the HADS (Hospital Anxiety and Depression Scale), which measures anxiety and depression [1][3][4]. However, it is more complex in comparison and is rarely used in the palliative-medical-clinical context. Another systematic review of the literature examined GAD-2 and GAD-7 for the detection of an anxiety disorder in any setting[2]. Three studies looked at GAD-2 to identify any anxiety disorder. With a cut-off of 3, the sensitivity was between 0.65 and 0.72; the specificity was high in two studies (0.92 and 0.88, respectively) but low in the third (0.39)[2].

Total the evidence base is very limited (ESAS) or to be assessed as indirect evidence (GAD-2) (SIGN LoE 3).

In clinical practice in Germany, the Generalized Anxiety Disorder-2 (GAD-2) and the Minimal Documentation System for Palliative Patients (MIDOS), the German version of the ESAS, can be used as screening instruments. The GAD-2 as an extraction of the PHQ-4 records worries and fears and the associated stress with two questions (see OL-Palliative Medicine-Figure 14)[2]. It can therefore also be used orally for patients and relatives. If the screening is positive, fears can be concretized through further targeted questions. The GAD-2 is also suitable as an instrument for progress screening. The MIDOS comprises seven questions, one of which is aimed at anxiety (see OL-Palliative Medicine-Figure 15). With the help of the MIDOS, a valid statement can be made as to whether a stressful fear was present at the time of the survey. Due to its short length, the GAD-2 is particularly suitable for clinical use in palliative care. With both GAD-2 and MIDOS (then with a numerical scale from 1–10), the test can also be carried out in interview form, depending on the patient's condition. The patient's answer must be well documented.

For the course, it is recommended that the questions of GAD-2 in the inpatient setting be carried out at least once a week - outpatient every 6–8 weeks - and / or after a change in behavior (see above) in interview form, provided the patient is able to do so. The MIDOS is recommended as an inpatient assessment once or twice a day[23]. If the MIDOS is used as a basic assessment at this frequency, no further additional screenings are required.

Over the past 2 weeks, how often have you felt affected by the following symptoms?Not at allOn individual daysMore than half the daysAlmost every day
Nervousness, anxiety, or tension0123
Not being able to stop or control worry0123

OL-Palliative Medicine-Figure 14: Screening questionnaire GAD-2 (Generalized Anxiety Disorder) [2]

Please tick how severe your complaints are today
anxiety□ None□ easy□ Medium□ Severe fear

OL palliative medicine Figure 15: MIDOS questionnaire (minimal documentation system), symptom fear[24]

If there is fear, and with the consent of the patient, an in-depth psychological-psychiatric exploration and assessment is required, which should be carried out by psychologists, licensed psychotherapists, specialists in psychiatry and psychotherapy or psychosomatics. For this purpose, the contents of the fears as well as effects on cognitive, emotional, physiological and behavioral levels are to be inquired about. The role of fear / fears in the history (e.g. mental disorders in the history or stressful experiences in the course of the illness) and the interactions in the relatives' system are important for the evaluation and assessment. Examples of questions for an in-depth exploration:

a) According to the S3 guideline anxiety disorders (ICD-10-relevant and subsyndromal):

  • Panic disorder / agoraphobia: Do you have sudden attacks in which you are frightened and in which you suffer from symptoms such as palpitations, tremors, sweating, shortness of breath, fear of death, etc.?
    Are you afraid or anxious in the following situations: crowds, confined spaces, public transport? Do you avoid such situations out of fear?
  • Generalized Anxiety Disorder: Feeling Nervous or Tense? Do you often worry about things more than other people?
    Do you feel like you are constantly concerned and not in control?
    Do you often fear that an accident might happen?
  • Social phobia: Are you afraid in situations where you fear that other people might judge you negatively, criticize your appearance, or view your behavior as stupid, embarrassing or awkward?
  • Specific phobia: Are you very afraid of certain things or situations such as insects, spiders, dogs, cats, forces of nature (thunderstorms, deep water), blood, injuries, splashes or heights?

b) For specific fears or general exploration:

  • What exactly is it that scares you / what makes you insecure? (If applicable: What do you mean when you say ...? Can you explain to me in more detail what you mean by ...?)
  • Do you have any idea what the cause of the uncertainty is (e.g. in the case of stressful somatic symptoms)?
  • How long have you had these fears? Do you know such fears from other situations in your life? Have you experienced similar symptoms before?
  • How often does this happen? Is this fear constant or is it linked to certain events? Are there also phases in which you can endure it well? What would have to be different to make you feel better?
  • On a scale from 1 (weak) to 10 (extremely strong): How strong is your fear? How impairing do you experience this fear / insecurity?
  • Does the uncertainty have an impact on you? If so, which ones (e.g. to sleep, to calm down, to relax, to be able to formulate clear thoughts, relationship with the environment / loved ones, treatment, relationships of trust, feeling of being in good hands)?
  • Have you spoken to anyone else about it? Do your relatives know about this?
  • Is it just this fear or are there other things that make you feel insecure, worry you?

If, in the course of in-depth exploration, it becomes apparent that fear is present in a strong form and / or with high levels of suffering, specialized diagnostics and treatment are required. These specialized diagnostics must also be carried out by psychologists, licensed psychotherapists, specialists in psychiatry and psychotherapy or psychosomatics. Treatment is carried out according to the individual situation by the professional group (s) that match the problem and treatment option (see also OL palliative medicine section 16.5: Specific non-drug procedures and OL palliative medicine section 16.6: Medicinal therapy). In the diagnosis of an anxiety disorder, a psychopathological finding must be made and test procedures from the relevant guideline must be used (see guideline on anxiety disorders)[8].

Fears often have causes that are not immediately apparent. Unresolved internal or external conflicts, e.g. in the family system, in life-threatening situations, can become more significant and cause acute fears. Family relationships can, for example, counteract acceptance and acceptance of the imminent end of life. A genogram and a look beyond the system boundaries of the nuclear family can provide support. The creation of a genogram can be helpful to locate pressures, but also resources in a relatives' system. It therefore also makes it possible to uncover possible fears and fear-related factors of all people in the system. Working out a genogram, e.g. as part of a basic assessment, also enables fears to be explored in clinical discussions. The questions of GAD-2 can also be included here. A tried and tested version for the palliative sector can be found on the homepage of the Psychology Section of the German Society for Palliative Medicine: www.dgpalliativmedizin.de/category/3-pba-dokumentationshilfe.html. Professional instruction for non-psychosocial professional groups is recommended for genogram work.

For patients who cannot express themselves at all or inadequately with regard to fear, e.g. due to dementia, somnolence, etc., an assessment of the extent of fear should be based on non-verbal characteristics such as motor restlessness, high muscular tension and indications of high sympathetic activity. The assessment of the relatives should also be included in the assessment. The relatives and the treating persons, who constantly work on the patient, are important experts in the non-verbal, physical expressions of the patient.

The algorithm of the Pan Canadian Practice Guideline suggests the procedure summarized below[11]. At the beginning of or during palliative treatment, when the patient is confronted with situations that he experiences as stressful, anxiety symptoms are screened and the patient's acute risk is assessed. Acute suicidality requires the involvement of psychiatric expertise. If this is not the case, anxiety in the palliative situation is divided into mild, moderate and severe symptom burden as a result of the screening. In the case of moderate and severe anxiety symptoms, an in-depth exploration is carried out. All three degrees of severity result in a differentiated therapy strategy with different treatment intensity (stepped care model). A primarily preventive and supportive strategy is used to treat mild anxiety. For all degrees of severity, including mild anxiety, psychoeducation, information on treatment options and self-help as well as practical support are part of the treatment strategy. In the case of moderate and severe anxiety, the broad spectrum of non-pharmacological and pharmacological intervention strategies are also used, which are carried out at a low frequency for the moderate symptom burden and high frequency for the severe symptom burden. Follow-up is recommended for all three degrees of severity.

Differential diagnosis

OL palliative medicine recommendation 16.6 (consensus-based): In patients with incurable cancer, anxiety in palliative situations should be differentiated from panic disorders, phobias, generalized anxiety disorders, adjustment disorders and post-traumatic stress disorders.
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background

The recommendation for differential diagnosis is based on the expert opinion of the guideline group.

Anxiety in palliative situations and ICD