Fear and anxiety with a cancer diagnosis is common and normal. A diagnosis of cancer, a potentially life-threatening illness, is by definition a traumatic experience, for yourself and for your family members. Fear is a natural reaction to trauma, and is part of your nervous system activation in response to threat. A cancer diagnosis also brings uncertainty; and uncertainty brings both hope and fear. It is not realistic to try and eliminate all your fear and anxiety, but rather to find ways to respond to your anxiety when it comes so that it doesn’t overwhelm you. Like all emotions, fear is information, it’s a signal, it’s our alarm system. It indicates that there is a threat or an unmet need, and like all emotions, it can serve to motivate us to take helpful action: for example, it can lead us to change our diet, or it can lead us to ask our medical team for information. Fear and anxiety is unproductive and problematic when it is excessive, chronic, and instead of generating productive actions, it interferes with everyday life.
When we talk about anxiety, we actually talk about 3 domains that act together. The first is the mental domain – our thoughts and feelings. The second is the physical domain, and the third is the behavioural domain. Sometimes we are more aware of one domain than the others, but all three always participate when we have anxiety. Anxiety becomes a concern when we identify in the mental domain excessive unproductive thoughts and feelings. Examples of unproductive thoughts are: regrets about the past (“I should have” or “if only”), or black and white thinking about the future (“this will never get better”). At times, anxiety will manifest more as anger and agitation, or through intrusive flashbacks or nightmares. Anxiety also always involves physical manifestations, such as: fatigue, muscle tension, headaches, nausea, difficulty sleeping, or loss of appetite.
Unproductive and problematic anxiety is one that triggers avoidance. For example, anxiety about how we look may make us avoid certain social situations. Self-medicating with drugs or alcohol is another example of avoidance as one engages in it so not to feel the underlying anxiety. Other problematic behavioural manifestations of anxiety include anger outbursts, or procrastination.
Unfortunately, the mental, physiological, and behavioural components of anxiety build on each other. What this means is that if you’re experiencing anxiety that something may be wrong and that results in physical symptoms; these symptoms make you more convinced that something is wrong. This then brings more anxiety, more physical symptoms, more self-checking, and reinforces the vicious cycle.
Anxiety usually comes in waves. Sometimes the triggers for the waves of anxiety are predictable. We usually see a peak of anxiety at diagnosis or before starting treatment. Other common triggers include medical scans (or waiting to get Coping with the Fear and Anxiety of a Cancer Diagnosis By Rinat Nissim, Ph.D. C. Psych Psychologist, Princess Margaret Cancer Center and Assistant Professor, Faculty of Medicine, University of Toronto their results), anniversary events (date of surgery), illness or death of someone you know, or new physical symptoms. However, some triggers of anxiety may seem confusing. For example, many individuals experience anxiety at the end of their cancer treatment. In fact, the end of treatment can be the time when you feel the most in need of support, but least able to ask for it and when it seems least available. Anxiety at this point often stems from the expectations of ending treatment (“I should be back to normal”) because often these expectations are diffi- cult to be met. Sometimes the anxiety is triggered by a sense of abandonment because the end of treatment means the end of the intensive medical attention that was provided during treatment. As with a soldier returning from battle, this is also the time to process emotions and grieve multiple tangible (changes in appearance or in physical abilities) and intangible losses (future plans that now need to be revised, or the loss of the illusions that we all tend to hold when we are healthy: of certainty, control, and invulnerability). One of the hardest things about anxiety and grief at end of treatment is that it may be hard for the people around you to understand this experience. They expect you to be happy and to go back to normal, and they may not be as available as they were during treatment.
The end of treatment is also often associated with a fear of recurrence, or a fear that cancer will come back or progress. Fear of recurrence is a universal concern of individuals with a cancer diagnosis and is one of the most frequent concerns in individuals who completed treatment, particularly amongst women and in younger individuals. Although the fear of recurrence tends to lessen over time, sudden re-experiencing is common. This fear is a concern when it is characterized by chronic thoughts about recurrence/progression that impact daily functioning and the ability to make plans for the future.
So how do you cope with the fear and anxiety? Most often, when we feel anxious, we tend to resist this experience, we tend to be at a tug of war with our anxiety, constantly telling ourselves things such as “It’s silly to be anxious”, or “I should be able to snap out of it” or “anxiety and stress will bring my cancer back.” Pulling harder in this tug of war comes naturally, but the harder you pull, the harder the anxiety pulls, and what this tug of war really does is escalate our anxiety and deplete our resources.
What we need to do sometimes is learn to accept the anxiety; drop the rope and stop the tug of war. Yes, dropping the rope is counterintuitive, yet can be the most productive action. Think about anxiety as a wave in the ocean that is coming at you – You can run from it, but then it’s going to catch up and knock you down. You can try to stand your ground, and resist it, but then it’s still going to knock you down. Or you can dive underneath it and let it wash over you. Accepting your anxiety does not mean you like or agree with your thoughts and feelings, nor does it mean that you’re giving up to them, it is more about observing them and letting them ‘wash over you’ instead of getting tangled up into a bigger knot.
This article is adapted from Dr. Nissim’s presentation at the Toronto Melanoma Patient Information Session on March 13th, 2017.