By Dr. Miriam Franco MSW, PsyD, MSCS
Professor, Sociology Department
Member, MSAA Healthcare Advisory Council
Anxiety in MS: Frequently Overlooked and Undetected
Anxiety is perhaps the most taxing and under-treated psychological effect of living with MS. It does not appear to result from the physical disease process of MS, but rather stems from the realities of living with MS. Individuals living with MS know that it’s the unpredictability, and therefore the difficulty, in planning and preparing for the effects of MS on your life, that drives one’s anxiety. Anxiety disorders are estimated to affect 43 percent of those with MS, and are also more common among women.
The scientific literature suggests that anxiety levels are higher at the onset of the disease and when it co-exists with moderate to severe depression. Tragically, the combination of untreated, sustained depression along with anxiety can produce higher rates of suicide among people with MS. Limited social support and higher rates of alcohol consumption also elevate anxiety disorders in MS.
Anxiety disorders are frequently overlooked and often undetected. As a result, they can worsen one’s quality of life and greatly reduce treatment adherence. One study suggests that only one-third of those with MS who have an anxiety disorder have been given a documented psychiatric diagnosis (Korostil & Feinstein, 2007). Frequently, if anxiety and depression co-exist, only a diagnosis of a depressive disorder is given.
Research suggests that approximately half of those with MS who have a diagnosable anxiety disorder are not receiving an anti-anxiety medication and/or psychotherapy. This is important to consider, because if an anxiety disorder co-exists with a depressive disorder, adequate treatment may require higher doses of an antidepressant medication for a longer period of time. This is something that many healthcare professionals may not be implementing if they are not well-versed in this area of treatment.
Some of the challenges of anxiety disorders are how to detect it, how to reduce it, and how to live with it. Fear is associated with having a real external threat. Stressful situations typically bring on some initial anxiety, like the first day of school, but for most people, this initial anxiety usually disappears with the passage of time and involvement in one’s new situation.
Anxiety represents a symbolic, perceived threat to one’s sense of self, which may be defined as how someone sees him or her self and the unique qualities that he or she possesses. As MS progresses, different challenges and new uncertainties must be faced. This can result in more adjustments, more losses, and more anxiety.
The Symptoms of Anxiety
The spectrum of anxiety disorders includes panic attacks, phobias, obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD). GAD is more prevalent in MS, followed by panic disorder and OCD. Those at higher risk are women, particularly those with a prior history of depression, excess drinking, and the presence of high social stressors. To be considered to have an anxiety disorder, a patient would present physiological and/or psychological symptoms.
Examples of physiological symptoms include:
- Increased heart rate or heart palpitations
- Dry mouth
- Shortness of breath
- Hot or cold sensations
- Tingling in fingers or toes
- Muscular tension
- Insomnia, specifically difficulty falling asleep
- Frequent urination
Examples of psychological symptoms include:
- Chronic unhappiness
- Frequent worry, guilt, or feeling out of control
- Feelings of inadequacy, feeling criticized, or easily embarrassed
- Rigidity, which is to be inflexible and less willing to make changes
- Hostility, feeling anger toward others
- Repeating certain behaviors or ruminative thoughts (pondering over something repeatedly)
- Over-anticipating things
- Excessive concern with physical health
- Negative thinking about the future
- Racing thoughts
Assessing and Treating Anxiety
Several screening tools or questionnaires can be used to assess levels of anxiety in MS. These include:
- The Hamilton Anxiety Scale (HAS)
- Hospital Anxiety and Depression Scale (HAD)
- State Trait Anxiety Inventory (STAI)
The first two tools listed use scales to rate 14 items and take about seven minutes each to complete; the third tool is an inventory of 40 self-reported items (relating to anxiety). Those who are anxious typically know that they are, however, if depression is also present, it is often assumed that depression takes precedence or that its treatment may lower the anxiety. Often, if you suffer from both depression and anxiety, a different kind of medication is needed, such as one of the SSRIs that treats both disorders.
Lowering anxiety requires many steps that include learning stress-reduction techniques. These techniques include:
- Interrupting and changing both “all or nothing” types of thinking, as well as catastrophic thinking, where an individual dwells on the worst possible outcomes
- Incorporating exercise into lifestyle where possible
- Breaking down fearful concerns into manageable, “present-oriented” solutions, aimed at resolving the issues at hand
- Problem-solving one step at a time
- Allowing and normalizing feelings of loss of control, while allowing the effect of any losses to be grieved and expressed
Learning to control your reactions and quiet yourself can allow you to feel anxiety when needed to problem-solve, but not to become so overwhelmed by it. Increasing the areas of where you can have control and prioritizing activities can also help. Developing a more spiritual, entrusting attitude has also been found to be helpful to many.
Psychotherapy, either psychodynamic or cognitive/behavioral, includes stress-reduction techniques such as guided imagery, biofeedback (a technique that teaches individuals how to control their body’s responses), and meditation. These can be very helpful to reduce anxiety. Medication management is also available.
For some, an antidepressant, such as certain SSRIs that work on depressive and anxious symptoms, is indicated. Examples include Celexa® (citalopram) or Lexapro® (escitalopram). Additionally, Effexor® (venlafaxine) or Cymbalta® (duloxetine hydrochloride) may also be considered. Specific anti-anxiety medications like Valium® (diazepam) may work on an as-needed basis, but these tend to have short half-lives. This means that they work only for short periods of time or to aid sleep, but they are not designed for long-term use.
When searching for a therapist to get help with your anxiety, you may want to ask the therapist the following questions:
- Do you have experience working with anxiety and with MS patients?
- What types of therapies do you use? (Cognitive therapy, psychodynamic therapy, group therapy, etc.)
- Do you work closely with physicians?
- Are your services covered by my insurance?
- Do you employ specific relaxation techniques such as guided imagery, meditation, biofeedback, hypnotherapy, and eye movement desensitization and reprocessing (EMDR) to lower stress and anxiety reactions? (EMDR is a newer, less-traditional type of psychotherapy that works to reduce emotional problems.)
- Do you also work with care partners and family members?
- How do you feel about using medications to help treat anxiety?
These questions will help to identify the best therapist for you.