Alleviating Anxiety: Optimizing Communication With the Anxious Patient

When we listen with curiosity, we don’t listen with the intent to reply. We listen for what’s behind the words.

—Roy T. Bennett, The Light in the Heart

Anxiety disorders are the most common psychiatric disorders in the United States, affecting an estimated 18% of adults (around 40 million people) (1). Although anxiety disorders are highly treatable, only about one third of those who meet diagnostic criteria receive specialized mental health treatment. Individuals with anxiety disorders visit their medical doctors 3 to 5 times more often than do those without anxiety. Often these patients present with physical symptoms—muscle tension, palpitations, gastrointestinal problems, pain, or other nonspecific medical complaints. Physicians of all disciplines require skill in forming a trusting alliance with their patients to elicit the symptom history that allows an accurate diagnosis and provides the essential backdrop for the patient to engage in treatment (1).

Individuals with anxiety disorders may be particularly sensitive to the inherent doctor-patient power differential. Doctor-patient relationships have been described on a continuum: At one extreme, the doctor makes decisions without patient input (paternalism) or bases decisions on the patient’s perceived preferences (doctor as agent) (2, 3). At the other extreme is the informed-decision-making model, where the doctor’s role is to offer information to the patient (consumer), who then becomes the sole decision maker (4, 5). In between are various models of shared decision making. For many patients with anxiety disorders, the ambiguity of the doctor-patient interaction is itself a stressor that may engender more anxiety. The concerns of all patients presenting for care—about whether they will truly be understood, receive a clear and accurate diagnosis, and be provided with safe and effective treatment in a manner that is sensitive to his or her individual needs—are magnified for the patient presenting with an anxiety disorder.

One model conceptualizing the doctor-patient relationship considers which voice is used by the physician and the patient in describing symptoms. According to Habermas’ theory of communicative action (6), the doctor or patient may use the “voice of medicine” (characterized by an objective, scientific attitude) or the “voice of the lifeworld” (characterized by “the patient’s contextually-grounded experiences of events and problems in her life” (p. 42). Barry and colleagues (7) postulated that for acute, simple medical problems, having both the doctor and the patient using the voice of medicine usually worked effectively. However, for more complex medical and emotional issues, having both the patient and the doctor using the voice of the lifeworld resulted in better outcomes, with the patient feeling he or she was recognized as a unique human being. The poorest outcomes occurred when patients used the voice of the lifeworld but felt their concerns were ignored when their doctor used the voice of medicine. The quality of care provided to patients is enhanced in a patient-centered medical model that includes a physician sensitized to the importance of dealing with the concerns of the lifeworld for patients with chronic physical and psychiatric conditions.

Within the patient-centered psychiatrist’s armamentarium is awareness of and openness to understanding each individual and his or her uniqueness within the context of that person’s life experience and attention to the influence of biopsychosocial and developmental risk and resilience factors. Patients are more satisfied when they feel they have agency—control over treatment decisions. Individuals with anxiety disorders may require extra encouragement to voice their opinions and concerns over treatment plans. When extra time is taken to truly engage in a discussion about preferences, fears, hopes, and priorities, patient motivation and adherence to a mutually agreed-on plan of care is enhanced. The physician’s ongoing curiosity about the patient, as manifested by a joint exploration of symptoms, treatment options, and effectiveness, is a key attribute in facilitating an improved outcome (8).

Clinical Vignette

Ms. Sanders was a 26-year-old married woman with a one-year-old child, Bobby. Ms. Sanders was contemplating returning to work as a bank teller and having Bobby attend day care. However, her chronically high level of anxiety had increased to a disabling level over the past several months. She was unable to sleep, getting up multiple times a night to ensure that Bobby was all right. She worried about all of the “horrible things” that could possibly happen to him in day care. She did not want to take little Bobby out of the house because she was afraid that he might be abducted or get hurt. She hesitated to give him solid foods, for fear that he could choke. She experienced a surge of terror if he sneezed or coughed, immediately calling the pediatrician for an appointment.

Bobby’s pediatrician expressed concern about Ms. Sanders’ level of anxiety. “Bobby is perfectly healthy, Ms. Sanders,” he had reassured her. After the second urgent pediatric visit that month for no discernible illness, the pediatrician had told Ms. Sanders that she needed to take care of herself, too. He referred her for a psychiatric evaluation of her anxiety and possible depression.

Ms. Sanders appeared wan, vigilant, and anxious as she entered the psychiatric waiting room. Bobby was held securely in her arms as she struggled to get through the door while pushing an empty stroller. She checked in with the receptionist and then sat in a chair as far from others as she could get, clutching Bobby closely. He squirmed and fussed in an attempt to get down, only to be clutched more tightly.

Dr. Kaplan smiled when she invited Ms. Sanders into her office. Bobby continued to squirm and whimper as Ms. Sanders sat down.

“Who is the cute little guy who came with you?” Dr. Kaplan inquired.

“Oh, I’m sorry. Was I not supposed to bring him?” Ms. Sanders blurted in a worried tone.

“No, no. I’m happy to meet him. What is his name?” Dr. Kaplan inquired.

“Bobby,” Ms. Sanders said dully.

“He’s very cute. How old is he?” Dr. Kaplan continued. They chatted for a while about Bobby, who started crying, frustrated by his confinement in his mother’s clutch. Dr. Kaplan got up and moved some breakable items from the coffee table. “Would you like to put down the blanket and let him move around?” Dr. Kaplan asked as Bobby’s howls became ever louder.

“Are you sure it’s okay?” Ms. Sanders questioned timidly.

“Yes,” replied Dr. Kaplan matter-of-factly.

Bobby crawled around the blanket and played with the toys his mother had provided. She swooped in quickly to retrieve him when he attempted to pull himself up. Dr. Kaplan provided distractions for Bobby to allow his mother to talk.

Finally, Ms. Sanders looked up at Dr. Kaplan with an expression of desperation. “I am worried all of the time, Dr. Kaplan. I can’t sleep. I am not eating very well. I am constantly afraid that something will happen to my precious Bobby. I simply couldn’t stand that. But his pediatrician seems to think that I am going to make Bobby a nervous wreck, as well. What can I do?”

Dr. Kaplan reassured Ms. Sanders that it is normal for new parents to worry about their babies. “But he is a year old now and looking healthy and robust. And see how he shows his toys to you? That suggests that he is well-bonded and secure. What are your thoughts about why you are so anxious about such a healthy, happy little boy?” Dr. Kaplan inquired.

Ms. Sanders stopped and thought for a moment. “I was raised by two very successful alcoholic parents,” Ms. Sanders mused. “I think I felt uncared for, even though I had everything I ever wanted—materially, that is. But not much in the way of attention.”

“Wow,” Dr. Kaplan replied with earnest amazement. “You are an insightful, caring mother. No wonder being there for Bobby is so important to you. How about we prioritize your concerns so that we are sure to deal with what is most important to you first?” Dr. Kaplan suggested.

“My sleep!” Ms. Sanders blurted. “I’m afraid to take even melatonin for fear that I won’t wake up if Bobby needs me.”

“And your partner?” Dr. Kaplan inquired.

“My husband just says to go back to sleep and stop worrying all of the time. I don’t think he understands at all,” Ms. Sanders replied. “Bobby is sleeping in our room—in his crib, of course. But Bob, his father, doesn’t seem to wake up when he cries. It’s all on me,” she confessed, a tear rolling slowly down her cheek before she could swish it away.

“Well,” Dr. Kaplan said empathically, “I understand why you feel so upset. That’s a lot of worry for one person to bear alone.”

They then set about jointly making a plan, first addressing Ms. Sanders’ need for sleep. Ms. Sanders suggested that she could talk to her husband and ask him to skip his usual beer before bedtime so that he would sleep more lightly, and she would request that he tend to Bobby during the first half of the night. She would take second shift. They then discussed a light sleeping aid (Ms. Sanders chose melatonin) and the next steps she should take in dealing with her anxiety.

“I don’t want to just take drugs,” Ms. Sanders said urgently. “I want to try to work out my issues with psychotherapy first.”

“That sounds fine,” Dr. Kaplan agreed. “A cognitive-behavioral approach will probably work very well for you. Do you want to start with that?”

“Yes,” answered Ms. Sanders resolutely—the first time she had sounded sure about anything all session. She even flashed a genuine smile as she buckled Bobby into his stroller and accepted Dr. Kaplan’s assistance with the door as she left the office.

Communication to Optimize Patient-Centered Care

Williams and colleagues (8) have reported that when doctors provide adequate information, patients are more likely to be satisfied. Other factors that improve patient satisfaction with the care provided by physicians include patient-centered, empathic communication; courteous behavior; partnership building; and positive affect. Physicians who invite patients to share their perspective by addressing the preferences, values, and needs of each patient enrich the doctor-patient relationship and enhance open communication. “Informed and empowered patients participate with their physicians in exploring options for overcoming disease and establishing the conditions for maximizing health consistent with their own sociocultural frame of reference” (9).

Tips for Optimizing Communication With an Anxious Patient

• 1.Provide a welcoming atmosphere to the waiting area and office.
• 2.Add a patient’s review to the review of systems to address important dimensions of care related to the psychiatric consultation (9):
  • A.Respect for the patient’s values, preferences, and expressed needs
  • B.Communication and education
  • C.Coordination and integration of care
  • D.Emotional support and alleviation of fears and anxieties
  • E.Appropriate involvement of the patient’s family and friends (as defined by the patient)
  • F.Continuity and transition of care
• 3.Request that your patient correct you or clarify what he or she means if you do not seem to understand what your patient is communicating (for any reason—language, culture, assumptions, and so on).
• 4.Ask, in a nonjudgmental and open manner, about the patient’s thoughts or beliefs about the cause of the presenting problem.
• 5.Through actions and questions, continually reinforce the message that each individual is unique. Demonstrate that you are curious about your patient’s life and interested in getting to know him or her in a meaningful way, including by gaining an understanding of how your patient views illness and healing.
• 6.From time to time, ask the patient how he or she feels the therapeutic interventions are going. Is he or she feeling comfortable with the treatment plan? Any midcourse corrections needed?
• 7.Acknowledge appreciation for the patient’s appropriate advocacy and collaboration in his or her care.