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Psychotherapy Casebook


Dean Schuyler, MD

Published: October 13, 2016


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Through this column, we hope that practitioners in general medical settings will gain a more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Schuyler is a psychiatrist and a member of the palliative care team at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina.

Prim Care Companion CNS Disord 2016;18(5):doi:10.4088/PCC.16f02039

Published online: October 13, 2016.

Corresponding author: Dean Schuyler, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (

Funding/support: None.

Potential conflicts of interest: None.

An anxiety disorder is a problem familiar to most psychiatrists and is characterized by feelings of worry strong enough to interfere with daily activities. Anxiety disorders are commonly encountered and thought to represent about 3 million cases seen in the United States by health care professionals each year.1

There are several issues related to anxiety that a physician working with older patients on a palliative care team may encounter. Why would an older patient, often with serious medical illness, be anxious? Are the causes of anxiety different in older patients compared to younger patients?

Many of my patients have chronic illnesses. For some of them, cancer is one of these illnesses. Recently, I heard a patient say, "I think about my cancer and its likely outcome 10 hours a day." I believe that much of the anxiety that people experience is self-generated. It emanates directly from the thoughts that people have. We all have thoughts.

Some inpatients spend significant periods of time alone, which often means alone with one’s thoughts. Unfortunately, the tapes that run through people’s minds rarely turn off by themselves. When one is alone and unoccupied, one is "alone with one’s head." Thoughts about chronic illness are, in fact, quite common. You might expect that an inpatient would ask a third-year medical resident about anxiety, especially if that doctor was assigned to his or her care. The assumption is that the resident physician would know more about the problem than the patient. Sadly, few of our patients seek help for their anxiety. Given that chronic medical illness is frequently found on medical units of a Veterans Administration hospital, many of our patients are anxious.

An individual having thoughts about, for example, cancer has a number of choices. One choice is to focus on the thought, often to enlarge the thought, and to dwell on the consequences of the thought. This path generally generates anxiety. I believe that this is one problem the patient mentioned earlier was alluding to when he said he thinks about his cancer 10 hour a day.

A point I make with each patient with whom I speak relates to the self-production of anxiety. When I say, "You are an anxiety-producing machine," older patients typically are not offended and know exactly what I mean. "It isn’ t cancer that is producing your anxiety, rather, it is you!"

A person does have a choice. One can choose to focus on these thoughts, with the consequence that one will generate anxiety. Or, one can choose to "distract" oneself. One popular distraction for people who cannot fall asleep is to "count sheep." At times this method of distraction works, but sometimes it doesn’ t, and even when it works, it may be useful once or twice but rarely does it solve the problem. A better alternative is to "engage" in an activity that occupies one’s mind. That is often my suggestion.

A common question that often follows is "What do you suggest that I do?" My response is that it would be arrogant of me to tell you what to do. Instead, I ask, "What are your interests?" I have invariably received some interesting answers. One man recently told me about a project he used to work at. I suggested to him that he continue!

Often, people cite symptoms they experience that limit their activity: "If I go outside, I will get short of breath. So, there is little I can do outside the house. I used to garden for hours, but that is no longer possible for me." My response is to direct the patient’s attention to alternatives inside the home. There is television and reading, as well as a variety of projects available to a person indoors. Any choice seems better than focusing on illness and generating anxiety.

As a person ages, often, there is less and less that he or she can control. In addition, loss due to death occurs with a greater frequency than it did earlier in life. In these ways, older patients may be more anxiety prone than their younger counterparts. One patient told me, "All my peers have passed on. I am the only one left." It is commonly known that a couple married for many years is disrupted by the death of one of its members. Over the subsequent year, death of the remaining partner is all too frequent. One consequence of successful aging is outliving your peers.

Periodically, an older man or woman is forbidden to drive a car. "We’ re taking away your license and keys because you are a danger to others on the road," some patients have been told. Unfortunately, this action, while warranted, often limits the individual to a smaller, more circumscribed world. This change may result in a world for which the patient is ill-prepared.

Therefore, losses and especially loss of control are issues seen commonly in the care of older patients. Chronic illness alone represents something the patient can often do little to control. I see many older people with anxiety. Defining that anxiety as self-generated has been acceptable to many of my patients. Further definition of the choices involved (distraction, engagement) presents the older patient with some things he or she can do to avoid generating anxiety. This approach has resulted in relief in a considerable number of cases.


1. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.

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