Overcoming Psychological Responses in Cancer Management

Phase

Normal, adaptive

Abnormal, maladaptive

Pre-diagnosis

Concern about the possibility of having cancer

Hyper-vigilance

Inappropriate preoccupation

Development of cancer symptoms without having the disease

Diagnosis

Shock

Disbelief

Initial, partial denial

Anger, hostility, persecutory feelings

Anxiety

Depression

Complete denial, without treatment refusal

Fatalistic treatment refusal on the grounds that death is inevitable

Clinical depression

Search for alternative (quack) cures

Initial treatment

Surgery

Fear of pain and death

Fear of anaesthesia

Grief reaction to changes in body image

Postponement of surgery

Search for nonsurgical alternatives

Postoperative reactive depression

Radiation therapy

Fear of x-ray equipment and of side effects

Fear of abandonment

Psychotic-like delusions/hallucinations

Chemo-therapy

Fear of side effects

Anxiety, mild depression

Changes in body image

Isolation

Altruistic feelings

Residual drug-induces psychoses

Severe isolation-induced psychotic disturbances

Organic brain syndrome/delirium

Post-treatment

Return to normal coping patterns

Fear of recurrence

Post-treatment anxiety and depression

Severe post-treatment anxiety and depression

Recurrence

Shock

Disbelief

Initial, partial denial

Anger, hostility, persecutory feelings

Anxiety

Depression

Severe reactive depression with insomnia, anorexia, restlessness, anxiety and irritability

Progressive disease

Frenzied search for new information, other consultants, and quack cures

Depression

Terminal/palliation

Fear of abandonment

Fear of loss of composure and dignity

Fear of pain

Unfinished business

Personal mourning with anticipation of death and a degree of acceptance

Fear of the unknown

Depression

Acute delirium

In the pre-diagnostic and diagnostic phases, psychiatric referrals are made when the patient’s psychiatric signs and symptoms cause severe distress and interfere with a management plan.

Referral indications:

Fatalistic treatment refusal, anger towards family, friends or a deity
Persistent depressive symptoms for more than 2 weeks

The psychiatric consultant takes the time to explore coping strategies for specific problems to hear out anguish, and to listen to the patients fears and expectations, armed with medical knowledge that permit dispelling fears that are unfounded. Patients must be helped to come to terms with the reality of a limited life span and the inevitability of death. This is an existential dilemma (Weissman and Worden 1976–1977) that may require obtaining a spiritual history, spiritual assessment and interventions that require religious personnel.

14.2.1 Psychiatric Illness in Cancer Patients

Incidence of psychiatric illness can be as high as 51% among patients with cancer with most of the psychiatrically ill patients having anxiety and mood disorders (Berard et al. 1998, Hardman et al. 1989, McCartney et al. 1989). In a series looking at 1721 cancer patients referred for psychiatric assessments, Adjustment disorders (34%) occurred most frequently followed by delirium (17.4%) and major depression (14.4%), (Akechi et al. 2001). The frequency of the top three disorders differed based on some patient characteristics (Table 14.2).

Table 14.2

Patients’ characteristics and psychiatric diagnosis (Akechi et al. 2001)

Characteristics	No (%)
Characteristics	Adjustment disorder	Major depression	Delirium
Gender
Male	273 (30.4)	111 (12.4)	218 (24.3)
Female	311 (37.8)	136 (16.5)	81 (9.8)
Age (years)
< 60	377 (40.5)	130 (14.0)	83 (8.9)
> 60	207 (26.2)	117 (14.8)	213 (26.9)
Performance status
0–2	442 (36.4)	182 (15.0)	94 (7.7)
3–4	141 (28.6)	151 (15.3)	210 (21.3)
Pain
Absent	224 (34.3)	88 (13.5)	47 (7.2)
Present	349 (35.4)	151 (15.3)	210 (21.3)

Assessment of psychiatric illness in cancer patients involves a comprehensive assessment of biological and psychosocial factors. The patient is evaluated in the context of his or her coping style, developmental history, phase of illness and psychiatric history with knowledge of the natural course of the illness and the common complications of treatment. Treatment needs to be characterised by therapeutic activism with the use of effective psychopharmacological and brief psychotherapeutic modalities to relieve symptoms rapidly and prevent complications due to preventable psychological trauma.

14.2.1.1 Adjustment Disorders

Most of these are related to anxiety and other mixed anxiety and depressed mood (Akechi et al. 2001).

Anxiety Disorders

Anxiety is often a response to existential plight and to the threat of deformity, abandonment, loss of control and dignity that comes with cancer.

Specific anxiety syndromes that are common in cancer include:

Anticipatory Nausea and Vomiting

Side effects of chemotherapy often include profound nausea and vomiting, a vivid visceral memory that may result in classical conditioning to associated stimuli in up to 75% of patients. Patients who vomit secondary to chemotherapy frequently develop an aversion to the hospital, staff and the sight and smell of medical implements.

Appropriate management strategies include;

Fixed and optimal anti-emetic treatment to block the initial episode of nausea and vomiting and avoid a conditioned response.
Minimise anxiety just before treatment by the use of benzodiazepines such as alprazolam or lorazepam.
Behaviour therapies may be useful.
Systemic desensitisation extinguishes the conditional response (Morrow and Morrell 1982) or cognitive distraction that blocks the perception of the conditioned stimulus may successfully eliminate the anxiety that cause due to classical conditioning.
Combining benzodiazepines with highly specific, centrally acting anti-emetics like ondansetron and dexamethasone has revolutionised chemotherapy and reduced the experience of nausea and vomiting.

Claustrophobia

Patients with anxiety in closed spaces have difficulties with MRI equipment (Melendez and McCrank 1993). They can be managed with anti-anxiety pre-medication and strategies to tailor and shorten the test. Good preparation with special attention to the patient’s anxieties would also be helpful.

14.2.1.2 Delirium

Delirium is a frequent result of cancer and its treatment. It is a neuro-psychiatric response rather than a psychological reaction but it always needs to be taken into consideration when carrying out psychiatric evaluations of cancer patients. Agitation and hyperalertness are the most common behavioural symptoms in cancer patients with delirium (Oloffson et al. 1996). Haloperidol has been found to be effective in patients with delirium (Akechi et al. 1996).

Other neuropsychiatric effects include; effects of metastatic brain tumours, leptomeningeal disease which is usually associated with mental status changes, cranial nerve changes and radicular signs. Nonspecific signs that prompt psychiatric referrals include headache, balance difficulties and seizures. Others include complex partial seizures, paraneoplastic syndromes and treatment related neuropsychiatric effects.

14.2.1.3 Depression

Depressive disorders in cancer patients may be a response to the psychosocial stress of cancer, a medical symptom of cancer or its treatment or it may be coincidental. Prevalence in Western literature ranges from 8% to 14% (Sellick and Crooks 1999). Adjustment disorder is higher: up to 25% (Derogatis et al. 1983). Pancreatic cancer has been associated with a higher proportion of dysphoria (Holland et al. 1986). Steroids and biological agents such as Interferon and the anticancer medication most commonly associated with affective instability. Patients who are generally most vulnerable to distress and are susceptible to depression have more physical symptoms, more financial and mental problems and lower ego strength (Veissmon AD, Coping with cancer. New York, McGraw Hill 1979, p. 67).

Diagnosis of depression is confounded by similar neuro-degenerative or physical symptoms in both depression and somatic diseases. The Zung self rating depressive scale has been proven as an effective and reliable screening tool for depression in cancer patients. (Dugan et al. 1998) The brief symptom inventory was also found to be a fair screen tool but the Beck depression inventory was overly sensitive (Beck and Steer 1984).

Suicide is rare in cancer patients. Risk factors include: