Is this a normal reaction to Is this a normal reaction to Cancer?Cancer?
Dr Siobhan MacHale
Consultant Liaison Psychiatrist
Beaumont Hospital
Sept 19th 2013
Impact of Cancer on Impact of Cancer on Psychological WellbeingPsychological Wellbeing
Huge variety (individual and over time)
Mild to severe, acute or chronic
‘‘Healthy emotional response’ Healthy emotional response’
3 phases
1. Initial reactionshock/disbelief
2. Distress anxiety/anger/low mood
3. Adjustment
Normal Reactions to an Normal Reactions to an Abnormal SituationAbnormal Situation
• Shock
• Anger and Irritability
• Denial
• Sadness
• Acceptance
Variety of ResponsesVariety of Responses
““Distress”Distress”
– More acceptable than ‘psychiatric’, ‘psychosocial’ or ‘emotional’
– Sounds ‘normal’ and less embarrassing
– Can be defined and measured by self-report
Distress in cancerDistress in cancer
A multifactorial unpleasant emotional experience of a psychological (cognitive, behavioural, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment.
Distress extends along a continuum, ranging from common normal feelings of vulnerability, sadness, and fears to problems that can become disabling , such as depression, anxiety, panic, social isolation, and existential and spiritual crisis.
Distress is “Normal”Distress is “Normal”
Continuum of Distress
Mild Moderate Severe(Normal, adaptive) (Disabling)
Cancer and DistressCancer and Distress
1. Distress is “normal”
2. Do not want to “medicalise” distress
3. Do not want to miss significant psychological problems
Previous Level of activity
Level of Activity
Time
Impact of Cancer and Psychological factors on activity level
Medical / Physical Problems
Psychological Problems
Why is distress missed?Why is distress missed?
‘Understandability’ of emotional response
Confusion re possible organic aetiology
Unsuitability of clinical setting for discussion
Stigma ‘Don’t ask, don’t tell’
90% of those with significant distress go unnoticed
Why does it matter?Why does it matter?
Associated with increased disability
Associated with poorer outcomes
Increased use of healthcare resources
Good response to treatment
Physical symptoms – pain, fatigue
Psychological – fears, sadness
Social – family, future
Spiritual – seeking comforting philosophical, religious, or spiritual beliefs
Existential – seeking meaning of life in the face of death
Advanced Cancer Requires Coping With
EXISTENTIAL CRISES IN CANCEREXISTENTIAL CRISES IN CANCER
DIAGNOSISOFCANCER
ADVANCINGDISEASE;DNR; HOSPICE
RECURRENCEOFDISEASE
COMPLETIONOFTREATMENT DEATH
INITIALTREATMENT
N.E.D. TERMINALPALLIATIVETREATMENT
Adapted from McCormick & Conley, 1995
“I could die from this.”
“I have survived -- will it Return?”
“I will likely die” -- depressed; anxious
“I am dying.”
Carers needsCarers needs• Family
• Mental health of Staff
- Physicians’ acknowledged feelings (anger, frustration, depression)
- AffectClinical decisionsBehavior with patientsQuality of careRisk of burnout
Meier et al, 2002
When Emotional Difficulties When Emotional Difficulties become overwhelming…become overwhelming…
1/4 to 1/3 patients have
disabling psychological
problems
Impact Impact
Uncertainty regarding the future Meaning of what has happened Loss of control Loss of independence Helplessness Fatigue Fear Death
ImpactImpactRelationships – family
partner (sexuality, fertility)childrenfriends
Body Image Self-esteem Leisure/Workdisfigurement sick role changescarring disability lossImagined financial
holidays
When Emotional Difficulties When Emotional Difficulties become overwhelming…become overwhelming…
Affect quality of life Ability to manage cancer treatments Fatigue, insomnia, low self-esteem, inactivity,
depression…
May exacerbate physical symptoms
Risk factors for psychiatric disorderRisk factors for psychiatric disorder
Patient – History of
psychiatric disorder (inc substance misuse)
– Social isolation
– Dissatisfaction with medical care
– Poor coping (eg not seeking info/ talking to friend)
Cancer– Limitation of activities – Disfiguring – Poor prognosis
Treatment – Disfiguring, unpleasant – Isolating (such as bone
marrow transplant) – Side effects
eg steroids
DepressionDepression
4x general population (10-20%) Response to perceived loss
Diagnosis of cancer may precipitate feelings similar to bereavement
Loss of eg
– parts of the body– the role in family or society– impending loss of life
MAJOR DEPRESSIVE EPISODEMAJOR DEPRESSIVE EPISODEFive or more of the following symptoms Five or more of the following symptoms
during the same twoduring the same two week period week period representing a change from normalrepresenting a change from normal
Depressed mood OR Decreased interest/ pleasure
+ Substantial weight change Insomnia or hypersomnia Fatigue or loss of energy Psychomotor retardation/ agitation
Feelings of worthlessness or inappropriate guilt Diminished ability to think or concentrate Recurrent thoughts of death or suicide/ DSH
AnxietyAnxiety
Response to a perceived threat– Apprehension, uncontrollable worry,
restlessness, panic attacks, and avoidance– Overestimate risks
– Heighten perceptions of physical symptoms (such as breathlessness in lung cancer)
– Post-traumatic stress symptoms (with intrusive thoughts and avoidance of reminders of cancer)
Neuropsychiatric Neuropsychiatric syndromessyndromes
Delirium and dementia (brain metastases)– Lung, breast, GI, melanoma
Paraneoplastic syndromes eg lung, ovary, breast, stomach,
Hodgkin's lymphoma
Delirium and prognosisDelirium and prognosis
Delirium is independently associated with reduced survival at 12 month (McCusker 2002)
In advanced cancer patients it is independently associated with worse prognosis to 30 days (Caraceni et al Cancer 2000)
50% of delirium episodes in PC are reversible (Lawlor Arch Int Med 2001)
Impact of delrium on survival curves after the beginning of Impact of delrium on survival curves after the beginning of palliative care programmes A, B and C identify three different palliative care programmes A, B and C identify three different
prognostic groups according to the PaP scoreprognostic groups according to the PaP score
0 30 60 90 120 150 180
DAYS
0
0,2
0,4
0,6
0,8
1
C
B
A
SUR
VIV
AL
%
Caraceni et al Cancer 1999
-- - = delirious
___ = not delirious
Adjustment disordersAdjustment disorders
Commonest psychiatric diagnosis in any medically ill patients
Most vulnerableMost vulnerable
Around time of diagnosisTreatment issues- awaiting, change, end
Discharge
Recurrence/progressionEnd of life
Coping and Stage of Coping and Stage of TreatmentTreatment
Diagnosis– Suspicion of cancer– Tests– Hearing the news
Coping and Stage of Coping and Stage of TreatmentTreatment
Treatment– Starting treatment - fears re
chemotherapy– Tiredness– Unable to manage at home, children,
husband
Coping and Stage of Coping and Stage of TreatmentTreatment
After surgery
Recurrence
Fear of progression
Sword of DamoclesSword of Damocles
Symptom Level Intervention Transient Distress
1
Patients & Families education
Persistent Mild Distress
2
Cancer team
(Education & Training)
Moderate Distress
3
Psycho-education & Social Work
Severe Distress (Clinical Disorders)
4
Clinical Psychology
& Psychiatry
Organic States/Psychosis /Suicidality
5
Psychiatry
Model of Care of Psycho-Oncology
RecognitionRecognition
Be alert to cues
Screening questions– Low mood– Lack of pleasure
Consider suicidal intent
Assessing anxiety and depression 1Assessing anxiety and depression 1
How are you feeling in yourself? Have you felt low or worried?
Have you ever been troubled by feeling anxious, nervous, or depressed?
What are your main concerns or worries at the moment?
What have you been doing to cope with these? Has this been helpful?
Assessing anxiety and depression 2Assessing anxiety and depression 2 What effects do you feel cancer and its treatment
are having on your life?
Is there anything that would help you cope with this?
Who do you feel you have helping you at the moment?
Have you any questions? Is there anything else you would like to know?
TreatmentTreatment
Information
Social support
Addressing worries
Anxiety management
Principles of treatmentPrinciples of treatment Sympathetic interest
and concern
Clearly identified therapist to coordinate all care
Effective symptomatic relief
Elicit & understand patient's beliefs/ needs
Collaborative planning of continuing care
Information and advice (oral and written)
Involve patient in treatment decisions
Involve family & friends Early recognition & Rx of
psychological complications
Clear arrangements to deal with urgent problems
Specialist TreatmentsSpecialist Treatments
Problem solving discussion
CBT for – psychological
complications– to help cope with
chemotherapy and other unpleasant treatments
Joint/ family interviews
Group support and treatment
Effective medication for pain, nausea etc
Antidepressant meds
Specialist treatmentsSpecialist treatments
Antidepressants are effective in treating depressed mood in cancer patients
CBT effective in relieving distress, especially
anxiety, and in reducing disability Psychological interventions can be effective
in relieving specific cancer related symptoms such as breathlessness
Copyright ©2002 BMJ Publishing Group Ltd.
Peveler, R. et al. BMJ 2002;325:149-152
Meta-analysis of RCTs comparing antidepressants vs placebo
Which antidepressant?Which antidepressant?
SSRIs eg escitalopram
Tricyclic antidepressants eg amitriptyline
Others inc NARIs, SNRIs eg mirtazapine
SSRIsSSRIs
Escitalopram 10 mg– Antidepressant– Anxiolytic
Side effects:– GI– agitation
Also considerAlso consider
NB Underlying physical illness/ drug interactions
Adequate dosage and compliance
Explanation of side-effects and timing of benefits
Consider specialist opinion
Myths about CancerMyths about Cancer
“There is nothing I can do about fatigue…..”
CBT based Self Help book– Dr S Collier & Dr A O’Dwyer St James’ Hosp
FatigueFatiguePrevious Level of Functioning
Level of Activity
Time
Myths about CancerMyths about Cancer
“I must be positive all the time if I am going to beat cancer…..”
No correct way to cope with cancer
Everyone experiences “low times” and “bad days”
No evidence that this will affect health
Myths about CancerMyths about Cancer
“My personality or stressful life caused cancer…..”
Human nature to search for a reason
Blaming can create false sense of security that we can control uncontrollable events
Can increase psychological difficulties
Myths about CancerMyths about Cancer
“Talking to my partner or family will only upset them…..”
Usually know
Increase distress
Difficult to get help
Myths about CancerMyths about Cancer
“Only “mad”people or “failures” seek psychological support…..”
Fear about cancer shakes the strongest individual
Uncertainty very difficult
It’s the THOUGHT that countsIt’s the THOUGHT that counts
Unhelpful Thinking MistakesUnhelpful Thinking Mistakes
When we are distressed our thinking often becomes distorted
Have thoughts that are not true or not completely true
See problems where there are noneBlow real problems out of proportion
Unhelpful Thinking MistakesUnhelpful Thinking Mistakes
Overestimate danger and setbacksUnderestimate our ability to cope
Thinking mistakes cause us to feel low, anxious and angry
All or Nothing ThinkingAll or Nothing ThinkingBlack or WhiteBlack or White
When we are distressed we see things as if there were only two possibilities
If treatment not 100% successful = useless
Enjoyed golf, walking, socialising
Energy low
Gave up everything
CatastrophisingCatastrophisingFortunetellingFortunetelling
Thinking the worst – So afraid not able to think of other more likely outcomes
Waiting on results: they will be bad, I can’t cope, I will die
Tired and irritable: My partner won’t put up with me, he’ll leave me
OvergeneralisationOvergeneralisation
Focus on one negative thing and decide that everything is wrong
Forget one appointment: cancer has affected my brain, can’t be trusted to remember anything anymore
Jumping to ConclusionsJumping to ConclusionsSuperstitious thinkingSuperstitious thinking
When distressed we tend to jump too quickly to negative conclusions-
Believe without having facts, without considering alternatives
Invited into office early: must be bad news
Magnifying and MinimisingMagnifying and Minimising
Exaggerate or magnify the negatives while down playing the positives
Fatigue: Does housework, shopping but can’t get back to work – I’m useless
Mind ReadingMind Reading
Assume you know what others are thinking about you.
Husband and wife following mastectomy
“my husband is no longer interested in me”
Changing Unhelpful Thinking Changing Unhelpful Thinking MistakesMistakes
1. Become aware of when we are making unhelpful thinking mistakes
2. Question the truth or helpfulness of the thought
3. Establish new more realistic or helpful thoughts
Positive effect on mood
Psychological problems –
highly treatable, understandable reactions
to the abnormal, unpredicted and unprepared-for experience
of being a cancer patient
Addition informationAddition information
www.psycho-oncology.info www.nccn.org
With thanks to With thanks to
Dr Sonya Collier
Principal Clinical Psychologist
Psycho-Oncology Service
St James’s Hospital