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