Psychiatric Aspects of Cancer
Jimmie C. Holland
Jessica Stiles
Introduction
Psycho-oncology addresses the two major psychiatric and psychological dimensions of cancer: first, the responses of patients and their families at all stages of disease and the psychological stresses on health professionals delivering their care. The patient and physician relationship, dependent on effective communication, impacts
the care of all patients, at every visit, at all sites and stages of cancer, and during all treatments. The second dimension addresses the psychological, behavioural, and social factors that influence cancer risk, detection, and survival.
the care of all patients, at every visit, at all sites and stages of cancer, and during all treatments. The second dimension addresses the psychological, behavioural, and social factors that influence cancer risk, detection, and survival.
Many cancer centres and hospitals now have multi-disciplinary psychosocial teams consisting of clinicians and clinical investigators from psychology, psychiatry, social work, nursing, and clergy. These teams provide consultation for patients and their caregivers, psychosocial education for oncology staff, and collaboration in studies in which quality of life is important. In addition, active research in brain, immune, and endocrine links is occurring, particularly in the mechanism of cytokines in producing ‘sickness behaviour’ that may provide a biological basis for common symptoms of fatigue, depression, anxiety, weakness, and cognitive chances in cancer patients.(1, 2)
Despite the fact that many cancer centres and oncology divisions now have a psycho-oncology or psychosocial unit, only a few centres have programmes that include both research and training.
This chapter describes the common psychiatric disorders and psychosocial challenges experienced by cancer patients and the range of interventions available.
Psychiatric disorders
A key challenge for the oncologist is the differentiation of expected, tolerable, transient distress associated with cancer, such as fear, worry, and sadness, from excessive, disabling, persistent distress requiring therapeutic intervention. Most psychiatric disturbances in patients with cancer relate to their illness or treatment side effects.(3) One-third of patients will experience distress that requires evaluation and treatment.(3, 4, 5 and 6) The percentage is greater among younger patients, those with sites of cancer with poorer prognosis, for example, brain, pancreas, lung, and those who are hospitalized with greater level of illness causing confusional states and greater anxiety and depression.(7,8)
Anxiety
Anxiety is the most common form of distress experienced by patients in the oncology setting (Table 5.3.7.1). It occurs with abnormal metabolic states: hypoxia, pulmonary embolus, sepsis, delirium, bleeding, cardiac arrhythmia, and hypoglycemia. Hormone-secreting neoplasms that produce psychiatric symptoms consistent with mood or anxiety disorder are pheochromocytoma, thyroid tumour, carcinoid, parathyroid adenoma, adrenocorticotropic hormone-producing tumour, insulinoma, and paraneoplastic syndrome, an immunologic non-metastatic central nervous system complications of several tumours (particularly, lung and ovary) that may present with mood or cognitive changes.
Numerous medications produce symptoms of anxiety: corticosteroids, neuroleptics, bronchodilators, thyroxine, and psychostimulants. The antiemetics, including metoclopramide and prochlorperazine, which are widely used for chemotherapy-related nausea and vomiting, produce restlessness, akathisias, and dystonias. Benzodiazepines promptly reduce the restless movements, anxiety, and agitation. Withdrawal states from alcohol, benzodiazepines, sedative-hypnotics, and opioids produce anxiety as prominent symptoms.
Some patients undergoing cyclic chemotherapy receiving highly emetogenic regimens develop anticipatory anxiety, nausea, and vomiting days to hours in advance of receiving the next cycle of treatment.(9, 10 and 11) More effective antiemetic regimens have significantly reduced the frequency and severity of this problem. However, behavioural interventions paired with antianxiety medications continue to assist in providing relief from this distress.
Table 5.3.7.1 Causes of anxiety in patients with cancer | ||||||||||||||||||||||||||||||||||||||||||||
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Patients who have pre-existing phobias, panic attacks, generalized anxiety disorder, or obsessive–compulsive disorder are at risk of experiencing symptom exacerbations during treatment (Table 5.3.7.1).(12) Phobias of needles, blood, hospitals, magnetic resonance imaging machines, or radiation simulators complicate a patient’s ability to tolerate hospital procedures or adhere to recommended treatments. Panic attacks superimposed on physical symptoms of dyspnea and tachycardia may be partially alarming to patients.(3,13) Patients with previous traumatic experiences may suffer a recurrence of intrusive re-experiences of painful memories, maladaptive avoidant behaviour or withdrawal, and hypervigilance.(14,15)
Cancer patients with OCD may have increased difficulty during treatment. Intrusive fears may lead to indecisiveness regarding treatment options and reluctance to accept interventions with known therapeutic efficacy. Excessively time-consuming rituals may interfere with a patient’s adherence to medical appointments. Inflexibility of thought, hostility, overwhelming distress, and occasionally poor insight contribute to the challenge of engaging these patients and assisting them in accepting interventions.
Management. Anticipatory anxiety prior to medical interventions responds to empathic validation of the fear, adequate preparation to set realistic expectations for the encounter, and rehearsal of the dreaded event.
Significant disabling anxiety symptoms are frequently treated pharmacologically with benzodiazepines, selective serotonin-reuptake inhibitors (SSRIs), mirtazapine, venlafaxine, buspirone, antihistamines, beta-blockers, or neuroleptics. Table 5.3.7.2 outlines the benzodiazepines commonly used and their initial and
therapeutic doses. A shorter half-life enhances control during the upward titration process and decreases the risk of accumulation and intoxications.
therapeutic doses. A shorter half-life enhances control during the upward titration process and decreases the risk of accumulation and intoxications.
Table 5.3.7.2 Common anxiolytic agents | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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