Illness phase
Mental reaction
Tasks to be managed by the patient
Diagnosis
Shock, fear
Accepting the diagnosis, coping with intense emotions
Disbelief, despair, depression
Making a decision regarding treatment
Anger
Notifying the social environment
Primary treatment phase
Anxiety, depression, loss of control and autonomy
Accepting illness and treatment
Loss of physical integrity
Coping with treatment side effects
Loneliness, loss of intimacy and sexual contacts
Establishment of viable relationships with the treatment team
Regaining mental and physical self-esteem
Remission
Relief, gratitude
Return to everyday life, living with uncertainty
Fear of recurrence and metastases, increased awareness of the body
Development of new perspectives on life, return to work
Recurrence
Shock, anxiety, depression
Accepting uncertainty of the future
Denial
Accepting the progression of the disease and the likelihood of death
Loss of hope and trust
Adaptation of the perspective of life to the new situation
Increased vulnerability
Search for meaning, feelings of guilt
Terminal stage
Fear of death, depression, demoralization
Dealing with death and dying, mourning the loss
Denial
Accepting one’s own death
Loss of control
Accepting the physical decline and the prognosis
Fear of loneliness
Arrangement of family affairs and legal matters and, parting from family and friends
Increasing dependence on doctors and nursing staff
Looking back at one’s own life, dealing with spiritual issues
Retreat
Anger and resentment
Diagnostic Categories
In the spectrum of mental disorders, the following diagnostic categories are mostly relevant in the context of cancer.
Acute Stress Disorder (ICD-10: F43.0)
A transient disorder, in a person who is apparently not mentally disturbed, develops in response to exceptional physical or mental stress, and which generally subsides within hours or days. The symptoms show a mixed and changing picture, starting with a kind of “stunning”, with a degree of narrowing of consciousness and limited attention, an inability to process stimuli and disorientation. This state may be followed by a further retreat from the social environment, or a state of restlessness and overactivity. Frequently, vegetative signs of panic anxiety such as tachycardia, sweating and blushing occur.
Adjustment Disorder (ICD-10: F43.2)
The symptoms include depressed mood, anxiety or worry. Particularly, in adolescents, social conduct disorders may be an additional symptom. A difference is made between short depressive and anxiety reactions, which do not last longer than 1 month, and longer reactions, which do not last longer than 2 years.
Problem “Fatigue”
Fatigue is expressed as great tiredness and exhaustion, reduced performance capacity and muscular weakness. It affects especially patients after radiation or chemotherapy. Ca. 30–40 % of patients suffer from chronic fatigue even after the treatment phase has been completed. Even when there is an overlap with depressive symptoms, fatigue is considered a syndrome in its own right. The basis is probably a complex interaction between the tumour disease, chemo- and radiotherapy, tumour anaemia, other secondary diseases, immunological processes and emotional coping processes .
Frequency
Especially in the first weeks after learning the diagnosis or in case of recurrence, 30–50 % of patients show symptoms of emotional distress. Usually this is an acute stress reaction with anxiety and depressive symptoms (see diagnostic categories). Psychiatric disorders in the strict sense are rare.
Onset and Course
Risk factors for mental decompensation in diagnosis or in case of recurrence include previous and current mental problems (especially depression, alcoholism, earlier suicide attempts), lack of social integration and support, current experience of separation and/or death, marriage and family problems, financial and professional problems, negative experiences of illness, uncontrollable pain, poor prognosis, an advanced tumour and physical and emotional exhaustion.
The course of mental well-being during cancer disease depends on the coping mechanisms that are available to a patient. The following coping forms have been found to be favourable :
An active confrontation with the disease (so-called fighting spirit)
Search for meaning and spirituality
Good interpersonal relationships and social support
Trust in the doctors
Unfavourable coping forms are:
Passive acceptance, resignation
Social withdrawal and isolation
Helplessness and hopelessness
Studies have shown that the availability of a wide range of disease-coping strategies and the targeted use, depending on the situation, enables a better adaptation to the disease process than the prevalence of only one strategy .
Practice
Recognition
The indication for psychosocial care of cancer patients results from the bio-psychosocial history.
Indications for Psychosomatic Basic Care
Anxiety and depressive reactions after receiving the diagnosis, or as part of therapy
Suicidality
Psycho-vegetative reactions such as nausea, weakness and fatigue, sleep and concentration problems (Fatigue syndrome)
Mental impairments and conflicts in the partnership, such as after surgery
Avoiding the public by face and larynx-operated patients, or after breast cancer
Changing roles in the family
Physically unexplained pain syndromes persisting for a long time despite symptomatic measures
Posttraumatic stress disorder, for example, after surgery with lots of complications
Basic Therapeutic Attitude
There is a very crucial balance between hope and acceptance. Hope, as positive anticipation, could promote the psychoneuroimmunologic system but without acceptance it may lead to an anxious attitude and aversive strategy and finally fade the hope of course in a very tragic way.
Acceptance of the reality of handicaps and death is a humanistic and existential point in cancer condition but without hope it can lead us to a passive and fatalistic attitude.
The doctor accepts the patient, even if he/she does not want to accept the knowledge of his disease. The doctor is not misled about the potentially powerful inner emotional involvement of the patient by the patient’s trivializing, indifference and silence. Fear, despair, gloom, withdrawal, anger and rage are considered adequate responses to the diagnosis. The aim is for the patient to be able to cope better with the disease. The patient regains control of his/her thoughts, his/her feelings and his/her behaviour and develops overall an active, problem-oriented attitude.
Basic Interventions
Information and Consultation (Psycho-education)
The first stage includes information and consultation of patients and their families about the disease and the resulting treatment measures with the aim of reducing helplessness and uncertainty due to lack of knowledge. Patients are encouraged to ask questions, to express fantasies of cancer development (subjective theory of disease) and the progression of the disease, and to talk about upsetting thoughts and feelings. This first stage should be offered to all patients after cancer diagnosis either as individual consultation or as part of a group counselling program. It requires basic knowledge of psycho-oncology and psychosomatic primary care .
Specific Measures for Pain, Fatigue, Nausea and Vomiting
For this, there are a wide range of intervention options: Progressive muscle relaxation, autogenic training, hypnosis, deep breathing, meditation, biofeedback, passive relaxation and fantasy trips (so-called guided imagination or visualization) . Another common problem with chemotherapy is the anticipatory vomiting and nausea. These side effects follow the rules of classical conditioning and can be influenced by a desensitization treatment. The main objective of these symptom-oriented methods is the development of positive ideas and pleasant body sensations. The techniques used also strengthen mental coping skills and increase self-control. The effectiveness of a combination of progressive muscle relaxation and imaginative techniques could be demonstrated in the reduction of pain in mucositis, a very common and painful complication of chemotherapeutic treatment (Syrjala et al. 1992) .
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