Is this a normal reaction to
Cancer?
Dr Siobhan MacHale
Consultant Liaison Psychiatrist
Beaumont Hospital
Sept 19th 2013
Impact of Cancer on
Psychological Wellbeing

Huge variety (individual and over time)

Mild to severe, acute or chronic
‘Healthy emotional response’
3 phases
1. Initial reaction
shock/disbelief
2. Distress
anxiety/anger/low mood
3. Adjustment
Normal Reactions to an
Abnormal Situation
•
Shock
•
Anger and Irritability
•
Denial
•
Sadness
•
Acceptance
Variety of Responses
“Distress”
– More acceptable than ‘psychiatric’,
‘psychosocial’ or ‘emotional’
– Sounds ‘normal’ and less embarrassing
– Can be defined and measured by self-report
Distress 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”

Continuum of Distress

Mild
(Normal, adaptive)
Moderate
Severe
(Disabling)
Cancer and Distress
1. Distress is “normal”
2. Do not want to “medicalise” distress
3. Do not want to miss significant psychological
problems
Impact of Cancer and Psychological
factors on activity level
Previous Level of activity
Level of
Activity
Medical / Physical Problems
Psychological Problems
Time
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?

Associated with increased disability

Associated with poorer outcomes

Increased use of healthcare resources

Good response to treatment
Advanced Cancer Requires Coping With

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
EXISTENTIAL CRISES IN CANCER
DIAGNOSIS
OF
CANCER
COMPLETION
OF
TREATMENT
INITIAL
TREATMENT
RECURRENCE
OF
DISEASE
N.E.D.
ADVANCING
DISEASE;
DNR;
HOSPICE
PALLIATIVE
TREATMENT
“I could
“I have
“I will
die from
this.”
survived -will it
Return?”
likely die” -depressed;
anxious
DEATH
TERMINAL
“I am
dying.”
Adapted from McCormick & Conley, 1995
Carers needs
• Family
• Mental health of Staff
- Physicians’ acknowledged feelings
(anger, frustration, depression)
- Affect
Clinical decisions
Behavior with patients
Quality of care
Risk of burnout
Meier et al, 2002
When Emotional Difficulties
become overwhelming…
1/4 to 1/3 patients have
disabling psychological
problems
Impact








Uncertainty regarding the future
Meaning of what has happened
Loss of control
Loss of independence
Helplessness
Fatigue
Fear
Death
Impact
Relationships –
family
partner (sexuality, fertility)
children
friends
Body Image
disfigurement
scarring
Imagined
Self-esteem
sick role
disability
Leisure/Work
change
loss
financial
holidays
When Emotional Difficulties
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 disorder

Patient
– History of

– Limitation of activities
psychiatric
disorder
– Disfiguring
– Poor prognosis
(inc substance misuse)
– Social isolation
– Dissatisfaction with
medical care
– Poor coping (eg not
seeking info/ talking to
friend)
Cancer

Treatment
– Disfiguring, unpleasant
– Isolating (such as bone
marrow transplant)
– Side effects
eg steroids
Depression

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 EPISODE
Five or more of the following symptoms
during the same two week period
representing 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
Anxiety

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
syndromes

Delirium and dementia (brain metastases)
– Lung, breast, GI, melanoma

Paraneoplastic syndromes
eg lung, ovary, breast, stomach,
Hodgkin's lymphoma
Delirium 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
palliative care programmes A, B and C identify three different
prognostic groups according to the PaP score
1
-- - = delirious
___ = not delirious
SURVIVAL %
0,8
0,6
A
0,4
B
0,2
C
0
0 et al Cancer
30
Caraceni
1999
60
90
DAYS
120
150
180
Adjustment disorders

Commonest psychiatric diagnosis in any
medically ill patients
Most vulnerable

Around time of diagnosis
 Treatment issues- awaiting, change, end


Discharge
Recurrence/progression
 End of life
Coping and Stage of
Treatment

Diagnosis
– Suspicion of cancer
– Tests
– Hearing the news
Coping and Stage of
Treatment

Treatment
– Starting treatment - fears re chemotherapy
– Tiredness
– Unable to manage at home, children,
husband
Coping and Stage of
Treatment

After surgery

Recurrence

Fear of progression

Sword of Damocles
Model of Care of Psycho-Oncology
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
Symptom
Recognition

Be alert to cues

Screening questions
– Low mood
– Lack of pleasure

Consider suicidal intent
Assessing 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 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?
Treatment

Information

Social support

Addressing worries

Anxiety management
Principles of treatment

Sympathetic interest
and concern

Information and advice
(oral and written)

Clearly identified
therapist to coordinate
all care

Involve patient in
treatment decisions

Involve family & friends

Early recognition & Rx
of psychological
complications

Clear arrangements to
deal with urgent
problems



Effective symptomatic
relief
Elicit & understand
patient's beliefs/ needs
Collaborative planning
of continuing care
Specialist Treatments

Problem solving
discussion

Group support and
treatment

CBT for
complications
– to help cope with
chemotherapy and other
unpleasant treatments

Effective medication
for pain, nausea etc
Joint/ family interviews

Antidepressant meds
– psychological

Specialist 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
Meta-analysis of RCTs comparing antidepressants vs placebo
Peveler, R. et al. BMJ 2002;325:149-152
Copyright ©2002 BMJ Publishing Group Ltd.
Which antidepressant?

SSRIs eg escitalopram

Tricyclic antidepressants eg amitriptyline

Others inc NARIs, SNRIs eg mirtazapine
SSRIs

Escitalopram 10 mg
– Antidepressant
– Anxiolytic

Side effects:
– GI
– agitation
Also consider

NB Underlying physical illness/ drug interactions

Adequate dosage and compliance

Explanation of side-effects and timing of benefits

Consider specialist opinion
Myths 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
Fatigue
Previous Level of
Functioning
Level of
Activity
Time
Myths 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 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 Cancer
“Talking to my partner or family will only
upset them…..”
Usually know
Increase distress
Difficult to get help
Myths 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 counts
E
Thoughts
Emotions
Behaviours
Body Feelings
EG of Simple CBT Model
Thoughts
“making myself worse”
“cancer is back”
Emotions
Behaviour
Anxiety
Fear
Depression
Avoid
hypervigilent
Physiology
Reduced activity tolerance
Panicky
Unhelpful 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 none
 Blow real problems out of proportion
Unhelpful Thinking Mistakes

Overestimate danger and setbacks
 Underestimate our ability to cope

Thinking mistakes cause us to feel low,
anxious and angry
All or Nothing Thinking
Black 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
Catastrophising
Fortunetelling

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
Overgeneralisation

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 Conclusions
Superstitious 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 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 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
Mistakes
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 information

www.psycho-oncology.info
 www.nccn.org
With thanks to
Dr Sonya Collier
Principal Clinical Psychologist
Psycho-Oncology Service
St James’s Hospital