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Psychiatric Aspects of

Medical Conditions: Cancer
Augusto B. Cruz Jr. M.D.
Consultation – Liaison Psychiatry

Outline




Psychological responses to cancer
Psychological factors affecting Cancer risk and
Progression
Psychiatric syndromes in Cancer patients
Psychiatric aspects of Cancer treatment
Dealing with families of patients with Cancer
Psychiatric Interventions in Cancer

Sources of Stress for Cancer patients
and their families
Uncertainty
of the future

Feelings isolation
stigma, guilt

Noxious side effects of
treatment

DISEASE CONTINUUM
Suspicion of Cancer

Diagnosis Treatment

Remission
Recurrence/Progression
Advanced Disease
Terminal Stage

RANGE OF EMOTIONS Disbelief hope anguish terror surrender rage disinterest acceptance yearning for death .

Psychiatrist’s task: ❏ ❏ ❏ ❏ Diagnose Treat Facilitate the patient’s strengths and adaptive capacity Bolster patient’s outside resources .

Phases of Cancer experience ❏ ❏ Diagnosis Initial treatment ■ ❏ ❏ ❏ ❏ Surgery/radiation therapy/chemotherapy Posttreatment Recurrence Progressive disease (advancing disease) Terminal/ palliation .

PRE DIAGNOSIS NORMAL ❏ Concern with the possibility of having cancer ❏ ❏ ❏ ABNORMAL MALADAPTIVE Hypervigilance Inappropriate preoccupation Development of cancer symptoms without having the disease .

partial denial Anger. persecutory feelings Anxiety Depression ❏ ❏ ❏ ❏ ABNORMAL MALADAPTIVE Complete denial with treatment refusal Fatalistic treatment refusal .DIAGNOSIS ❏ ❏ ❏ ❏ ❏ ❏ NORMAL Shock Disbelief Initial. hostility.death is inevitable Clinical depression Search for alternative cures .

INITIAL TREATMENT Surgery NORMAL ❏ ❏ ❏ Fear of pain or death Fear of anesthesia Grief reaction to changes in body image ❏ ❏ ❏ ABNORMAL MALADAPTIVE Postponement of surgery Seeking non-surgical alternatives Postoperative reactive depression .

INITIAL TREATMENT Radiation Therapy NORMAL ❏ ❏ fear of x-ray equipment and of side effects fear of abandonment ❏ ABNORMAL MALADAPTIVE Psychotic like delusions/ hallucinations .

INITIAL TREATMENT Chemotherapy NORMAL ❏ ❏ ❏ ❏ ❏ Fear of side-effects Anxiety. mild depression Changes in body image Isolation Altruistic feelings ❏ ❏ ❏ ABNORMAL MALADAPTIVE Residual drug-induced psychoses Severe isolationinduced psychotic disturbances Organic brain syndrome/ delirium .

POST TREATMENT NORMAL ❏ ❏ ❏ Return to normal coping patterns Fear of recurrence Post treatment anxiety and depression ❏ ABNORMAL MALADAPTIVE severe post treatment anxiety and depression .

RECURRENCE NORMAL ❏ ❏ ❏ ❏ ❏ ❏ Shock Disbelief Initial partial denial Anger. persecutory feelings Anxiety Depression ❏ ABNORMAL MALADAPTIVE severe reactive depression with insomnia. restlessness. anorexia. hostility. anxiety and irritability .

ADVANCING DISEASE NORMAL ❏ Frenzied search for new information. other consultants and ‘quack’ cures ❏ ABNORMAL MALADAPTIVE depression .

TERMINAL/PALLIATION NORMAL ❏ ❏ ❏ ❏ ❏ ❏ Fear of abandonment Fear of loss of composure and dignity Fear of pain Unfinished business Personal mourning Fear of unknown ❏ ❏ ABNORMAL MALADAPTIVE Depression Acute delirium .

2005) Depression Emotional distress Life stressors Anxiety Emotional expressiveness .Psychological Factors affecting Cancer Risk and Progression –”Controversial” (Levenson.

1983) The prevalence of psychiatric disorders among cancer patients 53% adjusting normally to stress 47% (+) clinically apparent psychiatric disorders 68% (+) reactive or 13% major depressive disorder situational anxiety and depression 8% organic mental disorder 4% (+) pre-existing anxiety d/o 7% personality disorder .Psychiatric Syndromes in Cancer Patients (Derogates.

2005) ❏ Cancer types: ■ ■ ■ ■ Oropharyngeal (2257%) Pancreatic (33-50%) Breast (1.(Derogatis) 0-38% (Levenson.Psychiatric Syndromes in Cancer Patients ❏ Depression ■ ■ 5-8% .5-46%) Lung (11-44%) .

Psychiatric Syndromes in Cancer Patients ❏ Depression ■ Etiology ❏ ❏ ❏ ❏ Stress related to the cancer diagnosis and treatment Medications Underlying neurological or medical problems Recurrence of preexisting affective disorder .

Psychiatric Syndromes in Cancer Patients ❏ Depression ■ Risk Factors ❏ ❏ ❏ ❏ Poor physical condition Advanced stage of disease with inadequately controlled pain History of depression Financial problems .

Psychiatric Syndromes in Cancer Patients ❏ Depression ■ Risk Factors ❏ ❏ ❏ Marital problems Lower ego strength Pancreatic. head and neck and lung CA .

worthlessness.Psychiatric Syndromes in Cancer Patients ❏ Depression ■ Diagnosis ❏ ❏ ❏ ❏ ❏ ❏ Social withdrawal Anhedonia Dysphoric mood Feelings of hopelessness. or guilt Poor self-esteem Suicidality . helplessness.

and loss of control A response to the existential plight of cancer . uncertainty.Psychiatric Syndromes in Cancer Patients ❏ Anxiety ■ ■ Is a normal response to threat.

2002) . comparable to normal population (Stark et al.Psychiatric Syndromes in Cancer Patients ❏ Anxiety ■ ■ It is common at crisis points Prevalence – 18%.

Psychiatric Syndromes in Cancer Patients ❏ Anxiety ■ Specific syndromes of anxiety can prevent the patient from accepting appropriate medical treatment ❏ ❏ ❏ ❏ Claustrophobia Needle Phobia Radiation phobia Anticipatory phobia .

Psychiatric Syndromes in Cancer Patients ❏ Anxiety ■ Diagnosis ❏ R/O organic causes ■ ■ Antiemetic phenothiazines Pulmonary embolism .

Psychiatric Syndromes in Cancer Patients ❏ Cancer-related Suicide ■ ■ Few cancer patients commit suicide (Fox at al 1982) Passive suicidal thoughts are relatively common .

Psychiatric Syndromes in Cancer Patients ❏ Cancer-related Suicide ■ Risk of suicide ❏ Male gender ❏ Advanced stage of the disease ❏ Poor prognosis ❏ Delirium with poor impulse control ❏ Inadequately controlled pain ❏ Depression .

Psychiatric Syndromes in Cancer Patients ❏ Cancer-related Suicide ■ Risk of suicide ❏ ❏ ❏ ❏ ❏ ❏ History of psychiatric illness Current or previous alcohol or substance abuse Previous suicide attempts Physical and emotional exhaustion Social isolation Extreme need for control .

medications. 40-85% .Psychiatric Syndromes in Cancer Patients ❏ Delirium ■ ■ common in cancer as a result of metabolic sequelae of the disease and treatment. metastatic tumors of the brain Prevalence – 5-30% becoming higher in terminal stage of the illness.

Neuropsychiatric side effects of drugs used in cancer treatment Hormones Corticosteroids Tamoxifen Aminoglutethimide insomnia. depression exacerbn menop sxs lethargy in first month . mania psychosis.lability.

psychosis delirium somnolence. lethargy delirium lethargy.Neuropsychiatric side effects of drugs used in cancer treatment Anticancer agents procarbazine L-Asparaginase Ifosfamide Cytarabine somnolence. seizures dysarthia with renal imp delirium and cerebellar signs .

sz fatigue. lethargy. Toxic sensory neuropathy ..Neuropsychiatric side effects of drugs used in cancer treatment Anticancer agents 5-Fluouracil Methotrexate Vincristine/blastine Paclitaxel Interferon delirium cerebellar sxs transient delirium dysphoria.

confusion depression. agitation. delusions halllucinations . hypersomnia slowed thinking confusion.Neuropsychiatric side effects of drugs used in cancer treatment Anticancer agents Interferon Interleukin-2 initial flu-like symptoms encephalopathy. depression paranoia. irritability.

Psychiatric aspects of Treatment ❏ ❏ ❏ ❏ Chemotherapy Radiation Bone Marrow transplant Surgery .

Dealing with the Family ❏ Factors that affect the family’s acceptance of a cancer patient ■ ■ ■ ■ ■ Ages and number of family members Their coping resources Their stability before the patient’s diagnosis Their ethnic and cultural background Role and responsibilities of each family member .

Dealing with the Family ❏ Problems that signal consultation ■ Pre-existing psychopathology and intrafamily conflicts ■ Differences in how family process information ■ Family exhaustion and abandonment ■ Inadequate acceptance .

Dealing with the Family ❏ Doctor/ Family relationship ■ ■ Frequent visits Allows time for question .

tricyclic antidep (nortriptylline/ desipramine) ➠ against depression +for neuropathic pain syndrome Anxiety – benzodiazepine Delirium .Psychiatric Intervention in Cancer ❏ Psychotherapy ■ ❏ Group/ self-therapy group Psychopharmacology ■ ■ ■ Depression – SSRI.Haloperidol .

Thank you!! .