fear of recurrence
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Norma Lee MA, MD, LMFT February 24, 2013. Fear of Recurrence. What we think, we become. All that we are arises with our thoughts. With our thoughts, we make the world. The Buddha. - PowerPoint PPT PresentationTRANSCRIPT
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Fear of Recurrence
Norma Lee MA, MD, LMFTFebruary 24, 2013
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What we think, we become.
All that we are arises with our thoughts. With our thoughts, we make
the world.The Buddha
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God, grant me the serenity to accept the
things I cannot change, the courage to change
the things I can, and the wisdom to know the
difference.Reinhold Neibuhr
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Outline•Fear of Recurrence•Psychiatric Considerations•Effects of Social Support•Effects of Coping Style•Cognitive Behavioral Therapy Techniques•Mindfulness Based Practices•Homework
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Is Fear All Bad?Beliefs/rules about the world either
protect you from or make you more vulnerable to emotional distress
Too much fear means less problem solving ability
Some degree of FOR helps people to maintain medical follow up
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Self-Regulation Model of Illness
•Every person has an illness representation based on somatic experiences/sensations•With an illness threat, cognitive and emotional processing systems tell the person how to act•If experiences/sensations are based on inaccurate information, the person’s illness representation may be false
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Self-Regulation Model of Illness
May cause them to feel unnecessarily worried, anxious or fearful
If illness representation makes sense to person then they consider coping strategy to be appropriate
When looking at coping strategies, must consider person’s illness representation, previous experiences and world view
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Fear of Recurrence
Quality of physician communication during initial diagnosis/initiation of treatment is a critical determinant of subsequent psychological well being
Not consistently related to time since diagnosis
Concerns and worries may persist long term
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Fear of RecurrenceYounger women more concerned
about: Potential disfigurement Loss of femininity, disability Feeling different or isolated Distress associated with treatment
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Fear of RecurrenceYounger women’s concerns:
Physical and mental quality of lifePerceived amount of impairmentChemotherapyHaving children
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Psychiatric ImpactPrevalence of psychiatric disorders
22-47%4% of women with all stages of
breast cancer met criteria for PTSD41% had subsyndromal criteria
Intense fearHelplessnessHorror after being diagnosed
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PTSDOther signs of PTSD
Intrusive thoughtsAvoidanceHyperarousal
PTSD symptoms correlated most significantly with:LymphedemaNumbness in hands, feet or chestOther physical problems
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Depression & Anxiety19% had depressionAlmost 100% had some level of anxietyDepression/anxiety levels affected by:
Being unaccompanied by spouse/partner to follow up visits
Not having someone to share problems with
Request to see a mental health providerUsing an alternative treatment
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What Impacts Depression & Anxiety Levels?
SleepEmotional StatusFatigueBody AppearanceSense of HopelessnessUncertainty about the future
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Why Depression is HarmfulStrong association between
helplessness and hopelessness, depression and shortened survival
Depression makes the odds of not following a treatment plan three times higher
Conversely, social support and a cohesive family improve the odds of compliance with medical care
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Why Depression is HarmfulPersistently depressed women may be
at risk of not only poor QOL but also premature death
They should be promptly referred for a mental health assessment
Quick screen: Do you feel depressed?Do things seem hopeless to you?
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When to Consider TherapyYour usual problem solving techniques
and coping skills aren’t workingYou feel stuckYou need someone who will just listenYou feel like you’re going crazyTALKING TO A THERAPIST DOES
NOT MEAN YOU ARE WEAK OR HAVE A CHARACTER FLAW!!
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Considering MedicationYou are having significant difficulty
getting through the day Consistently crying a lotConsistently too anxious to do what needs to get done
Feeling suicidal
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Therapy vs. MedicationMedication works fasterLonger term outcomes are best with
combination of medication and therapyTherapy teaches people skills they can
use foreverDistress may not be completely related
to cancer; therapy explores that
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Social SupportSignificant impact on quality of lifeWomen with high levels of support
had no meaningful impact on their QOL when they had cancer related intrusive thoughts
For women with low levels of support, the relationship between cancer related intrusive thoughts and QOL was significant and negative
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Social SupportWomen with fewer sources of
support have more fear of recurrence
Feeling understood by loved ones help women to monitor their thoughts about recurrence
Proximity to a loved one has a regulatory effect on emotional functioning and helps to control emotional and physiological responses to stressors
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Self-Efficacy
A person’s belief about his or her ability and capacity to accomplish a task or to deal with the challenges of life
Self-efficacy is a significant predictor of an active adjustment style and emotional well-being
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Coping & Coping Styles
Coping styles are learned, usually from one’s family of origin
Related to illness representationPrior traumatic and/or current
stressful life event can adversely affect one’s ability to cope
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Adaptive CopingActive coping and problem-solving
techniques result in better mood and adaptation
Flexibility in coping styles is crucialWomen who use available social
resources and support adapt better and may live longer than women who don’t
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Adaptive CopingInternal locus of control
Proactive vs. reactiveKnowing what you can control (you)
and what you cannot (everyone else)Acceptance of responsibilityEscape-avoidance
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Maladaptive CopingWomen who are passive or feel hopeless or
pessimistic are rigid in their coping style; may become isolated and reject help when it is offered and adapt more poorly
Factors significantly associated with a high or moderate FOR include a depressive and a problem-oriented coping style (vs. an affective-oriented coping style)
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Maladaptive Coping Internal and external cues can
contribute to fear of recurrenceSomaticFriends/family
Women who believe they are at risk of recurrence will be emotionally activated by neutral stimuli
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What Can Be Done To Help?
Women who received an intervention designed to improve knowledge or coping or to reduce distress did better than those who didn’tLess anxiety/depression, increased sense of control, improved body image, better sexual function, greater satisfaction with care, improved medication adherence
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Support GroupsIncreasing evidence that participation in
group activity offers a uniquely supportive and normalizing experience for many people
Group therapy has the ability to enrich QOL and help to prevent onset of depression
Added benefit with professional facilitator
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Meaning Making StudyRoutine care vs. four sessions that
explored meaning of thoughts and feelings regarding one’s cancer experience within the context of past events and future goals
Significantly higher levels of self-esteem, optimism and self-efficacy in meaning making group
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Cognitive-Behavioral Therapy (CBT)
Our thoughts (cognitions) influence how we feel (emotions) and how we act (behaviors)
It is not the cancer itself that produces the emotional response, but rather the meaning of the cancer to that person
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Principles of CBTWe all have automatic thoughts that are
based on experiences, not on realityWhen people are anxious, two things
occur:They overestimate that something bad will happen
They assume the worstThis is distorted thinking
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How CBT WorksCognitive reframing: for thoughts to
be valid, they must be based in reality
Goal is to have people develop the ability to view a situation objectively
Is there another way to look at the situation?
What is the worst thing that could happen?
Could you handle it?
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Principles of CBTRelaxation techniques are a crucial
part of cognitive-behavioral therapyThe ability to relax when starting to
feel anxious makes people confident that they can cope with other stressful situations
The ability to relax allows for clearer thinking when problem solving
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Principles of CBT
Exposure to feared situations is essential
Without exposure, people are able to continue with distorted thinking which only serves to increase behavioral and cognitive avoidance
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Mind/Body PracticesVariety of techniques designed to enhance
the mind’s capacity to influence bodily functions and symptoms. Examples:Relaxation, hypnosis, visual imagery, biofeedback
Therapies involving spirituality or expressive arts, such as visual art, music or dance
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Mind/Body PracticesVisualization relaxation is a skill that
can be learned; more practice leads to more effectively being able to relax
Massage: helpful in relieving pain, anxiety, fatigue and distress, as well as increasing relaxation
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Mind/Body PracticesA mindfulness-based practice such as
meditation may help alleviate cancer related cognitive impairment by engaging the person in an attention based mental activity
In cancer patients, mind/body therapies can reduce anxiety, depression and mood disturbances and assist their coping skills
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JournalingVery helpful for getting repetitive
thoughts out of your headNo editing!Gratitude Journal: three things
you’re grateful for each dayShown to decrease distress and improve coping and functioning
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Mindfulness Based Stress Reduction
Standardized form of meditation and yoga
Trains people to reduce their perceived level of stress by self-regulating arousal to stressful situations or symptoms
Has been shown to be effective in reducing anxiety, depression and stress in people with chronic pain
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Mindfulness Based Stress Reduction
Mindfulness: learning to be present in life as it is occurring, applying attitudes of kindness, patience, curiosity, acceptance, letting go and non-judging
Begin to realize the amount of emotional energy spent regretting the past or worrying about the future has resulted in missing the present moment
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InterventionSix week modified programLearned meditations, body scan,
visualizationLearned understanding of their
reaction to pleasant and unpleasant events
Had to practice daily
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MSBR StudySignificantly reduced symptoms of
anxiety, depression, fear of recurrenceImproved indicators of physical and
emotional quality of lifeEnergy, sleep, pain, social functioning
FOR remained prominent over time with 70% of women having fear after five years
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Effects of StressStress related psychosocial factors
are associated with: A higher cancer incidence in initially healthy people
Poorer survival in people diagnosed with cancer
Higher cancer mortality
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The Best Study Ever39 hours of sessions with a psychologist
over one year vs. regular careGoals: reduce distress, improve QOL,
improve health behaviors (diet, exercise, smoking cessation), facilitate cancer treatment compliance and facilitate medical follow up
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InterventionsPMR for stress reductionProblem solving for common issues,
e.g., fatigueIdentifying supportive family/friends
capable of providing assistanceUsing assertive communication to get
one’s psychological and medical needs met
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Areas AddressedStrategies to increase daily activity
(walking, exercise)Improving dietary habits (decreasing
fats)Finding ways to cope with treatment
side effects e.g., nauseaSkills for maintaining adherence to
medical treatment and follow up
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ResultsIntervention group had:
Significantly lower risk of breast cancer recurrence
Significantly lower risk of breast cancer death
Significantly lower risk of all-cause mortality
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Results
If cancer recurred, it was six months later than the control group
If someone died, it was over a year later than in the control group
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Which Patients Did Best?Patients with greatest reduction in
distress and physical symptoms:Practiced daily PMRUnderstood and remembered daily that continued stress could adversely affect their health and that it could be controlled/reduced by using the intervention techniques
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Other Interesting ResultsImmune changes secondary to stress
hormones may promote cancer growth or metastasis
As patients reported significant declines in their emotional distress and were found to have reduced symptoms and treatment related toxicities, their immune function was stabilized or improving
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Other Interesting ResultsIn the 17 months before detection,
patients who had a recurrence were found to have worsening immune function compared to disease free patients
Those patients also had higher cortisol levels and worse physical functioning, fatigue and QOL during that period
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Exercise & Stress ReductionEvidence for regular exercise is most
compelling for breast cancer survivorsPhysical activity can improve mood,
decrease depression and anxiety, improve body image and self esteem, reduce nausea and fatigue, enhance cardiovascular functioning, control weight, and potentially alter immune function
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Key Elements for Optimal Outcomes
Access to state of the art cancer careActive coping/active engagement in one’s carePerceived availability and if needed, use of
social supportHaving a sense of meaning or purpose in life
Can include someone to live for, spiritual belief or connectedness, a way to make sense of illness/ health, one’s place in the world
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HomeworkPut your own oxygen mask on firstTake time for yourself every dayStop judging yourself and comparing
yourself to others; life isn’t a contestTreat yourself as you would a friendDefinition of insanity: doing the
same thing over and over again and expecting different results
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Women are like teabags. We don’t know our true strength until we are in hot water.
Eleanor Roosevelt