psychiatric aspects of medical conditions(sbc) 2012

8/19/2019 Psychiatric Aspects of Medical Conditions(SBC) 2012

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Psychiatric Aspects of

Medical Conditions: Cancer Augusto B. Cruz Jr. M.D.

Consultation – Liaison Psychiatry


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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


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Uncertainty

of the future

Sources of Stress for Cancer patients

and their families

o!ious side effects of treatment

"eelings isolation

stigma# guilt


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DISEASE CONTINUUM

Suspicion of Cancer DiagnosisSuspicion of Cancer Diagnosis Treatment Treatment

RemissionRemission

Recurrence/ProgressionRecurrence/Progression

Advanced DiseaseAdvanced Disease

Terminal Stage Terminal Stage


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RANGE OF EMOTIONS

Disbelief hopeDisbelief hope anguish terroranguish terror

surrendersurrender

ragerage

disinterestdisinterest

acceptance yearning for deathacceptance yearning for death


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Psychiatrist$s task: Diagnose

%reat

"acilitate the patient$s strengths and adaptivecapacity

&olster patient$s outside resources


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Phases of Cancer e!perience Diagnosis

Initial treatment

'urgery(radiation therapy(chemotherapy

Posttreatment

)ecurrence

Progressive disease *advancing disease+

%erminal( palliation


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P), DIA-O'I' O)MA.

Concern with the possi/ility of having

cancer

A&O)MA.

MA.ADAP%I0,

1ypervigilance Inappropriate

preoccupation

Development of cancer

symptoms without

having the disease


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DIA-O'I' O)MA.

'hock

Dis/elief Initial# partial denial

Anger# hostility#

persecutory feelings

An!iety

Depression

A&O)MA.

MA.ADAP%I0,

Complete denial withtreatment refusal

"atalistic treatment

refusal 2 death is

inevita/le Clinical depression

'earch for alternative

cures


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II%IA. %),A%M,%

'urgery O)MA.

"ear of pain or death "ear of anesthesia

-rief reaction to

changes in /ody image

A&O)MA.

MA.ADAP%I0,

Postponement ofsurgery

'eeking non2surgical

alternatives

Postoperative reactivedepression


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II%IA. %),A%M,%

)adiation %herapy O)MA.

fear of !2ray e3uipmentand of side effects

fear of a/andonment

A&O)MA.

MA.ADAP%I0,

Psychotic likedelusions(

hallucinations


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II%IA. %),A%M,%

Chemotherapy O)MA.

"ear of side2effects An!iety# mild

depression

Changes in /ody image

Isolation

Altruistic feelings

A&O)MA.

MA.ADAP%I0,

)esidual drug2induced psychoses

'evere isolation2

induced psychotic

distur/ances Organic /rain

syndrome( delirium


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PO'% %),A%M,% O)MA.

)eturn to normalcoping patterns

"ear of recurrence

Post treatment an!iety

and depression

A&O)MA.

MA.ADAP%I0,

severe post treatmentan!iety and depression


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),CU)),C, O)MA.

'hock

Dis/elief

Initial partial denial

Anger# hostility#

persecutory feelings An!iety

Depression

A&O)MA.MA.ADAP%I0,

severe reactive

depression withinsomnia# anore!ia#restlessness# an!ietyand irrita/ility


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AD0ACI- DI',A', O)MA.

"ren4ied search fornew information# other

consultants and 53uack$

cures

A&O)MA.

MA.ADAP%I0,

depression


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%,)MIA.(PA..IA%IO O)MA.

"ear of a/andonment

"ear of loss ofcomposure and dignity

"ear of pain

Unfinished /usiness Personal mourning

"ear of unknown

A&O)MA.MA.ADAP%I0,

Depression

Acute delirium


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Psychological "actors affecting Cancer )isk and

Progression 67Controversial7 *.evenson# 899+

Depression

,motional

e!pressiveness

An!iety

,motional

distress

.ife stressors


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Psychiatric 'yndromes in Cancer

Patients *Derogates# ;+The prevalence of psychiatric

disorders among cancer patients

53% adjusting normally to stress47% (+) clinically apparent psychiatric disorders

6% (+) reactive or

situational an!iety

and depression

"3% major depressive

disorder% organic

mental disorder

7% personality

disorder

4% (+) pre#e!isting

an!iety d$o


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Patients Depression

2=? 2 *Derogatis+

92>=? *.evenson#

899+ Cancer types:

Oropharyngeal *882

@?+

Pancreatic *>>29?+ &reast *;2B?+

.ung *;;2BB?+


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Patients

Depression

,tiology 'tress related to the

cancer diagnosis andtreatment

Medications

Underlying

neurological or medical

pro/lems

)ecurrence of pre2

e!isting affective

disorder


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Patients

Depression )isk "actors

Poor physicalcondition

Advanced stage ofdisease withinade3uately

controlled pain 1istory of

depression

"inancial pro/lems


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Patients

Depression

)isk "actors

Marital pro/lems .ower ego strength

Pancreatic# head

and neck and lung

CA


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Patients

Depression Diagnosis

'ocial withdrawal

Anhedonia Dysphoric mood "eelings of

hopelessness#helplessness#

worthlessness# orguilt

Poor self2esteem 'uicidality


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Patients

An!iety Is a normal response to

threat# uncertainty# and

loss of control

A response to the

e!istential plight of

cancer


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Patients

An!iety It is common at crisis

points

Prevalence 6 ;=?#

compara/le to normal

population *'tark et al#

8998+


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Patients

An!iety 'pecific syndromes of

an!iety can prevent the

patient from accepting

appropriate medical

treatment Claustropho/ia

eedle Pho/ia

)adiation pho/ia

Anticipatory pho/ia


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Patients

An!iety

Diagnosis

)(O organiccauses

Antiemetic

phenothia4ines

Pulmonary

em/olism


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Patients

Cancer2related 'uicide

"ew cancer patients

commit suicide *"o! at

al ;


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Patients


is& of suicide

Male gender

Advanced stage ofthe disease

Poor prognosis

Delirium with poor

impulse control Inade3uately

controlled pain

Depression


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Patients


is& of suicide

1istory of psychiatric

illness Current or previous

alcohol or su/stance

a/use

Previous suicide

attempts Physical and emotional

e!haustion

'ocial isolation

,!treme need for

control


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Patients

Delirium common in cancer as a

result of meta/olic

se3uelae of the diseaseand treatment#medications# metastatictumors of the /rain

Prevalence 6 2>9?

/ecoming higher interminal stage of theillness# B92=?


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europsychiatric side effects of drugs

used in cancer treatment

1ormones

Corticosteroids insomnia#la/ility# mania

psychosis# depression%amo!ifen e!acer/n menop s!s

Aminoglutethimide lethargy in first month


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Anticancer agents

procar/a4ine somnolence# psychosis

delirium.2Asparaginase somnolence# lethargy

delirium

Ifosfamide lethargy# sei4uresdysarthia with renal imp

Cytara/ine delirium and cere/ellar

signs


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Anticancer agents

2"luouracil delirium cere/ellar s!s

Methotre!ate transient delirium0incristine(/lastine dysphoria# lethargy# s4

Paclita!el fatigue# %o!ic sensory

neuropathyInterferon


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Anticancer agents

Interferon initial flu2like symptoms

encephalopathy# confusiondepression# hypersomnia

slowed thinking

Interleukin28 confusion# agitation#

irrita/ility# depression

paranoia# delusions

halllucinations


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Psychiatric aspects of %reatment

Chemotherapy

)adiation

&one Marrow transplant 'urgery


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Dealing with the "amily "actors that affect the

family$s acceptance of a

cancer patient

Ages and num/er of familymem/ers

%heir coping resources

%heir sta/ility /efore the

patient$s diagnosis

%heir ethnic and cultural /ackground

)ole and responsi/ilities of

each family mem/er


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Dealing with the "amily Pro/lems that signal

consultation

Pre2e!isting

psychopathology andintrafamily conflicts

Differences in how

family process

information "amily e!haustion and

a/andonment

Inade3uate acceptance


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Dealing with the "amily

Doctor( "amily

relationship

"re3uent visits

Allows time for

3uestion


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Psychiatric Intervention in Cancer

Psychotherapy

-roup( self2therapy group

Psychopharmacology Depression 6 '')I tricyclic antidep

*nortriptylline( desipramine+ against

depression Efor neuropathic pain syndrome

An!iety 6 /en4odia4epine

Delirium 2 1aloperidol


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%hank youFF

psychiatric aspects of medical conditions(sbc) 2012

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