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

Psychiatrists task:

Diagnose
Treat
Facilitate the patients strengths and adaptive
capacity
Bolster patients 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

DIAGNOSIS

NORMAL
Shock
Disbelief
Initial, partial denial
Anger, hostility,
persecutory feelings
Anxiety
Depression

ABNORMAL
MALADAPTIVE
Complete denial with
treatment refusal
Fatalistic treatment
refusal - 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, hostility,
persecutory feelings
Anxiety
Depression

ABNORMAL
MALADAPTIVE
severe reactive
depression with
insomnia, anorexia,
restlessness, 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

Psychological Factors affecting Cancer Risk and

Progression Controversial (Levenson, 2005)

Depression

Emotional
distress

Life stressors

Anxiety

Emotional
expressiveness

Psychiatric Syndromes in Cancer

Patients (Derogates, 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

Depression

5-8% - (Derogatis)
0-38% (Levenson,
2005)

Cancer types:

Oropharyngeal (2257%)
Pancreatic (33-50%)
Breast (1.5-46%)
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

Psychiatric Syndromes in Cancer

Patients

Depression

Diagnosis

Social withdrawal
Anhedonia
Dysphoric mood
Feelings of
hopelessness,
helplessness,
worthlessness, or
guilt
Poor self-esteem
Suicidality

Psychiatric Syndromes in Cancer

Patients

Anxiety

Is a normal response to
threat, uncertainty, and
loss of control
A response to the
existential plight of
cancer

Psychiatric Syndromes in Cancer

Patients

Anxiety

It is common at crisis
points
Prevalence 18%,
comparable to normal
population (Stark et al,
2002)

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

Psychiatric Syndromes in Cancer

Patients

Delirium

common in cancer as a
result of metabolic
sequelae of the disease
and treatment,
medications, metastatic
tumors of the brain
Prevalence 5-30%
becoming higher in
terminal stage of the
illness, 40-85%

Neuropsychiatric side effects of drugs

used in cancer treatment
Hormones
Corticosteroids
Tamoxifen
Aminoglutethimide

insomnia,lability, mania
psychosis, depression
exacerbn menop sxs
lethargy in first month

Neuropsychiatric side effects of drugs

used in cancer treatment
Anticancer agents
procarbazine
L-Asparaginase
Ifosfamide
Cytarabine

somnolence, psychosis
delirium
somnolence, lethargy
delirium
lethargy, seizures
dysarthia with renal imp
delirium and cerebellar
signs

Neuropsychiatric side effects of drugs

used in cancer treatment
Anticancer agents
5-Fluouracil
Methotrexate
Vincristine/blastine
Paclitaxel
Interferon

delirium cerebellar sxs

transient delirium
dysphoria, lethargy, sz
fatigue,. Toxic sensory
neuropathy

Neuropsychiatric side effects of drugs

used in cancer treatment
Anticancer agents
Interferon

Interleukin-2

initial flu-like symptoms

encephalopathy, confusion
depression, hypersomnia
slowed thinking
confusion, agitation,
irritability, depression
paranoia, delusions
halllucinations

Psychiatric aspects of Treatment

Chemotherapy
Radiation
Bone Marrow transplant
Surgery

Dealing with the Family

Factors that affect the

familys acceptance of a
cancer patient

Ages and number of family

members
Their coping resources
Their stability before the
patients 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

Psychiatric Intervention in Cancer

Psychotherapy

Group/ self-therapy group

Psychopharmacology

Depression SSRI; tricyclic antidep

(nortriptylline/ desipramine) against
depression +for neuropathic pain syndrome
Anxiety benzodiazepine
Delirium - Haloperidol

Thank you!!