Symposium on Psychiatry in Internal Medicine
Psychological Aspects of Oncology Jimmie Holland, M.D. *
Cancer has long been viewed by physicians and laymen alike as a disease to be feared above all others. The fact that neither cause nor cure was known made such a response easily understood. In recent years, improved treatment and better understanding of the neoplastic process has led to increased frequency of cure in some cancers and longer survival in others. The improved prognosis for Stage I and Stage 11 Hodgkin's disease, acute lymphocytic leukemia, and osteogenic sarcoma are notable examples. Pessimism about the treatment of cancer has continued, however, outliving its rational application. The concept that cancer is an incurable disease has been hard to overcome among some physicians. That concept survives now more as a prejudice than as a fact. Lavoisier observed in 1789 that "in chemistry, as in normal philosophy, it is extremely difficult to overcome prejudices imbibed in early education, and to search for truth in any other road than the one we have been accustomed to follow."ll The increased survival of patients who have died in the past is often achieved, nevertheless, at considerable physical and emotional cost to the patient. Therapies demand a high level of commitment and cooperation if the patient is to tolerate the discomfort and side-effects of treatment, sometimes over months. The quality of life for patients during and after treatment has received increasing attention. Optimal management of the patient with cancer now demands not only that the physician utilize the most current medical treatment, but that he respond to the patient with understanding and empathy at all stages of illness. 6 This review of psychological issues in oncology thus addresses two major aspects: first, the principles that apply to psychological management of all patients with cancer, and second, diagnosis and management of psychiatric syndromes that may complicate the clinical course of some patients with cancer.
PSYCHOLOGICAL MANAGEMENT OF THE PATIENT WITH CANCER Cancer occurs in individuals who have attained all levels of emotional adjustment; no evidence exists at this point to assume that any *Associate Clinical Professor of Psychiatry, Albert Einstein College of Medicine at Montefiore Hospital and Medical Center, Bronx, New York.
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way of coping with stress or a particular personality type is more or less frequent in patients with cancer. Public information about this has far out-weighed available substantive data. 21 Most individuals who develop cancer fall within the range of "normal." Those who have had a preexisting poor psychological adjustment or actual psychiatric illness are at higher risk of emotional decompensation. They should be identified early and watched more carefully during the stresses of illness. Diagnosis of Cancer When a symptom suggesting possible cancer is found, individuals go through a series of responses that are normal but, if not anticipated by the physician, may be regarded as abnormal disturbance. From the time the symptom is identified, an individual may vacillate between "I know it's cancer" and "I know it's nothing." If the individual has had prior contact with cancer, the fear may be intensified. Anxiety, coupled with hope, characterize the emotions of the patient during the period of work-up by the physician. It behooves the doctor to convey both the serious nature of the situation and the need for continued work-up, while not creating alarm by premature speculation. Once the diagnosis is made, it should be conveyed without delay, together with an outline of the treatment plan. Telling and hearing the diagnosis of cancer are painful; yet this is being dealt with by physician and patient with more candor today. It would be a rarity to find a woman today who did not know that breast cancer was the reason for her mastectomy. Women also ask and are told how many positive axillary lymph nodes were identified at the time of surgery. That would not have been true even 5 years ago. The word cancer is becoming more openly used, but no rule should exist to always or never use the word cancer in discussing the diagnosis. The words used in initial discussion of the illness are much less important than conveying a sense of honesty, realistic hope, concern, and willingness to treat the patient's disease (whatever it is called), with competence and compassion. Patients tend to hear only the words they can best tolerate at a particular time, and an accurate understanding of the disease may occur only over some period of time. Words and explanations should be chosen that the patient can understand. Patients should never be told the patent untruth, "It is not cancer." Trust of the doctor-which may be needed later-can be jeopardized. Likewise, an approach which says "It's cancer and there's nothing to be done for you" is equally destructive and conveys a feeling, not of continuing care, but rather of abandonment by the doctor. Normal responses to hearing the diagnosis of cancer occur to a greater or lesser degree in every individual. First there is a feeling of shock and disbelief-"It isn't so." This is followed by anger, depressed mood, and a temporary disruption of appetite, sleep, and patterns of daily activity. Emotional restitution occurs with an adjustment to the distressing fact. These ubiquitous human responses to near-overwhelming loss or threat of loss have been documented in a variety of situations. Lindemann first defined the symptoms of acute grief in the survivors who lost relatives in the Cocoanut Grove disaster.1 4 Lifton described similar acute responses in the survivors of Hiroshima and N agasaki.13
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Hamburg noted the same progression in patients adjusting to severe burns and poliomyelitis. 4 Kiibler-Ross identified these reactions as visible responses to dying, but they are not unique to cancer or death.1° They occur in response to overwhelming loss or threatened loss of loved one, life, limb, or disaster. It is important to recognize the lack of specificity of these responses and also their transient nature as a part of normal grief or grief in anticipation of a possible loss. The initial weight loss in some patients may be caused in part by anorexia related to emotional distress surrounding diagnosis. 9 The acute response in patients with cancer abates as a plan for treatment is formulated which allows hope to return. FaInilies often fear that the patient will commit suicide if told he has cancer. Accurate data on suicides which occurred shortly after the person was given a diagnosis of cancer are not readily available. Only two known cases could be found in a survey of 219 physicians. 15 However, the risk of suicide as a result of discussing the patient's diagnosis with him has probably been exaggerated in the past, and with the increasingly common practice of open communication, the risk should diminish even further. Treatment Plan Aimed at Cure Preparation for the planned treatment procedure should be outlined in terms of the expected functional loss or deficit and possible sideeffects, with description of those deficits which are transient or permanent. Psychological preparation is important in all cancer surgery, but careful discussion should precede laryngectomy, colostomy, orchiectomy, and mastectomy, in which functional loss is particularly difficult to accept. Frank discussion of the possible nature and loss of sexual function must be initiated by the physician in the preoperative discussion. Both patient and spouse may be reluctant to ask questions about sexual dysfunction, in spite of their great concern. Increasing opportunity for cured patients to help others with the same disease has proven of mutual advantage. The person who has survived can offer unique hope and information to the patient going through the early phases of illness, while gaining emotional strength and mastery through helping others. Patients who have experienced mastectomies, laryngectomies, and colostomies have been particularly effective as volunteers. The increasing willingness of cured patients to acknowledge rather than hide the fact that they have had cancer is serving to diminish the pessimism about outcome, since previously individuals heard only of those who died of cancer. An attempt at cure is followed by a period of increasing hope, but anyone who has had cancer lives with a disquieting concern about the future. This important aspect of "living with cancer" and the "uncertainty of its outcome" has received less emphasis than "dying with cancer." Attempt at Cure Followed by Recurrent Disease Diagnosis of recurrent disease requires new adjustment. The threat to life cannot be denied. Insomnia, anorexia, restlessness, anxiety, and irritability may again occur, lasting for several days, as at the time of
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initial diagnosis; they may be more severe. The physician must explain the new development and outline a revised plan of treatment. He should convey continuing commitment to the patient's care through this new stage of disease, never taking away hope, while allowing opportunity for questions about the future, including the possibility of a fatal outcome. The day-to-day emotional state of the person with recurrent or metastatic cancer depends to a large measure on the presence of physical symptoms and the level of pain and discomfort. A cheerful outlook with optimism is easier when the patient feels well; the converse is readily apparent. Interpersonal relationships take on increased meaning, both with family and with medical personnel as well. Patients with advanced cancer expressed a need for increased physical closeness and affection from spouses in one study.12 Critically ill patients, irrespective of type of disease, as opposed to noncritically ill or healthy individuals, expressed more affection for others and wanted more affection and closeness from others.23 This information suggests that maximal and as nearly normal contact with family be maintained by keeping the patient at home as much as possible, and by developing more hotel-related facilities near hospitals which allow the patients to live with family, coming to clinics for radiotherapy and chemotherapy as needed. Understanding of the patient's heightened emotional ties to the physician and hospital staff and the attempt with advancing illness is clarified to be a "good" patient by recognizing the increased importance to these patients of the doctor-patient relationship. It also serves to emphasize the value of continuity of care by physician and hospital or clinic staff. When suicide does occur in a cancer patient, studies suggest that it occurs more often late than early in the clinical course, and is apt to occur in a person who gives danger signals of poorer psychological resources and less ability to adjust to illness. la The frequency of passive suicide remains unknown, since failure to cooperate in treatment may at times be an expression of a deliberate death wish. "Giving up" and "losing the will to live" are hard to assess since they occur temporally with advancing disease and may be the consequence rather than cause of advancing disease. Care of many patients with advanced and terminal disease places a psychological burden upon the responsible physician and nursing staffin a hospital or clinic. The frequent decisions about utilizing life-sustaining procedures and problems around care of difficult patients can lead to emotional distress in staff members, and cause friction among staff that diminishes the ability to give optimal medical care. Weekly meetings of staff led by a psychiatrist who works regularly with the group which focus on psychosocial problems of patients which have arisen in daily encounters are advantageous. 22 Anger or frustration aroused by care of certain patients can be controlled better when the reason for the patient's behavior and staff's response are clear. Psychological management of cancer patients and knowledge of the psychosocial issues in their care are increasingly becoming recognized as a necessary part of total training in oncology.I,18 Weekly seminars for Oncology Fellows and nurses, and meetings of families and patients are being instituted more commonly and appear helpful.
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Despite the general acceptance that prolonging dying is not ethically equivalent to prolonging meaningful life, decisions about selectively limited life-supportive measures are difficult ones, made with considerable deliberation, and often made alone by the physician who feels he can neither share nor discuss the decision with staff or family. A more open approach to this problem has been taken by formation of an Optimum Care Committee for hopelessly ill patients at the Massachusetts General Hospital.1 6 Beth Israel Hospital in Boston has carefully elucidated principles for "orders not to resuscitate. "17 Open discussion and development of stated policies concerning matters long kept hidden from public view is a recent and laudatory change.
PSYCHOLOGICAL EFFECTS OF TREATMENT Both radiotherapy and chemotherapy in cancer demand a high level of cooperation from patients. Careful descriptions of the treatment itself, the desired response, and the side-effects that must be tolerated to achieve the antitumor effect are required. Knowing that a side-effect may occur often makes it easier to accept when it does. The dictum that telling a patient the possible side-effects makes him more likely to complain of them is fallacious. A nurse or social worker familiar with the treatment should be available to reinforce and elaborate the physician's instructions, giving consistent support during treatment that often extends over months. They should be accessible by telephone and for longer discussions at times in clinic. Chemotherapy produces regular, anticipated periods of up to several days of significant illness from side-effects. Distressing symptoms with psychological consequences are nausea and vomiting, central nervous system effects, alopecia, generalized fatigue and weakness, and disruption of work, home, or school routines. NAUSEA AND VOMITING. Nausea and vomiting is significant during treatment with certain of the antineoplastic agents: cytoxan, CCNU derivatives, Adriamycin, MOPP regimen, platinum compounds, and actinomycin D. These antitumor agents are thought to activate the chemoreceptor trigger zones around the fourth ventricle-the antiemetic agents act by diminishing impulses reaching those areas. 2 Phenothiazines, particularly prochlorperazine (Compazine), are the most commonly used antiemetic drugs. Any antiemetic agent should be started 8 to 24 hours before the patient comes to the hospital or clinic for drug infusion. The mild sedating, antianxiety eff~ct also diminishes the conditioning which leads some patients to begin to vomit in anticipation of the treatment, especially with drugs that cause severe emesis, such as the platinum compounds. Ll-9- Tetrahydrocannabinol (THC), the active component of marijuana, had a remarkably better antiemetic effect given orally than placebo in a controlled study.20 It is receiving additional clinical trials. Reassurance, understanding and counseling by a nurse or physician present each time still constitute the most important support during treatment. Psychological techniques should be explored to attempt better con-
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trol of the anticipatory anxiety seen in some patients in whom nausea and vomiting is stimulated long before receiving the drug. NEUROTOXIC EFFECTS. Several drugs exert significant side-effects on the central nervous system, producing neurologic and mental symptoms. Patients not only fear the neurotoxic effect but they become concerned that the dysfunction may be permanent. The primary agents with these side-effects are L-Asparaginase, 5-fluorouracil, intrathecal methotrexate, procarbazine and vincristine/vinblastine. 24 L-Asparaginase produces mental changes of confusion, delirium, electroencephalographic slowing and depression, probably because of impaired protein synthesis. Mental changes were noted in 26 per cent of adult patients treated in one series. 7 5-Fluorouracilless often produces central nervous system side-effects, though cerebellar dysfunction with ataxia, dysarthria, and dizziness develops in some patients. Methotrexate does not cross the blood-brain barrier but, when given intrathecally, may produce a meningioencephalopathy with focal signs of meningeal irritation, paraparesis, and mental confusion. Procarbazine, used in treatment of Hodgkins's disease and lymphomas, acts as a monoamine oxidase inhibitor. It often produces significant peripheral neuropathy and altered level of consciousness, which may vary from drowsiness to coma. At times discontinuation of the drug is required. Vincristine and vinblastine produce a range of central nervous system dysfunctions: autonomic effects (producing constipation, gastrointestinal cramps, and impotence), seizures, altered mental function, and cranial nerve palsy. These neurotoxic side-effects are largely reversible, but cause major disruption in function for the patient during treatment. Corticosteroids, frequently employed as a part of chemotherapeutic regimens, produce distressing side-effects of moon face, acne, hyperphagia, obese habitus, overactivity, and insomnia. While producing euphoria or even hypomania early in their use, lability of emotion, depression, and steroid-induced psychosis may develop. Psychological disturbances may occur at any dosage of medication or on abrupt withdrawal. A psychotic reaction usually abates with lowering of the dose, but may continue and require psychiatric treatment. ALOPECIA. Loss of hair, on both body and scalp, is a common sideeffect of most chemotherapeutic agents. Total baldness is particularly distressing for those to whom appearance is most important: women, adolescents, and young adults of both sexes. Teenagers, who need to look like peers and to whom ridicule and admission of disease are frightening, have difficulty adjusting to this side-effect. The physician must explain, at the outset of treatment, the likelihood that the alopecia may occur, and suggest that a wig be obtained, and worn, before the hair loss occurs. Preparation for the loss and reassurance that it is temporary are important to psychological support. WEAKNESS AND FATIGUE. Fatigue and weakness, which occur with some antitumor agents, lead to absences and difficulty in maintaining performance at work and at school, adding to social stress. Altered work schedules are best tolerated in the context that they are temporary and, in the long run, are worth the gains in disease control and survival.
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IMMUNOTHERAPY. While still limited to use in cancer centers, immunotherapy is increasingly being used as an adjunctive therapy to surgery and chemotherapy. Adjustment is sometimes difficult when patients get extensive, red, painful lesions in response to the antigen given by multiple skin scratches. Lesions are uncomfortable, difficult to explain to others, and some patients may need considerable encouragement to adhere to a regimen over months.
Protected Environments Optimal chemotherapy for some sites of cancer requires substantial marrow depression and thus a significant risk of infection. Reverse isolation is often used, and more recently, plastic laminar air flow rooms have been used to decrease risk of infection. While therapeutically useful, the rooms enforce complete physical isolation of the patient from others. The isolation is psychologically tolerable for most, but some isolated patients complain about the loneliness and feeling of distance evoked by the fact that they cannot touch or be touched directly by another person. 8 PSYCHIATRIC SYNDROMES IN THE COURSE OF CANCER There are several significant psychiatric syndromes which may develop in the course of clinical cancer and its treatment. These fell within major areas: (1) central nervous system dysfunction associated with cancer and its treatment; (2) concurrent or complicating psychiatric illness; (3) serious emotional disturbance in response to illness, medical management, or faInily problems; (4) occurrence of anxiety, agitation, depression or suicidal risk. Diagnosis, management, use of psychopharmacologic drugs, and indication for consultation are outlined. Central Nervous System Dysfunction There are a number of related terms which are used interchangeably with organic mental changes: delirium, confusion, acute brain syndrome, and metabolic encephalopathy. Delirium is a broad term used for any syndrome of disturbed sensation, perception, memory, thought, or judgment as a result of altered cerebral functioning. 5 The presence of an acute mental disturbance or sudden personality change in a previously emotionally healthy individual who has cancer is most likely secondary to cerebral dysfunction related to disease or its treatment. Onset of a psychotic illness such as schizophrenia in a person without prior psychiatric history is infrequent, even under the emotional stress of cancer. An organic etiology should be suspected if visual or auditory hallucinations, a variable degree of disorientation, or transient confusion or somnolence are present. Careful work-up of the patient, utilizing history, physical and neurologic examination, and laboratory data including spinal fluid examination may be necessary to establish the cause. Diffuse slowing of the encephalogram is confirmatory evidence. Central nervous system dysfunction may occur from several causes
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in cancer. Direct effects occur by local extension of cancer, infiltration of brain or meninges in hematologic neoplasm, and by metastatic spread. Brain metastases are more common with cancer of certain sites, particularly lung and breast. Indirect nonmetastatic effects of cencer on the central nervous system are less well understood. Subacute cerebellar degeneration has been observed primarily with carcinoma of lung, ovary, and breast. Ataxia, dysarthria, impaired intellectual function, and memory develop over a period of weeks to months and may appear before discovery of the neoplasm. Increase in lymphocytes and protein occur in the cerebrospinal fluid in most cases. Two types of encephalopathy or encephalitis associated with carcinoma have been described: encephalitis observed by Corsellis prirrarily in patients with lung cancer and progressive multifocal leukoencephalopathy which occurs primarily as a complication of neoplastic disease of the lymphatic and reticuloendothelial systems. Progressive multifocalleukoencephalopathy is thought to be causeC! by an otherwise nonpathogenic virus in human beings associated with impaired immunosurveillance. 19 Both syndromes produce significant dementia and, though rare, should be considered in the patient with cancer who experiences memory and cognitive defects without sign of metastatic disease. Other common causes of delirium in cancer are bleeding resulting in cerebral anemia, hypovolemia, and circulatory impairment, metabolic derangements from fluid and electrolyte imbalance, hypoglycemia, hypercalcemia, liver failure, and kidney failure. Mild change in mental function often occurs prior to altered physical findings or change in laboratory data, particularly in occult bleeding or metabolic disequilibrium. As such, the presence of delirium in the cancer patient deserves immediate and careful work-up. Concurrent Psychiatric Illness
A patient who has had a prior history of psychiatric illness may experience an exacerbation of mental symptoms in the course of cancer. A major psychiatric illness, such as a schizophrenic episode, manicdepressive illness, or psychotic depression should be treated as a concurrent illness and is cause for psychiatric consultation and management. Serious Disturbance in Relation to Illness Some patients may, by personality or ways of coping with stress, be unable to adapt to illness, treatment, or rehabilitation, attaining less than optimal results from treatment that requires a high level of cooperation and participation. A hostile attitude, excessive dependency, manipulative behavior, or excessive demands for attention may compromise care and require psychiatric consultation. Each problem demands evaluation and a plan for management. The "psychological invalid" who cannot give up dependence acquired through illness occurs in cancer as in other diseases. The anxious patient may require consultation for demoralizing anxiety about repeated venipuncture, bone marrow aspirations, or uncomfortable wound dressings.
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Management of Anxiety, Agitation, Depression, or Suicidal Risk Management of a patient who becomes irrational, agitated, suicidal, or violent may sometimes require immediate control to prevent injury to the patient or others, and to prevent exhaustion. This picture most often occurs in a delirious state. Careful assessment of etiology is necessary, but control of behavior must sometimes be rapidly effected. Diazepam (Valium) is quickly effective, by either intramuscular or intravenous routes and is safer than barbiturates. Intravenous diazepam, 5 to 10 mg, has rapid effect and few side-effects, though resuscitation equipment should be available. Haloperidol, a butyrophenone, controls agitated behavior effectively in intramuscular injection of 0.5 to 1.0 mg. Action is rapid and when control is effected, the liquid concentrate can be substituted for longer term control, with dosage in about the same range. Agitation which is less acute should be controlled by oral use of a major tranquilizer. Trifluoperazine (Stelazine), 1 to 2 mg twice a day, is safe, even in older individuals, and often reduces confusion on the basis of central nervous system dysfunction. Thiorid~zine (Mellaril), 25 to 100 mg per day, is also effective. It should be kept in mind that both drugs lower the seizure threshold. Sedative-hypnotics may exacerbate delirium and should be avoided.
Psychopharmacologic Drug Use Caution should be exercised in prescribing any psychotropic drug until the etiology of a mental symptom is clear. The drug may mask symptoms of a developing organic brain syndrome, which is best treated by identifying and addressing the underlying cause. Pain, a critical problem in treatment of cancer, can be markedly enhanced by fear, anxiety, and depressed mood. Phenothiazines are useful adjuncts to control of pain, in diminishing the component related to emotional distress. Psychotropic drugs useful in cancer are divided by their major actions: sedative-hypnotics, antidepressants, and antipsychotic agents. SEDATIVE-HYPNOTICS. This group of drugs are central nervous system depressants which, in low doses, serve to diminish anxiety, and in high doses produce sleep.3 Daytime Sedation. Antianxiety drugs and minor tranquilizers are useful in the patient who is excessively anxious during medical work-up, when anticipation of uncomfortable laboratory procedures is present, and during the crises in which the course of disease is uncertain or altered. While widely used, controlled studies of actual effectiveness in physically ill patients, particularly cancer, have not been done. Benzodiazepines appear to be least habituating and are more specifically antianxiety in their effect, producing least drowsiness. Diazepam (Valium) in doses from 5 to 40 mg per day is effective in most individuals. Chlordiazepoxide (Librium) may be given in doses of 10 to 100 mg per day. Both are slowly metabolized and accumulation of active products may occur over several days. Diazepam may appear to have short actiol1 because of its lipid-solubility and rapid tissue-uptake but this is a false impression and caution should be used in increasing dose. 3
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Diazepam, 5 to 10 mg intravenous or intramuscularly, is an effective and safe premedication for the anxious patient prior to procedures such as bone marrow aspiration, sigmoidoscopy, or biopsy. Barbiturates, propanediols, and antihistamines are not recommended over benzodiazepines. Only in the presence of a concurrent psychiatric syndrome or incapacitating anxiety which presents with tachycardia, sweating, palpitation and agitation, would a betaadrenergic blocking agent be considered. Bedtime Sedation. The benzodiazepine derivative, flurazepam, has no potentiating effects upon other drugs, does not depress respiration, and has no significant effect upon REM sleep at a dose of 30 mg. These are distinct advantages over barbiturates which depress REM sleep, respiration, leave a morning "hangover," and are potent enzyme inducers, due to stimulation of the activity of liver microsomal drugmetabolizing enzymes. 3 Anticoagulants may require higher dosage to be effective when barbiturates are given. Since overdoses of barbiturates are extremely dangerous, caution should be exercised in giving large amounts to the patient with cancer who appears significantly depressed. Tuinol which contains 25 mg of secobarbital (short acting) and amobarbitallOO mg (intermediate range) is particularly hazardous in overdose. When a barbiturate is required, 100 mg of secobarbital or pentobarbital is effective and can be increased to 200 mg. Chloral hydrate is commonly used and is effective at a 1 to 2 gm dose at bedtime. It is detoxified to trichlorethanol, which is bound to protein. Potentiation of anticoagulants may thus occur. In addition, gastric irritation may occur. Glutethimide, because of its high lipid solubility, and strong respiratory depressant effect, has no advantage and is highly dangerous in overdose. ANTIDEPRESSANTS. Reaction to life-threatening illness, such as cancer, often produces a depressed mood. A realistic appraisal of altered function and outlook lead to anxiety, dysphoria, and a normal grieving for threatened potential losses. Antidepressants are less effective in these patients, and emotional support and reassurance are more effective. When, however, significant depression interferes with medical care in the patient with cancer, antidepressant therapy should be considered in consultation with a psychiatrist. The more nearly the depression resembles an endogenous (as opposed to reactive) illness, the more likely is drug therapy to be effective. Tricyclic antidepressants contain two major groups: dibenzazepine derivatives (imipramine and desipramine) and the dibenzocycloheptadiene derivatives (amitriptyline, nortriptyline, protriptyline). Amitriptyline has an additional sedative effect and may be given at bedtime in place of a hypnotic. A dosage of 50 mg at bedtime and 25 mg during the day can be increased to 150 mg per day over a week. Imipramine should be given in divided daytime doses beginning at 75 mg per day. All tricyclics often tend to be given in low and ineffective dosage. They have a cumulative effect and require 7 to 10 days to demonstrate any change in mood. Anticholinergic effects contraindicate their use in intestinal obstruction, glaucoma, and prostatic disease.
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Monoamine oxidase inhibitors should seldom be considered in the patient with cancer due to serious adverse side effects. In depressions which threaten life and compromise care during cancer, electroshock should be considered, given with anesthesia and succinylcholine to modify the seizure.
Management of the Family The family member closest to the patient-the spouse, parent, or child-usually bears the strain of illness with the patient. The family member needs open and honest communication with both the physician and the patient. The illness often increases family solidarity and appreciation, sometimes with increased pleasure in the commonplace of home life. Barriers to communication characterized by the patient "not letting the family know he knows" or the family "not letting the patient know they know" the diagnosis and outcome should be slowly removed. A conspiracy of silence has little consoling value at this time and increases the isolation of the patient from those he needs most. Family conflicts which distress the patient and which may cause guilt later in the survivors should be clarified when possible. The family's investment in the doctor as the one person who controls the fate of the loved one puts a strain on the relationship that can lead to difficulties and misunderstandings. The spouse may be irritable and critical of the medical care, which the physician must understand as a response to anxiety rather than the personal attack he feels. The response to news of death of the relative is tempered at times with relief and the rationalization that "I'm glad he doesn't have to suffer any more." The closest relative should have the opportunity to see the physician again a few weeks after the death to ask questions and to review details of the patient's illness and autopsy. They sometimes wish to discuss guilt for some action felt to have contributed to discomfort or earlier death of the patient. The opportunity to share the loss with the doctor who knew and respected the patient during the final illness becomes helpful in resolving the grief. A note to the survivor months after the loss, reflects continuing interest on the part of the staff for the family, reminding the relative that the patient has not been forgotton as just "another case."
SUMMARY The patient with cancer presents the physician with challenging psychological issues: maintenance of an effective and understanding physician-patient relationship, in the context of optimal medical care, and alertness to signs of significant psychologic symptoms that may occur more commonly in the course of cancer. The closest relative, also under great emotional stress, must be considered in communications about the patient's clinical state and treatment. Psychological aspects of oncology are a demanding component of total care of the cancer patient, yet an integral part of optimal cancer care.
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REFERENCES 1. Artiss, L. K., and Levine, A. S.: Doctor-patient relation in severe illness: A seminar for Oncology Fellows. New Eng. J. Med., 288:1210,1973. 1a.Farberow, N. L., Schneidman, E. W., and Leonard, C. V.: Suicide among general medical and surgical hospital patients and those with malignant neoplasms. Med. Bull. Veterans Admin., 9:1, 1963. 2. Goodman, L. J., and Gilman, A. (Eds.): Pharmacologic Basis of Therapeutics. New York, Macmillan, 5th ed., 1975, pp. 157-161. 3. Greenblatt, D., and Shader, R: Psychotropic drugs in the general hospital. In Shader, R, ed.: Manual of Psychiatric Therapeutics. Boston, Little, Brown and Co., 1975, pp. 1-27. 4. Hamburg, D., Hamburg, B., and DeGozg, S.: Adapt'''e problems and mechanisms in severely burned patients. Psychiatry, 16:1, 1953. 5. Heller, S., and Kornfeld, D.: Delirium and Related Problems. In Arieti, S., ed.: American Handbook of Psychiatry. 2nd ed., 1975, Vol. IV, pp. 45-66. 6. Holland, J.: Psychologic aspects of cancer. In Holland, J. H., and Frei, E., eds.: Cancer Medicine. Philadelphia, Lea & Febiger, 1973, pp. 991-1021. 7. Holland, J., Fasanello, S., and Ohnuma, T.: Psychiatric symptoms associated with L-asparaginase administration. J. Psych. Res., 10:165,1974. 8. Holland, J., Plumb, M., Yates, J., et al.: Psychological response of patients with acute leukemia to germ-free environments. Cancer, January 1977, in press. 9. Holland, J., Rowland, J., and Plumb, M.: Psychological aspects of anorexia in cancer patients. Cancer Research, February 1977, in press. 10. Kiibler-Ross, E.: On Death and Dying. New York, The Macmillan Co., 1970. 11. Lavoisier, A.: Elements of Chemistry. New York, Dover Books, 1975, pp. 93. 12. Leiber, L., Plumb, M., Gerstenzang, M., et al.: The communication of affection between cancer patients and their spouses. Psychosom. Med., 38:379, 1976. 13. Lifton, R J.: Death in Life: Survivors of Hiroshima. New York, Random House, 1967. 14. Lindemann, E.: Symptomatology and management of acute grief. Amer. J. Psychiatr., 101 :141,1944. 15. Oken, D.: What to tell cancer patients: a study of I"'",dical attitudes. J.A.M.A., 175 :1120, 1961. 16. Pontoppidan, H.: Clinical care committee, Massachusetts General Hospital, optimum care for hopelessly ill patients. New Eng. J. Med., 295 :362, 1976. 17. Rabkin, M., Gillerman, G., and Rice, N.: Orders not to resuscitate. New Eng. J. Med., 295 :364, 1976. 18. Richards, A. I., and Schmale, A. H.: Psychosocial conferences in medical oncology; role in a training program. Ann Intern. Med., 80:541, 1974. 19. Richardson, E.: Neurologic effects of cancer. In Holland, J. F., and Frei, E., eds.: Cancer Medicine. Philadelphia, Lea and Febiger, 1973, pp. 1057-1067. 20. Sallen, S., Zinberg, N., and Frei, E.: Anti-emetic effect of delta 9-tetrahydrocannabinolin patients receiving cancer chemotherapy. New Eng. J. Med., 293 :790, 1975. 21. Schmale, A., Morrow, G., and Ader, R.: Cancer, leukemia and related diseases: psychosomatic aspects. In International Encyclopedia of Neurology, Psychiatry, Psychoanalysis and Psychology. New York, Van Nostrand Reinhold Co., and copyrighted by Aesculapius Publishers, Inc. In Press, 1977. 22. Spikes, J., and Holland, J.: The physician and the dying patient. In Strain, J., and Grossman, S., eds.: PsycholOgical Care of the Medically Ill. New York, AppletonCentury-Crofts, 1975, pp. 138-150. 23. Thomas, J., and Weiner, E.: Psychological differences among groups of critically ill hospitalized patients and well controls. J. Counseling Clin. Psych., 42 :274, 1974. 24. Weiss, H., Walker, M., and Wiernik, P.: Neurotoxicity of commonly used antineoplastic agents. New Eng. J. Med., 291 :75 and 127, 1974. Montefiore Hospital and Medical Center Bronx, New York 10467
Psychological Aspects of Oncology Jimmie Holland, M.D. *
Cancer has long been viewed by physicians and laymen alike as a disease to be feared above all others. The fact that neither cause nor cure was known made such a response easily understood. In recent years, improved treatment and better understanding of the neoplastic process has led to increased frequency of cure in some cancers and longer survival in others. The improved prognosis for Stage I and Stage 11 Hodgkin's disease, acute lymphocytic leukemia, and osteogenic sarcoma are notable examples. Pessimism about the treatment of cancer has continued, however, outliving its rational application. The concept that cancer is an incurable disease has been hard to overcome among some physicians. That concept survives now more as a prejudice than as a fact. Lavoisier observed in 1789 that "in chemistry, as in normal philosophy, it is extremely difficult to overcome prejudices imbibed in early education, and to search for truth in any other road than the one we have been accustomed to follow."ll The increased survival of patients who have died in the past is often achieved, nevertheless, at considerable physical and emotional cost to the patient. Therapies demand a high level of commitment and cooperation if the patient is to tolerate the discomfort and side-effects of treatment, sometimes over months. The quality of life for patients during and after treatment has received increasing attention. Optimal management of the patient with cancer now demands not only that the physician utilize the most current medical treatment, but that he respond to the patient with understanding and empathy at all stages of illness. 6 This review of psychological issues in oncology thus addresses two major aspects: first, the principles that apply to psychological management of all patients with cancer, and second, diagnosis and management of psychiatric syndromes that may complicate the clinical course of some patients with cancer.
PSYCHOLOGICAL MANAGEMENT OF THE PATIENT WITH CANCER Cancer occurs in individuals who have attained all levels of emotional adjustment; no evidence exists at this point to assume that any *Associate Clinical Professor of Psychiatry, Albert Einstein College of Medicine at Montefiore Hospital and Medical Center, Bronx, New York.
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way of coping with stress or a particular personality type is more or less frequent in patients with cancer. Public information about this has far out-weighed available substantive data. 21 Most individuals who develop cancer fall within the range of "normal." Those who have had a preexisting poor psychological adjustment or actual psychiatric illness are at higher risk of emotional decompensation. They should be identified early and watched more carefully during the stresses of illness. Diagnosis of Cancer When a symptom suggesting possible cancer is found, individuals go through a series of responses that are normal but, if not anticipated by the physician, may be regarded as abnormal disturbance. From the time the symptom is identified, an individual may vacillate between "I know it's cancer" and "I know it's nothing." If the individual has had prior contact with cancer, the fear may be intensified. Anxiety, coupled with hope, characterize the emotions of the patient during the period of work-up by the physician. It behooves the doctor to convey both the serious nature of the situation and the need for continued work-up, while not creating alarm by premature speculation. Once the diagnosis is made, it should be conveyed without delay, together with an outline of the treatment plan. Telling and hearing the diagnosis of cancer are painful; yet this is being dealt with by physician and patient with more candor today. It would be a rarity to find a woman today who did not know that breast cancer was the reason for her mastectomy. Women also ask and are told how many positive axillary lymph nodes were identified at the time of surgery. That would not have been true even 5 years ago. The word cancer is becoming more openly used, but no rule should exist to always or never use the word cancer in discussing the diagnosis. The words used in initial discussion of the illness are much less important than conveying a sense of honesty, realistic hope, concern, and willingness to treat the patient's disease (whatever it is called), with competence and compassion. Patients tend to hear only the words they can best tolerate at a particular time, and an accurate understanding of the disease may occur only over some period of time. Words and explanations should be chosen that the patient can understand. Patients should never be told the patent untruth, "It is not cancer." Trust of the doctor-which may be needed later-can be jeopardized. Likewise, an approach which says "It's cancer and there's nothing to be done for you" is equally destructive and conveys a feeling, not of continuing care, but rather of abandonment by the doctor. Normal responses to hearing the diagnosis of cancer occur to a greater or lesser degree in every individual. First there is a feeling of shock and disbelief-"It isn't so." This is followed by anger, depressed mood, and a temporary disruption of appetite, sleep, and patterns of daily activity. Emotional restitution occurs with an adjustment to the distressing fact. These ubiquitous human responses to near-overwhelming loss or threat of loss have been documented in a variety of situations. Lindemann first defined the symptoms of acute grief in the survivors who lost relatives in the Cocoanut Grove disaster.1 4 Lifton described similar acute responses in the survivors of Hiroshima and N agasaki.13
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Hamburg noted the same progression in patients adjusting to severe burns and poliomyelitis. 4 Kiibler-Ross identified these reactions as visible responses to dying, but they are not unique to cancer or death.1° They occur in response to overwhelming loss or threatened loss of loved one, life, limb, or disaster. It is important to recognize the lack of specificity of these responses and also their transient nature as a part of normal grief or grief in anticipation of a possible loss. The initial weight loss in some patients may be caused in part by anorexia related to emotional distress surrounding diagnosis. 9 The acute response in patients with cancer abates as a plan for treatment is formulated which allows hope to return. FaInilies often fear that the patient will commit suicide if told he has cancer. Accurate data on suicides which occurred shortly after the person was given a diagnosis of cancer are not readily available. Only two known cases could be found in a survey of 219 physicians. 15 However, the risk of suicide as a result of discussing the patient's diagnosis with him has probably been exaggerated in the past, and with the increasingly common practice of open communication, the risk should diminish even further. Treatment Plan Aimed at Cure Preparation for the planned treatment procedure should be outlined in terms of the expected functional loss or deficit and possible sideeffects, with description of those deficits which are transient or permanent. Psychological preparation is important in all cancer surgery, but careful discussion should precede laryngectomy, colostomy, orchiectomy, and mastectomy, in which functional loss is particularly difficult to accept. Frank discussion of the possible nature and loss of sexual function must be initiated by the physician in the preoperative discussion. Both patient and spouse may be reluctant to ask questions about sexual dysfunction, in spite of their great concern. Increasing opportunity for cured patients to help others with the same disease has proven of mutual advantage. The person who has survived can offer unique hope and information to the patient going through the early phases of illness, while gaining emotional strength and mastery through helping others. Patients who have experienced mastectomies, laryngectomies, and colostomies have been particularly effective as volunteers. The increasing willingness of cured patients to acknowledge rather than hide the fact that they have had cancer is serving to diminish the pessimism about outcome, since previously individuals heard only of those who died of cancer. An attempt at cure is followed by a period of increasing hope, but anyone who has had cancer lives with a disquieting concern about the future. This important aspect of "living with cancer" and the "uncertainty of its outcome" has received less emphasis than "dying with cancer." Attempt at Cure Followed by Recurrent Disease Diagnosis of recurrent disease requires new adjustment. The threat to life cannot be denied. Insomnia, anorexia, restlessness, anxiety, and irritability may again occur, lasting for several days, as at the time of
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initial diagnosis; they may be more severe. The physician must explain the new development and outline a revised plan of treatment. He should convey continuing commitment to the patient's care through this new stage of disease, never taking away hope, while allowing opportunity for questions about the future, including the possibility of a fatal outcome. The day-to-day emotional state of the person with recurrent or metastatic cancer depends to a large measure on the presence of physical symptoms and the level of pain and discomfort. A cheerful outlook with optimism is easier when the patient feels well; the converse is readily apparent. Interpersonal relationships take on increased meaning, both with family and with medical personnel as well. Patients with advanced cancer expressed a need for increased physical closeness and affection from spouses in one study.12 Critically ill patients, irrespective of type of disease, as opposed to noncritically ill or healthy individuals, expressed more affection for others and wanted more affection and closeness from others.23 This information suggests that maximal and as nearly normal contact with family be maintained by keeping the patient at home as much as possible, and by developing more hotel-related facilities near hospitals which allow the patients to live with family, coming to clinics for radiotherapy and chemotherapy as needed. Understanding of the patient's heightened emotional ties to the physician and hospital staff and the attempt with advancing illness is clarified to be a "good" patient by recognizing the increased importance to these patients of the doctor-patient relationship. It also serves to emphasize the value of continuity of care by physician and hospital or clinic staff. When suicide does occur in a cancer patient, studies suggest that it occurs more often late than early in the clinical course, and is apt to occur in a person who gives danger signals of poorer psychological resources and less ability to adjust to illness. la The frequency of passive suicide remains unknown, since failure to cooperate in treatment may at times be an expression of a deliberate death wish. "Giving up" and "losing the will to live" are hard to assess since they occur temporally with advancing disease and may be the consequence rather than cause of advancing disease. Care of many patients with advanced and terminal disease places a psychological burden upon the responsible physician and nursing staffin a hospital or clinic. The frequent decisions about utilizing life-sustaining procedures and problems around care of difficult patients can lead to emotional distress in staff members, and cause friction among staff that diminishes the ability to give optimal medical care. Weekly meetings of staff led by a psychiatrist who works regularly with the group which focus on psychosocial problems of patients which have arisen in daily encounters are advantageous. 22 Anger or frustration aroused by care of certain patients can be controlled better when the reason for the patient's behavior and staff's response are clear. Psychological management of cancer patients and knowledge of the psychosocial issues in their care are increasingly becoming recognized as a necessary part of total training in oncology.I,18 Weekly seminars for Oncology Fellows and nurses, and meetings of families and patients are being instituted more commonly and appear helpful.
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Despite the general acceptance that prolonging dying is not ethically equivalent to prolonging meaningful life, decisions about selectively limited life-supportive measures are difficult ones, made with considerable deliberation, and often made alone by the physician who feels he can neither share nor discuss the decision with staff or family. A more open approach to this problem has been taken by formation of an Optimum Care Committee for hopelessly ill patients at the Massachusetts General Hospital.1 6 Beth Israel Hospital in Boston has carefully elucidated principles for "orders not to resuscitate. "17 Open discussion and development of stated policies concerning matters long kept hidden from public view is a recent and laudatory change.
PSYCHOLOGICAL EFFECTS OF TREATMENT Both radiotherapy and chemotherapy in cancer demand a high level of cooperation from patients. Careful descriptions of the treatment itself, the desired response, and the side-effects that must be tolerated to achieve the antitumor effect are required. Knowing that a side-effect may occur often makes it easier to accept when it does. The dictum that telling a patient the possible side-effects makes him more likely to complain of them is fallacious. A nurse or social worker familiar with the treatment should be available to reinforce and elaborate the physician's instructions, giving consistent support during treatment that often extends over months. They should be accessible by telephone and for longer discussions at times in clinic. Chemotherapy produces regular, anticipated periods of up to several days of significant illness from side-effects. Distressing symptoms with psychological consequences are nausea and vomiting, central nervous system effects, alopecia, generalized fatigue and weakness, and disruption of work, home, or school routines. NAUSEA AND VOMITING. Nausea and vomiting is significant during treatment with certain of the antineoplastic agents: cytoxan, CCNU derivatives, Adriamycin, MOPP regimen, platinum compounds, and actinomycin D. These antitumor agents are thought to activate the chemoreceptor trigger zones around the fourth ventricle-the antiemetic agents act by diminishing impulses reaching those areas. 2 Phenothiazines, particularly prochlorperazine (Compazine), are the most commonly used antiemetic drugs. Any antiemetic agent should be started 8 to 24 hours before the patient comes to the hospital or clinic for drug infusion. The mild sedating, antianxiety eff~ct also diminishes the conditioning which leads some patients to begin to vomit in anticipation of the treatment, especially with drugs that cause severe emesis, such as the platinum compounds. Ll-9- Tetrahydrocannabinol (THC), the active component of marijuana, had a remarkably better antiemetic effect given orally than placebo in a controlled study.20 It is receiving additional clinical trials. Reassurance, understanding and counseling by a nurse or physician present each time still constitute the most important support during treatment. Psychological techniques should be explored to attempt better con-
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trol of the anticipatory anxiety seen in some patients in whom nausea and vomiting is stimulated long before receiving the drug. NEUROTOXIC EFFECTS. Several drugs exert significant side-effects on the central nervous system, producing neurologic and mental symptoms. Patients not only fear the neurotoxic effect but they become concerned that the dysfunction may be permanent. The primary agents with these side-effects are L-Asparaginase, 5-fluorouracil, intrathecal methotrexate, procarbazine and vincristine/vinblastine. 24 L-Asparaginase produces mental changes of confusion, delirium, electroencephalographic slowing and depression, probably because of impaired protein synthesis. Mental changes were noted in 26 per cent of adult patients treated in one series. 7 5-Fluorouracilless often produces central nervous system side-effects, though cerebellar dysfunction with ataxia, dysarthria, and dizziness develops in some patients. Methotrexate does not cross the blood-brain barrier but, when given intrathecally, may produce a meningioencephalopathy with focal signs of meningeal irritation, paraparesis, and mental confusion. Procarbazine, used in treatment of Hodgkins's disease and lymphomas, acts as a monoamine oxidase inhibitor. It often produces significant peripheral neuropathy and altered level of consciousness, which may vary from drowsiness to coma. At times discontinuation of the drug is required. Vincristine and vinblastine produce a range of central nervous system dysfunctions: autonomic effects (producing constipation, gastrointestinal cramps, and impotence), seizures, altered mental function, and cranial nerve palsy. These neurotoxic side-effects are largely reversible, but cause major disruption in function for the patient during treatment. Corticosteroids, frequently employed as a part of chemotherapeutic regimens, produce distressing side-effects of moon face, acne, hyperphagia, obese habitus, overactivity, and insomnia. While producing euphoria or even hypomania early in their use, lability of emotion, depression, and steroid-induced psychosis may develop. Psychological disturbances may occur at any dosage of medication or on abrupt withdrawal. A psychotic reaction usually abates with lowering of the dose, but may continue and require psychiatric treatment. ALOPECIA. Loss of hair, on both body and scalp, is a common sideeffect of most chemotherapeutic agents. Total baldness is particularly distressing for those to whom appearance is most important: women, adolescents, and young adults of both sexes. Teenagers, who need to look like peers and to whom ridicule and admission of disease are frightening, have difficulty adjusting to this side-effect. The physician must explain, at the outset of treatment, the likelihood that the alopecia may occur, and suggest that a wig be obtained, and worn, before the hair loss occurs. Preparation for the loss and reassurance that it is temporary are important to psychological support. WEAKNESS AND FATIGUE. Fatigue and weakness, which occur with some antitumor agents, lead to absences and difficulty in maintaining performance at work and at school, adding to social stress. Altered work schedules are best tolerated in the context that they are temporary and, in the long run, are worth the gains in disease control and survival.
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IMMUNOTHERAPY. While still limited to use in cancer centers, immunotherapy is increasingly being used as an adjunctive therapy to surgery and chemotherapy. Adjustment is sometimes difficult when patients get extensive, red, painful lesions in response to the antigen given by multiple skin scratches. Lesions are uncomfortable, difficult to explain to others, and some patients may need considerable encouragement to adhere to a regimen over months.
Protected Environments Optimal chemotherapy for some sites of cancer requires substantial marrow depression and thus a significant risk of infection. Reverse isolation is often used, and more recently, plastic laminar air flow rooms have been used to decrease risk of infection. While therapeutically useful, the rooms enforce complete physical isolation of the patient from others. The isolation is psychologically tolerable for most, but some isolated patients complain about the loneliness and feeling of distance evoked by the fact that they cannot touch or be touched directly by another person. 8 PSYCHIATRIC SYNDROMES IN THE COURSE OF CANCER There are several significant psychiatric syndromes which may develop in the course of clinical cancer and its treatment. These fell within major areas: (1) central nervous system dysfunction associated with cancer and its treatment; (2) concurrent or complicating psychiatric illness; (3) serious emotional disturbance in response to illness, medical management, or faInily problems; (4) occurrence of anxiety, agitation, depression or suicidal risk. Diagnosis, management, use of psychopharmacologic drugs, and indication for consultation are outlined. Central Nervous System Dysfunction There are a number of related terms which are used interchangeably with organic mental changes: delirium, confusion, acute brain syndrome, and metabolic encephalopathy. Delirium is a broad term used for any syndrome of disturbed sensation, perception, memory, thought, or judgment as a result of altered cerebral functioning. 5 The presence of an acute mental disturbance or sudden personality change in a previously emotionally healthy individual who has cancer is most likely secondary to cerebral dysfunction related to disease or its treatment. Onset of a psychotic illness such as schizophrenia in a person without prior psychiatric history is infrequent, even under the emotional stress of cancer. An organic etiology should be suspected if visual or auditory hallucinations, a variable degree of disorientation, or transient confusion or somnolence are present. Careful work-up of the patient, utilizing history, physical and neurologic examination, and laboratory data including spinal fluid examination may be necessary to establish the cause. Diffuse slowing of the encephalogram is confirmatory evidence. Central nervous system dysfunction may occur from several causes
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in cancer. Direct effects occur by local extension of cancer, infiltration of brain or meninges in hematologic neoplasm, and by metastatic spread. Brain metastases are more common with cancer of certain sites, particularly lung and breast. Indirect nonmetastatic effects of cencer on the central nervous system are less well understood. Subacute cerebellar degeneration has been observed primarily with carcinoma of lung, ovary, and breast. Ataxia, dysarthria, impaired intellectual function, and memory develop over a period of weeks to months and may appear before discovery of the neoplasm. Increase in lymphocytes and protein occur in the cerebrospinal fluid in most cases. Two types of encephalopathy or encephalitis associated with carcinoma have been described: encephalitis observed by Corsellis prirrarily in patients with lung cancer and progressive multifocal leukoencephalopathy which occurs primarily as a complication of neoplastic disease of the lymphatic and reticuloendothelial systems. Progressive multifocalleukoencephalopathy is thought to be causeC! by an otherwise nonpathogenic virus in human beings associated with impaired immunosurveillance. 19 Both syndromes produce significant dementia and, though rare, should be considered in the patient with cancer who experiences memory and cognitive defects without sign of metastatic disease. Other common causes of delirium in cancer are bleeding resulting in cerebral anemia, hypovolemia, and circulatory impairment, metabolic derangements from fluid and electrolyte imbalance, hypoglycemia, hypercalcemia, liver failure, and kidney failure. Mild change in mental function often occurs prior to altered physical findings or change in laboratory data, particularly in occult bleeding or metabolic disequilibrium. As such, the presence of delirium in the cancer patient deserves immediate and careful work-up. Concurrent Psychiatric Illness
A patient who has had a prior history of psychiatric illness may experience an exacerbation of mental symptoms in the course of cancer. A major psychiatric illness, such as a schizophrenic episode, manicdepressive illness, or psychotic depression should be treated as a concurrent illness and is cause for psychiatric consultation and management. Serious Disturbance in Relation to Illness Some patients may, by personality or ways of coping with stress, be unable to adapt to illness, treatment, or rehabilitation, attaining less than optimal results from treatment that requires a high level of cooperation and participation. A hostile attitude, excessive dependency, manipulative behavior, or excessive demands for attention may compromise care and require psychiatric consultation. Each problem demands evaluation and a plan for management. The "psychological invalid" who cannot give up dependence acquired through illness occurs in cancer as in other diseases. The anxious patient may require consultation for demoralizing anxiety about repeated venipuncture, bone marrow aspirations, or uncomfortable wound dressings.
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Management of Anxiety, Agitation, Depression, or Suicidal Risk Management of a patient who becomes irrational, agitated, suicidal, or violent may sometimes require immediate control to prevent injury to the patient or others, and to prevent exhaustion. This picture most often occurs in a delirious state. Careful assessment of etiology is necessary, but control of behavior must sometimes be rapidly effected. Diazepam (Valium) is quickly effective, by either intramuscular or intravenous routes and is safer than barbiturates. Intravenous diazepam, 5 to 10 mg, has rapid effect and few side-effects, though resuscitation equipment should be available. Haloperidol, a butyrophenone, controls agitated behavior effectively in intramuscular injection of 0.5 to 1.0 mg. Action is rapid and when control is effected, the liquid concentrate can be substituted for longer term control, with dosage in about the same range. Agitation which is less acute should be controlled by oral use of a major tranquilizer. Trifluoperazine (Stelazine), 1 to 2 mg twice a day, is safe, even in older individuals, and often reduces confusion on the basis of central nervous system dysfunction. Thiorid~zine (Mellaril), 25 to 100 mg per day, is also effective. It should be kept in mind that both drugs lower the seizure threshold. Sedative-hypnotics may exacerbate delirium and should be avoided.
Psychopharmacologic Drug Use Caution should be exercised in prescribing any psychotropic drug until the etiology of a mental symptom is clear. The drug may mask symptoms of a developing organic brain syndrome, which is best treated by identifying and addressing the underlying cause. Pain, a critical problem in treatment of cancer, can be markedly enhanced by fear, anxiety, and depressed mood. Phenothiazines are useful adjuncts to control of pain, in diminishing the component related to emotional distress. Psychotropic drugs useful in cancer are divided by their major actions: sedative-hypnotics, antidepressants, and antipsychotic agents. SEDATIVE-HYPNOTICS. This group of drugs are central nervous system depressants which, in low doses, serve to diminish anxiety, and in high doses produce sleep.3 Daytime Sedation. Antianxiety drugs and minor tranquilizers are useful in the patient who is excessively anxious during medical work-up, when anticipation of uncomfortable laboratory procedures is present, and during the crises in which the course of disease is uncertain or altered. While widely used, controlled studies of actual effectiveness in physically ill patients, particularly cancer, have not been done. Benzodiazepines appear to be least habituating and are more specifically antianxiety in their effect, producing least drowsiness. Diazepam (Valium) in doses from 5 to 40 mg per day is effective in most individuals. Chlordiazepoxide (Librium) may be given in doses of 10 to 100 mg per day. Both are slowly metabolized and accumulation of active products may occur over several days. Diazepam may appear to have short actiol1 because of its lipid-solubility and rapid tissue-uptake but this is a false impression and caution should be used in increasing dose. 3
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Diazepam, 5 to 10 mg intravenous or intramuscularly, is an effective and safe premedication for the anxious patient prior to procedures such as bone marrow aspiration, sigmoidoscopy, or biopsy. Barbiturates, propanediols, and antihistamines are not recommended over benzodiazepines. Only in the presence of a concurrent psychiatric syndrome or incapacitating anxiety which presents with tachycardia, sweating, palpitation and agitation, would a betaadrenergic blocking agent be considered. Bedtime Sedation. The benzodiazepine derivative, flurazepam, has no potentiating effects upon other drugs, does not depress respiration, and has no significant effect upon REM sleep at a dose of 30 mg. These are distinct advantages over barbiturates which depress REM sleep, respiration, leave a morning "hangover," and are potent enzyme inducers, due to stimulation of the activity of liver microsomal drugmetabolizing enzymes. 3 Anticoagulants may require higher dosage to be effective when barbiturates are given. Since overdoses of barbiturates are extremely dangerous, caution should be exercised in giving large amounts to the patient with cancer who appears significantly depressed. Tuinol which contains 25 mg of secobarbital (short acting) and amobarbitallOO mg (intermediate range) is particularly hazardous in overdose. When a barbiturate is required, 100 mg of secobarbital or pentobarbital is effective and can be increased to 200 mg. Chloral hydrate is commonly used and is effective at a 1 to 2 gm dose at bedtime. It is detoxified to trichlorethanol, which is bound to protein. Potentiation of anticoagulants may thus occur. In addition, gastric irritation may occur. Glutethimide, because of its high lipid solubility, and strong respiratory depressant effect, has no advantage and is highly dangerous in overdose. ANTIDEPRESSANTS. Reaction to life-threatening illness, such as cancer, often produces a depressed mood. A realistic appraisal of altered function and outlook lead to anxiety, dysphoria, and a normal grieving for threatened potential losses. Antidepressants are less effective in these patients, and emotional support and reassurance are more effective. When, however, significant depression interferes with medical care in the patient with cancer, antidepressant therapy should be considered in consultation with a psychiatrist. The more nearly the depression resembles an endogenous (as opposed to reactive) illness, the more likely is drug therapy to be effective. Tricyclic antidepressants contain two major groups: dibenzazepine derivatives (imipramine and desipramine) and the dibenzocycloheptadiene derivatives (amitriptyline, nortriptyline, protriptyline). Amitriptyline has an additional sedative effect and may be given at bedtime in place of a hypnotic. A dosage of 50 mg at bedtime and 25 mg during the day can be increased to 150 mg per day over a week. Imipramine should be given in divided daytime doses beginning at 75 mg per day. All tricyclics often tend to be given in low and ineffective dosage. They have a cumulative effect and require 7 to 10 days to demonstrate any change in mood. Anticholinergic effects contraindicate their use in intestinal obstruction, glaucoma, and prostatic disease.
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Monoamine oxidase inhibitors should seldom be considered in the patient with cancer due to serious adverse side effects. In depressions which threaten life and compromise care during cancer, electroshock should be considered, given with anesthesia and succinylcholine to modify the seizure.
Management of the Family The family member closest to the patient-the spouse, parent, or child-usually bears the strain of illness with the patient. The family member needs open and honest communication with both the physician and the patient. The illness often increases family solidarity and appreciation, sometimes with increased pleasure in the commonplace of home life. Barriers to communication characterized by the patient "not letting the family know he knows" or the family "not letting the patient know they know" the diagnosis and outcome should be slowly removed. A conspiracy of silence has little consoling value at this time and increases the isolation of the patient from those he needs most. Family conflicts which distress the patient and which may cause guilt later in the survivors should be clarified when possible. The family's investment in the doctor as the one person who controls the fate of the loved one puts a strain on the relationship that can lead to difficulties and misunderstandings. The spouse may be irritable and critical of the medical care, which the physician must understand as a response to anxiety rather than the personal attack he feels. The response to news of death of the relative is tempered at times with relief and the rationalization that "I'm glad he doesn't have to suffer any more." The closest relative should have the opportunity to see the physician again a few weeks after the death to ask questions and to review details of the patient's illness and autopsy. They sometimes wish to discuss guilt for some action felt to have contributed to discomfort or earlier death of the patient. The opportunity to share the loss with the doctor who knew and respected the patient during the final illness becomes helpful in resolving the grief. A note to the survivor months after the loss, reflects continuing interest on the part of the staff for the family, reminding the relative that the patient has not been forgotton as just "another case."
SUMMARY The patient with cancer presents the physician with challenging psychological issues: maintenance of an effective and understanding physician-patient relationship, in the context of optimal medical care, and alertness to signs of significant psychologic symptoms that may occur more commonly in the course of cancer. The closest relative, also under great emotional stress, must be considered in communications about the patient's clinical state and treatment. Psychological aspects of oncology are a demanding component of total care of the cancer patient, yet an integral part of optimal cancer care.
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