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Psycho-Oncology
and Palliative Care:
Potential Contributions
Jimmie C. Holland, M.D.
Founding President,
International Psycho-Oncology Society
Attending Psychiatrist, Psychiatry& Behavioral Sciences
Memorial Sloan-Kettering Cancer Center
PSYCHO-ONCOLOGY Definition
• Multidisciplinary subspecialty of oncology
concerned with the emotional responses
of patients at all stages of disease, their
families and staff (psychosocial)
• The psychological, social and behavioral
variables that influence cancer prevention,
risk and survival (cancer control)
HISTORICAL BARRIERS – 1
Double Stigma
• Patients not told their diagnosis and
psychological responses could not
be explored
• Mental disorders/illness long feared
and stigmatized
HISTORICAL BARRIERS – 2
• Belief that subjective phenomena (pain,
feelings) could not be quantitatively
measured
• Patient’s self-report was considered
unreliable (only observer ratings
reliable)
• Social science methods were not
understood by basic scientists
Basic to Psycho-Oncology Research
• Developed and validated quantitative
measures of subjective symptoms
• QOL
Core and disease
specific modules
• Pain
• Fatigue
•
•
•
•
Distress
Anxiety
Depression
Delirium
Barriers to Psych-Oncology
Issues in Palliative Care
• Attitudes of medical staff that assume the
“nonphysical” psychological domain as less
important
• Attitudes of patients and family: “Think I’m
crazy”: embarrassed, angry by mental health
consultation
• Attitudes may discourage integration of mental
health member of palliative care team
Barriers to Psych-Oncology
Issues in Palliative Care
• Absence of training of palliative care team in
recognition, diagnosis and management of
distress and absence of an algorithm when to
refer to mental health
• Inadequate funding for mental health counselors
as compared to medical
• Absence of minimum standards and accountability
for psychological, social care and for meeting
existential, spiritual needs
Barriers to Psych-Oncology
Issues in Palliative Care
• Inadequate numbers of well-trained
mental health professionals in
psychosocial care
• Too few training programs
• Absence of oversight of staff in
management of psychosocial/
psychiatric problems
Advanced Cancer Requires
Coping With
• Physical symptoms (pain, fatigue)
• Psychological (fears, sadness)
• Social (family, future)
• Spiritual – seeking a comforting
philosophical, religious, or
spiritual beliefs
• Existential – seeking meaning of life
in the face of death
EXISTENTIAL CRISES IN CANCER
DIAGNOSIS
OF
CANCER
COMPLETION
OF
TREATMENT
INITIAL
TREATMENT
“I could
die from
this.”
RECURRENCE
OF
DISEASE
N.E.D.
“I have
survived -will it
Return?”
ADVANCING
DISEASE;
DNR; HOSPICE
PALLIATIVE
TREATMENT
“I will
likely die” -depressed;
anxious
DEATH
TERMINAL
“I am
dying.”
Adapted from McCormick & Conley, 1995
“We are not ourselves when nature,
being oppressed, commands the
mind to suffer with the body”
King Lear, Act II, Sc. IV, L 116-119
What to call this constellation of non
physical aspects of severe illness?
“Suffering of the mind”
“Existential crisis”
“Human side”
Overlapping psychological and spiritual
domains: psychospiritual crisis
Psychospiritual Crisis of ILLNESS
• Loss of meaning
• Loss of control (helpless)
• Need for connection to some larger
whole, greater than self
J. Kass, 1996
Spiritual and Religious
Beliefs Provide
• A way of coping and feeling in control despite
the uncertainty, treat of death, the unknown,
and loss
• A set of moral values
• Comforting rituals (prayer, mediation)
• An existential perspective (meaning of life,
death, connection to greater whole)
• Support (emotional and tangible) of those who
share similar beliefs
DISTRESS in Cancer
An unpleasant emotional experience of
a psychological, social and/or spiritual
nature which extends on a continuum
from normal feelings of vulnerability,
sadness and fears to disabling
problems such as depression, anxiety,
panic, social isolation and spiritual
crisis.
Adapted, NCCN
Contributions to Care - 1
• Psychological interventions unique for
palliative care
Meaning-centered therapies
 Frankl Meaning-Based
Breitbart
 Dignity-Conserving
Chochinov
 Meaning-Folkman
Holland
Folkman-based Psychotherapy
• Help patient reconcile life goals and
plans with constraints of illness
and loss
• Use beliefs, values, prior strengths,
to find a new and tolerable meaning
of life in the face of death
Contributions to Care - 2
• Concern for family members
 Identifying their concerns
Conflict, needs (distress levels are
as high as patients)
 Evaluation of minor children-guidance
in how to talk to them
 Grief counseling for family
Contributions to Care - 3
• Education of staff and patients that
seeking treatment for psychological
problems is not a sign of weakness
• Advocate as a team member to
psychosocial and “human” side of
care
Treatment Guidelines for
Mental Health Professionals
DSM-IV Diagnoses
Dementia
Delirium
Mood disorder (depression)
Adjustment disorder
(reactive anxiety/depression)
Anxiety disorder
Substance abuse
Personality disorder
Treatment Guidelines for
Social Work
Practical Problems
housing, assistance
Psychosocial Problems
family conflict
communication
culture/language
Treatment Guidelines for
Pastoral Counseling
Death/afterlife
Loss of faith/meaning
Grief
Isolation from religious community
Guilt
Hopelessness
• NCCN Clinical Practice Guidelines for
distress have been modified for end-oflife care – they should be tested in a
clinical setting
Holland & Chertkov, 2001
IOM Improving Palliative-Care
Contributions to Care – Burnout
Mental health of Staff
• Physicians’ acknowledged feelings
(anger, frustration, depression)
• Affect
Clinical decisions
Behavior with patients
Quality of care
Risk of burnout
Meier et al, 2002
Common Burnout Symptoms
PSYCHOLOGICAL
Frustration
Irritability
Tense, sad feeling
Anger
Withdrawn; “Numb”
Detached emotionally
Cynical about work
PHYSICAL
Fatigue
Insomnia
Headaches
Back aches
Appetite change
GI disturbance
UK Study 476 Oncologists
Burnout
Emotional exhaustion
31%
Low personal Accomplish 33%
Diminished Empathy
23%
Psychiatric Disorder (GHI)
28%
Ramirez et al, BMJ, 1995
Research Directions - 1
• Pro inflammatory cytokines as cause
for fatigue, poor concentration,
depression, anxiety
(↑ in pancreatic patients)
Research Directions - 2
• Cytokine-induced
Sickness behavior in animals
• Several cancer-related symptoms
• Fatigue
• Pain
• Anxiety
• Depression
• Cognitive loss
• Weakness
Research Directions - 3
C. Cleeland, et al, Cancer, 2003, Working Group
Research Directions - 4
• Genetic contributions to chemorelated cognitive deficit
APOE4 allele
• Fatigue (DYPD over expression)
“….the secret of the care of the
patient is in caring for the
patient.”
Peabody, JAMA
1926
IPOS Liaison to National
Psycho-Oncology Societies
[email protected]
www.apos-society.org
8th WORLD CONGRESS
PSYCHO-ONCOLOGY
"Multidisciplinary Psychosocial Oncology:
Dialogue and Interaction"
18 - 21 October 2006
Palazzo del Cinema
Venice, Italy
Details will continue to be posted on the conference website at
www.ipos2006.it