Lecture
Karavaeva T.A.
Among comorbid mental disorders in patients with oncological pathology, the most frequently diagnosed are anxiety disorders at the neurotic level, among which the leading positions are held by phobic anxiety, panic, and generalized anxiety disorders [4,10,17].
Phobic anxiety disorders (F40) – a group of disorders in
whose clinical picture there predominates a fear of certain situations or objects (external to the subject). As a result, the patient avoids such situations or endures them while overcoming a feeling of fear. It must be emphasized that phobic anxiety physiologically and behaviorally does not differ from other types of anxiety; it may vary in intensity from mild discomfort to terror; it is not reduced by the awareness that other people do not consider the given situation to be so dangerous or threatening; even the very idea of finding oneself in the phobic situation usually provokes anticipatory anxiety [5, 20]. Among oncological patients, such persistent phobias frequently develop as fear of death, fear of pain, fear of medical procedures and antitumor treatment, fear of being alone, dysmorphophobia (fear of deformity), agoraphobia, and social phobia. Phobic anxiety and depression in these patients often arise simultaneously. The decision to establish two diagnoses (phobic anxiety disorder and depressive episode) or only one is made taking into account the degree to which one disorder predominates over the other, as well as the sequence of their emergence.
Among the most frequent types of phobic anxiety disorders in patients with oncological diseases is thanatophobia (fear of death). This is a fairly well-delineated group of phobias, including
the fear of dying, of becoming helpless because of the illness, of being alone at the moment of death, of experiencing agonizing suffering, of pain, and of the very process of dying [19].
Another frequent form of phobic anxiety disorder in patients with neoplasms is social phobias, which represent one of the forms of impaired interpersonal interaction. The fear of attention from other people, the worry that those around them, upon learning of the illness, will turn away, will cease to communicate, will shun them, will consider them hopeless, is accompanied in parallel by resentment toward loved ones for their well-being, heightened demandingness toward them, and sometimes a manipulative attitude.
A patient with an oncological disease who strives to conceal his ailment is afraid of attention from those around him and is fixated on this. Even in situations where other people objectively pay him no negative attention, it seems to him that all eyes are fixed on him and that the assessment of his behavior or appearance is exclusively negative, contemptuous, or mocking. It seems to the patient that his diseased state is noticeable to those around him, and this intensifies the anxiety; a vicious circle arises. Against the background of anxious experiences, autonomic symptoms arise that further aggravate the patient's condition. Frequent symptoms are reddening of the face, trembling of the hands and voice. Among the symptoms, nausea, fear of vomiting, and urges toward or fear of urination or defecation are also noted. The fear may be isolated (for example, only the fear of eating in the presence of others because of the fear of nausea, vomiting, or encounters with a certain circle of acquaintances or colleagues) or diffuse, encompassing almost all social situations outside the family circle. Clearly, in such a case a substantial impairment of social functioning arises in the patient with an oncological disease. In the most pronounced manifestations, social isolation develops. The appearance of anxiety symptoms arises not only in situations
that provoke fear, or when thinking about them. Usually the fear is preceded by low self-esteem and a fear of criticism, of pity, and of a condescending attitude from those around [19].
As the third large group of phobic anxiety disorders
in patients with an oncological profile, specific (isolated) phobias are distinguished – a psychopathological disorder characterized by the presence of fear regarding a particular object or action. Often the fear is associated with a specific object that is the cause of real or presumed danger. The role of the trigger mechanism in a specific phobia is played by an isolated situation; finding oneself in it may provoke terror, panic. At the moment of fear, vivid autonomic manifestations are noted. Accordingly, a pronounced avoidance of such situations develops. It must be noted that the fear is irrational in nature and its strength does not correspond to the real danger of the object or situation. A significant emotional disturbance is determined either because of the symptoms or because of the striving to avoid situations, together with an awareness that they are excessive or unfounded. The objects of fear sometimes appear in anxious, nightmarish dreams. A distinction is made between fear of an object (for example, a doctor associated with the treatment of the neoplasm) and fear of a particular situation (for example, surgery and the postoperative period, chemotherapy, radiation treatment, invasive examination, being in the hospital, vomiting, involuntary urination or defecation, the sight of blood, etc.) with the need to avoid them. The reduction of adaptation depends on the extent to which the patient can avoid the phobic situation.
Panic disorder (episodic paroxysmal anxiety) (F41.0) – one of the most widespread borderline mental illnesses, characterized by recurrent attacks of sharply pronounced anxiety (panic) not directly connected with any specific situations or objects and therefore unpredictable and spontaneous. At their basis lies a breakdown of autonomic
regulation, most often provoked by prolonged mental strain, a decrease in the body's tolerance to emotional and physical load, and a situation of chronic stress connected with the course and treatment of the oncological disease. It must be emphasized that panic attacks: are not connected with the manifestation of danger or threat; are not confined to a known, predictable situation; arise under circumstances that do not provoke objective anxiety; have no aura before onset; are interspersed with anxiety-free periods between attacks; are not a consequence of direct physiological effects mediated by the action of any substances (for example, medicinal or narcotic) [2, 6, 15].
In the structure of the anxiety syndrome, 3 main components are distinguished:
directly subjective experiences, i.e. the symptom of anxiety in its proper sense;
fear of anticipating the attack, avoidance behavior;
autonomic disturbances – «autonomic crises»; more often sympathicotonic, less often mixed and vagoinsular [15, 22].
Typical clinical picture of an attack of the anxiety syndrome:
A characteristic onset with symptoms from the cardiovascular system – with a suddenly begun «strong heartbeat», a sensation of «skipped beats», «stoppage», discomfort or pain in the region of the heart. Most panic attacks are accompanied by a rise in arterial pressure, the figures of which may be quite significant.
The most pronounced disturbances are in the respiratory system: labored breathing, a feeling of lack of air with shortness of breath and hyperventilation, a «feeling of suffocation» [11, 18]. Describing the attack, patients report that «the throat seized up», «air stopped coming in», «it became stuffy». It is precisely these sensations that compel the patient to open windows and the balcony, to seek «fresh air» .
Less often, gastrointestinal disturbances are observed, such as nausea, vomiting, belching, unpleasant sensations in the epigastrium.
As a rule, at the moment of the crisis, dizziness, sweating, tremor with a feeling of chills, «waves» of heat and cold, paresthesias, and coldness of the hands and feet are observed.
In the concluding stage of the attack, polyuria or frequent loose stools are observed.
Objectively, a change in the color of the face, in the pulse rate, and fluctuations in blood pressure are determined, and a dissociation is not infrequently found between patients' subjective registration of autonomic disturbances and their severity on objective examination.
Patients with neoplasms not infrequently consider the autonomic disturbances accompanying the panic state to be a manifestation of the oncological disease and do not connect the episodes of panic with disturbances of the mental sphere.
Course of panic disorder
As it progresses, in «classic» cases a certain dynamic of panic disorder is characteristic, which usually passes through certain stages.
Stages of panic disorder:
symptomatically poor attacks;
full-blown panic attacks,
hypochondria,
limited phobic avoidance,
extensive phobic avoidance,
secondary depression.
As the panic attacks continue, they may become linked with various life circumstances, which come to act as, so to speak, conditioned phobic stimuli. Thus, panic attacks in oncological patients, once they have arisen, tend to become entrenched and
recur in similar situations (a medical facility, undergoing examination, public transport, etc.). Patients develop apprehensions about the possibility of the attacks recurring (anticipatory anxiety). Not infrequently, a persistent feeling of fear forms already after the first paroxysm and concerns the situation in which it arose (the hospital, the metro). If a patient with a tumor has an attack at home, while alone, a fear of remaining home alone often appears. This contributes to the formation of a special regimen of protective behavior, so-called avoidance behavior or phobic behavior [4, 15].
Generalized anxiety disorder (F 41.1) –
widespread and persistent anxiety and tension not confined to or predominantly provoked by any particular situations («free-floating anxiety»). Arising frequently against a background of initially high personal trait anxiety, reinforced by the very fact of the oncological pathology being established, the intensity and persistence of the anxious experiences may thereafter not depend on physical well-being, on the character of the treatment, or on the prognosis of the underlying disease. Patients are characterized by constant pessimistic thoughts, the expectation of an unsuccessful, catastrophic development of events, anxiety over trifles, negative cognitive distortions, an inability to make use of positive reinforcing stimuli; the greater part of the experiences are substantively connected with the oncological disease, the fear of death, existential problems, and impairment of social functioning [3, 7].
The disease is characterized by a chronic or recurrent course and may lead to pronounced maladjustment and increased suicidal risk, the danger of which is in any case characteristic of patients with oncological diseases. It must be emphasized that the anxiety lasts at least 6 months; encompasses various aspects of the patient's life, circumstances, and types of activity; is directed predominantly toward
upcoming events; is not amenable to control, it cannot be suppressed by an effort of will or by rational persuasion; it is disproportionate to the patient's actual life situation; is not infrequently accompanied by experiences of a feeling of guilt, which often lies at the basis of suicidal thoughts and behavior [7, 12].
The clinical picture is represented predominantly by 3 characteristic groups of symptoms of generalized anxiety disorder. First of all, these are emotional and affective disturbances (psychic symptoms) – worry and apprehensions that the patient finds difficult to control and that last longer than usual.
The second group of symptoms includes motor tension, which may be expressed in muscular tension, tremor, inability to relax, headache (usually bilateral and often in the frontal and occipital regions), aching muscular pains, rigidity of the muscles, especially the muscles of the back and shoulder region.
The third group of symptoms is represented by hyperactivity of the autonomic nervous system, which is expressed by increased sweating, tachycardia, dryness of the mouth, discomfort in the epigastrium and dizziness, and other symptoms of autonomic arousal [11, 16, 18].
The importance of correct and timely diagnosis of this pathology and of the choice of an adequate therapeutic strategy is determined not only by medical, clinical aspects, but also by the features of the social consequences of generalized anxiety disorder in oncological patients. Compared with other diseases of the anxiety spectrum, substantial maladjusting states are more often revealed that disrupt all spheres of the patient's life, sometimes to the point of paradoxical, autoaggressive behavior – refusal of treatment for the oncological disease, serious impairments of social functioning, avoidance of communication with relatives up to complete isolation, self-harming or
suicidal behavior [8, 16, 23]. Patients are characterized by dissatisfaction with life and an awareness of catastrophic distress, comparable to the changes revealed in major (endogenous) depression; not infrequently a feeling of guilt, helplessness, and the meaninglessness of existence is joined to this. A significant decrease in quality of life is noted (to a considerably greater degree than could be conditioned by the course and prognosis of the oncological pathology) across all indicators of general and somatic health, bodily pain (not connected with the tumor), the sensation of vitality, mental ill-health, and pronounced impairment of role and social functions. All this leads to an increase in the risk of suicidal behavior, which must be taken into account by the specialist who is engaged in the treatment of a patient with an oncological disease and comorbid anxiety disorders [12, 14].
Two types of course of generalized anxiety disorder are distinguished. In the chronic type of course the symptomatology is present constantly and may have either a continuous or an undulating character, when periods of insignificant improvement in well-being are possible, but not to the point of complete restoration of the mental state, of the leveling out of anxiety. The fluctuations in the intensity of the symptomatology's manifestation may either depend on external circumstances and intensify against a background of negative experiences objectively connected with the patient's actual situation (for example, the receipt of positive or negative information about the results of an examination, the prognosis of the oncological disease, therapeutic correction and its side effects), or be unconnected with them and occur spontaneously.
The recurrent course is characterized by periodic periods of satisfactory well-being, which may arise, for example, after psychopharmacotherapy has been carried out. But after various periods of time the anxiety symptomatology returns repeatedly.
Generalized anxiety disorder not infrequently precedes the development of depressive disorders. In these cases it is regarded as the primary disorder with the development of secondary depression [13, 20].
Prolonged hypochondriacal disorder (hypochondriacal phobias) against the background of a somatic disease (F45.2),
is characterized by an exaggerated interpretation of real somatic sensations, the presence of persistent ideas of a serious somatic affliction not corresponding to the real somatic distress caused by the course of the tumor process or its treatment. Patients with a hypochondriacal disorder process the sensations from their own body, in which they are «immersed», whence there arise more or less persistent suppositions of a worsening of the oncological disease, the joining of complications, and recurrence of the tumor. «They often regard as pathological phenomena the natural manifestations of the functioning of the internal organs (they monitor their normal breathing, listen anxiously to their heart, react with alarm to manifestations of abdominal bloating, the quantity of urine passed, etc.). In parallel: preoccupied with imaginary painful manifestations that they have «constructed», the patients ignore the actual threat» and miss real alarming symptoms connected with the oncological disease. In this case there occurs a «displacement from the patient's consciousness of problems and events not connected with the disease, a hypochondriacal detailing of thinking, an extreme concentration on one's own sensations, hypernosognosia, a striving for detailed study of the medical literature on one's disease with a subsequent «testing of the doctor for competence» .
In hypochondriacal phobias, described by A.V. Vasilyeva et al. as a hypochondriacal variant of protracted neurotic states, the clinical picture is dominated by emotionally colored obsessive experiences of fear with a clear plot in the form of a specific nosophobia –
of cancer, of the appearance of metastases, of the occurrence of a recurrence, intensifying in certain situations and connected with somatic distress, which is associated in the patients' representations with death and often begins with a sympatho-adrenal crisis. Criticism is preserved without the formation of the persistent panic anxiety characteristic of process (schizophrenic) diseases. The development of the obsessive fears is conditioned not by the physical suffering itself caused by the tumor, but by the patients' affective processing of this state .
Hypochondriacal dysthymia
In a number of cases, experiences of this kind acquire the picture of «hypochondriacal dysthymia», forming under conditions of the progression of the oncological ailment, which makes it impossible to continue occupational activity (the arrangement of disability status), the curtailment of all types of everyday activity, an increase in the need for medical care, and the developing hospitalism; in persons with various manifestations of a psychosomatic diathesis, development along the type of «hypochondriacal depression» occurs.
In the clinical picture of hypochondriacal depression in oncological diseases, dejection, apathy with passivity, an indifferent attitude toward the surroundings, and sometimes – suicidal thoughts predominate.
Also characteristic are the presence of anxiety with hypochondriacal phobias (fear of the repeated occurrence of the tumor process or of an exacerbation of its course) and agrypnia.
In the content of the depression, signs of demoralization are revealed - an awareness of hopelessness, of the futurelessness of existence, of one's own helplessness.
Asthenic disorders. Neurasthenia (F48.0)
In clinical terms, neurasthenia represents first and foremost a complex of non-psychotic asthenic, emotional-affective, volitional, and
somatovegetative disturbances. Neurasthenia in patients with neoplasms is a psychogenic (in the pathogenetic sense), stressogenic, functional disorder [1, 21].
Hyposthenic and hypersthenic variants of neurasthenia are distinguished, both of which occur in oncological diseases
.
Hyposthenic variant of neurasthenia in oncological diseases
In the hyposthenic variant, the main role is played by biological features of the personality in the form of an initial asthenic constitution, lowering the individual's tolerance even to ordinary average statistical loads, against the background of which the tumor process develops.
The disease begins gradually, and patients find it difficult to draw the boundary between the healthy and the diseased state; more often it precedes the detection of the underlying disease and the establishment of the oncological diagnosis.
Among the psychopathological manifestations, touchiness, sensitivity, tearfulness, helplessness, a feeling of insecurity in oneself and one's own strength, heightened impressionability, and anxiety predominate.
As the disease progresses, the clinical picture becomes more complicated owing to the joining of new symptoms; hypochondria increases. Having begun, the disease more often acquires a continuous and less often – an undulating character.
In the undulating course of the hyposthenic variant of neurasthenia that has developed against the background of neoplasms, even in periods of improvement of the somatic state or the onset of remission, residual symptomatology and a reduced tolerance of loads persist (to a greater degree than is conditioned by the underlying pathological process).
Complaints of an asthenic character come to the fore: increased fatigability, an inability to cope with everyday load, errors in the performance of actions. Breaks in activity do not bring relief and do not contribute to the restoration of strength. Against this background, anxiety symptomatology increases, connected with apprehensions of possible negative consequences of the oncological disease, of one's own inferiority.
The increase of anxiety with the development of dyssomnic disturbances further intensifies the asthenization; autonomic disturbances of both sympathetic and parasympathetic nature are noted, more often in the form of headache connected with an increase in the tone of the muscles of the head and neck, as well as unpleasant sensations in the region of the heart, pulsation of the vessels, and nonspecific gastrointestinal complaints.
Hypersthenic variant of neurasthenia in oncological diseases
In the hypersthenic variant, at the basis lie sthenic, categorical, ambitious personality features, when high achievements and perfectionism in the sphere of activity constitute especially significant components of the system of relationships, which leads to overstrain and disregard of the biological limits of load tolerance.
The main thing in the pathogenesis of neurasthenic disorders becomes the denial of the signaling function of fatigue as a «command» about the necessity of ceasing activity. In response, the individual applies additional volitional efforts, and this leads to affective and intellectual exhaustion. Despite their oncological disease, the limitations it imposes, and medical recommendations, such patients strive to overpower themselves, continue to work through force, strive to engage in sport, and exhaust themselves with excessive physical and mental activity. In doing so,
the real capabilities of the personality and the objective somatic state, altered as a consequence of the oncological process or antitumor treatment, are ignored, which determines the inability to cope with the tasks set while at the same time actively striving to accomplish them.
In the majority of cases, in the hypersthenic variant a subacute or gradual onset of the disease is characteristic; sometimes, however, an acute onset is encountered, which manifests with a sympatho-adrenal crisis against the background of a situation of strain and overwork.
In the undulating course, periods of complication of the symptomatology are noted with more or less prolonged periods of stabilization against the background of a favorable course of the tumor process, when a fixation of the newly arisen secondary symptoms occurs.
With the progression of the underlying disease, the neurasthenic disturbances pass to another level of complication of the clinical picture, which is always connected with a sharp exacerbation of the psychotraumatic situation caused by the oncological disease or with the appearance of a new stressor (e.g., metastasis) threatening the life or social status of the patient.
The neurotic disorder, as a rule, manifests with tension headaches, with sensations of a «stale head». Repeated efforts to overcome one's own capabilities and the struggle with the objective manifestations of the disease cause in patients a disturbance of the sleep-wakefulness rhythm, when excessive activity further aggravates the disturbances of falling asleep.
Sleep becomes superficial, intermittent, with anxious dreams reflecting worry about one's condition, without a feeling of rest in the mornings.
Of the psychopathological asthenic manifestations, coming to the fore
are irritable weakness and emotional lability,
which are manifested by short temper, excitability, aggressiveness, tearfulness, and a feeling of insecurity in oneself and one's own strength.
Affective outbursts are accompanied by patients' sincere regret over their lack of restraint. They endure with difficulty situations connected with the awaiting of examination results reflecting the dynamics of the development of the tumor process, in which the anxiety substantially intensifies.
Permanent and paroxysmal autonomic disturbances and combined (permanent-paroxysmal) ones are noted. Most frequently encountered were cardiovascular autonomic disturbances in response to negative emotional events, incorporated into the structure of the anxiety-depressive syndrome. In one third of patients, causeless (not connected with the oncological pathology and complications) low-grade fever is noted.
In the continuous course of the hypersthenic variant of protracted neurasthenia against the background of a progressive oncological disease, a subacute and gradual onset is noted with a gradual complication of the symptomatology and the joining of depressive and, subsequently, hypochondriacal disturbances.
In the structure of complaints there predominate pronounced anxiety, dyssomnic disturbances with difficulty falling asleep because of pronounced anxious ruminations and notions of one's own incompetence, inadequacy, and uselessness.
The autonomic disturbances are quite diverse, mainly of a general character: increased sweating, hot flushes or chills, hyperesthesia. Patients are unable to continue engaging in the activity that previously brought joy and contributed to the restoration of strength.
Gradually, owing to exhaustion, the hypersthenic phase passes into the hyposthenic one. The emotional-affective disturbances, acquiring a depressive coloring as the disease develops, reach the level of neurotic depression with the development of astheno-depressive and depressive-hypochondriacal syndromes.
With the joining of the depressive-hypochondriacal component, a retreat into illness is noted with subsequent pathocharacterological changes; the astheno-depressive disturbances limit social contacts and productive activity, the ability to follow expedient medical recommendations directed at alleviating the condition of the oncological patient, and this aggravates the hypochondriacal tendencies and the social maladjustment of the patients, contributes to a more severe course of the tumor process and to poor tolerance of therapeutic measures.
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