Lecture
Karavaeva T.A.
Historically, the concept of the heterogeneity of affective disorders has developed, in which one pole comprises the more severe so-called endogenous disturbances, whose emergence is attributed primarily to biological factors, and the other pole comprises the milder (non-psychotic) neurotic, reactive disorders, whose course is largely associated with the influence of unfavorable psychosocial factors.
In the modern phenomenological classification of mental disorders, these dichotomous conceptions have largely receded into the background. At the same time, numerous studies indicate that, over the course of a neurotic affective illness, an autochthonous emphasis of suffering not infrequently begins to manifest itself to an increasing degree. Thus, depressive states in cancer patients that arose as a psychogenic reaction to the illness not infrequently trigger endogenous mechanisms associated with the particular regulation of neurotransmitters, predominantly serotonin. The spectrum of affective depressive disturbances presenting in cancer patients includes reactive psychogenic depressive reactions, endoreactive affective disturbances, and depressive disorders of the endogenous type.
This situation reflects the multifactorial nature underlying the formation of affective spectrum disorders, in whose clinical presentation the combination (superimposition) of several unfavorable factors may be significant:
the nature of the stressful psychotraumatic impact, determined by the parameters and course of the cancer;
features of the premorbid period, including the presence of a psychopathological and/or psychosomatic diathesis (a predisposition to the development of mental or oncological pathology);
the patient's «vulnerable» age;
the absence of social support.
A more detailed examination of these components reveals the following:
1) Features of the stressogenic impact. The intensity and universality of the main psychotraumatic factor are important – the experiences associated with the diagnosis, development, treatment, and prognosis of the cancer, which carries the character of irreversibility and irreparability: possible death from the disease, «unjust», «undeserved» suffering, the sense of being «punished by fate» and of «sinfulness», a sharp decline in quality of life, the prospect of prolonged deprivation of health and activity.
2) Features of the premorbid period:
the presence of signs of a mental diathesis and, in particular – affective idiosyncrasy, infantilism, the presence of a personality radical reaching the level of pronounced accentuation; hypothymic states in response to negative events in the past;
physical exhaustion, asthenization.
3) A «vulnerable» age, reflecting complex socio-psychological stages of an individual's development: age-related crises, involution, young or old age.
4) The absence of social support owing to partial or complete loss of one's social environment, or to a conflict that led to the rupture of relationships.
As a result of the constellation of these factors, prolonged polymorphic affective disorders develop, which have a staged course of development, a tendency toward exacerbations, and may leave an imprint on the course of the underlying cancer and on the patient's attitude toward its treatment.
One of the most significant questions in the study of mental disorders in cancer patients is the identification of risk factors for the development of depressive states. As highly reliable factors, the form and localization of the malignant neoplasms have been identified; thus, depressive states are detected in cancer of the brain (41—93%), pancreas (up to 50%), head and neck (up to 42%), breast (up to 37%), organs of the female reproductive system (23%), and lungs (11%). No less important aspects influencing the frequency of depressive disorders include the severity of the physical condition, involvement of the neuroendocrine system, and the side effects of treatment of malignant neoplasms. Separately, one should note the factor of predisposition to affective disorders, manifested by a history of mental disorders (primarily disorders of the mature personality; of the affective and anxiety spectrum) [2, 13, 16]. The stage of the cancer has a significant influence on the frequency and severity of depressive disorders. At the initial – diagnostic stage, nosogenic factors predominate, realized predominantly in anxiety disorders of the neurotic level. Over time, during the period of treatment of the malignant neoplasm, the likelihood of development and the severity of affective disorders are determined by the dynamics of the disease and the traumatic nature of the methods of medical intervention. Among the factors predisposing to the formation of depression are both nosogenic factors (the impossibility of radical surgery, poor results of palliative treatment, cosmetic defects, etc.) and somatogenic
factors (side effects of pharmacotherapy, postcastration syndrome resulting from surgery or hormone therapy, postresection syndromes), etc. The greatest frequency and severity of depressive disorders are detected at the preterminal and terminal stages of the disease [11, 20].
A number of domestic studies have been devoted to the clinical picture of affective disorders in cancer of the stomach, pancreas, breast, uterus, and adnexa. Their results showed significant differences in the frequency and manifestations of depressive disorders (nosogenic depression, endoform depression, dysthymia) depending on the form of the malignant disease. The greatest frequency and severity were observed for anxiety – depressive reactions in cancer of the uterus and adnexa – 78%, whereas in cancer of the pancreas, on the contrary, endoform reactions had the greatest severity – 45%. It is worth noting that the lowest severity of depressive disorders was encountered in cancer of the stomach – 14.3% for anxiety-depressive reactions and 3.7% for endoform depressive reactions [1, 2, 6, 12].
The presence of depressive symptoms, the loss of meaning and goals owing to the uncertainty of future prospects, together with the helplessness and subjective incapacity accompanying this state, may aggravate the desire for a hastened death. In this connection, the problem of suicide prevention becomes pertinent in patients suffering from malignant tumors. The majority of studies aimed at identifying risk factors for committing suicide point to the severe physical condition of patients, up to complete physical incapacity, as well as to the presence of mental disorders. The most frequent of these was depression as a «reaction to the illness» [8, 18, 21].
The clinical picture of depressive reactions in cancer generally corresponds to the symptoms of clinical depression and is presented by emotional disturbances in the form of dejection,
a pessimistic assessment of prospects, vital melancholy, apathy, and anhedonia, with a distinct diurnal rhythm of the state and disturbance of vital functions, while at the same time retaining a distinct psychogenic complex associated with the situation of the cancer. In the work of Samushiya M.A. and Smulevich A.B., a special variant of bipolar disorder was described, given the name somatoreactive cyclothymia – close in its characteristics to bipolar disorder, but having substantial differences: the dependence of its dynamics on the comorbid oncological pathology. As a result of a special catamnestic study, it was demonstrated that in all patients, following an exacerbation or the formation of stable remissions, repeated depressive or hypomanic episodes, respectively, were detected.
Protracted depressive states (reactive depression) – F43.21
In the course of the development of prolonged depressive reactions in cancer patients, the following stages are distinguished.
The acute period may arise at a remove from the onset of the first symptoms of the tumor process and its initial diagnosis; it is characterized by pronounced depressive symptomatology with emotions of grief, the experience of the loss of health and happiness, fixation on the misfortune that has befallen, a sense of hopelessness and worthlessness of subsequent life, and loss of the meaning of continued existence. Patients complain that their strength has abandoned them, exhibit domestic incompetence, have difficulty making even simple decisions, take no interest in their surroundings, are indifferent to the problems of loved ones, and may remain for long periods in a single posture with eyes full of tears.
The subacute period is characterized by partial adaptation to the fact of the cancer and a softening of the depth of experiences; coming to the fore are ideational depressive manifestations with pessimism, self-reproach, surges of sorrowful memories, remorse over past mistakes, and a reappraisal of life values.
More complete emotional reactions appear, contact with others improves somewhat, and the ability to perform habitual duties is partially restored. The condition worsens only when the patient is left to himself, is in solitude, immersed in thoughts about his cancer and its unfavorable prospects, often at night as well, after a brief sleep full of oppressive dreams. A chance event recalling the painful experiences and the malignant disease may provoke an attack of melancholy and despair, and sometimes a more prolonged exacerbation.
The period of unstable stabilization is defined by the patient's distancing from the depressogenic complex of experiences, as a result of which situationally conditioned elements begin to sound in the patient's statements – elements that may have been blocked earlier but now come to the fore, contributing to the prolongation of the depressive state. Often, against this background, resentment and envy toward well-off people around arise. Also possible is the incorporation, as a new stressor, of a factor comparable in significance for the patient to the circumstances that initially led to the emergence of the neurotic experiences (for example, the occurrence of complications, the appearance of pain symptoms, receiving information about tumor growth from examination data), which intensifies the depth of the patient's depressive experiences [10].
The period of stabilization can be considered accomplished when the psychotraumatic situation is deactualized, the depressive symptomatology is reduced, and the pre-illness level of functioning is restored. Most often this may be observed with successful antitumor treatment and the achievement of remission. In this case, the adaptive potential of the personality, enriched by the experience of grief and suffering, not infrequently turns out to have grown, while the personality itself has «matured».
With a negative dynamic of protracted neurotic disorders
against the background of a progressing tumor process, the formation of pseudopsychopathy is possible:
in some cases there occurs an intensification of the premorbid personality disharmony, a decrease in stress resilience (an increase in vulnerability and intolerance of stress), and a hypochondriacal existence with avoidance of solving pressing problems and the appearance of social maladaptation;
in other cases there arises a depressive fixation on experiences caused by the cancer, which have led to a neurotic state with a blockade of the entire positively colored context of life; in this case, in the presence of aggravating circumstances (solitude, exhaustion, social maladaptation), there occurs, in essence, the formation of a depressive existence.
Protracted mixed anxiety and depressive disorder (F 41.2)
This nosological rubric entered ICD-10 as a category at the stage of study, uniting mild forms of affective and anxiety disorders. In the patient's mental status, symptoms of anxiety and depression coexist to a comparatively equal degree, and it is impossible to speak of a significant predominance of one or the other, since the intensity of these phenomena does not reach the degree that would allow them to be considered separately in a particular patient.
There are many different combinations of relatively «mild» symptomatic manifestations of the illness, when a lowered mood is combined with anxious tension. If, however, the symptoms are so pronounced that they allow a definite diagnosis to be made for each of these disorders, then both diagnoses should be coded and this rubric should not be used.
In pathogenetic terms, the connection between anxiety and mood disorders is not fully clear.
Two possible variants are considered:
The first – the anxiety disorder is caused by depression (a mood disorder) that developed against the background of the neoplasm, or vice versa. If this is so, then one disorder complicates the other, which is rather difficult to assess.
The second variant – both disorders arise against the background of a common predisposition, vulnerability, and represent different phenotypic (related) manifestations of one and the same genotypic feature, actualized against the background of
the cancer [22].
A certain dichotomy of symptoms is noted in anxiety and depression. Thus, for example, in anxiety the emotional symptoms are represented by irritability, tension, and fussiness, while in depression – by dejection, absence of emotions, and apathy. The somatic symptoms in anxiety include increased appetite, rapid breathing, and palpitations, whereas in depression, on the contrary, there is bradycardia, slowed breathing, and decreased appetite. The greatest differences are noted in the analysis of the cognitive sphere: anxiety disorders are characterized by hypervigilance, fear of the future, anxious anticipation of misfortune, concentration of attention on dangerous events or threat, and selective disturbances of attention; depressive disorders are characterized by decreased vigilance, fixation of experiences on events of the past, concentration of attention on losses, difficulties of motivation, and selective disturbances of memory.
In mixed anxiety and depressive disorder in cancer patients, characteristic features are mood fluctuations with a transition from despair to hope for a favorable resolution of the illness; decreased interest and ability to derive pleasure from usually
pleasant activities; a sense of powerlessness and of the futility of efforts in the struggle against the illness despite a fairly high level of activity; a high level of discontent
and irritability, manifested at both the verbal and non-verbal levels.
In the clinical picture, nonspecific autonomic symptoms, changeable in character and intensity, are also quite pronounced – increased fatigability, weakness, headaches, tremor, inability to relax, periodic attacks of palpitations, difficulty breathing, nausea, chills, intestinal disturbances, disturbances of the «sleep-wakefulness» cycle, sweating, dryness of the skin, hyperhidrosis of the palms
and feet, fluctuations of arterial pressure, and others. There is difficulty in their differentiated assessment owing to the fact that they may be associated with the underlying cancer or with complications against the background of radiation
and chemotherapy.
Endoreactive or endogenous depressive disorder
(F 32.1)
In this case, the cause of the depression is a deficiency of neurotransmitters in the CNS, predominantly noradrenaline, dopamine, and serotonin. Serotonergic mechanisms are involved in the realization of the symptomatology of impulsivity, anxiety, depression, and suicidality. Neurotransmitters act on surface synaptic receptors
and trigger cascades of intracellular reactions.
In cancer patients, endoreactive depression can more often be diagnosed – psychogenic experiences of the affective spectrum, caused by the underlying illness, trigger changes in the neurotransmitter system, and the depressive disorder then transitions to the endogenous level, reflecting the particular features of disturbances of the body's biological functions [15, 17].
Symptoms pathognomonic for endogenous depression:
ideas of self-accusation,
suicidal tendencies,
mood fluctuations, consisting of poor well-being in the mornings and its noticeable improvement toward evening (the latter is usually observed in mildly pronounced cyclothymic depression),
somatic disorders:
1. Protopopov's triad (mydriasis, tachycardia, constipation);
2. V.P. Osipov's dry-tongue symptom, observed, as a rule, with a considerable depth of hypothymia – the tongue is dry, covered with a fuliginous coating; not infrequently cracks appear, and hyposalivation is characteristic;
3. in prolonged depression the tongue looks congested and swollen, with tooth impressions along its edges; this symptom is also associated with the autonomic disturbances characteristic of depressive states;
4. the pupillary symptom (Athanassio's symptom) – the pupils' reaction to light is preserved, but there is no reaction to accommodation and convergence (in contrast to the Argyll Robertson symptom).
However, against the background of antitumor treatment and the course of the cancer itself, it is difficult, and sometimes impossible, to separate somatic symptoms of depressive origin from the underlying pathology; therefore, the clinical diagnosis of endogenous depressive disorders should be carried out on the basis of psychopathological manifestations [19].
Great importance is attached to the vitality of the depression, when the melancholy is localized by the patient in the region of the heart and has a peculiar «physical» character, expressed in such complaints as, for example, «melancholy squeezes my chest», «heavy on the heart», «as if there are stones in my chest», «I feel as though turned to stone», «there are no feelings». The manifestation of vitality indicates a pronounced severity of the
depressive state and is characterized by an increased risk of suicidal behavior, which in cancer patients is already high.
In endogenous depression, all experiences are accompanied by the affect of melancholy. The patient sees everything in a gloomy light; the future promises him no joys. Only bad, pessimistic thoughts come to mind. It is difficult to think, to reflect, to move, to talk. The patients' voice is quiet, barely audible; their movements are slow, performed as if with effort. It happens, however, that in states of melancholy the inner tension seeks and finds release in movement. Such patients seem not to know the feeling of fatigue; they go far from home, wander about, as if trying to drown their melancholy in walking.
The patient's facial expression is characteristic: the face is frozen, sorrowful.
The expression of sorrow appears especially distinctly in patients with Veraguth's symptom, in which the skin fold of the upper eyelid (not infrequently also the eyebrow at the boundary of the inner and middle third) is drawn upward, forming an angle, a kink, instead of the usual arch, which gives the patient's face a sorrowful expression. Insufficiency of lacrimation is often observed with this («melancholy with dry eyes»).
Classic depression is defined by a triad of features:
lowered mood (hypothymia, dysthymia),
slowed thinking,
motor retardation.
Considered characteristic of depression are the loss of the ability to feel joy, the loss of interests, and a decrease in the capacity for work.
The following syndromes are distinguished in the structure of depression:
emotional (melancholy, agonizing displeasure, loss of interests, estrangement from loved ones, unsociability, fear),
volitional (absence of pleasure from activity and occupation, decreased capacity for work and tolerance of load, difficulty making decisions, loss of will and initiative),
autonomic (inner tension, fatigability, absence of appetite, poor sleep, headache, palpitations, a feeling of heaviness in the chest),
intellectual-cognitive (pessimism, hypochondria, obsessive thoughts, memory impairment, a sense of one's own worthlessness, ideas of self-abasement, suicidal thoughts, slowing of thinking),
depersonalizational.
Depression in cancer may appear in various forms – grief, fear, melancholy, anxiety.
Of great importance for defining the depressive state is the characterization of the emotions of fear, anxiety, and melancholy inherent in the patient [7, 14]. These are not identical concepts.
Emotions of fear are associated with the experience, the feeling of immediate danger, of a concrete threat – of therapeutic procedures, surgical intervention, pain, injury, death.
Anxiety, on the other hand, consists in the anticipation of danger, real or imagined; it is always characterized by an indeterminate sense of threat. Anxiety is the anticipation of an unfavorable development of events, regardless of whether it actually occurs or not.
The picture of the depressive syndrome depends to a considerable extent on the degree of severity of the anxiety. Yu.L. Nuller, characterizing the range of severity of anxiety in depression, indicates that in relatively milder cases anxiety in cancer patients manifests itself as a feeling of inner tension, the expectation of something unpleasant, agitation, increased uncertainty, and doubts, while in severe cases – as agitation or anxious stupefaction up to deep stupor, a panicky sense of an impending catastrophe, an agonizing feeling of constriction in the chest, a sense of suffocation, and vital experiences.
Thus, the identification of psychogenic mechanisms conditioned by the psychotraumatic essence of the cancer by no means yet permits one to exclude with confidence an endogenous mental process. Often neurotic symptomatology, regarded by the patient as a reaction to the tumor process and unfavorable prognosis, turns out to be a facade concealing a developed endogenous depressive illness, upon which the psychoreactive mechanisms of the emotional attitude toward the illness and its consequences are superimposed.
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