Lecture
Karavaeva T.A.
The current stage of foreign and domestic medicine is characterized by heightened attention to the accurate and high-quality diagnosis of diseases and comorbid borderline mental disorders in patients with oncological pathology, since a correct and timely assessment of the patient's condition makes it possible to choose an optimal treatment strategy and thereby increase the effectiveness of the care provided, improve the quality of life and the course of the underlying disease. First and foremost, the accuracy of verifying a comorbid diagnosis of a borderline mental disorder is ensured by a clear definition of diagnostic criteria, a clinical assessment of the manifestations of psychopathological disturbances, and consideration of their connection with the course of the underlying oncological disease. The symptomatology of mental disturbances in patients with neoplasms is to a greater extent mediated by the content of the psychological experiences caused by the ongoing pathological process, the attitude toward the illness, its consequences, prognosis, and the patient's personality traits. Realizing the goal of a comprehensive and all-around approach to the treatment, recovery, and support of patients with oncological pathology must be ensured by creating clear and reproducible algorithms of diagnosis, therapy, and rehabilitation that take comorbid pathology into account and make it possible to solve specific tasks at various stages [1, 3].
The biopsychosocial paradigm of the emergence of mental disorders determines the relevance of their diagnosis and treatment in oncology and fosters the development of interdisciplinary connections between these areas of medicine. Making a diagnosis of an oncological disease triggers a whole range of experiences and causes the strongest psychological distress in
every person, which, given a deficit of coping mechanisms, may lead to the development of concomitant mental disorders. According to
DSM-V (the Diagnostic and Statistical Manual of mental disorders), diseases with a high risk of lethality are considered psychologically traumatic factors capable of subsequently causing the development of a mental disorder. Specific features of distress in individuals with malignant tumors are the direct experience of a threat to life at the time the diagnosis is established, as well as the chronic nature of this threat, in a number of cases a mutilating operation, and severe, prolonged, and toxic postoperative treatment capable of leading to the emergence of concomitant diseases. An oncological disease is accompanied by a number of physiological symptoms, such as pain, nausea, weakness, impairment of vital functions, and disability, which have a substantial influence on the emotional state of patients. The illness also places particular demands on the mental capacities for carrying out activities, leads to a limitation of contacts with the people around, loss of social status, and existence in the new role of a patient. In the emotional sphere of patients, especially in the terminal stage, there prevails a deep experience of doom, fear of relapse, of anticipated suffering and mutilation, and, ultimately, fear of death and total uncertainty at the thought of the future. All these factors may lead to the development of concomitant mental disorders.
Epidemiology
Studies devoted to assessing the prevalence of mental disorders among patients with malignant tumors demonstrate a wide scatter of figures – from 24 to 60% [9, 10, 17], which is associated with substantial methodological differences in approaches. At the same time, most researchers who summarize the literature data on this
problem agree that the level of mental pathology in patients with malignant neoplasms is significantly higher than in the healthy population and that nosogenic reactions (adjustment disorders, as a reaction to the underlying disease) predominate in the spectrum of mental disturbances in the patient population under consideration. It is also indicated that mental pathology has a significant unfavorable influence on the clinical and social prognosis of oncological diseases, including a shortening of survival times, a reduction in the level of adaptation, and a decline in the quality of life [11, 12].
According to foreign studies, about 30% of patients with tumor diseases experience adjustment disturbances, while 20% suffer from serious mental disorders [15]. In the work of Barraclough J., devoted to the prevalence of mental pathology in oncology, major depressive disorder occurs in 10–25% of patients with oncological diseases. Moreover, in a quarter of patients receiving palliative treatment, depression is the leading syndrome in the clinical picture of the mental disorder, whereas in the general population the prevalence of depression is 6–10%. Bergevin P. et al. in their study found that a history of depressive episodes increases the risk of the recurrent development of depression, as well as of other mental disorders in the presence of neoplasms.
In the study by L.R. Degoratis et al. of patients with oncological disorders, mental disorders were detected in almost 50% of the sample, most of which were adjustment disorder and psychotic depression. Other works devoted to the study of mental disorders in patients with a progressive malignant disease in the terminal stage showed similar results. Thus, some of them detected a level of adjustment disorders within the range of 9–35%, and of major depression – 8–26% [4, 8, 13, 16].
In the study by Kerrihard T. et al., with the help of such instruments as the Hospital Anxiety and Depression Scale (HADS), symptoms of anxiety were identified in 15–28% of patients [11]. Stark D.P. and House A. used a semi-structured interview for the purpose of the differential diagnosis of anxiety disorders in the presence of a malignant tumor. In their study it was found that generalized anxiety disorder accounts for 1.7–2.3%, adjustment disorder with anxiety – 3.9–4.2%, phobic disorder – 6.9%, and panic disorder – 1.3% [14].
Zabora J. et al. conducted one of the largest studies of the prevalence and intensity of psychopathological distress in individuals with malignant neoplasms, in which 4,496 patients were included. As a result of the work carried out, it was found that the intensity of distress reached a clinically significant level in 35.1% of cases [17]. The level of distress was significantly higher in patients with diagnoses of lung cancer (43.4%) and brain cancer (42.7%), whereas in gynecological cancer (29.6%), prostate cancer (30.5%), and colon cancer (31.6%) its level was significantly lower. In pancreatic oncology the highest levels of depression (56.3%) and anxiety (56.7%) were noted. The populations most susceptible to distress included people with a low income level, insufficient social support, and a very young or elderly (80–90 years) age [17].
The presence of depressive symptoms, the loss of meaning and goals in connection with 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, in patients suffering from malignant tumors the problem of suicide prevention becomes relevant. Most 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.
Algorithm for the diagnosis of mental disturbances in patients with oncological diseases
For the diagnosis of borderline mental disorders in patients with oncological diseases, the following methods are used:
The clinical-anamnestic method
The clinical-anamnestic method is aimed at elucidating the factors that took part in the formation of the patients' premorbid condition and in the development of psychopathological disorders. The influence of biological, somatic, social, and psychological provoking factors in the emergence and maintenance of the pathological process is assessed. The history of the emergence, course, and previous treatment experience of the oncological pathology, and its effectiveness, is studied.
The clinical-psychopathological method
The clinical-psychopathological method has as its goal the description of the mental pathology, the identification of the main signs of the disease (symptoms), the detection of their structure (syndromes) and dynamics (syndrome kinesis), as well as the determination of the patient's attitude toward his illness (both toward the mental state and toward the underlying oncological disease) and toward its individual manifestations, and the connection of psychopathological symptoms with the symptoms of the underlying disease
The clinical-pathogenetic method
The clinical-pathogenetic method makes it possible to assess the mechanisms of the emergence of borderline mental disorders and their clinical manifestations, and to identify the totality of processes that determine the onset, course, and outcome of the disease from the standpoint of the biopsychosocial paradigm of the development of diseases.
The experimental-psychological method
For differential diagnosis, assessment of the severity of clinical manifestations, characterization of psychological features, and determination of psychotherapeutic targets, it is expedient to use the experimental-psychological method, which may include the following techniques:
Symptomatic questionnaires: the questionnaire on the severity of psychopathological symptomatology (Symptom Check List-90-Revised – SCL-90-R); the Beck Anxiety Inventory (BAI); the Hamilton Anxiety Rating Scale (abbr. HARS); the Spielberger Anxiety Scale (State-Trait Anxiety Inventory – STAI);
the integrative anxiety test (IAT).
Techniques for the psychological diagnosis of the structure of the personality: the standardized clinical personality questionnaire MMPI (adapted by I.N. Gilyasheva, L.N. Sobchik, and T.L. Fedorova (1982)
– the full version of the MMPI); the «I – structural test» technique by G. Ammon
(ISTA), I. Burbiel (2003).
Techniques for the study of individual particular psychological features of the personality: the technique for determining the level of subjective control of the personality (LSC); the questionnaire for the study of personal beliefs «Personal Beliefs Test» (Kassinove H., Berger A., 1984); the multidimensional perfectionism scale (Multidimensional perfectionism scale
– MPS).
Techniques for the psychological diagnosis of risk factors for mental maladaptation: the «Life Style Index» technique (Life style index); the E. Heim technique (1988); the coping behavior technique (COPE); the Melbourne decision making questionnaire (MDMQ).
Techniques for the psychological diagnosis of the system of significant relationships: the questionnaire for the study of interpersonal problems
(Inventory of Interpersonal Problems (IIP); the technique for the study of the severity of intrapersonal conflicts, developed by S. Leder et al. (1973).
Screening for panic disorder
The Sheehan Anxiety Scale (ShARS) was developed by D.V. Sheehan in 1983. It is a screening test instrument for the diagnosis and self-diagnosis of anxiety-spectrum disorders. The technique was created in 1983 on the basis of a selection of symptoms of anxiety disorders and panic attacks and includes the most widespread manifestations of these disorders, including the somatic and autonomic manifestations of anxiety. The scale is intended for use in a population of adults with an established or suspected anxiety-spectrum disorder. The average score in panic disorder and agoraphobia is 57±20. The goal of therapy should be to achieve an anxiety level below 20 points.
For preliminary diagnosis it is expedient to use a screening technique for identifying generalized anxiety disorder – a questionnaire that represents a self-report scale including seven questions. The patient is asked to assess the severity of the following manifestations over the past 2 weeks:
experiencing anxiety, nervousness, or a feeling of being «on the verge of a breakdown»;
an inability to stop or control anxiety;
strong worry about various matters;
difficulty relaxing;
restlessness;
irritability and lack of restraint;
anxious forebodings of frightening events.
Each symptom is rated by severity from 0 to 3 points. The resulting sum reflects the patient's overall level of anxiety:
0–4 – a minimal level of anxiety;
5–6 – a moderate level of anxiety;
10–14 – a medium level of anxiety;
15–21 – a high level of anxiety.
The average severity in patients with GAD is 14.4 points.
Diagnostic algorithm
The diagnosis and verification of borderline mental disorders in patients with oncological diseases is carried out by a psychiatrist or a psychotherapist, using a complex of methods to determine the presence of the diagnostic criteria of the indicated diseases and for the differential diagnosis with other pathological conditions, also taking into account data obtained from other specialists (medical psychologists, social workers, physicians of other specialties – oncologists, therapists) .
At the first stage, the features of the clinical manifestations are carefully assessed: the severity of anxiety, depressive, and hypochondriacal disturbances, their duration and connection with the patient's current life circumstances, their characteristic dynamics, and their interdependence with the underlying oncological disease, its course, existing complications, therapy, side effects, and prognosis. Particular attention is paid to the risk of suicidal behavior. Data on previously prescribed treatment of anxiety and depressive disturbances and its results are informative. An assessment is made of the mental, somatic, and neurological statuses, and of the presence of comorbid mental and concomitant somatic pathology.
All types of antitumor treatment the patient is receiving are assessed in order to determine compatibility and mutual influence with psychotropic drugs for the choice of optimal psychopharmacotherapy. The very nature of the tumor is also of important significance for the choice of drug therapy aimed at relieving the psychopathological symptomatology, since the mechanism of action of the drugs may affect metabolic processes, and the endocrine, hematopoietic, immune, and other systems. As a result of the first stage, a preliminary verification of the diagnosis and a primary differential diagnosis (clinical) with other mental pathology are carried out.
At the second stage, the prescription and assessment of data from additional research methods is carried out. Their necessary scope is determined, and experimental-psychological and instrumental-laboratory examinations are performed. The goal of this stage is confirmation of the diagnosis and a detailed differential diagnosis with other diseases.
At the third stage, the personality and individual-psychological features of the patient are assessed, along with his physical and psychological adaptive resources and the influence of the course of the tumor disease upon them, the current life situation, the presence of supportive loved ones, the level of social activity, the degree and extent of the spheres of functioning impaired because of the underlying pathological process, the internal picture of the oncological disease and of the mental disorder, and the motivation for antitumor treatment, psychological help, psychotherapy, and psychopharmacotherapy. This makes it possible to determine the individual features of the disease, to assess the contribution of biological, psychological, and social factors to its development and course, to identify psychotherapeutic targets, to determine the strategy of psychopharmacotherapy, and to optimize the ratio of drug and psychotherapeutic treatment. Borderline mental disorders that develop against the background of oncological pathology are diseases in relation to which a comprehensive application of biological, psychotherapeutic, psychosocial, and psychoeducational methods and the use of various organizational forms of care are necessary . This corresponds to modern principles of a team, multiprofessional approach in working with oncological patients and to bringing the provision of care closer to modern conceptions of the unity of the regulatory somatic and mental mechanisms in the etiopathogenesis of various diseases.
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