Lecture
Karavaeva T.A.
Short-term psychogenic reactions are limited in time,
and the onset of their occurrence and course is almost always identifiable. They usually develop only in response to a specific maladaptive psychogenic situation. In oncological patients, acute psychogenic reactions most often arise upon initial notification of the presence of an oncological disease (the fact of the diagnosis being established) and upon awareness of an unfavorable prognosis (fatal outcome). Such states may occur both in individuals without signs of premorbid personality abnormalities and against a background of mental disorders.
Short-term psychogenic reactions (maladaptation in the narrow sense of the word) include the acute (shock) reaction to stress (F43.0) –
a transient disturbance of considerable severity that occurs in persons without an apparent mental disorder in response to exceptional physical and psychological stress and resolves within a few hours or days. In the case of an oncological disease, the stress may be an intense experience (for example, a threat to life safety due to a malignant pathology, awareness of the reality of death) or an unusually sudden and threatening change in the patient's social position and/or environment (for instance, loss of employment, loss of the ability to support loved ones or children, a mutilating, disabling operation) [13].
Acute shock reactions were described under the name «terror psychoses» (Schreckpsychosen), but the literature also features such definitions as «emotive shock», «acute affectogenic reactions», «crisis reactions», «reactions to extreme situations». A role in the occurrence and severity of acute reactions to stress is played by
a person's individual adaptive capacities and the particular features of their vulnerability and resilience to various stressogenic agents. The risk of developing such disorders increases with physical exhaustion, reduced immunity, insufficient weight against the background of oncological pathology and/or treatment, intoxication-related debilitation against the background of chemotherapy, or the presence in individuals of «organicity» (for example, reduced activity, restricted movement, advanced age, complications of the underlying disease).
In an oncological patient, at the moment of stress perceived as an acute psychic trauma, a fixation arises on such defense mechanisms as extreme identification and repression [10]. As a result, changes in consciousness and disturbances of perception and behavior are possible. Symptoms include: an initial state of stupefaction with some narrowing of the field of consciousness and reduced attention, an inability to react adequately to external stimuli, and disorientation. Autonomic signs of profuse anxiety (tachycardia, sweating, flushing) are frequent. Partial or complete amnesia of the stressful event occurs [4, 9].
The diagnosis of an «acute reaction to stress» is made when the condition corresponds to the following criteria:
The experience is caused by exposure to stress associated with awareness of the oncological disease and of an unfavorable social or medical prognosis.
The development of symptoms immediately following this, within an hour.
With the mitigation or removal of the stress and with emotional support, symptoms begin to subside in no more than 8 hours; if the stress persists (with ongoing acute experiences) – in no more than 48 hours.
The absence of signs of any other mental disorder, with the exception of generalized anxiety disorder (F41.1), as well as situations in which an episode of any preceding mental
disorder ended less than 3 months before the action of this stress.
Depending on the nature of the symptoms present, it is divided into group A and group B.
Group A includes the criteria of generalized anxiety disorder (F41.1), namely – predominantly general autonomic symptoms (increased or accelerated heartbeat, sweating, tremor or trembling, dry mouth); autonomic disturbances of the respiratory organs and gastrointestinal tract; symptoms relating to general well-being (a sensation of dizziness, unsteadiness, or faintness) or to mental state (derealization, depersonalization, fear of losing control, of going mad, or of dying); symptoms of «tension» (muscle tension or pain, restlessness and inability to relax, a feeling of nervousness or general mental tension, a sensation of a lump in the throat or difficulty swallowing) and some others. The observed disturbances must not meet the criteria of another mental disorder or be caused by a somatic illness or by the intake of chemical substances.
Group B includes the following symptoms:
withdrawal from expected social interaction – avoidance of communication with loved ones, physicians, and other medical staff, of familiarizing oneself with examination results, leaving the medical facility, etc.
narrowing of attention;
manifestations of disorientation;
anger or verbal aggression;
despair or hopelessness;
inadequate or purposeless hyperactivity;
uncontrollable and excessive grief (assessed in accordance with local cultural standards).
Taking into account the presentation of the above two groups of symptoms
«A» and «B», the acute reaction to stress is subdivided into:
mild (F43.00) – only group A symptoms are present;
moderate (F43.01) – group A symptoms and at least 2 symptoms from group B are present);
severe (group A symptoms and at least 4 symptoms from group B are present, or there is a dissociative stupor F44.2).
A distinction is made between hyperkinetic and hypokinetic forms of acute reactions to stress, both of which may be encountered in patients with oncological diseases.
Hyperkinetic form of the acute reaction to stress
In the hyperkinetic form, which to a certain extent corresponds to the «motor storm» reaction [23], patients' behavior loses its purposefulness; against a background of rapidly increasing anxiety and fear, chaotic psychomotor agitation arises with disorderly movements, aimless dashing about, and an urge to run somewhere (fugiform reaction). Orientation to the surroundings is disturbed. The duration of the motor agitation is short; as a rule, it ceases within 15—25 minutes.
Hypokinetic form of the acute reaction to stress
The hypokinetic form, corresponding to the «feigned death» reaction, is characterized by states of pronounced motor inhibition reaching complete immobility and mutism (affectogenic stupor). Patients usually remain in the place where the affect of fear arose; they are indifferent to what is happening around them, their gaze fixed into space. The duration of the stupor ranges from several hours to 2—3 days. Experiences relating to the acute period of pronounced disturbances are usually subject to amnesia.
Upon the conclusion of the acute reaction to stress, most patients exhibit symptoms of a transitional period of the disorder (affective
tension, sleep disturbances, psychovegetative disturbances, behavioral disturbances, etc.), or post-traumatic stress disorder (PTSD) occurs [11, 16].
Adjustment disorders
In the pathogenesis of adjustment disorders, the leading and essential role is played by the psychogenic (stress) factor, i.e., the impact of a psychotraumatic situation of varying degrees of severity and duration [12]. In patients with an oncological disease, the very fact of the diagnosis being established may already be a sufficient trigger for the development of adaptive disturbances. The duration of the disease, the mortal threat, invasive therapy, and the social restrictions associated with the disease ensure the duration and intensity of the stressful nosogenic impact. Each individual has a characteristic «adaptation barrier», i.e., a level of resilience to stress factors, which is breached under excessive impacts on a person's psyche and body. The stressogenicity of an oncological disease depends primarily on the patient's ideas about the nature of the disorder, its consequences, prognosis, and the severity of treatment. The resilience or vulnerability of the mental sphere is determined by individual predisposition, personality traits, defense mechanisms, coping mechanisms, and adaptive resources [14].
Adjustment disorders in patients with oncological diseases represent states of subjective distress and emotional disturbance that usually impede social functioning and productivity and arise during the period of adaptation to a significant change in life caused by a neoplasm, to a stressful burden in the form of a serious physical illness.
The manifestations are varied and include depressed mood, pessimistic thoughts and perception of the future, anxiety, restlessness (or a mixture of these); a feeling of being unable to cope, plan, or
continue to remain in the present situation; as well as some degree of reduced productivity in daily affairs. None of the symptoms is so significant or predominant as to indicate a more specific diagnosis.
The onset is usually within a month after the stressful event or life change (the diagnosis of an oncological disease, news of an unfavorable prognosis, preparation for investigative procedures or a stage of treatment – chemotherapy, surgical intervention, a change in professional status or level of social functioning, financial difficulties, oppressive life circumstances, and other things).
The diagnosis of an adjustment disorder in patients with oncological diseases depends on a careful assessment of the relationship between:
the form, content, and severity of the psychopathological symptoms and their connection with the course and prognosis of the oncological disease;
anamnestic data and personality (the history of the course of the oncological disease, the patient's tolerance of stressful situations, attitude toward and perception of the disease, premorbid personality features);
the stressful event, situation, and life crisis (all features of the stressful impact of the oncological disease, life circumstances, existential experiences of the questions of death, life, existence with pain, loneliness, meaning, etc.).
The presence of the third factor must be clearly established, and there must be compelling, though possibly presumptive, evidence that the disorder would not have appeared without it. In the case of a patient with an oncological disease, establishing such a connection is usually not difficult.
Practice shows that the prognosis is worse if situations of tension and stress are not acute and short-term but rather of a prolonged
nature and affect the individual's system of significant relationships; this fully applies to the occurrence and development of oncological pathology. Of great importance is the preservation of the ability of a patient with a malignant disease to engage in problem-solving behavior and adequate assessment of the situation [15]. Often the very presence of a high level of anxiety, frustration, and a feeling of helplessness is a psychotraumatic factor that substantially affects the patient's self-esteem. At the same time, initially immature, disharmonious personalities have limited capacities for modifying behavior and coping with stress; they lack the ability to classify events associated with the oncological disease in accordance with past experience, and they are more inclined toward stereotyped reactions along infantile patterns. Pathological forms of reacting to symptoms – bewilderment, ignoring, catastrophizing, denial, pathological fixation, formation of inadequate defenses, demanding excessive attention from those around them – are encountered far more often than rational adaptation.
One of the main complaints in adjustment disorder in oncological diseases is anxiety, which unexpectedly overwhelms the patient and is accompanied by pronounced autonomic reactions, which becomes especially distressing when the skill of assimilating emotions and adjusting to them is underdeveloped [2,5]. Such patients are more inclined to convert their anxiety into active but not always justified actions and have limited introspective abilities; clinging to «rationality», they completely ignore the «logic of emotions», and for them the loss of the usual level of working capacity becomes an additional psychotraumatic factor. Therefore, they often require the prescription of pharmacological therapy that, by reducing anxiety, would allow intellectual-mnestic activity to be maintained at an optimal level. Psychotherapy with this contingent of
patients requires time, since limited reflective abilities are in this case often combined with fear of the disease and its consequences, and the very situation of needing to turn to a psychologist or psychotherapist for help is perceived as humiliating, which heightens anxiety and complicates the building of a working therapeutic relationship.
Symptoms such as anxiety and depression in oncological disease may lead to so-called secondary disturbances, caused by the personality's reactions to the altered emotional state. Characteristic «anxiety about anxiety» or «depression over depression» not infrequently arise, whereby the secondary disturbances may be persistent and contribute to the development of neurotic fixation and demoralization. Timely prescription of adequate pharmacological therapy makes it possible to interrupt this «vicious circle» in a timely manner. The entire anxiety symptom complex, including autonomic disturbances, irritability, sleep disturbances, reduced concentration of attention, and impaired memorization, may be mistakenly interpreted by patients and regarded as manifestations of the oncological disease, which distances the patient from seeking medical help from a psychotherapist or psychiatrist.
Since adjustment disorders belong to the range of neurotic-level disturbances, the principal method of treatment for these conditions in oncological patients should be psychotherapy. Recently, in the comprehensive therapy of adjustment disorders, psychotropic drugs representing various pharmacological groups have been used ever more actively for the purpose of providing a comprehensive and more effective impact.
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