Anton C. Trinidad, MD, is Medical Director, Inpatient Psychiatric Services; Assistant Professor of Psychiatry and Behavioral Sciences, The George Washington University School of Medicine and Health Sciences, Washington, DC; Brandon A. Kohrt, MD, PhD, is Resident Physician in the same program; and Lorenzo Norris, MD, is Director, Psychiatric Consultation-Liaison Service, Assistant Professor of Psychiatry, also at The George Washington University.
Drs. Trinidad, Kohrt, and Norris have disclosed no relevant financial relationships.
Address correspondence to: Anton C. Trinidad, MD, The George Washington University, Department of Psychiatry and Behavioral Sciences, 2150 Pennsylvania Ave., NW, 8th Floor, Washington, DC 20037; Phone: 202-741-2894; Fax: 202-741-2891; email: email@example.com.
The patient is a 47-year-old woman who never married and has no psychiatric or significant medical history. One-and-a-half years before psychiatric consultation, the patient was diagnosed with invasive breast cancer with one positive lymph node and estrogen receptor negative. After a lumpectomy and two courses of chemotherapy, the patient was in remission for about 1 year until a new lymph node showed positive for cancerous cells.
She was receiving radiation treatment when she was referred to the psychiatrist by her oncology case worker; the patient had said she found it difficult to juggle the demands of her daily radiation treatments and the responsibilities of her job as a government agency program analyst.
However, during the intake assessment, the patient told the therapist that what she sought was a way to deal with her “overbearing and controlling” sister-in-law, who also had breast cancer and was herself in remission. The patient reported that the sister-in-law had “taken charge” of the patient’s treatments, calling her every day to inquire about them; also, she had appeared unannounced at the patient’s radiation appointments. The patient had not said anything to her sister-in-law, although the patient thought her privacy had been invaded because the sister-in-law would reveal details of the patient’s treatment to the patient’s brother.
In addition, the patient often was fatigued and unable to concentrate after her radiation appointments. Occasionally after her treatments, she would go home instead of going back to her office. Although the patient’s supervisor at work said she should go home if she did not feel well, he would call her frequently enough that the patient found it easier to deal with his needs by returning to the office instead of going home.
Mild Generalized Anxiety Disorder (GAD)
These issues, along with the fear of deterioration and spread of the cancer, meant the patient was anxious all the time, unable to get restful sleep, and feeling that she was waiting for “the other shoe to drop.” Her oncology case worker referred her to a support group, but she found it difficult to find the time for it. The psychiatrist-therapist diagnosed her with mild generalized anxiety disorder (GAD) and recommended a selective serotonin reuptake inhibitor (SSRI). The patient preferred to not take medications and elected to undergo cognitive behavioral therapy (CBT).
The A-B-C Model
After the initial assessment, the therapist hypothesized an underlying belief that the patient’s needs did not matter and that she could not take time to undergo radiation treatment free from other people’s agendas.
In cancer, there is evidence that CBT helps reduce pain,1 insomnia,2 fatigue,3 and depression.4 As a psychotherapeutic modality, CBT is usually time-limited, goal-oriented, and collaborative insofar as patients are encouraged to execute the goals that have been formulated in the session.5 The primary tenet of CBT is that faulty thinking or faulty beliefs result in symptoms and other unpleasant behavioral sequelae. These beliefs may be dormant until a significant life event activates them. This is known as the A-B-C model: Activating event → Belief → Consequence.
This is a useful construct when connecting the distress experienced by patients with cancer to their diagnosis as the main activating event. Using CBT strategies, patients can target this belief, re-assess its validity, and re-conceptualize it in order to lessen the degree of its depressive effect.
The A-B-C activating event for the patient — radiation treatment — had triggered the belief that she should still prioritize other people’s needs ahead of her own, resulting in anxiety.
The therapist introduced the patient to the CBT model; using guided self-discovery, the patient was encouraged to write down her automatic thoughts before and after radiation treatment, and when encountering the two anxiogenic figures in her life, her sister-in-law and her supervisor. Through role-playing, a typical CBT strategy, the therapist rehearsed conversations between the patient and the other two individuals, to help the patient prioritize her own needs.
The patient successfully negotiated a promise from her supervisor to not call her on days when she was at home recuperating. Her sister-in-law was more problematic; she took offense at the patient’s need for privacy, and cut off contact with the patient. This caused a relapse of GAD in the patient, during which time the therapist encouraged relaxation/imagery exercises and active recording and refutation of automatic thoughts. An example of the patient’s automatic thoughts and their refutations include:
“I have ruined my relationship with my sister-in-law,” refuted by, “I have no evidence that it is ruined. Though we are not in contact with each other, this can mean merely that she is not used to my newfound assertiveness.” Another was, “I am failing at work,” refuted by, “I am taking sick days. That does not mean failure — it means I am ill.”
The patient’s distress thermometer6 score decreased by more than 50% after six sessions of CBT. She found time to attend cancer support groups and often found herself actively helping other cancer patients who were having difficulties prioritizing their treatment. She concluded her radiation treatment and entered another period of remission from cancer.
This case underscores the utility of CBT in guiding a course of time-limited psychotherapy in someone whose anxiety complicates coping with radiation treatment. The investigation and reconfiguration of underlying dysfunctional beliefs in CBT operates with the assumption that the automatic thoughts are rooted ultimately in underlying schemas; challenging these schemas helps to prevent negative automatic thoughts.7–9 The case also implicates unpleasant affects and undesirable behaviors as potentially inimical to the completion of prescribed cancer treatment protocols — though this case shows the patient making it to her radiation treatment, she is overwhelmed by an underlying belief that sacrifices her own priorities in favor of other people’s.
Such a dynamic increases stress, a factor that is a natural co-occurrence with any cancer, but also, beyond a certain threshold, may be implicated in poor coping and poor prognosis.10 Some studies imply that depression and anxiety negatively influence outcomes in cancer; in a meta-analysis, depression increased cancer incidence, decreased survival time, and increased cancer-associated mortality.11 However, other studies have failed to show evidence for an effect of psychosocial coping on cancer outcomes,12 and others have argued that the association between depression and cancer outcomes is related to confounding factors.13 Immaterial of psychological distress’s ability to inflect longevity and survival, the quality of life of patients within the cancer care continuum (see Sidebar 1, page 440, and Sidebar 2, and the Figure) is a worthwhile focus.
: Cancer is first detected; through diagnostic tests or staging surgery, the cancer is staged.Remission Induction
: Process eradicating as many cancer cells as possible. Usually achieved through surgery, chemotherapy, radiation, and immunotherapy.Remission
: The absence of detectable tumor or abnormal cell load.Surveillance
: Patient is routinely monitored for signs of recurrence by physical examination and laboratory tests.Recurrence
: After a period of remission, new malignant cells or tumors are detected.Palliation
: Focus on comfort, pain management, symptom diminution, and personal and family integration in the final stages of a disease process, rather than remission.
Sidebar 2.Diagnosis Phase and Remission Induction Phase:
- Doubt and mistrust.
- Catastrophizing (thinking the worst).
- Paralysis and failure of usual modes of problem-solving.
- Acting out.
- Learned helplessness.
- Terror of treatment side effects including mental and behavioral side effects.
- Dependency and regression.
- Suicidal ideation.
- Failure at teamwork (family, treatment team).
- Existential issues (death, life’s meaning, review of accomplishments).
- Fear of recurrence.
- Taking stock of the consequences of cancer treatments (physical and emotional exhaustion, both personal and family, financial cost).
- Residual effects of treatments such as pain, neuropathies, or sexual function problems.
- Axis I psychiatric sequelae such as major depression, cognitive decline, and substance abuse/dependence.
- Fear of death.
- Anguish over what is left unfinished.
- Cognitive decline/delirium.
- Grief of the family.
- Review of life and integration of values and accomplishments.
- Spiritual explorations and connectedness.
Figure. The cancer care continuum does not follow a linear model. Depending on the biological severity of the cancer, patient preferences, and provider recommendations, individuals will move in different sequences along the pathway. Specific psychological factors should be addressed in keeping with the phase on the cancer care continuum. Source: Trinidad AC, Kohrt BA, Norris L.
Studies have shown cancer treatment can lead to posttraumatic stress disorder-like symptoms.14 These can be avoided with CBT which, in certain conditions, has been demonstrated to have the equivalent effects of psycho-tropic medication in the treatment of depression and GAD.15 Other studies have shown that cognitive behavioral therapy can be helpful in alleviating the emotional disorders concomitant with various medical diagnoses such as cancer. Determining the point where a patient is on the cancer care continuum can help devise CBT strategies, since dysfunctional beliefs predictably occur at specific points on the continuum.
- Portenoy RK. Treatment of cancer pain. Lancet. 2011;377(9784):2236–2247. doi:10.1016/S0140-6736(11)60236-5 [CrossRef]
- Espie CA, Fleming L, Cassidy J, et al. Randomized controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients with cancer.. J Clin Oncol. 2008;26(28):4651–4658. doi:10.1200/JCO.2007.13.9006 [CrossRef]
- Gielissen MFM, Verhagen S, Witjes F, Bleijenberg G. Effects of cognitive behavior therapy in severely fatigued disease-free cancer patients compared with patients waiting for cognitive behavior therapy: a randomized controlled trial. J Clin Oncol. 2006;24(30):4882–4887. doi:10.1200/JCO.2006.06.8270 [CrossRef]
- Hopko DR, Bell JL, Armento M, et al. Cognitive-behavior therapy for depressed cancer patients in a medical care setting. Behav. 2008;39(2):126–136.
- Beck J. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed. New York: The Guilford Press; 2011.
- Hegel MT, Collins ED, Kearing S, Gillock KL, Moore CP, Ahles TA. Sensitivity and specificity of the Distress Thermometer for depression in newly diagnosed breast cancer patients. Psychooncology. 2008;17(6):556–560. doi:10.1002/pon.1289 [CrossRef]
- Dozois DJA, Bieling PJ, Patelis-Siotis I, et al. Changes in self-schema structure in cognitive therapy for major depressive disorder: a randomized clinical trial. J Consult Clin Psychol. 2009;77(6):1078–1088. doi:10.1037/a0016886 [CrossRef]
- Halford WK, Bernoth-Doolan S, Eadie K. Schemata as moderators of clinical effectiveness of a comprehensive cognitive behavioral program for patients with depression or anxiety disorders. Behav Modif. 2002;26(5):571–593. doi:10.1177/014544502236651 [CrossRef]
- Beck AT, Clark DA. An information processing model of anxiety: automatic and strategic processes. Behav Res Ther. 1997;35(1):49–58. doi:10.1016/S0005-7967(96)00069-1 [CrossRef]
- Costanzo ES, Sood AK, Lutgendorf SK. Biobehavioral influences on cancer progression. Immunol Allergy Clin North Am. 2011;31(1):109–132. doi:10.1016/j.iac.2010.09.001 [CrossRef]
- Chida Y, Hamer M, Wardle J, Steptoe A. Do stress-related psychosocial factors contribute to cancer incidence and survival?Nat Clin Pract Oncol. 2008;5(8):466–475. doi:10.1038/ncponc1134 [CrossRef]
- Petticrew M, Bell R, Hunter D. Influence of psychological coping on survival and recurrence in people with cancer: systematic review. BMJ. 2002;325(7372):1066. doi:10.1136/bmj.325.7372.1066 [CrossRef]
- Lemogne C, Consoli SM. Depression and cancer: challenging the myth through epidemiology. Psycho-Oncologie. 2010;4(1):22–27. doi:10.1007/s11839-010-0242-x [CrossRef]
- Schwabish SD. Cognitive adaptation theory as a means to PTSD reduction among cancer pain patients. J Psychosoc Oncol. 2011;29(2):141–156. doi:10.1080/07347332.2010.548440 [CrossRef]
- DeRubeis RJ, Siegle GJ, Hollon SD. Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms. Nat Rev Neurosci. 2008;9(10):788–796. doi:10.1038/nrn2345 [CrossRef]