Normal psychological response to cancer diagnosis

The diagnosis of cancer for most people results in a predictable psychological pattern of distress over several weeks. The meaning of cancer is usually that of possible death, with pain, possible disability or disfigurement from treatment, loss of independence and self-esteem, and possible loss of significant relationships due to changed appearance or disability. This normal response is characterized by three phases: initial denial, an acute turmoil phase, and a period of adaptation. (7) It is similar to the response which results when one hears catastrophic news of any kind. First is a period of initial disbelief and denial in which the person doubts the diagnosis and questions that it may be a mistake. This is followed by period of 1 to 2 weeks of a turmoil phase characterized by intrusive thoughts about death and disease, poor concentration, irritability, anxious and depressed mood, anorexia, and insomnia. Some actually have weight loss related to the anorexia, which they attribute to cancer progression. They may have motor restlessness, and inability to carry out daily activities owing to preoccupation with concerns for the future. The third phase is one in which the acute turmoil symptoms begin to diminish and the reality of illness becomes more tolerable. Hope returns with beginning a treatment plan and a clear course of action to deal with the disease. Patients return to their prior level of coping and their prior level of psychological adjustment. Patients with prior psychiatric or personality disorder will have their adaptation coloured by these pre-existing factors (e.g. presence of generalized anxiety disorder or a prior episode of major depression). A psychiatric history revealing a prior disorder or an Axis II personality diagnosis should alert the psychiatrist to the potential for exacerbation of the psychiatric disorder in the context of the stresses of cancer treatment.

The psychiatrist may be called to evaluate a patient and control the distress related to one of the three phases. Symptoms often reach criteria for an adjustment disorder, usually with anxious and depressed mood. Sometimes symptoms do not reach criteria for a DSM-IV diagnosis, but fall within the subsyndromal category which characterizes many patients with distress. Crisis intervention psychotherapy with an anxiolytic agent and/or selective serotonin reuptake inhibitor ( SSRI) often substantially reduces symptoms and shortens the turmoil phase. It is important to keep in mind that this pattern of distress seen at diagnosis of cancer is repeated at subsequent transitional points of the illness, but with greater depressive symptoms: on learning of recurrence or progression of disease, on learning of treatment failure, and with news that no more treatment is possible.

TableJ delineates behavioural and social factors that impact on cancer morbidity and mortality: lifestyle and behaviours, low socio-economic and educational status, early detection and treatment compliance, and availability of social supports.

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