Psychosocial disorders are very common in patients with advanced malignancies with the commonest being anxiety and depression. Early identification and treatment will help in improving the quality of life of patients and their families and increasing compliance towards treatment and self care,

1. Adjustment disorders and
Distress in Palliative Medicine
TUTORIAL 17/03/2020
PRESENTER : DR RUPARNA KHURANA
MODERATOR : DR SUSHMA BHATNAGAR

2. • Definition (DSM V/ NCCN)
• Meaning : psychiatric disorder
• Context in palliative medicine
• What role do we play
• How to screen patients for an adjustment disorder and distress

3. DSM…
• Different categories of disorders??
PERSONALITY MOOD AFFECTIVE
TRAUMA NAD
STRESSOR RELATED
DISORDERS
• POST TRAUMATIC STRESS
DISORDER
• ACUTE STRESS DISORDER
• ADJUSTMENT DISORDERS
(INTRODUCED IN DSM III)

4. Umbrella term
• AD with depressed mood
• AD with anxiety
• AD with mixed depression
and anxiety
• AD with conduct
abnormality
• Unspecified

5. What all it includes
• Fall under the category of trauma and stressor related
disordres
• Transitory diagnosis
• Situational depression
• Subthreshold disorder
• Dump diagnosis

6. • many as 13% of inpatients in a general hospital
• situation, 10% in outpatients, and 13% in emergency rooms, In
• the general population, AD is associated with suicidal thoughts
• (30%); 58% of suicide attempters and 9–19% of suicide completers
• may be diagnosed with an AD. A study of 209 terminally ill cancer
• patients found that AD was present in 11–17%, compared to a
• depression prevalence of 7–12%; lower performance status, inadequate
• social support, and concern about being a burden were
• significantly associate

7. • medications, talking therapy,
• hypnosis, relaxation, and supportive therapy (McQuellon et al.,
• 1998; Roth and Massie, 2007; Arch and Craske, 2009; Otte et al.,
• 2011; Reinhold et al., 2011). Many patients find other complementary
• therapies helpful, which may include the entire gamut from
• meditation and reflexology, to Chinese herbs and spices (Wein,
• 2000; Anderson and Taylor, 2012).
• Talking therapies

8. • Adjustment disorder : group of emotional and behavioral symptoms
in response to a recognizable stressor
• Describes a maladaptive emotional and/or behavioural response to
an identifiable psychosocial stressor
• Experience difficulties adjusting after a stressful event
• Symptoms are disproportionate to the severity or intensity of the
stressor

9. • A group of emotional and behavioral disorders in response to a
variety of identifiable stressful events
• Symptoms represent an adaptation to these stressors or to their
continuing effects.
• Seen as far less stigmatizing

10. Epidemiology
• Principal diagnosis in OPD : 5% - 20%
• Approach 50% in hospital psychiatric consultation settings
• Women > Men

12. • Higher rate among persons exhibiting suicidal behavior, particularly
adolescents and young adults
• Three times more common as major depression (13.7 vs. 5.1%) in ill
medical inpatient

13. Stressors
• Knowledge that death is imminent
• family feuds
• inability to work
• financial crisi
• The perception of becoming a burden or losing control due to illness,
• physical pain or other symptoms, and being unable to complete
• life’s tasks, Other stressors relate to premorbid physical or psychiatric
• problems, such as obsessive–compulsive neurosis. Yet others
• occur as system issues, such as the threat of non-coverage by a
• health insurance company

14. • degree of distress and dysfunction that occur
• may vary with the severity and type of stressor, individual
• resilience, premorbid psychological health, education, and
preparation,
• support from family and health professionals, and other
• factors. Distress associated with adjustment is common, and to
• some extent, entirely normal

15. Etiology
• Single stressor to a symptom complex.
• The stressor The individual Interaction

17. • 5) Biological theorists

19. • Onset : within 3 month of a demonstrable stressor
• Duration of symptoms : not exceed 6 months
(except in prolonged depressive reaction)

20. • Diagnosis depends on a careful evaluation of the relationship
between
• (a)form, content, and severity of symptoms
• (b)previous psychiatric history and personality
• (c)stressful event, situation, or life crisis
• Normal bereavement

21. Management
Primary goals of treatment
 relieve symptoms
Achievement of a level of adaptive functioning that is comparable to,
or better than, the level of premorbid functioning.
• Brief therapies

22. • Supportive psychological approaches
• Cognitive-behavioral and psychodynamic interventions
• Relaxation techniques
• Assistance in finding alternative responses
• Date dialectical behavior therapy (DBT) has the best evidence base
• Practical measures may be useful to assist the person in managing the
stressful situation

23. • Ego enhancing therapy
• Coping strategy : helps the patient acknowledge the stressors.
• “Mirror therapy”

24. • Psychotherapy : treatment of choice
• Interpersonal psychotherapy : include psychoeducation about the
patient's role, a here and now frame work, formulation of the
problems from an interpersonal perspective, exploration of options
for changing dysfunctional behavior pattern

25. Pharmacological management
• Symptomatic treatment of insomnia, anxiety and panic attack
• Benzodiazepines and antidepressants

26. • DISTRESS

27. Definition
• Distress is a multifactorial unpleasant experience
of a psychological (ie, cognitive, behavioral, emotional)
social, spiritual, and/or physical nature
that may interfere with one’s ability to cope effectively
with cancer  its physical symptomsits treatment.

28. • Continuum
feelings of vulnerability/ sadness/fears
Depression, anxiety, panic, social isolation, and existential and
spiritual crisis.

29. Expected distress symptoms
• Fear and worry about the future
• Concerns about illness
• Sadness about loss of usual health
• Anger, feeling out of control
• Poor sleep/ appetite/ concentration/
• Preoccupation with thoughts of illness and death
• Concerns with disease/treatment side effects
• Concerns about social role (ie, as father, mother)
• Spiritual/existential concerns
• Financial worrie

30. Patients at increased risk of distress
• History of psychiatric disorder or substance use disorder
• History of depression/suicide attempt
• History of trauma and/or abuse (physical, sexual, emotional, verbal)
• Cognitive impairment
• Communication barriers
• Severe comorbid illnesses

31. Patients at increased risk of distress
• Social issues
• Family/caregiver conflicts
• Inadequate social support
• Living alone
• Financial problems
• Limited access to medical care
• Young or dependent children
• Younger age
• Immigration
• Loss of stable housing/shelter/living environment

32. Patients at increased risk of distress
• Current substance use
• Other stressors
• Spiritual/religious concerns
• Uncontrolled symptoms
• Cancer type associated with risk of depression (eg, pancreatic cancer,
head and neck cancer)

33. PERIODS OF INCREASED VULNERABILITY
• Finding / investigating a suspicious symptom
• During diagnostic workup
• Finding out the diagnosis
• Advanced cancer diagnosis
• Learning about genetic/familial cancer risk

34. PERIODS OF INCREASED VULNERABILITY
• Awaiting treatment
• Increase in symptom burden
• Significant treatment-related complication(s)
• Admission to/discharge from hospital
• Change in treatment modality
• Treatment failure
• End of active treatment
• Medical follow-up and surveillance
• Transition to survivorship
• Recurrence/progreression
• Transition to ned of life care

35. STANDARDS OF CARE FOR DISTRESS
MANAGEMENT
• Recognized, monitored, documented, and treated promptly at all
stages of disease and in all settings.
• Screening should identify the level and nature of the distress.
• Every patient should be screened at every medical visit

36. • Interdisciplinary institutional committees should be formed
to implement standards for distress management.
• Educational /training programs should be developed
• Licensed mental health professionals and certified chaplains
experienced in psychosocial aspects of cancer should be
readily available as staff members or by referral.
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37. • integral part of total medical care and is provided with appropriate
information about psychosocial services in the treatment center and
the community.
• Quality of distress management programs/services should be
included in institutional continuous quality improvemevnt project

38. • Ensure continuity of care
• Mobilize resources
• Consider medication to manage symptoms: Analgesics /Anxiolytics
Hypnotics/ Antidepressants/ Psychostimulants
• Support groups and/or individual counseling
• Family/couple/caregiver support and counseling
• Relaxation, meditation, creative therapies (eg, art, dance, music)
• Spiritual support
• Exercise
• Assess and strengthen coping strategies

39. • SCREENING TOOL FOR DISTRESS

41. MANAGEMENT
DT < 4
Managed by the primary oncology team
Expected distress
DT>4
Trigger a second line of questioning
Screen for anxiety/depression
Further referrals
Moderate-severe distreas
MILD DISTRESS
Prognostication/
communication/ Symptom
management

42. Positive screen for anxiety and depression
Referral to a mental health professional/ social worker/
spiritualcounselor
( problems identified in the Problem List)

43. Common symptoms that require further evaluation are
• Excessive worries and fears
• Excessive sadness, unclear thinking, despair and hopelessness
• Severe family problems/ social problems
• Spiritual or religious concerns

44. INTERVENTIONS
• Acknowledge/validate distress
• Clarify diagnosis, treatment options, and side effects
• Be sure patient understands disease and treatment options
• Discuss advance care planning
• Refer to appropriate patient education materials
• Educate patient that points of transition may bring increased
vulnerability to distress

45. Management strategies
PHARMACOTHERAPY
CBT/PSYCHOTHERAPY
ALTERNATIVE THERAPY

46. Alternative therapies
• Meditation, yoga, relaxation with imagery, massage, and music
therapy
• Depressive disorders and anxiety

47. NAM report
• CBT
• Supportive psychotherapy
• Family and couples therapy

48. Cognitive Behavioral Therapy
• Practicing relaxation techniques
• Enhancing problem-solving skills
• Identifying and correcting inaccurate thoughts associated with
feelings

49. • RCTs  CBT and cognitive-behavioral stress
management have been shown to effectively reduce psychological
symptoms (anxiety and depression)
as well as physical symptoms (pain and fatigue) in patients with cancer

50. Supportive Psychotherapy
• Flexibly meeting patients’ changing needs.
• Different types of group psychotherapy
• Supportive expressive group therapy
• Improve QOL/ psychological symptoms
• Improvements in mood and pain

51. SPT
• Expressive writing
• Supportive expressive group therapy
• Cognitive existential group therapy
• Meaning centred froup psychotherapy
• Dignity therapy