Page 1647 - Hematology_ Basic Principles and Practice ( PDFDrive )

1468 Part VIII Comprehensive Care of Patients with Hematologic Malignancies

TABLE Common Symptoms of Psychiatric Disorders
90.2
Adjustment Disorder Depression Anxiety Posttraumatic Stress Disorder
The development of Symptoms that are present for a 2-week Excessive worry and anxiety The person has been exposed to a
emotional or behavioral period and a change from previous for at least 6 months; traumatic event
symptoms in response to functioning the person finds it
an identifiable stressor difficult not to worry
1. Marked distress that is 1. Depressed mood most of the day Anxiety and worry have to 1. Reexperiencing symptoms such as
in excess of what would 2. Marked diminished interest or pleasure have three of the six images, thoughts, and perceptions
be expected for 3. Significant weight loss or decrease or following symptoms: 2. Persistent avoidance of stimuli and
exposure to the stressor increase in appetite 1. Restlessness numbing of general responsiveness
2. Significant impairment 4. Insomnia or hypersomnia 2. Fatigue 3. Persistent symptoms of increased
in social or 5. Psychomotor agitation or retardation 3. Difficulty concentrating arousal: sleep issues, anger or
occupational 6. Fatigue 4. Irritability irritability, difficulty concentrating,
functioning 7. Feelings of worthlessness or guilt 5. Muscle tension hypervigilance, and exaggerated
8. Diminished ability to think or concentrate 6. Sleep disturbance startle response
9. Recurrent thoughts of death, suicidal
ideation, or a plan for suicide
Data from American Psychiatric Association: Diagnostic and statistical manual of mental disorders, ed 4, Arlington, VA, 2000, American Psychiatric Association.

who have severe mental illness, who often have a history of disregard Network (NCCN) guidelines have been updated to work towards
and neglect from providers. 99 implementing standard screening. Indeed these guidelines now clearly
Most patients manifest transient psychologic symptoms that are advocate for distress to be recognized, monitored, documented,
103
responsive to support, reassurance, and information about what to and treated promptly at all stages of disease. In a strong show of
expect regarding the cancer course and its treatment. Some require support for distress screening, the American College of Surgeons
more aggressive psychotherapeutic interventions, such as pharmaco- Commission on Cancer has required cancer centers to implement
therapy and ongoing psychotherapy. The following guidelines can screening programs for psychosocial distress as a criterion for further
assist the clinician in identifying those patients who exhibit behavior accreditation. 104
suggesting the presence of a psychiatric syndrome. One tool that is easy to administer and that patients report as
105
General guidelines designed to assist in distinguishing patients capturing their problems is the distress thermometer. The term
who should be referred for evaluation by a trained psychiatric clini- “distress” was selected as it was felt to be more acceptable and less
cian include the following: stigmatizing than other related terms (e.g., psychiatric, psychosocial,
emotional). The tool is similar to pain measurement scales that ask
1. History of psychiatric hospitalization or significant psychiatric/ patients to rate their pain on a scale from 0 to 10, and consists of
personality disorder. two parts. The first part is a picture of a thermometer, and patients
2. Persistent refusal, indecisiveness, or noncompliance with regard to are asked to mark their level of distress. A rating of 4 or above
needed treatment. indicates that a patient has symptoms indicating a need for evaluation
3. Persistent symptoms of anxiety and depression that are unrespon- by a mental health professional and potentially has a need for referral
sive to usual support from health care providers or family members; for services. On the second part, the patient marks items that relate
symptoms may present in the form of constant fear associated to his or her distress from a six-item problem list (Fig. 90.2). 105,106
with treatment and procedures or excessive crying and feelings of Multiple studies have validated the use of this distress thermometer
hopelessness that worsen rather than improve with time. in various oncologic settings including stem cell transplant. 107,108 Lee
4. Abrupt, unexplained change in mood or behavior. et al found that the distress thermometer was a useful tool for screen-
108
5. Insomnia, anorexia, diminished energy out of proportion to ing transplant patients before admission. Interestingly, pretrans-
expected treatment effects. plant distress appeared to be highly predictive of distress following
108
6. Persistent suicidal ideation. transplant and was a feasible marker to screen patients for distress.
7. Unusual or eccentric behavior or confusion (may be indicative of Yet controversy remains about whether distress screening is of critical
an organic mental disorder). importance as is highlighted in a recent systematic review that found
8. Excessive guilt and self-blame for illness. that the distress did not improve in screened patients as compared
9. Evidence of dysfunctional family coping or complex family issues. with those who received usual care. 109
After referral to a psychiatric specialist, one or a combination of
therapeutic modalities may be used. Cancer and its treatment may MANAGEMENT OF PSYCHOSOCIAL PROBLEMS
precipitate an exacerbation of an underlying mental illness to which
a patient was predisposed and that may require extensive treatment Interventions for these patients center on the uniqueness of the
(e.g., hospitalization for a psychosis, ongoing pharmacotherapy, or experience. In the initial phase of the experience, 50% of patients
106
psychotherapy). A discussion of these specialized forms of treatment have psychologic distress, including both anxiety and depression.
is beyond the scope of this chapter. The reader is encouraged to A growing body of literature provides evidence that patients may
110
consult an appropriate standard textbook. 100 experience PTSD. Increased length of survival from time of diag-
nosis has highlighted the need for psychopharmacologic, psycho-
therapeutic, and cognitive and behaviorally oriented interventions to
SCREENING FOR PSYCHOLOGIC DISTRESS reduce distress, promote adjustment, and improve quality of life
for patients with hematologic malignancies. Cognitive behavioral
A number of tools have been developed to screen for psychologic therapy is a promising intervention that has been used with transplant
distress, but adoption and consistent incorporation into clinical care patients and shown to decrease PTSD symptoms and overall dis-
111
has been slow. 101,102 Most recently, National Comprehensive Cancer tress. Because of the increasing complexity of patient care, a