Fear of Recurrence Norma Lee MA, MD, LMFT February 24, 2013 What we think, we become. All that we are arises with our thoughts.
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Transcript Fear of Recurrence Norma Lee MA, MD, LMFT February 24, 2013 What we think, we become. All that we are arises with our thoughts.
Fear of Recurrence
Norma Lee MA, MD, LMFT
February 24, 2013
What we think, we
become.
All that we are arises with
our thoughts. With our
thoughts, we make the
world.
The Buddha
God, grant me the serenity to
accept the things I cannot
change, the courage to
change the things I can, and
the wisdom to know the
difference.
Reinhold Neibuhr
•Fear of Recurrence
•Psychiatric Considerations
•Effects of Social Support
•Effects of Coping Style
•Cognitive Behavioral Therapy Techniques
•Mindfulness Based Practices
•Homework
Is Fear All Bad?
Beliefs/rules about the world either protect
you from or make you more vulnerable to
emotional distress
Too much fear means less problem solving
ability
Some degree of FOR helps people to
maintain medical follow up
•Every person has an illness representation
based on somatic experiences/sensations
•With an illness threat, cognitive and
emotional processing systems tell the
person how to act
•If experiences/sensations are based on
inaccurate information, the person’s illness
representation may be false
Self-Regulation
Model of Illness
May cause them to feel unnecessarily
worried, anxious or fearful
If illness representation makes sense to
person then they consider coping strategy to
be appropriate
When looking at coping strategies, must
consider person’s illness representation,
previous experiences and world view
Fear of Recurrence
Quality of physician communication during
initial diagnosis/initiation of treatment is a
critical determinant of subsequent
psychological well being
Not consistently related to time since
diagnosis
Concerns and worries may persist long term
Fear of Recurrence
Younger women more concerned about:
Potential disfigurement
Loss of femininity, disability
Feeling different or isolated
Distress associated with treatment
Fear of Recurrence
Younger women’s concerns:
Physical and mental quality of life
Perceived amount of impairment
Chemotherapy
Having children
Psychiatric Impact
Prevalence of psychiatric disorders 22-47%
4% of women with all stages of breast cancer
met criteria for PTSD
41% had subsyndromal criteria
Intense fear
Helplessness
Horror after being diagnosed
PTSD
Other signs of PTSD
Intrusive thoughts
Avoidance
Hyperarousal
PTSD symptoms correlated most
significantly with:
Lymphedema
Numbness in hands, feet or chest
Other physical problems
Depression & Anxiety
19% had depression
Almost 100% had some level of anxiety
Depression/anxiety levels affected by:
Being unaccompanied by spouse/partner
to follow up visits
Not having someone to share problems
with
Request to see a mental health provider
Using an alternative treatment
What Impacts Depression
& Anxiety Levels?
Sleep
Emotional Status
Fatigue
Body Appearance
Sense of Hopelessness
Uncertainty about the future
Why Depression is Harmful
Strong association between helplessness
and hopelessness, depression and shortened
survival
Depression makes the odds of not following
a treatment plan three times higher
Conversely, social support and a cohesive
family improve the odds of compliance with
medical care
Why Depression is Harmful
Persistently depressed women may be at risk
of not only poor QOL but also premature
death
They should be promptly referred for a
mental health assessment
Quick screen: Do you feel depressed?
Do things seem hopeless to you?
When to Consider Therapy
Your usual problem solving techniques and
coping skills aren’t working
You feel stuck
You need someone who will just listen
You feel like you’re going crazy
TALKING TO A THERAPIST DOES NOT
MEAN YOU ARE WEAK OR HAVE A
CHARACTER FLAW!!
Considering Medication
You are having significant difficulty getting
through the day
Consistently crying a lot
Consistently too anxious to do what needs
to get done
Feeling suicidal
Therapy vs. Medication
Medication works faster
Longer term outcomes are best with
combination of medication and therapy
Therapy teaches people skills they can use
forever
Distress may not be completely related to
cancer; therapy explores that
Social Support
Significant impact on quality of life
Women with high levels of support had no
meaningful impact on their QOL when they
had cancer related intrusive thoughts
For women with low levels of support, the
relationship between cancer related
intrusive thoughts and QOL was significant
and negative
Social Support
Women with fewer sources of support have
more fear of recurrence
Feeling understood by loved ones help
women to monitor their thoughts about
recurrence
Proximity to a loved one has a regulatory
effect on emotional functioning and helps to
control emotional and physiological
responses to stressors
Self-Efficacy
A person’s belief about his or her ability and
capacity to accomplish a task or to deal with
the challenges of life
Self-efficacy is a significant predictor of an
active adjustment style and emotional wellbeing
Coping & Coping Styles
Coping styles are learned, usually from one’s
family of origin
Related to illness representation
Prior traumatic and/or current stressful life
event can adversely affect one’s ability to
cope
Adaptive Coping
Active coping and problem-solving
techniques result in better mood and
adaptation
Flexibility in coping styles is crucial
Women who use available social resources
and support adapt better and may live
longer than women who don’t
Adaptive Coping
Internal locus of control
Proactive vs. reactive
Knowing what you can control (you) and
what you cannot (everyone else)
Acceptance of responsibility
Escape-avoidance
Maladaptive Coping
Women who are passive or feel hopeless or
pessimistic are rigid in their coping style;
may become isolated and reject help when it
is offered and adapt more poorly
Factors significantly associated with a high
or moderate FOR include a depressive and a
problem-oriented coping style (vs. an
affective-oriented coping style)
Maladaptive Coping
Internal and external cues can contribute to
fear of recurrence
Somatic
Friends/family
Women who believe they are at risk of
recurrence will be emotionally activated by
neutral stimuli
What Can Be Done To Help?
Women who received an intervention
designed to improve knowledge or coping or
to reduce distress did better than those who
didn’t
Less anxiety/depression, increased sense
of control, improved body image, better
sexual function, greater satisfaction with
care, improved medication adherence
Support Groups
Increasing evidence that participation in
group activity offers a uniquely supportive
and normalizing experience for many
people
Group therapy has the ability to enrich QOL
and help to prevent onset of depression
Added benefit with professional facilitator
Meaning Making Study
Routine care vs. four sessions that explored
meaning of thoughts and feelings regarding
one’s cancer experience within the context
of past events and future goals
Significantly higher levels of self-esteem,
optimism and self-efficacy in meaning
making group
Cognitive-Behavioral
Therapy (CBT)
Our thoughts (cognitions) influence how we
feel (emotions) and how we act (behaviors)
It is not the cancer itself that produces the
emotional response, but rather the meaning
of the cancer to that person
Principles of CBT
We all have automatic thoughts that are
based on experiences, not on reality
When people are anxious, two things occur:
They overestimate that something bad
will happen
They assume the worst
This is distorted thinking
How CBT Works
Cognitive reframing: for thoughts to be
valid, they must be based in reality
Goal is to have people develop the ability to
view a situation objectively
Is there another way to look at the
situation?
What is the worst thing that could
happen?
Could you handle it?
Principles of CBT
Relaxation techniques are a crucial part of
cognitive-behavioral therapy
The ability to relax when starting to feel
anxious makes people confident that they
can cope with other stressful situations
The ability to relax allows for clearer
thinking when problem solving
Principles of CBT
Exposure to feared situations is essential
Without exposure, people are able to
continue with distorted thinking which only
serves to increase behavioral and cognitive
avoidance
Mind/Body Practices
Variety of techniques designed to enhance
the mind’s capacity to influence bodily
functions and symptoms. Examples:
Relaxation, hypnosis, visual imagery,
biofeedback
Therapies involving spirituality or
expressive arts, such as visual art, music or
dance
Mind/Body Practices
Visualization relaxation is a skill that can be
learned; more practice leads to more
effectively being able to relax
Massage: helpful in relieving pain, anxiety,
fatigue and distress, as well as increasing
relaxation
Mind/Body Practices
A mindfulness-based practice such as
meditation may help alleviate cancer related
cognitive impairment by engaging the
person in an attention based mental activity
In cancer patients, mind/body therapies can
reduce anxiety, depression and mood
disturbances and assist their coping skills
Journaling
Very helpful for getting repetitive thoughts
out of your head
No editing!
Gratitude Journal: three things you’re
grateful for each day
Shown to decrease distress and improve
coping and functioning
Mindfulness Based
Stress Reduction
Standardized form of meditation and yoga
Trains people to reduce their perceived level
of stress by self-regulating arousal to
stressful situations or symptoms
Has been shown to be effective in reducing
anxiety, depression and stress in people with
chronic pain
Mindfulness Based
Stress Reduction
Mindfulness: learning to be present in life
as it is occurring, applying attitudes of
kindness, patience, curiosity, acceptance,
letting go and non-judging
Begin to realize the amount of emotional
energy spent regretting the past or worrying
about the future has resulted in missing the
present moment
Intervention
Six week modified program
Learned meditations, body scan,
visualization
Learned understanding of their reaction to
pleasant and unpleasant events
Had to practice daily
MSBR Study
Significantly reduced symptoms of anxiety,
depression, fear of recurrence
Improved indicators of physical and
emotional quality of life
Energy, sleep, pain, social functioning
FOR remained prominent over time with
70% of women having fear after five years
Effects of Stress
Stress related psychosocial factors are
associated with:
A higher cancer incidence in initially
healthy people
Poorer survival in people diagnosed with
cancer
Higher cancer mortality
The Best Study Ever
39 hours of sessions with a psychologist over
one year vs. regular care
Goals: reduce distress, improve QOL,
improve health behaviors (diet, exercise,
smoking cessation), facilitate cancer
treatment compliance and facilitate medical
follow up
Interventions
PMR for stress reduction
Problem solving for common issues, e.g.,
fatigue
Identifying supportive family/friends
capable of providing assistance
Using assertive communication to get one’s
psychological and medical needs met
Areas Addressed
Strategies to increase daily activity (walking,
exercise)
Improving dietary habits (decreasing fats)
Finding ways to cope with treatment side
effects e.g., nausea
Skills for maintaining adherence to medical
treatment and follow up
Results
Intervention group had:
Significantly lower risk of breast cancer
recurrence
Significantly lower risk of breast cancer
death
Significantly lower risk of all-cause
mortality
Results
If cancer recurred, it was six months later
than the control group
If someone died, it was over a year later than
in the control group
Which Patients Did Best?
Patients with greatest reduction in distress
and physical symptoms:
Practiced daily PMR
Understood and remembered daily that
continued stress could adversely affect
their health and that it could be
controlled/reduced by using the
intervention techniques
Other Interesting Results
Immune changes secondary to stress
hormones may promote cancer growth or
metastasis
As patients reported significant declines in
their emotional distress and were found to
have reduced symptoms and treatment
related toxicities, their immune function
was stabilized or improving
Other Interesting Results
In the 17 months before detection, patients
who had a recurrence were found to have
worsening immune function compared to
disease free patients
Those patients also had higher cortisol
levels and worse physical functioning,
fatigue and QOL during that period
Exercise & Stress
Reduction
Evidence for regular exercise is most
compelling for breast cancer survivors
Physical activity can improve mood,
decrease depression and anxiety, improve
body image and self esteem, reduce nausea
and fatigue, enhance cardiovascular
functioning, control weight, and potentially
alter immune function
Key Elements for Optimal
Outcomes
Access to state of the art cancer care
Active coping/active engagement in one’s care
Perceived availability and if needed, use of
social support
Having a sense of meaning or purpose in life
Can include someone to live for, spiritual
belief or connectedness, a way to make sense
of illness/ health, one’s place in the world
Homework
Put your own oxygen mask on first
Take time for yourself every day
Stop judging yourself and comparing
yourself to others; life isn’t a contest
Treat yourself as you would a friend
Definition of insanity: doing the same thing
over and over again and expecting different
results
Women are like teabags. We don’t know
our true strength until we are in hot water.
Eleanor Roosevelt