Acute Psychological Disorders
Cancer patients have higher rates of psychological disorders compared to the general population. Having a psychological disorder does not inherently constitute a psychiatric emergency. Acute psychological disorders are differentiated by severe symptoms that call for urgent action. This section reviews common acute psychological disorders that may present in oncology settings, brief psychosocial interventions, and guidance on when psychiatric referral is clinically indicated.
Cultural Considerations:
The cultural background of a person affects how they may present with psychosocial distress. Many cultures stigmatize mental health concerns and thus patients may present with predominantly somatic complaints of unclear origin and only disclose concerns about anxiety, depression, or coping concerns on closer exploration or in private settings. Patients may present with fatigue, headaches, abdominal pain, sleep complaints, dizziness, paresthesias, syncope, weakness, or pain complaints that are not explained by known physiologic problems. Detailed history and specific questioning about anxious or depressive symptoms may help a person to more clearly express their concerns and allow for properly directed treatment.
Common Acute Psychological Disorders Clinical Presentation
| Anxiety Disorder | Chronic, preexisting anxiety that is exacerbated by a cancer diagnosis and/or treatment. Common symptoms include irritability/anger, anxious mood, worry, and fear that is excessive and difficult to control. |
| Panic Attacks | Brief episode (i.e., several minutes) of severe anxiety and physiological arousal. Often comorbid with chronic or adjustment-related anxiety and depression. May be associated with claustrophobia/medical phobia (e.g., medical imaging, needles). |
| Depressive Disorder | Chronic, recurrent, or single episode of severe depressive symptoms exacerbated by a cancer diagnosis and/or treatment. Common symptoms include depressed mood, withdrawal from hobbies/interests, isolation, frequent crying, fatigue, appetite disturbance, sleep difficulties, fatigue, low self-worth, guilt, helplessness, hopelessness, and suicidal ideation. |
| Adjustment Disorder | Significant and short-term anxious and/or depressive symptoms in response to a stressful life event (e.g., cancer) that notably interfere with functioning. |
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Posttraumatic Stress Disorder (PTSD)
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Intense, disturbing emotions following traumatic experiences that persist over time and emerge with exposure to triggers related to the original trauma, typically with threats to a person’s safety or life. May manifest with intense anger/irritability, tearfulness, flashbacks, nightmares, or avoidance of triggering stimuli. |
| Substance Use Disorders | Uncontrolled use of a substance despite harmful consequences. May manifest as chronic escalation in use of prescribed controlled substances, inability to reduce use over time, or interference in ability to function due to impairment from effects of substances. |
| Bipolar Disorder | Episodes of intensely elevated or depressed mood lasting days or weeks. Elevated mood, termed mania, is characterized by decreased need for sleep, excessive energy and/or irritability. Psychotic symptoms may be present including auditory hallucinations, paranoia, or bizarre behavior. |
| Chronic Psychotic Disorders (Schizophrenia, Schizoaffective Disorder) | Chronic or episodic psychotic symptoms which can include disorganized thinking, bizarre behavior, paranoid or delusional thought content, or auditory hallucinations. Early cognitive decline and globally impaired functioning is common. |
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Brief Psychosocial Interventions:
Regardless of presenting concern, education, emotional support, and validation are integral elements of all psychosocial interventions. Below are brief, evidence-based interventions that can be tailored to a cancer patient’s unique needs.
| Positive events scheduling |
What to do: 1) Find out what activities promote relaxation/positive mood 2) Encourage the patient to schedule at least 1 activity per day or 3) Plan an activity for the future (e.g., vacation)
What it can help: Depression, Anxiety, Adjustment Disorders, Substance Use Disorders |
| Deep breathing |
What to do: 1) Prompt the patient to place their hand on their stomach, inhale slowly, and feel their stomach rise and fall with their breath 2) Instruct the patient to hold the breath for a few seconds and to exhale slowly 3) Encourage the patient to practice several times daily for maximum benefit 4) If a heart rate monitor is available, it may be used to demonstrate how deep breathing lowers heart rate and blood pressure
What it can help: Anxiety, Panic Attacks, Depression, Adjustment Disorders, PTSD, Bipolar Disorder, Chronic Psychotic Disorders |
| Promote support |
What to do: 1) Ask who are the people in their life they go to when times are tough 2) Encourage reaching out to these supports during this time 3) Provide resources on relevant support groups
What it can help: Depression, Anxiety, Panic Attacks, Adjustment Disorders, Substance Use Disorders, PTSD, Chronic Psychotic Disorders |
| Positive imagery |
What to do: 1) Instruct the patient to close their eyes and imagine a place that makes them feel calm and relaxed 2) Immerse the patient in the imaginal experience by asking sensory-related questions (e.g., “What do you see?” “What can you smell?” “What do you hear?” etc.)
What it can help: Anxiety, Panic Attacks, Depression, Adjustment Disorders |
| Positive distraction |
What to do: 1) Identify activities the patient can easily engage in to distract from troublesome worries/thoughts (e.g., television, puzzles, coloring, reading, listening to music) 2) Engage in conversation about pleasant topics (e.g., hobbies, interests, family)
What it can help: Anxiety, Panic Attacks, Depression, Adjustment Disorders, Substance Use Disorders, Bipolar Disorder, Chronic Psychotic Disorders |
| Rehearsal of feared procedures |
What to do: 1) Teach the patient relaxation techniques (i.e., deep breathing, positive imagery) to use throughout the procedure 2) Show the patient pertinent medical equipment and demonstrate how they work (e.g., MRI machine, immobilization device) 3) Educate the patient on what they can expect throughout the procedure and answer any questions
What it can help: Anxiety, Panic Attacks, PTSD |
| Progressive muscle relaxation |
What to do: 1) Instruct the patient to patient to take slow, deep breaths 2) During inhalation, prompt the patient to tense a muscle group (e.g., arms) and to hold the breath/tension for five seconds 3) Instruct the patient to release the tension during exhalation 4) Repeat with all major muscle groups (i.e., legs, torso, head and neck)
What it can help: Anxiety, Panic Attacks, Depression, Adjustment Disorders, PTSD, Bipolar Disorder, Chronic Psychotic Disorders |
| Grounding techniques |
What to do: 1) Instruct the patient to take slow, deep breaths 2) Orient the patient to their surroundings by having them engage their senses (e.g., playing soothing music, rubbing something soft, naming things they can see)
What it can help: Anxiety, Panic Attacks, PTSD, Bipolar Disorder, Chronic Psychotic Disorders |
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When to refer to specialty mental health providers:
Even with early identification and intervention, there will be instances in which referral for specialty mental health treatment (i.e., psychiatric and/or psychotherapeutic services) will be warranted to best treat acute psychological disorders. Signs that a patient may benefit from a mental health referral include:
- Concern for acute risk for harm to self or others (refer to chapter of suicidal ideation)
- Concern for acute psychotic symptoms (e.g., hallucinations, delusions, odd/impulsive behavior, disorganized thinking, flat affect)
- Severe symptoms that interfere with treatment, persist for weeks, or are unresponsive to the interventions above
- Substance intoxication or withdrawal
Conclusion:
Acute presentation and exacerbation of anxiety, panic attacks, depression, PSTD, substance use concerns, bipolar disorder, and chronic psychotic disorders are common in oncology settings. Given severity of symtpoms, timely assessment and treatment is essential for high quality, comprehensive care. Brief psychosocial interventions are effective for managing acute distress in cancer patients with psychological disorders.