13.3 (17.4) Fear, anxiety and adjustment disorders

Question 1

Existential suffering/threat:
1. How many pall patients experience this (%)?
2. Name 5 interventions

Answer 1

1. 80%
2. 5 interventions:

• Maintaining daily routine
• Music therapy
• Social interaction
• Living in present (mindfulness)
• Managing Cancer and Living Meaningfully (CALM) intervention - brief, semi-structured, 1 on 1 psychotherapeutic intervention to treat depression and existential threat for 3-6 months

Fs:
HOMMESS

Hope
Other: exercise, music
Meaning: Dignity, CALM
Mindfulness
Education: psycho education
Spiritual
Supports (support group)

Question 2

What % of pall patients experience
1. Depression
2. Anxiety
3. Adjustment disorder

Answer 2

1. 30%
2. 10%
3. 1 in 7

Question 3

What to focus on when diagnosing the following in pall patient:
1. Depression
2. Adjustment disorder

Answer 3

1. Dysphoric mood, self pity, pessimism, anhedonia (loss of interest/pleasure)
2. Decrease in social function

Question 4

Name 5 risk factors to depression, anxiety, adjustment disorders

Answer 4

Patient related:
- Younger age*
- Lower function*

Fears:
- Loss of control (physical, social life, identity)
- Uncertainties of living with advanced illness
- Future pain*
- Fear of dying process/impending death

Social:
- Concerns with being a burden to one’s carers*
- Lower satisfaction with social support*

FS:
Female
Young
Past history
Family history
Disease symptoms
Decrease function
Social isolation

Question 5

Therapeutic approach (non medication) to depression, anxiety, adjustment disorder

Answer 5

CBT

Meaning centred therapy (eg CALM, dignity therapy, meaning centred therapy (MCT))

Mindfulness based interventions (eg MSBR, mindfullness based cognitive therapy (MBCT))

Note - should be provided by trained mental health providers (not generalists)

FS: HOMMESS

Question 6

Therapeutic approach to fear of disease progression

Answer 6

The Munich approach - CBT based approch to confront fear and develop coping strategies

Question 7

Therapeutic approach to wish for hastened death

Answer 7

Meaning of life interventions (encouraging gratitide)

Dignity therapies (aiming to resolve past conflict, promiting feelings of peace)

Question 8

Therapeutic approach applicable to carers and families

Answer 8

Psychoeducation (building confidence in caregiver role)
Family meeting
Mindfulness based interventions (increase awareness of present moment)

Question 9

List two factors that would make low mood or anxiety pathological

Answer 9

the severity of symptoms

the extent of disruption to normal functioning or of homeostatic adaptation

Question 10

How is adjustment disorder different than MDD/anxiety disorders

Answer 10

Two keys for adjustment disorder

• Trigger related - Usually occuring within 3 months of stressor that is excessive or causes significant impairment in functioning (but not meeting criteria for MDD/anxiety disorders)
• Usually resolves in 6 months

Question 11

List 5 categories of adjustment disorder

Answer 11

depressed mood
anxiety
mixed anxiety and depressed mood
disturbance of conduct
disturbance on emotions and conduct

Question 12

List five symptoms of anxiety

Answer 12

restlessness
Irritability 
difficulty concentrating
increased muscle tension
somatization
acute stress with nightmares
sleep disturbance
worries that cannot be rationally allayed
panic like attacks

FS: BE SKIM
Blank minded
Easily fatigued
Sleep disturbance
Keyed up
Irritability
Muscle tension

Question 13

List four medical conditions (including 4 substances) that can contribute to anxiety/depression

Answer 13

Vascular - anemia
Infection
Neoplasm - delirium, brain mets
Degenerative - fatigue, physical burden of symptoms
Iatrogenic - steroids, ETOH, smoking, street drugs
Congenital
Autoimmune
Trauma
Endocrine - hypothyroid/hyperthyroid
Neuro - dementia, Parkinson’s

Question 14

List four general types of management approaches for depression, anxiety and adjustment disorders

Answer 14

medications

Cognitive therapies 
- talking therapies
- hypnosis

Behavioural therapies 
- relaxation

supportive therapies

Question 15

List four types of talk therapy that can be helpful for adjustment disorders and anxiety

Answer 15

CBT
meaning centred therapy (MCT)
mindfullness based cognitive therapy (MBCT)
dignity therapy
group psychotherapy

Question 16

List four outcomes of dignity therapy

Answer 16

improve dignity*
improve self esteem*
improve meaning*
reduce distress
reinforce the will to live*

Improve helpless, hopelessness, meaning

Question 17

Tamoxifen should not be used with which three antidepressants. Why?

Answer 17

paroxetine
fluvoxamine
fluoxetine
Duloxetine

Tamoxifen metabolized by CYP2D6 into active form. Above SSRIs inhibit CYP2D6 and can lower tamoxifen levels. All are inhibitors of 2D6.

Venlafaxine, desvenlafaxine, Mirtazapine = safe (or citalopram / es citalopram)