4.13 clinical psychology in PC

Question 1

Research has been done on the factors leading to psychological distress in patients and caregivers. What are the three major stressors identified in the pathways to distress? Provide an example of each

Answer 1

a. cancer related stressors
- tumor burden
- pain and physical symptoms
- fatigue

b. treatment related stressors
- treatment morbidity

c. psychological stressors
-cancer diagnosis and progression
-difficult decisions
social isolation
threat to identity
threat to sense of dignity
change in appearance

Question 2

In people with advanced medical illness a host of medical factors can contribute to psychological suffering. List four possible contributors and an example for each

Answer 2

metabolic conditions (hypo/hypercalcemia)
neuro conditions (pain, CNS neoplasm)
endocrine conditions (hypothyroidism, cushings)
CV conditions - arrhythmia, cardiomyopathy
pulmonary conditions (hypoxia, asthma, PE)
medications (steroids, bronchodilators, interferon, antibiotics)

Question 3

List three features of demoralization syndrome

Answer 3

affective symptoms of existential distress including hopelessness or loss of meaning/purpose of life

cognitive attitudes of pessism, helplessness, sense of being trapped; personal failure

absence of drive or motivation to cope differently

associated features of social alienation or isolation and lack of support

Question 4

Depression is very common amongst people with advanced illness. List 6 risk factors for depression in people with advanced illness, without naming any specific diagnoses

Answer 4

illness associated with limited functionality 
insecure attachments
poor symptom control 
younger age
family or individual hx of depression
low perceived social supports
low optimism 
low self esteem
poor social function
hx of traumatic events

Question 5

Suicidality does occur in people with advanced illness. Please list 5 risk factors for suicidality in people with advanced illness

Answer 5

uncontrolled pain
depression
feelings of helplessness and hopelessness
delirium
high unrelieved physical symptom burden 
low family support
being a burden to others

Question 6

Not all desire to die statements indicate that the patient immediately wants their life to be over. Research has identified four major processes that may be taking place for a patient in making a wish to die statement. What are these processes

Answer 6

1. Expression of feelings and current reaction to their circumstances such as loss of autonomy and sense of dignity
2. a communication of distress and suffering or a communication to explore other options of relieving their distress
3. seeking of information about suicide or euthanasia
4. specifically seeking health professional assistance with hastened death or acknowledging intent for suicide

Question 7

A patient you are working with makes a desire to die statement. What are 3 things you will do after hearing this statement?

Answer 7

evaluate and understand their symptoms

assessing:
- mental status
- vulnerability
- pain control
- support system
- recent losses
- prior psych hx including EtOH/substance abuse
- prior suicide attempts and threats

Question 8

Determining the aetiology of somatic symptoms in people with advanced illness is extremely difficult. As such, diagnosing depression can be challenging since many of its clinical features are somatic. List three approaches to overcoming this diagnostic problem and outline any issues that may arise from these methods

Answer 8

-focus on cognitive and psychological symptoms (hopelessness/ guilt) rather than somatic symptoms
pitfall - risk further underestimation of mental d/o such as depression in advanced illness

-Include all symptoms regardless of etiology
pitfall - overidentification of mental d/o

-Substitutive approach in which somatic symptoms are replaced in the assessment of pt patients with somatic diseases
pitfall - difficult to distinguish psychological symptoms vs normal adaptive emotional response to EOL

Question 9

You identify a patient you are following as having depression in the setting of advanced illness. You recommend a psychological intervention for the patient. The patient asks what types of psychological interventions are available. Please list four types of psychological interventions that can be used for depression at EOL

Answer 9

CBT
cognitive analytic therapy
narrative interventions
relaxation
guided imagery
mindfullness based interventions
meaning focused interventions 
art therapy 
dignity therapy