Purpose of This PDQ Summary
Overview
Normal Adjustment

Coping Theory General Factors Influencing Adjustment Situation-Specific Influences on Adjustment         Hearing the diagnosis         Active cancer treatments         Posttreatment         Recurrence         Survivorship

Psychosocial Distress

Prevalence and Predictors of Distress Screening         Model screening programs         Self-report screening instruments Psychosocial Assessment Psychosocial Interventions for Distress         Psychosocial interventions

The Adjustment Disorders

Prevalence Course Problems in Diagnosing Adjustment Disorders Treatment         Individual and group counseling and psychotherapy         Pharmacotherapy

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Purpose of This PDQ Summary

This PDQ cancer information summary provides comprehensive, peer-reviewed information for health professionals about normal adjustment issues, and the pathophysiology and treatment of psychosocial distress and the adjustment disorders. This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board.

Information about the following is included in this summary:

• Prevalence.
• Assessment.
• Treatment.

This summary is intended as a resource to inform and assist clinicians and other health professionals who care for cancer patients during and after cancer treatment. It does not provide formal guidelines or recommendations for making health care decisions. Information in this summary should not be used as a basis for reimbursement determinations.

This summary is also available in a patient version, which is written in less technical language, and in Spanish.

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Overview

Studies examining the prevalence of mental disorders in cancer [1,2] show that most cancer patients do not meet the diagnostic criteria for any specific mental disorder; however, many patients do experience a variety of difficult emotional responses.[3] To effectively match patient needs and treatment interventions, health care professionals must be able to distinguish the periodic difficulties that characterize normal adjustment from more serious mental disorders.

Psychosocial distress exists on a continuum (see figure below) ranging from normal adjustment issues through the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Adjustment Disorders;[4] to a level close to, but below, the threshold (i.e., meets some diagnostic criteria but not all) of diagnosable mental disorders; to syndromes that meet the full diagnostic criteria for a mental disorder (e.g., major depressive disorder). This summary focuses primarily on the less severe end of this continuum: the normal adjustment issues, psychosocial distress,[5] and the adjustment disorders. (Refer to the PDQ summaries on Anxiety Disorder, Depression, and Post-Traumatic Stress Disorder for more information.)

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The Distress Continuum

 |---------|--------------|------------------|---------------------|----------|
   Normal            Adjustment         Subthreshold        Diagnosable Mental
   Adjustment        Disorders      to Mental Disorders     Disorders (e.g., major depressive disorder)
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References

1. Derogatis LR, Morrow GR, Fetting J, et al.: The prevalence of psychiatric disorders among cancer patients. JAMA 249 (6): 751-7, 1983.  [PUBMED Abstract]
   
   
2. Massie MJ, Holland JC: Overview of normal reactions and prevalence of psychiatric disorders. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 273-82. 
   
   
3. Bisson JI, Chubb HL, Bennett S, et al.: The prevalence and predictors of psychological distress in patients with early localized prostate cancer. BJU Int 90 (1): 56-61, 2002.  [PUBMED Abstract]
   
   
4. American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000. 
   
   
5. NCCN practice guidelines for the management of psychosocial distress. National Comprehensive Cancer Network. Oncology (Huntingt) 13 (5A): 113-47, 1999.  [PUBMED Abstract]
   
   

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Normal Adjustment

Adjustment or psychosocial adaptation to cancer has been defined [1-5] as an ongoing process in which the individual patient tries to manage emotional distress, solve specific cancer-related problems, and gain mastery or control over cancer-related life events. Adjustment to cancer is not a unitary, single event, but rather a series of ongoing coping responses to the multiple tasks associated with living with cancer. Patients are faced with multiple challenges that vary with the clinical course of the disease. Common periods of crisis and significant challenge include diagnosis, treatment (surgery, radiation, and chemotherapy), posttreatment and remission, recurrence and palliative care,[6] and survivorship.[3] Each of these events has certain coping tasks, particular existential questions, many common emotional responses, and specific problems.

Normal or successful adjustment is indicated in patients who are able to minimize disruptions to life roles, regulate emotional distress, and remain actively involved in aspects of life that continue to hold meaning and importance.[5]

Coping refers to the specific thoughts and behaviors a person uses in his or her efforts to adjust.[2] Coping style refers to the most common, more frequent, and longer-term style of coping that an individual tends to use across a variety of life situations. One’s coping style is often closely related to one’s overall disposition and personality (e.g., optimism, pessimism, introversion, extroversion).[7]

Coping strategies refer to those less frequently used and more situation-specific coping efforts, such as readjusting one’s daily routine or work schedule to adjust to the side effects of cancer treatment. Coping strategies are engaged in an effort to adjust. Although there are many successful coping strategies, three broad categories have been noted:[2,8-10]

1. Problem-focused.
2. Emotion-focused.
3. Meaning-focused.

Problem-focused strategies help patients manage specific problems by directly trying to alter problem situations. Emotion-focused strategies help a person regulate his or her degree of emotional distress, and meaning-focused strategies help patients understand why this has happened and what impact cancer will have on their life. In general, persons who adjust well typically remain committed and actively engaged in the process of coping with cancer and continue to find meaning and importance in their lives. Conversely, persons who do not adjust well often become disengaged, withdraw, and feel hopeless. Thus, assessing the degree of engagement versus giving up may be a way to distinguish between successful and unsuccessful adjustment.[5] For example, in a correlational study of adolescent cancer patients and their parents, engagement coping by the adolescent (including cognitive restructuring, seeking social support, expressing emotions, and problem solving) was associated with lower levels of distress; conversely, disengagement coping by parents (including problem avoidance, wishful thinking, social withdrawal, and self-criticism) was associated with increased distress.[11] In a prospective investigation of different types of problem-focused coping strategies,146 women with early-stage breast cancer were studied. Study results showed that a strategy of concentrating on symptoms, measured at the end of treatment, was predictive of less improvement in physical and mental quality of life at 6 months follow-up, while a strategy of information seeking was associated with greater improvement in physical quality of life. These findings suggest that problem-focused coping consists of a variety of specific coping strategies, some of which may be beneficial while others may not be beneficial to quality of life.[12]

In fact, one criticism of the literature on coping with cancer focuses on the assumption that “coping with cancer” is a single unitary event. In reality, coping with cancer involves coping styles and strategies that may differ and vary according to the nature of the stressors being encountered. For example, in a study of 52 adults receiving palliative care for cancer, patients participated in a semistructured interview during which they were asked about their most significant stressors and how they coped with these stressors. Three stressor domains were identified (social, physical, and existential), as were three categories of coping (problem-focused, emotion-focused, and emotion-focused avoidance). Results showed that most participants used a range of coping strategies; however, there were interactions between stressor domains and coping categories. Problem-focused strategies were used less frequently for the existential stressors, while emotion-focused strategies were used less frequently for the physical stressors.[13]

One cognitive theory of coping [14] proposes that in response to significant life events, a person asks two important questions: “Is this event personally significant to me?” and “What resources do I have to manage/control this event?” When an event is perceived to be of personal significance (nearly all cancer-related life events would be) and when one’s personal resources are perceived to be inadequate to the demands of managing the event, distress can occur. One way to conceptualize the amount of distress experienced by patients is the balance or ratio between perception of the demands that a situation (e.g., chemotherapy) places upon them and perception of the resources they possess (e.g., effective antiemetics) to effectively manage these demands:

Distress = Perceived Demands/Perceived Resources

Individuals with the same diagnosis or treatment regimen may experience very different levels of distress. A high level of distress could result from an individual’s perceptions that either the demands of a situation are very high or his or her resources are very low (or both). Conversely, low distress is the result of a perception that either the demands of a situation are very low or the individual’s resources are high.[15] To lower distress, therefore, either the perceived demands of the situation should be lowered, or the perceived resources should be increased.

Although there are some commonalities in normal adjustment to the varying stressors of cancer, there are also many individual differences. It is difficult to predict how individuals will cope with cancer, so it is important to recognize factors that influence adjustment to cancer. One study of women with stage II or III breast cancer reported that higher levels of stress measured postsurgically at the time of diagnosis predicted lower physical and psychological quality of life. The stress measures included (a) number of stressful life events in the past year, (b) cancer-related traumatic stress symptoms, and (c) perceived global stress; all measures were predictive.[16] Another study evaluated women with stage 0 breast cancer to stage III breast cancer (N = 89) at three time points: during treatment, at 3 weeks following end of treatment, and at 3 months posttreatment. Most survivors showed good adjustment on general distress indices. The factors predicting sustained distress included young age, history of depression or anxiety, and more extensive treatment. Younger age was the only factor that predicted greater distress across all evaluated measures.[17] Psychosocial adjustment/adaptation has been determined to be influenced by three broad categories of factors: cancer-derived, patient-derived, and society-derived.[4,18] Cancer-derived factors include the type of cancer, its stage, and its prognosis, as well as where a patient falls in the cancer continuum of diagnosis, treatment, and recurrence. Patient-derived factors include two types of resources: intrapersonal coping resources and interpersonal social support [19,20] (e.g., family support),[21] as well as consideration for stage of life [22] (i.e., developmental tasks—young adults may respond quite differently from older adults). Society-derived factors include the general societal views of cancer (e.g., stigma), as well as the influence society has on issues such as availability of treatments, open versus closed discussion of the illness, and popular beliefs about cause. The personality traits of optimism and pessimism might play a critical role in the psychological well-being of cancer patients. A German study investigated the impact of optimism and pessimism on psychological well-being in 161 newly diagnosed cancer patients with heterogeneous cancers.[23] Patients were assessed for optimism/pessimism and positive/negative emotions before the start of their first chemotherapy session and at 9 months' follow-up. Before the start of chemotherapy, psychological well-being was associated with higher optimism and lower pessimism. Only pessimism predicted negative change in psychological well-being at the 9-month follow-up. Additionally, only pessimism predicted heightened perception of chemotherapy-related side effects.

The availability of social support, as part of a social network, has been found to be related to mortality from breast cancer. In a longitudinal study of 2,835 female nurses with breast cancer, those who, before diagnosis, reported no close contacts (i.e., relatives, friends, or living children) had a twofold increased risk of mortality from breast cancer, compared with those who had more social contacts (i.e., 10 or more close relatives). This increased mortality was only found when comparing these two extremes in social ties, suggesting that women with relatively few social contacts or an intermediate number of contacts may not be at increased risk. Overall, these results suggest the important role of close relatives willing to step in and provide needed care.[19]

The process of adjusting to cancer can begin even before a diagnosis. Patients may respond with normal levels of fear, worry, and concern when they have unexplained symptoms or when they realize that they are undergoing testing to determine the presence of cancer. When they hear the diagnosis, their fears become realized, generating a psychological and existential plight (crisis).[24] Many people wonder, “Could I die from this?”

Receiving a diagnosis of cancer results in a crisis that includes expected and normal emotional distress. One author [25] has described the normal responses to the crisis of cancer as consisting of three phases:

1. Initial response.
2. Dysphoria.
3. Adaptation.

Phase I, the initial response, consists of disbelief, denial, and shock that the news is true. Some patients will attempt to prove that the diagnosis is not true (“Are you sure you have the right test results?”). Most patients will report a period of disbelief accompanied by an inability to clearly process information. They may feel numb or in shock, or as if, “This can’t be happening to me.” Such a high level of distress can be problematic because many times, immediately after informing patients of their diagnosis, physicians outline the treatment options. Under these emotional circumstances, many patients may be unable to understand or remember this important information. Thus, the presence of others or other means of being able to review the information can be extremely important (e.g., tape recording the discussion about the treatment plan or providing a second appointment at a later date, specifically for reviewing the treatment plan). Although there are many individual differences, this initial response of disbelief, denial, and shock usually lasts about a week in patients who adjust well.

Phase II, dysphoria, consists of a variable period of time (but usually lasting 1–2 weeks) during which the patient is slowly acknowledging the reality of the diagnosis. During this time patients will typically begin to experience a significant degree of distress in the form of depression, anxiety, insomnia, anorexia, poor concentration, and varying degrees of inability to function in daily roles. Intrusive thoughts of illness and death may occur very often and seem to be uncontrollable. As more information about treatment options is provided, correctly processed, and understood, feelings of hope and optimism begin to emerge more frequently through the dysphoria. Distress levels can be elevated for newly diagnosed patients awaiting surgery. Additional professional support to address problems such as fatigue, insomnia, and depressed mood can be helpful during this time.[26]

Phase III, longer-term adaptation, consists of the extended time during which more long-lasting and permanent adjustment occurs. This period consists of weeks and months. During this period, patients are utilizing a variety of coping strategies and styles.[9] Coping styles are longer-term, established ways for coping with many previous life events; coping strategies are situation-specific efforts to resolve particular cancer-related situations. This combination of longer-term coping styles and short-term coping strategies usually serves persons well in their efforts at adaptation. There is no single best way to cope. The individual differences persons bring to their encounters with cancer will result in varied coping styles and strategies.[5]

During the active treatment phase of the illness, a patient’s adjustment is focused primarily on coping with the many and varied stressors of treatment. These may include apprehension and fears about painful procedures, unwanted side effects (hair loss, nausea/vomiting, fatigue, pain), and disruptions to daily life. Disruptions that include changes in life roles are difficult for many patients (e.g., the breadwinner who can no longer work). Patients who adjust well are able to tolerate these short-term stressors via a cost-benefit approach in which they weigh the discomforts of short-term loss against the benefits of long-term gains (e.g., increased survival) and conclude, “It is worth it.”[25] Questions that often occur during active treatment include, “Will I survive this?” or “Will they get it all?” or “What side effects will I experience?” As these and related questions arise, patients utilize coping styles and strategies to adapt. Although many different coping strategies are useful during this phase, problem-focused coping—strategies designed to manage specific problem situations (e.g., fatigue, transportation to treatments, altered work schedules, role changes)—are often utilized.

Before active treatments are completed, most patients look forward to the conclusion of treatment with positive anticipation and hopes of returning to normal. However, the completion of active treatment can be a time of great ambivalence for cancer patients and their families. The completion of treatments suggests a time of celebration and relief, yet it can also be a time of heightened distress, with a renewed sense of vulnerability that comes with the cessation of active medical efforts to fight the disease.[27] Those who adjust well are able to balance their positive expectations with the realities of ongoing fears and apprehensions. Many patients report enhanced anxiety and worry related to fears of recurrence and decreasing frequency of medical surveillance via less frequent physician contacts. Other adjustment issues include living with uncertainty, returning to previous life roles, and hypervigilance to health concerns.[6] During remission, patients begin a sequence of regular follow-up appointments with their oncologist. Normal anxiety and worry often intensify as the dates of follow-up appointments approach. Normal anxiety comes from concerns about recurrence and the related emotional consequences (e.g., re-entry into the patient role and renewed feelings of loss of control).[28] Many patients find waiting for test results to be a particularly distressing experience.

In one of the few empirical studies of posttreatment adjustment, 94 women with stage 0, I, II, or III breast cancer who were completing radiation therapy were assessed on measures of depression, anxiety, and quality of life on the last day of treatment and at 2 weeks, 4 to 6 weeks, 3 months, and 6 months posttreatment. Results found elevated symptoms of depression, low-level anxiety, and diminished quality of life on the last day of treatment; however, by 2 weeks later, symptoms of depression decreased significantly and quality of life improved significantly. No other significant changes were found at any of the later posttreatment time periods, suggesting improvements in depression and quality of life occur quickly in most patients.[29]

In regard to predictors of posttreatment distress, a longitudinal, observational study of 151 women with early-stage breast cancer found that physical symptoms and side effects experienced during treatment were predictive of posttreatment cancer-related distress, amounting to 6% of the total 24% of variance accounted for.[30]

Normal adjustment to posttreatment and remission involves utilization of a variety of coping strategies; however, this phase often involves the frequent use of emotion-focused coping strategies (those designed to help regulate the normal emotional distress), given the variety of ambivalent emotional reactions. Those who adjust well are more likely to be comfortable expressing a wide range of both positive and negative emotions. Emotion-focused coping strategies include an honesty with one’s emotions, an awareness of one’s feelings, a nonjudgmental acceptance of one’s feelings, an ability to articulate these feelings to others, a willingness to approach the task of working through these emotions, and availability of support from others willing to listen and accept.

The transition from a curative treatment plan to one of palliative care is extremely difficult for cancer patients.[25] Extreme anguish often accompanies this transition as the patient faces renewed psychological distress, physical symptoms, and the existential crisis of death, all of which combine to result in the suffering often associated with advanced cancer.[31]

The normal adjustment to this crisis is characterized by initial shock, disbelief, and denial followed by a period of significant distress (e.g., depressed mood, difficulty concentrating, frequent intrusive thoughts of death). Normal adjustment may include periods of significant sadness and crying, periodic feelings of anger at God or one’s perceived higher power, periods of withdrawal and isolation, and even thoughts of giving up. However, as with the initial diagnosis, this distress is often followed by a gradual adjustment over a period of weeks. It is important to note that these common reactions do not necessarily indicate psychopathology. Although the intensity of these emotions might be similar to more severe psychopathology, their frequency of occurrence and duration tend to be shorter. Patients experiencing normal adjustment to recurrence and palliative care will typically rally from these strong emotions more quickly than those experiencing a true mental disorder. (Refer to the PDQ summaries on Depression, Anxiety Disorder, and Post-traumatic Stress Disorder for more information.)

Adjustment to recurrence and palliative care often involves shifting expectations from cure to healing. From this perspective, healing involves a process of becoming whole again,[32] of transforming one’s life in a variety of ways in the face of death. This process of adjustment involves maintaining hope, which is viewed as crucial in overall adaptation to crisis.[33] The patient who successfully adjusts to the crisis of recurrence often shifts expectations and maintains hope in a variety of meaningful life activities. For example, a patient who has confidence that pain and suffering can be controlled will have hope for future quality of life. Patients who believe they are loved and cared for will have hope in their future relationships. Religion and spirituality play a very important role in helping many patients maintain hope. Religion or spirituality can provide a belief structure that helps in coping with the crises of recurrence. During recurrence and palliative care, patients are likely to utilize meaning-based coping strategies and are likely to seek comfort in prayer and in their religious practices/rituals or spiritual beliefs. In addition, one study suggests that prognostic awareness in combination with inner peace is associated with better mental health and quality of death outcomes for patients with advanced cancer and for their surviving caregivers during bereavement.[34]

In a study of women with recurrent breast cancer, significant impairments in physical, functional, and emotional well-being were found within 1 month after recurrence; however, a patient’s self-efficacy (confidence in his or her ability to manage the demands of illness), social support, and family hardiness (family’s internal strength and ability to manage hardship and change) had positive effects on quality of life. Conversely, more distress about physical symptoms, additional life concerns, a sense of hopelessness, and a negative perception of illness or caregiving were associated with a lower quality of life.[35]

The adjustment from posttreatment to long-term survivorship is gradual and extends over many years. However, most patients, despite various cancer diagnoses and treatments, adjust well,[3] with some even reporting benefits to a cancer diagnosis (e.g., greater appreciation of life, reprioritizing of life values, strengthening of spiritual or religious beliefs).[36-39] Patients who have poorer adjustment tend to have greater medical problems, fewer social supports, poorer premorbid psychological adjustment, and fewer economic resources.[3]

As cancer treatments have improved, cancer is becoming a chronic illness, particularly with certain cancer types (e.g., prostate, breast). Each of the various psychosocial areas of functioning with a chronic illness has its own unique adjustment issues. For example, long-term adjustment to being a survivor of cancer involves considerations of how one adjusts psychologically, socially, sexually, vocationally, and of course, physically.

In general, studies of cancer survivors and healthy comparison groups have found no significant differences in measures of psychological distress, marital and sexual adjustment, social functioning, and overall psychosocial functioning.[3] However, there are some common areas of distress experienced by many cancer patients that are subthreshold or not severe enough to meet diagnostic criteria. These may include anxiety about recurrence, increased sense of vulnerability, lowered sense of control, conditioned reminders of chemotherapy (smells, sights) that produce anxiety and nausea, posttraumatic stress-like symptoms (such as persistent, intrusive thoughts, recurrent imagery associated with cancer treatments, feelings of estrangement from others),[40] and concerns about body image and sexuality.[3]

In one of the few prospective longitudinal studies of cancer survivors, 752 patients from 3 U.S. states were asked about a variety of psychosocial problems. About 1 year after diagnosis, 68% were concerned with their illness returning, approximately 60% were worried about recurrence, and 58% had fears of the future. In addition, approximately two out of three survivors were concerned about a physical health problem such as fatigue and loss of strength. Approximately 48% reported concerns with sleep difficulties, and 48% reported concerns with sexual dysfunction. Younger survivors (aged 18–54 years), women, nonwhites, unmarried survivors, and those with lower incomes reported more problems. In comparisons of four common cancers, the most concerns regarding problems in living were reported by those with lung cancer, followed by survivors of breast, colorectal, and prostate cancers.[41]

A large (n = 660) longitudinal study of women breast cancer survivors older than 65 years investigated factors associated with changes in emotional well-being. The overall findings suggest that the 5-year survivorship experience for most women is relatively stable, with few changes in emotional well-being. However, it was noted that women who had fewer than 12 years of formal education and women who perceived themselves as “never being cured” were more likely to experience declines in emotional well-being, while those who had better physical functioning, good emotional support, and the perception of positive physician-patient communication were less likely to have poor emotional health.[42]

References

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2. Folkman S, Greer S: Promoting psychological well-being in the face of serious illness: when theory, research and practice inform each other. Psychooncology 9 (1): 11-9, 2000 Jan-Feb.  [PUBMED Abstract]
   
   
3. Kornblith AB: Psychosocial adaptation of cancer survivors. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 223-41. 
   
   
4. Nicholas DR, Veach TA: The psychosocial assessment of the adult cancer patient. Prof Psychol 31 (2): 206-15, 2000. 
   
   
5. Spencer SM, Carver CS, Price AA: Psychological and social factors in adaptation. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 211-22. 
   
   
6. Loscalzo M, Brintzenhofeszoc K: Brief crisis counseling. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 662-75. 
   
   
7. Schou I, Ekeberg Ø, Ruland CM, et al.: Pessimism as a predictor of emotional morbidity one year following breast cancer surgery. Psychooncology 13 (5): 309-20, 2004.  [PUBMED Abstract]
   
   
8. Pearlin LI, Schooler C: The structure of coping. J Health Soc Behav 19 (1): 2-21, 1978.  [PUBMED Abstract]
   
   
9. Rowland JH: Intrapersonal resources: coping. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 44-57. 
   
   
10. Ahmad MM, Musil CM, Zauszniewski JA, et al.: Prostate cancer: appraisal, coping, and health status. J Gerontol Nurs 31 (10): 34-43, 2005.  [PUBMED Abstract]
    
    
11. Trask PC, Paterson AG, Trask CL, et al.: Parent and adolescent adjustment to pediatric cancer: associations with coping, social support, and family function. J Pediatr Oncol Nurs 20 (1): 36-47, 2003 Jan-Feb.  [PUBMED Abstract]
    
    
12. Ransom S, Jacobsen PB, Schmidt JE, et al.: Relationship of problem-focused coping strategies to changes in quality of life following treatment for early stage breast cancer. J Pain Symptom Manage 30 (3): 243-53, 2005.  [PUBMED Abstract]
    
    
13. De Faye BJ, Wilson KG, Chater S, et al.: Stress and coping with advanced cancer. Palliat Support Care 4 (3): 239-49, 2006.  [PUBMED Abstract]
    
    
14. Lazarus RS, Folkman S: Stress, Appraisal, and Coping. New York, NY: Springer Publishing Co, 1984. 
    
    
15. American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000. 
    
    
16. Golden-Kreutz DM, Thornton LM, Wells-Di Gregorio S, et al.: Traumatic stress, perceived global stress, and life events: prospectively predicting quality of life in breast cancer patients. Health Psychol 24 (3): 288-96, 2005.  [PUBMED Abstract]
    
    
17. Costanzo ES, Lutgendorf SK, Mattes ML, et al.: Adjusting to life after treatment: distress and quality of life following treatment for breast cancer. Br J Cancer 97 (12): 1625-31, 2007.  [PUBMED Abstract]
    
    
18. Holland JC: Clinical course of cancer. In: Holland JC, Rowland JH, eds.: Handbook of Psychooncology: Psychological Care of the Patient With Cancer. New York, NY: Oxford University Press, 1989, pp 75-100. 
    
    
19. Kroenke CH, Kubzansky LD, Schernhammer ES, et al.: Social networks, social support, and survival after breast cancer diagnosis. J Clin Oncol 24 (7): 1105-11, 2006.  [PUBMED Abstract]
    
    
20. Arora NK, Finney Rutten LJ, Gustafson DH, et al.: Perceived helpfulness and impact of social support provided by family, friends, and health care providers to women newly diagnosed with breast cancer. Psychooncology 16 (5): 474-86, 2007.  [PUBMED Abstract]
    
    
21. Baider L, Ever-Hadani P, Goldzweig G, et al.: Is perceived family support a relevant variable in psychological distress?. A sample of prostate and breast cancer couples. J Psychosom Res 55 (5): 453-60, 2003.  [PUBMED Abstract]
    
    
22. Ganz PA, Guadagnoli E, Landrum MB, et al.: Breast cancer in older women: quality of life and psychosocial adjustment in the 15 months after diagnosis. J Clin Oncol 21 (21): 4027-33, 2003.  [PUBMED Abstract]
    
    
23. Pinquart M, Fröhlich C, Silbereisen RK: Optimism, pessimism, and change of psychological well-being in cancer patients. Psychol Health Med 12 (4): 421-32, 2007.  [PUBMED Abstract]
    
    
24. Weisman AD, Worden JW: The existential plight in cancer: significance of the first 100 days. Int J Psychiatry Med 7 (1): 1-15, 1976-77.  [PUBMED Abstract]
    
    
25. Holland JC, Gooen-Piels J: Principles of psycho-oncology. In: Holland JC, Frei E, eds.: Cancer Medicine e.5. 5th ed. Hamilton, Ontario: B.C. Decker Inc, 2000, pp 943-58. 
    
    
26. Visser MR, van Lanschot JJ, van der Velden J, et al.: Quality of life in newly diagnosed cancer patients waiting for surgery is seriously impaired. J Surg Oncol 93 (7): 571-7, 2006.  [PUBMED Abstract]
    
    
27. Sherman AC, Simonton S: Family therapy for cancer patients: clinical issues and interventions. The Family Journal: Counseling and Therapy for Couples and Families 7(1): 39-50, 1999. 
    
    
28. Harpham WS: After Cancer: A Guide to Your New Life. New York, NY: WW Norton & Company, 1994. 
    
    
29. Deshields T, Tibbs T, Fan MY, et al.: Ending treatment: the course of emotional adjustment and quality of life among breast cancer survivors immediately following radiation therapy. Support Care Cancer 13 (12): 1018-26, 2005.  [PUBMED Abstract]
    
    
30. Jim HS, Andrykowski MA, Munster PN, et al.: Physical symptoms/side effects during breast cancer treatment predict posttreatment distress. Ann Behav Med 34 (2): 200-8, 2007 Sep-Oct.  [PUBMED Abstract]
    
    
31. Cherny NI, Coyle N, Foley KM: Suffering in the advanced cancer patient: a definition and taxonomy. J Palliat Care 10 (2): 57-70, 1994 Summer.  [PUBMED Abstract]
    
    
32. Dienstfrey H: Training for cancer: an interview with Michael Lerner. Advances: The Journal of Mind-Body Health 10 (2): 27-37, 1994. 
    
    
33. Beck AT, Weissman A, Lester D, et al.: The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol 42 (6): 861-5, 1974.  [PUBMED Abstract]
    
    
34. Ray A, Block SD, Friedlander RJ, et al.: Peaceful awareness in patients with advanced cancer. J Palliat Med 9 (6): 1359-68, 2006.  [PUBMED Abstract]
    
    
35. Northouse LL, Mood D, Kershaw T, et al.: Quality of life of women with recurrent breast cancer and their family members. J Clin Oncol 20 (19): 4050-64, 2002.  [PUBMED Abstract]
    
    
36. Polinsky ML: Functional status of long-term breast cancer survivors: demonstrating chronicity. Health Soc Work 19 (3): 165-73, 1994.  [PUBMED Abstract]
    
    
37. Curbow B, Somerfield MR, Baker F, et al.: Personal changes, dispositional optimism, and psychological adjustment to bone marrow transplantation. J Behav Med 16 (5): 423-43, 1993.  [PUBMED Abstract]
    
    
38. Belec RH: Quality of life: perceptions of long-term survivors of bone marrow transplantation. Oncol Nurs Forum 19 (1): 31-7, 1992 Jan-Feb.  [PUBMED Abstract]
    
    
39. Tartaro J, Roberts J, Nosarti C, et al.: Who benefits?: distress, adjustment and benefit-finding among breast cancer survivors. J Psychosoc Oncol 23 (2-3): 45-64, 2005.  [PUBMED Abstract]
    
    
40. Smith MY, Redd WH, Peyser C, et al.: Post-traumatic stress disorder in cancer: a review. Psychooncology 8 (6): 521-37, 1999 Nov-Dec.  [PUBMED Abstract]
    
    
41. Baker F, Denniston M, Smith T, et al.: Adult cancer survivors: how are they faring? Cancer 104 (11 Suppl): 2565-76, 2005.  [PUBMED Abstract]
    
    
42. Clough-Gorr KM, Ganz PA, Silliman RA: Older breast cancer survivors: factors associated with change in emotional well-being. J Clin Oncol 25 (11): 1334-40, 2007.  [PUBMED Abstract]
    
    

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Psychosocial Distress

Nearly every patient having to deal with a wide variety of stressors at different stages of disease and treatment experiences some level of distress;[1,2] however, only a small percentage of those in distress are currently receiving appropriate help.[3] Recent standards of care have been developed for the management of psychosocial distress.[1]

The National Comprehensive Cancer Network (NCCN) [1] has the broad goal of establishing standards of care so that all patients experiencing psychosocial distress will be accurately and routinely identified, recognized, and treated. These guidelines include recommendations for screening, triage, and initial evaluation, as well as referral and treatment guidelines for each participating profession: mental health (psychology and psychiatry), social work, palliative care, and pastoral care. Times most likely to require screening include those periods in the course of the illness when distress is most likely, such as shortly following diagnosis, start of treatment (surgery, radiation, chemotherapy), conclusion of a long course of treatment, periodically during posttreatment and remission, at time of recurrence, and with the transition to palliative care.

Because there continues to be a stigma attached to terms such as psychological, psychiatric, or even emotional, the term distress was chosen by the NCCN to represent an accurate yet less stigmatizing concept. It has been defined as “an unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with cancer treatment. It extends along a continuum, from common normal feelings of vulnerability, sadness, and fears, to problems that are disabling, such as true depression, anxiety, panic, and feeling isolated or in a spiritual crisis.”[1] (Refer to the Overview section of this summary.)

The psychometric properties of the NCCN rapid-screening measure (a 0–10 visual analogue scale, in the form of a thermometer labeled with “No Distress” at 0, “Moderate Distress” at the midpoint, and “Extreme Distress” at 10) have been investigated.[4] It was found to have reasonable convergent and divergent validity when compared to two more well-established, multidimensional symptom inventories. This very brief, rapid-screening procedure was found to have a moderate ability to accurately detect distress as defined by scores indicative of “caseness” on the two-symptom inventories. When testing specific cutoff scores to maximize sensitivity and specificity, no single cutoff was discovered that maximized accuracy of classification. Thus, it was recommended that varying cutoff scores result in different referral recommendations, such that low scores result in no referral, moderate scores result in an optional referral, and high scores strongly recommend further interventions. The accuracy of these ultrashort screening methods (containing fewer than five items and taking less than 2 minutes to complete) have been investigated.[4,5] A review of 38 studies testing the accuracy of these methods for identifying depression, anxiety, and distress found that the ultrashort methods achieve modest overall accuracy. These screening methods were best at ruling out anxiety, depression, or distress and performed poorly at accurately ruling in anxiety, depression, or distress, thereby resulting in a high number of false positives. Thus, it is recommended that when an ultrashort screening method is used, a more complete psychosocial assessment interview should follow the initial screening.

A few studies have investigated the prevalence of distress as measured by the NCCN Distress Thermometer.[4,6-10] Prevalence rates range from 22% to 58%. Different cutoff scores have been used, with most studies using a cutoff score of 4 or 5. Before these empirical investigations were conducted, the NCCN recommended use of a cutoff score of 5. An initial pilot study [8] reported that 28.6% of 93 men with prostate cancer reported distress scores higher than 5 on the 0–10 scale. Another study (n = 50) reported that 50% of men and women who were potential candidates for bone marrow transplant reported distress scores higher than 5. A third study [4] of 68 mixed types of cancer patients recommended the use of a range of cutoff scores with corresponding levels of intervention. For example, scores between 0 and 3 would receive no further services, scores between 4 and 6 would receive educational information about available resources (e.g., self-help groups, support groups, mental health professionals) and a referral that is at the option of the patient, and scores between 7 and 10 would receive complete psychosocial assessment and ongoing services by an appropriate health care professional. Utilizing this format, the study found that 22% of patients scored within the range of 7 to 10, and an additional 31% scored within the range of 4 to 6, resulting in 53% who reported distress scores higher than 4 on the scale of 1 to 10. The largest study to date (n = 380) reported that 58% of females and 42% of males reported distress scores higher than 4.[6] In regard to prevalence of distress along the clinical course, one study of 236 newly diagnosed breast cancer patients (awaiting their initial consultation with a surgical oncologist) found that 41% reported distress scores higher than 5 on the NCCN Distress Thermometer. In this same group of women, 11% reported symptoms suggestive of major depression, and 10% reported symptoms of posttraumatic stress.[11]

Regarding predictors of distress, in a large sample (n = 380) of patients with mixed cancer diagnoses, those reporting a score of 4 or higher on the Distress Thermometer were more likely to be women, to have poorer functional performance (self-reported Karnofsky Performance Scale), and to have reported (on the Problem List that accompanies the Distress Thermometer) problems with housing, dealing with children, dealing with partner, depression, fears, nervousness, sadness, worry, and 14 of 20 physical ailments.[6]

In regard to predictors of posttreatment distress, a longitudinal, observational study of 151 women with early-stage breast cancer found that physical symptoms and side effects experienced during treatment were predictive of posttreatment cancer-related distress, amounting to 6% of the total 24% of variance accounted for.[12] In addition, demographic variables associated with this posttreatment cancer-related distress included younger age, nonwhite racial status, and less formal education. Clinical variables associated with distress included having a mastectomy rather than lumpectomy, receiving hormonal treatment, and the presence of a diagnosable mental disorder at the time of recruitment into the study.

Screening and assessment have been viewed as two distinct processes.[13,14] Screening is a rapid method of identifying patients with psychosocial distress, typically done by using brief self-report questionnaires administered by non–mental-health professionals with the goal of determining who needs referral for more extensive assessment.[15] The psychosocial assessment of the cancer patient is a more in-depth clinical interview focused on factors relevant to coping and adaptation. Mental health professionals do the assessment interview with the goal of determining how well a patient is adjusting.[13]

Various comprehensive cancer centers have developed models for screening for psychosocial distress. Although there are notable differences, most models involve the following sequential steps: screening administration, scoring and evaluation, and referral. Most screening for psychosocial distress is focused on the individual patient; however, some family-focused screening procedures are being developed.[16]

Administration of a screening instrument involves a brief 5- to 10-minute process in which each patient answers a series of simple, straightforward questions about distress, either orally, or via a self-report questionnaire or computer. Answers are scored and evaluated on the basis of previously determined criteria. If scores are above the defined criteria, then a formal referral to the appropriate discipline (social work, psychology, psychiatry, palliative care, pastoral care) is made. Distress management then begins with a more comprehensive face-to-face psychosocial assessment interview [13] by a qualified health care professional (e.g., social worker, psychologist, psychiatrist, palliative care specialist, pastoral counselor). Few empirical studies have evaluated the impact of structured screening programs. In two randomized, longitudinal, intervention studies no significant differences in quality of life were found.[17,18] In one of these studies, however, a subgroup of moderately to severely depressed patients showed a significant reduction in depression following the intervention. Thus, further empirical evaluation of the effectiveness of screening programs is needed. The following examples will help to illustrate the process.

Memorial Sloan-Kettering Cancer Center has experimented with a distress thermometer modeled after those used to measure pain.[1] The descriptive anchor points on the thermometer include “no distress” at a rating of 0; “moderate distress” at a rating of 5; and “extreme distress” at a rating of 10. Patients are asked, “How would you rate your distress today, on a scale of 0 to 10?” Accompanying the thermometer is a problem list that helps to identify which potential sources of stress are relevant. The patient is asked to check those problems of most relevance. Categories of problems include practical (e.g., housing, insurance, transportation), physical (e.g., pain, nausea, fatigue), family or support (e.g., partner, children, friends), emotional (e.g., worry, sadness, depression, anger), and spiritual/religious (e.g., relating to God, loss of faith). The primary oncology team (oncologist, nurse, palliative care specialist, social worker) is responsible for administering and evaluating a patient’s response to this brief screening and arranging for referral, when necessary. Preliminary testing of this procedure used a cutoff score of 5 or higher as requiring further evaluation. Initial needs assessments have shown that 20% to 35% of patients report significant levels of distress.

At Johns Hopkins Cancer Center, all new patients are given an 18-item version of the Brief Symptom Inventory (BSI),[19] which lists 18 problems people sometimes experience (e.g., faintness or dizziness, no interest in things, loneliness, nausea or upset stomach). They are asked, “How much were you distressed by” each of the 18 problems “during the past 7 days including today?” The procedure is automated and utilizes existing clerical and support staff to distribute and retrieve the inventory during the first or second visit.[14] After computerized scoring is completed, professional staff is involved when offers for services are being provided. Those screened as having high distress are referred to a social worker for immediate follow-up, while those screened as having low distress are referred to the psychosocial orientation program. This is a structured, educational program designed to enhance the adaptation of patients by providing information about a range of psychosocial programs (e.g., disease-specific support groups, psychoeducational presentations).

The Oncology Symptom Control Research group at Community Cancer Care typically screens all incoming patients with the Zung Self-Rating Depression Scale (ZSDS).[20,21] The ZSDS is a 20-item self-report depression screen that has been used to detect depression and more general distress; single items are also used to screen for conditions such as fatigue.[22] Staff typically administer the screen while patients are in the waiting room. Scores are analyzed immediately after completion so that the medical oncologists can be briefed on any pertinent issues. In addition, patients scoring in the moderate range or higher are identified for further follow-up and more extensive interviews and assessment by either the staff psychiatrist or psychologist. Also, patients who trigger single items of interest, such as fatigue, are interviewed and followed for possible inclusion in a number of symptom-control research trials.

The NCCN single-item, rapid-screening instrument asks patients to rate their distress on a scale of 0 (“no distress”) to 10 (“extreme distress”). On an accompanying problem list they are asked to indicate what has been a problem for them in the past week. Studies [4,6,7,23] have tested the ability of the single-item measure to identify patients in distress, investigated sensitivity and specificity in an effort to recommend a cutoff score, and identified prevalence rates. One study [4] found the Distress Thermometer to have reasonable convergent and divergent validity when compared with two more well-established inventories (BSI and BSI-18; see table below) but did not recommend a specific cutoff score. A larger, multisite study (n = 380) found that a cutoff score of 4 resulted in acceptable sensitivity (.77, .70) and specificity (.68, .70) when compared with two other widely used yet longer self-report questionnaires (hospital anxiety and depression scale [HADS] and BSI; see table below).[6] Thus it appears that the single-item rapid-screening Distress Thermometer is comparable to other well-established self-report questionnaires (BSI, BSI-18, HADS) in accurately classifying patients with and without distress. The following table is a list of self-report screening instruments used for identification of psychosocial distress.

Self-report screening instruments must be scored, evaluated, and discussed with each patient. Triage—the process of communicating screening results, discussing each patient’s needs, and determining the best course of further action—is key to the successful use of screening. In fact, screening without availability of appropriate treatment resources is considered unethical. The NCCN standards of care [1] suggest distress rated as mild might result in a referral to a local self-help group, or management by the primary oncology team only. Distress rated as moderate to severe warrants referral to other appropriate professionals (psychologists, psychiatrists, social workers, palliative care specialists, or pastoral counselors), depending on the nature of the distress.

The primary oncology team (oncologist, nurse, palliative care specialist, social worker, and counselor) is responsible for successful triage. In some studies a significant percentage of patients who report moderate to high levels of distress refuse further assessment.[8,30,9,31] Thus, it is important to consider how the primary oncology team can introduce the need for further psychosocial assessment.

The relationship between a patient and the primary oncology team is important. Although there is no single best way to talk to patients about psychosocial needs, clinical experience suggests some important concepts. First, most patients will respond to the recommendations of health care professionals who exhibit trust, expertise, warmth, care, and concern. The member of the primary oncology team who has the closest professional relationship with the patient may be the best one to discuss further psychosocial assessment.

Choice of words is important. Words that suggest the stigma of serious mental illness, such as psychiatric, psychological, mental disorder, maladjustment, or mental illness, should be avoided—in favor of words such as distress, concerns, worries, uncertainties, or stressors from the illness or its treatment. When screening and referral are done routinely, patients can be accurately informed that this is a normal routine procedure done for all patients. Suggestions for word choice include the following:

• The questionnaire you filled out helps us to understand you as a whole person, and we want to provide the best care possible for you—physically, emotionally, socially, and spiritually.
• As you may realize, a serious illness can affect the quality of your life in many ways (emotionally, socially, work, relationships, finances, energy). There is much more to this illness than just the physical, and we want to be sure we are addressing these other dimensions of your life.
• Your concerns and worries are very understandable, given your illness and its treatment. We don’t want to ignore the (emotional, social, spiritual) aspects of your experience right now.
• We have found that many patients benefit greatly from a chance to talk further about their concerns with a (social worker, mental health professional, palliative care specialist, or pastoral counselor), and we would like to schedule that for you.
• For further explanation, we suggest an interview that lasts about 45 minutes with a professional who will:
  • Listen closely to you.
  • Want to know about your experiences with your illness.
  • Ask about you, your family and friends, and other support persons.
  • Ask about how you have been adjusting to your illness and may encourage you to continue (and give you feedback about) successful coping strategies you are already using.
  • Have suggestions about additional ways to address your concerns.

An assessment of psychosocial adaptation will follow screening and referral to an appropriate health care professional. The psychosocial assessment is typically a semistructured interview during which the professional is evaluating how well an individual patient, a patient’s family, and other significant people in a patient’s life are adapting to the current demands of the illness. In general, this assessment process will consider a wide variety of factors relevant to overall adaptation. (Refer to the General Factors Influencing Adjustment section of this summary.) The experienced interviewer assessing psychosocial adaptation will consider these and other relevant variables, while also establishing a working relationship with each patient through which to begin a process of ongoing counseling and/or psychotherapy when needed.

The efficacy of psychosocial interventions in adult cancer patients is supported by an extensive literature.[32-35] Reviews have concluded that, in general, psychosocial interventions for cancer patients have shown positive benefits.

Psychosocial interventions have generally been defined as nonpharmacologic interventions that include a variety of psychological and educational components. Typical components include relaxation training, cognitive and behavioral coping strategies, cancer education/information sessions, and group social support. Interventions have included various combinations of these components, have varied in length (single session to multiple weekly sessions), and have been administered in both individual and group formats. The most common patient population has been U.S. Caucasian women of middle to higher socioeconomic status who have breast cancer; however, some studies include mixed cancer diagnoses, and in recent years, more studies from European countries have appeared.[32] Outcome measures have varied and have included emotional adjustment (e.g., depression, anxiety), functional impairment (e.g., return to work, social roles), disease-related symptoms (e.g., nausea/vomiting, fatigue, pain), health behaviors (diet, smoking, exercise) and immune system functioning.[32,33] A biobehavioral model [32] hypothesizing psychological, behavioral, and biologic pathways from cancer stressors to disease outcome has guided much of this research; however, the most common outcome measured has been emotional adjustment.

Although positive benefits have been found, their clinical significance has been questioned. Reviewers have offered varying conclusions regarding the size of these positive effects,[33] ranging from negligible for depression, to small for overall emotional outcomes, to moderate for anxiety.[34]

Effect sizes may be related to the timing of the intervention and patient selection procedures. For most patients, levels of psychosocial distress are highest during the earliest days of their cancer experience and, for many, dissipate quickly. Thus, if interventions are offered later in the cancer experience (weeks or months after diagnosis and treatment), patients may be experiencing less distress than they would have experienced if interventions had been offered earlier, making large effects more difficult to detect.[36] In one study, 249 breast cancer patient-partner dyads were randomly assigned to one of four groups: a control group receiving standard disease management, a standardized psychoeducation group, a group receiving telephone counseling, or a group receiving psychoeducation plus telephone counseling. Patients and partners who received the study interventions had less side-effect distress and severity as well as higher levels of psychological well-being than those who received standard care. In addition, the study supports the efficacy of low-cost, replicable interventions by video and telephone to achieve these physical and psychological benefits.[37] Two meta-analytic reviews [33,34] report effect sizes of 0.19 for depression [34] and functional adjustment,[33] 0.24 for emotional adjustment,[33] 0.26 for treatment- or disease-related symptoms,[33] 0.28 for global measures of outcome,[33] and 0.36 [34] for anxiety. These positive effect sizes indicate that the average patient receiving the intervention is better off than between 57% and 65% of those not receiving the intervention.

In summary, it appears that when psychosocial interventions are offered to patients who are found to be experiencing distress (e.g., anxiety, depression), the efficacy of the intervention is very strong. Thus, the overall positive benefit for psychosocial interventions seems to be greater with those who seem to need it most.[34,33]

The studies described below are representative of randomized clinical trials testing the efficacy of small-group psychosocial interventions for U.S. women with early-stage breast cancer. Note that the studies vary in total treatment time, from 8 hours [38] to 20 hours [36,39] to 27 hours,[40] and have a variety of intervention components.

In the first study, investigators [36] tested the efficacy of a 10-week, 2-hours-per-week group cognitive-behavioral stress management intervention. One hundred newly treated women with breast cancer were randomly assigned to either the intervention or to a control condition. The psychosocial intervention consisted of ten 2-hour group sessions during which didactic material was presented, intermixed with a variety of experiential exercises and homework assignments. The overall intervention focused on learning to cope better with daily cancer-related stressors. Topics included progressive muscle relaxation with imagery, cognitive restructuring, interpersonal conflict resolution, assertion training, and enhanced social support. The control condition consisted of a day-long seminar in which participants received a condensed version of the intervention with significantly less time to interact within the group. Results showed (a) a decrease in depression, (b) no change in other measures of emotional distress, and (c) an increase in “benefit finding” (i.e., reporting that having breast cancer had made positive contributions to their lives) and optimism. In a second larger (n = 199) randomized study conducted by the same research group [39] on women with stage 0 to stage III nonmetastatic breast cancer, a similar intervention produced somewhat greater sustained decreases in cancer-related intrusive thoughts and sustained improvements in anxiety.

A second example is a study [40] of an 18-week, 1.5-hours-per-week group intervention consisting of psychoeducational strategies designed to reduce stress, enhance mood, alter health behaviors (diet, exercise, smoking), and enhance adherence to cancer treatments. Outcome measures included emotional distress, health behaviors, and immune responses. Two hundred twenty-seven women, all of whom had received surgery for regional breast cancer, were randomly assigned to either the intervention group or an assessment-only control condition. Results showed significantly less anxiety, improved social support, better dietary behaviors, and reduced smoking. Immune responses in the intervention group were consistent with the psychological and behavioral changes. This study is a strong example of efforts to measure changes in a variety of biobehavioral (psychological, behavioral, immune) variables after a psychosocial intervention.

The third study [38] evaluated an educational intervention consisting of 2-hour once-per-month group sessions for 4 consecutive months. Participants were 252 women younger than 50 years who had early-stage breast cancer, who had recently completed nonhormonal adjuvant treatment, and who were facing the transition from active treatment to posttreatment survivorship. They were randomly assigned to one of three groups: a standard medical care group, a nutrition education group, or a psychosocial education group. The psychosocial and nutrition education groups included information dissemination, discussion, and some activities/exercises. Topics rotated monthly, and participants could join a group at any time (i.e., the groups were open groups). In general, patient-to-patient interaction was minimal because sessions were more didactic presentations. The psychosocial education group presented topics relevant to younger women with breast cancer, such as talking with children about cancer, how to carry on with life after a diagnosis, relationships/intimacy with partners, hormones and cancer, and genetic bases of breast cancer. The nutrition education group included information about choosing fruits, vegetables, and low-fat foods and how to consistently incorporate these foods into daily life. Shopping, low-fat cooking, eating out, and other related topics were presented. Results showed that patients in both of the intervention groups reported fewer depressive symptoms and better physical functioning at a 13-month follow-up. This study is an example of a more targeted intervention designed for a specific patient population (younger women with breast cancer) at a specific time in their treatment course (soon after completion of active treatment).

A variety of individual psychosocial interventions have been studied. One study emphasized the development of problem-solving abilities. In this study, the psychosocial intervention consisted of ten 1.5-hour weekly individual psychotherapy sessions (either with or without a significant other present) that focused on training to become an effective problem solver. Four rational problem-solving tasks were emphasized that included skills in (a) better defining and formulating the nature of problems, (b) generating a wide range of alternative solutions, (c) systematically evaluating potential consequences of a solution while deciding on the optimal ones, and (d) evaluating the eventual outcome after solution implementation. Between-session homework with tasks relevant to each step was assigned, and patients received a written manual and were encouraged to refer to it as problems arose. One hundred thirty-two adult cancer patients with mixed cancer diagnoses were randomly assigned to two treatment groups and one wait-list control. The two treatment groups included individual problem-solving therapy alone and problem-solving therapy with a significant other (e.g., spouse, friend, adult child) present. Overall results showed that participants in the two treatment groups were more effective problem-solvers and experienced less psychological distress and improved quality of life. No differences between treatment groups were found.[41] In this example, an individual psychotherapeutic intervention designed to increase a patient’s problem-solving abilities was shown to result in a better quality of life and less psychological distress.

In a randomized trial of 411 mixed-diagnosis cancer patients,[42] traditional psychosocial care was compared with professionally administered and self-administered stress management for chemotherapy. The professional stress management consisted of a 60-minute individual educational session that included a review of common sources of chemotherapy-related stress and three specific stress-management techniques: paced abdominal breathing, progressive muscle relaxation with imagery, and the use of coping self-statements. The professional provided the patient with an audiotape of the individual session, prescribed daily practice of the three techniques, and met briefly with the patient before his or her first chemotherapy session. In the self-administered group, a professional met with each patient for approximately 10 minutes, provided him or her with a packet of instructional materials about coping with chemotherapy, and briefly instructed the patient on their use. These materials included a 15-minute videotape, a 12-page booklet, and a 35-minute relaxation audiotape. These materials included all of the same information provided in the professionally administered group. Patients in this group were instructed to first view the videotape and then review the booklet, following its instructions for further training, practice, and use of the various techniques.

Results of this novel approach found that patients in the self-administered intervention reported significantly better physical functioning, vitality, and mental health and fewer role limitations than those reported by either of the other two groups. Patients in the professionally administered group reported no better outcomes than patients in the traditional-care group. Costs of the self-administered group were found to be significantly lower than those of the other two groups.

A novel intervention [43] tested the effects of a brief (15- to 20-minute) clinic tour for new patients in a medical oncology clinic. The tour included an opportunity to see the phlebotomy, nursing, and chemotherapy areas; the distribution of written materials about clinic hours and procedures; and a time to ask questions. One hundred and fifty consecutively referred patients who had a variety of cancers were randomly assigned to either the clinic orientation condition or to standard care. Intervention patients showed less anxiety, less mood disturbance, and fewer depressive symptoms at a 1-week follow-up. In addition, these patients reported more knowledge of clinic procedures, more confidence in their physicians, and higher levels of satisfaction and hope. This is an example of how even a simple, minimal intervention can have positive benefits.

In one study, a group of women scheduled for excisional breast biopsy (N = 90) were randomly assigned either to a brief session (15 minutes) of hypnosis and guided relaxation delivered by trained clinical psychologists on the day of surgery or to an attention-control empathic listening session of equal length. Presurgery distress was measured by the visual analog scale (VAS) and the short version of the Profile of Mood States (SV-POMS). The hypnosis session markedly decreased anticipatory anxiety and increased relaxation measured just prior to the biopsy.[44]

The Comprehensive Health Enhancement Support System (CHESS) [45] is an online resource for cancer patients that has been available for more than 5 years. It has two components: (1) didactic material and (2) narrative information about medical, practical, and psychosocial issues. This study addressed the relative appeal and value of these two components separately for Caucasian and African American women who had been diagnosed with breast cancer (three-fourths of participants had early-stage disease). The average time spent online with either type of resource was slightly longer for African American women (didactic: 19.7 minutes, standard deviation [SD] = 31.10; narrative: 17.16 minutes, SD = 38.19) than for Caucasian women (didactic: 18.30 minutes, SD = 28.62; narrative: 15.78 minutes, SD = 36.60) but had substantially more effect. Before using the resource, African American women were markedly lower in health care participation; after use, African American women increased health care participation markedly, regardless of type of resource, surpassing the level of health care participation by Caucasian women, particularly in regard to the effect of the didactic services. This result suggests that while the use of both the didactic and narrative CHESS resources is valuable for both groups, it is particularly useful for African American women; the narrative resource version appears to differentially have more impact for Caucasian women.

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31. Razavi D, Delvaux N, Farvacques C, et al.: Screening for adjustment disorders and major depressive disorders in cancer in-patients. Br J Psychiatry 156: 79-83, 1990.  [PUBMED Abstract]
    
    
32. Andersen BL: Biobehavioral outcomes following psychological interventions for cancer patients. J Consult Clin Psychol 70 (3): 590-610, 2002.  [PUBMED Abstract]
    
    
33. Meyer TJ, Mark MM: Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 14 (2): 101-8, 1995.  [PUBMED Abstract]
    
    
34. Sheard T, Maguire P: The effect of psychological interventions on anxiety and depression in cancer patients: results of two meta-analyses. Br J Cancer 80 (11): 1770-80, 1999.  [PUBMED Abstract]
    
    
35. Barsevick AM, Sweeney C, Haney E, et al.: A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer. Oncol Nurs Forum 29 (1): 73-84; quiz 85-7, 2002 Jan-Feb.  [PUBMED Abstract]
    
    
36. Antoni MH, Lehman JM, Kilbourn KM, et al.: Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol 20 (1): 20-32, 2001.  [PUBMED Abstract]
    
    
37. Budin WC, Hoskins CN, Haber J, et al.: Breast cancer: education, counseling, and adjustment among patients and partners: a randomized clinical trial. Nurs Res 57 (3): 199-213, 2008 May-Jun.  [PUBMED Abstract]
    
    
38. Scheier MF, Helgeson VS, Schulz R, et al.: Interventions to enhance physical and psychological functioning among younger women who are ending nonhormonal adjuvant treatment for early-stage breast cancer. J Clin Oncol 23 (19): 4298-311, 2005.  [PUBMED Abstract]
    
    
39. Antoni MH, Wimberly SR, Lechner SC, et al.: Reduction of cancer-specific thought intrusions and anxiety symptoms with a stress management intervention among women undergoing treatment for breast cancer. Am J Psychiatry 163 (10): 1791-7, 2006.  [PUBMED Abstract]
    
    
40. Andersen BL, Farrar WB, Golden-Kreutz DM, et al.: Psychological, behavioral, and immune changes after a psychological intervention: a clinical trial. J Clin Oncol 22 (17): 3570-80, 2004.  [PUBMED Abstract]
    
    
41. Nezu AM, Nezu CM, Felgoise SH, et al.: Project Genesis: assessing the efficacy of problem-solving therapy for distressed adult cancer patients. J Consult Clin Psychol 71 (6): 1036-48, 2003.  [PUBMED Abstract]
    
    
42. Jacobsen PB, Meade CD, Stein KD, et al.: Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy. J Clin Oncol 20 (12): 2851-62, 2002.  [PUBMED Abstract]
    
    
43. McQuellon RP, Wells M, Hoffman S, et al.: Reducing distress in cancer patients with an orientation program. Psychooncology 7 (3): 207-17, 1998 May-Jun.  [PUBMED Abstract]
    
    
44. Schnur JB, Bovbjerg DH, David D, et al.: Hypnosis decreases presurgical distress in excisional breast biopsy patients. Anesth Analg 106 (2): 440-4, table of contents, 2008.  [PUBMED Abstract]
    
    
45. Wise M, Han JY, Shaw B, et al.: Effects of using online narrative and didactic information on healthcare participation for breast cancer patients. Patient Educ Couns 70 (3): 348-56, 2008.  [PUBMED Abstract]
    
    

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The Adjustment Disorders

The adjustment disorders, a diagnostic category of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),[1] are defined as reactions to an identifiable psychosocial stressor (e.g., cancer diagnosis) with a degree of psychopathology that is less severe than diagnosable mental disorders such as major depressive disorder or generalized anxiety disorder and yet are “in excess of what would be expected” or result in “significant impairment in social or occupational functioning.”

Diagnostic Criteria for the Adjustment Disorders

• Criterion A. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
• Criterion B. These symptoms or behaviors are clinically significant as evidenced by either of the following:
  • Marked distress that is in excess of what would be expected from exposure to the stressor.
  • Significant impairment in social or occupational (academic) functioning.
• Criterion C. The stress-related disturbance does not meet the criteria for another specific Axis I disorder and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.
• Criterion D. The symptoms do not represent bereavement.
• Criterion E. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months. Specify:
  • Acute if the disturbance lasts less than 6 months.
  • Chronic if the disturbance lasts for 6 months or longer.
• Specific subtypes represent the predominant symptoms and include:
  • With depressed mood.
  • With anxiety.
  • With mixed anxiety and depressed mood.
  • With disturbance of conduct.
  • With mixed disturbance of emotions and conduct unspecified.

 [Note: Adapted from American Psychiatric Association, 2000.[1]]

In the general population, adjustment disorders are thought to be common, though prevalence rates vary by population studied. In studies of community samples of children, adolescents, and the elderly, prevalence estimates have ranged from 2% to 8%. In outpatient mental health settings, prevalence rates have been as high as 10% to 30%; while in general hospital inpatients, prevalence rates have been as high as 12% of those referred for a mental health consultation.[1]

Nearly every cancer patient experiences what could be considered an identifiable stressor, whether that is diagnosis, treatment, recurrence, or side effects. The presence of an adjustment disorder is determined more by the patient’s response to the identifiable stressor, and whether that response is considered in excess of what would be expected or results in significant impairment, typically in social or occupational functioning.

One study [2] evaluated 215 randomly selected hospitalized and ambulatory cancer patients in three different cancer centers and found that of this group, slightly fewer than half (47% or 101 patients) met the diagnostic criteria for any mental disorder (DSM-III criteria). From this group of 101, 68% (69 patients) met the diagnostic criteria for an adjustment disorder. Of the entire 215 patients evaluated, approximately 32% were identified as meeting the diagnostic criteria for an adjustment disorder—the highest prevalence of any diagnostic category. Additional reviews [3] have continued to find adjustment disorders to be the most common mental disorder. In patients with advanced cancer, prevalence ranges from 14% to 34.7%; in terminally ill patients, rates range from 10.6% to 16.3%. These variable prevalence rates are influenced by stage of disease, type of cancer, diagnostic procedures used, and other patient variables. In a study of women with breast cancer undergoing adjuvant chemotherapy, a 36.1% prevalence rate was found.[4] In another study of terminally ill Japanese cancer patients referred to a palliative care unit, 16.3% were diagnosed with an adjustment disorder at the time of their initial referral, and 10.6% were diagnosed with an adjustment disorder at the time of their admission to the palliative care unit. Of patients diagnosed with adjustment disorder at initial referral, 42% had progressed to major depression at admission to the unit, and 42% had no diagnosis.[5] Thus, it seems safe to conclude that the adjustment disorders are the most commonly diagnosed mental disorder in the oncology setting.

As defined in the diagnostic criteria, an adjustment disorder begins within 3 months of the onset of an identifiable stressor and lasts no longer than 6 months after the stressor or its consequences have ceased. Two specifiers exist to discriminate between an acute adjustment disorder (<6 months) and a chronic adjustment disorder (>6 months). The cancer patient may experience a sequence of multiple, sequential stressors such as the diagnosis, the start of treatment, side effects of treatment, conclusion of treatment, and return to work. It is often difficult to determine when a stressor has ceased. It is not unusual to see a chronic adjustment disorder that persists because of the presence of multiple, sequential stressors. The persistent adjustment disorder may also progress to become a more serious mental disorder (e.g., major depressive disorder). Chronic adjustment disorders that persist and progress to more severe mental disorders appear more common in children and adolescents than in adults.[1] (Refer to the PDQ summary on Pediatric Supportive Care for more information.)

The adjustment disorders are an intermediate category between normal adjustment and a specific diagnosable mental disorder. In terms of their location within a hierarchy of increasingly severe mental disorders, the adjustment disorders are an intermediate category as follows:

• Major mental disorders (e.g., major depressive disorder, panic disorder, posttraumatic stress disorder, generalized anxiety disorder).
• Disorders not otherwise specified (NOS).
• Adjustment disorders.
• Problem-level diagnoses (e.g., partner relational problems, bereavement, physical abuse of child).
• Fluctuations in mood that represent normal adaptation.[6]

Screening instruments for the identification of adjustment disorder have been difficult to identify.[7,8] This intermediate status and the lack of any specific list of symptoms raise a number of problems with the adjustment disorder’s diagnostic category.[6] Most of the problems stem from lack of specificity and resulting subjectivity. This lack of specificity applies to both the identifiable stressor and the marked distress/significant impairment.

No criteria or guidelines exist in DSM-IV to quantify the nature of the psychosocial stressor(s). Given individual differences in coping abilities, certain stressors are likely to be very stressful for one patient and not stressful at all for another patient. With no quantifiable guidelines for measuring stressors, a diagnosis is often determined by the nature of an individual’s response. If a person responds with marked distress or significant impairment in functioning, it is often assumed that the life event was an identifiable stressor. However, the identification of a response that evidences marked distress or significant impairment also lacks specificity and is thus very subjective. Many of these diagnostic terms are too vague to be valid or reliable; thus, there is considerable variation in the use of the adjustment disorder category.

Despite these problems, the adjustment disorder category does provide a means of identifying an emotional or behavioral response in need of further treatment. Cancer patients are regularly confronted with a variety of stressors and thus face the potential of experiencing an adjustment disorder.

Although only one study has been targeted specifically at a population of cancer patients diagnosed exclusively with adjustment disorder, a number of studies have shown the benefits of psychosocial interventions with adult cancer patients (e.g., meta-analysis).[9] These interventions have included both individual [10] and group counseling [11-13] and have utilized a variety of theoretical approaches. In a randomized clinical trial for the treatment of adjustment disorders, 57 patients with mixed cancer types were randomly assigned to either an 8-week individual, problem-focused, cognitive-behavioral psychotherapy intervention or an 8-week individual, supportive counseling intervention.[14] Results showed that those receiving the problem-focused, cognitive-behavioral therapy exhibited a significant change in fighting spirit, coping with cancer, anxiety, and self-defined problems, both at the conclusion of the intervention and at the 4-month follow-up.

Cognitive-behavioral interventions have been widely studied. A cognitive-behavioral approach is based on the idea that mental, emotional, and even physical symptoms partly stem from one’s thoughts, feelings, and behaviors, resulting in poor adaptation.[15] Interventions focus directly on a patient’s thoughts, feelings, and behaviors with the goal of altering specific coping strategies and alleviating emotional distress. Cognitive-behavioral interventions include a variety of techniques such as:

• Relaxation training.
• Biofeedback.
• Contingency management.
• Problem-solving.[16]
• Cognitive restructuring.
• Distraction.
• Thought stopping.
• Coping self-statements.
• Mental imagery exercises.

Most studies have combined a variety of these approaches into a multicomponent treatment strategy designed to alleviate specific symptoms. Cognitive-behavioral approaches tend to be relatively short-term, brief interventions, well-suited to the oncology setting.[15,16] One study [17] randomly assigned 382 patients with different types of cancer to one of three groups: usual care, professionally led stress management, or self-administered stress management. The two intervention groups received stress management training that included abdominal breathing, progressive muscle relaxation training with guided imagery, and coping self-statements prior to the start of chemotherapy. The professionally led intervention group met with a mental health professional who taught them the stress management skills in one 60-minute session. The self-administered group received a packet of training materials that included a 15-minute videotape of instructions, a 12-page booklet on coping with chemotherapy, and a 35-minute audiotape of relaxation training instructions. Results showed enhanced quality of life over usual care in the self-administered group only. The professionally led group did not show any improvement in quality of life when compared with usual care.

A meta-analysis of 45 such studies investigating 62 treatment-control comparisons found significant beneficial effects in emotional adjustment.[9] Beneficial effect sizes for emotional adjustment ranged from .19 to .28, indicating that the average cancer patient receiving treatment was better off than 56.5% to 59.5% of those patients not receiving treatment. These interventions have been administered in both individual [10] and group formats,[18] indicating benefits in emotional adjustment from both formats at the conclusion of the intervention and at 6-month and 12-month follow-up assessments. One novel approach adapted a 6-week group format to a telephone conference call structure for breast cancer survivors; there was high acceptability and modest treatment effects immediately after the intervention but not at the 3-month follow-up.[19]

Another study found that a cognitive behavioral intervention to teach problem solving was effective in promoting better self-management of cancer-related symptoms, especially for patients aged 60 years or younger.[20]

No studies have specifically targeted a population of cancer patients diagnosed exclusively with adjustment disorder, in which the primary intervention was some form of pharmacotherapy. Given the nature of the adjustment disorders, clinical experience suggests that, if available, an initial trial of short-term counseling or psychotherapy designed to alter or eliminate the identified stressor (and thus alleviate symptoms) should be tried before pharmacotherapy.[6] As mentioned previously, sometimes the adjustment disorder may progress to a more severe mental disorder (e.g., major depressive disorder) and thus warrant consideration of pharmacotherapy. In addition, when the patient does not benefit from short-term psychotherapy, adding an appropriate psychotropic medication for a brief period of time (e.g., 2–3 weeks for antianxiety medications, 12 months for antidepressants) may facilitate the psychotherapy, allowing the patient to better employ available coping strategies. The specific pattern of emotional or behavioral symptoms will determine which type of psychotropic medication to consider. (Refer to the PDQ summaries on Depression and Anxiety Disorder for more information.)

References

1. American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000. 
   
   
2. Derogatis LR, Morrow GR, Fetting J, et al.: The prevalence of psychiatric disorders among cancer patients. JAMA 249 (6): 751-7, 1983.  [PUBMED Abstract]
   
   
3. Miovic M, Block S: Psychiatric disorders in advanced cancer. Cancer 110 (8): 1665-76, 2007.  [PUBMED Abstract]
   
   
4. Morasso G: Screening adjustment disorders related to mastectomy and its treatment. New Trends in Experimental and Clinical Psychiatry 13 (1): 90-3, 1997. 
   
   
5. Akechi T, Okuyama T, Sugawara Y, et al.: Major depression, adjustment disorders, and post-traumatic stress disorder in terminally ill cancer patients: associated and predictive factors. J Clin Oncol 22 (10): 1957-65, 2004.  [PUBMED Abstract]
   
   
6. Strain JJ: Adjustment disorders. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 509-17. 
   
   
7. Kirsh KL, McGrew JH, Dugan M, et al.: Difficulties in screening for adjustment disorder, Part I: Use of existing screening instruments in cancer patients undergoing bone marrow transplantation. Palliat Support Care 2 (1): 23-31, 2004.  [PUBMED Abstract]
   
   
8. Kirsh KL, McGrew JH, Passik SD: Difficulties in screening for adjustment disorder, Part II: An attempt to develop a novel self-report screening instrument in cancer patients undergoing bone marrow transplantation. Palliat Support Care 2 (1): 33-41, 2004.  [PUBMED Abstract]
   
   
9. Meyer TJ, Mark MM: Effects of psychosocial interventions with adult cancer patients: a meta-analysis of randomized experiments. Health Psychol 14 (2): 101-8, 1995.  [PUBMED Abstract]
   
   
10. Greer S, Moorey S, Baruch JD, et al.: Adjuvant psychological therapy for patients with cancer: a prospective randomised trial. BMJ 304 (6828): 675-80, 1992.  [PUBMED Abstract]
    
    
11. Telch CF, Telch MJ: Group coping skills instruction and supportive group therapy for cancer patients: a comparison of strategies. J Consult Clin Psychol 54 (6): 802-8, 1986.  [PUBMED Abstract]
    
    
12. Penedo FJ, Dahn JR, Molton I, et al.: Cognitive-behavioral stress management improves stress-management skills and quality of life in men recovering from treatment of prostate carcinoma. Cancer 100 (1): 192-200, 2004.  [PUBMED Abstract]
    
    
13. Goodwin PJ, Leszcz M, Ennis M, et al.: The effect of group psychosocial support on survival in metastatic breast cancer. N Engl J Med 345 (24): 1719-26, 2001.  [PUBMED Abstract]
    
    
14. Moorey S, Greer S, Bliss J, et al.: A comparison of adjuvant psychological therapy and supportive counselling in patients with cancer. Psychooncology 7 (3): 218-28, 1998 May-Jun.  [PUBMED Abstract]
    
    
15. Jacobsen PB, Hann DM: Cognitive-behavioral interventions. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 717-29. 
    
    
16. Allen SM, Shah AC, Nezu AM, et al.: A problem-solving approach to stress reduction among younger women with breast carcinoma: a randomized controlled trial. Cancer 94 (12): 3089-100, 2002.  [PUBMED Abstract]
    
    
17. Jacobsen PB, Meade CD, Stein KD, et al.: Efficacy and costs of two forms of stress management training for cancer patients undergoing chemotherapy. J Clin Oncol 20 (12): 2851-62, 2002.  [PUBMED Abstract]
    
    
18. Fawzy FI, Cousins N, Fawzy NW, et al.: A structured psychiatric intervention for cancer patients. I. Changes over time in methods of coping and affective disturbance. Arch Gen Psychiatry 47 (8): 720-5, 1990.  [PUBMED Abstract]
    
    
19. Heiney SP, McWayne J, Hurley TG, et al.: Efficacy of therapeutic group by telephone for women with breast cancer. Cancer Nurs 26 (6): 439-47, 2003.  [PUBMED Abstract]
    
    
20. Sherwood P, Given BA, Given CW, et al.: A cognitive behavioral intervention for symptom management in patients with advanced cancer. Oncol Nurs Forum 32 (6): 1190-8, 2005.  [PUBMED Abstract]
    
    

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Changes to This Summary (10/23/2008)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Normal Adjustment

Added text on a study of distress and quality of life following treatment for breast cancer (cited Costanzo et al. as reference 17).

Psychosocial Distress

Added text on a study of education, counseling, and adjustment among breast cancer patients and their partners (cited Budin et al. as reference 37).

Added text on the use of online information by breast cancer patients (cited Wise et al. as reference 45).

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  Treatment options for adult cancers.

• PDQ® Cancer Information Summaries: Pediatric Treatment

  Treatment options for childhood cancers.

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