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Psych iatry 2004 [ J U L Y ]20

[ M Y S C O P E O F P R A C TI C E ]

Cognitive Therapyfor Adjustment Disorderin Cancer Patients Dean Schuyler, MD

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Normal adjustment to cancer canbe defined as an ongoing process of trying to gain mastery or control overcancer-related events. 3 The specificchallenges confronting the patient varywith the clinical course of the disease.Common nodal points are diagnosis,surgery, radiation, chemotherapy, treat-ment ending, remission, recurrence,palliative care, or survivorship.

Successful adjustment is indicatedby minimal disruption to life roles,effective regulation of emotional dis-tress, and the capacity to remainactively involved in life. 4 Unsuccessfuladjustment is indicated by disengage-ment, withdrawal, and helplessness.The task of adjusting to cancer can beconceptualized as pitting the demandsof the situation against the resourcesthe individual possesses to meet them.

Issues and Reactions fo CancerDiagnosis

Holland et al 5 have specified normaladjustments to a diagnosis of cancer.Initially, there is disbelief, denial, andshock. Dysphoria, including sadnessand anxiety, follows. Successful copingcomprises the final stage. Once treat-ment is proposed and then instituted,there is apprehension about proce-dures, along with fear of unwanted sideeffects (eg, hair loss, vomiting, fatigue,pain). Disruption of daily life is anadjustment task for all. 5

When treatment ends, patientsoften feel vulnerable without activetherapy. This will strike the clinician asa "catch-22." This reaction competeswith a fear of recurrence and uncer-tainty regarding the future. Patientsmay become hyper-vigilant to healthconcerns. 5 These anxiety-evokingbeliefs are particularly bothersome asthe patient approaches a visit with hisor her oncologist or a diagnostic test.

When there is a recurrence of thecancer, or if the patient’s situation offersno possibility of cure, accepting theoption of palliative care ushers in a newset of necessary adjustments. Hollandand colleagues 5 have charted this periodas well. Normal adjustment to a plan forpalliative care may begin with sadness,crying, anger, and withdrawal, calling fora major shift in expectations. In thisprocess, the maintenance of hope iscentral to a good adaptation. Spiritualbeliefs, whether present premorbidly ornot, may play a role.

Speaking with cancer survivors,some patients have reported benefitsfrom having experienced the illness, 6

including a greater appreciation for life,reprioritizing, and a strengthening of spiritual beliefs.

Diagnosing Adjustment DisordersIn an early study published by

Derogatis et al 1 in 1983, 47% of 215cancer patients studied met criteria for

an emotional disorder. Of thesepatients, 68% had an adjustment disor-der (32% of the total sample). Morerecent surveys 2 have confirmed thatadjustment disorder is the most com-monly diagnosed emotional disorder inthe cancer patient. Two aspects of thisdiagnosis bear highlighting: (1) a per-sistent adjustment disorder mayprogress to a more serious mental dis-order; and (2) adjustment disordershave no specific symptom set, so this isoften a difficult diagnosis to make. 7

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision ( DSM-IV-TR ) 8

defines adjustment disorder as a reac-tion to an identifiable stressor (eg, thediagnosis of cancer). It is held to be lesssevere than a "diagnosable emotionaldisorder" such as major depression orgeneralized anxiety disorder, and it is inexcess of what is expected. Finally,adjustment disorder results in impairedsocial or occupational functioning.

TreatmentThere is no specific drug treatment

for an adjustment disorder. Only 2studies have focused specifically ontreating this problem in cancerpatients. In 1998, Moorey et al 9 ran-domly assigned 57 patients to an 8-week cognitive therapy protocol or to 8weeks of supportive psychotherapy.The group receiving cognitive therapy

A DIAGNOSIS OF CANCER INTERRUPTS THE LIFE OF A PATIENT AND HIS OR HER FAMILY.

Cancer treatment often entails continued investigation and therapy that typically hasside effects and offers the repeated warning to be vigilant. Cancer is often a life-threatening illness. k The field of psycho-oncology is well established, and clinicaloncologists often have a good awareness of the psychological challenges cancer posesto their patients. Despite the nature of the stressor , it is important to note that themajority of cancer patients do not meet diagnostic criteria for any emotional disorder. 1

Rather, their psychosocial stress can be conceptualized on a continuum ( Figure 1 )from normal adjustment to diagnosable mental disorders. 2

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showed "a significant change in spirit,coping, anxiety, and self-defined prob-lems" that persisted after a 4-monthfollow-up. 9 A second study published in2003 by Trask et al 10 found cognitivetherapy useful in reducing distress andincreasing quality of life in a group of

patients with melanoma.In July of 2000, I was offered the

opportunity to function as a psychiatricconsultant making weekly rounds withan oncologist in his university hospitaloutpatient clinic. 11 This experience,coupled with a career-long focus doingand studying cognitive therapy, 12 led tothe development of some ideas for aid-ing the adaptation of the cancerpatient. 13

What evolved was a pilot study

applying the principles of cognitivetherapy to the treatment of the cancerpatient with an accompanying adjust-ment disorder. Because of the signifi-cant distances which many cancerpatients in South Carolina traveled toreceive care at the Hollings CancerCenter at the Medical College of SouthCarolina, a remote teleconferencingcapability was built into the study. 14

Our findings supported the value of a brief (6 session) cognitive therapyintervention for the cancer patient withan adjustment disorder. 15 This outcomeheld, whether the therapy was con-ducted face-to-face in the clinic or uti-lizing teleconferencing equipment.

Cognitive TherapyThe model of cognitive therapy

seemed well suited to the task of aidingadjustment to cancer. Its primary focusis on meanings in the here-and-now. Itis designed to be short-term, conversa-tional, and collaborative in nature. Itencourages the cancer patient to con-sider a variety of ways of thinking thatmight aid in adaptation.

I worked with 17 cancer patients atthe Hollings Cancer Center inCharleston, South Carolina, eachreferred by their oncologist with a sus-pected diagnosis of an adjustment dis-order. Each patient received a diagnos-tic evaluation and, if the diagnosis wasconfirmed, the patient was invited to

join the study. Each patient in thestudy underwent 6 sessions of cogni-tive therapy with me. In group 1, allsessions were face-to-face in an officein the oncology clinic. In group 2, allsessions were conducted remotely, uti-lizing a videophone loaned to thepatient and used from his or her home.

The protocol I followed both in thestudy and in my outpatient practicebegan with teaching the patient thecognitive model. This process typicallytook 5 to 10 minutes, with additionaltime set aside for questions. I wouldbegin by saying to the patient,"Situations and events are seen asdirectly linked to reactions in primitiveanimals. When we build a larger brain(and progress from mice to humans),

one added capability is the assigning of a meaning to the event that is distress-ing. As an example, when you were ini-tially told of your cancer diagnosis,what were the initial beliefs that cameto mind?"

Cognitive therapy focuses first onidentifying the automatic thoughts ormeanings tied to the patient’s distress.Next, I would ask the patient if his orher meaning "made sense."Occasionally it does not, but most oftenthe meaning is seen as reasonable. Thesecond criterion is "strategic worth." Imay ask, "Does this meaning point youin a direction you want to go?"Especially in light of the associated dis-tress, the answer this time is nearlyuniform and is "no."

The third and final task of this cog-nitive therapy is to find alternativemeanings that work for the patient.Contributing options can be a jointexercise (involving the therapist andpatient) as long as the clinician’s offer-ings are not seen as "advice." In a typi-cal collaborative cognitive therapy, this

Figure 1.THE DISTRESS CONTINUUM

|---------|--------------|------------------|---------------------|----------|

Normal Adjustment Subthreshold DiagnosableAdjustment Disorders to Mental Disorders Mental Disorders

Psychosocial distress exists on a continuum ranging from normal adjustmentissues through the DSM-IV-TR Adjustment Disorders; to a level close to, butbelow, the threshold (ie, meets some diagnostic criteria but not all) of diagnos-able mental disorders; to syndromes that meet the full diagnostic criteria for amental disorder (eg, major depressive disorder).

Adapted from National Cancer Institute. Normal adjustment, psychosocial distress, and the adjustment disorders (PDQ). Updated 2004 Apr 22. Available at: http://www.can- cer.gov/cancertopics/pdq/supportivecare/adjustment/HealthProfessional

The task of adjusting to cancer can beof the situation against the resources the

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rarely seems to happen.

OutcomesThe study plan called for an even-

tual total of 25 patients in each group. Ileft the university in November of 2003, and started a part-time outpa-

tient psychiatric practice. The studywas discontinued and, not surprisingly,I received a number of referrals of patients with cancer and adjustmentproblems from my oncologist col-leagues.

Over my 3 years of contact withcancer patients, some issues havestood out as commonly encountered.The list begins with the statement, "Ihave no one to talk with about my can-cer." This aids the establishment of a

useful working relationship and typical-ly is associated with the patient work-ing hard at the tasks of therapy. A com-mon second question is, "Why me?"Searching for an explanation, the can-cer patient may see the diagnosis asretribution for an unworthy act. Evenin a patient for whom religion has notbeen a central concern, spiritual issues(eg, "What do I believe in?") invariablyare raised. For most cancer patients Ihave met, the disease is seen as rob-bing its victim of control over one’s life.It may help to distinguish those areasof continued control, those where con-trol is uncertain, and those beyond thepatient’s reach.

Typically, the time frame surround-ing a diagnosis of cancer seems to befuture oriented, even if that "future" isnot very distant from the present. Ihave found a derivative of the

Alcoholics Anonymous phrase, "Oneday at a time," to be a useful orienta-tion to suggest.

"What goes through your mindwhen you wake up in the morning?" Ioften ask. "That I am dying of cancer,"

is the common response. I then inquire,"How would it change things if youwere to instead ask yourself how youare feeling that day and then plan theday on that basis?"

Similarly, a frequent concernamong patients is, "How much time do

I have left?" We often discuss the diffi-culty to the oncologist of making a use-ful response to this question. Often, thedoctor won’t know, the patient won’tknow, and "only God knows." Thebroader issue here is the desire to pre-dict the future. This may take the formof a statement such as, "This is my lastbirthday/anniversary/Mother’s Day."

Analogies about the situations of otherpeople may be useful in cognitive ther-apy to challenge one of the patient’s

beliefs. More than once, I have relatedhow one of my family members whowas dying said goodbye to her oncolo-gist as he was leaving for a long-planned vacation—and ended up say-ing hello when he returned. You justnever know.

When clear cognitive errors aremade in the conclusions drawn by thepatient, I point them out. Polarization(ie, thinking categorically as in black orwhite; no grays), personalization(focusing only on the self), and over-generalization (drawing conclusionsbeyond the available data) are the mostcommon errors in thinking. Finally, thepatient will often focus on the depend-ency upon him or her of a spouse orchild. "What will they do once I’mgone?" the patient asks. When this con-cern is offered, we work as a team toproblem-solve some viable options forthe significant other.

When a cancer patient is referredto me who turns out to have a majordepression 16 complicating their adjust-ment, I offer a trial of a selective sero-tonin reuptake inhibitor (SSRI) in addi-

tion to brief cognitive therapy. When adiagnosable anxiety disorder is pre-sented, 17 a longer cognitive therapymay be offered, which may or may notbe supplemented by a trial of anantianxiety drug (eg, SSRI, venlafaxine,buspirone, or a long-acting benzodi-

azepine). For the vastly more commonadjustment disorder without any othercomplicating psychiatric diagnosis, ashort-term psychotherapy typically hasbeen adequate and greatly appreciated.

REFERENCES1. Derogatis LR, Morrow GR, Fetting J, et al. The preva-lence of psychiatric disorders among cancer patients.JAMA 1983;249:751–7.2. National Cancer Institute. Normal adjustment, psy-chosocial distress, and the adjustment disorders (PDQ).Updated 2004 Apr 22; cited 2004 Jun 25. Available at:http://www.cancer.gov/cancertopics/pdq/supportive-care/adjustment/HealthProfessional3. Kornblith AB. Psychosocial adaptation of cancer sur-vivors. In: Holland JC, Breitbart W, editors. Psycho-oncol-

ogy. New York: Oxford University Press; 1998:223–41.4. Spencer SM, Carver C S, Price AA. Psychological andsocial factors in adaptation. In: Holland JC, Breitbart W,editors. Psycho-oncology. New York: Oxford UniversityPress; 1998:943–58.5. Holland JC, Gooen-Piels J. Principles of psycho-oncol-ogy. In: Holland JC, Frei E, editors. Cancer medicine e.5.5th ed. Hamilton (Ontario): Decker; 2000:943–58.6. Polinsky ML. Functional status of long-term breastcancer survivors: demonstrating chronicity. Health Soc

Work 1994;19:165–73. Erratum in: Health Soc Work1994;19:297.7. Strain JJ. Adjustment disorders. In: Holland JC,Breitbart W, editors. Psycho-oncology. New York: OxfordUniversity Press; 1998:509–17.8. Diagnostic and statistical manual of mental disorders:DSM-IV-TR. 4th ed., text revision. Washington (DC):American Psychiatric Association; 2000.9. Moorey S, Greer S, Bliss J, Law M. A comparison of adjuvant psychological therapy and supportive coun-selling in patients with cancer. Psychooncology

1998;7:218–28.10. Trask PC, Paterson AG, Griffith KA, et al. Cognitive-behavioral intervention for distress in patients withmelanoma: comparison with standard medical care andimpact on quality of life. Cancer 2003;98:854–64.11. Schuyler D. Brief encounter. Prim Care Companion JClin Psychiatry 2003;5:232–3.12. Schuyler D. Cognitive therapy: a practical guide. New

York: WW Norton & Co; 2003.13. Schuyler D, Brescia F. Psychotherapy of a patient withterminal cancer. Prim Care Companion J Clin Psychiatry2002;4:111–2.14. Schuyler D. Remote brief psychotherapy. Prim CareCompanion J Clin Psychiatry 2003;5:182–4.15. Cluver JS, Schuyler D, Frueh BC, et al. Remote psy-chotherapy for terminally ill cancer patients. In press2004.16. Spiegel D. Cancer and depression. Br J PsychiatrySuppl 1996;(30):109–16.17. Stark D, Kiely M, Smith A, et al. Anxiety disorders incancer patients: their nature, associations, and relation to

quality of life. J Clin Oncol 2002;20:3137–48.

Dr. Schuyler is a psychiatrist in private prac-

tice in Charleston, SC.

conceptualized as pitting the demandsindividual possesses to meet them.