Coping Strategies and Mental Disorders Coping Strategies and Mental Disorders among Patients with Recurrent Breast among Patients with Recurrent Breast

CancerCancerPresented by: Hani Hamed DessokiPresented by: Hani Hamed Dessoki

Prof. of PsychiatryProf. of PsychiatryChairman of Psychiatry DepartmentChairman of Psychiatry Department

Beni-Suef University Beni-Suef University

Authors: Fatma Moussa*, Hani Hamed**, Akmal Moustafa ***, Noha Fatma Moussa*, Hani Hamed**, Akmal Moustafa ***, Noha Abdel Shafi****Abdel Shafi****

*Prof. of Psychiatry- Cairo Universitv, *Prof. of Psychiatry- Cairo Universitv, **Assist. Prof. of Psychiatry- Beni-Suef **Assist. Prof. of Psychiatry- Beni-Suef University- Beni-Suef- Egypt, ***Assist. University- Beni-Suef- Egypt, ***Assist. Prof. of Psychiatry- Cairo UniversityProf. of Psychiatry- Cairo University, , ****Assist. Prof. of Radiodiagnosis- National Cancer Institute-Cairo ****Assist. Prof. of Radiodiagnosis- National Cancer Institute-Cairo UniversitytUniversityt

Vienna, Vienna, WPAWPA

October, 2013October, 2013

DisclosureDisclosure

I have no significant financial or other relationship with the I have no significant financial or other relationship with the manufacturer of any product or service I intend to discuss. manufacturer of any product or service I intend to discuss.

The following information dose not contain clinical trial. The following information dose not contain clinical trial.

IntroductionIntroduction Coping has been defined as "constantly Coping has been defined as "constantly

changing cognitive and behavioral efforts to changing cognitive and behavioral efforts to manage specific external and/or internal manage specific external and/or internal demands that are appraised as taxingdemands that are appraised as taxing or or "exceeding the resources of the person "exceeding the resources of the person (Lazarus and Folkman, 1984)(Lazarus and Folkman, 1984)..

Coping may be positive Coping may be positive (adaptive or (adaptive or constructive coping) or negativeconstructive coping) or negative..

IntroductionIntroduction One positive coping strategy, "anticipating a problem One positive coping strategy, "anticipating a problem

is known as is known as proactive coping." It proactive coping." It "reduce[s] the "reduce[s] the stress of some difficult challenge by anticipating what stress of some difficult challenge by anticipating what it will be like and preparing for how [one is] going to it will be like and preparing for how [one is] going to cope with it cope with it (Giuliano et al., 2011). (Giuliano et al., 2011).

While adaptive coping methods While adaptive coping methods improve improve functioning, a maladaptive coping technique will just functioning, a maladaptive coping technique will just reduce symptoms while maintaining and strengthening reduce symptoms while maintaining and strengthening the disorder.the disorder.

Introduction Introduction contcont.. Cancer survivors may experience a battery of Cancer survivors may experience a battery of

sequelae in their survivorship, including physical sequelae in their survivorship, including physical discomfort discomfort and psychological concerns, such and psychological concerns, such as as uncertainty over the futureuncertainty over the future and persistent and persistent fear of recurrence (Vickberg 2001). fear of recurrence (Vickberg 2001).

In fact, one of the most frequently mentioned In fact, one of the most frequently mentioned components of distress among cancer survivors is components of distress among cancer survivors is fear of recurrence, even though there are no signs fear of recurrence, even though there are no signs of disease and it is one of the greatest of disease and it is one of the greatest psychosocial stressors confronting survivors and psychosocial stressors confronting survivors and families families (MacBride and Whyte 1998).(MacBride and Whyte 1998).

Introduction Introduction contcont..

All the patients reported fear of the future, particularly All the patients reported fear of the future, particularly in relation to death and knowing that cancer had in relation to death and knowing that cancer had returned was devastating because they were not returned was devastating because they were not prepared for this shock, although they knew the prepared for this shock, although they knew the chances of recurrence. chances of recurrence.

However, those with previous recurrence were not However, those with previous recurrence were not surprised by the diagnosis and were optimistic about a surprised by the diagnosis and were optimistic about a remission. remission.

Thus, there is evidence that recurrence is a critical Thus, there is evidence that recurrence is a critical point in that it means that the cancer has not been point in that it means that the cancer has not been controlled and may be uncontrollable in the controlled and may be uncontrollable in the future future ((Mahon et al.,1990).Mahon et al.,1990).

Introduction Introduction contcont..

Thus, depression can be a complicating problem for a Thus, depression can be a complicating problem for a substantial minority of people with chronic medical substantial minority of people with chronic medical illnesses, including cancer illnesses, including cancer (Hegel et al., 2008). (Hegel et al., 2008).

The The relationship between cancer and depression is bi-relationship between cancer and depression is bi-directional. directional.

More rapid progression and increased symptoms of More rapid progression and increased symptoms of cancer are associated with more severe depressioncancer are associated with more severe depression, , (Van et al., 2008), while comorbid (Van et al., 2008), while comorbid depression is depression is associated with increased functional impairment and associated with increased functional impairment and poorer quality of life over thepoorer quality of life over the course of chronic illness course of chronic illness (Van et al., 2008)(Van et al., 2008)..

Introduction Introduction contcont..

As cancer treatment improves, the disease is As cancer treatment improves, the disease is being being converted from a terminal to a chronic converted from a terminal to a chronic illness. illness.

Half of all people diagnosed with cancer will live Half of all people diagnosed with cancer will live to die of something else, so more people are to die of something else, so more people are living to cope with the disease, its treatment, the living to cope with the disease, its treatment, the threat of recurrence and complicating threat of recurrence and complicating psychiatric disorders.psychiatric disorders.

To assess the relation between mental disorder and recurrence of To assess the relation between mental disorder and recurrence of

breast cancer including mood symptoms and anxiety symptoms.breast cancer including mood symptoms and anxiety symptoms.

To detect the effect of coping strategies on recurrence of breast To detect the effect of coping strategies on recurrence of breast

cancer. cancer.

To detect the impact of disturbed body image due to the To detect the impact of disturbed body image due to the

recurrence of breast cancer.recurrence of breast cancer.

To study the impact of recurrence on the quality of life containing To study the impact of recurrence on the quality of life containing

its different aspects.its different aspects.

This study is a comparative case-control study aiming This study is a comparative case-control study aiming

at assessment of at assessment of the psychiatric co-morbidities in the psychiatric co-morbidities in

patients suffering from recurrent breast cancer.patients suffering from recurrent breast cancer.

Subjects:Subjects:

Subjects included in the study are 100 female patients; Subjects included in the study are 100 female patients;

all are recruited consecutively from diagnostic all are recruited consecutively from diagnostic

radiology department (mammogram and ultrasound radiology department (mammogram and ultrasound

unite) in the National Cancer Institute Cairo University. unite) in the National Cancer Institute Cairo University.

Divided into 2 groups: Group A and B.Divided into 2 groups: Group A and B.

Group A:Group A:

Consists of 30 patients who previously have diagnosed as Consists of 30 patients who previously have diagnosed as

recurrent breast cancer and coming to radiology department recurrent breast cancer and coming to radiology department

for follow up.for follow up.

Group B: Group B:

Consists of 70 patients who are referred for diagnostic Consists of 70 patients who are referred for diagnostic

radiology department (mammogram and ultrasound unite) radiology department (mammogram and ultrasound unite)

follow up after radical mastectomy. These 70 patients will be follow up after radical mastectomy. These 70 patients will be

assessed before having the radiology results. After assessed before having the radiology results. After

completing the battery included in this study subjects in completing the battery included in this study subjects in

group B will have their mammogram and ultrasound, group B will have their mammogram and ultrasound,

subsequently they will be divided into 2 groupssubsequently they will be divided into 2 groups

Group B1:Group B1:

18 patients who were discovered that they have a recurrent 18 patients who were discovered that they have a recurrent

breast cancer on follow up with radiology.breast cancer on follow up with radiology.

Group B2:Group B2:

52 patients who didn't have a recurrent breast cancer on 52 patients who didn't have a recurrent breast cancer on

follow up with radiology. follow up with radiology.

Groups B1 and B2 will be compared statistically with group A Groups B1 and B2 will be compared statistically with group A

for evidence of anxiety and depression revealed by the study for evidence of anxiety and depression revealed by the study

tools.tools.

Informed consent:Informed consent:

A written informed consent was taken from patients after A written informed consent was taken from patients after

discussing with them the aim of the study.discussing with them the aim of the study.

ProcedureProcedure

The patient’s interviews were done twice per week The patient’s interviews were done twice per week

(from November 2010 till November 2011).(from November 2010 till November 2011).

Each patient was interviewed twice in the same week.Each patient was interviewed twice in the same week.

All participants were subjected to the following:All participants were subjected to the following:

I-Present State Examination: (Wing et al., 1974)I-Present State Examination: (Wing et al., 1974)

Clinical assessment using the semi-structured Clinical assessment using the semi-structured

interview of Present State Examination (PSE) which is interview of Present State Examination (PSE) which is

useful for clinicians and researchers inuseful for clinicians and researchers in

screening the subjects with psychiatric disorders and screening the subjects with psychiatric disorders and

those who present with subclinical morbiditythose who present with subclinical morbidity

II-Psychometric tools:II-Psychometric tools:

1- Hamilton depression rating scale (HDRS)1- Hamilton depression rating scale (HDRS) (Hamilton, 1960) (Hamilton, 1960)

(Arabic version, Futtaim ,1998): (Arabic version, Futtaim ,1998):

2-Hamilton anxiety rating scale (HAM-A) 2-Hamilton anxiety rating scale (HAM-A) (Hamilton, 1959) (Hamilton, 1959)

(Arabic version Futtaim ,1998): (Arabic version Futtaim ,1998):

3- Body Images Scale 3- Body Images Scale (Shoukaire, 2002)(Shoukaire, 2002)::

This scale is self rated, formed of 26 items every one of This scale is self rated, formed of 26 items every one of

the subject answers in 3 grades from totally accepting the subject answers in 3 grades from totally accepting

to totally not accepting with score from 0 to 2 for each to totally not accepting with score from 0 to 2 for each

item. Normal range for males is (14 item. Normal range for males is (14 ++ 6) and for females 6) and for females

(16 (16 ++ 6) above which the body image is considered 6) above which the body image is considered

disturbed.disturbed.

4- Coping Processes Scale 4- Coping Processes Scale (Ibrahim, 1994)(Ibrahim, 1994): :

This scale is self rated, every one of the subjects This scale is self rated, every one of the subjects

answers in four grades to each phrase from totally answers in four grades to each phrase from totally

accepting to totally not accepting. Each one of the 11 accepting to totally not accepting. Each one of the 11

coping processes has certain phrases and each phrase coping processes has certain phrases and each phrase

take score from 1 to 4 then the total score for each take score from 1 to 4 then the total score for each

process is calculated.process is calculated.

5-5-European Organization for Research and Treatment of Cancer 30-European Organization for Research and Treatment of Cancer 30-item core item core

quality of life questionnaire (EORTC QLQ C-30) quality of life questionnaire (EORTC QLQ C-30) (Aaronson et al., 1993)(Aaronson et al., 1993)

Arabic version Arabic version (Manal et al, 2008).(Manal et al, 2008).

The QLQ-C30 is a 30-item self-report questionnaire covering The QLQ-C30 is a 30-item self-report questionnaire covering functional and symptom related aspects of QOL for cancer functional and symptom related aspects of QOL for cancer patients. It is grouped into five functional subscales (patients. It is grouped into five functional subscales (role, role, physical, cognitive, emotional and social physical, cognitive, emotional and social functioningfunctioning). In addition, ). In addition, there are three multi-item there are three multi-item symptom scales (fatigue, pain, and nausea and symptom scales (fatigue, pain, and nausea and vomiting), vomiting), There are three versions 1.0, 2.0 and 3.0.There are three versions 1.0, 2.0 and 3.0.

V - Radiology Study (mammography and ultrasound) :V - Radiology Study (mammography and ultrasound) :

Statistical analysisStatistical analysis

All collected questions will be revised for completeness All collected questions will be revised for completeness

and logical consistency. Results were evaluated and logical consistency. Results were evaluated

statistically by the Statistical Package for the Social statistically by the Statistical Package for the Social

Sciences (SPSS) version 20. Data were entered in a Sciences (SPSS) version 20. Data were entered in a

master table and categorical data were coded.master table and categorical data were coded.

There were no statistically significant There were no statistically significant differences between the three groups as regards differences between the three groups as regards the sociodemographic data including age, the sociodemographic data including age, marital status and education, but there were marital status and education, but there were statistically significant difference as regard the statistically significant difference as regard the occupation which means good matching for the occupation which means good matching for the groups.groups.

ResultsResults

1) Comparison between the three groups A, B1 and B2 1) Comparison between the three groups A, B1 and B2

as regards Hamilton depression rating scale (HDRS) as regards Hamilton depression rating scale (HDRS)

Hamilton

depression rating

scale (HDRS)

Group A

n = 30

Group B

PB1

n = 18

B2

n = 52

Mean43.0027.1123.96>0.000*Standard deviation+ 8.00+ 5.87+7.41

The degree of severity of Hamilton Depression rating The degree of severity of Hamilton Depression rating

scale in the three groupsscale in the three groups

Hamilton depression rating

scale

Group A n = 30

Group B Chi-square

PGroup B1

no=18Group B2

no=52

No.%No.%No%

Normal0.00.047.7 20.672

0.002*

Mild0.015.61223.1

Moderate0.0316.747.7

Severe30100.01477.73261.5

Total30100.018100.052100.0

2) Comparison between the three groups A, B1 and B2 2) Comparison between the three groups A, B1 and B2

as regards Hamilton Anxiety rating scale (HARS) as regards Hamilton Anxiety rating scale (HARS)

Hamilton anxiety

rating scale

(HARS)

Group A

n = 30

Group B

P

B1

n = 18

B2

n = 52

Mean39.1332.2231.44>0.000*

Standard deviation+7.19 + 6.68 +7.91

3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale

Coping process scaleGroup A

n = 30

Group B

P

Group B1n = 18

Group B2n = 52

No.%No.%No.%

HelplessnessLow00.000.000.00.001*

Normal13.3844.41936.5

High2996.71055.63363.5

Total30100.018100.052100.0

Mental disengagement

Low00.000.000.0

0.003*Normal1 3.3844.41325.0

High2996.71055.63975.0

Total30100.018100.052100.0

3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale (cont.)3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale (cont.)

Coping process scaleGroup A n =

30

Group B

P

Group B1n = 18

Group B2n = 52

No.%No.%No.%

Information& social support

Low00.000.000.0

0.662

Normal

826.7422.21732.7

High2273.31477.83567.3

Total30100.018100.052100.0

Positive reinterpretation

Low00.000.000.00.240

Normal

00.000.035.8

High30100.018100.04994.2

Total30100.018100.052100.0

3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale (Cont.)3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale (Cont.)

Coping process scaleGroup A

n = 30

Group B

P

Group B1n = 18

Group B2n = 52

No.%No.%No.%

Wishful thinking

Low00.000.011.90.006*

Normal1343.31372.24280.8

High1756.7527.8917.3

Total30100.018100.052100.0

TurningTo religion

Low00.000.000.0

0.501Normal930.0527.81019.2

High2170.01372.24280.8

Total3018100.052100.0

3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale (cont.)3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale (cont.)

Coping process scaleGroup A

n = 30

Group B

P

Group B1n = 18

Group B2n = 52

No.%No.%No.%

Emotional discharge

Low00.000.000.00.000*

Normal516.7422.23057.7

High2583.31477.82242.3

Total30100.018100.052100.0

AcceptanceLow00.000.000.00.066

Normal930.0738.92955.8

High2170.01161.12344.2

Total30100.018100.052100.0

3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale (cont.)3) Comparison between the three groups A, B1, B2 as regard the Coping Processes Scale (cont.)

Coping process scaleGroup A

n = 30

Group B

P

Group B1n = 18

Group B2n = 52

No.%No.%No.%Exercite restrain

Low826.7316.747.70.145Normal1550.01266.73975.0

High723.3316.7917.3Total30100.018100.052100.0

Denial Low00.000.000.00.018*Normal310.015.61630.8

High2790.01794.43669.2Total30100.018100.052100.0

Active coping

Low00.000.000.00.000*Normal826.7633.34382.7

High2273.31266.7917.3Total30100.018100.052100.0

Quality of Life Scale in Three Quality of Life Scale in Three GroupsGroups

There are no statistically significant There are no statistically significant differences regarding all domains of differences regarding all domains of quality of life scale between the quality of life scale between the three groups.three groups.

Positive CorrelationPositive Correlation

emotional discharge

Hamilton anxiety and depression rating scale

There is high frequency of psychiatric co-There is high frequency of psychiatric co-morbidities (especially anxiety) in recurrent morbidities (especially anxiety) in recurrent breast cancer patients. breast cancer patients.

The presence of psychiatric co-morbidities The presence of psychiatric co-morbidities increases the impairment in quality of life in increases the impairment in quality of life in recurrent breast cancer patients. recurrent breast cancer patients.

The breast cancer patients used certain The breast cancer patients used certain strategies to cope with their illness and the strategies to cope with their illness and the presence of anxiety and depression modifies the presence of anxiety and depression modifies the coping mechanisms used by them.coping mechanisms used by them.

ConclusionConclusion

Adequate referral system which ensures prompt Adequate referral system which ensures prompt

referral of recurrent breast cancer patients in oncology referral of recurrent breast cancer patients in oncology

inpatient and outpatient clinics to the liaison inpatient and outpatient clinics to the liaison

psychiatry clinic for early detection of psychiatric psychiatry clinic for early detection of psychiatric

manifestations and proper management. manifestations and proper management.

Implementation of educational programs for the Implementation of educational programs for the

working staffs (Doctors and nurses) in oncology to working staffs (Doctors and nurses) in oncology to

enhance the importance of screening for psychiatric enhance the importance of screening for psychiatric

disorders using simplified assessment scales.disorders using simplified assessment scales.

RecommendatioRecommendationn

LimitationsLimitations Longitudinal study is needed for assessment of the Longitudinal study is needed for assessment of the

psychological state of the patients when they knew psychological state of the patients when they knew to have cancer breast. to have cancer breast.

Larger sample is needed for better comparison after Larger sample is needed for better comparison after subdivision of the groups.subdivision of the groups.