Treating psychiatric reactions to medical illness
Personality affects response to chronic, disabling disease.
In some patients, sertraline can cause adverse gastrointestinal effects such as upset stomach or nausea. Other antidepressants such as mirtazapine could improve patients’ sleep and decrease nausea.
Mrs. M also begins cognitive-behavioral therapy (CBT) to help her deal with negative thoughts, and relaxation training to combat her anxiety before chemotherapy. We recommend a local breast cancer support group, and Mrs. M starts going twice a month. She feels relieved that other patients are experiencing feelings similar to hers.
Medication plus CBT has been shown to be the most effective treatment for patients who meet criteria for depression and anxiety disorders. CBT has been shown to help patients manage physical symptoms and reframe negative thoughts associated with many chronic illnesses, including breast cancer, Parkinson’s disease, epilepsy, rheumatoid arthritis, and multiple sclerosis.6-10
Core emotions. Medically ill patients experience a range of core emotions, which Lazarus11 identified as anger, anxiety, guilt, fright, shame, sadness, happiness, envy, relief, and hope. Identifying the source of these emotions is important to counseling patients effectively.
For example, a patient experiencing fright might fear death, pain, disability, stigma, disfigurement, or other eventualities. Mrs. M has said she can’t stop thinking about dying. By knowing what the patient fears (Table 1),12 we can more effectively reassure and offer support, even when little else can be done.
Table 1
Common fears of patients reacting to diagnosis of chronic illness
|
| Source: Reference 12 |
Defensive behaviors. Patient’s behavioral responses may be adaptive or maladaptive; treatment nonadherence is one maladaptive response (Box 2).13,14 The patient history can suggest how well a person has adapted to past losses and disappointments. Patients may try to protect themselves against emotional and physical pain with psychotic, immature, neurotic, or mature defense mechanisms.15
Psychotic defenses are characterized by regression until patients lose touch with reality. Delusions and fantasy isolate them from the harshness of a serious medical condition. Antipsychotic medication and patience are often indicated.16
Immature defenses—as seen in patients with borderline personality disorder—can irritate and alienate the medical team. Physicians may not understand why their best efforts are thwarted or negated. Well-intentioned, caring doctors often try harder when the verbal attacks begin, but soon even the hardiest can wither under the patient’s criticism and threats.
Depressed medically ill patients adhere poorly to treatment schedules and other recommendations, which may cut their chances of survival.13 Up to 2% of hospital discharges are initiated by patients against medical advice.
Causes of refusing or discontinuing treatment may include anger towards the medical team or caregiver,14 anxiety, or withdrawal from addictive substances. Some patients who sign themselves out may be psychotic or confused by delirium or dementia. Others may be in denial of their illness.
Untreated psychiatric disorders can cause illness-specific nonadherence. Patients with:
- depression might not have the energy or motivation to follow the treatment.
- bipolar disorder might feel they don’t need the treatment.
- psychotic disorders may feel threatened by the treatment or the doctor.
Psychiatric patients may avoid taking medications prescribed for medical illness if they fear side effects or interactions with their psychotropics. Some don’t tell their medical practitioners about their psychiatric diagnoses because of the stigma associated with mental illness.
Psychiatrists can counsel the medical team to:
- pull back and focus on setting treatment objectives
- encourage the patient to work as a team member to ensure the best possible care
- communicate with the patient and care team to prevent divisions among the staff.
Neurotic defenses are in play when patients blame themselves and suffer internally. Give them ample opportunities to explore their feelings.
Mature defenses are seen in those who show concern for others, may express humor, and can adaptively plan, thus gaining the respect of others. Spirituality and optimism allow them to feel more at peace and less controlled by the illness.
Support these patients by encouraging their coping skills. For example, if spirituality has helped before, it may again strengthen them and their families.
Improving coping skills. By recognizing which patients are struggling, you can provide support to strengthen their coping abilities. Initially, Mrs. M was using neurotic defense mechanisms and internalizing her emotions. With the help of CBT, she begins to rely on more mature defenses. Her improved coping skills allow her to share her feelings during group therapy and with her family.
