Academic journal article Journal of Cognitive Psychotherapy

Tailoring Cognitive-Behavioral Therapy to Treat Anxiety Comorbid with Advanced Cancer

Academic journal article Journal of Cognitive Psychotherapy

Tailoring Cognitive-Behavioral Therapy to Treat Anxiety Comorbid with Advanced Cancer

Article excerpt

Patients with advanced cancer often experience debilitating anxiety symptoms that interfere with quality of life and relate to worse medical outcomes. Although cognitive-behavioral therapy (CBT) is an empirically validated, first-line treatment for anxiety disorders, clinical trials of CBT for anxiety typically exclude patients with medical comorbidities in general, and those with terminal illnesses, such as advanced cancer, in particular. Moreover, CBT has generally targeted unrealistic fears and worries in otherwise healthy individuals with clinically significant anxiety symptoms. Consequently, traditional CBT does not sufficiently address the cognitive components of anxiety in patients with cancer, especially negative thought patterns that are rational but nonetheless intrusive and distressing, such as concerns about pain, disability, and death, as well as management of multiple stressors, changes in functional status, and burdensome medical treatments. In this article, we describe a treatment approach for tailoring CBT to the needs of this population. Three case examples of patients diagnosed with terminal lung cancer are presented to demonstrate the treatment methods along with outcome measures for anxiety and quality of life.

Keywords: cognitive-behavioral therapy; anxiety; cancer; quality of life

According to the CDC National Center for Health Statistics, 559,888 persons died from malignant neoplasms in 2006, making cancer the second leading cause of mortality in the United States (Heron et al., 2009). Although the majority of individuals will be understandably distressed or anxious in response to the diagnosis of terminal cancer, a significant minority will experience persistent debilitating anxiety symptoms that are maladaptive (Kadan- Lottick, Vanderwerker, Block, Zhang, & Prigerson, 2005). In their review of studies, Miovic and Block (2007) report that the prevalence of diagnosable anxiety disorders in individuals with advanced cancer at a given point in time ranges from approximately 2% to 14%. Investigators using screening instruments have observed rates of clinically significant anxiety symptoms as high as 30% to 40% (Delgado-Guay, Parsons, Li, Palmer, & Bruera, 2009; Hopwood & Stephens, 2000).

Elevated anxiety comorbid with advanced cancer is associated with a number of distressing symptoms, including dyspnea (Bruera, Schmitz, Pither, Neumann, & Hanson, 2000), fatigue (Tchekmedyian, Kallich, McDermott, Fayers, & Erder, 2003), nausea, and pain (Andrykowski, 1990; Delgado-Guay et al., 2009), as well as poor quality of life (Smith, Gomm, & Dickens, 2003). Given the symptom burden and incurable nature of metastatic disease, medical treatments for advanced cancer typically involve chemotherapy and/or radiation for the purpose of preventing tumor progression as well as for palliation. Anxiety may complicate such treatments for advanced cancer, with researchers observing relationships with decreased adherence to chemotherapy (Greer, Pirl, Park, Lynch, & Temel, 2008), longer hospital stays (Prieto et al., 2002), and more aggressive care at the end of life (Temel et al., 2008), though studies to date have largely been correlational in design.

Considering the high lifetime prevalence of anxiety disorders in the general population (i.e., 28.8%; Kessler et al., 2005), many individuals presenting to their oncologists will have a premorbid history of a primary DSM-IV anxiety disorder (American Psychiatric Association, 2000), which may be exacerbated by the stress of the cancer diagnosis. For others without such a history, adjusting to the major transitions of the disease state, such as diagnosis, medical appointments, stressful procedures, follow-up imaging studies, and threat of pain and functional incapacity, may cause significant anxiety symptoms. Additionally, conditioned responses (e.g., anticipatory nausea) may develop during the course of treatment (Andrykowski, 1990). …

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