Adjustment disorders and
Distress in Palliative Medicine
TUTORIAL 17/03/2020
PRESENTER : DR RUPARNA KHURANA
MODERATOR : DR SUSHMA BHATNAGAR

• Definition (DSM V/ NCCN)
• Meaning : psychiatric disorder
• Context in palliative medicine
• What role do we play
• How to screen patients for an adjustment disorder and distress

DSM…
• Different categories of disorders??
PERSONALITY MOOD AFFECTIVE
TRAUMA NAD
STRESSOR RELATED
DISORDERS
• POST TRAUMATIC STRESS
DISORDER
• ACUTE STRESS DISORDER
• ADJUSTMENT DISORDERS
(INTRODUCED IN DSM III)

Umbrella term
• AD with depressed mood
• AD with anxiety
• AD with mixed depression
and anxiety
• AD with conduct
abnormality
• Unspecified

What all it includes
• Fall under the category of trauma and stressor related
disordres
• Transitory diagnosis
• Situational depression
• Subthreshold disorder
• Dump diagnosis

• many as 13% of inpatients in a general hospital
• situation, 10% in outpatients, and 13% in emergency rooms, In
• the general population, AD is associated with suicidal thoughts
• (30%); 58% of suicide attempters and 9–19% of suicide completers
• may be diagnosed with an AD. A study of 209 terminally ill cancer
• patients found that AD was present in 11–17%, compared to a
• depression prevalence of 7–12%; lower performance status, inadequate
• social support, and concern about being a burden were
• significantly associate

• medications, talking therapy,
• hypnosis, relaxation, and supportive therapy (McQuellon et al.,
• 1998; Roth and Massie, 2007; Arch and Craske, 2009; Otte et al.,
• 2011; Reinhold et al., 2011). Many patients find other complementary
• therapies helpful, which may include the entire gamut from
• meditation and reflexology, to Chinese herbs and spices (Wein,
• 2000; Anderson and Taylor, 2012).
• Talking therapies

• Adjustment disorder : group of emotional and behavioral symptoms
in response to a recognizable stressor
• Describes a maladaptive emotional and/or behavioural response to
an identifiable psychosocial stressor
• Experience difficulties adjusting after a stressful event
• Symptoms are disproportionate to the severity or intensity of the
stressor

• A group of emotional and behavioral disorders in response to a
variety of identifiable stressful events
• Symptoms represent an adaptation to these stressors or to their
continuing effects.
• Seen as far less stigmatizing

Epidemiology
• Principal diagnosis in OPD : 5% - 20%
• Approach 50% in hospital psychiatric consultation settings
• Women > Men

• Higher rate among persons exhibiting suicidal behavior, particularly
adolescents and young adults
• Three times more common as major depression (13.7 vs. 5.1%) in ill
medical inpatient

Stressors
• Knowledge that death is imminent
• family feuds
• inability to work
• financial crisi
• The perception of becoming a burden or losing control due to illness,
• physical pain or other symptoms, and being unable to complete
• life’s tasks, Other stressors relate to premorbid physical or psychiatric
• problems, such as obsessive–compulsive neurosis. Yet others
• occur as system issues, such as the threat of non-coverage by a
• health insurance company

• degree of distress and dysfunction that occur
• may vary with the severity and type of stressor, individual
• resilience, premorbid psychological health, education, and
preparation,
• support from family and health professionals, and other
• factors. Distress associated with adjustment is common, and to
• some extent, entirely normal

Etiology
• Single stressor to a symptom complex.
• The stressor The individual Interaction

• 5) Biological theorists

• Onset : within 3 month of a demonstrable stressor
• Duration of symptoms : not exceed 6 months
(except in prolonged depressive reaction)

• Diagnosis depends on a careful evaluation of the relationship
between
• (a)form, content, and severity of symptoms
• (b)previous psychiatric history and personality
• (c)stressful event, situation, or life crisis
• Normal bereavement

Management
Primary goals of treatment
 relieve symptoms
Achievement of a level of adaptive functioning that is comparable to,
or better than, the level of premorbid functioning.
• Brief therapies

• Supportive psychological approaches
• Cognitive-behavioral and psychodynamic interventions
• Relaxation techniques
• Assistance in finding alternative responses
• Date dialectical behavior therapy (DBT) has the best evidence base
• Practical measures may be useful to assist the person in managing the
stressful situation

• Ego enhancing therapy
• Coping strategy : helps the patient acknowledge the stressors.
• “Mirror therapy”

• Psychotherapy : treatment of choice
• Interpersonal psychotherapy : include psychoeducation about the
patient's role, a here and now frame work, formulation of the
problems from an interpersonal perspective, exploration of options
for changing dysfunctional behavior pattern

Pharmacological management
• Symptomatic treatment of insomnia, anxiety and panic attack
• Benzodiazepines and antidepressants

• DISTRESS

Definition
• Distress is a multifactorial unpleasant experience
of a psychological (ie, cognitive, behavioral, emotional)
social, spiritual, and/or physical nature
that may interfere with one’s ability to cope effectively
with cancer  its physical symptomsits treatment.

• Continuum
feelings of vulnerability/ sadness/fears
Depression, anxiety, panic, social isolation, and existential and
spiritual crisis.

Expected distress symptoms
• Fear and worry about the future
• Concerns about illness
• Sadness about loss of usual health
• Anger, feeling out of control
• Poor sleep/ appetite/ concentration/
• Preoccupation with thoughts of illness and death
• Concerns with disease/treatment side effects
• Concerns about social role (ie, as father, mother)
• Spiritual/existential concerns
• Financial worrie

Patients at increased risk of distress
• History of psychiatric disorder or substance use disorder
• History of depression/suicide attempt
• History of trauma and/or abuse (physical, sexual, emotional, verbal)
• Cognitive impairment
• Communication barriers
• Severe comorbid illnesses

Patients at increased risk of distress
• Social issues
• Family/caregiver conflicts
• Inadequate social support
• Living alone
• Financial problems
• Limited access to medical care
• Young or dependent children
• Younger age
• Immigration
• Loss of stable housing/shelter/living environment

Patients at increased risk of distress
• Current substance use
• Other stressors
• Spiritual/religious concerns
• Uncontrolled symptoms
• Cancer type associated with risk of depression (eg, pancreatic cancer,
head and neck cancer)

PERIODS OF INCREASED VULNERABILITY
• Finding / investigating a suspicious symptom
• During diagnostic workup
• Finding out the diagnosis
• Advanced cancer diagnosis
• Learning about genetic/familial cancer risk

PERIODS OF INCREASED VULNERABILITY
• Awaiting treatment
• Increase in symptom burden
• Significant treatment-related complication(s)
• Admission to/discharge from hospital
• Change in treatment modality
• Treatment failure
• End of active treatment
• Medical follow-up and surveillance
• Transition to survivorship
• Recurrence/progreression
• Transition to ned of life care

STANDARDS OF CARE FOR DISTRESS
MANAGEMENT
• Recognized, monitored, documented, and treated promptly at all
stages of disease and in all settings.
• Screening should identify the level and nature of the distress.
• Every patient should be screened at every medical visit

• Interdisciplinary institutional committees should be formed
to implement standards for distress management.
• Educational /training programs should be developed
• Licensed mental health professionals and certified chaplains
experienced in psychosocial aspects of cancer should be
readily available as staff members or by referral.
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• integral part of total medical care and is provided with appropriate
information about psychosocial services in the treatment center and
the community.
• Quality of distress management programs/services should be
included in institutional continuous quality improvemevnt project

• Ensure continuity of care
• Mobilize resources
• Consider medication to manage symptoms: Analgesics /Anxiolytics
Hypnotics/ Antidepressants/ Psychostimulants
• Support groups and/or individual counseling
• Family/couple/caregiver support and counseling
• Relaxation, meditation, creative therapies (eg, art, dance, music)
• Spiritual support
• Exercise
• Assess and strengthen coping strategies

• SCREENING TOOL FOR DISTRESS

MANAGEMENT
DT < 4
Managed by the primary oncology team
Expected distress
DT>4
Trigger a second line of questioning
Screen for anxiety/depression
Further referrals
Moderate-severe distreas
MILD DISTRESS
Prognostication/
communication/ Symptom
management

Positive screen for anxiety and depression
Referral to a mental health professional/ social worker/
spiritualcounselor
( problems identified in the Problem List)

Common symptoms that require further evaluation are
• Excessive worries and fears
• Excessive sadness, unclear thinking, despair and hopelessness
• Severe family problems/ social problems
• Spiritual or religious concerns

INTERVENTIONS
• Acknowledge/validate distress
• Clarify diagnosis, treatment options, and side effects
• Be sure patient understands disease and treatment options
• Discuss advance care planning
• Refer to appropriate patient education materials
• Educate patient that points of transition may bring increased
vulnerability to distress

Management strategies
PHARMACOTHERAPY
CBT/PSYCHOTHERAPY
ALTERNATIVE THERAPY

Alternative therapies
• Meditation, yoga, relaxation with imagery, massage, and music
therapy
• Depressive disorders and anxiety

NAM report
• CBT
• Supportive psychotherapy
• Family and couples therapy

Cognitive Behavioral Therapy
• Practicing relaxation techniques
• Enhancing problem-solving skills
• Identifying and correcting inaccurate thoughts associated with
feelings

• RCTs  CBT and cognitive-behavioral stress
management have been shown to effectively reduce psychological
symptoms (anxiety and depression)
as well as physical symptoms (pain and fatigue) in patients with cancer

Supportive Psychotherapy
• Flexibly meeting patients’ changing needs.
• Different types of group psychotherapy
• Supportive expressive group therapy
• Improve QOL/ psychological symptoms
• Improvements in mood and pain

SPT
• Expressive writing
• Supportive expressive group therapy
• Cognitive existential group therapy
• Meaning centred froup psychotherapy
• Dignity therapy