Coping with it all (Part 2)
What problems require professional help?
Feeling overwhelmed by fear and distress
Intense worry and fear about what cancer will do to you and its threat to your future and that of your family can shake the heartiest among us. In this situation, you feel a mix of anxious and depressed feelings that get in your way in the extent that you are barely able to carry on your work, take care of yourself and your family, and take care of your home-in short, to engage in your daily basic activities.
In today’s fast-paced and highly stressed world, many people feel that they are barely able to keep their heads above water, juggling the normal concerns of work, family and other relationships, household, and finances. Suddenly, along comes cancer, which throws a wrench into works. You may want to say “Stop the world, I want to get off,” to borrow the title of the Broadway musical, but life doesn’t work that way. So while you schedule your chemo or radiation sessions or need time to recover from surgery, the kids still need to be fed, picked up at school, and dropped at the baby-sitter; the dog has to be walked; the bills still have to be paid (and now there are medical bills on top of the usual ones); and on and on. And you might feel lousy or exhausted to boot. The straw that breaks the camel’s back may be enough to send a champion coper into a tailspin, feeling you just can’t cope with anything else.
It is important to recognize that this, too, shall pass. But it is also essential to get the help you need. Friends, relatives, and neighbors who carpool the kids to school, cook for the family, and come to the hospital can be an enormous help. In addition to helping you put your fears and sadness in perspective, counseling can help you manage these crises and solve the domino effect that cancer may trigger.
A previous history of emotional problems
If you have previously had to deal with anxiety, such as phobia of needles, hospitals, or seeing blood, or if you have had agoraphobia, a fear of leaving home, you may be more troubled and emotionally upset by thoughts of going through treatment for cancer. Even the tests to diagnose cancer, such as CT scans, MRIs, and sonograms, are frightening to some people. The hospital visits and all travails that the treatments entail are frightening by themselves and add to the ordinary burden imposed by this serious illness. If you have had panic attacks under stress in the past, or if you are a generally nervous, anxious, and fearful person, you may need help.
If this is your pattern, it is best to preempt the problem and seek help before it arises so that it doesn’t interfere with your cancer treatment later. Discuss this concern with both your oncologist and your psychiatrist. Both physicians should be aware of all the medication you are taking (including any alternative or complementary treatments) so that drug interactions can be avoided. Together you and your doctors can develop a treatment plan.
When treatment situations provoke anxiety
Some people have been vulnerable to episodes of depression all their life. Developing a serious medical condition can bring depression back. We’ve said that it’s normal to be sad when you’re sick, but clinical depression is an illness of its own, and it can be fatal, through its risk of suicide. Professor Lewis Wolpert, in his book Malignant Sadness, wrote:
Depression is sadness that has become pathological. Just as cancer is a normal growth process that has gone out of control, so depression is a normal emotion that has become viciously disordered.
Victor a man or forty-five had finished treatment for lymphoma and was considered medically well and likely cured. He had a bout of depression in his thirties following a divorce but had managed for years to be free of its grip. Now, however, despite the good news, he found himself choosing to spend his nights alone. He was an avid reader and loved classical music, but he couldn’t pay attention to what he was reading and he couldn’t listen to music, not only did he not enjoy it, but it upset him more. At the office, he couldn’t stay focused on his work. Sleep was fitful, and he had no desire for food. Victor’s friends noticed that he wasn’t himself. Luckily ,Victor was referred by his hematologist for evaluation of his depression. Victor described his symptoms in a listless, dejected way, recalling his prior depression, which had been successfully treated with medication and psychotherapy. His brother had had severe depression and committed suicide. Also, his father had been depressed in his later years. Victor recognized his own vulnerability related to this family history. He was started on the antidepressant sertraline (Zoloft), to which he responded well in a couple of weeks, but he continued therapy over the following months to be sure that his early improvement continued.
A recent personal loss
Dealing with cancer is hard enough when other things are all right, but it comes much more difficult to bear if you are grieving from the death of someone very close to you. It can be crucial to get help to deal with this “double whammy” to prevent serious depression and to keep you from giving up and not pursuing your recommended course of treatment. Grieving for a loved one while you’re dealing with your own illness may lead to more thoughts about death. Under these circumstances, suicidal thoughts are more common and suicide is a higher risk. It is a good idea to seek a consultation with a mental health professional and share these thoughts. It is possible that grief counseling may be sufficient, but psychotherapy and a medication may be required to address the problem. In any case, persistent suicidal thoughts are not normal, and they should be a wake-up call to consult with someone. They are of serious concern and should be explored with a professional right away.
When parents or other family members have died from cancer
The diagnosis of cancer can bring back memories of living through the illness and death of a loved one, and it may evoke the fear that you will suffer the same fate.
Sharon was a youngster of eleven when her father was diagnosed with bladder cancer. Her dad was an invalid at home for five years and died when Sharon was sixteen. Her childhood was colored by her father’s illness and death. Her own diagnosis of ovarian cancer occurred at age thirty-six, when her children were ten and eight. She sought help to deal with her fearfulness, sadness, and recurring nightmares, which were about caring for her father. She recalled this childhood experience vividly and in detail about how difficult it had been for her as the oldest child. She related these memories to her own illness and realized how much she feared the same loss could happen to her children, whom she desperately wanted to protect. She rationally recognized that the doctor had assured her that her cancer was caught early and that she should be fine. She began to practice meditation daily for twenty minutes, which further added to her sense of control. She was able to see that her real concern was her identification with her two children and her anguish, as she imagined they might have to go through the same experiences as she did in childhood. Her anxiety went down to tolerable levels, and during her treatments she continued in counseling.
Memories of a major trauma earlier in life
A cancer diagnosis often ignites memories of traumatic events from the past that have been kept out of consciousness successfully for years. Suddenly, flashbacks and profoundly disturbing memories are rekindled: of combat experiences with their sense of vulnerability, fear, and death; of repressed experiences of childhood abuse; of World War II experiences in concentration camps, where the sense of helplessness, panic, despair, and death prevailed; of being trapped in a natural disaster, such as an earthquake, hurricane, or flood. Memories are frequently revived under the stress of dealing with cancer. These symptoms represent posttraumatic stress disorder (PTSD), in which the current trauma triggers memories of an earlier trauma, with renewed anxiety, depression, flashbacks, and overall distress.
It’s quite common, also, for news events of a sad or tragic nature to transiently increase fears, distress, and sadness. When Jackie Onassis died of lymphoma, there was a torrent of emotion from patients who were struggling with their own cancer illness. Some followed the story in newspapers or magazines and on TV, and they cried for her and for themselves. Others couldn’t read or watch what was happening; they felt too sad.
For people with cancer, the identification with a celebrity or a public figure who is ill or has died may carry an added meaning. It leads to the thought “if Jackie Onassis’s illness could take a sudden turn for the worse, so could mine.” The empathy for, or identification with, another can ignite fresh concern and preoccupation with illness and death. For most people, the uncertainty surrounding cancer never fully goes away, and these flashpoints simply bring it to center stage. Given a little time, distress related to the sad events in the news will recede into the background, and life and illness will feel manageable once more.
Sudden change in mood or mental function during cancer treatment
Some anticancer medications, particularly corticosteroids (also called steroids), interferon, pain medicines, and others, can cause a sudden, radical change in mood, mental function, and behavior. Families often react, saying, “Oh, his cancer is getting him down, he’s so depressed.” But when you look a bit more closely, it is clear that the change is due to a side effect of a medication. Indeed, a patient with cancer may become confused and unable to think clearly, entering a state of delirium, in which the brain is taking a hit from some toxic factor or event. The person may become confused about where he or she is and develop hallucinations, delusions, and fears of being harmed by someone.
Fran, a well-adjusted woman of sixty-five, came to the hospital for treatment of a painful spinal cord tumor. She was given steroids to reduce the pressure in her spine. On the third day, her family members were astounded when they came to visit her. She was terrified and told them, “There are people outside selling drugs, and the police are coming to bust me-save me!” Her adult children reported her reaction to her doctor, who explained that it was due to the high dose of steroids she was given. Her steroid dose was lowered and she was given olanzapine (Zyprexa) to reduce her frightening ideas. She soon became herself again, but she vividly remembered the strange feelings that were so alien to her. She commented, “I’m glad to learn it was a drug that made my brain play tricks on me, and I’m not going crazy.”
Physical symptoms causing distress
Almost any pain in the body is made worse when we are anxious, and this is especially true for people with cancer, whose first fear on feeling a pain will likely require medicines to control it, but psychological support, behavioral techniques (such as relaxation), and spiritual practices (such as meditation) can help a lot.
Nausea and vomiting from chemotherapy are remarkably better controlled today by anti-nausea drugs, which make it far easier to go through chemotherapy. However, anxiety about chemotherapy can increase the nausea and distress. People can even develop nausea just by thinking about the next treatment. This form of anxiety, an anticipatory symptom, is a kind of self-fulfilling prophecy. Scientifically, we understand it as learned or conditioned response, like that of Pavlov’s dogs, who reflexively salivated at the sound of a bell. Repeated chemotherapy treatments can trigger anticipatory nausea based on previous experience; the person expects it to happen so strongly that it does, in fact, occur before the stimulus is given. Reducing anxiety through a relaxation exercise, meditation, or an anti-anxiety medicine can eliminate this psychological side effect.
Fatigue and its causes are far better understood these days, and far more is being done about the problem. It is a cardinal symptom of which many patients complain. Fatigue affects three-quarters of patients with cancer at some time. It can range from having less energy than usual to finding yourself too exhausted to get out of bed or carry out the ordinary tasks you are used to doing everyday. Some people say, “Just lifting my finger is an effort.” And it can last from a few days to months. Fatigue can be caused by the cancer itself, by anemia, by treatments (particularly radiation and chemotherapy), by pain medications, or by depression. Tell your doctor about your fatigue so that its severity can be evaluated and its cause determined. Anemia can be treated and depression can be alleviated. Drugs called psychostimulants counter fatigue and improve energy levels.
Insomnia, which can involve trouble going to sleep, awakening during the night, or awakening too early in the morning, is a common complaint that makes it harder to cope with the daytime stresses of cancer. Surely, nighttime is when ”demons” and fears are apt to be on the loose, keeping you awake and allowing frightening thoughts to take over. Patients who aren’t sleeping become more fatigued and overwhelmed, so that coping becomes more difficult. Reading, meditation, or listening to relaxation tapes at bedtime is helpful for many people. Some individuals also need a medication to help them sleep during the crisis around illness. As with pain medicines, people fear addiction to sleep medications far beyond what is warranted, and they end up depriving themselves of something that could help them through the rough spots. If you’ve never had a drug problem, you’re not going to become addicted to a medicine given at bedtime in small doses and on a short-term basis so that you can get a good night’s rest. You can stop taking the medicine when the crisis period is over and your normal sleep patterns return, as they usually do. Discuss any sleep problems you’re having with your doctor, and share any concerns you might have about taking medication, so that they can be addressed.
Loss of appetite is another common symptom among patients with cancer. It can have many different causes, ranging from the cancer itself to the side effects of treatment to anxiety or depression. Sometimes, the smell or sight of food can trigger a feeling of revulsion after a lengthy course of chemotherapy. Well-meaning family members may become panicky and try to force food on the ill person, which only makes the problem worse. Let your doctor know if you have trouble eating or have lost your appetite. Both psychological approaches and medication can help.
In summary, both physical and psychological symptoms may result in distress that is severe enough to be evaluated and treated. The oncologist is the first line of defense, but some problems require a visit with a professional skilled in recognizing and treating the psychological and psychiatric problems that are common with cancer. Certain life experiences-prior trauma, recent loss of a loved one, or a history of emotional problems-make coping harder and may require referral to a counselor. Anxiety, depression, and confusion are types of distress that respond to treatments targeted to their cause. Pain, nausea and vomiting, fatigue, and loss of appetite often have psychological components. Be sure to allow yourself of help when needed; ask your oncologist for assistance in finding a professional who can address the psychological dimension.