Seminars in clinical neuropsychiatry最新文献

In seeking to learn more about the etiology and treatment of fatigue in patients with cancer, clinicians and researchers have been challenged to understand how fatigue can be distinguished from depression. Approaches currently used to study fatigue and depression in patients with cancer appear to be of limited usefulness in distinguishing these phenomena. This conclusion is supported by a review of studies in which the single-symptom and symptom-cluster approaches were used to measure fatigue and depression concurrently in patients with cancer. The review yielded consistent evidence of high positive correlations between fatigue and depression, even when attempts were made to eliminate overlapping item content. A consideration of causal mechanisms suggests why it remains difficult to distinguish between fatigue and depression. In addition to fatigue being a possible cause of depression and depression being a possible cause of fatigue, both fatigue and depression can share a common cause. That is, certain forms of cancer and cancer treatment can cause both fatigue and depression. These different mechanisms have implications for efforts to distinguish fatigue and depression and to identify appropriate treatments. For example, recently developed diagnostic criteria for a clinical syndrome of cancer-related fatigue might be useful in identifying fatigue that is caused by a major depressive disorder for which antidepressant therapy is generally indicated.

This article highlights findings from the cancer-specific and other medical caregiving literatures and details a 2-year longitudinal prospective investigation of mood among hematopoietic stem cell transplant (HSCT) patients and spousal caregivers (CGs). Emphases are on gender and role (patient, spouse). Couples (n = 131) completed the Profile of Mood States before HSCT, 6 months, 1 year, and 2 years after HSCT. Data from a nonmedical sample were also collected for normative comparison. Negative affect declined over time for both patients and CGs (P < 0.05), with gender differences among CGs (P < 0.01) but not patients (P > 0.05). Female CGs reported greater depression and anxiety than male CGs. In gender-specific normative comparisons, male and female patients and male CGs showed elevations in negative affect before transplant (P < 0.01) but not after (P > 0.05). Female CGs, in contrast, showed elevations at multiple time points (P < 0.01), suggesting slower resolution of distress over time. These results highlight the need to consider time, gender, and role when addressing emotional, marital, or psychiatric needs in couples. Further investigation is required to identify sources and long-term sequelae of negative affect among female CGs and their partners.

The diagnosis and treatment of cancer can be an extremely stressful, and possibly traumatic, experience. Not surprisingly, there is considerable research documenting the potential negative psychosocial sequelae of malignant disease. More recently, however, research has documented that a broad range of both positive and negative psychosocial outcomes might follow cancer diagnosis and treatment. This suggests that a sole focus on distress and dysfunction could paint an incomplete and potentially misleading picture of the cancer experience. Evidence suggesting that cancer could be a traumatic stressor for some patients is reviewed, as is evidence suggesting that it might precipitate both posttraumatic stress and posttraumatic growth, at times within the same individual. We conclude by offering a conceptual model of cancer as a psychosocial transition. Rather than viewing cancer as a trauma with uniformly negative effects on quality of life, it might be more appropriate to view cancer as a psychosocial transition with the potential for both positive and negative outcomes.

Recent studies have indicated the frequent occurrence of neuropsychologic deficits and cognitive complaints after systemic cancer chemotherapy. Most early reports were retrospective, but prospective longitudinal studies are underway. Although the available evidence suggests a fairly diffuse pattern of changes, memory and executive functions could be preferentially affected. Preliminary data also suggest that some individuals might be more vulnerable than others, leading to investigation of genetic and other risk factors. The greatest gap in our knowledge regarding chemotherapy-related cognitive changes is a lack of understanding of the mechanism or mechanisms that account for the observed changes. Several pathophysiological candidates include direct neurotoxic effects leading to atrophy of cerebral gray matter (GM) and/or demyelination of white matter (WM) fibers, secondary immunologic responses causing inflammatory reactions, and microvascular injury. Altered neurotransmitter levels and metabolites could constitute an additional mechanism related to neurotoxic effects. Advanced brain imaging techniques can directly or indirectly assess many of these mechanisms, but to date there has been very limited application of these tools. Morphometric magnetic resonance imaging (MRI), functional MRI (fMRI), diffusion tensor imaging (DTI), and MR spectroscopy (MRS) are noninvasive techniques that could yield important complementary data regarding the nature of neural changes after chemotherapy. Electrophysiological studies and targeted molecular imaging with positron emission tomography (PET) could also provide unique information. We review the minimal imaging data available at present and also note studies of other brain disorders or treatment effects that might serve as a model for imaging chemotherapy-induced changes. Large-scale prospective studies are needed to help isolate the pathophysiological mechanisms underlying the cognitive deficits associated with chemotherapy.

The patient with cancer faces many stressors during the course of the illness, including fears of death, disability, disfigurement, dependency, and abandonment, as well as disruptions in relationships, role functioning, and financial status. Although such concerns are universal, the level of psychological distress varies depending on psychologic, medical, and social factors. As people are becoming more optimistic about cancer survival as a result of improved cancer treatments, patients and their families are more interested in quality-of-life issues, including psychologic well-being and treatment of psychiatric issues, during and after cancer treatment. In this article, we discuss the psychopharmacologic management of the commonly seen psychiatric syndromes of anxiety, depression and delirium during cancer treatment.

Delirium is a frequent complication of cancer treatment and is associated with a high incidence of morbidity and mortality. This article summarizes recent literature on the epidemiology, mechanisms, and treatment of delirium in the patient with cancer. As data continue to emerge on risk factors and pathophysiological mechanisms, recognition of the distinctive features of delirium in specific cancer populations could contribute to a better understanding of consciousness, cognition, perception, and behavior during medical illness.

The use of increasingly aggressive methods of cancer treatment (e.g., cytotoxic doses of chemotherapy and total body irradiation) has resulted in the need for more effective management of pain, nausea, and other aversive side effects. One of the most promising approaches is nonpharmacologic intervention based on behavioral research and theory. The purpose of this article is to review the efficacy of behavioral intervention methods in controlling aversive side effects of cancer treatments. Sixty-seven published studies were identified for review. Results indicated that: (1) behavioral intervention can effectively control anticipatory nausea and vomiting in adult and pediatric patients undergoing cancer chemotherapy. However, evidence for the efficacy of behavioral intervention to control post-chemotherapy nausea and vomiting is mixed; (2) behavioral intervention integrating several behavioral techniques can decrease levels of anxiety and distress associated with invasive treatments and cancer diagnosis; and (3) although a variety of behavioral methods have been shown to reduce acute treatment-related pain, not all behavioral techniques are equally effective. Hypnotic-like methods involving relaxation, suggestion, and imagery appear to have the greatest impact on cancer-related pain management. The use of behavioral theory and techniques has an important place in the care of patients undergoing invasive cancer treatments.

This pharmacotherapy chapter outlines a series of recommendations regarding the delivery of medications for patients who present with posttraumatic stress disorders (PTSD) and related behavioral and emotional disturbances in the acute care medical setting. These recommendations integrate information previously articulated in PTSD treatment guidelines with clinical experiences derived from real world effectiveness trials. Information from clinical trials suggests that there are patient, provider, and system level considerations that serve to influence the delivery of pharmacotherapeutic interventions targeting PTSD in acute care. The current pharmacotherapy recommendations also integrate considerations regarding the delivery of psychotherapeutic interventions targeting PTSD among injured trauma survivors.