58 COGNITIVE THERAPY IN CLINICAL PRACTICE

Conclusions

This chapter has emphasised the need for a new treatment approach in hypochondriasis. A cognitive-behavioural formulation, emphasising the way in which psychological processes interact to produce the core features of the condition, has been described. We have tried to illustrate some of the strategies which, in combination with other more standard techniques, are specifically required for the treatment of hypochondriasis. More than in any other condition these patients are likely to have been dissatisfied with previous treatment; this is neither the fault of the patient nor of previous therapists, but rather is a consequence of the nature of the factors involved in the condition itself. Most hypochondriacal patients appear to have an involuntary style of attending to and interpreting well-intended information and reassurance in a way which acts to provide confirmation of their worst fears. Furthermore, given the beliefs which characterise this disorder, it is not surprising that they are frequently reluctant to accept psychological treatment. Treatment efforts with hypochondriacal patients all hinge on how effectively the patient has been engaged in treatment; we have described several ways in which this can be done. Finally, we emphasise the importance of using collaborative treatment strategies in order to help the patient reach and accept a positive psychological explanation of their symptoms rather than asking that the patient trust in our (uncertain) ability to rule out all possible physical causes. There is little point in depending on interventions which attempt to prove to the patient that the problem which has been troubling them so badly, and which is accompanied by so much distress, has no basis in fact. Even if this were to be possible in the majority of cases (and, by definition, it is not), patients continue to experience distress and perceive continuing physical disturbance, so that sooner or later they are likely to question the disproof they have been offered. We suggest that the use of cognitive-behavioural strategies such as those outlined here may lead to a more encouraging outlook for hypochondriacal patients.

Notes

1.Authorship is equal.

2.Paul Salkovskis is grateful for the support of the Medical Research Council of the United Kingdom.

References

American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, 3rd revised edn, Washington DC: American Psychiatric Press.

Barsky, A.J. and Klerman, G.L. (1983) ‘Overview: hypochondriasis, bodily complaints and somatic styles’, American Journal of Psychiatry 140:273–81.

Bianchi, G.N. (1971) ‘The origins of disease phobia’, Australia and New Zealand Journal of Psychiatry 5:241–57.

Leonhard, K. (1968) ‘On the treatment of ideohypochondriac and sensohypochondriac neuroses’, International Journal of Social Psychiatry 2: 123–33.

Marks, I.M. (1987) Fears, Phobias and Rituals, New York: Oxford University Press.

Nemiah, J.C. (1985) ‘Hypochondriasis’, in H.I.Caplan and B.J.Saddock (eds) Comprehensive Textbook of Psychiatry. Vol. 4, Baltimore: Williams & Wilkins, pp. 1538–43.

Pilowsky, I. (1967) ‘Dimensions of hypochondriasis’, British Journal of Psychiatry 113:89–93. Ryle, J.A. (1947) ‘Nosophobia’, Journal of Mental Science 94:1–17.

Salkovskis, P.M. (1989) ‘Somatic problems’, in K.Hawton, P.M.Salkovskis, J. Kirk, and D.M.Clark (eds) Cognitive Behaviour Therapy for Psychiatric Problems: a practical guide , Oxford: Oxford University Press.

Salkovskis, P.M. and Warwick, H.M.C. (1986) ‘Morbid preoccupations, health anxiety and reassurance: a cognitive behavioural approach to hypochondriasis’, Behaviour Research and Therapy 24:597–602.

Salkovskis, P.M. and Westbrook, D. (1987) ‘Obsessive-compulsive disorder: clinical strategies for improving behavioural treatments’, in H.R.Dent (ed.) Clinical Psychology: Research and Development, London: Croom Helm.

Warwick, H.M.C. and Salkovskis, P.M. (1985) ‘Reassurance’, British Medical Journal 290:1028.

Warwick, H.M.C. and Salkovskis, P.M. (1987) Clinical and Research Aspects of Hypochondriasis: A Review of Current Problems and A Cognitive-Behavioural Perspective, manuscript submitted for publication.

Chapter five

Cancer patients

Jan Scott

Introduction

The use and efficacy of cognitive behaviour therapy (CBT) in the treatment of primary major depressive disorders is now well established on both sides of the Atlantic (e.g. Rush et al. 1977; Blackburn et al. 1981). More recently, its use in anxiety disorders has been similarly well described (Beck et al. 1985). The use of CBT in the treatment of depression or anxiety that arises as a secondary consequence of physical illness has been less extensively researched. A small number of studies have been published in the literature pointing to the possible use of CBT in patients with multiple sclerosis (Larcombe and Wilson 1984), epilepsy (Tan and Bruni 1986), and irritable bowel syndrome (Schwarz and Blanchard 1986), as well as with those suffering from painful conditions such as rheumatoid arthritis (Bradley 1985), or coping with the consequences of coronary surgery (Valliant and Leith 1986) or myocardial infarction (Stern et al. 1984). The sample sizes were small; the applications of CBT varied between group, individual, and telephone sessions; the outcomes were variable, with evidence of both success and failure. These modest results may dampen some therapists’ enthusiasm for trying CBT with physically ill patients, but the studies quoted so far can only be regarded as a preliminary attempt to ‘test the water’. Few of the reports gave details of the problems of applying CBT to these patients and relatively little information is available on if, or how, the CBT approach was modified to tackle the specific needs of this group.

One of the most interesting potential applications of CBT to the physically ill is its use with cancer patients. Again there is a small, but growing, literature. Maguire and colleagues (1985) in the UK, and Worden (1987) and colleagues in the USA, have provided some preliminary studies in this area. The early results suggest that CBT can be an effective therapy for cancer patients, used either alone or in combination with antidepressant drugs. These groups of researchers also made preliminary attempts to identify factors that made some cancer sufferers more vulnerable to emotional disorders.

In this chapter I will briefly review the prevalance of psychological morbidity in cancer patients and outline why CBT may have a role to play in such disorders. In addition, I will describe some of the specifie issues that need to be addressed in applying CBT to this patient population and try to identify potential problem areas. A case study of the use of CBT in a female patient with breast cancer will be described to highlight some of the strategies that may be used.

Prevalence of psychological problems in cancer patients

The diagnosis of cancer represents a major and catastrophic life event to most individuals (McIntosh 1974). As Massie and Holland (1984) point out, an individual’s ability to adapt depends on the threat it poses to their ‘age-appropriate’ goals (e.g. family, career); their prior level of emotional adjustment; the presence of a social support network; and disease-related factors such as the site of the tumour, the presence of disabling symptoms, treatment variables, and prognosis. The commonest emotional response of any individual to the diagnosis of cancer follows the classical sequence of a crisis reaction: initial shock and disbelief are followed by anxiety, anger, guilt, and depression. The period of adjustment is variable, but the acute reaction usually begins to resolve over 7–14 days. In some cases, this adaptation may be considerably delayed or may never occur, whilst in others the illness is denied.

In a significant number of individuals the emotional response takes the form of a depressive or anxiety disorder. At least 25 per cent of post-mastectomy patients develop these disorders in the twelve to eighteen months following surgery (Morris 1979). A similar figure is reported for patients with a colostomy following treatment for bowel cancer (Devlin et al. 1971). Exacerbations of these symptoms may occur with evidence of recurrence of the cancer (Silberfarb et al. 1980), or at the end of the course of radiotherapy (Holland et al. 1979). Psychiatric morbidity may also be a direct consequence of specific chemotherapy regimes (Hughson et al. 1980).

Estimating the prevalence of psychiatric disorders in the physically ill is often problematic, but there is well-documented evidence that the actual level of morbidity in an oncology unit greatly exceeds that recognised by the staff caring for the

60 COGNITIVE THERAPY IN CLINICAL PRACTICE

patients (e.g. Levine et al. 1978). This lack of detection may be a function of the patients’ reluctance to reveal their fears or the staff’s failure to respond to verbal and non-verbal cues. Unfortunately, even when anxiety or depressive disorders are recognised they frequently remain untreated. Greer (1985) suggests that the staff tend to regard these conditions as an understandable response and so fail to consider that psychiatric help is either feasible or indicated.

The lack of adequate recognition and treatment of the emotional consequences of cancer is disappointing for two reasons. First, over the last decade there has been a rapid expansion in the physical therapies available to treat a wide variety of cancers. The survival times for many patients have been significantly lengthened, although some of the treatments are themselves difficult to tolerate. These factors have led to an increasing awareness of the need to maintain the quality of life experienced by the patient. It is no longer merely a question of being ‘grateful to be alive’. Second, there is evidence that the psychological response to the cancer may affect the length of survival. Several studies (e.g. Greer et al. 1979) indicate that the outcome at 5 years is better in those patients who either deny the existence of the illness or show a ‘fighting spirit’, shorter survival rates being associated with stoic acceptance or a helpless-hopeless response.

There are some data available on which individuals are most vulnerable to psychological problems. First, with regard to physical status, patients most at risk of psychological problems are those who undergo mutilating surgery (Dean et al. 1983), those with inadequately controlled pain, those in poorer physical health generally, and those with advanced stage illness (Holland et al. 1983). Patients who fail to cope with radiotherapy show ‘extremes of behaviour’ (e.g. withdrawal), engage poorly with health professionals, and have unrealistic expectations about their prognosis (Schmale et al. 1982). Poor psychosocial adjustment after mastectomy is associated with premorbid neurotic traits (Schonfield 1972), lack of close personal relationships (Weisman and Worden 1977), lack of employment (Bloom 1982), and a history of previous psychiatric disorder (Morris 1979). Weisman and Worden (1977) have also identified a group of poorly coping patients with a wide variety of different tumours. They found that ‘poor copers’ showed a long history of inadequate problem solving in a variety of situations.

Why use cognitive behaviour therapy?

Maguire and co-workers (1985) have often advocated the use of antidepressant or anxiolytic drugs in patients with cancer. They feel that there has been a reluctance to prescribe psychotrophic drugs because of the obvious ‘reactive’ nature of the psychological problems. In many instances the severity of the symptoms and the type of illness do warrant drug therapy. In other instances, pharmacotherapy is required in order to enable the patient to engage in counselling and support. However, the use of drugs in cancer patients presents a number of difficulties that may realistically make people wish to avoid prescribing them:

1.The patient’s psychological symptoms may not fit neatly into the pattern of a particular syndrome and may not show features that would be resolved by drug therapy. Often the presentation is a mixture of anxiety and depressive symptoms, frequently coming under the rubric of DSM III-R ‘adjustment disorder’ (American Psychiatric Association 1987). CBT may tackle the combination of problems presented in a more comprehensive way than pharmacological treatment.

2.Even when drugs seem to be indicated, patients with cancer are frequently more sensitive to their side-effects. This is particularly true of tricyclic antidepressants; cancer patients are less tolerant of the anticholinergic side-effects, possibly due to changes in hepatic enzyme activity (Massie and Holland 1984).

3.Antidepressant drugs may be contra-indicated because of interactions with other physical treatments. Monoamine oxidase inhibitors should not be combined with opiate analgesics. Tricyclic antidepressants are contra-indicated with the chemotherapeutic agent procarbazine (Massie and Holland 1984).

4.The risk of a suicide attempt may be high in a depressant and hopeless patient. Psychotropics may merely provide the patient with the means to carry this out.

5.It is important to consider the ‘message’ being given to patients and their families. With CBT, the statement being put forward focuses on helping the individual to participate actively in the development of coping strategies. Drug therapies make the patient the passive recipient of a ‘cure’. The patients’ preferences also become important here. Do they have more faith in pharmacology or do they prefer a psychological approach?

If pharmacotherapy is used, it should be seen as an adjunct to rather than a replacement for psychological treatment. However, as Worden (1987) points out, whilst there is a vast array of psychosocial interventions available for cancer patients, most are aimed at helping them and their families cope with dying. CBT differs from many of these therapies because it attempts to enable the patient to adjust to the problems of living. The focus is on controlling the quality of life in a situation where the ‘quantity’ may be an unpredictable variable. This is not to suggest that CBT should replace other psychological interventions. The use of counselling and supportive psychotherapies is generally known to be beneficiai (e.g. Bloom et al. 1978). However, it is interesting to note that some of the most effective programmes tend to incorporate many techniques that would come