Dynamics of Disease. Elizabeth Archer-Nanda, PMHCNS-C. Collaborators: Mary Helen Davis, MD Sarah Parsons, DO Rose Vick, PMHNP-C

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1 Dynamics of Disease Elizabeth Archer-Nanda, PMHCNS-C Collaborators: Mary Helen Davis, MD Sarah Parsons, DO Rose Vick, PMHNP-C 1

2 Norton Cancer Institute Louisville Oncology Med/Hem Onc Gyn Onc Ortho Onc Behavioral Onc Survivor Program Prevention Program Support Services Cancer Resource Center Patient Navigator Program Genetic Counseling Chaplain Social Work Financial Services Palliative Care 2

3 Psycho-Oncology System Roles Clinical Responsibilities: Individual, family, group Staff/Provider Care: Direct/Individual/ Personal Indirect/ Individual, group/professional Education: Individual 1:1, institutional, community and professional organizations Administration/Institutional : organizational values and goals, standards of care, codes of conduct, professionalism, culture change Team Building, role as communicator, care coordination Our patients / Ourselves, sanctuary in the workplace, balance/protection 3

4 Keys to Success/Barriers to Survival Administrative and Clinical Champions on both Medical and Mental Health side Culture Change within systems/ Buy in Mutually respectful and valued relationships Financial Financial Financial Sabatours Changes in Leadership 4

5 Psychiatric Disorders seen in Oncology Populations Adjustment Disorders Anxiety Disorders Mood Disorders Sleep Disorders Post Traumatic Stress Disorder Schizophrenia Delirium 5

6 Symptom Domain Fatigue Mild Cognitive Impairment/confusion Anxiety/Uncertainty Anticipatory anxiety Mind racing Loss of appetite/nausea Insomnia/Hypersomnia Energy/motivation Psychosomatic concerns/pain 6

7 Issue Domain Loss of control/autonomy Helplessness/hopelessness Quality of life Mortality/end of life /denial Family/Relationships Finances Disability Body image Attributional style 7

8 Dynamics of Disease Cancer as a non-event Cancer as a backburner issue Cancer as a temporary issue Cancer consumes the self Cancer as a cause/ identity Cancer as a positive growth factor Personal psychodynamics 8

9 Factors Impacting Disease Dynamics Disease Stage/State Preexisting mental illness Past medical experience Personality Factors Past Life Experiences: Trauma History Current Life Experiences Treatment Experience 9

10 Psychodynamics The interplay of motivational forces that gives rise to the expression of mental processes, as in attitudes, behavior or symptoms The interaction of various conscious or unconscious mental or emotional processes, especially as they influence personality, behavior and attitudes ( 10

11 Psychodynamics Attachment Abandonment Autonomy Rage Regression Resilience 11

12 Challenges of Treating the Medically Complex Patient Multiple medical providers; communication barriers Traditionally physical and emotional health have been separate Psychopharmacology is complex in oncology patient population; increased risk for drug interactions and multi-system implications 12

13 Case 1 63 y.o. man admitted with pre-existing diagnosis of Schizophrenia, psychotropic medications are discontinued at admission, patient decompensates off psychotropic regimen and learning of new lung cancer diagnosis Patient becomes terrified, has command hallucinations, disturbance in sleep, increased sadness, tearfulness, develops paranoia around diagnosis and physicians interventions Educated nursing staff about delusions, fearfulness, paranoia, provided management and communication strategies Dynamics: Rage, mistrust (both patient and staff), heightened level of paranoia, fear, forgiveness Outcome: Patient compliant with anticancer regimens, coordinated services with community oncologist and community psychiatrist, provided additional support during diagnostic and treatment phase to ensure patient stability and compliance 13

14 Case 2 52 y.o. female diagnosed with triple negative breast cancer referred after RN assessment of tearfulness and increased anxiety at first chemo treatment Pt reports increased feelings of hopelessness, helplessness, acute sense of impending doom, heightened anxiety, nightmares, racing thoughts especially at bedtime, reduced interest and motivation and anhedonia During the first clinical interview the patient was screened for past abuse and trauma history; patient makes first disclosure of childhood sexual abuse Additionally first husband died at age 29 from cancer dx, left patient to raise 2 small children Reviewed impact of past traumas on coping and experience of flooding feelings of helplessness Dynamics: regression, re-traumatization, fear, isolation, abandonment, autonomy & resilience Outcome: Patient complied with all cancer regimens, integrated past experiences and navigated multiple stressors along the way of chemo, anxiety stable 14

15 Case 3 50 y.o. man referred after diagnostic work up for Leukemia is negative, patient presents to Oncology clinic tearful, Oncologist requests crisis consultation Crisis appointment: patient has long history of traumatic childhood, issues with anger, irritability, stable until cancer diagnosis triggered issues of frustration, lack of control, emotional time travel Dynamics: increased issues of irritability, feelings of abandonment, intermittent suicidal thoughts coupled with anger, rage Outcome: patient engaging in psychotherapy and combined medication management for stabilization of mood, working on pharmacological and non-pharmacological strategies for stress reduction and disease management. Managing anticipatory anxiety related to upcoming laboratory testing. Currently no evidence of metastatic disease. 15

16 Case 4 37 y.o. female diagnosed with breast, recurs after one year with metastatic disease to the brain Patient referred for increased anxiety, reduced appetite, nausea Patient is married, mother of 2 children under 10 Dynamics: Autonomy, anger, fear, denial, abandonment, isolation, existential concerns, resilience Outcome: Pt participating in therapy, working toward goals for legacy building and dignity therapy. Exploring personal dynamics and family dynamics at work making open discussions about reality of illness more complex and difficulty to navigate. Remains active in anticancer treatments. 16

17 Benefits of an Integrated Approach On-site collaboration More rapid time to appointment Ease of provider communications Shared medical records Enhances value of mental health as part of medical team Increases understanding of complex factor which may affect treatment outcomes 17

18 What Matters Most How well did you Live? How well did you Love? How well did you Learn to Let Go? 18

Brain Research: Early Experiences Matter. Opening Minds, 2016

Brain Research: Early Experiences Matter Opening Minds, 2016 Disclosure I declare that neither I, or my immediate family, have a financial interest or other relationship with any manufacturer/s of a commercial