Psychiatric management of cancer pain

Suicide in obstructive lung, cardiovascular and oncological disease

Healthcare institutions face increasing demands stemming from the burden of noncommunicable diseases. The personal, social, financial and societal impact of these diseases are well-documented. However, the mental health concerns and trajectories of patients afflicted by chronic medical diseases have been under-recognized and are under-resourced. Despite that chronic diseases are associated with substantially increased risk of suicide, the medical world has largely failed to properly address suicide in the medically ill. Considering their high prevalence and mortality rate, this review article will highlight the mental health burden and suicide risk in obstructive lung, cardiovascular (including stroke) and oncological disease, in light of relevant data and conceptual models of suicide. Finally, general evidence-based suicide intervention strategies and potential selective adaptation of these strategies to the chronic medically ill patient populations and medical settings will be reviewed.

A comprehensive review of palliative care in patients with cancer

One of the most challenging roles for the psychiatrist is to help guide terminally ill patients physically, psychologically and spiritually through the dying process. Patients with advanced cancer, and other life-threatening medical illnesses are at increased risk for developing major psychiatric complications and have an enormous burden of both physical as well as psychological symptoms. In fact, surveys suggest that psychological symptoms such as depression, anxiety, and hopelessness are as frequent, if not more so, than pain and other physical symptoms in palliative care settings. Psychiatrists have a unique role and opportunity to offer competent and compassionate palliative care to those with life-threatening illness. In this article we provide a comprehensive review of basic concepts and definitions of palliative care and the experience of dying, and the role of the psychiatrist in palliative care including assessment and management of common psychiatric disorders in the terminally ill, with an emphasis on suicide and desire for hastened death. Psychotherapies developed for use in palliative care settings, and management of grief and bereavement are also reviewed.

Focused suggestion with somatic anchoring technique: rapid self-hypnosis for pain management

This article details a self-hypnosis technique designed to teach patients how to manage acute or chronic pain through directed focus. The focused suggestion with somatic anchoring technique has been used with various types of pain, including somatic pain (arthritis, post-injury pain from bone breaks, or muscle tears), visceral pain (related to irritable bowel disease), and neuropathic pain (related to multiple sclerosis). This technique combines cognitive restructuring and mindfulness meditation with indirect and direct suggestions during hypnosis. The case examples demonstrate how the focused suggestion with somatic anchoring technique is used with both acute and chronic pain conditions when use of long-term medication has been relatively ineffective.

Pain management in the elderly at the end of life

BACKGROUND

The treatment of older adults with pain is complex and affected by age-related changes in pharmacokinetics and pharmacodynamics. Chronic pain encompasses a complex array of sensory-discriminatory, motivational-affective, and cognitive-evaluative components. Because of this complexity, both pharmacologic and nonpharmacologic approaches should be considered to treat pain.

AIMS

Given the large number of older persons with pain at the end of life and the few data about this issue, the objective of this article is to review the treatment of pain in this population.

PATIENTS AND METHODS

We searched The Cochrane Library, MEDLINE and LILACS from 1990 to 2011 and the references in retrieved manuscripts. The search terms were pain AND elderly AND end of life.

RESULTS

There are evidences of undertreatment among elderly people. The association of nonpharmacologic resources with the pharmacological treatment can help reduce the use of analgesics minimizing the side effects of long term medication. Pharmacological treatment is escalated in an orderly manner from non-opioid to weak opioid to strong opioid. Adjuvant drugs like anticonvulsants and antidepressants may be necessary.

CONCLUSIONS

The sequential use of analgesics drugs and opioids are considered effective and relatively inexpensive for relieving pain, but no well designed specific studies in the elderly patient are available. There are not specific recommendations about the long-term use of complementary and alternative therapies and although their effectiveness remains unproven they should not be discouraged. Palliative sedation may be a valid palliative care option to relieve suffering in the imminently dying patient.

Application of Cognitive Behaviour Therapy to Patients Who Have Advanced Cancer

Patients who are diagnosed with advanced cancer frequently experience high levels of anxiety and depression. Few of the studies that evaluated psychological interventions with this cohort have demonstrated improvements in psychological measures in the period following therapy. However, a recent study that evaluated the efficacy of a group cognitive behaviour therapy (CBT) intervention with patients who had advanced breast cancer found improved outcomes on measures of mood and self-esteem following the intervention. This paper describes some of the CBT techniques used in the intervention, which might also be useful in the treatment of patients with other types of terminal illness.

Review article: palliative care in gynecologic oncology

Patients with advanced gynecologic malignancies have a multitude of symptoms; pain, nausea, and vomiting, constipation, anorexia, diarrhea, dyspnea, as well as symptoms resulting from intestinal obstruction, hypercalcemia, ascites, and/or ureteral obstruction. Pain is best addressed through a multimodal approach. The optimum palliative management of end-stage malignant intestinal obstruction remains controversial, with no clear guidelines governing the choice of surgical versus medical management. Patient selection for palliative surgery, therefore, should be highly individualized because only carefully selected candidates may derive real benefit from such surgeries. There remains a real need for more emphasis on palliative care education in training programs.

Differentiating and managing common psychiatric comorbidities seen in chronic pain patients

Pain patients often have comorbid psychiatric disorders that can complicate their management. Failure to recognize and address psychological comorbidities often limits pain treatment success. This paper describes some of the more commonly seen psychiatric comorbidities in pain patients, briefly discusses how the diagnoses are made, and provides some initial treatment guidelines. The multiaxial diagnostic system of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is described. Three common psychiatric issues seen in pain patients: anxiety, depression, and adjustment disorder, are discussed. A brief history of the DSM is also discussed.

Adjuvant Psychological Therapy with a Terminally III Patient: A Case Report

Adjuvant Psychological Therapy (APT), a cognitive behavioural treatment, has been developed to alleviate cancer-related anxiety and depression. It is being evaluated in a controlled study of patients with early cancer, but has not been used previously in patients with terminal cancer. This case report describes the use of APT in a severely anxious and depressed male patient with terminal carcinoma of the colon. His psychological progress until death is reported. Although no firm conclusions can be drawn from a single case, the results obtained were sufficiently encouraging to warrant a systematic study of APT in emotionally distressed patients with terminal illness.

Psychologic issues in palliative care

As medical science progresses and the life spans of patients with serious illnesses increase, the process that leads to death is becoming more feared than death itself. This fear is particularly intense in technologically advanced cultures with access to advanced medical care. The lives of patients who previously would have died rapidly are now often extended. As a result, images of suffering, such as dying in isolation and experiencing great pain, often are at the forefront of concerns about those struggling with terminal illnesses. This article provides medical practitioners with an overview of the issues and symptoms common in terminal illness, to help them work most effectively with their mental health colleagues.

Tailoring cognitive-behavioral treatment for cancer pain

Though it has been shown that cancer patients report cognitive, behavioral, and physiologic responses to pain, little attention has been paid to the benefits of cognitive-behavioral therapy (CBT) protocols tailored to patient characteristics. To determine whether a profile-tailored CBT treatment program was more effective than either standard CBT or usual care in changing outcomes for patients with cancer-related pain, 131 patients receiving treatment at four sites were randomly assigned to standard CBT, profile-tailored CBT, or usual care. CBT patients attended five 50-minute treatment sessions. When compared to standard CBT patients, profile-tailored CBT patients experienced substantial improvement from baseline to immediately post-intervention in worst pain, least pain, less interference of pain with sleep, and less confusion. From baseline to one-month post-intervention, profile-tailored patients saw greater improvement in less interference of pain with activities, walking, relationships, and sleep; less composite pain interference; and less mobility and confusion symptom distress. Standard CBT and usual care patients experienced little change. Compared to profile-tailored CBT patients, standard CBT patients showed greater improvement at six-months post-intervention with less average pain, less pain now, better bowel patterns, lower summary symptom distress, better mental quality of life, and greater improvement in Karnofsky performance status; usual care patients showed little change. More research is needed to refine the matching of cognitive-behavioral treatments to psychophysiologic patient profiles, and to determine a treatment period that does not burden those patients too fatigued to participate in a five-week program. Delivery of CBT by home visits, phone, or Internet needs to be explored further.

Emotional and cognitive burden of prostate cancer

The wide-ranging effects of prostate cancer can be an emotional burden to the patient and his family. Recognizing important periods during the diagnosis and treatment that can be particularly stressful, the symptoms indicating patients are at high risk for emotional distress, and the signs and symptoms of emotional distress can encourage improved communication, education, treatment, and referral to minimize the effects of the emotional distress.

The Epidemiology of Pain

Inadequate pain relief is a global concern for patients and practitioners. Many barriers still exist within the health care system to properly assess and treat pain. This article identifies the need to properly assess pain and develop a treatment plan that includes a discussion with the patient. Pain is not always cured and requires medical management the same as any other disease process.

Pain management in the hospitalized patient

Pain is unnecessary. Effective tools are available to help doctors evaluate pain in their patients. Unrelieved pain should be treated just like any other vital sign: with aggressive measures. Effective therapies are available to treat pain. Use guidelines to develop a rational plan to relieve pain. Side effects are manageable. Anticipate side effects and treat aggressively. Addiction rarely occurs. Trust your patient when they report pain. Tolerance and physical dependence can occur. Plan and you will succeed. Take the initiative and focus on relieving pain at your hospital. Your patients depend on it.

Psychiatric disorders and associated and predictive factors in patients with unresectable nonsmall cell lung carcinoma: a longitudinal study

BACKGROUND

Few longitudinal studies have investigated psychiatric disorders in patients with unresectable nonsmall cell lung carcinoma (NSCLC). This study addressed three questions: 1) Which psychiatric disorders are prevalent among patients with unresectable NSCLC? 2) What is the clinical course of psychological distress? 3) Which factors are associated with this distress, and do any antecedent variables predict subsequent psychological distress?

METHODS

A series of 129 consecutive patients with newly diagnosed, unresectable NSCLC participated. Psychiatric assessments were conducted by using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition revised between the time of diagnosis and initial treatment for NSCLC (baseline) and 6 months after diagnosis (follow-up). Potential associated and predictive variables, including sociodemographic, biomedical, and psychosocial factors, were explored.

RESULTS

The most common psychiatric disorder at baseline was nicotine dependence (67%), followed by adjustment disorders (14%), alcohol dependence (13%), and major depression (5%). At follow-up, adjustment disorders were diagnosed in 16% of patients, and major depression was diagnosed in 3% of patients. Thirty-five percent of patients who experienced depressive disorders (adjustment disorders and/or major depression) at baseline continued to experience the same disorders at follow-up. Multivariate analysis revealed that relatively younger age and pain were associated significantly with psychological distress at baseline. Only self-reported anxiety and depression at baseline could predict subsequent psychological distress.

CONCLUSIONS

Substance dependence and depressive disorders are common psychiatric disorders in patients with unresectable NSCLC. Although this form of malignant disease often is progressive, depressive disorders do not seem to increase during its clinical course. Pain management is essential for alleviating patients' depressive disorders, and self-rating depression and anxiety seems to be an indicator of subsequent depressive disorders.

Managing pain and psychological issues in palliative care

The management of psychological issues and pain in dying patients have steadily improved. With currently available drugs and techniques, it should be possible for nearly all women with terminal gynaecological cancer to be pain-free. The World Health Organization (WHO) Analgesic Ladder can be effectively utilized for pharmacological treatment of cancer pain. Most side-effects of opioid therapy can be well controlled. Patients whose pain cannot be adequately relieved by systemic opioid therapy may benefit from invasive anaesthetic or neurosurgical techniques. Terminal sedation should be used only after all other therapy has failed. This chapter describes the assessment and management of opioid analgesics and the treatment of their side-effects. Adjuvant analgesic drugs and therapies are also presented.

Delirium in the terminally ill

Delirium is highly prevalent in terminally ill patients, especially in the last weeks of life, when some cognitive impairment develops in as many as 85% of patients. Delirium is associated with increased morbidity in terminally ill patients and can interfere with pain and symptom control. The cause of delirium is usually multifactorial and often cannot be found or reversed in dying patients. Nonpharmacologic and pharmacologic interventions are effective in controlling the symptoms of delirium in terminally ill patients. Haloperidol and other newer neuroleptics are safe and effective in eliminating delirium for some patients. In approximately one third of patients, delirium can be managed successfully only by providing sedation.

[Chronic pain and depression: study of 92 patients]

Was examined the influence of depression in the occurrence and pain intensity. Patients presenting advanced cancer (n = 92) were evaluated. The patients were divided in 2 groups, with or without pain during the week preceding the interview. Pain and depression were evaluated. Pain was observed in 62.0% of the cases and lasted 10 months as an average. It was moderate in the majority of patients and severe in 1/5 of them. Depression was related with the presence and intensity of pain. Patients with pain presented higher depression scores than patients without pain (p < 0.05). Higher pain scores were also correlated with higher depressive scores (p < 0.05).

Nonpharmacological interventions with chronic cancer pain in adults

BACKGROUND

Pain is often poorly controlled in cancer patients. Chronic pain affects adult patients at all stages of cancer management. Optimal pain management may require attention to psychosocial variables and the inclusion of nonpharmacological techniques.

METHODS

Three nonpharmacological strategies that are effective in reducing pain caused by cancer--patient psycho-education, supportive psychotherapy, and cognitive-behavioral interventions--are reviewed. Recommendations for physicians to facilitate a mental health referral are also discussed.

RESULTS

Effective treatment of cancer pain begins with assessing the severity, characteristics, and impact of pain. Emotional distress (especially anxiety, depression, and beliefs about pain) has emerged as predictive of patient pain levels. Appropriate pain management may require a multidisciplinary approach.

CONCLUSIONS

Patient psycho-education has empowered patients to actively participate in pain control strategies. Supportive psychotherapy can assist patients in managing the stressors associated with cancer, and cognitive-behavioral therapy helps patients to recognize and modify the factors that contribute to physical and emotional distress.

Psychotropic adjuvant analgesics for pain in cancer and AIDS

The 'WHO Analgesic Ladder' is a well validated approach for the selection of appropriate analgesic therapy for cancer pain as well as pain in AIDS. The mainstay of analgesic intervention for cancer and AIDS pain of moderate to severe intensity continues to be the appropriate use of opioid analgesics. There is, however, a growing appreciation for the role of adjuvant analgesics, such as antidepressants and other psychotropic medications, at each step of the WHO Analgesic Ladder, particularly in the treatment of neuropathic pain. Knowledge of the indications and usefulness of psychotropic analgesic drugs in cancer and AIDS pain populations will be most important to clinicians practicing in psycho-oncology/AIDS settings, particularly since these drugs are useful not only in the treatment of psychiatric complications of cancer and AIDS, but also as adjuvant analgesic agents in the management of pain. This paper reviews the literature on the use of antidepressants, psychostimulants, neuroleptics, anticonvulsants and other psychotropic analgesics in the management of cancer and AIDS pain. Mechanisms of analgesia, drug selection, and recommendations for clinical usage are discussed. The appropriate and timely use of psychotropic adjuvant analgesic drugs represents an opportunity for active psychiatric contribution to the multidisciplinary management of cancer and AIDS pain.

Psychosocial issues and lung cancer: a behavioral approach

OBJECTIVES

To examine the psychosocial issues related to lung cancer with a specific focus on women and quality of life. To review the role of behavioral medicine as an approach to treatment, including individual, family, and group interventions.

DATA SOURCES

Review articles, book chapters, and research studies pertaining to the psychosocial issues encountered by patients with lung cancer and behavioral medicine interventions.

CONCLUSIONS

Behavioral interventions, used in addition to medical treatment, have been shown to reduce the nausea and vomiting associated with chemotherapy, decrease suffering from pain, and diminish anxiety associated with dyspnea. These mind/body approaches help to reduce emotional distress, promote improved quality of life, enhanced coping, a sense of control, and hopefulness.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play an active role in helping patient's and family members learn new coping skills that will help promote a sense of competence, control, and support. Relaxation, mediation, distraction, social support, and cognitive therapies are a few of the interventions to help enrich the lives of patients and their families.

Emotional distress in men with life-threatening illness

This descriptive survey explored the relationship of health status, functional status, stressful life events, stress resistance resources and emotional distress in 60 men with life-threatening illness (N = 30 with cancer and N = 30 with AIDS). Sixty-two percent met CES-D criteria for clinical depression. This study's results supported the hypotheses that poorer functional status and greater negative stressors are associated with both higher levels of hopelessness and depression. Twenty-four patients constituted a group with severe emotional distress. This group was significantly different from the less vulnerable group with poorer functional status (KPS), a greater number and severity of negative stressors, less satisfaction with social support, and less hopefulness.

Depression in patients with pancreatic carcinoma. Diagnostic and treatment issues

BACKGROUND

Cancer of the pancreas is a highly malignant illness with a very poor prognosis. Unfortunately, there has been little in the way of improvement in prognosis over the past 20 years. It is feared by patients because of its reputation as a deadly and often painful disease. Given these realities, it is not surprising that depression and cancer of the pancreas often occur co-morbidly. Depression and anxiety occur more frequently in patients with cancer of the pancreas than they do in patients with other forms of cancer. The etiology of depression in patients with cancer of the pancreas may be traced to more than the disease's poor prognosis, the pain it causes, or existential issues related to death and dying.

METHODS

Clinical and research data on the connection between depression and cancer of the pancreas were reviewed.

RESULTS

In many instances, symptoms of depression and anxiety may even precede knowledge of the diagnosis; one of several observations that have raised speculation that mood and anxiety syndromes are related to disruption in one of the physiologic functions of the pancreas (i.e., secretion of hormones, neurotransmitters, digestive enzymes, or bicarbonate).

CONCLUSIONS

Whatever its etiology, the identification and treatment of depression associated with cancer of the pancreas is an important way in which oncologists and mental health professional can collaborate to enhance quality of life in this unfortunate population of patients. Diagnosis and treatment of depressive disorders as they applied to patients with cancer of the pancreas were reviewed, and psychologic and pharmacologic treatment strategies to deal with these issues were outlined.

Psychiatric emergencies in terminally ill cancer patients

Delirium, depression, suicidal ideation, and severe anxiety are among the most commonly occurring psychiatric complications encountered in cancer pain patients. When severe, these disorders require as urgent and aggressive attention as do other distressing physical symptoms, such as escalating pain. Early diagnosis and treatment can result in effective management of these psychiatric emergencies.

Psychological variables and cancer pain

Pain can cause both physical and psychological distress that has a negative impact on a patient's quality of life. The purpose of this descriptive study was to determine whether cancer patients (N = 60) with pain (n = 30) had higher scores of depression, anxiety, somatization, and hostility than did cancer patients without pain (n = 30). The study was conducted in a midwestern medical center hospital during a 9-month period. Psychological variables were measured using subscales of the Brief Symptom Inventory (BSI). Patients who reported pain completed the McGill Pain Questionnaire (MPQ) and Visual Analogue Scale. Significant positive correlations were found between total MPQ scores and all four subscales of the BSI (r = 0.60-0.78, p < 0.05). Patients with pain scored higher on all four subscales of the BSI, with significant differences occurring in somatization (t = 2.05, p < 0.05) and hostility (t = 1.93, p < 0.05). The findings suggest a relationship between pain intensity and psychological status. Nursing interventions aimed at reducing these factors may help to decrease the pain, in addition to then decreasing the psychological distress experienced by patients with cancer.

Hospice and palliative care

The emergence of AIDS and the aging of the population, with the numerous malignant and debilitating maladies associated with growing older, have focused attention on the provision of cost-effective quality care by hospice and palliative care programs. Hospice and palliative care is a venerated system of care, which uses an interdisciplinary approach to address the medical, psychosocial, and spiritual issues that arise in the treatment of terminally ill patients. This interdisciplinary stratagem for symptom control is necessary to ensure that dying patients and their families are afforded dignity and quality of life through death and the period of familial bereavement. Although death is dominant in palliative situations, terminal care requires an affirmation of life and a recognition that dying is not an aberration of medical care but a natural and normal process. Palliative care, however, also requires a personal acceptance of death and an acknowledgment that dying does not denote a failure to provide good medical care but, rather, calls for an acquiescence that curative treatment is no longer feasible. Accordingly, the terminal state is an integral process and a time to reconcile differences so that patient and family may accept death with a minimum of physical, spiritual, and psychosocial anguish. This article discusses the various precepts cardinal to hospice and palliative care, including the philosophy of terminal care, the management of pain, the adverse effects of analgesic medications, the management of nonpain symptoms, the use of terminal sedation, and the stages of familial bereavement.

Stemming the tide: assisted suicide and the constitution

On November 8, 1994, Oregon became the first state in the nation to legalize assisted suicide. Passage of Proposition 16 was a milestone in the campaign to make assisted suicide a legal option. The culmination of years of effort, the Oregon vote followed on the heels of failed referenda in California and Washington, and other unsuccessful attempts to enact state laws guaranteeing the right to suicide assistance. Indeed, in 1993, four states passed laws strengthening or clarifying their ban against assisted suicide. No doubt, Proposition 16 is likely to renew the effort to legalize assisted suicide at the state level.

The battle over assisted suicide is also unfolding in the courts. Litigation challenging Proposition 16 on the grounds that it violates the equal protection clause is ongoing in Oregon. More significantly, three cases, two in federal courts and one in Michigan state court, have been brought to establish assisted suicide as a constitutionally protected right.

Identifying patients at risk for, and treatment of major psychiatric complications of cancer

A critically important aspect of supportive care in cancer is the prompt recognition and effective treatment of psychiatric complications. Psychiatric disorders such as depression, anxiety and delirium occur in a significant percentage of cancer patients, particularly as disease advances and as cancer treatments become more aggressive. This paper reviews factors that can be utilized to identify patients who are at increased risk for developing psychiatric complications, such as those with advanced disease, certain cancer treatments, uncontrolled physical symptoms, functional limitations, lack of social support, and past history of psychiatric disorder. Methods of diagnostic assessment and strategies for managing depression, anxiety, delirium and suicidal ideation are also reviewed.

Nonopioid agents for treatment of acute and subacute pain

OBJECTIVE

To review the available nonopioid options for alleviating pain.

DESIGN

The various categories of adjuvant agents and their mechanisms of action in the treatment of pain are summarized.

MATERIAL AND METHODS

Adjuvant therapies that directly diminish acute and subacute pain, those that counteract the side effects of opioids, and those that help manage concurrent psychiatric symptoms are discussed, and their recommended doses and adverse effects are outlined.

RESULTS

Adjuvant medications such as nonopioid analgesics (including acetaminophen and nonsteroidal anti-inflammatory drugs), corticosteroids, anticonvulsants, antidepressants, muscle relaxants, and antispasmodics can directly decrease pain. The three most common problems associated with opioid therapy are nausea, constipation, and sedation. Adjuvant drugs such as antiemetics, laxatives, and psychostimulants may counteract these side effects of opioids and thereby enable patients to tolerate adequate doses of opioid agents to relieve pain. In addition, adjuvant medications such as antidepressants, anxiolytics, and antipsychotics can be used to treat concomitant psychiatric symptoms that develop and aggravate existing pain. The choice of agents must be individualized to the patient's particular pain condition; once therapy has been initiated, the response must be continually monitored to optimize control of pain.

CONCLUSION

Nonopioid adjuvant agents should be considered an integral part of the management of acute and subacute pain.

Management of orofacial pain in cancer patients

Pain in patients with cancer may arise due to the primary disease, or due to therapy of the malignant disease. Pain may be caused by oral infection, oral mucositis, and by alteration in musculoskeletal and neurological function. The management of orofacial and oropharyngeal pain in patients with cancer is reviewed in this paper.

Pain in human immunodeficiency virus disease: a review

Pain is a symptom commonly experienced by people with HIV infection and its prevalence increases as the disease progresses. This article reviews the pathophysiology and clinical presentation of the various opportunistic infections, neoplasms and other HIV-related problems that may manifest as pain. The investigation of these conditions and their specific treatments, where available, are detailed. Because many of the conditions may be refractory to specific therapy, and the duration of investigations may be lengthy, symptomatic treatment should not be delayed. Guidelines are given on the symptomatic management of pain in these patients.

Radiation therapy and pain in patients with head and neck cancer

Pain is commonly present at the time of diagnosis of head and neck cancer. Pain occurs in all patients treated for oropharyngeal cancer. This study examined the prevalence, severity and characteristics of pain in patients treated with radiation therapy for cancer involving the head and neck and oral cavity. Pain increases throughout the course of radiation and persists following treatment and in some patients continues for 6-12 months. Pain frequently requires systemic analgesics in addition to oral rinses.

Rapid relief of anxiety in cancer patients with both alprazolam and placebo

This study evaluated 36 cancer patients who were enrolled in a randomized, double-blind, placebo-controlled trial conducted over a 4-week period to evaluate the efficacy of alprazolam in the treatment of anxiety associated with cancer. Hamilton Anxiety Scale scores declined significantly between baseline and the end of the first week of the study in both treatment groups. There was no significant difference in response between the patients receiving alprazolam and placebo. Similar results were obtained from other instruments. These results suggest that nondrug factors or spontaneous improvement may play a more important role than pharmacotherapy in the treatment of anxiety associated with cancer.

Psychosocial aspects of cancer pain

Pain, and especially cancer pain, is not a pure nociceptive, physical experience, but involves different dimensions of man, such as personality, affect, cognition, behavior and social relations. Cancer pain is best conceptualized as the convergence of multiple activated systems with feedback mechanisms to a complex, multidimensional model. The psychosocial aspects of this multidimensional model will be analyzed with special emphasis on results from recent research. Although most research has been conducted on the role of affect and cognition in cancer pain, data on other factors such as personality, behavior or social aspects exist and will be presented. In the second part of this paper the implications of these results for therapeutic strategies in clinical work will be discussed. Although a considerable body of knowledge exists to support the hypothesis of a multidimensional model of cancer pain, where psychosocial variables play an important role, only a few studies address the issue of to what degree different factors exercise their influence. This may be different from patient to patient and may change over the course of the disease. Whatever importance these single variables in the multidimensional model of cancer pain may have, the patient is best treated when none of these aspects is neglected in the assessment and all are taken care of in the treatment. A multidisciplinary team, with a psychiatrist as one of the team members, is often best prepared to fulfill this task.