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Psiconcologia e Riabilitazione

SERVIZIO SANITARIO REGIONALE EMILIA-ROMAGNA Azienda Sanitaria Locale di Ferrara. Psiconcologia e Riabilitazione. Luigi Grassi Sezione di Psichiatria, Università di Ferrara U.O. Clinica Psichiatrica / Emergenza - Urgenza

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Psiconcologia e Riabilitazione

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  1. SERVIZIO SANITARIO REGIONALE EMILIA-ROMAGNA Azienda Sanitaria Locale di Ferrara Psiconcologia e Riabilitazione Luigi Grassi Sezione di Psichiatria, Università di Ferrara U.O. Clinica Psichiatrica / Emergenza - Urgenza Dipartimento Assistenziale Integrato di Salute Mentale e Dipendenze Patologiche AUSL di Ferrara

  2. I Punti • Il trauma da cancro e la riabilitazione • La morbilità psicosociale e lo screening • L’area negletta della sessualità • Le necessità di migliorare le linee-guida su quest area

  3. Il trauma legato alle patologie tumorali Sintomi fisici Immagine corporea Performance Famiglia QoL CANCRO Relazioni Interpersonali Aspetti Psicologici Lavoro Spiritualità

  4. Il trauma legato alle patologie tumorali [Sumalla et al., Clin Psychol Rev, 2009]

  5. La Traiettoria della Malattia

  6. Crescita Post-Traumatica

  7. Crescita Post-Traumatica Stephen Z. Levine, Avital Laufer, Einat Stein, Yaira Hamama-Raz, Zahava Solomon Broad cluster of personal characteristicsthat facilitate the abilitytomanagedespite trauma (hardiness, optimism, self-enhancement, adaptivecoping, positive affect, senseofcoherence) Onlyoccursif trauma hasbeenupsettingenoughto drive the survivorto (positive) meaning-makingof the negative event (changes in self, interpersonal ties, spirituality, valuesof life)

  8. Supporto Sociale e PTG Regression analyses showed that getting support from family and friends, characterized by reassuring, comforting, and problem-solving at 3 months after diagnosis significantly predicted a greater perception of positive consequences of the illness at 8 years after diagnosis, helping cancer survivors to find positive meaning in their cancer experience.

  9. Il ruolo dell’esercizio fisico 34-41

  10. Il ruolo dell’esercizio fisico

  11. Supporto Psicosociale • High satisfaction with the individual psychosocial support intervention they received, irrespective of which profession provided the support • Pts in INS (specially trained oncology nurses) group  higher levels of benefit regarding disease-related problems, than “psychologists” group

  12. Componenti del supporto fonte di aiuto • Comunicazioen efficace • Informazione parametrata sui bisogni della persona e sul contesto • Supporto emozionale • Assistenza pratica • Continuità terapeutica • Identificazione e appropriata risposta a preoccupazioni specifiche [Clinical Practice Guidelines for the Psychosocial Care of Adults with Cancer 2003]

  13. Psychosocial Cancer Care • Psychosocial assessment is an essential component of cancer care and part of the oncology nurse's role in delivering quality cancer care. • Oncology nurses, advocacy organizations, and others inform patients that they should expect, and request when necessary, cancer care that includes a range of psychosocial services such as counseling, education, self-care programs, and support groups. www.ons.org

  14. Psychosocial Cancer Care • Oncology nurses incorporate existing evidence-based psychosocial assessments, interventions, and resources into practice, such as those that are available from the ONS and other nursing and healthcare organizations. • Standard-setting organizations create oversight mechanisms to ensure that psychosocial care and services are being delivered to patients with cancer throughout the care continuum. www.ons.org

  15. La Traiettoria della Malattia

  16. Morbilità Psicosociale • Prevalenza (DSM-ICD)  30-35% + condizioni psicosociali rilevanti (ansia per la salute, demoralizzazione)  25% (DCPR) 1 • Conseguenze negative per paziente /famiglia • QoL • Tempi riabilitazione • Aderenza ai trattamenti • Sopravvivenza 1 Fava et al., Psyhcother Psychosom, 1995

  17. Psychological Sequelae 791 long-survivors testicular cancer • Chronic fatigue 16% vs 24% (Hodgkin Lymphoma – LH) vs 10% (general populatongenerale – GP) • Anxiety (HADS) comparable to a LH and higher than GP • Depression (HAD-S) lower than LH and comparable to GP • Chronic Fatigue associated with anxiety, depression and young age at diagnosis [Fossa et al., JCO, 2003]

  18. Psychological Sequelae Cancer and Leukemia Group B Study • Stressfule events • Poor social support 153 long-survivors (20 years) Breast cancer • Symptoms/syndromes • associated with • [Kornblith et al., Cancer, 2003]

  19. Psychological Sequelae • 1,083 breast cancer survivors (mean - 47 months after diagnosis) • 38% moderate to high anxiety, 22% had moderate to high depression; PTSD 12%; overall psychological comorbidity 43% and 26% for a possible and probable psychiatric disorder. • Lower QOL and higher levels of anxiety in cancer survivors compared to age-adjusted normative comparison groups • Disease progress, detrimental interactions, less social support, a lower educational level, and younger age were predictors of psychological comorbidity • Participation in cancer rehabilitation 57%; other psychosocial support programs 24% • Insufficiently informed about support offers 46%

  20. Psychological Sequelae Significant correlations between FoP and intrusive thoughts, avoidance, hyperarousal and posttraumatic stress disorder diagnosis). Factors significantly associated with moderate and high FoP included a depressive coping style, intrusion, avoidance and hyperarousal symptoms

  21. NCCN Distress Management Guidelines

  22. Tiered Model of Care Acute Care: Intensive or comprehensive therapy for acute and complex problems eg. mental health team, psychiatrist. Severe distress Specialist Care: Specialised therapy for depression, anxiety, relationship problems eg. psychologist, psychiatrist. Moderate to severe distress Extended Care: Counselling, time limited therapy, skills training eg. psychologist, social work, QCF tele-based Cancer Counselling Service, chaplain. Moderate distress Supportive Care: Emotional, practical, spiritual, psychoeducation, decision support, peer support eg. social worker, peers, chaplain, Cancer Helpline. Mild to Moderate distress Universal Care: Information, brief emotional and practical support eg. health care team, QCF Cancer Helpline. Minimal to Mild distress [Hutchison et al., PO, 2006]

  23. Need for Education: Screening Programs Distress Screening Program in Ambulatory Care (DISPAC program)

  24. Need for Education: Screening Programs (cont’d) • 491 patients treated during the DISPAC period: 91.9% (451/491) completed the DIT (132 ± 75 seconds) • “Cases” 37.0% (167/451) • Recommendations for referrals given to 93.4% (156/167) • Acceptance of referral = 25% (39/156) • Proportion of targeted pts w/ MD or AD treated by PO service higher than during the usual care period (5.3% vs 0.3%) (p<0.001) [Shimizu et al., Psycho-Oncology 2009]

  25. Barriers to Accessing Support Health professional barriers • Although health care professionals are aware of support services, <60% feel these are helpful to patients • Physicians express concerns about psychosocial support groups and potential for psychological damage • Lack of training • Concerns about time [Del-Guidice et al 1997; Matthews et al 2002]

  26. Barriers to Accessing Support Patient Barriers • Almost half of distressed patients had not sought professional psychosocial support nor did they intend to do so in the future • Even when services are offered, they are refused in 38% of cases: • Lack of awareness of the benefits of psychosocial interventions • Stigma - young people use a vocabulary of 270 different words and phrases to describe people with mental illness – most are derogatory [Carlson et al 2004; Curry et al 2002; Jorm 2000; Pinfold et al 2003]

  27. La sessualità World Health Organization: sexuality is a central aspect of human being throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction • Sexuality: as the process of giving and receiving sexual pleasure associated with a sense of belonging or being accepted by another. • Intimacy: as the sharing of identity, closeness, and reciprocal rapport, more closely linked to communication issues rather than sexual function [Hughes, 2000; Shell, 2008]

  28. I disturbi della sessualità • Disturbi del desiderio sessuale • diminuzione o perdita del desiderio sessuale • evitamento della sessualità • Disturbi dell'eccitamento sessuale • difetto della risposta genitale femminile (diminuzione o perdita della lubrificazione) • difetto della risposta genitale maschile (impotenza e disturbo dell'erezione) • Disturbi dell'orgasmo • inibizioni dell'orgasmo maschile e femminile • eiaculazione precoce • Disturbi da dolore sessuale • vaginismo e dispareunia

  29. DisturbiSessualinellapopolazione • 43% donne e 31% uomini • Problemi più frequenti nelle donne • 33.4% perdita di interesse sessuale • 24.1% incapacità di raggiungere l’orgasmo • 21.2% diminuzione piacere sessuale • 18.8% difficoltà nel rapporto sessuale • 14.4% rapporti sessuali dolorosi [Laumann EO, Paik A, Rosen RC: JAMA 1999;281:537-544]

  30. DisturbiSessualinellapopolazione • Problemi più frequenti negli uomini • 28.5% eiaculazione precoce • 17% ansia da prestazione • 15.8% perdita di interesse sessuale • 10.4% incapacità a mantenere l’erezione [Laumann EO, Paik A, Rosen RC: JAMA 1999;281:537-544]

  31. Fattori che interferiscono sulla sessualità • Fattori di Base • Fatori demografici: ad es. età, sesso, fattori etnici • Fattori psicologici: ad es. ansia, depressione, immagine corporea • Problemi di salute cronica: ad es. diabete, patologie cardiache • Fattori relazionali: qualità del rapporto col partner • Fattori legati all’età: ad es. scarsa lubrificazone vaginale, disfunzione erettile

  32. Cancro e sessualità • Neoplasie prostatiche • Disfunzione erettile (85%) • Problemi di riduzione o assenza di orgasmo, riduzione rigidità erettile. • Climacturia • Neoplasie del testicolo • Perdita del desiderio (20%), disfunzione erettile (11.5%), disturbo dell’orgasmo (20%) e dell’eiaculazione (44%), diminuzione dell’ attività sessuale (44%), e del piacere sessuale (19%)

  33. Cancro e sessualità • Neoplasie mammella • Problemi di lubrificazione vaginale • Diminuzione attività sessuale e problemi di eccitazione • Neoplasie utero • Problemi di lubrificazione vaginale • Diminuzione attività sessuale e problemi di eccitazione • Neoplasie ovaio • Problemi sessuali (60%)

  34. Cancro e sessualità • Neoplasie testa-collo • Neoplasie apparato gastro-enterico • Neopalsie eaotlogiche • Neoplasie vescica • Nopalsie polmone

  35. Fattori che interferiscono sulla sessualità • Dopo la diagnosi di cancro • Fattori demografici: non modificati • Fattori psicologici: non modificati, migliorati, peggiorati • Problemi di salute cronica: non modificati, peggiorati • Fattori realzioniali: non modificati, migliorati, peggiorati • Fattori legati al tumore: menopausa indotta, immagine corporea, disfunzione erettile

  36. Cancro e sessualità

  37. Cancro e sessualità

  38. Riabilitazione Psicosociale • 5-6 group meetings (multidisciplinary) • Information and education on cancer and long-term consequences • Awareness about stress and stress response and ways to manage them • Maladaptive vs adpative coping: how to shift • Relaxation exercises and problem solving skills [Fawzy & Fawzy, 1992]

  39. Riabilitazione Psicosociale

  40. Target: breast cancer survivors with significant problems associated with partner relationship, body image, or sexual functioning • 6 week group psychoeducational intervention • Outcomes: emotional functioning and partner communication • No impact on emotional functioning • Improvement noted in relationship adjustment, communication and satisfaction with sexualactivity

  41. PsychosocialCancer Care “Today, it is not possible to deliver good-quality cancer care without addressing patients’ psychosocial health needs andevery individual treated for cancer can (and should expect to) have their psychological and social needs addressed alongside their physical needs” The reports and guidelines recommend the actions that health providers should undertake to ensure that this standard is met.

  42. Piano Oncologico Nazionale 2010-2012

  43. Grazie per l’attenzione Sebastiano Filippi (Bastianino) Visitazione (1568) Pinacoteca Nazionale, Ferrara

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