is a psychiatrist at Baylor College of Medicine in Houston, Texas, and a psychosomatic medicine specialist.

Jennifer Howse, MD

Tales From the Clinic: The Art of Psychiatry

, we accompany Anna, a breast cancer survivor, in her journey with anxiety and interpersonal and self-image issues post-remission. Through a deeply moving account, this fictional case reminds us that survival is harder than it looks, and often necessitates both pharmacological and psychotherapeutic interventions.

“Anna,” a 36-year-old female with breast cancer, in remission, and no prior psychiatric history is referred to psychiatry with panic attacks. She has less confidence in her ability to fulfill her prior role as a working mother—she has concerns of inability to meet the physical demands of raising her 2 young children, compounded by the guilt that her spouse is now their primary 

. She perseverates on issues regarding intimacy with her spouse and changes in her image. On top of that, she mentions her looming fear of death. In your treatment of her anxiety, you consider anxiety-contributing factors in breast cancer and survivorship, including factors that impact patients’ and/or their families’ quality of life, 

Anna is referred to the clinic by her oncologist after she screened positive for psychosocial distress. She has completed treatment for breast cancer, the most common cancer diagnosis in women.

 Anxiety is prevalent in women diagnosed with breast cancer during treatment and survivorship—1 of approximately 4 million breast cancer survivors in the United States by 2022.

 in breast cancer patients include previous mental health treatment, severe noncancer-related stressors, and lack of an intimate, confiding relationship.

 Anxiety is strongly associated with “increased health care use, reduced physical well-being, and physical disability.”

 While many believe survivorship would decrease anxiety, patients like Anna find that less frequent monitoring, endocrine therapies impacting estrogen levels, and decreased engagement with their medical support team may actually 

In your intake with Anna, she describes first feeling anxious when diagnosed with 

, then fearful about her mortality and treatment; this was reduced by initial disease-related educational efforts.

 Although she had been married for 10 years and had a strong relationship with her spouse, she worried she would burden him if she shared her 

. After all, he already had the additional stress of caring for their children and now functioning as their sole breadwinner. This struggle is shared by many breast cancer patients, as more than 25% of women diagnosed with breast cancer have children at home.

In fact, spouses and patients have similar levels of distress during diagnosis and treatment.

 Patients are good at predicting their spouses’ levels of distress, anxiety, depression, and anger, but “overestimate” their spouses’ need for assistance.

 On the spouse’s side, qualitative research of fathers and children after maternal breast cancer diagnosis identified that fathers may want more information regarding the diagnosis and treatment of their loved one or advice on how to navigate supporting their children. However, there are barriers to requesting assistance from the treatment team, as the fathers do not want to take the focus away from the patient.

 This was the experience for Anna and her spouse, “Colin.”

 patients’ partners for distress and unmet needs, which was done in Anna and Colin’s situation and allowed Colin’s needs to be met. Colin’s ability to cope had an inherent effect on Anna’s well-being. It was counterintuitive for Anna to rely on Colin for support, when she was concerned that she would be an additional burden to him. However, emotional support provided by spouses has been linked to decreased stress in both partners.

 Couples who openly engaged with each other experienced better adjustment with increased emotional expression, improved coping, and decreased conflict.

 Being a source of comfort for each other strengthened Anna and Colin’s relationship.It is important to consider that the patient is one part of a system. The patient can benefit from spouse involvement, especially regarding assistance with stress management. Unlike the breast cancer myth that survivors are destined to be left by their partners,

 the literature reveals that when controlling for confounding factors, breast cancer is not an independent risk factor for divorce.

Notably, this does not mean that a diagnosis has no impact on a marriage; it can strain an already fragile relationship. In fact, “among women with breast cancer, low marital satisfaction within 3 months of diagnosis predicted further marital difficulties.”

The course of Anna’s anxiety was consistent with the experience of many breast cancer patients, including intensification prior to her surgery and her first chemotherapy appointment. She was started on lorazepam while hospitalized, which helped with anxiety, nausea, and

, she declined continuing potentially addicting medications.

When managing anxiety, consider her ongoing cancer treatment. Some cancer treatments cause side effects, and discussion with the primary oncologist may allow for alternative efficacious treatments with less triggering adverse effect profiles for patients inclined toward somatic preoccupations.

 are a mainstay of treatment for anxiety, and medication interactions should be reviewed. Anna takes tamoxifen, an adjuvant endocrine therapy to prevent recurrence. As tamoxifen may contribute to symptoms of depression and anxiety, she may benefit from alternative adjuvant treatments—for instance, an aromatase inhibitor, if her oncologist deems it appropriate. Tamoxifen, a selective estrogen receptor modulator, needs to be converted to its active metabolite by CYP 2D6 to be more effective at suppressing cancer cell proliferation.

In selecting a medication regimen for Anna, you decide on venlafaxine and avoid potent CYP 2D6 inhibitors such as paroxetine and fluoxetine.

 Venlafaxine can have the added benefit of treating the vasomotor symptoms associated with estrogen suppression and 

. When it comes to alternative agents, you also consider agents commonly used to manage anxiety, which do not have United States Food and Drug Administration (FDA) indications. Gabapentin can help with vasomotor symptoms and neuropathic pain as well as anxiety.

 Propranolol can also be useful in the physical manifestations of anxiety. The clinical significance of beta blockade on breast cancer mortality and progression is under investigation, but preclinical data is promising.

Alternative therapies, pharmacologic and nonpharmacologic, for anxiety and stress management are also worth considering. Some patients use qigong to help with anxiety. Cochrane reviews have evaluated nonpharmacologic treatments for anxiety. The overall quality of the evidence has been very low to moderate; however, it reveals that cognitive behavioral therapy, yoga, and mindfulness-based relaxation are beneficial for decreasing anxiety. Anna has found some benefit to yoga practice in lowering anxiety, which is consistent with the literature.

 and yoga have been shown to be beneficial, particularly during ongoing cancer treatment and during remission.

 Prior to encouraging other exercise-based activities, you discuss Anna’s physical limitations and potential treatment toxicities (neuropathy) that impact her current level of engagement.

During this discussion, Anna reveals she no longer recognizes herself in the mirror and feels that her body image is impacted. She has suffered hair loss, lymphedema, scarring, and changes to breast and genitourinary tissues. Her ovarian failure and consequent inability to further reproduce weigh her down, as she reflects that she wanted more children and wonders how her lack of fertility will impact her relationship. The changes from her breast surgery impact her satisfaction with her physical appearance and her perception of being attractive to her partner.

She is actually at higher risk for poor body image, as she received a radical surgery—mastectomy with reconstruction over lumpectomy.

 Further evaluating the impacts on her body image, you consider other contributors such as changes in weight (both loss or gain), radiation, anxiety, 

, fatigue, and musculoskeletal pain symptoms.

 As research indicates, you counsel her to exercise and provide psychoeducation to improve her body image.

Despite her improvement in anxiety, she continues to feel out of step. In treatment, you examine her identity as a cancer survivor in addition to a mother, friend, spouse, and employee. She now struggles with feeling competent. Self-esteem can be impacted by a change in level of functioning, which can subsequently influence the ability to fulfill duties identified as part of her core sense of self.

 As you explore the impact on her self-esteem, you ask about her sexual functioning. Despite the breast cancer myth claiming that survivors cannot have a satisfying 

 patients are less likely to disclose dysfunction and subsequently do not receive help if their physicians do not initiate these conversations.

 Although decreased confidence in appearance and functioning, hypersensitivity, and irritation of tissues after radiation

 and treatment-induced estrogen deficiency can impact intimacy, women can still have sexual satisfaction. Anna has tried the first-line treatments including application of nonhormonal vaginal moisturizers routinely and use of water-based vaginal lubricants at the time of intercourse “to address both vulvar and vaginal dryness and mucosal irritation.” Having researched the topic, she knows to avoid potentially irritating agents that contain “warming agents, bactericides, microbicides, perfumes, and artificial colors and flavors.”

 You are able to educate her about the benefits of regular sexual activity, vaginal dilators, adjunctive stimulation with vibrators/self-stimulators, and sexuality-focused couples’ counseling.

 Although Anna seeks intimacy with her partner, she is not excited at the prospect of intercourse. She is interested in potentially trialing bupropion when she learns it can “increase sexual desire, arousal, orgasm intensity, and overall sexual satisfaction.”

As you consider the next best steps in her treatment, you remember that treatment-induced estrogen deficiency can include the genitourinary syndrome of menopause (GSM: vaginal and vulvar atrophy, vaginal dryness, and dyspareunia).

 Mild forms of GSM can respond to first-line treatments; however, moderate to severe symptoms of estrogen deficiency “usually require pharmacologic management.”

 If Anna’s symptoms are nonresponsive to first-line treatment in the setting of severe GSM, you plan to reach out to her oncologist, as per ACOG recommendations. For, although systemic hormone therapy is contraindicated given the “increased risk of breast cancer recurrence or new primary development,”

 her oncologist can help her weigh the risks and benefits of “vaginal estrogen therapy,” a controversial treatment, given the risk of increasing estrogen exposure systemically and decreasing the effectiveness of hormone suppression therapy.

Throughout her treatment, you remember that anxiety may manifest as fear of recurrence. After treatment, 70% of breast cancer patients “fear breast cancer relapse.”

 However, the “relapse rate is only 11% in the first 5 years and 20% within the next 10 years after completing therapy.”

 The 5-year survival rate for breast cancer patients was 75% in 1975 and had increased to 90% by 2017 due to regular testing and improved methods for treatment.

 While breast cancer mortality has improved, the morbidity manifests physically, emotionally, and socially.

To an extent, worry about recurrence is appropriate, but when it becomes “excessive,” it can impact a patient’s quality of life.

 Fear of cancer recurrence (FCR) “can manifest as an anxiety disorder, trauma- or stressor-related disorder, somatic symptom disorder […] or may exacerbate preexisting” conditions.

 FCR risk factors include preexisting anxiety, mood and trauma disorders, neuroticism, poorer physical health, positive margins and chemotherapy; however, “self-esteem, healthy coping, and sense of coherence” are protective.”

 When recurrence of breast cancer occurred, depression and anxiety were more likely to occur than at the initial diagnosis—45% at recurrence compared to 36% at initial diagnosis.

 With this in mind, you continue to monitor Anna for exacerbations in symptoms and plan to support her through periods of future surveillance.

is a psychiatrist at Baylor College of Medicine in Houston, Texas, and a psychosomatic medicine specialist. 

 is an undergraduate at University of California, Berkeley, majoring in psychology.

Breast cancer survivorship: where are we today?

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Associations between breast cancer survivorship and adverse mental health outcomes: a systematic review.

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Depression and anxiety in women with early breast cancer: five year observational cohort study. 

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Anxiety and depression in young women with metastatic breast cancer: a cross-sectional study. 

Anxiety and depression in cancer survivors.

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Psychosocial distress in women with breast cancer and their partners and its impact on supportive care needs in partners. 

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Are cancer survivors at an increased risk for divorce? A Danish cohort study.

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 Marital stability after breast cancer. 

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A randomized, controlled, double-blinded clinical trial of gabapentin 300 versus 900 mg versus placebo for anxiety symptoms in breast cancer survivors. 

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Managing genitourinary syndrome of menopause in breast cancer survivors receiving endocrine therapy. 

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Surviving Survivorship

 Tales From the Clinic: The Art of Psychiatry, 

we discuss delirium, an underrecognized, underdiagnosed medical condition. Elderly patients, who experience more delirium than their younger counterparts, often receive a misdiagnosis. They may be mistakenly labeled as having a mental illness and given psychotropic medications that have an elevated adverse effect burden.

“Mr Morris,” aged 70, had melanoma and, following treatment, is in remission. Mr Morris presents to your outpatient psychiatry clinic for an initial evaluation. He has never had medical issues otherwise and has never been diagnosed with a mental illness until a hospital stay about 6 months ago. His family provided collateral information. They were very concerned because, while he was hospitalized, he was “talking nonsense” and accusing his wife of 50 years of having an extramarital affair. He was also pacing and saying random things about memories which they thought were made up, such as the example above. Inquiring about this in your clinical assessment, the patient says, with some bashfulness, “Well, you know, we met at 15 and a lot of people liked her. I was the lucky one.” But he does not recall anything he said while hospitalized. He was discharged on haloperidol, but the family stopped it after reading about the black box warning for antipsychotics in older adults. A careful history taking is negative for psychotic symptoms including 

, and disorganization, and for negative symptoms of psychosis. Since being home and off medications, he is back to his usual self.

You ask for medical records and find out that the medication was started after an episode during which the psychiatry consult and liaison service consulted for overnight confusion and agitation. Mr Morris had started to pull out his IV lines and catheter, then tried to undress and walk down the hallway, but was falling down, given physical weakness. The medication was not stopped upon symptom resolution and patient discharge.

Mr Morris is diagnosed with delirium. According to the DSM-5, delirium is “a disturbance in attention and awareness” with an additional cognitive disturbance (eg, memory deficit, disorientation, language, visuospatial ability or perception) that develops over “hours to a few days,” “represents a change from baseline,” and “fluctuates in severity during the course of a day.” Furthermore, it is due to 1 or multiple underlying medical etiologies and is not better explained by another psychiatric diagnosis.

: hyperactive, hypoactive, and mixed. In our vignette, the acute agitation and interference with medical treatment quickly brings this patient to staff attention. However, the literature shows that delirium is missed in 57% to 83% of emergency department (ED) assessments, and in admitted patients, more than 90% of cases will be missed if it is not diagnosed in the ED.

 According to a prospective study in The University of Texas MD Anderson Cancer Center Emergency Medicine department, patients with cancer who presented with delirium are more likely to be admitted to the hospital, require an ICU admission, and have worse outcomes.

 In a retrospective chart review of 61 consecutive inpatient 

 consultations in patients with cancer, 16% of the consultations were for delirium, yet delirium was diagnosed by the palliative care team in 56% of the patients.

 In patients with advanced cancer, terminal delirium prevalence rates approach 90% in 

, its treatment (ie, radiation, chemotherapy), and noncancer-related pathology. In delirium, there are unmodifiable factors that predispose a patient to developing the condition and there are precipitating factors that can be clinically addressed. Common predisposing factors that increase the risk of developing delirium include older age, a neurocognitive disorder, visual and hearing impairments, and chronic organ dysfunction. Precipitating factors to consider include psychoactive medications (including opioids and corticosteroids), infections, hypoxia, withdrawal, metabolic derangement, dehydration, and acute infections, especially 

, the precipitating cause or causes should be treated. Lawlor studied delirium in patients with advanced cancer and determined that reversibility was most common when addressing the precipitating factors of psychoactive medications, specifically 

 The pathophysiology of delirium is complex, and there are hypotheses to explain the role of 

, oxidative stress, and neurotransmitters in the condition. Delirium is a state of low acetylcholine and high dopamine, which is important to consider when reviewing if a medication could be contributing to a patient’s delirium.

Psychoactive medications include opioids, 

, antidepressants, antihistamines, and anticholinergics. When delirium develops, it is important to consider these medications as potential precipitating factors. Anticholinergics and antihistamines commonly worsen delirium and should be discontinued. The duration of use and dose of benzodiazepines should be closely examined in 

 because the sudden cessation of a medication on which a patient is dependent could produce a withdrawal delirium; however, ongoing use in a patient without tolerance could result in intoxication.

 are frequently used for cancer-related pain. However, opioid toxicity can occur, especially with rapid dose escalation for pain control. Medication adjustments including opioid rotation are helpful in managing opioid toxicity and managing pain when side effects limit further uptitration.

 Opioid rotation is the practice of transitioning to a different opioid with the goal of optimizing the balance of pain control to side effects. The clinical practice guidelines for the European Society for Medical Oncology recommend opioid rotation, which can allow for dose reduction given opioid equianalgesic dosing.

Corticosteroids are more likely to have psychiatric sequelae at higher doses. Findings from 1 study revealed that the rate of psychiatric reactions is 1.3%, 4.6%, and 18.4% at doses of prednisone less than 40 mg/day, 41 to 80 mg/day, and greater than 80 mg/day, respectively.

, psychosis, and delirium can develop in the acute course of corticosteroid use. Depression, which is part of the differential diagnosis for hypoactive delirium, is more likely to develop with chronic steroid use.

 Although corticosteroids can contribute to delirium, they can also improve cognition by decreasing edema secondary to primary or metastatic brain tumors.

 It is important to consider the timeline of symptom development and treatment when considering the impact of corticosteroids in delirium. Delirium secondary to corticosteroid exposure is likely to occur within 1 to 2 weeks and at a higher incidence for higher doses.

Furthermore, delirium caused by corticosteroids has been associated with delirium-related distress.

 As clinically indicated, minimizing the dose and duration of treatment can improve delirium related to steroid administration.

Delirium is treated by correcting the precipitating factors; however, nonpharmacologic and pharmacologic strategies are used to assist in its management. Nonpharmacologic management includes frequent reorientation, patient access to glasses and hearing aids, familiar surroundings (consistent care team, family present or their pictures available), regulating sleep/wake cycles (lights on and blinds open the during day, but lights off and blinds closed at nighttime), clustering care to daytime hours, minimizing lines including IVs and urinary catheters, and encouraging patient mobilization.

 Regarding pharmacologic management, a 2018 Cochrane review of antipsychotic treatment in non-ICU delirious patients concluded that the current evidence to recommend for or against the use of antipsychotics is of low quality, as 

 had no statistically significant impact on delirium resolution or severity.

 In clinical practice, pharmacologic management with antipsychotics is primarily used to target distressing agitation, hallucinations, and delusions. In refractory agitated delirium, the involvement of palliative care and palliative sedation can also be considered.

During the investigation into the etiology and treatment of delirium in a patient, it is important to consider the goals of care. When goals of care are addressed early, a patient’s wishes are known to the team and the substitute decision maker if a patient’s mentation becomes altered. Established goals of care at the end of life allow palliation while limiting more aggressive interventions if it is the patient’s desire. Aggressive interventions at end of life have been associated with worse patient quality of life and worse 

It is always important to remember to consider the system you are treating, which is more than the patient. Breitbart et al showed that 53.5% of delirious patients recalled their delirium. Predictors of patients not recalling their delirium are greater “short-term memory impairment during the 

, the severity of the delirium episode itself, and the presence of perceptual disturbances.” However, more severe hallucinations and delusions, corticosteroid-induced delirium, and poorer Karnofsky Performance Status (KPS) Scale scores were correlated with more delirium-related distress for patients.

 Caregivers are more likely to be distressed when the patient has a hyperactive delirium, brain metastases, and KPS scores below 30, which indicate “severe physical debilitation and near death.” Nursing staff are more likely to be distressed when a delirious patient has more severe delirium and hallucinations.

 While treating the delirium, consider the potential traumatic impact upon the patient, family, and staff, and offer ongoing support.

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Characteristics, findings, and outcomes of palliative care inpatient consultations at a comprehensive cancer center.

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Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study.

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Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. 

Delirium: an underrecognized, underdiagnosed medical condition. 

Jennifer Howse, MD

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Surviving Survivorship

Delirium: Don’t Miss It