A Case Report of a Woman Breast Cancer Survivor

Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. (2010) Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.682 Fear of Recurrence: A Case Report of a Woman Breast Cancer Survivor with GAD Treated Successfully by CBT Sébastien Montel* Laboratory of Health Psychology, EA 4360, APEMAC, Paul Verlaine Univer- sity—Metz, Metz Cedex, France

General anxiety disorder (GAD) characterized by persistent, excessive and unrealistic worry about everyday things can affect every- body, including cancer patient survivor. In this paper, we present a case report of a breast cancer survivor with GAD treated by cognitive–behavioural therapy (CBT), who was excessively worried about recurrence of the disease 2 years after the end of any treatment. Cognitive reframing, associated to behavioural exposure and relaxation, were used in order to treat this woman. We describe precisely how the therapy was conducted. Results showed a substantial improvement of the fear of recurrence which ‘naturally’ extended to other stressful situations not worked during the therapy. Actually, these results are encouraging since it showed that CBT can be efficient in complicated situation involving survivor of a serious disease like cancer who additionally suffers from an anxiety disorder. It also underlines how it is important to be concerned by the distress of cancer survivors. Copyright © 2010 John Wiley & Sons, Ltd.

Key Practitioner Message: • Fear of recurrence is a real problem for cancer’s survivors. • Cancer’s survivors affected by psychic disorders need a special psychological assistance. • CBT prove to be efficient with these patients.

Keywords: Cancer Survivor, CBT, Fear of Recurrence, GAD

Introduction less to stop it. They often expect the worst, even when there is no apparent reason for concern. This Generalized anxiety disorder (GAD) is character- anxiety or worry occurs for at least 6 months. Exag- ized by persistent, excessive and unrealistic worry gerated and unrelenting worry often centres on about everyday things. People with the disorder, issues of health, family, money or work, and it can which is also referred to as GAD, feel that worry- interfere with all aspects of a person’s life (APA, ing is beyond their control and they are power- 2000). Several models have been proposed to explain the cognitive process in GAD (e.g. the intolerance of * Correspondence to: Sébastien Montel, UFR SHA, Univer- sity Paul Verlaine of Metz, Ile du Saulcy-BP 80794, 57012 uncertainty model: Dugas, Gagnon, Ladouceur, & Metz Cedex 01, France. Freeston, 1998; Dugas, Letarte, Rheaume, Freeston, E-mail: [email protected] & Ladouceur, 1995; Ladouceur, Talbot, & Dugas, K1

1997; the emotion dysregulation model: Mennin (56%) of former breast cancer patients indicated et al., 2002). The metacognitive model (Wells, moderate to severe concerns about disease recur- 1995, 1997) is remarkable enough. In this model, rence. Health and death worries were the most worry is viewed not only as a symptomatic con- prominent. sequence of anxiety, but also as an active coping However, concerns and worries tend to decrease with threat driven by metacognitive beliefs. In this with the time (Lampic et al., 1994). Moreover, even perspective, worry is used to cope with anticipated though this fear of recurrence is not exceptional danger or threat. When a trigger (image, thought) in most of cancer survivors (Lee-Jones & Dixon, is encountered, positive metacognitive beliefs 1997), it is easy to imagine how cancer survivors (e.g. ‘Worrying is useful to me since it helps me who suffer with GAD are even more vulnerable to to cope’) lead the subject to continue to worry this kind of fear. Excessive anxiety may produce until it meets its goals of generating acceptable increased vigilance to somatic sensations resulting coping responses. It is what the author calls Type in false positives, the identification of a symptom 1 worrying. But when negative beliefs (e.g. ‘Worry that is unrelated to the disease (Salkovskis, 1989). may have an effect on my health’) appear patho- Cognitive behaviour therapy (CBT) proved to be logical, worrying characteristics of GAD are also especially efficient in the treatment of GAD (Khele, present. Then, the subject with GAD believes that 2008; Norton & Price, 2007). Osborn, Demoncada, the worry is uncontrollable and potentially dan- and Feuerstein (2006) showed that CBT was also gerous. Such negative appraisal is called Type 2 effective for anxiety of cancer survivors. worry or metaworry. It leads to an escalation of Moorey and Greer (1989, 2002) put forward the anxiety so that subject experience need to worry importance of adjuvant psychological and cogni- in order to feel that he is able to cope. The dis- tive therapy for cancer patients to promote the sonance between positive and negative beliefs expression of negative emotions and a fighting can be deleted by avoiding triggers for worrying spirit. The intervention program developed by precocely (e.g. behavioural avoidance, reassurance these authors is based on CBT framework and seeking). But these responses prevent the subject is applicable at every stages of the illness. This to experience that worrying can be controlled, and model illustrates the interaction between thoughts, that is harmless. emotions, physical manifestations of emotions and So what happen when GAD meet a serious associated behaviours. The premise is that it is disease like cancer? During the active phase of the not the illness itself that produces the emotional disease, GAD patients may fear that no one will response, but the meaning of the illness for the care for them even though they have adequate and person involved. willing social support, or that the disease outcome Actually, into psychotherapy, it is important to will be wrong despite the optimism of the physi- take account of illness beliefs and representations. cians. Several years after, patients with GAD may Indeed, in accordance with Leventhal, Meyer, and be excessively worried about a potential recurrence Nerenz’s common sense model of illness (1980), a of the disease. Many studies on cancer survivors person’s fear of recurrence will vary depending on showed that concerns and worries are still present their illness representation. after treatments and may be persistent (Constanzo In this paper, we present a case report of a breast et al., 2007; Kornblith & Ligibel, 2003; Lampic et al., cancer survivor with GAD treated by CBT, who 1994; Thomas, Glynee-Jones, Chait, & Marks, 1997) was excessively worried about recurrence of the whatever the culture or gender (Matthews, 2003; cancer 2 years after the end of any treatment. Thompson, Littles, Jacob, & Coker, 2006). Earle, Neville, and Fletcher (2007) matched 1111 survivors to 4444 controls. Cancer survivors were more likely than controls to have a mental health CASE REPORT diagnosis, accounted for mostly by anxiety and Subject Description sleep disorders. Survivors had more outpatient medical visits in general and specifically more Ms X is a woman of 60 years. She has been diag- mental health visits than did controls. nosed with a breast cancer more than 2 years ago. van den Beuken-van Everdingen et al. (2009) She underwent a lumpectomy followed by radio- measured the prevalence of concerns about disease therapy. Now, she is under medical supervision recurrence in former breast cancer patients and since the end of the radiotherapy. She has medical K1 identified potential predictors. More than half exam about every 6 months. All the medical exams

Situation Cognitions A conflict with a « This situation could family’s member. reactivate my cancer ». “If I’m disturbed my cancer’ll come back”. Consequences Distress Angry Anxiety

Behaviour Emotions Avoidment Anxiety Isolation

Figure 1. The conceptualisation of the Ms X’s case proved to be negative from the end of the treat- GAD). She used to take bromazepam (anxiolytic) ment until now. one-fourth daily. She took the decision to consult a psychologist The conceptualization of this complex case is under the advice of her physicians and her family presented in Figure 1. who observed that Ms X was more and more anxious. Description of the Therapy The diagnosis made on the basis of the DSM- IV-TR (APA, 2000) confirmed the presence of a The therapy included 15 seances of 30–45 minutes. GAD, a trouble which was likely ancient in the After having explained the aim of a CBT, the first life of Ms X. Indeed, Ms X presented for several séances were devoted to the establishment of the years, a persistent, excessive and unrealistic worry diagnosis and to the choice of the problem on about everyday things. This worry was source of which we will work. During these first seances, impairment in her everyday life even though Ms we took some times to investigate the illness beliefs X learnt to use her own coping strategies to cope of Ms X. Then, Ms X chose to work primarily on with this trouble. However, since the beginning of her fear of recurrence which impaired her daily her cancer, and more especially since the end of life very much. her treatment, Ms X felt that her anxiety increased We gave to Ms X some information about GAD. and was more focused on the potential recurrence We helped her to understand the relationship of cancer. Indeed, Ms X reported more and more between this trouble and her fear of recurrence. ruminations about recurrence and potential conse- We used a diagram in order to explain to Ms X the quences in her life. Of course, the fear of death was interaction existing between emotion, cognition showing just beneath the surface. She recognized and behaviour. We also explain to Ms X the inter- having more and more difficulties to cope with the est to do between each seance the homework that uncertainty. we will prescribe to her. Indeed, it reinforces what No specific event was reported by Ms X as related is acquired during the therapy. Ms X also benefited to the beginning of the GAD. However, the end of during the CBT from several seances of relaxation the treatment seemed to be a critical period for her (including imagery) and was able to practise this GAD evolution. technique at home. We encouraged Ms X to use When we have met Ms X the first time, she was relaxation as soon as she felt that the first signs of married and had two children who live their own anxiety occur. life. She was retired. Her family was evoked by Ms The main technique used during this therapy X as supportive materially and emotionally. was cognitive reframing. According to Beck (1975), Ms X did not present any psychiatric history the problem is with one’s thinking. Most often, except anxiety disorders (claustrophobia and an anxious patient has distorted/maladaptive/ K1

dysfunctional/irrational thinking. He tends to * Between each seances patient was invited to practice at home anticipate the worst. The objective of the cognitive reframing is to help patient to conform his/her S1-S3*: Diagnostic; thinking to reality. The main assumption of this Informations about GAD, CBT; technique is that we can be taught to thinking dif- Choice of a stressing situation ferently. If we think differently, we will feel better. on wich to work In order to help Ms X to better identify the stressing situations, emotions, beliefs and behaviour, we used the technique of Beck which consists to fill a table with several column including the problem’s situation and the emotion, belief and behaviour associated. Between each seances of CBT, Ms X S4-S8*: Cognitive reframing; had to fill this table. It allowed us to have some Relaxation (imagery) material to work during the therapy. We tried to show to Ms X how to put a new ‘frame’ around a thought. She had to understand that different frames can draw out different aspects of a picture. Our aim was to give her the ability to view a situ- S9-15*: Cognitive reframing; Exposure; ation differently without deny the reality of the Relaxation situation. As a result, she will be helped to improve her ability to cope. Given the changes of her way of thinking after Figure 2. Ms X CBT treatment some seances, we used behavioural technique (exposure) in order to confront Ms X to what she fears (Figure 2). and convenient self-rating instrument for anxiety and depression in patients with both somatic and Evaluation of the Therapy mental problems, and with equally good sensitiv- ity and specificity as other commonly used self- In order to appreciate the efficacy of our interven- rating screening instruments (Bjelland et al., 2002; tion, we used several self-report questionnaires. 1 Herrmann, 1997). Moreover, it has been validated The State-Trait Anxiety Inventory (STAI) afforded in cancer populations (Moorey, Greer, & Watson, us to assess anxiety. The STAI Form Y serves as an 1991; Razavi, Delvaux, & Farvacques, 1990). The indicator of two types of anxiety, the state and trait Penn State Worry Questionnaire (PSWQ) (Meyer, anxiety, and measure the severity of the overall Miller, Metzger, & Borkovec, 1990) assessed anxiety level. The STAI Form Y is an administered worries and is particularly relevant for the GAD. analysis of reported anxiety symptoms. The first In scoring the PSWQ, a value of 1, 2, 3, 4 and 5 is subscale measures state anxiety, the second mea- assigned to a response depending upon whether sures trait anxiety. The range of scores is 20–80, the item is worded positively or negatively. The the higher the score indicating greater anxiety total score of the scale ranges from 16 to 80. (Spielberger, Gorsuch, & Lushene, 1970). Some of the questions relate to the absence of anxiety, and are reverse scored. Results of the STAI can RESULTS be used in the formulation of a clinical diagnosis; to help differentiate anxiety from depression. Its Rapidly during the therapy, the fear of recurrence validity and reliability have been well established took a more subtle form. The belief that the least (Spielberger et al., 1970, Spielberger, Reheiser, Rit- symptom would announce the recurrence of the terband, Sydeman, & Unger, 1995). disease stopped to be replaced by the belief that The Hospital Anxiety and Depression (HAD) the least stressful situation could have an effect rating scale (Zigmond & Snaith, 1983) was used to on her emotion, and then, could trigger the recur- assess depression and anxiety. This scale enclose rence of the cancer. Thus, Ms X tended to avoid two different subscales of seven items each, one any situations that she perceived as risky. There- for depression and one another for anxiety. The fore, we decided to use behavioural technique of sum of these two subscales corresponds to a total exposure by confronting Ms X to the situations she K1 score. It has been established as a much-applied feared. We encouraged her to keep contact with

Table 1. Ms X self-report during CBT

At the beginning of the therapy Situation Emotion(s) Beliefs Behaviour Oedema+ pain into the Anxiety It’s the cancer which comes back. Attempt to do something in breast operated. order to think less.

During the therapy (S4–5) Situation Emotion(s) Beliefs Behaviour Conflict with a member Anxiety This situation could be damaging Avoidance of any contact with of her family. for me because it could reactivate people who could be potentially the disease. dangerous for her.

A the end of the therapy (S14–15) Situation Emotion(s) Beliefs Behaviour Her mother-in-law make Sadness It is due to the fact that my Choose to take some good times her some reproaches. mother-in-law is aged and ill. They for her rather than to be worried are no reasons that this situation excessively by the situation. affects my health.

15 Before CBT 10 End of CBT

0 STAI- Y-A STAI-Y-B

Figure 3. Scores of anxiety (STAI-A and B)

the member of her family with whom she had a CBT. As it is showed in Figure 3, the improvement conflict. She applied our counsel by continuing to was especially observable on trait anxiety, which take care of this person (e.g. she accompanied her is logical for a patient with a GAD. The decrease to the doctor) and by continuing to invite her at of the score of anxiety was remarkable since it was home despite the stress induced. This early inter- of 36% on the STAI-B (trait anxiety) and of 80% on vention prevents Ms X to fall into the trap of the the HAD-anxiety subscale. As we can see on Figure avoidance which generally reinforces the disorder. 4, the level of depression is low before and at the By confronting herself to the stressful situation, end of the CBT. its coping abilities were reinforced, and she could The score of Ms X’s worries decreased substan- observe that the stress decreased through the time. tially from 42 to 30 points (29%) on PSWQ as we Table 1 gives some examples of the beliefs of Ms can observe in Figure 5. X at the beginning of the CBT, then during the We also want to underline that, as the PSWQ therapy. We can observe the change of her beliefs showed it, even though the fear of recurrence was with the time. present more than ever at the beginning of the Figures 3 and 4 display the level of anxiety and therapy, the worries of Ms X extended to many depression of Ms X before and at the end of the other situations (e.g. worries about her children, K1

8 Before CBT 6 End of CBT

0 HAD-D HAD-A HAD-T

Figure 4. Scores of depression and anxiety (HAD)

45 40 35 30 25 Before CBT 20 End of CBT 15 10 5 0 PSWQ

Figure 5. Score of worries (PSWQ)

about her sister who did not give news for a long than the one which consist to worry and to avoid. time, about works into her home . . .). However, The extension of the benefit of the CBT on we tried to focus our therapy on a single situation situations not worked during the treatment has chosen by Ms X: the fear of recurrence. Interest- already been observed in other anxiety disorders ingly, we noticed an extension of the benefit of like phobia (Montel, 2009; Montel & Leduc, 2008). the CBT to many other situations of Ms X’s life. It seems that people who benefit from CBT learn Indeed, the decrease on the PSWQ score revealed useful techniques to cope with different situa- this extension. tions more or less close one another. It is a form Actually, out of questionnaires scoring, Ms X of ‘unconscious learning’ which likely refers to the described a large benefit of our intervention in her procedural memory. Thus, after several seances of daily life. CBT, Ms X was able to say that most of situations, even though stressing, are controllable. We would like to underline the importance of DISCUSSION the relaxation therapy associated to the CBT in the improvement of Ms X’s anxiety level (Borkovec & According to previous works (Dugas et al.,1995, Costello, 1993; Norton & Price, 2007). Indeed, the 1998; Ladouceur et al.,1997), we noticed that Ms ability to get relaxed when symptoms of anxiety X overestimated the usefulness of worry and that occur, gives the patient the confidence that he/she she was unable to tolerate uncertainty. When con- is able to cope with stressing situations. fronted to negative beliefs she tended to avoid very Finally, behavioural exposure to situations that much (Wells, 1995, 1997). The CBT helped her to the patient fears is absolutely essential, in order re-evaluate her beliefs and to tolerate emotions to, first, prevent behavioural and cognitive avoid- associated to situations she feared. She learnt to ance, and second, be conscious of his/her cognitive K1 develop other more functional coping strategies distortions about the situations.

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