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Psychological impact of Thyroid Cancer

1. How does one know if they are experiencing ‘normal’ anxiety and/or depression, or a degree of it that requires treatment?

   Rodin (May 1/07)

   The diagnosis of depression or anxiety is often difficult to make in the presence of thyroid or other medical diseases. There is no easy way to tell the difference between symptoms of depression or anxiety and they can be amplified by too much or too little thyroid hormone. Typically, the symptoms of hyperthyroidism resemble those of anxiety and of hypothyroidism resemble those of depression. Patients with symptoms of depression or anxiety should have their thyroid hormone levels checked.

   I am attaching a screening measure for depression and anxiety, which may be of some help to your members to assess their symptoms and to communicate with their doctors. Antidepressant medication can be useful for those with moderate to severe and persistent symptoms of depression. Unhappiness, which does not meet these criteria, may not need to be treated with antidepressant medication. Symptoms of depression and anxiety can be triggered by thyroid hormone alterations. Most often hyperthyroidism mimics and may trigger anxiety and hypothyroidism mimics or triggers depression. The antidepressant and anti-anxiety medications now in common use, differ in their side effects more than in their effectiveness, so that doctors need to consider what sensitivities or other medical conditions are present. Antidepressant medication can be prescribed by family physicians but should be used selectively not to treat unhappiness of all kinds. Like all medications, these drugs have side effects and therefore should only be used when indicated.

    

   Screening Questionnaire This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability unless you are requested to skip over a question. Rate the following, by "not at all", "several days", "more than half the days" or "nearly every day". 1.    Over the last 2 weeks, how often have you been bothered by any of the following problems? a.   ___ Little interest or pleasure in doing things b.   ___ Feeling down, depressed, or hopeless c.   ___ Trouble falling or staying asleep, or sleeping too much d.   ___ Feeling tired or having little energy e.   ___ Poor appetite or overeating f.   ___ Feeling bad about yourself, or that you are a failure, or have let yourself or your family down g.   ___ Trouble concentrating on things, such as reading the newspaper or watching television h.   ___ Moving or speaking so slowly that other people could have noticed? Or the opposite -- being so    fidgety or restless that you have been moving around a lot more than usual i.   ___ Thoughts that you would be better off dead or of hurting yourself in some way   2.    Questions about anxiety: a.   In the last 4 weeks, have you had an anxiety attack suddenly feeling fear or panic? ___Yes ___ No If you checked NO, go to question #3. b.   ___ Has this ever happened before? c.   ___ Do some of these attacks come suddenly out of the blue that is, in situations where you don't expect to be nervous or uncomfortable? d.   ___ Do these attacks bother you a lot or are you worried about having another attack? e.   ___ During your last bad anxiety attack. Did you have symptoms like shortness of breath, sweating, your heart racing or pounding, dizziness or faintness, tingling or numbness, or nausea or an upset stomach?  3.   If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Choose from: ___ "Not difficult at all", ___ "somewhat difficult", ___ "very difficult", ___ "extremely difficult".   If you scored more than four items with a rating above "not at all", speak with your doctor. Source: Robert L. Spitzer; Kurt Kroenke; Janet B. W. Williams; and the Patient Health Questionnaire Primary Care Study Group JAMA. 1999; 282:1737-1744.

   Editor’s Note:

   The Mood Disorders Society of Canada has a webpage www.mooddisorderscanada.ca with a self help guide to depression that our readers might find helpful. For professional assistance, check with the psychosocial oncology program in the cancer treatment center where you are being treated. More and more programs are developing specialized services in this area.

2. Thyroid cancer and its effects on anxiety levels: Are my feelings ‘normal’?

   Drucker (Oct 1/06)

   Thyroid cancer often affects young patients, more frequently women than men. Although papillary and follicular thyroid cancer is highly treatable and has an excellent prognosis, the diagnosis of cancer is frequently frightening and may have psychological consequences that persist even once the cancer has been successfully treated. Once previously healthy individuals are told that they have thyroid cancer, it is quite common to experience some degree of panic and become frightened. This can last for days to weeks, and in some individuals, it can take years before regaining a former sense of confidence in one’s health. Although most forms of thyroid cancer have an excellent prognosis, the word cancer and its connotations is frightening to most people, and fear of the unknown and what lies ahead is not uncommon.

    A common scenario preceding the initial diagnosis is for the usual patient to be in reasonably good health, not feel sick, and simply have a small thyroid nodule that usually does not cause any symptoms. Indeed many patients have had their thyroid nodules for years prior to a diagnosis of thyroid cancer, and often have had several previously normal biopsies, and no symptoms. Hence, it often comes as a great shock when one is transformed from a very healthy person with a small imperceptible bump in the neck, to a patient with a diagnosis of cancer.

   Despite an abundance of positive reassurance, and lots of statistics that suggest a very good to excellent prognosis, and despite being told 'not to worry' by friends, family and medical professionals, the majority of patients are understandably shocked, alarmed and often experience large amounts of anxiety, which at times can be disabling.

   It is quite normal to feel physically ill, and experience a sense of dread or panic at the diagnosis of any cancer, no matter how good the prognosis. Cancer is a terrifying word. At the end of the day, all of us would rather not have any cancer, no matter how good the prognosis. The uncertainty that lies ahead, coupled with the multiple hospital and physicians visits, technical terms, strange drugs, surgery, hypothyroidism, radioactive iodine and isolation, and disruption of our normal daily activities can be a bit too much to handle while trying to always remain outwardly calm and confident.

   Many patients may not have an excellent support network, or may not want to burden loved ones and friends with their real fears and anxieties. Hence, although apparently surrounded by friends and family, many patients will feel quite lonely and they often will feel like they need to be brave and tough, while having no one they can or wish to confide in or complain to.

   An important component of dealing with the acute anxiety that accompanies a thyroid cancer diagnosis is the provision of gentle reassurance on an ongoing basis, without being patronizing. It is not unusual for patients to start to notice various sore throats, twinges, aches, tingling, numbness and pains that previously may have gone unrecognized. Most of us have these inexplicable minor twinges, spasms, aches or body sensations all the time; they are fleeting and they don't usually bother us. However, once a diagnosis of cancer has been made, patients may become nervous and more easily frightened when sore throats, tightness in the neck, choking sensations, or occasional tingling is noticed. Furthermore, during a severe throat, viral, bacterial or dental infections, lymph nodes may appear (a normal reaction to the infection) in the neck that can be frightening for the patient with a history of thyroid cancer. The neck, voice, or throat area is frequently the source of unusual sensations in patients with anxiety. It is generally useful to discuss these complaints, anxiety and associated concerns with a physician, as usually considerable reassurance can be obtained once an assessment of the problem is carried out.

   Many patients, particularly young individuals, will have their confidence in their own health disrupted for the first time, by the diagnosis of thyroid cancer and may have significant ongoing anxiety that they do not wish to share with others, as they "don't wish to complain or be a nuisance etc to friends or family". It is helpful to acknowledge that these concerns are very common in the patient population with thyroid cancer and constitute a normal reaction to the diagnosis of cancer. Discussion of the treatment process, and the excellent prognosis, taken together with ongoing reassurance and support usually leads to a progressive diminution in anxiety, increase in confidence and a gradual return to a more normal life. In a small minority of patients, anxiety may be persistent and chronically disabling, interfering with a normal return to the activities of daily living and enjoyment of life. Such patients may benefit from joining a support group of thyroid cancer survivors (see Thyroid Cancer Canada  [www.thyroidcancercanada.org] or ThyCa:Thyroid Cancer Survivors Association [www.thyca.org]) or from professional counselling.

   In the vast majority of patients, once a treatment plan is formulated, and treatment is completed, anxiety generally gradually diminishes, and fades into the background. Although anxiety can return at any time, particularly if one perceives abnormal sensations in the head and neck, or a small bump is detected, the majority of these instances resolve and do not represent recurrences of thyroid cancer. When there is any doubt, it is helpful to seek the counsel and assessment of your physician.