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Case history

image A 19-year-old woman presented with a cough and was found to have a large mediastinal mass. Investigations confirmed Hodgkin's lymphoma (nodular sclerosing type, stage II disease). She was treated with hybrid chemotherapy and mediastinal radiotherapy, leading to disease remission. She re-presented 7 years later with a palpable cervical lymph node. Further investigation identified widespread relapse of her lymphoma. Holistic needs assessment (HNA) revealed distress and psychological concerns around swallowing. She was treated with four cycles of gemcitabine, dacarbazine, cyclophosphamide, vincristine and prednisolone chemotherapy but her disease progressed. Further lines of chemotherapy including vinblastine, basiliximab, and etoposide, methylprednisolone, cytarabine and cisplatin preceded an allogenic stem cell transplant from her sister. Treatment was complicated by numerous side effects including peripheral neuropathy, premature ovarian failure and osteopenia. She also developed graft versus host disease of the mouth and skin.

Since her relapse she complained of difficulties swallowing tablets and expressed concerns and fears about tablet taking. No organic basis for her dysphagia was found and she was referred to psycho-oncology for assessment and management of symptoms. Assessment confirmed anxiety and dysfunctional thinking about swallowing tablets. She believed she would choke and become ill. The perceived risk of asphyxiation far outweighed the consequences of non-compliance; consequently, adherence to medication had become problematic and patchy. She was struggling with adjustment and the psychological consequences of having recurrent disease and a challenging prognosis. She felt out of control and overwhelmed by two interconnected threats to her very survival and was feeling increasingly helpless. Following a course of cognitive behavioural therapy (CBT) her symptoms improved and swallowing of her supportive medications became manageable. As her disease has progressed she has accessed intermittent support from the psycho-oncology team.

What psychological therapy options were considered in this case?

What is CBT and how did it work in this case?

What are potential barriers to effective therapy?

What is the evidence base for CBT?

How can psychological issues be identified and managed?

What psychological therapy options were considered in this case?

The primary goal was to improve adherence to her essential oral oncology treatment by overcoming difficulties swallowing tablets. Several forms of psychological therapy have demonstrable efficacy in oncology including mindfulness, acceptance and commitment therapy, solution-focused therapy, supportive counselling and CBT. Her adjustment was compromised by dysfunctional thinking and a powerful belief that she could not take tablets. Patient preference for CBT became evident. Collaborative decision making led to agreement on CBT, as it could target her dysfunctional thinking, imagery, anxious preoccupation, and safety behaviours which were maintaining the problematic tablet taking (Figure 12.1). She was well informed and aware of her options having previously attempted self-help.

Figure 12.1

Scheme of difficulties taking tablets, and associated thoughts, feelings and behaviours.

What is CBT and how did it work in this case?


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