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Comparison of Psychiatric Manifestations in Carcinoma of the Pancreas, Retroperitoneal Malignant Lymphoma, and Lymphoma in Other Locations
Comparison of Psychiatric Manifestations in Carcinoma of the Pancreas, Retroperitoneal Malignant Lymphoma, and Lymphoma in Other Locations IVAN FRAS, M.D. and EDWARD M. LITIN, M.D. • Psychiatric symptoms in carcinoma of the pancreas have been described in the literature previously!'6 and have been the object of an intensive study at our institution. 7 The results of the study showed a high over-all incidence (76 per cent) of psychiatric symptoms in patients with carcinoma of the pancreas. In the course of these investigations, four patients with retroperitoneal malignant lymphoma were also referred for study. Because similar psychiatric symptoms in these patients raised the question of a possible role of the retroperitoneal location of the neoplasm 6 • R in the occurrence of such symptoms, we decided to do a retrospective, comparative study of patients with carcinoma of the pancreas, retroperitoneal lymphoma, and lymphoma of other locations. A higher incidence of psychiatric symptoms among the patients with retroperitoneal neoplasm as compared to those without retroperitoneal neoplasm would lend some support to the possibility that the retroperitoneal location was associated with the psychiatric manifestations. MATERIALS AND METHODS The records of patients with carcinoma of the pancreas and those with malignant lymphoma were reviewed. Only those cases in which the diagnosis was histologically verified by biopsy or autopsy were included in the study.
Mayo Clinic and Mayo Foundation: Section of Psychiatry (Dr. Litin). :\1ayo Graduate School of Medicine (University of Minnt>sota), Rochester: Resident in PsychiatrY (Dr. Fras). Dr. Fras is now affiliated with the Broome County Mental Health Clinic, Binghamton, New York. September-October, 1967
The patient population of this study consisted of 78 patients with primary carcinoma of the pancreas, 35 with retroperitoneal malignant lymphoma and 51 with malignant lymphoma in other than retroperitoneal locations as far as this could be determined on the basis of the autopsy reports. The age distribution was comparable in all three groups, the highest incidence being in the seventh decade. The number of males was much greater in the group with carcinoma of the pancreas than in the groups with lymphoma. Each record was read carefully, and any mention of psychiatric symptoms was noted. The wide variety of interest and sophistication in the emotional aspects of the patients among the physicians' reports made a reliable evaluation of psychiatric symptoms difficult whenever these were referred to by brief and incomplete statements. The psychiatric symptoms therefore were divided into "definite," when they were adequately described. and "possible," when they were inadequately described. In addition, we separated all psychiatric manifestations into two categories: 1) Those that appeared to be manifestations of the illness as such, before the diagnosis was made and often before the onset of other (somatic) symptoms, and 2) those that were long-standing, chronic emotional problems or appeared secondary to the diagnosis or the long-standing illness. Conclusions could be drawn with more validity for the second category, since the descriptions were more detailed and more precise; the chronic problems often were the same for decades and could be noted from the records of previous visits. \\Then the neoplastic process, prior to being diagnosed, had brought about a marked exaggeration of pre275
PSYCHOSOMATICS TABLE I. THE INCIDENCE OF PSYCHIATRIC SYMPTOMS IN 164 PATIENTS WITH MALIGNANCY Carcinoma of the pancreas
Symptoms Definite Possible Total
(78 patient s) Number Per cent 10 13
Malienant retroperitoneal lymphoma (35 patients) Number Percem
22
28
I 4
32
41
5
vious traits, this was considered a manifestation of the present illness. This was observed infrequently in carcinoma of the pancreas but was more common in malignant lymphoma. RESULTS
Carcinoma of the Pancreas.-Among the 78 records of patients with carcinoma of the pancreas, psychiatric symptoms were described as a definite and integral part of the present illness (the carcinoma) in ten cases (13%). Three of the patients were considered depressed, one having the pattern previously described as characteristic for carcinoma of the pancreas: psychiatric hospitalization for depression, with electroconvulsive therapy because of their conviction that they had cancer, before an advanced carcinoma of the pancreas was diagnosed. The other seven patients were considered to be suffering from anxiety. Four of the ten patients had been referred to psychiatrists: three with the diagnosis of depression and one, of anxiety. Twenty-two others (29%) may have had psychiatric symptoms. Of these 22 patients, 13 may have had anxiety (suggested by terms like "anxiety state," "apprehensive," "anxious," "nervous"); five patients may have had depression ("no ambition," "no interest," "no pep"); two patients may have had feelings of premonition of serious illness ("patient thought he had a tumor," "is convinced she has cancer"), and hvo patients may have had both anxiety and depression. Previous emotional difficulties ( anxiety states) were noted in two patients; in one, these were intensified as part of the present illness. Retroperitoneal M alig1Wnt Lymphoma.-Of the 35 patients with this diagnosis, only one was described as having definite psychiatric symptoms. These consisted of depression with associated mild anxiety, and they outdated any 276
3 _II 14
Malignant lymphoma of other locations
(5 I patients) Number Per cent
2
5 7
4
10 14
other symptoms. Four more patients (12%) had possible psychiatric symptoms consisting of depression or anxiety or both, either preceding the somatic symptoms or occurring in connection with these. Not included among these were two other patients in whom chronic emotional difficulties had been noted many years earlier and were not intensified by the neoplastic process.
Malig1Wnt Lymphoma in Other Than Retroperitoneal Locations.-In two of the 51 patients in this group, psychiatric symptoms of anxiety, depression, and feelings of premonition of serious illness were noted definitely as part of the presenting symptomatology of the lymphoma. Five other patients may have had such symptoms. In an additional five patients, there were adequate descriptions of chronic psychiatric difficulties that had been present for many years before the lymphoma was first noticed or of psychiatric symptoms secondary to the prolonged illness. DISCUSSION
The incidence of psychiatric symptoms was higher in carcinoma of the pancreas than in the other two groups and the two groups with malignant lymphomas did not appreciably differ between each other in this respect. Reviewing case records without seeing the patient has many limitations and shortcomings, especially when psychiatric phenomena are investigated. The results must therefore be interpreted with caution, and any conclusions must be considered tentative. The chief advantage of such a retrospective approach is the ease with which a relatively large and unselected patient population can be obtained and reviewed. Only work with patients directly, however, can provide the necessary details. The present study suggests two conclusions: That psychiatric symptoms as part of the total symptomatology of the neoplasm are more Volume VIII
MANIFESTATIONS OF CARCINOMA-FRAS AND LITIN
frequent and more impressive in carcinoma of the pancreas than in malignant lymphoma, and that the occurrence of these psychiatric symptoms does not appear to be related to the retroperitoneal location of the neoplasm, since there was no difference between their incidence in patients with retroperitoneal lymphoma and those with lymphoma in other locations. The psychiatric symptoms in carcinoma of the pancreas, therefore, may be related to factors other than the retroperitoneal location. It is difficult to tabulate the difference in impressions that we obtained from reading the various records. The psychiatric symptoms in carcinoma of the pancreas stood out more clearly and seemed to have made a stronger impression on the physician who recorded them, even though we classified many of them as "possib]e," often onlY because of lack of precise information. \Ve believe that these impressions have been corroborated by our study based on patient interviews.7 Psychiatric symptoms have been described in patients with lymphoma by Greene," main]y in relation to the preceding loss of a significant relationship such as "object )oss." Since that study and the present one differed in method (Greene's findings were based on interviews with patients), their respective findings cannot be compared. There were, however, a few patients with lymphoma in our study in whom "object ]oss" ( usually
death of a close person) was followed by depression and anxiety, apparently before the manifest onset of the disease. REFERENCES
1. Birnbaum, D. and Kleeber~, J.: Carcinoma of the pancreas: A clinical study based on 84 cases. Ann. Intem. Med., 48:1171-1184, 1958. 2. Kant, 0.: A deceptive psychoneurosis. Psychiat. Quart., 20: 129-134, 1946. 3. Karliner, W.: Psychiatric manifestations of cancer of the pancreas. New York }. Med., 56:22512252, 1956. 4. Perlas, A. P. and Faillace, L. A.: Psychiatric manifestations of carcinoma of the pancreas. Amer. }. Psychiat., 121: 182, 1964. 5. Savage, C. and Noble, D.: Cancer of the pancreas: Two cases simulatin~ psycho~('nic illness. }. Nero. Ment. Dis., 120:62-65, 1954. 6. Yaskin, J. C.: Nervous symptoms as earliest manifestations of carcinoma of the pancreas. }.A.M.A., 96:1664-1668, 1931. 7. Fras, I., Litin, E. M. and Pearson, J. S.: Comparison of psychiatric symptoms in carcinoma of the pancreas with those in two other intraalxlominal neoplasms. Read at the meetin~ of the American Psychiatric Association, Atlantic City, May 9 to 13, 1966. Amer. }. Psychiat., 123, No. 12, 1553-1562, June 1967. 8. Latter, K. A. and Wilbur, D. L.: Psychic and neurologic manifestations of l'arcinoma of the pancreas. Mayo Clin. Proc., 12:457-462, 1937. 9. Greene, W. A.: The psychosocial settin~ of the development of leukemia and lymphoma. Ann. N.Y. AClUl. Sci., 125:794-801, 1966.
97 Chestnut Street Binghamton, New York
Any excuse will serve a tyrant. AESOP,
o
o
550 B.C.
o
If any l'ount on two days, or any more, to come, He is a fool; for a man has no morrow. Til with good luck he has got throu~h today. SOPHOCLES,
September-October, 1967
400 B.C.
277
Mayo Clinic and Mayo Foundation: Section of Psychiatry (Dr. Litin). :\1ayo Graduate School of Medicine (University of Minnt>sota), Rochester: Resident in PsychiatrY (Dr. Fras). Dr. Fras is now affiliated with the Broome County Mental Health Clinic, Binghamton, New York. September-October, 1967
The patient population of this study consisted of 78 patients with primary carcinoma of the pancreas, 35 with retroperitoneal malignant lymphoma and 51 with malignant lymphoma in other than retroperitoneal locations as far as this could be determined on the basis of the autopsy reports. The age distribution was comparable in all three groups, the highest incidence being in the seventh decade. The number of males was much greater in the group with carcinoma of the pancreas than in the groups with lymphoma. Each record was read carefully, and any mention of psychiatric symptoms was noted. The wide variety of interest and sophistication in the emotional aspects of the patients among the physicians' reports made a reliable evaluation of psychiatric symptoms difficult whenever these were referred to by brief and incomplete statements. The psychiatric symptoms therefore were divided into "definite," when they were adequately described. and "possible," when they were inadequately described. In addition, we separated all psychiatric manifestations into two categories: 1) Those that appeared to be manifestations of the illness as such, before the diagnosis was made and often before the onset of other (somatic) symptoms, and 2) those that were long-standing, chronic emotional problems or appeared secondary to the diagnosis or the long-standing illness. Conclusions could be drawn with more validity for the second category, since the descriptions were more detailed and more precise; the chronic problems often were the same for decades and could be noted from the records of previous visits. \\Then the neoplastic process, prior to being diagnosed, had brought about a marked exaggeration of pre275
PSYCHOSOMATICS TABLE I. THE INCIDENCE OF PSYCHIATRIC SYMPTOMS IN 164 PATIENTS WITH MALIGNANCY Carcinoma of the pancreas
Symptoms Definite Possible Total
(78 patient s) Number Per cent 10 13
Malienant retroperitoneal lymphoma (35 patients) Number Percem
22
28
I 4
32
41
5
vious traits, this was considered a manifestation of the present illness. This was observed infrequently in carcinoma of the pancreas but was more common in malignant lymphoma. RESULTS
Carcinoma of the Pancreas.-Among the 78 records of patients with carcinoma of the pancreas, psychiatric symptoms were described as a definite and integral part of the present illness (the carcinoma) in ten cases (13%). Three of the patients were considered depressed, one having the pattern previously described as characteristic for carcinoma of the pancreas: psychiatric hospitalization for depression, with electroconvulsive therapy because of their conviction that they had cancer, before an advanced carcinoma of the pancreas was diagnosed. The other seven patients were considered to be suffering from anxiety. Four of the ten patients had been referred to psychiatrists: three with the diagnosis of depression and one, of anxiety. Twenty-two others (29%) may have had psychiatric symptoms. Of these 22 patients, 13 may have had anxiety (suggested by terms like "anxiety state," "apprehensive," "anxious," "nervous"); five patients may have had depression ("no ambition," "no interest," "no pep"); two patients may have had feelings of premonition of serious illness ("patient thought he had a tumor," "is convinced she has cancer"), and hvo patients may have had both anxiety and depression. Previous emotional difficulties ( anxiety states) were noted in two patients; in one, these were intensified as part of the present illness. Retroperitoneal M alig1Wnt Lymphoma.-Of the 35 patients with this diagnosis, only one was described as having definite psychiatric symptoms. These consisted of depression with associated mild anxiety, and they outdated any 276
3 _II 14
Malignant lymphoma of other locations
(5 I patients) Number Per cent
2
5 7
4
10 14
other symptoms. Four more patients (12%) had possible psychiatric symptoms consisting of depression or anxiety or both, either preceding the somatic symptoms or occurring in connection with these. Not included among these were two other patients in whom chronic emotional difficulties had been noted many years earlier and were not intensified by the neoplastic process.
Malig1Wnt Lymphoma in Other Than Retroperitoneal Locations.-In two of the 51 patients in this group, psychiatric symptoms of anxiety, depression, and feelings of premonition of serious illness were noted definitely as part of the presenting symptomatology of the lymphoma. Five other patients may have had such symptoms. In an additional five patients, there were adequate descriptions of chronic psychiatric difficulties that had been present for many years before the lymphoma was first noticed or of psychiatric symptoms secondary to the prolonged illness. DISCUSSION
The incidence of psychiatric symptoms was higher in carcinoma of the pancreas than in the other two groups and the two groups with malignant lymphomas did not appreciably differ between each other in this respect. Reviewing case records without seeing the patient has many limitations and shortcomings, especially when psychiatric phenomena are investigated. The results must therefore be interpreted with caution, and any conclusions must be considered tentative. The chief advantage of such a retrospective approach is the ease with which a relatively large and unselected patient population can be obtained and reviewed. Only work with patients directly, however, can provide the necessary details. The present study suggests two conclusions: That psychiatric symptoms as part of the total symptomatology of the neoplasm are more Volume VIII
MANIFESTATIONS OF CARCINOMA-FRAS AND LITIN
frequent and more impressive in carcinoma of the pancreas than in malignant lymphoma, and that the occurrence of these psychiatric symptoms does not appear to be related to the retroperitoneal location of the neoplasm, since there was no difference between their incidence in patients with retroperitoneal lymphoma and those with lymphoma in other locations. The psychiatric symptoms in carcinoma of the pancreas, therefore, may be related to factors other than the retroperitoneal location. It is difficult to tabulate the difference in impressions that we obtained from reading the various records. The psychiatric symptoms in carcinoma of the pancreas stood out more clearly and seemed to have made a stronger impression on the physician who recorded them, even though we classified many of them as "possib]e," often onlY because of lack of precise information. \Ve believe that these impressions have been corroborated by our study based on patient interviews.7 Psychiatric symptoms have been described in patients with lymphoma by Greene," main]y in relation to the preceding loss of a significant relationship such as "object )oss." Since that study and the present one differed in method (Greene's findings were based on interviews with patients), their respective findings cannot be compared. There were, however, a few patients with lymphoma in our study in whom "object ]oss" ( usually
death of a close person) was followed by depression and anxiety, apparently before the manifest onset of the disease. REFERENCES
1. Birnbaum, D. and Kleeber~, J.: Carcinoma of the pancreas: A clinical study based on 84 cases. Ann. Intem. Med., 48:1171-1184, 1958. 2. Kant, 0.: A deceptive psychoneurosis. Psychiat. Quart., 20: 129-134, 1946. 3. Karliner, W.: Psychiatric manifestations of cancer of the pancreas. New York }. Med., 56:22512252, 1956. 4. Perlas, A. P. and Faillace, L. A.: Psychiatric manifestations of carcinoma of the pancreas. Amer. }. Psychiat., 121: 182, 1964. 5. Savage, C. and Noble, D.: Cancer of the pancreas: Two cases simulatin~ psycho~('nic illness. }. Nero. Ment. Dis., 120:62-65, 1954. 6. Yaskin, J. C.: Nervous symptoms as earliest manifestations of carcinoma of the pancreas. }.A.M.A., 96:1664-1668, 1931. 7. Fras, I., Litin, E. M. and Pearson, J. S.: Comparison of psychiatric symptoms in carcinoma of the pancreas with those in two other intraalxlominal neoplasms. Read at the meetin~ of the American Psychiatric Association, Atlantic City, May 9 to 13, 1966. Amer. }. Psychiat., 123, No. 12, 1553-1562, June 1967. 8. Latter, K. A. and Wilbur, D. L.: Psychic and neurologic manifestations of l'arcinoma of the pancreas. Mayo Clin. Proc., 12:457-462, 1937. 9. Greene, W. A.: The psychosocial settin~ of the development of leukemia and lymphoma. Ann. N.Y. AClUl. Sci., 125:794-801, 1966.
97 Chestnut Street Binghamton, New York
Any excuse will serve a tyrant. AESOP,
o
o
550 B.C.
o
If any l'ount on two days, or any more, to come, He is a fool; for a man has no morrow. Til with good luck he has got throu~h today. SOPHOCLES,
September-October, 1967
400 B.C.
277