Oncologie : Article pp.235-242 du Vol.7 n°4 (2013)

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ORIGINAL ARTICLE /ARTICLE ORIGINAL DOSSIER

Beyond psychiatric classification in oncology: psychosocial dimensions in cancer and implications for care

Au-delà de la classification psychiatrique en oncologie : aspects psychosociaux du cancer et répercussions pour les soins

L. Grassi · M.G. Nanni

Received: 13 October 2013; Accepted: 12 November 2013

AbstractAlthough the field of psychological reactions of patients in response to cancer and cancer treatment has been the object of intense psycho-oncology research, the DSM and ICD nosological systems fail to give proper space to this area. Both the ICD and DSM rubrics Psycho- logical Factors affecting a Medical Condition fail to fully describe the several psychosocial implications of cancer.

The development of Diagnostic Criteria for Psychosomatic Research (DCPR) is in line with the psychosomatic and biopsychosocial tradition and has given a new impulse to this area by translating psychosocial variables into opera- tional tools for psychosocial variables with prognostic and therapeutic implications in medically ill patients. The application of the DCPR has been shown to be useful in a more precise identification of several psychological conditions affecting cancer patients. The DCPR dimensions of health anxiety, demoralization and alexithymia have been recog- nized in oncology, with a low overlap with a formal DSM psychiatric diagnosis; the DCPR dimensions dealing with the patients’ ways of perceiving, experiencing, evaluating, and responding to their health status (abnormal illness behaviour) have also been demonstrated, while more data are needed with regard to the complex area of somatization and somatic symptom presentation of distress in cancer patients, for which the DCPR clusters of somatization (functional somatic symptoms secondary to psychiatric disorders, persistent somatization, conversion symptoms, and anniversary reaction) can be of help. More research and the possible refinement of DCPR clustering dimensions are needed in order to understand the several and multiform psychosocial responses of cancer patients across the trajectory of the disease.

Keywords Psychosocial dimensions · DSM5 · DCPR · Psycho-oncology · Cancer

Résumé Bien que le champ des réactions psychologiques des patients en réponse au cancer et au traitement du cancer ait fait l’objet de recherches intensives en matière de psycho- oncologie, les systèmes nosologiques DSM et ICD n’accor- dent pas suffisamment d’importance à ce domaine. Les rubriques concernant les facteurs psychologiques des sys- tèmes ICD et DSM affectant un état pathologique ne décri- vent pas dans leur intégralité les nombreuses conséquences psychosociales du cancer. Le développement de critères diagnostiques pour la recherche psychosomatique (DCPR) s’aligne sur la tradition psychosomatique et biopsychoso- ciale et a permis de donner un nouvel élan à ce domaine en transposant des variables psychosociales à des outils opéra- tionnels pour les variables psychosociales ayant des implications pronostiques et thérapeutiques chez des patients malades. L’application des DCPR a démontré leur utilité pour l’indentification plus précise de plusieurs conditions psychologiques affectant les patients atteints d’un cancer.

Les dimensions des DCPR concernant l’anxiété, la démora- lisation et l’alexithymie liées à la santé ont été reconnues en oncologie, avec une faible coïncidence avec un diagnostic DSM psychiatrique formel. Les dimensions des DCPR rela- tives à la manière dont les patients perçoivent, ressentent, évaluent et réagissent à leur état de santé (comportement anormal lié à la maladie) ont également été prouvées. Cepen- dant, il sera nécessaire de fournir davantage de données concernant les zones complexes de somatisation et de symp- tômes somatiques signalant de l’anxiété chez les patients atteints d’un cancer, pour lesquels les groupes de somatisation des DCPR (symptômes somatiques fonctionnels secon- daires pour les troubles psychiatriques, somatisation persis- tante, symptômes de conversion et les réactions anniversaires) peuvent être utiles. Des recherches supplé- mentaires et un éventuel affinement des dimensions de

L. Grassi (*) · M.G. Nanni

Institute of Psychiatry, Department of Biomedical and

Specialty Surgical Sciences, University of Ferrara, Ferrara, Italy e-mail : luigi.grassi@unife.it

DOI 10.1007/s11839-013-0436-4

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regroupement des DCPR sont nécessaires afin de com- prendre les réactions psychosociales, nombreuses et complexes, des patients atteints d’un cancer tout au long de l’évolution de la maladie.

Mots clésDimensions psychosociales · DSM5 · DCPR · Psycho-oncologie · Cancer

Introduction

The psychological reactions of patients in response to cancer and cancer treatment has been the object of psycho-oncology research since the first studies carried out by Sutherland in the‘50s. He thoughtfully pointed out that the psychology of the cancer patient is the psychology of a person under a spe- cial and severe form of stress, during which many funda- mental underlying convictions, based on the life-history of the person and his or her experiences (e.g. pattern of relationship with attachment figures) are brought to the surface [60].

He also described six clinical types of psychological reactions commonly seen after cancer diagnosis and treatment, namely dependency, anxiety, postoperative depression, hypochondriac response, obsessive-compulsive reactions, and paranoid reactions [61]. Subsequent research confirmed the importance of assessing psychosocial responses, especially anxiety and depression, as a significant disorder need- ing for attention at the diagnostic level and as a variable associated with a decrease in patients’ quality of life [43,46,47]. When the Diagnostic Statistical Manual for Mental Disorders 3^rd edition (DSM-III) was available in clinical settings, more data were collected as far as psychiatric disorders in cancer patients were concerned. The first multicentre studies in the US, the PSYCOG study, indicated that about 40% of cancer patients met the criteria for a psychiatric disorder, mainly adjustment disorders [9]. PSYCOG results were confirmed by a number of other investigations in several countries, such as the United Kingdom [35], Italy [24], Belgium [55], Australia [37,39], Spain [53] and Ger- many [57], showing a 35-40% prevalence of psychiatric disorders, according to the DSM or the International Classi- fication of Disorders (ICD). A series of questions and unan- swered queries persist, however, in clinical psycho-oncology practice. Are ICD and DSM psychiatric classification systems specifically reliable in cancer settings? Is there the risk that a pure psychiatric approach may reduce instead of enlarge the vision of the multiform phenomenology of psychosocial suffering in cancer patients? What other possible methods or tools can be used, without losing an evidence- based approach but integrating it with a value-based approach in oncology? The aim of this review is to present some of the limits of the traditional psychiatric approach and related nosography and to suggest the use of other systems

coming from the biopsychosocial / psychosomatic medicine tradition [17,18], to be integrated with clinical practice expertise in oncology.

The limits of the traditional psychiatric approach to cancer

Although it is clear that having a system codifying the diverse clinical disorders observable in oncology settings (e.g. delir- ium, post-traumatic stress disorder) is helpful, it is also evident that for the large area of emotional reactions and other psychosocial factors or dimensions, which are so important in medically ill patients, including cancer patients, both the ICD- 10 and the DSM used an oversimplified approach. The ICD- 10 summarized this area in Chapter 21 under the heading

“Factors influencing health status and contact with health system”(code Z00-Z99), while the following revisions (Clinical Modification/Procedure Coding System version) until the most recent ICD-10-CM/PCS 2010, created the code “Psy- chological and behavioural factors associated with disorders or diseases classified elsewhere”(code F54) within the chapter “Behavioural syndromes associated with physiological disturbances and physical factors”[67]. The category, as indicated in the ICD-10,“should be used to record the presence of psychological or behavioural influences thought to have played a major part in the aetiology of physical disorders which can be classified to other chapters. Any resulting mental disturbances are usually mild, and often prolonged (such as worry, emotional conflict, apprehension) and do not justify by themselves the use of any of the categories in this chapter.” No further indication about the clinical characteristics of maladaptive or maladjustment coping styles is provided. On the other side, the DSM also dedicated a short summary to this vast area as“Psychological factors affecting a medical condition”under the chapter“Other conditions that may be a focus of clinical attention”. This chapter indicated that Axis I disorders, Axis II disorders, psychological symptoms or personality traits that do not meet the full criteria for a specific mental disorder, maladaptive health behaviours, or physiological responses to environmental or social stressors should be taken into account if they influence the course or outcome of cancer or place the individual at a significantly higher risk for an adverse outcome. More recently, the DSM5 gave more dignity to this section by integrating it (code 316; corresponding to F54 code in the ICD-10) within the chapter “Somatic symptom and related disorders”, although the criteria were basically the same of DSM-IV (Tables 1, 2).The same problems of more recent DSM classifications emerge, such as the overlapping between psychiatric diagnoses (Axis I) and psychosocial dimensions (personality traits and maladaptive coping) and the lack of explanation as how to assess the dimensions mentioned.

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The need for an integrated psychiatric / psychosocial approach in oncology

The need for a different approach has emerged in psycho- oncology literature of the last twenty-five years. A series of studies has shown that psychosocial factors, other than psychiatric diagnoses, have a remarkable role in negatively influencing the patients’ quality of life, their interpersonal relationships, behavioural dimensions (e.g. adherence to treatment, maladaptive coping and maintenance of at-risk behaviour) and possibly prognosis and survival [22]. In a study of one hundred cancer patients, a series of attitudes and perceptions of health status, subsumed under the con- cept of abnormal illness behaviour (e.g. affective inhibition,

disease conviction in spite of medical reassurance, frictions in interpersonal relationships, inability to perceive the role of psychological factors in symptom perceptions) were shown to be related to depressive states, not necessarily meeting the criteria of a DSM or ICD psychiatric disorder [29,30]. Fur- thermore, maladaptive coping styles, such as hopelessness- helplessness and anxious preoccupation, have been related to other psychosocial dimensions, including poor social support and personality variables, such as external locus of control, irrespective of a formal psychiatric diagnosis [31]. The dimension of demoralization, as a clinical syndrome sepa- rated from major depression, has been shown to be extremely important both in psychiatry and oncology. Loss of meaning and hope can determine a sense of worthlessness Table 1 Diagnostic criteria for Psychological Factors Affecting Other Medical Condition, Cancer (adapted and modified from DSM-5).

A. A medical symptom or condition (other than a mental disorder) is present.

B. Psychological or behavioural factors adversely affect the general medical condition in one of the following ways:

(1) the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition (2) the factors interfere with the treatment of the medical condition (e.g., poor adherence)

(3) the factors constitute additional well-established health risks for the individual

(4) the factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention

C. The psychological and behavioural factors in Criterion B are not better explained by another mental disorder (e.g. panic disorder, major depressive disorder, post-traumatic stress disorder)

Specifying current severity:

Mild: increases medical risk (e.g. inconsistent adherence with treatment)

Moderate:aggravates underlying medical condition (e.g. anxiety aggravating cancer symptoms)

Severe: results in medical hospitalization or emergency room visit

Extreme: results in severe, life-threatening risk (e.g. ignoring medical symptoms)

Table 2 Diagnostic criteria of some DCPR dimensions [11,14,51,58].

Illness denial

Persistent denial of having a physical disorder and of the need for treatment (e.g., lack of compliance, delayed seeking of medical attention for serious and persistent symptoms, counterphobic behaviour) as a reaction to the symptoms, signs, diagnosis, or medical treatment of a physical illness

The patient has been provided with a lucid and accurate appraisal of the medical situation and management to be followed Alexithymia

At least 3 of the following 6 characteristics must be present : inability to use appropriate words to describe emotions; tendency to describe details instead of feelings; lack of a rich fantasy life; thought content associated more with external events than fantasy or emotions; unawareness of the common somatic reactions that accompany the experience of a variety of feelings; occasional but violent and often inappropriate outbursts of affective behaviour

Demoralization

A feeling state characterized by the patient’s consciousness of having failed to meet his or her own expectations (or those of others) or being unable to cope with some pressing problem; the patient experiences feelings of helplessness, hopelessness, or giving up

The feeling state should be prolonged and generalized (at least 1 month in duration)

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on one’s own life and in the future which, according to several authors [1,7,38], is the hallmark of demoralization as a syndrome to be measured in clinical settings. A number of recent studies has shown that existential distress (demoralization) in cancer patients is in fact related to confrontation with existential stressors that, throughout the illness across all disease stages, impair the sense of mastery and compe- tence. While global sense of meaning has an important pro- tecting factor regarding the development of demoralization and distress symptoms [62], loss of dignity also has been found to be related to demoralization, indicating the need to examine through a multiperspective approach, the several aspects of psychosocial implications of cancer [63]. The role of psychological factors, including hopelessness, emotional control (repression), in moulding the course of cancer has also been traditionally studied in oncology. In a prospective study of 578 breast cancer patients it has been shown that a hopelessness response (rather than a formal DSM diagnosis of major depression) is implicated in increasing the risk of relapse or death both at 5 years after diagnosis and 10 years later [64,66], with new analysis confirming these results [65]. Other studies showed that antiemotionality (emotional non-expression or repression) and hopelessness were associated with shorter survival while cognitive escape-avoidance (denial / minimization) were related to longer survival in both early-stage breast cancer [40] and melanoma patients [41]. More recently, a 20-year analysis of breast cancer patients showed that psychological control and control- related coping were related to cancer outcomes [2].

The Diagnostic Criteria for Psychosomatic Research (DCPR) approach

These data confirm that the assessment of the different psychosocial dimensions in medically ill patients, and specifically in cancer patients should be a routine approach in clinical care. A number of psychometric instruments has been proposed to be applied in order to measure psychosocial dimensions and these are available in clinical practice. How- ever, the risk of reducing the complex subjective and experi- ential dimensions in multiple-choice instruments has been raised by Fava et al. [15,16], who consider a more structured and clinical approach as the necessary way to overcome the problem of reductionism in medicine and the clinimetric perspective as the intellectual home for the reproduction and standardization of clinical intuition. The Research Domain Criteria project (RDoC) is a different approach that has been launched for research purposes by the National Institute of Mental health (NIMH Strategic Plan-Strategy 1.4) (http://

www.nimh.nih.gov/research-priorities/rdoc/index.shtml), as a way to classify psychopathology based on dimensions of observable behaviour and neurobiological measures in order

to translate rapid progress in basic neurobiological and behavioural research to an improved integrative understanding of psychopathology. This, however does not seem to answer the needs emerging from cancer settings.

On the contrary, the Diagnostic Criteria for Psychoso- matic Research (DCPR) approach seems to have many interesting applications in oncology and psycho-oncology. The DCPR [12] has in fact been specifically proposed, since its beginning, with the aim of translating psychosocial variables that were derived from psychosomatic research into opera- tional tools for psychosocial variables with prognostic and therapeutic implications in clinical settings whereby medically ill patients can be identified. The DCPR consists of twelve clinical categories (or clusters) which, through a semi-structured interview, explore a variety of possible psychological conditions and emotional responses to medical illness. Four clusters are related to patients’ways of perceiving, experiencing, evaluating, and responding to their health status that are subsumed into the construct of abnormal illness behaviour (AIB) (disease phobia, thanatophobia, health anxiety, and illness denial), four clusters related to the con- cept of somatization proposed by Lipowski [42] (functional somatic symptoms secondary to psychiatric disorders, persistent somatization, conversion symptoms, and anniversary reaction) and four related to psychological dimensions that have been frequently and consistently found in medical patients (alexithymia, type A behaviour, irritable mood, and demoralization) [11,14,51]. The DCPR have been proved to be extremely helpful in medical settings to show the adjunctive role of the system in increasing the understanding of psychosocial dimensions in comparison with DSM or ICD approaches [14]. Regarding the ICD-10, the application of DCPR was able to catch, among patients referred for psychiatric consultation, certain dimensions and syndromes (demoralization, alexithymia, illness denial, and type A behaviour) that the ICD was not able to elicit as psychiatric diagnosis [20]. Regarding the DSM, in a large sample of more than 1500 medically ill patients, submitted to both DSM-IV and the DCPR interviews, non-specific psychological distress, irritability and affective disturbances with somatization emerged as three general clusters from the DCPR analysis [13]. Demoralization was identified in one third of medically ill patients while major depression was present in 16%. Forty-three per cent of patients with major depression were not classified as demoralized, and 69.0% of those with DCPR demoralization did not reach the criteria for major depression [44]. When depression was more specifically studied, [33] it was found to be phenomenologically characterized by at least two clusters, using the DCPR: depressed somatizers and irritable/anxious depression. The somatizer cluster included 58.6% of the cases and was characterized by DCPR somatization syndromes (persistent somatization, functional somatic

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symptoms secondary to a psychiatric disorder, conversion symptoms, and anniversary reactions) and DCPR alexithymia. The anxious/irritable cluster was evident in 41.4% of the total sample and included DCPR irritable mood and type A behaviour and DSM-IV anxiety disorders. The concomi- tant application of the DCPR among patients with a DSM-IV diagnosis of adjustment disorders [25] showed that abnormal illness behaviour (health anxiety, thanatophobia, nosophobia and illness denial) (54%), somatization (functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion symptoms and anniversary reaction) (37%) and demoralization (33%) were diagnosable, besides the less informative DSM sub-specification of Adjustment disorders (i.e., with depressed mood; with anxiety; with mixed anxiety and depressed mood; with disturbance of conduct; with mixed disturbance of emotions and conduct; unspecified). A study on the prevalence and characteristics of anniversary reactions (somatic symptoms occurring at the anniversary of specific events) among medically ill patients [49] indicated that DCPR syndromes related to somatization, abnormal illness behaviour, irritable mood, demoralization and alexithymia were present in a large proportion cases and that almost 40% of patients meeting the diagnosis of anniversary reaction did not receive any DSM-IV psychiatric diagnosis.

Similar results about the integrative role of the DCPR, when used in medicine, were found among patients with specific diseases, such as dermatological, [45] cardiac [54]

and gastroenterological disorders [48]. More recently, data relative to the comparison between the DCPR and the DSM-5 have been produced with results indicating that the DCPR-based proposal was more sensitive in detecting psychological factors relevant to illness course and provided a better characterization of such factors [34].

The application of the DCPR in oncology

Interesting and clinically useful results quite recently emerged in the application of the DCPR in oncology. In a study of 146 patients with a diagnosis of cancer within 18 months and a good performance status, who were evaluated by using both DSM-IV and DCPR, it has been indicated that about one half of the subjects met the criteria for a DSM- IV diagnosis (DSM-cases), mainly Adjustment disorders and Mood disorders, while more than two-third presented symptoms meeting the criteria for at least one DCPR syndrome [32]. The most frequent DCPR dimensions were health anxiety (37.7%), demoralization (28.8%) and alexithymia (26%), with lower percentages of patients reporting irritable mood, Type A behaviour, thanatophobia and illness denial. An overlap between DSM-IV and DCPR diagnoses was found for less than half of the sample, while among

those who had no formal DSM-IV psychiatric diagnosis (55.5%), two thirds received a DCPR diagnosis, with a 58% rate of false negatives if only the DSM-IV had been used. In a different study on breast cancer patients, the same authors [27] showed that one third of the subjects presented symptoms meeting the criteria for at least one DCPR syndrome and a further one quarter had more than one DCPR syndrome. Health anxiety, demoralization, alexithymia and irritable mood were the most commonly reported DCPR constellations. In general, patients with DCPR syndromes reported higher levels of sadness, more physical symptoms, poorer well-being, poorer leisure activity and lower support from interpersonal ties than women without any DCPR syndrome. They also showed higher scores on the assessment of worries and preoccupation related to cancer (e.g., the illness itself, the effects of treatment, feeling different from others, the impact on sexual life, and the future). There were significant relationships between the sin- gle DCPR dimensions and coping styles, with patients having a diagnosis of DCPR-health anxiety reporting higher scores of anxious preoccupation coping (i.e. anxiety and ten- sion concerning their illness); those meeting the DCPR criteria for demoralization had higher scores on the hopelessness coping (i.e. a tendency to adopt a pessimistic and hopeless-helpless attitude towards his/her illness); those meeting the DCPR criteria of alexithymia had higher scores of avoidance coping (i.e. a tendency to avoid confrontation with illness). As far as alexithymia and alexithymic traits are concerned, a more recent study of medically ill patients, including cancer patients, found that about 1/3 of those meeting the DCPR criteria for this dimension had no DSM-IV psychiatric comorbidity, about one quarter had depressed somatization with alexithymic features while the remaining appeared as having alexithymic illness behaviour, alexithymic somatization and alexithymic anxiety [50]. The DCPR potential to give some insights within the area of somatization and psychological concomitants of somatic symptom presentation in cancer patients, especially long- survivors of cancer, seems extremely promising. In general, somatization and somatic symptom presentation is a complex area in patients affected by a demonstrated medical illness. As far as oncology is concerned, somatization in cancer has been often overlooked or completely ignored, mainly due to the presumption that if somatic symptoms occur in a patient with cancer, these are due to the disease itself and/or its progression. However, complaints of tiredness, fatigue, poor concentration and irritability, probably related to psychological factors, are frequently reported by cancer patients. Data regarding abnormal illness behaviour and somatization have been reported by a few studies carried out in oncology. Hypochondriasis, a high tendency to evalu- ate in somatic terms bodily functions, and somatization were shown to be unchanged in patients recovered from cancer

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who were evaluated at the time of the diagnosis and six years later in a prospective study [29]. Results in line with these findings were also reported in a study of cancer patients referred for psychiatric consultation by Chaturvedi et al.

[5] who found that one quarter had prominent somatic presentation with multiple somatic symptoms including pain, fatigue and sensory symptoms. This confirmed an association between somatization, depressed mood, and cancer. In a large cancer patients’study, Carlson et al. reported a high prevalence of psychological distress in cancer patients (37%) and among patients with psychological distress, somatization, followed by depression and anxiety, were the most frequent reported symptoms. The complexity but the importance of this clinical and research area has been underlined by Chaturvedi et al. [6] and Grassi et al. [23], who indicated that somatic symptoms magnify disability resulting from cancer, interfere with treatment adherence and deci- sions, cause delay in recovery, result in poor outcome and recurrence, and reduce overall well-being and quality of life.

Secondly, somatic symptoms in cancer may complicate the diagnosis of major depression due to the overlap of symptoms occurring as a result of the underlying disease, depression or somatoform disorder. Furthermore, somatic symptoms in cancer are unique in being interrelated each other with one somatic symptom causing other somatic symptoms (for example, pain causing fatigue). The DCPR, with its specific heading dedicated to somatization and somatic symptom presentation [19,59], can help by answering some of the questions mentioned above and better understanding this clinical area in patients affected by cancer, mainly in those with early stage of cancer, after completion of treatment and long-survivors.

Discussion

Allowing clinicians to have significant information on the psychosocial concomitants of cancer and cancer treatment is essential in clinical practice. In spite of the advantage of having nosological systems (i.e. DSM and ICD) to help in ordering psychiatric settings, a number of clinical conditions and psychosocial dimensions encountered in oncology are formally marginalized by these systems. The heading of

“Psychological factors affecting a medical condition” of the DSM seems in fact not specific and definite enough to catch psychosocial dimensions that the psychosomatic tradition has repeatedly underlined as important in oncology. As indicated by Fava [10] and Fava and Sonino [17,18], the assessment of psychosocial factors affecting individual vul- nerability (life events, chronic stress and allostatic load, wellbeing, and health attitudes), evaluation of psychosocial correlates of medical disease (psychiatric disturbances, psychological symptoms, illness behaviour and quality of life),

and the application of psychological therapies to medical disease (lifestyle modification, treatment of psychiatric comorbidity, and abnormal illness behaviour) are the essence of a broader psychosomatic approach, rather than traditional psychiatric approach, to medical illness. It is evident that this approach can favour the comprehension of the several con- sequences of cancer diagnosis and treatment. Significant body changes (e.g., physical mutilations, stomas, pain, nau- sea and vomiting, hair loss, fatigue) and consequently the image of its own body (physical level); loss of certainties, instability of one’s own emotional state (e.g. fears, anxiety, worries, sadness), change of perspective in the future and threat of possible death and dying (psychological level);

sense of meaning, including one’s own personal values, meaning of time and being, transcendence (spiritual level);

sense of belonging (“to be with”) in the family, in the micro- cosm of close relationships and in the macrocosm of society (e.g. work, social activity, policy) (interpersonal level), are all dimensions that a broader psychosomatic approach - not exclusively a traditional psychiatric nosography - can elicit [22]. The development of the DCPR system has the potential to fill this gap and give some insight to psychosocial concomitants of cancer. A series of clinical studies in oncology, as well as in medical settings in general, has in fact shown that this system can facilitate the identification of psychosocial conditions (e.g. demoralization, type A behaviour, irritable mood and alexithymia). Specification of the phenomenology of some psychosocial dimensions can be reached by using the DCPR interview which is able to give precise information of the patients’ psychological problems. The role of demoralization, giving-up and hopelessness, avoidance/

emotional repression, as significant dimensions to be consid- ered in cancer patients has emerged in psycho-oncology literature. Through the use of DCPR, it has been confirmed that demoralization is a construct that is not necessarily related to major depression and that it should be examined carefully. The relationship of demoralization and hopelessness should also be investigated in cancer patients. In fact, hopelessness, rather than major depression according the DSM-IV, has been found to be a significant factor implicated in suicidal ideation and wish to die among cancer patients [3,56] and one of the key elements in the relationship between individual psychosocial response and cancer progression [1,40,64]. The DCPR construct of alexithymia and its relationship with other psychological factors or coping mechanisms such as avoidance also deserves attention in oncology [8]. On the one hand, the component of difficulty in identifying feelings of the alexithymia construct was significantly higher in cancer patients experiencing pain [52].

On the other hand, it has been shown that alexithymia and repressive coping styles have been related to higher levels of psychological distress in cancer patients [26,36]. Thus, if it is true that new paradigms (e.g., holistic, humanistic,

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narrative and narrative-evidence-based medicine,) have been repeatedly proposed as a way to combat modern biotechno- logical reductionism (including crude nosography) and to put the person in all his/her dimensions at the centre of the therapeutic encounter, it follows that integrating the traditional view of psychosocial suffering with more subtle and meaningful constructs is in line with an evidence-based and, at the same time, value-based oncology [21]. In summary, the DCPR represents an interesting tool that can provide clinicians with a more specific framework, with respect to usual psychiatric nosographic systems, such as the DSM-5 and the upcoming ICD-11. The need for more research and the possible refinement of DCPR clustering dimensions, according to the data that emerged in its application in clinical contexts, seem to be the next steps in the DCPR-based approach to understand the several and multiform psychosocial responses of cancer patients across the trajectory of the disease.

Acknowledgments The present paper has been supported by the University of Ferrara Local Research Funding (FAR).

Conflit d’intérêt:the Authors declare no conflict of interest.

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