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Education And Debate

ABC of Breast Diseases: Psychological aspects

BMJ 1994; 309 doi: (Published 17 December 1994) Cite this as: BMJ 1994;309:1649
  1. P Maguire


    Psychological morbidity

    Most women who present with breast lumps are emotionally distressed. A substantial proportion of women whose lumps prove to be benign remain distressed and may become clinically anxious or depressed, particularly if they suffer from chronic breast pain.

    Up to 30% of women with breast cancer develop an anxiety state or depressive illness within a year of diagnosis, which is three to four times the expected rate in matched community samples. After mastectomy 20-30% of patients develop persisting problems with body image and sexual difficulties. Breast conserving surgery reduces problems with body image, but this is offset by increased fears of recurrence. Consequently, the type of surgery does not affect psychiatric morbidity. Immediate breast reconstruction after mastectomy may reduce this morbidity provided that the possible complications have been discussed fully and understood, that the patient wants it for herself and not because of pressure from others, and that it is carried out expertly. Psychiatric morbidity further increases when radiotherapy or chemotherapy is used.

    Problems of recognition

    Reasons for non-disclosure of psychological morbidity

    • Problems are inevitable

    • Problems cannot be alleviated

    • To avoid burdening health professionals

    • To avoid being judged inadequate

    • Relevant questions not asked by health professionals

    • Cues met by distancing, such as “you are bound to be upset”

    Few patients mention psychological morbidity because they do not think that it is acceptable to do so. Doctors can promote disclosure of such problems by asking questions and clarifying the responses about patients' perceptions of the nature of their illness and their reactions to it and about their experience of losing a breast or having radiotherapy or chemotherapy. By being empathic, making educated guesses about how a patient is feeling, and summarising what has been disclosed, doctors promote both disclosure and expression of related feelings.

    Disclosure by patients

    Inhibited by
    • Closed questions

    • Leading questions

    • Multiple questions

    • Questions with a physical focus

    • Offering advice or reassurance especially …

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