Sociotropy, autonomy, stress, and depression in Cushing syndrome

Personality characteristics and quality of life in patients treated for Cushing's syndrome

OBJECTIVE

Psychological distress does not always disappear upon proper endocrine treatment of Cushing's syndrome, and quality of life may still be compromised. Little is known on the personality correlates that may be involved. The aim of this study was to provide a controlled assessment of personality characteristics and quality of life in patients successfully treated for Cushing's syndrome.

DESIGN

A single-centred, controlled, prospective study.

PATIENTS

Twenty-four consecutive outpatients who were in remission upon proper treatment of Cushing's syndrome for at least 1 year and no more than 3 years (20 with pituitary-dependent Cushing's disease and four with a cortisol-secreting adrenal adenoma; 5 M/19 F; mean age 34.5, SD = 10.6; range 18-57 years) were compared with 24 healthy control subjects matched for sociodemographic variables.

MEASUREMENTS

Both patients and controls were administered two self-rating scales: (a) tridimensional personality questionnaire (TPQ), a 100-item inventory that yields three scales: novelty seeking, harm avoidance and reward dependence. (b) symptom rating test (SRT), a 46-item scale for assessing psychological distress and quality of life with six subscales (anxiety, depression, somatic symptoms, anger-hostility, cognitive symptoms, psychotic symptoms).

RESULTS

There were no significant differences in personality dimensions, as measured by the TPQ, between patients and controls. The results did not change when the four patients with an adrenal adenoma were excluded and only the 20 with pituitary-dependent Cushing's disease were considered. As to the SRT scale, patients with Cushing's syndrome displayed significantly higher scores in anxiety (P= 0.046), depression (P= 0.013), and psychotic symptoms (P= 0.006), with a generalized compromised quality of life (P= 0.02). Again, no differences were found in evaluating the 20 patients with Cushing's disease separately.

CONCLUSIONS

Even though personality traits other than those explored here may be involved, the results seem to exclude the presence of latent dysfunctional attitudes and beliefs contributing to long-standing psychological disturbances, even in the pituitary-dependent form of Cushing's syndrome. Data from larger populations might provide further insight in this field. The findings of a compromised quality of life are in agreement with the recent literature and have implications for the long-term management of patients.

The search for safer glucocorticoid receptor ligands

Steroidal glucocorticoids are commonly used due to their powerful antiinflammatory activity. However, despite their excellent efficacy, severe side effects frequently limit the use of these drugs. The search for novel glucocorticoids with reduced side effects has been intensified by the discovery of new molecular details regarding the function of the glucocorticoid receptor. These new insights may pave the way for novel, safer therapies that retain the efficacy of currently prescribed steroids.

Psychiatric disorders associated with Cushing's syndrome. Epidemiology, pathophysiology and treatment

Cushing's syndrome is caused by a chronic excess of glucocorticoids. A number of psychiatric and psychological disturbances may be associated with the condition, regardless of its aetiology. Major depression is the most common comorbid disorder. Other psychopathological aspects of Cushing's syndrome in adults include mania, anxiety disorders and cognitive dysfunction. The presence of depression connotes a severe clinical presentation and, in patients with hypothalamic-pituitary forms of Cushing's syndrome, is prognostically useful. Inhibitors of corticosteroid production (e.g. ketoconazole, metyrapone, aminoglutethimide), rather than antidepressant drugs, are generally successful in relieving depressive symptoms, as well as other disabling symptoms. These drugs can be used to control symptoms prior to surgical treatment of Cushing's syndrome. Long-standing hypercortisolism may cause some degree of irreversible pathological damage and induce highly individualised affective responses based on each patient's psychological assets and liabilities. As a result, upon normalisation of cortisol levels, treatment may still be required, and should encompass both psychotherapeutic strategies (particularly cognitive-behavioural therapies that have been found to be effective in affective disorders) and psychotropic drug treatment [antidepressants such as tricyclic agents and selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors]. In patients with severe anxiety, benzodiazepines (e.g. clonazepam in small doses) may also be helpful.

Psychosomatic aspects of Cushing's disease

The past decades have witnessed an increasing understanding of the psychosomatic aspects of Cushing's disease. Stressful life events were found to precede its onset in controlled studies. Major depression is a common, life-threatening complication of Cushing's syndrome, regardless of its etiology. The presence of depression connotes severity of clinical presentation and entails prognostic value (patients with hypothalamic-pituitary forms are more likely to relapse after successful treatment if they presented with depression). Quality of life of patients with Cushing's disease is seriously compromised. Recovery has a natural course to run and may be considerably influenced by affective responses based on highly individualized psychological assets and liabilities. The psychobiological correlates of Cushing's disease have considerable etiological, clinical and therapeutic implications. Such implications also extend over the nonendocrine forms of major depression.