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Aspects of Pituitary Tumors
Nicoletta Sonino, Giovanni Favi, Franco Fallo, and Marco
Boscaro. From The Institute of Semeiotica Medica, University
of Padua, Italy and the Affective Disorders Program, Department
of Psychology, University of Bologna, Italy.
study of the interrelationships between the endocrine and psychic
apparatus is displaying a curious tendency. On the one hand, the
last decade has witnessed an upsurge of interest in the limbic-hypothalamic
control of hormonal function. Such an area of research, often subsumed
under the rubric of psychoneuroendocrinology, encompasses the use
of pharmaceutical probes, the study of endocrine dysfunction in
psychiatric illness (notably depression), laboratory research paradigms
(e.g.) experimental stress, and the merging field of neuroimmunoendocrinology.
On the other hand, the relationship of endocrine disease to psychological
distress, despite an impressive body of research evidence [1-3],
is largely neglected in the literature concerned with clinical endocrinology.
Standard textbooks and journal reviews by and large ignore or only
incidentally mention the psychiatric correlates of endocrine disorders.
Clinical endocrinology seems to depart from other areas of medicine
(e.g. cardiology) that have become increasingly concerned with the
issues of psychological well-being, functional capacity and social
and interpersonal aspects of medical illness, in the area of research
defined as quality of life. .
Lipowski  stated, `how a person experiences the pathological
process, what it means to him, and how this meaning influences his
behavior and interaction with others are all integral components
of disease viewed as a total human response,'. We will try to outline
some of the endocrine areas where an increased attention to the
psychological aspects of disease may have important clinical and
 underscored the role of `psychic traumas' in pituitary disease,
yet his leads were not followed by other investigators. In a recent
study , stressful life events prior to illness onset were investigated
by means of a semistructured research interview  in 30 healthy
patients with Cushing's syndrome and 30 healthy controls. Losses,
undesirable events, and uncontrolled events were significantly more
frequent in patients than controls , similar to what had been
found in major depression. When the objective negative impact and
the likelihood of an event being the consequence of illness were
evaluated by a blind rater, patients with Cushing's syndrome reported
significantly more "negative" and "independent"
events than controls. A pathogenetic role for recent life events
in Cushing's disease in a final common pathway of genetic, neurophysiological,
biochemical and behavioral events, was suggested. Life events might
also be relevant in increasing individual vulnerability to relapse
in Cushing's disease.
despite several clinical observations, the contribution of recent
life events to the onset of endocrine disorders such as hyperprolactinemia
and polycystic ovary syndrome, has not been investigated in a controlled
way by reliable probes. Schmale  remarks that the patient's
history (trauma in childhood, poorly adapted family, anniversaries,
etc.) is the most important step in evaluating the personal significance
of the life setting. A biographic and clinical investigation of
101 patients with hyperprolactinemia and/or galactorrhea suggested
that exposure during childhood to an environment characterized by
an absent, alcoholic, or violent father may condition some women
to develop and/or galactorrhea later in life as a response to specific
environmental changes. Similarly, early neurotic traits, such as
enuresis, were significantly more frequent in 20 women with hyperprolactinemic
amenorrhea than in 21 patients with normoprolactinemic amenorrhea,
suggesting a decreased catecholaminergic activity in reaction to
depressive disorders are a severe and life-threatening complication
of endocrine disorders such as Cushing's syndrome, Addison's disease,
hyperthyroidism, hypothyroidism and hyperprolactinemic amenorrhea,
as reviewed in detail elsewhere . Other psychiatric symptoms,
ranging from anxiety to psychotic disturbances and cognitive impairment
may be present, even though to a lesser degree then depression.
It is of interest that in other endocrine disorders, such as acromegaly
 and hirsutism , an increased prevalence of psychiatric
illness compared to general medical patients was not found. Starkman
et al.  showed how the elevated levels of catecholamines secreted
by pheochromocytomas are not sufficient to elicit an anxiety disorder.
These data should point to the fact that the occurrence of an organic
affective syndrome in endocrine disease may not simply be the consequence
of increased hormonal levels, but the expression of a more general
suprapituitary derangement. A depressed mood may have a profound
influence on quality of life and on how a person experiences the
endocrine disease process and his interactions with others. A treatment
primarily directed to the physical condition may be more effective
than antidepressant drugs in organic affective syndromes. Examples
are provided by the effect of steroid synthesis inhibitors upon
depression in Cushing's syndrome or by the action of antithyroid
drugs on anxiety in hyperthyroidism . On the other hand, clinical
endocrinologists may tend to underestimate psychiatric symptoms
as readily suppressible by adequate medical or surgical treatment....
on quality of life may herald a welcome psychosomatic approach in
endocrine research and practice. The term "psychosomatic"
refers to the postulate that the mind and body are two inseparably
linked aspects which are differentiated for methodological and communicative
purposes only  and that the person invariably functions, reacts
and acts as an integrated mind-body unit . Using Engel's 
appraisal of current medical education, we may say that the average
endocrinologist today completes his formal education with impressive
capabilities to deal with most of the technical aspects of endocrine
disease, yet when it comes to dealing with the psychosocial aspects
of patient care "he displays little more than the native ability
and personal qualities with which he entered medical school' [21,
p. 169]. Further, the considerable body of knowledge about human
behavior and affective disorders that has accumulated over the years
lies as only marginal and incidental to hormonal disturbances, instead
of fostering the biopsychosocial comprehension of endocrine disease.
Cushing  wondered whether the "psychic instability or the
disturbance on internal secretion" was the primary factor in
pituitary disease. Time has come for a more wide-spread endorsement
of his teachings.
VI: Behavioral disturbances associated with endocrine disorders.
Ann Rev Med 1986;37:205-214.
GA, Sonino N, Morphy MA: Major depression associated with endocrine
disease. Psychiat Dev 1987;4:321-348.
A, Perez-Echeverria MJ, Jimenez-Azmarez A, Sancho MA: Emotional
disturbanecs in endocrine patients. Br J Psychiatry 1988;152:807-812.
GA, Magnani B: Quality of life. A review of contemporary confusion.
Med Sci Res 1988;16:1051-1054.
ZJ: Psychosocial aspects of disease. Ann Intern Med 1969;71:1197-1206.
TW (ed): Stressful Life Events. Madison, International Universities
H: Psychic disturbaences associated with disorders of the ductless
glands. Am J Insanity 1913;69:965-990.
N, Fava GA, Grandi S, Mantero F, Boscaro M: Stressful life events
in the pathogenesis of Cushing's syndrome. Clin Endocrinol 1988;
ES: Methodology of life events research; in Fava GA, Wise TN (eds):
Research Paradigms in Psychosomatic Medicine. Basel, Karger, 1987,
AH: Importance of life setting for disease onset. Modern Treatment
MCP, Sobrinho LG, Calhaz-Jorge C, Santos MA, Mauricio JC, Sausa
MFF: Psychosomatic factors in patients with hyperprolactinemia
and/or galactorrhea. Obstet Gynecol 1980;55:591-595.
M, Guaraldi GP, Borofsky GL, Mastrogiacomo I: Childhood's enuresis
in the history of women with hyperprolactinemic, Int J Psychiat
E, Brown GW: Life events, psychiatric disturbance and physical
illness. Br J Psychiatry 1980; 136:326-338.
RT, Clark J, Elbadawy MHF, Cliffe MJ: Psychiatric morbidity in
acromegaly. Acta Psychiat Scand 1987;75:635-663.
GA, Grandi S, Savron G, Bartolucci G, Santarsierno G, Trombini
G, Orlandi C: Psychosomatic assessment of hirsute women. Psychother
MN, Zelnic TC, Nesse RM, Cameron OG: Anxiety in patients with
pheochromocytomas. Arch Intern Med 1985;145:248-252.
I:Behaviral and drug treatments of phobic and obsessive compulsive
disorders. Psychother Psychosom 1986;46:35-44.
GA, Grandi S, Canestrari R: Prodromal symptoms in panic disorde
with agoraphobia. Am J Psychiatriy 1988;145:1564-1567.
AH:Reactions to illness. Psychiat Clin N Am 1979;2:321-330.
I: Abnormal illness behavior. Psychother Psychosom 1986;46:76-84.
GL: The biopsychosocial model and the education of heatlh professionals.
Ann NY Acad Sci 1978:310:169-181.
pituitary tumor survivors perspective:
presented as an address by Robert Knutzen at the Pituitary
Awareness Days at the University of Virginia, May 26-27, 1995.
in medical literature and anecdotally, we find clear and unmistakable
links between sexual dysfunction and pituitary problems. Hormonal/medical
therapy is directed at treating sexual dysfunction. Regrettably,
no consensus has been reached on how these sexual problems affect
the emotional and psychological well being of patients.
medical community in unevenly divided in its recognition of emotional
and psychological factors in the lives of pituitary tumor patients
in general. Usually, these emotional/psychological factors are ignored
or lightly dismissed. Whereas there is general recognition that
Cushings patients are often "depressed" as a result of
high cortisol levels, it is presumed that the "problems"
go away with a successful lowering of these levels.
a patient, I recognize the extremely thin veneer of credibility
afforded to me by the scientific and medical community, but I am
prepared to risk the criticism by insisting that the issue be studied
and discussed in depth. Even among our scientific advisors, the
opinions are nearly 180 degrees apart, except on Cushing's depression
where near unanimity reigns.
the risk of alienating some in the medical community, however I
am prepared to hide behind the skirts and opinions of Dr. Robert
Gagel of the University of Texas, who reports that hyperprolactinoma
patients struggle with most severe and difficult psychological issues.
Dr. Louis Sobrinho of Portugal conducted studies which led him to
conclude that a high percentage of hyperprolactinemic women were
daughters of abusive, absent or alcoholic fathers.
to Dr. Anne Klibanski, studies along these lines are currently ongoing
at Harvard University.
my suggestion, my friend and personal physician Dr. Shereen Ezzat
at the University of Toronto conducted a survey and interviews with
the help of a clinical psychologist and wrote "Living with
Acromegaly" for the September 1992 issue of "Endocrinology
and Metabolism Clinics of North America."
says, among other things, "extremely little, however, has appeared
in the literature about mental and emotional attitudes in patients
with acromegaly....The incidence and severity of psychopathology
associated with acromegaly are still largely undocumented. It has
been suggested, however, that the disorder may be commonly associated
with psychosocial disturbances."
also writes, "hyperprolactinemic patients with amenorrhea have
been reported to have a greater frequency of depression, hostility
and anxiety than normal prolactinomic controls."
the 3 male and female acromegalic patients surveyed, the majority
of female patients, but only half of male patients, reported significant
reduction in sexual desire or enjoyment.
of the acromegalic patients indicated that their personality was
altered by their medical condition.
from Europe, Dr. Giovanni Fava, editor in chief of "Psychotherapy
and Psychosomatics," published by S. Karger AG, Basil, Switzerland,
regularly sends us his group's findings. In one of his most recent
articles he writes, "an impressive body of knowledge has accumulated
on the relationship of endocrine disease to psychological distress,
or endocrine dysfunction in psychiatric illness, notably depression,
and on the limbic-hypothalamic control of hormone function."
the other hand, the role of stressful life events which may increase
vulnerability to endocrine disorders has been largely neglected,
discussions with many hundreds of patients in North America, Europe
an Australia, I will unequivocally state that our problems go far
deeper than two inches behind the eyes.
surgical skills and skillful, sensitive medical attention in and
of itself, in many patients, is not sufficient for recovery.
those of is with secreting tumors find it extremely difficult to
"balance out" and return to whatever passes for normal.
great number of us do not remember what normal is or was and struggle
with emotional issues which are almost solely controlled by the
pituitary/ hormonal functions. It is clear that the old adage "mind
over matter" holds true for many. However, mind over hormone
is an entirely different issue, requiring skills, medicines and
consideration previously not given to pituitary patients.
hope that discussions today will open the way to more research and
better care for pituitary patients in this area.
need exists to classify, understand, and name the sexual, emotional
and psychological problems we struggle with, without stigmatizing
ourselves in the eyes of our insurers, the public at large, or our
failure of so many pituitary patients to readjust to family, social
and work relationships after surgery and medical care is alarming.
It is clear to a growing number of us that some extra steps are
required on the ladder to recovery. Our challenge to endocrinologists,
neurosurgeons, radiologists and others is to consider the first
step, for free. Gather systematic data in a meaningful format, agreed
upon amongst you, regarding the psychosocial adjustment made or
faced by patients post medical , surgical treatment. In two years,
let's examine the data and take the next steps.
of us are neither lazy, indifferent or ungrateful for skillful care
and intervention. We are just not emotionally cured.
with other chronic, life-threatening or life-altering illnesses
have an inner tool kit available to help them cope, adjust and repair
the emotional and psychological damage, I would argue that those
of us with pituitary tumors have had hand grenades thrown in out
need new tools. Hopefully, by working together, we can create them.