Generalized anxiety disorder (GAD) severely impacts social functioning, distress levels, and utilization of medical care compared with that of other major psychiatric disorders. Neither pharmacological nor psychotherapy interventions have adequately controlled cardinal symptoms of GAD: pervasive excessive anxiety and uncontrollable worry. Research has established cognitive behavioral therapy (CBT) as the most effective psychotherapy for controlling GAD; however, outcomes remain at only 50% reduction, with high relapse rates. Mindfulness has been integrated with CBT to treat people suffering from numerous psychiatric disorders, with mindfulness based stress reduction (MBSR) being the most researched. Preliminary evidence supports MBSR’s potential for controlling GAD symptoms and key researchers suggest mindfulness practices possess key elements for treating GAD. Classical mindfulness (CM) differs significantly from MBSR and possesses unique potentials for directly targeting process and state GAD symptoms inadequately treated by CBT. This article introduces the theory and practice of CM, its differences from MBSR, and a critical review of MBSR and CBT treatments for GAD. CM strategies designed to complement CBT targeting cardinal GAD symptoms are outlined with a case study illustrating its use.

Why me?" This question of causal attribution is pervasive among cancer patients-so pervasive, in fact, that it is the basis for the name of the largest national breast cancer patient support network. As work in the field of psychooncology has advanced, the emotional aspects of cancer have been publicized and have entered the minds of lay audiences everywhere. A 2001 survey by Stewart and colleagues of Canadian breast cancer survivors, recurrence free for an average of nearly 9 years, found that 42% of them believed that stress caused breast cancer-a belief that is without scientific foundation-while only 27% felt that genetics and 15% felt that diet were involved in causing breast cancer. 1 Remarkably, 60% of the women attributed their lack of recurrence to having a positive attitude and only 4% to use of tamoxifen.While there has been much publicity on lifestyle factors that can cause cancer, from excessive sun exposure to smoking, there clearly is a substantial part of the public who are predisposed to believe that emotional factors are a cause of cancer. Integrative practitioners, who emphasize lifestyle adaptations in treatment of cancer, not to mention causation, are invariably familiar with patients who react to their awareness of cancer's lifestyle connections with paralyzing self-blame and guilt. "Blame the victim" scenarios, or statements that cancer has been caused or progressed because of emotional stress, frustration of significant needs in life, or negative thoughts or emotions, appear to have been prominent in interactions with some alternative practitioners working with cancer patients. In addition, research studies have raised the possibility that psychosocial interventions might improve cancer survival, suggesting to many that psychosocial factors might also cause cancer. To explore the role that both alternative psychologies and research on psychosocial oncology may play in such self-blame, we have asked 2 insightful researchers to participate in this Point-Counterpoint. The 2 respondents have different assessments of the question of whether psychosocial factors might influence cancer causation or survival. Roger Dafter, PhD, is

Objectives/Hypothesis: Psychosocial distress is common among patients with head and neck cancer (HNC) and is associated with poorer quality of life and clinical outcomes. Despite these risks, distress screening is not widely implemented in HNC care. In this study, we investigated the prevalence of psychosocial distress and its related factors in routine care of patients with HNC.Methods: Data from medical records between September 2017 and March 2020 were analyzed. Psychosocial distress was measured by the National Comprehensive Cancer Network's Distress Thermometer (DT), and a modified HNC-specific problem list; depression and anxiety were assessed using the Patient Health Questionnaire-4. Descriptive statistics and logistic regression were conducted to report prevalence of distress, depression and anxiety, and factors associated with clinical distress. Implementation outcomes, including rates of referrals and follow-up for distressed patients, are also reported.Results: Two hundred and eighty seven HNC patients completed the questionnaire (age 64.3 AE 14.9 years), with a mean distress score of 4.51 AE 3.35. Of those, 57% (n = 163) reported clinical distress (DT ≥ 4). Pain (odds ratio [OR] = 3.31, 95% CI = 1.75-6.26), fatigue (OR = 2.43, 95% CI = 1.1.7-5.05), anxiety (OR = 1.63, 95% CI = 1.30-2.05), and depression (OR = 1.51, 95% CI = 1.04-2.18) were significantly associated with clinical distress (P < .05). Of patients identified as distressed, 79% received same-day psychosocial evaluation.Conclusions: Clinical distress was identified in 57% of patients who completed the questionnaire, suggesting that an ultra-brief psychosocial screening protocol can be implemented in routine ambulatory oncology care, and identifies patients whose distress might otherwise go unrecognized.

43 (47%) patients were still alive. The median prior irradiation dose to the skull base region was 6360 cGy for those without TLN and 6760 cGy for those with TLN (PZ.055). Median re-irradiation proton dose was 60 CGE without TLN and 7 0CGE with TLN (PZ.419). Twelve patients (13%) were found to have temporal lobe necrosis with median time to development of 8 months. Of these patients, 6 patients had right-sided TLN, 5 had left-sided, and 1 patient had bilateral TLN. The median total mean dose to 2 cc to the right temporal lobe was 51.87 CGE for those without TLN and 75.10 CGE for those with TLN (PZ.057); median max pixel dose to the right was 68.80 CGE without TLN and 110.13 CGE with TLN (PZ.040). On the left side, median total mean dose to 2 cc was 32.29 CGE with no TLN and 59 CGE with TLN (PZ.211) and median max pixel dose was 55.19 CGE without TLN and 71.34 CGE with TLN (PZ.560). All patients were determined to have grade 1 TLN per CTCAE 4.0 with only radiographic evidence and were clinically asymptomatic except for one patient with grade 2 toxicity requiring medical management with steroids. Conclusion: Among patients treated in the re-irradiation setting with proton therapy, 13% of patients developed TLN that was only apparent radiographically except for one who was treated medically. Analysis of more detailed dosimetric data with longer follow-up data are underway to better ascertain the significance of these findings.

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