Motivation and emotion/Book/2016/Chemotherapy effects on motivation

Overview
This chapter focuses on how chemotherapy affects patients' willingness to complete everyday tasks, such as shopping or cooking and social interactions. There are links between chemotherapy and a reduced desire to complete activities. This chapter will provide information on the motivational side effects of chemotherapy.

This chapter will:
 * Define chemotherapy
 * Define motivation
 * Understand the effects chemotherapy have on motivation
 * Understand the theories and research around chemotherapy and motivation

How it Works
Chemotherapy is a drug treatment regime, used mainly for cancers, that blocks or slows down cell growth. Chemotherapy drugs can also be referred to as cytotoxics, which means poisonous (toxic) to cells (cyto). Chemotherapy is often used in conjunction with other treatments, like surgery and radiotherapy. Chemotherapy is used to either shrink a tumour or completely eradicate it, depending on the severity and size of the tumour. This works as cancer cells take longer to regenerate when compared with other cells in the body. This means between treatments the healthy cells are able to recover from the drugs but cancer cells are not, meaning more cancer cells are destroyed with each treatment session (Mothoneos, 2015). Chemotherapy is not cancer cell specific, meaning it has degenerative effect on other healthy cells in the body like white blood cells or platelets. Damage to these healthy cells causes a range of side effects from chemotherapy (Sugerman, 2013).

Administration


Most commonly chemotherapy is administered to the patient through intravenous (IV) infusion. This is where the drug is infused directly into to the patient's veins usually through a cannula or a central venous access device (CVAD). Central venous access devices are small tubes of plastic that can remain in a vein for long periods of time, they can be externally fitted like a peripherally inserted central catheter (PICC) or internally fitted like a port (Montheos, 2015). Whilst PICCs are a set of tubes that protrude from the internal aspect of the upper arm, a port is fitted internally in the chest wall and is not visible. Chemotherapy drugs may also be administered orally via tablet or liquid, although this is less common. Usually chemotherapy is given to the patient at a hospital or clinic. These sessions often take anywhere from 20 minutes to several hours and, depending on the cancer type, may be administered daily, weekly, biweekly or possibly monthly with time between treatments to rest and recover (Sugerman, 2013).

Motivation
A person who is activated or energised to complete a task is considered motivated. Different factors affect an individuals' motivation level and orientation. Psychologists have developed two main theories regarding motivation, intrinsic motivation and extrinsic motivation (Deci & Ryan, 2000). Both of these types of motivation can be responsible for an individuals completion of everyday tasks.

Intrinsic
Intrinsic motivations are motivating factors that arise from within the individual. It is completing a task purely for its inherent satisfactions rather than for a separable consequence (Deci & Ryan, 2000). These factors are generally more personal and the individual does not perform the action for an external reward, rather a personal gratification. Intrinsic motivation is the natural desire to engage in an activity purely because the individual gains personal satisfaction. Intrinsic motivation often depends on the person and type of activity with levels of motivation differing from person to person, task to task (Deci & Ryan, 2000).

Extrinsic
Extrinsic motivation is motivation that is driven by external entities, such as incentives, consequences and rewards. Incentives are used as an indicator before behaviour is undertaken. Incentives create an expectation of the situation, therefore past experiences or environmental factors can determine how likely the individual is going to be to proceed with the action. Similar to that of operant conditioning in which an individual undertakes behaviour to gain reinforcement or avoid punishment (Skinner, 1953), an incentive in motivation is predominately directed towards acquiring rewards. These rewards or incentives act as external positive reinforcers for an individual to perform an action (Deci & Ryan, 2000). External motivators are different depending on the individual, what may be an incentive for one person won’t be for another. The strength of the reinforcer also depends on the length of time between the action and the reward, for example immediate reward or to avoid a punishment will lead to a higher rate of the action being performed. For example cleaning your room to avoid being reprimanded by a parent is an immediate reward, however where when there is a longer time period between the two the quality of the reward may need to be stronger. Studying for a exam may lead to the long-term reward of good grades, therefore the external motivators need to be stronger.

Chemotherapy Side Effects and Motivation
The main effect of chemotherapy is to reduce tumour size through the cessation or slowing of cell growth. In doing so, chemotherapy can produce a number of side effects. These side effects can range from mild things, such as hair loss, to more severe things like haemoglobin depletion. The severity and number of side effects experienced by the patient often differs from patient to patient and also depends on the type and dose of the chemotherapy drug administered (Sugerman, 2013). These side effects experienced by chemotherapy patients can often effect their motivation to complete their everyday tasks. Different side effects can mainly damage an individual's intrinsic motivation but can also have an effect on their extrinsic motivation. Some of the major side effects from chemotherapy and how they affect intrinsic and extrinsic motivation are explained below.

Mental Fatigue
Mental fatigue and exhaustion has been marked as one of the most incapacitating side effects of chemotherapy, with 70 to 100% of people on chemotherapy experiencing fatigue (Abu-Saad, Candel, Courtens, de Jong & Schouten, 2005). Mental fatigue refers to cognitive symptoms like reduced attention or having difficulty concentrating as well as slowed processing speeds. Fatigue is not only the most common side effect experienced by chemotherapy patients, it has the largest impact on motivation. Fatigue is the side effect that has the largest impact on intrinsic motivation, where the patient purely cannot find any value in completing day to day activities. When chemotherapy is combined with surgical procedures a patients level of mental fatigue is greater and their motivation is reduced significantly more compared to patients only undergoing chemotherapy. Mental fatigue seems to remain constant despite the cancer and is not dependent the type of chemotherapy drug administered (Abu-Saad, Candel, Courtens, de Jong & Schouten, 2005). There have also links between mental fatigue symptoms and increased levels of depression (Harper & Littlewood, 2005).

Nausea, Vomiting & Appetite Loss
Nausea, vomiting and loss of appetite is one of the most common side effects experienced by patients undergoing chemotherapy. Loss of appetite is usually a result of the nausea and vomiting caused by chemotherapy, where the patient is simply put off the thought of eating, but it can also be a result of changes in sense of taste. Changes in taste can reduce the pleasure of consuming food. Aside from eating for survival, pleasure is a main component of our motivation to eat, so without taste and this pleasure sensation, intrinsic motivation to eat is severely reduced (Belqaid, Bernhardson, McGreevy & Orrevall, 2013). Chemotherapy patients can also develop painful mouth ulcers. These ulcers can reduce the patients desire to eat because of the pain they can cause. These factors can affect a chemotherapy patients' intrinsic motivation when it comes not only to cooking food but purchasing groceries, as patients often suggest the thought of food makes them feel nauseous.

Hair Loss & Skin Changes
Of all the side effects chemotherapy can have on a patient, hair loss may cause the most stress and anxiety mainly due to the considerable speed at which hair is lost. This hair loss can include the loss of all body hair, not just scalp hair, including eyebrows. Chemotherapy also has effects on the skin causing dryness, itchiness and combined with the associated reduction in haemoglobin leaves the patient looking pale and ill. These cosmetic changes can induce extreme anxiety among people receiving treatment and has caused people to reject treatment (Botchkarev, Haslam, Paus & Sharov, 2013). This also leads to changes in a patients body image. Hair loss and changes in the skin usually lead to the patient having a more negative perception of what they look like. This can damage the person's self confidence which in turn has an effect on their intrinsic motivation to complete daily activities. With lowered self confidence individual's are more likely to hide away and are less likely to be motivated to go out in public to complete activities of daily living or participate in social activities. Individuals are also less motivated to return to the workplace because of this anxiety about their body image (Manthey, Munstedt, Sachsse & Vahrson (1997).

However, there are programs in place to help combat this reduced body image and help patients regain motivation to return to their daily activities, 'Look Good, Feel Better' is an example of one of these programs. Look Good, Feel Better is a program dedicated to teaching cancer patients how to manage appearance related side effects of chemotherapy. This program teaches patients skin care, how to apply make up, and provides headwear demonstrations, helping to empower them and inspire self confidence.

Haemoglobin, White Blood Cell and Platelet Depletion


Depletion of haemoglobin stores, or anaemia, might have the largest impact on chemotherapy patients motivation to complete day to day tasks. Anaemia is very common among chemotherapy patients with about 67% experiencing it at some point during their treatment (Harper & Littelwood, 2005). Reduced haemoglobin stores means the body has less oxygen carrying capacity, this in turn produces high levels of not physical fatigue and contributes to mental fatigue. Anaemia affects every physiological system within the body. Patients rate fatigue as having the greatest impact on their every day life because as physical and mental exhaustion increase, levels of motivation decrease (Harper & Littlewood, 2005).

A reduction of white blood cells is one of the more severe side effects caused by chemotherapy. If the white blood cell count drops low enough the patient is considered neutropenic and the body's ability to fight infection is severely reduced. This impacts on the patients intrinsic and extrinsic motivation to go out into public places, as the risk of infection and sepsis is high and not worth the consequences of falling ill which can often lead to hospitalisation. Neutropenia has been linked with a reduction in social activity because of the reduced motivation of patients to present themselves in a public place and potentially expose themselves to infections which may have serious consequences. Patients have reported disturbances to their daily activities caused by the depletion of white blood cells (Beaumont, et al. 2008).

Platelets are a product of blood that stops bleeding and allows clotting to occur in the case of a cut or bruise. When these stores are depleted, chemotherapy patients are more susceptible to having a major injury from something that would be considered minor for someone without these depleted platelet stores. Even shaving can be considered a risky behaviour. This can make activities otherwise considered safe quite risky to chemotherapy patients, which in turn can effect their motivation to participate in these activities (Montheos, 2015).

Mental Health
All of the above side effects as well as the diagnosis of a serious illness, such as cancer, can have a large impact on a patients mental health. Additionally, medications used to treat cancers, such as chemotherapy, can cause the onset of depressive illness. Higher levels of depression are associated with these adverse affects of chemotherapy (Fridiksdottir, Gunnarsdottir & Saevarsdottir, 2010). Depression also has links with mental fatigue, another side effect of chemotherapy (Harper & Littlewood, 2005). Depression is well known for having effects on individuals intrinsic motivation, with people suffering from depression finding it harder to to motivate themselves to do many day to day activities. The side effects of chemotherapy may not only produce higher rates of depression but anxiety also. Physical changes to the body may cause patients to have increased anxiety about going out in public (Manthey, Munstedt, Sachsse & Vahrson, 1997). Mental health plays an important role in intrinsic motivation, with motivation being severely hampered by the onset of these illnesses.

Quick Quiz
Here are some true and false revision questions - choose the correct answers and click "Submit": {A cannula is a type of CVAD - True + False
 * type=""}

{Money incentives are a type of intrinsic motivation - True + False
 * type=""}

{Fatigue is the chemotherapy side effect that has the biggest influence on motivation + True - False
 * type=""}

{Most chemotherapy patients have increased intrinsic motivation - True + False
 * type=""}

Conclusion
The side effects of chemotherapy can be detrimental to the patients quality of life. These side effects often affect the individual's desire to complete basic everyday tasks, with fatigue having the largest effect (Abu-Saad, Candel, Courtens, de Jong & Schouten, 2005). Chemotherapy mainly affects the patients intrinsic motivation but can often affect factors of extrinsic motivation also. Physical changes, such as hair loss or mouth ulcers, as well as mental changes, such loss of concentration, both have significant effects on a patient's motivation to complete everyday activities. Mental health plays an important role in a person's motivation to complete day to day tasks. The high prevalence of mental health disorders among chemotherapy patients contributes to the lack of motivation experienced (Fridiksdottir, Gunnarsdottir & Saevarsdottir, 2010). Some side effects have major impacts on motivation while others have only minor impacts. Only the main side effects are mentioned here, it is well known that there are many more that effect patients everyday life (Koktvet, Nielson & Pederson, 2012).