b'negatively impact activities of daily living (ADLs),Social Effectsgeneral functionality, and mobilization. Patients mayThe social impact of lymphedema and lymphatic describe their symptoms as swelling, soreness, tender-disease encompasses struggles in multiple domains, ness, aching, burning, stabbing, numbness, heaviness,including condition-related self-disclosure to social tightness, rigidity, fatigue, and tiredness. 149Associated networks, social stigma (i.e., related to wearing physical difficulties present in daily tasks such ascompression garments), occupational and educational cleaning, cooking, dressing, shopping, and self-carelimitations and restrictions, and sexual dysfunction. activities 150 . Patients are also prone to recurrentCultural factors and related distress may be found episodes of cellulitis or erysipelas. Lymphatic system- within the familial unit. For example, the patients associated structural changes and impaired antigen- social role within the family may be challengedpresentation mechanisms may lead to a reduction inor exacerbated by unsupportive or unhelpful the skins ability to prevent pathogen entry, resulting inresponses to limitations in ADLs or role expectations. chronic or recurrent soft tissue infections151 . Unfavorable prognoses or diagnoses (i.e. previous Psychological Effects cancer diagnosis) may influence whether patients Lymphedema and lymphatic diseases negativelychoose to disclose a diagnosis of lymphedema 158 . impact psychosocial well-being due to diminishedCompression garments exacerbate distress asQoL, stigmatization, disruption of interpersonalpatients may be considered by themselves or othersrelationships, and the development of psychologicalas unsightly; additionally, such garments serve as a problems such as anxiety and depression. Majorconstant reminder of the cancer experience in BCRL. contributing factors to the psychosocial effects ofLymphedema and the use of compression garments these chronic diseases include physical symptoms, are further associated with adverse occupation lack of social and emotional support, time-consumingfunctionality and outcomes, including reduced work medical care, lack of sensitivity and awarenessproductivity, delay in return to work, unemployment, amongst the public, inadequate health insurance, decreased income, and diminished work capacity 159 . and associated financial burdens 147 . Body image Unsurprisingly, detrimental effects are also frequently and sexuality-related concerns may manifest withdescribed in patients familial and romantic relation-depression, anxiety, and stress. In breast cancerships. Patients with lymphedema and sexual challenges patients, psychosocial sequelae of breast cancer may struggle with feeling misunderstood by their have been associated with oncological treatments, partners, shame, poor self-esteem, and sexual pain including surgery, radiation, chemotherapy, andand dysfunction 148 . hormone therapy. Body image and self-confidence may be marred by dissatisfactory cosmetic outcomesSocial impairment has also been reported in patients from surgery, body (notably breast) asymmetrywith lipedema and those with facial vascular and/or following radiation, and ovarian failure withlymphatic malformations. A higher prevalence of social menopausal symptoms and infertility secondary impairment (fearfulness, loneliness, isolation) in the to chemotherapy and hormonal therapy 152 . later stages of lipedema is linked to increased exposure to weight stigma 156 . Patients with facial Notably, increased risk for depressive symptomsvascular and/or lymphatic malformations, particularly during the menopause transition has been observed teenagers, experience difficulties with public in large, longitudinal studies such as the Harvard appearances and making new friends. Parents ofStudy of Mid-life Mood and Cycles 153 , the Australianthese patients have also reported experiences ofLongitudinal Study of Womens Health 154 , and theloss, accusations of child abuse 160 , negative stares,Seattle Midlife Womens Health Study 155 . In patientsand avoidance of public places, including that of with lipedema, many have experienced psychologicalenrolling their child in daycare 161 .distress due to weight-shaming, given the increased prevalence of comorbid obesity or a misconception Psychotherapeutic Considerationsof lipedema as obesity. Research has shown aPatients at all stages of lymphedema treatment should prevalence of depression among patients withbe routinely screened for anxiety, depression, and lipedema between 31 and 59% and eating disorders concerns regarding sexual well-being. The Patient at 18% 156 . In patients with oral maxillofacial vascularHealth Questionnaire-9 162and the Generalized Anxiety malformations, increased anxiety and depressiveDisorder 7-item scale 163are reliable and valid measures symptoms were associated with facial vascularof depression and anxiety severity, respectively. malformations and decreased utility of social Psychotherapy should be offered and may be helpful support with poor emotional illness perception 157 . in addressing loss, anticipatory grief, self-worth, and These findings underline the necessity of providingnormalization of the experience. It is imperative that patients with lymphedema and lymphatic diseases providers within the care team assess how patients feel with appropriate psychological consultation. about lifestyle modifications, changes in family roles, | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|39'