Post-traumatic Stress Disorder

Summary Type: Supportive care
Summary Audience: Health professionals
Summary Language: English
Summary Description: Expert-reviewed information summary about post-traumatic stress disorder in cancer patients, cancer survivors, and their family members. Assessment and treatment of this disorder are discussed.

Post-traumatic Stress Disorder

Overview

For a number of years, investigators have reported stress or trauma-related symptoms, such as avoidant behaviors, intrusive thoughts, and heightened arousal, in survivors of cancer.^1,2,3,4 These symptoms resemble those seen in persons who have experienced traumatic events such as military combat, violent personal assault (e.g., rape), natural disasters, or other threats to life and are referred to collectively as post-traumatic stress disorder (PTSD).^5,6,7,8,9,10 Thus the occurrence of PTSD and trauma-related symptoms in patients with cancer has been under increasing study, influenced by changes in the diagnostic criteria for PTSD in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).⁵ The third edition of the DSM ¹¹ specifically excluded patients with medical illnesses such as cancer from PTSD. The diagnostic criteria for PTSD in the DSM-IV-TR, however, specifically include "being diagnosed with a life-threatening illness" as one example of a traumatic event.¹² Thus, people with histories of cancer can now be evaluated and considered at risk for PTSD.

Reviews note that post-traumatic stress has been studied in a variety of cancers including melanoma, Hodgkin's lymphoma, breast cancer, and mixed cancers. Studies have varied, however, in whether they assessed patients for the full syndrome of PTSD (i.e., all DSM-IV criteria met) or only some of the PTSD-related symptoms (e.g., intrusive thoughts as measured by the Impact of Events Scale). Thus, incidence rates have varied accordingly. The incidence of the full syndrome of PTSD (meeting full DSM-IV diagnostic criteria) ranges from 3% to 4% in early-stage patients recently diagnosed to 35% in patients evaluated after treatment. When incidence of PTSD-like symptoms (not meeting the full diagnostic criteria) are measured, the rates are higher, ranging from 20% in patients with early-stage cancer to 80% in those with recurrent cancer.

Factors suggesting which patients might be at increased risk for the development of PTSD have not been extensively studied; however, one study of women with early-stage breast cancer ¹³ found that younger age, lower income, and fewer years of formal education were associated with PTSD-like symptoms. Another study of men and women treated with bone marrow transplant ¹⁴ found that lower levels of social support and the use of avoidance coping correlated significantly to a higher number of PTSD-like symptoms.

Although no specific therapies for PTSD in the cancer setting have been developed, treatment modalities used with other people with PTSD can be useful in alleviating distress in cancer patients and survivors.

¹ Kornblith AB, Anderson J, Cella DF, et al.: Quality of life assessment of Hodgkin's disease survivors: a model for cooperative clinical trials. Oncology (Huntingt) 4 (5): 93-101; discussion 104, 1990.

² Alter CL, Pelcovitz D, Axelrod A, et al.: Identification of PTSD in cancer survivors. Psychosomatics 37 (2): 137-43, 1996 Mar-Apr.

³ Kornblith AB, Anderson J, Cella DF, et al.: Hodgkin disease survivors at increased risk for problems in psychosocial adaptation. The Cancer and Leukemia Group B. Cancer 70 (8): 2214-24, 1992.

⁴ Koocher G, O'Malley J: The Damocles Syndrome: Psychosocial Consequences of Surviving Childhood Cancer. New York: McGraw-Hill, 1981.

⁵ American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association, 1994.

⁶ Solomon Z, Garb R, Bleich A, et al.: Reactivation of combat-related posttraumatic stress disorder. Am J Psychiatry 144 (1): 51-5, 1987.

⁷ Baider L, Sarell M: Coping with cancer among holocaust survivors in Israel: an exploratory study. J Human Stress 10 (3): 121-7, 1984 Fall.

⁸ Perry S, Difede J, Musngi G, et al.: Predictors of posttraumatic stress disorder after burn injury. Am J Psychiatry 149 (7): 931-5, 1992.

⁹ Green BL, Lindy JD, Grace MC, et al.: Chronic posttraumatic stress disorder and diagnostic comorbidity in a disaster sample. J Nerv Ment Dis 180 (12): 760-6, 1992.

¹⁰ Rundell JR, Ursano RJ, Holloway HC, et al.: Psychiatric responses to trauma. Hosp Community Psychiatry 40 (1): 68-74, 1989.

¹¹ American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R. 3rd rev. ed. Washington, DC: American Psychiatric Association, 1987.

¹² American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.

¹³ Cordova MJ, Andrykowski MA, Kenady DE, et al.: Frequency and correlates of posttraumatic-stress-disorder-like symptoms after treatment for breast cancer. J Consult Clin Psychol 63 (6): 981-6, 1995.

¹⁴ Jacobsen PB, Sadler IJ, Booth-Jones M, et al.: Predictors of posttraumatic stress disorder symptomatology following bone marrow transplantation for cancer. J Consult Clin Psychol 70 (1): 235-40, 2002.

Prevalence

Reviews of the literature ¹ note that post-traumatic stress has been studied in a variety of cancers including melanoma, Hodgkin's lymphoma, breast cancer, and mixed cancers. The incidence of the full syndrome of post-traumatic stress disorder (PTSD) (meeting the full DSM-IV diagnostic criteria) ranges from 3% to 4% in early-stage patients recently diagnosed to 35% in patients evaluated after treatment. When incidence of PTSD-like symptoms (not meeting the full diagnostic criteria) are measured, the rates are higher, ranging from 20% in patients with early-stage cancer to 80% in those with recurrent cancer.

The earliest research (predating DSM-IV) on PTSD among survivors of cancer concentrated on the prevalence and characteristics of the disorder in patients who were or are undergoing treatment, adult and child survivors of cancer, and/or the family members of these patients and survivors. A wide variety of cancer types were studied, including leukemia,² breast cancer, and head and neck cancers.³ Much of the earlier research dealt with survivors of Hodgkin's disease, probably because diagnoses at an early age and higher rates of survival resulted in a larger population available for study.⁴ These survivors were found to have a particularly high prevalence of intrusive thoughts and avoidance behaviors, even though they were many years posttreatment.^5,6,7 Most of these studies investigated PTSD-like symptoms, rather than the complete mental disorder with all diagnostic criteria.

The first study of cancer patients utilizing the current DSM-IV diagnostic criteria looked at 27 patients (mostly breast cancer), all at least 3 years postdiagnosis and no longer receiving any cancer treatments. In this study, a prevalence rate of 4% for current PTSD and 22% lifetime prevalence was found.⁸ Those who met criteria for lifetime prevalence were noted to have higher levels of general psychologic distress, suggesting that individuals with a history of PTSD are at a substantial risk for continued emotional difficulties.

Studies using the Structured Clinical Interview for DSM (SCID) ⁹ have found prevalence rates of PTSD between 3% and 10% in adult cancer patients. Most of these studies looked at women with early-stage breast cancer, evaluated a few months to a few years after their cancer treatments. Similarly, in a prospective study of 115 patients with all stages of breast cancer being treated in a comprehensive cancer center, 4% met the full diagnostic criteria for PTSD; 41% met the subsyndromal criteria for PTSD (experiencing intense fear, helplessness, or horror after being diagnosed with cancer). This set of subsyndromal criteria was a weak predictor of PTSD (12%) but an equally useful predictor of major depressive disorder, global anxiety disorder, and past major depressive disorder, and it may better serve as a marker for elevated distress.¹⁰ In a few studies of patients with bone marrow transplants, slightly higher prevalence rates have been reported, ranging from 5% ¹¹ to 12% to 19% ¹² to as high as 35%.¹³ The range in prevalence appears to be influenced by time of assessment (higher rates occurring with more time since transplant) and the assessment method used. Studies reporting lower rates typically used a self-report questionnaire,¹⁴ whereas those reporting higher rates ¹³ used the SCID and evaluated for symptoms at multiple times since diagnosis (i.e., lifetime prevalence).

¹ Gurevich M, Devins GM, Rodin GM: Stress response syndromes and cancer: conceptual and assessment issues. Psychosomatics 43 (4): 259-81, 2002 Jul-Aug.

² Lesko LM, Ostroff JS, Mumma GH, et al.: Long-term psychological adjustment of acute leukemia survivors: impact of bone marrow transplantation versus conventional chemotherapy. Psychosom Med 54 (1): 30-47, 1992 Jan-Feb.

³ Manuel GM, Roth S, Keefe FJ, et al.: Coping with cancer. J Human Stress 13 (4): 149-58, 1987 Winter.

⁴ Cella DF, Pratt A, Holland JC: Persistent anticipatory nausea, vomiting, and anxiety in cured Hodgkin's disease patients after completion of chemotherapy. Am J Psychiatry 143 (5): 641-3, 1986.

⁵ Kornblith AB, Anderson J, Cella DF, et al.: Comparison of psychosocial adaptation and sexual function of survivors of advanced Hodgkin disease treated by MOPP, ABVD, or MOPP alternating with ABVD. Cancer 70 (10): 2508-16, 1992.

⁶ Kornblith AB, Anderson J, Cella DF, et al.: Quality of life assessment of Hodgkin's disease survivors: a model for cooperative clinical trials. Oncology (Huntingt) 4 (5): 93-101; discussion 104, 1990.

⁷ Kornblith AB, Anderson J, Cella DF, et al.: Hodgkin disease survivors at increased risk for problems in psychosocial adaptation. The Cancer and Leukemia Group B. Cancer 70 (8): 2214-24, 1992.

⁸ Alter CL, Pelcovitz D, Axelrod A, et al.: Identification of PTSD in cancer survivors. Psychosomatics 37 (2): 137-43, 1996 Mar-Apr.

⁹ Spitzer RL, Williams JB, Gibbon M, et al.: The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry 49 (8): 624-9, 1992.

¹⁰ Palmer SC, Kagee A, Coyne JC, et al.: Experience of trauma, distress, and posttraumatic stress disorder among breast cancer patients. Psychosom Med 66 (2): 258-64, 2004 Mar-Apr.

¹¹ Widows MR, Jacobsen PB, Fields KK: Relation of psychological vulnerability factors to posttraumatic stress disorder symptomatology in bone marrow transplant recipients. Psychosom Med 62 (6): 873-82, 2000 Nov-Dec.

¹² Jacobsen PB, Widows MR, Hann DM, et al.: Posttraumatic stress disorder symptoms after bone marrow transplantation for breast cancer. Psychosom Med 60 (3): 366-71, 1998 May-Jun.

¹³ Mundy EA, Blanchard EB, Cirenza E, et al.: Posttraumatic stress disorder in breast cancer patients following autologous bone marrow transplantation or conventional cancer treatments. Behav Res Ther 38 (10): 1015-27, 2000.

¹⁴ Weathers FW, Litz BT, Herman DS, et al.: The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility: Paper Presented at the Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX, October 1993. Available online. Last accessed August 19, 2005.

Diagnostic Criteria and Characteristics

PTSD was initially characterized as an anxiety disorder that developed in response to a severe trauma in which an individual experienced, witnessed, or was confronted by actual or threatened death, injury, or loss of physical integrity of self or others. The DSM-IV stipulated for the first time that being diagnosed with a life-threatening illness or learning that one's child had such an illness qualifies as a stressful event.¹

In 1994, the application of PTSD to patients with cancer began with the redefinition of the trauma criteria in the DSM-IV to include life-threatening illness.¹ The essential feature of this disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor.² These events elicit responses of intense fear, helplessness, or horror and trigger 3 clusters of PTSD symptoms. Symptoms from each of the following 3 clusters must be present for an individual to meet the full criteria for a diagnosis of PTSD:

• Reexperiencing the trauma (nightmares, flashbacks, and intrusive thoughts).
• Persistent avoidance of reminders of the trauma (avoidance of situations, numbing of general responsiveness, and restricted range of affect).
• Persistent increased arousal (sleep difficulties, hypervigilance, and irritability).

These symptoms must last for at least 1 month and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Symptoms that last for at least 1 day but less than 1 month and that cause significant distress or impairment in social, occupational, or other important areas of functioning might meet the diagnostic criteria for Acute Stress Disorder (ASD). ASD is often a prodrome to PTSD.

The Conceptual Fit of PTSD and Cancer

Conceptual and practical problems can arise in the application of PTSD to cancer patients and survivors. The basic concept of an extreme traumatic stressor has been described variously as an event involving direct personal experience that involves actual or threatened death or serious injury.² This event can be protracted and continuous but is more frequently a single, time-limited event (e.g., rape, natural disaster). In this context, for the person who has experienced a diagnosis of cancer, the exact nature of the trauma is unclear. Is it the actual diagnosis, aspects of the treatment process, information given about recurrence, negative test results, or some other aspect of the cancer experience? Identifying a discrete stressor within the multiple crises that constitute a cancer experience is much more difficult than it is for other traumas. In one study of breast cancer patients ³ who underwent autologous bone marrow transplant, more PTSD-like symptoms were reported at the time of initial diagnosis.

Another concern regarding conceptual fit is related to reexperiencing the trauma. Diagnostic criteria B require persistent reexperiencing of the traumatic event, implying that the patient would first encounter a trauma and then, at a later time, reexperience it in various ways. In a study of women with early-stage breast cancer, however, researchers ⁴ found that the traumatizing aspects of the cancer experience were receiving the diagnosis and waiting for test results from node dissection. Arguing that these "information traumas" are future oriented and tend to cause intrusive worry about the future—not intrusive recollections of past events—the authors questioned whether cancer fits a conceptual model of PTSD trauma. Reexperiencing the trauma is often measured in terms of unwanted intrusive thoughts of the traumatic event. The cognitive processing of a current and ongoing health threat with uncertain outcome might differ significantly from unwanted intrusive thoughts about a single past event. Some researchers have argued that not all intrusive thoughts are negative or indicate reexperiencing a trauma, but rather that they might represent appropriate vigilance and attention to potential symptoms that could result in appropriate help-seeking.^5,6,

Conversely, a unique study assessing the physiological reactivity of breast cancer patients to a personalized imagery script of their most stressful experiences with breast cancer found elevated physiologic responses that were comparable to those of PTSD patients who had experienced other (noncancer-related) traumas. This finding suggests a good fit between cancer patients and the PTSD trauma model, as it shows comparable symptoms of increased arousal in cancer patients. Also, in a factor analytic study ⁷ designed to confirm the presence of the 3 broad PTSD symptom clusters (reexperiencing, avoidance of reminders, and hyperarousal), researchers found some tentative support for the DSM-IV symptom clusters in a sample of breast cancer survivors.

Further research will be needed to continue to investigate the important question of how well the conceptual model of PTSD as an anxiety response to a major life trauma fits the life experience of patients with cancer. Reviews have argued both in favor of ⁸ and against ⁶ the continued use of trauma models for conceptualizing the experience of cancer. Others have proposed alternate conceptual models.^5,9,

¹ American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association, 1994.

² American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.

³ Mundy EA, Blanchard EB, Cirenza E, et al.: Posttraumatic stress disorder in breast cancer patients following autologous bone marrow transplantation or conventional cancer treatments. Behav Res Ther 38 (10): 1015-27, 2000.

⁴ Green BL, Rowland JH, Krupnick JL, et al.: Prevalence of posttraumatic stress disorder in women with breast cancer. Psychosomatics 39 (2): 102-11, 1998.

⁵ Deimling GT, Kahana B, Bowman KF, et al.: Cancer survivorship and psychological distress in later life. Psychooncology 11 (6): 479-94, 2002 Nov-Dec.

⁶ Palmer SC, Kagee A, Coyne JC, et al.: Experience of trauma, distress, and posttraumatic stress disorder among breast cancer patients. Psychosom Med 66 (2): 258-64, 2004 Mar-Apr.

⁷ Cordova MJ, Studts JL, Hann DM, et al.: Symptom structure of PTSD following breast cancer. J Trauma Stress 13 (2): 301-19, 2000.

⁸ Gurevich M, Devins GM, Rodin GM: Stress response syndromes and cancer: conceptual and assessment issues. Psychosomatics 43 (4): 259-81, 2002 Jul-Aug.

⁹ Cordova MJ, Andrykowski MA: Responses to cancer diagnosis and treatment: posttraumatic stress and posttraumatic growth. Semin Clin Neuropsychiatry 8 (4): 286-96, 2003.

Risk Factors, Protective Factors, and Hypothesized Mechanism

A variety of sociodemographic, disease-related, psychosocial, and psychological variables have been investigated to determine their relationship to post-traumatic stress disorder (PTSD). At present, no clear picture emerges about who is at increased risk of developing PTSD following diagnosis or treatment of cancer.

Sociodemographic Variables

Few patient characteristics have been shown to predict the occurrence of PTSD. High levels of psychologic distress have been correlated with both stress symptoms ^1,2,3 and full-syndrome PTSD diagnoses in adult survivors.¹ In addition, trait anxiety was found to predict post-traumatic symptoms in the parents of survivors of childhood cancer.⁴ Women who are survivors of cancer and who have a diagnosis of lifetime PTSD tend to have a history of exposure to trauma.¹ Demographic characteristics such as age, sex, and education level at time of diagnosis have not been reliable predictors of stress symptoms.^1,5,6

Demographic variables that have been associated with a higher incidence of PTSD include younger age,^7,8 fewer years of formal education, and lower income;^9,10 however, one study ¹ failed to find any significant differences between the mean age of cancer patients with or without PTSD. In noncancer community samples, PTSD occurs almost twice as often in women; however, the gender differences in incidence of PTSD in cancer patients has been mixed.

Disease-Related Variables

Disease-related variables that have been associated with a higher incidence of PTSD in patients who underwent bone marrow transplant include more advanced disease and a longer hospital stay.¹¹ Other studies, however, have found no association between time since diagnosis and treatment, severity of disease, or type of cancer treatment received.^1,8,10 The relationship between disease stage and post-traumatic symptoms has not been adequately studied. Most studies have not found an association; however, they typically include a limited range of disease stages or are studying early-stage cancer.¹²

The time since diagnosis and treatment has been shown to correlate with and predict post-traumatic symptoms in survivors of osteogenic sarcoma ² and Hodgkin's lymphoma.^6,13 Specifically, persons who were farther from diagnosis and treatment tended to exhibit fewer symptoms. This effect, however, has not been found in studies of patients with recent recurrences,^14, survivors of breast cancer,¹ or survivors of childhood cancers.¹⁵ Duration of treatment, rather than time since treatment, has been shown to predict stress symptoms in survivors of childhood cancer.^15,

The presence of pain and other physical symptoms has been shown to correlate with levels of intrusive thoughts.² Cancer recurrence has also been shown to increase the likelihood of stress symptoms in patients.^14,

Psychosocial and Psychological Variables

The experience of past traumatic events appears to be an important psychosocial risk factor associated with post-traumatic symptoms,^16,17 as was found in both early-stage ¹⁸ and metastatic breast cancer.¹⁹ Previous trauma in combination with recent stressful life events was significantly related to post-traumatic symptoms.^20,

Other psychosocial risk factors such as premorbid psychopathology,^21,22 high levels of general psychologic distress,²³ and dysfunctional coping and attributional styles ^16,24,25 have been linked to a risk for PTSD in war veterans, Holocaust survivors, and other disaster victims. In addition, several investigators have linked predisposing genetic factors ²⁶ and other biologic factors (e.g., overly reactive hormonal systems and reduced hippocampal volume) to risk for PTSD.^27,28,29 Among social factors, the quality of the recovery environment, often measured in terms of social support, has been shown to affect risk for PTSD following exposure to combat ²¹ and burn injury.³⁰ The effect of threat to life and body integrity has been documented in samples of adults and families ^1,4,13 but not children.^15,

Psychological variables that have been related to a higher incidence of PTSD include a history (precancer diagnosis) of PTSD,⁹ increased use of avoidance coping, and lower levels of social support.^31,

Protective Factors

Greater perceived availability of social support is associated with fewer stress response symptoms in early-stage breast cancer patients ^18,20 and in bone marrow transplant patients.^31,

The availability and timeliness of accurate health-related information may also offer protection from stress response symptoms. Women who met the diagnostic criteria for Acute Stress Disorder (ASD) reported significantly less satisfaction with the communication of their cancer diagnosis;³² similarly, women who were unaware of their cancer stage reported higher stress response symptoms than those who were more knowledgeable about the stage of their disease.³³ To the extent that adequacy of information reflects the quality of a patient's relationship with medical staff, another protective factor may be the quality of those relationships. Difficult patient-staff relationships have been reported to be predictors of stress response symptoms in women with cancer.^34,

Hypothesized Mechanisms

PTSD is precipitated by an intensely distressing event; however, this factor alone is not sufficient to explain the disorder. Not everyone exposed to a traumatic stressor develops the full-blown syndrome (or subsets of symptoms) or qualifies for the diagnosis. Attempts to explain these differences and to predict who is vulnerable have focused on psychologic (i.e., learning theory), biologic (especially hormonal), and social (i.e., social support) factors. Early studies of Vietnam War veterans suggested a 2-factor learning theory to account for trauma-related pathology.^35,36 The same theory has more recently been applied to development of PTSD in patients with cancer.^37,38,39

PTSD symptoms develop as a function of both classical conditioning and instrumental learning. Classical conditioning accounts for the fear responses elicited by various stimuli that are associated with the original traumatic event. Neutral stimuli (e.g., smells, sounds, and visual images) previously paired with the aversive stimuli (e.g., chemotherapy or painful procedures) eventually evoke anxiety, arousal, and fear when presented alone, even after the trauma has ended. Higher order conditioning and stimulus generalization account for the exacerbation and extension of symptoms to additional stimuli. Once established, PTSD symptoms are maintained through instrumental learning, i.e., avoidant responses are reinforced because avoidance of the stimuli prevents unpleasant feelings and thoughts.

Estimates from epidemiologic studies suggest that on average, 25% to 33% of individuals who are exposed to traumatic events, including cancer, develop PTSD.^27,40 Although the disorder appears to be a result of learning processes, many factors have been suggested to explain why one person develops PTSD and another does not.

¹ Alter CL, Pelcovitz D, Axelrod A, et al.: Identification of PTSD in cancer survivors. Psychosomatics 37 (2): 137-43, 1996 Mar-Apr.

² Kornblith AB, Herr HW, Ofman US, et al.: Quality of life of patients with prostate cancer and their spouses. The value of a data base in clinical care. Cancer 73 (11): 2791-802, 1994.

³ Kornblith AB, Anderson J, Cella DF, et al.: Quality of life assessment of Hodgkin's disease survivors: a model for cooperative clinical trials. Oncology (Huntingt) 4 (5): 93-101; discussion 104, 1990.

⁴ Stuber ML, Gonzalez S, Meeske K, et al.: Post-traumatic stress after childhood cancer II: a family model. Psychooncology 3: 313-319, 1994.

⁵ Kornblith AB, Anderson J, Cella DF, et al.: Comparison of psychosocial adaptation and sexual function of survivors of advanced Hodgkin disease treated by MOPP, ABVD, or MOPP alternating with ABVD. Cancer 70 (10): 2508-16, 1992.

⁶ Kornblith AB, Anderson J, Cella DF, et al.: Hodgkin disease survivors at increased risk for problems in psychosocial adaptation. The Cancer and Leukemia Group B. Cancer 70 (8): 2214-24, 1992.

⁷ Cordova MJ, Studts JL, Hann DM, et al.: Symptom structure of PTSD following breast cancer. J Trauma Stress 13 (2): 301-19, 2000.

⁸ Green BL, Rowland JH, Krupnick JL, et al.: Prevalence of posttraumatic stress disorder in women with breast cancer. Psychosomatics 39 (2): 102-11, 1998.

⁹ Mundy EA, Blanchard EB, Cirenza E, et al.: Posttraumatic stress disorder in breast cancer patients following autologous bone marrow transplantation or conventional cancer treatments. Behav Res Ther 38 (10): 1015-27, 2000.

¹⁰ Cordova MJ, Andrykowski MA, Kenady DE, et al.: Frequency and correlates of posttraumatic-stress-disorder-like symptoms after treatment for breast cancer. J Consult Clin Psychol 63 (6): 981-6, 1995.

¹¹ Jacobsen PB, Widows MR, Hann DM, et al.: Posttraumatic stress disorder symptoms after bone marrow transplantation for breast cancer. Psychosom Med 60 (3): 366-71, 1998 May-Jun.

¹² Gurevich M, Devins GM, Rodin GM: Stress response syndromes and cancer: conceptual and assessment issues. Psychosomatics 43 (4): 259-81, 2002 Jul-Aug.

¹³ Cella DF, Tross S: Psychological adjustment to survival from Hodgkin's disease. J Consult Clin Psychol 54 (5): 616-22, 1986.

¹⁴ Cella DF, Mahon SM, Donovan MI: Cancer recurrence as a traumatic event. Behav Med 16 (1): 15-22, 1990 Spring.

¹⁵ Stuber ML, Meeske K, Gonzalez S, et al.: Post-traumatic stress after childhood cancer I: the role of appraisal. Psychooncology 3: 305-312, 1994.

¹⁶ Davidson JR, Foa EB: Diagnostic issues in posttraumatic stress disorder: considerations for the DSM-IV. J Abnorm Psychol 100 (3): 346-55, 1991.

¹⁷ Baider L, Sarell M: Coping with cancer among holocaust survivors in Israel: an exploratory study. J Human Stress 10 (3): 121-7, 1984 Fall.

¹⁸ Andrykowski MA, Cordova MJ: Factors associated with PTSD symptoms following treatment for breast cancer: test of the Andersen model. J Trauma Stress 11 (2): 189-203, 1998.

¹⁹ Butler LD, Koopman C, Classen C, et al.: Traumatic stress, life events, and emotional support in women with metastatic breast cancer: cancer-related traumatic stress symptoms associated with past and current stressors. Health Psychol 18 (6): 555-60, 1999.

²⁰ Green BL, Krupnick JL, Rowland JH, et al.: Trauma history as a predictor of psychologic symptoms in women with breast cancer. J Clin Oncol 18 (5): 1084-93, 2000.

²¹ Green BL, Grace MC, Lindy JD, et al.: Risk factors for PTSD and other diagnoses in a general sample of Vietnam veterans. Am J Psychiatry 147 (6): 729-33, 1990.

²² Smith EM, North CS, McCool RE, et al.: Acute postdisaster psychiatric disorders: identification of persons at risk. Am J Psychiatry 147 (2): 202-6, 1990.

²³ Jacobsen PB, Sadler IJ, Booth-Jones M, et al.: Predictors of posttraumatic stress disorder symptomatology following bone marrow transplantation for cancer. J Consult Clin Psychol 70 (1): 235-40, 2002.

²⁴ Green BL, Lindy JD, Grace MC: Posttraumatic stress disorder. Toward DSM-IV. J Nerv Ment Dis 173 (7): 406-11, 1985.

²⁵ Mikulincer M, Solomon Z: Attributional style and combat-related posttraumatic stress disorder. J Abnorm Psychol 97 (3): 308-13, 1988.

²⁶ True WR, Rice J, Eisen SA, et al.: A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms. Arch Gen Psychiatry 50 (4): 257-64, 1993.

²⁷ Yehuda R, Resnick H, Kahana B, et al.: Long-lasting hormonal alterations to extreme stress in humans: normative or maladaptive? Psychosom Med 55 (3): 287-97, 1993 May-Jun.

²⁸ Yehuda R, Boisoneau D, Lowy MT, et al.: Dose-response changes in plasma cortisol and lymphocyte glucocorticoid receptors following dexamethasone administration in combat veterans with and without posttraumatic stress disorder. Arch Gen Psychiatry 52 (7): 583-93, 1995.

²⁹ Bremner JD, Randall P, Scott TM, et al.: MRI-based measurement of hippocampal volume in patients with combat-related posttraumatic stress disorder. Am J Psychiatry 152 (7): 973-81, 1995.

³⁰ Perry S, Difede J, Musngi G, et al.: Predictors of posttraumatic stress disorder after burn injury. Am J Psychiatry 149 (7): 931-5, 1992.

³¹ Widows MR, Jacobsen PB, Fields KK: Relation of psychological vulnerability factors to posttraumatic stress disorder symptomatology in bone marrow transplant recipients. Psychosom Med 62 (6): 873-82, 2000 Nov-Dec.

³² McGarvey EL, Canterbury RJ, Koopman C, et al.: Acute stress disorder following diagnosis of cancer. International Journal of Rehabilitation and Health 4 (1): 1-15, 1998.

³³ Naidich JB, Motta RW: PTSD-related symptoms in women with breast cancer. Journal of Psychotherapy in Independent Practice 1 (1): 35-54, 2000.

³⁴ Carlier IV, Gersons BP: Partial posttraumatic stress disorder (PTSD): the issue of psychological scars and the occurrence of PTSD symptoms. J Nerv Ment Dis 183 (2): 107-9, 1995.

³⁵ Keane TM, Zimering RT, Caddell JM, et al.: A behavioral formulation of posttraumatic stress disorder in Vietnam veterans. Behavior Therapist 8(1): 9-12, 1985.

³⁶ Charney DS, Deutch AY, Krystal JH, et al.: Psychobiologic mechanisms of posttraumatic stress disorder. Arch Gen Psychiatry 50(4): 294-305, 1993.

³⁷ Cella DF, Pratt A, Holland JC: Persistent anticipatory nausea, vomiting, and anxiety in cured Hodgkin's disease patients after completion of chemotherapy. Am J Psychiatry 143 (5): 641-3, 1986.

³⁸ Redd WH, Dadds MR, Futterman AD, et al.: Nausea induced by mental images of chemotherapy. Cancer 72 (2): 629-36, 1993.

³⁹ Jacobsen PB, Bovbjerg DH, Redd WH: Anticipatory anxiety in women receiving chemotherapy for breast cancer. Health Psychol 12 (6): 469-75, 1993.

⁴⁰ Greenberg DB, Goorin A, Gebhardt MC, et al.: Quality of life in osteosarcoma survivors. Oncology (Huntingt) 8 (11): 19-25; discussion 25-6, 32, 35, 1994.

Assessment of Post-traumatic Stress Disorder in the Cancer Setting

A timely and careful assessment of cancer patients is critical to identify the symptoms of post-traumatic stress disorder (PTSD), to note the deleterious impact of the symptoms on functioning, and to plan interventions targeted at the most distressing symptoms. It is also critical that the assessment distinguishes between the full DSM-IV PTSD syndrome (meets all required diagnostic criteria) and PTSD-related symptoms only.

The most difficult aspect of PTSD assessment in the cancer setting is the determination of precisely when to evaluate the patient. Diagnosis is complicated because cancer is not an acute or discrete event, but is an experience marked by repeated traumas and indeterminate length. Thus, an individual may exhibit the symptoms of PTSD at any point from diagnosis through treatment, to treatment completion and, possibly, to recurrence.¹ Patients such as Holocaust survivors whose history of victimization causes PTSD or its symptoms can have the symptoms activated by any number of stimuli encountered during their treatment (e.g., clinical procedures such as being inside magnetic resonance imaging or computed tomography scanners). While such patients may have more difficulty in adjusting to cancer and cancer treatment, their PTSD symptomatology is likely to vary greatly according to their circumstances. The relative predominance of specific PTSD symptoms may wax and wane throughout the cancer experience and beyond.^2,

The definition in the DSM-IV indicates that although PTSD symptoms usually begin within the first 3 months after trauma, there may be a delay of months or even years before symptoms appear.^2,3 These findings support the necessity for long-term monitoring of survivors of cancer and their family members.

At least one study found that individuals who have experienced a traumatic event may exhibit early symptoms without meeting the full criteria for a diagnosis of PTSD.⁴ Nonetheless, the appearance of these early symptoms was found to predict later development of full PTSD syndrome. These results lend further credence to the need for both repeated and long-term follow-up of individuals exposed to the trauma of cancer. (Refer to the PDQ summary on Normal Adjustment and the Adjustment Disorders for further information.)

The difficulty in properly diagnosing PTSD may be compounded by the overlapping of PTSD symptoms with those of other psychiatric disorders and by the time-related aspects of normal adjustment. For example, irritability, poor concentration, hypervigilance, excessive fear, and disturbed sleep are also symptoms of generalized anxiety disorder. Other arousal and avoidance symptoms are common to PTSD, phobias, and panic disorder, but loss of interest, sense of a foreshortened future, avoidance of other people, and sleep impairment might suggest both PTSD and depressive disorders. Even normal reactions to the diagnosis and treatment of life-threatening disease can consist of responses such as intrusive thoughts, disassociation and depersonalization, sleep disturbances, and heightened arousal. Therefore, clinicians and researchers must be particularly attuned to the causes, duration, and severity of PTSD-like symptoms when considering PTSD among several diagnoses. For instance, in a study of women with breast cancer, 41% reported experiencing "intense fear, helplessness, or horror" (DSM-IV PTSD diagnostic criterion A2); however, on further comprehensive diagnostic interview, only 4% met the full PTSD criteria. Assessment must be able to distinguish between general psychological distress and symptoms of PTSD.^5,

The accurate diagnosis of PTSD also requires the use of reliable and valid instruments. Most recent studies have used the PTSD module of the Structured Clinical Interview for DSM-III-R–Nonpatient Edition (SCID-NP).⁶ This is a clinician-administered, structured clinical interview that is time intensive and may not be feasible in settings without adequately trained mental health professionals. However, one study ⁷ investigated the utility of a cost-effective screening tool, the PTSD Checklist-Civilian Version (PCL-C).⁸ In this study of 82 women diagnosed with breast cancer assessed 6 to 72 months after cancer treatment, use of the PCL-C resulted in a sensitivity of .60 and specificity of .99. Other cutoff scores for the PCL-C that could be used were discussed, depending on the clinical resources available in specific cancer treatment settings. Most research studies have used the Impact of Events Scale, a self-report of intrusive thoughts;⁹ however, it is important to note that this is not designed to be an assessment procedure for PTSD.

Comorbidity

In attempting to diagnose PTSD, it is important to be aware that this disorder is often marked by comorbid psychopathology. Substance abuse, affective disorders, and other anxiety disorders are consistently encountered in samples of people with PTSD.^2,10,11,12 It has been reported that war veterans with PTSD exhibited substantial comorbid pathology that included major depression (32% to 72%), alcohol dependence (65%), drug dependence (40%), social phobia (50%), and obsessive-compulsive disorder (10%).¹³ High rates of concurrent disorders have also been documented in other trauma victims. For example, 40% to 42% of disaster survivors with PTSD also qualified for a diagnosis of major depression, and 20% to 42% met the criteria for concurrent generalized anxiety disorder.^13,14 While this has not yet been studied in cancer patients or survivors, the presence of co-occurring psychiatric disorders in Vietnam War veterans and other trauma victims would indicate that cancer clinicians should be alert to the need to identify and treat such related syndromes in their patients.

¹ Greenberg DB, Goorin A, Gebhardt MC, et al.: Quality of life in osteosarcoma survivors. Oncology (Huntingt) 8 (11): 19-25; discussion 25-6, 32, 35, 1994.

² American Psychiatric Association.: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association, 1994.

³ Solomon Z, Garb R, Bleich A, et al.: Reactivation of combat-related posttraumatic stress disorder. Am J Psychiatry 144 (1): 51-5, 1987.

⁴ Perry S, Difede J, Musngi G, et al.: Predictors of posttraumatic stress disorder after burn injury. Am J Psychiatry 149 (7): 931-5, 1992.

⁵ Deimling GT, Kahana B, Bowman KF, et al.: Cancer survivorship and psychological distress in later life. Psychooncology 11 (6): 479-94, 2002 Nov-Dec.

⁶ Spitzer RL, Williams JB, Gibbon M, et al.: The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry 49 (8): 624-9, 1992.

⁷ Andrykowski MA, Cordova MJ, Studts JL, et al.: Posttraumatic stress disorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD Checklist-Civilian Version (PCL-C) as a screening instrument. J Consult Clin Psychol 66 (3): 586-90, 1998.

⁸ Weathers FW, Huska JA, Keane TM: PCL-C for DSM-IV. Boston, Mass: National Center for PTSD-Behavioral Science Division, 1991.

⁹ Sundin EC, Horowitz MJ: Impact of Event Scale: psychometric properties. Br J Psychiatry 180: 205-9, 2002.

¹⁰ Rundell JR, Ursano RJ, Holloway HC, et al.: Psychiatric responses to trauma. Hosp Community Psychiatry 40 (1): 68-74, 1989.

¹¹ Davidson JR, Foa EB: Diagnostic issues in posttraumatic stress disorder: considerations for the DSM-IV. J Abnorm Psychol 100 (3): 346-55, 1991.

¹² Green BL, Lindy JD, Grace MC: Posttraumatic stress disorder. Toward DSM-IV. J Nerv Ment Dis 173 (7): 406-11, 1985.

¹³ Keane TM, Wolfe J: Comorbidity in post-traumatic stress disorder: an analysis of community and clinical studies. J Appl Soc Psychol 20(21): 1776-1788, 1990.

¹⁴ Smith EM, North CS, McCool RE, et al.: Acute postdisaster psychiatric disorders: identification of persons at risk. Am J Psychiatry 147 (2): 202-6, 1990.

Treatment

The chronic and sometimes devastating psychologic and interpersonal sequelae of post-traumatic stress disorder (PTSD) necessitates timely and effective treatment of people with this syndrome.^1,2 The avoidant responses associated with PTSD often delay or prevent these individuals from seeking professional assistance. While no specific therapies for PTSD in the cancer setting have been developed, treatment modalities used with other people with PTSD can help alleviate distress in cancer patients and survivors.^3,4

Most clinicians recommend using a multimodal approach, choosing components to meet the specific needs of each patient and taking into account any concurrent psychiatric disorders such as depression or substance abuse. Multiple modalities are frequently considered in a crisis intervention approach to facilitating adjustment of cancer patients.

The crisis intervention model comprises a broad range of therapies that can be helpful in the treatment of PTSD. The goals of this model are to reduce symptoms and restore patients to their usual levels of functioning. In this model, the therapist often takes an active, directive stance with the patient, focusing on resolving concrete problems, teaching specific coping skills, and providing a safe and supportive environment.^5,

Cognitive-behavioral techniques have proven especially helpful within the crisis intervention setting. Some of these methods include helping the patient to understand symptoms, teaching effective coping strategies and stress management techniques (such as relaxation training), restructuring cognitions, and providing exposure to opportunities for systematic desensitization of symptoms.⁶ In a single case study, a 10-session cognitive-behavioral intervention for a male cancer patient 3 years post–bone marrow transplant with PTSD was found to be effective. This study used a combination of cognitive coping strategies, relaxation procedures, relapse prevention, and generalization techniques; benefits were found to be maintained at a 6-month follow-up.⁷ Behaviorally oriented approaches to sexual therapy may also be useful when the avoidance manifested by patients is decreased sexual activity and avoidance of intimate situations.

Support groups also appear to benefit people who experience post-traumatic symptoms. In the group setting, such patients can receive emotional support and encounter others with similar experiences and symptoms, thereby validating their own experiences and learning a variety of coping and management strategies.

For patients with particularly distressing or severe symptoms, psychopharmacology may provide an additional means of treatment. Several classes of medications have been used in the treatment of individuals with PTSD.^8,9 For example, tricyclic and monoamine oxidase-inhibitor antidepressants are commonly used, particularly when the symptoms of PTSD are accompanied by depression. Serotonin-reuptake inhibitors such as fluoxetine are effective in reducing the hyperarousal and intrusive symptoms of PTSD.¹ Antianxiety medications may help reduce overall arousal and anxiety symptoms. Infrequently, antipsychotic medications may reduce severe intrusive flashbacks.

¹ Davidson JR, Foa EB: Diagnostic issues in posttraumatic stress disorder: considerations for the DSM-IV. J Abnorm Psychol 100 (3): 346-55, 1991.

² Alter CL, Pelcovitz D, Axelrod A, et al.: Identification of PTSD in cancer survivors. Psychosomatics 37 (2): 137-43, 1996 Mar-Apr.

³ Foa EB: Psychosocial treatment of posttraumatic stress disorder. J Clin Psychiatry 61 (Suppl 5): 43-8; discussion 49-51, 2000.

⁴ Adshead G: Psychological therapies for post-traumatic stress disorder. Br J Psychiatry 177: 144-8, 2000.

⁵ Perry S, Difede J, Musngi G, et al.: Predictors of posttraumatic stress disorder after burn injury. Am J Psychiatry 149 (7): 931-5, 1992.

⁶ Mikulincer M, Solomon Z: Attributional style and combat-related posttraumatic stress disorder. J Abnorm Psychol 97 (3): 308-13, 1988.

⁷ DuHamel KN, Ostroff JS, Bovbjerg DH, et al.: Trauma-focused intervention after bone marrow transplantation: A case study. Behav Ther 31 (1): 175-86, 2000.

⁸ Marmar CR, Neylan TC, Schoenfeld FB: New directions in the pharmacotherapy of posttraumatic stress disorder. Psychiatr Q 73 (4): 259-70, 2002 Winter.

⁹ Davidson JR: Pharmacotherapy of posttraumatic stress disorder: treatment options, long-term follow-up, and predictors of outcome. J Clin Psychiatry 61 (Suppl 5): 52-6; discussion 57-9, 2000.

Changes to This Summary (08/24/2005)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

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• PDQ® - NCI's Comprehensive Cancer Database.
  • Full description of the NCI PDQ database.

Additional PDQ Summaries

• PDQ® Cancer Information Summaries: Adult Treatment
  • Treatment options for adult cancers.
• PDQ® Cancer Information Summaries: Pediatric Treatment
  • Treatment options for childhood cancers.
• PDQ® Cancer Information Summaries: Supportive Care
  • Side effects of cancer treatment, management of cancer-related complications and pain, and psychosocial concerns.
• PDQ® Cancer Information Summaries: Screening/Detection (Testing for Cancer)
  • Tests or procedures that detect specific types of cancer.
• PDQ® Cancer Information Summaries: Prevention
  • Risk factors and methods to increase chances of preventing specific types of cancer.
• PDQ® Cancer Information Summaries: Genetics
  • Genetics of specific cancers and inherited cancer syndromes, and ethical, legal, and social concerns.
• PDQ® Cancer Information Summaries: Complementary and Alternative Medicine
  • Information about complementary and alternative forms of treatment for patients with cancer.

Important:

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