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.[1-4] 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).[5-10] Acute stress disorder (ASD) is a Diagnostic and Statistical Manual of Mental Disorders (DSM) mental disorder with a profile similar to that of PTSD but a shorter time to onset, within 4 weeks of a traumatic event. 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 DSM, fourth edition (DSM-IV). The DSM, third revised edition (DSM-III-R), specifically excluded patients with medical illnesses such as cancer from PTSD. The diagnostic criteria for PTSD in the DSM-IV, text revision (DSM-IV-TR), however, specifically include “being diagnosed with a life-threatening illness” as one example of a traumatic event. 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 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 Event Scale [IES]). 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) is measured, the rates are higher, ranging from 20% in patients with early-stage cancer to 80% in those with recurrent cancer.
In one German study, patients with breast cancer (n = 127) were evaluated for PTSD immediately postsurgery and 6 months after the first assessment. The assessments included screening instruments for ASD and PTSD, such as the IES-Revised (IES-R) and the PTSD Checklist-Civilian (PCL-C). First assessment also included a semistructured interview with the Structured Clinical Interview for DSM (SCID). On the basis of the SCID, 2.4% of participants met the criteria for mild to moderate cancer-related PTSD, and 2.4% were diagnosed with ASD. However, the screening instruments IES-R and PCL-C identified PTSD in 18.5% of participants at the first assessment and in 11.2% to 16.3% of participants at the second assessment. The study authors seem to suggest that unlike the SCID, the screening instruments IES-R and PCL-C measure diffuse emotional distress and adjustment problems and not precise PTSD symptoms. One of the main differences between symptom-based measures such as the PCL-C and an actual SCID-based diagnosis is the dysfunction caused by the symptoms. The symptoms are rather common, but only a very small percentage of people who have the symptoms are disabled by them.
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  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  found that lower levels of social support and the use of avoidance coping correlated significantly to a higher number of PTSD-like symptoms. One German study mentioned earlier  that evaluated patients with breast cancer for PTSD and ASD concluded that patients with lifetime PTSD (8.7%) were much more likely to experience cancer-related ASD or PTSD (odds ratio 14.1).
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.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.References
- 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. [PUBMED Abstract]
- Alter CL, Pelcovitz D, Axelrod A, et al.: Identification of PTSD in cancer survivors. Psychosomatics 37 (2): 137-43, 1996 Mar-Apr. [PUBMED Abstract]
- 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. [PUBMED Abstract]
- Koocher G, O'Malley J: The Damocles Syndrome: Psychosocial Consequences of Surviving Childhood Cancer. New York: McGraw-Hill, 1981.
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association, 1994.
- Solomon Z, Garb R, Bleich A, et al.: Reactivation of combat-related posttraumatic stress disorder. Am J Psychiatry 144 (1): 51-5, 1987. [PUBMED Abstract]
- Baider L, Sarell M: Coping with cancer among holocaust survivors in Israel: an exploratory study. J Human Stress 10 (3): 121-7, 1984 Fall. [PUBMED Abstract]
- Perry S, Difede J, Musngi G, et al.: Predictors of posttraumatic stress disorder after burn injury. Am J Psychiatry 149 (7): 931-5, 1992. [PUBMED Abstract]
- 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. [PUBMED Abstract]
- Rundell JR, Ursano RJ, Holloway HC, et al.: Psychiatric responses to trauma. Hosp Community Psychiatry 40 (1): 68-74, 1989. [PUBMED Abstract]
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-III-R. 3rd rev. ed. Washington, DC: American Psychiatric Association, 1987.
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR. 4th rev. ed. Washington, DC: American Psychiatric Association, 2000.
- Mehnert A, Koch U: Prevalence of acute and post-traumatic stress disorder and comorbid mental disorders in breast cancer patients during primary cancer care: a prospective study. Psychooncology 16 (3): 181-8, 2007. [PUBMED Abstract]
- 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. [PUBMED Abstract]
- 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. [PUBMED Abstract]