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Post-traumatic Stress Disorder (PDQ®)

  • Last Modified: 06/15/2012

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Prevalence

Reviews of the literature [1] note that post-traumatic stress has been studied in a variety of cancers, including melanoma, Hodgkin lymphoma, breast cancer, and mixed cancers. The incidence of the full syndrome of post-traumatic stress disorder (PTSD) (meeting the full Diagnostic and Statistical Manual of Mental Disorders, fourth edition [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 had been or were 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 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.[5-7] 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).

As an illustration of the distinction between these tools, a German study evaluated patients with breast cancer (n = 127) for PTSD immediately postsurgery and 6 months after the first assessment.[15] The assessments included screening instruments for acute stress disorder (ASD) and PTSD, such as the Impact of Event Scale-Revised (IES-R) and the PTSD Checklist-Civilian (PCL-C). The first assessment also included a semistructured interview using the 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. Authors of the study seem to suggest that unlike 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 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.

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

  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.  [PUBMED Abstract]

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

  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.  [PUBMED Abstract]

  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.  [PUBMED Abstract]

  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.  [PUBMED Abstract]

  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.  [PUBMED Abstract]

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

  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.  [PUBMED Abstract]

  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.  [PUBMED Abstract]

  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.  [PUBMED Abstract]

  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.  [PUBMED Abstract]

  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.  [PUBMED Abstract]

  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 October 16, 2013. 

  15. 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]