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 patients with cancer.
The crisis intervention model comprises a broad range of therapies that can be helpful in the treatment of post-traumatic stress symptoms. 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.[Level of evidence: II]
Cognitive-behavioral techniques have proven especially helpful within the crisis intervention setting. Some of these methods include the following:
- Helping the patient understand symptoms.
- Teaching effective coping strategies and stress management techniques (such as relaxation training).
- Restructuring cognitions.
- Providing exposure to opportunities for systematic desensitization of symptoms.
In a single case study, a 10-session cognitive-behavioral intervention for a male cancer patient who was 3 years post–bone marrow transplant and who had 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.[Level of evidence: III] 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] (See the table below for pharmacological treatments for PTSD.) For example:
- Tricyclic and monoamine oxidase-inhibitor antidepressants are commonly used, particularly when the symptoms of PTSD are accompanied by depression.
- Selective serotonin reuptake inhibitors such as fluoxetine are effective in reducing the hyperarousal and intrusive symptoms of PTSD.
- Antianxiety medications may help reduce overall arousal and anxiety symptoms. Infrequently, antipsychotic medications may reduce severe intrusive flashbacks.
|Medication||Dosing (mg/day)||Target Symptomsc||Evidence Basis|
|RCT = randomized controlled trial; SSRIs = selective serotonin reuptake inhibitors.|
|aAdapted from Berger et al. and Asnis et al.|
|bAll studies conducted in noncancer patients only. No studies on pharmacological treatments for PTSD conducted in patients with cancer have been reported.|
|cPTSD symptom clusters are as follows: cluster B, re-experiencing; cluster C, avoidance/numbing; cluster D, hyperarousal.|
|dConsidered first-line treatments for PTSD.|
|eFDA approved for the treatment of PTSD.|
|fUsed mainly as augmentation to SSRIs or serotonin-potentiating non-SSRIs.|
|Sertralinee||50–200||All symptom clusters||Several RCTs|
|Paroxetinee||20–50||All symptom clusters||Several RCTs|
|Fluoxetine||20–60||All symptom clusters||Several RCTs|
|Fluvoxamine||50–300||All symptom clusters||Open label|
|Citalopram||20–60||All symptom clusters||Open label|
|Escitalopram||10–20||All symptom clusters||Open label|
|Venlafaxine||37.5–225||All symptom clusters||Open label|
|Duloxetine||30–120||All symptom clusters||Open label|
|Trazodone||50–300||Insomnia, possibly other clusters||Open label|
|Mirtazapine||15–45||Insomnia, possibly other clusters||Open label|
|Imipramine||50–225||Possibly all clusters||One RCT|
|Other Agents Used as Augmentation Therapy Onlyf|
|Risperidone||1–6||Clusters B and D, possibly cluster C||Several RCTs|
|Olanzapine||5–20||Possibly all clusters||One RCT|
|Quetiapine||25–300||Possibly all clusters||Open label|
|Lamotrigine||50–400||Clusters B and C||One RCT|
|Prazosin||2–6||All symptom clusters (primary target symptom: nightmares)||Several RCTs|
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- 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.
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- Berger W, Mendlowicz MV, Marques-Portella C, et al.: Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review. Prog Neuropsychopharmacol Biol Psychiatry 33 (2): 169-80, 2009. [PUBMED Abstract]
- Asnis GM, Kohn SR, Henderson M, et al.: SSRIs versus non-SSRIs in post-traumatic stress disorder: an update with recommendations. Drugs 64 (4): 383-404, 2004. [PUBMED Abstract]