| 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 qualified 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:
- 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 have argued that not all intrusive thoughts
are negative or indicate reexperiencing a trauma,
but 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]
References
American Psychiatric Association.:
Diagnostic and Statistical Manual of Mental
Disorders: DSM-IV. 4th ed. Washington, DC: American
Psychiatric Association, 1994.
American Psychiatric Association.: Diagnostic
and Statistical Manual of Mental Disorders:
DSM-IV-TR. 4th rev. ed. Washington, DC: American
Psychiatric Association, 2000.
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]
Green BL, Rowland JH, Krupnick JL, et al.: Prevalence
of posttraumatic stress disorder in women with
breast cancer. Psychosomatics 39 (2): 102-11,
1998. [PUBMED Abstract]
Deimling GT, Kahana B, Bowman KF, et al.: Cancer
survivorship and psychological distress in later
life. Psychooncology 11 (6): 479-94, 2002 Nov-Dec.
[PUBMED Abstract]
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]
Cordova MJ, Studts JL, Hann DM, et al.: Symptom
structure of PTSD following breast cancer. J
Trauma Stress 13 (2): 301-19, 2000. [PUBMED
Abstract]
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]
Cordova MJ, Andrykowski MA: Responses to cancer
diagnosis and treatment: posttraumatic stress
and posttraumatic growth. Semin Clin Neuropsychiatry
8 (4): 286-96, 2003. [PUBMED Abstract]
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