| Introduction
This patient summary on posttraumatic
stress disorder is adapted from the summary
written for health professionals by cancer experts.
This and other credible information about cancer
treatment, screening, prevention, supportive
care, and ongoing clinical trials, is available
from the National Cancer Institute. Better treatment
of many cancers has resulted in more patients
experiencing longer periods of disease-free
survival. This has also led to more patients
experiencing psychological problems, which are
collectively called posttraumatic stress disorder.
This brief summary describes posttraumatic stress
disorder, its symptoms, and its treatment.
Overview
Some survivors of cancer experience
trauma-related symptoms similar to symptoms
experienced by people who have survived highly
stressful situations, such as military combat,
natural disasters, violent personal attack (such
as rape), or other life-threatening events.
This group of symptoms is called posttraumatic
stress disorder (PTSD) and includes avoiding
situations related to the trauma, continuously
thinking of the trauma, and being overexcited.
People with histories of cancer
are considered to be at risk for PTSD. The physical
and mental shock of having a life-threatening
disease, of receiving treatment for cancer,
and living with repeated threats to one's body
and life are traumatic experiences for many
cancer patients.
Diagnosis and Symptoms
Posttraumatic stress disorder
(PTSD) is defined as the development of certain
symptoms following a mentally stressful event
that involved actual death or the threat of
death, serious injury, or a threat to oneself
or others. For the person who has experienced
a diagnosis of cancer, the specific trauma that
triggers PTSD is unclear. It may be the actual
diagnosis of a life-threatening illness, aspects
of the treatment process, test results, information
given about recurrence, or some other aspect
of the cancer experience. Learning that one's
child has cancer is traumatic for many parents.
Because the cancer experience involves so many
upsetting events, it is much more difficult
to single out one event as a cause of stress
than it is for other traumas, such as natural
disasters or rape. The traumatic event may cause
responses of extreme fear, helplessness, or
horror and may trigger PTSD symptoms.
PTSD in cancer survivors may
be expressed in these specific behaviors:
- Reliving the cancer experience
in nightmares or flashbacks and by continuously
thinking about it.
- Avoiding places, events,
and people connected to the cancer experience.
- Being continuously overexcited,
fearful, irritable, and unable to sleep.
To be diagnosed as PTSD, these
symptoms must last for at least one month and
cause significant problems in the patient's
personal relationships, employment, or other
important areas of daily life. Patients who
have these symptoms for less than one month
often develop PTSD later.
Risk Factors, Protective
Factors, and the Development of PTSD
As many as one third of people
who experience an extremely upsetting event,
including cancer, develop posttraumatic stress
disorder (PTSD). The event alone does not explain
why some people get PTSD and others don't. Although
there is no clear answer as to which cancer
survivors are at increased risk of developing
PTSD, certain mental, physical, or social factors
may make some people more likely to experience
it.
Individual and social
factors
Individual and social factors
that have been associated with a higher incidence
of PTSD include younger age, fewer years of
formal education, and lower income.
Disease-related factors
Certain disease-related factors
are associated with PTSD:
- In patients who received
a bone marrow transplant, PTSD occurs more
often when there is advanced disease and a
longer hospital stay.
- In adult survivors of bone
cancer and Hodgkin's lymphoma, people for
whom more time has passed since diagnosis
and treatment tended to show fewer symptoms.
- In survivors of childhood
cancer, symptoms of PTSD occur more often
when there was a longer treatment time.
- Interfering thoughts occur
more often in patients who experienced pain
and other physical symptoms.
- Cancer that has returned
has been shown to increase stress symptoms
in patients.
Mental factors
Mental factors may affect the
development of PTSD in some patients:
- Previous trauma.
- Previous psychological problems.
- High level of general stress.
- Genetic factors and biological
factors (such as a hormone disorder) that
affect memory and learning.
- The amount of social support
available.
- Threat to life and body.
- Having PTSD before being
diagnosed with cancer.
- The use of avoidance to
cope with stress.
Protective factors
Certain factors may decrease
a person's chance of developing PTSD. These
include increased social support, accurate information
about the stage of the cancer, and a satisfactory
relationship with the medical staff.
How PTSD may develop
PTSD symptoms develop by both
conditioning and learning. Conditioning explains
the fear responses caused by certain triggers
that were first associated with the upsetting
event. Neutral triggers (such as smells, sounds,
and sights) that occurred at the same time as
upsetting triggers (such as chemotherapy or
painful treatments) later cause anxiety, stress,
and fear even when they occur alone, after the
trauma has ended. Once established, PTSD symptoms
are continued through learning. The patient
learns that avoiding the triggers prevents unpleasant
feelings and thoughts, so coping by avoidance
continues.
Although conditioning and learning
are part of the process, many factors may explain
why one person develops PTSD and another does
not.
Assessment
It is important that cancer
patients undergo a careful assessment for posttraumatic
stress disorder (PTSD) so that early symptoms
may be identified and treated. The timing of
this assessment will vary with the individual
patient. Cancer is an experience of repeated
traumas and undetermined length. The patient
may experience stress symptoms anytime from
diagnosis through completion of treatment and
cancer recurrence. In patients who have a history
of victimization (such as Holocaust survivors)
and who have PTSD or its symptoms from these
experiences, symptoms can be started again by
certain triggers experienced during their cancer
treatment (for example, clinical procedures
such as being inside MRI or CT scanners). While
these patients may have problems adjusting to
cancer and cancer treatment, their PTSD symptoms
may vary, depending on other factors. The symptoms
may become more or less prevalent during and
after the cancer treatment.
Symptoms of PTSD usually begin
within the first 3 months after the trauma,
but sometimes they do not appear for months
or even years afterwards. Therefore, cancer
survivors and their families should be involved
in long-term monitoring.
Some people who have experienced
an upsetting event may show early symptoms without
meeting the full diagnosis of PTSD. However,
these early symptoms predict that PTSD may develop
later. Early symptoms also indicate the need
for repeated and long-term follow-up of cancer
survivors and their families.
Diagnosing PTSD can be difficult
since many of the symptoms are similar to other
psychiatric problems. For example, irritability,
poor concentration, increased defensiveness,
excessive fear, and disturbed sleep are symptoms
of both PTSD and anxiety disorder. Other symptoms
are common to PTSD, phobias, and panic disorder.
Some symptoms, such as loss of interest, a sense
of having no future, avoidance of other people,
and sleep problems may indicate the patient
has PTSD or depression. Even without PTSD or
other problems, normal reactions to the cancer
diagnosis and treatment of a life-threatening
disease can include interfering thoughts, separating
from people and the world, sleep problems, and
over-excitability.
Questionnaires and interviews
are used by health care providers to assess
if the patient has symptoms of stress and to
determine the diagnosis.
Other problems may also exist
in addition to PTSD. These problems can include
substance abuse, emotional problems, and other
anxiety disorders, including major depression,
alcohol dependence, drug dependence, social
fears, and/or obsessive-compulsive disorder.
Treatment
Effects of posttraumatic stress
disorder (PTSD) are long-lasting and serious.
It may affect the patient's ability to have
a normal lifestyle and may interfere with personal
relationships, education, and employment. Because
avoiding places and persons associated with
cancer is part of PTSD, the syndrome may prevent
the patient from seeking medical treatment.
It is important that cancer survivors receive
information about the possible psychological
effects of their cancer experience and early
treatment of symptoms of PTSD. Therapies used
to treat PTSD are those used for other trauma
victims. Treatment may involve more than one
type of therapy.
The crisis intervention method
tries to lessen the symptoms and return the
patient to a normal level of functioning. The
therapist focuses on solving problems, teaching
coping skills, and providing a supportive setting
for the patient.
Some patients are helped by
methods that teach them to change their behaviors
by changing their thinking patterns. Some of
these methods include helping the patient understand
symptoms, teaching coping and stress management
skills (such as relaxation training), teaching
the patient to reword upsetting thoughts, and
helping the patient become less sensitive to
upsetting triggers. Behavior therapy is used
when the symptoms are avoidance of sexual activity
and intimate situations.
Support groups may also help
people who experience posttraumatic stress symptoms.
In the group setting, patients can receive emotional
support, meet others with similar experiences
and symptoms, and learn coping and management
skills.
For patients with severe symptoms,
medications may be used. These include antidepressants,
antianxiety medications, and when necessary,
antipsychotic medications.
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