| 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.
Return to
The American Academy of Experts in Traumatic
Stress Homepage
National Cancer Institute
http://www.cancer.gov |
