| 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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