Post-traumatic stress disorder – prevalent and persistent

Oxana Palesh and Cheryl Koopman

Post-traumatic stress disorder (PTSD) is prevalent in patients with breast cancer, and African American, Asian and younger women are disproportionally affected. PTSD is associated with adverse effects on psychological and physical health and might be an indicator of other risk factors. It is important to screen and treat for PTSD, and more research is needed.

This article was first published in Nature Reviews Clinical Oncology vol.10 no.5, and is published with permission. © 2013 Nature Publishing Group. doi:10.1038/nrclinonc.2013.49

Receiving a diagnosis of breast cancer is likely to have a considerable impact on the psychological wellbeing of the patient. In a recent observational study, Vin-Raviv et al.[1] reported that 23% of 1139 women with newly diagnosed localised breast cancer experienced post-traumatic stress disorder (PTSD) symptoms. Although the PTSD symptoms decreased over time, 16.5% had PTSD at first follow up (4 months after diagnosis); 12.6% had PTSD at the second follow up (6 months after diagnosis), and a minority of patients (12.1%) experienced persistent PTSD (defined as having PTSD at two consecutive interviews). Among these patients with breast cancer, African American and Asian women experienced disproportionally more PTSD when compared with white women. Indeed, African American women were 48% more likely to have PTSD than their white counterparts, and this difference was even more pronounced for Asian women with breast cancer, who were 69% more likely to have PTSD compared to white patients. Furthermore, younger women (<50 years of age) were significantly (P<0.01) more likely to report PTSD compared to older women.

PTSD as a psychiatric diagnosis des-cribes a pattern of distress response experienced by some individuals in the aftermath of a traumatic event. PTSD was originally observed in the military context, but more recently it has been recognised in the context of serious medical illness.[2] Individuals diagnosed with PTSD suffer from three types of symptoms: intrusive distressing thoughts and feelings related to the event (such as distressing flashbacks of receiving the cancer diagnosis); persistent emotional numbing and avoidance of reminders of the traumatic event (for example, feeling emotionally distant from loved ones); and increased hyperarousal (such as difficulty falling or staying asleep).[2] Life-threatening illnesses, such as cancer, pose unique risks for PTSD compared to most types of time-limited traumatic events, such as military combat, rape, or accidents.[3] Much of the traumatic stress associated with cancer is focused on future threats (such as recurrence) rather than on past events. Furthermore, the experience of having cancer poses a risk of cumulative trauma due to uncertainties regarding recurrence, metastases, and shortened survival rather than the reliving of a singular traumatic event.[3]

It is remarkable that Vin-Raviv et al.[1] found that almost a quarter of women recently diagnosed with breast cancer had PTSD, considering that in the general US adult population the lifetime prevalence of PTSD is approximately 8%.2 Perhaps, this high prevalence of PTSD can be attributed to cancer-specific characteristics – it is not only a life-threatening illness, but also an illness in which the threats of recurrence, metastases and untimely death are always present. In addition, cancer treatments are noxious because they create numerous adverse effects that unfold over months and even years. In previous research, having more post-surgical treatment was associated with greater PTSD symptoms in women with recently diagnosed localised breast cancer.[4] In women with metastatic breast cancer, the incidence of PTSD was 52%,[5] more than double the 23% found among women with localised breast cancer in the present study. Although the latter study[5] focused on women who were seeking help for their psychological distress, it underscores the potentially traumatic nature of metastatic breast cancer.

PTSD is an indicator of psychological vulnerability that can also signal the presence of other adverse health-related characteristics, such as low socioeconomic status and poor physical and mental health-related quality of life.[6] In patients with breast cancer, those who have PTSD are also more likely to have other current or past psychiatric disorders and prior history of violent trauma.[6] In addition, it is also associated with greater functional impairment, such as employment absenteeism.[6] There is considerable evidence that PTSD contributes to worse health outcomes via multiple pathways.[7] These pathways include: greater health risk behaviours (for example, smoking); biological alterations (such as deregulation of the hypothalamic–pituitary–adrenal axis); psychological alterations (including depression); attentional processes (for example, altered pain perception); and illness behaviour (such as health-care utilisation) – all of these behaviours have the potential to contribute to greater morbidity and shorter survival.[7]

A major strength of the present study[1] is its large, ethnically diverse and multicentre sample, which enabled the examination of racial disparities in PTSD. The finding that a greater percentage of African American women than white women had PTSD is notably similar to a finding in men with prostate cancer.[8] Furthermore, the present study found that Asian patients were also more likely to have PTSD than white patients with breast cancer. The authors of the study appropriately point out that minority ethnic group status is often associated with risk factors that might help to account for the development of PTSD (for example, less access to medical treatment).[1] Specific cultural characteristics, such as greater stigma associated with medical illness, might also help to explain the racial differences in PTSD, although further investigation of such possibilities is necessary.

Increasing attention is being directed towards addressing patients’ needs for psychosocial care. The National Comprehensive Cancer Network (NCCN) has established clinical guidelines for identifying, referring, and treating distressed patients with cancer.[9] The NCCN guidelines constitute a major step forward in addressing these needs. Although the guidelines do not specifically address PTSD in cancer, they lay the foundation for developing a framework to ameliorate distress in patients with cancer. Going forward, it is important to consider how these guidelines can be applied and provide the bridge for further efforts to treat and address the needs of patients with cancer who have PTSD.[9] Interventions that are easily accessible might be particularly attractive to this population given the high burden of cancer treatments. For example, in a previous randomised clinical trial, a web-based support group demonstrated efficacy in reducing PTSD symptoms in women with primary breast cancer.[10]

PTSD is prevalent and persistent in a significant minority of patients with breast cancer; thus, patients should be screened and treated for PTSD. The burgeoning literature on PTSD and other forms of impairment[1,4–6] associated with breast cancer is consistent with the study finding suggesting that younger women have higher levels of symptomatology, underscoring the importance of screening younger female patients with breast cancer for PTSD. Although, pharmacological and behavioural treatments have been used successfully in veterans, patients with HIV, and other trauma survivors, very few treatments are designed to be implemented in patients with breast cancer who are in active treatment. It is important to treat symptoms of any disorder early to prevent the development of chronic problems and to ameliorate distress associated with having a cancer diagnosis. The types of psychological treatment should vary according to the intensity of co-occurring medical treatment. For example, during active medical treatment, brief tailored behavioural interventions such as stress management training should be the primary focus, whereas during the survivorship phase, more-intensive psychological treatments are warranted (for example, supportive and cognitive behavioural therapy).[3]

References

1. N Vin-Raviv et al. Racial disparities in posttraumatic stress after diagnosis of localized breast cancer: the BQUAL study. JNCI http://dx.doi.org/10.1093/jnci/djt024

2. American Psychiatric Association. (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th edn (Text Revision)

3. LN French-Rosas, J Moye and AD Naik. (2011) Improving the recognition and treatment of cancer-related posttraumatic stress disorder. J Psychiatr Pract 17:270–276

4. C Koopman et al. (2002) Traumatic stress symptoms among women with recently diagnosed primary breast cancer. J Trauma Stress 15:277–287

5. LD Butler, C Koopman, C Classen et al. (1999) Traumatic stress, life events, and emotional support in women with metastatic breast cancer: cancer-related traumatic stress symptoms associated with past and current stressors. Health Psychol 18:555–560

6. RA Shelby, DM Golden-Kreutz, and BL Andersen. (2008) PTSD diagnoses, subsyndromal symptoms, and comorbidities contribute to impairments for breast cancer survivors. J Trauma. Stress 21:165–172

7. PP Schnurr and BL Green, in: Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress. (2004) edited by PP Schnurr and BL Green. American Psychological Association, pp 247–275

8. JQ Purnell et al. (2011) Racial disparities in traumatic stress in prostate cancer patients: secondary analysis of a National URCC CCOP Study of 317 men. Support Care Cancer 19:899–907

9. JC Holland et al. Distress management. (2013) J Natl Compr Canc Netw 11:190–209

10. AJ Winzelberg et al. (2003) An evaluation of an internet support group for women with primary breast cancer. Cancer 97:1164–73

Author affiliations

Oxana Palesh and Cheryl Koopman, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California

Acknowledgements

This research was supported by funds from the National Cancer Institute K07CA132916 and the California Breast Cancer Research Grants Program Office of the University of California, Grant Number 17AB-1600

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