Are we missing PTSD in our patients with cancer? Part I
Posted: Wed Feb 19, 2020 4:49 pm
Abstract
Posttraumatic Stress Disorder (PTSD) can be defined by the inability to recover from a traumatic event. A common misconception is that PTSD can only develop in circumstances of war or acute physical trauma. However, the diagnostic criteria of PTSD were adjusted in the Diagnostic Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) to include the diagnosis and treatment of a life-threatening illness, such as cancer, as a traumatic stressor that can result in PTSD. The word ‘cancer’ is so strongly linked to fear, stigma, and mortality, that some patients are fearful to even say ‘the C word’. Therefore, it is not surprising that patients may experience a diagnosis of cancer as sudden, catastrophic, and/or life-threatening. Cancer-related PTSD (CR-PTSD) can negatively affect a patient’s psychosocial and physical well-being during treatment and into survivorship. Unfortunately, CR-PTSD often goes undiagnosed and, consequentially, untreated. This article provides a general overview of PTSD with cancer as the traumatic event in order to define CR-PTSD, and reviews the growing pool of literature on this topic, including prevalence, risk factors, characterization, and treatment of CR-PTSD. The purpose of this article is to spread awareness of this relatively newly defined and commonly missed disorder among patients with cancer to clinicians and patients alike.
Cancer is many people’s worst fear, often linked with stigma, suffering and mortality. A cancer diagnosis may be perceived as life threatening, compounded by the physical burden and uncertainty inherent in many cancer treatments. The word ‘cancer’ is typically associated with chemotherapy, hair loss, nausea, and other physical symptoms and abnormalities, but cancer can also often have a significant emotional impact on the patient and their family. Approximately 40% of patients with cancer experience significant emotional and social distress during treatment (Pranjic, Bajraktarevic & Ramic, 2016), with approximately one-third of patients developing distress that requires specialized intervention (Grassi, Spiegel & Riba, 2017).
Unfortunately, many patients are not referred or do not accept referral to psycho-oncology services to be assessed and treated, as high levels of sadness and anxiety are often perceived as ‘normal’ reactions to cancer diagnosis and treatment; thus mood, anxiety and other psychological disorders are commonly mistaken for unexpected ‘manageable’ sadness and preoccupation with the disease (Grassi, Spiegel & Riba, 2017). Patients are often told by well-meaning loved ones that they should “think positively” and “fight the cancer” and, in turn, may feel that by expressing fear or sadness they are being ‘weak’. Furthermore, some patients fear that negative emotions may adversely impact their immune system when, in fact, feeling sad or fearful during adaptation or anticipatory grief is common. Whilst processing these emotions is difficult, they are transitory and lead to a stronger emotional position. Suppressing these emotions may increase the risk of depression, reduce authentic communication and lead to sleep difficulties. The question of how mood and anxiety disorders adversely impact outcome is controversial; the greatest evidence for the likely mechanism is reduced treatment compliance and less adherence to a healthy lifestyle.
Existing literature supports the notion that many patients with cancer are interested in receiving psychosocial support for the emotional and social distress they experience during diagnosis, treatment and survivorship, and highlights the positive impact of receiving specialized psychosocial oncology care. A recent study found that 13% of patients with cancer undergoing radiotherapy expressed a desire for psychological support (Riedl, Gastl, Gamper, Arnold, Dejaco, Schoellmann & Rumpold, 2018). Multiple studies reveal that psychological intervention can increase quality of life for patients with cancer (Li, Li, Shi, Wang, Zhang, Shao & Wang, 2017). In contrast, patients with untreated distress have poorer cancer outcomes and are less compliant with treatment and surveillance regiments (Chen, Hsu, Felix, Garst, & Yoshizaki, 2017; Parikh, De Ieso, Garvey, Thachil, Ramamoorthi, Penniment & Jayaraj, 2015). One other less well recognized or investigated, yet often devastating psychological disorder affecting a significant portion of patients with cancer, is cancer-related post-traumatic stress disorder (PTSD).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516338/
Posttraumatic Stress Disorder (PTSD) can be defined by the inability to recover from a traumatic event. A common misconception is that PTSD can only develop in circumstances of war or acute physical trauma. However, the diagnostic criteria of PTSD were adjusted in the Diagnostic Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) to include the diagnosis and treatment of a life-threatening illness, such as cancer, as a traumatic stressor that can result in PTSD. The word ‘cancer’ is so strongly linked to fear, stigma, and mortality, that some patients are fearful to even say ‘the C word’. Therefore, it is not surprising that patients may experience a diagnosis of cancer as sudden, catastrophic, and/or life-threatening. Cancer-related PTSD (CR-PTSD) can negatively affect a patient’s psychosocial and physical well-being during treatment and into survivorship. Unfortunately, CR-PTSD often goes undiagnosed and, consequentially, untreated. This article provides a general overview of PTSD with cancer as the traumatic event in order to define CR-PTSD, and reviews the growing pool of literature on this topic, including prevalence, risk factors, characterization, and treatment of CR-PTSD. The purpose of this article is to spread awareness of this relatively newly defined and commonly missed disorder among patients with cancer to clinicians and patients alike.
Cancer is many people’s worst fear, often linked with stigma, suffering and mortality. A cancer diagnosis may be perceived as life threatening, compounded by the physical burden and uncertainty inherent in many cancer treatments. The word ‘cancer’ is typically associated with chemotherapy, hair loss, nausea, and other physical symptoms and abnormalities, but cancer can also often have a significant emotional impact on the patient and their family. Approximately 40% of patients with cancer experience significant emotional and social distress during treatment (Pranjic, Bajraktarevic & Ramic, 2016), with approximately one-third of patients developing distress that requires specialized intervention (Grassi, Spiegel & Riba, 2017).
Unfortunately, many patients are not referred or do not accept referral to psycho-oncology services to be assessed and treated, as high levels of sadness and anxiety are often perceived as ‘normal’ reactions to cancer diagnosis and treatment; thus mood, anxiety and other psychological disorders are commonly mistaken for unexpected ‘manageable’ sadness and preoccupation with the disease (Grassi, Spiegel & Riba, 2017). Patients are often told by well-meaning loved ones that they should “think positively” and “fight the cancer” and, in turn, may feel that by expressing fear or sadness they are being ‘weak’. Furthermore, some patients fear that negative emotions may adversely impact their immune system when, in fact, feeling sad or fearful during adaptation or anticipatory grief is common. Whilst processing these emotions is difficult, they are transitory and lead to a stronger emotional position. Suppressing these emotions may increase the risk of depression, reduce authentic communication and lead to sleep difficulties. The question of how mood and anxiety disorders adversely impact outcome is controversial; the greatest evidence for the likely mechanism is reduced treatment compliance and less adherence to a healthy lifestyle.
Existing literature supports the notion that many patients with cancer are interested in receiving psychosocial support for the emotional and social distress they experience during diagnosis, treatment and survivorship, and highlights the positive impact of receiving specialized psychosocial oncology care. A recent study found that 13% of patients with cancer undergoing radiotherapy expressed a desire for psychological support (Riedl, Gastl, Gamper, Arnold, Dejaco, Schoellmann & Rumpold, 2018). Multiple studies reveal that psychological intervention can increase quality of life for patients with cancer (Li, Li, Shi, Wang, Zhang, Shao & Wang, 2017). In contrast, patients with untreated distress have poorer cancer outcomes and are less compliant with treatment and surveillance regiments (Chen, Hsu, Felix, Garst, & Yoshizaki, 2017; Parikh, De Ieso, Garvey, Thachil, Ramamoorthi, Penniment & Jayaraj, 2015). One other less well recognized or investigated, yet often devastating psychological disorder affecting a significant portion of patients with cancer, is cancer-related post-traumatic stress disorder (PTSD).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516338/