Assessment of Post-traumatic Stress Disorder in the Cancer Setting
A timely and careful assessment of cancer patients is critical to identify the symptoms of post-traumatic stress disorder (PTSD), to note the deleterious impact of the symptoms on functioning, and to plan interventions targeted at the most distressing symptoms. It is also critical that the assessment distinguishes between the full Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), PTSD syndrome (meets all required diagnostic criteria) and PTSD-related symptoms only.
The most difficult aspect of PTSD assessment in the cancer setting is the determination of precisely when to evaluate the patient. Diagnosis is complicated because cancer is not an acute or discrete event, but is an experience marked by repeated traumas and indeterminate length. Thus, an individual may exhibit the symptoms of PTSD at any point from diagnosis through treatment, to treatment completion and, possibly, to recurrence. Patients such as Holocaust survivors whose history of victimization causes PTSD or its symptoms can have the symptoms activated by any number of stimuli encountered during their treatment (e.g., clinical procedures such as being inside magnetic resonance imaging or computed tomography scanners). While such patients may have more difficulty in adjusting to cancer and cancer treatment, their PTSD symptomatology is likely to vary greatly according to their circumstances. The relative predominance of specific PTSD symptoms may wax and wane throughout the cancer experience and beyond.
Basal cell carcinoma (BCC) is the most common malignancy in people of European descent, with an associated lifetime risk of 30%. While exposure to ultraviolet radiation (UV) is the risk factor most closely linked to the development of BCC, other environmental factors (such as ionizing radiation, chronic arsenic ingestion, and immunosuppression) and genetic factors (such as family history, skin type, and genetic syndromes) also potentially contribute to carcinogenesis. In...
The definition in the DSM-IV indicates that although PTSD symptoms usually begin within the first 3 months after trauma, there may be a delay of months or even years before symptoms appear.[2,3] These findings support the necessity for long-term monitoring of survivors of cancer and their family members.
At least one study found that individuals who have experienced a traumatic event may exhibit early symptoms without meeting the full criteria for a diagnosis of PTSD. Nonetheless, the appearance of these early symptoms was found to predict later development of full PTSD syndrome. These results lend further credence to the need for both repeated and long-term follow-up of individuals exposed to the trauma of cancer. (Refer to the PDQ summary on Adjustment to Cancer: Anxiety and Distress for further information.)
The difficulty in properly diagnosing PTSD may be compounded by the overlapping of PTSD symptoms with those of other psychiatric disorders and by the time-related aspects of normal adjustment. For example, irritability, poor concentration, hypervigilance, excessive fear, and disturbed sleep are also symptoms of generalized anxiety disorder. Other arousal and avoidance symptoms are common to PTSD, phobias, and panic disorder, but loss of interest, sense of a foreshortened future, avoidance of other people, and sleep impairment might suggest both PTSD and depressive disorders. Even normal reactions to the diagnosis and treatment of life-threatening disease can consist of responses such as intrusive thoughts, disassociation and depersonalization, sleep disturbances, and heightened arousal. Therefore, clinicians and researchers must be particularly attuned to the causes, duration, and severity of PTSD-like symptoms when considering PTSD among several diagnoses. For instance, in a study of women with breast cancer, 41% reported experiencing "intense fear, helplessness, or horror" (DSM-IV PTSD diagnostic criterion A2); however, on further comprehensive diagnostic interview, only 4% met the full PTSD criteria. Assessment must be able to distinguish between general psychological distress and symptoms of PTSD.