Although receiving a diagnosis of cancer is often colloquially referred to as traumatic, the validity and utility of the posttraumatic stress disorder (PTSD) construct in the context of malignant disease has been debated. DSM-IV-TR considered life-threatening illness as a potential traumatic stressor, inspiring a sizable literature 

the prevalence and correlates of cancer- related PTSD.

 However, changes to the DSM-5 PTSD criteria and more enduring conceptual issues call into question the applicability of PTSD to the cancer experience.

Prevalence estimates based on DSM-IV-TR criteria suggest that although self-reported symptoms are common, only a minority of patients with cancer meet formal diagnostic criteria for cancer-related PTSD. Across studies, more than 50% of patients with cancer meet the DSM-IV-TR stressor criteria (ie, they perceive cancer to involve a threat to their life or physical integrity), and they experience fear, helplessness, or horror. Individuals who have received a diagnosis of cancer appear to be 

 to experience PTSD than controls without a history of cancer.

 Prevalence varies according to mode of assessment, with self-report measures (eg, PTSD Checklist) yielding higher rates than structured clinical interviews (eg, SCID, CAPS)

 found that self-report based prevalence rates ranged from 7.3% to 11.2%, depending on method for determining clinical significance. The clinical interview based prevalence was 6.4% for current PTSD and 12.6% for lifetime PTSD. Another 10% to 20% of patients may experience subsyndromal PTSD symptomology.

 The more stringent diagnostic criteria of DSM-5 have not been thoroughly evaluated in patients with cancer and may yield even lower rates

Other markers of distress have been linked with cancer-related PTSD. Depression, anxiety, global distress, and quality-of-life decrements have been positively 

 Thus, although a small minority of patients with cancer may have diagnosable PTSD, subthreshold symptoms may be impairing and warrant clinical attention. Interestingly, a meta-analysis revealed a weak positive relationship between PTSD symptoms and posttraumatic growth in cancer patients.

 This is consistent with what is often seen clinically: post-cancer trauma symptoms may coexist with finding meaning, strengthened relationships, enhanced spirituality, bolstered sense of personal strength, and clearer life priorities.

Several factors appear to confer vulnerability to developing PTSD symptoms following cancer.

 Younger age, lower socioeconomic status, past trauma, preexisting mental health conditions, more advanced disease, more intensive treatment, peritraumatic dissociation and distress, more recent treatment completion, and poor/negative social support have been linked to greater cancer-related PTSD. These risk factors parallel known risk factors for PTSD following other traumas and suggest assessment targets in oncology (

Conceptual, diagnostic, and assessment issues

Differences between cancer and stressors traditionally viewed as traumatic per DSM (eg, war/combat, physical/sexual violence, motor vehicle accident, terrorism) have been recognized. In contrast to traumas that involve threats that are sudden, external, discrete, and immediate, cancer involves threats that are slowly unfolding (eg, detection, diagnosis, treatment, adverse effects), internal (ie, cancer cells), ever-present (ie, one’s body, potential disease recurrence), and future- oriented (eg, disease progression and death).

What constitutes cessation of the traumatic stressor is unclear in cancer. Once diagnosed with cancer, one is never truly free of the threat. Even when time-limited treatments (eg, surgery, radiation, a course of chemotherapy) have been completed, maintenance chemotherapy, hormone blockade, medical surveillance and follow-up, and the realistic risk of disease recurrence make for a chronic stressor. This calls into question whether there is a post-trauma point at which to assess posttraumatic stress in patients with cancer.

Changes to the PTSD diagnostic criteria in DSM-5 raise additional questions. Although cancer would appear to meet Criterion A (the stressor criterion; directly experiencing “actual or threatened death, serious injury . . .” ), the accompanying text says that to qualify as a traumatic stressor, medical incidents or conditions must involve “sudden, catastrophic experiences (eg, waking during surgery, anaphylactic shock”). The DSM-IV-TR stipulation that a traumatic event evokes “fear, helplessness, or horror” was removed in DSM-5. Although some data suggest that cancer may meet the DSM-5 stressor criteria for a proportion of patients, data regarding the prevalence of sudden, catastrophic experiences among patients with cancer are lacking.

Other DSM-5 PTSD diagnostic criteria must also be carefully considered in the context of cancer.

Per DSM-5, a requisite number of symptoms from 4 clusters must be present:

at least 2 negative alterations in cognitions or mood; or

These symptoms must be present for more than a month, cause clinically significant distress or impairment, and not be attributable to physiological effects of a substance or medical condition.

Post-cancer trauma symptoms may coexist with finding meaning, strengthened relationships, enhanced spirituality, bolstered sense of personal strength, and clearer life priorities.

Evaluating the presence of PTSD symptoms necessitates careful assessment of the spirit and letter of the criteria while guarding against potential pathologizing within normal limits responses to the cancer experience. For instance, worries about future disease recurrence differ from recurrent, involuntary, and intrusive distressing memories of one’s initial diagnosis, and residual conditioned nausea from chemotherapy differs from fear-related physiological reactions to reminders of cancer. Similarly, avoiding medical follow-up due to fear of receiving bad news is not technically the same as avoiding external reminders such as conversations because they arouse distressing memories and emotions about one’s past cancer experience. Recurring thoughts about a provider missing an earlier cancer diagnosis would not constitute persistent, distorted cognitions that lead to blaming others, and feeling alienated from friends who disappeared or were not supportive should not be confused with “feelings of detachment or estrangement” from others. Regular self-exam and surveillance for signs of recurrence should not be construed as hypervigilance, and persistent concentration and sleep problems may reflect late effects of chemotherapy rather than symptoms of hyperarousal. Thus, whereas patients may endorse many cancer- related PTSD symptoms on a self-report checklist, thoughtful diagnostic interviewing is needed to determine whether there really is PTSD.

Mental health assessment in patients with cancer may proceed along a continuum, from screening to specialized evaluation. The National Comprehensive Cancer Network’s (NCCN) distress screening thermometer and accompanying problem checklist can detect emotional, physical, social, spiritual, and practical concerns, and may trigger referral to a mental health practitioner.10 Self- report measures of depression (eg, Patient Health Questionnaire-9 [PHQ-9]), anxiety (eg, Generalized Anxiety Disorder 7-item [GAD-7]), and PTSD (eg, Posttraumatic Stress Disorder Checklist for DSM-5 [PCL-5]) quantify subjective symptom levels and provide clinical cutoffs; however, given the potential for false-positives in medical populations including patients with cancer, they are not a substitute for clinical interview.

With the previously noted conceptual issues in mind, structured diagnostic interviews and thorough psychosocial assessments provide more definitive information regarding differential diagnosis and context in which to understand a patient’s apparent trauma symptoms. Furthermore, such data can help determine whether their presentation would be more appropriately deemed an adjustment disorder, an exacerbation of a preexisting mood or anxiety disorder, or a 

of PTSD stemming from a pre-cancer trauma.

A limited evidence base is available to inform treatment of cancer-related PTSD. 

 identified 8 published studies (including 5 randomized clinical trials) that analyzed treatment outcomes specifically for patients symptomatic for cancer-related PTSD. Significant methodological limitations (eg, small samples sizes, unclear randomization, non-blinding of participants, therapy offered to patients still undergoing active cancer treatment) limit conclusions that can be drawn from these studies. In that light, cognitive behavioral therapy (CBT; imaginal and in vivo exposure, cognitive restructuring) and eye movement desensitization and reprocessing (EMDR) showed benefit in those with elevated cancer-related PTSD symptoms. Other intervention approaches that were not specifically designed for cancer-related PTSD, including supportive-expressive group and cognitive behavioral stress management, have also shown an effect on cancer-related 

Evidence to guide psychopharmacologic treatment of cancer-related PTSD is lacking. Decisions should be informed by clinical practice guidelines for PTSD and for management of distress in patients with cancer.

The following case illustrates the nuances of assessment and treatment of cancer-related PTSD.

“John” was a 51-year-old cisgender, heterosexual, Mexican American married male. He attended 2 years of college, was the father of 2 daughters, and worked in IT. He presented disease free for scheduled follow-up to his oncologist 1 year after completing radiation and chemotherapy for early-stage non-Hodgkin lymphoma. His elevated distress screen (7/10 on the NCCN thermometer, with endorsement of depression, fears, nervousness, worry, and sleep problems) triggered referral to a clinical psychologist. His scores on self-report measures of depression, anxiety, and PTSD exceeded clinical cutoffs. John reported a history of childhood physical abuse and panic disorder as a youth, which spontaneously resolved without treatment. He reported that prior to his cancer diagnosis, he was “happy and doing well at work and at home.”

However, John shared that “I’ve never been the same since my diagnosis and going through treatment.” He recalled how frightened he was when he heard the word cancer during his diagnostic interview, “I was terrified and it felt unreal—it was like I was on the ceiling of the exam room looking down at myself and the doctor.” He described frequent upsetting memories and daydream-like flashbacks (“like a movie playing over in my mind”) of his diagnosis, the severe adverse effects of treatment (nausea, pain from mucositis), and the fear and isolation from his wife and children he experienced when he was hospitalized for a life-threatening infection during chemotherapy.

John reported feeling nervous and panicky in medical settings; he avoided his children’s appointments and refused to visit family and friends in the hospital because “it brings it all back.” He tried to push thoughts, memories, and emotions about his cancer experience away and avoided conversations about cancer. He described thinking that “I can’t control anything in my life,” and persistently felt anxious and vulnerable, and felt disconnected, numb, and emotionally distanced from his wife and children. He reported feeling “wired and on edge” all the time and being irritable and “short” with others.

John expressed shame, particularly given the mental health stigma in his culture (“I should be strong—this is not normal”). He tried to keep these “crazy” reactions to himself, especially because family, friends, and health providers kept saying that he should feel fortunate, “move forward,” and focus on his future. In light of this presentation, John was given a diagnosis of cancer-related PTSD.

John’s treatment utilized components of CBT and supportive-expressive therapy. Psychoeducation provided reassurance that his reactions were consistent with those of many other trauma survivors and helped him understand the role that avoidance and negative appraisal of his reactions had in maintaining his distress. Imaginal exposure entailed having him repeatedly describe in detail the most upsetting parts of his cancer experience, including his diagnosis and frightening hospitalization; he also listened to audio recordings of these accounts several times per week.

During in vivo exposure, John visited various medical settings he had been avoiding, initially accompanied by his therapist and eventually on his own, staying in each setting (sometimes for more than an hour) until his anxiety subsided. He also had conversations he had been avoiding with family and friends about his experiences and asked them to refrain from reassuring him and to “just listen.” Cognitive restructuring helped John challenge extreme negative beliefs about himself and the world, identifying the many controllable aspects of his life. He learned and practiced self-regulation strategies to reduce tension and anxiety, including mindful breathing, imagery, and muscle relaxation.

Throughout treatment, John was able to face the reality of an uncertain future that could realistically include disease recurrence, expressed and processed his fear and sadness about the possibility of dying of his illness, and clarified his priorities, including increasing his emotional connection with his wife and children. At the conclusion of 3 months of weekly therapy, John’s symptoms were considerably reduced; he no longer met criteria for PTSD. Perhaps more importantly, John described greater experience of positive affect and appreciation of life, enhanced closeness with family and friends, and greater comfort at work and in the community.

Diagnosis and treatment of cancer may elicit PTSD in a minority of patients; subclinical symptoms are more common and are associated with reduced quality of life. Conceptual issues in applying the trauma lens to the cancer experience highlight the importance of thorough assessment and discerning differential diagnosis. Diagnosis and treatment of cancer-related PTSD should and can be informed by existing evidence-based frameworks from oncology and traumatic stress.

 is an Associate Professor, Department of Psychology, Palo Alto University, Palo Alto CA; Staff Psychologist, VA Northern California Health Care System. He reports no conflicts of interest concerning the subject matter of this article.

1. Cordova MJ, Riba MB, Spiegel D. Post-traumatic stress disorder and cancer. 

2. Kangas M. DSM-5 trauma and stress-related disorders: implications for screening for cancer-related distress. 

3. Swartzman S, Booth JN, Munro A, Sani F. 

Posttraumatic stress disorder after cancer diagnosis in adults: a meta-analysis

4. Abbey G, Thompson SBN, Hickish T, Heathcote D. 

A meta-analysis of prevalence rates and moderating factors for cancer-related post-traumatic stress disorder

5. Andrykowski MA, Cordova MJ, Studts JL, Miller TW. Posttraumatic stress disorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD Checklist-Civilian Version (PCL-C) as a screening instrument. 

6. Shand LK, Cowlishaw S, Brooker JE, et al. 

Correlates of posttraumatic stress symptoms and growth in cancer patients: a systematic review and meta-analysis

Trauma and Transformation: Growing in the Aftermath of Suffering. 

Thousand Oaks, CA: Sage Publications; 1995.

The relationship between post-traumatic stress and post-traumatic growth in cancer patients and survivors: a systematic review and meta-analysis

9. Andrykowski M, Steffens R, Bush H, Tucker T. Lung cancer diagnosis and treatment as a traumatic stressor in DSM-IV and DSM-5: prevalence and relationship to mental health outcomes. 

10. Riba MB, Donovan KA, Andersen B, et al. Distress management, version 3.2019: NCCN clinical practice guidelines in oncology. 

11. Dimitrov L, Moschopoulou E, Korszun A. 

Interventions for the treatment of cancer-related traumatic stress symptoms: a systematic review of the literature

Stress Management Intervention for Women With Breast Cancer. 

Washington, DC: American Psychological Association; 2003.

13. Antoni MH, Wimberly SR, Lechner SC, et al. 

Reduction of cancer-specific thought intrusions and anxiety symptoms with a stress management intervention among women undergoing treatment for breast cancer

14. Guideline Development Panel for the Treatment of PTSD in Adults, American Psychological Association. Summary of the clinical practice guideline for the treatment of posttraumatic stress disorder (PTSD) in adults. 

Articles

While only a minority of patients with cancer may have diagnosable PTSD, subthreshold symptoms in some patients may be debilitationg enough that clinicians should be aware of the phenomenon.

Cancer-Related Posttraumatic Stress Disorder: Assessment and Treatment Considerations

Dr Richard Bogan discusses the ins and outs of sleep and psychiatric disorders and shares his thoughts about a recent FDA approval of XYWAV (calcium, magnesium, potassium, and sodium oxybates), indicated for the treatment of narcolepsy. XYWAV, 

, is "the first FDA approved new treatment option indicated for both cataplexy and excessive daytime sleepiness in people living with narcolepsy in more than 15 years." 

Dr Bogan is Medical Director, SleepMed of South Carolina; Chief Medical Officer, SleepMed, Inc; Associate Clinical Professor, University of South Carolina School of Medicine; and Associate Clinical Professor, Medical University of South Carolina in Charleston, SC.

Dr. Bogan is Medical Director, SleepMed of South Carolina; Chief Medical Officer, SleepMed, Inc; Associate Clinical Professor, University of South Carolina School of Medicine; and Associate Clinical Professor, Medical University of South Carolina in Charleston, SC.

Videos

A sleep specialist highlights what to watch out for in your patients.

Intersection of Sleep and Psychiatric Disorders

There was a consensus in the old psychiatric literature that cancer was rare in patients with psychotic illnesses such as schizophrenia, as noted in an 1891 article

. Since many researchers at the end of 19th century believed that cancer was a disease brought on by civilization (largely caused by the resultant stress), this observation surprised early researchers, who thought cancer would be more rather than less prevalent in the context of mental illness and its related stresses.

The association of cancer and schizophrenia changed over time. Early studies were based on the ratio of cancer deaths to total deaths in a given population. These studies concluded that patients with psychosis showed a significantly decreased incidence of cancer. Later investigators decided that this conclusion was unwarranted because mortality from other causes (tuberculosis being the main culprit at the time) was higher in patients with psychiatric disorders than in the population at large. Thus, cancer mortality being comparatively low was merely an illusion.

 Later still, researchers realized that important factors such as age, sex, type of cancer, and medication use should be considered before meaningful results could emerge.

For the most part, current thinking is that mortality from cancer is higher in schizophrenia than in the general population, but the actual incidence of most cancers is approximately the same.

This, however, does not apply to all cancers. For example, data have shown that patients with schizophrenia have a higher rate of breast cancer and a lower rate of melanoma and prostate cancer than controls. High incidence of breast cancer may be due to such 

as low rates of parity and breast feeding in women with schizophrenia, high incidence of smoking, hyperprolactinemia, and adiposity secondary to antipsychotic medication.

There is also speculation that genetic links may exist between the 2 diseases.

 Similarly, the low incidence of melanoma may be explained by the main environmental risk for this cancer (ie, sun exposure). Individuals with schizophrenia live their lives relatively unexposed to sun, as shown by the very low vitamin D levels in this population.

 The low rate of prostate cancer is attributed to yet other reasons—reduced sexual activity and hyperprolactinemia induced by antipsychotic drugs.

 Inexplicably, the rates of lung cancer in schizophrenia are not raised despite the fact that patients with psychiatric disorders are very often heavy smokers.

Altogether, cancer rates in schizophrenia appear to be lower than might be expected given the serious risk factors (ie, smoking and adiposity) found in this population. Two explanations have been advanced—tumor suppressor genes among genes involved in schizophrenia and tumor suppressant effects of antipsychotic medication.

 It is always possible, however, that reduced cancer rates in patients with schizophrenia may simply reflect low rates of screening and underdiagnosis as well as premature death (ie, due to tuberculosis and now cardiovascular disease).

Cancer mortality rates in schizophrenia do not reflect a reduced incidence. They are high, especially for stomach cancer, lung cancer, and breast cancer (

 examined the records of almost 35,000 veterans with lung cancer and found that those with a diagnosis of schizophrenia showed significantly poorer survival than their peers.

With respect to breast cancer, a Finnish study that controlled for age, year of cancer diagnosis, and comorbidity found significantly elevated breast cancer mortality in patients with severe mental illness.

 The researchers thought the elevation might be partly explained by cancer stage at presentation.

The discrepancy between roughly equal incidence and higher mortality is probably attributable to a variety of factors including patient, doctor, and system factors (

 For example, it has been observed that fewer patients with severe mental illness receive chemotherapy or radiation post-mastectomy compared with the general population of patients with breast cancer.

A 2020 systematic review of all cancer screening (breast, cervix, colon, lung, stomach, ovary, and prostate) publications included information on close to 5 million individuals with and without mental illness.

 The majority were women, and the median quality of all the studies was judged as high. The findings indicated that cancer screening is significantly less frequent in people with mental illness than it is in the general population. According to Howard and colleagues,

 the relative failure of patients with severe mental illness to seek cancer screening were due transportation issues, lack of reminders, and not being familiar with the process. As a result of decreased screening, cancers come to medical attention at relatively later stages and are, therefore, less amenable to treatment. In turn, these cancers are more likely to lead to treatment non-response and early death.

If the stage of presentation were not a confounding factor, would there still be a disparity in cancer care between those with psychotic illness and those without?

 Other considerations play a part, such as enrollment in trials of cancer drugs. Protocols often exclude individuals with schizophrenia on the assumption that they may not be competent to consent or will be unable to adhere to the protocol.

 Tests of competency can, of course, be administered prior to consent, so decisional capacity should not be a major drawback.

Similarly, it is possible that physicians minimize the clinical significance of the complaints from patients with psychotic disorders, attributing such complaints to psychotic phenomena (eg, diagnostic overshadowing)

 This may be due to patients’ communication difficulties and poor recall, but also to mental illness stigma, which is prevalent even among physicians. It has also been reported that patients with schizophrenia have a high pain threshold, so they may not complain until late stages of disease.

 Moreover, patients may have little family encouragement to visit their doctor when symptoms manifest. Patients with psychotic illness may be difficult to treat, not only because of relatively poor adherence to treatment regimens, but also because of extensive comorbidities, namely the high prevalence of obesity, diabetes, and cardiovascular disease. Finally, there may be 

associated with interactions among the various drugs required for the various disorders.

Outright treatment refusal may also occur, which would necessitate tests of decisional capacity and, if necessary, surrogate consent. The onus is on the psychiatric staff to liaise with non-psychiatric medical practitioners and advocate for their patients.

Disparities have been found even with end-of-life care between patients with schizophrenia and the general population.

 Such a comparison was made between 2500 patients with schizophrenia and 200,000 controls, all of whom had died in hospital as a result of cancer. The researchers also undertook a sub-analysis between the patients with schizophrenia and 10,000 controls matched 1 to 4 in terms of age, sex, and site of the primary cancer. They found that patients with schizophrenia were more likely to die younger (by 8 years) and have a shorter duration between time of diagnosis and time of death. Patients with schizophrenia were more likely than controls to receive palliative care in the last month of life but less likely to receive chemotherapy, surgery, imaging investigations, endoscopies, or blood transfusions.

A potential reason for the disparity is the increased comorbidities associated with patients who have schizophrenia. There was a large number of lung cancer deaths among the participants in this study, so another potential reason for the discrepancies was the high rate of smoking in schizophrenia populations. Interestingly, the patients with schizophrenia were less likely to have recorded metastases at the time of death than their matched controls, suggesting to the researchers that they had undergone fewer diagnostic explorations or had died of their primary cancer prior to the development of metastases, perhaps because of a delay in treatment initiation. Such a delay may be due to the fact that patients with schizophrenia were less likely than controls to have had family doctors.

Patients with schizophrenia were more likely to die younger (by 8 years) and have a shorter duration between time of diagnosis and time of death.

The results were interpreted cautiously, but the researchers stressed that evident 

 care exist. They concluded that providing clinical care to an individual with comorbid schizophrenia and cancer requires expertise in both oncology and psychiatry and necessitates training that does not exist at present. It also requires improved coordination of care among the different branches of medicine.

The issue of antipsychotics and their contribution to the cancer-schizophrenia connection is complicated. On one side are the arguments that antipsychotics predispose to cancer or make treatment less effective than it would be otherwise. On the other side are arguments that antipsychotics have anti-tumor properties.

Similarly, there have been back-and-forth discussions on antipsychotics contributing to mortality in schizophrenia via induced obesity, metabolic problems, and prolactin elevation. Most of this literature deals with the association between schizophrenia and premature death due to cardiovascular causes.

Interesting, a meta-analysis of 20 studies on the relationship between long-term mortality and exposure to antipsychotic medication in patients with schizophrenia showed that patients not taking antipsychotics had a higher mortality than those who did.

 This does not, however, exonerate antipsychotics. Patients not taking antipsychotics may receive inferior medical care, and they may have higher rates of suicide and fatal accidents. This study does not specifically address cancer mortality and the use of antipsychotics.

The controversy about cancer mortality and schizophrenia rages most fiercely around the topic of breast cancer. A critical review by 

 found that while a large body of evidence supports the involvement of prolactin in breast carcinogenesis, results of human studies remain equivocal as to the role of antipsychotics-induced hyperprolactinemia either in increasing the risk of cancer or in contributing to high mortality. The researchers concluded that a high incidence of nulliparity, and the prevalence in the schizophrenia population of obesity, diabetes mellitus, and unhealthy behaviors (eg, alcohol dependence, smoking, low physical activity), is of greater relevance to breast cancer mortality than antipsychotics.

At the same time, there is emerging evidence that at least some antipsychotics protect against cancer. Sertindole was found to be effective against breast cancer cell lines, with the suggestion that it might be able to stop breast to brain metastases.

 Other studies have found antipsychotics to be effective treatments for glioblastomas and a wide variety of other malignancies.

 These studies are thought-provoking, but they need replication.

For the clinician, this brief review recommends close health monitoring of patients with psychotic illness to prevent or treat weight gain and prolactin elevation. Should patients with schizophrenia develop cancer, there are no good reasons to take them off an effective antipsychotic drug regimen. However, drug interactions with chemotherapeutic agents may need to be checked.

More broadly, physicians need to treat patient complaints at face value even when they are communicated in a disorganized way. Decisional competence and ability to follow through on complicated therapeutic protocols should not be based on diagnosis alone; competency screening is important in such cases. To truly address the problem, all patients with schizophrenia should be linked to a primary care physician, psychiatrists and oncologists should develop a common language, and psychiatry should be more firmly integrated with the rest of medicine.

is Professor Emerita, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. She reports no conflicts of interest concerning the subject matter of this article.

1. Snow H. Cancer in its relations to insanity. 

2. Ananth J, Burnstein M. Cancer: less common in psychiatric patients? 

3. Catalá-López F, Suárez-Pinilla M, Suárez-Pinilla P, et al. Inverse and direct cancer comorbidity in people with central nervous system disorders: A meta-analysis of cancer incidence in 577,013 participants of 50 observational studies. 

4. Kyrgiou M, Kalliala I, Markozannes G, et al. 

Adiposity and cancer at major anatomical sites: umbrella review of the literature

5. Byrne EM, Ferreira MAR, Xue A, et al. Is Schizophrenia a risk factor for breast cancer? — evidence from genetic data. 

6. Kim S, Kim K, Myung W, et al. Two-sample Mendelian randomization study for schizophrenia and breast cancer. 

7. Gandini S, Sera F Cattaruzza MS, et al. Meta-analysis of risk factors for cutaneous melanoma: II. Sun exposure. 

8. Valipour G, Saneei P, Esmaillzadeh A. Serum vitamin D levels in realtion to schizophrenia: a systematic review and meta-analyss of observational studies. 

9. Raviv G, Laufer M, Baruch Y, et al. Risk of prostate cancer in patients with schizophrenia. 

10. Zhuo C, Zhuang H, Gao X, et al. Lung cancer incidence in patients with schizophrenia: meta-analysis. 

11. Zhuo C, Wang D, Zhou C, et al. Double-edged sword of tumour suppressor genes in schizophrenia. 

12. Huang J, Zhao D, Liu Z, et al. Repurposing psychiatric drugs as anti-cancer agents. 

13. Seeman MV. Schizophrenia mortality: barriers to progress. 

14. Ajdacic-Gross V, Tschopp A, Bopp M, et al. Cancer comortality patterns in schizophrenia and psychotic disorders: a new methodological approach for unique databases. 

15. Ni L, Wu J, Long Y, et al. Mortality of site-specific cancer in patients with schizophrenia: a systematic review and meta-analysis. 

16. Bradford DW, Goulet J, Hunt M, et al. A cohort study of mortality in individuals with and without schizophrenia after diagnosis of lung cancer. 

17. Ahlgrén-Rimpiläinen AJ, Arffman M, Suvisaari J, et al. Excess mortality from breast cancer in female breast cancer patients with severe mental illness. 

18. Zhou L, Bi Y, Liang M, et al. A modality-specific dysfunction of pain processing in schizophrenia. 

19. Seeman MV. Schizophrenia and cancer: low incidence, high mortality. 

20. Shinden Y, Kijima Y, Hirata M, et al. Clinical characteristics of breast cancer patients with mental disorders. 

21. Solmi M, Firth J, Miola A, et al. Disparities in cancer screening in people with mental illness across the world versus the general population: prevalence and comparative meta-analysis including 4 717 839 people. 

22. Howard LM, Barley EA, Davies E, et al. 

Cancer diagnosis in people with severe mental illness: practical and ethical issues

23. Irwin KE, Henderson DC, Knight HP, et al. Cancer care for individuals with schizophrenia. 

24. Humphreys K, Blodgett JC, Weiss Roberts L. The exclusion of people with psychiatric disorders from medical research. 

25. Irwin KE, Moy B, Fields LE, et al. Expanding access to cancer clinical trials for patients with mental illness. 

26. Jones S, Howard L, Thornicroft G. ‘Diagnostic overshadowing’: worse physical health care for people with mental illness. 

27. Fond G, Salas S, Pauly V, et al. End-of-life care among patients with schizophrenia and cancer: a population-based cohort study from the French national hospital database. 

28. Vermeulen J, van Rooijen G, Doedens P, et al. Antipsychotic medication and long-term mortality risk in patients with schizophrenia; a systematic review and meta-analysis. 

29. de Mooij LD, Kikkert M, Theunissen J, et al. Dying too soon: Excess mortality in severe mental illness. 

30. De Hert M, Peuskens J, Sabbe T, et al. 

Relationship between prolactin, breast cancer risk, and antipsychotics in patients with schizophrenia: a critical review

31. Zhang W, Zhang C, Liu F, et al. Antiproliferative activities of the second-generation antipsychotic drug sertindole against breast cancers with a potential application for treatment of breast-to-brain metastases. 

32. Lee JK, Nam DH, Lee J. Repurposing antipsychotics as glioblastoma therapeutics: Potentials and challenges. 

33. Zhuo C, Xun Z, Hou W, et al. Surprising anticancer activities of psychiatric medications: Old drugs offer new hope for patients with brain cancer. 

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https://www.cancer.gov/about-cancer/understanding/disparities

35. Ji J, Chen X. Incidence of cancer in patients with schizophrenia and their first-degree relatives: a population-based study in 

Patients with schizophrenia often have worse outcomes than their peers without the diagnosis. How you can support your patient in ensuring a better cancer prognosis?

Special Issues in Schizophrenia and Cancer

We are very appreciative of the opportunity to present some excellent articles on the interface between psychiatry and oncology, which we know will be useful to you in your practice.

Jimmie Holland, MD, a pioneer and one of the founders of the field of psycho-oncology, mentored many of us and advocated all of us to study, understand, teach, research and care about, and provide for the emotional and psychological needs of people with cancer. She lived and breathed a biopsychosocial approach in the screening, evaluation, treatment, and management of distress, a sixth vital sign.

The articles in Part I of this Special Report discuss PTSD in cancer, special issues for patients with schizophrenia and cancer, and distress management.

Thanks to Dr Holland and others, if you are interested in learning more and want to get active in this field, there are major organizations, founded by Dr Holland, such as the International Psycho-Oncology Society, founded in 1984 and the American Psychosocial Oncology Society, founded in 1986. Dr Holland also gave us Psycho-Oncology, one of our premier peer-reviewed journals, for which she served as founder and co-editor in chief. Dr Grassi and I were honored and privileged to take over the reins of the World Psychiatric Association Section on Psycho-Oncology and Palliative Care from Dr Holland.

There is an active and very productive Interest Group on Psycho-Oncology within the Academy of Consultation-Liaison Psychiatry (ACLP) organization, with many wonderful presentations highlighted at the annual meetings of ACLP. With increasing numbers of US psychiatry residents choosing fellowship training in consultation-liaison psychiatry, clinical and research rotations, electives, and core lectures on psycho-oncology are part of the curriculum in Residency Review Committee-accredited consultation liaison fellowship programs. More and more medical students are interested in this field, as well.

Dr Holland was the inaugural chair of the Distress Guidelines of the National Comprehensive Cancer Network (NCCN). She played a key role in the development of the Distress Thermometer, which enables patients and clinicians to talk the same language to discuss anxiety, depression and other issues that can be distressing, on a scale of zero-to-10, similar to the way pain is discussed and measured. I (Riba) was humbled to be asked to take over as chair of the NCCN Distress Guidelines after we lost Dr Holland on Christmas Eve 2017. Her imprint on our field and on our profession will be long lasting and for that, we are so grateful.

We know you will find these articles in Part I, and later in Part II, to be stimulating and useful—we hope that the information will help you in your multi-disciplinary work with patients and families. We also encourage you to check out some of the organizations previously listed should you want to get more involved in the journals, NCCN, and other guidelines that are updated regularly and provide cutting-edge information based on evidence-based findings.

 is Professor, Department of Psychiatry, and Director, PsychOncology, University of Michigan Rogel Cancer Center, Ann Arbor, MI; Dr Grassi is Professor and Chair of Psychiatry, University of Ferrara, Department of Biomedical and Specialty Surgical Sciences, and Director, University Hospital Psychiatry Unit, S. Anna University Hospital and Health Authorities Ferrara, Italy. They report no conflicts of interest concerning the subject matter of this Special Report.

Introduction: The Interface Between Psychiatry and Oncology

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Jonathan Shedler, PhD is known internationally as an author, researcher, and clinical educator. His 2010 article 

The Efficacy of Psychodynamic Psychotherapy

 won worldwide acclaim for establishing psychodynamic therapy as an evidence-based treatment. His research and writing on personality are shaping contemporary views of personality syndromes and their treatment. He is co-creator of the 

Shedler-Westen Assessment Procedure (SWAP)

, a clinician-completed psychological test for personality assessment and clinical case formulation. He is co-author (with Nancy McWilliams) of the Personality Syndromes section of the Psychodynamic Diagnostic Manual (PDM-2). He is a sought-after international speaker and provides clinical consultation to mental health professionals worldwide. Dr Shedler is clinical professor of psychiatry at the University of California, San Francisco.

Over the past 2 decades, Dr Shedler has emerged as one of the most articulate and prominent defenders of the psychoanalytic tradition of psychotherapy, and he has been on a mission to remedy the misconceptions about psychodynamic thinking that are rampant in psychiatry and psychology. His ire is particularly directed at the misapplication of “evidence-based” therapy, where assumptions of research protocols are being used to constrain clinical practice in ways that are not only unjustified but also harmful. I have found myself drawn to his ideas because he offers a distinct psychodynamic perspective on the ways in which decontextualized descriptive diagnoses, biomedical formulations, and manualized interventions have led to an impoverished view of human suffering. Dr Shedler is one of those rare individuals who can combine scientific rigor, clinical wisdom, and penetrating insight into the human condition, and are able to do so with refreshing honesty and great personal charm.

 I was fortunate during my psychiatry residency training to have a wonderful supervisor for my long-term psychotherapy patients. He was a psychiatrist and a psychoanalyst, and he helped broaden my clinical and conceptual horizons (Drew Clemens, if you are reading this, here’s a shout out to you!). I read Nancy McWilliams’ book on psychoanalytic psychotherapy, 

 by Freud, Kohut's articles on self-psychology, essays by Aisha Abbassi, and so forth. Contrary to many older psychiatrists who had rebelled against “psychoanalytic dogma,” I was coming to this literature with a relatively untainted perspective and didn't feel the need to approach it with antagonism.

I was struck by how much “wisdom” there is in the psychoanalytic literature but also how difficult it is to translate that wisdom into contemporary scientific thinking in psychiatry. It felt like a living reminder of what Thomas Kuhn refers to as the “incommensurability” of scientific paradigms, that differences in concepts, methods, and target problems make it such that different scientific paradigms are “always talking at least slightly at cross-purposes.”

 You are well-familiar with the world of scientific research as well as psychoanalysis. How do you feel about the difficulty of communication between these 2 ways of thinking?

 I do not see scientific and psychoanalytic thinking as different ways of thinking. Good scientific thinking is critical thinking. Good clinical thinking is critical thinking. What are our assumptions? Can we articulate them? Can we justify them? What do we think we know and why? What would lead us to revise it? Scientists and practitioners should ask these questions. There aren’t separate ways of thinking. There is critical thinking and lack thereof.

The problem is that researchers and psychotherapists operate in different silos and often have little understanding of one another’s work—or the questions they consider relevant. Academic psychiatrists who pursue research careers may not have patients after residency, let alone practice psychotherapy. Academic psychologists may never work with a patient in their lives. Unless they get meaningful personal therapy, they cannot know what happens in psychotherapies of depth, insight, and relationship. Many researchers have trouble even conceptualizing psychotherapy as something with a purpose other than alleviating DSM symptoms. That is not its purpose.

One purpose of psychoanalytic therapy is to insert spaces for reflection where they have not previously existed and so create opportunities to know ourselves more fully, connect with others more deeply, and live life more congruently. Alleviating DSM symptoms is far down the list of what patients want from psychotherapy and what experienced psychotherapists focus on. That is not opinion; those are empirical findings.

So, why do psychotherapy researchers proceed from the assumption that outcome means DSM-based symptom checklists? There is no scientific reason we cannot operationalize the kinds of psychological changes patients want and experienced therapists work toward. Researchers make different assumptions. The result is psychotherapy research with little relevance to the practice of psychotherapy.

 A lot of psychiatrists who underwent training in the 70s and 80s have negative memories of their encounters with psychoanalysis. I have heard too many personal “horror stories” from psychiatrists I deeply respect to dismiss them as exceptions. In your view what accounts for this experience of mass discontent and disenchantment? What do you think are the major mistakes made by the psychoanalytic community that led to their “downfall” and loss of dominance in the profession? To what extent was it a misapplication of psychoanalytic ideas to severe mental illness such as schizophrenia (in the form of notions such as the “schizophrenogenic mother”)?

The horror stories are real; I’ve heard them too. Actually, I’ve lived some of them. There is an apt 

 from Kevin Philips: “Any ideology that enjoys success first fulfills itself and then indulges in some hubris.” When psychoanalysis was the dominant paradigm, it indulged in some horrific hubris. Psychoanalytic training institutes were arrogant and insular. They separated themselves from other sources of knowledge and were openly disdainful of empirical research. Establishment psychoanalysis was the purview of MDs and psychologists were excluded. The medical authoritarianism of the time combined with the insularity of the analytic institutes and created a mix of superiority and dogma. It did not help that treatment and training took place in secrecy. Under those circumstances, abuses were inevitable.

Psychoanalysis is still paying for the excesses of decades past, probably deservedly. But the backlash against psychoanalytic knowledge is also impoverishing our thinking in the mental health professions. We are losing vitally important ways of understanding and alleviating human suffering. Fundamental, timeless truths are being lost or trivialized. One fundamental truth is that none of us fully know our own hearts and minds, and what we don’t know can hurt us. An aim of psychodynamic or psychoanalytic therapy is to help us know aspects of self that were previously unknown, so we can become better and more whole versions of ourselves. (For a jargon-free introduction to contemporary dynamic thought, see my monograph 

That Was Then, This is Now: Psychoanalytic Psychotherapy for the Rest of Us

You asked about schizophrenia. Obviously, schizophrenia—or more likely, the range of conditions we call schizophrenia—has biological and genetic diatheses. No living psychoanalyst would say otherwise. So, to answer your question, of course it was a misapplication of psychoanalytic concepts. There was an 

 assumption that mental illness is caused by intrapsychic conflict and reasoning proceeded from that assumption. Again, it comes back to unexamined assumptions.

But aren’t we seeing the same kind of arrogance and reductionism in psychiatry today? How many make 

 assumptions that mental and emotional distress should be understood in terms of brain circuitry or chemistry? I cannot tell you how many depressed patients I’ve worked with in psychotherapy, successfully, or my supervisees have worked with, who had been on one medication after another for years or decades with little benefit. The idea that their difficulties could have 

—meanings that could be understood and potentially reworked—was foreign to them. It was also, apparently, foreign to the doctors who treated their depression previously, because no one even raised it as a possibility (see my blog post 

These patients often go from antidepressants to mood stabilizers to atypicals, not necessarily in that order. When they don’t improve, the answer seems to be more medication. We see polypharmacy nightmares, with patients on 5 or 6 or more psychiatric medications, and they are just as depressed as when they started. Some in psychiatry talk the talk about a biopsychosocial model but the walk is bio and nothing else. How is that less dogmatic or reductionist than the notion of a schizophrenogenic mother?

 What is your view on the relationship between clinical psychology and medicine? There is a tendency within psychiatry to conceptualize clinical psychology as falling within the purview of the medical model (under the umbrella of the biopsychosocial model). Cognitive behavioral therapists certainly appear to have made little attempt to distance themselves from the medical model. My own inclination is that clinical psychology and medicine are complementary with overlapping but different historical roots, perspectives, training skills, and target populations . . . and this constant tension of trying to fit clinical psychology within the medical framework may not be the healthiest thing for either profession.

It’s complicated and I’ve written a little about it in a 

 post. Your understanding is correct: Psychology has its own history, concepts, and methods. Wilhelm Wundt established the first experimental psychology laboratory in 1879 at the University of Leipzig, applying scientific methods to study mental life at a time when medicine still practiced bloodletting.

We would do well to build on psychological concepts and methods instead of trying to shoehorn psychology into a medical model that doesn’t necessarily fit. For example, we could study psychological processes that underlie mental and emotional suffering—not DSM categories. We could study how psychological changes can alter the trajectory of a life, not just symptom lists. The methodology exists.

My coinvestigators and I developed a personality assessment method for this purpose, called the 

 that is clinically relevant and empirically grounded.

 A research team led by Bob Spitzer conducted a “consumer preference” study comparing 5 systems for personality diagnosis that had been proposed for DSM-5, and psychiatrists and psychologists overwhelmingly preferred ours. It was more faithful to the personality syndromes seen in clinical practice and more relevant to clinical treatment. But there were too many vested interests jockeying for influence in the run up to DSM-5.

In this interview, Dr Aftab and Dr Shedler discuss the relationship between the psychoanalytic worldview and the medical model, and they reexamine the role of psychodynamic psychotherapy in contemporary psychiatry and psychology.

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