5 Key Concepts in Cancer-Related PTSD

August 17, 2020

Are patients with cancer also vulnerable to PTSD?

While having a diagnosis of—and being treated for—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 documenting 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 while self-reported symptoms are common, only a small minority of cancer patients meet formal diagnostic criteria for cancer-related PTSD. Across studies, more than 50% of cancer patients meet the DSM-IV-TR stressor criteria, and they experience fear, helplessness, or horror. Estimate show 6.4% to 12.6% will meet the PTSD criteria.

About 10% to 20% of patients may experience subsyndromal PTSD symptomology. Although these patients may not receive a diagnosis of PTSD, the symptoms may be impairing and warrant clinical attention.

Younger age, lower socioeconomic status, past trauma, pre-existing 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 patients.

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). Plus, what constitutes cessation of the traumatic stressor is unclear in cancer. This all calls into question whether there is a post-trauma point at which to assess post-traumatic stress in cancer patients.

A limited evidence-base is available to inform treatment of cancer-related PTSD. Some research has shown that cognitive behavioral therapy (CBT; imaginal and in vivo exposure, cognitive restructuring) and eye movement desensitization and reprocessing (EMDR) benefit those with elevated cancer-related PTSD symptoms. Supportive-expressive group and cognitive behavioral stress management have also shown an effect on cancer-related PTSD symptoms. Meanwhile, evidence to guide psychopharmacologic treatment of cancer-related PTSD is lacking.

For more on this topic, see Cancer-Related Posttraumatic Stress Disorder: Assessment and Treatment Considerations, on which this slideshow is based.