December 14, 2011

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Most people conceptualize posttraumatic stress disorder (PTSD) as a condition rooted in horror on a grand scale: war, acts of terrorism, and cataclysmic natural disasters. Historically, when patients with cancer and other life-threatening diseases were plagued by intense distress about memories about their diagnosis or treatment, their symptoms didn't count.

Disease-related traumatic symptoms were explicitly excluded from the criteria for PTSD in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) of the American Psychiatric Association.

By 1994, when the DSM-IV was published, it recognized that trauma associated with the diagnosis and treatment of a major illness could lead to unshakable symptoms of re-experiencing, avoidance, and increased arousal that are serious enough to impair one’s functioning.

Today, the "bible" of psychiatric diagnosis is undergoing yet another revision, soon to be unveiled as DSM-V. The proposed PTSD criteria are likely to allow for the diagnosis not only in individuals who have experienced exposure to "actual or threatened" death, serious injury, or sexual violation, but also in those who have witnessed or heard about such exposure, or been connected with extreme exposure to reminders of such an event. The DSM-V will also include expanded symptom criteria for diagnosing PTSD in children, including pediatric cancer patients.

The National Cancer Institute notes that unlike some time-limited traumatic events, cancer may expose patients to "repeated traumas of undetermined length," followed by endless concern over recurrence.

A recent overview from Baylor University researchers speaks to the need to recognize and treat cancer-related PTSD, which has been reported to have a lifetime incidence of 3% to 22% among survivors.

The group’s findings, published in the Journal of Psychiatric Practice (2011:4:270-276), summarize findings from a number of studies. The authors determined that three clusters of symptoms central to a PTSD diagnosis were commonly found in studies of cancer survivors. These are:

• Frequent intrusive thoughts (including flashbacks and nightmares): 16%-28%

• High levels of emotional numbness and avoidance: 15%-34%

• Hypervigilance and physiological arousal: 25%.

A threshold of symptoms from these clusters is required for diagnosis of PTSD, but many cancer patients may experience significant, sub-threshold reminders of the trauma of their experience.

Anyone who has listened well when survivors tell their stories will recognize the numb recounting of a particularly frightening procedure, the anxious catch in the breath while recalling the hearing of bad news delivered long ago.

The Baylor investigators point out that increasing rates of cancer and survivorship heighten the need for recognition and treatment of PTSD, which doesn’t simply fade away with time. Untreated, the disorder can perpetuate nonadherence, increase pain and disability, and undermine patients’ will to live, they note, "add[ing] morbidity to already difficult care."

Next week: Recognizing Resiliency and Risk in Cancer Patients

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