Post-traumatic Stress and PTSD in People with Cancer

Symptoms of Post-Traumatic Stress and PTSD in People with Cancer

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What's known about post-traumatic stress in people with cancer?. Flickr.com/creative commons/bottled_void

Do people with cancer really experience post-traumatic stress disorder? Certainly having cancer is stressful, but when does this stress become a greater concern?  What is considered "normal stress" in cancer patients and cancer survivors, and what instead suggests that someone is suffering from a condition which needs to be addressed to live as healthy as possible?

What is Post-Traumatic Stress (PTS) and Post-Traumatic Stress Disorder (PTSD)?

Post-traumatic stress disorder (PTSD) is an anxiety disorder that occurs after someone experiences a life-threatening situation or the threat of serious injury or death.

Most people are familiar with PTSD in people who have survived the atrocity of war, or physical assaults such as rape, but more recently, serious illness has been added to the list of causes.

In 1994, the DSM-IV (The Diagnostic and Statistical Manual of Mental Disorders) was expanded to include life-threatening illnesses as traumatic events which could contribute to the development of PTSD. As such, it's now felt that many people who are diagnosed and living with cancer experience the same distressful symptoms as those who have experienced violent crimes and natural disasters.

For the purpose of this article, post-traumatic stress (PTS) or post-traumatic stress symptoms (PTSS) are considered similar to PTSD, but of a shorter duration or a milder degree.

Why Do Cancer Patients and Cancer Survivors Develop PTSD?

People with cancer develop post-traumatic stress by a process of conditioning and learning.

In this process an upsetting trigger such as surgical pain, chemotherapy, your initial diagnosis, or a grueling hospitalization, is linked with neutral triggers such as sights (the cancer center,) sounds (even a special song you listened to during radiation therapy,) smells (such as the medicinal smell of a hospital unit,) or touch.

Later on, distressing symptoms may be triggered by exposure to the neutral stimulus alone. For example, hearing that song list you played during chemotherapy might cause you to feel fearful, begin crying, or startle easily. You may avoid visiting a friend at the cancer center where you had surgery because the sights and smells cause you to lose your appetite and become irritable.

How Common is PTS and PTSD in People with Cancer?

Several studies have looked at the incidence of PTSD in people with several forms of cancer. Combined, it appears that 3-4 percent of newly diagnosed cancer patients, and as many as 35 percent of cancer patients after treatment, meet the criteria for PTSD. On the other hand, people who have "PTSD-like symptoms" include 20 percent of newly diagnosed cancer patients and up to 80% of patients with a cancer recurrence.

Cancer Caregivers May Also Experience PTS and PTSD

People rarely experience cancer in isolation, and as such, cancer is usually considered a family disease.

Not only do family members worry about helping stressed loved ones with cancer, caregivers may struggle with post-traumatic stress symptoms themselves. In fact, in a recent study looking at people with head and neck cancer, it was found that partners experience higher levels of post-traumatic stress than patients.

When Do PTS and PTSD Occur in People with Cancer?

Post-traumatic stress and post-traumatic stress disorder may occur anytime after a diagnosis of cancer - and even during the "could-it-be?" stage. While often symptoms develop within 3 months of a significantly stressful time, they may not occur for years or even decades after treatment has been completed. Common times associated with the onset of symptoms include:

  • At the time of diagnosis.
  • When a cancer recurs.
  • Situations which bring to the forefront the fear of recurrence.
  • Painful times due to the cancer, pain from surgeries, and from tests and procedures.
  • Long treatment programs, such as multiple sessions of chemotherapy or radiation therapy.
  • Long hospitalizations.
  • At the end of treatment.
  • When a cancer becomes terminal.

Risk Factors

Why do some people with cancer develop PTSD, but not others? Nobody is sure why, but there are factors that increase the risk that a cancer patient will develop PTSD or experience some degree of post-traumatic stress symptoms. Some of these include:

  • A younger age at diagnosis.
  • More advanced and/or more aggressive cancers.
  • A longer duration of cancer treatment.
  • Cancer recurrence.
  • Being female, especially minority females.
  • A history of PTSD and/or other mental health conditions before a diagnosis of cancer.
  • High stress levels.
  • Being single.
  • A history of trauma.
  • Low levels of social support.
  • A lower income level.
  • A lower education level.
  • A history of drug or alcohol abuse.

Signs and Symptoms

Of course, some anxiety is normal after being diagnosed with a potentially life-threatening disease like cancer. Nearly everyone feels frightened at times, distracted at others, and has difficulty concentrating.  The difference between "normal" stress and anxiety in cancer patients and PTSD is often related to the severity of the symptoms, the number of symptoms, and how they interfere with life. Some symptoms may include:

  • Nightmares.
  • Avoiding people and places that remind someone of cancer.
  • Loss of interest in activities you once enjoyed.
  • Flashbacks.
  • Guilt.
  • Shame.
  • Hopelessness.
  • Helplessness.
  • Insomnia and other sleeping problems.
  • Feeling emotionally numb.
  • Feeling detached from other people.
  • Sadness.
  • Being easily startled.
  • Becoming frightened easily.
  • Excitability.
  • Memory problems.
  • Difficulty concentrating.
  • Irritability.
  • Invasive thoughts.
  • Loss of appetite.
  • Crying.
  • Hallucinations - auditory or visual.
  • Self-destructive behaviors such as alcohol and drug abuse, taking unnecessary risks.

Diagnostic Criteria for Post-Traumatic Stress Disorder in Cancer Patients

To meet the criteria of post-traumatic stress disorder,  people must experience symptoms in each of  following 3 categories.

  1. Re-experiencing the trauma (re-living the cancer experience) - for example, having nightmares and flashbacks.
  2. Persistent avoidance of reminders of the trauma - for example, avoiding clinics or hospitals, or people associated with the cancer, or feeling emotionally numb or detached.
  3. Persistent increased arousal - for example, suffering from insomnia, irritability, becoming frightened easily, or startling easily.

Also, for a diagnosis to be made, the symptoms must be present for at least 1 month and cause problems in relationships, employment, activities of daily living, or significant distress.

Post-Traumatic Stress Symptoms Without a Diagnosis of PTSD

Cancer survivors may have several symptoms of PTSD but not meet the criteria described above. That said, many of the tips discussed below may be helpful for people with milder degrees of post-traumatic stress. It's also important to note that over time, someone who does not yet meet the criteria for a diagnosis of PTSD may develop symptoms consistent with these criteria later on. Long-term monitoring is very important.

Treatments

The best treatment for PTSD is usually a combination of treatments.  Some of these include:

Resources for Finding Help:

Non-Medication/Non-Therapist Treatments for PTSD

PTSD and PTSD-like symptoms are under-treated in people with cancer, which makes sense. After all, common "triggers" are the sites, sounds, and smells in a medical clinic, and even the site of a medication. It's important to talk to your doctor about all options, but a few often overlooked treatments include:

  • Involvement in a support group. There are even online support groups specifically designed for people with cancer suffering from post-traumatic stress.
  • Relaxation training.
  • Alternative therapies - Some therapies that may be helpful when combined with medical care include meditation, guided imagery, massage therapy, mindfulness-based stress reduction, qigong, prayer, yoga, aromatherapy, music therapy, art therapy, or journaling.

Consequences of Untreated PTSD in People With Cancer

Consequences of undiagnosed and untreated PTSD are serious and can include:

  • Interference with treatment as people avoid cancer treatments and follow-up care.
  • Predisposition to other mental illness, drug abuse, and alcohol abuse.
  • Social isolation and loss of important relationships.
  • Loss of employment.
  • Poor quality of life.

Tips for Coping With Post-Traumatic Stress

  • Don’t try to go it alone.
  • Surround yourself with positive people.
  • Avoid negative people.  You know who I'm talking about.  Are there people in your life who "encourage" you to be stressed out?
  • Don't be afraid to talk about it.  Keep in mind that it takes courage to ask for help.
  • Get enough sleep whenever possible.  The following article may help: Managing Sleep Problems When You Have PTSD.
  • Get regular exercise.
  • Eat a healthy diet.
  • Avoid stimulants such as caffeine and nicotine.
  • Avoid alcohol.
  • Practice stress relief.
  • Find a new passion - perhaps a new hobby or a new creative outlet.
  • Try a handful of blueberries.  A recent study on rodents found that a blueberry-enriched diet caused changes in the brain thought to be beneficial for PTSD.
  • Add a little salmon, flax, or a few walnuts to your diet. One study found a diet high in omega-3 fatty acids reduced the symptoms of PTSD.

Prevention/Factors That Lower Risk

While it may not be possible to prevent post-traumatic stress symptoms completely, there are factors associated with a lower risk including:

  • Having a strong social support system.
  • Being educated about your particular type of cancer.
  • Having good relationships with health care providers.

Next steps

Fortunately, a fairly new concept called "post-traumatic growth" also occurs for many cancer survivors.  Some people may call this the "blessings of cancer" or the "gifts of cancer." Studies have found that people who have lived with a diagnosis of cancer often develop greater empathy for others, an increased appreciation of life, and personal growth. If you are struggling with finding meaning after cancer, see if you can find ways to connect with others in the cancer community who have faced similar challenges.

As a final note, not only have many cancer survivors found that reciting a loving kindness meditation helps them cope with the disease, but a few studies have actually found that such meditations are beneficial in coping with PTSD. Our favorite loving kindness meditation goes as follows.

"My I be filled with loving-kindness.

May I be healthy and well.

May I be peaceful, content and at ease.

May I be filled with joy."  - The Path of the Heart by Jack Kornfield

And here is an article on how to practice a loving kindness meditation.

Sources:

American Psychological Society. Blueberries show promise as treatment for post-traumatic stress disorder. Press Release 03/15/15.

French-Rosas, L., Moye, J., and A. Naik. Improving the recognition and treatment of cancer-related posttraumatic stress disorder. Journal of Psychiatric Practice. 2011. 17(4):270-6.

Gold, J. et al. The relationship between posttraumatic stress disorder, mood states, functional status, and quality life in oncology patients. Pain and Symptom Management. 2012. 44(4):520-31.

Kearney, D. et al. Loving-kindness meditation for posttraumatic stress disorder: a pilot study. Journal of Traumatic Stress. 2013. 26(4):426-34.

Kim, S. et al. Mind-body practices for posttraumatic stress disorder. Journal of Investigative Medicine. 2013. 61(5):827-34.

Matsumura, K., Noguchi, H., Nishi, D., and Y. Matsuoka. The effect of omega-3 fatty acids on psychophysiological assessment for the secondary prevention of posttraumatic stress disorder: an open-label pilot study. Global Journal of Health Science. 2011. 4(1):3-9.

Moye, J., and S. Rouse. Posttraumatic Stress in Older Adults: When Medical Diagnoses or Treatments Cause Traumatic Stress. Psychiatric Clinics of North America. 2015. 38(1):45-57.

Perez, S. et al. Posttraumatic stress symptoms in breast cancer patients: temporal evolution, predictors, and mediation. Journal of Traumatic Stress. 2014. 27(2):224-31.

Posluszny, D. et al. Posttraumatic stress disorder symptoms in newly diagnosed patients with head and neck cancer and their partners. Head & Neck. 2014 May 12. (Epub ahead of print)

Vin-Raviv, N. et al. Racial disparities in posttraumatic stress after diagnosis of localized breast cancer: the BQUAL study. Journal of the National Cancer Institute. 2013. 105(8):563-72.

Wachen, J. et al. Cancer-related PTSD symptoms in a veteran sample: association with age, combat PTSD, and quality of life. Psychooncology. 2014. 23(8):921-7.

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