Cancer and Post-traumatic Stress Disorder

by National Cancer Institute

Some survivors of cancer experience trauma-related symptoms similar to symptoms experienced by people who have survived highly stressful situations, such as military combat, natural disasters, violent personal attack (such as rape), or other life-threatening events. This group of symptoms is called posttraumatic stress disorder (PTSD) and includes avoiding situations related to the trauma, continuously thinking of the trauma, and being overexcited.

People with histories of cancer are considered to be at risk for PTSD. The physical and mental shock of having a life-threatening disease, of receiving treatment for cancer, and living with repeated threats to one's body and life are traumatic experiences for many cancer patients.

Diagnosis and Symptoms

Posttraumatic stress disorder (PTSD) is defined as the development of certain symptoms following a mentally stressful event that involved actual death or the threat of death, serious injury, or a threat to oneself or others. For the person who has experienced a diagnosis of cancer, the specific trauma that triggers PTSD is unclear. It may be the actual diagnosis of a life-threatening illness, aspects of the treatment process, test results, information given about recurrence, or some other aspect of the cancer experience. Learning that one's child has cancer is traumatic for many parents. Because the cancer experience involves so many upsetting events, it is much more difficult to single out one event as a cause of stress than it is for other traumas, such as natural disasters or rape. The traumatic event may cause responses of extreme fear, helplessness, or horror and may trigger PTSD symptoms.

PTSD in cancer survivors may be expressed in these specific behaviors:

• Reliving the cancer experience in nightmares or flashbacks and by continuously thinking about it.
• Avoiding places, events, and people connected to the cancer experience.
• Being continuously overexcited, fearful, irritable, and unable to sleep.

To be diagnosed as PTSD, these symptoms must last for at least one month and cause significant problems in the patient's personal relationships, employment, or other important areas of daily life. Patients who have these symptoms for less than one month often develop PTSD later.

Risk Factors, Protective Factors, and the Development of PTSD

As many as one third of people who experience an extremely upsetting event, including cancer, develop posttraumatic stress disorder (PTSD). The event alone does not explain why some people get PTSD and others don't. Although there is no clear answer as to which cancer survivors are at increased risk of developing PTSD, certain mental, physical, or social factors may make some people more likely to experience it.

Individual and social factors

Individual and social factors that have been associated with a higher incidence of PTSD include younger age, fewer years of formal education, and lower income.

Disease-related factors

Certain disease-related factors are associated with PTSD:

• In patients who received a bone marrow transplant, PTSD occurs more often when there is advanced disease and a longer hospital stay.
• In adult survivors of bone cancer and Hodgkin's lymphoma, people for whom more time has passed since diagnosis and treatment tended to show fewer symptoms.
• In survivors of childhood cancer, symptoms of PTSD occur more often when there was a longer treatment time.
• Interfering thoughts occur more often in patients who experienced pain and other physical symptoms.
• Cancer that has returned has been shown to increase stress symptoms in patients.

Mental factors

Mental factors may affect the development of PTSD in some patients:

• Previous trauma.
• Previous psychological problems.
• High level of general stress.
• Genetic factors and biological factors (such as a hormone disorder) that affect memory and learning.
• The amount of social support available.
• Threat to life and body.
• Having PTSD before being diagnosed with cancer.
• The use of avoidance to cope with stress.

Protective factors

Certain factors may decrease a person's chance of developing PTSD. These include increased social support, accurate information about the stage of the cancer, and a satisfactory relationship with the medical staff.

How PTSD may develop

PTSD symptoms develop by both conditioning and learning. Conditioning explains the fear responses caused by certain triggers that were first associated with the upsetting event. Neutral triggers (such as smells, sounds, and sights) that occurred at the same time as upsetting triggers (such as chemotherapy or painful treatments) later cause anxiety, stress, and fear even when they occur alone, after the trauma has ended. Once established, PTSD symptoms are continued through learning. The patient learns that avoiding the triggers prevents unpleasant feelings and thoughts, so coping by avoidance continues.

Although conditioning and learning are part of the process, many factors may explain why one person develops PTSD and another does not.

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