Introduction
Overview
Diagnosis and Symptoms
Risk Factors, Protective Factors, and the Development of PTSD

Individual and social factors Disease-related factors Mental factors Protective factors How PTSD may develop

Assessment
Treatment
Get More Information From NCI
Changes to This Summary (07/16/2007)
Questions or Comments About This Summary
About PDQ

Introduction

This patient summary on posttraumatic stress disorder is adapted from the summary written for health professionals by cancer experts. This and other credible information about cancer treatment, screening, prevention, supportive care, and ongoing clinical trials, is available from the National Cancer Institute. Better treatment of many cancers has resulted in more patients experiencing longer periods of disease-free survival. This has also led to more patients experiencing psychological problems, which are collectively called posttraumatic stress disorder. This brief summary describes posttraumatic stress disorder, its symptoms, and its treatment.

Overview

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

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 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 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.

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.

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.

Assessment

It is important that cancer patients undergo a careful assessment for posttraumatic stress disorder (PTSD) so that early symptoms may be identified and treated. The timing of this assessment will vary with the individual patient. Cancer is an experience of repeated traumas and undetermined length. The patient may experience stress symptoms anytime from diagnosis through completion of treatment and cancer recurrence. In patients who have a history of victimization (such as Holocaust survivors) and who have PTSD or its symptoms from these experiences, symptoms can be started again by certain triggers experienced during their cancer treatment (for example, clinical procedures such as being inside MRI or CT scanners). While these patients may have problems adjusting to cancer and cancer treatment, their PTSD symptoms may vary, depending on other factors. The symptoms may become more or less prevalent during and after the cancer treatment.

Symptoms of PTSD usually begin within the first 3 months after the trauma, but sometimes they do not appear for months or even years afterwards. Therefore, cancer survivors and their families should be involved in long-term monitoring.

Some people who have experienced an upsetting event may show early symptoms without meeting the full diagnosis of PTSD. However, these early symptoms predict that PTSD may develop later. Early symptoms also indicate the need for repeated and long-term follow-up of cancer survivors and their families.

Diagnosing PTSD can be difficult since many of the symptoms are similar to other psychiatric problems. For example, irritability, poor concentration, increased defensiveness, excessive fear, and disturbed sleep are symptoms of both PTSD and anxiety disorder. Other symptoms are common to PTSD, phobias, and panic disorder. Some symptoms, such as loss of interest, a sense of having no future, avoidance of other people, and sleep problems may indicate the patient has PTSD or depression. Even without PTSD or other problems, normal reactions to the cancer diagnosis and treatment of a life-threatening disease can include interfering thoughts, separating from people and the world, sleep problems, and over-excitability.

Questionnaires and interviews are used by health care providers to assess if the patient has symptoms of stress and to determine the diagnosis.

Other problems may also exist in addition to PTSD. These problems can include substance abuse, emotional problems, and other anxiety disorders, including major depression, alcohol dependence, drug dependence, social fears, and/or obsessive-compulsive disorder.

Treatment

Effects of posttraumatic stress disorder (PTSD) are long-lasting and serious. It may affect the patient's ability to have a normal lifestyle and may interfere with personal relationships, education, and employment. Because avoiding places and persons associated with cancer is part of PTSD, the syndrome may prevent the patient from seeking medical treatment. It is important that cancer survivors receive information about the possible psychological effects of their cancer experience and early treatment of symptoms of PTSD. Therapies used to treat PTSD are those used for other trauma victims. Treatment may involve more than one type of therapy.

The crisis intervention method tries to lessen the symptoms and return the patient to a normal level of functioning. The therapist focuses on solving problems, teaching coping skills, and providing a supportive setting for the patient.

Some patients are helped by methods that teach them to change their behaviors by changing their thinking patterns. Some of these methods include helping the patient understand symptoms, teaching coping and stress management skills (such as relaxation training), teaching the patient to reword upsetting thoughts, and helping the patient become less sensitive to upsetting triggers. Behavior therapy is used when the symptoms are avoidance of sexual activity and intimate situations.

Support groups may also help people who experience posttraumatic stress symptoms. In the group setting, patients can receive emotional support, meet others with similar experiences and symptoms, and learn coping and management skills.

For patients with severe symptoms, medications may be used. These include antidepressants, antianxiety medications, and when necessary, antipsychotic medications.

Get More Information From NCI

Call 1-800-4-CANCER

For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 9:00 a.m. to 4:30 p.m. Deaf and hard-of-hearing callers with TTY equipment may call 1-800-332-8615. The call is free and a trained Cancer Information Specialist is available to answer your questions.

Chat online

The NCI's LiveHelp® ¹ online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 9:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.

Write to us

For more information from the NCI, please write to this address:

NCI Public Inquiries Office

Suite 3036A

6116 Executive Boulevard, MSC8322

Bethesda, MD 20892-8322

Search the NCI Web site

The NCI Web site ² provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use our “Best Bets” search box in the upper right hand corner of each Web page. The results that are most closely related to your search term will be listed as Best Bets at the top of the list of search results.

There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.

Find Publications

The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator ³. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237), TTY at 1-800-332-8615.

Changes to This Summary (07/16/2007)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

Questions or Comments About This Summary

If you have questions or comments about this summary, please send them to Cancer.gov through the Web site’s Contact Form ⁴. We can respond only to email messages written in English.

About PDQ

PDQ is a comprehensive cancer database available on NCI's Web site.

PDQ is the National Cancer Institute's (NCI's) comprehensive cancer information database. Most of the information contained in PDQ is available online at NCI's Web site ². PDQ is provided as a service of the NCI. The NCI is part of the National Institutes of Health, the federal government's focal point for biomedical research.

PDQ contains cancer information summaries.

The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries are available in two versions. The health professional versions provide detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions provide current and accurate cancer information.

The PDQ cancer information summaries are developed by cancer experts and reviewed regularly.

Editorial Boards made up of experts in oncology and related specialties are responsible for writing and maintaining the cancer information summaries. The summaries are reviewed regularly and changes are made as new information becomes available. The date on each summary ("Date Last Modified") indicates the time of the most recent change.

PDQ also contains information on clinical trials.

A clinical trial is a study to answer a scientific question, such as whether one method of treating symptoms is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. Some patients have symptoms caused by cancer treatment or by the cancer itself. During supportive care clinical trials, information is collected about how well new ways to treat symptoms of cancer work. The trials also study side effects of treatment and problems that come up during or after treatment. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients who have symptoms related to cancer treatment may want to think about taking part in a clinical trial.

Listings of clinical trials are included in PDQ and are available online at NCI's Web site ⁵. Descriptions of the trials are available in health professional and patient versions. Many cancer doctors who take part in clinical trials are also listed in PDQ. For more information, call the Cancer Information Service 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615.

Glossary Terms

A drug used to treat depression.

Feelings of fear, dread, and uneasiness that may occur as a reaction to stress. A person with anxiety may sweat, feel restless and tense, and have a rapid heart beat. Extreme anxiety that happens often over time may be a sign of an anxiety disorder.

In healthcare, a process used to learn about a patient’s condition. This may include a complete medical history, medical tests, a physical exam, a test of learning skills, tests to find out if the patient is able to carry out the tasks of daily living, a mental health evaluation, and a review of social support and community resources available to the patient.

Pertaining to biology or to life and living things. In medicine, refers to a substance made from a living organism or its products. Biologicals may be used to prevent, diagnose, treat or relieve of symptoms of a disease. For example, antibodies, interleukins, and vaccines are biologicals. Biological also refers to parents and children who are related by blood.

Primary bone cancer is cancer that forms in cells of the bone. Some types of primary bone cancer are osteosarcoma, Ewing sarcoma, malignant fibrous histiocytoma, and chondrosarcoma. Secondary bone cancer is cancer that spreads to the bone from another part of the body (such as the prostate, breast, or lung).

A procedure to replace bone marrow that has been destroyed by treatment with high doses of anticancer drugs or radiation. Transplantation may be autologous (an individual's own marrow saved before treatment), allogeneic (marrow donated by someone else), or syngeneic (marrow donated by an identical twin).

A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

Treatment with drugs that kill cancer cells.

Having to do with the examination and treatment of patients.

A type of research study that tests how well new medical approaches work in people. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease. Also called a clinical study.

Computed tomography scan. A series of detailed pictures of areas inside the body taken from different angles; the pictures are created by a computer linked to an x-ray machine. Also called computed tomography scan, computerized tomography, computerized axial tomography scan, and CAT scan.

A mental condition marked by ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life. Other symptoms of depression include feelings of worthlessness and hopelessness, loss of pleasure in activities, changes in eating or sleeping habits, and thoughts of death or suicide. Depression can affect anyone, and can be successfully treated. Depression affects 15-25% of cancer patients.

The process of identifying a disease, such as cancer, from its signs and symptoms.

The length of time after treatment for a specific disease during which a patient survives with no sign of the disease. Disease-free survival may be used in a clinical study or trial to help measure how well a new treatment works.

In medicine, a disturbance of normal functioning of the mind or body. Disorders may be caused by genetic factors, disease, or trauma.

Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.

Monitoring a person's health over time after treatment. This includes keeping track of the health of people who participate in a clinical study or clinical trial for a period of time, both during the study and after the study ends.

Inherited; having to do with information that is passed from parents to offspring through genes in sperm and egg cells.

A cancer of the immune system that is marked by the presence of a type of cell called the Reed-Sternberg cell. The two major types of Hodgkin lymphoma are classical Hodgkin lymphoma and nodular lymphocyte-predominant Hodgkin lymphoma. Symptoms include the painless enlargement of lymph nodes, spleen, or other immune tissue. Other symptoms include fever, weight loss, fatigue, or night sweats. Also called Hodgkin disease.

One of many chemicals made by glands in the body. Hormones circulate in the bloodstream and control the actions of certain cells or organs. Some hormones can also be made in the laboratory.

The number of new cases of a disease diagnosed each year.

A procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue. MRI makes better images of organs and soft tissue than other scanning techniques, such as computed tomography (CT) or x-ray. MRI is especially useful for imaging the brain, the spine, the soft tissue of joints, and the inside of bones. Also called magnetic resonance imaging, nuclear magnetic resonance imaging, and NMRI.

The National Cancer Institute, part of the National Institutes of Health of the United States Department of Health and Human Services, is the Federal Government's principal agency for cancer research. The National Cancer Institute conducts, coordinates, and funds cancer research, training, health information dissemination, and other programs with respect to the cause, diagnosis, prevention, and treatment of cancer. Access the National Cancer Institute Web site at http://www.cancer.gov. Also called NCI.

PDQ is an online database developed and maintained by the National Cancer Institute. Designed to make the most current, credible, and accurate cancer information available to health professionals and the public, PDQ contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, complementary and alternative medicine, and supportive care; a registry of cancer clinical trials from around the world; and directories of physicians, professionals who provide genetics services, and organizations that provide cancer care. Most of this information, and more specific information about PDQ, can be found on the NCI's Web site at http://www.cancer.gov/cancertopics/pdq. Also called Physician Data Query.

An anxiety disorder that develops in reaction to physical injury or severe mental or emotional distress, such as military combat, violent assault, natural disaster, or other life-threatening events. Having cancer may also lead to post-traumatic stress disorder. Symptoms interfere with day-to-day living and include reliving the event in nightmares or flashbacks; avoiding people, places, and things connected to the event; feeling alone and losing interest in daily activities; and having trouble concentrating and sleeping. Also called PTSD.

In medicine, action taken to decrease the chance of getting a disease or condition. For example, cancer prevention includes avoiding risk factors (such as smoking, obesity, lack of exercise, and radiation exposure) and increasing protective factors (such as getting regular physical activity, staying at a healthy weight, and having a healthy diet).

Cancer that has recurred (come back), usually after a period of time during which the cancer could not be detected. The cancer may come back to the same place as the original (primary) tumor or to another place in the body. Also called recurrent cancer.

A method used to reduce tension and anxiety, and control pain.

Checking for disease when there are no symptoms. Since screening may find diseases at an early stage, there may be a better chance of curing the disease. Examples of cancer screening tests are the mammogram (breast), colonoscopy (colon), Pap smear (cervix), and PSA blood level and digital rectal exam (prostate). Screening can also include checking for a person’s risk of developing an inherited disease by doing a genetic test.

A network of family, friends, neighbors, and community members that is available in times of need to give psychological, physical, and financial help.

The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.

Care given to improve the quality of life of patients who have a serious or life-threatening disease. The goal of supportive care is to prevent or treat as early as possible the symptoms of a disease, side effects caused by treatment of a disease, and psychological, social, and spiritual problems related to a disease or its treatment. Also called palliative care, comfort care, and symptom management.

An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.

A set of symptoms or conditions that occur together and suggest the presence of a certain disease or an increased chance of developing the disease.

Treatment.