For a number of years, investigators have reported stress- or trauma-related symptoms such as avoidant behaviors, intrusive thoughts, and heightened arousal in survivors of cancer.[
These symptoms experienced by cancer survivors fall under the "Trauma- and Stressor-Related Disorders" category in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). The category includes acute stress disorder, adjustment disorders, and post-traumatic stress disorder (PTSD).[
Reviews note that post-traumatic stress (PTS) has been studied in a variety of cancers, including:[
Most of the studies to date have used the criteria of the DSM, fourth edition (DSM-IV) because they were conducted before publication of the DSM-5. This summary will primarily refer to the studies conducted using the DSM-IV criteria.
Studies have varied in the assessment of patients for the full syndrome of PTSD (i.e., all DSM criteria met) or only some of the PTSD-related symptoms (e.g., intrusive thoughts as measured by the Impact of Event Scale). As a result, incidence rates have varied.
Factors suggesting which patients might be at increased risk of developing PTS and PTSD have not been extensively studied; however, one study of women with early-stage breast cancer [
Another study of men and women treated with bone marrow transplant [
Although no specific therapies for PTS symptoms in the cancer setting have been developed, treatment modalities used with other people with PTSD can be useful in alleviating distress in cancer patients and survivors.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
Reviews of the literature [
The incidence of the full syndrome of post-traumatic stress disorder (PTSD) (meeting all Diagnostic and Statistical Manual of Mental Disorders [DSM] diagnostic criteria) ranges from 3% to 4% in patients recently diagnosed with early-stage disease to 35% in patients evaluated after treatment. When the incidence of PTSD-like symptoms (not meeting the full diagnostic criteria) is measured, rates are higher, ranging from 20% in patients with early-stage cancer to 80% in those with recurrent cancer.
The earliest research (predating the DSM, fourth edition [DSM-IV]) on PTS among cancer survivors concentrated on the prevalence and characteristics of the disorder in patients who had undergone or were undergoing treatment, adult and child cancer survivors, and/or their family members. A wide variety of cancer types was studied, including leukemia,[
The first study of cancer patients using the DSM-IV diagnostic criteria looked at 27 patients (most with breast cancer), all at least 3 years postdiagnosis and no longer receiving any cancer treatments. A prevalence rate of 4% for current PTSD and 22% lifetime prevalence was found.[
Studies using the Structured Clinical Interview for DSM (SCID) [
In a few studies of patients who underwent bone marrow transplants, slightly higher prevalence rates have been reported, ranging from 5% [
As an illustration of the distinction between these tools, a German study evaluated patients with breast cancer (n = 127) for PTSD immediately postsurgery and 6 months after the first assessment.[
One of the main differences between symptom-based measures such as the PCL-C and an actual SCID-based diagnosis is the dysfunction caused by the symptoms. The symptoms are rather common, but only a very small percentage of people who have the symptoms are disabled by them.
A variety of sociodemographic, disease-related, psychosocial, and psychological variables have been investigated to determine their relationship to post-traumatic stress (PTS) related to cancer. At present, no clear picture emerges about who is at increased risk of developing PTS after a diagnosis of or treatment for cancer.
Few patient characteristics have been shown to predict the occurrence of PTS. High levels of psychological distress have been correlated with both stress symptoms [
Disease-related variables that have been associated with a higher incidence of PTSD in patients who underwent bone marrow transplant include more advanced disease and a longer hospital stay.[
The time since diagnosis and treatment has been shown to correlate with and predict post-traumatic symptoms in survivors of osteogenic sarcoma [
The presence of pain and other physical symptoms has been shown to correlate with levels of intrusive thoughts.[
Psychosocial and Psychological Variables
The experience of past traumatic events appears to be an important psychosocial risk factor associated with PTS symptoms,[
Other psychosocial risk factors such as premorbid psychopathology,[
Psychological variables that have been related to a higher incidence of PTSD include:
Greater perceived availability of social support is associated with fewer stress-response symptoms in patients with early-stage breast cancer [
The availability and timeliness of accurate health-related information may also offer protection from stress-response symptoms. Women who met the diagnostic criteria for acute stress disorder reported significantly less satisfaction with the communication of their cancer diagnosis.[
PTSD is precipitated by an intensely distressing event; however, this factor alone is not sufficient to explain the disorder. Not everyone exposed to a traumatic stressor develops the full-blown syndrome (or subsets of symptoms) or qualifies for the diagnosis. Attempts to explain these differences and to predict who is vulnerable have focused on the following:
Early studies of Vietnam War veterans suggested a two-factor learning theory to account for trauma-related pathology.[
PTSD symptoms develop as a function of both classical conditioning and instrumental learning. Classical conditioning accounts for the fear responses elicited by various stimuli that are associated with the original traumatic event. Neutral stimuli (e.g., smells, sounds, and visual images) previously paired with the aversive stimuli (e.g., chemotherapy or painful procedures) eventually evoke anxiety, arousal, and fear when presented alone, even after the trauma has ended. Higher-order conditioning and stimulus generalization account for the exacerbation and extension of symptoms to additional stimuli. Once established, PTSD symptoms are maintained through instrumental learning, that is, avoidant responses are reinforced because avoidance of the stimuli prevents unpleasant feelings and thoughts.
Estimates from epidemiological studies suggest that on average, 25% to 33% of individuals who are exposed to traumatic events, including cancer, develop PTSD or subsyndromal PTSD.[
Diagnostic Criteria of Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)
The diagnostic criteria for PTSD and ASD changed considerably in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Changes from the fourth edition to the DSM-5 included the following:[
Criterion A, which is necessary for PTSD and ASD diagnoses, specifically states, "A life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event. Medical incidents that qualify as traumatic events involve sudden, catastrophic events." Thus, for the experience of cancer to meet Criterion A, it must entail acute and extreme adverse events in the context of cancer and/or cancer treatments. Events such as the cancer diagnosis, side effects of cancer treatments, and distress, worries, or negative thoughts about prognosis do not automatically qualify as trauma. Furthermore, patients with cancer can only be diagnosed with ASD or PTSD if they experience specific trauma-related symptoms, many of which are focused on or related to re-experiencing symptoms and intrusive memories. Fear of recurrence or worries about prognosis do not qualify as PTSD or ASD symptoms.
The four core clusters of symptoms for a PTSD diagnosis are as follows:
These symptoms must last for at least 1 month and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Post-Traumatic Stress (PTS) and PTSD in the Cancer Setting
A timely, careful assessment of patients with cancer is critical to identify symptoms of cancer-related PTS, to note the deleterious impact of the symptoms on functioning, and to plan interventions targeted at the most distressing symptoms. It is also critical that the assessment distinguish between the full DSM PTSD syndrome (meets all required diagnostic criteria) and PTS-related symptoms only.
The most difficult aspect of PTS assessment in the cancer setting is the determination of precisely when to evaluate the patient. Diagnosis is complicated because cancer is not an acute or discrete event, but an experience marked by repeated trauma and indeterminate length. An individual may exhibit the symptoms of PTS at any point from diagnosis through treatment, to treatment completion and, possibly, to recurrence.[
The definition in the DSM-5 indicates that although PTSD symptoms usually begin within 3 months after trauma, there may be a delay of 4 or more months or even years before symptoms appear.[
At least one study found that individuals who have experienced a traumatic event may exhibit early symptoms without meeting the full criteria for a diagnosis of PTSD.[
The difficulty of properly diagnosing PTS may be compounded by the overlapping of PTS symptoms with those of other psychiatric disorders and by the time-related aspects of normal adjustment. For example, irritability, poor concentration, hypervigilance, excessive fear, and disturbed sleep are also symptoms of generalized anxiety disorder. Other arousal and avoidance symptoms are common to PTSD, phobias, and panic disorder, but loss of interest, sense of a foreshortened future, avoidance of other people, and sleep impairment might suggest both PTSD and depressive disorders. Even normal reactions to the diagnosis and treatment of life-threatening disease can consist of responses such as:
Clinicians and researchers must be particularly attuned to the causes, duration, and severity of PTSD-like symptoms when considering PTSD among several diagnoses. For instance, in a study of women with breast cancer, 41% reported experiencing "intense fear, helplessness, or horror"; however, on further comprehensive diagnostic interview, only 4% met the full PTSD criteria. Assessment must be able to distinguish between general psychological distress and symptoms of PTSD.[
The accurate diagnosis of PTSD also requires the use of reliable and valid instruments. Many studies have used the PTSD module of the Structured Clinical Interview for DSM-III-R–Nonpatient Edition.[
In attempting to diagnose PTSD, it is important to be aware that this disorder is often marked by comorbid psychopathology. Substance abuse, affective disorders, and other anxiety disorders are consistently encountered in samples of people with PTSD.[
High rates of concurrent disorders have also been documented in other trauma victims. For example, 40% to 42% of disaster survivors with PTSD also qualified for a diagnosis of major depression, and 20% to 42% met the criteria for concurrent generalized anxiety disorder.[
The Conceptual Fit of PTS and Cancer
Conceptual and practical problems can arise in the application of PTS to cancer patients and survivors. The basic concept of an extreme traumatic stressor has been described variously as an event involving direct personal experience that involves actual or threatened death or serious injury.[
Another concern regarding conceptual fit is related to re-experiencing the trauma. In a study of women with early-stage breast cancer, researchers found that the traumatizing aspects of the cancer experience were receiving the diagnosis and waiting for test results from node dissection.[
Conversely, a unique study assessing the physiological reactivity of patients with breast cancer to a personalized imagery script of their most stressful experiences with the cancer found elevated physiologic responses that were comparable to those of PTSD patients who had experienced other (non–cancer-related) traumas. This finding suggests a good fit between patients with cancer and the PTSD trauma model, as it shows comparable symptoms of increased arousal in patients with cancer. Also, in a factor analytic study designed to confirm the presence of the three broad PTSD symptom clusters (re-experiencing, avoidance of reminders, and hyperarousal), researchers found some tentative support for the DSM-IV symptom clusters in a sample of breast cancer survivors.[
In a study of 74 women breast cancer survivors interviewed at 18 months postdiagnosis via the SCID, three groups were identified: one meeting the full criteria for PTSD (n = 12), another meeting partial but not full criteria for PTSD (i.e., subsyndromal, n = 5), and a no-PTSD group (n = 47). Further analyses investigated group differences. Some notable factors affecting the full-criteria PTSD group compared with the subsyndromal and no-PTSD groups included the following:[
Further research is needed to continue to investigate the important question of how well the conceptual model of PTSD as an anxiety response to a major life trauma fits the life experience of patients with cancer. Reviews have argued both in favor of [
The chronic and sometimes devastating psychological and interpersonal sequelae of post-traumatic stress disorder (PTSD) necessitates timely and effective treatment .[
Most clinicians recommend using a multimodal approach, choosing components to meet the specific needs of each patient and taking into account any concurrent psychiatric disorders such as depression or substance abuse. Multiple modalities are frequently considered in a crisis intervention approach to facilitating adjustment of patients with cancer.
The crisis intervention model comprises a broad range of therapies that can be helpful in the treatment of post-traumatic stress symptoms. The goals of this model are to reduce symptoms and restore patients to their usual levels of functioning. In this model, the therapist often takes an active, directive stance with the patient, focusing on the following: [
Cognitive-behavioral techniques have proven especially helpful within the crisis intervention setting. Some of these methods include the following:[
In a single case study, a 10-session cognitive-behavioral intervention for a male cancer patient who was 3 years post–bone marrow transplant and had PTSD was found to be effective. This study used a combination of cognitive coping strategies, relaxation procedures, relapse prevention, and generalization techniques. Benefits were maintained at a 6-month follow-up.[
Support groups also appear to benefit people who experience post-traumatic symptoms. In the group setting, such patients can receive emotional support and encounter others with similar experiences and symptoms, thereby validating their own experiences and learning a variety of coping and management strategies.
For patients with particularly distressing or severe symptoms, psychopharmacology may provide an additional means of treatment. Several classes of medications have been used to treat individuals with PTSD.[
|Medication||Dosing (mg/day)||Target Symptomsc||Evidence Basis|
|RCT = randomized controlled trial; SSRIs = selective serotonin reuptake inhibitors.|
| a Adapted from Berger et al.[
|b All studies conducted in patients without cancer only. No studies have been reported on pharmacological treatments for PTSD conducted in patients with cancer.|
|c PTSD symptom clusters are as follows: cluster B, re-experiencing; cluster C, avoidance/numbing; cluster D, hyperarousal.|
|d Considered first-line treatments for PTSD.|
|e FDA approved for the treatment of PTSD.|
|f Used mainly as augmentation to SSRIs or serotonin-potentiating non-SSRIs.|
|Sertralinee||50–200||All symptom clusters||Several RCTs|
|Paroxetinee||20–50||All symptom clusters||Several RCTs|
|Fluoxetine||20–60||All symptom clusters||Several RCTs|
|Fluvoxamine||50–300||All symptom clusters||Open label|
|Citalopram||20–60||All symptom clusters||Open label|
|Escitalopram||10–20||All symptom clusters||Open label|
|Venlafaxine||37.5–225||All symptom clusters||Open label|
|Duloxetine||30–120||All symptom clusters||Open label|
|Trazodone||50–300||Insomnia, possibly other clusters||Open label|
|Mirtazapine||15–45||Insomnia, possibly other clusters||Open label|
|Imipramine||50–225||Possibly all clusters||One RCT|
|Other Agents Used as Augmentation Therapy Onlyf|
|Risperidone||1–6||Clusters B and D, possibly cluster C||Several RCTs|
|Olanzapine||5–20||Possibly all clusters||One RCT|
|Quetiapine||25–300||Possibly all clusters||Open label|
|Lamotrigine||50–400||Clusters B and C||One RCT|
|Prazosin||2–6||All symptom clusters (primary target symptom: nightmares)||Several RCTs|
The cancer treatment experience may be considered a significant traumatic event, given the nature of diagnosis, the number of invasive and painful procedures, and the often-long hospitalizations that children and their families must endure. On the basis of this exposure model, a number of studies have examined whether children treated for cancer are at a significantly higher risk for developing symptoms of post-traumatic stress disorder (PTSD). The results of these studies have been mixed.[
Other studies suggest that survivors of childhood cancer have an increased risk for PTS symptoms and PTSD after treatment is finished. In a study of 78 adults aged 18 to 41 years who had been treated for childhood cancer, 20.5% met the criteria for a diagnosis of PTSD at some time since the end of their treatment. Clinically significant events of intrusive symptoms (9%) and avoidant symptoms (16.7%) were reported in the sample, and the symptoms were associated with elevated reports of anxiety and other measures of psychological distress.[
Similarly, a study of 182 adolescent and young adult cancer survivors who were more than 5 years from diagnosis and more than 2 years from completion of cancer treatment found that 16% met the criteria for PTSD. A relationship between PTSD and higher levels of other psychological problems was also reported.[
Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.
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.
This summary is written and maintained by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® Cancer Information for Health Professionals pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the diagnostic criteria for and treatment of cancer-related post-traumatic stress and related symptoms. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Cancer-Related Post-Traumatic Stress are:
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Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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PDQ® Supportive and Palliative Care Editorial Board. PDQ Cancer-Related Post-Traumatic Stress. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/about-cancer/coping/survivorship/new-normal/ptsd-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389172]
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Last Revised: 2023-01-09
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