**8. Risk factors for cancer – Related PTSD**

Many of the risk factors associated with adult cancer-related PTSD mirror the risk factors for PTSD from other traumas such as combat (e.g., Foy et al., 1987). Incidence and severity of cancer-related PTSD are affected by factors that occur before and during the cancer experience (Gurevich et al., 2002).

### **8.1 Gender, age, and socio-economic status**

Pre-cancer factors, for example, gender, age, socio-economic status, and trauma history are associated with cancer-related PTSD. In terms of gender, female patients appear to be at greater risk for developing PTSD than their male counterparts (Kangas et al., 2002). Younger age at diagnosis also is a potential risk factor (Epping-Jordan et al., 1999; Kangas et al., 2002). Specifically, younger women may experience more distress due to the perception that cancer is more threatening to their lives; older women who have lived out the majority of their lifespan, on the other hand, may be less worried about recurrence, and thus display more positive mental adjustment (Glanz & Lerman, 1992). Socio-economic circumstances, specifically, lower income has been found to be associated with developing cancer-related PTSD; that is, it may be the case that fewer material resources combined with the stress of a cancer diagnosis may make the cancer experience more traumatic (Cordova et al., 1995).

#### **8.2 Personality, history, and disease characteristics**

Personality characteristics/traits such as neuroticism, pessimism, a pre-cancer history of affective disorders such as depression, or having a history of traumatic experiences may increase a patient's vulnerability to developing PTSD in the context of cancer (Andrykowski & Cordova, 1998; Epping-Jordan et al., 1999; Glanz & Lerman, 1992). Ineffective and maladaptive coping strategies, for example, staunch avoidance regarding the diagnosis of cancer as well as a pre-cancer coping style of avoidance, have been linked with PTSD relating to cancer (e.g., Butler et al., 1999; Jacobsen et al., 2002). It is reasonable to expect that characteristics of the disease process, itself, may contribute to distress and suffering in the form of PTSD. Specifically, research shows that, indeed, risk increases for PTSD in the case of malignant recurrence or the more advanced the stage of the disease (e.g., Andrykowski & Cordova, 1998). Additionally, research suggests a greater likelihood of patients developing cancer-related PTSD when more aggressive or invasive treatments are used (Gurevich et al., 2002).

#### **8.3 Social support**

238 Post Traumatic Stress Disorders in a Global Context

perceptions of the cancer experience, and posttraumatic stress (Alderfer et al., 2003). The findings showed that close to half of the sample (49%) reported mild posttraumatic stress, and more worrisome, that 32% indicated moderate to severe levels. Additionally, one-fourth of the siblings thought their brother/sister would die just during cancer treatment alone, and more than half of the sample viewed the experience of cancer as scary. These perceptions, not surprisingly, were found to be related to PTS. These siblings reported a greater number of PTS symptoms than did an adolescent comparison group who were not psychologically affected by their sibling's illness, yet did report similar levels of general anxiety. Overall, studies that have investigated PTS reactions in siblings of children with cancer estimate that between 29–38% of the siblings exhibit moderate to severe cancerrelated PTS---which can occur years after the treatment for cancer has ended (Alderfer et al.,

Many of the risk factors associated with adult cancer-related PTSD mirror the risk factors for PTSD from other traumas such as combat (e.g., Foy et al., 1987). Incidence and severity of cancer-related PTSD are affected by factors that occur before and during the cancer

Pre-cancer factors, for example, gender, age, socio-economic status, and trauma history are associated with cancer-related PTSD. In terms of gender, female patients appear to be at greater risk for developing PTSD than their male counterparts (Kangas et al., 2002). Younger age at diagnosis also is a potential risk factor (Epping-Jordan et al., 1999; Kangas et al., 2002). Specifically, younger women may experience more distress due to the perception that cancer is more threatening to their lives; older women who have lived out the majority of their lifespan, on the other hand, may be less worried about recurrence, and thus display more positive mental adjustment (Glanz & Lerman, 1992). Socio-economic circumstances, specifically, lower income has been found to be associated with developing cancer-related PTSD; that is, it may be the case that fewer material resources combined with the stress of a cancer diagnosis may make the cancer experience more traumatic (Cordova et al., 1995).

Personality characteristics/traits such as neuroticism, pessimism, a pre-cancer history of affective disorders such as depression, or having a history of traumatic experiences may increase a patient's vulnerability to developing PTSD in the context of cancer (Andrykowski & Cordova, 1998; Epping-Jordan et al., 1999; Glanz & Lerman, 1992). Ineffective and maladaptive coping strategies, for example, staunch avoidance regarding the diagnosis of cancer as well as a pre-cancer coping style of avoidance, have been linked with PTSD relating to cancer (e.g., Butler et al., 1999; Jacobsen et al., 2002). It is reasonable to expect that characteristics of the disease process, itself, may contribute to distress and suffering in the form of PTSD. Specifically, research shows that, indeed, risk increases for PTSD in the case of malignant recurrence or the more advanced the stage of the disease (e.g., Andrykowski & Cordova, 1998). Additionally, research suggests a greater likelihood of patients developing cancer-related PTSD when more aggressive or invasive treatments are used (Gurevich et al.,

2003; Packman et al., 2004).

experience (Gurevich et al., 2002).

2002).

**8. Risk factors for cancer – Related PTSD** 

**8.1 Gender, age, and socio-economic status** 

**8.2 Personality, history, and disease characteristics** 

In 1979, Berkman and Syme published their seminal study linking social relationships to mortality. Three decades later, reliable links between social support and better physical health outcomes continue to be demonstrated, with epidemiological studies showing that those with low levels of social support have higher rates of mortality (Berkman *et al.*, 2000; Uchino, 2004). Moreover, research indicates that social support is associated with improved immune function (e.g., Dixon et al., 2001; Lutgendorf et al., 2005). Thus, the possibility that social factors may be related to certain patients manifesting PTSD during the distress of cancer is congruent with this literature. Data have shown social support to be inversely associated with intrusive thoughts (DSM criterion B) and avoidance of cancer reminders of the cancer experience (DSM criterion C) (Andrykowski & Cordova, 1998; Jacobsen et al., 2002). In women with metastatic breast cancer, the size of a woman's emotional support network was found to predict avoidant symptoms in the patient (Butler et al., 1999). In terms of relational quality, a salient aspect of significant others in our lives is that of being supportive during times of personal disclosure, that is, the sharing of intimate information with trusted others. In the context of cancer, negative responses from others after a patient disclosed concerns and fears about her disease have been found to be associated with greater PTSD symptomatology (Cordova et al., 2001).

The issue of quality of life is a major line of research in cancer populations. A study by Lewis and colleagues (2001) investigated the moderating effect of social support on the relationship between cancer-related intrusive thoughts and quality of life. Sixty-four breast cancer survivors (of unspecified time since diagnosis or treatment) completed self-report measures of: social support (disclosure of thoughts/feelings to significant others); cancerrelated intrusive thoughts; and, quality of life. After controlling for demographic and treatment variables, the appraised level of social support was found to moderate the negative impact of cancer-related intrusive thoughts on both physical and psychological quality of life measures. Specifically, no significant relationship was found for cancer-related intrusive thoughts and quality of life in women who had endorsed high levels of social support. For women with low levels of perceived support, however, the data revealed a significant and negative relationship between cancer-related intrusive thoughts and participants' quality of life. These data suggest that appraised levels of social support in breast cancer patients may mitigate the impact of traumatic events during a woman's distressing breast cancer experience (Lewis et al., 2001). In sum, research indicates that certain demographic, personal and/or historical characteristics as well as biopsychosocial factors contribute to the multifactorial process of a cancer patient's experience. Data support the notion also that multiple factors appear to influence individual vulnerability and manifestation of posttraumatic symptoms in cancer patients.

#### **9. Conclusion**

Overall, findings regarding adult prevalence rates in adults with breast and mixed gender/mixed cancer types are consistent with previous estimates of current cancer-related PTSD prevalence in adult patients, that is, rates ranging from 0 to 32% (Hamann et al., 2005). Several points were highlighted. First, eight of the 11 studies identified in the summary review and listed in Table 3 involved women with breast cancer. Consequently, most of the present state of knowledge about PTSD in cancer patients is based upon this cancer population. Generalizability to other disease populations or to individuals diagnosed with

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different types of cancer thus is limited. Additionally, all but two of the investigations were cross-sectional studies with variance regarding time from either diagnosis or treatment to the study when the assessments occurred. Cross-sectional data limits clinical usefulness and understanding about the trajectory patterns of PTSD in those with cancer; future studies that are prospective or longitudinal in design with large sample sizes are recommended. These findings stand in contrast to the surprising stark paucity of research as to psychological adjustment such as PTSD and risk or predictive factors in men with prostate cancer who end up needing a prostatectomy. Much more research in the future is needed imperatively in this area to fill this gap in the literature. Similarly, further research investigating PTSD and related factors with large sample sizes in pediatric populations are suggested.

Over the past decade, increasing empirical evidence indicates that having a child diagnosed with a malignant disease process is psychologically traumatic for the parents. Specifically, symptoms of PTSD---the reexperiencing of traumatic events, physiologic arousal, and behaviors to avoid cues related to the cancer experience---have been documented in parents (especially mothers), whose children had completed cancer treatment (e.g., Brown et al., 2004; Manne et al., 2004). One study involving 150 families of adolescent childhood cancer survivors 1 to 10 years after completing cancer treatment found that practically all of the families (99%) had at least one parent who met PTSD symptom criteria for reexperiencing (Kazak et al., 2004). Moreover, 20% of the families were found to have at least one parent who met criteria for being diagnosed with current PTSD.

Research into posttraumatic stress in the bereaved and siblings of children with cancer were reviewed, with limited quantity and quality of studies noted. Large-scale epidemiological studies are needed to comprehensively estimate prevalence rates of posttraumatic stress for these emerging, psychologically affected populations. A severe absence of investigation exists regarding PTSD among the bereaved of a cancer patient, and adequate estimates of prevalence do not exist at this time. It must be emphasized that the absence of sufficient data in certain types of cancer populations---such as males with prostate cancer, the bereaved or sibling groups---limits intervention approaches and clinical efficacy. A plethora of welldesigned studies ultimately will enable targeted and successful interventions for those suffering with cancer-related PTSD. Only then, will clinical care truly be capable of providing the needed services for those traumatically affected by cancer. Members of the significant family-and-friends system need not struggle helplessly as they live with and function in the context of a "life-threatening" malignant illness.

In closing, future investigations are needed in order to develop targeted, effective and appropriate psychological interventions to address PTSD in cancer patients as well as to educate them about coping with life in the context of cancer. This will be especially salient in the future, based on current philosophical and medical zeitgeist, as the number of cancer survivors continues to increase.

#### **10. References**


different types of cancer thus is limited. Additionally, all but two of the investigations were cross-sectional studies with variance regarding time from either diagnosis or treatment to the study when the assessments occurred. Cross-sectional data limits clinical usefulness and understanding about the trajectory patterns of PTSD in those with cancer; future studies that are prospective or longitudinal in design with large sample sizes are recommended. These findings stand in contrast to the surprising stark paucity of research as to psychological adjustment such as PTSD and risk or predictive factors in men with prostate cancer who end up needing a prostatectomy. Much more research in the future is needed imperatively in this area to fill this gap in the literature. Similarly, further research investigating PTSD and

Over the past decade, increasing empirical evidence indicates that having a child diagnosed with a malignant disease process is psychologically traumatic for the parents. Specifically, symptoms of PTSD---the reexperiencing of traumatic events, physiologic arousal, and behaviors to avoid cues related to the cancer experience---have been documented in parents (especially mothers), whose children had completed cancer treatment (e.g., Brown et al., 2004; Manne et al., 2004). One study involving 150 families of adolescent childhood cancer survivors 1 to 10 years after completing cancer treatment found that practically all of the families (99%) had at least one parent who met PTSD symptom criteria for reexperiencing (Kazak et al., 2004). Moreover, 20% of the families were found to have at least one parent

Research into posttraumatic stress in the bereaved and siblings of children with cancer were reviewed, with limited quantity and quality of studies noted. Large-scale epidemiological studies are needed to comprehensively estimate prevalence rates of posttraumatic stress for these emerging, psychologically affected populations. A severe absence of investigation exists regarding PTSD among the bereaved of a cancer patient, and adequate estimates of prevalence do not exist at this time. It must be emphasized that the absence of sufficient data in certain types of cancer populations---such as males with prostate cancer, the bereaved or sibling groups---limits intervention approaches and clinical efficacy. A plethora of welldesigned studies ultimately will enable targeted and successful interventions for those suffering with cancer-related PTSD. Only then, will clinical care truly be capable of providing the needed services for those traumatically affected by cancer. Members of the significant family-and-friends system need not struggle helplessly as they live with and

In closing, future investigations are needed in order to develop targeted, effective and appropriate psychological interventions to address PTSD in cancer patients as well as to educate them about coping with life in the context of cancer. This will be especially salient in the future, based on current philosophical and medical zeitgeist, as the number of cancer

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**12** 

*1,3UK 2Australia* 

**Posttraumatic Stress Disorder after Stroke:** 

*2Australian Centre for Posttraumatic Mental Health, University of Melbourne,* 

Paul Norman1, Meaghan L. O'Donnell2, Mark Creamer2 and Jane Barton3

Stroke is a sudden and devastating illness that occurs when the blood supply to the brain is cut off due to a blood clot or when blood vessels supplying the brain burst, thereby damaging or destroying brain cells. Stroke is the third most common cause of death after heart disease and all cancers in both the UK and the US. In the UK approximately 100,000 people have a stroke each year, with stroke causing over 50,000 deaths. Stroke predominantly affects older people, with almost 80% of first-time strokes occurring in people aged 65 years or older. Stroke is a leading cause of severe, long-term disability. Stroke survivors may experience a range of ongoing problems including weakness or paralysis, problems with balance and coordination, speech and language impairments (e.g., aphasia), cognitive and psychological problems, and emotional lability. As well as the direct care costs, which have been estimated to be £2.8 billion per annum, stroke accounts for £1.8 billion per annum in lost productivity and disability and £2.4 billion per annum in informal care costs in the UK. In the US, the direct and indirect costs of stroke for 2010 have been estimated to be \$73.3 billion (American Stroke Association, 2011; Stroke Association, 2011). Elevated levels of psychological distress have been documented after stroke, although research to date has focused almost exclusively on depression and general anxiety symptoms (e.g., Fure et al., 2006; Hackett et al., 2005; Leppavuoir et al., 2003). However, stroke has many of the characteristics of events likely to trigger post-traumatic stress disorder (PTSD) symptoms in that it is unexpected, uncontrollable and potentially lifethreatening (Field et al., 2008). Stroke is a "frightening experience" with the symptoms (e.g., weakness or numbness down one side of the body or face, problems with balance and coordination, problems with communication, confusion) appearing suddenly and without warning (Stroke Association, 2011). Thus, in addition to coping with chronic stressors that may arise from ongoing disability, stroke survivors also have to come to terms with the

sudden, unexpected and life-threatening nature of the stroke event itself.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994, p. 424), defines PTSD as "the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's

**1. Introduction** 

**A Review of Quantitative Studies** 

*1Department of Psychology, University of Sheffield,* 

*3Sheffield Health and Social Care NHS Trust,* 

