**7.2 The bereaved**

236 Post Traumatic Stress Disorders in a Global Context

studies for current cancer-related PTSD were documented as ranging from 4.7% to 71%; the mean prevalence rate was 31% with a median of 17%. It must be pointed out that the prevalence rate finding of 71% comes from a study with a small sample size of only seven participants who were identified as "newly diagnosed." Therefore, the possibility that this assessment may have occurred within the first month of diagnosis calls into question the appropriateness and validity of these data. Unfortunately, the small number of studies in this area of current PTSD prevalence as well as the questionable data provided limit the scope of this review; therefore, conclusions about prevalence rates in this population are

Each year in the United States, approximately 14,000 children are diagnosed with cancer (Ries et al., 2008). The diagnosis of cancer is a traumatic experience for both the child and the family, which understandably causes a great of deal of disruption within the family system. The following review will encompass literature regarding posttraumatic stress among 1) parents of children with cancer, 2) the bereaved following the death of a cancer patient, and

Having a child diagnosed with cancer is one of the most severe stressors that parents could possibly ever experience; the threat of their child's death and feelings of helplessness converge as the entire family faces the uncontrollable enemy of cancer (Kazak, 1998; Patterson et al., 2004). The change of the A1 event criterion of PTSD in the *DSM-IV*  (American Psychiatric Association, 1994) to include "the diagnosis of a life threatening disease" as potentially traumatizing, expanded the range of traumatic effects to include the patient's interpersonal domain. Consequently, an individual's witnessing of or learning about a significant person [to him/her] being diagnosed with a terminal illness is now viewed as potentially traumatizing. Family members and loved ones torturously stand by as their beloved endures periods of devastating illness effects, physical and psycho-spiritual pain, or highly invasive treatments that produce debilitating fatigue---all of which may be followed by uncertain terminal illness and possible death. Family members typically are involved in making hard calls or decisions regarding the patient, which, in itself, is a

The psychological sequelae of childhood cancer in both the children and their parents are well documented, which consists of post-traumatic stress symptoms, anxiety, and depression (Kazak, 2005; Kazak et al., 2005). More specifically, the sequelae as to parental risk for affective and stress reactions range from 9% to 40% for the above disorders for a period of up to 3 years after the child's diagnosis (Kazak et al., 2004; Stoppelbein & Greening, 2007). Barakat and colleagues found that the parents of childhood cancer survivors showed significantly higher levels of post-traumatic stress symptoms (PTSS) than a comparison group of parents (1997). Similarly, Kazak found significant elevation in PTSD scores in parents of survivors in contrast to parents of never-ill children (Kazak et al., 1997). Indeed, the line of research exploring distress in relatives of cancer survivors indicate that the relatives are usually at least as distressed as the cancer survivors (especially mothers)---if not more so (e.g., Couper et al., 2006**;** Mosher & Danoff-Burg, 2004; Tuinmann et al., 2004). Kazak and colleagues (2004) found current PTSD prevalence for parents of adolescent

potential independent risk factor for PTSD (Azoulay et al., 2004, 2005).

prohibitive at this time.

**7.1 Parent and child** 

**7. PTSD: All in the family** 

3) the siblings of children diagnosed with cancer.

It has been estimated that for every person that dies five close friends or family members are affected (Zisook et al., 1998), therefore, the bereaved family and friends of cancer patients are at risk of developing psychological traumatic disorders as well as complicated grief. Indeed, the existing PTSD literature for the most part ignores bereaved individuals despite the fact that such individuals meet the A1 stressor criterion of the *DSM* (American Psychiatric Association, 1994). One of the few studies in this area investigated pre- and postloss bereavement levels of posttraumatic stress symptoms (intrusion and avoidance) in 50 partners of women with metastatic/recurrent breast cancer as well as the relationship of these symptoms to past, current, and anticipatory stressors (Butler et al., 2005). The data indicated that 17 (34%) of the bereaved partners experienced clinically

significant PTS symptom levels prior to the patients' deaths; specifically, prior to loss, partners' symptoms were positively associated with their current level of perceived stress and anticipated impact of the loss. However, following the death of the loved one, partners' posttraumatic stress symptoms were predicted by higher pre-loss levels of symptoms, past family deaths, and anticipated impact of the loss.

A more recent study investigated PTSD and PTSD predictors in bereaved individuals who had experienced the loss of a close relative to cancer and were attending counseling (Elklit et al., 2010). A total of 251 bereaved relatives, with ages ranging from 14 to 76 (M = 41.3), were recruited at a counseling service that assisted cancer patients and their relatives. The findings indicated that the prevalence of current PTSD was 40% in this sample. Furthermore, hierarchical logistic regression analysis showed that the following variables moderated the risk for PTSD: full-time employment, perceived control, and a secure attachment style. An extended period of caretaking as well as high levels of somatization and dissociation also were associated with an increased risk of PTSD (Elklit et al., 2010).

### **7.3 The forgotten children: Siblings**

As parents become distressed over the condition of their child diagnosed with cancer, they likely will spend extended periods of time at home or in the hospital attending to the needs of that child. As the stress of the malignant disease process takes its biopsychosocial toll on the child and the parents, the time will come, undoubtedly, when the adults will not be able to physically and emotionally meet the needs of their other children in the family (Alderfer & Kazak, 2006). It is not surprising, then, that the siblings of children with cancer become increasingly at risk for affective, behavioral, and school problems (Aldelfer & Hodges, 2010; Alderfer et al., 2010). Siblings of children with cancer experience feelings of anger, fear, grief, guilt, helplessness, insecurity, jealousy, loneliness, loss, resentment, and shock, (e.g., McGrath, 2001; Nolbris et al., 2007; Woodgate, 2006). Furthermore, investigations examining sibling distress increasingly indicate that a marked subset of siblings with a brother or a sister with cancer display post-traumatic stress (PTS) symptoms.

One study investigated whether 78 adolescent siblings of childhood cancer survivors experience posttraumatic stress; the participants completed self-report measures of anxiety,

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

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

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

**8.3 Social support** 

greater PTSD symptomatology (Cordova et al., 2001).

manifestation of posttraumatic symptoms in cancer patients.

**9. Conclusion** 

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., 2003; Packman et al., 2004).
