Lecture
The situation of an oncological diagnosis and the course of the disease itself can be regarded as psychologically traumatic, and accordingly classified among the extreme psychotraumatic stressors that may contribute to the development of post-traumatic stress disorder (PTSD). According to the DSM-V criteria, a diagnosis of PTSD is made if, first, the person witnessed or was involved in a situation in which death, a threat to life, a life-threatening injury, or a threat to physical integrity took place, or if the individual was otherwise confronted with an identical situation. Second, in response to this situation the subject must experience marked helplessness, fear, or horror. Consequently, an event is considered psychotraumatic if death, serious injury, or a threat to life occurs, and also if the individual's spectrum of experiences in response to the event includes a marked negative affect [1, 2]. The criteria set out in ICD-10 also reflect these fundamental characteristics of the disorders. Thus, the diagnosis of an oncological disease meets these criteria, since it carries an objective threat to life and is accompanied by marked emotional distress. Moreover, it is important to point out a substantial difference in the specific nature of traumatization in oncological pathology, which may affect the dynamics of the course of PTSD – a life-threatening disease threatens a person's future life, in contrast to event-based types of trauma, which, as a rule, are events of the past, imprinted in memory and influencing the present. Oncological pathology carries a chronic character of threat to life,
in addition, the severe aspects of treating oncological diseases, such as surgery with a risk of fatal outcome, chemotherapy, and postoperative effects, may be additional sources of stressful impact. The features of the subjective experience of illness in cancer patients, such as a sense of loss of control, a feeling of danger, the experience that physical integrity is under threat and the associated sense of helplessness, become significant factors in the development of a reactive state [8, 12].
The results of studies of PTSD among patients with various types of oncological disease demonstrate a prevalence of its full variant (the presence of all criteria) and of individual post-traumatic symptoms ranging from 5% to 35% [12, 14, 16]. A number of studies focus on the risk factors for the formation of PTSD in oncology. In them it was established that the presence of maladaptive personality traits in the premorbid state, dissociative manifestations immediately after the trauma, disability following the traumatic event, loneliness, unsatisfactory social status, and maladaptive coping strategies for dealing with stress, combined with a life-threatening disease, may lead to the development of clinically significant PTSD [11].
N.V. Tarabrina conducted a comprehensive study of post-traumatic stress in women with breast cancer (BC). The study included 75 women who had undergone surgery and completed treatment for a diagnosis of «breast cancer». A separate criterion was a period of no less than 3 months after the end of treatment. As a result of the study conducted, it was found that 41.3% of BC patients exhibited individual signs of post-traumatic stress, and in 24% of women the psychological distress reached a level corresponding to the clinical picture of post-traumatic stress disorder.
As a result, the main etiological factors capable of leading to the development of post-traumatic stress symptoms were identified –
a sense of threat to life, the chronic course of the disease, and the mutilating nature of the surgery.
In the course of the work, risk factors for the occurrence of PTSD in breast cancer patients were identified, which include:
the characteristics of women's education and social status,
basic life beliefs,
the presence of prior psychotraumas in the history.
It was found that patients without signs of PTSD were characterized by a significantly higher level of education, which can be interpreted by the fact that a high level of education influences the choice of the most effective coping strategies employed by a person to overcome traumatic events.
In addition, it was revealed that non-working women exhibited more intense symptoms of intrusions (invasion, obsessive re-experiencing of the traumatic material), physiological arousal, and somatic components of depression.
Patients without clinically pronounced signs of PTSD, on the contrary, were distinguished by having a job or involvement in some other sphere of activity that allowed them to switch away from thoughts about the disease.
Patients with signs of PTSD were distinguished by a significantly more negative image of their own «Self», by a conviction of their own lack of success and inability to control the events happening to them. Patients with a high intensity of post-traumatic stress reactions were also characterized by a greater number of life stresses before the disease, and they assessed the impact of the traumatic situations they had experienced on their own life as more significant.
In addition, in the group of women with clinically pronounced PTSD, the phenomenon of cumulative stress was identified: a chain of accumulating stressful events before the disease, a greater number of stresses in
general, a high level of personal anxiety, and an inability to cope with situations of tension [16].
In two independent studies by M.A. Andrykowski and P.B. Jacobsen et al., devoted to studying the presence of post-traumatic stress disorder in BC patients, PTSD criteria were identified in 12–19% of patients. At the same time, patients who were less informed
about their disease, who had advanced stages of the illness and long periods of hospital stay, were distinguished by a greater number of PTSD symptoms.
The prevalence of the disorder was higher in women subjected to more intensive methods of treatment (surgery) than in those treated conservatively. The dependence of the disorder's symptoms was associated with the degree of threat to life [9, 11].
Intensive therapy and resuscitation measures are among the strongest traumatizing factors in oncological disease and, as a rule, are accompanied by feelings of helplessness and fear of death. During intensive therapy, patients are almost entirely dependent on medical personnel, while, for example, artificial lung ventilation makes verbal contact impossible.
In the work of J.C. Richter et al., devoted to the problem of PTSD after prolonged and painful intensive treatment, it was shown that patients with injuries had a significantly higher risk of developing PTSD than in other diseases. The prevalence of PTSD according to the data of this work was not related to the severity of the injury or the duration of treatment.
In other works devoted to PTSD in the group of patients who underwent a short course of intensive therapy after a serious injury, mental disorders (PTSD, anxiety and depressive disorders) were identified in 25.5% of cases [15].
In a study that used questionnaires distributed by email, in patients who had previously been treated in the intensive care unit,
significant levels of PTSD were identified – up to 38%. In other published works on cases of PTSD after intensive therapy, the prevalence ranged between 5% and 14%. Thus, resuscitation measures and painful invasive procedures cannot be regarded as an additional risk factor for the development of PTSD [13].
With the aim of identifying risk factors for PTSD, Y-L. Lee and Sh. J. Santacroce conducted a study of patients who had undergone acute leukemia and achieved complete recovery, the time interval since recovery being three years. The average age of the group was 27.4 years. As a result, it was found that 13% of participants had a clinically significant level of the disorder. Higher rates relative to others were identified in patients who lived alone, had low social benefits, and had not undergone bone marrow transplantation. In the clinically significant PTSD group there were far more people living alone than in the group with the absence of this disorder [12].
The reaction to the impact of stressors may vary depending on the personal characteristics of the patients, their life attitudes and values, age, and family status, and is an integrative response to the cognitive appraisal and emotional significance of one or another aspect of the psychotraumatic situation of the disease. Thus, an important task of contemporary research in the field of psycho-oncology is the identification of risk factors for the development of mental disorders as a consequence of a severe somatic disease, including predictors of the development of PTSD [12, 16].
Some studies put forward the assumption that young age, female sex, pain syndrome, a particular localization of the oncological lesion, chemotherapy, brain metastases, a history of major depression, and a lack of social support are risk factors for the development of PTSD in the terminal
stage of cancer. However, none of the works provides sufficient data to confirm these facts.
Post-traumatic stress disorder (F43.1) is one of the borderline mental disorders, in the development of which a fundamental place is occupied by nonspecific disturbances at the neurotic level. Post-traumatic stress disorder (PTSD) arises after a latent period lasting from several weeks to several (usually no more than 6) months [1, 3].
This is connected with the fact that an acutely arising life-threatening situation may subsequently, at relatively remote stages of neurosogenesis, provoke the development of mental and associated somatic disorders in the form of PTSD. Such a condition arises in a large number of people after a shared, uniting situation they have experienced, usually one that developed suddenly, the consequences of which, despite sometimes considerable temporal remoteness, continue to exist as an individually significant psychogenic factor.
There is no doubt that patients with oncological pathology constitute a risk group with respect to the development of PTSD in them, since the experiences arising in the process of processing information about the disease and the chronic threat to life most strongly contribute to the development of psychopathological disturbances.
Depending on the onset and duration of the symptoms typical of PTSD, there are 3 variants of its manifestation:
Acute, with a duration of 1–3 months (in the case where the disorder develops immediately after the life-threatening event and lasts less than
1 month).
Chronic, with a duration of more than 3 months.
With delayed onset (the characteristic symptoms begin to appear no earlier than 6 months after the impact of the traumatic event).
For patients with oncological pathology, this type of course is more often encountered in cases of recurrence of the oncological pathology.
At the initium of the disease in patients with the initial stages of an oncological disease, sleep disorders, irritability and explosiveness, and a decline in certain cognitive functions (especially memory and attention) more often come to the fore. The patients appear withdrawn, estranged, sometimes malicious. They make contact with those around them with difficulty, and within families they soon become strangers, because, burdened with their own experiences, they cannot share either the sorrows or the joys of the household. Often some of them experience contradictory feelings: on the one hand, they take offense at family members and medical personnel, blaming those around them for a lack of attention, care, and sympathy,
on the other – they reject displays of warmth, avoid communication, and become irritated at attempts to help, support, or ease their condition.
In general, the behavioral features of patients with PTSD in pronounced cases can resemble the picture of a psychopath-like state. At the same time, the patients experience deep dejection, anxiety, and anguish, sometimes with a sense of guilt, a feeling of the uselessness of their life, up to the appearance of suicidal thoughts; they suffer from persistently recurring memories of the situation they experienced (the diagnosis of a neoplasm, the stay in hospital, the difficult surgery), and moreover these obsessive memories often take the form of suddenly arising vivid imaginal representations (flashbacks), lasting from a few seconds to several hours and accompanied by depression, fear, sweating, and other autonomic disturbances, which are generally characteristic of these patients and may occupy a rather prominent place among their complaints. The patients actively avoid situations reminiscent of the stressful event. This may lead to a refusal of the necessary treatment for the oncological disease, of indicated
diagnostic procedures, to the disregard of complications,
and to a pseudo-superficial attitude toward the social consequences of the disease. In addition, the patients are constantly troubled by sleep disturbance: they fall asleep poorly, and then often wake up from nightmarish dreams reproducing what they have experienced. A fear of falling asleep is formed.
A.B. Smulevich and V.G. Rotshtein note that the clinical picture of the early stage of the formation of PTSD encompasses subacute mental disturbances, which are often characterized by derealization and depersonalization disorders; anxious-depressive states with a sense of fear for one's life, tearfulness, and nightmarish dreams; depressive reactions with conversion inclusions; reactions of the euphoric type with loquacity and a sharp underestimation of the severity of one's oncological disease and somatic condition; and obsessive-phobic disorders (frightening imaginal memories of how the news of the malignant pathology or unfavorable prognosis wounded them). Obsessive memories usually arise without any external stimuli whatsoever, but the experiences accompanying them may be so strong that the patient feels them as if the tragic events (suffering, pain, helplessness, death) were happening at that very moment. Even more pronounced reactions arise in response to external stimuli (reminders, participation, sympathy of relatives, colleagues, doctors) that remind the patient of events connected with the tumor pathology.
More pronounced mental disturbances may also develop (depression, anxiety disorders, binge alcoholism, etc.). The duration of such states ranges from several weeks to several months. Especially persistent are depressive and obsessive-phobic disorders in the form of an obsessive fear of death from the oncological disease and of suffering, and sleep disturbances. In many cases these experiences do not correspond to the actual prognosis, which may be favorable, yet the patient perceives their condition
as progressive and inevitably leading to an unfavorable outcome.
At a more remote stage (after 12—14 months) states are possible that are characterized by sleep disturbance, a feeling of despair and hopelessness, an extremely pessimistic assessment of one's own fate and of the surrounding reality, and the associated appearance of suicidal thoughts. This state may be so severe that it leads to a loss of working capacity to a greater degree than the oncological disease itself. But in many patients, with successful treatment of the oncological pathology, restored working capacity, and formally satisfactory social adaptation, reduced manifestations of chronic PTSD persist: episodic sleep disturbances with nightmarish dreams and affective lability.
In characterizing the further development of PTSD, attention is drawn to the combination of two groups of clinical phenomena: continuing surges (revivals) in the patient's consciousness of past experiences connected with the manifestations of the oncological disease, with accompanying affective reactions (anxiety, horror, fear), and avoidant behavior, i.e., the striving to escape from everything that may recall the tragic event, including from the indicated staged preventive examination and medical monitoring [11].
The syndromogenesis of this disorder is characterized by a general stereotype of development, proceeding from a reaction to the oncological event to a chronified, painful mental state.
In addition, the following signs of PTSD are present (as with other psychogenic disorders characteristic of patients with oncological pathology):
The establishment of the fact that the disorder arose in connection with a psychological trauma, stressful event, or situation (both short-lasting and long-lasting) of a threatening or catastrophic nature,
connected with the neoplasm, which is capable of causing distress in almost any individual.
The presence of a connection between the mental disturbances and the psychotraumatic situation that retains its relevance for the patient – the ongoing course of the oncological pathology, the period of its active surgical, radiation, or chemotherapeutic treatment, or current worries about the consequences of the disease in the future or about its prognostic unfavorableness.
The reflection in the patient's painful experiences of the psychological trauma caused by the oncological disease (the criterion of psychologically understandable connections). There are persistent memories or a «revival» of the stressor in obsessive reminiscences, vivid recollections, or recurring dreams, or a repeated experiencing of grief upon exposure to circumstances that recall or are associated with the oncological pathology.
The actual avoidance or the patient's striving to avoid circumstances that recall or are associated for them with the oncological suffering (which was not observed prior to the impact of this stressor).
In cases of the development of PTSD in patients with malignant diseases, it is advisable to use psychotherapy directed first and foremost at the reintegration of the mental integrity disrupted as a result of the trauma. The task of psychosocial interventions is to create a new cognitive model of life activity, an affective reappraisal of the traumatic experience, and a restoration of the sense of the value of one's own personality and of the ability to continue to exist in the world. The key moment of psychotherapy for patients with PTSD is the integration of that alien, unacceptable, terrible, and incomprehensible thing that happened to the patient into their identity, that is, into their self-conception (self-image).
At the same time, the traumatic experience is accompanied by a mass of
disordered affective reactions, among which the key ones
are fear, anger, shame, and guilt. The etiology of PTSD is connected with the impact of an overwhelmingly strong psychotraumatic factor on the human psyche and is understood by specialists unambiguously. As for the pathogenesis, there exist various models of the development of the disorder discussed in the professional literature, among which the following 4 varieties of PTSD have received the greatest recognition: fear-based PTSD, anger-based, guilt-based, and shame-based
(shame-based). Depending on the nature of the collision of the trauma with the internal structure of the personality, the traumatic event either signifies for the person a loss of status and social attractiveness, implying their personal responsibility and evoking excessive feelings of shame and guilt; or it is perceived as an injustice, and the clinical picture corresponds to the experience of feelings of humiliation and anger. In these situations the patient's personality suffers to varying degrees. If the traumatic experience of a sense of guilt extends to the patient's personality, it may pass into deep-seated beliefs about one's own culpability, whereby the avoidance symptoms are based not on fear but on the experience of shame and guilt; in the case where the sense of Self is attacked but not destroyed, the experiences of feelings of humiliation and anger are, as a rule, limited to the event-based type of trauma
.
An important feature of post-traumatic stress disorder in oncological disease is the fact that the patient experiences not only an immediate sense of threat to life at the time the diagnosis is established, but also the chronic character of this threat. In connection with this, standard psychotherapy techniques cannot be applied, since the main goal of the psychotherapeutic treatment of patients is not so much to help them free themselves from the pursuing memories of the trauma as to enable the patient to become actively and responsibly engaged in the present. For this, they need not only to find an appropriate place for the traumatic event that occurred within the overall temporal perspective of their life and personal history, but also to rid themselves of the feeling of helplessness characteristic of persons with PTSD, which, in the case of a malignant pathology, is intensified because of the presence of an objective threat of death.
Comments