Using a mixed methods sequential explanatory approach to identify the roles of social and cognitive factors in the development and maintenance of cancer-related PTSD in cancer survivors.

Aims: Identify the mean prevalence of CR-PTSD, factors related to trauma, and the development and maintenance of PTSD, in cancer survivors. Background: Systematic reviews reveal that CR-PTSD is uncommon, and it is unclear a) what makes this experience traumatic, and b) what factors are implicated in the development, and maintenance of PTSD in this population. Methods: A mixed-methods sequential explanatory approach was used. Phase 1 consisted of three studies: a) random-effects meta-analysis of PTSD prevalence statistics and moderating factors in cancer survivors (k=25, n=4189); b) a cross-sectional analysis of PTSD and contributing factors in a PTSD Clinic for cancer survivors (n=60); and c) a prospective analysis of the role of emotion schemas and processing styles and how they predict adaptation to stress in a sample of students (n=24). Phase 2 was conducted to find follow-up explanations for Phase 1 results. Study 4 (Phase 2) consisted of two clinical case studies from the PTSD Clinic – one with adjustment disorder, and the other with severe chronic CR-PTSD. Results: Study 1 revealed that PTSD prevalence in breast cancer survivors was 5.8% (95% CI=3.3-10%), and that there were no significant study-level moderators that predicted differences in prevalence. Similar results were found for Study 2, although when adjusted for age, those with CR-PTSD suffered from more impoverished emotional experiences than those without CR-PTSD. These differences were rendered non-significant when depression symptoms were added as a covariate. Study 3 revealed that increases in anxiety during a stressor were best predicted by emotion schemas related to the lack of comprehensibility of emotions. Findings from Study 4 suggested that aspects of the cancer experience was very traumatic for both patients, but that the course/development of disorder was influenced by the social-cognitive processes involving the interaction of the patient’s emotion schemas and coping strategies, with the quality of their support system. Conclusions: Cancer can be traumatic under certain conditions, and PTSD is uncommon in cancer survivors, but clinical samples of cancer survivors with and without PTSD suggest that CR-PTSD is characterised by severe problems experiencing, linking, and labelling emotions. Preliminary evidence from case studies reveal that the combination of a) an appraisal of the cancer as traumatic, b) an invalidating social network, and c) emotionally avoidant coping styles throughout the cancer treatment, may predispose traumatised cancer survivors to PTSD

A meta-analysis of prevalence rates and moderating factors for cancer-related post-traumatic stress disorder.

Objective Systematic reviews highlight a broad range of cancer-related post-traumatic stress disorder (CR-PTSD) prevalence estimates in cancer survivors. This meta-analysis was conducted to provide a prevalence estimate of significant CR-PTSD symptoms and full diagnoses to facilitate the psychological aftercare of cancer survivors. Methods A systematic literature search was conducted for studies using samples of cancer survivors by using validated clinical interviews and questionnaires to assess the prevalence of CR-PTSD (k = 25, n = 4189). Prevalence estimates were calculated for each assessment method using random-effects meta-analysis. Mixed-effects meta-regression and categorical analyses were used to investigate study-level moderator effects. Results Studies using the PTSD Checklist—Civilian Version yielded lower event rates using cut-off [7.3%, 95% confidence intervals (CI) = 4.5–11.7, k = 10] than symptom cluster (11.2%, 95% CI = 8.7–14.4, k = 9). Studies using the Structured Clinical Interview for Diagnostic and Statistical Manual, Fourth Edition (SCID), yielded low rates for lifetime (15.3%, 95% CI = 9.1–25, k = 5) and current CR-PTSD (5.1%, 95% CI = 2.8–8.9, k = 9). Between-study heterogeneity was substantial (I2 = 54–87%). Studies with advanced-stage samples yielded significantly higher rates with PTSD Checklist—Civilian Version cluster scoring (p = 0.05), and when assessing current CR-PTSD on the SCID (p = 0.05). The effect of mean age on current PTSD prevalence met significance on the SCID (p = 0.05). SCID lifetime prevalence rates decreased with time post-treatment (R2 = 0.56, p < 0.05). Discussion The cancer experience is sufficiently traumatic to induce PTSD in a minority of cancer survivors. Post-hoc analyses suggest that those who are younger, are diagnosed with more advanced disease and recently completed treatment may be at greater risk of PTSD. More research is needed to investigate vulnerability factors for PTSD in cancer survivors