Psychosomatics 45:7-16, February 2004
© 2004 The Academy of Psychosomatic Medicine
Identification of Traumatic Stress Reactions in Women at Increased Risk for Breast Cancer
Nangel M. Lindberg, Ph.D., and
David K. Wellisch, Ph.D.
Received Oct. 24, 2002; revision received March 13, 2003; accepted March 18, 2003. From the University of California, Los Angeles, School of Medicine, Los Angeles. Address reprint requests to Dr. Lindberg, P.O. Box 920811, Needham, MA 02492; nlindberg{at}attbi.com (e-mail).
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ABSTRACT
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It has been shown that the diagnosis and treatment of cancer may constitute a traumatic event that generates in patients and some of their family members traumatic reactions that are consistent with the symptom profile of posttraumatic stress disorder (PTSD). The present study was conducted to establish the degree to which women at increased familial risk for breast cancer showed such traumatic reactions and to establish which demographic or psychological variables may contribute to the experience of such traumatic reactions in at-risk individuals. Seventy-three women from the Revlon UCLA Breast Center High Risk Clinic were assessed for traumatic reactions that might be consistent with the DSM-IV criteria for PTSD. The results showed that women at increased risk for breast cancer exhibited traumatic responses similar to those reported by cancer patients. When the authors used a self-report instrument that maps onto DSM-IV criteria, 4% of the study subjects reported symptoms consistent with criteria for a potential diagnosis of PTSD, and an additional 7% of the subjects reported symptoms consistent with potentially subclinical levels of PTSD, according to DSM-IV criteria.
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INTRODUCTION
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According to DSM-IV,1 posttraumatic stress disorder (PTSD) follows exposure to a trauma in which an individual is confronted with "actual or threatened death or serious injury, or a threat to the physical integrity of self or others" and in which the individual's response involves intense fear, helplessness, or horror.1 PTSD is characterized by a symptom constellation that includes reexperiencing of the trauma (i.e., intrusive thoughts, dreams, or flashbacks of the traumatic event), persistent avoidance of stimuli associated with the trauma (i.e., avoidance of trauma-related situations, psychological "numbing," a sense of a foreshortened future), and hyperarousal (i.e., sleep difficulties, irritability, poor concentration, and hypervigilance).
In recent years, there has been an effort to determine whether the diagnosis and treatment of a life-threatening illness, such as cancer, may constitute a traumatic stressor that could generate traumatic reactions, including the experiencing of PTSD symptoms; as such, the identification of symptoms consistent with PTSD in cancer survivors has become a growing area of research.2–7 To date, the available literature seems to consistently indicate that adult cancer survivors do, in fact, exhibit such traumatic reactions, with a minority of them meeting criteria for current or lifetime PTSD related specifically to the experience of cancer.3–5 In addition, the literature has shown that a larger percentage of individuals report significant symptoms of traumatic stress responses.8 Many of these individuals report symptoms for some but not all of the symptom cluster categories required in order to meet the criteria specified in the DSM-IV for the diagnosis of PTSD.
The finding that patients diagnosed with and treated for cancer do experience traumatic reactions, including the symptoms consistent with the PTSD constellation, suggests that individuals who are at an increased familial risk for developing cancer, particularly those who have had a close family member suffer from the disease, may also exhibit such symptoms. Although these individuals at familial risk have not personally had the life-threatening experience of cancer, they are fully aware of their vulnerability to the disease, and furthermore, they have often been first-hand witnesses to a close family member contending with the diagnosis and treatment of cancer.
In fact, according to DSM-IV's own criterion A, a life stressor can be considered traumatic if it involves "actual or threatened death or serious injury, or the threat to the physical integrity of the individual or family member" (emphasis added). In order to be considered a traumatic stressor, the event must evoke "feelings of horror and intense fear" in those exposed to it. The current DSM-IV formulation for the diagnosis of the PTSD symptom profile places equal emphasis on objective factors (e.g., the severity of the event experienced by the individual) and subjective factors (e.g., the meaning ascribed to the experienced event) in the determination of the disorder.9 In a fashion consistent with this formulation, several studies have documented the diagnosis of PTSD and of significant PTSD-like symptoms among individuals secondarily affected by the trauma of cancer, namely, the parents of child cancer survivors.10,11
The documentation of traumatic reactions, including PTSD-like symptoms, in oncology patients and their family members (for a comprehensive review, see Smith et al.9) and the fact that the current PTSD diagnostic formulation allows for a family member's death or injury to constitute a traumatic event sparked our interest in this area. We sought to determine whether the experience of cancer in the family and the individual's identification with the cancer patient might stimulate in at-risk individuals traumatic stress reactions, including the symptomatic elements of the PTSD experience. Determining the presence of traumatic reactions, including the symptoms of PTSD, in this at-risk population could have a significant impact on our psychoeducational interventions for the reduction of distress and the fostering of adequate screening behaviors. Women at risk for breast cancer have been shown to experience clinically significant levels of anxiety and depression.12–15 Such symptoms are often targeted in intervention programs directed at this population, primarily through identifying and challenging dysfunctional negative cognitions, cognitive restructuring, and relaxation training.16 However, the presence of significant traumatic responses and symptoms consistent with PTSD in this population would require a different therapeutic approach, one rooted in the empirically validated treatment for traumatic reactions and which generally emphasize the narrative of the trauma, the exploration and "working-through" of the traumatic memories, and the exploration and management of feelings, such as the anger, fear, avoidance, and reexperiencing that often accompany such traumatic reactions.17
To date, we are aware of no published information regarding the extent to which individuals at risk for cancer present symptoms of PTSD or about the psychosocial characteristics of at-risk individuals who may present such symptoms. In order to shed some light on the relationship between cancer risk and traumatic reactions, the present study sought to establish the degree to which women at familial risk for breast cancer present symptoms consistent with the PTSD constellation.
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METHOD
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Participants
The participants were patients at the UCLA/Revlon High Risk Clinic, which cares for women who are at familial risk for breast cancer and who have a history of at least one first-degree relative with the disease. Women who were eligible for participation 1) had a mother or a sister with breast cancer, regardless of the relative's health status at the time of the study, 2) were above the age of 18, and 3) had never been diagnosed with invasive cancers. Given the high rates of participation in previous studies conducted at the University of California, Los Angeles, High Risk Clinic, potential participants in this study were likely representative of all patients treated at this facility. Out of 75 consecutive patients seen and contacted, only two declined to participate in the study (yielding a participation rate of 97.4%), citing time constraints that prevented them from filling out the required questionnaires.
The study group thus consisted of 73 women with a mean age of 43 years (SD=13, range=19–77). The majority of the participants were Caucasian (79.5%) and married (54.8%). This was a highly educated group, with 75.3% having a college or advanced degree. While this group was not representative of the general population at high risk for breast cancer, the group was highly representative of women attending high-risk clinics and programs for the prevention of breast cancer and of the samples of published studies regarding this population.15,18–22
The participants reported that the total number of relatives with breast cancer ranged from one to eight, with a mean of 2.6 relatives per patient. In terms of the number of relatives afflicted with breast cancer, most participants had one (30.1%), two (23.3%), three (21.9%), or four (15.1%) relatives with the illness, with the remainder having five or more relatives with breast cancer. Most participants reported having a mother (73%) or a sister (17.5%) with cancer. Additionally, 9.5% of the participants reported having both a sister and a mother suffering from the disease.
Most participants reported that their relative was healthy and that the breast cancer was in remission (39.7%). A large percentage of participants reported their relative to be ill, either from breast cancer (11%) or from non-cancer-related illnesses (43.8%). A small percentage of participants reported that their relative had passed away (5.5%), and all reported deaths were due to breast cancer. On average, the participants were interviewed 15.2 years after their relative's diagnosis (SD=12.9), with a range from 0 to 52 years.
Most participants (70.8%) had never had a biopsy. Among the ones who had, 16.7% had undergone only one biopsy, with the remaining 12.5% having had more than one biopsy. Most participants (65.5%) had never been diagnosed with any abnormal breast changes; however, almost one-third of the participants (29.3%) had been diagnosed with fibrocystic disease; 3.4% had been diagnosed with atypical ductal hyperplasia, and 1.7% had been diagnosed with lobular carcinoma in situ.
Measures
The data reported in the present study are based on participants for whom complete information was available. Because of unforeseen time constraints, 10 participants were unable to complete the Impact of Event Scale—Revised (IES-R);23 thus, analyses of the data generated by this instrument are based on complete data available from 63 participants.
Although this instrument was not specifically developed for the diagnosis of PTSD, it is one of the most widely used self-report instruments for the assessment of posttraumatic reactions.24 This instrument is an updated revision of the original instrument,25 and it has been previously used to evaluate stress reactions related to the experience of cancer.2,26 The IES-R contains three subscales that reflect the three dimensions of the DSM-IV criteria for the evaluation of PTSD: avoidance, intrusiveness, and hyperarousal; it includes one item regarding dissociation (cluster B, item 3, in DSM-IV) that parallels the DSM-IV diagnostic criteria for PTSD. Thus, while it is not designed to formally assess PTSD, the IES-R maps specifically and directly onto the symptoms used in DSM-IV for the diagnosis of the disorder. Even though our subjects completed only the IES-R because this version of the instrument contains all of the original IES item pool, the IES-R was scored so that it yielded IES scores. This is a standard practice that allows for the present results to be compared with previous studies that used the original version of the measure.23,24
In order to complete the IES-R, the participants were asked to answer each of the questions with respect to a relative to whom they felt close and with whom they had spent a significant amount of time during diagnosis and treatment of breast cancer. Most participants reported thinking about their mother's (67.1%) or their sister's (21.4%) breast cancer, while the remaining 11.4% reported thinking about a grandmother, an aunt, or another close relative with the disease.
The State-Trait Anxiety Inventory (STAI)27 is a 40-question instrument that measures the current level of anxiety ("state") and a characterological or enduring level of anxiety ("trait"). Responses are on a 4-point Likert scale ("almost never," "sometimes," "often," and "almost always"). This test has excellent concurrent validity (levels up to r=0.80) and reliability (r=0.77).27 The STAI manual reports high internal consistency for both the trait scale and the state scale, which was replicated in this study with internal consistency scores of 0.89 (state anxiety) and 0.91 (trait anxiety).
The Center for Epidemological Studies Depression Scale (CES-D Scale)28 is a 20-question instrument that measures depressive symptoms. The test has excellent concurrent validity (levels up to r=0.72) and split-half and coefficient alpha reliability (r=0.85 for the general population; r=0.90 for the clinical population);28 the current study yielded an internal consistency score of 0.92. While not constituting a clinical diagnosis of depression, scores at or above 16 on the CES-D Scale are considered indicative of clinically significant symptoms of depression.
In order to assess personal risk for developing breast cancer, participants were asked to provide an estimate of their likelihood of developing breast cancer in their lifetime, on a scale of 0% to 100%, with higher scores indicating higher perceived risk of developing breast cancer.
The participants were asked to rate how upset or distressed they felt regarding their relative's diagnosis at the time the diagnosis was made. Distress was measured on a 5-point scale ranging from 1 ("least upsetting event") to 5 ("most upsetting event experienced").
The participants were asked to rate how upset or distressed they felt when they first saw the surgical results of their relative's surgical treatment for breast cancer. Amount of distress was measured on a 5-point scale, ranging from 1 ("least upsetting event") to 5 ("most upsetting event experienced").
The participants were asked to rate the degree to which their relative's breast cancer had resulted in important changes in the participants' daily routines (e.g., working or studying part-time only in order to take care of an ill relative). Change was measured on a 4-point scale, with 1=no change, 2=minimal change, 3=moderate change, and 4=extensive change.
The participants were asked to rate the degree to which their relative's breast cancer had resulted in important changes in their long-term life plans (e.g., deciding not to have children or deciding not to leave home to go to school). Change was measured on a 4-point scale, with 1=no change, 2=minimal change, 3=moderate change, and 4=extensive change.
Procedures
During their initial visit to the high-risk clinic, the patients were invited to participate in the study, were given a description of the study, and advised regarding confidentiality; the patients were assured that their participation would in no way would affect their care at the clinic. After providing written informed consent, the participants privately provided psychosocial background information and completed the self-report measures.
To calculate the presence of traumatic distress consistent with PTSD-like symptoms in our group, the IES-R was used in the following manner:
- In order to obtain a conservative assessment of traumatic distress, only responses above 3 ("quite a bit" or "extremely") were considered to be an endorsement of an IES-R item. Responses below 3 ("a little," "moderately," and "not at all") were considered nonendorsements.
- Embedded in the IES-R are the three symptom clusters used in DSM-IV as diagnostic criteria for PTSD (intrusion, arousal, and avoidance), with IES-R items directly mapping onto the symptoms specified in DSM-IV for the diagnosis of PTSD. In order to meet DSM-IV criteria, individuals must exhibit at least one symptom of intrusion, at least two symptoms of arousal, and three or more symptoms of avoidance.1 Thus, for the purpose of determining the number of patients endorsing items in a manner that satisfied DSM-IV criteria for PTSD, participants in the present study needed to endorse at least six symptoms in the requisite symptom categories (i.e., 1 intrusion + 2 arousal + 3 avoidance=6).
- For the purpose of determining the number of patients endorsing items in a manner indicative of significant distress but not sufficient to meet DSM-IV criteria, subjects endorsing the required number of symptoms in only two of the three requisite categories were defined as exhibiting "subclinical" symptoms.
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RESULTS
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Risk Perception
The participants' mean ratings of their perceived risk for developing breast cancer in their lifetime was 45.6% (SD=26.3%).
Perceived Level of Distress
In terms of the assessment of the participants' level of distress at the relative's diagnosis, most participants (66.1%) rated their distress at the time of their relative's diagnosis as either "very upsetting" or "the most upsetting ever," with 21% stating that they had been "upset." Forty-three participants (58.9%) reported seeing the surgical scars after their relative's cancer treatment. Among these participants, close to one-half (53.5%) described seeing their relative's surgical scars as a "moderately upsetting" to "upsetting" event, with 44.2% describing it as "very upsetting" to the "most upsetting" stressful event ever experienced. Only one subject described seeing the surgical results as a "least upsetting" event.
In terms of the degree to which the participants felt that their relative's breast cancer had resulted in important changes in the participants' own daily routines, about half (46.3%) of the participants reported moderate to extensive changes, with the other half (53.8%) reporting either only minimal changes or no changes at all. In terms of long-term changes in their life plans, about one-third of the participants (36.4%) reported moderate to extensive changes, with the remaining two-thirds reporting only minimal changes (30.3%) or no changes at all (33.3%).
General Anxiety
Analyses of STAI results revealed that the participants had elevated scores on both STAI subscales. Complete data for the STAI was available for 55 participants; the mean score for the STAI state measure was 37.58 (SD=10.86) and for the STAI trait, 38.72 (SD=9.49). Both mean scores are close to the clinical cutoff point of the 40th percentile, indicating significant symptoms of anxiety. Among participants, 45.5% scored above the clinical cutoff point for the STAI state measure, and 51.9% scored above the clinical cutoff point for the STAI trait measure, indicating significant symptoms of anxiety.
Depression
Examination of the CES-D Scale yielded a mean score of 11.52 (SD=10.60). Almost one-third of our group (28.8%) received scores above 16, which is considered a cutoff point indicating clinically significant symptoms of depression.
Posttraumatic Stress Reactions
Analysis of the IES-R showed mean total scores to be 15.22 (SD=12.02). The mean scores for the separate subscales were avoidance, 6.10 (SD=6.29), intrusion, 6.5 (SD=4.81), and arousability 3.15 (SD=3.94). When we scored only the pool of items that comprise the original IES form, the participants obtained a mean total score of 17.7 (SD=14.1), with a mean of 8.9 (SD=6.9) for the intrusion subscale, and 8.8 (SD=9.2) for the avoidance subscale.
Table 1 shows a comparison of scores on the original IES for the present study, previous studies of breast cancer patients,2,26 and survivors of a nuclear plant accident.29 As can be seen, the scores found in the present study for the total scale and the avoidance and intrusion subscales are close to those reported by other breast cancer patients and by individuals living near the Three Mile Island nuclear accident and are higher than the scores obtained by individuals living further away from that incident.
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TABLE 1. Scores on the Impact of Event Scale for Patients With Breast Cancer and Those at High Risk for Breast Cancer
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When we used the IES-R as a means to extrapolate potentially diagnosable participants, three subjects (4%) endorsed items in a manner that satisfied the DSM-IV criteria for a PTSD diagnosis. Table 2 shows the percentage of participants considered to be potentially diagnosable with PTSD according to the IES-R and compares it to that of previous studies that similarly identified cancer patients who were considered to be potentially diagnosable with PTSD by using either the IES-R30 or a structured clinical interview.3,26
Table 2 also shows the percentage of participants in the present study and in these who, through self-report symptom endorsement on the IES-R, may potentially meet DSM-IV criteria for each of the PSTD symptom clusters. As shown, 37% of the participants in the present study met criteria for the intrusion symptom cluster, 8% met criteria for the avoidance symptom cluster, and 7% met criteria for the arousal symptom cluster.
Five subjects (6.8%) endorsed the required number of IES-R items for two of the three symptom clusters specified in the DSM-IV and were thus considered to be potentially presenting subclinical symptoms of PTSD. In all, 10.9% of the participants were, by self-report on the IES-R, clinically or subclinically potentially diagnosable with PTSD by means of conventional DSM-IV criteria.
Table 3 shows the percentage of participants who had clinical and subclinical potential for meeting PSTD criteria by their endorsement of IES-R items and compares it with findings of clinical and subclinical levels of PTSD among breast cancer patients in studies that previously reported other self-report measures2 or structured clinical interviews.4 Of the three participants in our study who reported a death from breast cancer of a relative, none was among those potentially meeting criteria for diagnosis or subclinical level of PTSD.
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TABLE 3. Prevalence of PTSD Diagnosis and Subclinical PTSD for Patients With Breast Cancer and Those at High Risk for Breast Cancer
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In order to examine possible contributors to participants' traumatic stress reactions, a series of correlations were conducted between total scores on the IES-R and several demographic and symptom variables, including the STAI trait and state scales, the CES-D Scale, personal perception of vulnerability to breast cancer, age at the time of the interview, and number of years elapsed since the relative's diagnosis of breast cancer. Given their common tapping into the domain of anxiety, we expected to find significant correlations between the IES-R and the trait and state subscales of the STAI. Indeed, significant correlations were found between the IES-R total score and the scores on the STAI state (R=0.51) and trait subscales (R=0.36). Significant correlations were also found between scores on the avoidance scale of the IES-R and the STAI state (R=0.41) and trait subscales (R=0.40) and between the IES-R intrusion (R=0.31) and arousal subscales (R= 0.42) and the STAI state subscale (p 0.05). These scales of the IES-R were not found to be significantly associated with the STAI trait subscale.
In examining the relationship between the depressive symptom profile and traumatic stress reactions, we found the CES-D Scale to be significantly associated with total IES-R scores (R=0.34, p0.05) and with scores on the IES-R arousal scale (R=0.41, p0.01) but not to be significantly associated with scores on the avoidance or intrusion subscales of the IES-R.
We also sought to explore whether the time elapsed since exposure to the traumatic stress (i.e., since the relative's diagnosis) was significantly associated with IES-R scores; no significant associations were found between time since the relative's diagnosis and IES-R variables, with the exception of a significant negative association between years elapsed since the relative's diagnosis and the participants' scores on the IES-R intrusion subscale (R=–0.33, p<0.01). Further examination with the Bonferroni correction for multiple tests revealed that participants whose relative was diagnosed fewer than 10 years before the initial interview reported significantly higher levels of intrusion on the IES-R intrusion subscale (mean=8.33, SD=5.06) than the participants whose relatives were diagnosed between 11 and 20 years ago (mean=4.38, SD=2.75) (F=4.29, df=1, 60, p=0.02). No significant associations were found between the IES-R and other demographic variables, including age at interview and the number of relatives affected with breast cancer.
Attempting to determine what variables might be associated with scores on the IES-R, the participants' experiences with breast biopsies were examined. Analyses revealed no differences in total IES-R scores (F=0.70, df=1, 60, p=0.41), the IES-R arousal subscale (F=0.25, df=1, 61, p=0.62), the IES-R avoidance subscale (F=0.02, df=1, 61, p=0.88), and the IES-R intrusion subscale (F=1.18, df=1, 61, p=0.28) among subjects who had never undergone a breast biopsy and those who had experienced one or more breast biopsies. Similarly, when analyzing the time elapsed since the participants' relatives were diagnosed with cancer, no significant differences were found among subjects who exhibited potential subclinical and clinically significant symptoms of PTSD (mean=13.54, SD=10.87) and those for whom no potentially significant symptoms were found (mean=15.37, SD=14.36) (F=1.81, df=1, 60, p=0.67). The analysis of participants' perceived risk perception of their vulnerability to breast cancer yielded no significant differences for the participants who potentially had subclinical and clinical symptoms of PTSD (mean=49.57, SD=20.61) and for those with no endorsement of potentially significant symptoms (mean=43.93, SD=25.84) (F=0.31, df=1, 58, p=0.58).
The study also examined a possible relation between endorsement of a significant number of items on the IES-R and participants' compliance with various cancer screening tests. Analyses revealed no significant differences in the level of compliance with cancer screening practices for the participants potentially exhibiting subclinical and clinical symptoms of PTSD and those with no endorsement of potentially significant symptoms. Specifically, no differences were found in compliance with Pap smears for the participants who exhibited potential symptoms of PTSD (mean=4.5, SD=1.06) and for those with no significant symptoms (mean=4.49, SD=1.06) (F=0.00, df=1, 59, p=0.98). No differences were found in the participants' compliance with mammography screening for those with significant symptoms on the IES-R (mean=4.57, SD=0.78) and for those with no significant symptoms (mean=4.21, SD=1.39) (F=0.45, df=1, 48, p=0.50). Similarly, no significant differences were found in the participants' compliance with breast self-examination for the participants endorsing a significant number of symptoms on the IES-R (mean=3.25, SD=1.75) and those not endorsing a significant number of items on the instrument (mean=3.07, SD=1.48) (F=0.09, df=1, 60, p=0.76).
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DISCUSSION
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To our knowledge, this is the first assessment of the experience of traumatic reactions, including PTSD-like symptoms, among first-degree relatives of breast cancer patients. The finding of such traumatic reactions in this high-risk population underlines the importance of conducting a thorough clinical assessment of different manifestations of anxiety. Given our use of the IES-R, a self-report instrument, the present study did not in any way attempt to make a formal clinical diagnosis of PTSD. However, this well-validated instrument documented in this at-risk population significant traumatic stress responses of a kind and level similar to those found in other traumatized populations.
It is important to note the controversy in the trauma literature regarding the inclusion of cancer as a traumatic stressor because, unlike other traumas, cancer is not a discrete, short-lived event, but rather a series of events, beginning with detection and diagnosis, proceeding through active treatment, and concluding with posttreatment recovery or death; these events may extend over a period of months or even years. Additionally, the immediacy and degree of life threat that cancer poses varies considerably. Nevertheless, subjective responses to cancer diagnosis and treatment by patients and their relatives typically includes feelings of fear, horror, and helplessness.9 We believe that the traumatic stress responses that have been documented in the present study support and concur with the findings of previous studies that have found PTSD-like reactions in oncology patients and their family members.2,4,10,11,26
Beyond its acceptance as a traumatic stressor in the diagnostic formulation of PTSD, this issue appears to be particularly complex for women with familial risk for breast cancer. The complexity derives in part from the fact that these individuals have not only witnessed the trauma and life-threatening nature of breast cancer in a first-degree relative but that they are also vulnerable to that same disease at an unknown future time. This state of ongoing vulnerability has previously been labeled the "Damocles syndrome."32 Originally, the term was applied to young cancer patients living with a fear of recurrence looming over them. These investigators suggested that this concept and term may be broadened and extended to the population at familial risk for breast cancer, with the feeling of impending illness adding to their experience of traumatization.
Our study's participants presented a prevalence of PTSD-like symptoms that was strikingly similar to the rates other studies have found among breast cancer and other oncology patients. This finding lends support to the notion that witnessing breast cancer in a close relative and being vulnerable to breast cancer may be as recurrently traumatic psychologically as is actually having breast cancer. In the studies we reviewed, the only notable exception to this pattern of similar prevalence rates was cancer patients who had undergone stem-cell transplantation,30 who had a prevalence rate three to five times that of the other patient samples and who presented a different pattern of scores on the PTSD subscales.
Among patients who had undergone stem-cell transplants, the PTSD symptom pattern reflected relatively less intrusion of thoughts and images about cancer or its treatment, as measured with the IES-R intrusion subscale. In contrast, these patients presented relatively more avoidance and emotional arousal, as measured with the avoidance and arousal subscales of the IES-R. By contrast, our study group and other groups of cancer patients without stem-cell transplantation endorsed more intrusive thoughts and imagery and far less avoidance or arousal.
It is clear that stem-cell transplantation is a therapy far more invasive and threatening, both physically and psychologically, than conventional treatment for breast cancer, such as radiation and chemotherapy. It is possible that this highly invasive and demanding therapy may have induced an "activation" reflex that results in high levels of arousal and avoidance. On the other hand, breast cancer patients undergoing conventional treatment and women at familial risk for breast cancer appear more prone to a cognitively mediated "mulling over" response that results in relatively more symptoms of intrusion compared with the activated fight-or-flight response of patients with stem-cell transplants.
The comparison of PTSD symptoms among close and distant survivors of a nuclear accident presents an interesting dichotomy. The symptom pattern of the present study group resembles much more than that of survivors who were in "close" proximity to a nuclear accident, and it differed from that of the survivors of a more "distant" nuclear accident. The metaphorical relationship of this for the present study is noteworthy: women at familial risk for breast cancer can be seen as survivors of a kind of "meltdown" in the close (family network) proximity; it could be said that these women have, in fact, witnessed at close proximity the "meltdown" of the myth of family invulnerability. Although relatively few individuals in our group experienced the death of their relative with breast cancer, by virtue of the close emotional and physical proximity to their ill relative, all of the participants in our study witnessed the vulnerability, anxiety, and fear associated with the diagnosis and treatment of breast cancer. While death may not have literally been present, the trauma associated with the possibility of death was indeed present.
In our study, we reported the percentage of subjects for whom a diagnosis of PTSD could potentially be extrapolated from the self-report measure, as well as the percentage of subjects who endorsed subclinical levels of PTSD-like symptoms. It is important to note that several patients who did not meet the criteria for any one particular symptom cluster lacked only one symptom in a symptom cluster, while potentially having twice as many of the required symptoms in other symptom clusters. Clinicians must carefully consider that failure to meet diagnostic criteria may provide a somewhat deceptive picture, given that some patients considered subclinical in terms of their PTSD diagnosis may nevertheless exhibit potentially disturbing and disabling symptoms.
Finally, we feel that the exploration of traumatic reactions and PTSD symptoms among women at risk for breast cancer is particularly important because these women are already burdened with a legacy of genetic vulnerability. That this vulnerability may be compounded by chronic feelings of anxiety, depression, and recurring, intrusive thoughts and images, as well as the avoidance of particular situations (e.g., breast cancer screening procedures, such as mammographies or breast self-examinations) that may go unnoticed, seems to be a potentially dangerous combination. We have previously found that risk perception and anxiety specific to certain screening procedures may reduce compliance.33 In our clinical experience with this population, once disturbing, intrusive thoughts are able to be verbalized in a safe, supportive, and containing environment, the associated anxiety characteristic of PTSD symptoms may diminish significantly.
Thus, we would suggest that all such high-risk patients be given the time and opportunity to detail key memories of the experiences regarding breast cancer in their families. In our clinical experience, virtually all of our clinic patients opt to go though this narrative process with us. For the roughly 90% who do not report clinical or subclinical symptoms of PTSD, this is cathartic and sufficient. For the 10% who do exhibit such symptoms, more is often necessary. What is required is more time, more intense focus, and repetition of the cathartic narrative experiences of their traumas and associated feelings. This usually cannot be done in the context of the high-risk clinic and instead requires triage and referral to qualified therapists. In our experience, this segment of our patient population often has more complex and unresolved family experiences related to breast cancer and hence appears to be more burdened with symptoms of anxiety and depression. Thus, consideration of psychopharmacological interventions is also potentially important. It is likely that a clinic-based population such as ours will feel more vulnerable and traumatized by family experiences with breast cancer than a community-based population; this is illustrated by our findings in a previous study of a community-based population of the daughters of breast cancer patients, in which no significant differences were found in anxiety and depression symptoms between such daughters and a well-matched comparison group.34
Several limitations of the present study should be noted. In addition to the weakness of cross-sectional research for examining temporal relationships, our assessment of traumatic events and the degree of distress and life changes regarding a relative's diagnosis were retrospective. There is evidence for the potential biasing that current mood may have upon retrospective recall for the past,35 and the degree to which this occurred in the study, if at all, is not known. In addition, it is clear that the optimal strategy for diagnosing PTSD is a multimodal approach in which a variety of different types of data (e.g., social, cognitive, familial, and work functioning), collected from different sources and by different methods, is gathered and evaluated. More commonly, in clinical settings, the PTSD diagnosis is established through the use of a structured clinical interview. In research settings, however, financial and time constraints have made it necessary to use PTSD symptom self-report measures, such as the IES in its original and revised versions. Although measures within this category do not provide a comprehensive diagnosis of PTSD, they are useful in providing information about symptom severity and frequency. Although the use of the IES in the present study was not intended for formal diagnostic assessment of PTSD, we believe this instrument to have adequate and widely documented psychometric properties (for a description of cross-validating procedures, see Zilberg et al.36). We believe that it is a useful tool in describing and demonstrating that PTSD-like manifestations can develop in the context of a familial risk for breast cancer.
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REFERENCES
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- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV). Washington, DC, American Psychiatric Association, 1994
- Cordova MJ, Andrykowski MA, Kenady DE, McGrath PC, Sloan DA, Redd WH: Frequency and correlates of PTSD-like symptoms following treatment for cancer. J Consult Clin Psychol 1995; 63:981–986[CrossRef][Medline]
- Alter CL, Pelcovitz D, Axelrod A, Goldenberg B, Harris H, Meyers B, Grobois B, Mandel F, Septimus A, Kaplan S: Identification of PTSD in cancer survivors. Psychosomatics 1996; 37:137–143[Abstract/Free Full Text]
- Andrykowski MA, Cordova MJ, Studus MJ, Miller TW: Posttraumatic stress disorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD Checklist—Civilian Version (PCL-C) as a screening instrument. J Consult Clin Psychol 1998; 66:586–590[CrossRef][Medline]
- Andrykowski MA, Cordova MJ: Factors associated with PTSD symptoms following treatment for breast cancer: test of the Anderson model. J Trauma Stress 1998; 11:189–203[CrossRef][Medline]
- Cordova MJ, Studts JL, Hann DM, Jacobsen PB, Andrykowski MA: Symptom structure of PTSD following breast cancer. J Trauma Stress 2000; 13:301–319[CrossRef][Medline]
- Andrykowski MA, Cordova MJ, McGrath PC, Sloan DA, Kenady DE: Stability and change in posttraumatic stress disorder symptoms following breast cancer treatment: a 1-year follow-up. Psychooncology 2000; 9:69–78[CrossRef][Medline]
- Carlier IVE, Gersons BPR: Partial posttraumatic stress disorder (PTSD): the issue of psychological scars and the occurrence of PTSD symptoms. J Nerv Ment Dis 1995; 183:107–109[Medline]
- Smith MY, Redd WH, Peyser C, Vogl D: Post-traumatic stress disorder in cancer: a review. Psychooncology 1999; 8:521–537[CrossRef][Medline]
- Pelcovitz D, Goldenberg B, Kaplan S, Weinblatt M, Mandel F, Meyers B, Vinciguerra V: Posttraumatic stress disorder in mothers of pediatric cancer survivors. Psychosomatics 1996; 37:116–126[Abstract/Free Full Text]
- Stuber ML, Christakis DA, Houskamp B, Kazak AE: Posttrauma symptoms in childhood leukemia survivors and their parents. Psychosomatics 1996; 37:254–261[Abstract/Free Full Text]
- Croyle RT, Smith KR, Botkin JR, Baty B, Nash J: Psychological responses to BRCA1 mutation testing: preliminary findings. Health Psychol 1997; 16:63–72[CrossRef][Medline]
- Gilbar O: Women with a high risk for breast cancer: psychological symptoms. Psychol Rep 1997; 80:800–802[Medline]
- Valdimarsdottir HB, Bovbjerg DH, Kash KM, Holland JC, Osborne MP, Miller DG: Psychological distress in women with a familial risk of breast cancer. Psychooncology 1995; 4:133–141
- Lerman C, Daly M, Sands C, Balshem A, Lustbader E, Heggan T, Goldstein L, James J, Engstrom P: Mammography adherence and psychological distress among women at risk for breast cancer. J Natl Cancer Inst 1993; 85:1074–1080[Abstract/Free Full Text]
- Fawzy IF, Fawzy NW: Psychoeducational interventions, in Psychooncology. Edited by Holland JC. New York, Oxford University Press, 1998, pp 676–693
- Foa EB, Keane TM, Friedman MJ (eds): Effective Treatments for PTSD. New York, Guilford, 2000
- Kash KM, Holland JC, Halper MS, Miller DG: Psychological distress and surveillance behaviors of women with a family history of breast cancer. J Natl Cancer Inst 1992; 84:24–30[Abstract/Free Full Text]
- Zakowski SG, Valdimarsdottir HB, Bovbjerg DH, Borgen P, Holland J, Kash K, Miller D, Mitnick J, Osborne M, Van Zee K: Predictors of intrusive thoughts and avoidance in women with family histories of breast cancer. Ann Behav Med 1997; 19:362–369[Medline]
- Thirlaway K, Fallowfield L, Nunnerley H, Powles T: Anxiety in women "at risk" of developing breast cancer. Br J Cancer 1996; 73:1422–1424[Medline]
- Lerman C, Schwartz MD, Lin TH, Hughes C, Narod S, Lynch H: The influence of psychological distress on use of genetic testing for cancer risk. J Consult Clin Psychol 1997; 65:414–420[CrossRef][Medline]
- Audrain J, Schwartz MD, Lerman C, Hughes C, Peshkin BN, Biesecker B: Psychological distress in women seeking genetic counseling for breast-ovarian cancer risk: the contributions of personality and appraisal. J Behav Med 1997; 19:370–377
- Weiss D, Marmar CR: The Impact of Event Scale—Revised, in Assessing Psychological Trauma and PTSD: A Practitioner's Handbook. Edited by Wilson JP, Keane TM. New York, Guilford, 1996, pp 399–411
- Joseph S: Psychometric evaluation of Horowitz's Impact of Event Scale: a review. J Trauma Stress 2000; 13:101–113[CrossRef][Medline]
- Horowitz MJ, Wilner N, Alvarez W: Impact of Event Scale: a measure of subjective stress. Psychosom Med 1979; 41:209–218[Abstract/Free Full Text]
- Green B, Rowland JH, Krupnick JL, Epstein SA, Stockton P, Stern NM, Spertus IL, Steakley C: Prevalence of posttraumatic stress disorder in women with breast cancer. Psychosomatics 1998; 39:102–111[Abstract/Free Full Text]
- Spielberger CD, Gorsuch RL, Lushene RD: STAI Manual. Palo Alto, Calif, Consulting Psychologists Press, 1970
- Radloff LS: The CES-D Scale: a self-report depression scale for research in the general population. J Applied Psychol Measurement 1977; 1:385–401[CrossRef]
- Davidson LM, Baum A: Chronic stress and PTSD. J Consult Clin Psychol 1986; 54:303–308[CrossRef][Medline]
- Roper K, Simoneau T, McRae C: PTSD among women breast cancer survivors treated with stem cell transplant, in Abstracts of the Pan-American Congress of Psychosocial and Behavioral Oncology. New York, Oct. 20–23, 1999
- Weathers FW, Huska JA, Keane TM: The PSTD Checklist-Civilian Version (PCL-C). Boston, National Center for Posttraumatic Stress Disorder, Boston Veterans Affairs Medical Center, 1991
- Koocher GP, O'Malley JE: The Damocles Syndrome. New York, McGraw-Hill, 1981
- Lindberg NM, Wellisch DK: Anxiety and compliance among women at high risk for breast cancer. Ann Behav Med 2001; 23:298–304[CrossRef][Medline]
- Wellisch DK, Gritz ER, Schain W, Wang HJ, Siau J: Psychological functioning of daughters of breast cancer patients, part I: daughters and comparison subjects. Psychosomatics 1991; 32:324–336[Abstract/Free Full Text]
- Eich E: Mood as mediator for place dependent memory. J Exp Psychol Gen 1995; 124:293–308[CrossRef][Medline]
- Zilberg NJ, Weiss DS, Horowitz MJ: Impact of Event Scale: a cross-validation study and some empirical evidence supporting a conceptual model of stress response syndromes. J Consult Clin Psychol 1982; 50:407–414[CrossRef][Medline]
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