Psychosomatics 39:102-111, April 1998
© 1998 The Academy of Psychosomatic Medine
Prevalence of Posttraumatic Stress Disorder in Women With Breast Cancer
Bonnie L. Green, Ph.D.,
Julia H. Rowland, Ph.D.,
Janice L. Krupnick, Ph.D.,
Steven A. Epstein, M.D.,
Patricia Stockton, Ph.D.,
Nicole M. Stern, B.A.,
Ilyse L. Spertus, B.A., and
Caryn Steakley, R.N., M.S.W.
Received December 6, 1996; revised March 25, 1997; accepted July 21, 1997. From the Department of Psychiatry, Georgetown University. Address reprint requests to Dr. Green, Department of Psychiatry, Georgetown University, 310 Kober Cogan Hall, Washington, DC 20007.
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ABSTRACT
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This study investigated whether diagnosis and treatment of breast cancer produced posttraumatic stress disorder (PTSD) in adult women. One hundred sixty women with early stage node-negative breast cancer completed self-report questionnaires and underwent a full diagnostic assessment (Structured Clinical Interview for DSM-III-R). PTSD symptoms were common; however, only 3% of the women interviewed met stringent criteria for cancer-related PTSD in the 4–12 months following the completion of their medical treatment. Thus, breast cancer produced considerable distress, but low rates of PTSD, and may not fit well as a Criterion A stressor event for PTSD. Caution is urged for an assumption of a PTSD diagnosis based on self-reported symptoms.
Key Words: Posttraumatic Stress Disorder • PTSD • Breast Cancer • Cancer • Women
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INTRODUCTION
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The occurrence of posttraumatic stress disorder (PTSD) following exposure to traditional stressors such as rape, assault, or combat is well documented,1 with numerous studies indicating that about 20%–25% of persons who experience such stressors meet criteria for this diagnosis. Up to one-third of those persons will continue to meet PTSD criteria for as long as the follow-up period.1–4 Life-threatening illness was identified for the first time as a potential Criterion A stressor event for PTSD in the recent edition of DSM-IV.5 However, few studies exist to document the empirical validity of this link.
Holland and Rowland6 noted that following a diagnosis of cancer, a normal stress response, characterized by shock, numbness, and denial and often including despair and hopelessness, is common. Later, anger, disruptive anxiety, and depressive symptoms may be seen as well. Such early reports suggested that cancer might be a traumatic stressor. Earlier research also suggested that cancer is associated with some symptoms of PTSD. Cella and Tross7 found that male survivors of Hodgkin's disease showed lower motivation for intimacy and higher avoidant thinking about illness than a comparison group of physically healthy men. In a later study, markedly elevated levels of intrusion and avoidance were found on the Impact of Event Scale8 in a sample of 40 patients evaluated within 30 days of a cancer recurrence.9 In that study, 78% of the patients reported that their initial diagnosis of cancer was less distressing than the recurrence, suggesting that more imminent threat may be more strongly associated with PTSD symptoms.
More recently, a few investigators have focused specifically on PTSD symptoms and estimated rates of the diagnosis in cancer survivors. Cordova and colleagues10 used the Impact of Event Scale and a PTSD checklist covering DSM-IV symptoms (PTSD Checklist–Civilian Version11) to assess 55 women with nonmetastatic breast cancer who were 6 to 60 months posttreatment. They estimated that from 5% to 10% of their sample would meet current diagnostic criteria for PTSD. Alter and colleagues12 used a standardized diagnostic assessment as part of the DSM-IV field trials for PTSD to examine a small sample (n=27) of women with cancer, of whom 81% had breast cancer, and who were at least 3 years postdiagnosis. These authors found current PTSD rates of only 4% (n=1), but lifetime rates of 22%. Although the current rates in these studies are relatively low, Alter et al.'s lifetime rates are consistent with those reported for other traumas.
Interestingly, children and adolescents may show higher rates of PTSD associated with having cancer (about one-third) than adults,13,14 although the former's posttraumatic reactions appear to be related to the medical procedures endured rather than to the cancer diagnosis per se.13 Further, parents of these children report high rates of PTSD symptoms (e.g., 34%–40% estimated from self-report;13 30%–46% by interview14 ). For parents, the stressor is the illness and possible death of their child.
At the time this study was originally designed and funded, life-threatening illness had not yet been incorporated in the DSM as a potential Criterion A stressor event for PTSD, and no studies existed on this question. For conceptual-theoretical reasons, we were interested in the fit of life-threatening illness with the PTSD model. Thus, the study was designed to determine the extent to which women reporting significant distress following diagnosis and treatment of breast cancer would meet diagnostic criteria for PTSD, as well as which individual characteristics would predict development of cancer-related PTSD.
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METHODS
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Subjects
A total of 160 women with early stage breast cancer were recruited from 3 cancer centers in the Washington, DC, community. The women were identified through a variety of mechanisms, including tumor registries, surgical schedules, pathology rosters, and medical oncology rosters. To be eligible for study, a woman had to be between the ages of 25 and 75, have no history of cancer before her breast cancer, and be 4–12 months postcancer treatment. This time frame was chosen to ensure that a woman was not still experiencing the acute effects of treatment, yet was close enough in time to diagnosis to recall her reactions to her illness and therapy. All participants had to have been diagnosed with either Stage 1 or Stage 2 node-negative breast cancer. This group of cancers was chosen because they are localized to the breast and confer an excellent prognosis. About 93% of women with node-negative breast cancer survive for 5 years or more; by contrast, the long-term survival rate from any breast cancer is about 50%.15 Ongoing oral hormonal therapy (tamoxifen) was not an exclusion criterion, nor was prior psychiatric history. Because it was felt that type or extent of treatment might affect the degree of stress experienced, an attempt was also made during the recruitment process to stratify for therapy received, for example, mastectomy vs. lumpectomy plus radiation, with or without adjuvant chemotherapy (four groups).
The thoroughness of the resources used suggests that we were able to obtain the names of most of the eligible patients at participating centers during the study period. Of the 264 women invited to participate, 160 (61%) were eventually interviewed. Among the nonparticipants, 5% had recurrence of breast cancer or missed our posttreatment cut-off. Another 13% could not be reached by phone. The majority (82%) declined either by returning our reply form (described later) and/or by stating they were too busy, not interested, or too distressed. The nonparticipants were older (mean=60.41, standard deviation [SD]=11.55) than the participants (mean=53.40, SD=9.66), and a higher proportion were African American than any other racial category (76% vs. 29%).
Instruments
The participants completed a comprehensive battery of self-report measures and underwent a structured psychiatric interview. Included in the self-report battery were demographic information and medical history, along with a number of standardized measures. We detail next only those instruments that were used to collect the data in this report.
Trauma History Questionnaire (THQ).
The THQ16 is a self-report instrument developed at our center to gather data about a subject's lifetime history of exposure to traumatic events, including crime, sexual assault/abuse, physical assault/abuse, war, tragic death, and disaster. Based on the high-magnitude stressor interview from the DSM-IV PTSD field trials,17 the THQ has been used with several clinical and nonclinical samples and is currently undergoing revisions based on these data. It shows good test-retest reliability over a several-week period (r's=0.60–1.00 for personally experienced events). In this study, the instrument was used to assess events that might produce noncancer PTSD. Self-report responses were followed up with detailed questions during the interview to evaluate whether the reported events met Criterion A for PTSD.
Impact of Event Scale (IES).
The IES was originally developed by Horowitz and colleagues18 and modified by Zilberg and colleagues8 to measure the intrusive and avoidant components of the stress response. It consists of 15 items—7 items in the intrusion subscale, and 8 items in the avoidant subscale—scored 0, 1, 3, or 5. It has been used in numerous studies on trauma and PTSD and has excellent reliability and validity.
Brief Symptom Inventory (BSI).
The BSI19 is a 52-item short form of the Symptom Checklist-90 that asks the subject to report symptom-related distress on a scale from 0 to 4. It has nine symptom-specific scales and a Global Severity Index. It has been used in numerous studies of PTSD and of cancer, and allowed us to place our sample contextually within this literature.
Stressful Illness Experiences (SIE).
The SIE was developed by the investigators to assess a full range of experiences across the course of cancer diagnosis and treatment that might be stressful and that might be targets for intrusive thinking. Specific events were generated from our clinical experience with these patients (e.g., discovery of a mass or lump herself, having to decide between lumpectomy vs. mastectomy), with a few items being added following pilot testing. The women rated each of the 30 experiences on a scale ranging from 1 (not at all stressful) to 5 (extremely stressful), or not applicable.
Structured Clinical Interview for DSM-III-R (SCID).
Following the elaboration of the THQ, the subjects received the full SCID20 interview for past and current diagnoses. Acute stress disorder (ASD: a module based on the draft criteria for DSM-IV) and PTSD were assessed separately and independently for cancer and for noncancer stressor events. The cancer ASD and PTSD modules referred to "your cancer diagnosis and treatment" as the A criterion and had the subject focus on her individually most stressful experiences as elicited on the SIE. Since PTSD symptoms were rearranged, but not changed, between DSM-III-R and DSM-IV, we were able to generate DSM-IV diagnoses for PTSD.
Interviewers
The interviewers were postbachelor- and master's-level female research assistant/graduate students. Training for the SCID consisted of a series of activities: viewing tapes created for training purposes by the SCID developers, observing interviews conducted by the investigators who had previously been trained in the SCID, conducting role-play interviews with the investigators, and conducting interviews of the subjects in the presence of the investigators. At each stage, the cases were discussed with regard to interview format and scoring. A sample of 30 cases assessed by 2 raters (1 conducting the interview and 1 observing) was used to assess interrater reliability. Kappas for cancer-related PTSD were 0.79 for lifetime and 1.00 for current; the kappa for lifetime noncancer PTSD was 0.84. The kappa for any depression diagnosis was 0.77 and for any anxiety diagnosis was 1.00. Given the low base rates of these disorders, the kappas were considered to be adequate.
Procedure
When a potential subject was identified, a research nurse (CS) reviewed her chart to confirm eligibility. With doctors' permission, the subjects meeting inclusion criteria were sent a letter asking them to participate, which included a reply form that permitted them to decline study entry. The subjects were sent an invitation, and those who did not reply received a follow-up phone call. At the time of that contact, the nature and requirements of the study were detailed, and if the woman agreed to study entry, an appointment was made for the interview session. The interviews were usually conducted at the institution where the subject received her cancer treatment. At the time of that visit, the women provided written informed consent, completed the self-report measures, and then were interviewed. The entire procedure took from 90 minutes to 3 hours. The subjects were paid $30 for their participation.
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RESULTS
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Descriptive and Medical Information
Mean age of the sample was 53.40 (SD=9.66, range: 26–75). Two-thirds of the sample were white (66%), 27% were African American, and 7% were Asian American or Latina. Fifty-eight percent of the women were married or living with a partner, 19% were separated or divorced, and 23% were single or widowed. Only 19% had children under the age of 18 living with them. Most were employed at least part-time (67%), and most (64%) were college graduates. Family income was high: only 12% of families had incomes under $30,000, whereas 57% had incomes of $60,000 or above.
With regard to their breast cancer treatment, 19% had mastectomy alone, and 19% had mastectomy followed by adjuvant chemotherapy; 38% had breast conservation (lumpectomy) with radiation, whereas 24% had conservation with chemotherapy. The women were an average of 6.5 months posttreatment for their cancer. Fifty-two percent were taking tamoxifen at the time of the interview.
The three most stressful experiences that applied to all women were (in order) "having a doctor tell you that you have breast cancer," "waiting for results of the final surgery and/or axillary node dissection," and "waiting period prior to breast surgery."
Clinical Status
The diagnosis of cancer-related PTSD was relatively rare. Allowing any repetitive intrusive thoughts to qualify for the "B" criterion, 5% (n=8) of the women in the sample had a postcancer PTSD diagnosis, and 2.5% (n=4) continued to have the diagnosis at the time of the interview (see Table 1). Technically, however, "B" symptoms cover only reexperiencing, not future-oriented ruminations, even if these are intrusive. Thus, symptoms such as intrusive fear of recurrence, worrying or ruminating about having cancer, or dreaming about dying would not meet this criterion. Only 5 of the 8 lifetime cases (3% of the sample) met this more stringent criterion, including recollections, whereas the other 3 received the diagnosis based only on more general thoughts about their cancer. Three of the 4 cases of current PTSD met these stringent criteria (1.9% of sample).
PTSD symptoms, on the other hand, were common. Thirty-six percent of the women reported having experienced at least 1 symptom of intrusion (not necessarily reexperiencing) since their diagnosis (20% currently), and 27% had 2 or more symptoms of hyperarousal (i.e., met full criteria [11% currently]). Only 8% met full criteria (3 symptoms) for avoidance/numbing (4% currently), which determined the upper limit for the full PTSD diagnosis. If we arbitrarily reduced the required "C" (avoidance/numbing) symptoms from 3 to 2, we added 6 cases (another 3.8%), of "subsyndromal" PTSD by using liberal criteria, or 2 cases (1.2%) by using stringent criteria. About one-third (36%) of the women had 3 or more PTSD symptoms.
On the IES, the mean was 8.6 for the Intrusion scale and 9.8 for Avoidance. These means are higher than those of motor vehicle-accident victims without a psychiatric diagnosis (4.85 and 3.81, respectively21) but lower than those of motor vehicle-accident victims with PTSD (24.11 and 24.30, respectively21) or community (nontreatment) subjects who recently lost a parent (13.2 and 9.1, respectively8). The mean of the Global Severity Index (GSI) of the BSI was 0.47 (Table 2). This falls at the 57th percentile for nonpatients and is comparable to the somewhat elevated scores observed in other cancer survivor samples.7,22
The incidence of noncancer PTSD in this sample was relatively low as well. Of those women reporting a noncancer event that the interviewer judged to be a possible Criterion A stressor (n=95, or 59%), 7.4% met lifetime criteria for PTSD (see Table 1). This figure comprised 4.4% of the total sample. The events associated with noncancer PTSD were rape or molestation (4 cases) and 1 case each of traumatic bereavement, another life-threatening illness, and a daughter's attempted suicide. No one met full criteria for current noncancer PTSD. Of note was the finding that there was no overlap between the women with cancer and noncancer PTSD. Thus, 7%–9% of the sample met full lifetime criteria for PTSD from any source. No one met full criteria for cancer-related acute stress disorder.
Among the other DSM diagnoses observed, the most common was major depression, in which lifetime incidence, as assessed on the SCID, was 28% (see Table 2). Most of these diagnoses preceded the cancer. However, 11% of the women met criteria for postcancer major depressive disorder (MDD); 6 women (4%) had their first MDD episode following their cancer diagnosis, and another 12 women had a recurrence at this time. A total of 46% of our sample met criteria for any lifetime diagnosis on the SCID, and 12% had a current diagnosis.
PTSD was comorbid to a moderate extent with depression. Of the eight women with lifetime cancer-related PTSD, four had lifetime histories of major depression as well, and two had postcancer MDD. Of the four current cases of cancer-related PTSD, one also had current MDD. Noncancer PTSD overlapped with MDD to an even greater extent. Of the seven cases of lifetime noncancer PTSD, five also had histories of MDD. There was no overlap between cancer-PTSD and other anxiety disorders.
There were no differences by type of surgery, or by whether or not the woman had adjuvant chemotherapy, in number of PTSD symptoms or continuous scores on the other symptom reports. Further, the women who continued to take tamoxifen did not differ on number of PTSD symptoms from those who were not taking the medication. There was also no relationship between number of PTSD symptoms and time since diagnosis (r=0.08, NS; range: 3.6–19.6 months), or between PTSD symptoms and time since the end of treatment (r=-0.07, NS; range: 3.8–12.3 months). The IES indices were significantly negatively correlated with age: Intrusion, r=-0.29 (P<0.001); avoidance, r=-0.16 (P<0.05).
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DISCUSSION
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Overall, relatively low rates of cancer-related PTSD were observed in this sample of breast cancer survivors: 5% at any time postcancer diagnosis (up to 20 months) or treatment (up to 1 year) with liberal criteria, and only 3% with more stringent criteria. These rates are lower than those associated with more traditional traumatic events such as rape, war, disaster, and accidents in general samples, in which average lifetime rates of PTSD are four to five times higher in the general population.1,2,4 Even in our present sample, with relatively low rates of PTSD overall, noncancer PTSD rates were twice as high as cancer-related rates (7.4% vs. 3%). For a severe traditional stressor, sexual assault, the PTSD rate in the present sample was 22%.
The relatively low current PTSD rates are consistent with those of Alter et al.12 and Cordova et al.,10 who reported current rates of 4% and 5%–10%, respectively. The slightly higher rates in Cordova et al. are likely attributable to their use of self-report measures. These measures tend to overestimate diagnoses, as there is not the opportunity for an interviewer to assess the severity and/or clinical significance of a particular symptom or to determine whether symptoms arose or worsened only following the cancer. Levels of Intrusion (8.6) and Avoidance (9.8) on the IES were also comparable to those found in the Cordova et al.10 study (7.4 and 9.0, respectively) , scoring the IES in the same manner (Andrykowski MA, personal communication, 1996). Our lifetime cancer-PTSD subjects had higher GSI scores than Alter et al.'s PTSD subjects (0.83 vs. 0.59), whereas our non-PTSD subjects had very similar scores (0.45 vs. 0.48). Thus, it appears that our subjects were similarly or slightly more distressed at the time of data collection as subjects from the other two studies. Also comparable among the studies was the finding that type of treatment did not relate to outcome. However, the younger women were at greater risk for PTSD symptoms than the older women.
Less clear is an explanation for the difference between our lifetime rate of cancer-related PTSD (3%–5%) and that reported by Alter et al.12 (22%). While the 2 samples had similar percentages of subjects who met lifetime reexperiencing criteria (36% vs. 48%) and arousal criteria (27% vs. 30%), only 8% of our sample met full avoidance/numbing criteria, compared with 30% of Alter et al.'s sample. Since the samples seem otherwise quite comparable, this finding suggests that avoidance was being assessed quite differently in the two studies. An alternative explanation lies in the possibility that the difference in time since the end of treatment relates specifically to numbing symptoms, that is, numbing symptoms may increase over time. Indeed, as women return to their daily lives, it seems possible that avoidance or denial of their disease might become more prominant; this might even be an adaptive response. On the other hand, this trend would not fit well with other information. First, neither our study nor other studies showed a relationship between time since diagnosis or treatment and number of PTSD symptoms. While we believe that our study had a sufficient range to test this hypothesis, other studies had even broader ranges. If lifetime PTSD diagnosis were a function of time, one would expect a relationship within studies between time elapsed and number of symptoms or prevalence of diagnosis. Second, longitudinal data on PTSD from other events indicates that the risk for PTSD is highest immediately following the event and declines over time,23 stabilizing at about 3 months. This finding drove the acute/chronic PTSD demarcation for DSM-IV.5 Cross-sectional studies support this finding as well.2,3 If risk for PTSD increases over time following cancer, this course would differ from that of PTSD associated with other types of events. Nevertheless, longitudinal studies are recommended to evaluate this and other possibilities.
The Alter et al. study12 may also be atypical. Studts and colleagues,24 as a follow-up to the Cordova et al.10 study, reported that in a brief telephone interview covering lifetime PTSD criteria, according to the SCID, they also found relatively low rates of lifetime cancer-related PTSD (9%). In any case, the present study is the largest conducted to date that used structured diagnostic interviews, which sampled from multiple sources across three centers. Further, it was conducted by a team with considerable expertise in both PTSD in other contexts25,26 and psychological responses to cancer.6
Several explanations may be advanced to account for the low incidence observed for cancer-related PTSD in all three studies. First, it may be that the high level of resources available to the middle-class to upper middle-class subjects who participated in the three studies served to buffer the stress of diagnosis and treatment. Cordova et al.10 found a negative correlation between income and PTSD symptoms and between educational level and PTSD symptoms, indicating that women with higher income and more education fared better. In our study, avoidance was modestly negatively associated with income (r=-0.16, P<0.05), and GSI was negatively associated with educational level (r=-0.26, P<0.01). Further, even though our sample had more minority subjects than either of the other samples, the low participation of African Americans in our study suggests that this group is underrepresented. Thus, it needs to be acknowledged that samples investigated to date are limited and that women with fewer resources or samples with more ethnic diversity might exhibit higher rates of PTSD and/or levels of distress. On the other hand, Kessler et al. found no overall association of PTSD with social class in the general population.2
Second, because breast cancer is predominantly a disease of older women, the relatively older age of our sample (compared with other at-risk PTSD groups) may have affected incidence. For example, the rate of noncancer PTSD in our sample (4.4%) was lower than that generally reported, that is, about 9%–10% for women in general.2,4 Norris27 found PTSD rates in older subjects (60 or older) to be consistently and significantly lower than for younger subjects, and Kulka et al.3 and Green et al.25 found higher rates of PTSD in younger soldiers than in older ones. The studies of PTSD in child and adolescent survivors14 also support the importance of age as a risk factor for PTSD. Further, younger women in our sample were at higher risk for PTSD. Seven of the eight women with cancer-related PTSD in our sample were younger than the mean age of the sample. Six of the women were 47 or younger. This latter association is consistent with a PTSD model that would predict more PTSD symptoms when the event is unanticipated (as it is for younger women). Younger women are also more likely to have young families to care for, in addition to simply expecting to live longer than older women, both of which may be associated with more rumination, worrying, and avoidance in the face of the cancer.
A third way of understanding the relatively low rates of PTSD in our sample is the type of cancer studied. Women diagnosed with early stage breast cancer may not be as traumatized by their illness because the prognosis is excellent, hence the perceived threat to life is less. By contrast, it might be expected that observed rates of PTSD would be higher among women with locally advanced or metastatic disease, for whom the prognosis is guarded or poor. We are exploring this possibility in a follow-up to the present study. However, PTSD rates in our sample with more advanced disease seem quite similar to date to those in the early stage sample, and other studies have not found stage of disease to predict outcome.10,12 To the extent that cancer treatments become more noxious and intrusive, however, this might change. Patients undergoing painful medical procedures may develop PTSD or have their symptoms exacerbated, because of these procedures (e.g., bone marrow transplant), which may meet the "A" Criterion for PTSD as a tangible bodily assault in line with more traditional events.
Finally, it may be that having cancer does not truly "fit" a trauma model, as defined in DSM-IV. Phenomenologically, assessment of cancer-related PTSD posed several challenges. Although earlier investigators have "counted" ruminative and future-oriented thoughts as intrusive symptoms, it is not clear that these symptoms truly meet criteria for PTSD. Further, the most stressful experiences for these women were not those related to the physical assault of cancer treatment. According to our SIE questionnaire, the most stressful experiences for the participants were receiving the cancer diagnosis from their physician and waiting for the results of the node dissection. These findings underscore the clinical impression that the "traumatizing" aspects of the cancer experience may involve the receipt of information rather than the physical intrusiveness of treatment. This "information" stressor28 is an abstract and future-oriented one, since women at this stage are not physically ill. Thus, the nature of the cancer stressor may not fit the PTSD model well, based as it is on an imminent death encounter or immediate physical assault.29 Having cancer may have the potential to produce a stress reaction, but not necessarily PTSD, suggesting that a critical requirement for most PTSD may be the immediacy of the loss or assault and the "survival mode" (fight or flight) that such an event engenders, along with the biological overload produced.30,31 This conceptualization is consistent with the fact that we found no cases of cancer-related acute stress disorder, a diagnosis that requires sustained (at least 48 hours) dissociation and heightened anxiety. Unfortunately, as our study was originally based on DSM-III-R, we did not collect data about the extent to which the cancer diagnosis produced feelings of fear, helplessness, or horror (Criterion A25), which could address this point further. If studies of life-threatening illness were to require actual recollections of the event for Criterion B (reexperiencing), PTSD prevalence could be expected to be even lower than those reported to date.
Low rates of PTSD do not necessarily imply a lack of clinically significant distress, however. One-quarter to one-third of the women had intrusive and arousal symptoms and continued to experience these at the time of the interview. Forty-one percent of the women also reported at least one avoidance/numbing symptom. Thus, clinically, they might be appropriately diagnosed as having an adjustment disorder. Further, PTSD was comorbid with other disorders, especially major depression, consistent with the literature,26 and major depression occurred alone. The depression diagnoses, especially the recurrences and first episodes that followed cancer diagnosis and treatment, are particularly noteworthy, especially in light of a recent meta-analysis of psychological symptoms following cancer that found depression to be the only area where cancer patients differed from the general population.32 About 12% of the sample had a current psychiatric diagnosis, and symptom levels were slightly higher than in the general population (57th percentile for nonpatients on the GSI). As all of these symptoms can be very distressing, and associated with other aspects of functioning, the need for assessment and intervention with these women seems clear. Further, as mentioned earlier, frightening medical procedures associated with cancer and other life-threatening illnesses may also precipitate or exacerbate distress. Thus, there are a number of important reasons to evaluate psychological distress and PTSD in these patients.
Although a substantial number of women reported PTSD symptoms following their breast cancer diagnosis and treatment, low rates of the diagnosis were observed. These figures may underestimate the incidence of cancer-related PTSD attributable to the good prognosis, older age, and/or relatively high socioeconomic status of our sample. However, a number of the findings, including those about the most stressful aspects of the cancer, suggest that receiving a breast cancer diagnosis does not fit the PTSD model well. The breast cancer experience does not seem to have the immediacy of threat to life or bodily integrity usually associated with external trauma. We urge continued study of this important issue, so that future editions of the DSM may rely on empirical data about which illnesses and medical conditions are more likely to cause PTSD. Further, we urge caution in applying the PTSD diagnosis based only on symptom reports and/or on a relatively untested conceptualization.
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ACKNOWLEDGMENTS
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This work was funded by a grant (Grant No. RO1–MH49742) from the National Institute of Mental Health to Bonnie L. Green, M.D., principal investigator.
The authors thank the physicians at Georgetown University Medical Center and the Lombardi Cancer Center for their help and assistance, Dr. John Lynch and other physicians at the Washington Hospital Center, and Dr. Karen Weihs and other physicians at George Washington Medical Center, all in Washington, DC.
This work was presented at the annual meeting of the Academy of Psychosomatic Medicine, Palm Springs, California, November 1995; the annual meeting of the International Society for Traumatic Stress Studies, Boston, Massachusetts, November 1995; and the annual meeting of the Association for the Advancement of Behavior Therapy, Washington, DC, November 1995.
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ABSTRACT
INTRODUCTION