Factors associated with PTSS/PTSD

A number of static risk factors have been linked to the occurrence and development of posttraumatic stress responses in AYA cancer survivors (Table 4). While these fixed, unalterable factors may not be amenable to treatment or intervention, they may be utilized by clinicians in primary preventive efforts.


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Female sex has generally been associated with risk for cancer-related PTSS/PTSD, although the magnitude and consistency of this association is unclear. While one study identified female sex as a significant contributor to PTSS (β=0.13),22 another reported a negligible odds ratio (OR) for female sex (OR =0.17),24 and one-third found no association.25

Individuals diagnosed at older ages have been reported to exhibit more PTSS. Diagnosis during adolescence has been associated with a higher frequency of PTSD symptoms when compared with children diagnosed at school age,34 and young adults have demonstrated greater rates of PTSD16 and higher scores on the PTSD-RI and IES than child and adolescent survivors.23

Several studies have documented positive associations between medical late effects and posttraumatic stress responses (r=0.49;17 r=0.32;31 and r=0.43),35 as well as perceived impact of late effects and PTSD (t[179] =-2.85),26 while other research found no association.23

Greater treatment intensity has been associated with the risk of PTSD (OR =1.36; 95% confidence interval [CL]: 1.06–1.74)16 and anxiety and avoidance,34 although one study found no significant association between chart-derived ratings of treatment intensity and PTSS.23

Lower educational level,16 unemployment,35 having a history of stressful events,22 and having experienced a relapse or recurrence21 also emerged as salient predictors of PTSS/ PTSD. It should be noted that for long-term follow-up studies, lower education and unemployment may actually be a consequence of PTSS/PTSD symptoms rather than a predictor; prospective longitudinal research would be needed to confirm causal associations.

Other treatment and demographic factors, such as time since treatment and age at diagnosis, were not consistently associated with PTSS. The presence of a repressive adaptation style was associated with lower levels of PTSS and PTSD,19,21,32 while trait and general anxiety were associated with greater PTSS.22,23

The more malleable, dynamic predictors of posttraumatic stress are likely to be the target of future intervention. Results of several studies suggest that perceived severity of cancer diagnosis/life threat and other subjective appraisals are related to posttraumatic stress. In a model predicting PTSS, survivor appraisal of life threat and treatment intensity significantly contributed to PTSS (β=0.22).22

Another study found that young adult survivors with PTSD were more likely to self-report higher current life threat and rate their cancer treatment as more intense.23 Though perceptions are often functions of personality, perceptions are amenable to change, making them ideal targets for treatment and intervention. Delayed progress toward developmental goals (eg, personal, educational, family/relationship goals) was associated with increased risk for PTSD/PTSS in a young adult sample of survivors (t[169] =5.32).26

Lack of family/social support was found to contribute to the occurrence of PTSS/PTSD as well; one study of young adult survivors found that living alone was correlated with PTSS and PTSD, providing support for the relationship between social support and posttraumatic stress;24 another study found that social support significantly predicted PTSS (β=0.17).22

Other psychosocial factors such as psychological distress, quality of life, and family functioning have been strongly associated with posttraumatic stress responses. Specifically, families described as chaotic36 or having difficulty with problem solving, affective responsiveness, and affective involvement18 were associated with PTSD among AYA cancer survivors.

In terms of relational risk factors, exposure to PTSD in the home may put survivors at greater risk for the development of PTSS. Parents with anxiety or families consumed with cancer-related fears may influence the extent to which survivors experience and/or express distress symptoms.

For example, one study reported that AYA cancer survivors with mothers diagnosed with PTSD were seven times more likely to develop PTSD themselves.36 Intervention efforts directed at reducing posttraumatic responses among young cancer survivors should include family systems models.

Table 3 – DSM-5: posttraumatic stress disorder criteria
DSM-5 criteria Operationalization Considerations for AYA cancer survivors
Criterion A
Exposure to traumatic event threatening death or serious injury of self or others
Direct exposure; witnessing event; learning that event occurred to close other; experiencing repeated exposure to details of event Cancer not a discrete event
Risk of focusing illusion
Criterion B
Intrusion (one or more symptom[s] required)
Intrusive recollections
Repetitive play with event-related themes*
Distressing dreams
Frightening dreams without recognizable content*
Flashbacks/recurring of the event
Trauma-specific reenactment in play*
Internal/external cue(s) triggering
Psychological distress, or
Physiological reactivity
Well-founded fears about relapse/future health
Criterion C
Avoidance (three or more symptom[s] required)
Effortful avoidance of memories, thoughts, feelings, about event
Effortful avoidance of external reminders about event Emotional numbing
Long-term care/late effects make avoidance difficult
Cognitive impairment
Psychosocial sequelae
Possibility of recurrence
Criterion D
Negative alterations in cognition and mood (two or more symptom[s] required)
Inability to remember aspect of event
Persistent negative beliefs about self, other, the world
Persistent distorted cognitions about cause/consequence of event; blame of self or others
Persistent negative emotional state
Diminished interest in activities
Feelings of detachment
Persistent inability to experience positive emotions
Cognitive impairment
Possibility of recurrence
Psychosocial sequelae/elevated risk of depression
Criterion E
Alterations in arousal and reactivity (two or more symptom[s] required)
Irritability or outbursts of anger
Reckless/self-destructive behavior
Hypervigilance
Exaggerated startle response
Concentration difficulty
Difficulty falling or staying asleep
Neurocognitive late effects
Sleep-related late effects
Criterion F
Duration of disturbance
Symptoms persist more than 1 month Late effects typically persist beyond 30 days
Criterion G
Functional impairment
Significant distress or impairment in social, occupational, or other important areas of functioning Cancer therapy late effects may impact functioning
Criterion H
Exclusion
Disturbance not attributable to physiological effects of substance or medical condition Psychosocial, neurocognitive symptoms potentially attributable to cancer therapy-related late effects
Note: *In children.
Abbreviations: DSM-5, Diagnostic and Statistical Manual of Mental Disorders, fifth edition; AYA, adolescent and young adult.