The lifetime prevalence of posttraumatic stress disorder (PTSD) is approximately 7% in the general population, but it is much higher in those who have survived a serious illness, such as cancer.
PTSD is a diagnosable condition that is defined by the DSM-5 as a trauma-related disorder that develops after an individual experiences or witnesses a traumatic event, or learns of a family member who experienced a violent or accidental traumatic event, involving actual or threatened death, serious injury, or sexual violence. Symptom manifestation, intensity, duration (>1 month) and the degree to which they disturb a person’s social/occupational functioning help differentiate PTSD from other responses related to traumatic or stressful events.
Symptoms
• Intrusive thoughts (i.e., nightmares, distressing memories)
• Avoidance (i.e., cognitive/behavioral avoidance of trauma reminders)
• Negative mood and cognitions (e.g., feelings of anger/guilt, negative beliefs about self/others).
• Hyperarousal (i.e., anger outbursts, hypervigilance, exaggerated startle response)
Inquiring and listening for themes associated with PTSD (e.g., trauma, avoidance, negative views of self/others/the world, difficulty trusting others, guilt, shame, moral injury) should prompt the palliative care team to consider PTSD.
Serious Illness and PTSD. The diagnosis of a life-limiting illness and experiencing related symptoms can elicit feelings of vulnerability and helplessness that may trigger PTSD symptoms.
• Those living with PTSD may avoid or may be blocked from using coping strategies (remaining physically/mentally occupied, misusing substances to numb emotional experiences, etc.).
• Anxiety and emotional distress can complicate a patient’s ability to make medical decisions, renegotiate interpersonal relationships, and handle existential themes.
• Illness-related functional decline can lead to reliance on others for personal care, which can exacerbate PTSD symptoms: this can lead to tension in relationships and social isolation.
• Medications with hypnotic or sedative properties (e.g., benzodiazepines) may precipitate intrusive thoughts or hyperarousal symptoms via disinhibitory properties.
• Pain influences PTSD symptoms and vice versa.
Non-pharmacologic, psychotherapeutic approaches have been recognized for PTSD: exposure therapy, cognitive processing therapy, and eye movement desensitization reprocessing (EMDR) — however, these may not always be practical in patients with serious illness.
A stepwise psychosocial approach, allowing for interventions based on patients’ needs and prognosis, has been proposed for PTSD in the seriously ill.
• Assess the patient’s perceived sense of safety and facilitate a safe environment for the patient.
• Provide psychoeducation to the patient, family, and clinical team about PTSD symptoms. Teach coping strategies.
• Employ trauma-focused psychotherapeutic methods with a mental health professional.
Pharmacotherapy has been associated with modest reductions in distressing PTSD symptoms. Choosing a medication should be based on life expectancy, comorbid symptoms/illnesses, and the main goal of palliating distressing symptoms.
• Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacotherapeutics for PTSD.
• Serotonin norepinephrine reuptake inhibitors (SNRIs) — venlafaxine or duloxetine — should be considered if there is neuropathic pain.
• Mirtazapine is frequently used to treat depression in palliative care settings.
• Alpha-adrenergic antagonists — prazosin may reduce nightmare severity and frequency in adults, children, and adolescents.
• Benzodiazepines and antipsychotics are not recommended, and may even worsen core PTSD symptoms.
• Ketamine, MDMA, and cannabinoids are not recommended.
See reference for more information. Adapted from Sable-Smith A, Hiroto K, Periyakoil VJ. Assessment and treatment of PTSD at the end of life. Palliative Care Network of Wisconsin. Fast facts and concepts #398. Internet. Accessed on May 29, 2020.