Psycho-Oncology Psycho-Oncology 24: 190–196 (2015) Published online 16 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.3627

Symptoms of posttraumatic stress in Australian women with ovarian cancer Lyndel K. Shand1,2, Joanne E. Brooker2,3*, Sue Burney2,4, Jane Fletcher2 and Lina A. Ricciardelli1 1

School of Psychology, Deakin University, Burwood, Victoria, Australia Cabrini Monash Psycho-oncology, Cabrini Health, Malvern, Victoria, Australia 3 Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia 4 School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia 2

*Correspondence to: Abstract Cabrini Monash Psycho-oncology, Cabrini Health, 183 Wattletree Objective: The aim of the study was to assess the prevalence and nature of symptoms of posttraumatic stress disorder (PTSD) in women with ovarian cancer. A further aim was to examine the demographic, Road, Malvern, Victoria 3144, medical and psychosocial factors associated with PTSD symptoms. Australia. E-mail: joanne. Method: One hundred and eight women with ovarian cancer were assessed for PTSD, quality of life, [email protected] depression, anxiety, posttraumatic growth, optimism, coping and social support. Results: Clinically significant symptoms were experienced by 9.25% of participants for PTSD, 5.6% for depression and 13.9% for anxiety. Poorer quality of life was associated with total PTSD symptoms, and avoidance and intrusive symptoms. Depression was associated with avoidance and intrusive symptoms. Anxiety was associated with total, avoidance, intrusive and hyperarousal symptoms. Finally, coping by substance use/self-blame was associated with total, avoidance and hyperarousal PTSD symptoms. Conclusions: Levels of PTSD in women with ovarian cancer were equivalent to that of the general population. Poorer quality of life, depression, anxiety and maladaptive coping, characterised by avoidance, Received: 2 March 2014 substance use and self-blame, were associated with increased symptoms of PTSD. Revised: 26 June 2014 Copyright © 2014 John Wiley & Sons, Ltd. Accepted: 28 June 2014

Background Ovarian cancer is the leading cause of deaths from gynaecological cancer in developed countries [1–3]. Women are frequently diagnosed with advanced stage disease because of the vague nature of the presenting symptoms [4]. Consequently, prognosis for survival is poor, with 5 year survival rates ranging from 43% to 44% [1–3]. Although many individuals with cancer suffer psychological distress during their cancer experience, for some, the severity adversely impacts functioning such that it requires psychiatric intervention [5]. There is a strong association between increased psychological distress and poorer quality of life (QoL) in women with cancer [6]. Further, many patients experience the diagnosis and treatment of cancer as traumatic, and for some, psychological reactions to cancer include symptoms of posttraumatic stress disorder (PTSD) [7]. Posttraumatic stress disorder was originally classified as an anxiety disorder in the previous edition of the Diagnostic and Statistical Manual (DSM-IV-R) [8]. It was defined as a cluster of symptoms that fell into three categories: (a) persistent re-experiencing of the event through re-occurring and intrusive thoughts, feelings and flashbacks (criteria B); (b) active avoidance of stimuli associated with the trauma and numbing of emotional and general responsiveness (criteria C); and (c) persistently increased arousal, such as difficulties with concentration and sleeping (criteria D) [9]. Copyright © 2014 John Wiley & Sons, Ltd.

In the current edition, DSM-5, PTSD is now classified as a trauma-related and stressor-related disorder, with a fourth cluster of symptoms added encompassing negative alterations in cognitions and mood associated with the traumatic event [8]. The prevalence of clinical levels of PTSD symptoms in cancer patients has ranged from 0% to 32% [7]. This wide range can be attributed to differences in assessment, with the use of self-report measures tending to inflate prevalence rates compared with structured clinical interviews [7]. Diagnosing PTSD in cancer patients is more complex compared with individuals who have experienced acute traumas. This is due both to the diagnostic criteria used to define PTSD and the nature of the traumatic event. In people with cancer, many of the symptoms outlined in the diagnostic criteria for PTSD can potentially be accounted for by disease-related factors and treatment side effects [10]. For example, a sense of a foreshortened future, difficulty concentrating and falling asleep are common concerns among people with cancer. In addition, compared with other acute traumatic events, there is usually a series of related stressors in the cancer population, including initial suspicion of cancer, investigations, subsequent diagnosis and distressing treatment side effects [11]. The complex and ongoing nature of cancer as a traumatic event means it is likely that symptoms of PTSD may manifest differently in this population compared with symptoms arising from acute traumatic events [7].

PTSD in ovarian cancer

The majority of studies examining the prevalence and predictors of PTSD symptoms in people with cancer has focused on those with breast cancer, with little focus on women with ovarian cancer. In one longitudinal study of 121 women with ovarian cancer in the UK, 13% experienced persistent symptoms of PTSD, with 57% experiencing symptoms intermittently from diagnosis to 3 months post-treatment [12]. In this study, younger age was a significant predictor of PTSD. In another study of 58 survivors of early-stage ovarian cancer, 26% reported clinically significant symptoms of PTSD at 3 years post-diagnosis [13]. In this study, PTSD symptoms were strongly associated with poorer QoL. However, the study was focused on survivors of early-stage disease, who represent less than half of all women diagnosed with ovarian cancer [3]. The nature of PTSD symptoms in women with ovarian cancer was not described in the aforementioned studies. In addition, with the exception of overall QoL, psychosocial correlates of PTSD, such as coping and social support, were not examined. Studies indicate that younger age, more advanced disease, depression, anxiety, poor social support, an avoidant coping style and poorer QoL are associated with symptoms of PTSD [7,14,15]. However, there are no studies examining whether these factors are associated with PTSD symptoms in women with ovarian cancer. In addition, no researchers have examined whether positive psychological responses, such as posttraumatic growth and optimism, are associated with PTSD symptoms in this population. This study examined the prevalence, severity and nature of PTSD symptoms in women with ovarian cancer. It also examined whether age, relationship status, time since diagnosis or current treatment status were related to PTSD symptoms. QoL, depression, anxiety, posttraumatic growth, optimism, coping and social support were also examined. As the data were collected prior to the release of DSM-5, the focus of the study was on PTSD symptoms specified in DSM-IV-R.

Method Study design and participants Following ethics approval from Cabrini Health, Monash Health and Deakin University, women were recruited by seeking volunteers via several cancer consumer organisations. The study was advertised in electronic newsletters and on the web and social media sites of each organisation. Information about the study was also sent directly to participants of recent clinical trials at a major metropolitan hospital. Interested women completed a self-administered anonymous survey, either online or by mail. Eligibility criteria were as follows: 18 years or older, English speaking, residents of Australia and having received a primary diagnosis of ovarian cancer at least 6 months prior to completing the study questionnaire. The sample consisted Copyright © 2014 John Wiley & Sons, Ltd.

191

of 108 women with ovarian cancer aged between 29 and 83 years, with a mean age of 56.36 (SD = 10.36) years. Eighty-one percent of the participants were born in Australia, 69% were in a relationship, 57% had attained a tertiary education and 55% were employed at the time of the study. In addition, 57% had been diagnosed with late stage disease. Sixty percent of the participants were disease free at the time of the study, with 29% currently in treatment.

Measures Surveys included questions about age, country of birth, language spoken at home, relationship status, religion, education level and employment status. In addition, participants were asked to provide information about time since diagnosis, stage of disease (at diagnosis and current), and types and frequencies of treatments received. The following validated measures were also completed. The PTSD Checklist – Civilian Version was used to assess the presence of PTSD symptoms, including avoidance, intrusions and hyperarousal over the past month [16]. Total symptom severity scores were obtained by summing scores for each of the items. The symptom cluster scoring method was utilised to determine probable cases of PTSD. Responses were assessed as to whether the individual met DSM-IV-R criteria for diagnosis (i.e., minimum of one symptom from criteria B, three from criteria C and two from criteria D). Bothersome symptoms rated as ‘moderately’, ‘quite a bit’ and ‘extremely’ were counted as ‘present’. Participants who had a total symptom severity score of ≥50 and also met DSM-IV-R criteria were classified as a likely PTSD case. This cut-off score has been used in previous studies of PTSD in oncology populations [16,17]. High internal consistency was demonstrated in the current study for the total scale (α = 0.91) and subscales (intrusions α = 0.79; avoidance α = 0.86; arousal α = 0.80). The Functional Assessment of Cancer Therapy – Ovarian Cancer was used to assess QoL [18]. Respondents rate the extent to which they had experienced various diseaserelated issues over the previous 7 days across five domains: physical, emotional and functional well-being (seven items each), social/family well-being (six items) and ovarian cancer symptoms (12 items). Higher scores indicate poorer QoL. High internal consistency was demonstrated in the current study for the total scale score (α = 0.94). The Hospital Anxiety and Depression Scale was utilised to assess current symptoms of depression and anxiety [19]. Each subscale consists of seven items, with higher scores indicating more distress. High internal consistency for the scale (α = 0.86) as well as each subscale (anxiety α = 0.79; depression α = 0.83) was found in the present study. The Posttraumatic Growth Inventory was used to assess posttraumatic growth occurring from the participants’ experience of ovarian cancer [20]. This scale consists of 21 items, with five subscales (relating to others, new Psycho-Oncology 24: 190–196 (2015) DOI: 10.1002/pon

L. K. Shand et al.

192

possibilities, personal strength, spiritual change and appreciation of life). Internal consistency was high in the current study for the overall scale (α = 0.93). The Life Orientation Test – Revised was used to assess generalised optimism [21]. This scale consists of ten items; six of which are summed to provide an overall score for optimism. Internal consistency in the current study was high (α = 0.88). The Brief COPE was used as a measure of coping [22]. The scale consists of 28 items, which assess the following coping styles: self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioural disengagement, venting, positive reframing, planning, humour, acceptance, religion and selfblame. Items can be summed to obtain total scale scores, or the data can be analysed (e.g. using factor analysis) to create higher order factors that describe patterns of coping styles unique to the study participants [22]. The Social Support Provision Scale was used as a more extensive measure of social support [23] than the COPE. The scale is used to assess the extent to which the social relationships of respondents provide social support across six dimensions: attachment, social integration, reassurance of worth, reliable alliance, guidance and opportunity for nurturance. Half of the items indicate the presence of a type of support, whereas the remaining indicate the absence of a type of support. The total scale demonstrated high internal consistency (α = 0.91) in the present study.

total social support (as measured by the Social Support Provision Scale) were entered in the second block.

Results Demographic and medical sample characteristics The correlation matrix between demographic factors, medical factors and psychological variables is presented in Table S1. Demographic and medical factors were unrelated to PTSD symptoms.

Clinical symptoms of posttraumatic stress disorder The examination of the symptom severity scores and the number and type of PTSD symptoms endorsed according to the symptom cluster scoring method indicated that 9.25% of participants met the diagnostic criteria for PTSD. Overall, 29.6% of the participants did not meet criteria for any of the symptom clusters, 27.8% met criteria for at least one symptom cluster, 29.6% for two symptom clusters, and 13% met criteria for all three symptom clusters. The individual items on the PTSD Checklist – Civilian Version endorsed by the participants as ‘moderately’, ‘quite a bit’ or ‘extreme’ were ranked from highest to lowest prevalence. The most commonly endorsed symptom was a sense of foreshortened future, experienced by 53% of participants. In addition, difficulties falling asleep and concentrating were experienced by 45% and 39% of the sample, respectively, and 29% reported experiencing intrusive thoughts, memories and images.

Statistical methods Analyses were conducted using the Statistical Package for the Social Sciences (SPSS, 22.0) with p-values set at

Symptoms of posttraumatic stress in Australian women with ovarian cancer.

The aim of the study was to assess the prevalence and nature of symptoms of posttraumatic stress disorder (PTSD) in women with ovarian cancer. A furth...
141KB Sizes 0 Downloads 3 Views