Traumatische und psychosoziale Belastungen bei Patienten mit akuter Tumorerkrankung

 

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Zusammenfassung

Eine Krebsdiagnose bedeutet für die Betroffenen die Konfrontation mit einer lebensbedrohlichen Erkrankung und kann daher als traumatisches Erlebnis aufgefasst werden. Erschwert wird dieser Umstand dadurch, dass eine Krebserkrankung zumeist kein einmaliges Ereignis, sondern ein anhaltender Stressor ist. Ziel der vorliegenden Studie war a) die Untersuchung der psychotraumatischen und komorbiden Belastung von Tumorpatienten akut und im Verlauf, b) die Erhebung möglicher protektiver Faktoren sowie c) die Identifikation von Risikofaktoren für die Entwicklung einer posttraumatischen Stressreaktion (PTSR) nach Tumordiagnose. Die Stichprobe bestand aus 46 Patienten, die sich wegen einer neu aufgetretenen Tumorerkrankung aus diagnostischen oder therapeutischen Gründen einer chirurgischen Behandlung unterziehen mussten. Untersucht wurden die posttraumatische Belastung, dissoziative Reaktionen, Angst, Depressivität, kognitiv-emotionale Belastung, soziale Unterstützung sowie Krankheitsverarbeitung. Mehr als 25 % der Patienten wies akut (T1) und nahezu 40 % vier Monate später (T2) eine klinisch relevante PTSR auf. Bei Frauen trat PTSR deutlich häufiger auf, vor allem in der Katamnese. Ein systematischer Zusammenhang zwischen der Art des Tumors zu T1 und dem Auftreten einer PTSR zu T2 konnte nicht festgestellt werden. Patienten mit PTSR zu T2 zeigten in der Akutphase höhere Werte für Angst und Depressivität. Als wichtigste Prädiktoren für die Entwicklung klinisch bedeutsamer posttraumatischer Symptome in der 4-Monats-Katamnese ergaben sich die Zugehörigkeit zum weiblichen Geschlecht, der PTSR-Befund zu T1 sowie erhöhte Depressivitätswerte. Die Ergebnisse bestätigen die klinische Relevanz psychotraumatischer Screeninguntersuchungen bei Patienten mit akuten Krebserkrankungen sowohl für diagnostische als auch therapeutische Fragestellungen.

Abstract

For patients, being diagnosed with cancer means being confronted with a life-threatening illness and can thus be considered a traumatic experience. This situation is compounded by the fact that having cancer is usually not an isolated event but is generally a long-term stressor. The aim of the present study was a) the assessment of psychotraumatic and comorbid distress in tumor patients both in the acute stage (T1) and over time (T2), b) the identification of possible protective factors, and c) the identification of risk factors for the development of a posttraumatic stress reaction (PTSR) following the diagnosis of a tumor. The sample consisted of 46 patients who had to undergo surgical treatment for a newly developed tumor for either diagnostic or therapeutic purposes. The following psychosocial factors were examined: posttraumatic stress, dissociative reactions, anxiety, depression, cognitive-emotional distress, social support and processing the illness. More than 25 % of the patients demonstrated signs of a clinically relevant PTSR at the acute stage (T1) and almost 40 % did so four months later (T2). Significantly more women showed a PTSR at both points of measurement, but particularly at follow-up. No significant relationship could be found between the type of the tumor at T1 and the emergence of a PTSR at T2. Patients with PTSR at T2 showed higher scores for anxiety and depression. The most important predictors for the development of clinically relevant posttraumatic symptoms at the four-month follow-up examination were female sex, PTSR at T1 as well as elevated levels of depression. The results indicate the clinical relevance of psychotraumatic screening examinations in patients with acute cancer illnesses both for diagnostic as well as therapeutic investigations.

Literatur

• 1 Koocher G P, O'Malley J E. The Damocles syndrome: Psychosocial consequences of surviving childhood cancer. New York, Toronto; McGraw-Hill 1981
  Google Scholar
• 2 Kelly B, Raphael B, Smithers M, Swanson C, Reid C, McLeod R, Thomson D, Walpole E. Psychological responses to malignant melanoma. An investigation of traumatic stress reactions to life-threatening illness.  General Hospital Psychiatry. 1995;  17 (2) 126-134
  PubMedGoogle Scholar
• 3 Smith M Y, Redd W H, Peyser C, Vogl D. Post-traumatic stress disorder in cancer: A review.  Psycho-Oncology. 1999;  8 (6) 521-537
  CrossrefPubMedGoogle Scholar
• 4 Schmitt A. Posttraumatische Belastungsstörungen bei Krebserkrankungen: Diagnostik und Epidemiologie.  Zeitschrift für Psychosomatische Medizin und Psychotherapie. 2000;  46 (1) 35-56
  PubMedGoogle Scholar
• 5 Andrykowski M A, Cordova M J. Factors associated with PTSD symptoms following treatment for breast cancer: Test of the Andersen Model.  Journal of Traumatic Stress. 1998;  11 (2) 189-203
  CrossrefPubMedGoogle Scholar
• 6 Jacobsen P B, Widows M R, Hann D M, Andrykowski M A, Kronish L E, Fields K K. Posttraumatic stress disorder symptoms after bone marrow transplantation for breast cancer.  Psychosomatic Medicine. 1998;  60 (3) 366-371
  PubMedGoogle Scholar
• 7 Tjemsland L, Soreide J A, Malt U F. Posttraumatic distress symptoms in operable breast cancer III: Status one year after surgery.  Breast Cancer Research and Treatment. 1998;  47 (2) 141-151
  CrossrefPubMedGoogle Scholar
• 8 Alter C L, 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 (2) 137-143
  PubMedGoogle Scholar
• 9 Cordova M J, Andrykowski M A, Kenady D E, McGrath P A, Sloan D A, Redd W H. Frequency and correlates of posttraumatic stress disorder-like symptoms after treatment for breast cancer.  Journal of Consulting and Clinical Psychology. 1995;  63 (6) 981-986
  PubMedGoogle Scholar
• 10 Andrykowski M A, Cordova M J, Studts J L, Miller T W. 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.  Journal of Consulting and Clinical Psychology. 1998;  66 (3) 586-590
  PubMedGoogle Scholar
• 11 Green B L, Krupnick J L, Rowland J H, Epstein S A, Stockton P, Spertus I, Stern N M. Trauma history as a predictor of psychologic symptoms in women with breast cancer.  Journal of Clinical Oncology. 2000;  18 (5) 1084-1093
  PubMedGoogle Scholar
• 12 Cordova M J, Studts J L, Hann D M, Jacobsen P B, Andrykowski M A. Symptom structure of PTSD following breast cancer.  Journal of Traumatic Stress. 2000;  13 (2) 301-319
  CrossrefPubMedGoogle Scholar
• 13 Pitman R K, Lanes D M, Williston S K, Guillaume J L, Metzger L J, Gehr G M, Orr S P. Psychophysiologic assessment of posttraumatic stress disorder in breast cancer patients.  Psychosomatics. 2001;  42 (2) 133-140
  CrossrefPubMedGoogle Scholar
• 14 Andrykowski M A, Cordova M J, McGrath P C, Sloan D A, Kenady D E. Stability and change in posttraumatic stress disorder symptoms following breast cancer treatment: A 1-year follow-up.  Psycho-Oncology. 2000;  9 (1) 69-78
  CrossrefPubMedGoogle Scholar
• 15 McGarvey E L, Canterbury R J, Koopman C, Clavet G J, Cohen R, Largay K, Spiegel D. Acute Stress Disorder following diagnosis of cancer.  International Journal of Rehabilitation and Health. 1998;  4 (1) 1-15
  CrossrefPubMedGoogle Scholar
• 16 Tjemsland L, Soreide J A, Malt U F. Traumatic distress symptoms in early breast cancer: II. Outcome six weeks post surgery.  Psycho-Oncology. 1996b;  5 295-303
  CrossrefPubMedGoogle Scholar
• 17 Kazak A E, Stuber M L, Barakat L P, Meeske K, Guthrie D, Meadows A T. Predicting posttraumatic stress symptoms in mothers and fathers of survivors of childhood cancers.  Journal of the American Academy of Child and Adolescent Psychiatry. 1998;  37 (8) 823-831
  PubMedGoogle Scholar
• 18 Stuber M L, Kazak A E, Meeske K, Barakat L, Guthrie D, Garnier H, Pynoos R, Meadows A. Predictors of posttraumatic stress symptoms in childhood cancer survivors.  Pediatrics. 1997;  100 (6) 958-964
  CrossrefPubMedGoogle Scholar
• 19 Koren D, Arnon I, Klein E. Acute stress response and posttraumatic stress disorder in traffic accident victims: A one-year prospective, follow-up study.  American Journal of Psychiatry. 1999;  156 (3) 367-373
  PubMedGoogle Scholar
• 20 Schnyder U, Moergeli H, Nigg C, Klaghofer R, Renner N, Trentz O, Buddeberg C. Early psychological reactions to life-threatening injuries.  Critical Care Medicine. 2000;  28 (1) 86-92
  PubMedGoogle Scholar
• 21 Schnyder U, Moergeli H, Klaghofer R, Buddeberg C. Incidence and prediction of posttraumatic stress disorder symptoms in severely injured accident victims.  American Journal of Psychiatry. 2001;  158 (4) 594-599
  CrossrefPubMedGoogle Scholar
• 22 Malt U F, Olafsen O M. Psychological appraisal and emotional response to physical injury: A clinical, phenomenological study of 109 adults.  Psychiatric Medicine. 1992;  10 (3) 117-134
  PubMedGoogle Scholar
• 23 Pynoos R S, Frederick C, Nader K, Arroyo W, Steinberg A, Eth S, Nunez F, Fairbanks L A. Life threat and posttraumatic stress in school-age children.  Archives of General Psychiatry. 1987;  44 (12) 1057-1063
  PubMedGoogle Scholar
• 24 Feinstein A, Dolan R. Predictors of post-traumatic stress disorder following physical trauma: An Examination of the stressor criterion.  Psychological Medicine. 1991;  21 (1) 85-91
  PubMedGoogle Scholar
• 25 Perry S, Difede J, Musngi G, Frances A J, Jacobsberg L. Predictors of posttraumatic stress disorder after burn injury.  American Journal of Psychiatry. 1992;  149 (7) 931-935
  PubMedGoogle Scholar
• 26 Landsman I S, Baum C G, Arnkoff D B, Craig M J, Lynch I, Copes W S, Champion H R. The psychosocial consequences of traumatic injury.  Journal Behavioral Medicine. 1990;  13 (6) 561-581
  PubMedGoogle Scholar
• 27 Manne S L, DuHamel K, Gallelli K, Sorgen K, Redd W H. Posttraumatic stress disorder among mothers of pediatric cancer survivors: diagnosis, comorbidity, and utility of the PTSD checklist as a screening instrument.  Journal of Pediatric Psychology. 1998;  23 (6) 357-366
  PubMedGoogle Scholar
• 28 Spiegel D, Sands S, Koopman C. Pain and depression in patients with cancer.  Cancer. 1994;  74 (9) 2570-2578
  PubMedGoogle Scholar
• 29 Naidich J B. PTSD-related symptoms in women with breast cancer. Ph. D. dissertation. Hofstra; University 1997 (Dissertation Abstracts International, 1997, 58/04-B, 2132)
  Google Scholar
• 30 Brewin C R, Watson M, McCarthy S, Hyman P, Dayson D. Intrusive memories and depression in cancer patients.  Behaviour Research and Therapy. 1998;  36 (12) 1131-1142
  CrossrefPubMedGoogle Scholar
• 31 Barak Y, Achiron A, Rotstein Z, Elizur A, Noy S. Stress associated with asbestos: The trauma of waiting for death.  Psycho-Oncology. 1998;  7 (2) 126-128
  CrossrefPubMedGoogle Scholar
• 32 Flatten G, Erli H J, Hardörfer V, Jünger S, Paar O, Petzold E R. Psychotraumatologie in der Unfallmedizin - Zum Stand der psychischen Versorgung von Unfallopfern in Deutschland.  Der Unfallchirurg. 2002;  105 231-236
  CrossrefPubMedGoogle Scholar
• 33 Flatten G, Jünger S, Wälte D. Der Aachener Fragebogen zur Traumaverarbeitung.  (unveröffentlicht) 1997
  Google Scholar
• 34 APA (ed) .Diagnostic and statistical manual of mental disorders: DSM-IV (4^th edition). Washington, DC; American Psychiatric Association 1994
  Google Scholar
• 35 Wittchen U, Zaudek M, Fydrich T. SKID-DSM-IV. Strukturiertes klinisches Interview.  Göttingen, Bern, Toronto; Hogrefe 1997
  Google Scholar
• 36 Harvey A G, Bryant R A. The relationship between acute stress disorder and posttraumatic stress disorder: A 2-year prospective evaluation.  Journal of Consulting and Clinical Psychology. 1999;  67 (6) 985-988
  CrossrefPubMedGoogle Scholar
• 37 Schützwohl M, Maercker A. Effects of varying diagnostic criteria for posttraumatic stress disorder are endorsing the concept of partial PTSD.  Journal of Traumatic Stress. 1999;  12 (1) 155-165
  CrossrefPubMedGoogle Scholar
• 38 Herrmann C, Buss U, Snaith R P. HADS-D Hospital Anxiety and Depression Scale - Deutsche Version. Ein Fragebogen zur Erfassung von Angst und Depressivität in der somatischen Medizin. Textdokumentation und Handanweisung. Bern, Göttingen, Toronto; Verlag Hans Huber 1995
  Google Scholar
• 39 Hütter B O, Fischer G. Die Impact of Event Scale. Köln; Universität Köln, Institut für Psychologie, Abteilung Klinische Psychologie und Psychotherapie 1997
  Google Scholar
• 40 Horowitz M, Willner N, Alvarez W. Impact of Event Scale - A measure of subjective stress.  Psychosomatic Medicine. 1979;  41 (3) 209-218
  CrossrefPubMedGoogle Scholar
• 41 Sommer G, Fydrich T. Soziale Unterstützung: Diagnostik, Konzepte, F-SozU (DGVT Materialien, Nr. 22). Tübingen; DGVT Verlag 1989
  Google Scholar
• 42 Sommer G, Fydrich T. Entwicklung und Überprüfung eines Fragebogens zur sozialen Unterstützung (F-SozU).  Diagnostica. 1991;  37 160-178
  PubMedGoogle Scholar
• 43 Spielberger C D, Gorsuch R L, Lushene R E. The State-Trait Anxiety Inventory: Test manual for form X. Palo Alto, California; Consulting Psychologists Press 1970
  Google Scholar
• 44 Laux L, Glanzmann P, Schaffner P, Spielberger C D. Das State-Trait-Angstinventar. Theoretische Grundlagen und Handanweisung. Weinheim; Beltz Test 1992
  Google Scholar
• 45 Muthny F A. FKV-LIS (Freiburger Fragebogen zur Krankheitsverarbeitung). Manual. Weinheim; Beltz Test GmbH 1989
  Google Scholar
• 46 Brosius G. SPSS/PC+ Basics und Graphics: Einführung und praktische Beispiele. London, Hamburg; McGraw Hill 1988
  Google Scholar
• 47 Bortz J. Statistik für Sozialwissenschaftler (5. vollständig überarbeitete und aktualisierte Auflage. Berlin, Heidelberg, New York; Springer 1999
  Google Scholar
• 48 Fydrich T, Geyer M, Hessel A, Brähler E. Fragebogen zur sozialen Unterstützung (F-SozU): Normierung an einer repräsentativen Stichprobe.  Diagnostica. 1999;  45 212-216
  CrossrefPubMedGoogle Scholar
• 49 Mundy E A, Blanchard E B, Cirenza E, Gargiulo J, Maloy B, Blanchard C G. Posttraumatic stress disorder in breast cancer patients following autologous bone marrow transplantation or conventional cancer treatments.  Behaviour Research and Therapy. 2000;  38 (10) 1015-1027
  CrossrefPubMedGoogle Scholar
• 50 Madianos M G, Papaghelis M, Ioannovich J, Dafni R. Psychiatric disorders in burn patients: A follow-up study.  Psychotherapy and Psychosomatics. 2001;  70 (1) 30-37
  CrossrefPubMedGoogle Scholar
• 51 Roca R P, Spence R J, Munster A M. Posttraumatic adaptation and distress among adult burn survivors.  American Journal of Psychiatry. 1992;  149 (9) 1234-1238
  PubMedGoogle Scholar
• 52 National Cancer Institute .Post-traumatic stress disorder: Overview; applying posttraumatic stress disorder to cancer; diagnostic criteria and characteristics; prevalence; mechanisms, etiology, and risk factors; assessment of PTSD in the cancer setting; treatment. Cancer Web, National Cancer Institute 2000 (www: graylab.ac.uk/cancernet/306317.html)
  Google Scholar
• 53 Widows M R, Jacobsen P B, Fields K K. Relation of psychological vulnerability factors to posttraumatic stress disorder symptomatology in bone marrow transplant recipients.  Psychosomatic Medicine. 2000;  62 (6) 873-882
  PubMedGoogle Scholar
• 54 Cohen S, Wills T A. Stress, social support and the buffering hypothesis.  Psychological Bulletin. 1985;  98 (2) 310-357
  CrossrefPubMedGoogle Scholar
• 55 Classen C, Butler L D, Koopman C, Miller E, DiMiceli S, Giese-Davis J, Fobair P, Carlson R W, Kraemer H C, Spiegel D. Supportive-expressive group therapy and distress in patients with metastatic breast cancer: A randomized clinical intervention trial.  Archive of General Psychiatry. 2001;  58 (5) 494-501
  CrossrefPubMedGoogle Scholar
• 56 Flatten G, Wälte D, Erli H J, Jünger S, Petzold E R. Self-efficacy in acutely traumatized patients and the risk of developing posttraumatic stress reactions. Journal of Traumatic Stress (in press) 2003
  Google Scholar
• 57 Neria Y, Bromet E J. Comorbidity of PTSD and depression: Linked or separate incidence.  Biological Psychiatry. 2000;  48 (9) 878-880
  CrossrefPubMedGoogle Scholar
• 58 Shalev A Y, Peri T, Canetti L, Schreiber S. Predictors of PTSD in injured trauma survivors: A prospective study.  American Journal of Psychiatry. 1996;  153 (2) 219-225
  PubMedGoogle Scholar
• 59 van der Kolk B A, Fisler R E, Bloom S L, Morton J. Dissociation and the fragmentary nature of traumatic memories: Overview.  British Journal of Psychotherapy. 1996;  12 (3) 350-371
  PubMedGoogle Scholar
• 60 Seedat S, Stein D J. Trauma and post-traumatic stress disorder in women: A review.  International Clinical Psychopharmacology. 2000;  15 (Suppl 3) S25-S33
  PubMedGoogle Scholar
• 61 Stein M B, Walker J R, Forde D R. Gender differences in susceptibility to posttraumatic stress disorder.  Behaviour Research and Therapy. 2000;  38 (6) 619-628
  CrossrefPubMedGoogle Scholar
• 62 Breslau N, Davis G C, Andreski P, Peterson E L, Schultz L R. Sex differences in posttraumatic stress disorder.  Archives of General Psychiatry. 1997;  54 (11) 1044-1048
  Google Scholar
• 63 Breslau N, Kessler R C, Chilcoat H D, Schultz L R, Davis G C, Andreski P. Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma.  Archives of General Psychiatry. 1998;  55 (7) 626-632
  Google Scholar
• 64 Udwin O, Boyle S, Yule W, Bolton D, O'Ryan D. Risk factors for long-term psychological effects of a disaster experienced in adolescence: Predictors of post-traumatic stress disorder.  Journal of Child Psychology and Psychiatry. 2000;  41 (8) 969-979
  CrossrefPubMedGoogle Scholar
• 65 Maes M, Delmeire L, Mylle J, Altamura C. Risk and preventive factors of post-traumatic stress disorder (PTSD): Alcohol consumption and intoxication prior to a traumatic event diminishes the relative risk to develop PTSD in response to that trauma.  Journal of Affective Disorders. 2001;  63 (1 - 3) 113-121
  CrossrefPubMedGoogle Scholar
• 66 Reebye P, Moretti M M, Wiebe V J, Lessard J C. Symptoms of posttraumatic stress disorder in adolescents with conduct disorder: Sex differences and onset patterns.  Canadian Journal of Psychiatry. 2000;  45 (8) 746-751
  PubMedGoogle Scholar
• 67 Weisæth L. Importance of high response rates in traumatic stress research.  Acta Psychiatrica Scandinavica. 1989;  355, Suppl 131-137
  PubMedGoogle Scholar
• 68 Blanchard E B, Hickling E J, Taylor A E, Loos W R, Forneris C A, Jaccard J. Who develops PTSD from motor vehicle accidents?.  Behaviour Research and Therapy. 1996;  34 (1) 1-10
  PubMedGoogle Scholar
• 69 McFarlane A C. The aetiology of post-traumatic stress disorders following a natural disaster.  British Journal of Psychiatry. 1988a;  152 116-121
  PubMedGoogle Scholar
• 70 McFarlane A C. The longitudinal course of posttraumatic morbidity. The range of outcomes and their predictors.  Journal of Nervous and Mental Disease. 1988b;  176 (1) 30-39
  PubMedGoogle Scholar
• 71 McFarlane A C. The aetiology of post-traumatic morbidity: Predisposing, precipitating and perpetuating factors.  British Journal of Psychiatry. 1989;  154 221-228
  PubMedGoogle Scholar
• 72 McFarlane A C. Posttraumatic stress disorder: A model of the longitudinal course and the role of risk factors.  Journal of Clinical Psychiatry. 2000;  61 (Suppl 5) 15-20
  PubMedGoogle Scholar
• 73 Frommberger U H, Stieglitz R D, Nyberg E, Schlickewei W, Kuner E, Berger M. Prediction of posttraumatic stress disorder by immediate reactions to trauma: A prospective study in road traffic accident victims.  European Archive of Psychiatry and Clinical Neuroscience. 1998;  248 (6) 316-321
  CrossrefPubMedGoogle Scholar
• 74 Fawzy F I, Cousins N, Fawzy N W, Kemeny M E, Elashoff R, Morton D. A structured psychiatric intervention for cancer patients. I. Changes over time in methods of coping and affective disturbance.  Archives of General Psychiatry. 1990;  47 (8) 720-725
  PubMedGoogle Scholar

Dr. med. Guido Flatten

Klinik für Psychosomatik und Psychotherapeutische Medizin · Universitätsklinikum der RWTH Aachen

Pauwelsstraße 30

52074 Aachen

Email: GFlatten@ukaachen.de