Post-Traumatic Stress After Cancer or ICU Care

Fear, bad dreams, and a jolt of dread in a hospital corridor are common after cancer treatment or a stay in intensive care. Most of it settles. Some of it does not, and that smaller group has a condition with a name and treatments that work. This page explains the difference, and what to ask for.

NIMH is clear on this point. Many people who live through a dangerous event have symptoms at first, and "most people will recover from these symptoms." Most do not develop PTSD.

NCI draws a similar line. It describes cancer-related post-traumatic stress, or PTS, which can appear at any point from diagnosis through treatment, after treatment ends, or at recurrence. NCI notes that cancer-related PTS "may or may not lead to post-traumatic stress disorder."

So the goal is not to label yourself. It is to notice when symptoms stop easing and start running your life.

NIMH sets out the criteria. An adult must have all of the following for at least 1 month:

• At least one re-experiencing symptom.
• At least one avoidance symptom.
• At least two arousal and reactivity symptoms.
• At least two cognition and mood symptoms.

Re-experiencing covers flashbacks, which means reliving the event with physical signs such as a racing heart or sweating. It also covers recurring memories or dreams, distressing thoughts, and physical signs of stress.

Avoidance means staying away from places, events, or objects that remind you of the experience. It also means avoiding the thoughts and feelings tied to it.

Arousal and reactivity covers being easily startled, feeling tense or on edge, trouble concentrating, trouble falling or staying asleep, irritability and angry outbursts, and risky or destructive behavior.

Cognition and mood covers trouble remembering key parts of the event, negative thoughts about yourself or the world, exaggerated blame of yourself or others, ongoing fear, anger, guilt or shame, loss of interest in things you used to enjoy, social isolation, and difficulty feeling happiness or satisfaction.

Children under 6 can look different. NIMH lists bed-wetting, trouble speaking, acting the trauma out in play, and unusual clinginess. Older children and teens usually look more like adults, though they may also become disruptive or destructive.

Most trauma research studies one terrible event. Cancer is not one event.

NCI makes this point directly. Screening matters because the cancer experience "is more than one stressful event" and involves many stressors across time. NCI also notes that the specific cause of cancer-related PTS may be unknown, which makes it harder to identify than trauma from a single incident.

Triggers can be ordinary things. NCI explains that neutral triggers such as smells, sounds, and sights, if they were present during an upsetting event, can later cause anxiety, stress, and fear on their own. MRI and CT scanners are named examples.

This is why a routine scan can produce a reaction that looks out of proportion. It is not out of proportion. It is a learned alarm.

Critical illness leaves its own mark. Clinicians call it post-intensive care syndrome, or PICS. It is defined as new and lasting declines in physical, cognitive, and mental health after an ICU stay, once other causes have been ruled out.

The published figures for adult ICU survivors are substantial:

• PTSD in up to 50%.
• Cognitive dysfunction in up to 80%.
• Physical impairment in 25% to 80%.
• Depression in 29% at 12 months after discharge.

Delirium is part of the picture. A longer period of delirium in the ICU is linked to a higher risk of cognitive impairment one year after discharge.

Families are affected too. Up to 75% of family members of ICU patients develop symptoms, described as PICS-F.

Two things help. ICU diaries, written by staff and family during the stay, are linked to lower rates of depression and anxiety in survivors and lower PTSD risk in family members. The ABCDEF bundle, which covers pain assessment, breathing and awakening trials, sedation choices, delirium management, early movement, and family engagement, is the standard prevention approach.

If you or a relative spent time in intensive care during cancer treatment, say so at your follow-up visit. Ask whether a PICS follow-up clinic exists in your area.

NCI lists factors linked to higher risk. These include recurrent cancer, long treatment during childhood, advanced breast cancer, lengthy surgery, a history of earlier trauma, anxiety disorders, high general stress, lack of social support, and coping mainly by avoiding.

NIMH adds that earlier adversity, especially in childhood, can raise the chance of PTSD later in life.

NCI also lists protective factors: good social support, clear information about the cancer stage, and an open relationship with the care team.

The VA National Center for PTSD names three trauma-focused psychotherapies as the strongest options.

• Cognitive Processing Therapy (CPT) teaches you how to reframe negative thoughts about the trauma.
• Prolonged Exposure (PE) teaches you to regain control by facing feelings and situations you have avoided since the trauma.
• Eye Movement Desensitization and Reprocessing (EMDR) helps you process the trauma while attending to a back-and-forth movement or sound.

NCI also describes crisis intervention, which focuses on immediate problem solving and coping skills, cognitive behavioral therapy, and support groups.

For medicines, the VA names three: sertraline (Zoloft), paroxetine (Paxil), and venlafaxine (Effexor). It says people may start to feel better in about 4 to 6 weeks, and that the effect takes a few weeks to notice.

NCI adds that selective serotonin reuptake inhibitors are used to reduce the stress response, that tricyclic antidepressants and monoamine oxidase inhibitors are options when depression occurs alongside, and that antianxiety medicines and antipsychotics are sometimes used for severe flashbacks.

No treatment works for everyone, and none of these is a guarantee. But they are real options with evidence, and they are worth asking for by name.

NCI states that the care team will look for symptoms of PTS or PTSD, and that screening may be needed more than once. Cancer care runs for years. A single question at one appointment does not settle it.

Ask for a referral to a mental health clinician who works with medical trauma. Ask which of the three trauma-focused therapies they offer.

If you are thinking about suicide, have worked out how you would do it, or feel you cannot keep yourself safe tonight, do not wait for a clinic appointment. Call or text the 988 Suicide and Crisis Lifeline at 988, or chat at 988lifeline.org. Call 911, or go to an emergency department, if you have already acted on those thoughts or are about to.

• Do my symptoms meet the 1-month mark, and which clusters do they fall into?
• Which specific triggers set them off: scans, smells, the infusion room?
• Was I in intensive care, and should I be assessed for PICS?
• Does this clinic offer CPT, PE, or EMDR, and what is the wait?
• If medicine is suggested, which one, and when should I expect a change?
• Who checks on this again in 3 months if nothing improves?

• Cancer-Related Post-traumatic Stress (PDQ) Patient Version — National Cancer Institute.
• Post-Traumatic Stress Disorder — National Institute of Mental Health.
• Post-Traumatic Stress Disorder (topic page) — National Institute of Mental Health.
• PTSD Treatment Basics — VA National Center for PTSD.
• Medications for PTSD — VA National Center for PTSD.
• Postintensive Care Syndrome — StatPearls, NCBI Bookshelf.