Support Care Cancer (2012) 20:14251434

DOI 10.1007/s00520-011-1225-6

ORIGINAL ARTICLE

Acute stress in patients with brain cancer

during primary care
Simone Goebel & Hans Strenge & H. Maximilian Mehdorn

Received: 13 January 2011 / Accepted: 21 June 2011 / Published online: 30 June 2011
# Springer-Verlag 2011
e-mail: goebels@nch.uni-kiel.de

Abstract
Purpose This study investigated whether diagnosis and
neurosurgical removal of a brain tumour induced Acute
Stress Disorder (ASD) in adults. We also aimed to
identify
factors associated with the development of ASD in this
specific patient group and setting.
Methods Forty-seven consecutive patients with
intracranial
neoplasms completed a variety of self-report
questionnaires
and underwent a structured clinical interview (SCID)
within
the first 4 weeks after tumour detection on average 1
week
after neurosurgical treatment. Moreover, the Diagnostic
and
Statistical Manual of Mental Disorders, 4th edition
(DSM-IV),
A1 and A2 criterion and thus the characteristics of the
traumatic event were explored in detail.
Results ASD symptoms were common. Twenty-three
percent of the patients met stringent criteria of ASD and
another 4% suffered from subsyndromal ASD.
Predisposing
factors previously reported in literature with the
exception
of previous trauma could not be identified in this study
(e.g., sex, age, intelligence).
Conclusion It has been critically discussed whether the
diagnosis of ASD is appropriate in cancer patients due
to
the often future-related nature of cancer-related
traumatic
events. The diagnosis of ASD was justified in the vast
S. Goebel (*) : H. M. Mehdorn
Department of Neurosurgery,
University Hospital Schleswig-Holstein,
Arnold-Heller-Str. 3,
24105 Kiel, Germany

H. Strenge
Department of Medical Psychology and Medical Sociology,
University Hospital Schleswig-Holstein,
Diesterwegstr. 10-12,
24113 Kiel, Germany

majority of affected patients due to the specific, acute and

past traumatic experiences in concordance with the DSM
and International Statistical Classification of Diseases and
Related Health Problems (ICD) trauma definitions. Thus,
ASD is a common and relevant psychiatric comorbidity in
patients with brain tumours. Our data highlight both the
need for the routine psychological assessment as well as of
psychosocial support in this early treatment phase.
Keywords Intracranial tumour . Acute stress . Mental
disorder . Patients . Primary care

Introduction
During the past years, researchers have stressed the
specific needs and burdens of patients with brain

1426

tumour patients regarding both research and treatment

of
psychosocial comorbidity [12].
To date, there are only few studies assessing the
psychological state of this patient group during the early
treatment
phase [1, 9]. Moreover, most studies solely relied on
selfreport screening instruments despite the fact that for
the
comprehensive assessment of psychological sequelae
of
cancer, these should be supplemented by a structured
clinical
interview [13]. One recent study [14] demonstrated
that more
than one third of patients with an intracranial tumour
suffered
from a psychiatric disorder as assessed via the
Structured
Clinical Interview for Diagnostic and Statistical Manual
of
Mental Disorders, 4th edition (DSM-IV) (American
Psychiatric Association, 1994) (SCID-IV; [15, 16]). Acute Stress
Disorder (ASD) was with a prevalence of 19% the most
prominent psychiatric sequela for patients.
Traumatic stress is a specific area of possible
psychiatric
morbidity in cancer patients. Traditionally, only
extraordinarily threatening experiences beyond the normal
range of
experiences were considered to be potentially
traumatic.
The DSM-IV, however, focuses on the subjective and
individual psychological responses in potentially
traumatic
situations. Therefore, a person needs to be exposed to,
or

tumours (BT) (e.g., [14]). These include the often

deflating prognosis, rapid deterioration of neurological
functioning (e.g., paralysis, sensory impairment) as well
as physiological and biological effects specific to brain
tumours such as seizures, personality changes or impairments
in the areas of language and cognition [5]. Altogether, patients
with BT rank among those cancer patients suffering from the
highest psychosocial burden [6, 7]. Patients often suffer from
anxiety, depression, or elevated levels of distress [1, 3, 8, 9].
This is of high clinical relevance, as mood disorders are
associated with a decrease in Health-Related Quality of Life
and presumably even a shorter time of survival [4, 8]. Thus,
it has been stressed that diagnosis and treatment of emotional
distress is crucial for patients with brain cancer [3, 10].
However, at the same time, information and psychosocial
support are still more difficult to assess for patients with BT
compared to other cancer patients [11]. Recent research has
demonstrated an ongoing and profound neglect of brain
witness, an event that involves actual or threatened
death,
or a threat to the physical integrity of oneself or
others
(criterion A1), and he or she needs to react with
intense
fear, helplessness, or horror (criterion A2).
Moreover, the
DSM-IV recognizes, for the first time, that traumatic
stress
reactions may be precipitated by life-threatening
illness.
This development has contributed to greater focus
on the
issue of stress reactions following cancer (e.g.,
[17]). ASD
was introduced in the DSM-IV to describe
psychological
stress reactions within the initial month after
experiencing a
traumatic event with the aim of identifying those
individuals who would subsequently develop Posttraumatic
Stress
Disorder (PTSD). To date, only few studies have
prospectively assessed the incidence of ASD in adult cancer
patients [1820]. These studies demonstrated that a
considerable proportion of cancer patients suffer from ASD
within
the first weeks after tumour diagnosis.
This study focuses for the first time on the
question
whether diagnosis and neurosurgical treatment of
brain
tumours might cause significant acute psychological
stress
reactions. We also aimed to identify factors
associated with the
development of ASD in this specific patient group
and setting.

Materials and methods

Subjects
During a recruiting phase of 18 months, 109 possible
eligible participants hospitalized at the Department of

Support Care Cancer (2012) 20:14251434

Neurosurgery, University Hospital Schleswig-Holstein,

Kiel were identified by the attending physician. Of
those, eight (7%) declined to participate due to either
fatigue (n= 3) or high emotional distress (n=5). Another
six patients (6%) could not be seen due to organizational problems (e.g., discharge ahead of schedule).
Twenty-four (22%) patients met at least one of the
following exclusion criteria: age below 18 or over
80 years, history of cancer, concomitant neurological
diseases, previous life-threatening illness, a history of
significant brain impairment, severe medical complications, or a Karnofsky index below 50 indicating a nonsatisfactory medical condition. Moreover, aphasic disorders as diagnosed via the German Golden Standard
for Assessment of Aphasia (Aachener Aphasie Test
[AAT]; [21]) as well as severe cognitive disabilities as
indicated by scores below 24 in the Mini Mental State
Examination (MMSE; [22]) served as exclusion criteria.
Of the remaining 68 patients, 21 patients (31%) had not
received the diagnosis within the last 28 days and were
therefore excluded. The resulting sample consists of 47
patients with brain cancer (WHO II, III or IV).
Participants were consecutively interviewed after surgery.
Written, informed consent was obtained from eligible
patients. All participants were right-handed. First language of
all patients was German. Participants and non-participants did
not differ in terms of age, gender, and tumour stage (p>0.2).
None of the patients had started chemotherapy or radiotherapy at the time of testing.
Procedure
This study has been approved by the appropriate ethics
committee and performed in accordance with the ethical
standard laid down in the 1964 Declaration of Helsinki.
Patients were tested within 3 to 11 days after neurosurgical removal of the tumour during in-patient stay (Mx=
5.83; SD=1.72). All examinations fell within the first 28 days
after the subjects received the diagnosis due to the
detection of the neoplasms via CT or MRT (range 11
28 days, Mx=19.04; SD=5.60). At the beginning of the
examination, it was established whether a patient met the
inclusion criteria. If so, aim and requirements of the
study were detailed and patients gave written consent to
participate in the study. This was followed by an
extensive exploration and anamnesis. Afterwards, the
structured clinical interviews were completed followed
by self-report measures. The procedure took from 75 to
150 min. Depending on the physical state of the patients
as well as available appointments, 40 (85%) of the
included patients also underwent an extensive standardized
neuropsychological assessment as described below. This was
scheduled during a second visit.
Psychological measures

Support Care Cancer (2012) 20:14251434

Assessment

ASD symptomatology was assessed with both

clinician and
self-report measures.

Structured Clinical Interview for DSM-IV (SCID [15, 16])

The SCID is a widely used structured clinical interview
for the
assessment of mental disorders according to the DSMIV
criteria. We used the modules for assessment of cancerrelated
ASD and lifetime PTSD. In addition to the A criterion as
described above, the diagnostic criteria for ASD consist
of
dissociation (e.g., emotional numbing, derealization, or
depersonalization), reexperiencing symptoms including
intrusions or flashbacks, marked avoidance, significant
anxiety
and/or increased arousal as well as evidence of
significant
stress or impairment. Probes were added to the
interview to
determine whether each symptom was attributable to
physical
causation (e.g., deficits in sleeping or concentration). If
so,
the symptom was not scored in the SCID.
Clinician Administered PTSD Scale (CAPS; [23, 24]) The
CAPS is a structured clinical interview that is based on
DSM-IV criteria for PTSD and possesses sound reliability, sensitivity and validity [25]. The CAPS includes
detailed questions regarding the nature of the
traumatic
event and thus enabling the substantiated assessment
of
the A1 and A2 criterion. The CAPS also enables the
assessment of PTSD symptomatology and its severity
as
well as consequences. However, since we focused on
ASD, this part of the CAPS was not included.
Acute Stress Disorder Scale (ASDS; [26, 27]) The ASDS
consists of 19 items, in which participants are asked to
rate the
intensity of symptoms associated with acute stress
disorders.
Items can be rated from 1 to 5. Symptoms of
derealization and
depersonalization are assessed by five items, four items
each
assess intrusion and avoidance and six items ask for
symptoms
of hyperarousal. The ASDS possesses good validity,
reliability, sensitivity and specificity for identification of
acutely
traumatized individuals at risk for developing PTSD
[27].
Cambridge Depersonalisation Scale State (CDSS; [28,
29])
The Cambridge Depersonalisation Scale State Version
(copies available on request) is a 22-item scale derived
from the Cambridge Depersonalisation Trait Scale.
Respondents are asked to rate the current intensity of

symptoms relevant to depersonalisation and

derealization
on a visual analogue scale ranging from 0% to
100%.
Impact of Event ScaleRevised (IES-R; [30, 31]) The
IESR aims to assess symptoms of intrusion, avoidance,
and

Items are scored 0, 1, 2, or 3.

1427

hyperarousal over the past 7 days. It consists of 22 items. Scale

scores are formed for the three subscales, which reflect intrusion
(seven items), avoidance (eight items), and hyperarousal (seven
items). Items are scored 0, 1, 3, or 5. It has been used in
numerous studies on trauma and has excellent reliability and
validity. The term distressing event was replaced by the term
diagnosis of the neoplasm. For statistical analysis, the sum of
intrusion, avoidance, and hyperarousal was used with a cut-off
score of or above 30 to indicate at least moderate symptomatology as proposed by Creamer and colleagues [32].
Posttraumatic Stress Diagnostic Scale (PDS, [33]) This
self-report measure yields a PTSD diagnosis, a measure of
severity and a list of traumatic experiences. Participants
were only presented with the list of 13 possible traumatic
experiences and had to rate for each whether they had
experienced it any time before. Dependent measure was the
number of reported previous traumatic experiences.
Hospital Anxiety and Depression Scale (HADS; [34, 35])
The HADS is a widely used questionnaire to assess
symptoms of anxiety and depression in patients with
somatic complaints with satisfying reliability and
validity. It consists of 14 items, seven per subscale.

Additional measures
Demographic data were obtained by using a semi-structured
interview. Medical charts were reviewed to obtain information
about disease stage and treatment characteristics. Patients
awareness of the diagnosis as well as characteristics of the
traumatic experience were assessed via a semi-structured
interview. Premorbid intelligence was estimated by a formula
using educational and socio-demographic data [36], similar to
the formula of Barona and Chastian [37].1
Cognitive functioning was assessed via a comprehensive
neuropsychological test battery which was composed
according to the procedures drawn by Taphoorn and Klein
[5]. Digit Span (Forward and Backwards; [38]) served as an
indicator of verbal short-term and working memory. For
assessment of visuo-motor speed, we used the Trail-Making
Test (TMT)-A. The TMT-B additionally assesses processes
of divided attention and executive functioning [39]. A
German version of the Controlled Oral Word Administration
Test COWAT [40] using the letters L-B-S was chosen
for assessment of lexical fluency. Visuo-perception was

Premorbid IQ is calculated as follows: 82.08+0.22age + level of

education + level of occupation + level of media use. For each of the
last three predictors, one out of a different number of possible
constants is selected according to detailed criteria.

1428

assessed via the ability of object recognition, using the

subtest
Object Decision from the Visual Object and Space
Perception
Battery [41]. Visuo-construction was assessed via the
Rey
Osterrieth Complex Figure (ROCF; [42]). The delayed
recall
of the ROCF serves as indicator for non-intentional
visual memory. Assessment of anterograde verbal
memory was performed by the Buschke Selective Remaining
Test BSRT [43] consisting of 12 items using a delayed
recall interval of 20 min.

Support Care Cancer (2012) 20:14251434

from 95 to 133 (Mx=114.8; Sx=9.4). All patients reported

good or very good satisfaction with their social support
(one 4-scaled question during exploration: very good, good,
sufficient, not sufficient). Table 1 provides more details.
Table 1 Demographic and medical characteristics (n=47)

Statistical analysis
Statistical analyses were performed using the Statistical
Package for the Social Sciences (SPSS) version 14.0.
Descriptive statistics were used to characterize the
demographic and psychosocial characteristics of the study sample, 1
the
prevalence of ASD and the characteristics of the cancerrelated
traumatic events. Neuropsychological test results were
converted to z-scores. This allows for the standardisation of
the
different classification systems used in clinical

Neuropsychology and thus for the

comparison of different
test results. The
original distribution is
transformed into one
with a mean of
zero and a standard
deviation of 1. Thus, zscores quantify the
original scores in terms
of the number of
standard deviations
(SD) that each score
differs from the mean of
the distribution.
Patients scoring 1.5 SD
below the mean (i.e.,
patients with z-

sc

or

es

of

ai

1.

5)

er

cl

as

si

fi

garding
Variable
test. Associations between variables including diagnosis
of
Marital status
ASD were calculated using Spearmans correlation
Married
coeffiPartnership
cients. 2 tests were used to analyze differences in Widowed
the
distribution of categorial variables between groups. For
all
other group comparisons, MannWhitney U-tests were
used.
Two-tailed significance tests were conducted using a
significance level of p<0.05. Retrospective power analyses
were
performed with G*power (see Ref. [44]) in order to
facilitate
the interpretation of statically non-significant results
with

35

75

15

12

26

Elementary school

19

40

Junior high School

20

43

10

21

Glioblastoma

8
22

17
47

Astrocytoma

14
27

29
58

Single
Children
None
Younger than 18 years
Older than 18 years
Educational level

High school certificate/university degree

Employment status
Currently employed
Retired
Housekeeper/unemployed
Post-surgery histopathologic classification

Oligoastrocytoma

11

Oligodendroglioma

13

Tumour-lateralization
Right

26
8

55
17

Left

21

45

35

75

Tumour size in cm (maximal dimension)

1.06.3

Range

respect to the sample size. Sensitivity describes the

true
positive rate, i.e., the proportion of patients suffering
from
ASD who were correctly identified via the screening
instruments (sensitivity=true positive/(true
positive+false
negative)). Concordantly, specificity describes the true
negative rate and thus the proportion of patients
without ASD
with a negative test result in the screening
questionnaires
(specificity=true negative/(true negative+false
positive).

26

No

21

Parietal

18

Occipital

Initial symptoms/reason for seeking medical consulta

55
45
Epileptic seizure

17

Motoric/sensoric symptoms

11

Vertigo/nausea

36
36
23
19
9
38

Headache

Demographic and medical sample characteristics

Language/cognition/personality
Vision disorders

Twenty-four (51%) of the 47 patients were male and 23

female. The median age of sample was 51.7 (SD=13.7)
with a range from 21 to 79. Estimated premorbid IQ
ranged

None (incidental findings)

Multiple ratings possible

5

Support Care Cancer (2012) 20:14251434

a

Eleven patients (23%) fulfilled all DSM-IV criteria for

ASD according to SCID and CAPS. Another two patients
(4%) suffered from subsyndromal ASD. For classification

Yes

Tumour-localization (mainly affected cerebral lobe)

5
Frontal
17
6
Temporal
9

Results

Prevalence of cancer-related ASD and results

of accompanying measures

3.5
2 (1.5)

Mx (SD)
Adjacent oedema

11

of subsyndromal ASD, we 10
followed the instructions
21
of
11
23
Schtzwohl and Maercker [45],
who suggested
this
2
4
classification as adequate if all but one DSM-IV
criteria
are fulfilled. These 13 patients were grouped for
further
analysis as patients suffering from (full or
subsyndromal)
ASD. Table 2 gives an overview about the

classification of
patients according to the screening instruments.
1429

Fulfilment of individual diagnostic criteria

Twenty-seven patients (57%) fulfilled both the A1 and
A2
criterion and thus experienced the situation as
traumatic
(Table 3). The results regarding the A criterion from
SCID
and CAPS were identical. The focus of the ASD
diagnosis as
formulated in the DSM-IV lies explicitly on the B
criterion for

related traumatic events yielded the following results: 11

patients (85%) described receiving the diagnosis as a
traumatic experience; one patient (8%) described deathanxiety after diagnosis as traumatizing. The remaining patient
described future-related fears (fear of functional loss).
Fulfilment of ASD diagnosis and results of other diagnostic
measures
Comparison of patients who fulfil or do not fulfil criteria
for ASD provided the following results: The former
achieved higher test scores in the ASDS, the CDSS well
as the IES-R (p < 0.01). The same is true for the
frequencies of patients who were classified as impaired
by each of the instruments (p<0.01). Moreover, Patients
with ASD were more likely to suffer from clinical relevant
anxiety (HADS >11; p=0.01), but not depression (p=0.18).
However, patients with ASD scored higher in both the
anxiety and the depression score of the HADS (p<0.01).

Intercorrelations between measures

which therefore detailed frequencies are displayed in Table 3.
Correlations between HADS scores and all measures of
Characteristics of tumour-related traumatic events
traumatic stress were small but significant (Rho<0.3; p<
0.05), whilst all measures of traumatic stress showed at
The majority of patients (n=38; 81%) experienced the least medium intercorrelations (Rho>0.3; p<0.05).
discovery of the neoplasm as unexpected and
frightening
Neuropsychological data
and reported relevant emotional burden after the
None of the psychological test scores was correlated with any
diagnosis.
Receipt of diagnosis was the most frequently distressing of
the neuropsychological test scores (p>0.2). The only exception
event. However, 16 patients (34%) described futureyielded the depression score of the HADS: This was correlated
oriented
fears as most distressful (Table 4). Thus, these patients negatively with both immediate and delayed free recall in
verbal semantic memory (r=0.358 and 0.386, respectively;
reported that fears regarding an event in the future
p<0.05). The total sample was impaired in the areas of
(e.g.,
surgery-related anxiety during the preoperative phase) visuo-motor speed, visuo-construction, as well as verbal and
figural memory. Moreover, about half of the included
had
patients were considerably impaired in those domains. For
been most distressing.
details, see Table 5. Comparison between patients with or
The separate analysis of the 13 patients suffering
without full or subsyndromal ASD showed no differences
from full
or subsyndromal ASD regarding the characteristics of
cancerTable 2 Number and percentage of patients meeting the
respective
cut-off scores in the applied self-report measures (n=47)
Cut-off score
Patients meeting the
cut-off score
n
ASDS
CDSS

56

regarding the frequency of impaired patients (p>0.2) in any of

the cognitive measures. The same is true, if the z-converted
raw scores were compared between both groups (p>0.2).

17
21

Influencing variables

70

8
10

IES-R I+A+H

30

16

34

Demographic data

HADS Anxiety

11

15

HADS Depression

11

19

ASDS Acute Stress Disorder Scale, CDSS Cambridge

Depersonalization Scale State, IES-R Impact of Event Scale (sum of the

All dependent measures were analyzed for both frequency

three
scales intrusion, avoidance, and hyperarousal), HADS
Hospital
Anxiety and Depression Scale

(proportion of patients classified as impaired) and intensity

(raw scores) with regard to the following demographic

variables: gender, age, premorbid IQ, living in a stable

relationship, being wage-earners, having (young) children.

1430
Table 3 ASD cluster and
symptoms endorsed by
patients
(n=47)

Support Care Cancer (2012) 20:14251434

Cancer-related ASD symptoms
A Traumatic event, subjective reaction (CAPS and SCID) (2)a
A1 Traumatic event

27
32

57
68

A2 Subjective reaction

27

57

13

26

B1 Numbing, detachment, absence of emotional responsiveness

16

34

B2 Reduced awareness of surroundings

19

40

B3 Derealization

15

32

B4 Depersonalization

10

21

B Dissociative symptoms (SCID) (3)a

C Intrusion (SCID)

25

53

D Avoidance (SCID)

17

36

B5 Dissociative amnesia
Number of criteria that need
to
be fulfilled for diagnosis of
ASD

E Anxiety/arousal (SCID)

None of these variables was associated with

psychological
morbidity (p>0.15). Retrospective power analyses
revealed
low statistical power for the conducted tests, ranging
from
0.07 to 0.39.
Medical data
The following medical factors were examined with
regard
to their relation to frequency as well as intensity of
psychological symptomatology. None of the following
factors was associated with any of the dependent
measures:
WHO stage, extend of tumour resection, acute onset of
tumour symptomatology, tumour size, oedema, tumour
lateralization/localization, Karnofsky index (p>0.2).
Again,
retrospective power analyses revealed low statistical
power
for the conducted tests, ranging from 0.15 to 0.29.

not experienced one or more traumatic event did not

differ with regard to any of the dependent measures (p>
0.2) with exception of the tendency for a significant
difference in the CDSS (p=0.066). Number of previous
traumatic events was not correlated with any of the
dependent measures with exception of the CDSS (r=
0.316; p=0.03). Diagnosis of life time PTSD was fulfilled
in eight patients (17%). None of those participants
however reported persistent PTSD symptoms within the
last 4 weeks prior to the tumour diagnosis. Of this
subgroup, 50% (n= 4) fulfilled diagnostic criteria for
ASD. For patients without lifetime PTSD, the same was
true for seven of 39 patients (18%). The 2 test revealed a
tendency towards a significant difference regarding these
frequencies (p=0.051).

Clinical identification of acute stress

Previous exposure to traumatic events
For implementation in daily practice, the application of a
Based on the SCID and PDS, 19 (40%) of our patients
reported experiencing at least one traumatic event
prior to
detection of the brain tumour. Patients who respectively
9
had

Table 4 Type and frequency of brain-tumour-related traumatic

events
Cancer-specific traumatic eventsa
Detection of the neoplasm/receiving the diagnosis
Fear of functional loss

Fear of having cancer and going to die

structured clinical interview as well as of a variety of

supplemental questionnaires might not be feasible. Thus,
we evaluated the capability of the applied screening
instruments for the detection of full or subsyndromal ASD
as diagnosed via the SCID. The IES-R showed with 77%
the highest sensitivity (correctly identified ASD cases) and
Fear of surgery

a good specificity (82% true negative classifications). The

CDSS showed a sensitivity of 62% and a specificity of 87%
whereas the ASDS identified 54% of the ASD cases
correctly with a specificity of 97%. Sensitivity of both
HADS subscales for detecting ASD was below 50% and
n
%
thus non-sufficient.
4

Emotional burden of the family

Discussion

Major epileptic seizure

None

In this study, acute traumatic stress in patients with brain

cancer during primary care was examined for the first time.

Most distressful event (open question), one answer per

patient

Support Care Cancer (2012) 20:14251434

1431

Table 5 Neuropsychological measures (z-scores) of the whole sample (n=40) as well as for patients with (n=11) or without (n=29) full
or
20
43
subsyndromal ASD
All
Mx (SD)

With ASD
% impaired

Mx (SD)

Without ASD
% impaired

Mx (SD)

% impaired

Digits Forward
Digits Backwards

0.454 (1.176)

15
35

0.645 (1.077)
1.266 (1.203)

15
46

0.381 (1.202)

0.945 (0.977)

0.822 (0.927)

15
32

TMT-A

01.664 (2.986)

45

1.581 (3.001)

39

1.701 (2.443)

47

TMT-B

62

2.456 (3.093)
0.041 (1.147)

69

2.297 (3.228)
0.413 (1.172)

59

COWAT: Letters

2.341 (3.119)
0.310 (1.182)

VOSP: object decision

0.588 (1.388)

23

0.358 (1.096)

24

0.676 (1.432)

21

ROCFcopy

2.023 (2.163)
0.179 (0.913)

58

1.702 (1.053)

46

2.146 (2.303)
0.291 (0.918)

62

ROCFrecall
BSRT: supraspan

0.568 (1.013)

15

0.429 (0.882)

15

0.621 (1.040)

15

BSRT: average recall

1.226 (1.425)

50

1.189 (1.597)

55

1.240 (1.423)

48

BSRT: delayed recall

1.324 (1.331)

50

1.534 (1.546)

55

1.366 (1.324)

48

2.171 (2.394)

55

1.758 (1.421)

55

2.329 (2.486)

55

BSRT: recognition

0.114 (0.394)

Digits Forward and Backwards digit span from the Wechsler Memory ScaleRevised, TMT Trail-Making Test A and B, COWAT Controlled
Oral
Word Association Test (lexical verbal fluency), VOSP Visual Object and Space Perception Battery, ROCF: Rey Osterrieth Complex
Figure Test,
BSRT Buschke Selective Reminding Test

We used a prospective approach and a variety of

assessment
instruments.
The findings of this study indicate that a considerable
(n=47)
proportion of patients with a brain tumour suffers from
clinical relevant ASD symptomatology within the first
n
%
4 weeks after detection of the neoplasm: 28% of our
sample suffered from full or subsyndromal ASD.
27
57
However,
8
17
57% of the patients described the situation as
6
13
traumatic and
fulfilled the DSM-IV A criterion. Moreover, the2 majority
4
of
1
2
our sample reported relevant emotional burden after
the
a
diagnosis and fulfilled at least one ASD criterion. Thus,
it
was demonstrated that acute stress reactions are a
frequent
and relevant mental comorbidity for patients with brain
cancer during primary care. In a previous study from

our
group, 19% of 26 patients with intracranial tumours
suffered from ASD. The difference in the prevalence
between the two studies was likely influenced by
the fact
that about one quarter of the patients from the
previous
study did not meet the time criterion (duration since
diagnosis >1 month) and thus ASD could not be
diagnosed.
However, as both sample sizes are small, this
cannot be
answered on the basis of the existing data.
When interpreting these results, some additional
factors
have to be taken into account: (1) A great number
of
patients was excluded due to severe cognitive,
aphasic, or
physical disabilities. Thus, we assessed only those
patients
that were least impaired by the disease and
therefore might

be less affected than others (e.g., [10]). (2) Moreover,

in
none of our patients peri- or postoperative
complications
occurred which might put an additional burden on
patients.

Additionally, five patients declined to participate because of

high psychological burden and marked avoidance. Thus,
again patients with most severe emotional burden might
have been not included. (3) We included only those patients
who received the diagnosis of the neoplasm within the last
28 days. Different biases might hence result: The sample
might, on the one hand, include a higher proportion of
medically severely endangered patients who have to be
operated immediately in order to avoid life-threatening
conditions resulting in higher psychological distress. On the
other hand, patients who were diagnosed within the last
28 days could be less traumatized by the diagnosis,
8
resulting in less avoidance
9
behaviour and simply
7
immediately following the medical referral for neurosurgical
treatment. (4) Moreover, our patients were tested while
still recovering from
stay.
5
9 brain surgery during in-patient
4
This might have inflated responses as they were still in a
potentially stressful setting. These possible biases could
be reduced if patients were recruited from an MRT centre
rather than the neurosurgical unit.
In our study, we found no associations between cognitive
measures and measures of traumatic stress. Moreover,
group comparisons between patients with or without ASD
showed no differences with regard to the neuropsychological profile. Regarding cognitive performance in ASD,
previous research has linked deficits in the areas of memory,
high-level attentional resources, executive function and
working memory with ASD in non-medical subjects [46,
47]. There are different possible explanations for this
discrepancy, including the high rate of cognitive deficits
studies. It should also be noted that patients in this
study
were assessed within a week from receiving brain
1432
surgery
and were still inpatients. This may further explain
in our patients (and in patients without ASD in
why the
particular), the small sample size and the small number
current findings contrast to other ASD cancer
of patients with ASD, resulting in diminished statistical
studies in
power for group comparisons. There are only few
the literature which have documented sociostudies
demographic
assessing cognitive functioning in ASD to date.
factors being associated with ASD.
Recently,
It has been critically discussed whether the
the link between cognition and PTSD has been quesdiagnosis
tioned [48]. Thus, this issue warrants further
of ASD is appropriate in cancer patients due to the
clarification.
often
A multitude of factors has been associated with the
future-related nature of cancer-related traumatic
development of ASD amongst which rank gender,
events
education/
(e.g., [20]). In our sample, all but one ASD-patients
intelligence, or age (e.g., [19, 49]). These could not be
(> 93%)
replicated by our data. Only previous exposure to
reported specific, acute and past traumatic
traumatic
experiences in
events and lifetime PTSD were marginally associated
concordance with the DSM and International
with
Statistical
ASD. This is important for clinical practice as our data
Classification of Diseases and Related Health
indicates that it might be difficult to predict acute stress
Problems
responses in this acute setting via objective data.
(ICD) trauma definitions. Thus, for the majority of
However, this should be assessed in future studies with
patients
larger sample sizes. This point is not only stressed by
identified as ASD cases in this study, ASD can be
the
considered
small n of our study but also by the retrospective power
a valid and appropriate diagnosis. This is supported
analyses as well as the sample sizes of n>80 in the
by the
cited

fact that there were no indicators for organically

induced
traumatic stress responses as demonstrated by the
Support Care Cancer (2012) 20:14251434
following
factors: First, no patient suffered from dissociation who
vincing properties with regard to both sensitivity and
did
specificity. Interestingly, of all applied instruments the
not fulfil the DSM-IV A criterion as established via a
IES-R also identified the highest proportion of patients
comprehensive psychological interview. Second, none
as suffering from clinically relevant psychological morbidity
of
independent of specific traumatic stress responses. This is
the medical factors including tumour localization
consistent with previous research which has recommended the
showed
IES-R or the IES [36, 50] as screening tool for the
any relation to ASD symptomatology. Third, cognitive
identification of relevant but unspecific emotional burden
performance was not correlated with acute stress. Thus,
in early stages of physical diseases [51, 52]. Regarding the
diagnosis and treatment of traumatic stress in this
self-report measures specifically designed for assessment of
patient
acute traumatic stress symptoms (ASDS, CDSS), less
group should be accounted for in the same manner as patients met the ASD cut-off scores compared to the
has
SCID-ASD module. Usually however, self-report measures
been proposed for other cancer populations (e.g., [17]).
tend to inflate prevalence rates (e.g., [53]). Both the ASDS
In all screening instruments for traumatic stress
and the CDSS are relatively new screening instruments
(ASDS,
and until now, only few studies have assessed their
CDSS, IES-R), patients with ASD scored significantly
psychometric properties. Thus, it might be that these
higher than patients without ASD which had to be
instruments possess a high specificity but a lower
expected
sensitivity. However, the discrepancy to previous studies
with regard to the validity of self-report instruments
might also be due to the specifics of brain tumour
comprising items primarily related to trauma
patients and/or the neurosurgical setting, which however
symptoms.
would have to be answered in future studies.
Regarding the routine assessment of acute stress in
Some limitations of the current study should be
brain
carefully considered. First, the small sample size means
cancer patients however, only the IES-R showed conthat the study outcomes are preliminary, as non-significant

Support Care Cancer (2012) 20:14251434

outcomes may be due to power issues. Second, no measure of

patients current functional well-being, including healthrelated quality of life was included which would have
strengthened the study design.
The following clinical conclusions can be drawn from
our paper: Acute stress is an important topic in a
considerable proportion of patients with brain cancer. No
predictors were identified which would allow for the
prediction of ASD. Thus, the routine assessment of ASD
is indicated. However, as sensitivity of ASD-specific
screening instruments was low in our study and even the
IES-R as most suitable screening instrument for ASD
identified only about three quarters of ASD patients
correctly, to date there is no appropriate screening
instrument for ASD in brain cancer patients. One recent
study [54] demonstrated that the Distress Thermometer
(DT; [55]), a single-item rapid screening measure, was
well suited for the routine identification of brain cancer
patients suffering from psychiatric morbidity as assessed
via the SCID. The DT has been specifically validated for
patients with brain cancer and exhibited excellent
psychometric
properties for application in this population [54]. Thus, future
research could assess the ability of the DT to detect traumatic
stress in patients with brain cancer. Moreover, future studies
should also assess the incidence of PTSD in brain cancer
patients as well as the ability of ASD to identify patients at
risk for developing subsequent PTSD. This is of high clinical
relevance as the negative impact of traumatic stress on
Quality of Life as well as on emotional, social, and
occupational functioning is serious (e.g., [56]).
Finally,
research findings should result in the development
of targeted

interventions for patients with brain cancer.

Conflict of interest This study was not funded. The authors

have
full control of all primary data and agree to allow the journal to
review
the data if requested. There are no conflict of interests and no financial
disclosures by any of the authors.

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