Frequency and correlates of posttraumatic-stress-disorder-like symptoms after treatment for breast cancer

The Role of Mental Adjustment in Mediating Post-Traumatic Stress Disorder Symptoms and Social Support in Chinese Ovarian Cancer Patients: A Cross-Sectional Study

Background

Post-traumatic stress disorder (PTSD) can manifest in individuals following a traumatic event. There is a paucity of studies focusing on PTSD symptoms in ovarian cancer (OC) patients. This study aimed to investigate the association of social support, mental adjustment and PTSD symptoms in Chinese OC patients with a view to exploring whether mental adjustment could mediate the relationship.

Methods

A cross-sectional study was conducted from January 2015 to December 2016. A total of 171 OC subjects were recruited and the effective response rate was 81.3%. The PTSD Checklist-Civilian Version (PCL-C), Mini-Mental Adjustment to Cancer scale (Mini-MAC) and Duke-UNC Functional Social Support Questionnaire were disseminated to the patients. The Chinese Mini-MAC was used in this study focusing on three components, namely negative emotion, positive attitude, and cognitive avoidance. Hierarchical linear regression analyses were employed to investigate the association of social support and PTSD symptoms, and the role of mental adjustment in their mediation.

Results

The prevalence of PTSD symptoms was 17.3% in OC patients. PTSD symptoms were negatively related with both social support and positive attitude, and positively associated with negative emotion and cognitive avoidance. Social support was negatively associated with negative emotion and cognitive avoidance, and positively related with positive attitude. In addition, negative emotion and positive attitude mediated the association between social support and PTSD symptoms.

Conclusion

PTSD symptoms in OC patients should be paid attention to. Social support and mental adjustment were positive resources associated with PTSD symptoms. Moreover, mental adjustment could mediate the relation between social support and PTSD symptoms in OC patients. Therefore, intervention management that focusing on improving perceived social support as well as strengthening mental adjustment, especially negative emotion and positive attitude, may be useful for reducing PTSD symptoms in this context.

Post-Traumatic Stress Disorder Symptoms from Multiple Stressors Predict Chronic Pain in Cancer Survivors

Background: Despite the association between chronic pain and post-traumatic stress disorder (PTSD), little is known about the longitudinal course of pain and PTSD during cancer treatment. Objectives: We examined the prevalence of PTSD and chronic pain at three time periods in veterans with a diagnosis of cancer, and the relationship between the experience of pain and PTSD. Methods: Participants (N = 123) with oral-digestive cancers were recruited from the Veterans Healthcare System (age M = 65.31 and SD = 9.13; 98.4% male) and completed face to face interviews at 6, 12, and 18 months post-diagnosis. Measures included the Post-traumatic Stress Disorder Checklist-Stressor-Specific version (PCL-S), Primary care PTSD (PC-PTSD), and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Impact Scale. Results: About one-third (26.8%) of the sample had chronic pain, defined as elevated pain at two time periods. About one-fifth (20.3%) endorsed symptoms of combat-related PTSD at 6 months, and 22.8% endorsed symptoms of cancer-related PTSD, exceeding a clinical cutoff for older adults (12 months = 21.1%, 18 months = 23.1%). Changes over time were observed for cancer-related PTSD symptom clusters of hyperarousal (F = 3.85 and p = 0.023) and emotional numbing (F = 4.06 and p = 0.018) with a statistically significant quadratic function increasing at 18 months. In logistic regression, individuals with both combat and cancer-related PTSD symptoms at six months had 8.49 times higher odds of experiencing chronic pain (χ² = 25.91 and p < 0.001; R² = 0.28). Conclusions: Persisting pain may be a concern in veterans with cancer. Individuals who have experienced traumatic events with persisting PTSD symptoms may be at elevated risk for chronic pain. Veterans with PTSD symptoms from both cancer and combat are at the highest risk to experience chronic pain.

Stress and Growth in Cancer: Mechanisms and Psychotherapeutic Interventions to Facilitate a Constructive Balance

Post-traumatic stress and growth are common responses to adverse life events such as cancer. In this article, we establish how cancer becomes a "fertile land" for the emergence of stress and growth responses and analyze the main mechanisms involved. Stress-growth responses on adjusting to cancer is potentially determined by factors like the phase of the illness (e.g., initial phases vs. period of survivorship), patient's coping strategies, meaning-making, and relationships with significant others. We also review the mechanisms of constructive and adaptative stress-growth balances in cancer to study the predictors, interrelated associations, triggering mechanisms, long-term results, and specific trajectories of these two responses to cancer. Finally, we update the evidence on the role of these stress-growth associations in psychologically adjusting to cancer. Together with this evidence, we summarize preliminary results regarding the efficacy of psychotherapeutic interventions that aim to facilitate a constructive psychological balance between stress and growth in cancer patients. Recommendations for future research and gaps in knowledge on stress-growth processes in this illness are also highlighted. Researchers are encouraged to design and use psychotherapeutic interventions according to the dynamic and changeable patients' sources of stress and growth along the illness. Relevant insights are proposed to understand the inconsistency of stress-growth literature and to promote psychotherapeutic interventions to facilitate a constructive balance between these key responses in cancer.

Colorful Screams of Silent Emotions: A Study with Oncological Patients

Background:

Art, as a product of human behavior, is the expression of emotions from inner states and may provide catharsis, purification, and release. Several branches of art, most notably music, dance, and painting, can be used for treatment purposes, especially in the case of psychological disorders. Cancer, which is defined as uncontrolled cell growth, has been an important health issue throughout history, but the recent increase in its frequency has made it one of the most significant public health problems. Both the physiological distress the disease subjects the body to and the accompanying emotional distress are important factors to be considered in cancer treatment.

Aims:

In this study, the role of art in expressing emotions of oncological patients was investigated.

Materials and Methods:

During the treatment period, patients were interviewed about their experiences, feelings, expectations and perceptions. The picture was used as an expression of emotions.

Results:

Communication between the patient and doctor is one of the most important elements in the treatment process, and it has come to the fore in branches of medicine, such as oncology, because of its positive contribution to treatment compliance. In general, the study showed a pronounced positivity and expectations on the part of patients from the hope-life-healing process rather than oncological treatment.

Conclusion:

In this study, we aim to demonstrate how the artistic expression of emotions, in particular, through painting, has a positive effect on healing, hope, and the interactions between cancer patients under oncological treatment and medical professionals.

Symptoms of posttraumatic stress disorder among hospitalized patients with cancer

BACKGROUND

Patients with cancer experience many stressors placing them at risk for posttraumatic stress disorder (PTSD) symptoms, yet little is known about factors associated with PTSD symptoms in this population. This study explored relationships among patients' PTSD symptoms, physical and psychological symptom burden, and risk for hospital readmissions.

METHODS

We prospectively enrolled patients with cancer admitted for an unplanned hospitalization from August 2015-April 2017. Upon admission, we assessed patients' PTSD symptoms (Primary Care PTSD Screen), as well as physical (Edmonton Symptom Assessment System [ESAS]) and psychological (Patient Health Questionnaire 4 [PHQ-4]) symptoms. We examined associations between PTSD symptoms and patients' physical and psychological symptom burden using linear regression. We evaluated relationships between PTSD symptoms and unplanned hospital readmissions within 90-days using Cox regression.

RESULTS

We enrolled 954 of 1,087 (87.8%) patients approached, and 127 (13.3%) screened positive for PTSD symptoms. The 90-day hospital readmission rate was 38.9%. Younger age, female sex, greater comorbidities, and genitourinary cancer type were associated with higher PTSD scores. Patients' PTSD symptoms were associated with physical symptoms (ESAS physical: B = 3.41; P < .001), the total symptom burden (ESAS total: B = 5.97; P < .001), depression (PHQ-4 depression: B = 0.67; P < .001), and anxiety symptoms (PHQ-4 anxiety: B = 0.71; P < .001). Patients' PTSD symptoms were associated with a lower risk of hospital readmissions (hazard ratio, 0.81; P = .001).

CONCLUSIONS

A high proportion of hospitalized patients with cancer experience PTSD symptoms, which are associated with a greater physical and psychological symptom burden and a lower risk of hospital readmissions. Interventions to address patients' PTSD symptoms are needed and should account for their physical and psychological symptom burden. Cancer 2018. © 2018 American Cancer Society.

Psychological Considerations and Interventions in Inflammatory Bowel Disease Patient Care

The presence of psychological comorbidities, specifically anxiety and depression, is well documented in inflammatory bowel disease (IBD). The drivers of these conditions typically reflect 4 areas of concern: disease impact, treatment concerns, intimacy, and stigma. Various demographic and disease characteristics increase risk for psychological distress. However, the risk for anxiety and depression is consistent throughout IBD course and is independent of disease activity. Early intervention before psychological distress becomes uncontrolled is ideal, but mental health often is unaddressed during patient visits. Understanding available psychological treatments and establishing referral resources is an important part of the evolution of IBD patient care.

Evaluation of coping as a mediator of the relationship between stressful life events and cancer-related distress

OBJECTIVE

Lifetime stressful life events (SLEs) may predispose oncology patients to cancer-related distress (i.e., intrusive thoughts, hyperarousal, avoidance). Coping may influence cancer-related distress by mediating this relationship. This study sought to (a) determine the prevalence and impact of lifetime SLEs among oncology outpatients receiving chemotherapy and (b) examine the relationship between SLEs and cancer-related distress and the mediating role of coping on this relationship.

METHOD

Patients (n = 957), with breast, gastrointestinal, gynecologic or lung cancer, who were undergoing chemotherapy, completed the Life Stressor Checklist-Revised (LSC-R), a measure of lifetime SLEs. Cancer-related distress was assessed with the Impact of Event Scale-Revised. Coping strategies since beginning chemotherapy were assessed with the Brief COPE; 2 latent variables (engagement and disengagement coping) were identified based on these scores. LSC-R scores (number of SLEs and perceived impact during the prior year) were evaluated in relation to demographic and clinical characteristics. Structural equation modeling was used to evaluate the relationship between LSC-R and Impact of Event Scale-Revised scores and the mediating role of engagement and disengagement coping on this relationship.

RESULTS

On average, patients reported 6.1 (SD = 4.0; range = 0-23 out of 30) SLEs. Patients who were not married/partnered, had incomes <$30,000/year, or who had lower functional status or greater comorbidity had higher LSC-R scores. The relationship between more SLEs and more severe cancer-related distress was completely mediated by disengagement coping. Engagement coping did not mediate this relationship.

CONCLUSIONS

Disengagement coping, including behavioral disengagement, avoidance, and denial, should be targeted to mitigate cancer-related distress. (PsycINFO Database Record

Prevalence and Positive Correlates of Posttraumatic Stress Disorder Symptoms among Chinese Patients with Hematological Malignancies: A Cross-Sectional Study

PURPOSE

Positive psychological constructs have been given increasing attention in research on the coping resources of cancer-related distresses. However, little research is available on posttraumatic stress disorder (PTSD) in patients with hematological malignancies. The purposes of this study were to assess the prevalence of PTSD symptoms and to explore the associations of perceived social support (PSS), hope, optimism and resilience with PTSD symptoms among Chinese patients with hematological malignancies.

METHODS

A cross-sectional study was conducted during the period from July 2013 through April 2014. A total of 225 inpatients with hematological malignancies, which were eligible for the study, completed the Post-traumatic Stress Checklist-Civilian Version, Multidimensional Scale of Perceived Social Support, Adult Hope Scale, Life Orientation Scale-Revised, and Resilience Scale. Hierarchical regression analysis was performed to explore the correlates of PTSD symptoms.

RESULTS

Overall, the prevalence of PTSD symptoms was 10.7%. Initially, PSS was negatively associated with PTSD symptoms (β = -0.248, P < 0.01). However, when positive psychological variables were added, optimism was negatively associated with PTSD symptoms (β = -0.452, P < 0.01), and gender had a significant effect on PTSD symptoms. Women were more vulnerable to these symptoms than men (β = 0.123, P < 0.05). When the analysis was performed separately by gender, only optimism showed a significantly negative association with PTSD symptoms in both men (β = -0.389, P < 0.01) and women (β = -0.493, P < 0.01).

CONCLUSIONS

Some patients with hematological malignancies suffer from PTSD symptoms. The positive effects of PSS and optimism on PTSD symptoms suggest that an integrated approach to psychosocial intervention from both external and internal perspectives could have practical significance. Gender difference should be considered in developing potential interventions in reducing cancer-related PTSD symptoms.

The impact of events scale: a comparison of frequency versus severity approaches to measuring cancer-specific distress

OBJECTIVE

The Impact of Events Scale (IES) is one of the most widely used measures of event-specific distress. The IES assesses the frequency with which respondents experience intrusive thoughts and avoidant behaviors over the past week. Our aim is to demonstrate the benefit of a severity-based measurement approach of the IES compared with a frequency-based measurement approach.

METHODS

A mixed group of post-treatment cancer survivors (N = 325; M = 31.8 years old) completed measures assessing quality of life (Functional Assessment of Cancer Therapy-General), psychological adjustment (Mental Health Inventory), and cancer-related distress (IES). The IES was keyed to the cancer experience and administered with standard (frequency) and modified (severity) response options.

RESULTS

Classical reliability analyses and bifactor modeling were conducted on both versions of the IES. Reliability estimates suggest that the IES severity items were more highly intercorrelated than the IES frequency items. Both versions of the IES were highly correlated (r = 0.82), showing the presence of a dominant general factor. Bifactor modeling suggested that the severity items generally provided higher levels of discrimination than the frequency items. Validity correlations with the Functional Assessment of Cancer Therapy-General and Mental Health Inventory demonstrated that the IES severity performed as good as or better than the IES frequency.

CONCLUSIONS

Given the high correlations and similarity in content, the IES severity items largely assess the same construct as the IES frequency items. However, IES severity items generally showed improved psychometric properties and similar or higher correlations with quality of life and psychological adjustment. The IES severity approach appears to be a more informative method for assessing cancer-specific distress.

Psychosocial interventions addressing the needs of Black women diagnosed with breast cancer: a review of the current landscape

BACKGROUND

Poorer health outcomes and lower survival rates have been well documented among African American/Black (Black) women diagnosed with breast cancer. Black women are 41% more likely to die from breast cancer than White women despite a lower incidence rate. Apart from pharmacotherapy, psychosocial interventions are recommended by the Institute of Medicine as standard medical care for breast cancer patients at all phases of treatment. The current review is the first attempt to systematically evaluate the literature on the influence of psychosocial interventions for Black women diagnosed with breast cancer.

METHODS

This systematic review aimed to adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comprehensive computerized literature search of CINAHL, PsycINFO, PubMed, and Web of Science was conducted to obtain relevant studies.

RESULTS

Interventions demonstrated improved mood, decreased distress, increased ability to cope with intrusive thoughts and cancer-related stress, personal growth, and improved social well-being. However, aspects unique to this population require additional scientific inquiry. Over 80% of empirical interventions focused on Black women diagnosed with breast cancer have been concentrated on the posttreatment phase. There is a paucity of work at the time of diagnosis and during treatment.

CONCLUSIONS

To address gaps in the scientific literature, more work is needed to better understand how psychosocial interventions can improve the health trajectory for Black women diagnosed with breast cancer particularly in the areas of seeking help and support, identifying culturally acceptable methods for engaging support networks, and identifying best practices for enhancing coping skills.

Cancer-related PTSD symptoms in a veteran sample: association with age, combat PTSD, and quality of life

OBJECTIVE

The diagnosis and treatment of cancer is a potentially traumatic experience that may evoke posttraumatic stress symptoms (PTSS) among survivors. This paper describes the rates of endorsement of cancer-related PTSS along with the relationship of demographic, cancer, and combat variables on PTSS and quality of life.

METHODS

Veterans (N = 166) with head and neck, esophageal, gastric, or colorectal cancers were recruited through tumor registries at two regional Veterans Administration Medical Centers. Standardized scales were used to assess self-report of PTSS, combat, and quality of life.

RESULTS

Most participants (86%) reported experiencing at least some cancer-related PTSS; 10% scored above a clinical cutoff for probable PTSD. In linear regressions, younger age and current combat PTSS were associated with cancer-related PTSS, whereas disease and treatment characteristics were not; in turn, cancer-related PTSS were negatively associated with physical and social quality of life.

CONCLUSIONS

Individual characteristics and psychosocial factors may play a larger role than disease-related variables in determining how an individual responds to the stress of cancer diagnosis and treatment. Given the rates of reported cancer-related PTSS in this sample, and other non-veteran samples, clinicians should consider screening these following diagnosis and treatment, particularly in younger adults and those with previous trauma histories.

Cancer as a Criterion A Traumatic Stressor for Veterans: Prevalence and Correlates

The diagnosis of cancer is an uncontrollable stressor posing the threat of death and disfigurement, often followed by repeated exposure to aversive reminders in the form of noxious treatments, persisting side effects, reengagement at times of surveillance, and the threat of recurrence. The phenomenon of cancer as a traumatic stressor is explored in this study, with a focus on the prevalence and correlates of posttraumatic stress disorder (PTSD) Criterion A in a sample of 170 mostly male adults who received health care at VA Medical Centers in Boston or Houston. Participants were interviewed 6 months after diagnosis with head and neck, gastro-esophageal, or colorectal cancers. Approximately half-42.9% to 65.9% depending on cut-score used-perceived cancer to be a traumatic stressor involving actual/threatened death or injury or threat to physical integrity as well as fear, helplessness, or horror. Younger veterans and those with current combat PTSD symptoms were more likely to perceive cancer as a traumatic stressor, as were those who perceived their prognosis as uncertain; 12% had PTSD symptoms above a PCLC cut score of 50, which is similar to incidence rates of PTSD associated with other traumatic stressors. Cancer, therefore, appears to be a serious and for some, traumatic stressor, suggesting the importance of screening for cancer related PTSD in cancer survivors, particularly those most at risk.

Assessing rumination in response to illness: the development and validation of the Multidimensional Rumination in Illness Scale (MRIS)

The cognitive style of rumination extends existing cognitive models of emotional response to illness. In the absence of a specific measure, we developed the Multidimensional Rumination in Illness Scale (MRIS). In Study 1, an initial 60-item pool was tested, followed by confirmation of the factor structure in Study 2. In Study 1 participants (n = 185) completed the pilot version of the MRIS, then in Study 2 (n = 163) a reduced 41-item model was tested. Study 1: Exploratory factor analysis of a reduced 32-item scale indicated an initial four-factor solution for the MRIS (Intrusion, Brooding, Instrumental, Preventability), with satisfactory internal consistency and stable factor structure across gender. Study 2: Following scale revision, confirmatory factor analysis substantiated the adequacy of a three-factor MRIS structure, and good internal consistency, test-rest reliability, and concurrent and discriminant validity was demonstrated for the MRIS. The MRIS exhibited good psychometric properties in the current sample, providing a comprehensive assessment of the cognitive style of rumination in the context of physical illness.

Racial disparities in posttraumatic stress after diagnosis of localized breast cancer: the BQUAL study

BACKGROUND

Little is known about the development of posttraumatic stress disorder (PTSD) over time among women diagnosed with breast cancer. This study examines changes in PTSD symptoms in the first 6 months after diagnosis and assesses racial/ethnic differences in PTSD symptomatology over time.

METHODS

We recruited women with newly diagnosed breast cancer, stages I to III, from three sites in the United States. Three telephone interviews were conducted: baseline at about 2 to 3 months after diagnosis, first follow-up at 4 months after diagnosis, and second follow-up at 6 months after diagnosis. We measured traumatic stress in each interview using the Impact of Events Scale; recorded sociodemographic, tumor, and treatment factors; and used generalized estimating equations and polytomous logistic regression modeling to examine the associations between variables of interest and PTSD.

RESULTS

Of 1139 participants, 23% reported symptoms consistent with a diagnosis of PTSD at baseline, 16.5% at first follow-up, and 12.6% at the second follow-up. Persistent PTSD was observed among 12.1% participants, as defined by having PTSD at two consecutive interviews. Among participants without PTSD at baseline, 6.6% developed PTSD at the first follow-up interview. Younger age at diagnosis, being black (odds ratio [OR] = 1.48 vs white, 95% confidence interval [CI] =1.04 to 2.10), and being Asian (OR = 1.69 vs white, 95% CI = 1.10 to 2.59) were associated with PTSD.

CONCLUSIONS

Nearly one-quarter of women newly diagnosed with breast cancer reported symptoms consistent with PTSD shortly after diagnosis, with increased risk among black and Asian women. Early identification of PTSD may present an opportunity to provide interventions to manage symptoms.

Cancer-related intrusive thoughts predict behavioral symptoms following breast cancer treatment

OBJECTIVE

Behavioral symptoms are common in breast cancer survivors, including disturbances in energy, sleep, and mood, though few risk factors for these negative outcomes have been identified. Our study examined intrusive thoughts as a predictor of lingering symptoms in breast cancer survivors in the year following treatment.

METHOD

Data come from the Moving Beyond Cancer psychoeducational intervention trial, aimed at easing the transition from patient to survivor. Women (n = 558) completed psychosocial questionnaires within 4 weeks posttreatment and again 2, 6, and 12 months later. We examined intrusive thoughts about cancer at the baseline assessment as a predictor of fatigue, sleep problems, pain, breast cancer-specific symptoms, depressive symptoms, negative affect, and quality of life using growth curve modeling, controlling for study condition and other covariates.

RESULTS

Intrusive thoughts were associated with higher levels of all symptoms at baseline and at the 12-month assessment. Intrusive thoughts also influenced the trajectory of pain, depressive symptoms, negative affect, and physical functioning over time; women with higher intrusions at baseline started worse and improved over time, whereas those with lower intrusions remained at a constant, lower level over time. Intrusions were not associated with the trajectory of fatigue, sleep, breast cancer-specific symptoms, or mental functioning; women with higher intrusions at baseline started worse and remained worse over time.

CONCLUSION

Intrusive thoughts are associated with enduring elevations in behavioral symptoms and impaired quality of life in the year after breast cancer treatment and may be a risk factor for poor outcomes.

Beta-blockers may reduce intrusive thoughts in newly diagnosed cancer patients

OBJECTIVE

A cancer diagnosis provokes significant levels of emotional distress, with intrusive thoughts being the most common manifestation among breast cancer survivors. Cancer-related intrusive thoughts can take the form of emotional memories, flashbacks, nightmares, and intrusive images. Emotional arousal after a severe life stressor prolongs adrenergic activation, which in turn may increase risk for post-traumatic symptomatology. However, antihypertensive beta-blockers block adrenergic activation and are known to reduce traumatic memories and related psychological distress. Thus, the current study examined the association between beta-blocker use and the severity of cancer-related intrusive thoughts and related symptoms following a cancer diagnosis.

METHODS

The 174 breast and 36 female colorectal cancer patients who had recently undergone diagnostic screening or biopsy included 39 beta-blocker users and 171 non-users. Prior to any cancer treatment including surgery, participants completed questionnaires that included the Impact of Events Scale and the Center for Epidemiological Studies Depression Scale. Analyses controlled for age, education, cancer stage, cancer type, days since diagnosis, marital status, depression, and comorbidities.

RESULTS

Although the high rates of cancer-related distress in this sample were similar to those of other studies with recently diagnosed patients, beta-blocker users endorsed 32% fewer cancer-related intrusive thoughts than non-users.

CONCLUSIONS

Recently diagnosed cancer patients using beta-blockers reported less cancer-related psychological distress. These results suggest that beta-blocker use may benefit cancer patients' psychological adjustment following diagnosis, and provide a promising direction for future investigations on the pharmacological benefits of beta-blockers for cancer-related distress.

Validation of the Mishel's uncertainty in illness scale-brain tumor form (MUIS-BT)

The Mishel uncertainty in illness scale (MUIS) has been used extensively with other solid tumors throughout the continuum of illness. Interventions to manage uncertainty have been shown to improve mood and symptoms. Patients with primary brain tumors (PBT) face uncertainty related to diagnosis, prognosis, symptoms and response. Modifying the MUIS to depict uncertainty in PBT patients will help define this issue and allow for interventions to improve quality of life. Initially, 15 experts reviewed the content validity of the MUIS-brain tumor form (MUIS-BT). Patients diagnosed with PBT then participated in the study to test validity and reliability. Data was collected at one point in time. Six out of 33 items in the original MUIS were modified to better describe PBT patients' uncertainty. 32 of the 186 patients in the second-stage of the study were newly diagnosed with PBT, 85 were on treatment, and 69 were followed-up without active treatment. The validity of the MUIS-BT was demonstrated by its correlations with mood states (P < 0.01) and symptom severity (P < 0.01) and interference (P < 0.01). The MUIS-BT measures four constructs: ambiguity/inconsistency, unpredictability of disease prognosis, unpredictability of symptoms and other triggers, and complexity. Cronbach's alphas of the four subscales were 0.90, 0.77, 0.75 and 0.65, respectively. The 33-item MUIS-BT demonstrated adequate select measures of validity and reliability in PBT patients. Based on this initial validation and significant correlations with symptom distress and mood states, further understanding of uncertainty and evaluation of measures to help manage patients' uncertainty can be evaluated which in turn may improve coping and quality of life.

Millon Behavioral Medicine Diagnostic (MBMD) Predicts Health-Related Quality of Life (HrQoL) over time among men treated for localized prostate cancer

Prostate cancer treatment presents multiple challenges that can negatively affect health-related quality of life (HrQoL), and that can be further compromised by maladaptive personality styles and psychological adjustment difficulties. This study examined the utility of a comprehensive psychosocial screening tool to identify psychosocial traits that prospectively predict HrQoL status among men treated for localized prostate cancer. The Millon Behavioral Medicine Diagnostic (MBMD) was administered to 66 men (M age = 68 years, 59% White) treated by either radical prostatectomy or radiotherapy along with standard measures of general and prostate-cancer-specific quality of life assessed at a 12-month follow-up. Higher scores on both summary MBMD Management Guides (Adjustment Difficulties and Psych Referral) and higher scores on personality styles characterized by avoidance, dependency, depression, passive aggressiveness, and self-denigration predicted lower HrQoL (β range = -.21 to -.50). Additionally, higher scores on the MBMD Depression, Tension-Anxiety, and Future Pessimism scales predicted lower HrQoL. Finally, higher scores on the MBMD Intervention Fragility and Utilization Excess scale also consistently predicted poorer mental and physical health functioning over time. These results point to the utility of the MBMD to help screen for potential impairments in mental and physical health functioning in men undergoing treatment for prostate cancer.

Mind matters in cancer survival

OBJECTIVE

The very name "psycho-oncology" implies interaction between brain and body. One of the most intriguing scientific questions for the field is whether or not living better may also mean living longer.

METHODS

Randomized intervention trials examining this question will be reviewed.

RESULTS

The majority show a survival advantage for patients randomized to psychologically effective interventions for individuals with a variety of cancers, including breast, melanoma, gastrointestinal, lymphoma, and lung cancers. Importantly, for breast and other cancers, when aggressive anti-tumor treatments are less effective, supportive approaches appear to become more useful. This is highlighted by a recent randomized clinical trial of palliative care for non-small cell lung cancer patients.There is growing evidence that disruption of circadian rhythms, including rest-activity patterns and hypothalamic-pituitary-adrenal (HPA) axis function, affects cancer risk and progression. Women with metastatic breast cancer have flatter diurnal cortisol patterns than normal, and the degree of loss of daily variation in cortisol predicts earlier mortality. Mechanisms by which abnormal cortisol patterns affect metabolism, gene expression, and immune function are reviewed. The HPA hyperactivity associated with depression can produce elevated levels of cytokines that affect the brain. Tumor cells can, in turn, co-opt certain mediators of inflammation such as NFkB, interleukin-6, and angiogenic factors to promote metastasis. Also, exposure to elevated levels of norepinephrine triggers release of vascular endothelial growth factor, which facilitates tumor growth.

CONCLUSIONS

Therefore, the stress of advancing cancer and management of it is associated with endocrine, immune, and autonomic dysfunction that has consequences for host resistance to cancer progression.

The influence of prenatal trauma, stress, social support, and years of residency in the US on postpartum maternal health status among low-income Latinas

This study examined the associations of prenatal psychosocial factors, including depressive symptoms, post-traumatic stress disorder symptoms, trauma exposure including intimate partner violence, perceived stress, and social support, with perceived postpartum health status. Low-income Latinas (N = 203) were recruited from two health plans within the first 12 weeks of their pregnancies and followed through 3 months after birth. Participants completed semi-structured interviews conducted in English or Spanish within the first 12 weeks of pregnancy, and again at 12 weeks postpartum. Perceived health status was measured by the SF-12. Participants with complete follow-up data (n= 193) were used in data analysis. Women were mostly foreign-born (75%) with low-incomes (59%) and reported postpartum health status in the average range (M = 102.5; SD = 12.2). Overall health status was positively associated with decreased levels of perceived stress (P < .0001), being foreign-born and having resided in the US <10 years (P = .003). Emotional well-being was positively linked with being foreign-born and having resided in the US <10 years (P = .002), increased levels of social support (P = .01), and decreased levels of perceived stress (P < .001). Exposure to non-specific IPV trauma (P = .01) and health problems experienced during pregnancy or delivery (P = .05) were negatively associated with physical health status. Prenatal psychosocial factors and length of residency in the US are differentially predictive of overall postpartum health status and emotional well-being, and have less impact on physical well-being after birth. Health professionals are encouraged to assess these factors in early pregnancy.

Religious Practice and Spirituality in the Psychological Adjustment of Survivors of Breast Cancer

Religion and spirituality are resources regularly used by patients with cancer coping with diagnosis and treatment, yet there is little research that examines these factors separately. This study investigated the relationships between religious practice and spirituality and quality of life (QoL) and stress in survivors of breast cancer. The sample included 130 women assessed 2 years following diagnosis. Using hierarchical multiple regression analysis, the authors found that spiritual well-being was significantly associated with QoL and traumatic stress, whereas religious practice was not significantly associated with these variables. The results suggest that it may be helpful for clinicians to address spirituality, in particular with survivors of breast cancer.

Posttraumatic stress disorder (PTSD) in survivors of Hodgkin's lymphoma: prevalence of PTSD and partial PTSD compared with sibling controls

OBJECTIVES

Studies of posttraumatic stress disorder (PTSD) document a significant proportion of cancer survivors reporting severe posttraumatic stress symptoms, even when they do not meet full diagnostic criteria. However, few studies have directly examined the clinical significance of these 'partial PTSD' symptoms in survivors. This study aimed to investigate the prevalence of PTSD symptoms in a cohort of long-term survivors of Hodgkin's lymphoma (HL) and to explore the clinical relevance of the partial PTSD phenomenon by assessing impairment of function secondary to sub-threshold symptomatology.

METHODS

The Posttraumatic Diagnostic Scale was completed by 105 HL survivors and 101 sibling controls. Survivors' age at time of participation ranged from 24 to 71 years, age at time of diagnosis ranged from 6 to 61 years, and the median time since diagnosis was 16 years (range = 7-34).

RESULTS

Posttraumatic stress disorder prevalence was not significantly higher in HL survivors (13%) compared with sibling controls (6.9%, p = 0.098). However, a significantly larger proportion of survivors (35.2%) met criteria for partial PTSD compared with siblings (17.8%, p = 0.004). Moreover, the majority of the survivors with partial PTSD (86.5%) reported experiencing some functional impairment related to these posttraumatic stress symptoms.

CONCLUSIONS

A significant number of HL survivors experience posttraumatic stress symptoms severe enough to result in functional impairment. This finding underscores the importance of future research detailing the psychological and functional outcomes in survivors with partial PTSD and of careful clinical practice that assesses for functional impairment secondary to partial PTSD symptomatology, in male and female survivors, even years after completion of therapy.

The impact of cancer and quality of life for post-treatment non-Hodgkin lymphoma survivors

OBJECTIVE

Recent work suggests that perceptions of the impact of cancer on survivors' lives are associated with physical and mental health and quality of life (QOL) outcomes. This study examines the association between the Impact of Cancer Version 2 Scales (IOCv2) and these outcomes in a large sample of survivors of adult non-Hodgkin lymphoma (NHL).

METHODS

Participants completed a mailed survey to assess physical and mental health (SF-36), cancer-specific QOL (FACT-G) and perceived impact of cancer (IOCv2). Hierarchical multiple regression models, in which demographic, clinical, psychosocial and IOCv2 measures were added sequentially, were employed to evaluate their contribution to explain variance in SF-36 and FACT-G scores.

RESULTS

A total of 652 post-treatment NHL survivors participated. Survivors with comorbidities and negative appraisals of life threat and treatment intensity reported worse physical and mental health and QOL (all p<0.05). After controlling for demographic and clinical characteristics, younger respondents reported better physical but worse mental health and QOL (all p<0.01). Lower IOCv2 Negative Impact (all p<0.001) and higher Positive Impact (all p<0.05) scores were associated with better physical and mental health and QOL after controlling for demographic, clinical and psychosocial characteristics.

CONCLUSIONS

Findings suggest that perceptions of cancer's impact on survivors' lives may influence or be influenced by health status and functioning and QOL. Longitudinal research is needed to establish causality, which could lead to the development of interventions targeting survivors' impact of cancer concerns, and ultimately to the enhancement of overall health and QOL.

An exploratory model of the relationships between cancer-related trauma outcomes on quality of life in non-Hodgkin lymphoma survivors

Given that more than one third of some cohorts of cancer survivors exhibit post-traumatic stress disorder (PTSD) symptomatology, this study examines how trauma outcomes might relate to quality of life (QOL). Eight hundred thirty survivors of adult lymphoma were assessed for PTSD, post-traumatic growth (PTG) and QOL. Structural equation modeling revealed that QOL was best explained by the model in which stressors (e.g., co-morbidities) were mediated by PTSD and PTG. Trauma outcomes mediated the relationship between specific stressors and QOL. These findings support using PTSD and PTG as a diagnostic framework in understanding symptomatology in survivors.

Intrusive thoughts and psychological adjustment to breast cancer: exploring the moderating and mediating role of global meaning and emotional expressivity

The aim of this study was to investigate the moderating and mediating role of global meaning and emotional expressivity in the relationship between intrusive thoughts and psychological adjustment (as indicated by mental health status) in a sample of breast cancer patients (N=153). Coping with cancer was also included as an intervening variable to be tested. Moderating effects were explored using a series of hierarchical regression analysis, while multiple mediated effects were tested through bootstrapping procedures. Results showed that global personal meaning had both direct and indirect (mediating) effects on psychological adjustment. Emotional expressivity had neither moderating nor mediating effects on psychological adjustment. These results indicated that a strong sense of personal meaning and purpose in life, and an integrated understanding of self and life may lessen the impact of intrusive thoughts on breast cancer patients' psychological adjustment and mental health status. Implications of the findings for clinical practice and recommendations for future research are discussed.

The role of socioeconomic status in adjustment after ductal carcinoma in situ

BACKGROUND

A large body of literature suggests that socioeconomic status (SES) is positively associated with mental and physical health. However, little research has examined the impact of SES on psychological adjustment after a major stressor. The current study examined whether SES (education and financial status) was associated with distress (anxiety and depression) in women diagnosed with ductal carcinoma in situ (DCIS). This study also explored whether social support explained the association between SES and distress and whether social support buffered the impact of low SES on distress.

METHODS

A total of 487 women with newly diagnosed DCIS were enrolled in the study. Participants completed questions about sociodemographic, psychosocial, and clinical characteristics at the time of enrollment and 9 months after their diagnosis.

RESULTS

Financial status was inversely associated with anxiety and depression at the 9-month follow-up. Financial status also predicted change in anxiety and depression. Women with high financial status reported a decline in anxiety and depression during the study period, whereas women with medium or low financial status reported an increase in anxiety and depression. In addition, the probability of exceeding the screening threshold suggestive of clinical depression increased with decreasing financial status. Education was not associated with anxiety or depression. The presence of social support did not explain the association between financial status and change in distress. Social support did not buffer the effect of low SES on anxiety and depression.

CONCLUSIONS

Women with medium or low SES were vulnerable to escalating anxiety and depression after a DCIS diagnosis.

Barriers to mental health service use among hematopoietic SCT survivors

This study examined barriers to mental health service use and their demographic, medical, and psychosocial correlates among hematopoietic stem cell transplant (HSCT) survivors. A sample of 253 HSCT survivors who were 1- to 3-years post-transplant completed measures of demographic, physical, psychological, and social characteristics as well as a newly modified measure of barriers to mental health service use. Only 50% of distressed HSCT survivors had received mental health services. An exploratory factor analysis of the barriers to mental health service use scale yielded four factors: Scheduling Barriers, Knowledge Barriers, Emotional Barriers, and Illness-related Barriers. Patients with higher social constraints (perceived problems discussing the illness experience with significant others) reported higher levels of all four types of barriers. General distress and transplant-related posttraumatic stress symptoms were positively associated with emotional, knowledge, and illness-related barriers to mental health service use, whereas physical and functional well-being were inversely associated with these barriers. Having more knowledge barriers and more emotional barriers predicted a lower likelihood of receiving mental health services, as did lower levels of education and general distress. Results suggest that a significant number of HSCT survivors may benefit from education about mental health services that is tailored to individual barriers.

Posttraumatic growth and PTSD symptomatology among colorectal cancer survivors: a 3-month longitudinal examination of cognitive processing

INTRODUCTION

The experience of cancer can be understood as a psychosocial transition, producing both positive and negative outcomes. Cognitive processing may facilitate psychological adjustment.

METHODS

Fifty-five post-treatment, colorectal cancer survivors (M=65.9 years old; SD=12.7), an average of 13 months post-diagnosis, were recruited from a state cancer registry and completed baseline and 3-month questionnaires assessing dispositional (social desirability), cognitive processing (cognitive intrusions, cognitive rehearsal), and psychological adjustment variables (posttraumatic growth (PTG), posttraumatic stress disorder (PTSD) symptomatology, depression, anxiety, positive affectivity).

RESULTS

PTSD symptomatology was positively associated with depression, anxiety, and negatively associated with positive affectivity. In contrast, PTG scores were unrelated to PTSD symptomatology, depression, anxiety, and positive affectivity. In addition, PTG was independent of social desirability. Notably, after controlling for age at diagnosis and education, multiple regression analyses indicated that cognitive processing (intrusions, rehearsal) was differentially predictive of psychological adjustment. Baseline cognitive intrusions predicted 3-month PTSD symptomatology and there was a trend for baseline cognitive rehearsal predicting 3-month PTG.

CONCLUSIONS

Additional research is needed to clarify the association between PTG and other indices of psychological adjustment, further delineate the nature of cognitive processing, and understand the trajectory of PTG over time for survivors with colorectal cancer.

Emotional distress impacts fear of the future among breast cancer survivors not the reverse

INTRODUCTION

Fear of the future is one of the most stressful aspects of having cancer. Research to date has conceptualized fear of the future as a precursor of distress or stress-response symptoms. Yet it is equally plausible that distress would predict increased fear of the future or that they would have a reciprocal influence on each other. The purpose of the present study was to examine the bidirectional relations between fear of the future and distress as well as intrusion and avoidance among breast cancer survivors at 3, 7, 11, and 15 months after diagnosis.

METHODS

We used a bivariate latent difference score model for dynamic change to examine these bidirectional relationships among 146 early-stage breast cancer survivors. Using Lisrel version 8.80, we examined four models testing different hypothesized relationships between fear of the future and distress and intrusion and avoidance.

RESULTS

Based on model fit evaluation, our data shows that decreases in distress over time lead to a reduction of fear of the future but that changes in fear do not lead to changes in distress. On the other hand, there is no relationship between changes in fear of the future and intrusion and avoidance over time.

DISCUSSION

Ongoing fear of the future does not appear to be a necessary condition for the development of stress-response symptoms.

IMPLICATIONS FOR CANCER SURVIVORS

Future studies need to explore the role of distressing emotions in the development and exacerbation of fear of the future among cancer survivors.

Strategies used in coping with a cancer diagnosis predict meaning in life for survivors

The search for meaning in life is part of the human experience. A negative life event may threaten perceptions about meaning in life, such as the benevolence of the world and one's sense of harmony and peace. The authors examined the longitudinal relationship between women's coping with a diagnosis of breast cancer and their self-reported meaning in life 2 years later. Multiple regression analyses revealed that positive strategies for coping predicted significant variance in the sense of meaning in life--feelings of inner peace, satisfaction with one's current life and the future, and spirituality and faith--and the absence of such strategies predicted reports of loss of meaning and confusion (ps < .01). The importance and process of finding meaning in the context of a life stressor are discussed.

Emotional Self-Efficacy, Stressful Life Events, and Satisfaction with Social Support in Relation to Mood Disturbance among Women Living with Breast Cancer in Rural Communities

This study evaluated the relationships of emotional self-efficacy, stressful life events, and social support with mood disturbance among women diagnosed with breast cancer who live in rural communities. Eighty-two women completed measures of demographic characteristics, medical status, and psychosocial variables. Using multiple regression analysis, we found that greater mood disturbance was related to having less emotional self-efficacy (p < 0.001) and to having experienced more stressful life events (p = 0.02), while satisfaction with social support was not significantly related to mood disturbance (adjusted R2 = 0.39). Women living with breast cancer in rural communities who have experienced multiple stressful life events may have an increased risk for mood disturbance, whereas having greater emotional self-efficacy may provide resilience against mood disturbance.

Traumatic stress, perceived global stress, and life events: prospectively predicting quality of life in breast cancer patients

The authors investigated the relationship between stress at initial cancer diagnosis and treatment and subsequent quality of life (QoL). Women (n = 112) randomized to the assessment-only arm of a clinical trial were initially assessed after breast cancer diagnosis and surgery and then reassessed at 4 months (during adjuvant treatment) and 12 months (postadjuvant treatment). There were 3 types of stress measured: number of stressful life events (K. A. Matthews et al., 1997), cancer-related traumatic stress symptoms (M. J. Horowitz, N. Wilner, & W. Alvarez, 1979), and perceived global stress (S. Cohen, T. Kamarck, & R. Mermelstein, 1983). Using hierarchical multiple regressions, the authors found that stress predicted both psychological and physical QoL (J. E. Ware, K. K. Snow, & M. Kosinski, 2000) at the follow-ups (all ps < .03). These findings substantiate the relationship between initial stress and later QoL and underscore the need for timely psychological intervention.

Risk factors associated with posttraumatic stress disorder symptomatology in HIV-infected women

This study examined risk factors for posttraumatic stress disorder (PTSD) symptomatology in a sample of 102 HIV-positive women. The magnitude of HIV-related PTSD symptoms was associated with a greater number of HIV-related physical symptoms, more extensive history of pre-HIV trauma, less perceived availability of social support, greater degree of perceived stigma, and greater degree of negative life events. Hierarchical multiple regression analysis revealed three individual predictors of PTSD symptomatology: total impact of negative life events, total stigma score, and total number of present symptoms. Stigma emerged as the strongest individual predictor. Social support failed to moderate relationships between PTSD symptomatology and HIV-related physical symptoms and negative life events. These findings may inform helping professionals about risk factors associated with PTSD symptomatology in HIV-positive women.

How do cancer patients who try to take control of their disease differ from those who do not?

The objective of this study was to compare patients who do and do not describe their coping strategies as attempts to control their cancer. This was a cross-sectional study of adult, oncology outpatients from an urban medical centre diagnosed 6-24 months previously. Using open-ended questions, we asked participants if they tried to 'control' their cancer or situation. If 'yes', how? If 'no', how had they 'dealt with' it? The Hospital Anxiety and Depression Scale (HAD) measured anxiety and depression. The Mental Adjustment to Cancer Scale (MAC) assessed six coping styles. Of the 44 participants, 57% were female. The mean age was 57 years. Eighteen (41%) said they used control strategies (control-yes), 11 (25%) said they did not (control-no), and 15 (34%) gave unclear responses (control-unclear). Participants cited 97 different coping strategies that were grouped into proactive (e.g. lifestyle changes) and reactive strategies (e.g. stoic behaviour). In comparing these groups, the control-yes group was more likely to be younger (P = 0.0001), live with other(s) (P = 0.003), be confident of being cured (P = 0.006), have greater 'fighting spirit' on the MAC (P = 0.04) and use more proactive strategies (P = 0.0001). The conclusion of this study is that cancer patients use many coping strategies, but those who think of them as methods of control are younger and more confident of being cured, and use more proactive strategies.

Depressive symptoms after breast cancer surgery: relationships with global, cancer-related, and life event stress

For women with breast cancer, rates of depression are the third highest of any cancer diagnostic group. Stress, defined as life events or perceptions of stress, is associated with depressive symptoms. However, little is known about the relationships between different types of stress and these symptoms in women with breast cancer. This relationship was tested in 210 women assessed after initial surgical treatment for regional breast cancer. Using Hierarchical Multiple Regression, three types of stress were examined: the occurrence of five stressful life events in the year prior to cancer diagnosis, perceptions of global stress, and perceptions of cancer-related traumatic stress. Other potentially relevant correlates of depressive symptoms were also examined, including the personality trait neuroticism, sociodemographics, and disease/treatment characteristics. Fifty-three percent of the variance in depressive symptoms was accounted for by three stress variables (perceptions of global and cancer-related traumatic stress and the life event-major financial difficulty) and two control variables (neuroticism and racial group). Specifically, global stress perceptions coupled with cancer-related intrusive thoughts and financial concerns along with the tendency towards negativity (neuroticism) may conspire to heighten a women's risk for depressive symptoms. Assessing multiple sources of stress would improve our ability to identify women 'at risk' for depressive symptoms and provide appropriate intervention.

Symptoms of posttraumatic stress and death anxiety in persons with HIV and medication adherence difficulties

The present study examined the frequency and correlates of self-reported symptoms of posttraumatic stress among patients with HIV and medication adherence problems. Self-report data revealed that more than half of participants met diagnostic criteria for posttraumatic stress disorder (PTSD) according to the Posttraumatic Diagnostic Scale PDS. Death anxiety was associated with overall PTSD symptom severity scores as well as severity scores for reexperiencing, avoidance, and arousal symptoms. The association between death anxiety and total PTSD severity, reexperiencing and avoidance symptom scores remained after controlling for depression and satisfaction with social support. Anxiety, as manifested by PTSD symptoms should be routinely assessed among patients with HIV, and variables such as death anxiety, social support, and depression are appropriate targets for mental health interventions.

Biobehavioral outcomes following psychological interventions for cancer patients

Psychological interventions for adult cancer patients have primarily focused on reducing stress and enhancing quality of life. However, there has been expanded focus on biobehavioral outcomes--health behaviors, compliance, biologic responses, and disease outcomes--consistent with the Biobehavioral Model of cancer stress and disease course. The author reviewed this expanded focus in quasiexperimental and experimental studies of psychological interventions, provided methodologic detail, summarized findings, and highlighted novel contributions. A final section discussed methodologic issues, research directions, and challenges for the coming decade.

Breast cancer surgery: comparing surgical groups and determining individual differences in postoperative sexuality and body change stress

Women diagnosed and surgically treated for regional breast cancer (N = 190) were studied to determine the sexual and body change sequelae for women receiving modified radical mastectomy (MRM) with breast reconstruction in comparison with the sequelae for women receiving breast-conserving therapy (BCT) or MRM without breast reconstruction. The sexuality pattern for women receiving reconstructive surgery was one that was significantly different--with lower rates of activity and fewer signs of sexual responsiveness--than that for women in either of the other groups. Significantly higher levels of traumatic stress and situational distress regarding the breast changes were reported by the women receiving an MRM in contrast to the women treated with BCT. Using a model to predict sexual morbidity, regression analyses revealed that individual differences in sexual self-schema were related to both sexual and body change stress outcomes.