The Common Sense of Counseling Psychology: Introducing the Common-Sense Model of Self-Regulation

The goal of therapy is typically to improve clients' self-management of their problems, not only during the course of therapy but also after therapy ends. Although it seems obvious that therapists are interested in improving client's self-management, the psychotherapy literature has little to say on the topic. This article introduces Leventhal's Common-Sense Model of Self-Regulation, a theoretical model of the self-management of health, and applies the model to the therapeutic process. The Common-Sense Model proposes that people develop illness representations of health threats and these illness representations guide self-management. The model has primarily been used to understand how people self-manage physical health problems, we propose it may also be useful to understand self-management of mental health problems. The Common-Sense Model's strengths-based perspective is a natural fit for the work of counseling psychologists. In particular, the model has important practical implications for addressing how clients understand mental health problems over the course of treatment and self-manage these problems during and after treatment.

Successful self-management among non-insulin-treated adults with Type 2 diabetes: a self-regulation perspective

AIMS

To clarify the role of self-monitoring of blood glucose (SMBG) in the self-management of Type 2 diabetes from the patient's perspective, using in-depth interviews with non-insulin-treated adults to investigate how they learned to manage their diabetes effectively and whether SMBG played a significant role in this process.

METHODS

Individual interviews were conducted with 14 non-insulin-treated adults with Type 2 diabetes who had significantly improved their glycaemic control [64% women; 50% black; 21% Hispanic; mean age 60 years; mean HbA(1c) concentration 43 mmol/mol (6.1%)]. Interviews were transcribed and analysed by a coding team, applying the concept of illness coherence from the Common Sense Model of Self-Regulation.

RESULTS

The majority of participants relied on SMBG to evaluate their self-management efforts. Key themes included: adopting an experimental approach; experiencing 'a-ha' moments; provider-assisted problem-solving; using SMBG and other feedback to evaluate when their efforts were working; and normalizing diabetes-specific behaviour changes as being healthy for everyone.

CONCLUSIONS

Our qualitative data are consistent with the argument that SMBG, if implemented appropriately with enough education and provider access, can be a powerful tool for non-insulin-treated adults with Type 2 diabetes to monitor their self-management. Establishing sufficient conditions for illness coherence to develop while individuals are learning to use SMBG could increase their sense of personal control in managing a complex and demanding illness.

HIV and HCV health beliefs in an inner-city community

Chronic infection with the hepatitis C virus (HCV) is more prevalent than human immunodeficiency virus (HIV) infection, but more public health resources are allocated to HIV than to HCV. Given shared risk factors and epidemiology, we compared accuracy of health beliefs about HIV and HCV in an at-risk community. Between 2002 and 2003, we surveyed a random patient sample at a primary care clinic in New York. The survey was organized as domains of Common Sense Model of Self-Regulation: causes ('sharing needles'), timeline/consequences ('remains in body for life', 'causes cancer') and controllability ('I can avoid this illness', 'medications may cure this illness'). We compared differences in accuracy of beliefs about HIV and HCV and used multivariable linear regression to identify factors associated with relative accuracy of beliefs. One hundred and twenty-two subjects completed the survey (response rate 42%). Mean overall health belief accuracy was 12/15 questions (80%) for HIV vs 9/15 (60%) for HCV (P < 0.001). Belief accuracy was significantly different across all domains. Within the causes domain, 60% accurately believed sharing needles a risk factor for HCV compared to 92% for HIV (P < 0.001). Within the timeline/consequences domain, 42% accurately believed HCV results in lifelong infection compared to 89% for HIV (P < 0.001). Within the controllability domain, 25% accurately believed that there is a potential cure for HCV. Multivariable linear regression revealed female gender as significantly associated with greater health belief accuracy for HIV. Thus, study participants had significantly less accurate health beliefs about HCV than about HIV. Targeting inaccuracies might improve public health interventions to foster healthier behaviours and better hepatitis C outcomes.

Underuse of breast cancer adjuvant treatment: Patients' knowledge, beliefs, and medical mistrust

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Background: We surveyed breast cancer patients in New York City to understand why women did not receive radiotherapy (RT) following lumpectomy, chemotherapy, or hormonal therapy for hormone receptor negative or positive tumors >1 cm, respectively. Methods: 258 New York City women recently surgically treated for a new primary stage I or II breast cancer were surveyed about their experience of care, knowledge and beliefs about breast cancer and its treatment. Adjuvant treatment data were obtained from in and out-patient chart abstraction. Principal components factor analysis was used to create scales of adjuvant treatment beliefs and knowledge, medical mistrust, physician communication about treatment and social support. Scales were scored to 100. Bivariate and multivariate analyses were conducted to determine differences between treated and untreated women; odds ratios were converted to adjusted relative risks. Results: Compared to treated women, untreated women were less likely to know adjuvant therapies increase survival (66 vs 75; p < 0.0001), had greater mistrust (64 vs 53; p = 0.001), and less self efficacy (92 vs 97; p < 0.05); there was no association between physician communication of treatment information and patient knowledge and beliefs about adjuvant treatment (r = 0.8; p = 0.21). Multivariate analysis found that compared to those who were treated, untreated women were more likely to be 70 years or older (OR = 4.46; 95%CI: 1.9–10.7), more likely to have a comorbidity (OR = 3.39;1.5–7.9), more likely to express mistrust in the medical delivery system (OR = 1.03;1.0–1.1), and less likely to believe adjuvant treatments beneficial (OR = 0.91; 0.87–0.96) (model c = 0.84; p =< 0.0001). Conclusions: Patient knowledge and beliefs about treatment and medical mistrust are mutable factors associated with underuse of adjuvant therapies. Despite physicians' discussion of treatment, patients do not have a clear understanding of treatments' benefits and risks. This disconnect between what is said and what is heard may be mediated and addressed by dealing with patients' trust in and concerns about the medical delivery system.

No significant financial relationships to disclose.

Value for the future and preventive health behavior

Many everyday decisions require trade-offs between immediate and delayed benefits. Although much research has assessed discounting of delayed outcomes by using hypothetical scenarios, little research has examined whether these discounting measures correspond to real-world behavior. Three studies examined the relationship between scenario measures of time preference and preventive health behaviors that require an upfront cost to achieve a long-term benefit. Responses to time preference scenarios showed weak or no relationship to influenza vaccination, adherence to a medication regimen to control high blood pressure, and adherence to cholesterol-lowering medication. The finding that scenario measures of time preference have surprisingly little relationship to actual behaviors exemplifying intertemporal trade-offs places limits on the applications of time preference research to the promotion of preventive health behavior.

Explaining retrospective reports of symptoms in patients undergoing chemotherapy: anxiety, initial symptom experience, and posttreatment symptoms

This study evaluated different perspectives on the relationship of trait anxiety to symptom report. Baseline trait anxiety was related to (a) initial symptoms reported 2 days after beginning chemotherapy, (b) posttreatment symptoms reported 2 days after cessation of medication, and (c) retrospective reports of initial symptoms (made concurrently with posttreatment reports). Associations were significant for vague psychophysiological symptoms but not for concrete visible symptoms. Path models indicated that the relationship of anxiety to retrospective report of vague symptoms was due to both enhanced encoding and facilitated recall of symptoms. Further analyses revealed, however, that this relationship reflects symptoms stability rather than anxiety-related differences in attention. Anxious and nonanxious patients appear to be equally accurate in their retrospective report of symptoms.

Population risk, actual risk, perceived risk, and cancer control: a discussion

Given the difficulty of converting population-based estimates of cancer risk into precise statements of individual risk, it is not surprising that (a) individual differences in risk perception are at best poorly correlated to the best available determination of "actual risk" and to behaviors to prevent and detect and treat cancer, and (b) success in bringing perceived risk into line with actual risk has been limited. These inconsistencies are of concern because individual perceptions of risk are thought to be important motivators of action for the prevention and early detection and treatment of cancer. Following the reviewer's suggestion that risk perceptions are readily influenced by contextual factors, we suggest examining risk perception in a self-regulatory framework in which both risk judgments and motivated action are products of underlying representations of cancer and the self. Self-assessments of risk may access only a part of the data necessary for motivation, whereas motivation to sustain action calls on a larger number of concrete features of the database (symptoms, time loss, consequences). Studies of cancer risk perception can make a major contribution to our understanding of processes involved in self-appraisals and self-management to maximize well-being and to avoid catastrophic disease.

Gender differences in processing information for making self-assessments of health

OBJECTIVE

This study proposes that women's greater inclusiveness of various sources of information when making self-assessed health (SAH) judgments accounts for the finding that SAH is a weaker predictor of mortality in women than in men.

METHODS

Data from a sample of 830 elderly residents of a retirement community and a 5-year mortality follow-up study were used to examine the bases for women's and men's reports of negative affect (NA) and judgments of SAH. The degree to which each health-related measure accounts for the SAH-mortality association in each gender group was examined.

RESULTS

The findings support two possible explanations for the lower accuracy of SAH as a predictor of mortality among women: 1) In both men and women, NA is associated with poorer SAH, but in men, NA is more closely linked to serious disease in conjunction with other negative life events, whereas in women, NA reflects a wider range of factors not specific to serious disease. 2) Men's SAH judgments reflect mainly serious, life-threatening disease (eg, heart disease), whereas women's SAH judgments reflect both life-threatening and non-life-threatening disease (eg, joint diseases).

CONCLUSIONS

Women's SAH judgments and NAs are based on a wider range of health-related and non-health-related factors than are men's. This difference can explain gender differences in the accuracy of SAH judgments and may be related to other documented differences in women's physical and mental health and illness behavior. The findings emphasize the need to study the bases of NA and other self-evaluations separately for women and men.

Positive affect and function as influences on self-assessments of health: expanding our view beyond illness and disability

Longitudinal data from 851 elderly residents of a retirement community (mean age = 73 years) were used to examine the correlates of self-assessments of health (SAH) and the predictors of changes in SAH over several follow-up periods ranging from 1 to 5 years. The authors hypothesized that indicators of positive health, including feelings of energy and positive mood, social support, and active functioning, are as important in determining current and future SAH as negative indicators such as disease history, disability, medication, and negative mood. Results of cross-sectional and longitudinal analyses showed that functional ability, medication use, and negative affect were salient to people judging their health, but positive indicators of activity and mood had an even stronger, independent effect. These findings show the importance of attending to the full illness-wellness continuum in studying people's perceptions of health.

Medication adherence in rheumatoid arthritis patients: older is wiser

OBJECTIVES

To create a profile of individuals nonadherent to their medications in an age-stratified sample (ages 34-84) of community-dwelling rheumatoid arthritis patients. The relative contributions of age, cognitive function, disability, emotional state, lifestyle, and beliefs about illness to nonadherence were assessed.

DESIGN

A direct observation approach was used in conjunction with structural equation modeling. All participants were administered a preliminary assessment battery. Medications were then transferred to vials with microelectronic caps that recorded medication events for all medications for the next 4 weeks.

PARTICIPANTS AND SETTING

A volunteer sample of 121 community-dwelling rheumatoid arthritis (RA) patients were recruited from newspaper ads, posters, and via informal physician contact from private rheumatology practices in Atlanta and Athens, Georgia. Written verification of the RA diagnosis and a disease severity rating were obtained from personal physicians before patients were enrolled in the study. Patients were tested in a private physician's office, and their medication adherence was monitored electronically for a month in their every-day work and home settings.

MEASUREMENTS AND RESULTS

Structural equation modeling techniques were used to develop a model of adherence behavior. Cognitive and psychosocial measures were used to construct latent variables to predict adherence errors. The model of medication adherence explained 39% of the variance in adherence errors. The model demonstrated that older adults made the fewest adherence errors, and middle-aged adults made the most. A busy lifestyle, age, and cognitive deficits predicted nonadherence, whereas coping with arthritis-related moods predicted adherence. Illness severity, medication load, and physical function did not predict adherence errors. Omission of medication accounted for nearly all errors.

CONCLUSION

Despite strong evidence for normal, age-related cognitive decline in this sample, older adults had sufficient cognitive function to manage medications. A busy lifestyle and middle age were more determinant of who was at risk of nonadherence than beliefs about medication or illness. Thus, practicing physicians should not assume that older adults have insufficient cognitive resources to manage medications and that they will be the most likely to make adherence errors. Very busy middle-aged adults seem to be at the greatest risk of managing medications improperly.

Trait anxiety, symptom perceptions, and illness-related responses among women with breast cancer in remission during a tamoxifen clinical trial

Postmenopausal women with breast cancer in remission (N = 140) who were participating in a randomized clinical trial of tamoxifen chemoprevention therapy completed measures of trait anxiety, symptoms, cancer worry, and breast self-examinations (BSEs) during the first 6 months of the trial. Trait anxiety was associated with heightened sensitivity to tamoxifen-induced symptoms (but not with tendencies to report increases in symptoms unrelated to tamoxifen use), greater tendencies to attribute symptoms to tamoxifen use, and greater cancer worry. Tamoxifen use increased BSE rates among high-anxiety participants. For low-anxiety participants, tamoxifen use increased cancer worry but not BSE rates. Trait anxiety appears to be associated with vigilant activation of illness-related representations that trigger attentiveness to sensations, worry, and protective coping in response to somatic cues.

Trait anxiety, symptom perceptions, and illness-related responses among women with breast cancer in remission during a tamoxifen clinical trial

Postmenopausal women with breast cancer in remission (N = 140) who were participating in a randomized clinical trial of tamoxifen chemoprevention therapy completed measures of trait anxiety, symptoms, cancer worry, and breast self-examinations (BSEs) during the first 6 months of the trial. Trait anxiety was associated with heightened sensitivity to tamoxifen-induced symptoms (but not with tendencies to report increases in symptoms unrelated to tamoxifen use), greater tendencies to attribute symptoms to tamoxifen use, and greater cancer worry. Tamoxifen use increased BSE rates among high-anxiety participants. For low-anxiety participants, tamoxifen use increased cancer worry but not BSE rates. Trait anxiety appears to be associated with vigilant activation of illness-related representations that trigger attentiveness to sensations, worry, and protective coping in response to somatic cues.

It's long-term stressors that take a toll: comment on Cohen et al. (1998)

In an extremely well-controlled study, Cohen et al. (1998) add to prior knowledge of stress-illness relationships by showing that self-reports of stress occurrence and duration of 1 month or more, rather than estimates of stressor severity, predict susceptibility to experimentally induced colds (i.e., viral replication and cold symptoms). Although ruling out obvious behavioral and personality factors as causes of the association of stressors to colds, they were unable to identify mediational immune factors, a deficit attributable to the difficulty of assessing the multi-layered, dynamic physiological processes within the bidirectional connections of the nervous (stress) and immune systems. The findings provide an interesting complement to data, showing that people use stressor duration in evaluating the illness implications of somatic symptoms (Cameron et al., 1995), and suggest caution with regard to overestimating the prevalence of stress-induced colds in natural settings.

It's long-term stressors that take a toll: comment on Cohen et al. (1998)

In an extremely well-controlled study, Cohen et al. (1998) add to prior knowledge of stress-illness relationships by showing that self-reports of stress occurrence and duration of 1 month or more, rather than estimates of stressor severity, predict susceptibility to experimentally induced colds (i.e., viral replication and cold symptoms). Although ruling out obvious behavioral and personality factors as causes of the association of stressors to colds, they were unable to identify mediational immune factors, a deficit attributable to the difficulty of assessing the multi-layered, dynamic physiological processes within the bidirectional connections of the nervous (stress) and immune systems. The findings provide an interesting complement to data, showing that people use stressor duration in evaluating the illness implications of somatic symptoms (Cameron et al., 1995), and suggest caution with regard to overestimating the prevalence of stress-induced colds in natural settings.

Negative affect relates to cross-sectional but not longitudinal symptom reporting: data from elderly adults

To test hypotheses about the relationship between negative affect and symptom reports, symptom reports of 4 groups of elderly participants (N = 76; mean age = 73.5 years) were compared: those high on measures of both depression and anxiety, those high on one measure and low on the other, and those low on both measures. Symptom reports were obtained before and after 3 simultaneously given active inoculations (influenza; tetanus toxoid; and keyhole limpet hemocyanin, a neoantigen) and 3 similarly given placebo injections. Cross-sectional analyses replicated associations between negative affect and reports of elevated systemic (flulike) symptoms. Local symptoms (sore arm and redness at injection site) increased significantly from before to after active inoculations. Reports of systemic symptoms declined from before to after for both active and placebo inoculations regardless of affect groups. The results add to previous research showing that negative affect is related to cross-sectional symptom reporting but not to increases in symptom reporting from before to after a symptom-producing inoculation procedure.

Negative affect and self-report of physical symptoms: two longitudinal studies of older adults

The ability of negative affect (NA) to predict somatic complaints 6 months later was examined. State NA, including anxious affect (AA) and depressive affect (DA), was measured in 2 separate samples of older adults averaging 62 and 73 years of age. In the first study, DA reliably predicted later complaints, and a corresponding trend was noted for NA. The second study showed that state NA and its 2 constituent variables predicted somatic complaints associated with acute illness (e.g., colds) 6 months later. The second study also examined trait measures of the 3 predictor variables and found that NA and AA, but not DA, were associated with subsequent somatic complaints. However, these trait effects were less robust than those attributable to their state counterparts. The authors conclude that negative mood states are the more consistent predictors of later physical symptom reports.

Negative affect relates to cross-sectional but not longitudinal symptom reporting: data from elderly adults

To test hypotheses about the relationship between negative affect and symptom reports, symptom reports of 4 groups of elderly participants (N = 76; mean age = 73.5 years) were compared: those high on measures of both depression and anxiety, those high on one measure and low on the other, and those low on both measures. Symptom reports were obtained before and after 3 simultaneously given active inoculations (influenza; tetanus toxoid; and keyhole limpet hemocyanin, a neoantigen) and 3 similarly given placebo injections. Cross-sectional analyses replicated associations between negative affect and reports of elevated systemic (flulike) symptoms. Local symptoms (sore arm and redness at injection site) increased significantly from before to after active inoculations. Reports of systemic symptoms declined from before to after for both active and placebo inoculations regardless of affect groups. The results add to previous research showing that negative affect is related to cross-sectional symptom reporting but not to increases in symptom reporting from before to after a symptom-producing inoculation procedure.

Negative affect and self-report of physical symptoms: two longitudinal studies of older adults

The ability of negative affect (NA) to predict somatic complaints 6 months later was examined. State NA, including anxious affect (AA) and depressive affect (DA), was measured in 2 separate samples of older adults averaging 62 and 73 years of age. In the first study, DA reliably predicted later complaints, and a corresponding trend was noted for NA. The second study showed that state NA and its 2 constituent variables predicted somatic complaints associated with acute illness (e.g., colds) 6 months later. The second study also examined trait measures of the 3 predictor variables and found that NA and AA, but not DA, were associated with subsequent somatic complaints. However, these trait effects were less robust than those attributable to their state counterparts. The authors conclude that negative mood states are the more consistent predictors of later physical symptom reports.

Conservation of energy, uncertainty reduction, and swift utilization of medical care among the elderly: study II

This study examined age differences in the timing of the decision to seek medical care. The data were obtained from a longitudinal study of 366 community dwelling adults aged 45 to 93 years. Subjects were paired for age, gender, and health status, and both members of a pair were interviewed when either one initiated a medical visit for a new problem. This allowed the authors to examine delay in care-seeking for individuals with new symptoms who did not seek care as well as those who did. Survival analysis was used to test hypotheses respecting age differences for total delay (the time from first noticing symptoms until calling for care) and its two constituent phases: appraisal delay (symptom onset until deciding one was ill) and illness delay (decision one was ill until calling for care). Older persons were expected to be more avoidant of uncertainty and conserving of physical and psychic resources and thus quicker to seek care. The results and findings on reasons for delay support the uncertainly avoidance hypothesis but did not replicate signs of higher levels of avoidance behavior by middle-aged subjects than by older subjects.

Seeking medical care in response to symptoms and life stress

Analyses tested the following contrasting hypotheses: a) The occurrence of a new symptom in the presence of ongoing life stress increases the attribution of symptoms to illness and increases the use of health care; b) new symptoms occurring in the presence of ongoing life stress are attributed to stressors if they are ambiguous indicators of illness, and they are unlikely to motivate care-seeking if the stressor, i.e., the perceived cause, is of recent onset. The 43-to-92-year old subjects in this longitudinal study were less likely to seek care for the ambiguous symptoms they experienced during the previous week if there was a concurrent life stressor that began during the previous 3 weeks; these symptoms were attributed to stress rather than to illness, and subjects tolerated the emotional distress caused by the combination of a stressor and an ambiguous symptom. Subjects were less willing to tolerate the combined distress of an ambiguous symptom and a concurrent life stressor if the stressor onset was not recent; under such conditions, subjects were more likely to seek health care. Current life stressors did not affect care-seeking for symptoms that were clear signs of disease; these symptoms were readily identified as health threats in need of medical attention. The findings contribute to a better theoretical understanding of how individuals perceive their physical states and how they cope with stress. Practical implications of these findings for increasing efficient use of health care services are also discussed.

Modeling adherence to colorectal cancer screening

BACKGROUND

An explanatory framework referred to as the Preventive Health Model was used to identify factors associated with prospective adherence to colorectal cancer screening.

METHODS

Data on sociodemographic, psychosocial, social influence, and program factors were collected via telephone survey for 501 older adult members of an independent practice association-type health maintenance organization. Subjects were later mailed fecal occult blood tests for completion and return. Adherence was defined as the return of the tests within 90 days.

RESULTS

Structural analysis shows that for men (N = 145), perceived self-efficacy (OR = 1.4), salience and coherence of testing (OR = 2.3 for a 5-point increment on a 30-point scale), and exposure to health education interventions (OR = 6.8) were significant independent predictors of intention to adhere and of adherence. Among women (N = 185), predictors were age (OR = 1.8) and salience and coherence of testing (OR = 1.8 for a 5-point increment on a 30-point scale).

CONCLUSIONS

These findings indicate that for both men and women, adherence is influenced strongly by the extent to which the behavior is judged to make sense in everyday life. It also appears that additional education and encouragement may persuade men and younger women to participate in screening.

Symptom representations and affect as determinants of care seeking in a community-dwelling, adult sample population

The cognitive and emotional determinants of health-care utilization were assessed for middle-aged and older adults matched on age, gender, and health status. Both members of a pair were interviewed when either initiated a medical visit. Interviews were based on a self-regulatory model that assumed that Ss would use symptoms to create and update representations and coping procedures. Care seekers reported more symptoms than did matched controls but did not report more symptoms than did matched controls with new symptoms. The mere presence of atypical symptoms was insufficient to trigger care seeking. Care seeking is driven by well-developed representations of a serious health threat, perceptions of inability to cope with the threat, advice to seek care, and life stress.

Symptom representations and affect as determinants of care seeking in a community-dwelling, adult sample population

The cognitive and emotional determinants of health-care utilization were assessed for middle-aged and older adults matched on age, gender, and health status. Both members of a pair were interviewed when either initiated a medical visit. Interviews were based on a self-regulatory model that assumed that Ss would use symptoms to create and update representations and coping procedures. Care seekers reported more symptoms than did matched controls but did not report more symptoms than did matched controls with new symptoms. The mere presence of atypical symptoms was insufficient to trigger care seeking. Care seeking is driven by well-developed representations of a serious health threat, perceptions of inability to cope with the threat, advice to seek care, and life stress.

Conservation of energy, uncertainty reduction, and swift utilization of medical care among the elderly

This study examined age differences in the timing of the decision to seek medical care. Two cohorts, one of middle-aged (40 to 55 years, n = 88) and one of older patients (65 and over, n = 80), who sought medical care when symptomatic were interviewed at the time of their visit. Age differences were examined with respect to total delay (the time from first noticing symptoms until calling for care), as well as its two constituent phases: appraisal delay (symptom onset until deciding one was ill) and illness delay (decision one was ill until calling for care). Older persons were expected to be more conserving of physical and psychic resources, and thus quicker in seeking care. The cohort effect was expected to be most visible for symptoms judged to be of uncertain seriousness. The delay results and ancillary findings on reasons given for delay are generally supportive of the hypotheses, with the caveat that the cohort difference also reflects higher levels of avoidance behavior by the middle-aged than by the older subjects.

Autonomic correlates of illness imagery

Psychophysiological responses to imagery of self-relevant illness threats were examined for high and low extreme groups of hypervigilants and health care utilizers. Heart rate, skin conductance, and respiration were the physiological measures recorded; self-reports of perceived illness vulnerability, negative affect, image clarity, and image realness were the psychological measures obtained. Responses to neutral, exercise, and illness threat scenes were compared. Hypervigilants showed an increased heart rate response to imagery of illness scenes, whereas all other groups returned more quickly to baseline levels. The results are similar to those reported by Lang for snake phobics. They also lend some support to Horowitz's theory of intrusive imagery, in which self-relevant, anxiety-provoking events tend to continuously intrude upon one's thoughts, and this intrusive imagery was reflected cardiovascularly. There could be several possible underlying mechanisms for these findings.

I know distraction works even though it doesn't!

Resistance is high to findings negating commonsense beliefs. If McCaul, Monson, and Maki's (1992) four studies are taken seriously, we will address new questions about the components of analgesic interventions--specifically, whether distraction works only when combined with a competing affect, an analgesic cognition, or both. Addressing these questions should increase our understanding of the mechanisms involved in pain processing and may increase our ability to intervene and modify chronic as well as acute pain. Laboratory studies offer an efficient route to such understanding, although the question of generalization will always lurk in the background.

Effects of tamoxifen on cardiovascular risk factors in postmenopausal women

OBJECTIVE

To determine the effects of tamoxifen on risk factors for cardiovascular disease in disease-free postmenopausal women.

DESIGN

Double-blind, placebo-controlled, randomized 2-year clinical trial.

SETTING

University health sciences center.

PATIENTS

Clinically postmenopausal women (140) with a diagnosis of axillary node-negative breast cancer, who were disease-free by laboratory and clinical evaluations.

MEASUREMENTS

Levels of total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, apolipoprotein A-I, apolipoprotein B, glucose, weight, blood pressure, and reported exercise and work activity were measured.

MAIN RESULTS

Postmenopausal women receiving tamoxifen were evaluated at 3- or 6-month intervals during a 2-year assessment period and showed a mean decrease of 12% in total cholesterol levels (at 24 months -0.672 mmol/L; 95% CI, -0.839 to -0.505 mmol/L) and a mean decrease of 20% in calculated low-density lipoprotein (LDL) cholesterol levels (at 24 months, -0.725 mmol/L; 95% CI, -0.868 to -0.583 mmol/L) (P less than 0.001). Women with greater baseline cholesterol levels had greater decreases with tamoxifen treatment. Levels of HDL cholesterol decreased in patients treated with tamoxifen, but this decrease was only statistically significant at one of five measurement times. Apolipoprotein A-I levels increased significantly at the two time points at which it was measured (P = 0.02), and apolipoprotein B levels decreased significantly at these times (P less than 0.01) in patients treated with tamoxifen. Plasma glucose levels, reported exercise and work activity, reported smoking, weight, and systolic and diastolic blood pressures did not change with treatment.

CONCLUSION

During 2 years of treatment, tamoxifen showed generally favorable effects on the lipid and lipoprotein profile of treated postmenopausal women. These effects may partially explain the decrease in adverse events and in mortality related to coronary heart disease seen in patients receiving adjuvant tamoxifen treatment.

Smoking prevention: towards a process approach

Current studies of smoking prevention treat the adolescent as a target of influence, they emphasize the acquisition of skills for resisting peer pressure and give too little attention to motivation for resistance. Studies consistent with this social learning framework show moderate reductions in the incidence of smoking for the short term; recent, long-term follow-ups show no reduction in experimental over control conditions. We propose a re-examination of the influence framework and suggest that adolescents use smoking and dress, to project an image of self that will increase the likelihood of success in the formation of relationships in which participants share feelings and attitudes toward each other and the adult world. We also suggest that adults focus upon external, perceptible, and remote threats, e.g. smoking is seen as evil, a response to peer pressure, and a long term threat to health, and ignore discourse about proximal, subjective feelings respecting the changing sexual urges and feelings of social anxiety that accompany adolescence. The socialization of these affects is left to the peer group. It is suggested that future programs intensify their focus on motivation for resisting smoking based upon a revised view of the adolescents objectives in self definition, and combine this with the best of the current skills approaches.

The behavioral dynamics of clinical trials

Two ways of approaching the design of long-term clinical trials are presented and contrasted. The first, termed the "static" view, emphasizes close adherence to formal rules of study design. The second, termed the "dynamic" view, emphasizes the behavioral aspects of patient participation in trials of long duration. The dynamic view is discussed in detail, with discussion of how recruitment of participants, random assignment to conditions, compliance with protocol, and measurement of outcomes are affected by behavioral dynamics. Data from a recently completed tamoxifen toxicity trial are used to illustrate the points and to focus the discussion of behavioral dynamics on the design of a chemoprevention trial for breast cancer using tamoxifen.

Contribution of concrete cognition to emotion: neutral symptoms as elicitors of worry about cancer

The relationship between worry about cancer and judged cancer risk was examined among 54 expatients who had been cured of breast cancer and 81 women with no history of cancer. Worry required both a perception of substantial risk and the presence of concrete perceptual cues. Worry promoters include visits to a physician and concrete, noncancerlike symptoms (e.g., fever, pain). Supporting analyses indicate that the symptom effects are not due to self-report biases or attributions of symptoms to cancer but are the result of a reminder process whereby vulnerability beliefs are aroused by somatic cues. Judged cancer risk was unrelated to affective cues, suggesting that across-time variation in worry about cancer reflects the onset and offset of symptom episodes rather than a shift in risk appraisals. Expatients were more worried overall than nonpatient controls. The results have implications for controlling disease worry and initiating preventive behaviors.

Beliefs about aging and illness in a community sample

Findings from recent studies have demonstrated age group differences in coping with illness. One explanation for these age group differences has received little attention: perceptions of illness may differ with age and these differences in perception may account for the observed differences in coping. The purpose of this study was to examine the effects of age on illness perceptions along dimensions that influence coping. Specifically, we explored perceptions about aging as a cause of illness and perceptions about the effect of age on seriousness, curability and controllability of illness. Four hundred fifty-one community-dwelling adults (age range 20 to 90 years) participated in the study. The pattern of results showed respondents of all ages expressing the belief that aging is associated with increased susceptibility to disease and lowered potential for control or cure. Implications of these beliefs for health monitoring and coping with illness are discussed.

An experiment in common sense: education at blood pressure screening

This study compared the impact of three educational messages about hypertension used at a worksite blood pressure screening program. The messages sought to change beliefs and health behaviors related to hypertension. Each participant who had either been previously diagnosed as hypertensive or had an elevated blood pressure at screening was randomly assigned to view one of three slide/tape messages about high blood pressure: (1) a standard (control) message, and one of two experimental messages; (2) a standard message combined with action plans or (3) a standard plus action plan message combined with information on "wellness thinking" as opposed to relying on the presence of symptoms to monitor blood pressure level. Self-report measures obtained immediately after viewing the slide/tapes, 1 week and 9 months later included intentions to change behavior, reports of changes made in health behaviors, and beliefs about the reliance on symptoms to monitor blood pressure level. Both experimental messages containing action plan information led to stronger reported intentions and reported behavior change up to 9 months later, but few differences were statistically significant. Subjects who received "wellness thinking" information were less likely to attribute symptoms to high blood pressure up to one week later, but these differences disappeared at the nine month follow-up. Results suggest that effective education about hypertension should include specific information on strategies for reducing blood pressure.

Active coping reduces reports of pain from childbirth

Two studies were conducted in which pain and negative moods during labor were examined in relation to two key, independent variables: instructions to monitor labor contractions given to parturients on admission to the labor service and attendance at LaMaze (childbirth preparation) classes. In Study 1 (N = 48) pain and negative moods showed a sharp decline at Stage 2 (active labor) for women told to monitor and those who had attended classes; there was no decline for the control group. In Study 2 (N = 29), women attending LaMaze classes reported a similar decline in pain during active labor and were more energetic and less tired at admission. Of the three different mechanisms used to derive hypotheses, schema-directed coping provided the best account for the decline in pain and distress during active labor. A second mechanism, accurate expectations, seemed to account for the enhanced energy at the point of admission, in anticipation of birth.

Side effects and emotional distress during cancer chemotherapy

Chemotherapy side effects, patient distress, and patient-practitioner communication were evaluated in an inception sample of 238 patients with breast cancer or malignant lymphoma. Participants were interviewed at five points during their first six cycles of therapy, and a subsample kept brief daily symptom diaries. Nausea, hair loss, and tiredness were each experienced by more than 80% of patients. By cycle 6, 46% of patients had thoughts about quitting therapy, but only a few had told medical staff. Patients' ratings of the objective difficulty of treatment increased over time, varied by treatment regimen, and were predicted by the experience of side effects, with the number of different side effects serving as the best predictor. In contrast, emotional distress was less sensitive to the directly assessable characteristics of treatment. Communication between patient and practitioner was found to be inadequate in a number of respects (i.e., patients did not fully anticipate the toxicities of treatment and did not report their concerns to medical staff). Communication may be impeded by inaccuracies in a patient's recall of treatment difficulties and by a patient's inability or unwillingness to attend to all presented information. More frequent opportunities for patient-practitioner discussion are necessary.

Illness representations and matching labels with symptoms

Three studies are reported that show that health-relevant information (e.g., blood pressure [BP] or symptoms) initiates an active cognitive search process that results in the construction of an illness representation. Study 1 showed that informing subjects that their BP was elevated affected two attributes of illness representation: identity (label and symptoms), and time line or expected chronology of the health threat. Subjects given a high-BP reading reported symptoms commonly associated with high BP, especially if they attributed the high-BP reading to stress. Study 2 showed that the active search process uses causal information (a third attribute of representations) to give meaning to symptoms. Specifically, subjects used environmental cues to interpret whether familiar, unfamiliar, and ambiguous symptoms were due to illness or to stress. In Study 3 we showed that the constructive process, initiated by a high-BP reading, is directed by prior beliefs about the time line for developing high BP and by the presence of external cues about the stressfulness of the subject's daily life. Subjects who believed BP was labile and that they were under high daily stress or who believed BP was stable and that they were under low daily stress reported more symptoms. The significance of these findings for understanding how people process diagnostic labels and symptom information involved in the construction of illness representations is discussed.

Active coping reduces reports of pain from childbirth

Two studies were conducted in which pain and negative moods during labor were examined in relation to two key, independent variables: instructions to monitor labor contractions given to parturients on admission to the labor service and attendance at LaMaze (childbirth preparation) classes. In Study 1 (N = 48) pain and negative moods showed a sharp decline at Stage 2 (active labor) for women told to monitor and those who had attended classes; there was no decline for the control group. In Study 2 (N = 29), women attending LaMaze classes reported a similar decline in pain during active labor and were more energetic and less tired at admission. Of the three different mechanisms used to derive hypotheses, schema-directed coping provided the best account for the decline in pain and distress during active labor. A second mechanism, accurate expectations, seemed to account for the enhanced energy at the point of admission, in anticipation of birth.

The role of cigarettes in the initiation and progression of early substance use

This study examined progression in substance use from initiation to eventual regular use and provided information on a number of levels. Cigarette use was shown to fall on a cumulative (Guttman) scale of use with other drugs (e.g., marijuana, beer, liquor, stimulants or depressants). Also, cigarettes were the drug with the youngest mean age of onset which would still fall on a Guttman scale with other drugs shown to scale in previous research. Finally, it was shown that having tried only cigarettes or marijuana made one significantly more likely to be using other drugs two years later.

The quitting experience for smokers in sixth through twelfth grades

The present study examined the withdrawal process for adolescents who had attempted to quit smoking. A sample of 622 6th through 12th graders were interviewed. Smoking status was reported prior to attempting to quit and its relationship with the withdrawal experience was evaluated. Although over half of those who smoked regularly reported trying to quit, 78% of the "quitters" were smoking six months after their quit attempt. Experiencing adverse withdrawal symptoms was related to smoking at daily levels before quitting; delaying trying to quit was associated with initiation of smoking at an early age; and quitting success was predicted by early quitting age, lower pre-quitting smoking levels, a lack of a prior quitting failure, and peer smoking. The results suggest that smoking intervention programs for adolescents should include components facilitating the quitting process that take into consideration youngsters' smoking and quitting histories.

The role of motion sickness in predicting anticipatory nausea

Susceptibility to motion sickness has been demonstrated to be a predictor of anticipatory nausea in cancer patients receiving chemotherapy. However, previous research did not test whether motion sickness increases anticipatory nausea only by increasing the base rate of posttreatment nausea and vomiting (which has traditionally served as the unconditioned stimulus in the conditioning model for anticipatory nausea) or, alternatively, whether motion sickness might facilitate the association of external stimuli to posttreatment nausea and vomiting. Using two different analytic approaches--a series of logistic analyses that controlled for drug-induced nausea and vomiting following the initial injection, along with an event history analysis which allows for updating on the posttreatment nausea and vomiting factors--motion sickness was found to be an independent predictor of anticipatory nausea. Further, the predictive power of motion sickness is also independent of the effects of pretreatment anxiety, taste during injection, and age.

Is the smoking decision an 'informed choice'? Effect of smoking risk factors on smoking beliefs

The argument that people freely choose to smoke assumes that individuals at the point of initiation of smoking (often in adolescence) hold accurate beliefs about smoking. Smoking beliefs and the presence of known smoking risk factors were assessed in interviews with a sample of 895 urban young people. The respondents greatly overestimated the prevalence of adult and peer smoking, negative attitudes of their peers were greatly underestimated, a large proportion believed that they would be less likely than other people to contract a smoking-related illness if they became smokers, and there was a general lack of understanding of the adverse consequences experienced upon smoking cessation. These misperceptions were more common among youngsters who were smokers, who intended to smoke, or who had friends or family members who smoked. Because misinformation among young people is widespread and those at greatest risk for smoking are the most misinformed, the tobacco industry's argument that the decision to smoke reflects an "informed choice" is without merit.

Impact of symptoms and aging attribution on emotions and coping

Two experimental studies and a large field study were designed to examine how symptom severity, symptom duration, symptom ambiguity, and the association of symptoms with aging affected emotional responses and coping with illness threats. In Study 1, 280 respondents from the surrounding community reported the emotional and coping responses they would manifest to scenarios that varied the severity, duration, and ambiguity (i.e., labeled vs. unlabeled) of a common set of symptoms. Severity had more of an impact on coping strategies than did duration or illness label; severe symptoms elicited stronger emotional upset and a higher incidence of both self-care behaviors and seeking of medical care. Symptoms of longer duration also resulted in increased seeking of medical care. Responses of the 334 adults participating in Study 2 replicated and extended these findings: A closed-ended item asking participants whether the symptoms could be attributed to aging showed that attribution of symptoms to aging increased with age, was more frequent for mild symptoms, and was associated with reduced emotional response to symptoms and a tendency to delay seeking treatment. Participants in the field study (168 patients seeking medical care for a variety of symptoms) completed interviews tracing symptom processing and emotional and coping reactions. The results provided evidence for the external validity of the scenario studies, as the attribution of symptoms to aging was greater for older than younger patients and resulted in a significant tendency to delay seeking medical care. Results of these studies suggest that symptom experience and symptom interpretation must be considered in the study of coping responses to illness threats.

The effects of health information in a worksite hypertension screening program

Two studies assessed the potential impact of health education messages at worksite blood pressure screenings. The messages sought to: motivate hypertensives to enter or return to treatment, motivate normotensives to improve health habits and discourage inappropriate use of blood pressure screening by normotensives. A total of 473 participants in the two studies viewed slide/tape shows about blood pressure and/or health promotion. Individuals with elevated readings at screening viewed either a show containing standard blood pressure information or an experimental show which emphasized the asymptomatic nature of high blood pressure and which described some concrete strategies for coping with high blood pressure. In both studies, individuals with normal readings at screening viewed a standard show or an experimental show which emphasized coping strategies for preventing high blood pressure. In addition, in Study 2, some normotensive individuals viewed one of several experimental shows which focused on health promotion. Results indicate that the experimental programs were significantly more effective than the standard programs in achieving appropriate followup of screening results for both normotensives and hypertensives. Implications for worksite blood pressure screenings are discussed.

Psychosocial consequences of cancer chemotherapy for elderly patients

The purpose of this study was to determine whether elderly patients receiving cancer chemotherapy experience more emotional distress, difficulty with side effects, and disruption in activities than younger patients. A sample of 217 patients receiving initial chemotherapy treatment for breast cancer or lymphoma was interviewed several times over the first 6 months of treatment. Patients ranged in age from 19 to 83. Included in the interviews were questions on presence, duration, and severity of side effects; response of disease to treatment; and 0-10 ratings of emotional distress, difficulty, and life disruption due to chemotherapy. Information on drugs given, doses, and schedules was obtained from medical charts. In general, elderly patients reported no more difficulty with treatment or emotional distress than did younger patients. This general pattern held across disease types, with some exceptions. These results, combined with previously published studies on the physiological effects of chemotherapy in the elderly, indicate that aggressive treatment should not be withheld from older patients simply because of their age.

Anxiety and drug taste as predictors of anticipatory nausea in cancer chemotherapy

Interview data from 192 patients receiving cytotoxic chemotherapy for the first time were analyzed to identify factors predictive of the development of anticipatory nausea. Posttreatment nausea and vomiting (particularly vomiting), tastes of drugs during injections, and anxiety before injections were all associated with an increased probability of anticipatory nausea. An index consisting of those three variables, plus age, was found to have good predictive power, even when the predictor variables were assessed only at the first chemotherapy administration and the index was used to predict the development of anticipatory nausea at any time during the first six chemotherapy cycles.