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Posttraumatic growth moderates the effects of posttraumatic stress symptoms on adjustment and positive affective reactions in digestive system cancer patients a
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Hasida Ben-Zur , Miri Cohen & Julia Gouzman a
School of Social Work, University of Haifa, Haifa, Israel Published online: 13 Oct 2014.
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Psychology, Health & Medicine, 2014 http://dx.doi.org/10.1080/13548506.2014.969747
Posttraumatic growth moderates the effects of posttraumatic stress symptoms on adjustment and positive affective reactions in digestive system cancer patients Hasida Ben-Zur*, Miri Cohen and Julia Gouzman School of Social Work, University of Haifa, Haifa, Israel
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(Received 26 March 2014; accepted 23 September 2014) The study aims were twofold: (1) To investigate the associations of posttraumatic stress symptoms (PTSS) and posttraumatic growth (PTG) with adjustment and affective reactions of digestive system cancer patients and (2) To assess the moderating effects of PTG on the associations of PTSS with adjustment and affective reactions. The sample consisted of 200 respondents 1–4 years following diagnosis and treatment for digestive system cancer. Participants completed questionnaires assessing PTSS, PTG, adjustment, positive affect (PA), and negative affect (NA). The results showed that PTG was positively associated with adjustment and PA, while PTSS was negatively associated with these outcomes and positively associated with NA. Moderation effects of PTG were also observed: The negative associations between PTSS and adjustment or PA were weaker under high levels than under low levels of PTG. It was concluded that PTG is important both as a contributor to better adjustment and PA, as well as a moderator of the detrimental effects of PTSS on adjustment and PA following recovery from cancer. Thus, when developing post-cancer intervention programs, PTG should be viewed as a factor to be encouraged and nurtured for the benefit of cancer patients’ adjustment and their long-term well-being. Keywords: digestive system cancer; posttraumatic growth; posttraumatic stress symptoms; adjustment; positive and negative affect
Theoretical background Progress in the detection and early treatment of cancer resulted in many cancer survivors, or persons who live with cancer for long periods (GLOBCAN, 2014). Cancer survivors, however, may suffer from illness manifestations and treatment symptoms. They may also experience psychological trauma because of the threat to their physical and psychological integrity combined with uncertainty about treatment effects and recovery (Kash, Mago, & Kunkel, 2005). The focus of the present investigation is digestive system cancer, which is a threat to both genders, though more frequently discovered in males. In Israel, in 2011, in a population of 7836,600 people (75.4% Jews, 20.6% Arabs, 4% others), 5526 new cases of digestive system cancer were diagnosed (22% of all cancers; Ministry of Health Israel, 2011), with a resulting number of deaths of 3025 (29%; Central Bureau of Statistics Israel, 2011). *Corresponding author. Email: [email protected] Note: This article has been amended slightly since original publication to correct two errors in Table 4. For more information, see Erratum http://dx.doi.org/10.1080/13548506.2014.979049 © 2014 Taylor & Francis
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A life-threatening illness is defined in the DSM-IV (American Psychiatric Association, 1994) as a highly stressful, traumatic event that might result in posttraumatic stress disorder (PTSD). PTSD is divided into three main clusters: intrusive thoughts (re-experiencing), avoidance, and hyperarousal. With regard to cancer particularly, PTSD may be reflected in specific behaviors such as reliving the cancer experience in nightmares, flashbacks or thoughts; avoiding anything connected with the cancer experience; and being continuously overexcited and irritable (National Cancer Institute, 2013). PTSD rates among cancer patients are reported as ranging between 0 and 32% (e.g. Kangas, Henry, & Bryant, 2002). Pre-illness stressors or distress, and demographic variables (e.g. female gender and young age), as well as psychosocial variables (e.g. low social support) and medical variables (advanced stage and recurrence) are predictors of PTSD among cancer patients and survivors (Kangas, Henry, & Bryant, 2005; Koutrouli, Anagnostopoulos, & Potamianos, 2012). PTSD symptoms are associated with outcomes of cancer diagnosis and treatments such as low adjustment, negative emotions, and low levels of well-being. Previous research results showed that posttraumatic stress symptoms (PTSS) in breast cancer patients were related to higher depressive symptoms (Golden-Kreutz & Andersen, 2004), and to lower levels of physical and mental quality of life (Golden-Kreutz et al., 2005; Shelby, Golden-Kreutz, & Andersen, 2008). A study of post-treatment colorectal cancer survivors (Salsman, Segerstrom, Brechting, Carlson, & Andrykowski, 2009) showed that PTSD at baseline predicted higher depression and anxiety, and lower positive affectivity three months later. One possible explanation for the distress and disruption of the patients’ adjustment and well-being can be found in the cognitive processing inherent in PTSD: Intrusive thoughts and ruminations may cause cancer patients to be more susceptible to negative emotions, impair their functioning, and prolong distress (Morrill et al., 2008), mainly due to the uncontrollability of such PTSD-related cognitions (Salsman et al., 2009). The present study focused on posttraumatic growth (PTG) and its role as a moderator of the effects of PTSD on cancer patients’ adjustment and affective reactions. PTG is conceived as positive psychological changes occurring in the aftermath of highly stressful events. The term PTG denotes more than simply survival or a return to baseline conditions before the traumatic event occurred: it is the experience of improvement following a struggle with the new, posttraumatic reality, brought about by cognitive processing and restructuring (Tedeschi & Calhoun, 2004). As pointed out by Sawyer, Ayers, and Field (2010), the most detailed models that account for the occurrence of PTG assume that the experience of a highly stressful or traumatic event violates an individual’s basic beliefs about the self and the world, and that some type of meaning-making or cognitive processing to rebuild these beliefs and goals occurs, resulting in perceptions that one has grown through the process. (p. 437)
In contrast to PTSD, the cognitive processing in PTG is considered deliberate and controlled (Salsman et al., 2009). Notably, PTG and PTSD are different outcomes of the same traumatic event, are affected by the same predictors (e.g. young age, lower education), and are related to the shuttering of core beliefs about life and justice (Koutrouli et al., 2012). Nevertheless, they are presumed to have different implications for adjustment and well-being: While PTSD is related to negative outcomes such as depression, anxiety, and low levels of quality of life, PTG has been associated with positive outcomes for cancer patients, such
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as well-being and less depression or global distress (i.e. negative affect [NA], overall mood; Helgeson, Reynolds, & Tomich, 2006), as well as better psychological adjustment and physical health (Sawyer et al., 2010). Furthermore, Morrill et al. (2008), studying breast cancer survivors, found that PTG moderated the associations between PTSD and depression or quality of life. Similarly, Park, Chmielewski, and Blank (2010) showed that PTG moderated the effects of intrusive thoughts on positive affect (PA) and NA, life satisfaction, and spiritual well-being among younger adult cancer survivors, and Silva, Moreira, and Canavarro (2012) found that PTG buffered the negative impact of breast cancer on psychological and social quality of life and on depression. Such outcomes could result from the cognitive processing which characterizes PTG, and which differs from PTSD cognitions in its focus on important positive changes in the domains of appreciation of life, relationships with others, personal strength, new life possibilities, and spirituality (Tedeschi & Calhoun, 2004). Aims and hypotheses The present study aimed to assess the effects of PTSS and PTG on adjustment and well-being of digestive system cancer patients. Although PTSS and PTG effects were studied among cancer patients, digestive system cancer patients have been rarely examined in spite of the relatively high frequency of this type of cancer and its prevalence among both men and women around the world and in Israel, in particular. Furthermore, PTG in cancer patients was mostly studied in relation to anxiety or depression and less to psychosocial adjustment and well-being In the present study, psychosocial adjustment was conceptualized as an outcome of the process of managing problems and gaining mastery (Folkman & Greer, 2000; Morrow, Chiarello, & Derogatis, 1978), measured as satisfactory functioning in various spheres of life such as family, work, social networks, and sexual functioning (Morrow et al., 1978). Affective reactions which are related to adjustment, namely, low NA and high PA (Han et al., 2008), were utilized to characterize psychological well-being. PA represents the extent to which an individual feels enthusiastic, active or alert, while NA represents emotional distress and unpleasant feelings (e.g. fear; Watson, Clark, & Tellegen, 1988). The hypotheses were: H1. High levels of PTSS will be negatively related to adjustment and PA, and positively related to NA. H2. High levels of PTG will be positively related to adjustment and PA, and negatively related to NA.
Additionally, it was assumed that PTG can function as a moderator of PTSS effects, blocking its deleterious effects on adjustment and affective reactions. The following moderation hypothesis was also posited: H3. PTG will moderate the associations between PTSS and adjustment or affective reactions.
Following Salsman et al. (2009), we also included a measure of social desirability to correct for self-report biases.
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Method Sample and procedure The sample consisted of 200 patients diagnosed with digestive system cancer at stages I–IV (patients with primary local tumors to tumors that have spread to local or distant organs), who were free of the disease, and treated in three medical centers and one health service in Israel. Tables 1 and 2 present means, SDs, or frequencies/percentages for the demographic/background and illness-related variables, respectively. The patients’ average age was 62.52, with more than half male patients. The average time from cancer diagnosis was 2.07 years, and most had cancer-removing surgery (93.5%) without a stoma (89%). Most had been treated with chemotherapy, with more than half diagnosed with colon cancer. The respondents rated a number of side effects of the illness and its treatment, (see Table 2) on a five-point scale (0 = not at all to 4 = a great deal). The side effect ratings were averaged to yield a total score (M = 1.21). Additionally, the respondents indicated whether they had any chronic diseases, and the total score of chronic diseases was the number of diseases indicated by the respondent (M = 1.63). Patients were asked to participate in the study if their age was in the range of 45–70 years, and if they did not require repeated medical treatment, or did not suffer from mental illness. The main reasons for refusal (20%) were lack of time or interest, refusal to discuss the disease, or not feeling well. The questionnaires were completed by the respondents during home visits by one of the researchers (J.G.), to allow questionnaire completion in pleasant surroundings devoid of hospital sights, sounds, and smells. The research was approved by the ethic boards of each of the medical centers and the health service. Instruments Functional status was evaluated by the Eastern Cooperative Oncology Group (ECOG; Oken et al., 1982), a one-item measure used by a physician to assess how the disease affects patients’ daily living abilities. The score range of the ECOG is 0–4, from 0 = fully active to 4 = completely disabled. In the present study, the score range was 0–2, and it was reversed so that 2 represented fully active (53%), 1 represented
Table 1. Means, SDs, and frequency distributions of demographic and background variables (n = 200).
Age Years of education Number of children Gender (men) Religion (Jewish) Religiosity (secular) Family status (married) Work status (no) Income (average and above) Significant event (yes) Family history of cancer (yes)
M
SD
62.52 14.59 2.75
6.18 3.84 1.18
Frequency 115 195 132 158 100 119 90 124
Percentages 57.5 97.5 66.0 79.0 50.0 60.7 45.0 62.0
Psychology, Health & Medicine Table 2.
Means, SDs, and frequency distributions of the illness-related variables (n = 200).
Time from diagnosis (years) Mean ratings of side effects Pain Fatigue Insomnia Nausea Concentration/memory problems Other Mean number of chronic diseases
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Stage I II III IV Type of cancer Colon Pancreatic Rectal Stomach Other Treatment Chemotherapy Radiotherapy Other Chronic diseases Hypertension Diabetes Hyperlypedemia Heart disease Renal failure Neurologic disease Other
M
SD
2.07 1.21 1.07 1.94 1.39 0.56 0.86 1.43 1.63
1.06 0.99 1.39 1.57 1.57 1.17 1.33 1.76 1.55
Frequency
Percentages
22 71 93 14
11.0 35.5 46.5 7.0
131 26 19 14 10
65.5 13.0 9.5 7.0 5.0
164 51 11
82.0 25.5 5.5
65 37 35 15 6 1 50
32.5 18.5 17.5 7.5 3 0.5 25
restricted but ambulatory and able to carry out light work (37.5%), and 0 represented ambulatory and capable of self-care but unable to carry work (9.5%). Posttraumatic growth inventory (Tedeschi & Calhoun, 1996) is a 21-item scale measuring the degree of positive changes experienced in the aftermath of traumatic events. Each answer is rated on a seven-point Likert scale (0 = not experiencing the change, 6 = experiencing it to a very high degree). The questionnaire reliability in cancer population studies (Lelorain, Bonnaud-Antignac, & Florin, 2010) was .93, and the Hebrew form used in breast cancer research (Cohen & Numa, 2011) showed similar high reliability (.93). Table 3 presents the means, SDs and alpha levels of this and the other research measures. Posttraumatic symptom scale-self-report (Foa, Riggs, Dancu, & Rothbaum, 1993) is a self-report version consisting of 17 items which correspond directly to DSM-IV symptoms. Symptom frequency is reported on a four-point scale (1 = did not occur, 4 = occurred five times or more per week). The respondents were asked to refer to their illness and rate the symptoms during the preceding month. The inventory contains three subscales: re-experiencing, avoidance, and arousal. Foa et al. (1993) reported an internal
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Table 3. Means, SDs, and Pearson product-moment correlations of PTSS, PTG, adjustment, PA, and NA, and social desirability. Measure
Mean
SD
α
1
2
3
4
5
1. 2. 3. 4. 5. 6.
.51 2.76 3.31 3.05 1.02 .49
.58 1.16 .50 .68 .77 .28
.91 .92 .89 .81 .84 .71
– .09 −.67* −.32* .64* −.08
– .03 .29* .00 −.08
– .45* −.50* .12
– −.24* −.10
−.06
PTSS PTG Adjustment Positive affect Negative affect Social desirability
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Note: PTSS = posttraumatic stress symptoms; PTG = posttraumatic growth. *p < .01.
reliability of .91 and a one-month test–retest reliability of .74 for the total score. The Hebrew form reliability was in the range of .88–.92 (Gil, 2005). Another scoring method of this scale is similar to the PTSD assessment of 0 or 1, made by counting several symptoms from each subscale (Foa et al., 1993). Accordingly, in this study, the rate of PTSD was 24%. Psycho-social adjustment to illness scale-self-report (short form; Rodrigue, Kanasky, Jackson, & Perri, 2000) is a short scale consisting of 26 items. It is based on the original 46-item scale which was developed for assessing cancer patients’ psychosocial adjustment (Morrow et al., 1978). The alpha for the total score was .87 (Rodrigue et al., 2000), and the Hebrew version showed good reliability values (see Kulik & Kronfeld, 2005). Positive and negative affect schedule (Watson et al., 1988) is a 20-item self-report measure of PA (10 items) and NA (10 items), used in its Hebrew form (Ben-Zur, 2002). Each item is rated on a five-point scale (0 = very slightly or not at all, 4 = extremely). Watson et al. (1988) reported alpha coefficients ranging from .86–.90 for the PA subscale and .84–.87 for the NA subscale, and similar reliabilities were found for the Hebrew version (.78 and .83, respectively; Ben-Zur, 2002). Social desirability questionnaire (short version) is an eight-item version based on the original 33-item scale which aims to identify the extent to which individuals exhibit social desirability bias (Crowne & Marlowe, 1964). Each item was rated True or False (0 or 1). After reversing the appropriate items in the direction of social desirability, the higher the average score, the higher the level of social desirability. The Hebrew form showed medium level of reliability (.66; Ben-Zur, 2002). Statistical analyses Descriptive analyses, Pearson product-moment correlations, and hierarchical regressions for testing the hypotheses were conducted, using the SPSS program version 19. Preliminary correlation analyses between demographic or illness-related variables and either adjustment or affective reactions led to the selection of 10 variables (e.g. age and side effects) as control variables in the regressions, with stage and functional status converted each into two categories (see Table 4). Hierarchical regression analyses were applied to the dependent variables of adjustment, PA, and NA, using as independent variables PTSS, PTG, and PTSS × PTG, the 10 control variables and social desirability. PTSS and PTG scores were centered (Aiken & West, 1991) before creating the multiplication term PTSS × PTG, which represented the interaction assessed by an Internet program (Jose, 2008; ModGraph-I). A conservative significance level of p < .01 was used to test the research hypotheses.
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Table 4. Hierarchical regression coefficients of adjustment and affective reactions on demographics and illness-related variables, PTSS, PTG, and the PTSS × PTG interaction. Adjustment
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Variable
β
95% CI
Positive affect
Negative affect
β
β
Step 1 Constant (B value) Gender Age Education Children Work status Religiosity Significant event Stage Side effects Functional status Social desirability R2 F(11,188)
2.19** −.01 .02 .05 −.08 .02 .04 .03 −.06 −.20** .32** .01 .52 18.38**
1.38, −.11, −.01, −.01, −.07, −.09, −.07, −.07, −.15, −.16, .21, −.15,
3.00 .08 .01 .02 .01 .13 .15 .12 .04 −.04 .44 .19
2.31** .11 .00 .08 −.08 −.06 .11 .12 .02 −.13 .11 −.15 .15 3.05**
Step 2 PTSS PTG R2 F(13,186) R2 change F(2,186) change
−.40** .13* .62 23.81** .11 26.41**
−.44, −.25 .02, .10
Step 3 PTSS × PTG R2 F(14,185) R2 change F(1,185) change
.13* .64 23.54** .02 8.12*
.04, .18
95% CI 0.78, −.03, −.02, −.01, −.12, −.29, −.04, −.02, −.15, −.20, −.07, −.67,
95% CI −1.46, .11, −.02, −.02, −.06, .00, −.10, −.14, −.30, −.02, −.16, −.36,
3.83 .33 .02 .04 .04 .12 .36 .33 .20 .02 .38 −.04
0.045 .19* .00 .00 .03 .13 .06 .03 −.09 .11 .04 −.02 .22 4.80**
1.55 .46 .02 .02 .10 .41 .30 .21 .04 .20 .28 .26
−.27* .33** .27 5.34** .12 15.37**
−.49, −.14 .11, .26
.63** −.10 .48 13.07** .26 45.97**
.66, 1.00 −.14, .01
.19* .30 5.72** .03 8.09*
.06, .35
.01 .48 12.08** .00 .03 (n.s.)
−.13, .15
Notes: All beta coefficients are from Step 3. Gender, men = 0; women = 1; work status, 0 = not working, 1 = working part/full time; religiosity, 0 = secular, 1 = traditional/religious/very religious; significant event, 0 = no, 1 = yes; stage, 0 = I/II, 1 = III/IV; functional status, 0 = restricted/ambulatory self-care, 1 = fully active. PTSS = posttraumatic stress symptoms; PTG = posttraumatic growth. *p ≤ .01; **p < .001.
Results Table 3 presents the means, SDs, and Pearson product-moment correlations between PTSS, PTG, adjustment, and affective reactions: PTSS was negatively correlated with adjustment and PA, and positively correlated with NA. PTG and adjustment were positively correlated with PA, while adjustment was negatively correlated with NA. PTG was not significantly correlated either with PTSS, adjustment, or NA. The first regression analysis was applied to adjustment as a dependent variable showing that PTSS contributed negatively and PTG contributed positively to adjustment (see Table 4). The PTSS × PTG interaction was also significant, suggesting that PTG moderated the negative association between PTSS and adjustment: the relationship was stronger in the lower levels of PTG and weaker in the higher levels (see Figure 1). Although all three slopes were significant at the p < .001 level (High PTG: b = −.22, SE = 0.06, t = −3.76; Medium PTG: b = −.34, SE = 0.04, t = −7.69; Low PTG:
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b = −.47, SE = 0.06, t = −8.13), notably, the slope under the high levels of PTG was half the size of the slope under the low levels of PTG. The second regression analysis was applied to PA, showing stronger effects than those obtained for adjustment: PTSS contributed negatively, while PTG contributed positively to PA. The PTSS × PTG interaction was also significant, suggesting that PTG moderated the negative association between PTSS and PA: the simple slope for the high level of PTG was not significant (b = −.08, SE = 0.12, t = −0.63, n.s.), while the simple slopes for the medium and low levels of PTG were highly significant (b = −.31, SE = 0.09, t = −3.51, p < .0001, and b = −.55, SE = 0.12, t = −4.54, p < .0001, respectively; see Figure 2). The third regression, which included NA as the dependent variable, showed a PTSS positive contribution to NA, but no significant effects of PTG or the PTSS × PTG interaction. Discussion The study was conducted with digestive system cancer patients one to four years following diagnosis, who were free of the disease at that time. PTSD rate among these patients was 24%, that is, in the higher range levels of similar studies conducted among heterogeneous cancer patients (e.g. Kangas et al., 2002; Koutrouli et al., 2012). The first hypothesis (H1) was fully confirmed: PTSD was negatively associated with adjustment
Figure 1. PTG moderates the effects of PTSS on adjustment. Note: PTSS and PTG levels: medium = mean, high = 1SD above the mean, low = 1SD below the mean (Aiken & West, 1991).
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Figure 2. PTG moderates the effects of PTSS on PA. Note: PTSS and PTG levels: medium = mean, high = 1SD above the mean, low = 1SD below the mean (Aiken & West, 1991).
and PA, and positively associated with NA. These results are in line with other studies showing the negative effects of PTSD on quality of life of cancer patients (e.g. Shelby et al., 2008) or their affective reactions (e.g. Salsman et al., 2009). Hence, the study provides further evidence of the disturbing impact of PTSD on the adjustment and affectivity of the recovering cancer patient. In contrast to PTSD effects, PTG was found to have ameliorating effects on adjustment and affective reactions, with the second hypothesis (H2) confirmed in part: PTG was positively related to better adjustment and PA. These results accord with findings of positive effects of PTG regarding better adjustment or quality of life among breast cancer patients (Morrill et al., 2008), cancer/HIV patients (Sawyer et al., 2010), or a variety of traumatic events including cancer (Helgeson et al., 2006). However, PTG was not significantly negatively related to NA as hypothesized in H2, and this is in contrast to research findings showing it lessens distress (e.g. Helgeson et al., 2006; Sawyer et al., 2010), but in line with others indicating no significant associations of PTG with anxiety (Helgeson et al., 2006). In the present study, PTG was associated with the positive aspects of recovery from cancer, presumably strengthening the constructive processes in adjustment and contributing to positive emotion and good mood. Most importantly, PTG moderated the association of PTSD with adjustment and PA as hypothesized (H3), though not the PTSD and NA association. Thus, PTG is a protective factor lowering the negative effects of PTSD on adjustment and PA, the significant processes for the recovering cancer patients. These findings are in line with PTG effects
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in weakening the effects of PTSD on quality of life among breast cancer patients (Morrill et al., 2008). This study has several advantages: It was conducted with a relatively large sample (n = 200) of digestive system cancer patients, a type of cancer that is prevalent among both genders, yet has rarely been investigated in the past. Additionally, the study included a measure of social desirability, which controls for certain biases characterizing self-report measures. However, the study also has several disadvantages. The study was cross-sectional, and therefore, cause and effect directions cannot be determined unequivocally. Furthermore, common method variance (CMV; Siemsen, Roth, & Oliveira, 2010) might have inflated the simple correlations between the variables investigated. However, this is less of a problem for the moderation (interaction) effects, which may even be weakened by CMV, as claimed by Siemsen et al. (2010). It should also be noted that the study was conducted among Jewish participants, who have adopted values of Western culture. Although PTG is considered a universal phenomena (Weiss & Berger, 2010), different cultures vary in their influence on the appraisals and cognitions that are represented in PTG (Calhoun, Cann, & Tedeschi, 2010), and therefore the results may not be generalized to the Arab population in Israel. The study results have both theoretical and practical implications. They show that PTG positively affects cancer patients’ adjustment, and also has protective advantages through its moderating effects in regard to PTSD. Thus, PTG may function as a personal psychosocial resource (Morrill et al., 2008), buffering the effects of stressful events on well-being. Furthermore, these results imply that PTG processes should be encouraged among cancer patients. Several psycho-social interventions, either in individual or group settings, were found beneficial to personal growth among cancer patients, such as existential (Garlan, Butler, Rosenbaum, Siegel, & Spiegel, 2010–2011) or meaning-focused therapy (Breitbart, 2002). However, more studies are needed to assess the effect of such interventions on PTG processes. References Aiken, L.S., & West, S.G. (1991). Multiple regression: Testing and interpreting interactions. Newbury Park, CA: Sage. American Psychiatric Association. (1994). DSM-IV: Diagnostic and statistical manual of mental disorders (4th ed.). Washington: American Psychiatric Publishing. Ben-Zur, H. (2002). Coping, affect and aging: The roles of mastery and self-esteem. Personality and Individual Differences, 32, 357–372. doi:10.1016/S0191-8869(01)00031-9 Breitbart, W. (2002). Spirituality and meaning in supportive care: Spirituality- and meaningcentered group psychotherapy interventions in advanced cancer. Supportive Care in Cancer, 10, 272–280. doi:10.1007/s005200100289 Calhoun, L.G., Cann, A., & Tedeschi, R.G. (2010). The posttraumatic growth model: Sociocultural considerations. In T. Weiss & R. Berger (Eds.), Posttraumatic growth and culturally competent practice: Lessons learned from around the globe (pp. 1–14). Hoboken, NJ: Wiley. Central Bureau of Statistics Israel. (2011). Retrieved September 10, 2014, from www.cbs.gov.il/ reader Cohen, M., & Numa, M. (2011). Posttraumatic growth in breast cancer survivors: A comparison of volunteers and non-volunteers. Psycho-Oncology, 20, 69–76. doi:10.1002/pon.1709 Crowne, D.P., & Marlowe, D. (1964). The approval motive: Studies in evaluative dependence. New York, NY: Wiley. Foa, E.B., Riggs, D.S., Dancu, C.V., & Rothbaum, B.O. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473. doi:10.1002/jts.2490060405
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Posttraumatic growth moderates the effects of posttraumatic stress symptoms on adjustment and positive affective reactions in digestive system cancer patients a
a
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Hasida Ben-Zur , Miri Cohen & Julia Gouzman a
School of Social Work, University of Haifa, Haifa, Israel Published online: 13 Oct 2014.
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Psychology, Health & Medicine, 2014 http://dx.doi.org/10.1080/13548506.2014.969747
Posttraumatic growth moderates the effects of posttraumatic stress symptoms on adjustment and positive affective reactions in digestive system cancer patients Hasida Ben-Zur*, Miri Cohen and Julia Gouzman School of Social Work, University of Haifa, Haifa, Israel
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(Received 26 March 2014; accepted 23 September 2014) The study aims were twofold: (1) To investigate the associations of posttraumatic stress symptoms (PTSS) and posttraumatic growth (PTG) with adjustment and affective reactions of digestive system cancer patients and (2) To assess the moderating effects of PTG on the associations of PTSS with adjustment and affective reactions. The sample consisted of 200 respondents 1–4 years following diagnosis and treatment for digestive system cancer. Participants completed questionnaires assessing PTSS, PTG, adjustment, positive affect (PA), and negative affect (NA). The results showed that PTG was positively associated with adjustment and PA, while PTSS was negatively associated with these outcomes and positively associated with NA. Moderation effects of PTG were also observed: The negative associations between PTSS and adjustment or PA were weaker under high levels than under low levels of PTG. It was concluded that PTG is important both as a contributor to better adjustment and PA, as well as a moderator of the detrimental effects of PTSS on adjustment and PA following recovery from cancer. Thus, when developing post-cancer intervention programs, PTG should be viewed as a factor to be encouraged and nurtured for the benefit of cancer patients’ adjustment and their long-term well-being. Keywords: digestive system cancer; posttraumatic growth; posttraumatic stress symptoms; adjustment; positive and negative affect
Theoretical background Progress in the detection and early treatment of cancer resulted in many cancer survivors, or persons who live with cancer for long periods (GLOBCAN, 2014). Cancer survivors, however, may suffer from illness manifestations and treatment symptoms. They may also experience psychological trauma because of the threat to their physical and psychological integrity combined with uncertainty about treatment effects and recovery (Kash, Mago, & Kunkel, 2005). The focus of the present investigation is digestive system cancer, which is a threat to both genders, though more frequently discovered in males. In Israel, in 2011, in a population of 7836,600 people (75.4% Jews, 20.6% Arabs, 4% others), 5526 new cases of digestive system cancer were diagnosed (22% of all cancers; Ministry of Health Israel, 2011), with a resulting number of deaths of 3025 (29%; Central Bureau of Statistics Israel, 2011). *Corresponding author. Email: [email protected] Note: This article has been amended slightly since original publication to correct two errors in Table 4. For more information, see Erratum http://dx.doi.org/10.1080/13548506.2014.979049 © 2014 Taylor & Francis
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A life-threatening illness is defined in the DSM-IV (American Psychiatric Association, 1994) as a highly stressful, traumatic event that might result in posttraumatic stress disorder (PTSD). PTSD is divided into three main clusters: intrusive thoughts (re-experiencing), avoidance, and hyperarousal. With regard to cancer particularly, PTSD may be reflected in specific behaviors such as reliving the cancer experience in nightmares, flashbacks or thoughts; avoiding anything connected with the cancer experience; and being continuously overexcited and irritable (National Cancer Institute, 2013). PTSD rates among cancer patients are reported as ranging between 0 and 32% (e.g. Kangas, Henry, & Bryant, 2002). Pre-illness stressors or distress, and demographic variables (e.g. female gender and young age), as well as psychosocial variables (e.g. low social support) and medical variables (advanced stage and recurrence) are predictors of PTSD among cancer patients and survivors (Kangas, Henry, & Bryant, 2005; Koutrouli, Anagnostopoulos, & Potamianos, 2012). PTSD symptoms are associated with outcomes of cancer diagnosis and treatments such as low adjustment, negative emotions, and low levels of well-being. Previous research results showed that posttraumatic stress symptoms (PTSS) in breast cancer patients were related to higher depressive symptoms (Golden-Kreutz & Andersen, 2004), and to lower levels of physical and mental quality of life (Golden-Kreutz et al., 2005; Shelby, Golden-Kreutz, & Andersen, 2008). A study of post-treatment colorectal cancer survivors (Salsman, Segerstrom, Brechting, Carlson, & Andrykowski, 2009) showed that PTSD at baseline predicted higher depression and anxiety, and lower positive affectivity three months later. One possible explanation for the distress and disruption of the patients’ adjustment and well-being can be found in the cognitive processing inherent in PTSD: Intrusive thoughts and ruminations may cause cancer patients to be more susceptible to negative emotions, impair their functioning, and prolong distress (Morrill et al., 2008), mainly due to the uncontrollability of such PTSD-related cognitions (Salsman et al., 2009). The present study focused on posttraumatic growth (PTG) and its role as a moderator of the effects of PTSD on cancer patients’ adjustment and affective reactions. PTG is conceived as positive psychological changes occurring in the aftermath of highly stressful events. The term PTG denotes more than simply survival or a return to baseline conditions before the traumatic event occurred: it is the experience of improvement following a struggle with the new, posttraumatic reality, brought about by cognitive processing and restructuring (Tedeschi & Calhoun, 2004). As pointed out by Sawyer, Ayers, and Field (2010), the most detailed models that account for the occurrence of PTG assume that the experience of a highly stressful or traumatic event violates an individual’s basic beliefs about the self and the world, and that some type of meaning-making or cognitive processing to rebuild these beliefs and goals occurs, resulting in perceptions that one has grown through the process. (p. 437)
In contrast to PTSD, the cognitive processing in PTG is considered deliberate and controlled (Salsman et al., 2009). Notably, PTG and PTSD are different outcomes of the same traumatic event, are affected by the same predictors (e.g. young age, lower education), and are related to the shuttering of core beliefs about life and justice (Koutrouli et al., 2012). Nevertheless, they are presumed to have different implications for adjustment and well-being: While PTSD is related to negative outcomes such as depression, anxiety, and low levels of quality of life, PTG has been associated with positive outcomes for cancer patients, such
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as well-being and less depression or global distress (i.e. negative affect [NA], overall mood; Helgeson, Reynolds, & Tomich, 2006), as well as better psychological adjustment and physical health (Sawyer et al., 2010). Furthermore, Morrill et al. (2008), studying breast cancer survivors, found that PTG moderated the associations between PTSD and depression or quality of life. Similarly, Park, Chmielewski, and Blank (2010) showed that PTG moderated the effects of intrusive thoughts on positive affect (PA) and NA, life satisfaction, and spiritual well-being among younger adult cancer survivors, and Silva, Moreira, and Canavarro (2012) found that PTG buffered the negative impact of breast cancer on psychological and social quality of life and on depression. Such outcomes could result from the cognitive processing which characterizes PTG, and which differs from PTSD cognitions in its focus on important positive changes in the domains of appreciation of life, relationships with others, personal strength, new life possibilities, and spirituality (Tedeschi & Calhoun, 2004). Aims and hypotheses The present study aimed to assess the effects of PTSS and PTG on adjustment and well-being of digestive system cancer patients. Although PTSS and PTG effects were studied among cancer patients, digestive system cancer patients have been rarely examined in spite of the relatively high frequency of this type of cancer and its prevalence among both men and women around the world and in Israel, in particular. Furthermore, PTG in cancer patients was mostly studied in relation to anxiety or depression and less to psychosocial adjustment and well-being In the present study, psychosocial adjustment was conceptualized as an outcome of the process of managing problems and gaining mastery (Folkman & Greer, 2000; Morrow, Chiarello, & Derogatis, 1978), measured as satisfactory functioning in various spheres of life such as family, work, social networks, and sexual functioning (Morrow et al., 1978). Affective reactions which are related to adjustment, namely, low NA and high PA (Han et al., 2008), were utilized to characterize psychological well-being. PA represents the extent to which an individual feels enthusiastic, active or alert, while NA represents emotional distress and unpleasant feelings (e.g. fear; Watson, Clark, & Tellegen, 1988). The hypotheses were: H1. High levels of PTSS will be negatively related to adjustment and PA, and positively related to NA. H2. High levels of PTG will be positively related to adjustment and PA, and negatively related to NA.
Additionally, it was assumed that PTG can function as a moderator of PTSS effects, blocking its deleterious effects on adjustment and affective reactions. The following moderation hypothesis was also posited: H3. PTG will moderate the associations between PTSS and adjustment or affective reactions.
Following Salsman et al. (2009), we also included a measure of social desirability to correct for self-report biases.
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Method Sample and procedure The sample consisted of 200 patients diagnosed with digestive system cancer at stages I–IV (patients with primary local tumors to tumors that have spread to local or distant organs), who were free of the disease, and treated in three medical centers and one health service in Israel. Tables 1 and 2 present means, SDs, or frequencies/percentages for the demographic/background and illness-related variables, respectively. The patients’ average age was 62.52, with more than half male patients. The average time from cancer diagnosis was 2.07 years, and most had cancer-removing surgery (93.5%) without a stoma (89%). Most had been treated with chemotherapy, with more than half diagnosed with colon cancer. The respondents rated a number of side effects of the illness and its treatment, (see Table 2) on a five-point scale (0 = not at all to 4 = a great deal). The side effect ratings were averaged to yield a total score (M = 1.21). Additionally, the respondents indicated whether they had any chronic diseases, and the total score of chronic diseases was the number of diseases indicated by the respondent (M = 1.63). Patients were asked to participate in the study if their age was in the range of 45–70 years, and if they did not require repeated medical treatment, or did not suffer from mental illness. The main reasons for refusal (20%) were lack of time or interest, refusal to discuss the disease, or not feeling well. The questionnaires were completed by the respondents during home visits by one of the researchers (J.G.), to allow questionnaire completion in pleasant surroundings devoid of hospital sights, sounds, and smells. The research was approved by the ethic boards of each of the medical centers and the health service. Instruments Functional status was evaluated by the Eastern Cooperative Oncology Group (ECOG; Oken et al., 1982), a one-item measure used by a physician to assess how the disease affects patients’ daily living abilities. The score range of the ECOG is 0–4, from 0 = fully active to 4 = completely disabled. In the present study, the score range was 0–2, and it was reversed so that 2 represented fully active (53%), 1 represented
Table 1. Means, SDs, and frequency distributions of demographic and background variables (n = 200).
Age Years of education Number of children Gender (men) Religion (Jewish) Religiosity (secular) Family status (married) Work status (no) Income (average and above) Significant event (yes) Family history of cancer (yes)
M
SD
62.52 14.59 2.75
6.18 3.84 1.18
Frequency 115 195 132 158 100 119 90 124
Percentages 57.5 97.5 66.0 79.0 50.0 60.7 45.0 62.0
Psychology, Health & Medicine Table 2.
Means, SDs, and frequency distributions of the illness-related variables (n = 200).
Time from diagnosis (years) Mean ratings of side effects Pain Fatigue Insomnia Nausea Concentration/memory problems Other Mean number of chronic diseases
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Stage I II III IV Type of cancer Colon Pancreatic Rectal Stomach Other Treatment Chemotherapy Radiotherapy Other Chronic diseases Hypertension Diabetes Hyperlypedemia Heart disease Renal failure Neurologic disease Other
M
SD
2.07 1.21 1.07 1.94 1.39 0.56 0.86 1.43 1.63
1.06 0.99 1.39 1.57 1.57 1.17 1.33 1.76 1.55
Frequency
Percentages
22 71 93 14
11.0 35.5 46.5 7.0
131 26 19 14 10
65.5 13.0 9.5 7.0 5.0
164 51 11
82.0 25.5 5.5
65 37 35 15 6 1 50
32.5 18.5 17.5 7.5 3 0.5 25
restricted but ambulatory and able to carry out light work (37.5%), and 0 represented ambulatory and capable of self-care but unable to carry work (9.5%). Posttraumatic growth inventory (Tedeschi & Calhoun, 1996) is a 21-item scale measuring the degree of positive changes experienced in the aftermath of traumatic events. Each answer is rated on a seven-point Likert scale (0 = not experiencing the change, 6 = experiencing it to a very high degree). The questionnaire reliability in cancer population studies (Lelorain, Bonnaud-Antignac, & Florin, 2010) was .93, and the Hebrew form used in breast cancer research (Cohen & Numa, 2011) showed similar high reliability (.93). Table 3 presents the means, SDs and alpha levels of this and the other research measures. Posttraumatic symptom scale-self-report (Foa, Riggs, Dancu, & Rothbaum, 1993) is a self-report version consisting of 17 items which correspond directly to DSM-IV symptoms. Symptom frequency is reported on a four-point scale (1 = did not occur, 4 = occurred five times or more per week). The respondents were asked to refer to their illness and rate the symptoms during the preceding month. The inventory contains three subscales: re-experiencing, avoidance, and arousal. Foa et al. (1993) reported an internal
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Table 3. Means, SDs, and Pearson product-moment correlations of PTSS, PTG, adjustment, PA, and NA, and social desirability. Measure
Mean
SD
α
1
2
3
4
5
1. 2. 3. 4. 5. 6.
.51 2.76 3.31 3.05 1.02 .49
.58 1.16 .50 .68 .77 .28
.91 .92 .89 .81 .84 .71
– .09 −.67* −.32* .64* −.08
– .03 .29* .00 −.08
– .45* −.50* .12
– −.24* −.10
−.06
PTSS PTG Adjustment Positive affect Negative affect Social desirability
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Note: PTSS = posttraumatic stress symptoms; PTG = posttraumatic growth. *p < .01.
reliability of .91 and a one-month test–retest reliability of .74 for the total score. The Hebrew form reliability was in the range of .88–.92 (Gil, 2005). Another scoring method of this scale is similar to the PTSD assessment of 0 or 1, made by counting several symptoms from each subscale (Foa et al., 1993). Accordingly, in this study, the rate of PTSD was 24%. Psycho-social adjustment to illness scale-self-report (short form; Rodrigue, Kanasky, Jackson, & Perri, 2000) is a short scale consisting of 26 items. It is based on the original 46-item scale which was developed for assessing cancer patients’ psychosocial adjustment (Morrow et al., 1978). The alpha for the total score was .87 (Rodrigue et al., 2000), and the Hebrew version showed good reliability values (see Kulik & Kronfeld, 2005). Positive and negative affect schedule (Watson et al., 1988) is a 20-item self-report measure of PA (10 items) and NA (10 items), used in its Hebrew form (Ben-Zur, 2002). Each item is rated on a five-point scale (0 = very slightly or not at all, 4 = extremely). Watson et al. (1988) reported alpha coefficients ranging from .86–.90 for the PA subscale and .84–.87 for the NA subscale, and similar reliabilities were found for the Hebrew version (.78 and .83, respectively; Ben-Zur, 2002). Social desirability questionnaire (short version) is an eight-item version based on the original 33-item scale which aims to identify the extent to which individuals exhibit social desirability bias (Crowne & Marlowe, 1964). Each item was rated True or False (0 or 1). After reversing the appropriate items in the direction of social desirability, the higher the average score, the higher the level of social desirability. The Hebrew form showed medium level of reliability (.66; Ben-Zur, 2002). Statistical analyses Descriptive analyses, Pearson product-moment correlations, and hierarchical regressions for testing the hypotheses were conducted, using the SPSS program version 19. Preliminary correlation analyses between demographic or illness-related variables and either adjustment or affective reactions led to the selection of 10 variables (e.g. age and side effects) as control variables in the regressions, with stage and functional status converted each into two categories (see Table 4). Hierarchical regression analyses were applied to the dependent variables of adjustment, PA, and NA, using as independent variables PTSS, PTG, and PTSS × PTG, the 10 control variables and social desirability. PTSS and PTG scores were centered (Aiken & West, 1991) before creating the multiplication term PTSS × PTG, which represented the interaction assessed by an Internet program (Jose, 2008; ModGraph-I). A conservative significance level of p < .01 was used to test the research hypotheses.
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Table 4. Hierarchical regression coefficients of adjustment and affective reactions on demographics and illness-related variables, PTSS, PTG, and the PTSS × PTG interaction. Adjustment
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Variable
β
95% CI
Positive affect
Negative affect
β
β
Step 1 Constant (B value) Gender Age Education Children Work status Religiosity Significant event Stage Side effects Functional status Social desirability R2 F(11,188)
2.19** −.01 .02 .05 −.08 .02 .04 .03 −.06 −.20** .32** .01 .52 18.38**
1.38, −.11, −.01, −.01, −.07, −.09, −.07, −.07, −.15, −.16, .21, −.15,
3.00 .08 .01 .02 .01 .13 .15 .12 .04 −.04 .44 .19
2.31** .11 .00 .08 −.08 −.06 .11 .12 .02 −.13 .11 −.15 .15 3.05**
Step 2 PTSS PTG R2 F(13,186) R2 change F(2,186) change
−.40** .13* .62 23.81** .11 26.41**
−.44, −.25 .02, .10
Step 3 PTSS × PTG R2 F(14,185) R2 change F(1,185) change
.13* .64 23.54** .02 8.12*
.04, .18
95% CI 0.78, −.03, −.02, −.01, −.12, −.29, −.04, −.02, −.15, −.20, −.07, −.67,
95% CI −1.46, .11, −.02, −.02, −.06, .00, −.10, −.14, −.30, −.02, −.16, −.36,
3.83 .33 .02 .04 .04 .12 .36 .33 .20 .02 .38 −.04
0.045 .19* .00 .00 .03 .13 .06 .03 −.09 .11 .04 −.02 .22 4.80**
1.55 .46 .02 .02 .10 .41 .30 .21 .04 .20 .28 .26
−.27* .33** .27 5.34** .12 15.37**
−.49, −.14 .11, .26
.63** −.10 .48 13.07** .26 45.97**
.66, 1.00 −.14, .01
.19* .30 5.72** .03 8.09*
.06, .35
.01 .48 12.08** .00 .03 (n.s.)
−.13, .15
Notes: All beta coefficients are from Step 3. Gender, men = 0; women = 1; work status, 0 = not working, 1 = working part/full time; religiosity, 0 = secular, 1 = traditional/religious/very religious; significant event, 0 = no, 1 = yes; stage, 0 = I/II, 1 = III/IV; functional status, 0 = restricted/ambulatory self-care, 1 = fully active. PTSS = posttraumatic stress symptoms; PTG = posttraumatic growth. *p ≤ .01; **p < .001.
Results Table 3 presents the means, SDs, and Pearson product-moment correlations between PTSS, PTG, adjustment, and affective reactions: PTSS was negatively correlated with adjustment and PA, and positively correlated with NA. PTG and adjustment were positively correlated with PA, while adjustment was negatively correlated with NA. PTG was not significantly correlated either with PTSS, adjustment, or NA. The first regression analysis was applied to adjustment as a dependent variable showing that PTSS contributed negatively and PTG contributed positively to adjustment (see Table 4). The PTSS × PTG interaction was also significant, suggesting that PTG moderated the negative association between PTSS and adjustment: the relationship was stronger in the lower levels of PTG and weaker in the higher levels (see Figure 1). Although all three slopes were significant at the p < .001 level (High PTG: b = −.22, SE = 0.06, t = −3.76; Medium PTG: b = −.34, SE = 0.04, t = −7.69; Low PTG:
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b = −.47, SE = 0.06, t = −8.13), notably, the slope under the high levels of PTG was half the size of the slope under the low levels of PTG. The second regression analysis was applied to PA, showing stronger effects than those obtained for adjustment: PTSS contributed negatively, while PTG contributed positively to PA. The PTSS × PTG interaction was also significant, suggesting that PTG moderated the negative association between PTSS and PA: the simple slope for the high level of PTG was not significant (b = −.08, SE = 0.12, t = −0.63, n.s.), while the simple slopes for the medium and low levels of PTG were highly significant (b = −.31, SE = 0.09, t = −3.51, p < .0001, and b = −.55, SE = 0.12, t = −4.54, p < .0001, respectively; see Figure 2). The third regression, which included NA as the dependent variable, showed a PTSS positive contribution to NA, but no significant effects of PTG or the PTSS × PTG interaction. Discussion The study was conducted with digestive system cancer patients one to four years following diagnosis, who were free of the disease at that time. PTSD rate among these patients was 24%, that is, in the higher range levels of similar studies conducted among heterogeneous cancer patients (e.g. Kangas et al., 2002; Koutrouli et al., 2012). The first hypothesis (H1) was fully confirmed: PTSD was negatively associated with adjustment
Figure 1. PTG moderates the effects of PTSS on adjustment. Note: PTSS and PTG levels: medium = mean, high = 1SD above the mean, low = 1SD below the mean (Aiken & West, 1991).
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Figure 2. PTG moderates the effects of PTSS on PA. Note: PTSS and PTG levels: medium = mean, high = 1SD above the mean, low = 1SD below the mean (Aiken & West, 1991).
and PA, and positively associated with NA. These results are in line with other studies showing the negative effects of PTSD on quality of life of cancer patients (e.g. Shelby et al., 2008) or their affective reactions (e.g. Salsman et al., 2009). Hence, the study provides further evidence of the disturbing impact of PTSD on the adjustment and affectivity of the recovering cancer patient. In contrast to PTSD effects, PTG was found to have ameliorating effects on adjustment and affective reactions, with the second hypothesis (H2) confirmed in part: PTG was positively related to better adjustment and PA. These results accord with findings of positive effects of PTG regarding better adjustment or quality of life among breast cancer patients (Morrill et al., 2008), cancer/HIV patients (Sawyer et al., 2010), or a variety of traumatic events including cancer (Helgeson et al., 2006). However, PTG was not significantly negatively related to NA as hypothesized in H2, and this is in contrast to research findings showing it lessens distress (e.g. Helgeson et al., 2006; Sawyer et al., 2010), but in line with others indicating no significant associations of PTG with anxiety (Helgeson et al., 2006). In the present study, PTG was associated with the positive aspects of recovery from cancer, presumably strengthening the constructive processes in adjustment and contributing to positive emotion and good mood. Most importantly, PTG moderated the association of PTSD with adjustment and PA as hypothesized (H3), though not the PTSD and NA association. Thus, PTG is a protective factor lowering the negative effects of PTSD on adjustment and PA, the significant processes for the recovering cancer patients. These findings are in line with PTG effects
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in weakening the effects of PTSD on quality of life among breast cancer patients (Morrill et al., 2008). This study has several advantages: It was conducted with a relatively large sample (n = 200) of digestive system cancer patients, a type of cancer that is prevalent among both genders, yet has rarely been investigated in the past. Additionally, the study included a measure of social desirability, which controls for certain biases characterizing self-report measures. However, the study also has several disadvantages. The study was cross-sectional, and therefore, cause and effect directions cannot be determined unequivocally. Furthermore, common method variance (CMV; Siemsen, Roth, & Oliveira, 2010) might have inflated the simple correlations between the variables investigated. However, this is less of a problem for the moderation (interaction) effects, which may even be weakened by CMV, as claimed by Siemsen et al. (2010). It should also be noted that the study was conducted among Jewish participants, who have adopted values of Western culture. Although PTG is considered a universal phenomena (Weiss & Berger, 2010), different cultures vary in their influence on the appraisals and cognitions that are represented in PTG (Calhoun, Cann, & Tedeschi, 2010), and therefore the results may not be generalized to the Arab population in Israel. The study results have both theoretical and practical implications. They show that PTG positively affects cancer patients’ adjustment, and also has protective advantages through its moderating effects in regard to PTSD. Thus, PTG may function as a personal psychosocial resource (Morrill et al., 2008), buffering the effects of stressful events on well-being. Furthermore, these results imply that PTG processes should be encouraged among cancer patients. Several psycho-social interventions, either in individual or group settings, were found beneficial to personal growth among cancer patients, such as existential (Garlan, Butler, Rosenbaum, Siegel, & Spiegel, 2010–2011) or meaning-focused therapy (Breitbart, 2002). However, more studies are needed to assess the effect of such interventions on PTG processes. References Aiken, L.S., & West, S.G. (1991). Multiple regression: Testing and interpreting interactions. Newbury Park, CA: Sage. American Psychiatric Association. (1994). DSM-IV: Diagnostic and statistical manual of mental disorders (4th ed.). Washington: American Psychiatric Publishing. Ben-Zur, H. (2002). Coping, affect and aging: The roles of mastery and self-esteem. Personality and Individual Differences, 32, 357–372. doi:10.1016/S0191-8869(01)00031-9 Breitbart, W. (2002). Spirituality and meaning in supportive care: Spirituality- and meaningcentered group psychotherapy interventions in advanced cancer. Supportive Care in Cancer, 10, 272–280. doi:10.1007/s005200100289 Calhoun, L.G., Cann, A., & Tedeschi, R.G. (2010). The posttraumatic growth model: Sociocultural considerations. In T. Weiss & R. Berger (Eds.), Posttraumatic growth and culturally competent practice: Lessons learned from around the globe (pp. 1–14). Hoboken, NJ: Wiley. Central Bureau of Statistics Israel. (2011). Retrieved September 10, 2014, from www.cbs.gov.il/ reader Cohen, M., & Numa, M. (2011). Posttraumatic growth in breast cancer survivors: A comparison of volunteers and non-volunteers. Psycho-Oncology, 20, 69–76. doi:10.1002/pon.1709 Crowne, D.P., & Marlowe, D. (1964). The approval motive: Studies in evaluative dependence. New York, NY: Wiley. Foa, E.B., Riggs, D.S., Dancu, C.V., & Rothbaum, B.O. (1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459–473. doi:10.1002/jts.2490060405
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