Psychological Medicine, 1991, 21, 51-57 Printed in Great Britain
Relationships between emotional control, adjustment to cancer and depression and anxiety in breast cancer patients MAGGIE WATSON,1 STEVEN GREER, LINDA ROWDEN, CHRISTINE GORMAN, BERNADETTE ROBERTSON, JUDITH M. BLISS AND ROBERT TUNMORE From the Cancer Research Campaign Psychological Medicine Research Group and the Section of Epidemiology, Institute of Cancer Research and the Royal Marsden Hospital, Sutton, Surrey
The possible relationship between psychological responses among breast cancer patients and disease outcome continues to be an area of controversy and debate. Two parallel findings are reported separately in the literature: first, that emotional control is more common among women with breast cancer than in women with benign breast disease or in healthy controls and second, that a helpless attitude towards the disease is related to a poor prognosis. These previously unrelated psychological responses are examined here in a group of women (N = 359) with early stage breast cancer, who were seen one to three months after diagnosis. The relationships between emotional control, adjustment to cancer and psychological morbidity were examined. Prevalence levels of 16 and 6% were observed for anxiety and depression respectively, which are lower than reported more generally in the literature. The results indicated a highly significant association between scores for the tendency to control emotional reactions and a fatalistic attitude toward cancer. A significant association was observed between anger control and a helpless attitude. Psychological morbidity was also linked to type of adjustment to cancer. The data are interpreted in terms of a process model of psychological responses which suggests that emotional control (an important component of the Type C behaviour pattern) fatalism, helplessness and psychological morbidity are linked. SYNOPSIS
Vassilaros, 1986; Grassi et al. 1986) and a recent r e v i e w ( Gr0SS) 1 9 g 9 ) c o n c ] u d e d t h a t the data There is an increasing literature relating to indicated that emotional suppression might psychological responses and prognosis in breast contribute some degree of risk in cancer progcancer and a number of reviews (Fox, 1978; Cox nosis. In addition, several studies have reported & Mackay, 1982; Greer & Watson, 1987; that a helpless attitude toward the disease was of Temoshok, 1987; Watson, 1988; Gross, 1989) prognostic significance (Schmale & Iker, 1961; conclude that psychological factors may be of Greer et al. 1979; Di Clemente & Temoshok, some prognostic importance. We have pre- 1985; Pettingale et al. 1985; Jensen, 1987; viously described a Type C behaviour pattern, Antoni & Goodkin, 1988). These two strands of with suppression of anger being a predominant research, concerning on the one hand emotional feature (Greer & Watson, 1985; Watson, 1990). control and on the other helplessness, appear to Studies have shown that women with breast have proceeded in parallel. Are these psychocancer are more likely to control emotions than logical responses linked? Temoshok (1987) those with benign breast disease or healthy attempted to draw them together theoretically controls (Morris et al. 1981; Wirsching et al. by suggesting that they represent different stages 1982; Pettingale et al. 1985; Anagnostopoulos & along a continuum. She proposed that 'chronically blocked expression of needs and feelings' Add es for '. /, ' correspondence. Dr Maggie Watson, CRC Psychological Medicine Group, The Royal Marsden Hospital, Downs
t
Road, Sutton, Surrey SM2 5PT.
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be a belief that it is 'useless to express o n e s 51
52
M. Watson and others
needs'. Thus the Type C individual might be seen as chronically hopeless and helpless, suggesting that those showing a pattern of Type C behaviour would be more likely to develop feelings of helplessness under extreme stress. This hypothesis was put forward to explain why some studies found emotional control associated with cancer outcome measures whereas others found that a helpless attitude was related to outcome. Further research is clearly needed to clarify Type C behaviour and what constitutes its important elements and how it relates to the helpless/hopeless response observed in other studies. In addition, some studies have suggested that depression is of prognostic significance although the evidence is equivocal (Jansen & Muenz, 1984; Holland et al. 1986; Hislop et al.
1987; Jamison et al. 1987; Persky et al. 1987). The aim of the present study, therefore, was to examine for any associations between measures of emotional control, adjustment to cancer and levels of depression and anxiety in a sample of women recently diagnosed with breast cancer, in order to clarify whether these responses were related in the way suggested by Temoshok (1987). On the basis of the model described and the existing evidence, we would predict that there would be an association between the tendency towards emotional control and feelings of helplessness in women who have recently learned they have breast cancer and that helpless responses could, in turn, be associated with more symptoms of depression.
Procedure and design
Patients were seen individually at out-patient or treatment clinics between 1 and 3 months after diagnosis and were asked to complete the questionnaires as part of a study investigating psychological aspects of cancer. Two questionnaires, designed for and validated upon cancer patient samples, were used to assess the psychological responses of emotional control and adjustment to cancer. The Courtauld Emotional Control Scale (CECS) (Watson & Greer, 1983) was used to determine the extent to which patients showed a tendency to control feelings of anger, anxiety and depression. Adjustment to cancer was assessed using the Mental Adjustment to Cancer Scale (Watson et al. 1988) which includes the responses described as 'helpless/
hopeless', 'fighting spirit', 'fatalism' and 'anxious pre-occupation'. A more detailed description of these responses is given elsewhere (Watson et al. 1988). This scale was recently compared with the original clinical interview method described by Greer and colleagues (Greer et al. 1979) and found to have good validity (Greer et al. 1989). The psychometric properties of both questionnaires have been independently replicated in other cancer patient groups (Grassi et al. 1985; Schwartz et al. 1989). Psychological morbidity was assessed using the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983), a measure specifically designed for use with medical patients and recently validated with cancer patients (Razavi et al. 1989). This scale is divided into two, assessing anxiety and depression as separate METHOD dimensions. In addition to the psychological Patients measures described data were obtained for A consecutive series of early stage breast cancer disease stage. Associations between the measures patients (TV = 380) treated primarily by wide were examined using Spearman's non-paralocal excision and radiotherapy at the Royal metric correlation technique (all tests were 2Marsden Hospital, were approached and as- tailed) and comparisons between groups, unless sessed as part of a study in which selected otherwise indicated, used Student's / test. Mulpatients were entered into a controlled psycho- tiple comparisons were made but were allowed therapy trial. Several eligibility conditions had for in the interpretation of the results. to be satisfied and these were; age between 18 and 75 inclusive, no apparent intellectual imRESULTS pairment, an estimated duration of survival of 12 months or more, and resident within an The majority of patients had localized disease approximate 50-mile radius of the hospital. Of (A^= 271) with the remainder (N = 88) having the eligible patients approached 360 (95 %) loco-regional disease (i.e. lymph node involveagreed and 20 (5 %) refused to participate. ment). Data on disease stage were missing for
53
Psychological responses in breast cancer patients
Table 1. Mean scores for emotional control, adjustment to cancer and psychological morbidity (N = 359) Courtauld Emotional Control Scale (N = 308)
Mental Adjustment to Cancer Scale (N = 356)
Anger 16-2 (4-8)
Anxiety 171 (4-8)
Depression 17-5 (50)
Total 50-7 (12-5)
Helplessness 8-7 (2-6)
Fighting spirit 51 6 (6-0)
Fatalism 17-9 (3-8)
Anxious preoccupation 20-6 (3-9) Depression 2-7 (2-6)
Anxiety 5-6 (4-0)
Hospital Anxiety and Depression Scale {N = 359)
Standard deviations are given in parentheses.
Table 2. Correlation coefficients for emotional control and adjustment to cancer Mental adjustment to cancer scale
Courtauld Emotional Control Scale Anger Anxiety Depression Total
Helplessness
Fighting spirit
Fatalism
017* 018* Oil 017*
004 -007 006 001
0-24" 0-25" 0-25" 0-30"
Anxious preoccupation
001 001 000 001
*/> 005.
one patient who was therefore excluded from the analyses as the possibility of metastatic involvement could not be ruled out. The mean age of the sample was 55-8 (S.D. 10-6) with a range from 25 to 75. Comparisons between patients with local and loco-regional disease indicated that there were no significant differences on any of the psychological measures and for the purpose of analysis the groups were combined. Table 1 gives means and standard deviations for each of the psychological measures. Emotional control and adjustment to cancer Possible associations between emotional control and adjustment to cancer were examined. The results indicated (Table 2) a highly significant association (P < 0001) between a 'fatalistic' attitude towards the cancer diagnosis and the tendency to control each of the negative emotions described. There were significant associations between 'helplessness' and the tendency
to control anger and anxiety (P < 0005). There were no associations observed between emotional control and the tendency to adopt a ' fighting spirit' or an 'anxious preoccupation' with the disease. A strong association was observed between helplessness and fatalism as measured on the MACS (P < 00001) and other subscales of the MACS were also inter-correlated (see Table 3). Dividing the sample into high or low emotional controllers, on the basis of a median split using the CECS total scores, comparisons indicated that helplessness was significantly higher (P = 0015) in those who were high emotional controllers (mean = 9 1 , S.D. = 2-7) than in low emotional controllers (mean = 8-3, S.D. = 2-5). A highly significant difference was observed between the high and low emotional controllers for'fatalism' (P < 00001), with high emotional controllers (mean = 18-8, S.D. = 4'0) being more likely to report a fatalistic attitude towards cancer than low emotional controllers (mean = 16-9, S.D. = 3-4). Any possible effects of
54
M. Watson and others
Table 3. Intercorrelations between the subscales of the Mental Adjustment to Cancer Scale
Helplessness Anxious preoccupation Fatalism
Fighting spirit
Helplessness
-0-47"* -005
0-41***
-007
0-45"»
Table 4. Correlation coefficients for Hospital Anxiety and Depression Scores and other psychological responses
Anxious preoccupation
018*
• * / " < 0-001; * • • / > < 00001.
age were also tested for each CECS subscale. An analysis of variance which used age, grouped by decade, indicated no main effect of age for control of anger (F (5,306) = 1-50, P = 0-19). There was marginal evidence of a significant trend with increasing age for control of anxiety (F (5,307) = 2-87, P = 0015) and stronger evidence for control of depression (F(5,307) = 4-43, P < 0001). However, a test of simple effects using the Scheffe procedure indicated that no two age groups were significantly different from each other. Depression/anxiety, emotional control and adjustment to cancer An examination of the relationships between depression and anxiety and emotional control indicated evidence of weak associations between HADS anxiety and CECS anxiety (P = 0-024) and HADS depression and CECS depression (P = 0039), with higher levels of psychological morbidity being associated with a tendency to control their expression (see Table 4). The HADS does not assess feelings of anger, thereby precluding any assessment of possible associations with anger control. Comparisons of high versus low emotional controllers indicated that higher levels of HADS anxiety were reported (P = 0005) for high (mean = 6-5, s.D. = 4-2) than for low (mean = 5-2, s.D. = 3-7) emotional controllers. This difference was not observed for HADS depression scores (P = 0-22). Significant associations were observed between psychological morbidity and the measure of adjustment to cancer (MACS). Both HADS anxiety and HADS depression were highly significantly associated with scores on all sub-scales of the MACS. The results indicated that increased 'helplessness', 'fatalism' and 'anxious preoccu-
Hospital Anxiety and Depression Scale
Mental Adjustment to Cancer Fighting spirit Helplessness Anxious preoccupation Fatalism Courtauld Emotional Control Scale Anger Anxiety Depression
Anxiety
Depression
-017" 0-44"" 0-60"" O-23"
-0-29" 0-40* • • 0-43*" 0-22"
004 0 13* Oil
009 007 0-12*
•P < 0 0 5 ; " P < O-00I ; * • * / > < 0 0 0 0 1 .
Table 5. Number of patients falling above and below the thresholds on the Hospital Anxiety and Depression Scale Hospital Anxiety and Depression Scale
Anxiety 5s 10
Depression ;
All patients
Above Below
56(16%) 303(84%)
21 (6%) 338(94%)
Local disease
Above Below
41 (15%) 230(85%)
16(6%) 255(94%)
Loco-regional disease
Above Below
15(17%) 73(83%)
5(6%) 83(94%)
pation' were associated with more symptoms of both depression and anxiety (P < 0001). Fighting spirit was significantly, but negatively, associated with depression and anxiety (P < 0001), indicating that psychological morbidity was lower for those showing this attitude toward their disease. The underlying prevalence of psychological morbidity in the sample, regardless of other psychological responses assessed, was also examined. Patients were divided into high and low morbidity on the basis of HADS cut-off scores. The cut-offs, suggested by the test authors (Zigmond & Snaith, 1983) are from 8 to 10 for depression and anxiety, separately. The use of cut-offs was examined within a separate pilot study (N = 79) of patients attending the Royal Marsden Hospital between 1986 and 1987. The cut-offs derived from our pilot sample were calculated by taking one standard deviation
Psychological responses in breast cancer patients
above the distribution mean. Thus, the derived cut-offs from our pilot sample were; HADSanxiety ^ 10, HADS- depression ^ 8. Using these specific criteria it was observed that for anxiety and depression, respectively, 16 and 6% fell above the threshold set to identify significant morbidity. There was no association observed between the proportion falling above or below the threshold, and stage of disease (see Table 5). The two HADS sub-scales were highly significantly associated (P < 0-0001), suggesting that depression and anxiety are not entirely independent on this scale. DISCUSSION The most striking finding from this study relates to the significant associations between the tendency to control emotional responses and an attitude of fatalism towards the disease. We also found (/') a predicted association between control of anger and helplessness and (if) an association between control of anxiety and helplessness; the rather low but significant coefficients suggest some caution should be exercised here. The strongest association, however, appears to occur between emotional control and fatalism. The issue is complicated somewhat by the fact that the fatalism and helplessness subscales are highly significantly associated, indicating that they may be separate but related responses. The helplessness sub-scale has a strong emotional component to it, reflected by items such as 'I feel I can't do anything to cheer myself up', 'I feel that life is hopeless' and by the somewhat stronger association observed with HADS depression scores than was shown by the fatalism sub-scale. The fatalism sub-scale, on the other hand is not only more 'cognitive' in flavour but seems to fit more with what is referred to as an 'external locus of control', for example, 'I've left it all to my doctors', 'I feel that nothing I can do will make any difference'. One might speculate that the helplessness sub-scale measures an emotional reaction and the fatalistic sub-scale a more enduring attitude regarding perception of control. This merits further investigation. An examination of the relationships of emotional control and style of adjustment to cancer, to the level of psychological morbidity, provided insights into the possible mechanisms involved
55
in coping. Suppression of feelings of depression and anxiety was related to higher scores for both of these emotional responses, confirming the frequent observation that effective coping involves some ventilation of emotions. Encouraging patients to ventilate emotions may be beneficial for an enhanced quality of life and these responses appear to be amenable to change by therapeutic intervention (Collinge, 1987). A stronger relationship was observed between adjustment to cancer and emotional disturbance with responses of helplessness, fatalism and anxious preoccupation all being associated with more symptoms of depression and anxiety. However, given the cross-sectional nature of the assessment the direction of causality between the responses observed cannot be ascertained. It is impossible to say, for instance, whether depressed and anxious patients are more likely to feel helpless as a consequence of their mood disturbance or whether it is the reverse. We hope to clarify this to some extent by following up these patients and repeating our assessments one year later. Fighting spirit was inversely related to depression and anxiety scores, suggesting that it is either an adaptive response or a response which reflects earlier adaptation to stress, i.e. that those who adapt well are more likely to report a fighting spirit subsequently. Overall, the data suggest a link between emotional control and a helpless and/or fatalistic attitude towards cancer when these are assessed using standardized and valid instruments during the period some 1-3 months after the diagnosis when most patients were being treated for their breast cancer. The data show a link between the previously independent responses described in the literature. They go one step towards confirming the hypothesis that, following an especially severe stress such as the diagnosis of breast cancer, the 'Type C facade breaks down, exposing the chronic but hidden hopelessness' (Temoshok, 1987). Thus, the two strands of research previously described separately become linked in a model which explains their relationship to each other. It can also be seen that these psychological responses are inextricably linked with the stress experienced and this is reflected in their relationship to reported levels of depression and anxiety. However, the present study has its limitations. The responses measured were cross-sectional not
56
M. Watson and others
longitudinal, and it has already been pointed out (Heim et al. 1987) that there can be considerable variation and change in coping, depending on the illness and the time at which coping is assessed. For this purpose we are conducting a follow-up of our patients in order to re-assess their responses at one year after the original assessment. Some comment is also required on the levels of psychological morbidity we have observed, as these are generally lower than reported elsewhere in the literature. One explanation may lie with the method we have used to assess morbidity. If our cut-offs for significant morbidity were set particularly high then this might explain the figures. The cut-offs taken were ^ 8 and ^ 1 0 for depression and anxiety respectively. Razavi and colleagues (1989) have shown that a HADS-anxiety cut-off of 8 has a 64% 'hit rate' (i.e. picked up this percentage of those with adjustment disorders according to DSM-III-R criteria) and that a HADS depression cut-off of 7 has only a 59 % sensitivity; with 28 and 25 % false positive rates, respectively. Their results suggest a slightly higher cut-off might more clearly identify true 'cases' and reduce the false positives. Given their findings our cut-offs may not be significantly distorting the true morbidity level and may indeed slightly reduce the false positive rate. The concentration of our assessments during the 1-3 month period after diagnosis has been deliberately chosen in order to avoid the more transient affective responses which occur at the time of diagnosis and remit spontaneously. Assessments made at the time of diagnosis show higher morbidity rates, as demonstrated in the study by Derogatis et al. (1983) than do those made at 3 and 12 months after the diagnosis. If our rates are not distorted, it is encouraging to see that the levels of significant morbidity are lower than previously reported and suggest some changes may be occurring in the clinical management of oncology patients and the support services now increasingly being offered. In summary, we have viewed emotional control as a component of the Type C behaviour pattern and have examined its relationship to attitudes of helplessness and fatalism in order to learn if these responses, previously described separately, were related. The results confirm a relationship between Type C and a fatalistic
attitude and to a lesser degree feelings of helplessness. These responses were, in turn, related to increased depression and anxiety and our results provide support for Temoshok's (1987) hypothesis. Given the observed relationships between emotional control, adjustment to cancer and psychological morbidity, it will be of some interest to examine their prognostic importance in breast cancer and that is our eventual aim. However, further research is needed to examine coping processes and longitudinal changes; the Type ' C concept also awaits further clarification. The patients who so willingly participated are gratefully acknowledged. Gillian Chesney provided invaluable assistance throughout and has made a significant contribution along with Arlene White and Sheila Anderson who carried out much of the routine work involved. Discussions with other colleagues have been valuable, in particular Dr J. Baruch and Dr S. Moorey. This study is supported by the Cancer Research Campaign, the Macmillan Cancer Relief Fund and the H. L. Dowsett Will Trust Fund. CRCfunded COMPACT computer software was used for data management.
REFERENCES Anagnostopoulos, F. & Vassilaros, S. T. (1986). Personality attributes of women who develop breast cancer. Paper presented at the 16th European Conference on Psychosomatic Research, Athens, Greece. Antoni, M. & Goodkin, K. (1988). Host moderator variables in the promotion of cervical neoplasia. I. Personality facets. Journal of Psychosomatic Research 32, 327-338. Cox, T. & Mackay, C. (1982). Psychosocial factors and psychophysiological mechanisms in the aetiology and development of cancers. Sofia/ Science and Medicine 16, 381 396. Collinge, W. (1987). Effects of a complementary cancer therapy program on coping and quality of life. Doctoral thesis of University of California, Berkeley, USA. Derogatis, L., Morrow, G., Fetting, J., Penman, D., Piasetsky, S., Schmale, A. M., Henrichs, M. & Carnicke, C. (1983). The prevalence of psychiatric disorders among cancer patients. Journal of the American Medical Association 249, 751 757. Di Clemente, R. J. &Temoshok, L. (1985). Psychological adjustments to having cutaneous malignant melanoma as a predictor of followup clinical status. Psychosomatic Medicine 47, 81. Fox, B. H. (1978). Pre-morbid psychological factors as related to cancer incidence. Journal of Behavioral Medicine 1, 45-133. Grassi, L., Watson, M. & Greer, S. (1985). Le Courtauld Emotional Control Scale (CEC) di Watson e Greer. Bollettino di Psicologia Applicata 176, 3-10. Grassi, L., Nappi, G., Susa, A. & Molinari, S. (1986). Eventi stressanti supporto sociale e caratteristiche psicologiche in pazienti aflecte da carcinoma della mammella. Revista di Psichiatria 21, 315-328.
Psychological responses in breast cancer patients Greer, S. & Watson, M. (1985). Towards a psychobiological model of cancer: psychological considerations. Social Science and Medicine 20, 773-777. Greer, S. & Watson, M. (1987). Mental adjustment to cancer: its measurement and prognostic importance. Cancer Surveys 6, Greer, S., Morris, T. & Pettingale, K. (1979). Psychological response to breast cancer: effect on outcome. Lancet ii, 785-787. Greer, S., Moorey, S. & Watson, M. (1989). Patient's adjustment to cancer: the Mental Adjustment to Cancer (MAC) Scale versus clinical ratings. Journal of Psychosomatic Research, 33, 373-377. Gross, J. (1989). Emotional suppression in cancer onset and progression. Social Science and Medicine 12, 1239-1248. Heim, E., Augustiny, K., Blaser, A., Burki, C , Kuhne, D., Rothenbuhler, M., Schaflher, L. & Valach, L. (1987). Coping with breast c a n c e r - a longitudinal prospective study. Psychotherapy and Psychosomatics 48, 44-59. Hislop, T., Waxier, N., Coldman, A., Elwood, J. & Kan, L. (1987). The prognostic significance of psychosocial factors in women with breast cancer. Journal of Chronic Disease 40, 729-735. Holland, J., Korzun, A., Tross, S., Cella, D., Norton, L. & Wood, W. (1986). Psychosocial factors and disease-free survival (DFS) in Stage II breast carcinoma. Proceedings of ASCO, 5, March, 237. Jamison, R., Burish, T. & Wallston, K. (1987). Psychogenic factors in predicting survival of breast cancer patients. Journal of Clinical Oncology 5, 768-772. Jensen, M. (1987). Psychobiological factors predicting the course of breast cancer. Journal of Personality 55, 317-342. Jensen, M. & Muenz, L. (1984). A retrospective study of personality variables associated with fibrocystic disease and breast cancer. Journal of Psychosomatic Research 28, 35-42. Morris, T., Greer, S., Petlingale, K. & Watson, M. (1981). Patterns of expression of anger and their psychological correlates in women with breast cancer. Journal of Psychosomatic Research, 25,111-117. Persky, V., Kempthorne-Rawson, J. & Shekelle, R. (1987). Per-
57
sonality and risk of cancer: 20 year follow-up of the Western Electric study. Psychosomatic Medicine 49, 435-449. Pettingale, K. W., Morris, T., Greer, S. & Haybittle, J. (1985). Mental attitudes to cancer: an additional prognostic factor. Lancet i, 750. Razavi, D., Delvaux, N., Farvacques, C. & Robaye, E. (1989). The screening of adjustment disorders and major depressive disorders in hospitalized cancer patients. British Journal of Psychiatry 156, 79-83. Schmale, A. & Iker, H. (1961). The affect of hopelessness and the development of cancer. Psychosomatic Medicine 28, 714-721. Schwartz, C , Daltroy, L., Brandt, U. & Stolbach, L. (1989). A psychometric analysis of the Mental Adjustment to Cancer Scale. (Submitted for publication). Temoshok, L. (1987). Personality, coping style, emotion and cancer: towards an integrative model. Cancer Surveys 6, 545-567. Watson, M. (1988). Psychological factors in cancer progression. Is there a case? Cancer Journal 2, 76-77. Watson, M. (1990). Breast cancer-is there a psychological risk factor in disease progression? Paper presented at the International Psychoneuroimmunology Symposium, Hannover, Germany. To be published by Hogrefe-Huber International. Watson, M. & Greer, S. (1983). Development of a questionnaire measure of emotional control. Journal of Psychosomatic Research 27, 299-305. Watson, M., Greer, S., Young, J., Inayat, Q., Burgess, C. & Robertson, B. (1988). Development of a questionnaire measure of adjustment to cancer. The MAC scale. Psychological Medicine 18, 203-209. Wirsching, M., Stierlin, H., Hoffman, F., Weber, G. & Wirsching, B. (1982). Psychological identification of breast cancer patients before biopsy. Journal of Psychosomatic Research 26, 1-10. Zigmond, A. & Snaith, R. (1983). The Hospital Anxiety and Depression Scale. Ada Psychiatrica Scandinavica 67, 361-370.
Relationships between emotional control, adjustment to cancer and depression and anxiety in breast cancer patients MAGGIE WATSON,1 STEVEN GREER, LINDA ROWDEN, CHRISTINE GORMAN, BERNADETTE ROBERTSON, JUDITH M. BLISS AND ROBERT TUNMORE From the Cancer Research Campaign Psychological Medicine Research Group and the Section of Epidemiology, Institute of Cancer Research and the Royal Marsden Hospital, Sutton, Surrey
The possible relationship between psychological responses among breast cancer patients and disease outcome continues to be an area of controversy and debate. Two parallel findings are reported separately in the literature: first, that emotional control is more common among women with breast cancer than in women with benign breast disease or in healthy controls and second, that a helpless attitude towards the disease is related to a poor prognosis. These previously unrelated psychological responses are examined here in a group of women (N = 359) with early stage breast cancer, who were seen one to three months after diagnosis. The relationships between emotional control, adjustment to cancer and psychological morbidity were examined. Prevalence levels of 16 and 6% were observed for anxiety and depression respectively, which are lower than reported more generally in the literature. The results indicated a highly significant association between scores for the tendency to control emotional reactions and a fatalistic attitude toward cancer. A significant association was observed between anger control and a helpless attitude. Psychological morbidity was also linked to type of adjustment to cancer. The data are interpreted in terms of a process model of psychological responses which suggests that emotional control (an important component of the Type C behaviour pattern) fatalism, helplessness and psychological morbidity are linked. SYNOPSIS
Vassilaros, 1986; Grassi et al. 1986) and a recent r e v i e w ( Gr0SS) 1 9 g 9 ) c o n c ] u d e d t h a t the data There is an increasing literature relating to indicated that emotional suppression might psychological responses and prognosis in breast contribute some degree of risk in cancer progcancer and a number of reviews (Fox, 1978; Cox nosis. In addition, several studies have reported & Mackay, 1982; Greer & Watson, 1987; that a helpless attitude toward the disease was of Temoshok, 1987; Watson, 1988; Gross, 1989) prognostic significance (Schmale & Iker, 1961; conclude that psychological factors may be of Greer et al. 1979; Di Clemente & Temoshok, some prognostic importance. We have pre- 1985; Pettingale et al. 1985; Jensen, 1987; viously described a Type C behaviour pattern, Antoni & Goodkin, 1988). These two strands of with suppression of anger being a predominant research, concerning on the one hand emotional feature (Greer & Watson, 1985; Watson, 1990). control and on the other helplessness, appear to Studies have shown that women with breast have proceeded in parallel. Are these psychocancer are more likely to control emotions than logical responses linked? Temoshok (1987) those with benign breast disease or healthy attempted to draw them together theoretically controls (Morris et al. 1981; Wirsching et al. by suggesting that they represent different stages 1982; Pettingale et al. 1985; Anagnostopoulos & along a continuum. She proposed that 'chronically blocked expression of needs and feelings' Add es for '. /, ' correspondence. Dr Maggie Watson, CRC Psychological Medicine Group, The Royal Marsden Hospital, Downs
t
Road, Sutton, Surrey SM2 5PT.
'"
jfi
d th
.T
Jf
c
,
f
j
th
,
J
be a belief that it is 'useless to express o n e s 51
52
M. Watson and others
needs'. Thus the Type C individual might be seen as chronically hopeless and helpless, suggesting that those showing a pattern of Type C behaviour would be more likely to develop feelings of helplessness under extreme stress. This hypothesis was put forward to explain why some studies found emotional control associated with cancer outcome measures whereas others found that a helpless attitude was related to outcome. Further research is clearly needed to clarify Type C behaviour and what constitutes its important elements and how it relates to the helpless/hopeless response observed in other studies. In addition, some studies have suggested that depression is of prognostic significance although the evidence is equivocal (Jansen & Muenz, 1984; Holland et al. 1986; Hislop et al.
1987; Jamison et al. 1987; Persky et al. 1987). The aim of the present study, therefore, was to examine for any associations between measures of emotional control, adjustment to cancer and levels of depression and anxiety in a sample of women recently diagnosed with breast cancer, in order to clarify whether these responses were related in the way suggested by Temoshok (1987). On the basis of the model described and the existing evidence, we would predict that there would be an association between the tendency towards emotional control and feelings of helplessness in women who have recently learned they have breast cancer and that helpless responses could, in turn, be associated with more symptoms of depression.
Procedure and design
Patients were seen individually at out-patient or treatment clinics between 1 and 3 months after diagnosis and were asked to complete the questionnaires as part of a study investigating psychological aspects of cancer. Two questionnaires, designed for and validated upon cancer patient samples, were used to assess the psychological responses of emotional control and adjustment to cancer. The Courtauld Emotional Control Scale (CECS) (Watson & Greer, 1983) was used to determine the extent to which patients showed a tendency to control feelings of anger, anxiety and depression. Adjustment to cancer was assessed using the Mental Adjustment to Cancer Scale (Watson et al. 1988) which includes the responses described as 'helpless/
hopeless', 'fighting spirit', 'fatalism' and 'anxious pre-occupation'. A more detailed description of these responses is given elsewhere (Watson et al. 1988). This scale was recently compared with the original clinical interview method described by Greer and colleagues (Greer et al. 1979) and found to have good validity (Greer et al. 1989). The psychometric properties of both questionnaires have been independently replicated in other cancer patient groups (Grassi et al. 1985; Schwartz et al. 1989). Psychological morbidity was assessed using the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983), a measure specifically designed for use with medical patients and recently validated with cancer patients (Razavi et al. 1989). This scale is divided into two, assessing anxiety and depression as separate METHOD dimensions. In addition to the psychological Patients measures described data were obtained for A consecutive series of early stage breast cancer disease stage. Associations between the measures patients (TV = 380) treated primarily by wide were examined using Spearman's non-paralocal excision and radiotherapy at the Royal metric correlation technique (all tests were 2Marsden Hospital, were approached and as- tailed) and comparisons between groups, unless sessed as part of a study in which selected otherwise indicated, used Student's / test. Mulpatients were entered into a controlled psycho- tiple comparisons were made but were allowed therapy trial. Several eligibility conditions had for in the interpretation of the results. to be satisfied and these were; age between 18 and 75 inclusive, no apparent intellectual imRESULTS pairment, an estimated duration of survival of 12 months or more, and resident within an The majority of patients had localized disease approximate 50-mile radius of the hospital. Of (A^= 271) with the remainder (N = 88) having the eligible patients approached 360 (95 %) loco-regional disease (i.e. lymph node involveagreed and 20 (5 %) refused to participate. ment). Data on disease stage were missing for
53
Psychological responses in breast cancer patients
Table 1. Mean scores for emotional control, adjustment to cancer and psychological morbidity (N = 359) Courtauld Emotional Control Scale (N = 308)
Mental Adjustment to Cancer Scale (N = 356)
Anger 16-2 (4-8)
Anxiety 171 (4-8)
Depression 17-5 (50)
Total 50-7 (12-5)
Helplessness 8-7 (2-6)
Fighting spirit 51 6 (6-0)
Fatalism 17-9 (3-8)
Anxious preoccupation 20-6 (3-9) Depression 2-7 (2-6)
Anxiety 5-6 (4-0)
Hospital Anxiety and Depression Scale {N = 359)
Standard deviations are given in parentheses.
Table 2. Correlation coefficients for emotional control and adjustment to cancer Mental adjustment to cancer scale
Courtauld Emotional Control Scale Anger Anxiety Depression Total
Helplessness
Fighting spirit
Fatalism
017* 018* Oil 017*
004 -007 006 001
0-24" 0-25" 0-25" 0-30"
Anxious preoccupation
001 001 000 001
*/> 005.
one patient who was therefore excluded from the analyses as the possibility of metastatic involvement could not be ruled out. The mean age of the sample was 55-8 (S.D. 10-6) with a range from 25 to 75. Comparisons between patients with local and loco-regional disease indicated that there were no significant differences on any of the psychological measures and for the purpose of analysis the groups were combined. Table 1 gives means and standard deviations for each of the psychological measures. Emotional control and adjustment to cancer Possible associations between emotional control and adjustment to cancer were examined. The results indicated (Table 2) a highly significant association (P < 0001) between a 'fatalistic' attitude towards the cancer diagnosis and the tendency to control each of the negative emotions described. There were significant associations between 'helplessness' and the tendency
to control anger and anxiety (P < 0005). There were no associations observed between emotional control and the tendency to adopt a ' fighting spirit' or an 'anxious preoccupation' with the disease. A strong association was observed between helplessness and fatalism as measured on the MACS (P < 00001) and other subscales of the MACS were also inter-correlated (see Table 3). Dividing the sample into high or low emotional controllers, on the basis of a median split using the CECS total scores, comparisons indicated that helplessness was significantly higher (P = 0015) in those who were high emotional controllers (mean = 9 1 , S.D. = 2-7) than in low emotional controllers (mean = 8-3, S.D. = 2-5). A highly significant difference was observed between the high and low emotional controllers for'fatalism' (P < 00001), with high emotional controllers (mean = 18-8, S.D. = 4'0) being more likely to report a fatalistic attitude towards cancer than low emotional controllers (mean = 16-9, S.D. = 3-4). Any possible effects of
54
M. Watson and others
Table 3. Intercorrelations between the subscales of the Mental Adjustment to Cancer Scale
Helplessness Anxious preoccupation Fatalism
Fighting spirit
Helplessness
-0-47"* -005
0-41***
-007
0-45"»
Table 4. Correlation coefficients for Hospital Anxiety and Depression Scores and other psychological responses
Anxious preoccupation
018*
• * / " < 0-001; * • • / > < 00001.
age were also tested for each CECS subscale. An analysis of variance which used age, grouped by decade, indicated no main effect of age for control of anger (F (5,306) = 1-50, P = 0-19). There was marginal evidence of a significant trend with increasing age for control of anxiety (F (5,307) = 2-87, P = 0015) and stronger evidence for control of depression (F(5,307) = 4-43, P < 0001). However, a test of simple effects using the Scheffe procedure indicated that no two age groups were significantly different from each other. Depression/anxiety, emotional control and adjustment to cancer An examination of the relationships between depression and anxiety and emotional control indicated evidence of weak associations between HADS anxiety and CECS anxiety (P = 0-024) and HADS depression and CECS depression (P = 0039), with higher levels of psychological morbidity being associated with a tendency to control their expression (see Table 4). The HADS does not assess feelings of anger, thereby precluding any assessment of possible associations with anger control. Comparisons of high versus low emotional controllers indicated that higher levels of HADS anxiety were reported (P = 0005) for high (mean = 6-5, s.D. = 4-2) than for low (mean = 5-2, s.D. = 3-7) emotional controllers. This difference was not observed for HADS depression scores (P = 0-22). Significant associations were observed between psychological morbidity and the measure of adjustment to cancer (MACS). Both HADS anxiety and HADS depression were highly significantly associated with scores on all sub-scales of the MACS. The results indicated that increased 'helplessness', 'fatalism' and 'anxious preoccu-
Hospital Anxiety and Depression Scale
Mental Adjustment to Cancer Fighting spirit Helplessness Anxious preoccupation Fatalism Courtauld Emotional Control Scale Anger Anxiety Depression
Anxiety
Depression
-017" 0-44"" 0-60"" O-23"
-0-29" 0-40* • • 0-43*" 0-22"
004 0 13* Oil
009 007 0-12*
•P < 0 0 5 ; " P < O-00I ; * • * / > < 0 0 0 0 1 .
Table 5. Number of patients falling above and below the thresholds on the Hospital Anxiety and Depression Scale Hospital Anxiety and Depression Scale
Anxiety 5s 10
Depression ;
All patients
Above Below
56(16%) 303(84%)
21 (6%) 338(94%)
Local disease
Above Below
41 (15%) 230(85%)
16(6%) 255(94%)
Loco-regional disease
Above Below
15(17%) 73(83%)
5(6%) 83(94%)
pation' were associated with more symptoms of both depression and anxiety (P < 0001). Fighting spirit was significantly, but negatively, associated with depression and anxiety (P < 0001), indicating that psychological morbidity was lower for those showing this attitude toward their disease. The underlying prevalence of psychological morbidity in the sample, regardless of other psychological responses assessed, was also examined. Patients were divided into high and low morbidity on the basis of HADS cut-off scores. The cut-offs, suggested by the test authors (Zigmond & Snaith, 1983) are from 8 to 10 for depression and anxiety, separately. The use of cut-offs was examined within a separate pilot study (N = 79) of patients attending the Royal Marsden Hospital between 1986 and 1987. The cut-offs derived from our pilot sample were calculated by taking one standard deviation
Psychological responses in breast cancer patients
above the distribution mean. Thus, the derived cut-offs from our pilot sample were; HADSanxiety ^ 10, HADS- depression ^ 8. Using these specific criteria it was observed that for anxiety and depression, respectively, 16 and 6% fell above the threshold set to identify significant morbidity. There was no association observed between the proportion falling above or below the threshold, and stage of disease (see Table 5). The two HADS sub-scales were highly significantly associated (P < 0-0001), suggesting that depression and anxiety are not entirely independent on this scale. DISCUSSION The most striking finding from this study relates to the significant associations between the tendency to control emotional responses and an attitude of fatalism towards the disease. We also found (/') a predicted association between control of anger and helplessness and (if) an association between control of anxiety and helplessness; the rather low but significant coefficients suggest some caution should be exercised here. The strongest association, however, appears to occur between emotional control and fatalism. The issue is complicated somewhat by the fact that the fatalism and helplessness subscales are highly significantly associated, indicating that they may be separate but related responses. The helplessness sub-scale has a strong emotional component to it, reflected by items such as 'I feel I can't do anything to cheer myself up', 'I feel that life is hopeless' and by the somewhat stronger association observed with HADS depression scores than was shown by the fatalism sub-scale. The fatalism sub-scale, on the other hand is not only more 'cognitive' in flavour but seems to fit more with what is referred to as an 'external locus of control', for example, 'I've left it all to my doctors', 'I feel that nothing I can do will make any difference'. One might speculate that the helplessness sub-scale measures an emotional reaction and the fatalistic sub-scale a more enduring attitude regarding perception of control. This merits further investigation. An examination of the relationships of emotional control and style of adjustment to cancer, to the level of psychological morbidity, provided insights into the possible mechanisms involved
55
in coping. Suppression of feelings of depression and anxiety was related to higher scores for both of these emotional responses, confirming the frequent observation that effective coping involves some ventilation of emotions. Encouraging patients to ventilate emotions may be beneficial for an enhanced quality of life and these responses appear to be amenable to change by therapeutic intervention (Collinge, 1987). A stronger relationship was observed between adjustment to cancer and emotional disturbance with responses of helplessness, fatalism and anxious preoccupation all being associated with more symptoms of depression and anxiety. However, given the cross-sectional nature of the assessment the direction of causality between the responses observed cannot be ascertained. It is impossible to say, for instance, whether depressed and anxious patients are more likely to feel helpless as a consequence of their mood disturbance or whether it is the reverse. We hope to clarify this to some extent by following up these patients and repeating our assessments one year later. Fighting spirit was inversely related to depression and anxiety scores, suggesting that it is either an adaptive response or a response which reflects earlier adaptation to stress, i.e. that those who adapt well are more likely to report a fighting spirit subsequently. Overall, the data suggest a link between emotional control and a helpless and/or fatalistic attitude towards cancer when these are assessed using standardized and valid instruments during the period some 1-3 months after the diagnosis when most patients were being treated for their breast cancer. The data show a link between the previously independent responses described in the literature. They go one step towards confirming the hypothesis that, following an especially severe stress such as the diagnosis of breast cancer, the 'Type C facade breaks down, exposing the chronic but hidden hopelessness' (Temoshok, 1987). Thus, the two strands of research previously described separately become linked in a model which explains their relationship to each other. It can also be seen that these psychological responses are inextricably linked with the stress experienced and this is reflected in their relationship to reported levels of depression and anxiety. However, the present study has its limitations. The responses measured were cross-sectional not
56
M. Watson and others
longitudinal, and it has already been pointed out (Heim et al. 1987) that there can be considerable variation and change in coping, depending on the illness and the time at which coping is assessed. For this purpose we are conducting a follow-up of our patients in order to re-assess their responses at one year after the original assessment. Some comment is also required on the levels of psychological morbidity we have observed, as these are generally lower than reported elsewhere in the literature. One explanation may lie with the method we have used to assess morbidity. If our cut-offs for significant morbidity were set particularly high then this might explain the figures. The cut-offs taken were ^ 8 and ^ 1 0 for depression and anxiety respectively. Razavi and colleagues (1989) have shown that a HADS-anxiety cut-off of 8 has a 64% 'hit rate' (i.e. picked up this percentage of those with adjustment disorders according to DSM-III-R criteria) and that a HADS depression cut-off of 7 has only a 59 % sensitivity; with 28 and 25 % false positive rates, respectively. Their results suggest a slightly higher cut-off might more clearly identify true 'cases' and reduce the false positives. Given their findings our cut-offs may not be significantly distorting the true morbidity level and may indeed slightly reduce the false positive rate. The concentration of our assessments during the 1-3 month period after diagnosis has been deliberately chosen in order to avoid the more transient affective responses which occur at the time of diagnosis and remit spontaneously. Assessments made at the time of diagnosis show higher morbidity rates, as demonstrated in the study by Derogatis et al. (1983) than do those made at 3 and 12 months after the diagnosis. If our rates are not distorted, it is encouraging to see that the levels of significant morbidity are lower than previously reported and suggest some changes may be occurring in the clinical management of oncology patients and the support services now increasingly being offered. In summary, we have viewed emotional control as a component of the Type C behaviour pattern and have examined its relationship to attitudes of helplessness and fatalism in order to learn if these responses, previously described separately, were related. The results confirm a relationship between Type C and a fatalistic
attitude and to a lesser degree feelings of helplessness. These responses were, in turn, related to increased depression and anxiety and our results provide support for Temoshok's (1987) hypothesis. Given the observed relationships between emotional control, adjustment to cancer and psychological morbidity, it will be of some interest to examine their prognostic importance in breast cancer and that is our eventual aim. However, further research is needed to examine coping processes and longitudinal changes; the Type ' C concept also awaits further clarification. The patients who so willingly participated are gratefully acknowledged. Gillian Chesney provided invaluable assistance throughout and has made a significant contribution along with Arlene White and Sheila Anderson who carried out much of the routine work involved. Discussions with other colleagues have been valuable, in particular Dr J. Baruch and Dr S. Moorey. This study is supported by the Cancer Research Campaign, the Macmillan Cancer Relief Fund and the H. L. Dowsett Will Trust Fund. CRCfunded COMPACT computer software was used for data management.
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sonality and risk of cancer: 20 year follow-up of the Western Electric study. Psychosomatic Medicine 49, 435-449. Pettingale, K. W., Morris, T., Greer, S. & Haybittle, J. (1985). Mental attitudes to cancer: an additional prognostic factor. Lancet i, 750. Razavi, D., Delvaux, N., Farvacques, C. & Robaye, E. (1989). The screening of adjustment disorders and major depressive disorders in hospitalized cancer patients. British Journal of Psychiatry 156, 79-83. Schmale, A. & Iker, H. (1961). The affect of hopelessness and the development of cancer. Psychosomatic Medicine 28, 714-721. Schwartz, C , Daltroy, L., Brandt, U. & Stolbach, L. (1989). A psychometric analysis of the Mental Adjustment to Cancer Scale. (Submitted for publication). Temoshok, L. (1987). Personality, coping style, emotion and cancer: towards an integrative model. Cancer Surveys 6, 545-567. Watson, M. (1988). Psychological factors in cancer progression. Is there a case? Cancer Journal 2, 76-77. Watson, M. (1990). Breast cancer-is there a psychological risk factor in disease progression? Paper presented at the International Psychoneuroimmunology Symposium, Hannover, Germany. To be published by Hogrefe-Huber International. Watson, M. & Greer, S. (1983). Development of a questionnaire measure of emotional control. Journal of Psychosomatic Research 27, 299-305. Watson, M., Greer, S., Young, J., Inayat, Q., Burgess, C. & Robertson, B. (1988). Development of a questionnaire measure of adjustment to cancer. The MAC scale. Psychological Medicine 18, 203-209. Wirsching, M., Stierlin, H., Hoffman, F., Weber, G. & Wirsching, B. (1982). Psychological identification of breast cancer patients before biopsy. Journal of Psychosomatic Research 26, 1-10. Zigmond, A. & Snaith, R. (1983). The Hospital Anxiety and Depression Scale. Ada Psychiatrica Scandinavica 67, 361-370.
