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Anxiety, Emotional Suppression, and Psychological Distress Before and After Breast Cancer Diagnosis
Anxiety, Emotional Suppression, and Psychological Distress Before and After Breast Cancer Diagnosis YUMI IWAMITSU, PH.D., KAZUTAKA SHIMODA, M.D., PH.D. HAJIME ABE, M.D., PH.D., TOHRU TANI, M.D., PH.D. MASAKO OKAWA, M.D., PH.D., ROSS BUCK, PH.D.
The authors examined the influence of anxiety and emotional suppression on psychological distress in 21 patients with breast cancer and 72 patients with benign breast tumor. The patients with breast cancer who suppressed emotion and had chronically high levels of anxiety felt higher levels of emotional distress both before and after the diagnosis. Such patients need psychological interventions, including encouragement to express and communicate their emotions, immediately after disclosure of the diagnosis to help maintain psychological adjustment in the face of the disease. (Psychosomatics 2005; 46:19–24)
P
atients who receive a diagnosis of breast cancer generally are greatly shocked and upset. However, individual breast cancer patients differ in the extent to which they report feeling psychological distress. Watson and Greer1 proposed that emotional suppression or control is a factor in these individual differences. They viewed emotional suppression as a component of the type C behavior pattern, which was originally defined by Temoshok,2 as involving a “chronically blocked expression of needs and feelings” and the belief that it is “useless to express one’s needs.” Eysenck3 and Gross4 suggested that the type C pattern is associated with the onset and prognosis of cancer. Previous studies have examined anxiety and depression symptoms in breast cancer patients to explore the relationship of these symptoms with psychiatric morbidity and cancer prognosis.5,6 Hall et al.7 showed that the majority of women with early breast cancer experienced anxiety and/or depression within 3 months of their initial surgery. In addition, they identified anxiety disorder in 49.6% of women with breast cancer and depressive illness in 37.2% during the first 3 months after their initial surgery. Iwamitsu et al.8 found that although the affective status of breast cancer patients who openly expressed negative emotions was not altered after the disclosure of the diagnosis, Psychosomatics 46:1, January-February 2005
compared with before the diagnosis, emotional distress was significantly increased in the patients who inhibited negative emotions, particularly those who inhibited anxiety after disclosure of the diagnosis. Anxiety as well as emotional suppression may be a factor in the psychological adjustment to cancer. Burgess et al.9 reported that high levels of anxiety were associated with psychological maladjustment, including hopelessness and helplessness in response to the diagnosis and low internal locus of control. We hypothesized that patients with breast cancer who chronically feel anxiety in daily life would feel more psychological distress under stress than those who do not generally feel anxiety. Furthermore, we hypothesized that breast cancer patients who suppress anxiety and negative emotion would feel comparatively greater Received Aug. 27, 2003; revision received March 2, 2004; accepted April 1, 2004. From the Department of Medical Psychology, Graduate School of Medical Sciences, Kitasato University, Kanagawa; the Department of Psychiatry, Dokkyo University School of Medicine, Tochigi, Japan; the Department of Psychiatry and Surgery, Shiga University of Medical Science, Shiga, Japan; and the Department of Communication Sciences, University of Connecticut, Storrs. Address correspondence and reprint requests to Dr. Iwamitsu, Department of Medical Psychology, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan; [email protected] (e-mail). Copyright 䉷 2005 The Academy of Psychosomatic Medicine.
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Emotional Suppression in Breast Cancer Patients psychological distress after the disclosure of their diagnosis, compared with patients who did not suppress anxiety and negative emotion. In the present study, we investigated the influence of anxiety and emotional suppression on psychological distress in breast cancer patients after they are told the diagnosis. The Profile of Mood States (POMS) was used to study differences in emotional response among patients with breast cancer and patients with benign tumor who were characterized in terms of levels of anxiety and presence of emotional suppression or expression. Furthermore, we compared the emotional responses of the two patient groups after they received their diagnoses. METHOD Participants One hundred twenty-five female patients visited the outpatient clinic of the Department of Surgery at Shiga University of Medical Science Hospital from November 1999 to January 2002. They attended the clinic so that biopsy and histological studies could be performed. Of the 125 patients, 102 provided written informed consent. Of these patients, 23 received a diagnosis of breast cancer after biopsy and histological study. Seventy-nine patients were determined to have benign tumors. Two breast cancer patients and seven patients with benign tumor did not fill out the questionnaires completely, therefore, data for a total of 93 patients (21 with breast cancer and 72 with benign tumor; mean age⳱45.5 years, SD⳱9.6, range⳱25–72) were analyzed in the present study. Measures POMS The self-rated POMS10 includes 65 items (rated on a scale from 0, “not at all,” to 4, “very much so”) that make up six subscales: tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment. As a global measure of affective state, a total mood disturbance score was calculated by summing the scores on the six subscales, with vigor-activity negatively weighted. Courtauld Emotional Control Scale The Courtauld Emotional Control Scale measures the extent of the suppression or control of anger, depression, anxiety, and total negative emotion in daily life. The scale was constructed by Watson and Greer1 on the basis of reports by Morris et al.11 that 20
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breast cancer patients tend to suppress anger and anxiety during their adult lives more so than do patients with benign breast tumors. The scale was designed to allow more objective assessment of the extent of emotional control. Items were selected on the basis of results of semistructured clinical interviews with patients who were awaiting breast biopsy. Test-retest reliability values over the passage of 3–4 weeks were 0.86, 0.89, and 0.84 for anger, depression, and anxiety, respectively. The Courtauld Emotional Control Scale is a self-rating questionnaire consisting of 21 items (seven items in each subscale) scored from 1, “not at all,” to 4, “very much so.” In accordance with Watson and Greer’s methods, we used factor analysis (principal-component analysis with varimax rotation) of the scores of the 93 patients to select items for the subscales. For each subscale, we selected items with a loading of more than 0.40 on one factor. Five anger items, four depression items, and four anxiety items were so selected. Internal consistency (Cronbach’s alpha) coefficients were 0.79, 0.83, and 0.83 for anger, depression, and anxiety, respectively, which were reasonably close to the values found for the original version (0.86, 0.88, and 0.88 for anger, depression, and anxiety, respectively). Therefore, each of the subscales we developed showed adequate internal consistency. Cronbach’s alpha for total negative emotion (the total of 13 items in the anger, depression, and anxiety subscales) was 0.89. The mean scores of the 93 patients on the Courtald Emotional Control Scale were 12.5 (SD⳱3.5) for anger, 10.2 (SD⳱3.0) for depression, 9.3 (SD⳱3.0) for anxiety, and 32.0 (SD⳱8.0) for total negative emotion. Manifest Anxiety Scale The Manifest Anxiety Scale12 measures the extent of chronic anxiety reactions. This selfrated questionnaire consists of 65 items, scored on a scale from 0 “no” to 1 “yes.” Possible total scores range from 0 to 50. Procedures The 102 patients were asked to complete the POMS, Courtauld Emotional Control Scale, and Manifest Anxiety Scale during their first visit to the outpatient clinic. At the second visit, they were informed of the results of the biopsy and histological investigation and were told the diagnosis. Immediately after being given the diagnosis, the patients were asked to complete the POMS. As noted earlier, two of the 23 patients with breast cancer and seven of the 79 Psychosomatics 46:1, January-February 2005
Iwamitsu et al. patients with benign tumors filled out the questionnaires incompletely and were excluded from the analysis.
tween the high- and low-anxiety groups for the Manifest Anxiety Scale score (F⳱98.29, df⳱1, 92, p⬍0.01, effect size⳱0.72).
Data Analysis RESULTS The 21 patients with breast cancer were assigned to one of two groups on the basis of the cutoff point of the median Courtauld Emotional Control Scale total negative emotion score (median⳱32). The 72 patients with benign tumors were assigned to groups in the same way. This procedure produced a negative emotion suppression group and a negative emotion expression group within each diagnostic group. The 21 breast cancer patients were also assigned to one of two groups (high anxiety and low anxiety) on the basis of the cutoff point of the median Manifest Anxiety Scale score (median⳱17.5). The 72 benign tumor patients were also assigned to either a high or a low anxiety group. This procedure resulted in four subgroups of patients within each overall diagnostic group: high anxiety–expression, low anxiety–expression, high anxiety–suppression, and low anxiety–suppression. Table 1 shows the mean Courtauld Emotional Control Scale total negative emotion and Manifest Anxiety Scale scores for each group. The scores were analyzed in separate three-way analyses of variance (ANOVAs) (two patient groups [benign tumor patients versus breast cancer patients] ⳯ two emotional suppression groups [suppression versus expression] ⳯ two anxiety groups [high versus low anxiety]). As expected, the results showed highly significant differences between the suppression and expression groups for the Courtauld Emotional Control Scale score (F⳱88.66, df⳱1, 92, p⬍0.01, effect size⳱0.70) and beTABLE 1.
The POMS total mood disturbance scores before and after patients were told the diagnosis were compared for the eight patient groups. Figure 1 shows these changes. Mixedmodel ANOVAs (two anxiety groups [high versus low anxiety] ⳯ two emotional suppression groups [suppression versus expression], with repeated measures for clinic visit [first visit versus second visit]) were conducted. For the patients with breast cancer, strong main effects were observed for both anxiety (F⳱13.25, df⳱1, 17, p⬍0.01, effect size⳱0.66) and emotional suppression (F⳱16.47, df⳱1, 17, p⬍0.01, effect size⳱0.70). That is, the POMS total mood disturbance scores in the high anxiety group were higher than those in the low anxiety group, and the POMS total mood disturbance scores in the suppression group were higher than those in the expression group. Further, a significant interaction between emotional suppression and clinic visit was observed (F⳱4.71, df⳱1, 17, p⬍0.05, effect size⳱0.47). Subsequent testing revealed that the total mood disturbance scores in the suppression group were significantly higher at the second clinic visit (after patients received the diagnosis), compared with the first visit (F⳱9.41, df⳱1, 10, p⬍0.05, effect size⳱0.69). However, the total mood disturbance scores in the expression group were not significantly different between two clinic visits, and the scores of patients in the expression group were consistently low.
Scores on the Courtauld Emotional Control Scale and the Manifest Anxiety Scale of Patients With Breast Cancer and Patients With Benign Tumor With High and Low Levels of Anxiety and Emotional Suppression or Expressiona Patients With High Levels of Anxiety Patients With Emotional Suppression
Scale and Patient Group
N
Courtand Emotional Control Scale total negative emotion score Patients with breast cancer 5 Patients with benign breast tumor 14 Manifest Anxiety Scale score Patients with breast cancer 5 Patients with benign breast tumor 14
Patients With Low Levels of Anxiety
Patients With Emotional Expression
Patients With Emotional Suppression
Patients With Emotional Expression
Mean
SD
N
Mean
SD
N
Mean
SD
N
Mean
SD
37.00 39.76
2.83 6.00
5 20
29.00 25.57
5.05 4.93
6 21
38.17 37.67
5.00 4.79
5 17
24.20 27.78
7.26 3.66
21.60 23.06
5.86 4.62
5 20
24.60 24.43
5.03 5.87
6 21
12.17 11.48
1.83 4.52
5 17
8.80 11.50
3.70 4.63
a High and low anxiety groups consisted of patients with scores at or above and below, respectively, the median score of 17.5 on the Manifest Anxiety Scale. Emotional suppression and expression groups consisted of patients with scores at or above and below, respectively, the median score of 32 on the Courtauld Emotional Control Scale.
Psychosomatics 46:1, January-February 2005
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Emotional Suppression in Breast Cancer Patients In contrast, for the patients with benign tumor, a main effect for anxiety was observed (F⳱7.45, df⳱1, 68, p⬍0.01, effect size⳱0.31), with highly anxious patients showing high total mood disturbance. Further, the interaction between anxiety and clinic visit approached significance (F⳱2.88, df⳱1, 68, p⬍0.10, effect size⳱0.20). Subsequent testing showed that the total mood disturbance scores in the high anxiety group were higher than those in the low anxiety group at the first visit (F⳱10.58, df⳱1, 68, p⬍0.01, effect size⳱0.37). We conducted a one-way ANOVA analyzing total mood disturbance data from the four anxiety-suppression groups (high anxiety–expression, low anxiety–expression, high anxiety–suppression, and low anxiety–suppression) separately for each clinic visit for the breast cancer patients,
because we observed differences in the total mood disturbance scores in the four groups, as Figure 1 shows. A main effect of anxiety-suppression was revealed both for the first visit (before diagnosis) (F⳱4.77, df⳱3, 17, p⬍0.05, effect size⳱0.46) and for the second visit (after diagnosis) (F⳱13.28, df⳱3, 17, p⬍0.01, effect size⳱0.68). A subsequent Tukey’s test showed a significant difference, with the low anxiety–expression group reporting lower total mood disturbance scores than the high anxiety–suppression group at the first visit (p⬍0.01). After the diagnosis, the total mood disturbance scores of the low anxiety–expression group were much lower than those of the other three groups (p⬍0.01).
FIGURE 1.
The results indicated that 1) breast cancer patients who felt chronically anxious felt more psychological distress, compared with those who did not generally feel anxious; 2) breast cancer patients who suppress negative emotion felt more emotional distress than those who express negative emotion after disclosure of the diagnosis; 3) the high anxiety–suppression group felt a higher level of emotional distress than the low anxiety–expression group, both before and after the diagnosis; and 4) the patients with benign tumor who were highly anxious felt more psychological distress in general, and in particular felt more distress at the first visit, than those who did not feel anxious. Our aim was to identify reported anxiety, emotional suppression, and psychological distress before and after diagnosis in breast cancer patients, compared with benign tumor patients. We found that the breast cancer patients who suppressed negative emotion reported more psychological distress both at their first visit to the outpatient clinic and after disclosure of the diagnosis, compared with those who express negative emotion. Also, those who were chronically anxious reported more psychological distress than those who were not anxious. The patients with breast cancer who both expressed emotion and were not anxious reported little psychological distress, even after they were told the cancer diagnosis. In previous research on emotional suppression, Watson et al.13 reported that breast cancer patients with emotional suppression tend to adopt an attitude of fatalism and helplessness in relation to cancer. These responses toward cancer were, in turn, related to higher levels of depression and anxiety. Our results support the findings of Watson et al. In our study, breast cancer patients with emotional sup-
Changes in Profile of Mood States Total Mood Disturbance Scores After Being Given the Diagnosis of Breast Cancer or Benign Tumor in Patients With High and Low Levels of Anxiety and With Emotional Suppression or Expressiona Patients With Breast Cancer
Patients With Benign Tumor
High anxiety– supression group (N=5) High anxiety– expression group (N=5) Low anxiety– supression group (N=6) Low anxiety– expression group (N=5)
High anxiety– supression group (N=14) High anxiety– expression group (N=20) Low anxiety– supression group (N=21) Low anxiety– expression group (N=17)
Mean Profile of Mood States Total Mood Disturbance Score
100
80
60
40
20
0 First (before diagnosis)
Second (after diagnosis)
First (before diagnosis)
Second (after diagnosis)
Clinic Visit Suppression and expression groups consisted of patients with scores at or above and below, respectively, the median score of 32 on the Courtauld Emotional Control Scale. High and low anxiety groups consisted of patients with scores at or above and below, respectively, the median score of 17.5 on the Manifest Anxiety Scale. a
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DISCUSSION
Psychosomatics 46:1, January-February 2005
Iwamitsu et al. pression reported more psychological distress, and in particular more depression and fatigue, after disclosure of the breast cancer diagnosis. As Temoshok2 suggested, emotional suppression may be linked to helplessness or hopelessness in breast cancer patients who are experiencing severe stress. We suggest that disclosure of the diagnosis is a point of overwhelming stress and a critical time to intervene with treatment. In particular, patients who suppress emotion need to be encouraged to express their needs and their feelings so that they do not to develop patterns of depression and hopelessness/helplessness, which have been found to be associated with poorer prognosis or cancer death in longitudinal studies.6,14 Second, we found that increasing psychological distress was related to anxiety. Breast cancer patients with high anxiety also reported more psychological distress than those with low anxiety. This finding suggests that a high level of trait anxiety as a personality characteristic is also a key factor in psychological adjustment to cancer. It is interesting to note that the highly anxious benign tumor patients felt more psychological distress at their first visit to the outpatient clinic, compared with their second visit, when they were told the diagnosis. Visiting the outpatient clinic was associated with tension and depressive symptoms in these patients. This result may reflect the vulnerability to stress for people with chronically high levels of anxiety. It is noteworthy that the breast cancer patients who suppressed negative emotion and had chronically high levels of anxiety felt higher levels of emotional distress than those who expressed negative emotion and did not have anxiety before or after the diagnosis. The patients who suppressed negative emotion and were chronically anxious had double factors leading them to feel anxious and depressed in the process of the treatment. Although they are sensitive to the stressful situation, they may believe that suppressing negative emotion is the best way to cope with cancer. However, as a result of not expressing negative emotion, psychological distress may be maintained over time, and they can come to feel helplessness/hopelessness in the course of treatment. Reardon and Buck15 suggested that people who suppress negative emotion may need emotional education to learn how to communicate their negative and positive emotion accurately under extreme stress. By accurately com-
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municating emotions, patients are more likely to receive genuine social and emotional support and feedback and to deal adequately with the negative and unfamiliar feelings associated with their serious illness. Patients must acknowledge and understand the unfamiliar and frightening feelings associated with a cancer diagnosis in order to learn how to express and cope with these feelings effectively, that is, to develop emotional competence. Social support is known to be a very important factor in somatic and mental health.16 Suppressing negative emotion may be an effective way to maintain superficially agreeable human relationships but at the cost of authentic and genuine emotional expression and communication. Temoshok2 proposed that the type C pattern of coping often appears outwardly to be effective. Because persons with the type C pattern of coping are friendly and helpful to others, they are often considered to be socially desirable persons. However, when such a person is faced with extreme stress, such as being informed of a breast cancer diagnosis, this coping style is not effective. Patients who cope with stress by suppressing negative emotion need psychological intervention immediately after disclosure of the diagnosis, particularly if they are also chronically anxious. It should be noted that, although we measured the psychological distress of the benign tumor patients at the first visit and after they were told the diagnosis, we did not measure their psychological distress at later times. Cunningham et al.17 reported that benign tumor patients who receive routine clinical breast examinations worried significantly more than healthy comparison women. In conclusion, we suggest that patients who suppress emotion and chronically feel high levels of anxiety need psychological interventions, including support for and acceptance of the expression of negative emotion, immediately after the disclosure of the diagnosis of breast cancer in order to maintain their psychological adjustment in the face of the disease. Family counseling to encourage the expectation of and acceptance of the patient’s expression of negative emotion should also be considered. In the future, we plan to conduct longitudinal studies to examine the effects of chronic anxiety and suppression of negative emotion on psychological distress and treatment outcomes. This study was supported by Grant-in-Aid for Scientific Research #15730315 from the Ministry of Education of Japan.
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Emotional Suppression in Breast Cancer Patients
References
1. Watson M, Greer S: Development of a questionnaire measure of emotional control. J Psychosom Res 1998; 27:299–305 2. Temoshok L: Personality, coping style, emotion and cancer: towards an integrative model. Cancer Surv 1987; 6:545–567 3. Eysenck HJ: Cancer, personality and stress: prediction and prevention. Adv Behav Res Ther 1994; 16:167–215 4. Gross J: Emotional suppression in cancer onset and progression. Soc Sci Med 1989; 12:1239–1248 5. Epping-Jordan JE, Compas BE, Osowiecki DM, Oppedisano G, Gerhardt C, Primo K, Krag DN: Psychological adjustment in breast cancer: process of emotional distress. Health Psychol 1999; 18:315–326 6. Watson M, Haviland JS, Greer S, Davidson J, Bliss JM: Influence of psychological response on survival in breast cancer: a population-based cohort study. Lancet 1999; 354:1331–1336 7. Hall A, A’Hern R, Fallowfield L: Are we using appropriate selfreport questionnaires for detecting anxiety and depression in women with early breast cancer? Eur J Cancer 1999; 35:79–85 8. Iwamitsu Y, Shimoda K, Abe H, Tani T, Okawa M: Differences in emotional distress between tumor patients with emotional inhibition and those with emotional expression. Psychiatry Clin Neurosci 2003; 57:289–294 9. Burgess C, Morris T, Pettingale KW: Psychological response to cancer diagnosis, II: evidence for coping styles. J Psychosom Res 1988; 32:263–272 10. McNair DM, Lorr M, Droppleman LF: Manual for the Profile of
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Mood States. San Diego, Educational and Industrial Testing Service, 1971 11. Morris T, Greer S, Pettingale KW, Watson M: Patterns of expression of anger and their psychological correlates in women with breast cancer. J Psychosom Res 1981; 25:111–117 12. Taylor JA: A personality scale of manifest anxiety. J Abnorm Soc Psychol 1953; 48:285–290 13. Watson M, Greer S, Rowden L, Gorman C, Robertson B, Bliss JM, Tunmore R: Relationships between emotional control, adjustment to cancer and depression and anxiety in breast cancer patients. Psychol Med 1991; 21:51–57 14. Temoshok L, Heller BW, Sagebiel RW, Blois MS, Sweet DM, DiClemente RJ, Gold ML: The relationship of psychosocial factors to prognostic indicators in cutaneous malignant melanoma. J Psychosom Res 1985; 29:139–153 15. Reardon KK, Buck R: Emotion, reason, and communication in coping with cancer. Health Psychol 1989; 1:41–54 16. Buck R: Emotional communication, emotional competence, and physical illness: a developmental-interactionist view, in Emotion, Inhibition, and Health. Edited by Traue HC, Pennabaker JW. Seattle, Hogrefe & Hubner, 1993, pp 32–56 17. Cunningham LL, Dnarykowski MA, Wilson JF, McGrath PC, Sloan DA, Kenady DE: Physical symptoms, distress, and breast cancer risk perceptions in women with benign breast problems. Health Psychol 1998; 17:371–375
Psychosomatics 46:1, January-February 2005
The authors examined the influence of anxiety and emotional suppression on psychological distress in 21 patients with breast cancer and 72 patients with benign breast tumor. The patients with breast cancer who suppressed emotion and had chronically high levels of anxiety felt higher levels of emotional distress both before and after the diagnosis. Such patients need psychological interventions, including encouragement to express and communicate their emotions, immediately after disclosure of the diagnosis to help maintain psychological adjustment in the face of the disease. (Psychosomatics 2005; 46:19–24)
P
atients who receive a diagnosis of breast cancer generally are greatly shocked and upset. However, individual breast cancer patients differ in the extent to which they report feeling psychological distress. Watson and Greer1 proposed that emotional suppression or control is a factor in these individual differences. They viewed emotional suppression as a component of the type C behavior pattern, which was originally defined by Temoshok,2 as involving a “chronically blocked expression of needs and feelings” and the belief that it is “useless to express one’s needs.” Eysenck3 and Gross4 suggested that the type C pattern is associated with the onset and prognosis of cancer. Previous studies have examined anxiety and depression symptoms in breast cancer patients to explore the relationship of these symptoms with psychiatric morbidity and cancer prognosis.5,6 Hall et al.7 showed that the majority of women with early breast cancer experienced anxiety and/or depression within 3 months of their initial surgery. In addition, they identified anxiety disorder in 49.6% of women with breast cancer and depressive illness in 37.2% during the first 3 months after their initial surgery. Iwamitsu et al.8 found that although the affective status of breast cancer patients who openly expressed negative emotions was not altered after the disclosure of the diagnosis, Psychosomatics 46:1, January-February 2005
compared with before the diagnosis, emotional distress was significantly increased in the patients who inhibited negative emotions, particularly those who inhibited anxiety after disclosure of the diagnosis. Anxiety as well as emotional suppression may be a factor in the psychological adjustment to cancer. Burgess et al.9 reported that high levels of anxiety were associated with psychological maladjustment, including hopelessness and helplessness in response to the diagnosis and low internal locus of control. We hypothesized that patients with breast cancer who chronically feel anxiety in daily life would feel more psychological distress under stress than those who do not generally feel anxiety. Furthermore, we hypothesized that breast cancer patients who suppress anxiety and negative emotion would feel comparatively greater Received Aug. 27, 2003; revision received March 2, 2004; accepted April 1, 2004. From the Department of Medical Psychology, Graduate School of Medical Sciences, Kitasato University, Kanagawa; the Department of Psychiatry, Dokkyo University School of Medicine, Tochigi, Japan; the Department of Psychiatry and Surgery, Shiga University of Medical Science, Shiga, Japan; and the Department of Communication Sciences, University of Connecticut, Storrs. Address correspondence and reprint requests to Dr. Iwamitsu, Department of Medical Psychology, Graduate School of Medical Sciences, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan; [email protected] (e-mail). Copyright 䉷 2005 The Academy of Psychosomatic Medicine.
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Emotional Suppression in Breast Cancer Patients psychological distress after the disclosure of their diagnosis, compared with patients who did not suppress anxiety and negative emotion. In the present study, we investigated the influence of anxiety and emotional suppression on psychological distress in breast cancer patients after they are told the diagnosis. The Profile of Mood States (POMS) was used to study differences in emotional response among patients with breast cancer and patients with benign tumor who were characterized in terms of levels of anxiety and presence of emotional suppression or expression. Furthermore, we compared the emotional responses of the two patient groups after they received their diagnoses. METHOD Participants One hundred twenty-five female patients visited the outpatient clinic of the Department of Surgery at Shiga University of Medical Science Hospital from November 1999 to January 2002. They attended the clinic so that biopsy and histological studies could be performed. Of the 125 patients, 102 provided written informed consent. Of these patients, 23 received a diagnosis of breast cancer after biopsy and histological study. Seventy-nine patients were determined to have benign tumors. Two breast cancer patients and seven patients with benign tumor did not fill out the questionnaires completely, therefore, data for a total of 93 patients (21 with breast cancer and 72 with benign tumor; mean age⳱45.5 years, SD⳱9.6, range⳱25–72) were analyzed in the present study. Measures POMS The self-rated POMS10 includes 65 items (rated on a scale from 0, “not at all,” to 4, “very much so”) that make up six subscales: tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment. As a global measure of affective state, a total mood disturbance score was calculated by summing the scores on the six subscales, with vigor-activity negatively weighted. Courtauld Emotional Control Scale The Courtauld Emotional Control Scale measures the extent of the suppression or control of anger, depression, anxiety, and total negative emotion in daily life. The scale was constructed by Watson and Greer1 on the basis of reports by Morris et al.11 that 20
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breast cancer patients tend to suppress anger and anxiety during their adult lives more so than do patients with benign breast tumors. The scale was designed to allow more objective assessment of the extent of emotional control. Items were selected on the basis of results of semistructured clinical interviews with patients who were awaiting breast biopsy. Test-retest reliability values over the passage of 3–4 weeks were 0.86, 0.89, and 0.84 for anger, depression, and anxiety, respectively. The Courtauld Emotional Control Scale is a self-rating questionnaire consisting of 21 items (seven items in each subscale) scored from 1, “not at all,” to 4, “very much so.” In accordance with Watson and Greer’s methods, we used factor analysis (principal-component analysis with varimax rotation) of the scores of the 93 patients to select items for the subscales. For each subscale, we selected items with a loading of more than 0.40 on one factor. Five anger items, four depression items, and four anxiety items were so selected. Internal consistency (Cronbach’s alpha) coefficients were 0.79, 0.83, and 0.83 for anger, depression, and anxiety, respectively, which were reasonably close to the values found for the original version (0.86, 0.88, and 0.88 for anger, depression, and anxiety, respectively). Therefore, each of the subscales we developed showed adequate internal consistency. Cronbach’s alpha for total negative emotion (the total of 13 items in the anger, depression, and anxiety subscales) was 0.89. The mean scores of the 93 patients on the Courtald Emotional Control Scale were 12.5 (SD⳱3.5) for anger, 10.2 (SD⳱3.0) for depression, 9.3 (SD⳱3.0) for anxiety, and 32.0 (SD⳱8.0) for total negative emotion. Manifest Anxiety Scale The Manifest Anxiety Scale12 measures the extent of chronic anxiety reactions. This selfrated questionnaire consists of 65 items, scored on a scale from 0 “no” to 1 “yes.” Possible total scores range from 0 to 50. Procedures The 102 patients were asked to complete the POMS, Courtauld Emotional Control Scale, and Manifest Anxiety Scale during their first visit to the outpatient clinic. At the second visit, they were informed of the results of the biopsy and histological investigation and were told the diagnosis. Immediately after being given the diagnosis, the patients were asked to complete the POMS. As noted earlier, two of the 23 patients with breast cancer and seven of the 79 Psychosomatics 46:1, January-February 2005
Iwamitsu et al. patients with benign tumors filled out the questionnaires incompletely and were excluded from the analysis.
tween the high- and low-anxiety groups for the Manifest Anxiety Scale score (F⳱98.29, df⳱1, 92, p⬍0.01, effect size⳱0.72).
Data Analysis RESULTS The 21 patients with breast cancer were assigned to one of two groups on the basis of the cutoff point of the median Courtauld Emotional Control Scale total negative emotion score (median⳱32). The 72 patients with benign tumors were assigned to groups in the same way. This procedure produced a negative emotion suppression group and a negative emotion expression group within each diagnostic group. The 21 breast cancer patients were also assigned to one of two groups (high anxiety and low anxiety) on the basis of the cutoff point of the median Manifest Anxiety Scale score (median⳱17.5). The 72 benign tumor patients were also assigned to either a high or a low anxiety group. This procedure resulted in four subgroups of patients within each overall diagnostic group: high anxiety–expression, low anxiety–expression, high anxiety–suppression, and low anxiety–suppression. Table 1 shows the mean Courtauld Emotional Control Scale total negative emotion and Manifest Anxiety Scale scores for each group. The scores were analyzed in separate three-way analyses of variance (ANOVAs) (two patient groups [benign tumor patients versus breast cancer patients] ⳯ two emotional suppression groups [suppression versus expression] ⳯ two anxiety groups [high versus low anxiety]). As expected, the results showed highly significant differences between the suppression and expression groups for the Courtauld Emotional Control Scale score (F⳱88.66, df⳱1, 92, p⬍0.01, effect size⳱0.70) and beTABLE 1.
The POMS total mood disturbance scores before and after patients were told the diagnosis were compared for the eight patient groups. Figure 1 shows these changes. Mixedmodel ANOVAs (two anxiety groups [high versus low anxiety] ⳯ two emotional suppression groups [suppression versus expression], with repeated measures for clinic visit [first visit versus second visit]) were conducted. For the patients with breast cancer, strong main effects were observed for both anxiety (F⳱13.25, df⳱1, 17, p⬍0.01, effect size⳱0.66) and emotional suppression (F⳱16.47, df⳱1, 17, p⬍0.01, effect size⳱0.70). That is, the POMS total mood disturbance scores in the high anxiety group were higher than those in the low anxiety group, and the POMS total mood disturbance scores in the suppression group were higher than those in the expression group. Further, a significant interaction between emotional suppression and clinic visit was observed (F⳱4.71, df⳱1, 17, p⬍0.05, effect size⳱0.47). Subsequent testing revealed that the total mood disturbance scores in the suppression group were significantly higher at the second clinic visit (after patients received the diagnosis), compared with the first visit (F⳱9.41, df⳱1, 10, p⬍0.05, effect size⳱0.69). However, the total mood disturbance scores in the expression group were not significantly different between two clinic visits, and the scores of patients in the expression group were consistently low.
Scores on the Courtauld Emotional Control Scale and the Manifest Anxiety Scale of Patients With Breast Cancer and Patients With Benign Tumor With High and Low Levels of Anxiety and Emotional Suppression or Expressiona Patients With High Levels of Anxiety Patients With Emotional Suppression
Scale and Patient Group
N
Courtand Emotional Control Scale total negative emotion score Patients with breast cancer 5 Patients with benign breast tumor 14 Manifest Anxiety Scale score Patients with breast cancer 5 Patients with benign breast tumor 14
Patients With Low Levels of Anxiety
Patients With Emotional Expression
Patients With Emotional Suppression
Patients With Emotional Expression
Mean
SD
N
Mean
SD
N
Mean
SD
N
Mean
SD
37.00 39.76
2.83 6.00
5 20
29.00 25.57
5.05 4.93
6 21
38.17 37.67
5.00 4.79
5 17
24.20 27.78
7.26 3.66
21.60 23.06
5.86 4.62
5 20
24.60 24.43
5.03 5.87
6 21
12.17 11.48
1.83 4.52
5 17
8.80 11.50
3.70 4.63
a High and low anxiety groups consisted of patients with scores at or above and below, respectively, the median score of 17.5 on the Manifest Anxiety Scale. Emotional suppression and expression groups consisted of patients with scores at or above and below, respectively, the median score of 32 on the Courtauld Emotional Control Scale.
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Emotional Suppression in Breast Cancer Patients In contrast, for the patients with benign tumor, a main effect for anxiety was observed (F⳱7.45, df⳱1, 68, p⬍0.01, effect size⳱0.31), with highly anxious patients showing high total mood disturbance. Further, the interaction between anxiety and clinic visit approached significance (F⳱2.88, df⳱1, 68, p⬍0.10, effect size⳱0.20). Subsequent testing showed that the total mood disturbance scores in the high anxiety group were higher than those in the low anxiety group at the first visit (F⳱10.58, df⳱1, 68, p⬍0.01, effect size⳱0.37). We conducted a one-way ANOVA analyzing total mood disturbance data from the four anxiety-suppression groups (high anxiety–expression, low anxiety–expression, high anxiety–suppression, and low anxiety–suppression) separately for each clinic visit for the breast cancer patients,
because we observed differences in the total mood disturbance scores in the four groups, as Figure 1 shows. A main effect of anxiety-suppression was revealed both for the first visit (before diagnosis) (F⳱4.77, df⳱3, 17, p⬍0.05, effect size⳱0.46) and for the second visit (after diagnosis) (F⳱13.28, df⳱3, 17, p⬍0.01, effect size⳱0.68). A subsequent Tukey’s test showed a significant difference, with the low anxiety–expression group reporting lower total mood disturbance scores than the high anxiety–suppression group at the first visit (p⬍0.01). After the diagnosis, the total mood disturbance scores of the low anxiety–expression group were much lower than those of the other three groups (p⬍0.01).
FIGURE 1.
The results indicated that 1) breast cancer patients who felt chronically anxious felt more psychological distress, compared with those who did not generally feel anxious; 2) breast cancer patients who suppress negative emotion felt more emotional distress than those who express negative emotion after disclosure of the diagnosis; 3) the high anxiety–suppression group felt a higher level of emotional distress than the low anxiety–expression group, both before and after the diagnosis; and 4) the patients with benign tumor who were highly anxious felt more psychological distress in general, and in particular felt more distress at the first visit, than those who did not feel anxious. Our aim was to identify reported anxiety, emotional suppression, and psychological distress before and after diagnosis in breast cancer patients, compared with benign tumor patients. We found that the breast cancer patients who suppressed negative emotion reported more psychological distress both at their first visit to the outpatient clinic and after disclosure of the diagnosis, compared with those who express negative emotion. Also, those who were chronically anxious reported more psychological distress than those who were not anxious. The patients with breast cancer who both expressed emotion and were not anxious reported little psychological distress, even after they were told the cancer diagnosis. In previous research on emotional suppression, Watson et al.13 reported that breast cancer patients with emotional suppression tend to adopt an attitude of fatalism and helplessness in relation to cancer. These responses toward cancer were, in turn, related to higher levels of depression and anxiety. Our results support the findings of Watson et al. In our study, breast cancer patients with emotional sup-
Changes in Profile of Mood States Total Mood Disturbance Scores After Being Given the Diagnosis of Breast Cancer or Benign Tumor in Patients With High and Low Levels of Anxiety and With Emotional Suppression or Expressiona Patients With Breast Cancer
Patients With Benign Tumor
High anxiety– supression group (N=5) High anxiety– expression group (N=5) Low anxiety– supression group (N=6) Low anxiety– expression group (N=5)
High anxiety– supression group (N=14) High anxiety– expression group (N=20) Low anxiety– supression group (N=21) Low anxiety– expression group (N=17)
Mean Profile of Mood States Total Mood Disturbance Score
100
80
60
40
20
0 First (before diagnosis)
Second (after diagnosis)
First (before diagnosis)
Second (after diagnosis)
Clinic Visit Suppression and expression groups consisted of patients with scores at or above and below, respectively, the median score of 32 on the Courtauld Emotional Control Scale. High and low anxiety groups consisted of patients with scores at or above and below, respectively, the median score of 17.5 on the Manifest Anxiety Scale. a
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DISCUSSION
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Iwamitsu et al. pression reported more psychological distress, and in particular more depression and fatigue, after disclosure of the breast cancer diagnosis. As Temoshok2 suggested, emotional suppression may be linked to helplessness or hopelessness in breast cancer patients who are experiencing severe stress. We suggest that disclosure of the diagnosis is a point of overwhelming stress and a critical time to intervene with treatment. In particular, patients who suppress emotion need to be encouraged to express their needs and their feelings so that they do not to develop patterns of depression and hopelessness/helplessness, which have been found to be associated with poorer prognosis or cancer death in longitudinal studies.6,14 Second, we found that increasing psychological distress was related to anxiety. Breast cancer patients with high anxiety also reported more psychological distress than those with low anxiety. This finding suggests that a high level of trait anxiety as a personality characteristic is also a key factor in psychological adjustment to cancer. It is interesting to note that the highly anxious benign tumor patients felt more psychological distress at their first visit to the outpatient clinic, compared with their second visit, when they were told the diagnosis. Visiting the outpatient clinic was associated with tension and depressive symptoms in these patients. This result may reflect the vulnerability to stress for people with chronically high levels of anxiety. It is noteworthy that the breast cancer patients who suppressed negative emotion and had chronically high levels of anxiety felt higher levels of emotional distress than those who expressed negative emotion and did not have anxiety before or after the diagnosis. The patients who suppressed negative emotion and were chronically anxious had double factors leading them to feel anxious and depressed in the process of the treatment. Although they are sensitive to the stressful situation, they may believe that suppressing negative emotion is the best way to cope with cancer. However, as a result of not expressing negative emotion, psychological distress may be maintained over time, and they can come to feel helplessness/hopelessness in the course of treatment. Reardon and Buck15 suggested that people who suppress negative emotion may need emotional education to learn how to communicate their negative and positive emotion accurately under extreme stress. By accurately com-
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municating emotions, patients are more likely to receive genuine social and emotional support and feedback and to deal adequately with the negative and unfamiliar feelings associated with their serious illness. Patients must acknowledge and understand the unfamiliar and frightening feelings associated with a cancer diagnosis in order to learn how to express and cope with these feelings effectively, that is, to develop emotional competence. Social support is known to be a very important factor in somatic and mental health.16 Suppressing negative emotion may be an effective way to maintain superficially agreeable human relationships but at the cost of authentic and genuine emotional expression and communication. Temoshok2 proposed that the type C pattern of coping often appears outwardly to be effective. Because persons with the type C pattern of coping are friendly and helpful to others, they are often considered to be socially desirable persons. However, when such a person is faced with extreme stress, such as being informed of a breast cancer diagnosis, this coping style is not effective. Patients who cope with stress by suppressing negative emotion need psychological intervention immediately after disclosure of the diagnosis, particularly if they are also chronically anxious. It should be noted that, although we measured the psychological distress of the benign tumor patients at the first visit and after they were told the diagnosis, we did not measure their psychological distress at later times. Cunningham et al.17 reported that benign tumor patients who receive routine clinical breast examinations worried significantly more than healthy comparison women. In conclusion, we suggest that patients who suppress emotion and chronically feel high levels of anxiety need psychological interventions, including support for and acceptance of the expression of negative emotion, immediately after the disclosure of the diagnosis of breast cancer in order to maintain their psychological adjustment in the face of the disease. Family counseling to encourage the expectation of and acceptance of the patient’s expression of negative emotion should also be considered. In the future, we plan to conduct longitudinal studies to examine the effects of chronic anxiety and suppression of negative emotion on psychological distress and treatment outcomes. This study was supported by Grant-in-Aid for Scientific Research #15730315 from the Ministry of Education of Japan.
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Emotional Suppression in Breast Cancer Patients
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