- Email: [email protected]
Anxiety, optimism and symptom reporting following surgery for acoustic neuroma
Journal of Psychosomatic Research, Vol. 46, No. 3, pp. 257–260, 1999 Copyright 1999 Elsevier Science Inc. All rights reserved. 0022-3999/99 $–see front matter
S0022-3999(98)00093-2
ANXIETY, OPTIMISM AND SYMPTOM REPORTING FOLLOWING SURGERY FOR ACOUSTIC NEUROMA GERHARD ANDERSSON Abstract—In this study, a sample of 141 patients operated on for acoustic neuroma tumor were followed-up. The patients completed questionnaires on residual symptoms, hearing problems, anxiety, and optimism. Postoperative facial function was assessed by the treating physician. Multiple regression analyses showed that anxiety, age, and facial function were associated with symptom reporting. Anxiety was also related to hearing problems. Optimism was not associated with either symptoms or hearing problems. Results on the Beck Anxiety Inventory showed that relatively few patients had a moderate degree of anxiety. 1999 Elsevier Science Inc. Keywords: Vestibular schwannoma; Cancer; Beck Anxiety Inventory; Life Orientation Test; Hearing Coping Assessment.
INTRODUCTION
Acoustic neuroma is a benign tumor of the Schwann cells, located near the cerebellopontine angle of the brain stem. It generally arises from the vestibular branch of the eighth cranial nerve. Because early detection and management have increased, most patients survive and can continue to lead a fairly normal life after treatment [1]. In recent years, patient factors, in terms of quality of life and remaining symptoms, have received increased research interest [2–5]. Among the residual symptoms that may occur after surgery are facial nerve paralysis, eye dryness, unilateral deafness, tinnitus, headache, and dizziness/unsteadiness [2–5]. Moreover, in a clinically significant proportion of patients, psychological factors such as anxiety may be present and thus influence the reporting of physical symptoms. A few recent studies have explored psychological consequences following acoustic neuroma, mostly focusing on depression [6, 7]. These studies indicate that the operation may affect patients negatively, which of course must be seen in relation to the potentially life-threatening nature of the condition. Parving et al. [2] found that 57% of their operated patients experienced negative psychological consequences, and Jørgensen and Pedersen [8] found that 51% patients had psychological problems. However, positive psychological effects have also been observed, for
Departments of Psychology and Audiology, Uppsala University, Uppsala, Sweden. Address correspondence to: Dr. Gerhard Andersson, Department of Psychology, Uppsala University, Box 1225, SE-751 42 Uppsala, Sweden. Phone: 146-18-18-21-16; Fax: 146-18-18-21-23; E-mail: [email protected].
257
258
G. ANDERSSON
Table I.—Mean results, sds and internal consistencies for the Acoustic Neuroma Symptom Questionnaire (ANSQ), the Hearing Coping Assessment (HCA), the Life Orientation test (LOT) and the Beck Anxiety Inventory (BAI) Scale ANSQ HCA LOT BAI
m
sd
a
37.0 20.1 22.9 6.3
15.2 8.4 4.4 5.3
0.69 0.90 0.73 0.83
instance, in a study by Wiegand et al. [9], who found that 18% of the patients they evaluated felt more optimistic about themselves after surgery. Although there are published outcome studies, there is a lack of psychological studies using established psychological measures. This study will focus on anxiety and dispositional optimism, both being popular constructs in psychological research on cancer [10, 11]. The aim was to investigate symptoms following acoustic neuroma surgery, levels of anxiety and optimism, and the possible relation between these two latter constructs and the experience of symptoms. METHOD Subjects A sample of 156 patients received a questionnaire booklet by post and 141 replied with usable responses (90% response rate). The patients included had been operated on between 1988 and 1994 in Uppsala, Sweden, for acoustic neuroma using a translabyrinthine approach to tumor removal. The proportion of left/right side tumors was equal (47.5% right side) as was gender distribution (48% males). The mean age at operation was 53.2 years (sd514.6, range 19–86), and mean duration between operation and follow-up was 3.3 years. Tumor size, assessed by intracranial CT/MRI diameter, was, on average, 27.3 mm (sd510.6).
Measures The questionnaire booklet included a symptom questionnaire (Acoustic Neuroma Symptom Questionnaire; ANSQ) [3] consisting of 22 questions answered according to a five-step scale (“do not agree at all” to “totally agree”). Questions were asked dealing with both positive and negative aspects of the surgery and residual symptoms, including facial nerve function, hearing, tinnitus, headache, dizziness, balance, and eye dryness. Responses were summed yielding a total score. Also included were the Hearing Coping Assessment (HCA) [12] for assessment of subjective hearing loss, the Life Orientation Test (LOT) for measuring optimism [13], and the Beck Anxiety Inventory (BAI) for measuring anxiety [14]. Except for the LOT, for which higher scores indicate more optimism, higher scores signify more problems.
Clinical rating Facial function was assessed after surgery by a physician using a grading system devised by House and Brackmann [15], with six degrees of facial functioning ranging from normal (House I) to total paralysis (House VI).
RESULTS
Mean results and internal consistencies for the scales are presented in Table I. Using the cut-off score of 19 on the BAI [16], six patients had moderate anxiety problems (4.4%). Two sets of multiple regressions were conducted entering tumor size, age, clinician-assessed facial function, the LOT, and the BAI as predictors. To-
Acoustic neuroma
259
tal score on the ANSQ was used as the first dependent variable and total score on the HCA as the second dependent variable. Results showed that, for the prediction of symptoms, as assessed by the ANSQ, a significant multiple regression was found [R50.53, R2adj.50.26, F(5,126)59.66, p,0.0001]. Three independent variables reached significance in the model: age (b50.32, p,0.0001); facial function (b50.37, p,0.0001); and the BAI (b50.18, p,0.05). Tumor size and the LOT did not reach significance. A significant multiple regression was also found for the HCA [R50.30, R2adj.50.05, F(5,124)52.33, p,0.05]. Only the result on the BAI reached significance as a contributor to the regression (b50.26, p,0.01). DISCUSSION
The main findings from this retrospective study were that anxiety, age, and facial function were associated with symptom reporting following acoustic neuroma surgery. Anxiety was also related to hearing problems. Optimism was not associated with either symptoms or hearing problems. Unfortunately, a major point of criticism that this outcome study shares with others on acoustic neuroma surgery is the lack of preoperative data. Prospective studies on the importance of psychological factors are needed. Other psychological constructs, such as depression [6], should also be considered in future research. The result for the BAI showed a relatively low rate of anxiety as has been observed in other cancer studies [11]. Its association with symptom reporting and hearing problems was expected given the pervasive influence of negative affect on symptom reporting. More surprising was the inability of the LOT to predict symptoms. This is in contrast to other cancer studies using the instrument [17], and also compared with studies on hearing impairment and tinnitus [18]. Age was a significant predictor of residual symptoms as assessed by the ANSQ. This finding is concordant with Rigby et al. [5] who found younger patients to be more disabled at follow-up. Impaired facial function is often mentioned as the worst residual problem following surgery [1], and indeed, clinician-assessed facial function predicted symptom reporting. Among the questions in the ANSQ were questions on facial function, indicating a correspondence between clinician and patient ratings. In conclusion, although anxiety was uncommon, there is some evidence that it is associated with symptom reporting. There could be a proportion of patients who suffer psychological distress and for which physical symptoms may at least be partly aggravated by psychological factors. Hence, early assessment and recognition of these factors could improve treatment and postoperative rehabilitation. Acknowledgments—The preparation of this manuscript was supported by the Sasakawa Young Leaders’ Fellowship Fund and the Swedish Medical Research Council. Dr. Helge Rask-Andersen is acknowledged for initiating the study.
REFERENCES 1. Eldridge R, Parry D. Summary: vestibular schwannoma (acoustic neuroma) consensus development conference. Neurosurgery 1992;30:962–964. 2. Parving A, Tos M, Thomsen J, Møller H, Buchwald C. Some aspects of life quality after surgery for acoustic neuroma. Arch Otolaryngol Head Neck Surg 1992;118:1061–1064.
260
G. ANDERSSON
3. Andersson G, Ekvall L, Kinnefors A, Nyberg G, Rask-Andersen H. Evaluation of quality of life and symptoms following translabyrinthine acoustic neuroma surgery. Am J Otolaryngol 1997;18: 421–426. 4. van Leeuwen JPPM, Braspenning JCC, Meijer H, Cremers CWRJ. Quality of life after acoustic neuroma surgery. Ann Otol Rhinol Laryngol 1996;105:423–430. 5. Rigby PL, Shah SB, Jackler RK, Chung JH, Cooke DD. Acoustic neuroma surgery: outcome analysis of patient-perceived disability. Am J Otolaryngol 1997;18:427–435. 6. Blomstedt GC, Katial H, Henriksson M, Ekholm A, Ja¨a¨skela¨nen JE, Pyykko¨ I. Depression after surgery for acoustic neuroma. J Neurol Neurosurg Psychiatry 1996;61:403–406. 7. Kalayam B, Young RC, Tsuboyama GK. Mood disorders associated with acoustic neuromas. Int J Psychiatry Med 1994;24:31–43. 8. Jørgensen BG, Pedersen CB. Acoustic neuroma. Follow-up of 78 patients. Clin Otolaryngol 1994; 19:478–484. 9. Wiegand DA, Fickel V. Acoustic neuroma—the patient’s perspective: subjective assessment of symptoms, diagnosis, therapy, and outcome in 541 patients. Laryngoscope 1989;99:179–187. 10. Andersson G. The benefits of optimism: a meta-analytic review of the Life Orientation Test. Person Individ Diff 1996;21:719–725. 11. Van’t Spijker A, Trijsburg RW, Duivenvoorden HJ. Psychological sequelae of cancer diagnosis: a meta-analytic review of 58 studies after 1980. Psychosom Med 1997;59:280–293. 12. Andersson G, Melin L, Lindberg P, Scott B. Development of a short scale for self-assessment of experiences of hearing impairment: the Hearing Coping Assessment. Scand Audiol 1995;24:147–154. 13. Scheier MF, Carver CS. Optimism, coping, and health: assessment and implications of generalized outcome expectancies. Health Psychol 1985;4:219–247. 14. Beck AT, Epstein N, Brown G, Steer R. An Inventory for measuring clinical anxiety. Psychometric properties. J Consult Clin Psychol 1988;56:893–897. 15. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93: 146–147. 16. Kabacoff RI, Segal DL, Hersen M, Van Hasselt VB. Psychometric properties and diagnostic utility of the Beck Anxiety Inventory and the State-Trait Inventory with older adult psychiatric outpatients. J Anx Disord 1997;11:33–47. 17. Friedman LC, Nelson DV, Baer PE, Lane M, Smith FE, Dworkin RJ. The relationship of dispositional optimism, daily life stress, and domestic environment to coping methods used by cancer patients. J Behav Med 1992;15:127–141. 18. Andersson G. The role of optimism in patients with tinnitus and in patients with hearing impairment. Psychol Health 1996;11:697–707.
S0022-3999(98)00093-2
ANXIETY, OPTIMISM AND SYMPTOM REPORTING FOLLOWING SURGERY FOR ACOUSTIC NEUROMA GERHARD ANDERSSON Abstract—In this study, a sample of 141 patients operated on for acoustic neuroma tumor were followed-up. The patients completed questionnaires on residual symptoms, hearing problems, anxiety, and optimism. Postoperative facial function was assessed by the treating physician. Multiple regression analyses showed that anxiety, age, and facial function were associated with symptom reporting. Anxiety was also related to hearing problems. Optimism was not associated with either symptoms or hearing problems. Results on the Beck Anxiety Inventory showed that relatively few patients had a moderate degree of anxiety. 1999 Elsevier Science Inc. Keywords: Vestibular schwannoma; Cancer; Beck Anxiety Inventory; Life Orientation Test; Hearing Coping Assessment.
INTRODUCTION
Acoustic neuroma is a benign tumor of the Schwann cells, located near the cerebellopontine angle of the brain stem. It generally arises from the vestibular branch of the eighth cranial nerve. Because early detection and management have increased, most patients survive and can continue to lead a fairly normal life after treatment [1]. In recent years, patient factors, in terms of quality of life and remaining symptoms, have received increased research interest [2–5]. Among the residual symptoms that may occur after surgery are facial nerve paralysis, eye dryness, unilateral deafness, tinnitus, headache, and dizziness/unsteadiness [2–5]. Moreover, in a clinically significant proportion of patients, psychological factors such as anxiety may be present and thus influence the reporting of physical symptoms. A few recent studies have explored psychological consequences following acoustic neuroma, mostly focusing on depression [6, 7]. These studies indicate that the operation may affect patients negatively, which of course must be seen in relation to the potentially life-threatening nature of the condition. Parving et al. [2] found that 57% of their operated patients experienced negative psychological consequences, and Jørgensen and Pedersen [8] found that 51% patients had psychological problems. However, positive psychological effects have also been observed, for
Departments of Psychology and Audiology, Uppsala University, Uppsala, Sweden. Address correspondence to: Dr. Gerhard Andersson, Department of Psychology, Uppsala University, Box 1225, SE-751 42 Uppsala, Sweden. Phone: 146-18-18-21-16; Fax: 146-18-18-21-23; E-mail: [email protected].
257
258
G. ANDERSSON
Table I.—Mean results, sds and internal consistencies for the Acoustic Neuroma Symptom Questionnaire (ANSQ), the Hearing Coping Assessment (HCA), the Life Orientation test (LOT) and the Beck Anxiety Inventory (BAI) Scale ANSQ HCA LOT BAI
m
sd
a
37.0 20.1 22.9 6.3
15.2 8.4 4.4 5.3
0.69 0.90 0.73 0.83
instance, in a study by Wiegand et al. [9], who found that 18% of the patients they evaluated felt more optimistic about themselves after surgery. Although there are published outcome studies, there is a lack of psychological studies using established psychological measures. This study will focus on anxiety and dispositional optimism, both being popular constructs in psychological research on cancer [10, 11]. The aim was to investigate symptoms following acoustic neuroma surgery, levels of anxiety and optimism, and the possible relation between these two latter constructs and the experience of symptoms. METHOD Subjects A sample of 156 patients received a questionnaire booklet by post and 141 replied with usable responses (90% response rate). The patients included had been operated on between 1988 and 1994 in Uppsala, Sweden, for acoustic neuroma using a translabyrinthine approach to tumor removal. The proportion of left/right side tumors was equal (47.5% right side) as was gender distribution (48% males). The mean age at operation was 53.2 years (sd514.6, range 19–86), and mean duration between operation and follow-up was 3.3 years. Tumor size, assessed by intracranial CT/MRI diameter, was, on average, 27.3 mm (sd510.6).
Measures The questionnaire booklet included a symptom questionnaire (Acoustic Neuroma Symptom Questionnaire; ANSQ) [3] consisting of 22 questions answered according to a five-step scale (“do not agree at all” to “totally agree”). Questions were asked dealing with both positive and negative aspects of the surgery and residual symptoms, including facial nerve function, hearing, tinnitus, headache, dizziness, balance, and eye dryness. Responses were summed yielding a total score. Also included were the Hearing Coping Assessment (HCA) [12] for assessment of subjective hearing loss, the Life Orientation Test (LOT) for measuring optimism [13], and the Beck Anxiety Inventory (BAI) for measuring anxiety [14]. Except for the LOT, for which higher scores indicate more optimism, higher scores signify more problems.
Clinical rating Facial function was assessed after surgery by a physician using a grading system devised by House and Brackmann [15], with six degrees of facial functioning ranging from normal (House I) to total paralysis (House VI).
RESULTS
Mean results and internal consistencies for the scales are presented in Table I. Using the cut-off score of 19 on the BAI [16], six patients had moderate anxiety problems (4.4%). Two sets of multiple regressions were conducted entering tumor size, age, clinician-assessed facial function, the LOT, and the BAI as predictors. To-
Acoustic neuroma
259
tal score on the ANSQ was used as the first dependent variable and total score on the HCA as the second dependent variable. Results showed that, for the prediction of symptoms, as assessed by the ANSQ, a significant multiple regression was found [R50.53, R2adj.50.26, F(5,126)59.66, p,0.0001]. Three independent variables reached significance in the model: age (b50.32, p,0.0001); facial function (b50.37, p,0.0001); and the BAI (b50.18, p,0.05). Tumor size and the LOT did not reach significance. A significant multiple regression was also found for the HCA [R50.30, R2adj.50.05, F(5,124)52.33, p,0.05]. Only the result on the BAI reached significance as a contributor to the regression (b50.26, p,0.01). DISCUSSION
The main findings from this retrospective study were that anxiety, age, and facial function were associated with symptom reporting following acoustic neuroma surgery. Anxiety was also related to hearing problems. Optimism was not associated with either symptoms or hearing problems. Unfortunately, a major point of criticism that this outcome study shares with others on acoustic neuroma surgery is the lack of preoperative data. Prospective studies on the importance of psychological factors are needed. Other psychological constructs, such as depression [6], should also be considered in future research. The result for the BAI showed a relatively low rate of anxiety as has been observed in other cancer studies [11]. Its association with symptom reporting and hearing problems was expected given the pervasive influence of negative affect on symptom reporting. More surprising was the inability of the LOT to predict symptoms. This is in contrast to other cancer studies using the instrument [17], and also compared with studies on hearing impairment and tinnitus [18]. Age was a significant predictor of residual symptoms as assessed by the ANSQ. This finding is concordant with Rigby et al. [5] who found younger patients to be more disabled at follow-up. Impaired facial function is often mentioned as the worst residual problem following surgery [1], and indeed, clinician-assessed facial function predicted symptom reporting. Among the questions in the ANSQ were questions on facial function, indicating a correspondence between clinician and patient ratings. In conclusion, although anxiety was uncommon, there is some evidence that it is associated with symptom reporting. There could be a proportion of patients who suffer psychological distress and for which physical symptoms may at least be partly aggravated by psychological factors. Hence, early assessment and recognition of these factors could improve treatment and postoperative rehabilitation. Acknowledgments—The preparation of this manuscript was supported by the Sasakawa Young Leaders’ Fellowship Fund and the Swedish Medical Research Council. Dr. Helge Rask-Andersen is acknowledged for initiating the study.
REFERENCES 1. Eldridge R, Parry D. Summary: vestibular schwannoma (acoustic neuroma) consensus development conference. Neurosurgery 1992;30:962–964. 2. Parving A, Tos M, Thomsen J, Møller H, Buchwald C. Some aspects of life quality after surgery for acoustic neuroma. Arch Otolaryngol Head Neck Surg 1992;118:1061–1064.
260
G. ANDERSSON
3. Andersson G, Ekvall L, Kinnefors A, Nyberg G, Rask-Andersen H. Evaluation of quality of life and symptoms following translabyrinthine acoustic neuroma surgery. Am J Otolaryngol 1997;18: 421–426. 4. van Leeuwen JPPM, Braspenning JCC, Meijer H, Cremers CWRJ. Quality of life after acoustic neuroma surgery. Ann Otol Rhinol Laryngol 1996;105:423–430. 5. Rigby PL, Shah SB, Jackler RK, Chung JH, Cooke DD. Acoustic neuroma surgery: outcome analysis of patient-perceived disability. Am J Otolaryngol 1997;18:427–435. 6. Blomstedt GC, Katial H, Henriksson M, Ekholm A, Ja¨a¨skela¨nen JE, Pyykko¨ I. Depression after surgery for acoustic neuroma. J Neurol Neurosurg Psychiatry 1996;61:403–406. 7. Kalayam B, Young RC, Tsuboyama GK. Mood disorders associated with acoustic neuromas. Int J Psychiatry Med 1994;24:31–43. 8. Jørgensen BG, Pedersen CB. Acoustic neuroma. Follow-up of 78 patients. Clin Otolaryngol 1994; 19:478–484. 9. Wiegand DA, Fickel V. Acoustic neuroma—the patient’s perspective: subjective assessment of symptoms, diagnosis, therapy, and outcome in 541 patients. Laryngoscope 1989;99:179–187. 10. Andersson G. The benefits of optimism: a meta-analytic review of the Life Orientation Test. Person Individ Diff 1996;21:719–725. 11. Van’t Spijker A, Trijsburg RW, Duivenvoorden HJ. Psychological sequelae of cancer diagnosis: a meta-analytic review of 58 studies after 1980. Psychosom Med 1997;59:280–293. 12. Andersson G, Melin L, Lindberg P, Scott B. Development of a short scale for self-assessment of experiences of hearing impairment: the Hearing Coping Assessment. Scand Audiol 1995;24:147–154. 13. Scheier MF, Carver CS. Optimism, coping, and health: assessment and implications of generalized outcome expectancies. Health Psychol 1985;4:219–247. 14. Beck AT, Epstein N, Brown G, Steer R. An Inventory for measuring clinical anxiety. Psychometric properties. J Consult Clin Psychol 1988;56:893–897. 15. House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg 1985;93: 146–147. 16. Kabacoff RI, Segal DL, Hersen M, Van Hasselt VB. Psychometric properties and diagnostic utility of the Beck Anxiety Inventory and the State-Trait Inventory with older adult psychiatric outpatients. J Anx Disord 1997;11:33–47. 17. Friedman LC, Nelson DV, Baer PE, Lane M, Smith FE, Dworkin RJ. The relationship of dispositional optimism, daily life stress, and domestic environment to coping methods used by cancer patients. J Behav Med 1992;15:127–141. 18. Andersson G. The role of optimism in patients with tinnitus and in patients with hearing impairment. Psychol Health 1996;11:697–707.