The psychological profile of women attending breast-screening tests

Sm. Sci. Med. Vol. 31. No. 10, pp. 1177-1185, 1990 Printedin Great Britain.All rightsreserved

Copyright 0

0277-9536190 S3.00 + 0.00 1990 PergamonPressplc

THE PSYCHOLOGICAL PROFILE OF WOMEN ATTENDING BREAST-SCREENING TESTS SHULAMITH KREITLER,’ SAMARIO CHAITCHIK'and HANSKREITLER’ ‘Department of Psychology, Tel Aviv University and 2Director, Oncology Institute, Ichilov Medical

Center and Medical School, Tel Aviv University, Ramat Aviv, Tel Aviv 69978, Israel Abstract-Though the benefits of early detection of breast cancer are generally known, only few women attend breast-screening examinations. The study was designed to gain insight into the problem by exploring the psychological profile of clinic attenders. In order to find out whether there is such a profile. 210 self-referred women were compared with 210 nonattending women, from the same working and social environments, matched in age, education and occupational level. All subjects were administered IO tests in 7 domains. The tests were administered as part of a health survey. The results showed that clinic attenders scored higher on negative emotions and total emotions and lower on positive emotions; higher on repression; lower on daydreams; lower on range of self-concept, references to others and negative self-references but higher on positive self-references; scored higher on self-references describing oneself in a functional and in a passive way and scored lower on those describing oneself in terms of one’s attitudes, body and appearance; scored lower on neuroticism; scored lower on different somatic complaints and health orientation but higher in alexithymia. No differences were found in authoritarianism, locus of control and self-complexity. Conclusions are that there is a psychological profile of clinic attenders, that it is focused on dysphoric emotions, psychological disease promotion and defensiveness and that it includes characteristics of the construct that is sometimes called the cancer-prone personality. Key word-breast-screening, cancer-prone, breast cancer, health orientation, alexithymia, repressiveness, self complexity, negative emotions

INTRODUCI’ION

Breast cancer is the commonest type. of cancer in women in the Western world affecting 1 in every 10 women [l-3] and its incidence is rising [4]. A great number of studies showed that detection of breast cancer at an early stage leads to better prognosis [5] and higher survival rate [6,7]. Given the evidence that breast self-examination is not sufficiently reliable and precise [8], the importance of medical examination for the early detection of cancer is even further increased. Medical examination may bring about the detection of breast cancer 12-18 months earlier than breast self-examination [9, lo]. Yet, the percentage of women, especially those at risk, who attend such clinics is usually in the range of lS-30% [l 11. Even when women are addressed personally and urged to attend, the percentage rises only to 65-70% for a single appearance but decreases below 50% for recurrent examinations [12, 131. Studies showed that the reason for the low rate of attendance is not the absence of information about the availability of possibilities for the examination or about its importance [14]. Also women who got all the necessary information [15], even doctors (16, 17] and even highrisk women who chose to join a program for close surveillance of symptoms [18] do not follow the recommended regimen for early detection. These findings give rise to the hypothesis that personality and motivational factors are likely to play a role in preventing women from attending breast examinations [19]. However, very little information exists about this theme. Most of the available information is based on studies comparing self-referred women to breast cancer screening clinics with those ss”

11/m--H

who answer invitations to attend. The results showed that the self-referred ones have more breast cancers, have more often breast symptoms, are more likely to have specific worries about breast disease than about health in general and are of a higher social class [20-221. Further studies focused primarily on the role of sociodemographic factors, and showed that individuals of higher and younger age, of lower educational level and lower socioeconomic class are less likely to undergo the recommended examinations for the early detection of cancer [see review in 231. A different approach is based on applying the health belief model, analyzing perceived benefits and costs of undergoing an examination for the early detection of breast cancer. Studies showed that there are low perceived benefits of such an examination but high costs reflected in the difficulties to secure an appointment and the danger of having cancer detected [24,25]. Since it has become relatively easy and nonexpensive to be examined, fear remains as the major deterrent. Indeed, fear has often been mentioned as a likely reason why women avoid breast screening [e.g. 19). But it has also been mentioned as a positive motivator, especially when coupled with information about the specific action that may be undertaken [26,271. Since in the case of breast screening the action is clear, fear should act as a positive factor. Thus, the major question becomes: Why is it that in some women the degree or effects of fear are such that they do not show up for breast examination, whereas in others the degree or effects are such that the women do show up? In other words, what are the psychological differences between women who elect to attend a breast-screening clinic and those who do not?

1177

1178

SHULAMITH KREITLERef al.

The question becomes particularly significant in view of the claim of some investigators that elective attendance at a breast-screening clinic does not reflect any personality characteristics but is prompted merely by legitimate concern about breast disease on the part of women who are actually at increased risk for breast cancer [20,22]. Thus Morris and Greer [20] studied women who showed up in the clinic and found that their scores on the Eysenckian measures of extraversion and neuroticism did not differ from norms of British women in the general population. They also found that women with benign breast disease did not differ from those without disease in these scores on Spielberger’s State Anxiety Inventory but scored higher on State Anxiety. However, these findings cannot be regarded as conclusive since they are based on comparing women with or without benign breast disease or by comparing the scores of the attenders with the norms of the general population which represent the scores of both attenders and nonattenders. Such comparisons cannot replace the required comparison of women who showed up in the clinics with those who did not. Our study was designed to address the issue of the personality dynamics underlying elective attendance at a clinic by comparing women who show up for examinations with those who do not. We expected that information about the characteristic personality profile of the attenders would enable convincing more women to expose themselves to the available screening procedures. The selection of tests for determining the psychological profile of the clinic attenders was guided mainly by our attempt to examine a broad range of domains so as to get a fairly comprehensive personality profile of clinic attenders. Accordingly, seven domains were sampled in this study: (a) Socioeconomic characteristics, including educational, occupational and cultural background, and an overall index of social competence (see Method). (b) Various emotional responses, including both negative emotions, such as anxiety and depression as well as positive ones, such as love and joy. (c) Personality traits, including authoritarianism, locus of control, daydreaming and repressiveness (defined in terms of high defensiveness and low anxiety; see Method). (d) Self concept-its complexity and contents. The self concept was defined as a set of cognitive contents describing the self, coded in terms of general content categories, such as function, emotional reactions or actions [28], derived from a general system for the assessment of meanings [29]. Of special interest in the present context are complexity, represented by the number of different content categories the individual used for describing herself, as well as the specific content categories and the positive and negative references to oneself. (e) Mental health, as reflected in neuroticism.

(f) Psychosomatic tendencies, as reflected in the number of psychosomatic complaints in different domains (e.g. digestion, breathing) and alexithymia. The latter denotes an inability to describe one’s emotions and a restricted internal life, characteristic of psychosomatic patients [30, 3 I]. (g) Attitudes supporting health, as reflected in cognitive orientation scores. These scores reflecting beliefs of four types (about self, goals, norms and reality) were found to be higher in healthier individuals and seem to represent an overall nonconscious orientation toward the maintenance of health [32]. Except for the first domain (see Introduction), the other six domains have hardly been studied up to now in the context of behavior designed to enable early detection of cancer. Exceptions are studies which show that psychiatric patients tend to ignore potential cancer symptoms for excessively long periods [33-351 [see domain (e)]; or that women with higher scores on some internal control subscales tend to practice breast self-examination more than those with lower scores [36] [see domain (c)l. On the basis of these findings and psychological information about individuals who take active care of their health, we had more specific expectations in regard to some of the examined variables. Concerning socioeconomic characteristics, the a priori equating of the groups in age, education and occupational level limited the possibility of setting up hypotheses to the variables of marital history and family history of cancer. In view of the evidence that married people have in general better health and lower mortality [37,38], we expected clinic attenders to include more married women. Further, since acquaintance with cancer in the family might alert a person to the issue of cancer morbidity and detection, we expected clinic attenders to have more canceraffected relatives than the controls. In the emotional domain, we expected the clinic attenders to score lower on the negative emotions, especially depression, hostility and anxiety, and higher on the positive emotions, particularly love and joy. These expectations were based on findings indicating that negative emotions were related with increased risks for different diseases [39,40], whereas joyful feelings were related to better health [37,41,42]. We assumed that persons scoring high on negative affectivity might be too stressed, pessimistic and preoccupied to undertake actions designed to maintain their health, whereas persons scoring high on positive emotions might be more highly motivated to do something for themselves and to preserve their good state of health. Concerning personality traits, we expected that clinic attenders would score higher on authoritarianism because clinic attendance may involve conformity, obedience to regulations and the desire for clarity (in our case, in regard to one’s state of health, properties that are in general higher in authoritarians [43]). We also expected clinic attenders to score high on internal control because of the evidence that internals engage more than externals in taking care of their health and comply more with health regimen

Psychological profile of clinic attenders [44,45]. Further, we expected clinic attenders to score lower than the nonattenders on repressiveness because it was shown to reduce active coping which is necessary for health maintenance [46]. In regard to daydreaming, we expected clinic attenders to score low on all varieties of this construct because daydreaming might imply a tendency to withdraw from reality. Thus, it would contradict the focus on reality reflected in showing up voluntarily in a breast-screening clinic. In regard to the self-concept, we expected clinic attenders to have a higher self-esteem (namely, more positive than negative self-references) because selfesteem was shown to be related to a high sense of control [47,48]. As noted above, we tended to regard clinic attendance as reflecting internal control. Concerning the more specific content categories, we expected clinic attenders to score higher on those that reflect actional and functional self-references, or reveal concern with one’s body and its external appearance. The reason was that the former represent an active coping stance and the latter bodily awareness, both of which may promote exposure to medical examinations. In regard to mental health, we followed studies showing that neurotic persons are at higher risk of premature mortality from disease-related causes but also from accidents [49]. These findings suggest that neurotics do not take good care of their health. Accordingly, we expected the clinic attenders to score lower on neuroticism than the controls. In regard to psychosomatic tendencies, our reasoning was that somatic complaints reflect an awareness of symptoms and a tendency for transforming psychological issues into somatic problems [31,50], both of which may be more characteristic of clinic attenders than of the controls. Therefore we expected for clinic attenders higher scores on different somatic complaints and alexithymia. Finally, concerning the cognitive orientation for health, our expectation was based on studies which showed that this orientation predicted successfully (a) in a group of undergraduates, who would suffer in the course of eight subsequent months of common health troubles like the flu; (b) in a group of men undergoing hernia operations, who would suffer from fever and other complications following the operation; and (c) in a group of persons 5&70 years old, who has high levels of the different physiological risk factors for coronary heart disease like cholesterol or high blood pressure [32]. In view of this information, we expected the cognitive orientation for health to be higher in clinic attenders than in the controls. METHOD

Subjects The subjects were 210 women who attended on their own the breast-screening clinics of the Israeli National Cancer Association (where examination is for free and open to anyone even without physician referral) and 210 women who did not attend the clinic and were matched to the experimental sample in age, education and occupational level (see Table 1 for descriptive information about the samples). The matching in these demographic variables was done

1179

because these variables are most likely to affect psychological factors of the kind that may be expected to differentiate between clinic attenders and nonattenders, for example, health orientation [32]. Follow-up of the subjects revealed that none of the clinic attenders was found to suffer from breast cancer. Procedure The experimental subjects were contacted when they arrived in the clinic. The control subjects were selected out of a large number of women in different working places. These women were first administered the questionnaires, on a random basis. Then they were informed through salient advertisements in their working places about the possibility to undergo breast-screening examinations in the clinics sponsored by the Israeli Cancer Association. Four weeks later they were asked in the framework of a brief health-oriented questionnaire whether they were aware of the clinic services, whether they had undergone breast screening at the clinics in the course of the last month, or whether they had been examined elsewhere or at any other time in the past. The control subjects were selected out of those women who answered the first question positively and both of the other questions negatively (they formed 86% of the originally tested women). All those who had answered the first question positively also mentioned that they had read the advertisements. In both the experimental and control groups the questionnaires were presented as part of a presumed population survey about different attitudes. Only 0.5% of the addressed women refused to participate. Each subject was administered 5 randomly selected questionnaires out of the total 10 and the Background Information Questionnaire. Instruments and measures (1) Background Information Questionnaire, which provided the information presented in Table 1, was used for constructing the social competence index [5 l] and in the case of the clinic attenders included also a question about the reasons for addressing the clinic. (2) Emotional Responses were assessed by a checklist of 39 adjectives concerning 10 emotions, including the MAACL [52] (assessing depression, anxiety and hostility), the MACL [53] (assessing social affection, i.e. love, fear, elation, i.e. joy, vigor and fatigue) and adjectives about contentment and jealousy added for the sake of completeness [54]. The subjects responded by checking how frequently they felt each (never = 1, sometimes = 2, often = 3). The scores were the sums of the responses to the items composing each cluster. (3) F scale (551 for the assessment of authoritarianism. (4) The Locus of Control [56] scale. (5) The Short Form of the Imaginal Processes Inventory [571 for the assessment of ‘positive-constructive daydreaming’ (i.e. positive: enjoyable and vivid daydreams that stimulate ideas and promote problem solving), guilt and fear-of-failure daydreaming* (i.e. negative: daydreams with depressing, frightening or panicky qualities) and poor attentional control (that reflects tendencies toward mindwandering, susceptibility to boredom and distractibility). (6) The social desirability and anxiety scales for the assessment of repression

1180

SHULAMI~KREITLER~~

01.

Table I. Demographic and other background information about the clinic attenders (cxpcrimcntal group) and nonattenders (control group) Variable

Experimental

Control

40.9 yr 11.3yr

40.5 yr 11.7yr

Elsewhere Unknown

65.7% 33.8% 0.5%

63.3% 36.7%

Cultural background

European/American Middle-East/North African Unknown

63.3% 20.5% 16.2%

69.5% 22.4% 8.1%

No. of years in Israel (if born elsewhere)

Mean SD

36.3 yr 5.8 yr

29.4 yr 4.5 yr

Marital status

Married Divorced Widowed Single

74.3% 6.7% 3.3% 15.7%

76.2% 8.1% I .4% 14.3%

No. of children

Mean SD % With no children

kc

Mean

SD Place of birth

lSI7lCl

1.85

I so

1.47 20.0%

1.32 23.3%

Profess./techn.

13.3 yr 2.7 yr 16.7% 50.0% 33.3%

12.8 yr 3.5 yr 10.0% 54.8% 35.2%

Yes No Full position Partial position

69.5% 30.5% 12.6% 21.4%

72.4% 27.6% 78.9% 21.1%

Index of social compctencc

Mean SD

12.6 2.8

13.1 2.4

First degree rclativcs with cancer

Yes No Unknown

22.4% 58.1% 19.5%

29.0% 52.8% 18.2%

Years of education Level of occupation

Work at present

Extent of work (if working)

Mean SD ~J;rBki&ed

None of the comparisons of the groups in terms of the variables listed in this table yielded significant findings. Continuous variables were compared by r-tests, discrete ones by the chi-square test or the binomial test on the raw scores (not the percentages. presented here for the sake of easier orientation). In the cast of ‘marital status’ the groups were compared not only on the four categories but also on the two categories ‘mar&d and ‘unmarried’ (the latter including ‘divorced’. ‘widowed’ and ‘single’). In the cast of ‘first degree blood relatives with cancer’ the groups were compared also without considering the ‘unknown’ category which includes missing values and cases when the cause of death was not known. The social competence index represents 6 variables (marital status, education, occupational level, work, stability of working place and employment history), each evaluated on a 3-point scale, so that its range is 6-18 (Ziglcr and Glick, 1986. pp. 46-47). For the categories of ‘level of occupation’ set ibid.

[58], defined as high defensiveness and low anxiety. (7) The self-concept measure [28], based on coding 20 responses to the ‘Who-Am-I?’ question in terms of different content categories, provides a profile of the frequencies with which the subject used each of the content categories, as well as a measure of self-complexity (assessed by the total number of content categories used), percentages of positive and negative self-descriptions, and number of references to others. (8) Eysenck’s [59] Neuroticism scale. (9) Psychosomatic tendencies were assessed by 61 items, based on different sources [60-62], referring to 18 domains (e.g. digestion, sweating), to which the subjects responded by rating their frequency (on a l-7 scale) and intensity (on a l-5 scale). Each score represented a product of these ratings. The scores for the different domains were sums of these products for the relevant items. (10) Alexithymiu was assessed by the SchallingSifneos Personality Scale [30]. (11) Attitudes toward health were assessed by the cognitive orientation questionnaire of health [32] that provides a measure of the motivation supporting health in terms of four belief types (about self, goals, norms and general).

RESULTS

The major causes mentioned by the clinic attenders for addressing the clinic were the pressure of a friend or relative (21.90%), adherence to a self-imposed routine (‘I undergo such a test once a year’) (19.5%), the occurrence of a cancer case in the family or among one’s acquantances (16.2%), information in the media (viz. the press) about the benefits of early detection of cancer (20%), public advertisements about the availability of the service of screening (10.5%), and ‘don’t know’ or ‘no response* (11.9%). Table 1 shows that the experimental and control groups did not differ on demographic variables, including those on which they were equated, as well as in the incidence of cancer in the family. Thus, the expectations that clinic attenders would include more married women and more women with family relatives affected by cancer were not supported. Table 2 indicates that the groups differed significantly on 50 of the 83 variables on which they were compared. The percentage of variables with significant results (60.24%) far exceeds that expected by

Psychological

protie of clinic attenders

1181

Table 2. Means, SDs and mean comparisons for variables that yielded significant difkences between clinic attenders and nonattenders Nonattenders

Attenders Variable

Emotional rrspons~~ Depression

Anxiety Hostility Fear Fatigue Jealousy Social affection Elation (joy) Contentment Negative emotions Positive emotions Sum total of emotions

Mean

SD

Mean

SD

t .-rest

18.78 12.47 IO.71 z I:38 2.49 7.14 13.82 46.74 23.45 77.29

4.50 2.57 2.51 1.19 0.91 0.49 0.63 I .22 2.28 9.17 3.56 8.94

16.34 II.50 9.34 3.03 3.29 I .65 2.79 7.78 14.95 41.86 25.63 73.78

4.13 2.15 2.22 I.01 0.76 0.64 0.46 I.47 2.48 ::: 6.26

5.548*** 2.973.. 4. I82’** 2.42, 5.927..* 3.362*** 3.996”* 3.415*** 3.44799. 4.191*** 4.012**’ 3.296***

75.53 39.97 19.38 22.13

15.27 8.89 4.22 4.55

80.01 43.93 17.48 19.54

13.17 9.61 5.34 4.76

2.276’ 3.103.. 2.871. 4.020’**

33.02 0.33 0.09 2.39 27.24 11.47 283.55 43.29

18.07 0.18 0.09 I.69 16.39 9.01 127.22 6.37

38.48 0.26 0.12 3.00 33.51 15.00 378.07 40.87

9.91 0.12 0.09 2.00 16.01 10.06 144.38 5.55

2.712’. 3.351’9. 2.419. 2.380, 2.792.’ 2.678’* 5.03399. 2.929.

33.55 33.97 32.31 31.91 1.03

13.07 13.66 19.22 18.75 __

62.40 57.70

13.87 16.47 15.91 14.88 1.06

15.512*** ll.362*** 11.103*** I I .924*** 7.199***

Personality traits

Positive + negative dayd-ing Low attentional control Dcfmsiveness Repressiveness &If-COnCCpl

Total No. of responses Proportion of positive responses Proportion of negative responses References to others Complaints: lassitude Complaints: mental trouble Complaints: total Alexithymia Attitutes orienting roward health

Cognitive orientation of health Reliefs about norms Reliefs about goals Reliefs about self General beliefs Cognittve orientation score

1.23

59.35 59.77

2.17

In ‘emotional responses’ and psychosomatic tendencies’: complaints, the number of items in each of the clusters is different. ‘Negative emotions’ includes depression’, ‘anxiety’, ‘hostility’. ‘fear’ and ‘jealousy’; ‘Positive emotions’ includes ‘social affection’, ‘elation’ and ‘contentment’. In ‘self=concept: content categories’ the scores are proportions out of the total number of response units in the subject’s questionnaire. In ‘attitudes orienting toward health’, the cog. orientation score (a standard score of this questionnaire) is the sum of the binary scores (0 or I) assigned to each of the four belief types in accordance with whether the score was above (= I) or below (0 0) the group’s mean. lP < 0.05; ‘.P < 0.01; l**p < 0.001.

chance (S%, i.e. 4.15 variables; CR = 7.598, P < 0.001). In the domain of emotional responses the groups differed significantly (Table 2) in 9 out of the 10 emotions (all except ‘vigor’): the clinic attenders scored higher than the controls on the total frequency of emotions and on all negative emotions (depression, anxiety, hostility, fear) as well as fatigue but not jealousy (where they scored lower) and scored lower on all positive emotions (social affection, elation, contentment). The factor analyses (Table 3) show that in clinic attenders the major emotional factor is dysphoria (accounting for 54% of the variance), whereas the positive emotions are loaded partly on a second weaker factor and a third unstable one. In contrast, in the control group, the major factor (65.6% of the variance) represents the positive emotions, whereas the second much weaker one represents three negative emotions. Thus, the results for negative and positive emotions were contrary to those expected. In the domain of personality traits, clinic attenders did not differ significantly from nonattenders in authoritarianism and locus of control, and scored higher on repression, especially due to higher scores on defensiveness. Thus, the findings did not confirm

the expected about authoritarianism and locus of control, and were contrary to the expected in regard to repressiveness. Daydreaming was the only personality trait that yielded results in line with the expected. Table 2 shows that the combined frequencies of positive and negative daydreams as well as poor attentional control were lower in clinical attenders than in the controls. In regard to the self-concept, the findings show that clinic attenders had a more restricted self-concept (i.e. they used fewer units of contents for describing themselves) but not a less complex one (i.e. they used the same number of content categories). Further, as expected, they communicated about themselves fewer negative items and more positive ones. In describing themselves they referred less often to other human beings and to interpersonal relations in general. There were significant differences in 11 of the 30 content categories of the tests, indicating that clinic attenders as compared to nonattenders grasp themselves more in terms of their function (e.g. their role in life, profession), the actional and emotional reactions of others to them (rather than their own active actions or what they themselves feel), and their state and situation (socially, healthwise, etc.). It is also characteristic for them to conceive of themselves

1182 Table 3. Results of factor analyses on the 10 clusters of emotional reqxmses in the groups of clinic attenders and nonattenders Grow

Variables

Attenders

Depression Anxiety Hostility Fear Jealousy Social affection Contentment Elation Vigor Eigenvalue Percent of variance

Nonattenders

Factor I

Factor II

0.77 0.75 0.54 0.82 0.55

Factor JJJ

-0.52

0.63 0.59

Depression Contentment Social affection Elation (joy) Anxiety Fear Vigor Eigenvalue Percent of variance

2.94 54.0

1.89 34.8

-0.60 0.75 0.59 0.73

0.66

0.60 0.67 0.55 0.61 11.3

0.67 0.55 3.22 65.6

0.70 0.55 11.3

1.13 23.1

The factors were derived by Vatimax rotation after Kaiser normalization. The table presents the variable loadings on the factors. Only loadings of SO.50 are presented. Only factors with eigcnvalue 3 1.00 and/or percentage of accounted variance P 10% are presented. Please note that the third factor is probably unstable due to eigenvaluc 4 1.00.

temporally (e.g. to mention precisely when different events occurred) and causally (i.e. to present the causes for what they did or their state). Further, clinic attenders describe themselves less than the controls in terms of their body (i.e. their external appearance and parts of their body), their views and attitudes and the general groups to which they belong (i.e. cultural, national, ethnic, sexual). In regard to the specific content categories, the findings about the functional and actional aspects were in line with the expected but those concerning the body were contrary to the expected. In regard to mental health, Table 2 shows that, as expected, clinic attenders scored lower than the controls on neuroticism. Concerning psychosomatic tendencies, contrary to expectation, they scored lower on

11 of the 18 domains of psychosomatic symptoms as well as in the total score, but as expected scored higher on alexithymia. Factor analyses of the psychosomatic complaints (Table 4) yielded for clinic attenders four clearly differentiated and easily identifiable factors (accounting for 84.2% of the variance): ‘digestion’, ‘tension’, ‘liquid secretions’, and ‘fatigue’. In contrast, in the controls there were only two factors (accounting for 76.3% of the variance) which were so lowly differentiated that no titles could be fitted to them. Finally, in regard to attitudes promoting health, the findings contradicted the expectation. Table 2 shows that in each of the four belief types separately as well as in the overall index, the clinic attenders scored lower than the nonattenders. Moreover, the

Table 4. Results of factor analyses on the I5 clusters of somatic complaints in the groups of clinic attenders and nonattenders Grow

Variables

Attenders

Excretion Mouth Digestion Heart Muscle tension Mental Pain Renal function Sweating Breathing Lassitude Eigenvalue Percentage of variance

Nonattenders

Mental Lassitude Digestion Pain Getting fever Muscle tension Mouth Eigenvalue Percentage of variance

Factor I

Factor JJ

Factor III

Factor IV

0.72 0.67 0.78 0.64

0.72 0.66 0.55 0.84 0.88

4.39 42.2

1.81 17.3

I .42 13.6

0.66 0.56 1.15 11.1

0.62 0.8 I 0.52 0.70

6.48 65. I

0.66 0.53 0.62 1.11 Il.2

The factors were derived by Varimax rotation after Kaiser normalization. The table presents the variable loadings on the factors. Only loadings ~0.50 are presented. Only factors with eigenvalue > 1.00 and/or percentage of accounted variance > 10% are presented. The number of clusters is I5 because ‘mouth’ and ‘bitter mouth’ were combined.

Psychological

prolilc

of clinic attenders

1183

Table 5. Results of a discriminant analysis with the four belief types as independent variables and attendance versus nonattendance at the clinic as the dependent vanable Standardized canonical discriminant function coefficients for function I Beliefs about norms General beliefs Beliefs about self Beliefs about goals

0.6886 0.3564 -0.2773 -0.5674

Canonical discriminant functions Evaluated at group meaos Group 1 (attenders) Group 2 (nonattenders)

-0.33744 0.3719s

Predicted group membership Prediction results: Actual groups Group I (attenders) Group 2 (nonattenders) Percentage of correct prediction

No. of cases

Grow

105 105

79 30

I

Group 2 26 75

75.24

71.43

Total: 73.33

The discriminant analysis was done by a stepwise method (methods: Wilks). Only one function was derived.

discriminant analysis (Table 5) shows that the four belief types define one discriminant function and allow for classifying correctly the subjects in 73.3% of the cases (which provides a 23.3% improvement over chance, CR = 4.92, P < 0.001). DISCUSSION

The findings show that clinic attenders differ from nonattenders in the majority of the tested psychological variables. Thus, it seems justifiable to conclude that there is a psychological profile characteristic of clinic attenders. The profile obtained for clinic attenders can be organized around three major foci. The first is the salience of dysphoric emotions, manifested through the higher scores on negative emotions, lower scores on positive emotions, and the primacy of the factor on which the dysphoric emotions are loaded. The second focus is the psychological diseasepromotion, manifested especially through their lower scores on the four belief types of the cognitive orientation questionnaire of health and their higher scores on alexithymia. The cognitive orientation scores suggest the operation of a matrix of pathogenic beliefs which together form a vector orienting toward the production of physiopsychological conditions related to promoting or facilitating disease development. The high scores on alexithymia indicate a deficient ability to integrate somatic information into emotional experience and characterize psychosomatic and somatic patients of different categories 130,311. While this does not contradict the higher differentiation in regard to the somatic field found in clinic attenders, it corresponds to their repressiveness and accounts for their consistently lower scores on somatic complaints and their tendency in the self-concept test not to present themselves in terms of their body and external appearance. Thus, low awareness of the body and of somatic disturbances may subserve disease promotion in general and the mechanism of somatization in particular. Notably, also the salience of negative affectivity suggests a tendency antithetical to good physical health [40]. Finally, the third focus is defensiveness, manifested in higher scores on repressiveness, lower scores on daydreaming and poor attentional control, using a restricted range of contents in describing oneself, presenting an enhanced positive image of oneself

while de-emphasizing the negative aspects, not referring to one’s views when describing oneself, lower scores on somatic complaints, and higher scores on alexithymia, that among other things reflects suppression of inner-body information and impoverished fantasy life [24,39]. It would also be possible to identify extraversion rather than defensiveness as the element common to these findings. Extraversion, with its emphasis on realism and limited internal life, corresponds also to the different characteristics of the clinic attenders in describing themselves (i.e. emphasis on functions, evoked emotional reactions, temporal aspects, disregard for views and values). In line with this conception the high defensiveness scores could be reinterpreted as social desirability and the highly positive self-image as sociability. However, identifying defensiveness as the focal characteristic is more in keeping with the findings of the other two foci. Emphasis on defensiveness raises the hypothesis that these individuals suffer from some deep-rooted unresolved psychological or psychophysiological problem that is responsible for their dysphoria, weak orientation toward health and defensiveness. This hypothesis would have to be tested in future research. Insofar as the findings revealed a set of psychological tendencies characteristic of clinic attenders they support our general expectation that there is such a psychological profile. But a large number of specific hypothese were not confirmed. Especially surprising are the findings suggesting that clinic attenders have psychological tendencies toward physical disease (mainly the lower scores on the cognitive orientation of health, and the higher scores on alexithymia and negative emotions). This would contradict the fact that the clinic attenders exposed themselves voluntarily to a medical examination designed to help maintain their health. No less intriguing is the defensiveness we found in clinic attenders. Defensiveness could or should have led them to deny the possibilities of cancer and thus avoid examinations for the early detection of cancer. But, on the contrary, it led them to undergo these examinations. One way to reconcile the different intriguing findings is to assume that clinic attenders have a psychological propensity toward disease of which they may or may not be aware and are defending themselves against its deleterious or harmful effects by undergoing medical examinations.

SHuuMtm

1184

KltErrtEa et of.

Of particular interest may be the similarity that the psychological profile of the clinic attenders bears to what has sometimes been called the cancer-prone personality [63]. The three major characteristics attributed to the cancer-prone person are (a) repressive style, reflected in restricted introspective capacity and a ‘reality orientation’ [64,65], (b) restricted or suppressed expression of emotions in general, especially of anger [64,66], and (c) a tendency toward dysphoria, especially hopelessness and depression [67,68]. It may be noted that several of the findings concerning clinic attenders correspond to these characteristics. In line with the first characteristic, clinic attenders scored higher in repressiveness and lower on the different daydreaming scales. Fewer somatic complaints, self-descriptions in terms of functional aspects and self-presentation in a more positive than negative manner also fall within the range of the repressive style. In line with the second characteristic, clinic attenders scored higher on alexithymia that assesses restricted emotional responsiveness [30,3 11. Indeed, they did not score lower on the sumtotal of emotions but this is probably due mainly to the high level of negative emotions in clinic attenders. Our data does not enable examining the specific claim about suppression of anger because we did not assess emotional expression. Finally, in line with the third characteristic, clinic attenders scored higher on depression and anxiety and lower on the positive emotions. Thus, there seems to be some basis for the conclusion that clinic attenders share the psychological characteristics constituting the construct of the cancer-prone personality. This conclusion suggests that clinic attenders may be a selected sample of individuals at psychological risk for cancer. Further research is needed for establishing whether that is so and how this set of characteristics affects or is effected by clinic attendance. Concerning the motivational determinants of clinic attendance, some of the findings suggest forces that might lower the motivation to attend, e.g. weak health orientation, whereas others suggest forces that may promote it, e.g. realism, low neuroticism, even defensiveness, that might keep anxiety at check and dysphoria, because of the sour-grapes approach it implies. Thus, it seems plausible that clinic attenders have a personality structure that, on the one hand, is psychologically related to susceptibility to disease, but on the other hand, enables them to face checkups that enhance their chances of good prognosis. If so, future research should focus on finding out how to adjust for different women the right amount of anxiety elicitation. This would enable presenting the issue of early cancer detection in such a way that it would neither be a victim of the women’s defensiveness and thus be overlooked, nor be a victim of their realism and thus be dismissed as inconsequential.

20.

Acknowledgement-The authors would like to thank Mrs Rina Chaitchik for her help in collecting the data.

21.

REFERENCES

1. Hellman S., Harris J. R., Cancellos G. P. and Fisher B. Cancer of the breast. In Princ@les and Pructice of

2.

3. 4. 5. 6. 7.

8.

9.

10.

11.

12.

13.

14. 15.

16.

17.

18. 19.

22.

Oncology (Edited by DeVita V. T.. Hellman S. and Rosenberg S. A.), Chap. 27. Lippincott, Philadelphia, PA, 1982. Rowland J. H. and Holland J. C. Breast cancer. In Handbook of Pyschooncology (Edited by Holland J. C. and Rowland J. H.), pp. 188-207. Oxford University Press, New York, 1989. Cancer Facts and Figures-1988, p. 10. American Cancer Society, New York, 1988. American Cancer Society, New York. Am. Cancer Sot. Newsl. VIII, 26 Jan., 1987. Cancer Facts and Figures 1984. American Cancer Society, New York, 1983. Levv S. M. Behavior and Cancer. Jossey-Bass, San Francisco, CA. 1985. Annual Cance> Statistics Review Including Cancer Trends: 1950-1985. National Cancer Institute. Division of Cancer Prevention and Control and Division of Cancer Treatment, 6 Jan., 1988. Miller A.. Chamberlain J. and Tsechkovski M. Selfexamination in the early detection of breast cancer. J. chron. Dis. 38, 527-540, 1985. Penn W. and Hendriks J. Die Bedeutung von breitangelegten Vorsorgeuntersuchungen fuer die Prognose des Mammacarzinoms. Cbirurg 55, 211-217, 1980. Slater P. E., Melnik Y., Katz L. and Davies A. M. The early breast cancer detection program of the Israel cancer association: a retrospective evaluation. Israel J. med. Sci. 17, 827-838, 1981. Baurmann H. Moeglichkeiten und Grenzen der Krebsfrueherkennung. Eine kritische Studie zur Gesundheitserziehung aus medizinischer und psychologischer Sicht. Med Dissertation, Mainz University, Mainz. 1986. Verbeek A. L. M., Hendriks J. H. C. L., Holland R. et al. Reduction of breast cancer mortality through mass screening with modem mammography: first results of the Nijmegen project 1975-1981. Luncet 1, 1222-1224, 1984. U.K. Trial of Early Detection of Breast Cancer Group. Trial of early detection of breast cancer: description of method. Br. J. Cancer 44, 618627, 1984. Westhoff K. and Halbach-Suarez C. Cognitive orientation and the prediction of decisions in a medical examination context. Eur. J. Person. 3, 61-71, 1989. Wilkes E., Schoenfeld E. R., Ruesch D. C. and Mettli C. J. The planning, execution and evaluation of a breast cancer detection awareness program. J. Cancer Educ. 3, 247-255, 1988. Chamberlain R. M., Lane M., Weinberg A. D. and Carbonari J. P. Application of cancer prevention knowledge: a longitudinal follow-up study of medical students. J. Cancer Educ. 2, 93-106, 1987. Mulvihill J., Safyer A. and Bening J. Prevention in familial breast cancer: counseling and prophylactic mastectomy. Preuettt. Med. 11, 500-511, 1982. Buttlar C. A. and Templeton A. C. The size of breast masses at presentation: the impact of prior medical training. Cancer 51, 1750-1753, 1983. Baines C. J. Imoediments to recruitment in the Study: Canadian National Breast Screening resnonse and resolution. ControBed Clin. Trials 5, 129-138, 1984. Morris T. and Greer S. Psychological characteristics of women electing to attend a breast screening clinic. C/in. Oncol. 8, 113G19, 1982. Chamberlain J., Rogers P., Price J. L., Ginks S., Nathan B. E. and Bum I. Validity of clinical examination and mammography as screening tests for breast cancer. Luncet 2, 10261030, 1975. Hobbs P., Sellwood R. A. and George W. 0. Selfselection and self-referral in breast screening. C/in. Oncol. 6, 143-151, 1980.

Psychological profile of clinic attenders 23. Holland J. C. Fears and abnormal reactions to cancer in physically healthy individuals. In Handbook of Psychooncology (Edited by Holland J. C. and Rowland J. H.), pp. 13-21. Oxford University Press, New York, 1989. 24. Antonovsky A. and Hartman H. Delay in the detection of cancer: a review of the literature. Hlth Educ. Monogr. 2, 98-128,

Hum. Behav. 7. 248-254.

50. 51.

52.

1966.

28. Kreitler S. and Kreitler H. Psychosemantic aspects of the self. In Self and Identity (Edited by Hone& ‘I’. M. and Yardley K. M.), pp. 338-358. Routledge & Kegan Paul, London, 1987. 29. Kreitler S. and Kreitler H. The Cognitiue Foundations of Personalitv Traits. Plenum, New York. 1990. 30. Apfel R. j. and Sifneos P. E. Alexithymia: concept and measurement. Psychother. Psychosom. 32, 180-190, 1979. 31. Shipko S. Alexithymia and somatixation. Psychother. Psychosom. 37, 193-201,

47. Blatt S. J., D’Afllitti J. P. and Quinlan D. M. Experience of depression in normal young adults. J. Abnorm. Psychol. 85, 383-389, 1976. 48. Fry P. S. Thematic contents of depressive cognitions in the elderly. In The Self in Anxiety, Stress and Depression

49.

1974.

25. Green L. W. and Roberts B. J. The research literature on why women delay in seeking medical care for breast symptoms. Hlth Educ. Monogr. 2, 129-177, 1974. 26. Leventhal H. Fear communications in the acceptance of preventive health practices. Bull. N.Y. Acad. Med. 41, 1144-l 168, 1965. 27. Kirscht J. P., Haefner D. P., Kegeles S. S. and Rosenstock I. M. A national study of-health beliefs. J. Hlth

1982.

32. Kreitler S. and Kreitler H. The psychological protile of the health oriented individual. Eur. J. Person. In press. 33. Lynch H. T. and Krush A. J. Breast carcinoma and delay in treatment surgery. Gynecol. Obstet. Invest. 128, 1027-1032. 34. Lynch H. T., Krush T. P. and Krush A. Psychodynamics in cancer detection: a patient with advanced cancer of the lip. Psychosomatics 7, 152-157, 1966. 35. Talbot J. A. and Linn L. Reactions of schizonhrenics to life-threatening disease. Psychiot. Q. SO, 218l227, 1978. 36. Murray M. Locus of control. self concept, attitudes to cancer and attendance for screening. Paper presented at the International Conference on Health Psychology, 18-22 Sept., 1989, Cardiff, England, 1989. 37. Argyle M. The Psychology of Happiness. Methuen, London, 1987. 38. Lynch J. J. The Broken Heart. Basic Books, New York, 1977. 39. Friedman H. S. and Booth-Kewley S. The ‘diseaseprone personality’: a meta-analytic view of the construct. Am. Psychol. 42, 539-555, 1987. 40. Watson D. and Pennebaker J. W. Health complaints, stress and distress: exploring the central role of negative affectivity. Psvchol. Reo. %. 234254. 1989. 41. Cousins N. Anatomy of an illness (as perceived by the patient). New Engl. J. Med. 295, 1458-1463, 1976. 42. McClelland D. C. Motivation and immune function in health and disease. Paper presented at the Meeting of the Society of Behavioral Medicine, New Orleans, LA, 1985. 43. Cherry F. and Byrne D. Authoritarianism. In Personality Variables in Social Behavior (Edited by Blass T.). pp. 109-133. Erlbaum, Hillsdale, NJ, 1977. 44. Strickland B. R. Internal-external expectancies and cardiovascular functioning. In Choice and Perceived Control (Edited by Perlmuter L. C. and Monty R. A.), pp. 221-231. Erlbaum, Hillsdale, NJ, 1979. 45. Weaver R. Internality, externality and compliance as related to chronic home dialysis patients. Unpublished Master’s Thesis, Emory University, 1972. 46. Moos R. H. and Solomon G. F. Personality correlates of the functional incapacity of patients with physical disease. J. chron. Dis. 18, 1019-1038. 1965.

1185

53.

54. 55.

56.

(Edited by Schwartxer R.), pp. 313-321. Elsevier, New York, 1984. Sims A. Neurosis and mortality: investigating an association. J. psychosom. Res. 28, 353-362, 1984. Pennebaker J. W. The Psychology of Physical Symptoms. Springer, New York, 1982. Zigler E. and Glick M. Developmental Approach to Adult Psychopathology, pp. 43-67. Wiley, New York, 1986. Zuckerman M. and Lubin B. Manual for the Multiple Affect Adjective Checklist. Educational and Industrial Testing Services, San Diego, CA, 1965. Nowlis V. Research with the Mood Adjective Check List. In Affect, Cognition and Personality (Edited by Tomkins S. S. and Izard C. E.), pp. 352-389. Spinger, New York, 1965. Frijda H. H. The Emotions, pp. 176-259. Cambridge University Press. New York. 1986. Adomo T. W., Frenkel-Brunswick E., Levinson D. J. and Sanford R. N. The Authoritarian Personality, PP. 255-257. Hamer & Row. New York. 1950. Rotter J. B. Generalized expectancies for internal versus external control of reinforcement. Psychol. Monogr. 80,

No. 1, 609, 1966. 57. Huba G. I., Aneshensel C. S. and Singer J. L. Develop-

ment of scales for three second-order factors for inner experience. Multivariate Behav. Res. 16, 18 l-206, 198 1. 58. Weinberger D. A., Schwartz G. E. and Davidson R. J. Low anxious, high anxious and repressive coping styles: psychometric patterns and behavioral physiological responses to stress. J. Abnorm. Psychol. 88, 369-380, 1979. 59. Eysenck H. J. and Eysenck S. B. G. Manual of the Eysenck Personality Questionnaire (EPQ). Hodder &

Stoughton, London, 19756. 60. Attanasio V., Andrasik F., Blanchard E. B. and Arena

J. G. Psychometric properties of the SUNYA revision of the psychosomatic symptom checklist. J. behar. Med. 7, 247-258, 1984. 61. Eysenck H. J. The Scientific Study of Personality, p. 95.

Routledge & Kegan Paul, London, 1958. item screening score of psychiatric symptoms indicating impairment. J. Hlth

62. Langner T. S. A twenty-two

Hum. Behav. 3, 269-276, 1962. 63. Temoshok L. and Heller B. W. On comparing apples,

oranges and fruit salad: a methodological overview of medical outcome studies in psychosocial oncology. In Psychosocial Stress and Cancer (Edited by Cooper C. L.), pp. 231-260. Wiley, London, 1984. 64. Dattore P. J., Shontz F. C. and Coyne L. Premorbid personality differentiation of cancer and non-cancer groups: a- test of a hypothesis of cancer proneness. J. Counsel. Clin. Psvchol. 48. 388-394. 1980. 65. Bahnson C. B. and Bahnson M. B. Role of the ego

defences: denial and repression in the aetiology of malignant neoplasm. Ann. N. Y. Acad. Sci. 125.827-845, 1966. 66. Morris T.. Greer S., Pettingale K. W. and Watson M. Patterns of the expression of anger and their psychological correlates in women with breast cancer. J. psychosom. Res. 25, 111-117, 1981. 67. Schmale A. and Iker H. Hopelessness as a predictor of cervical cancer. Sot. Sci. Med. 5, 95-100, 1971. 68. Becker H. Psychodynamic aspects of breast cancer; younger and older patients. Psychother. Psychosom. 32, 287-296,

1979.