ARTICLE
Auteur(s) : Vincent
Jadoulle1, Leila Rokbani2, David
Ogez2, Johanna Maccioni3, Guy
Lories3, Marilou Bruchon-Schweitzer4, Aymery
Constant4
1Centre de guidance, de formations et de services
ASBL, Université catholique de Louvain, Grand Place, 43, B-1348
Louvain-la-Neuve, Belgium
2Service de psychopathologie, Cliniques universitaires
Saint-Luc, Université catholique de Louvain, avenue Hippocrate,
10/2162, B-1200 Brussels, Belgium
3Faculté de psychologie et des sciences de l’éducation,
Université catholique de Louvain, place du Cardinal-Mercier, 10,
B-1348 Louvain-la-Neuve, Belgium
4Laboratoire de psychologie de la santé, Université
Victor-Segalen Bordeaux 2, 3ter place de la Victoire, Bordeaux
Cedex, France
Cancer is a traumatic stressor, which mobilizes complex
psychological adaptive processes. The coping construct refers to
the attempt to ward off, to reduce or to assimilate an existing or
expected demand or stress (for instance the confrontation with
cancer), either by intrapsychic efforts or by action [1]. Coping is
a transactional process, which depends on situational factors, and
on the person’s support system, but also on hisor her intrinsic
resources and characteristics. The dispositional determinants
encompass different cognitive traits (e.g., beliefs, locus of
control, perceived control, perceived self-efficacy, causal
attributions, learned helplessness) and personality factors (e.g.,
optimism or pessimism, resilience, hardiness, sense of coherence,
negative and positive affectivity) [2].Several studies have
examined the efficiency of coping styles on the psychological
adaptation of subjects confronted with different aversive events.
Globally, strategies actively dealing with the problem are often
accompanied by a better psychological prognosis [3], contrary to
durable use of defensive strategies (denial, avoidance, emotional
repression) [1]. Palliative coping, which consists in looking for
quietness and comfort, was less studied, and its effects are
contradictory, although more often dysfunctional [4-6]. Coping
strategies focused on the affects are generally found to be
dysfunctional [2]. In the case of cancer, a fighting spirit is
generally considered as an efficient coping style, as well as other
active strategies like instrumental ones [2, 7-9]. Data about the
efficacy of so-called “avoiding coping” are contradictory. For
instance, Manuel et al. [10] found that initial avoidance in cancer
patients was associated to lower distress 4 to 6 weeks later. On
the contrary, Mc Caul et al. [11] found higher distress and lower
quality of life 4 months after cancer diagnosis in patients
initially using avoiding coping, and Dunkel-Schetter et al. [12]
observed a positive correlation between avoidance and psychological
distress in cancer patients. Denial also appears as an ambiguous
coping style in cancer. Stanton and Snider [13] in a prospective
study in breast cancer patients, showed that denial was accompanied
by an increased distress, and Vickberg [14] observed that use of
denial by women with breast cancer to face their fear of recurrence
was associated with increased emotional perturbations. On the
contrary, Watson et al. [15] found among breast cancer patients
hospitalized for mastectomy that deniers had less mood disorders
than non-deniers. Psychological effects of palliative coping have
been very little investigated in cancer patients. Coping by
focusing on the emotional consequences of the cancer disease, such
as helplessness-hopelessness and emotional or anxious
preoccupation, seem to be maladaptive styles accompanied by high
levels of psychological distress [2, 16-18].The three most
stressful experiences when facing cancer happen in the “acute
period”, when the subject is waiting for the results of the
diagnostic testing, receives the diagnosis and is waiting for
surgery [19]. But cancer is a particular stressor, which cannot be
reduced to the memory of this initial trauma: stress persists in
the “chronic period” in the form of persistent threats of
recurrence, extension and death. Coping responses may change with
time and with this evolution of the nature of the stressor.
Moreover, we can suspect that a same coping strategy may produce
various effects over time. However, when studying the psychological
efficiency of coping in cancer, few studies have investigated the
same group of patients in both acute and chronic situations. As
mentioned above, this efficacy is still debated, notably with
regard to avoiding and palliative coping. Intending to provide a
complementary contribution to this question, and hypothesizing that
the effects of coping styles probably differ over time, we decided
to study their efficacy in acute and chronic periods in a sample of
breast cancer women. The main aims of this research are thus to
compare coping styles in acute and chronic periods and to determine
their efficiency on psychological adaptation during each of these
periods.
Methods
Subjects and study design
Patients were in treatment for a first breast cancer in the
gynaecological unit of the « Cliniques Universitaires
Saint-Luc », Brussels (Belgium). We evaluated them during the
acute and chronic stress periods: in hospital, the day before
surgery (T1), and by mail, six months later (T2). Exclusion
criteria were previous breast cancer (n = 10), cognitive disorders
(n = 3) and insufficient knowledge of French language (n = 6).
Despite the fact that it could introduce a selection bias, we
voluntarily excluded patients that clinicians considered too
fragile to answer the psychometric questionnaires (n = 22).
Thirty-one patients refused to participate, leaving 154 patients
who gave informed consent and who were included in the study.
Post-surgical histological analyses revealed that 3 patients
suffered from benign tumours and were excluded. The final study
population consisted of 151 patients, including 107 who provided T1
and T2 evaluations and 44 who provided T1 evaluations only. Table
1( Table 1 ) shows the main
characteristics of the study patients. The Hospital’s Institutional
Review Board approved the study. Confidentiality of the
participants was protected. The psychometric evaluation was based
on the following self-rated questionnaires.
Table 1 Characteristics of the study patients (n =
151)
|
Mean age (years)
|
56.8 (SD ± 10.5)
|
|
Delay between diagnosis and T1 (days)
|
22.0 (SD ± 20.0)
|
|
Delay between T1 and T2 (days)
|
183.8 (SD ± 19)
|
|
Type of surgery (%)
|
Tumorectomy
|
9.3
|
|
Quadrantectomy
|
62.2
|
|
Mastectomy
|
28.5
|
|
Post-surgical TNM gradation (%)
|
Tis
|
8.6
|
|
T1a
|
4.6
|
|
T1b
|
17.2
|
|
T1c
|
39.7
|
|
T2
|
26.5
|
|
T3
|
3.3
|
|
N0
|
72.8
|
|
N1
|
19.2
|
|
N2
|
7.3
|
|
N3
|
0.7
|
|
M0
|
98.0
|
|
M1
|
2.0
|
Self-rated questionnaires
The CHIP scale (Coping with Health Injuries and Problems
Scale)
Few coping scales adapted to medical contexts evaluate palliative
strategies and avoidance. The CHIP is such a self-report scale. It
was developed to assess coping styles in subjects experiencing
various health problems [20]. It includes 4 sub-scales of 8 items,
identifying 4 coping styles : distraction (that is a form of
avoidance with actions and cognitions aimed at avoiding
preoccupation with the health problem), palliative
coping (self-help responses used to alleviate the
unpleasantness of the situation, by making oneself comfortable,
getting rest, changing the surroundings, etc.), and also
instrumental coping (active problem-focused strategies, such
as to seek help and to try to learn more about illness) and
emotional preoccupation (emotion-oriented coping, focusing on
the emotional consequences of the health problem). The factorial
structure of the CHIP is stable and replicable. The scale was
validated in its original English form [21]. A French version was
studied in Canadian cancer patients, and showed a good temporal
stability [22]. As this version is not available, we translated the
original one in French, with an inverted translation method.
The HADS (Hospital Anxiety and Depression Scale)
This instrument, developed for use in general medical patients,
consists of two sub-scales, respectively measuring anxiety (HADS-A)
and depression (HADS-D) [23]. HADS is a well-validated psychometric
scale in medical patients. Its total score is described in the
literature as representative of overall psychological distress
[24]. Nevertheless, as HADS-A and -D scores provided different
results, we do not expose total HADS scores. The bi-factorial
structure of HADS has been confirmed in the context of cancer, in a
sample of 568 patients [25].
Statistics
“t Student” tests, Pearson-moment correlations (r) and multiple
regression analyses were performed. As conventionally admitted, p
values ≤ 0.05 were considered as significant [26].
Results
Comparison of T1 And T2 Mean Scores
The t Student tests showed that the mean of the HADS-A scores
decreased between T1 and T2, while that of HADS-D was stable (table
2( Table 2 )). Means of distraction and
palliative coping did not change, while those of instrumental
coping and of emotional preoccupation decreased.
Table 2 t Student tests for paired samples: comparison
of the mean scores of each sub-scale in T1 and T2
|
HADS/CHIP
|
T1 mean
|
T2 mean
|
t
|
p
|
|
11.0 (± SD 4.7)
|
8.1 (± SD 4.0)
|
5.77
|
≤ 0.001
|
|
– D
|
4.1 (± 3.4)
|
4.2 (± 3.5)
|
– 0.82
|
0.414
|
|
55.0 (± 14.0)
|
54.1 (± 15.1)
|
0.78
|
0.436
|
|
– palliative
|
44.0 (± 15.0)
|
43.5 (± 14.8)
|
– 0.27
|
0.790
|
|
– instrumental
|
59.0 (± 12.0)
|
50.4 (± 14.0)
|
6.23
|
≤ 0.001
|
|
– emotional preoccupation
|
56.0 (± 14.0)
|
51.6 (± 15.6)
|
2.74
|
0.007
|
Intra-CHIP correlations
Each T1 coping style was correlated with its own use in T2: this
was the case for distraction (r = 0.533, p ≤ 0.001), palliative (r
= 0.472, p ≤ 0.001), instrumental (r = 0.351, p ≤ 0.001) and
emotional strategies (r = 0.558, p ≤ 0.001) (table 3( Table 3 )).
Table 3 Pearson: moment correlations between CHIP in T1
and T2
|
CHIP T2
|
CHIP T1
|
|
Distract.
|
Palliat.
|
Instrum.
|
Emotion. preocc.
|
|
Distract.
|
0.533**
|
-0.072
|
– 0.052
|
– 0.089
|
|
Palliative
|
0.006
|
0.472**
|
0.122
|
0.070
|
|
Instrum.
|
0.169
|
0.239*
|
0.351**
|
0.137
|
|
Emotion. preocc.
|
0.062
|
0.217*
|
0.128
|
0.558**
|
Intra-HADS correlations
HADS-A and HADS-D scores were positively correlated, in T1 (r =
0.556, p ≤ 0.001) and in T2 (r = 0.567, p ≤ 0.001). For each
sub-scale, psychological T1 distress was related to T2 distress
(table 4( Table 4 )).
Table 4 Pearson: moment correlations between HADS in T1
and T2
|
HADS T1
|
HADS T2
|
|
HADS-A
|
HADS-D
|
|
HADS-A
|
0.536**
|
0.228*
|
|
HADS-D
|
0.409**
|
0.446**
|
Correlations between CHIP and HADS
CHIP and HADS in T1
Correlation analyses between CHIP and HADS in T1 showed positive
relationships between emotional preoccupation and anxiety (r =
0.469, p ≤ 0.001) or depression (r = 0.402, p ≤ 0.001) (table 5(
Table 5 )). There was also a negative
correlation between distraction and depression (r = -0.230, p ≤
0.005). In multiple regression analyses, we considered CHIP T1
sub-scales as independent variables and we successively chose each
HADS T1 sub-scale as a dependent variable. Emotional preoccupation
and distraction contributed to the variance of HADS-D (p ≤ 0.001,
standardized β or st.β= respectively 0.410 and -0.273). Regarding
HADS-A, the only contributive independent variable was emotional
preoccupation (p ≤ 0.001, β st. = 0.476).
Table 5 Pearson: moment correlations between CHIP and
HADS in T1
|
CHIP T1
|
HADS T1
|
|
HADS-A
|
HADS-D
|
|
Distraction
|
– 0.052
|
– 0.230*
|
|
Palliative
|
0.047
|
0.079
|
|
Instrumental
|
0.073
|
0.052
|
|
Emotional preoccupation
|
0.469*
|
0.402*
|
CHIP and HADS in T2
Six months after diagnosis, we again found positive correlations
between emotional preoccupation and anxiety (r = 0.590, p ≤ 0.001)
or depression (r = 0.565, p ≤ 0.001), and a negative one between
distraction and depression (r = -0.416, p ≤ 0.001) (table 6( Table 6 )). Furthermore, palliative coping was
positively associated with depression (r = 0.338, p ≤ 0.001). In
multiple regression analyses, T2 CHIP sub-scales were selected as
independent variables, and each T2 HADS sub-scale was successively
chosen as a dependent one. Only emotional preoccupation contributed
to the variance of HADS-A (p ≤ 0.001, β st. = 0.651). The three
variables correlated with HADS-D contributed to the variance of the
latter in the multiple regression: distraction (p ≤ 0.001, β st. =
-0.378), palliative coping (p ≤ 0.001, β st. = 0.257) and emotional
preoccupation (p ≤ 0.001, β st. = 0.538).
Table 6 Pearson: moment correlations between CHIP and
HADS in T2
|
CHIP T2
|
HADS T2
|
|
HADS-A
|
HADS-D
|
|
Distraction
|
– 0.054
|
– 0.416*
|
|
Palliative
|
0.125
|
0.338*
|
|
Instrumental
|
0.110
|
0.132
|
|
Emotional preoccupation
|
0.590*
|
0.565*
|
CHIP in T1 and HADS in T2
Positive correlations were observed between emotional preoccupation
in T1 and anxiety (r = 0.389, p ≤ 0.001) or depression (r = 0.319,
p ≤ 0.001) in T2 (table 7( Table 7 )).
Distraction in T1 was negatively related to depression in T2 (r =
-0.233, p ≤ 0.017), and palliative strategies in T1 were positively
associated with anxiety (r = 0.195, p ≤ 0.046). In multiple
regression analyses with T1 CHIP sub-scales as independent
variables, distraction and emotional preoccupation contributed to
the variance of T2 HADS-D (p ≤ 0.002 and ≤ 0.001, β
st. =-0.300 and 0.311). T1 palliative strategies were not
selected as significant contributors to the variance of T2 HADS-A,
contrary to T1 emotional coping (p ≤ 0.001, β st. = 0.386). Thus,
the correlation between T1 palliative coping and T2 HADS-A was the
only result not confirmed by multiple regression.
Table 7 Pearson: moment correlations between CHIP in T1
and HADS in T2
|
CHIP T1
|
HADS T2
|
|
HADS-A
|
HADS-D
|
|
Distraction
|
0.064
|
– 0.233*
|
|
Palliative
|
0.195*
|
0.170
|
|
Instrumental
|
0.014
|
0.078
|
|
Emotional preoccupation
|
0.389**
|
0.319**
|
Discussion
Evolution of psychological distress
The decrease in anxiety shown by the t Student test between T1 and
T2 is logical as the acute context is known to be more disquieting
than the chronic one [19]. The correlation between T1 and T2 HADS-A
scores means that the most anxious patients during the acute period
are also the most anxious during the chronic period. The mean
depression score does not change over time, and the T1 and T2
depressive levels are correlated. Furthermore, there is an
association between anxiety and depression, both during the acute
and the chronic periods. These data suggest that patients
developing an anxious or a depressive reaction to the diagnosis and
to the expectation of surgery are at risk of being still distressed
6 months later.
Emotional preoccupation: a coping style and/or an adaptation
measure?
Correlations as well as multiple regressions show that emotional
preoccupation is linked with anxiety and depression, both in T1 and
in T2. This coping in T1 is also related to the T2 distress
variables. This is in agreement with the literature data
identifying emotional coping as maladaptive. However before
concluding too quickly to a negative effect of emotional
preoccupation on psychological adaptation, we must ask whether
these statistical relationships reflect an ambiguity of this
“coping” measure. The emotional CHIP sub-scale is presented by its
authors as a coping dimension, but in fact its items investigate
frustration, anger, anxiety and worry, items that could correspond
to negative affectivity rather than to cognitive or behavioural
efforts for gaining adjustment. As a consequence we can hypothesize
that so-called CHIP emotional coping above all reflects the
patient’s psychological adaptation. This ambiguity is well known
about some MAC sub-scales: anxious preoccupation and
hopeless-helplessness of the MAC are related to distress measures
such as HADS scores [18], and these correlations might me due to
the fact that their items also assess involuntary emotional
reactions to cancer [27, 28].
Evolution of coping styles
The mean distraction and palliative scores are stable over time.
The decrease of the instrumental mean scores may be explained by
the lower necessity of seeking information and treatment in the
chronic context. The decrease of the mean emotional preoccupation
score is related to the evolution of the level of anxiety. Each T1
coping sub-scale score is positively related to its corresponding
T2 score. Thus, even if instrumental coping is less used in T2, the
acute or chronic nature of the stressor does not seem to influence
the profile of adjustment strategies favoured by our patients.
These results are in contradiction with our hypothesis but agree
with data of Gross et al., who found no significant differences
between coping styles 2 and 30 days after mastectomy (except for
patients who had benefited from an immediate reconstruction, which
was never the case in our subjects) [29].
Effects of coping styles on psychological adaptation
- • Instrumental coping. We found no correlation between
instrumental coping and the HADS scores. This absence of
correlation could mean that instrumental strategies globally do not
improve (nor deteriorate) the patients’ anxio-depressive levels:
this coping mode would have no particular effect on adaptation,
either during the acute or the chronic period. This result is in
contradiction with literature data in favour for an efficacy of
active coping strategies on psychological adaptation.
- • Distraction. Correlations and multiple regressions
show a negative correlation of distraction with depression in T1
and T2. There were no significant correlations concerning
distraction and anxiety. Correlations and multiple regressions also
showed that the use of distraction during the acute period was
accompanied by a weak depressive level during the chronic period.
These different observations suggest some hypotheses:
- – distraction may protect against depression during both
the acute and the chronic periods, and its use in acute
circumstances may also protect against depression in T2;
- – and/or depressed women in T1 and T2 do not choose to
use distraction for facing cancer. One can hypothesize that
depressed patients do not possess the energy to display distracting
behaviours. The non-distractive attitude could thus be a symptom of
the restriction of their activities.The latter hypothesis would
mean that the distraction CHIP sub-scale could also be a “hybrid”
dimension, measuring coping style and adaptation level. The first
hypothesis would plead for a protective effect of distraction,
which would be an efficient coping strategy.
- – Correlation between distraction in T1 and depression
in T2 may also be statistically explained by their correlation in
T1 and in T2 and by the stability of distraction and of depression
over time.
- • Palliative coping. Correlations and multiple
regressions show a positive correlation between palliative coping
and depression in T2, but not in T1 nor with anxiety. This allows
us to propose the following hypotheses:
- – palliative strategies used during the chronic period
have a deleterious impact on the mood of the patients ;
- – and/or depressed women adopt this kind of behaviour,
whether for facing cancer or whether because these attitudes are a
symptom of their psychological disorder. Seeking quietness or rest
and taking refuge in sleeping may not constitute efforts for facing
illness but might be depressive symptoms. For this reason
palliative the CHIP sub-scale might also be an ambiguous dimension,
potentially assessing both coping and adaptation.Correlations also
show a link between palliative behaviour in T1 and stronger anxiety
6 months later, but this relationship was not confirmed by multiple
regression.
Methodological limits
This prospective study extends only on a limited period of 6
months. The CHIP Scale has been validated in its English original
form, but not yet in this French version. Our results could be used
later together with data from other cohorts in order to validate
this French translation. We only relied on self-reported
questionnaires, which may include some misinterpretations. For
example, social desirability may amplify active coping responses
and diminish emotional coping scores and distress responses. Our
design suffers from a selection-bias, since some patients refused
to participate and since clinicians excluded patients that were
assessed as too fragile. The results have not been controlled for
cancer gradation and type of treatment.
Conclusion
In our sample of 151 breast cancer women (with 107 T1 and T2
evaluations and 44 T1-only evaluations), the anxio-depressive
scores measured 6 months after surgery were related to the scores
at diagnosis, with a decrease of the level of anxiety and a
stability of the mood. The coping scores observed during the
chronic period were also related to acute period scores, with a
decrease of instrumental strategies and a stability of distraction
and palliative coping.
Our study illustrates the methodological difficulties for
interpreting correlations between the so-called coping measures and
the distress variables in terms of efficiency or non efficiency of
the strategies. Indeed, as with the MAC scale, the CHIP scale seems
to include hybrid sub-scales, measuring globally both coping modes
and adaptation levels. This is most apparent for emotional
preoccupation, whose relationships with negative affectivity are
undeniable, but it could also be the case of other sub-scales.
These observations should invite researchers to develop more
specific instruments for coping assessment. Despite these
precautions, our results plead for a deleterious impact of
palliative coping on mood during the chronic stress period, and for
a mood protecting effect of distraction during the acute and
chronic periods (table 8( Table 8 )).
Conversely there appears to be no effect of these coping styles on
anxiety. Results about palliative coping illustrate that a
so-called coping mode may have different effects following the
stage of disease. In our sample, instrumental coping has neither
positive nor negative effects. One must be even more careful when
interpreting statistical relationships between coping styles in the
acute situation and adaptation 6 months later, even if these
correlations are in favour of a protective effect of distraction on
mood and an absence of effect of instrumental coping.
When researchers tend to distinguish among cancer patients which
coping styles are efficient, neutral or harmful, they must thus
develop longitudinal designs taking into account the evolution of
the nature of the stressor over time. Data about efficacy of coping
styles are important to collect and analyze because one has
different psychotherapeutic methods to modify the coping profile of
patients, and thus their psychological adaptation. These findings
could have important consequences on the psychological follow-up
and the quality of life of women with breast cancer.
Table 8 Hypotheses about the effects of coping styles
on mood
|
Effects
|
In T1
|
In T2
|
From T1 to T2
|
|
Deleterious
|
|
Palliative coping
|
|
|
Neutral
|
Instrumental coping Palliative coping
|
Instrumental coping
|
Instrumental coping Palliative coping
|
|
Protective
|
Distraction
|
Distraction
|
Distraction
|
References
1 Heim E. Coping and adaptation in cancer. In: Cooper CL,
Watson M, eds. Cancer and stress. Psychological, biological
and coping studies. Chichester: John Wiley and sons, 1991: 197-235.
2 Bruchon-Schweitzer M. Psychologie de la santé: modèles,
concepts et méthodes. Paris: Dunod, 2002.
3 Paulhan I. Les stratégies d’ajustement au
« coping ». In: Bruchon-Schweitzer M,
Dantzer R, eds. Introduction à la psychologie de la santé.
Paris: Presses Universitaires de France, 1994.
4 Thompson RJ, Gil KM, Abrams MR,
Phillips G. Stress, coping, and psychological adjustment of
adults with sickle cell disease. J Consult Clin Psychol 1992; 60:
433-40.
5 Lindqvist R, Carlsson M, Sjoden PO. Coping
strategies and quality of life among patients on hemodialysis and
continuous ambulatory peritoneal dialysis. Scand J Caring Sci 1998;
12: 223-30.
6 Macrodimitris SD, Endler NS. Coping, control, and
adjustment in Types 2 diabetes. Health Psychol 2001; 20:
208-16.
7 Burgess C, Morris T, Pettingale KW.
Psychological response to cancer diagnosis – II. Evidence for
coping styles (coping styles and cancer diagnosis). J Psychosom Res
1988; 32: 263-72.
8 Cayrou S, Dickès P. Version française de l’échelle
d’ajustement mental du cancer (Mental Adjustment to Cancer). Paris:
Editions et Applications Psychologiques, 2002.
9 Drageset S, Lindstrom TC. The mental health of women
with suspected breast cancer: the relationship between social
support, anxiety, coping and defence in maintaining mental health.
J Psychiatr Ment Health Nurs 2003; 10: 401-9.
10 Manuel GM, Roth S, Keefe FJ, Brantley BA.
Coping with cancer. J Human Stress 1987; 13: 149-58.
11 Mac Caul KD, Sandgren AK, King B,
O’Donnell S, Branstetter A, Foreman G. Coping and
adjustment to breast cancer. Psycho-oncology 1999; 8: 230-6.
12 Dunkel-Schetter C, Feinstein LG, Taylor SE,
Falke RL. Patterns of coping with cancer. Health Psychol 1992;
11: 79-87.
13 Stanton AL, Snider PR. Coping with a breast cancer
diagnosis: a prospective study. Health Psychol 1993; 12: 16.
14 Vickberg SM. The possibility of breast cancer
recurrence: coping with perceived threats. Dis Abstr Int (Section
B: The Sciences and Engineering) 2000; 61: 2227.
15 Watson M, Greer S, Blake S, Shrapnell K.
Reactions to a diagnosis of breast cancer. Relationship between
denial, delay and rates of psychosocial morbidity. Cancer 1984; 53:
2008-12.
16 Compas BE, Stoll MF, Thomsen AH,
Oppedisano G, Epping-Jordan JE, Krag DN. Adjustment
to breast cancer: age-related differences in coping and emotional
distress. Breast Cancer Res Treat 1999; 54: 195-203.
17 Epping-Jordan JE, Compas BE, Osowiecki DM,
Oppedisano G, Primo K, Krag DN. Psychological
adjustment in breast cancer: processes of emotional distress.
Health Psychol 1999; 18: 315-26.
18 Cayrou S, Dickès P, Gauvain-Piquard A,
Dolbeault S, Desclaux B, Viala AL, et al.
Validation d’une version française de la MAC. Psychologie et
Psychométrie 2001; 22: 29-58.
19 Gurevich M, Devins GM, Rodin GM. Stress
response syndromes and cancer: conceptual and assessment issues.
Psychosomatics 2002; 43: 259-81.
20 Endler NS, Parker JDA, Summerfeldt LJ. Coping
with health problems: developing a reliable and valid
multidimensional measure. Psychol Assess 1998; 10: 195-205.
21 Endler NS, Parker JDA. Coping with health injuries
and problems: Manual. Toronto: Multi-Health System, 2000; (66).
22 Endler NS, Courbasson CM, Fillion L. Coping
with cancer: the evidence for the temporal stability of the
French-Canadian version of the Coping with Health Injuries and
Problems (CHIP). Pers Individ Dif 1998; 25: 711-7.
23 Zigmond AS, Snaith RP. The Hospital Anxiety and
depression scale. Acta Psychiatr Scand 1983; 67: 361-70.
24 Crawford JR, Henry JD, Crombie C,
Taylor EP. Brief report normative data for the HADS from a
large non-clinical sample. Br J Clin Psychol 2001; 40: 429-34.
25 Moorey S, Greer S, Watson M, Gorman C,
Rowden L, Tunmore R, et al. The factor structure and
factor stability of the hospital anxiety and depression scale in
patients with cancer. Br J Psychiatry 1991; 158: 255-9.
26 Howell DC. Statistical methods for psychology (5th
Edition). Belmont: Duxbury Press, 2002.
27 Nordin K, Glimelius B. Reactions to
gastrointestinal cancer: variation in mental adjustment and
emotional well-being over time in patients with different
prognoses. Psychooncology 1998; 7: 413-23.
28 Nordin K, Berglund G, Terje I,
Glimelius B. The Mental Adjustment to Cancer Scale: a
psychometric analysis and the concept of coping. Psychooncology
1999; 8: 250-9.
29 Gross RE, Burnett CB, Borelli M. Coping
responses to the diagnosis of breast cancer in postmamectomy
patients. Cancer Pract 1996; 4: 204-11.
|
Printable version
Version PDF