Intrusive thoughts and avoidance in breast cancer: Individual differences and association with psychological distress

Abstract

Eighty-five women with newly diagnosed breast cancer were classified on the basis of high and low levels of cancer-related intrusive thoughts and avoidance at diagnosis, and their psychological adjustment was studied prospectively at 3 and 6 months post diagnosis. Patients who initially reported high levels of both intrusive thoughts and avoidance and those who reported high levels of intrusive thoughts but low avoidance experienced the highest levels of anxiety and depression symptoms, and continued intrusive thoughts and avoidance. Patients who were high in avoidance but low in intrusive thoughts also experienced adjustment problems, including increased intrusive thoughts, when compared with patients who were low in both types of symptoms. The findings highlight the value of considering subgroup differences in patterns of intrusion and avoidance as predictors of subsequent psychological adjustment to breast cancer.     

Intrusion, avoidance, and daily negative affect among couples coping with prostate cancer: a dyadic investigation

In the present study we examined how husbands' and wives' intrusive thoughts of prostate cancer (i.e., thinking about it when not meaning to) and avoidance (i.e., efforts to not think about cancer) related to their own and each other's average negative affect over a subsequent 14-day period. We examined whether congruence or similarity in intrusion about illness, but not avoidance, would be associated with less negative affect as this response to cancer could potentially facilitate adjustment. Fifty-nine husbands and wives completed measures of intrusion and avoidance after the diagnosis of prostate cancer and reported on their daily negative affect for 14 days. Using the actor-partner interdependence model, both patients and their wives who had high levels of intrusive thoughts experienced less negative affect when the other member of the couple also experienced high levels of intrusive thoughts. Those who had higher levels of avoidance had spouses who had higher levels of negative affect regardless of their own levels of avoidance. Congruence in responses to cancer may be adaptive for intrusion but not avoidance because the use of intrusive thoughts by both husbands and wives can allow couples to process the diagnosis of cancer, facilitating psychological adjustment, whereas avoidance does not. The current investigation adds to our understanding of how people within a marital dyad affect each other as they adjust to a cancer diagnosis.     

Psychological adjustment in breast cancer: processes of emotional distress.

The process of psychological adjustment to breast cancer was examined at diagnosis and at 3- and 6-month follow-ups in a sample of 80 women with Stage I-Stage IV breast cancer. At diagnosis, symptoms of anxiety/depression were predicted by low dispositional optimism, and this path was partially mediated by use of emotion-focused disengagement coping. Younger age also was predictive of anxiety/depression symptoms at time of diagnosis, and this relationship was fully mediated by magnitude of intrusive thoughts. At 3 months, changes in anxiety/depression symptoms were predicted only by intrusive thoughts. At 6 months, low dispositional optimism reemerged as a significant predictor of changes in anxiety/depression and again was partially mediated by the use of emotion-focused disengagement coping. Independent effects for problem-focused engagement and disengagement and emotion-focused engagement coping were also found at 6 months. Implications of these data for psychosocial interventions with breast cancer patients are highlighted.     

The role of objective versus perceived life threat in the psychological adjustment to cancer

Several studies in the oncology literature have used disease stage as a measure of life threat. According to the transactional model of stress (Lazarus and Folkman, ), however, the individual's perception of a threatening situation is more strongly related to distress than the objective event itself. Thus, the present study examined whether cancer patients’ perceived life threat (PLT) is more strongly associated with psychological adjustment than a more objective index of disease prognosis (i.e., cancer stage). In addition, based on cognitive processing theories, this study examined whether intrusive thoughts and avoidance, cognitive characteristics of posttraumatic stress disorder (PTSD), mediate the relationship between PLT and distress. Patients diagnosed with various types of cancer (N = 97) completed questionnaires assessing PLT, cancer-related intrusive thoughts and avoidance, distress, and quality of life. Consistent with theoretical predictions, regression analyses showed that PLT, but not disease stage, was significantly related to psychological distress and quality of life. In addition, intrusive thoughts and avoidance mediated the relationship between PLT and distress. Taken together, these findings suggest that cancer patients’ PLT is more strongly related to distress than is cancer stage and that this association is partly due to cognitive symptoms that are part of PTSD symptomatology. Thus, patients who appraise their illness as life threatening may benefit from cognitive interventions aimed at reducing distress associated with intrusive thoughts.     

Intrusive Thoughts and Psychological Adjustment to Breast Cancer: Exploring the Moderating and Mediating Role of Global Meaning and Emotional Expressivity

The aim of this study was to investigate the moderating and mediating role of global meaning and emotional expressivity in the relationship between intrusive thoughts and psychological adjustment (as indicated by mental health status) in a sample of breast cancer patients (N = 153). Coping with cancer was also included as an intervening variable to be tested. Moderating effects were explored using a series of hierarchical regression analysis, while multiple mediated effects were tested through bootstrapping procedures. Results showed that global personal meaning had both direct and indirect (mediating) effects on psychological adjustment. Emotional expressivity had neither moderating nor mediating effects on psychological adjustment. These results indicated that a strong sense of personal meaning and purpose in life, and an integrated understanding of self and life may lessen the impact of intrusive thoughts on breast cancer patients’ psychological adjustment and mental health status. Implications of the findings for clinical practice and recommendations for future research are discussed.     

Situational and Dispositional Goal Adjustment in the Context of Metastatic Cancer

Striving toward goals is associated with higher levels of subjective well‐being; however, many potential roadblocks to goal achievement exist. The current study extends the understanding of goal regulation processes in its examination of the relationships between dispositional and situational goal adjustment to a profound stressor and their associations with psychological adjustment. Women (N = 103; M age = 57.2 years; 82% Caucasian) with metastatic breast cancer completed semistructured interviews and self‐report measures at study entry and 3 months later. Measures of dispositional and situational goal reengagement were significantly correlated, but dispositional and situational goal disengagement were unrelated. Greater dispositional and situational goal disengagement abilities were associated with fewer cancer‐related intrusive thoughts at Time 1. Dispositional and situational reengagement were positively associated with life satisfaction and sense of purpose and negatively associated with depressive symptoms at Time 1. However, greater initial situational goal disengagement predicted an increase in depressive symptoms over time. Both how an individual typically responds to goal blockage, as well as how an individual is currently responding to a specific blocked goal, appear related to psychological adjustment.     

Dispositional and stressor-related emotion regulation in the context of a chronic, life-limiting stressor

In the context of efforts to regulate emotion during chronic stressors, both dispositional response tendencies (affect intensity, negative and positive expressivity) and stressor‐related coping through emotional approach (processing and expressing emotions) are relevant to adjustment. In women with metastatic breast cancer (N = 103), contributions of self‐reported emotional processing and expression related to cancer, as well as dispositional expressivity to adaptive outcomes across 3 months were examined. In the context of high dispositional expressivity, an increase in emotional expression predicted improvements in depressive symptoms and life satisfaction. Emotional processing at study entry predicted increased depressive symptoms and intrusive thoughts, and declining life satisfaction among highly expressive women. Increasing emotional processing predicted improved depressive symptoms in the context of high expressivity. Increases in emotional approach coping were associated with a more arduous cancer experience. Findings highlight the importance of the person‐situation fit in linking emotion‐related constructs to adjustment during unremitting stressors.     

Does Overgeneralized Autobiographical Memory Facilitate or Inhibit Intrusive Images? Its Relation to Depressive Symptoms

People with high levels of depressive symptoms experience overgeneralized autobiographical memory (OGM) in voluntary recall and intrusive images in involuntary recall. The present study examined the relationship between OGM and intrusive images and the influence of depressive symptoms on this relationship over 1 week. Fifty‐three students completed self‐report questionnaires, autobiographical memory test, and the trauma film paradigm. Subsequently, they reported intrusive images from the trauma film in a diary for 1 week. Hierarchical multiple regression showed that individuals with higher levels of depressive symptoms experienced more intrusive images than did individuals with low depressive symptoms. An interaction effect between negative memory specificity and depressive symptoms revealed that number of intrusive images was related to high negative memory specificity (i.e. low OGM) in individuals with higher levels of depressive symptoms. These results support the functional avoidance strategy of OGM in analogue trauma stimuli, especially in individuals with higher depressive symptoms.Copyright © 2017 John Wiley & Sons, Ltd.     

Traumatic stress, life events, and emotional support in women with metastatic breast cancer: cancer-related traumatic stress symptoms associated with past and current stressors.

This study examined levels of intrusion and avoidance symptoms and their relationships to past life stress, current emotional support, disease-related variables, and age in 125 women with metastatic breast cancer. The results indicate that a sizable proportion of these women experienced clinically significant levels of intrusion and avoidance symptoms related to their cancer, particularly those with both more stressful past life events and higher current levels of aversive emotional support. Additionally, both types of symptoms were associated with shorter time since recurrence, and avoidance symptoms were associated with smaller emotional support networks. These results indicate that metastatic breast cancer is an emotionally traumatic event for a significant proportion of women, particularly those with past life stressors and unsupportive social environments.     

Unsuccessful suppression is associated with increased neuroticism,intrusive thoughts,and rumination

Studies of thought suppression, the reduction in accessibility for intentionally unrehearsed and actively avoided thoughts, vary dramatically in the level of suppression reported. The purpose of our research was to explore individual differences associated with self-reports of the success, failure, or avoidance of thought suppression in everyday life. Participants completed a survey measuring intrusive thoughts, neuroticism, rumination, and autobiographical knowledge of suppression tendencies and capabilities. Individuals who reported successful suppression were less neurotic, ruminative, and experienced less thought intrusion than individuals who reported unsuccessful suppression attempts. Our findings suggest that the high-ends of the neuroticism and intrusive thought spectrums are occupied by individuals who unsuccessfully attempt to suppress undesirable information, while successful suppressors differ minimally from non-suppressors.     

A comparison of thought suppression to an acceptance-based technique in the management of personal intrusive thoughts: a controlled evaluation

Research suggests that suppressing unwanted thoughts is not possible, leads to a subsequent increase in frequency of the suppressed thoughts, and results in higher levels of distress. Because thought suppression may have negative effects, an alternative, acceptance-based approach has been proposed. The current paper reports the outcomes of two studies. Study I examined the relationships between two naturally occurring strategies of thought management (thought suppression and acceptance), symptoms of psychopathology, and experiences with personally relevant intrusive thoughts. Results showed that those who naturally suppress personally relevant intrusive thoughts have more, are more distressed by, and have a greater "urge to do something" about the thoughts, while those who are naturally more accepting of their intrusive thoughts are less obsessional, have lower levels of depression, and are less anxious. Study II compared three groups (thought suppression, acceptance, and monitor-only groups) on the frequency and distress associated with experiencing personally relevant intrusive thoughts. Results revealed that those instructed to suppress their personal intrusive thoughts were unable to do so and experienced an increased level of distress after suppression, whereas those instructed to use an acceptance-based strategy experienced a decrease in discomfort level (but not thought frequency) after having used such a strategy. These data offer initial evidence that acceptance may be a useful alternative to the suppression of personally relevant intrusive thoughts.     

Emotion regulation moderates relationships between body image concerns and psychological symptomatology

The study investigated the moderating role of emotion regulation (ER) in relationships between body image concerns and psychological symptomatology. A community sample of 533 boys and girls (11-20 years) completed measures assessing body image thoughts and feelings, domain-specific and general ER strategies, drive for thinness, and bulimic, depressive and anxiety symptoms. Results indicated that ER moderated relationships between body image concerns and both bulimic and depressive symptoms, but not relationships between body image concerns and drive for thinness or anxiety symptoms. Adolescents who reported frequent body image concerns were more likely to have higher levels of bulimic symptoms if they tended to use avoidance and internal dysfunctional ER strategies. Furthermore, adolescents who reported frequent body image concerns were more likely to have higher levels of depressive symptoms if they used positive rational acceptance and internal functional strategies infrequently. Implications of the findings for prevention and intervention are discussed.     

Predictors of depressive symptoms among breast cancer patients during the first year post diagnosis

It is important to identify predictors of psychological health among breast cancer patients that can be relatively easily identified by medical care providers. This article investigates the role of one class of such potential predictors: easily identified demographics that have potential social and/or practical implications. Specifically, we examined whether income, marital status, presence of children in the home, education, travel distance, age and rurality interact with time to predict psychological health over the first year post diagnosis. Two hundred and twenty five breast cancer patients receiving radiation treatment completed four surveys over the course of 13 months that included measures of both their physical health and depressive symptoms. The results revealed that women who were not married had children living in the home or had to travel long distances to receive radiation treatment reported higher levels of depressive symptoms across the entire study. Women with lower incomes reported increased depressive symptoms, but only after the completion of treatment. Younger women reported elevated depressive symptoms during initial treatment, but this effect dissipated after the completion of treatment. The current results suggest that demographic patient characteristics may indeed be useful in identifying both when and for whom depressive symptoms are particularly likely to be problematic.     

Negative Intrusive Thoughts and dissociation as Risk Factors for Self‐Harm

Relationships between self‐harm and vulnerability factors were studied in a general population of 432 participants, of whom 30% reported some experience of self‐harm. This group scored higher on dissociation and childhood trauma, had lower self‐worth, and reported more negative intrusive thoughts. Among the non‐harming group, 10% scored similarly to the self‐harmers on the dissociation and self‐worth scales, and engaged in potentially maladaptive behaviors that are not defined as indicating clinical self‐harm, but experienced fewer negative intrusive thoughts. This group may be at risk of future self‐harm if they begin to experience negative intrusive thoughts. If negative intrusive thoughts are playing a causal role, then therapeutic approaches tackling them may help those who are currently self‐harming.     

A path analysis of factors associated with distress among first-degree female relatives of women with breast cancer diagnosis.

Patterns and predictors of psychological distress in first-degree female relatives (N = 624) of newly diagnosed breast cancer patients were explored. First-degree female relatives who were high monitors reported greater cancer-specific and general distress than did low monitors. Greater optimism was associated with lower cancer-specific distress. Optimism's effect on general distress was moderated by women's level of monitoring. Greater optimism was associated with lower general distress for both high and low monitors, but the effect was stronger for high monitors than for low monitors. Avoidance and engaged coping were associated with higher distress. A close relationship with the cancer patient was related to higher cancer-specific distress but lower general distress. Further understanding of the process of adjustment in these women awaits longitudinal study.     

Intrusive memories and depression in cancer patients

Matched samples of depressed and nondepressed cancer patients were interviewed about past life events, particularly experiences of death and illness. They identified and described any spontaneous intrusive visual memories they had experienced in the past week corresponding to these events. About one quarter reported such memories and, as predicted, the majority of intrusive memories concerned illness, injury and death. The mean levels of intrusion and avoidance were equivalent to patients with post-traumatic stress disorder. Consistent with prediction, depressed patients reported significantly more intrusive memories than controls, and described the memories as typically beginning with or being exacerbated by the onset of depression. Greater numbers of intrusive memories were associated with more maladaptive coping, and greater avoidance with deficits in autobiographical memory functioning.     

Effects of traumatic stress and perceived stress on everyday cognitive functioning

Stressful or traumatic events have been shown to impair cognitive functioning on laboratory-based tasks due to stress-related intrusive thoughts and avoidance. However, research on the effects of stress on everyday cognitive functioning has been lacking. A sample of 909 undergraduates completed measures of perceived stress, PTSD symptoms, and everyday cognitive failures. The results revealed that both perceived stress and PTSD symptoms uniquely predicted cognitive failures, even after controlling for a number of potentially confounding variables. Additionally, there was a significant interaction. Participants with low scores on both measures of stress reported the fewest occurrences of everyday cognitive failures. In contrast, participants with elevated scores on either measure of stress reported higher levels of cognitive failures. These results suggest that there are unique negative effects of perceived stress and PTSD symptoms on everyday cognitive functioning and sharpen our understanding of the relationship between stress and cognition.     

Are Individuals Always Aware of Their Trauma-Related Intrusive Thoughts? A Study of Meta-Awareness

Individuals are not always aware of their mental content. We tested whether lack of awareness occurs in those who have experienced trauma, with and without posttraumatic stress disorder (PTSD). We also examined the role of proposed cognitive mechanisms (working memory and inhibition) in explaining unnoticed intrusions. Individuals with PTSD (n = 44), and varying levels of symptoms (high posttraumatic stress [PTS]: n = 24; low PTS: n = 37) reported on intrusive thoughts throughout a reading task. Intermittently, participants responded to probes about whether their thoughts were trauma related. Participants were “caught” engaging in unreported trauma-related thoughts (unnoticed intrusions) for between 24 and 27% of the probes in the PTSD and high PTS groups, compared with 15% of occasions in the low PTS group. For trauma-related intrusions only, participants lacked meta-awareness for almost 40% of probes in the PTSD group, which was significantly less than that observed in the other groups (～60%). Contrary to predictions, working memory and response inhibition did not predict unnoticed intrusions. The results suggest that individuals who have experienced significant trauma can lack awareness about the frequency of their trauma-related thoughts. Further research is warranted to identify the mechanisms underpinning the occurrence of unnoticed intrusions.     

Effects of traumatic stress and perceived stress on everyday cognitive functioning

Stressful or traumatic events have been shown to impair cognitive functioning on laboratory-based tasks due to stress-related intrusive thoughts and avoidance. However, research on the effects of stress on everyday cognitive functioning has been lacking. A sample of 909 undergraduates completed measures of perceived stress, PTSD symptoms, and everyday cognitive failures. The results revealed that both perceived stress and PTSD symptoms uniquely predicted cognitive failures, even after controlling for a number of potentially confounding variables. Additionally, there was a significant interaction. Participants with low scores on both measures of stress reported the fewest occurrences of everyday cognitive failures. In contrast, participants with elevated scores on either measure of stress reported higher levels of cognitive failures. These results suggest that there are unique negative effects of perceived stress and PTSD symptoms on everyday cognitive functioning and sharpen our understanding of the relationship between stress and cognition.     

Life Satisfaction and Positive Adjustment as Predictors of Emotional Distress in Men With Coronary Heart Disease

This two-wave longitudinal study examines the ability of life satisfaction and adjustment strategies to predict anxious and depressive symptoms in coronary heart disease male patients. Studies have shown that most heart attack survivors report these symptoms, which may worsen the prognosis of the disease. At Time 1, immediately after the first cardiac episode, eighty-eight men reported their life satisfaction levels, adjustment strategies used, and anxious and depressive symptoms experienced. At Time 2, six months later, sixty-three of those patients reported only their anxious and depressive symptoms again. The results showed that, after controlling for demographic variables, anxious and depressive symptoms at Time 1 were predicted by positive adjustment and life satisfaction. At Time 2, after controlling for both demographic variables and Time 1-emotional symptoms, none of the psychological variables predicted anxious symptoms, while depressive symptoms were only predicted by life satisfaction. It is concluded that an adequate level of life satisfaction may help to decrease emotional distress, both short and long term, while the use of positive adjustment strategies is especially important immediately after diagnosis.