Barriers to mental health service use among hematopoietic SCT survivors.

This study examined barriers to mental health service use and the demographic, medical and psychosocial correlates of these barriers among hematopoietic SCT (HSCT) survivors. A sample of 253 HSCT survivors who were 1 to 3 years posttransplant completed measures of demographic, physical, psychological and social characteristics as well as a newly modified measure of barriers to mental health service use. Only 50% of distressed HSCT survivors had received mental health services. An exploratory factor analysis of the barriers to mental health service use scale yielded four factors: scheduling barriers, knowledge barriers, emotional barriers and illness-related barriers. Patients with higher social constraints (perceived problems discussing the illness experience with significant others) reported higher levels of all four types of barriers. General distress and transplant-related posttraumatic stress symptoms were positively associated with emotional, knowledge and illness-related barriers to mental health service use, whereas physical and functional well-being were inversely associated with these barriers. Having more knowledge barriers and more emotional barriers predicted a lower likelihood of receiving mental health services, as did lower levels of education and general distress. Results suggest that a significant number of HSCT survivors may benefit from education about mental health services that is tailored to individual barriers.

Social support, intrusive thoughts, and quality of life in breast cancer survivors.

This study explores the moderating effect of social support on the relationship between cancer-related intrusive thoughts and quality of life. Sixty-four breast cancer survivors completed self-report measures of appraisal social support (the disclosure of thoughts and feelings to significant others), cancer-related intrusive thoughts, and quality of life. Controlling for demographic and treatment variables, the negative impact of cancer-related intrusive thoughts on both physical and mental quality of life measures was moderated by appraisal social support. For women with high levels of appraisal support, cancer-related intrusive thoughts had no significant relationship with quality of life. However, for women with low levels of appraisal support, the relationship between cancer-related intrusive thoughts and quality of life was significant and negative. These results suggest that appraisal social support can mitigate the impact of traumatic life events.

Behavioral intervention for cancer treatment side effects.

The use of increasingly aggressive methods of cancer treatment during the last 20 years has brought clinical attention to the need for more effective management of pain, nausea, and other aversive side effects of state-of-the-art cancer therapy. One of the most promising approaches to effective management is nonpharmacologic intervention based on behavioral research and theory. The purpose of this review is to examine the effectiveness of behavioral intervention methods in the control of aversive side effects of cancer treatments. Fifty-four published studies using a variety of research designs were identified for review. Results indicated the following: 1) Behavioral intervention can effectively control anticipatory nausea and vomiting in adult and pediatric cancer patients undergoing chemotherapy; however, the evidence for the efficacy of behavioral intervention to control post-chemotherapy nausea and vomiting is less clear. 2) Behavioral intervention integrating several behavioral methods can ameliorate anxiety and distress associated with invasive medical treatments. 3) Although a variety of behavioral methods have been shown to reduce acute treatment-related pain, there is increasing evidence that these methods are not equally effective. Hypnotic-like methods, involving relaxation, suggestion, and distracting imagery, hold the greatest promise for pain management. Unfortunately, research is scant on the use of behavioral intervention to control prolonged pain associated with invasive medical procedures. It is clear that the application of behavioral theory and methods has an important place in the care of patients undergoing invasive cancer treatments.

Global meaning and psychological adjustment among survivors of bone marrow transplant.

The purpose of the present study was to examine global meaning (i.e. the belief that life has purpose and coherence) and psychological adjustment in survivors of bone marrow transplantation (BMT). Eighty-five survivors of BMT participated in a telephone interview. Regression analyses demonstrated that after controlling for physical functioning, stressor severity, and gender, global meaning was inversely related to global psychological distress and BMT-related psychological distress (i.e. posttraumatic stress disorder-like symptoms related to the cancer treatment). Global meaning was also positively related to mental health aspects of quality of life (e.g. emotional functioning and social functioning). These findings suggest that global meaning may be an important factor in the psychological adjustment of BMT survivors.

Anxiety and depression in mothers of children undergoing bone marrow transplant: symptom prevalence and use of the Beck depression and Beck anxiety inventories as screening instruments.

This study examined anxiety and depressive symptoms among 115 mothers of children undergoing bone marrow transplant and evaluated the ability of the Beck Anxiety Inventory (BAI; A. T. Beck, N. Epstein, et al., 1988) and the Beck Depression Inventory (BDI; A. T. Beck, 1978) to serve as screening tools for assessing generalized anxiety disorder (GAD), panic disorder (PD), and major depressive disorder (MDD). Mothers with BAI or BDI scores greater than or equal to 14 were administered a structured clinical interview. An additional 20% was randomly selected for interview to determine whether the scale cutoff was an accurate screening method. Among the 64 mothers interviewed, 20% received at least I of the 3 diagnoses. Although the BAI did not demonstrate predictive accuracy in assessing GAD and PD, the BDI did in assessing MDD. The results suggest that a subset of mothers may have an anxiety or depressive disorder and that investigators should use caution before using the BAI as a screening instrument for anxiety disorder.

Association of psychological vulnerability factors to post-traumatic stress symptomatology in mothers of pediatric cancer survivors.

The current study investigated whether individual differences in coping style, lifetime experience of traumatic events, perceived social support, and perceived social constraints were associated with symptoms of post-traumatic stress among 72 mothers of children who had successfully completed cancer treatment. Results suggested that more perceived social constraints and less perceived belonging support were associated with significantly more post-traumatic stress symptomatology, and this association was present after controlling for the effects of child age. Monitoring coping style and lifetime traumatic events were not significantly predictive of post-traumatic stress symptoms. The results of this study indicate that a sense of belonging to a social network as well as comfort expressing cancer-related thoughts and feelings to friends and family may play a key role in mothers' long-term adjustment to this extremely difficult life experience.

Intrusive thoughts and psychological distress among breast cancer survivors: global meaning as a possible protective factor.

Previous research has consistently demonstrated a positive association between intrusive thoughts about stressful experiences and psychological distress. The strength of this relation, however, has varied considerably across studies. To examine the possibility that an individual's sense of global meaning (i.e., the existential belief that one's life has purpose and order) may moderate the relation between intrusive thoughts and psychological distress, the authors conducted telephone assessments of 61 women who had survived breast cancer. Results confirmed that the frequency of intrusive thoughts was positively related to psychological distress. Global meaning, moreover, moderated the relation between intrusive thoughts and psychological distress consistent with the authors' hypotheses. Among women with lower global meaning, more frequent intrusive thoughts were associated with higher psychological distress. No association was found between intrusive thoughts and psychological distress among those participants with higher global meaning.

A meta-analysis of hypnotically induced analgesia: how effective is hypnosis?

Over the past two decades, hypnoanalgesia has been widely studied; however, no systematic attempts have been made to determine the average size of hypnoanalgesic effects or establish the generalizability of these effects from the laboratory to the clinic. This study examines the effectiveness of hypnosis in pain management, compares studies that evaluated hypnotic pain reduction in healthy volunteers vs. those using patient samples, compares hypnoanalgesic effects and participants' hypnotic suggestibility, and determines the effectiveness of hypnotic suggestion for pain relief relative to other nonhypnotic psychological interventions. Meta-analysis of 18 studies revealed a moderate to large hypnoanalgesic effect, supporting the efficacy of hypnotic techniques for pain management. The results also indicated that hypnotic suggestion was equally effective in reducing both clinical and experimental pain. The overall results suggest broader application of hypnoanalgesic techniques with pain patients.

Post-traumatic stress disorder in cancer: a review.

The stressor criterion for Post-Traumatic Stress Disorder (PTSD) has been recently modified to include life-threatening illnesses, such as cancer, as precipitating traumatic events. We sought to examine the empiric evidence for cancer's inclusion as a traumatic stressor. Nine published studies assessing PTSD in cancer survivors and/or family members were identified in the literature. The studies were predominantly small (n<100) and cross-sectional. Study target groups included one or more of the following: children cancer survivors, parents of pediatric survivors and adult cancer survivors. There was considerable inter- and intra-study variability in the type and stage of cancer diagnosed and in the type of treatment regimens participants had undergone. Only three studies utilized a validated PTSD diagnostic tool to evaluate the disorder. Evidence of full-blown PTSD was found for adults and parents, and for children in all but one instance. These results suggest that a PTSD symptom assessment provides valuable clinical information concerning the post-treatment adjustment of cancer survivors and their immediate family members.

Behavioral interventions in the diagnosis, treatment and rehabilitation of children with cancer.

Behavioral interventions used to reduce distress and increase cooperation in children undergoing cancer treatment incorporate: contingency management, cognitive/attentional distraction, hypnosis, systematic desensitization, modeling and behavioral rehearsal. In most cases clinical interventions integrate these procedures into a multimodal intervention package. Although in most behavioral interventions the 'therapist' is a nurse, social worker or child psychologist; parents often take an active role in behavioral intervention. Early return to school can 'normalize' the child's life in the midst of coping with cancer and can promote optimal rehabilitation. More research is needed on the integration of behavioral methods with other therapeutic methods (e.g., pharmacologic). Indeed, research in this area of pediatric oncology must be continuously updated as advances in other areas may affect clinical decisions regarding preferred psychosocial intervention methods.

Validation of the PTSD Checklist-Civilian Version in survivors of bone marrow transplantation.

Life-threatening illness now qualifies as a precipitating stessor for posttraumatic stress disorder (PTSD). We examined the validity of the PTSD Checklist-Civilian Version (PCL-C; Weathers, Litz, Herman, Juska, & Keane, 1993), a brief 17-item inventory of PTSD-like symptoms, in a sample of 111 adults who had undergone bone marrow transplantation an average of 4.04 years previously. Exploratory factor analysis of the PCL-C identified four distinct patterns of symptom responses: Numbing-Hyperarousal, Dreams-Memories of the Cancer Treatment, General Hyperarousal, Responses to Cancer-Related Reminders and Avoidance-Numbing. Respondents meeting PTSD symptom criteria on the PCL-C had significantly lower physical, role, and social functioning, greater distress and anxiety, and significantly more intrusive and avoidant responses than individuals who did not meet PTSD symptom criteria.

Demographics, family histories, and psychological characteristics of prostate carcinoma screening participants.

BACKGROUND: The goals of this study were to 1) understand the reasons that men seek prostate carcinoma screening, in light of the ongoing medical controversy surrounding screening; and 2) assess the level of psychological distress and perceived risk among men seeking screening, and whether or not these variables were dependent on a man's family history of prostate carcinoma. METHODS: The subjects were 126 men (40% had a family history of prostate carcinoma) who participated in a free prostate carcinoma detection program. Questionnaires, which were completed prior to prostate carcinoma screening, included demographic and medical information, reasons for screening participation, general and cancer-related psychological distress, and perceived risk for prostate carcinoma. RESULTS: Among both family history groups, self-referral was the most common reason for attending the screening, compared with receiving a recommendation from a health professional or from a friend or family member. Men with a positive family history were not more distressed than those without a family history; but as the authors predicted, men with a positive family history of prostate carcinoma did report higher levels of perceived risk relative to those without a family history. In addition, an interaction revealed that psychological distress was greater among men with a family history only among those who also reported elevated perceived risk. CONCLUSIONS: Similar to other prostate carcinoma screening programs, men in the current sample largely elected to attend the screening on their own. Furthermore, although perceived risk was higher among men with a family history compared with those without a family history, psychological distress was greater among men with a family history only among those who also reported elevated perceived risk. Thus, among men with a family history of the disease, perceived risk may be a marker of elevated psychological distress. Screening programs should assess family history and perceived risk because of the potential psychological implications for screening participants.

Posttraumatic stress disorder among mothers of pediatric cancer survivors: diagnosis, comorbidity, and utility of the PTSD checklist as a screening instrument.

OBJECTIVE: To examine posttraumatic stress disorder (PTSD) in mothers of survivors of childhood cancer. Comorbidity of anxiety and depressive disorders, prevalence of subclinical PTSD, and the utility of a self-report measure as a screening instrument for PTSD were also investigated. METHOD: Mothers (n = 65) completed a questionnaire self-report PTSD checklist (PCL-C). Mothers were administered several modules of the SCID: nonpatient edition by telephone, including the PTSD, Generalized Anxiety, and Major Depressive Disorder modules. RESULTS: We diagnosed 6.2% of the sample with current PTSD. An additional 20% had subclinical PTSD. One of four mothers with PTSD diagnoses had a comorbid diagnosis of an anxiety and depressive disorder. The PCL-C evidenced diagnostic utility as a screening instrument. However, a moderate number of false-positives would result if the recommended cut-off on the instrument was used. CONCLUSIONS: The PCL-C had diagnostic utility in screening mothers of childhood cancer survivors. The presence of comorbid diagnoses such as anxiety and depression should be examined.

Patients' pretreatment expectations of chemotherapy-related nausea are an independent predictor of anticipatory nausea.

Based on extensive research with animals, classical conditioning theorists have come to regard contingency as the primary factor in the development of conditioned responses. However, recent experimental work with humans has suggested the possibility that participant expectations may also directly contribute to the development of conditioned responses. To date, this phenomenon has not been investigated in clinical settings. Anticipatory nausea (AN) in chemotherapy patients, widely viewed as the best established example of classical conditioning in clinical medicine, provides an opportunity to examine the contributions of patient expectations to the development of a conditioned response outside the laboratory. The present study of 59 breast cancer patients supported the hypothesis that pretreatment patient expectations make a significant (p < .03) contribution to the development of AN after statistically controlling for the strongest conditioning predictor, contingency. These data imply that patient expectations should be considered when evaluating conditioned responses to aversive medical treatments.

Imagery in human classical conditioning.

Many clinical strategies use patients' imagery to explore and treat phobic and posttrauma reactions, however little attention has been paid to the underlying assumption that imagery of relevant stimuli may help maintain conditioned behavior. In this article, the authors examine the premise that mental images can potentiate and substitute for physical stimuli in human classical conditioning. The authors review empirical evidence to detail the role of images of conditioned stimuli (CS) and unconditioned stimuli (US) during pre-exposure to stimuli, the actual pairing of the CS and US, and extinction when the CS is presented alone. The evidence suggests that mental imagery can facilitate or diminish the outcome of classical conditioning in humans and, more tentatively, that mental images can substitute for actual US and CS in autonomic conditioning. They argue that researchers should explore the role of mental imagery in conditioning through the use of advances in the measurement of imagery. Finally, they analyze anxiety and trauma reactions as examples of how applied areas can be used to explore and benefit from developments in this area.

Frequency and correlates of posttraumatic-stress-disorder-like symptoms after treatment for breast cancer.

Diagnosis of life-threatening illness now meets Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria for traumatic stressor exposure for posttraumatic stress disorder (PTSD). Quality of life (QOL) and PTSD-like symptoms were assessed in 55 women posttreatment for breast cancer. PTSD symptom measures included the PTSD Checklist--Civilian Version (PCL-C) and the Impact of Events Scale. QOL was assessed using the 20-item Medical Outcomes Study Questionnaire. PTSD symptomatology was negatively related to QOL, income, and age. Time since treatment, type of cytotoxic treatment, and stage of disease were unrelated to PTSD symptoms. With suggested criteria for the PCL-C, 5% to 10% of the sample would likely meet DSM-IV PTSD criteria. Findings suggest that in survivors of breast cancer, these symptoms might be fairly common, may exceed the base rate of these symptoms in the general population, are associated with reports of poorer QOL, and, therefore, warrant further research and clinical attention.

Predictors of depressive symptomatology among parents of newly diagnosed children with cancer.

Examined predictors of depressive symptoms among 59 parents providing primary care to children newly diagnosed with cancer. Parents were studied for a 3-month period. The parent providing primary care to the child during medical treatment completed measures of depressive symptoms, endorsement of family routines, family functioning, amount of assistance from the spouse in providing care to the child, child behavior problems, as well as measures of the severity of the child's treatment regimen. A strong relationship was found between child behavior problems and parent depressive symptomatology. Although disease-related factors such as the child's functional impairment played a role in the parent's depressive symptoms, results revealed that the child's behavior problems were most strongly associated with parent depressive symptoms and that family cohesiveness also had a contributory role in the maintenance of parent depressive symptoms.

An analysis of a behavioral intervention for children undergoing venipuncture.

An examination of factors was conducted to determine the effectiveness of the distraction component of a behavioral intervention (use of a party blower). In one condition, parents were instructed to coach children in the use of a party blower and to praise child cooperation. In a second condition, nurses were instructed to assist parents in coaching the child. Parents used the coaching skills they learned and got their children to use the distraction technique. Use of the distraction technique was associated with less crying. Encouragement from a health care professional and intervention early in the procedure did not enhance the intervention's effectiveness. Older children and children who were less distressed during the initial phase of the procedure were less likely to reject the intervention.