Scandinavian Journal of Psychology, 2010, 51, 8491

DOI: 10.1111/j.1467-9450.2009.00727.x

Health and Disability

Cancer, acute stress disorder, and repressive coping
ANETTE FISCHER PEDERSEN and ROBERT ZACHARIAE
Psychooncology Research Unit, University of Aarhus and Aarhus University Hospital, Denmark

Pedersen, A. F. & Zachariae, R. (2010). Cancer, acute stress disorder, and repressive coping. Scandinavian Journal of Psychology, 51, 8491. The purpose of this study was to investigate the association between repressive coping style and Acute Stress Disorder (ASD) in a sample of cancer patients. A total of 112 cancer patients recently diagnosed with cancer participated in the study. ASD was assessed by the Stanford Acute Stress Reaction Questionnaire, and repressive coping was assessed by a combination of scores from the Marlowe-Crowne Social Desirability Scale, and the Bendig version of the Taylor Manifest Anxiety Scale. Signicantly fewer patients classied as repressors were diagnosed with ASD compared to patients classied as non-repressors. However, further investigations revealed that the lower incidence of ASD in repressors apparently was caused by a low score on anxiety and not by an interaction effect between anxiety and defensiveness. Future studies have to investigate whether different psychological mechanisms are responsible for the lower incidence of ASD in repressors and true low-anxious patients. Key words: Acute stress disorder, anxiety, cancer, defensiveness, repressive coping. Anette Fischer Pedersen, Psychooncology Research Unit, Department of Psychology, University of Aarhus, Jens Chr. Skous Vej 4, 8000 Aarhus C, DK- Denmark. E-mail: anettefp@psy.au.dk

INTRODUCTION Despite many improvements in cancer treatment, being diagnosed with cancer is still a life-threatening experience. As cancer patients often experience severe emotional turmoil and have symptoms of anxiety and depression immediately after diagnosis (McGarvey, Canterbury, Koopman et al., 1998b), it has been recognized that a life-threatening illness may trigger traumatic stress reactions (American Psychiatric Association, 1994). The shock of being diagnosed with cancer may be especially distressing for patients referred to chemotherapy as this treatment is often induced due to dissemination of the cancer disease. Dissemination of the cancer reduces chances of being cured from the disease. Furthermore, patients have often negative expectations to chemotherapy due to the side effects such as hair loss, nausea, vomiting, and irreversible loss of fertility (Andersen, 2002).

person, and the persons response to this event should involve intense fear, helplessness, or horror (Bryant & Harvey, 2000). Second, ASD is characterized by re-experiencing the traumatic event, for example in ashbacks, nightmares, or recurrent thoughts. Third, ASD is characterized by avoidance of stimuli and situations that remind the person about the traumatic event. These stimuli could be thoughts, activities, places, people, or conversations. Fourth, the diagnostic criteria for ASD require that the person must display marked arousal. Symptoms of arousal may include insomnia, irritability, concentration difculties, restlessness, and hyper vigilance. Fifth, to fulll the ASD diagnosis, persons must report symptoms of dissociation which also distinguishes this diagnosis from the diagnosis of PTSD. Symptoms of dissociation include numbing, depersonalization, dissociative amnesia, and reduced awareness and are assumed to reect a defensive reaction when exposed to overwhelming stress (Sterlini & Bryant, 2002).

Acute stress disorder In 1994, the diagnosis of Acute Stress Disorder (ASD) was introduced in the DSM-IV in order to describe stress responses in the rst month after the experience of a traumatic event (American Psychiatric Association, 1994). The symptoms of an ASD diagnosis are in many ways similar to symptoms of a PTSD diagnosis. One aspect that differentiates the ASD diagnosis from the PTSD diagnosis is the duration of symptoms as the ASD diagnosis refers to the experience of stress symptoms that occur from 2 days to 4 weeks after the traumatic event (Harvey & Bryant, 2002). The rst diagnostic criteria for ASD is the requirement that the person should have experienced an event that has been threatening to either himself or another

ASD in cancer patients The incidence of ASD in adult cancer patients has been assessed to 28% in a sample of patients with rst onset of head and neck or lung malignancy (Kangas, Henry & Bryant, 2005a; Kangas, Henry & Bryant, 2007) and to 33% in a sample of patients with different types of cancer, primarily breast cancer or cancer of the reproductive organs (McGarvey et al., 1998b). It has been proposed that ASD contributes to the development of PTSD (Bryant, Guthrie & Moulds, 2001; Moulds & Bryant, 2002). However, one study has shown that both the positive and negative predictive power of ASD with respect to developing PTSD when diagnosed with cancer is only moderate (Kangas, Henry & Bryant, 2005b). Thus, the results of this study

2009 The Authors. Journal compilation 2009 The Scandinavian Psychological Associations. Published by Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. ISSN 0036-5564.

Scand J Psychol 51 (2010)

Cancer, acute stress disorder, and repressive coping

85

revealed that only about 53% of cancer patients diagnosed with ASD met criteria for full PTSD after 6 months. Furthermore, about 36% of patients diagnosed with PTSD after 6 months did not meet criteria for ASD in the rst month after their diagnosis. Even though the ASD diagnosis may only be a moderate predictor of subsequent PTSD in cancer patients, ASD reects major psychological distress in the period after the diagnosis of the disease. Studies have shown that cancer patients with ASD behave more impulsively, e.g. display more impulsive spending, give away personal belongings, and have thoughts about suicide (McGarvey, Canterbury & Cohen, 1998a; McGarvey et al., 1998b). Thus, ASD affects the quality of life of the cancer patients and their relatives. Furthermore, studies have indicated that ASD may affect the cognitive functioning of the patients. First, results from a study of survivors of motor vehicle accidents have shown an association between ASD and a tendency to overestimate risk of future negative events and a tendency to overestimate the possible negative consequences of such possible negative events (Warda & Bryant, 1998). Second, it has been suggested that the overwhelming stress characterizing individuals with ASD may impede optimal encoding and organization of information (Harvey & Bryant, 2002). This could potentially make it difcult to remember information from doctors and other health personnel which may increase risk of noncompliance.

association between absorption and acute posttraumatic stress in people who had witnessed a fatal aircraft collision (Taylor, Asmundson, Carleton & Brundin, 2007).

Repressive coping In stress research, it has for a long time been recognized that some individuals insist on not being emotionally upset even though physiological measurements suggest the opposite (Weinberger, Schwartz & Davidson, 1979). Repressive coping is a term that refers to this non-expression of negative emotions (Weinberger, 1990). There is some controversy about whether the non-expression of negative emotions is induced by a deliberate intention of making a favorable impression on other people (so-called impression management) or reects unconscious, self-deceptive processes with the purpose of diverting attention away from stimuli that may be a threat to the self-image. Experiments with a bogus pipeline, i.e. a lie detector replica, suggest that repressive coping involves self-deception (Weinberger et al., 1979). However, some repressors tended to show an increase in anxiety when exposed to the experimental condition which has been interpreted as evidence of other-deception (Paulhus, 1984). Taken together, the results may suggest that repressors are a heterogeneous group with regard to self-deception. Weinberger has suggested a two-dimensional assessment method for repressive coping. This method combines scores on a scale of negative affectivity, often anxiety, with scores the Marlowe-Crowne Social Desirability Scale (MCSDS) (Crowne & Marlowe, 1960), a scale believed to measure defensiveness. Four categories are deduced from this classication procedure: repressors (high MCSDS, low anxiety), true low-anxious (low MCSDS, low anxiety), true high-anxious (low MCSDS, high anxiety), and defensive high-anxious (high MCSDS, high anxiety). In contrast to most other attempts of measuring repressive coping, the Weinberger-method makes it possible to make a distinction between repressors and true low-anxious (Weinberger, 1990). Results of previous studies have shown repressors to selectively avoid threatening information (Krahe, 1999) and to possess illusions of unrealistic optimism and positive self-evaluations (Myers & Brewin, 1996). Results of one study have suggested that these cognitive mechanisms may promote psychological well-being when diagnosed with serious illness (Ginzburg, Solomon & Bleich, 2002). Thus, in this study it was shown that a repressive coping style decreases risk of ASD after myocardial infarction (MI). The purpose of this study is to investigate whether repressive coping is also protective of ASD inpatients with cancer. Both cancer and MI are serious medical conditions, but whereas MI is a sudden and unanticipated event, a cancer diagnosis is an informational threat focusing on the future (Gurevich, Devens & Rodin, 2002). Thus, when diagnosed with cancer, it is the mere knowledge that one has the disease and the anticipated future threats of pain and bodily disguration that constitute the traumatic experience. In the

Known risk-factors for ASD Not much is known about the factors that increase risk of an ASD diagnosis following a cancer diagnosis. From the previous studies investigating the incidence of ASD in adult cancer patients, we know that ASD is more common in female cancer patients than in male cancer patients (Kangas et al., 2005b; McGarvey et al., 1998b). Furthermore, in female cancer patients, younger age, low social support from friends, and low satisfaction with communication between health care professionals and patient are associated with increased incidence of ASD (McGarvey et al., 1998b). However, these factors are not associated with increased risk in male cancer patients. As dissociation is a key symptom of ASD, it has been argued that certain personality dimensions known to predispose individuals to dissociation when faced with overwhelming stress could be a risk factor for ASD (Butler, Duran, Jasiukaitis, Koopman & Spiegel, 1996). Absorption (Tellegen & Atkinson, 1974) is a personality trait that predisposes individuals to become highly involved in imaginative and sensory experiences. It has been dened as a characteristic of the individual that involves an openness to experience emotional and cognitive alterations across a variety of situations (Roche & McConkey, 1990), and absorption has been shown to be an important predictor of hypnotizability (Zachariae, Jorgensen & Christensen, 2000). Absorption has been found to partially mediate the relationship between traumatic experiences and schizotypical symptoms (Berenbaum, Thompson, Milanak, Boden & Bredemeier, 2008), and the results of one single study have shown an

2009 The Authors. Journal compilation 2009 The Scandinavian Psychological Associations.

86 A. F. Pedersen and R. Zachariae study showing a negative association between repressive coping and risk of ASD, the lower incidence of ASD was also found in true low-anxious patients. Therefore, another purpose of this study will be to test both the independent and the interactive effects of trait-anxiety and defensiveness on risk of ASD.

Scand J Psychol 51 (2010) test-retest reliabilities had previously been shown to be 0.86 and 0.80 for MCSDS and 0.84 and 0.79 for TMAS-B. Absorption was assessed by a 15-item version of the Tellegen Absorption Scale (TAS) (Tellegen & Atkinson, 1974). Scores on the TAS have been shown to correlate with hypnotic responsiveness and hypnotic depth (Tellegen Atkinson, 1974). Total scores on the Danish translation of the TAS have been shown to correlate with total scores on the Harvard Group Scale of Hypnotic Susceptibility, Form A (Shor & Orne, 1962) which is a reliable and valid measure of hypnotic susceptibility (Zachariae et al., 2000).

METHOD Procedure
This cross-sectional study was conducted as part of a larger study of infectious complications in cancer patients. The participants in this study were cancer patients referred to chemotherapy at the department of oncology at Aarhus University Hospital in the period from November 2003 to December 2005. The patients had lung cancer, bladder cancer, ovarian cancer, or sarcomas. A total of 257 patients were invited to participate in the study. The patients were informed orally about the investigation at one of their pre-examinations before starting chemotherapy. If the patient consented to participate they were given a questionnaire package to complete at home and bring with them at the day of their rst chemotherapy.

Statistics
Categorical data were analyzed with chi2 tests. Continuous data were analysed with students t-tests for independent samples and one-way analyses of variance (ANOVAs) with subsequent pair wise comparisons conducted with Tukey post-hoc tests correcting for multiple comparisons. Correlation analyses (continuous data) were conducted by calculating Pearsons R. Additional analyses were conducted using two-way between-groups ANOVA. A signicance level of 0.05 (two-tailed) was chosen.

RESULTS A total of 134 patients participated in the study (response rate: 52%). Due to exclusion criteria related to the larger study such as fever and treatment with antibiotics shortly before completing the questionnaires, 22 patients (9%) were excluded from the study. Thus, the results in the study are based on responses from 112 patients (participation rate: 44%). Of the 112 patients, 52 (46%) were men (mean age 62.4 years) and 60 (54%) were women (mean age 58.7 years). The patients were recently diagnosed with lung cancer (63.4%), ovarian cancer (19.6%), bladder cancer (15.2%), or sarcoma (1.8%). Patients were included in the study with varying time intervals since they had received their cancer diagnosis: 27.7% of the patients were included less than 1 month after they had received their cancer diagnosis; 66.1% were included between 1 and 3 months after the cancer diagnosis; and 3.6% were included more than 3 months after their cancer diagnosis. Among the 112 patients, 13 patients (11.6%) had been diagnosed with a cancer disease previously. Patient demographics are shown in Table 1.

Measurements
Acute Stress Disorder (ASD) was assessed by the Stanford Acute Stress Reaction Questionnaire (SASRQ) (Cardena, Koopman, Classen, Waelde & Spiegel, 2000). This self-report questionnaire follows DSM-IV criteria for acute stress disorder and consists of 30 items concerning dissociative, intrusive, avoidant, and hyperarousal symptoms. On a six-point Likert scale, ranging from zero (not experienced) to ve (very often experienced), the participants were asked to rate the extent to which they suffered from each of the symptoms in response to being diagnosed with cancer. With respect to criteria from DSM-IV, subjects were identied as having clinical ASD when they endorsed (1) at least three highly rated (a score of 35) dissociative symptoms; at least one highly rated intrusive symptom; at least one highly rated avoidant symptom; and at least one highly rated hyperarousal symptom. The SASRQ assesses also the severity of ASD, which is calculated as the mean total score. The SASRQ has been used in a number of studies and has been shown to possess high test-retest reliability and high internal consistency across various populations (Cardena et al., 2000; Cardena, Grieger, Staab, Fullterton & Ursano, 1997; Koopman, Gore-Felton & Spiegel, 1997; McGarvey et al., 1998b). The questionnaire was translated into Danish by three independent translators, and a nal version was negotiated. The questionnaire was then back-translated into English compared to the original version. Discrepancies were noted and adjustments were made accordingly in the Danish version. The internal reliability of the Danish version of the SASRQ was very satisfactory with a Cronbachs alpha of 0.96 for the scale as a whole and Cronbachs alphas ranging from 0.80 to 0.90 for the subscales dissociation, reexperience, avoidance, and hyperarousal. Cronbachs alpha for the subscale impaired functioning which consists of only two items was 0.58. Repressive coping was assessed by a combination of scores on the Marlowe-Crowne Social Desirability Scale (MCSDS) (Crowne & Marlowe, 1960) and Taylor Manifest Anxiety Scale Bendig short form (TMAS-B) (Bendig, 1956). The participants were divided into four groups according to whether they scored above or below the median scores (Weinberger, 1990). The Danish translations of the MCSDS and the TMAS-B had previously been tested in a large sample of healthy volunteers and shown to have acceptable internal reliability (Christensen, Jrgensen & Zachariae, 1999). Four- and 12-week

Acute Stress Disorder Womens scores on the SASRQ (M 47.1, SD 27.7) were signicantly higher than mens scores (M 30.1, SD 27.4) (t(112) )3.24, p < 0.01). Thirty-nine patients (34.8%) reached the diagnostic criteria for ASD, and 76 patients (65.2%) did not reach the diagnostic criteria for ASD. The diagnosis of ASD was not dependent on age (t(112) 0.84, p 0.36), type of cancer disease (chi2 2.95, p 0.57), disease stage (chi2 2.82, p 0.42), WHO performance status (chi2 0.54, p 0.76), major invasive procedures before chemotherapy (chi2 0.63, p 0.53), or cancer history (chi2 0.31, p 0.58). Signicantly more women than men reached the diagnostic criteria of an ASD diagnosis (chi2 5.26, p < 0.05). Among male cancer patients, 12 patients (23.5%) reached the diagnostic criteria

2009 The Authors. Journal compilation 2009 The Scandinavian Psychological Associations.

Scand J Psychol 51 (2010) Table 1. Sample characteristics N Type of cancer Non small cell lung cancer (NSCLC) Small cell lung cancer (SCLC) Ovarian cancer Cancer of the bladder Sarcoma NSCLC (%) Aim of treatment Adjuvant Curative Life-prolonging %

Cancer, acute stress disorder, and repressive coping

87

% Men

Mean age

% Women

Mean age

63 8 22 17 2 SCLC (%)

56.3 7.1 19.6 15.2 1.8

56 38 0 76 0 Ovarian cancer (%)

62.60 61.33 62.00

44 62 100 24 100

58.79 66.80 57.27 62.75 45.00 Sarcoma (%)

Cancer of the bladder (%)

5 (7.9) 10 (15.9) 48 (76.2)

1 (12.5) 7 (87.5)

7 (31.8) 12 (54.5) 3 (13.6)

17 (100.0)

2 (100.0)

Table 2. Distribution of ASD according to repressive coping style (N 112) Repressors No. ASD Subclinical ASD No ASD 4 5 22 % 12.9 16.1 71.0 True low-anxious No. 4 2 21 % 14.8 7.4 77.8 True high-anxious No. 20 10 7 % 54.1 27.0 19.0 Defensive high-anxious No. 11 1 5 % 64.7 5.9 29.4

for ASD. Among female cancer patients, 27 patients (44.3%) reached the diagnostic criteria for ASD. The relation between ASD and comorbidity did not reach statistical signicance (t(112) )1.60, p 0.07). There was a near-signicant tendency that patients diagnosed with ASD reported higher levels of absorption than patients not diagnosed with ASD (t(112) )1.96, p 0.053).

Repressive coping While there were no differences in womens scores on the MCSDS (M 21.6, SD 4.8) and mens scores on the MCSDS (M 22.0, SD 4.6), womens scores on the TMAS-B (M 6.2, SD 4.8) were signicantly higher than mens scores on the TMAS-B (M 3.9, SD 3.2) (t(112) )3.01, p < 0.01). The classication of coping styles was based on a 2 2 combination using the total sample median score as the cut-off value on the MCSDS (high MCSDS score: >22) and genderspecic median scores as cut-off points on the TMAS-B (high TMAS-B score in men: >3; high TMAS-B score in women: >5). Based on this classication, 31 patients (27.7%) were categorized as repressors, and the remaining 81 patients (72.3%) were categorized as non-repressors: 27 patients (24.1%) were categorized as true low-anxious, 37 patients (33.0%) were categorized as true high-anxious, and 17 patients (15.2%) were categorized as defensive high-anxious). A series of analyses indicated that repressive coping was unrelated to gender (chi2 0.14, p 0.83), age (t(112) )1.63, p 0.11), type of cancer

disease (chi2 3.8, p 0.44), disease stage (chi2 0.70, p 0.87), WHO performance status (chi2 2.17, p 0.34), major invasive procedures before chemotherapy (chi2 1.01, p 0.37), comorbidity (t(112) 1.11, p 0.27), or cancer history (chi2 0.55, p 0.46). There was a non-signicant tendency that low-anxious patients (i.e. repressors and true low-anxious) reported less absorption than high-anxious patients (i.e. true high-anxious and defensive high-anxious) (t 1.67, p 0.098). The mean score on the TAS of low-anxious patients was 3.9 (SD 3.9), and the mean score on the TAS of high-anxious patients was 7.3 (SD 14.8).

Repressive coping and ASD A chi2 test revealed a statistically signicant relation between repressive coping and ASD (chi2 24.03, p < 0.0001). As seen in Table 2, only 12.9% of the repressors and 14.8% of the true low-anxious patients reached the diagnostic criteria for an ASD diagnosis compared to 54.1% of the true high-anxious and 64.7% of the defensive high-anxious. A one-way analysis of variance was conducted to examine the association between repressive coping and the severity of ASD. There was a statistically signicant difference at the p < 0.05 level in SASRQ total scores for the four coping groups (repressors, true low-anxious, true high-anxious, and defensive high-anxious) (F(3, 112) 18.39, p 0.0001). Post-hoc comparisons using the Bonferroni test indicated that repressors [M 23.5, SD 20.9] and true low-anxious patients [M 23.1,

2009 The Authors. Journal compilation 2009 The Scandinavian Psychological Associations.

88 A. F. Pedersen and R. Zachariae

Table 3. Pearson correlation coefcients between predictor and outcome variables (N 112) Dissociation Absorption MCSDS TMAS MCSDS X TMAS cross product 0.27** )0.30** 0.68** )0.59** Reexperience 0.14 )0.17 0.67** )0.50** Hyperarousal 0.19 )0.36** 0.70** )0.46** Avoidance 0.15 )0.17 0.59** )0.64**

Scand J Psychol 51 (2010)

SASRQ total score 0.23* )0.29** 0.74** )0.62**

* Correlations are signicant at p < 0.05 level; ** correlations are signicant at p < 0.01 level.

Table 4. Summary of a linear multiple regression analysis with severity of ASD as dependent variable (N 112) Independent variables Performance status Comorbidity Disease stage Age Absorption Anxiety Defensiveness Repressive coping (continuous variable) B )3.78 2.08 0.32 )0.18 0.23 0.76 )2.38 0.14 Standard error 3.60 2.78 2.18 0.23 0.20 2.13 1.48 0.10 b )0.08 0.06 0.01 )0.05 0.09 1.12 )0.40 0.63 95% CI for B )10.92 3.37 )3.43 7.60 )4.00 4.65 )0.63 0.28 )0.16 0.62 3.33 11.78 )5.33 0.56 )0.06 0.33 p 0.30 0.46 0.88 0.45 0.24 0.001 0.11 0.16 Part corr. )0.07 0.05 0.01 )0.05 0.08 )0.23 )0.11 0.01

SD 17.3] scored signicantly lower on the SASRQ than true high-anxious patients [M 57.2, SD 28.3] and defensive high-anxious patients [M 55.2, SD 26.2]. Repressors did not differ signicantly from true low-anxious patients, and true high-anxious patients did not differ signicantly from defensive high-anxious. To investigate main effects versus possible interactive effects of anxiety and defensiveness on severity of ASD, we conducted a two-way between-groups ANOVA. The results revealed a statistically signicant main effect for TMAS-B on total scores on the SASRQ [F(1, 112) 49.72, p < 0.001] but no statistically signicant main effect for MCSDS [F(1, 112) 15.16, p 0.87]. The effect size for TMAS-B was large (partial eta squared 0.32). Also, there was no statistically signicant interaction effect between TMAS-B and MCSDS [F(1, 112) 0.07, p 0.80]. Using cut-offs when differentiating repressors from the remaining groups may result in a somewhat arbitrary classication. In addition, using the resulting categorical data may reduce statistical power. As repressive coping is dened as a combination of scores on social desirability and anxiety, an alternative way of operationalizing repressive coping is based on the computing of the cross-product of the MCSDS- and TMAS-B-scores, after reversal of the TMAS-B-scores (Nyklicek, Vingerhoets, Van Heck & Van Limpt, 1998; Zachariae, Jensen, Pedersen et al., 2004). This method results in a continuous variable with true high-anxiety representing one end and repressive coping representing the other end of the continuum. Patients with ASD [M 245.15, SD 115.48] scored signicantly lower on the MCSDS X TMAS-B cross product than patients without ASD [M 375.04, SD 120.78] (t(112) 4.74, p < 0.0001). A series of correlation analyses were conducted to explore relations between repressive coping as a continuous

measure and scores on the ASD symptom subscales of the SASRQ (i.e. dissociation, reexperience, hyperarousal, and avoidance) and severity of ASD (i.e. SASRQ total score). The results are shown in Table 3. To investigate the unique contribution of possible predictors of severity of ASD in cancer patients, we conducted a standard, linear regression analysis. Performance status, disease stage, comorbidity score, age, total score on absorption, trait-anxiety (total scores on the TMAS-B), defensiveness (total scores on the MCSDS), and repressive coping as continuous variable were entered as independent variables. The dependent variable was severity of ASD (total scores on the SASRQ). The results of the regression analysis are shown in Table 4. The regression model explained 57% of the variance in severity of ASD [F(8, 112) 16.49, p < 0.001]. Of the independent variables entered in the model, only total scores on the TMAS-B made a signicant contribution to severity of ASD. This variable was positively related to severity of ASD (B 7.56, SE 2.13, b 1.12, p 0.001) and explained 5.4% of its variance.

DISCUSSION The results of this study showed that about one-third of newly diagnosed cancer patients experienced clinically signicant stress reactions with symptoms severe enough to meet criteria for the ASD diagnosis. This proportion of ASD patients is similar as the proportion found in a previous study assessing ASD in cancer patients using the same instrument (SASRQ) (McGarvey et al., 1998b). As also found in the previous study, ASD is apparently more prevalent among female cancer patients than among male cancer patients. We found a prevalence of ASD in female and male cancer patients of 41.5%

2009 The Authors. Journal compilation 2009 The Scandinavian Psychological Associations.

Scand J Psychol 51 (2010)

Cancer, acute stress disorder, and repressive coping

89

and 22.2%, respectively whereas the previous study found a prevalence of ASD in female and male cancer patients of 38% and 15%, respectively. Another study assessing the prevalence of ASD in cancer patients reported a prevalence of 28% (Kangas et al., 2005a), a prevalence also very similar to the results of this study. The results of this study revealed an association between repressive coping and decreased prevalence of acute stress disorder among cancer patients. This result is in accordance with previous ndings showing an association between repressive coping and decreased prevalence of acute stress disorder in survivors of myocardial infarction (MI) (Ginzburg et al., 2002), and could be explained by repressors tendency to perceive and interpret threatening information in a way that promotes well-being (Krahe, 1999; Myers & Brewin, 1996; Weinberger, 1990). Traditionally, repressive coping has been regarded as a stable personality trait hypothesized to be associated with an increased vulnerability to illness and disease (Weinberger, 1990). In accordance with this hypothesis, repressive copers have been found to show signs of immune dysregulations, and the results of a few studies have shown repression and restriction of emotions to be associated with poor prognosis in cancer patients (Jensen, 1987; Weihs, Enright, Simmens & Reiss, 2000). As a consequence, psychological interventions aimed at reducing the use of repressive coping have been suggested as an integral part of the treatment of cancer patients (Jensen, 1987). However, recent research has shown that repressive coping may be a context-sensitive emotional coping response. For instance, results have shown a transient increase in the use of repressive coping four weeks after a cancer diagnosis (Zachariae et al., 2004). Twelve weeks after the cancer diagnosis, levels of repressive coping were not different from levels obtained before the cancer diagnosis (Zachariae et al., 2004). The temporary increase in the use of repressive coping after a cancer diagnosis and the ndings revealing a lower prevalence of ASD in patients using repressive coping assessed one month after the diagnosis could suggest that repressive coping is a helpful coping strategy in the acute phase after a cancer diagnosis and that one should be reluctant to intervene during this period. However, the interpretation of the results of the present study is complicated as the lower incidence of ASD was also found in true low-anxious patients. This result corresponds to a recent study in which ASD was found to be associated to trait anxiety (Kangas et al., 2007). In our study, the results of a two-way between-groups ANOVA revealed a main effect for anxiety on severity of ASD, but not for defensiveness. Furthermore, the results did not reveal an interaction effect between anxiety and defensiveness on ASD severity, as the effect of anxiety (TMAS-B total scores) on severity of ASD (SASRQ total scores) was not dependent on level of defensiveness (MCSDS). Likewise, the results of a linear regression analysis, compensating for reduced power due to categorical data, revealed that traitanxiety alone explained more of the variance than the cross product of anxiety and defensiveness. Taken together, these results

could indicate that the low incidence of ASD in repressors is a result of the low anxiety reporting rather than a result of the interaction of low anxiety and high defensiveness (repressive coping). Another aspect that complicates the interpretation of the results is that the sum scores on the TMAS-B correlated highly with the sum scores on the SASRQ. Thus, one may question whether the TMAS-B and the SASRQ in this case are measuring the same construct, namely negative affectivity. Whereas the low rates of ASD in true low-anxious patients are assumed to reect reality, we do not know whether the low rates of ASD in repressive patients reect their true experiences of the situation or merely reect their unwillingness to report negative emotions as an attempt to appear as a competent and self-controlled person (impression management) as is assumed to be the case with repressors low score on the anxiety scale. As both sum scores on the TMAS-B and on the SASRQ may reect negative affectivity, it is encumbered with great unreliability to conclude that repressive coping protects against ASD based on results from a cross-sectional study. The results of cross-sectional studies nding an association between repressive coping and ASD may simply show that negative affectivity correlates with negative affectivity. We found a (non-signicant, p 0.05) tendency that patients diagnosed with ASD reported higher levels of absorption than patients not diagnosed with ASD. Our ndings are in accordance with the ndings of a study of witnesses to a fatal aircraft collision (Taylor et al., 2007). However, given the correlational nature of the present research, we cannot conclude that absorption plays a role in the development of ASD. Only future longitudinal research can test this possibility. This study has been conducted as part of another study and the design of this study has, therefore, some limitations. For instance, the study is retrospective and the patients have completed the questionnaire package with varying time intervals since they received their cancer diagnosis. Under optimum conditions, acute stress disorder should have been measured with a xed time interval since diagnosis. Furthermore, the majority of patients were diagnosed with rst onset of a cancer disease. However, a minor group of patients (11.6%) were experiencing a relapse of their cancer disease, and it could be hypothesized that their stress reaction would be qualitatively different from patients who experience the rst onset of cancer. However, research has shown that the recurrence phase of the disease is a painful experience to the patient characterized by heightened concerns about death and fear about the future (Grifths, Humphris, Skirrow & Rogers, 2008). Thus, recurrence of a cancer disease often means a transition from being a cancer patient with a potentially curable disease to being a cancer patient with a non-curable disease. Another potential limitation of this study is the use of a self-report questionnaire (the SASRQ) to measure ASD. This questionnaire has been used in various populations such as survivors of a restorm and survivors of an earthquake (Cardena et al., 2000). The instrument has also been used previously in patients with serious medical conditions such as MI (Ginzburg et al., 2002)

2009 The Authors. Journal compilation 2009 The Scandinavian Psychological Associations.

90 A. F. Pedersen and R. Zachariae and cancer (McGarvey et al., 1998b). The part of patients diagnosed with ASD has been relatively great in samples of cancer patients compared to survivors of an MI (33% in cancer patients compared to about 17% in survivors of an MI). A possible reason of why so many cancer patients compared to patients with heart disease are diagnosed with ASD could be that symptoms of ASD may be confounded with symptoms of the cancer disease and cancer treatment. For instance, problems with recalling critical experiences associated with the traumatic event are anticipated to be a symptom of avoidance. However, it is also possible that cancer patients have trouble with recalling specic situations because of the side effects of treatment, including fatigue, concentration decits, and impaired consciousness during chemical treatments (Kangas, Henry & Bryant, 2002). Likewise, treatment side effects such as insomnia, irritability, and concentration decits may also overlap with symptoms of arousal. Future studies need to investigate the magnitude of problems with symptom confusion in cancer patients to avoid false-positive cases of ASD in this group of respondents. A high number of false-positive cases of ASD among cancer patients may explain why ASD has been found to be a poor predictor of PTSD in this patient group (Kangas et al., 2005b). Taken together, the results of this cross-sectional study revealed a low incidence of ASD in both repressors and in true low-anxious patients. With respect to repressors, we do not know whether the low level of symptoms of ASD reects unconscious self-deception, impression management or reality, for example due to low levels of absorption. Future studies have to investigate long-term effects of repressive coping on traumatic stress in cancer patients. A follow-up investigation may contribute with information about whether different psychological mechanisms are responsible for the lower incidence of ASD in repressors and true low-anxious patients. Furthermore, future studies have to investigate whether the transient increase in use of repressive coping after a cancer diagnosis contributes to the low predictive power of ASD concerning development of PTSD.

Scand J Psychol 51 (2010) Butler, L. D., Duran, R. E., Jasiukaitis, P., Koopman, C. & Spiegel, D. (1996). Hypnotizability and traumatic experience: A diathesis-stress model of dissociative symptomatology. American Journal of Psychiatry, 153, 4263. Cardena, E., Grieger, T., Staab, J., Fullterton, C. & Ursano, R. (1997). Memory disturbances in the acute aftermath of disasters. In J. D. Read & S. Lindsay (Eds.), Recollections of trauma (p. 568). New York: Plenum. Cardena, E., Koopman, C., Classen, C., Waelde, L. C. & Spiegel, D. (2000). Psychometric properties of the Stanford Acute Stress Reaction Questionnaire (SASRQ): A valid and reliable measure of acute stress. Journal of Traumatic Stress, 13, 719734. Christensen, S., Jrgensen, M. M. & Zachariae, R. (1999). Reliability and validity of a Danish adaptation of the Weinberger construct of repressive coping: Preliminary data. The (non)expression of emotions in health and disease. Tilburg University, The Netherlands. Crowne, D. P. & Marlowe, D. (1960). A new scale of social desirability independent of psychopathology. Journal of Consulting Psychology, 24, 349354. Ginzburg, K., Solomon, Z. & Bleich, A. (2002). Repressive coping style, acute stress disorder, and posttraumatic stress disorder after myocardial infarction. Psychosomatic Medicine, 64, 748757. Grifths, M. J., Humphris, G. M., Skirrow, P. M. & Rogers, S. N. (2008). A qualitative evaluation of patient experiences when diagnosed with oral cancer recurrence. Cancer Nursing, 31, E11 E17. Gurevich, M., Devens, G. M. & Rodin, G. M. (2002). Stress response syndromes and cancer: conceptual and assessment issues. Psychosomatics, 43, 259281. Harvey, A. G. & Bryant, R. A. (2002). Acute stress disorder: a synthesis and critique. Psychological Bulletin, 128, 886902. Jensen, M. R. (1987). Psychobiological factors predicting the course of breast cancer. Journal of Personality, 55, 317342. Kangas, M., Henry, J. L. & Bryant, R. A. (2002). Posttraumatic stress disorder following cancer: A conceptual and empirical review. Clinical Psychology Review, 22, 499524. Kangas, M., Henry, J. L. & Bryant, R. A. (2005a). Predictors of posttraumatic stress disorder following cancer. Health Psychology, 24, 579585. Kangas, M., Henry, J. L. & Bryant, R. A. (2005b). The relationship between acute stress disorder and posttraumatic stress disorder following cancer. Journal of Consulting and Clinical Psychology, 73, 360364. Kangas, M., Henry, J. L. & Bryant, R. A. (2007). Correlates of acute stress disorder in cancer patients. Journal of Traumatic Stress, 20, 325334. Koopman, C., Gore-Felton, C. & Spiegel, D. (1997). Acute stress disorder symptoms among female sexual abuse survivors seeking treatment. Journal of Child Sexual Abuse, 6, 85. Krahe, B. (1999). Repression and coping with the threat of rape. European Journal of Personality, 13, 1526. McGarvey, E. L., Canterbury, R. J. & Cohen, R. B. (1998a). Evidence of acute stress disorder after diagnosis of cancer. Southern Medical Journal, 91, 864866. McGarvey, E. L., Canterbury, R. J., Koopman, C., Clavet, G. J., Cohen, R., Largay, K. et al. (1998b). Acute stress disorder following diagnosis of cancer. International Journal of Rehabilitation and Health, 4, 115. Moulds, M. L. & Bryant, R. A. (2002). Directed forgetting in acute stress disorder. Journal of Abnormal Psychology, 111, 175179. Myers, L. B. & Brewin, C. R. (1996). Illusions of well-being and the repressive coping style. British Journal of Social Psychology, 35, 443457. Nyklicek, I., Vingerhoets, A. J., Van Heck, G. L. & Van Limpt, M. C. (1998). Defensive coping in relation to casual blood pressure and

REFERENCES
American Psychiatric Association (1994). DSM-IV. Diagnostic and statistical manual of mental disorders. 4th edn. Washington DC: American Psychiatric Association. Andersen, B. L. (2002). Biobehavioral outcomes following psychological interventions for cancer patients. Journal of Consulting and Clinical Psychology, 70, 590610. Bendig, A. W. (1956). The development of a short form of the Manifest Anxiety Scale. Journal of Consulting Psychology, 20, 384. Berenbaum, H., Thompson, R. J., Milanak, M. E., Boden, M. T. & Bredemeier, K. (2008). Psychological trauma and schizotypal personality disorder. Journal of Abnormal Psychology, 117, 502 519. Bryant, R. A., Guthrie, R. M. & Moulds, M. L. (2001). Hypnotizability in acute stress disorder. American Journal of Psychiatry, 158, 600604. Bryant, R. A. & Harvey, A. G. (2000). New DSM-IV diagnosis of acute stress disorder. American Journal of Psychiatry, 157, 18891891.

2009 The Authors. Journal compilation 2009 The Scandinavian Psychological Associations.

Scand J Psychol 51 (2010) self-reported daily hassles and life events. Journal of Behavioural Medicine, 21, 145161. Paulhus, D. L. (1984). Two-component models of socially desirable responding. Personality and Individual Differences, 6, 598609. Roche, S. M. & McConkey, K. M. (1990). Absorption: Nature, assessment, and correlates. Journal of Personality and Social Psychology, 59, 91101. Shor, R. E. & Orne, E. C. (1962). Harvard Group Scale of Hypnotic Susceptibility, Form A. Palo Alto, CA: Culsulting Psychologists Press. Sterlini, G. L. & Bryant, R. A. (2002). Hyperarousal and dissociation: A study of novice skydivers. Behaviour Research and Therapy, 40, 431437. Taylor, S., Asmundson, G. J., Carleton, R. N. & Brundin, P. (2007). Acute posttraumatic stress symptoms and depression after exposure to the 2005 Saskatchewan Centennial Air Show disaster: prevalence and predictors. American Journal of Disaster Medicine, 2, 217230. Tellegen, A. & Atkinson, G. (1974). Openness to absorbing and self-altering experiences (absorption), a trait related to hypnotic susceptibility. Journal of Abnormal Psychology, 83, 268277. Warda, G. & Bryant, R. A. (1998). Cognitive bias in acute stress disorder. Behavioral Research and Therapy, 36, 11771183.

Cancer, acute stress disorder, and repressive coping

91

Weihs, K. L., Enright, T. M., Simmens, S. J. & Reiss, D. (2000). Negative affectivity, restriction of emotions, and site of metastases predict mortality in recurrent breast cancer. Journal of Psychosomatic Research, 49, 5968. Weinberger, D. A. (1990). The construct validity of the repressive coping style. In J. L. Singer (Ed.), Repression and dissociation: Implications for personality theory, psychopathology, and health (pp. 337386). Chicago: University of Chicago Press. Weinberger, D. A., Schwartz, G. E. & Davidson, R. J. (1979). Lowanxious, high-anxious, and repressive coping styles: Psychometric patterns and behavioral and physiological responses to stress. Journal of Abnormal Psychology, 88, 369380. Zachariae, R., Jensen, A. B., Pedersen, C. G., Jrgensen, M. M., Christensen, S., Lassesen, B. et al. (2004). Repressive coping before and after diagnosis of breast cancer. Psychooncology, 13, 547561. Zachariae, R., Jorgensen, M. M. & Christensen, S. (2000). Hypnotizability and absorption in a Danish sample: Testing the inuence of context. International Journal of Clinical and Experimental Hypnosis, 48, 306314. Received 9 July 2008, accepted 10 February 2009

2009 The Authors. Journal compilation 2009 The Scandinavian Psychological Associations.

Copyright of Scandinavian Journal of Psychology is the property of Blackwell Publishing Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.