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Anxietate La Pacienti Cu Cancer

Anxietate La Pacienti Cu Cancer

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Psycho-Oncology Psycho-Oncology 18: 1147–1155 (2009) Published online 12 January 2009 in Wiley InterScience (www.interscience.

wiley.com). DOI: 10.1002/pon.1512

Intrusive cognitions and their appraisal in anxious cancer patients
Katriina L. Whitaker1,2Ã, Maggie Watson1,2 and Chris R. Brewin2
1 2

Psychological Medicine, Royal Marsden NHS Foundation Trust, UK Clinical, Educational and Health Psychology, University College London, London, UK

* Correspondence to: University College London, Gower Street, London, WC1E 7HN, UK. E-mail: k.whitaker@ucl.ac.uk

Abstract
Objective: Previous research found that anxious cancer patients experience uncontrollable negative intrusive cognitions that have an impact on coping and are associated with significant psychological distress. This is the first study to examine the appraisal of intrusive cognitions in an anxious group of cancer patients. Methods: A sample of 139 anxious cancer patients was assessed for evidence of intrusive phenomena, including memories, images and thoughts. Patients completed the Response to Intrusions Questionnaire and the Impact of Event Scale in relation to intrusive cognitions. Results: Forty-eight percent (67/139) reported frequent, uncontrollable intrusive cognitions. Intrusive thoughts and images were equally as common and images were associated with increased distress and uncontrollability. A significant positive linear relationship was found between the number of intrusions and anxiety severity (Po0.05). Negative appraisal of intrusive cognitions was associated with anxiety (Po0.01) and depression severity (Po0.01), intrusion-specific distress (Po0.01), rumination (Po0.01) and cognitive avoidance (Po0.01), after controlling for intrusion frequency. Conclusion: Negative appraisal of intrusive cognitions plays a significant role in psychological distress and intrusion-specific distress in anxious cancer patients. Finding similarities in the types of intrusive cognitions reported by cancer patients and other anxious populations highlights the potential applicability of psychological therapies developed to reduce the frequency and impact of intrusive cognitions. Copyright r 2009 John Wiley & Sons, Ltd.
Keywords: anxiety; cancer; intrusive cognitions; appraisal; coping

Received: 3 September 2008 Revised: 3 November 2008 Accepted: 5 November 2008

Introduction
Previous research showed that anxious cancer patients experience uncontrollable negative intrusive cognitions that are often associated with feelings of sadness, helplessness–hopelessness and interfere with daily life [1]. However, intrusions are less common than found in psychiatric populations (e.g. [2]) and associated with less distress [1]. Possible explanations for the finding that intrusive cognitions are less impacting for anxious cancer patients include the relatively mild levels of anxiety reported by cancer patients and the possibility that cancer patients appraise cognitions in a qualitatively different way from other groups. Negative appraisal of intrusive cognitions has been identified as a key cognitive mechanism that mediates the management of intrusive cognitions in PSTD [3] and depression [4]. Cancer patients have reported experiencing negative intrusive cognitions, often about illness, injury or death [1]. However, because cancer patients have the stressor of a physical

illness, intrusions may be appraised as a normal stress response reaction, rather than a sign of mental fragility. It is important to apply cognitive models [3] of intrusive symptoms to cancer patients, to ascertain whether intrusive cognitions are qualitatively different for physically ill patients, compared with patients with depression or anxiety disorders. As previously shown experiencing intrusive cognitions is related to anxiety in cancer patients and understanding the mechanisms involved is key to uncovering ways to alleviate intrusive cognitions and psychological distress. Following our previous work, which established the relationship between intrusive cognitions and anxiety in cancer patients by comparing anxious and non-anxious patients, this study investigates a new anxious sample of cancer patients to examine the role of negative appraisal. Although intrusive thoughts have been extensively investigated in cancer patients [5] and the presence of intrusive imagery has now also been considered [1], the appraisal of such cognitions has

Copyright r 2009 John Wiley & Sons, Ltd.

11]. (5) there would be a positive association between negative appraisal of intrusive cognitions and intrusion associated distress after controlling for intrusion frequency and (6) negative appraisal of intrusive cognitions would be associated with the extent to which patients engaged in maladaptive coping strategies to control their intrusions. For example.e. (2) verbal intrusions (i. (2) Patients referred to the Psychological Medicine Service at the hospital were sent an invitation pack inviting them to take part. Patients who expressed an interest in taking part. These findings have been replicated in prospective research [10. L. as they prevent a change in the meaning of the trauma and subsequent recollections [3. yet to be investigated.6].17]. retrospective studies have shown that negative appraisal of intrusive cognitions was associated with PTSD severity and intrusion-specific distress. because modifying negative appraisals may be a successful treatment approach for reducing anxiety. negative meanings that individuals assign to the cancer experience) may influence emotional responses. Method Patients and procedure The study was approved by the Royal Marsden Hospital Local Research Ethics Committee. The cognitive approach to the maintenance of intrusive cognitions [3] also predicted that the negative meaning assigned to intrusive cognitions would lead to maladaptive coping strategies. previous research showed that intrusive verbal thoughts were more common than intrusive visual imagery [1].e. Understanding appraisal of intrusions is important for therapeutic reasons. after controlling for intrusion frequency in ambulance workers [7]. the meaning of events to an individual with cancer has been highlighted as key to understanding anxiety [15] and previous research has found a link between the negative appraisal of disease-threat and severity of stress response scores [16. completed on site or at home and returned by mail. Negative appraisal of intrusions has also been related to overall traumatic grief and depression in the bereaved [12] and negative appraisal of intrusive memories was positively associated with intrusion-related distress and level of depression in student samples [4] and a dysphoric sample [13]. suppression and distraction in motor vehicle accident survivors [9] and negative interpretation of intrusive memories was significantly related to cognitive avoidance in a student sample [4]. either on the telephone or in person. Ltd. which include experiences such as intrusive cognitions. either on the telephone or in person. Psycho-Oncology 18: 1147–1155 (2009) DOI: 10. negative meaning of intrusive cognitions was significantly related to coping strategies used to control intrusive cognitions such as avoidance. but did not meet criteria for anxiety. and motor vehicle accident survivors [9].g. The concept of intrusion appraisal was first discussed by Ehlers and Steil [3] and later elaborated by Ehlers and Clark [6] in their cognitive approach to posttraumatic stress disorder. Although intrusion appraisal has not yet been considered in cancer patients. The following hypotheses were proposed: (1) there would be a positive linear relationship between the number of intrusions reported and anxiety severity. ‘I am going mad’) determines how distressing the intrusions are and the extent to which patients engage in coping strategies to control the intrusions. to ensure eligibility. if a time lapse of more than 21 days had passed. The present study investigated negative appraisal of intrusive cognitions in anxious cancer patients and assessed how cancer patients cope with intrusive cognitions. Patients interviewed also completed the IES. they were asked to repeat the HADS questionnaire. The invitation pack included the HADS to send back with the reply form expressing an interest in taking part. victims of physical or sexual assault [8]. Coping strategies are implicated in symptom maintenance. it has been suggested that imagery is different from verbal representations of the same material because it is associated with increased emotional responses [18].e. In support of this. Copyright r 2009 John Wiley & Sons. In line with this. For all participants. thoughts) would be more common than visual intrusions (i. Whitaker et al. RIQ items and coping scales in response to any reported intrusions. Assessing the presence.1002/pon . rumination. Patients scoring X8 were invited to participate in the study interview. They suggested that the meaning attributed to the experience of intrusive recollections (e. However. were contacted by telephone to inform them that they were ineligible. after controlling for intrusion frequency. appraisal of.1148 K. Patients identified as anxious (X8) were contacted by telephone to arrange an interview. Two groups of patients were approached: (1) A consecutive series of patients attending outpatient clinics were screened using the HADS. images and memories) (3) visual intrusions would be more distressing than verbal intrusions. In support of this model. and coping with intrusive cognitions in a large anxious cancer sample also allows further exploration of the characteristics of intrusive cognitions in anxious cancer patients. the cognitive model of adjustment [14] predicts that negative appraisal (i. (4) there would be a positive association between negative appraisal of intrusive cognitions and anxiety/ depression severity.

Appraisal in anxious cancer patients 1149 Outpatient screening Of 870 cancer patients approached in the outpatient clinics at the Royal Marsden NHS Foundation Trust.49.83. including memories.4%). 1 had poor English.62]. From outpatient screening and psychological medicine referrals. two did not feel anxious. Po0. P 5 0. Images were defined as a specific visual picture. Po01].3%).71] or sex [w2(1) 5 1. For example. P 5 0. 3 5 hours). 100 5 all of the time). shame. guilt. Memories were defined as a visual image of a specific event and its surrounding context that occurred in the past. 2 5 minutes. 30 patients had lymphomas (21. Following this. ethnic origin [w2(1) 5 3.e. P 5 0. interference with daily life Psycho-Oncology 18: 1147–1155 (2009) DOI: 10. A further 153 patients (55%) did not respond to invitations to interview. P 5 0.30]. P 5 0. 20 patients had urological cancer (14.30. or depression [t(139) 5 À1. devoid of any surrounding context would be classified as an image. Po0.53]. Intrusive cognitions: A structured interview assessed the presence of repetitive intrusive phenomena.22].6%).01] and were significantly more likely to be of Non-Caucasian ethnicity [w2(1) 5 16. time since diagnosis [t(272) 5 0. P 5 0. P 5 0.80 power requires a sample size of 64 participants [20] and therefore at least 64 patients were required to report intrusive cognitions.1002/pon . two felt too ill. 2 patients were too distressed and 12 did not specify a reason for refusal.5%).07] or sex [w2(1) 5 0.36. 55 patients had breast cancer (39.8%). Copyright r 2009 John Wiley & Sons. 1 was recently widowed.39. Structured Clinical Interview for DSM-IV: All patients were asked whether their anxiety/concerns were related or unrelated to the cancer diagnosis. Final interview sample A priori power calculations indicated that to detect a medium effect size (r 5 0. P 5 0. 66 (47%) responded and were interviewed. present or future. P 5 0. sadness.53. The scale has been validated in cancer patients [21]. a family member’s disembodied ill face. two did not want to talk about their illness. Sixteen (2%) patients declined to participate at the screening stage. Interview session Psychological medicine referrals Of 278 patients referred to the Psychological Medicine Service. 100 5 very much so). adjustment with anxiety or adjustment with mixed anxiety and depression.05].23]. anger. 139 patients combined were interviewed and 67 reported intrusive cognitions. A further 348 (40%) of patients did not return the HADS. a 5 0. However. age [t(139) 5 0. whereas being in a specific hospital on a particular day with a family member who was dying would be classified as a memory. Questions asked in relation to intrusive cognitions included a description of the intrusion. Of the total sample.1%) and 68 patients were interviewed in person (48. At the screening phase. patients were asked to identify and concentrate on the two most intrusive cognitions.89. major depression and adjustment disorder were assessed using sub-sections of the Structured Clinical Interview for DSM-IV Disorders (SCID. present or future that did not meet criteria for memory.50. Definitions were based on those of Patel et al. there were no significant differences between responders and non-responders on time since diagnosis [t(856) 5 0.36. 1 person did not have enough time and 21 did not give a reason for their refusal. non-responders were significantly younger than responders [t(865) 5 3. If more than one intrusion was reported. Responders and non-responders did not differ on anxiety [t(139) 5 À0.9%).32]. 11 patients had gastro-intestinal cancer (7. responders were significantly more likely to be female than non-responders [w2(1) 5 4. frequency (0 5 none of the time.19. For the interview stage. Twenty-four (8%) scored below cut-off on the HADS and thus a total of 73 patients were interviewed. However.57] or disease stage [w2(2) 5 0. 9 patients had lung cancer (6. Measures Screening Hospital Anxiety and Depression Scale (HADS): The HADS [19] is a 14-item self-report scale developed for the measurement of depression and anxiety in physically ill populations.62. ethnic origin [w2(1) 5 0. 6 patients had gynaecological cancer (4. adjustment with depressed mood. associated emotions (i. Thoughts were included if they consisted of verbal content referring to the past. Seventy-one patients were interviewed on the telephone (51. P 5 0. [23]. generalised anxiety disorder. anxiety and helplessness. relating to the past.37.21.05) with 0. responders and non-responders did not differ on time since diagnosis [t(139) 5 À1. Ltd. P 5 0.22. The diagnosis of adjustment disorder was made based on predominant symptoms. [22]). P 5 0.5%). Patients who scored 8 or above on the anxiety subscale (28%) were categorised as anxious [19] and selected for the interview stage of the study.9%) and 8 patients had head and neck cancers (5.55. duration (1 5 seconds.58]. 506 (58%) completed and returned the Hospital Anxiety and Depression Scale (HADS. 97 (35%) completed and returned the HADS. Of these 141 anxious patients. 0 5 not at all. There were no significant differences between responders and non-responders on age [t(273) 5 À0. [19]).32. images and thoughts [23].78]. Twenty-eight (10%) declined to participate.07].

Finally. sex. Po0. ethnic origin and marital status had no effect on whether patients reported intrusive cognitions (P40. w2(1) 5 6. patients were asked whether it felt as though they were reliving the memory (0 5 not at all. Independent t-tests revealed that time since diagnosis significantly affected whether patients reported intrusive cognitions [t(137) 5 À2.05). suppression (‘I try to push the intrusions out of my mind’) and rumination (‘I dwell on it’). participants were asked how vivid the image was (0 5 hazy memory. For images that were not past events. Number and type of intrusive cognitions Sixty-seven patients (48%) reported an intrusive cognition.05) as anxiety level increases.1150 K. Ltd. SD 5 39. ‘I will not achieve goals that are important to me’ (replaced ‘I will not be able to do my job properly’ [12]).27. (0 5 not at all. mildly anxious (n 5 53. 100 5 severely). patients were asked if the image was related to an event that had actually happened.21] and this relationship remained [R 5 0.36. Po0. r 5 0. moderately anxious (n 5 55. 100 5 very much so).05]. Whitaker et al.21 P 5 0. patients recruited from Psychological Medicine were significantly more likely to report intrusive cognitions than patients recruited from outpatient screening [w2(1) 5 5.05. 100 5 clearest and most vivid memory). a 15item self-report scale. uncontrollability (0 5 not at all. High internal consistency. They were also more likely to be diagnosed with anxiety or depression using the SCID compared with outpatients. 100 5 completely) and associated distress (0 5 not at all. Cramer’s V 5 0. consists of intrusion and avoidance sub-scales. patients screened through Psychological Medicine. clinical and psychological characteristics of the total sample. ‘I have a psychological problem’.22). Patients were required to rate from 1 (totally disagree) to 7 (totally agree) for each item. Intrusive cognitions and anxiety In order to investigate the relationship between number of intrusive cognitions and anxiety level. The items were adopted from previous research (e.g. L. Po0. Recruitment.60 months. For images of past events. the total sample was divided into three groups according to pre-defined criteria [26].’I am inadequate’.40. of whom 14 patients reported at least one additional intrusion. A polynomial contrast analysis showed that the mean number of intrusions increases (contrast estimate 5 0. Impact of Event Scale (IES): The IES [24]. Appraisal of intrusive cognitions: Response to Intrusions Questionnaire (RIQ): Six items measuring negative appraisal of intrusive cognitions from the RIQ [7] were used including ‘Something is wrong with me’.20]. Po0.01. the group of patients reporting intrusive cognitions were significantly more likely to meet criteria for DSM-IV diagnoses (30/67) than those not reporting intrusive cognitions (17/72). However. ‘I cannot cope’. Psychological Medicine patients had significantly longer post diagnosis and were quicker to return the HADS. SD 5 58.05] after controlling for sample type (Psychological Medicine or Outpatient).36. HADS 5 11–14) and severely anxious (n 5 31. HADS 5 8–10). test re-test reliability and validity have been reported [25]. demographic and clinical influences on reporting intrusive cognitions There was no significant difference in whether patients reported intrusive cognitions according to whether they were interviewed on the telephone or in person [w2(1) 5 0. are presented in Table 1.18. Coping with intrusive cognitions: Patients were asked to rate on a 100-point scale (0 5 not used at all. Internal consistency for the negative appraisal scale was high (a 5 0. The presence of intrusive cognitions was not related to treatment type [w2(1) 5 0. The group of patients reporting intrusive cognitions had significantly longer post diagnosis (mean 5 49.67) than patients not reporting intrusive cognitions (mean 5 28.05.20]. Comparisons showed that patients recruited from Psychological Medicine referrals were significantly more anxious and depressed than patients meeting the cut-off for anxiety via outpatient screening. ‘Some day I will go out of my mind’. A one-way ANOVA indicated a significant overall effect of anxiety category on the number of intrusive cognitions reported [F(2.00 P 5 0.95. Patients from Psychological Medicine were more likely to have advanced disease. and patients screened through outpatients.46.86). Of these. Po0. Results Participant characteristics The demographic.1002/pon . seven patients Psycho-Oncology 18: 1147–1155 (2009) DOI: 10. 100 5 severely). P 5 0. The linear relationship between anxiety and intrusive cognitions may explain why a higher number of patients from Psychological Medicine reported intrusive cognitions than patients screened in outpatient clinics as the former were significantly more anxious.90 months. 100 5 used very much) the extent to which they engaged in three coping strategies—distraction (‘I try to distract myself’).136) 5 3. For memories and images. Copyright r 2009 John Wiley & Sons. 100 5 very much so) and accompanying emotional and physical sensations (0 5 not at all. HADS 5 15–21). whereas patients from outpatient screening were more likely to have locally advanced disease. three patients reported two intrusive memories. [9]).98] or disease stage [w2(2) 5 3. Po0.55]. Age.

Four of the eight reported images were related to a past event and the four remaining intrusive images were future Copyright r 2009 John Wiley & Sons.88 (50.6) 47 (64.35.4) 4 (5.1) (68.18 Po0.03) 8.08 (12.44. to be moderately to severely distressing.04) 6. r 5 0.25 w2(1) 5 0. 1 was both future and present oriented and 1 was both future and past oriented.7) w2(2) 5 1.58. P 5 0.01ÃÃ. to interfere moderately with daily life.05) 7. P 5 0.0) 30 (45. Characteristics of intrusive cognitions Table 3 shows the mean characteristics of intrusive cognitions.35 (between patients meeting criteria or not) reported an intrusive memory and an intrusive thought.85) 29. Ltd.4) 50 (68.14 (6.6) 92 (66. Fifty-eight (72%) of the intrusive cognitions related to the person’s own experience of having cancer and 13 (16%) of the intrusions related to a relative’s illness.5) (21. clinical and psychological characteristics of the total sample (N 5 139).5) (15.02. Demographic. oriented.02 (2.84 (3.97 (3.38 (5. 1 was related to past event.44 (37. P 5 0.18 Po0.5) 34 (51.4) (2. intrusive cognitions were reported to occur just over half the time in the past week. P 5 0.4) (5.2) 9 (13.23 w2(1) 5 16.2) 10 (15.7) 9 (13.7) 3 (4.7) 38 (27.18) 38.14 (4. 31 were intrusive memories.97 71 (51.6) 45 (68.8) 49 (74.3) 15 (22.03) 51.9) w2(2) 5 9.5) 1 (1.5) 8 (12.05.27 (4.1) 20 (14.67.01ÃÃ Cramer’s V 5 0. 8 were intrusive images and 42 were intrusive thoughts.03 (7.3) 20 95 20 4 (14.7) 1 4 16 10 (1.2) (34. P 5 0.9) 26 (35. Of the 81 intrusions reported in total.1002/pon . t(137) 5 2.2) 51 (77.22 (12.5) w2(1) 5 1. one patient reported an intrusive image and an intrusive thought and three patients reported an intrusive memory and an intrusive image. r 5 0.5.1) 35 (53.6) 5 (3.6) 17 (12.5) 14 (21.01 (two-tailed).1) (1.9) (13. See Table 2 for examples of different types of intrusive cognitions reported.7) (8.1) 2 (2. Intrusions most often lasted for minutes rather than being fleeting or lasting for hours. To investigate the difference between specific characteristics of visual Psycho-Oncology 18: 1147–1155 (2009) DOI: 10.4) 35 (25. t(137) 5 3.12. and to be severely uncontrollable.27 30 (41. r 5 0.1) 1 (1. t(137) 5 2.4) (68.48) 11.2) 11 (7. In total. 75% of reported intrusions were specifically related to cancer and 10 (12%) were unrelated to illness or death.5) 23 (31.50) 12. patients recruited from Psychological Medicine (n 5 73) and patients recruited from Outpatient Clinics (n 5 66) Characteristic Total sample Psychological Medicine patients Outpatients Difference between Psychological Medicine and outpatients Continuous variables [Mean (SD)] Age Months since diagnosis Days since HADS completion HADS anxiety score HADS depression score Categorical variables [n (%)] Sex Male Female Ethnic origin White British Other Marital status Single Married/living with a partner Separated/divorced Widowed Cancer stage Early Locally advanced Advanced Unknown Treatment On treatment Post-treatment Undecided DSM-IV diagnoses Does not meet criteria Generalized Anxiety Disorder (GAD) Major Depressive Disorder (MDD) Both GAD and MDD Adjustment disorder—depression Adjustment disorder—anxiety Adjustment disorder—mixed ÃPo0.2) 8 (12.4) 12 (8.09.25 Po0.1) 39 (53. t(137) 5 3.8) 69 (49.3) 0 (0) 0 (0) 1 (1.21 w2(1) 5 1.65.3) 65 (46.3) (14. injury or death (three specifically from cancer).Appraisal in anxious cancer patients 1151 Table 1.4) 2 (1.4) (50. Of the total sample of cognitions (n 5 81).05Ã.37) t(137) 5 1.6) 3 (4.5) 11 50 11 1 37 6 25 5 (15.09) 8.5) 55 (83.8) 17 (25.41 (59.73) 5.30 43 (31) 96 (69) 101 (72. r 5 0.5) 1 (1.2) 2 (1.48 (11.2) 13 (9.88 (3. ÃÃPo0. Thirty-four (81%) of thoughts were future oriented.00ÃÃ Cramer’s V 5 0.2) 3 (2. Po0.26) 53.) 37 (50.51.45) 7.2) (6.01ÃÃ.30 Po0.70) 11.00.05Ã. 52.45) 47.16. P 5 0.

For patients reporting two or more intrusions.05) 49.31ÃÃ 0.83) 69.6) 4 (12. Correlates of negative appraisal (RIQ) of intrusive cognitions (n 5 67) Negative appraisal Anxiety Depression Intrusion uncontrollability Intrusion distress IES total IES avoidance IES intrusion Distraction Suppression Rumination ÃPo0.22Ã 0. r 5 0.98 t(65) 5 À2. P 5 0.60) 34. L.30 (24.63.42ÃÃ 0.41ÃÃ (images and memories combined) and verbal intrusions.01 (one-tailed).8) Visual intrusions Mean (SD) 56. depression.64 (8.45) 85.2) 12 (14. P 5 0.42ÃÃ 0.96.19 0.95) 54. Partial correlation controlling for frequency 0. intrusion-related distress and intrusion-specific coping.74. SD 5 21.64) 42.70.01.05.25.08 0.69 (9.09 t(65) 5 À0. going to attack me and feeling humiliated Horrific monster type faces with sharp horrible teeth.58 t(65) 5 0.45.30 t(65) 5 À1.56.85 (23. one intrusion was randomly selected to be included in the analysis. or similar to those experienced during the actual event (mean 5 82.93) 19.10. r 5 0. P 5 0. the cancer is not going to go away Boss at work.05. patients reported experiencing emotions the same as. (mean 5 89.82 (24.4) 6 (17.32 (13. respectively).05.26.69) 69.01) 70.37) 9 (27. A Fisher exact test showed that visual intrusions were more often shorter in duration than verbal intrusions.94 (26.33 (12. anxiety.74 and mean 5 85. Re-experiencing physical sensations was reported ‘a little’ (mean 5 37. although both intrusions usually lasted for minutes. SD 5 43.90 (7. Typical content of cancer-related and cancer-unrelated intrusive cognitions Timescale Intrusions related to cancer Memory Past Image Future Thought Future Intrusions unrelated to cancer Memory Past Image Future Thought Future Content Having high-dose chemotherapy.37ÃÃ 0.00 (24.43 (23.81) 17 (21) 52 (64. although this difference did not reach statistical significance. Whitaker et al. Visual intrusions were also more uncontrollable than verbal intrusions.47) 22.17) 45. visual intrusions (n 5 33) and verbal intrusions (n 5 34) Characteristic All intrusions Mean (SD) 56. ÃÃPo0.29 t(65) 5 À1.28) 15. Correlates of negative intrusion appraisal (RIQ) Table 4 contains the correlations between negative appraisal of intrusions. For intrusive memories. Cramer’s V 5 0.2.64).3) 20 (60.15) 20.31ÃÃ 0.24 t(65) 5 À2.10 0.08 0.09) 18.65 (7.05. Po0.39) 1 (3) 27(79. including intrusion and avoidance.29ÃÃ 0.52.1002/pon . Psycho-Oncology 18: 1147–1155 (2009) DOI: 10. r 5 0.1) Verbal intrusions Mean (SD) 59.01 0. SD 5 41.15 (23.34 Table 4. Po0. independent t-tests were conducted.27 Fisher exact test o0.34ÃÃ 0.28ÃÃ 0.23Ã 0. smell of sweet corn and messing the bed because I am incontinent Looking down on myself at my own funeral and seeing my friend and family who are crying and hearing music playing I am going to die.70 (7.47.33ÃÃ 0.57) and reported moderately reliving the memory (mean 5 54.49) 39.68 (8.00 (27. Characteristics of all intrusive cognitions (n 5 81).6) Difference between visual and verbal intrusions Frequency Interference Uncontrollability Distress IES total IES avoidance IES intrusion Duration n (%) Seconds Minutes Hours t(65) 5 0.50.59 (14.27ÃÃ 0.85 (19.45 (34.93 (32.15 0. Po0. Ltd. SD 5 15. Visual intrusions were associated with significantly more subjective distress.43) 81.09 (31. Table 2. snarling and mutating coming towards me Fears about flat being destroyed Table 3.1152 K.40) 75. Intrusive memories and intrusive images were reported to be extremely vivid Copyright r 2009 John Wiley & Sons.17 0. SD 5 27. P 5 0.31) 18.52). according to the IES.

futureoriented intrusive images were relatively uncommon. seeing them. Future experimental research may be required to resolve inconsistencies and elucidate the role of thought suppression on the frequency and impact of intrusive cognitions. with the majority of patients describing contextualised imagery anchored in the past.10. Rumination and intrusion avoidance were also associated with negative appraisal. where a greater proximity to diagnosis is associated with a higher frequency and severity of stress response symptoms [36]. These relationships remained after controlling for intrusion frequency. This contradicts previous research. As predicted. However. supporting the notion that experiences such as intrusive cognitions exist on a continuum from non-clinical [4. Although based on a specific set of definitions developed in previous studies. for example. Another unexpected finding was that time since diagnosis was higher in the group of patients reporting intrusive cognitions than those not reporting intrusive cognitions. such strategies may serve to exacerbate rather than ameliorate intrusive cognitions. Also. negative appraisal of intrusive cognitions was related to general psychological symptoms. Future research should also assess whether factors such as imaging ability or hypnotisability [35] impact whether individuals experience visual intrusions. Ltd. The present study made novel comparisons between visual and verbal intrusions in cancer Copyright r 2009 John Wiley & Sons.Appraisal in anxious cancer patients 1153 Negative appraisal was positively correlated with anxiety. Overall the results support the notion that negative appraisal of intrusive cognitions plays a role in the development of emotional distress after cancer diagnosis. the confirmation that verbal and visual intrusions are distinguishable in this population supports theoretical and applied research that emphasises their independence [27. Negative appraisal was also positively correlated with intrusion-specific coping. For example. Clearly cancer patients do perceive intrusions as a sign of mental fragility.11]. Distraction may have been unrelated to psychological distress because it is not necessarily a negative coping strategy. Thus. Reports of ongoing intrusive cognitions in the present study highlight the prolonged nature of cancer as a stressor that can precipitate intrusive symptomatology throughout the course of the disease. rumination.1002/pon . student [29] and dysphoric samples [13]. including anxiety and depression severity. So far. intrusive imagery was more likely to last for seconds compared with intrusive thoughts.7].34]. irrespective of intrusion frequency. unlike in some studies of patients with anxiety disorders [2]. The data supported the alternative explanation that lower frequency intrusions are related to lower anxiety levels in cancer than in psychiatric samples. It was also found that those cancer patients with intrusions tended to appraise them in a negative way. This follows a pattern of results reported in PTSD samples [7. Instead. patients. Specifically. suggested that imagery has a greater impact on emotion than verbal representations of the same material. including avoidance (IES) and rumination. which in turn lead to the maintenance of distress [3].27] to clinical levels [23. Psycho-Oncology 18: 1147–1155 (2009) DOI: 10. in support of previous research [1]. Holmes et al. This is in line with the suggestion that cognitive avoidance and rumination used in response to intrusive cognitions paradoxically prevent the elaboration and integration of intrusive cognitions and help maintain negative appraisals [30]. and also to intrusion-specific characteristics. A number of unexpected findings require explanation. suppression and distraction were not associated with general distress in the present study. after controlling for intrusion frequency. research has focussed almost exclusively on the presence of intrusive thoughts in cancer patients [5]. Discussion The present study replicates and extends our previous finding that approximately half of anxious cancer patients experience frequent negative intrusive cognitions that are distressing. images trigger episodes in autobiographical memory [33] and images often include personal involvement in events [18]. Previous research also found no relationship between rumination and suppression of intrusive cognitions and depression [4]. As predicted. depression and intrusion-related distress. as a sign that they could not cope or had a psychological problem. after controlling for intrusion frequency. similar levels of visual and verbal intrusions were reported. although others did report a relationship [7]. because images are more like actual percepts [32]. interfering. comparisons of visual and verbal intrusions revealed that visual intrusions were associated with significantly more subjective distress (intrusion and avoidance) than verbal intrusions. memories were more prominent. the bereaved [12]. leaving an entire category of intrusions unexplored. and was equivalent to a depressed sample [13]. The linear relationship between anxiety and intrusive cognitions appears to be robust. such as distress and uncontrollability. mean negative appraisal of intrusive cognitions was higher in cancer patients than in ambulance workers and non-clinical populations [4. Contrary to prediction. These findings are consistent with previous work that emphasised the fleeting nature of intrusive imagery [31] and the special relationship between imagery and emotion [18]. This contradicts one explanation for the lower frequency and impact of intrusions in cancer patients compared with psychiatric samples [1]. uncontrollable and commonly related to future concerns.28].

38:537–558.38:251–265. other appraisals may play a role in the presence and maintenance of intrusive cognitions in cancer patients [37].1002/pon . 8. Dunmore E. Moulds ML. Clark DM. Psycho-Oncology 18: 1147–1155 (2009) DOI: 10. Bryant B. Ehlers A. Kandris E. which may be due to the age differences between the samples and the finding that non-responders are significantly younger than responders.37:809–829.93:125–132. psychological therapies developed elsewhere to reduce the impact of intrusions may provide a reduction in distress for cancer patients reporting these experiences. The role of negative interpretations of grief reactions in emotional problems after bereavement. McManus F. We would also like to thank the patients at the Royal Marsden NHS Foundation Trust who so kindly gave their time to participate in this research. References 1. 10. 2. Bryant RA. Recruitment rates for Psychological Medicine referrals were even lower (35%). Ltd.23:217–249. and intrusion-specific distress. Ehlers A.g. PTSD symptoms. Boelen PA. the number of correlations conducted may increase the probability that relationships were encountered. Posttraumatic stress disorder following cancer—a conceptual and empirical review. Oxford. Ehlers A. van den Hout MA. although this cannot be clarified as these patients did not complete the HADS. simply asking cancer patients about whether they experience intrusive cognitions may help normalise the experience. Clin Psychol Rev 2002. Behav Res Ther 2000. Moorey S. van den Bout J. Ehlers A. 9. Overall. Williams AD. Intrusive cognitions and anxiety in cancer patients. Copyright r 2009 John Wiley & Sons. Also. For example.1154 K. J Behav Ther Exp Psychiatry 2003. Clark DM. The finding that the negative appraisal of intrusive cognitions plays a significant role in anxiety and depression severity. J Abnormal Psychol 1998. Prospective research is required as the crosssectional design precludes causal interpretation. Psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents. The use of safety behaviours to manage intrusive memories in depression. Br J Clin Psychol 1999. Clark DM. 4.46:573–580. Ehlers A. The fact that negative appraisals associated with these intrusions have been identified suggests that the exposure treatments commonly employed with intrusive memories and images might have to be supplemented by procedures aimed at identifying and modifying the negative meanings attached to them [9]. Finally. the recruitment rates for outpatients were significantly lower in the present study (48%) compared with our previous study [1] with prostate cancer patients (65%). Clark DM.107(3):508–519. 12. followed by psycho-education to explain the function of intrusions and the negative consequences of avoidance. internal threat appraisal encompasses individual perceptions of the self as capable. 5.g. Although we considered negative internal appraisals.39:1063–1084. 14.34:225–238. if intrusive cognitions reported by cancer patients show similarities to those found in other clinical populations. Lang TJ. Behav Res Ther 1999. For example. Mayou RA. Watson M. Behav Cognitive Psychother 1995. J Psychosom Res 2008. Acknowledgements This research was supported by a Cancer Research UK doctoral studentship [Grant no: C3763/A3744]. acceptable and in control.38(6):601–610. Moulds ML. Ehlers A. J Affect Disord 2006. the present study adds to our understanding of intrusive cognitions in cancer patients.38:319–345. Dunmore E. Cognitive Behaviour Therapy for People with Cancer. Clohessy S. 3. Hackmann A. Maintenance of intrusive memories in posttraumatic stress disorder: a cognitive approach. Whitaker KL. Oxford University Press. Greer S. Limitations of the present study include the inability to draw conclusions about directionality. Also. 11. Recurrent images and early memories in social phobia. Henry JL. Ehlers A. 7. A cognitive model of posttraumatic stress disorder. although the consistent pattern found across correlations and concordance with previous research means it is unlikely our findings were found by chance. 13. Behav Res Ther 2008. This was because patient demands needed to be minimised while replicating previous research as closely as possible (e. Intrusion-specific coping was assessed with single-item measures that may have compromised the reliability of the assessment and underestimated the effect of intrusion coping on negative appraisal. L. 2002. Starr S. Kangas M. Behav Res Ther 2000. external threat appraisals (e. disease-specific threat) have consistently played a role in psychological models of cancer such as the cognitive model of adjustment [14] and found to be related to stress response symptoms [16]. Steil R. Steil R. Cognitive factors involved in the onset and maintenance of PTSD. 6. in addition to how individuals perceive their reaction to intrusive cognitions [37]. [4]). Whitaker et al. The role of negative interpretations of intrusive memories in depression. Brewin CR. A prospective study of the role of cognitive factors in persistent posttraumatic stress disorder after physical or sexual assault. which may be because patients referred to Psychological Medicine were at the peak of their anxiety and therefore less likely to participate. There are thus a number of additional therapeutic approaches that might prove beneficial for cancer patients reporting these experiences. Behav Res Ther 2000. Another limitation is that PTSD was not assessed in the present study. In particular. strengthens the argument that intrusive cognitions are an important area of research in psychooncology. Behav Res Ther 2001.22(4):499–524. There are significant clinical implications of the present study. response to intrusive memories and coping in ambulance workers.64:509–517. Dysfunctional meaning of posttraumatic intrusions in chronic PTSD.

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