Psychological Assessment Copyright 1997 by the American Psychological Association, Inc.

1997, Vol. 9, No. 3, 269-276 1040-3590/97/S3.00

Factor Structure of the Psychosocial Adjustment to Illness Scale

(Self-Report) for Persons With Cancer
Thomas V. Merluzzi and Mary Ann Martinez Sanchez
University of Notre Dame

The Psychosocial Adjustment to Illness Scale (PAIS-SR) is a frequently used self-report measure,
yet its factor structure, reliability, and validity have not been tested adequately on a sample of persons
with cancer. A group of persons with cancer (N = 502) completed the PAIS-SR and other measures
of adjustment and coping. A principal-axis factor analysis with varimax rotation yielded 7 factors:
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Social and Leisure Activities (.86), Job and Household Duties (.85), Psychological Distress (.87),
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Sexual Relationship (.92), Relationships With Partner and Family (.70), Health Care Orientation
(.61), and Help From Others (.63). Values in parentheses are Cronbach's as for the factors; a for
the entire scale was .93. Correlations with measures of disease impact, adjustment, and coping
support the validity of the PAIS-SR and its use for cancer research.

Advances in medical care and changing attitudes toward ill-
nesses such as cancer and renal disease have resulted in increas-
ing numbers of people who are living longer with chronic dis-
eases. Treatments for many serious and chronic diseases have
severe side effects that may tax the person's coping capacity.
This increase in longevity and the severity of side effects have
provoked a concomitant interest in the psychosocial adjustment
of those who survive serious diseases and endure treatments for
those diseases. That interest has spawned a number of measures
to assess adjustment (e.g., Derogatis & Derogatis, 1990; Viet &
Ware, 1983) and quality of life (e.g., Cella et al., 1993). The
relevance of the concept of adjustment to illness is underscored
by the finding from a prospective longitudinal study that for
the same disease the cost of health care for people who are
poorly adjusted to chronic illness is approximately $24,000 an-
nually compared with approximately $10,000 for their well-
adjusted counterparts (Browne et al., 1990).
One of the most prevalent measures of adjustment appearing
in the health psychology literature is the Psychosocial Adjust-
ment to Illness Scale, which was devised by Derogatis and his
colleagues (Derogatis & Derogatis, 1990; Morrow, Chiarello, &
Derogatis, 1978). There are two versions of the Psychosocial
Adjustment to Illness Scale. One is administered in a structured
interview format (PAIS); the other is a self-report form
(PAIS-SR).
Thomas V. Merluzzi and Mary Ann Martinez Sanchez, Department
of Psychology, University of Notre Dame.
We wish to acknowledge the support of Rafat Ansari, Thomas Troeger,
David Taber, Juan Garcia, Rhonda Critchlow, and the staff of Michiana
Hematology-Oncology; Marti Verfurth, executive director of Memorial
Hospital's Regional Cancer Center, and her staff; and the many dedicated
undergraduates in the seminar on psychooncology who served as research
assistants. Also, we would like to extend our gratitude to the many persons
with cancer who graciously agreed to participate in this research.
Correspondence concerning this article should be addressed to
Thomas V. Merluzzi, Department of Psychology, University of Notre
Dame, Notre Dame, Indiana 46556. Electronic mail may be sent via the
Internet to merluzzi.l@nd.edu.
The PAIS was devised originally for, and initially validated
on, persons with cancer and their families (Morrow et al.,
1978). A recent review of measures of psychological function-
ing used in.research on adjustment to cancer (Gotay & Stern,
1995) indicated that the PAIS is still widely used to assess
psychosocial adjustment in persons with cancer. However, Gotay
and Stern (1995) have strongly endorsed the need for research
on the psychometric properties of those measures and their re-
finement. Furthermore, they suggest that factor analytic and va-
lidity studies need to be conducted to ascertain the structure
and quality of measures used in psychosocial oncology research.
The PAIS-SR is very similar to the PAIS in that both mea-
sures contain 46 items that cover seven domains of psychosocial
functioning. The subscale Health Care Orientation assesses "pa-
tient attitudes, quality of information, and the nature of the
patient's expectations about his/her disorder and its treatment"
(Derogatis & Derogatis, 1990, p. 8). Vocational Environment
taps "perceived quality of job performance, job satisfaction,
lost time, job interest, and a number of other variables that are
associated with the nature of vocational adjustment'' (p. 8). The
items that compose the Domestic Environment scale ' 'measure a
number of aspects of family living, including financial impact
of the illness, quality of relationships, family communications,
and effects of physical disabilities" (p. 9). The Sexual Relation-
ship scale assesses "sexual interest, frequency, quality of perfor-
mance, and level of satisfaction" (p. 10). Extended Family
Relationships contains items that assess "any negative impact
of the illness upon communication, quality of relationships, in-
terest in interacting with family and other variables reflective of
this domain" (p. 11). The Social Environment scale is used to
"determine the degree to which the patient has suffered incur-
sions due to illness into his/her typical social and leisure activi-
ties" (p. 12). Finally, Psychological Distress covers "indicators
of psychological distress such as anxiety, depression and hostil-
ity, as well as reduced self-esteem, body image problems and
inappropriate guilt" (p. 13).
The PAIS-SR continues to be used in research on adjustment
to cancer (e.g., Gotcher, 1992; Howes, Hoke, Winterbottom, &
Delafield, 1994; Lowery, Jacobsen, & DuCette, 1993; Mer-

269
 270 MERLUZZI AND MARTINEZ SANCHEZ
luzzi & Martinez Sanchez, 1997), including bone marrow trans-
plantation (Andrykowski et al., 1992; Jenkins, Linington, &
Whittaker, 1991); choice of breast surgery (Wolberg, Tanner,
Romsaas, Trump, & Malec, 1987); and family functioning
(Friedman et al., 1988). It also has been used to study adjust-
ment to lupus (Engle, Callahan, Pincus, & Hochberg, 1990);
renal disease (Fricchione et al., 1992); heart surgery (Langelud-
decke, Tennant, Fulcher, Baird, & Hughes, 1989); pain (Crook,
Tunks, Kalaher, & Roberts, 1988); and hypertension (DeVon &
Powers, 1984).
Although the PAIS-SR has been used extensively in research
on adjusting to cancer, its psychometric properties, in particular
its internal consistency and factor structure, have not been re-
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ported. Internal consistency data are available for a small sample
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of cardiac patients but no such data on persons with cancer have
been provided in the PAIS manual. Also, internal consistency
data are provided for the PAIS (i.e., interview format) based
on lung cancer patients; however, the sample size is quite small
(N = 89), and there have been some revisions of the PAIS since
those internal consistency values were reported (Derogatis &
Derogatis, 1990). Finally, a review of many studies that used
the PAIS-SR revealed no additional internal consistency data.
In many research studies authors reported the internal consis-
tency values for the interview format of the PAIS -while using
the self-report version.
A factor analysis of the PAIS (i.e., interview format) on data
derived from 120 lung cancer patients was presented in the
manual (Derogatis & Derogatis, 1990). The authors reported a
seven-factor solution. In part, the solution does appear to support
the original scales of the PAIS. However, there are several prob-
lems involved in the interpretation of that factor analysis. First,
the sample was quite small (TV = 120). Tabachnick and Fidell
(1996) suggested that for factor analyses a sample size of 100
is poor, 200 is fair, 300 is good, and 500 is very good. Second,
the sample consisted of only lung cancer patients, and therefore
the results may not be generalized to another type of cancer.
Third, only factor loadings of greater than .40 are reported in
the manual. Fourth, although 80% of the items had a factor
pattern that did correspond to the original scales of the PAIS,
20% did not. Finally, the factor analysis was performed on data
derived from the PAIS, which is conducted in interview format,
and therefore the reported structure may vary from the PAIS-
SR, which uses the self-report format.
The purpose of this study was to conduct a factor analysis
of the PAIS-SR on data obtained from a large sample of patients
who had a variety of cancer diagnoses. The goals were to con-
firm the seven conceptual scales of the PAIS-SR, provide infor-
mation concerning internal consistency, and investigate its valid-
ity by examining correlations with other measures. We antici-
pated that the PAIS-SR would (a) correlate negatively with
measures of disease impact, functional status, and stage at diag-
nosis, (b) correlate positively with measures of adjustment, so-
cial support, and coping, and (c) have a weak or no relationship
to demographic variables.
Method
Participants
A sample of 502 persons with cancer (331 women, 171 men) was
recruited for participation in this research from two sites: a hospital-
based regional cancer center and a large private-practice oncology clinic.
Participants ranged in age from 21 to 90 years, with a median of approxi-
mately 60. Sixty-nine percent of the participants were married, 13%
widowed, and 7% divorced. Equal numbers (36%) were employed or
retired, and 14% were full-time homemakers. Approximately 55% made
$25,000 per year or less, and 45% made more than $25,000 per year.
Most participants had completed high school (44%), some had attended
college (18%), and still fewer had earned college degrees (8%). Most
were Protestant (55%) and Caucasian. Members of minority ethnic
groups constituted 8% of the sample, but it had a broad range of age
and socioeconomic status (SES).
A variety of cancer diagnoses were represented: breast (37%),
lymphoma (13%), lung (13%), colorectal (8%), prostate (5%), uter-
ine/ovarian/cervical (8%), leukemia (3%), brain (3%), organ/stom-
ach (2%), testicular (2%), and other (6%). Most had been treated
with chemotherapy (72%), surgery (66%), radiation (49%), or some
combination of these treatments. Forty-nine percent had been diagnosed
less than a year and 51% more than a year before participating in this
research. For 124 participants in this sample, the following information
on stage of cancer (at diagnosis) was obtained: Stage 1, 24%; Stage 2,
28%; Stage 3, 10%; Stage 4, 26%; not staged, 12%.
Materials
Psychosocial Adjustment to Illness Scale—Self Report. Participants
completed the Psychosocial Adjustment to Illness Scale (PAIS-SR; De-
rogatis & Derogatis, 1990), which correlates with measures of depres-
sion and global adjustment. Other validity studies have demonstrated its
ability to discriminate between "good" and "bad" adjusters to renal
dialysis (Derogatis & Derogatis, 1990). The only reported internal con-
sistency coefficients in the manual were from a sample of 69 cardiac
patients. Across seven scales those coefficients alpha ranged from .47
to .85.
For each of 46 items in the PAIS-SR, participants chose one of
four responses, which are graded to represent poor-to-good adjustment.
Generally, high scores are indicative of poor adjustment. We reversed the
scoring, however, so that a high score was indicative of good adjustment,
because correlations with other measures were easier to interpret if, for
all measures, high scores indicated positive psychological or physical
states. For the analyses conducted in this research, raw scores were used
instead of standard scores because there was no need for comparisons
with other populations or clinical interpretation.
The measures presented next were used to assess the validity of the
PAIS-SR. These measures were chosen on the basis of their strong
psychometric properties (i.e., reliability and validity) and their use in
health psychology research.
Disease impact. The Sickness Impact Profile (SIP; Bergner, Bobbit,
Carter, & Gilson, 1981) was used to determine the functional impact
of disease on the person's activity. The participants completed the scales
of this measure, which relate to the disease's physical impact and impair-
ment of independence (i.e., ambulation, mobility, and body care and
movement) but not psychosocial impact. A score was obtained by sum-
ming the scale values of each of the endorsed items and dividing the
sum by the number of scale items within that category. Then a total
score was obtained by summing the category scores and multiplying
that score by 100. A higher score is indicative of greater impairment.
This measure has been used extensively in research on coping with
cancer.
The Karnofsky Performance Status scale (KPS; Karnofsky, Abel-
mann, & Graver, 1948) was designed to assess the general physiological
and functional impact of cancer. This measure relates the disease to
daily functioning and has found widespread usage in cancer research
(Greico & Long, 1984; Karoly, 1985). Ratings were done by a health
care professional, and scores could range from 0 (dead) to 100 (normal
with no complaints).
 FACTOR STRUCTURE OF THE PAIS-SR
Adjustment. The Mental Health Index (MHI), developed by Viet
and Ware (1983), is an indicator of psychological distress and psycho-
logical well-being in the general population. The scale consists of 38
items that were rated on a 0-5 scale, with higher scores indicating
greater psychological well-being.
Social support. The Interview Schedule for Social Interaction (Ber-
geman et al., 1990) contains 24 items for which the participant indicated
(on a 3-point scale) how often a supportive behavior occurred and, on
the same scale, how satisfied he or she was with that support. A greater
level of support was associated with higher scores on this measure.
Coping. The COPE Scale (Carver, Scheier, & Weintraub, 1989) is
a 52-item measure that contains scales for problem-focused and emotion-
focused coping. Participants indicated on a 4-point scale the extent to
which each item applied to them ( 1 = 7 usually don't do this at all to
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4 = 1 usually do this a lot). High scores are indicative of high levels
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of problem- or emotion-focused coping.
Religiosity was assessed by asking participants to rate three questions
on 7-point Likert scales: (a) How often do you attend religious services?
(b) How often do you pray? and (c) Are you a spiritual person? A total
religiosity score was computed by summing the responses with a high
score, indicative of more religiosity.
The Cancer Behavior Inventory (CBI; Merluzzi & Martinez Sanchez,
1997) is a 43-item measure of self-efficacy for coping with cancer. Each
item describes a coping behavior (e.g., coping with treatment-related
side effects), which the patients rated (on a 9-point scale) in terms of
their confidence that they could perform the behavior. The CBI has a
Cronbach's alpha of .96 and correlates with measures of coping with
cancer.
Medical and demographic information. For some of the participants,
information was obtained from charts, such as stage at diagnosis, time
since diagnosis, type of treatments received, and so on. The participants
also completed an extensive demographics sheet.
Procedure
Data were collected by undergraduate research assistants (RAs) who
were enrolled in a seminar on psychooncology and received information
about the medical and psychological aspects of cancer. They also role-
played to improve their communication skills with persons with cancer,
were engaged in a discussion of ethical issues in the conduct of research
(e.g., confidentiality), and toured the treatment facilities. The training
lasted for 10 hr over a 4-week period. The RAs received this training
because they had no previous research experience with cancer patients.
RAs approached patients in the waiting rooms of the two research
sites and asked them to participate in a study exploring ways that people
cope with cancer. Informed consent was obtained, and the participant
was given a booklet to complete that contained the PAIS-SR and the
other measures. The RA answered any questions, and on rare occasions
(for less than 1% of the sample), assisted the participant in the comple-
tion of the questionnaires. Because data collection continued over 2
years, with three distinct testing periods, some of the questionnaire
packets varied depending on the length or number of questionnaires
included. Thus, the participants took from 15 to 45 min to complete the
packet. Some participants were allowed to take the questionnaire packet
home. A reminder letter was sent if the packet was not received within
a week. Across all samples tested, approximately 60% of people who
had been approached agreed to participate. Approximately 80% of par-
ticipants completed the research materials during their office visits.
About 55% of those who had taken the questionnaires home mailed
them back to the office.
Results
Preliminary Analyses
Because data were collected from two sites, a clinic and a
hospital, analyses were conducted to determine whether the
271
global scores of the PAIS-SR differed as a function of site.
Approximately 85% of the participants were tested at the clinic,
whereas the remaining were recruited from the hospital. A ran-
dom sample of 100 participants from the clinic were compared
with the 78 from the hospital. No overall difference was found
on the global score of the PAIS-SR; thus, the data from all
participants were grouped together for further analyses.
Factor Analysis
The goals of the factor analysis were threefold. The first goal
was to confirm the conceptually derived scales of the PAIS-
SR, the second was to examine the internal consistency of the
factors, and the third was to explore the relationship of the
factors of the PAIS-SR with other measures used in research
on coping with cancer. On the basis of those goals and the
recommendations of Floyd and Widaman (1995), a principal-
axis (common factors) factor extraction was chosen. Also, be-
cause the original scales of the PAIS-SR were developed to tap
distinct domains of functioning, an orthogonal rotation (i.e.,
varimax) was used. That rotation method was also used in the
factor analysis of the interview format of the PAIS that was
reported in the PAIS manual.
Although a seven-factor solution was needed to test the con-
firmation hypothesis, six-, seven-, and eight-factor solutions
were examined. However, we determined that a seven-factor
solution was not only adequate but also optimal on the basis of
scree curve analysis, variance accounted for (52%, unrelated;
44%, rotated), and relationship to the conceptually derived
scales (see Table 1). The seven factors were labeled as follows
(with eigen-values in parentheses): Social and Leisure Activities
(11.04), Job and Household Duties (3.48), Psychological Dis-
tress (2.24), Sexual Relationship (2.02), Relationship With
Partner and Family (1.81), Health Care Orientation (1.68), and
Help From Others (1.40). The variance accounted for was less
than that reported in the PAIS manual (63%) for the factor
analysis of the interview version of the scale. The difference in
variance accounted for between the solutions may be due to
two key distinctions between those analyses. First, the factor
analysis reported in the manual was performed on the interview
form of the PAIS, which may have produced more reliable
scores than the self-report version (i.e., the interviewer may
have assisted in the clarification of the questions and response
options). Second, the analysis reported in the manual was per-
formed on only lung cancer patients, whereas, in this study there
was a mixture of cancer diagnoses. Thus, the solution reported
here for the self-report version may contain more unexplained
variance than the solution for the interview version reported in
the PAIS manual.
The factor structure that emerged does overlap with the origi-
nal scales of the PAIS-SR. Correlations of the original concep-
tually derived scales and the empirically derived factors indi-
cated that the original Social Environment scale and the Social
and Leisure Activities factor correlated .98. The Vocational En-
vironment scale and the Job and Household Duties factor corre-
lated .94. The Psychological Distress, Sexual Relationship, and
Health Care Orientation scales correlated with the Psychological
Distress, Sexual Relationship, and Health Care Orientation fac-
tors .99, .96, and .87, respectively. The Domestic Environment
 272 MERLUZZI AND MARTINEZ SANCHEZ

Table 1
Factor Analyses of the Psychosocial Adjustment to Illness Scale—Self Report
Factor loadings
Original Item
scale no. Item summary 1 2 3 4 5 6 7

Factor 1: Social and Leisure Activities

SE 38 Interest in social activities .72 .19 .17 .17 .06 .09 .13
SE 36 Interest in leisure activities .72 .18 .16 .17 .07 -.02 .14
SE 37 Participation in leisure activities .70 .27 .16 .23 -.03 .03 .06
SE 39 Participation in social activities .69 .31 .23 .20 .01 .07 .05
SE 35 Actual participation in activities .66 .29 .19 .24 -.01 .00 .08
SE 34 Leisure activities and hobbies .61 .26 .21 .13 .02 .06 .10
EF 32 Socialize with extended family .33 .17 .08 .06 .18 -.01 .09
.02 -.05 .21 .21
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EF 30 Interest in extended family .26 .01 .20

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Factor 2: Job and Household Duties

VE 10 Job performance .22 .75 .11 .16 .09 .00 .14
VE 9 Interference with job .25 .74 .13 .15 .06 .00 .13
VE 13 Changing job goals .20 .58 .15 .06 .09 .10 .07
DE 17 Interference with household duties .39 .57 .23 .16 -.02 .04 .19
DE 21 Extent of physical disability .36 .56 .21 .18 -.01 .04 .16
VE 11 Lost time at work .14 .53 .10 .13 .06 .04 .13
VE 12 Importance of job .08 .48 .03 .02 .12 .20 .02
HCO 5 Expectations of outcomes .32 .44 .37 .06 .02 .15 .04
HCO 2 Special attention to illness -.10 -.19 - .09 -.08 .09 .08 .04

Factor 3: Psychological Distress

PD 41 Depression .23 .13 .70 .10 .14 .15 .17
PD 40 Anxiety .15 .09 .66 .04 .02 .21 .18
PD 44 Worry .22 .15 .62 .05 .07 .18 .07
PD 45 Self-deprecation .25 .28 .55 .15 .16 .18 .00
PD 42 Anger .03 .02 .54 .02 .22 .12 .19
PD 43 Self-blame .13 .25 .53 .15 .15 .20 .03
PD 46 Illness affects appearance .20 .17 .41 .06 .10 .11 .04

Factor 4: Sexual Relationship

SR 26 Sexual satisfaction .18 .14 .11 .82 .07 -.04 .04
SR 25 Sexual activities .20 .16 .10 .82 .06 -.03 .08
SR 24 Sexual interest .19 .09 .10 .72 .01 .06 .08
SR 27 Sexual performance .21 .20 .05 .67 .04 .08 -.00

Factor 5: Relationship With Partner and Family

DE 15 Relationship with partner -.00 .05 .13 .02 .73 .07 .06
SR 23 Changes in relationship with partner .01 .09 .17 .08 .70 .02 .04
SR 28 Arguments with partner -.00 .04 .14 .08 .66 .03 .12
EF 29 Contact with extended family .23 -.06 - .05 -.03 .39 .11 .26
EF 33 Getting along with extended family .15 -.02 .00 -.02 .38 .23 .33
DE 19 Communication with family .23 .09 .23 -.01 .37 .10 .27
DE 16 General relationship with family -.00 .15 .10 -.00 .23 -.02 .22

Factor 6: Health Care Orientation

HCO 8 Getting complete information .05 .02 .08 .07 -.02 .58 .06
HCO 3 Quality of medical care .01 .02 .14 .06 .07 .57 .05
HCO 6 Information from medical staff .01 .13 .10 -.01 -.02 .53 .05
HCO 7 Trusting treatments .05 .10 .21 -.03 .12 .42 .08
HCO 4 Treatment and medical staff .00 .04 .08 .02 .03 .38 .05
VE 14 Problems with coworkers, etc. .08 .25 .08 .00 .26 .27 .19
HCO 1 Attention to health care needs -.02 -.11 .06 -.11 .07 .19 -.01

Factor 7: Help From Others

EF 31 Help from extended family .28 .08 .09 -.00 .13 .15 .64
DE 20 Needing help from others .08 .14 .14 .06 .09 .05 .58
DE 18 Shifts in family duties .04 .15 .13 .15 .15 .09 .45
DE 22 Financial hardship .08 .17 .24 .04 .16 .11 .32

Note. Boldface type indicates the factor with the highest loading. SE = Social Environment, EF = Extended
Family, VE = Vocational Environment, DE = Domestic Environment, HCO = Health Care Orientation, PD =
Psychological Distress, SR = Sexual Relationship.
 FACTOR STRUCTURE OF THE PAIS-SR 273

scale and the Help From Others factor correlated .82. The Ex-
tended Family scale and the Relationship with Partner and Fam-
ily factor had no strong counterparts.
Internal Consistency Analyses
Coefficient alpha for the entire 46-item PAIS-SR scale was
.93 for this sample. Analyses of the reliability of the original
conceptually derived scales revealed a range of values from .50
to .87, and the alpha values for the scales derived from the factor
analysis were somewhat higher than those for the original scales,
ranging from .61 to .92 (see Table 2).
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chological Distress (Factor 3), which had a very strong correla-
tion with the MHI.
Social support. The positive correlations of the Psychologi-
cal Distress, Relationships With Partner and Family, and Health
Care Orientation factors with the ISSI indicated that more social
support is associated with better adjustment to cancer in those
domains. However, it is interesting to note that for Help From
Others, a factor for which we anticipated a positive correlation,
none was obtained.
Coping. The correlations of the factors of the PAIS-SR
with the CBI, a measure of self-efficacy for coping with cancer,
reflected a relationship between confidence in one's ability to
perform a variety of coping behaviors (e.g., cope with treat-

ment-related side effects, ask doctors questions, maintain a posi-

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Correlations of the PAIS With Other Measures tive attitude, etc.) and positive adjustment. Clearly, confidence
in the ability to execute coping behaviors and strategies contri-
The unweighted factor scores from the 46-item PAIS-SR were butes to more positive adjustment to cancer.
correlated with measures of disease impact, adjustment, social The correlations of the factors with the Problem Focused
support, coping, and medical and demographic information. (PF) and Emotion Focused scales of the COPE were mixed and
Disease impact and stage. As anticipated, the factors of the not as anticipated. For example, the negative correlation of the
PAIS-SR were correlated negatively with the SIP and positively Social and Leisure Activities factor with the COPE-PF indicates
with the KPS, indicating that increases in the impact of the that higher levels of problem-focused coping are associated with
disease were associated with decreased adjustment (Table 3). poorer social adjustment. We expected the opposite. Similarly,
That relationship was particularly true of those factors that in- greater emotion-focused coping was associated with poorer ad-
volve social (Factor 1), vocational, household (Factor 2), or justment with respect to Help From Others. That is, managing
sexual activities (Factor 4), as well as receiving help from others emotions was associated with poorer adjustment to receiving
(Factor 7). Also, stage at diagnosis was correlated with adjust- help from others. Other correlations are more interpretable. For
ment across most of the factors of the PAIS-SR. The more example, greater emotion-focused coping was associated with
advanced the stage of the disease at diagnosis, the poorer the better adjustment on the Health Care Orientation factor. Perhaps
adjustment in most domains. However, the strength of those controlling extreme emotions allows better access to medical
correlations was less than that of the SIP. information and better treatment by medical staff. Finally, a
Adjustment. Relatively strong correlations with the MHI single significant correlation with Religiosity on the Health Care
across all factors are indicative of a pervasive mental health Orientation factor may indicate that those who endorsed engag-
component in the PAIS-SR. That was particularly true for Psy- ing in religious practices were better adjusted with respect to
the medical aspects of the disease than those who did not engage
in religious practices.
Table 2 Demographic and medical. Time since diagnosis was not
Cronbach 's Alpha Coefficients for the Original Scales of the related to adjustment. Age, on the other hand, had an interesting
PAIS-SR and the Seven-Factor Solution pattern of correlations with the factors. The correlations of age
with Psychological Distress and Relationship With Partner and
Scale a Family indicate that greater adjustment is associated with in-
creasing age. Thus, older people who have cancer may be better
Original scales adjusted psychologically and in their close relationships than
Social Environment .83
Vocational Environment .84 younger people. The negative correlation of age with the Sexual
Psychological Distress .87 Relationship factor may reflect the effects of both disease
Sexual Relationship .84 and age.
Domestic Environment .74 The correlations of income with several factors of the PAIS-
Health Care Orientation .50
Extended Family .51 SR attest to the notion that SES has an effect on adjustment to
Total scale (46 items) .93 disease. The greater the income of the person with cancer, the
Seven-factor solution greater the adjustment in Social and Leisure Activities, Job and
Social/Leisure Activities .87 Household Duties, Sexual Relationship, and Help From Others.
Job and Household .85 Education was minimally related to adjustment, except that
Psychological Distress .87
Sexual Relationship .92 more highly educated people with cancer adjust better with
Partner/Family Relationships .70 respect to their sexual relationship.
Health Care Orientation .61
Help From Others .63
Total scale (46 items) .93 Discussion

Note. PAIS-SR = Psychosocial Adjustment to Illness Scale—Self- With some exceptions, the original conceptually derived
Report. scales of the PAIS-SR emerged in the factor solution. Two of the
 274 MERLUZZI AND MARTINEZ SANCHEZ

Table 3
Correlations of the Factors of the PAIS-SR With Disease-Related Measures
and Demographic Variables
Factor

Measure

Disease impact
SIP _ 49** -.54** -.30** -.40** -.16** -.12** -.31**
KPS" .40** .44** .16 .21** .02 .18* .33**
MHI" .35** .50** .71** .33** .41** .46** .46**
Support
issr .16 .15 .18* .08 .33 .25** .07
Coping
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CBI" .39** .38** .48** .27** .26** 27** .31**

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COPE PEb -.19* -.18 -.15 -.18 -.23* .05 -.14

COPE EF" -.12 -.16 -.12 -.15 -.19 .25** -.26**
Religiosity0 .13 .13 .07 -.03 .10 .25* -.06
Medical
Stage" -.38** -.39** -.18* -.33** -.14 -.21* -.23**
Time* .07 .00 -.01 .01 -.09 .00 .00
Demographic
Age" -.11* -.07 .20** -.22** .20** .10* .06
Education' .10* .03 .01 .18** .00 -.05 .07
Income" 22** .17** .07 .17** .08 -.01 .32**

Note. PAIS-SR = Psychosocial Adjustment to Illness—Self-Report. Factors: 1 = Social and Leisure

Activities, 2 = Job and Household Duties, 3 = Psychological Distress, 4 = Sexual Relationship, 5 =
Relationships With Partner and Family, 6 = Health Care Orientation, 7 = Help From Others. SIP = Sickness
Impact Profile; KPS = Karnofsky Performance Scale; MHI = Mental Health Index; ISSI = Interview
Schedule for Social Interaction; CBI = Cancer Behavior Inventory; COPE PF = Problem Focused Coping;
COPE EF = Emotion Focused Coping; Time = time since diagnosis.
a
Data compiled across all 502 participants. b Data derived from 124 women with breast cancer. c Data
derived from 137 persons with a variety of cancer diagnoses.
* p < .05. ** p < .01.

original scales, Psychological Distress and Social Environment,
emerged intact in the factor analysis. The Social Environment
items were strongly associated with Factor 1. The two additional
items in Factor 1, from the original Extended Family scale, were
associated with this factor, which may reflect interest in social
activities with the extended family. Thus, Factor 1 emerged as
similar to the original Social Environment scale and reflects
interest and involvement in social and leisure activities. Mainte-
nance of those activities is tantamount to positive adjustment to
illness.
The original Sexual Relationship scale did emerge, in part,
as Factor 4. However, it is interesting to note that two items
from the original scale appeared to be associated more strongly
with Factor 5 (Relationship With Partner and Family) than with
Factor 4 (Sexual Relationship). A close examination of these
items revealed that, in the case of one item (Item 23) the content
focuses on how an illness can cause problems in a relationship
with a spouse or partner. There is no mention of sexual problems
in that item. The other item (Item 28) does mention interference
with a couple's sexual relationship but tends to emphasize, to
a greater extent, the fact that illness may cause arguments. The
association of those two items with Factor 5 (Relationships With
Partner and Family) does confirm their emphasis on relation-
ships rather than on sexual interest or performance.
Items from the Vocational Environment scale did emerge on
Factor 2, which reflected the degree to which the illness inter-
feres with the performance of one's job. In addition, two items
from the Domestic Environment Scale loaded on that factor.
These items focused on the degree to which the person is physi-
cally disabled (Item 21) and how much the illness interferes
with household duties and chores (Item 17). These items had
relatively high loadings on Factor 2 but also had moderate load-
ings on Factor 1, which may indicate that physical disability
and interference with routine household activities is also associ-
ated with the ability to engage in leisure and social activities.
We might have expected Item 18 from the Domestic Environ-
ment scale, dealing with shifts in family duties, to load on Factor
2 (Job and Household Duties); however, it was one of four
items to form Factor 7 (Help From Others). Factor 7 also has
one item from the Extended Family Scale, which reflects the
need for help from the extended family. This factor represents
the support one might get from family and friends to help com-
pensate for the impact of the illness. However, the negative
correlations of this factor with measures of disease impact indi-
cate that more impaired individuals have a more difficult time
adjusting to the help they receive from others.
The most unique scale to emerge from the factor analysis is
Factor 5, Relationship With Partner and Family. It draws items
from the original Domestic Environment, Sexual Relationship,
and Extended Family scales. This factor represents the quality
of the significant relationships in the patient's life. The items
cohere around a theme of how the patient's illness has affected
those relationships, which in turn has an impact on adjustment.
The correlations with measures of disease impact and stage
 FACTOR STRUCTURE OF THE PAIS-SR
support the notion that cancer and its treatments may take their
toll on patients and that in turn reduces their level of adjustment.
That reduction in level of adjustment is found to a greater extent
in the social, vocational, and sexual domains than in other do-
mains. Thus, it appears that limitations on physical activity have
direct bearing on adjustment in domains that involve remaining
active. These correlations are significant and strong but do allow
for other influences on adjustment. The similarity in the pattern
of correlations between the SIP, which is self-report, and the
KPS, which is "other" report, provide some measure of confi-
dence in the findings. Moreover, there are implications for medi-
cal and psychological practice. To the extent that medical and
psychological interventions either prevent debilitating states or
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
provide for recovery from those states, the level of adjustment
This document is copyrighted by the American Psychological Association or one of its allied publishers.
will be maintained or increased.
The correlations of the PAIS-SR with the MHI illustrate the
strong and pervasive emotional health component in the PAIS-
SR and therefore support its validity as a measure of adjustment.
That relationship was particularly evident in the correlation of
the MHI with the Psychological Distress factor of the PAIS-
SR. The correlations with the CBI also illustrate the psychologi-
cal nature of the PAIS-SR. Greater self-efficacy for coping with
cancer is associated with greater adjustment to the disease. Not
only does this support the validity of the PAIS-SR, it also
indicates that improvements in efficacy expectations may im-
prove adjustment. Thus, interventions designed to improve effi-
cacy may also improve psychosocial adjustment.
We anticipated that social support would be positively related
to adjustment. The correlation of social support with Relation-
ships With Partner and Family indicates that support from family
and friends is tantamount to positive adjustment to disease. Of
course, the reverse may also be true: Positive adjustment with
respect to relationships may preserve or strengthen social sup-
port. A more interesting finding is that social support is associ-
ated with positive adjustment to the medical system. Support
from one's social network may allow individuals to navigate
through the medical maze of information and obtain high-quality
medical care. In a similar vein, although many of the correla-
tions of the PAIS-SR with religiosity were not significant, the
one that was significant was with Health Care Orientation. Per-
haps greater religiosity evokes more trust in and satisfaction
with the medical treatment people receive and therefore more
comfort and better adjustment to the medical aspects of the
disease.
The positive correlations of age with the Psychological Dis-
tress factor and the negative correlation of age with the Sexual
Relationship factor may reveal the small but not insignificant
role that life stage plays in coping with serious illness. With
respect to Psychological Distress, perhaps with age comes an
increase in coping capacity based on a lifetime of experiences.
Also, a disease such as cancer may be more normative in old
age than in youth and therefore more expected. That is, con-
tracting cancer at a young age may be nonnormative and there-
fore less easy to adjust to when compared with contracting it
in old age.
The relationship between Help From Others and income is
an interesting one. With greater income there is more positive
adjustment to the help one might need. The questions that consti-
tute this factor contrast the help one may receive now that was
275
not needed before the disease. Perhaps people who have more
material resources are able to take advantage of not only family
resources (e.g., paying a relative for transportation) but also
commercial services that make daily living easier (e.g., a house-
cleaning service). Thus, having greater financial resources may
allow for better adjustment because it provides the ability to
maintain certain aspects of one's lifestyle despite the disease.
Conclusion
The PAIS-SR is an internally consistent measure with a fac-
tor structure that taps seven domains of adjustment to disease.
The validation data suggest that it is significantly related to
variables that have been associated with adjustment to cancer.
Moreover, its global approach to psychosocial adjustment as
well as its component'scales or factors give the PAIS-SR some
advantage over other measures that tap a single dimension (e.g.,
depression, mood, etc.). In fact, Gotay and Stern (1995) sug-
gested that the PAIS-SR may be more like a quality-of-life
measure than a measure of psychological state. On the other
hand, it is not as broad based as the better quality-of-life mea-
sures (e.g., Cella et al., 1993).
Future research should investigate the stability of the PAIS-
SR over time or changes as a function of interventions, disease
status, and life events. Also, given the amount of medical care
services required by poorly adjusted patients when compared
with well adjusted patients, the PAIS-SR could be used as a
screening device to target those who may need interventions to
improve their adjustment to cancer. A profile based on the factors
of the PAIS-SR could help identify areas that need attention.
Considering that research has established that persons with can-
cer who receive psychological treatment live longer than those
who do not (Spiegel, Bloom, Kraemer, & Gottheil, 1989), ad-
justment may be a key variable in those outcomes.
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Received August 1, 1996
Revision received February 27, 1997
Accepted March 3, 1997 •