Existential Threat – A Cancer Diagnosis Prof Robin Davidson Consultant Clinical Psychologist May 2007

Common psychological symptoms in cancer patients % % Worrying72 Worrying72 Feeling sad67 Feeling sad67 Feeling nervous62 Feeling nervous62 Difficulty sleeping53 Difficulty sleeping53 Feeling irritable47 Feeling irritable47 Difficulty concentrating40 Difficulty concentrating40

a cancer diagnosis can lead to; General distress General distress Anxiety Anxiety Depression Depression Psychosocial withdrawal Psychosocial withdrawal Fatigue Fatigue

“A transitional life event” – Parkes (1971) “A teachable moment” – McBride (2000) “Post traumatic growth” – Cordova (2001)

Many studies have demonstrated permanent positive health and mental health outcomes (healthier lifestyle) behaviours following a cancer diagnosis. Often these changes occur spontaneously, variously labelled as: ‘Positive sequelae’ ‘Growth’ ‘Benefit finding’

The ‘teachable moment’ is characterised by a propensity to critically examine many aspects of ones life and a heightened motivation to change both physical and psychological behaviours. - Andrykowski etal (2006)

Effects of traumatic experiences like negative health diagnosis, disasters, bereavement can be associated with positive consequences -Thornton & Perez (2005)

In order to understand the psychological impact of an existential threat I will draw on the following literature: Post traumatic stress disorder Post traumatic stress disorder Denial Denial Dispositional optimism Dispositional optimism The transtheoretical model of motivational change. The transtheoretical model of motivational change.

Post Traumatic Growth (Tedeschi 1995) Refers to positive changes in life philosophy, relationships and personal growth. Refers to positive changes in life philosophy, relationships and personal growth. Emerges with the struggle to find meaning in a negative event. Emerges with the struggle to find meaning in a negative event. The event must have sufficient emotional power to challenge previously held beliefs about the world and the individuals place in it. The event must have sufficient emotional power to challenge previously held beliefs about the world and the individuals place in it. This leads to cognitive reprocessing and restructuring of the events. This leads to cognitive reprocessing and restructuring of the events.

Dimensions of PTG Social Social Cognitive Cognitive Emotional Emotional Physical Physical Spiritual Spiritual

Psychosocial Behaviours Reordering of life priorities Reordering of life priorities Increased spiritual awareness Increased spiritual awareness Greater empathy Greater empathy Involvement in altruistic activity Involvement in altruistic activity

Trauma experience Re-experiencing: Re-experiencing: Nightmares, flashbacks, intrusive thoughts Nightmares, flashbacks, intrusive thoughts Avoidance Avoidance Detachment,emotional numbness,avoidance of reminders Detachment,emotional numbness,avoidance of reminders Hyperarousal Hyperarousal Anxiety,irritability,startle response Anxiety,irritability,startle response

Trauma Theories of trauma adaptation suggest that active processing of a traumatic event leads to more positive psychological adjustment. Emotional expression and positive social experience predicts extent of post traumatic growth. (Mann 2004)

Risk factors for PTSD Ozer et al peritraumatic psychological processes, not prior characteristics, are the strongest predictors

Trauma Principle It is the experience of the event, not the event itself, that is traumatizing.

Awareness of one’s emotions or thoughts is diminished and avoided. Awareness of one’s emotions or thoughts is diminished and avoided. Disruption in memory, identity or perception of the environment. Disruption in memory, identity or perception of the environment. Time seems slower or faster Time seems slower or faster Feeling that the event isn’t real Feeling that the event isn’t real Impression of leaving one’s body Impression of leaving one’s body Victims report “changes in their perception of time, space, and self during the traumatic event.” Victims report “changes in their perception of time, space, and self during the traumatic event.” Can’t escape physically so you escape psychologically Can’t escape physically so you escape psychologically What is dissociation?

exposure to extreme stressors is necessary but not sufficient to cause distress. exposure to extreme stressors is necessary but not sufficient to cause distress. “trauma” as a subjective response of an individual, not the quality of an event. “trauma” as a subjective response of an individual, not the quality of an event. the distressing experience that is cancer heightens a psychological capacity that is already present the distressing experience that is cancer heightens a psychological capacity that is already present Overview

Harperetal (2007) Psychosocial and health behaviour change post diagnosis After diagnosis over half the sample initiated significant dietary and exercise change. Post diagnosis 80% report regular reflection on life's priorities. Positive health outcomes are durable i.e. they become a stable lifestyle pattern.

Adjustment influenced by: Perceived control Perceived control Problem-focussed, engagement coping Problem-focussed, engagement coping Hopefulness Hopefulness Dispositional optimism Dispositional optimism Fighting spirit Fighting spirit Emotional expression Emotional expression Acceptance at diagnosis Acceptance at diagnosis Humour Humour

Best psychological variable to predict post-trauma growth is dispositional optimism

Behavioural Self-Regulation Theory – Life Orientation (Scheier & Carver 1992) Dispositional Optimism : The belief that one will have more favourable than unfavourable outcomes in life. Optimists use more adaptive coping strategies Optimists use more adaptive coping strategies Optimists recover from cancer more quickly Optimists recover from cancer more quickly Optimists less anxious/depressed after diagnosis Optimists less anxious/depressed after diagnosis Measured by 12-item Life Orientation Test

Denial Anna Feud – unconscious defence against painful, overwhelming external reality Anna Feud – unconscious defence against painful, overwhelming external reality Cognitive theory - self protective, avoidance strategy Cognitive theory - self protective, avoidance strategy Comparative constructs – e.g avoidance, distancing, minimising, suppression, repression Comparative constructs – e.g avoidance, distancing, minimising, suppression, repression

Denial Systematic review – Vos & De Haes (2007) 26 papers look at relationship between denial and quality of life. Passive escape strategies Poorer QoL Active distractive strategies Better QoL i.e. coping styles on the MAC are – fighting spirit, helplessness, fatalism, denial, anxious, preoccupation

Smith & Lazarus (1993) – Appraisal Threat Threat Challenge Challenge Importance Importance Control Control

Folkman & Lazarus (1985) – Coping Emotion-focused coping ; avoidance coping Self control Self control Escape avoidance Escape avoidance Positive reappraisal Positive reappraisal Problem-focus coping ; approach Coping Seeking social support Seeking social support Accepting responsibility Accepting responsibility Planned problem solving Planned problem solving Managing external aspects of the stress Managing external aspects of the stress

Dealing with existential threat Post Traumatic growth social context life orientation threat appraisal trauma processing coping style