Jpn J Clin Oncol 2014;44(9)818 – 825 doi:10.1093/jjco/hyu089 Advance Access Publication 15 July 2014
The Relationship Between Emotional Suppression and Psychological Distress in Breast Cancer Patients After Surgery Yuki Nakatani1,*, Yumi Iwamitsu1, Masaru Kuranami2, Shigemi Okazaki1,3, Hiroe Shikanai1, Kenji Yamamoto4, Masahiko Watanabe5 and Hitoshi Miyaoka6 1
Department of Medical Psychology, Kitasato University, Graduate School of Medical Sciences, Sagamihara, Yamato Municipal Hospital, Yamato, 3Higashiyamato General Hospital, Higashiyamato, 4Department of Psychiatry, Tokai University, School of Medicine, Isehara, 5Department of Surgery, Kitasato University, School of Medicine, Sagamihara and 6Department of Psychiatry, Kitasato University, School of Medicine, Sagamihara, Japan 2
*For reprints and all correspondence: Yuki Nakatani, Department of Medical Psychology, Kitasato University, Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0373, Japan. E-mail:
[email protected] Received April 25, 2014; accepted June 11, 2014
Objective: The purpose of this study was to examine the relationship between emotional suppression and psychological distress in breast cancer patients after surgery. We examined this relationship using questionnaires at the first visit to the breast cancer outpatient clinic at our hospital and after surgery, as well as interviews after surgery. Methods: A total of 31 breast cancer patients were asked to complete the Courtauld Emotional Control Scale and the Profile of Mood States at their first visit to the outpatient clinic. Patients were also asked to complete the Profile of Mood States between 1 and 6 months after surgery. Trained clinical psychologists conducted the interviews, asking patients to speak freely about their current anxieties, worries and thoughts. Based on the median Courtauld Emotional Control Scale score of 42 points, participants were divided into emotional suppression and emotional expression groups. Results: The Total Mood Disturbance score, as well as each of the subscale (except vigor) scores of the Profile of Mood States, were significantly higher in the emotional suppression group than the emotional expression group. The emotional suppression group expressed significantly more negative emotions and fewer positive emotions than the emotional expression group. Conclusions: Patients with emotional suppression felt and expressed more psychological distress after surgery. This finding highlights the need for medical staff to comprehend the psychological traits of breast cancer patients, including emotional suppression, in the early stages of breast cancer in order to provide adequate psychological support. Key words: breast cancer – emotional suppression – interview – post-operative treatments – psychological distress
INTRODUCTION Developments in cancer treatment have increased the chances for longer survival (1). Breast cancer patients, however, tend to experience psychological distress during diagnosis and treatment that Friedman et al. (2) believe may affect long-term
functioning. A diagnosis of breast cancer can be worrying (3) and is frequently associated with anxiety and depression (4), but breast cancer patients also experience psychological distress after surgery due to the psychological burden of longterm treatments (5) such as chemotherapy, radiotherapy and
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Jpn J Clin Oncol 2014;44(9)
endocrine treatment. These therapies can have debilitating side effects (6–11). Furthermore, patients undergoing treatments also experience psychological distress from a fear of recurrence. About 30% of breast cancer patients will experience recurrence within 10 years post-operatively (12). Even after the 10th post-operative year, cancer still recurs with a more fixed frequency (12). Therefore, psychological distress is frequently observed in breast cancer patients during the clinical course of this disease (12). Roughly 10 to 30% of breast cancer patients suffer from post-operative psychiatric morbidities such as anxiety and/or depression (13 – 16), while most patients gradually return to daily life while receiving treatments after surgery through hospitalization or at outpatient clinics (17). Thus, it is important to focus on post-operative psychological distress in these patients. Many factors, including trait anxiety (18), emotional suppression (19), neuroticism (20) and optimism (2), can increase psychological distress in breast cancer patients. Emotional suppression in particular has attracted considerable attention. Morris et al. (21) found that breast cancer patients were more likely to report suppressed anger and anxiety than patients with benign breast disease. Watson and Greer (22) developed the Courtauld Emotional Control Scale (CECS), which measures the tendency to suppress negative emotions in daily life. Watson et al. (19) revealed that breast cancer patients with emotional suppression tended to feel hopelessness and had a fatalistic attitude. Iwamitsu et al. (23) developed the Japanese version of the CECS, validated it, and reported that Japanese breast cancer patients with emotional suppression had increased psychological distress after diagnosis compared with patients with emotional expression (24). Emotional suppression has been defined as ‘suppressing the expression of emotions consciously while recognizing the emotions’ (25). Ando et al. (26) suggested that emotional suppression might dynamically affect the psychological distress of breast cancer patients. These studies underscore the need to consider emotional suppression as an important factor that influences psychological distress in breast cancer patients. As discussed above, patients tend to experience psychological distress regarding side effects and the fear of recurrence. Therefore, it will be informative to examine the relationship between emotional suppression as a key interpersonal difference and psychological distress among breast cancer patients after surgery. Through this, we hope to determine whether emotional suppression is involved in psychological distress after surgery and explore ways to link these findings to the treatment of breast cancer patients. Okazaki et al. (18) examined psychological response in breast cancer patients at their first clinical visit with a detailed interview analysis and revealed that patients had negative emotions before the visit and expressed more negativity during the visit. While the study also highlighted the need to comprehend the multi-faceted nature of psychological response by analyzing interview contents in detail, it did not examine the relationship between psychological response and emotional suppression. Based on the approach suggested by Okazaki et al. (18), we previously examined the relationship
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between psychological response and emotional suppression after a diagnosis of breast cancer by analyzing interview contents (27). We revealed that breast cancer patients with emotional suppression felt higher levels of psychological distress and expressed more negative emotions than patients with emotional expression after receiving the diagnosis (27). No interview-based studies have examined this relationship in breast cancer patients after surgery. As mentioned above, patients tend to suffer from side effects and the fear of recurrence after surgery. Therefore, it is important to examine this relationship with a focus on emotional suppression after surgery. The purpose of this study was to examine the relationship between emotional suppression and psychological distress in breast cancer patients after surgery. In particular, we focused on interview contents after surgery to examine this relationship by dividing patients into two groups. This relationship was further examined using the Profile of Mood States (POMS) at the first visit and after surgery. Patients completed the questionnaire at a time that coincided with the analysis of interview contents, i.e. after surgery.
METHODS SUBJECTS Written informed consent was obtained from 242 patients at their first visit to the breast cancer outpatient clinic at Kitasato University Hospital between November 2004 and January 2007. Seventy-four of the patients were diagnosed with breast cancer, and 32 of the diagnosed patients were interviewed following surgery. One patient was excluded due to an incomplete questionnaire, giving a final total of 31 patients for the study (mean + SD; age: 57.9 + 11.8 years; days after surgery: 105.9 + 41.0 days; data unknown for two patients). Descriptive characteristics of the breast cancer patients are presented in Table 1. This study was approved by the Ethics Committee at the Kitasato University School of Medicine. ASSESSMENTS POMS The POMS includes 65 items rated on a five-point scale from 0 (not at all) to 4 (extremely). This self-rating scale includes six subscales: Tension – Anxiety, Depression – Dejection, Anger – Hostility, Vigor – Activity, Fatigue – Inertia and Confusion – Bewilderment. As a global measure of affective state, a Total Mood Disturbance (TMD) score can be calculated as a sum of the subscales, with Vigor– Activity negatively weighted. The Japanese version of POMS was used for this study. The validity and reliability of the Japanese version of POMS has been established (28). CECS The CECS was developed by Watson and Greer to measure the extent of suppressed anger, depression and anxiety in
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Psychological distress in cancer patients
Table 1. Patient characteristics
months after surgery, we asked patients to complete the POMS again. Trained clinical psychologists conducted the interviews, asking the patients to speak freely about their current anxieties, worries and thoughts.
Emotional Emotional suppression expression group (N ¼ 16) group (N ¼ 15) Age
56.94 + 13.84
59.67 + 9.77
F(1,29) ¼ 0.397, P ¼ ns
Courtauld Emotional Control Scale (mean + SD)
50.06 + 6.38
35.2 + 3.67
F(1,29) ¼ 62.04, P , 0.01
Stage I
8
9
II
5
6
III
1
0
Tis
1
0
Unknown
1
0
2
0
Junior college
2
3
Vocational school
0
1
High school
7
9
Junior high school
0
1
Unknown
5
1
Married
12
14
Divorced
0
1
Not married
1
0
Widowed
3
0
Education University
Marital status
x 2(1) ¼ 0.02, P ¼ 1.0
Surgery Breast-conserving surgery Mastectomy
11
10
5
5
x 2(2) ¼ 0.65, P ¼ 0.82
Past treatment history (including current treatment) Chemotherapy
3
5
Radiotherapy
8
8
Hormonal therapy
5
4
Unknown
1
1
addition to total negative emotions in daily life (17). This selfrating questionnaire consists of 17 items scored from 1 (not at all) to 4 (extremely). The Japanese version consists of six anger subscales, five depression subscales and six anxiety subscales. The validity and reliability of the Japanese version of CECS has been established (23).
OVERVIEW OF ANALYSIS Based on the median CECS score of 42 points, participants were divided into an emotional suppression group (16 patients; mean + SD ¼ 50.1 + 6.4) and an emotional expression group (15 patients; mean + SD ¼ 35.2 + 3.7). Iwamitsu et al. (23) reported mean + SD CECS scores of 44.7 + 8.7 and 42.0 + 8.5 in test and re-test in 79 college students. These scores are similar to those of the present study. One-way analysis of variance was conducted to confirm differences in CECS scores and age between the two groups (emotional suppression group vs. emotional expression group). Fisher’s exact tests were conducted for group (emotional suppression group vs. emotional expression group) surgery (breastconserving surgery vs. mastectomy) to compare frequencies. Similar analyses were conducted for group (emotional suppression group vs. emotional expression group) treatment (chemotherapy vs. radiotherapy vs. hormonal therapy; except unknown). Two-way analysis of variance was conducted for group (emotional suppression group vs. emotional expression group) session (first visit vs. after surgery) to compare the TMD score and each subscale score. To examine psychological response of breast cancer patients, summary content analysis (29) was used to review all participant interviews. Two of four trained analysts assigned code names to the interview content independently and performed blind analysis. Based on this, similar codes were aggregated and categorized, and category names were assigned. Each of the four researchers checked the codes and categories and then discussed placement until an agreement was reached. To clarify differences in the frequency of coded interview items about emotions for each group, chi-square tests were performed for emotional suppression group vs. emotional expression group negative emotion vs. other categories. x 2 tests were also conducted for emotional suppression group vs. emotional expression group positive emotion vs. other categories and for emotional suppression group vs. emotional expression group coping behavior vs. other categories, as long as each category had a frequency .15%. Finally, each coded interview category was calculated as a percentage of the total frequency in each group. The Statistical Package for Social Sciences (SPSS: version 16) was used.
RESULTS PATIENT DEMOGRAPHICS
PROCEDURE Patients were asked to complete the CECS and POMS at their first visit to the outpatient breast clinic. Between 1 and 6
One-way analysis of variance confirmed that the emotional suppression group had a significantly higher CECS score than the emotional expression group [F(1,29) ¼ 62.04, P , 0.01].
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According to Fisher’s exact tests, there were no characteristic differences between the emotional suppression and expression groups with respect to age, marital status, education, surgery and treatments (Table 1). RELATIONSHIP BETWEEN EMOTIONAL SUPPRESSION PSYCHOLOGICAL DISTRESS
AND
Two-way analysis of variance was conducted for group (emotional suppression group vs. emotional expression group) session (first visit vs. after surgery) to compare the TMD score and each subscale score. The analysis revealed that TMD and Depression – Dejection scores in the emotional suppression group were significantly higher than those of the emotional expression group [F(1,29) ¼ 9.52 and 9.40, P , 0.01, hp 2 ¼ 0.247 and 0.245]. Tension – Anxiety, Anger – Hostility and Fatigue – Inertia scores in the emotional suppression group were significantly higher than those of the emotional expression group [F(1,29) ^ 4.53, P , 0.05, hp 2 ¼ 0.197, 0.135 and 0.195]. The Vigor – Activity score in the emotional expression group was significantly higher than those of the emotional suppression group [F(1,29) ¼ 4.17, P % 0.05, h p 2 ¼ 0.126]. Two-way analysis of variance also revealed that the Vigor – Activity score after surgery was significantly higher than that at first visit [F(1,29) ¼ 4.86, P , 0.05, hp 2 ¼ 0.144] (Fig. 1). INTERVIEW CONTENT CATEGORIES FOR EACH GROUP Table 2 shows interview content categories in both emotional suppression and emotional expression groups. The frequency of coded interview items was 206 in the emotional suppression group and 230 in the emotional expression group (including multiple answers). x 2 tests were conducted to compare the emotional suppression and emotional expression groups to each coded interview category compared with the others, as long as each category appeared in .15% of the interview content. The emotional suppression group expressed significantly more negative emotions (31.1 vs. 17.8%) [x 2 (1) ¼ 10.42, P , 0.01] and significantly fewer positive emotions (15.1 vs. 24.8%) [x 2 (1) ¼ 6.39, P , 0.05] than the emotional expression group.
DISCUSSION The results of this study showed that TMD and each subscale (except vigor) score of the POMS were significantly higher in the emotional suppression group than the emotional expression group. Iwamitsu et al. (30) reported that breast cancer patients with emotional suppression experienced more psychological distress than those with emotional expression after a breast cancer diagnosis. In addition, breast cancer patients with emotional suppression reportedly experienced more psychological distress than those with emotional expression postdiagnosis and 3 months after discharge (24,31). Our results
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after surgery are consistent with these reports. We also found that patients with emotional suppression consistently felt psychological distress after diagnosis and after surgery. We previously examined the relationship between emotional suppression and psychological distress after diagnosis, and the following categories were extracted from interview contents: ‘negative emotions’, ‘positive emotions’ and ‘coping behavior’ (27). However, in the present study, ‘physical symptoms’, ‘good physical condition’, ‘no physical symptoms’, ‘social support’ and ‘objective fact’ were newly extracted in addition to the three categories mentioned above, after surgery. We also found that patients in both groups experienced many physical symptoms after surgery that were not observed after diagnosis. Their side effects were debilitating: chemotherapy can lead to nausea, constipation, deformed nails and hair loss (6,7); radiotherapy may cause skin changes and itchiness (8,9); and endocrine treatment can trigger hot flashes and headaches (10,11). Our results, in which patients also experienced side effects after surgery, support these reports. Furthermore, Safaee et al. (32) reported that patients may experience acute side effects of treatment in addition to cancer-related symptoms, which can lead to psychological distress (32 – 34). Patients were also in fear of recurrence (34). Our analysis of interview contents revealed that patients felt various negative emotions including anxiety, shock, and distress, with respect to their treatments and side effects. We also found that after surgery, patients used more coping behavior than patients in our previous study after diagnosis (27). For example, as realistic behavior, some patients bought wigs before receiving chemotherapy, got sufficient rest, and collected information regarding treatments from other patients. As realistic thought, others attempted to control their weight. We suggest that while patients after diagnosis in our previous study used coping behavior only to deal with their diagnosis (27), patients, after surgery, attempted to use coping behavior to deal with their treatments, relieve their physical symptoms, and reduce their psychological distress, including anxiety regarding their treatments and the fear of recurrence. We found that more ‘negative emotions’ were expressed in the emotional suppression group than the emotional expression group. We also found that patients with emotional suppression expressed more negative emotions, including resignation, conflict, and fear, compared with patients with emotional expression. Nakatani et al. (27) similarly found that patients with emotional suppression expressed more negative emotions after diagnosis than patients with emotional expression. However, patients in the present study reported more negative emotions about their treatments, which were not expressed after diagnosis. In particular, patients with emotional suppression tended to feel more anxious about breast cancer itself and their treatments than patients with emotional expression. Some studies have reported that college students with emotional suppression actually increased their negative emotions by suppressing them (35,36). Quartana et al. (37) reported that negative emotional suppression may be associated with greater intrusive thoughts, which suggests that
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Psychological distress in cancer patients
Figure 1. The Profile of Mood States in the emotional suppression and expression groups at first visit and after surgery.
patients such as those in our study could have accumulated a number of intrusive thoughts by suppressing negative emotions. Breast cancer patients with emotional suppression
continue trying to suppress negative emotions in stressful situations and tend to experience higher levels of psychological distress (27,30). As a result, they would have increased
Jpn J Clin Oncol 2014;44(9)
Table 2. Categories extracted from interview content analysis in the emotional suppression and expression groups
Table 2. Continued Category
Category
Subcategory
Suppression group [% (item)]
Expression group [% (item)]
31.1 (64)
17.8 (41)
Anxiety
15.5 (32)
9.1 (21)
Distress
2.9 (6)
2.2 (5)
Shock
1.9 (4)
2.2 (5)
Irritation
1.9 (4)
0.4 (1)
Escape
1.5 (3)
0.4 (1)
Dissatisfaction
1.5 (3)
0.9 (2)
Resignation
1.5 (3)
0 (0)
Conflict
1.5 (3)
0 (0)
Dislike
1.0 (2)
0.9 (2)
Fear
1.0 (2)
0 (0)
0 (0)
0.9 (2)
Subcategory
Social support Negative emotions
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Suppression group [% (item)]
Expression group [% (item)]
3.9 (8)
2.6 (6)
Family
2.4 (5)
1.7 (4)
Friends
1.0 (2)
0 (0)
d
0.5 (1)
0.8 (2)
8.3 (17)
6.1 (14)
Others Objective fact
Treatment
4.9 (10)
3.5 (8)
Personality
0 (0)
0.9 (2)
3.5 (7)
1.2 (4)
Otherse a
Other negative emotions, including concern, surprise and depression. Other coping behaviors, including dependence, collecting information, avoidance and refusal of treatment. c Other physical symptoms, including stiffness of hands, varicose veins in the legs, fever, decreased white blood cells, hair loss, swollen lymph nodes, nausea/fatigue, insomnia, back pain, strained lower back, shoulder trouble, dermatitis, pain at wound sites, cannot lift arms, poor physical health, sore feet/legs, perspire and experience dizziness, radiation pneumonia and fatigue and stiffness. d Other types of social support, including close friends, other friends and acquaintances. e Other objective facts, including values, information from the media, communication, course of treatment, return to work, stop treatment, change treatment, examination results, work and diversions. b
Bitterness Othersa Positive emotions
1.0 (2)
0.8 (2)
15.1 (31)
24.8 (57)
Optimism
7.3 (15)
6.5 (15)
Reception
5.3 (11)
6.5 (15)
Relief
1.9 (4)
8.3 (19)
Joy
0.5 (1)
2.6 (6)
Preparation Coping behavior
Realistic behavior 15.5 (32)
18.7 (43)
Realistic thought
5.8 (12)
4.4 (10)
Diversion
5.8 (12)
4.8 (11)
Positive thought
2.4 (5)
4.4 (10)
Others
Fatigue Vomiting Loss of appetite Vascular pain Weight loss Othersc
Good physical condition
Good physical health
1.0 (2)
1.2 (3)
8.3 (17)
10.4 (24)
1.9 (4)
1.7 (4)
0 (0)
1.3 (3)
1.0 (2)
1.3 (3)
0 (0)
0.9 (2)
0 (0)
0.9 (2)
5.5 (11)
4.0 (10)
2.9 (6)
3.9 (9)
1.5 (3)
1.7 (4)
Good appetite
1.0 (2)
0.4 (1)
Good sleeping habits
0.5 (1)
0.9 (2)
0 (0)
0.9 (2)
Return to normal weight No physical symptoms
0.9 (2) 33.5 (77)
b
Physical symptoms
0 (0) 30.6 (63)
0 (0)
0.9 (2)
No fatigue
0 (0)
0.4 (1)
Normal appetite
0 (0)
0.4 (1) Continued
psychological distress and expressed more negative emotions. With respect to positive emotions, optimism was the most frequent in the emotional suppression group and relief was the most frequent in the emotional expression group. We also showed that the emotional suppression group expressed fewer ‘positive emotions’ than the emotional expression group. These results suggest that patients with emotional suppression tended to suppress both negative and positive emotions after surgery. Nezlek and Kuppens (38) reported that the suppression of positive emotions affects emotional experience more than the suppression of negative emotions in daily emotional regulation. We found that patients with emotional suppression felt more psychological distress from suppressing positive emotions after surgery. Through this study, we learned that patients experienced many physical symptoms, had negative and positive emotions, and used coping behavior related to their treatments after surgery. We also found that patients with emotional suppression tended to consistently experience psychological distress and express more negative emotions and fewer positive emotions through the course of their disease after surgery, compared with patients with emotional expression. Thus, our results show that a better understanding of psychological responses in breast cancer patients could be cultivated by examining and quantifying interview content in detail. Indeed, comprehending the extent of emotional suppression in breast cancer patients in a timely manner is important. Psychological support should be provided to enable the
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Psychological distress in cancer patients
expression of moderately negative emotions and positive emotions in patients with emotional suppression in order to ease their psychological distress. Our findings highlight the need for medical staff to comprehend the psychological traits of breast cancer patients, including emotional suppression, in the early stages of breast cancer in order to provide adequate psychological support. The sample size of this study was relatively small with 31 participants, and these participants received various treatments. Unfortunately, we could not examine their physical condition and each treatment in detail. Moreover, we did not examine the relationship between psychological distress and each treatment. In addition, although we examined the relationship between emotional suppression and psychological distress after surgery, there is a possibility that differences existed with time after surgery (from 1 to 6 months). Accordingly, this study should be expanded to address these aspects. We also examined interview contents and psychological distress in patients after surgery, but should consider a longitudinal study involving patients with emotional suppression and emotional expression. Finally, further studies on psychological responses will allow us to make an informed proposal for psychological support in breast cancer patients.
Acknowledgements The authors acknowledge the contributions of all participants.
Funding The present study was supported by JSPS KAKENHI grant numbers 18530543 and 22530757.
Conflict of interest statement None declared.
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