Δείκτες Ψυχοπαθολογίας Και Χαρακτηριστικά Προσωπικότητας Σε Γυναίκες Που Πάσχουν Από Καρκίνο Του Μαστού

Abstract

Objective: Numerous studies have documented that a significant proportion of breast cancerpatients experiences psychiatric morbidity. The objective of the present study was to assessthe psychopathological profile of Greek women with breast cancer, to identify factorsassociated in particular with depression, anxiety, general psychopathology and PTSD,examine the impact of distinct personality factors and life events and their implication withbreast cancer, as well as patterns of body image perceptions, sexual behaviors, interpersonalrelationships and quality of life on the affected women.This was achieved for the psychopathology symptoms, personality traits and life events, viathe comparison of women suffering from breast cancer, with a control group of healthywomen, who were followed up over the course of one year, while the sexual behavior,interpersonal relationships, body image and quality of life was measured only in the breastcancer patients group.Material and Methods: Participants (n=180 women) were recruited from a SpecializedOncology Breast Cancer Department of a General Hospital and Breast Outpatients Clinic ofanother specialized in the Diseases of the Breast Hospital (109 with breast cancer and 71controls). Breast cancer patients were studied at different stages of the disease. The presentstudy was designed to be a cross-sectional one. The control group consisted of healthy womenattending routine follow up appointments. General psychopathology was assessed via theSCL-90-R.The Montgomery-Asberg Depression Rating Scale (MADRS) and the SpielbergerState-Trait Anxiety Inventory (STAI) were used for the evaluation of depression and anxiety,while PTSD was evaluated using the IES Scale.Personality traits were evaluated in both groups with the use of the following Psychometrictools:Introversion-Extraversion-Neurotisism-Psychoticism : Eysenck Personality Questionnaire(EPQ), Alexithymia : Schalling-Sifneos Βeth Israel Hospital Personality Questionnaire :(BIHPQ), Personality Type-C as a personality trait : (Personality Type-C Scale,) Ηοstility andDirection of Hostility Questionnaire: (HDHQ), Locus of Control of Behavior (L.C.B.SCALE), Obsessional thinking: LEYTON Obsessional Inventory (L.O.I), ObsessiveCompulsive symptoms: ΜΑUDSLEY Obsessive Compulsive Inventory (M.O.C.I), Physicaland Social Anhedonia : PAS and SAS (CHAPMAN et al), Ιrrational Beliefs ( ELLISΙrrational Beliefs Survey/ Scale (I.B.S), Hypochondriasis: WHITELEY Index (W.I),Depersonalization-Derealization (D/D Scale).Body Image, Sexuality and Interpersonal relationships were measured in the breast cancergroup, with questionnaires created at the Department of Psychiatry of Eginition UniversityHospital, for the specific needs of the present study. The impact of Life Events was measuredusing the HOLME –RAHE Social Readjustment Scale ( SAS) and finally the quality of life inthe breast cancer group was measured with the Quality of life Questionnaire for Cancerpatients (QLQ-C 30).Demographics and clinical characteristics of the participants were also recorded. Data weremodeled using multiple linear regression analysis. Results: Mean age was 54.7 ± 18.1 years for the control group and 51.2 ± 9.5 years for thepatients’ group (p=0.288).1) Psychopathology-Personality traits: Mean scores on SCL-90-R, MADRS and STAI weresignificantly higher in the cancer group, compared to controls (p<0.05).2) Women in the breast cancer group present with high State Anxiety scores and even higherTrait Anxiety (p<0.01) ones.3) Multiple regression analysis revealed that after controlling for various sociodemographicand clinical variables, breast cancer was independently and positively associated with allpsychological measures (p<0.05).Regression coefficients ranged from 0.19 (SCL-90-R,psychotism) to 0.33 (MADRS).4) Lower scores on anger/aggressiveness and the STAI (both state and trait) were found inwomen with high educational level. Furthermore, psychiatric treatment was associated withhigher scores on somatization, depression, phobic anxiety and SCL-90-R general index. Also,divorced/widowed women had higher scores on obsessionality and MADRS, compared tomarried women.5) Concerning PTSD, the results of our study show that there is a significantly high score inthe breast cancer group in the dimension of IES avoidance (p=0,019).There was no differencein the intensity of PTSD symptoms between the two groups (p=0,485).6) Women in the breast cancer group had higher scores in both expressions of hostility in thefollowing dimensions of HDHQ: extroverted hostility (HDHQ extroverted, criticism ofothers, projective-paranoid hostility) and introverted hostility (HDHQ guilt, self criticism,introverted hostility).Furthermore women with breast cancer who were consuming alcoholhad even higher score in the dimensions of projective-paranoid hostility and self criticism ofthis scale.7) The comparison between the two groups regarding the personality traits total scores ofLocus of Control of Behavior (LCB), Type-C, Alexithymia (Sifneos), Ιrrational Beliefs(Ellis), Obsessional thinking (Leyton- trait,) showed a statistically significant difference in alldimensions of the above scales, in the breast cancer group (p<0,001), as well as theExtraversion-Neurotisism-Psychoticism Scale (EPQ) (p=0,071).8) Women in the breast cancer group show higher score correlation between the Type-C totalscore and the General Psychopathology scores, in the dimensions of personal inferiority,anxiety and depression( SCL-IS, ANX, DEP).9) There is a correlation among the dimension of General psychopathology SCL- depression,the dimensions of HDHQ Hostility- guilt and introversion and the high correlation of GeneralPsychopathology total score in the breast cancer group.10)There was no significant difference regarding the type of surgery (mastectomy or tumordissection) in the subgroups within the breast cancer group, in any of the GeneralPsychopathology (SCL-90), (Hostility) HDHQ, STAI (Trait-State), Depression (MARDS),PTSD (IES) dimensions, as well as Extraversion-Neuroticism-Psychoticism (EPQ total score),Locus of Control of Behavior (LCB total score), Alexithymia (SIFNEOS totalscore),Obsessional thinking (Leyton –Trait total score), Depersonalization-Derealization (D/Dtotal score) (p>0,05).11) There was no significant difference between the two subgroups regarding the presence ofmetastasis (metastasis/non metastasis), within the breast cancer group, in any of the GeneralPsychopathology (SCL-90), Hostility (HDHQ), State-Trait (STAI), PTSD (IES) dimensionsand Depression (MARDS total score), Extraversion-Neuroticism-Psychoticism (EPQ totalscore), Irrational beliefs (ELLIS (total score), Type-C (total score), Alexithymia (Sifneos totalscore), Depersonalization-Derealization (D/D total score) (p>0,05). 12) Higher scores in General Psychopathology total score and the dimensions ofSomatization, Obsessionality, Paranoid ideation, Trait-Anxiety, Criticism of others, Irrationalbeliefs, extroverted Hostility and Extraversion-Neuroticism-Psychoticism, were observed inthe breast cancer group with problematic/difficult relationships with the husband.2. Psychometric scales -Quality of life: 1) The correlations of the psychometric scales withthe quality of life in the breast cancer group, showed that in those scales where anxiety anddepression, present as the central measurement factors, the higher the total score is, the higheris the impact on the affected women of supplementary subjective symptoms, increasing thepsychological and somatic morbidity. Women in this group with low total Locus of Control ofBehavior seem to have a greater internal locus of control and thus bigger ability to cope andadjust to difficulties, resulting in overall better quality of life.2) High Trait-Anxiety leads to a disproportionate extreme increase of State-Anxiety for thegiven situation and the combination of both, can affect further the state of health, theemotional, cognitive and social functioning and the subjective somatic symptoms of nausea,vomiting and anorexia, downgrading the quality of life.3) The increase of the PTSD total score and PTSD intrusive thoughts decreases the state ofhealth, emotional, somatic and social functioning and overall quality of life and creates anincrease in somatic complains.4) Worse state of health, emotional, social functioning and overall quality of life seem to bepresent in those women of the breast cancer group that tend to attribute blame on themselves(guilt, self- criticism, introjections) as well as the ones who present with increased paranoidprojectivehostility, due to the fact that it tends to increase insecurity, suspiciousness and thusanxiety and depression, creating a difficulty to trust and collaborate with the therapeutic team.5) Social functioning as one of the components of quality of life, is also negatively impactedby the tendency of those members of the breast cancer group, to attribute blame onto others(criticism of others, extroversion of hostility), increasing their interpersonal/social difficulties.6) Those women in the breast cancer group with high Depersonalization/Derealization scores,relevant to dissociative phenomena related to history of psychological trauma, (in our case thedisease, its course and the treatment), serve as similar traumas increasing their anxiety,somatic complains and worsening those aspects of the quality of life represented by theirinterpersonal difficulties, social role, emotional and cognitive functioning.7) Higher scores in the breast cancer group in the dimensions of 12) Higher scores in General Psychopathology total score and the dimensions ofSomatization, Obsessionality, Paranoid ideation, Trait-Anxiety, Criticism of others, Irrationalbeliefs, extroverted Hostility and Extraversion-Neuroticism-Psychoticism, were observed inthe breast cancer group with problematic/difficult relationships with the husband.2. Psychometric scales -Quality of life: 1) The correlations of the psychometric scales withthe quality of life in the breast cancer group, showed that in those scales where anxiety anddepression, present as the central measurement factors, the higher the total score is, the higheris the impact on the affected women of supplementary subjective symptoms, increasing thepsychological and somatic morbidity. Women in this group with low total Locus of Control ofBehavior seem to have a greater internal locus of control and thus bigger ability to cope andadjust to difficulties, resulting in overall better quality of life.2) High Trait-Anxiety leads to a disproportionate extreme increase of State-Anxiety for thegiven situation and the combination of both, can affect further the state of health, theemotional, cognitive and social functioning and the subjective somatic symptoms of nausea,vomiting and anorexia, downgrading the quality of life.3) The increase of the PTSD total score and PTSD intrusive thoughts decreases the state ofhealth, emotional, somatic and social functioning and overall quality of life and creates anincrease in somatic complains.4) Worse state of health, emotional, social functioning and overall quality of life seem to bepresent in those women of the breast cancer group that tend to attribute blame on themselves(guilt, self- criticism, introjections) as well as the ones who present with increased paranoidprojectivehostility, due to the fact that it tends to increase insecurity, suspiciousness and thusanxiety and depression, creating a difficulty to trust and collaborate with the therapeutic team.5) Social functioning as one of the components of quality of life, is also negatively impactedby the tendency of those members of the breast cancer group, to attribute blame onto others(criticism of others, extroversion of hostility), increasing their interpersonal/social difficulties.6) Those women in the breast cancer group with high Depersonalization/Derealization scores,relevant to dissociative phenomena related to history of psychological trauma, (in our case thedisease, its course and the treatment), serve as similar traumas increasing their anxiety,somatic complains and worsening those aspects of the quality of life represented by theirinterpersonal difficulties, social role, emotional and cognitive functioning.7) Higher scores in the breast cancer group in the dimensions of 12) Higher scores in General Psychopathology total score and the dimensions ofSomatization, Obsessionality, Paranoid ideation, Trait-Anxiety, Criticism of others, Irrationalbeliefs, extroverted Hostility and Extraversion-Neuroticism-Psychoticism, were observed inthe breast cancer group with problematic/difficult relationships with the husband.2. Psychometric scales -Quality of life: 1) The correlations of the psychometric scales withthe quality of life in the breast cancer group, showed that in those scales where anxiety anddepression, present as the central measurement factors, the higher the total score is, the higheris the impact on the affected women of supplementary subjective symptoms, increasing thepsychological and somatic morbidity. Women in this group with low total Locus of Control ofBehavior seem to have a greater internal locus of control and thus bigger ability to cope andadjust to difficulties, resulting in overall better quality of life.2) High Trait-Anxiety leads to a disproportionate extreme increase of State-Anxiety for thegiven situation and the combination of both, can affect further the state of health, theemotional, cognitive and social functioning and the subjective somatic symptoms of nausea,vomiting and anorexia, downgrading the quality of life.3) The increase of the PTSD total score and PTSD intrusive thoughts decreases the state ofhealth, emotional, somatic and social functioning and overall quality of life and creates anincrease in somatic complains.4) Worse state of health, emotional, social functioning and overall quality of life seem to bepresent in those women of the breast cancer group that tend to attribute blame on themselves(guilt, self- criticism, introjections) as well as the ones who present with increased paranoidprojectivehostility, due to the fact that it tends to increase insecurity, suspiciousness and thusanxiety and depression, creating a difficulty to trust and collaborate with the therapeutic team.5) Social functioning as one of the components of quality of life, is also negatively impactedby the tendency of those members of the breast cancer group, to attribute blame onto others(criticism of others, extroversion of hostility), increasing their interpersonal/social difficulties.6) Those women in the breast cancer group with high Depersonalization/Derealization scores,relevant to dissociative phenomena related to history of psychological trauma, (in our case thedisease, its course and the treatment), serve as similar traumas increasing their anxiety,somatic complains and worsening those aspects of the quality of life represented by theirinterpersonal difficulties, social role, emotional and cognitive functioning.7) Higher scores in the breast cancer group in the dimensions of psychological rigidity,irritability, health ruminations, punctuality, order and obsessional thinking, increase somaticcomplains, worsening thus the quality of life.3. Psychometric questionnaires–Body image, Sexuality, Interpersonal relationships:1) The majority of the breast cancer sample (67,6%), were happy with their overall bodyimage and felt comfortable enough with their body image (78,8%) to expose it naked to theirpartner, despite the changes due to surgery and treatment.2) A big proportion (48,6%), felt that their image, despite the changes, remained veryattractive, while half of the women of the sample (56,8%), felt that their sexual attractivenesshad not been affected to a significant degree.3) Half of the women in the breast cancer group (48,6%), considered satisfactory or verysatisfactory the frequency of sexual contacts with their partner and the majority did notpresent any changes from their usual behavior, during the year prior to the study, with regardsto their sexual desire, sexual arousal, sexual functioning and activity, sexual satisfaction andfear or anxiety around their sexual behavior. 4) A big majority of the participants (37,5%) stated that what really had a negative impact ontheir sexual functioning, was not breast cancer itself, but underline conflict in the relationshipwith their partner.5) The majority of women did not report symptoms of vaginal bleeding, or pain, vaginaldryness-infections, pain during the intercourse or difficulty in achieving orgasm.6) The majority of women had a long term (>10years), stable, harmonious relationship withtheir partner during the course of the year that preceded the study, accepted willingly, theirpartner’s sexual desire and stated (55,2%) that their sexual relationship occupied an importantrole in their lives.4. Psychometric questionnaires-Life Events: 1) Women suffering from breast cancerpresented a significantly higher score in the Anhedonia Scale.2) Subgroups comparisons regarding the type of surgery (mastectomy/tumor dissection) didnot show significant total scores differences, regarding the comparison of Life Events Scale tothe Anhedonia, Obsessionality and Depersonalization-Derealization Scales.3) A significant positive correlation was found between Life Events and the ObsessiveCompulsive Inventory and Anhedonia total scores, as well as the dimensions of the HostilityScale self-criticism, direction of hostility and the total score of the PTSD dimensions.4) A significant positive correlation was found between Obsessive Compulsive Inventory totalscore, the Hostility Scale in the dimensions of introversion, guilt, acting-out hostility and theLocus of Control of Behavior total score.5) Multivariate analysis with dependent variables in the Anhedonia Scale, Life Events ScaleObsessive Compulsive Inventory and Depersonalization-Derealization Scale and independentvariables of demographic and personal history data revealed that: only breast cancer wasindependently, positively associated and able to predict the scores in the Anhedonia Scalebetween the two groups, showing that breast cancer patients had higher scores compared tothe healthy controls.6) The increase of age correlated with higher scores in the Life Event Scale.Conclusions: The present cross-sectional study is the only cross-sectional study in theliterature, designed to concomitantly assess the impact of indices of psychopathology andlife events between a breast cancer group and a group of controls, in relation with aconstellation of personality traits linked with each other and with breast cancer via theunderlying network of chronic stress, anxiety and depression, and the impact of bothpsychopathology and personality traits on the quality of life of the breast cancer group. It isthe first controlled study ever, to assess General Psychopathology per se, in relation withbreast cancer. Furthermore it assessed body image perceptions, sexual behavior andinterpersonal relationships in the affected women. The results of this study testify that:1) Anxiety, depression, intrusive PTSD thoughts and overall psychopathology are morefrequent in breast cancer patients, than in a control population and that breast cancer makes alarger independent contribution to all psychopathology measures, than any of the otherinvestigated variables.2) Personality traits like Neuroticism, Psychotisicm, Trait Anxiety, Hostility, Type-C,Alexithymia, Ιrrational Beliefs, Obsessional thinking and Locus of Control of Behaviorshowed a statistically significant difference in all dimensions of the above scales in the breastcancer group, providing a measure of the association between depressive symptoms and theirintensity in a specific time point in the General psychopathology scale, in the affected women,underlying the subjective tendency of these women to introvert the emotions of hostility andguilt. The above highlights the relationship between depressiveness, trait anxiety and the introjections of negative emotions, suggesting a characteristic personality profile in the breastcancer group, a lot more extensive compared to the profile of personality Type-C,traditionally associated in the literature with cancer and especially breast cancer. The aboveput the emphasis on the relationship between depressiveness and anxiety as an underlinestable personality trait and the introjections of negative emotions, leading to a pronounceddifficulty of these women to control and counterbalance their emotional reactions, so that theyexperience in a subjective level, disproportionate psychological distress, resulting in aconstant state of chronic stress.3) No difference has been observed within the breast cancer subgroups concerning the type ofsurgery (mastectomy-tumor dissection) and the stage of the disease (metastasis-nonmetastasis) regarding Anxiety, Depression, PTSD, General Psychopathology and personalitytraits.4) In the breast cancer group, marital conflict increased General Psychopathology scores andpersonality traits scores of extroverted Hostility and Extraversion-Neuroticism-Psychoticism,suggesting that problematic interpersonal relationships can induce certain generalpsychopathology symptoms at a specific point in time and intensify underlying personalitytraits.5) Higher scores in Anxiety, Depression and PTSD in the breast cancer group, increase thepsychological and somatic morbidity, affecting negatively the quality of life. Worse state ofhealth, emotional, social functioning and overall quality of life seem to be present in thosewomen who tend to attribute blame onto themselves under the form of guilt, self-criticismintrojections and also present with increased paranoid-projective hostility.6) The above features tend to increase insecurity, suspiciousness, anxiety and depression andhave a negative impact on social functioning, an important component of the quality of life,due to the tendency of the affected women, to also attribute blame onto others increasingtheir interpersonal/social difficulties, including therapeutic alliance with the treating team .7) Higher scores in the breast cancer group in the dimensions of psychological rigidity,irritability, health ruminations, punctuality, order and obsessional thinking increase somaticcomplains, worsening the quality of life.8)The majority of the women in the breast cancer group, who answered the Body Image,Sexuality, Interpersonal relationships questionnaire did not report a change in their body,breast image and sexual behavior due to the cancer surgery and treatment. Furthermore, majornegative impact on their sexuality was attributed more to interpersonal conflict in the couple,rather than breast cancer and the side effects of the treatments.In an attempt to summarize the trends in the existent literature and the results and conclusionsof the present study, it seems fair to say, that different personality traits probably do not havea direct effect on the development of Breast Cancer, but are vulnerability factors that canpotentially modify the impact of other variables, like, depression and life events.Clinical practice and research independently of their divergences regarding the relationshipbetween somatic illness and psychological functioning finally arrive at similar results andconclusions, all concerning anxiety and depression.The findings of the present study, suggest that this highly vulnerable patient group should beclosely followed in order to prevent, identify and timely treat any mental health problems thatmay arise.