Journal of Consulting and Clinical Psychology 2002, Vol. 70, No. 1, 235–240
Copyright 2002 by the American Psychological Association, Inc. 0022-006X/02/$5.00 DOI: 10.1037//0022-006X.70.1.235
BRIEF REPORTS
Predictors of Posttraumatic Stress Disorder Symptomatology Following Bone Marrow Transplantation for Cancer Paul B. Jacobsen, Ian J. Sadler, Margaret Booth-Jones, Elizabeth Soety, Michael A. Weitzner, and Karen K. Fields University of South Florida and Moffitt Cancer Center This study examined the prevalence and predictors of posttraumatic stress disorder (PTSD) symptoms in 70 men and women treated with bone marrow transplantation for cancer. Findings indicated that the number of symptoms present ranged from 0 to a possible high of 17 (M ⫽ 3.0, SD ⫽ 3.9). As predicted, lower social support and higher avoidance coping 1 month pretransplant predicted greater PTSD symptom severity an average of 7 months posttransplant. These variables remained significant predictors of symptom severity even after accounting for pretransplant levels of psychological distress. Additional analyses indicated the presence of a significant interaction between social support and avoidance coping, with patients high in avoidance coping and low in social support reporting the most severe symptoms. These findings identify patients at risk for psychological disturbance posttransplant and can serve to guide future intervention efforts.
Butler, Koopman, Classen, & Spiegel, 1999; Widows et al., 2000), greater use of avoidance coping (Hampton & Frombach, 2000; Widows et al., 2000), more precancer stressors (Andrykowski & Cordova, 1998; Tjemsland, Soreide, & Malt, 1998), psychiatric disorder prior to cancer diagnosis (Widows et al., 2000), and more impaired psychosocial functioning prior to cancer diagnosis (Tjemsland et al., 1998) are associated with greater PTSD symptomatology. With one exception (Tjemsland et al., 1998), these studies are limited methodologically by the use of cross-sectional designs in which the psychological factors are measured concurrently with PTSD symptomatology. Accordingly, it is not possible in many instances to distinguish whether the psychological variables are influencing PTSD symptomatology or vice versa. To address this limitation, the present study used a longitudinal design in which the psychological variables of interest were assessed before patients underwent bone marrow transplantation (BMT) for treatment for cancer1 and PTSD symptomatology was assessed approximately 8 months later. We hypothesized that patients who reported greater use of avoidance coping and reduced social support before BMT would report more severe PTSD symptomatology after BMT. This pattern of results would be consistent with prior cross-sectional research (Andrykowski & Cordova, 1998; Hampton & Frombach, 2000; Widows et al., 2000) and with a social– cognitive-processing model of trauma recovery (Lepore, Silver, Wortman, & Wayment, 1996). According to this model,
The diagnosis and treatment of cancer can be a traumatic experience with long-lasting psychological effects. Consistent with this view, a number of studies have documented the presence of posttraumatic stress disorder (PTSD), as defined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV; American Psychiatric Association, 1994), in adult cancer patients (Alter et al., 1996; Andrykowski, Cordova, Studts, & Miller, 1998; Green et al., 1998; Widows, Jacobsen, & Fields, 2000). Although a relatively small percentage of patients in these studies were found to meet diagnostic criteria for PTSD (range ⫽ 3% to 6%), considerable variability is evident in the severity of PTSD symptoms. For example, one study of women with breast cancer reported that the number of PTSD symptoms present ranged from 0 to 15 of a possible 17 (Andrykowski & Cordova, 1998). Research into psychological factors associated with individual differences in PTSD symptomatology among cancer patients has shown that poorer social support (Andrykowski & Cordova, 1998;
Paul B. Jacobsen, Ian J. Sadler, and Elizabeth Soety, Department of Psychology, University of South Florida, and Psychosocial and Palliative Care Program, Moffitt Cancer Center, Tampa, Florida; Margaret BoothJones and Michael A. Weitzner, Department of Oncology, University of South Florida, and Psychosocial and Palliative Care Program, Moffitt Cancer Center; Karen K. Fields, Department of Oncology, University of South Florida, and Blood and Marrow Transplant Program, Moffitt Cancer Center. This research was supported by an American Cancer Society Institutional Research Grant award to the Moffitt Cancer Center. We thank James Partyka, Heather Belanger, and Susan Arab for their assistance with data collection and manuscript preparation. Correspondence concerning this article should be addressed to Paul B. Jacobsen, Department of Psychology, University of South Florida, 4202 East Fowler Avenue, PCD4118G, Tampa, Florida 33620. E-mail:
[email protected]
1 BMT is an aggressive form of cancer treatment in which the patient’s immune system is deliberately compromised by means of high-dose chemotherapy, radiotherapy, or both and subsequently restored through introduction of blood or marrow products obtained from a donor (allogeneic transplantation) or from the same patient prior to transplant (autologous transplantation). Both forms of transplantation are associated with considerable morbidity (B. R. Smith, 1997), including life-threatening complications, and thus have the potential to be high-magnitude stressors.
235
BRIEF REPORTS
236
greater use of avoidance coping and reduced social support would be expected to provide individuals with fewer opportunities to process or habituate to trauma-related thoughts, images, and memories. To the extent that these factors interfere with cognitive processing, there would be less integration of the traumatic experience into new or preexisting mental schemas and greater likelihood that traumatic material would remain active and capable of precipitating intrusive thoughts and other symptoms of PTSD.
Method Participants To be eligible for the current study, patients had to (a) have completed either autologous or allogeneic BMT for cancer, (b) be 18 years of age or older, (c) be able to speak and read English, (d) have completed at least 8 years of formal education, (e) have completed a routine clinical psychosocial evaluation prior to BMT, (f) be approximately 6 months posttransplant, and (g) and have no clinical evidence of disease progression or recurrence at the most recent follow-up visit. Seventy of 103 eligible patients (68%) agreed to participate and provided complete data. There were no significant differences ( p ⱕ .05) between participants (n ⫽ 70) and eligible nonparticipants (n ⫽ 33) with regard to age, gender, education, ethnicity, marital status, employment status, type of cancer diagnosis, length of hospitalization, or type of BMT.
Procedure Approximately 1 month before their scheduled transplants, patients underwent a routine psychosocial assessment conducted with all BMT candidates that included administration of self-report measures of psychological distress, social support, and coping (see below). At 5 months posttransplant, medical records were reviewed to identify individuals who met the remaining eligibility criteria. Letters were sent to eligible patients describing a study of quality-of-life outcomes, of which the current investigation of PTSD symptomatology was one component, and informing them that they would be contacted by telephone to discuss participation. Posttransplant measures that are the focus of this report are described below. Patients who provided verbal informed consent during the telephone contact were given an appointment for an outpatient research visit. They were also sent a written informed consent form and a questionnaire that included a demographic information form and a self-report measure of PTSD symptomatology (see below). Patients were asked to complete the questionnaire at home in the days just before their outpatient visit. On arriving for their appointment, patients returned the signed consent forms and questionnaires before completing additional clinician-administered measures.
These ratings were used to compute scores for scales that have been labeled Logical Analysis, Positive Reappraisal, Seeking Guidance and Support, Problem Solving, Cognitive Avoidance, Acceptance or Resignation, Seeking Alternative Rewards, and Emotional Discharge. The first four scales are conceptualized as measuring approach coping, and the latter four scales are conceptualized as measuring avoidance coping (Moos, 1993). Scores for the four approach subscales were summed to yield a total approach coping score (Cronbach’s ␣ ⫽ .83), and scores for the four avoidance subscales were summed to yield a total avoidance coping score (Cronbach’s ␣ ⫽ .78). Profile of Mood States (POMS). The POMS (McNair, Lorr, & Droppleman, 1992), a 65-item measure of psychological distress, was also administered during the pretransplant evaluation. Participants indicated how well each item described how they had been feeling during the past week (0 ⫽ not at all, 4 ⫽ extremely). As in previous research with cancer patients (Carver et al., 1993), scores on the Tension–Anxiety, Depression– Dejection, and Anger–Hostility subscales were summed to yield a total distress score (Cronbach’s ␣ ⫽ .93). Interpersonal Support Evaluation List—Short Form (ISEL–SF). The ISEL–SF (Peirce, Frone, Russell, & Cooper, 1996), a brief measure of social support, was also completed during the pretransplant evaluation. The full-length version of the ISEL (Cohen, Mermelstein, Kamarck, & Hoberman, 1985) consists of 40-items that respondents rate in terms of how true or false the statements are of them (1 ⫽ completely false, 4 ⫽ completely true). The ISEL–SF retains 5 items each from the original Tangible Support, Appraisal Support, and Belonging Support subscales. A total social support score was calculated by summing ratings for all 15 items (Cronbach’s ␣ ⫽ .81). PTSD Checklist—Civilian Version (PCL–C). The PCL–C (Weathers, Litz, Herman, Huska, & Keane, 1993), a 17-item self-report measure that reflects DSM–IV symptom criteria for PTSD, was completed during the posttransplant evaluation. Participants were instructed to consider their experience with cancer and its treatment and to rate how much they had been bothered by each symptom during the past month (1 ⫽ not at all, 3 ⫽ moderately, 5 ⫽ extremely). The PCL–C yields a total score as well as subscale scores for Intrusion, Avoidance–Numbing, and Arousal. According to the scale developers (Weathers et al., 1993), respondents are considered likely to meet DSM–IV criteria for PTSD if (a) they endorse (i.e., rate as “moderately” or greater) one or more intrusion symptoms, three or more avoidance–numbing symptoms, and two or more arousal symptoms in accordance with DSM–IV criteria or (b) they obtain a total score of 50 or greater. Previous research with cancer patients (Andrykowski et al., 1998; Widows et al., 2000) indicates that both scoring methods possess high diagnostic efficiency relative to interview-based methods of diagnosing PTSD (range ⫽ .90 –.98). The PCL–C can also be used as a continuous measure of the severity of PTSD symptomatology. A total PTSD severity score was created by summing the 17 symptom ratings (Cronbach’s ␣ ⫽ .93).
Results Measures Demographic data form. Demographic data were obtained posttransplant through use of a standard self-report questionnaire. Variables assessed included age, gender, race and ethnicity, marital status, and education level. Medical review form. Medical charts were reviewed posttransplant to obtain information about disease and treatment characteristics. Variables assessed included cancer diagnosis, type of BMT, and dates of admission and discharge for BMT. Coping Responses Inventory (CRI). The CRI (Moos, 1993), a selfreport measure of coping responses to stressful life circumstances, was administered during the pretransplant evaluation. Participants rated how often (0 ⫽ not at all, 3 ⫽ fairly often) they had used each of the 48 coping responses listed in the CRI in dealing with their cancer and its treatment.
Study participants ranged in age from 23 to 65 years (M ⫽ 48, SD ⫽ 9). The majority of participants were female (76%), White non-Hispanic (93%), currently married (64%), and had some schooling beyond high school (60%). Eighty-three percent of the sample underwent autologous transplantation, and 17% underwent allogeneic transplantation. The majority of patients were diagnosed with breast cancer (67%), followed by leukemia (12%), multiple myeloma (13%), and lymphoma (8%). Mean length of hospitalization was 24 days (SD ⫽ 12; range ⫽ 16 –95). Participants averaged 6.9 months postdischarge (SD ⫽ 1.2; range ⫽ 5.1– 10.6) at the time of follow-up assessment. The mean score on the PCL–C for the sample was 29.4 (SD ⫽ 11.2; range ⫽ 17–70). Participants reported an average
BRIEF REPORTS
of 3.0 symptoms (SD ⫽ 3.9; range ⫽ 0 –17) as evidenced by moderate or greater intensity ratings on individual PCL–C items. Using the cutoff method (total PCL–C score ⱖ 50), we identified 4 participants (6%) as likely to merit a formal diagnosis of PTSD. Using the symptom method (at least moderate ratings of one intrusion symptom, three avoidance–numbing symptoms, and two arousal symptoms), we identified 6 participants (9%) as likely to merit a formal diagnosis of PTSD. Correlations between PTSD symptom severity and demographic, medical, and psychological variables appear in Table 1. There were no significant ( p ⬍ .05) associations between any of the demographic and medical variables assessed and PTSD symptom severity posttransplant. As predicted, greater use of avoidance coping and reduced social support prior to transplant were significantly related ( p ⱕ .001) to greater PTSD symptom severity posttransplant.2 Greater psychological distress prior to transplant was also significantly related ( p ⬍ .0001) to more severe PTSD symptomatology posttransplant. Approach coping was not significantly related to PTSD symptom severity ( p ⫽ .63). A multiple regression analysis was performed to identify the variance in PTSD symptomatology accounted for by the three psychological variables measured prior to transplant for which significant results were obtained. Psychological distress was entered into the analysis first to provide a conservative test of the predictive value of social support and avoidance coping. As shown in Table 2, this variable accounted for 30% of the variability in PTSD symptom severity ( p ⬍ .0001). The two remaining variables were allowed to enter the analysis using a forward selection method. Social support accounted for 6% additional variability ( p ⫽ .01) followed by avoidance coping, which accounted for 5% of the remaining variability in PTSD symptom severity ( p ⫽ .02). Additional regression analyses were undertaken to determine the presence of interactions among the three psychological variables. A significant interaction was found between social support and avoidance coping ( p ⫽ .005). This interaction accounted for 7% of the variability in PTSD symptom severity not already
Table 1 Correlations of Demographic, Medical, and Psychological Variables With PTSD Symptom Severity Predictor variable
PTSD severity PCL–C
p
Gender (male vs. female) Age (years) Education (years) Race/ethnicity (White non-Hispanic vs. other) Marital status (married vs. other) Time since discharge (months) Length of hospitalization (days) BMT type (allogeneic vs. autologous) Cancer diagnosis (breast vs. other) Psychological distress (POMS) Approach coping (CRI) Avoidance coping (CRI) Social support (ISEL–SF)
.03 .09 ⫺.16 ⫺.18 ⫺.003 ⫺.08 ⫺.01 .04 ⫺.06 .55 ⫺.05 .42 ⫺.38
.80 .47 .18 .14 .98 .50 .95 .74 .63 ⬍ .0001 .63 .0002 .001
Note. PTSD ⫽ posttraumatic stress disorder; PCL–C ⫽ PTSD Checklist—Civilian Version; BMT ⫽ bone marrow transplantation; POMS ⫽ Profile of Mood States; CRI ⫽ Coping Responses Inventory; ISEL–SF ⫽ Interpersonal Support Evaluation List—Short Form.
237
Table 2 Multiple Regression Analysis of PTSD Symptom Severity Variable

⌬R2
p
Psychological distress Social support Avoidance coping Avoidance Coping ⫻ Social Support
0.55 ⫺0.26 0.24 ⫺3.30
.30 .06 .05 .07
⬍ .0001 .01 .02 .005
Note. F(4, 65) ⫽ 15.05, p ⬍ .0001. The p values refer to the significance of change in R2. PTSD ⫽ posttraumatic stress disorder.
explained by psychological distress, social support, and avoidance coping (see Table 2). On the basis of methods developed by Aiken and West (1991), analyses were conducted to characterize the nature of the interaction (see Figure 1). Specifically, regression analyses were performed to determine whether the simple slope of equations using social support to predict PTSD symptom severity differed significantly from zero at specified levels of avoidance coping. At a high level of avoidance coping (1 SD above the group mean), there was evidence of a significant relationship between PTSD symptom severity and level of social support, t(66) ⫽ ⫺4.55, p ⬍ .0001. As shown in Figure 1, participants who were high in avoidance coping and low in social support were predicted to report more severe PTSD symptomatology than participants who were high in both avoidance coping and social support. A different pattern emerged at a low level of avoidance coping (1 SD below the group mean), where there was no evidence of a significant relationship between level of social support and PTSD symptom severity, t(66) ⫽ 0.53, p ⫽ .60.
Discussion Depending on the PCL–C scoring method used, 6% to 9% of participants in the current study were considered likely to merit a DSM–IV diagnosis of PTSD. These prevalence rates are similar to those previously reported for cancer patients treated with BMT (M. Y. Smith, Redd, DuHamel, Vickberg, & Ricketts, 1999; Widows et al., 2000). Although a relatively small percentage of the sample appeared to meet diagnostic criteria for PTSD, there was evidence that PTSD symptom severity varied considerably among study participants. The number of symptoms that participants reported being present at moderate or greater intensity on the PCL–C ranged from 0 to 17 of a possible 17. Furthermore, total scores on the PCL–C ranged from a low of 17 to a high of 70 out of a possible range of 17 to 85. Similar variability in PTSD symptom severity has been reported in prior research in which the PCL–C was administered to samples of cancer patients (Cordova et al., 1995; Jacobsen et al., 1998; Widows et al., 2000). Demographic and medical factors assessed in the current study failed to demonstrate significant univariate associations with PTSD symptom severity. In contrast, at least two previous studies 2 To evaluate the possibility that the observed relation between avoidance coping and PTSD symptom severity may be due to overlapping item content, we conducted an additional analysis using a revised PCL–C total score that excluded the five Avoidance subscale items. Results indicated that avoidance coping remained significantly correlated with PTSD symptom severity (r ⫽ .40, p ⬍ .001).
238
BRIEF REPORTS
Figure 1. Interaction between avoidance coping and social support. PTSD ⫽ posttraumatic stress disorder.
of cancer patients have reported that younger age (Cordova et al., 1995; Green et al., 1998; Tjemsland et al., 1998) and less education (Cordova et al., 1995; Jacobsen et al., 1998) are associated with greater PTSD symptom severity. The absence of significant results for age in the current study may be due to restrictions in the age range of potential participants. BMT is typically not performed with elderly individuals because of the increased mortality risk (Peters, 1997) and, consistent with this practice, there were no participants in the present study above 65 years of age. In contrast, all three previous studies reporting positive associations involved patients undergoing other forms of cancer treatment and included individuals greater than 65 years of age. The absence of a significant association between education and PTSD severity cannot be explained on the same basis, as participants’ education levels varied from 9 to 20 years. Although our finding is inconsistent with results reported in two previous studies, it should be noted that one other study of cancer patients also found education to be unrelated to PTSD symptom severity (Widows et al., 2000). In contrast to the pattern of results for demographic and medical factors, psychological factors assessed in the current study accounted for a sizable amount of the variability in PTSD symptomatology. Univariate analyses indicated that social support and avoidance coping each accounted for 14% or more of the variability in PTSD symptom severity. Moreover, social support and avoidance coping continued to account for significant variability in PTSD symptom severity (6% and 5%, respectively) after controlling for pretransplant levels of psychological distress. Not surprisingly, pretransplant levels of psychological distress accounted for a substantial amount of the variability in PTSD symptom severity (30%). This result is similar to findings from one of the few other longitudinal investigations of PTSD symptomatology in cancer patients. In this study (Tjemsland et al., 1998), women who reported prior to breast cancer surgery the presence of one or more negative life events or more impaired psychosocial functioning in the past year were found to have greater PTSD symptomatology 1 year later. These findings regarding avoidance coping and social support confirm and extend prior research. Greater use of avoidant-coping
strategies (e.g., escape–avoidance, distancing, and denial) has repeatedly been shown to be associated with increased PTSD symptomatology in other populations, including veterans and crime and accident victims (Blake, Cook, & Keane, 1992; Bryant & Harvey, 1995; Harrison & Kinner, 1998; Sutker, Davis, Uddo, & Ditta, 1995; Wolfe, Keane, Kaloupek, Mora, & Wine, 1993). Similarly, greater social support has been shown to be associated with decreased PTSD symptomatology in veterans, burn victims, and community samples (Davidson, Hughes, Blazer, & George, 1991; Green, Grace, Lindy, Gleser, & Leonard, 1990; King, King, Fairbank, Keane, & Adams, 1998; Perry, Difede, Musngi, Frances & Jacobsberg, 1992). Previous studies with cancer patients have also shown that higher levels of avoidance coping (Hampton & Frombach, 2000; Widows et al., 2000) and lower levels of social support (Andrykowski et al., 1998; Butler et al., 1999; Widows et al., 2000) are associated with greater PTSD symptomatology. However, unlike these studies in which avoidance coping, social support, and PTSD symptomatology were measured concurrently, findings from the current study are predictive in nature. That is, levels of avoidance coping and social support were measured prior to transplant and were found to predict levels of PTSD symptomatology approximately 8 months later. Thus, the current study provides the strongest empirical support to date for the view that avoidance coping and social support play a causal role in the development of PTSD symptomatology in cancer patients. Findings from the present study also indicated that the effects of avoidance coping and social support on PTSD symptom severity are interactive. That is, there was evidence that social support had a greater impact on PTSD symptom severity in individuals more reliant on avoidance coping. Among these individuals, a high level of social support was estimated to be associated with 50% less PTSD symptom severity than a low level of social support. These results can be understood in terms of a social– cognitive model of trauma recovery (Lepore et al., 1996), in which the cognitive processing of a traumatic event through social interactions is viewed as an important component of psychological recovery. Consistent with this model, results suggested that the presence of a supportive social environment could encourage individuals who might otherwise rely on avoidant forms of coping to cognitively process traumatic material. For example, supportive friends or relatives may have been able to elicit discussion of traumatic aspects of the cancer experience from individuals who would be unlikely to initiate such discussions on their own. By so doing, these supportive environments may serve to prevent or reduce the development of PTSD symptomatology in at-risk individuals. The use of a longitudinal design in the present study represents a notable methodologic improvement over most previous research on PTSD symptomatology in cancer patients. Nevertheless, several limitations remain. One limitation involves the lack of data on the presence and severity of PTSD symptomatology in the pretransplant period. Although regression analysis indicated that social support and avoidance coping remained significant predictors of PTSD symptomatology after controlling for pretransplant levels of psychological distress, their predictive value above and beyond pretransplant levels of PTSD symptomatology is unknown. A second limitation involves the inclusion of only a single follow-up assessment. Inclusion of multiple follow-up assessments would have allowed for identification of the time course of PTSD symp-
BRIEF REPORTS
tom development and the stability of PTSD symptoms in the posttransplant period. Participation bias is a third limitation. Thirty-two percent of individuals eligible for the current study were not represented in the final sample. Although these nonparticipants did not differ from participants on any of the demographic or medical variables that were assessed, we cannot rule out a possible relationship between nonparticipant status and PTSD symptom severity. Indeed, it is quite plausible that individuals experiencing greater PTSD symptomatology would be more likely to decline participation in a desire to avoid unpleasant reminders of their cancer treatment. Avoidance coping and lack of social support were found to be important risk factors for development of PTSD symptomatology following BMT. In addition to confirming and extending prior research, these findings have both theoretical and clinical implications. In terms of theory, results support the utility of a social– cognitive model of trauma recovery. Consistent with this model, there was evidence that the presence of a supportive social environment may moderate the impact of cognitive processes likely to impede psychological recovery in traumatized individuals. In terms of clinical practice, results yield a psychological profile of BMT candidates at increased risk for PTSD symptomatology following treatment completion. In addition to their usefulness in identifying at-risk individuals, these findings suggest the use of cognitive– behavioral interventions, used effectively against PTSD in other populations (Meadows & Foa, 2000), in which avoidance of traumatic material is challenged in an emotionally supportive environment. In light of accumulating evidence that many cancer patients experience PTSD symptomatology for months or even years following treatment completion, there is a compelling need to identify treatments that can effectively address these disturbing symptoms.
References Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting interactions. Thousand Oaks, CA: Sage. Alter, C. L., Pelcovitz, D., Axelrod, A., Goldenberg, B., Harris, H., Meyers, B., et al. (1996). Identification of PTSD in cancer survivors. Psychosomatics, 37, 137–143. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Andrykowski, M. A., & Cordova, M. J. (1998). Factors associated with PTSD symptoms following treatment for breast cancer: Test of the Andersen model. Journal of Traumatic Stress, 11, 189 –203. Andrykowski, M. A., Cordova, M. J., Studts, J. L., & Miller, T. W. (1998). Posttraumatic stress disorder after treatment for breast cancer: Prevalence of diagnosis and use of the PTSD Checklist—Civilian Version (PCL–C) as a screening instrument. Journal of Consulting and Clinical Psychology, 66, 586 –590. Blake, D. D., Cook, J. D., & Keane, T. M. (1992). Post-traumatic stress disorder and coping in veterans who are seeking medical treatment. Journal of Clinical Psychology, 48, 695–704. Bryant, R. A., & Harvey, A. G. (1995). Avoidant coping style and posttraumatic stress following motor vehicle accidents. Behaviour Research and Therapy, 33, 631– 635. Butler, L. D., Koopman, C., Classen, C., & Spiegel, D. (1999). Traumatic stress, life events, and emotional support in women with metastatic breast cancer: Cancer-related traumatic stress symptoms associated with past and current stressors. Health Psychology, 18, 555–560. Carver, C. S., Pozo, C., Harris, S. D., Noreiga, V., Scheier, M. F.,
239
Robinson, D. S., et al. (1993). How coping mediates the effect of optimism on distress: A study of women with early stage breast cancer. Journal of Personality and Social Psychology, 65, 375–390. Cohen, S., Mermelstein, R., Kamarck, T., & Hoberman, H. (1985). Measuring the functional components of social support. In I. G. Sarason & B. R. Sarason (Eds.), Social support: Theory, research, and application (pp. 73–94). Dordrecht, The Netherlands: Martinus Nijhoff. Cordova, M. J., Andrykowski, M. A., Kenady, D. E., McGrath, P. C., Sloan, D. A., & Redd, W. H. (1995). Frequency and correlates of posttraumatic-stress-disorder-like symptoms after treatment for breast cancer. Journal of Consulting and Clinical Psychology, 63, 981–986. Davidson, J. R. T., Hughes, D., Blazer, D. G., & George, L. K. (1991). Post-traumatic stress disorder in the community: An epidemiological study. Psychological Medicine, 21, 713–721. Green, B. L., Grace, M. C., Lindy, J. D., Gleser, G. C., & Leonard, A. (1990). Risk factors for PTSD and other diagnoses in a general sample of Vietnam veterans. American Journal of Psychiatry, 147, 729 –733. Green, B. L., Rowland, J. H., Krupnick, J. L., Epstein, S. A., Sto`ckton, P., Stern, N. M., et al. (1998). Prevalence of posttraumatic stress disorder in women with breast cancer. Psychosomatics, 39, 102–111. Hampton, M. R., & Frombach, I. (2000). Women’s experience of traumatic stress in cancer treatment. Health Care for Women International, 21, 67–76. Harrison, C. A., & Kinner, S. A. (1998). Correlates of psychological distress following armed robbery. Journal of Traumatic Stress, 11, 787–798. Jacobsen, P. B., Widows, M. R., Hann, D. M., Andrykowski, M. A., Kronish, L. E., & Fields, K. K. (1998). Posttraumatic stress disorder symptoms following bone marrow transplantation for breast cancer. Psychosomatic Medicine, 60, 366 –371. King, L. A., King, D. W., Fairbank, J. A., Keane, T. M., & Adams, G. A. (1998). Resilience-recovery factors in post-traumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74, 420 – 434. Lepore, S. J., Silver, R. C., Wortman, C. B., & Wayment, H. A. (1996). Social constraints, intrusive thoughts, and depressive symptoms among bereaved mothers. Journal of Personality and Social Psychology, 70, 271–282. McNair, D. M., Lorr, M., & Droppleman, L. F. (1992). EdITS manual for the Profile of Mood States. San Diego, CA: Educational and Industrial Testing Service. Meadows, E. A., & Foa, E. B. (2000). Cognitive behavioral treatment for PTSD. In A. Y. Shalev, R. Yehuda, & A. C. McFarlane (Eds.), International handbook of human responses to trauma. The Plenum series on stress and coping (pp. 337–346). New York: Kluwer Academic/Plenum. Moos, R. H. (1993). Coping Responses Inventory Adult Form: Professional manual. Odessa, FL: Psychological Assessment Resources. Peirce, R. S., Frone, M. R., Russell, M., & Cooper, M. (1996). Financial stress, social support, and alcohol involvement: A longitudinal test of the buffering hypothesis in a general population survey. Health Psychology, 15, 38 – 47. Perry, S. P., Difede, J., Musngi, G., Frances, A. J., & Jacobsberg, L. (1992). Predictors of posttraumatic stress disorder after burn injury. American Journal of Psychiatry, 149, 931–935. Peters, W. P. (1997). Autologous bone marrow transplantation. In J. F. Holland, E. Frei, R. C. Bast, D. W. Kufe, D. L. Morton, & R. R. Weichselbaum (Eds.), Cancer medicine (4th ed., Vol. 1, pp. 1279 – 1294). Baltimore: Williams & Wilkins. Smith, B. R. (1997). Stem cell transplantation. In V. T. Devita, S. Hellman, & S. A. Rosenberg (Eds.), Cancer: Principles and practice of oncology (5th ed., Vol. 2, pp. 2621–2639). Philadelphia: Lippincott-Raven. Smith, M. Y., Redd, W., DuHamel, K., Vickberg, S. J., & Ricketts, P. (1999). Validation of the PTSD Checklist—Civilian Version in survi-
240
BRIEF REPORTS
vors of bone marrow transplantation. Journal of Traumatic Stress, 12, 485– 499. Sutker, P. B., Davis, J. M., Uddo, M., & Ditta, S. R. (1995). War zone stress, personal resources, and PTSD in Persian Gulf War returnees. Journal of Abnormal Psychology, 104, 444 – 452. Tjemsland, L., Soreide, J. A., & Malt, U. F. (1998). Posttraumatic distress symptoms in operable breast cancer III: Status one year after surgery. Breast Cancer Research and Treatment, 47, 141–151. Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist: Reliability, validity, and diagnostic utility. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.
Widows, M. R., Jacobsen, P. B., & Fields, K. K. (2000). Relation of psychological vulnerability factors to posttraumatic stress disorder symptomatology in bone marrow transplant recipients. Psychosomatic Medicine, 62, 873– 882. Wolfe, J., Keane, T. M., Kaloupek, D. G., Mora, C. A., & Wine, P. (1993). Patterns of positive readjustment in Vietnam combat veterans. Journal of Traumatic Stress, 6, 179 –193.
Received September 1, 2000 Revision received May 2, 2001 Accepted May 11, 2001 䡲
