Medical ‐ Surgical Nursing Journal 2017; 6(2‐3): 9‐16.
Published online 2018 February 14 Original Article
Evaluation of the Relationship between Post‐traumatic Stress Disorder and Post‐traumatic Growth in Women with Breast Cancer
Ali Navidian1, Malihe Sharmi2
1. Associate Professor, Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran 2. MSc Student, Departemant of Clinical Psychology, Zahedan Branch, Islamic Azad University, Zahedan, Iran
*Correspondence: Malihe Sharmi, Zahedan Branch, Islamic Azad University, Zahedan, Iran. Email: firstname.lastname@example.org A R T I C L E I N F O
Received: 18 November 2017 Revised: 22 January 2018 Accepted: 28 January 2018
Background: Coping with life-threatening illnesses such as cancer leads to the comprehension of its positive outcomes along with its negative consequences. However, the exact relationship between these positive and negative outcomes in female patients with breast cancer is unknown. Therefore, this study aimed to determine the relationship between post-traumatic stress disorder and growth (PTSD and PTG) in women with breast cancer referred to Chemotherapy Ward of Ali Ibn Abi Talib Hospital in Zahedan, Iran, 2017. Methods: This correlational study was conducted on 136 patients with breast cancer referred to the Chemotherapy Ward of Ali Ibn Abi Talib Hospital in 2017. The samples were selected through the convenience sampling method during 3 months. Data were collected using Post-traumatic Growth Inventory and PTSD Checklist. Data analysis was performed in SPSS, version 21 using descriptive statistics, Pearson’s correlation coefficient test, and linear regression. Results: According to the results of Pearson’s correlation coefficient, there was a significant and indirect correlation between PTG and PTSD and its dimensions (r=- 0.34). Moreover, a significant and indirect relationship was observed between PTG and all dimensions of PTSD. Regarding the results of linear regression, PTSD and its dimensions determined only 16% of PTG (P=0.001). Conclusion: Considering the fact that the variable of PTSD and its dimensions is a predictor of PTG in patients with breast cancer, it is recommended to pay more attention to PTSD in order to increase the PTG in these patients.
Key words: Breast cancer Post‐traumatic stress Post‐traumatic growth
Trauma is defined as a sudden, unexpected, shocking, and uncommon experience.1 There are various types of trauma that can cause serious morbidity and mortality.2 One of these traumas is cancer, which its potential traumatic nature has significantly drawn attentions in the past decade.3 Cancer, as a stressful and traumatic experience is increasing, which affects various aspects of the life of patients.4, 5 According to the annually-updated cancer statistics from the National Cancer Institute, about 1.5 million new cancer cases are diagnosed every year.6 More than half of the cancer cases and 60% of the mortalities occur in less developed countries.7 Meanwhile, breast cancer is the most common cancer among women in both developed and developing countries. In 2012, about 1.67 million new cases of breast cancer were diagnosed.8
Diagnosis of cancer is a major stressful life event, which negatively affects the socio-
psychological condition and the quality of life of patients due to adverse symptoms and outcomes such as anxiety and depression, fear of cancer recurrence and metastasis, fear of future, fatigue, pain, physical limitations, and the possibility of social isolation.9 Cancer is among the disorders that can cause post-traumatic stress disorder (PTSD). This disorder usually occurs after an extremely stressful and emotional accident, which is not considered as an ordinary life event and is often traumatic and unbearable for most people.10, 11
Psychosocial adaptability to cancer can be regarded as a psychosocial process, which occurs when the patients face with disease- and treatment- related changes. Therefore, it is recommended to consider cancer diagnosis as a facilitator of life changes with both negative and positive outcomes instead of considering cancer as a major stress.9 In fact, cancer is a life-threatening situation, which causes suffering and fear of death in affect the
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physical and psychological performance of patients.12
Although cancer diagnosis is associated with the symptoms of PTSD and can bring about the sense of fear, destruction, and lack of control, it can provide an opportunity for growth and compatibility.13 People experience two responses to critical incidents including a negative reaction that is associated with PTSD symptoms and a positive response that is known as PTG.14 The structure of PTG was first introduced by Tedeschi and Calhoun in 1996 and refers to positive psychological changes caused by dealing with the challenging conditions of life and traumatic events. On the other hand, growth does not necessarily mean the end of pain and chaos or a favorable attitude toward crisis, loss, or trauma.15 The PTG is defined as more appreciation of life, improved interpersonal communications and personal strength, changed life priorities, identification of possible new coping options, and spiritual evolution.13
It is nearly two decades that the post-traumatic model developed by Tedeschi and Calhoun in 1996 has been considered as the most comprehensive model with an emphasis on spiritual factors. They beleive that PTG involves change in three areas of perception, knowledge, and skills, which enable individuals to recognize the positive changes in their interpersonal relationships, self-perception, and philosophy of life.15 Feeling stronger, higher level of self-confidence, more experience and confrontation with the challenges of the future are among the perceptual changes in oneself. On the other hand, relationship and cooperation with others, and increased emotional expression and individual emotions are related to interpersonal communications, and change in values and life priorities are among the changes in the dimensions of spirituality and philosophy of life.11 There is a close association between increasing interest in the positive effects of a disaster and positive psychology movement. Seligman et al. in 2005 stated that happiness is dependent on the ability to understand bad conditions as a good condition and sense of happiness to a certain extent.16
Over the past 20 years, there has been significant scientific interest in the evaluation of not only the negative effects of traumatic events, but also the positive changes that occur after dealing with trauma.10 According to the literature, PTG was assessed in patients with cancers, spinal cord damage, brain injury, stroke, cardiovascular events, thyroid diseases, multiple sclerosis, lupus, and acquired immune deficiency syndrome.17, 18 More than 83% of individuals who experienced life- threatening diseases, natural disasters, and accidents
reported at least one positive.14 The PTG was observed in females with breast cancer even five years after the cancer diagnosis.19 Patients with cancer start a journey that begins with diagnosis and is determined by the activation of unknown life schemes, interaction with healthcare professionals, therapeutic regimens, and physical and mental stressors. However, a positive approach to evaluation of the world and people appears along with these distresses.9
Despite the high incidence rate of cancer, the relevant mortality rate is declining due to the development of screening, diagnosis, and treatment modalities. Therefore, many people live with this disease. Formerly, there was a high emphasis on negative dimensions of cancer. On the other hand, there are controversial results regarding PTSD and PTG. Several studies demonstrated the indirect relationship between these variables, whereas other studies determined the simultaneous and independent occurrence of these two variables. In addition, assorted studies indicated no association between them.20 To the best of our knowledge, no study was conducted to simultaneously assess these two variables in patients with breast cancer. With this background in the mind, this study aimed to evaluate the relationship between PTSD and PTG in women with breast cancer referred to the Chemotherapy Ward of Ali Ibn Abi Talib Hospital in Zahedan, Iran, 2017. 2. Methods
This descriptive- analytic, and correlational
study was conducted on patients with breast cancer referred to the Chemotherapy Ward of Ali Ibn Abi Talib Hospital in Zahedan, Iran, 2017.
2.2. Participants and settings
Regarding the limitations of these patients due to surgery, problems caused by chemotherapy, and deterioration and relapse of the disease, the eligible patients were selected through convenience sampling method during 3 months. The patients aged 20 years old and older, whose diseases were diagnosed from 6 month to 5 years ago without metastases, according to the medical record, cognitive impairments, known psychological disorders, and experience of recent streeful life event (except for cancer) were included in this study. On the other hand, the most important items of the exclusion criteria entailed the lack of consent for participation in the study and deteroriation of the disease during the intervention. Finally, 136 eligible
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patients participated in this study and asked to complete the questionnaires. 2.3. Instruments
Data were collected using Post-traumatic Growth Inventory that consists of three parts of demographic characteristics, 21 items on PTG, and 17 items on PTSD. This questionnaire is designed as a self-assessment tool that includes 21 items to estimate PTG. Additionally, the items are scored based on the 6-point Likert-scale from 0 (experiencing no change) to 5 (experiencing significant changes).
Accordingly, the total score ranged from 0 to 105, the low scores demonstrated less growth and vice versa. The original form of this questionnaire consists of five subscales including relating to others, new possibilities, personal strength, spiritual changes, and value of life. It is worth mentioning that the reliability of this tool was confirmed by Tedeschi and Calhoun in 1996 as the Cronbach’s alpha of 0.90.The range of Cronbach’s alpha for each subscale was estimated to be 0.67-0.85. According to the results of a study performed by Tedeschi and Calhoun, the individuals who experienced a psychological trauma achieved higher scores compared to others.21 In Iran, discriminant and convergent validity and reliability (α=0.92) of the questionnaire were approved by Seyed Mahmoudi et al.22 In the current study, the reliability of the tool was calculated as the Cronbach’s alpha of 0.88.
The PTSD Checklist (PCL) is a self-report scale, which is used as a diagnostic support tool for assessing the level of disorder and screening of patients to separate them from normal population and other patients. This checklist contains three dimensions of signs and symptoms of recurrent experience of trauma (five items), emotional numbing (seven items), and avoidance or hyperarousal symptom (five items).
The items were scored based on a 5-point Likert scale from 1 (never) to 5 (very often). The total score ranged from 17 to 85, the low scores were indicative of low perceived stress and vice versa.
Two studies have been carried out into this c