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Doi:10.1016/s0140-6736(08)61078-8Psychological adjustment to chronic disease
Denise de Ridder, Rinie Geenen, Roeline Kuijer, Henriët van Middendorp Lancet 2008; 372: 246–55
This Review discusses physiological, emotional, behavioural, and cognitive aspects of psychological adjustment to
Department of Clinical & Health
chronic illness. Reviewing the reports of the past decade, we identify four innovative and promising themes that are
Psychology, Utrecht University,
relevant for understanding and explaining psychological adjustment. In particular, the emphasis on the reasons why
The Netherlands Research
people fail to achieve a healthy adjustment has shifted to the identiﬁ cation of factors that help patients make that
Institute for Psychology &
adjustment. To promote psychological adjustment, patients should remain as active as is reasonably possible,
Health, Utrecht, Netherlands
acknowledge and express their emotions in a way that allows them to take control of their lives, engage in
self-management, and try to focus on potential positive outcomes of their illness. Patients who can use these strategies
have the best chance of successfully adjusting to the challenges posed by a chronic illness.
relationships),3 the absence of psychological disorders, the Chronic illnesses are disorders that persist for an extended presence of low negative aﬀ ect and high positive aﬀ ect, period and aﬀ ect a person’s ability to function normally. adequate functional (eg, work) status, and the satisfaction Some chronic diseases (eg, rheumatoid arthritis) need and wellbeing in various life domains.4 Several models long-term pharmacological treatment and are often have been proposed on how patients could achieve these [email protected]
characterised by progressive physical disability and pain. outcomes, including: the model of cognitive adaptation, Others (eg, diabetes) can be medically controlled, but only which emphasises illness acceptance and perceptions of at the cost of strict adherence to disease management control over illness;5 the personality model that emphasises regimens. Thus, a chronic illness has the potential to the role of personality factors (such as optimism or induce profound changes in a person’s life, resulting in neuroticism) in adjustment; and the stress and coping negative eﬀ ects on quality of life and wellbeing.1 model that emphasises strategies used by patients to deal After the medical diagnosis of chronic illness, patients with adaptive tasks imposed by disease.6 The authoritative are confronted with new situations that challenge their stress and coping model acknowledges that chronic illness habitual coping strategies. As a result, they must ﬁ nd consists of several challenges, but at the same time, it new ways of coping to adjust to their altered condition.2 highlights—more than other models of adjustment— We use the terms adjustment and psychological processes of appraisal and coping that explain why some adjustment interchangeably to refer to the healthy patients successfully identify and act on opportunities to rebalancing by patients to their new circumstances. Most manage these tasks whereas others might fail to do so. patients eventually reach a state of good psychological More recently, the stress and coping model has been adjustment, but for about 30% of patients, the adjustment extended with the model of self-regulation, which allows phase is prolonged and sometimes unsuccessful.2 patients to deal with illness more proactively.7 Both models At least ﬁ ve key elements of successful adjustment to a show the active role that patients may have in adjusting to chronic illness have been identiﬁ ed: the successful the challenges posed by their condition, and they have performance of adaptive tasks (eg, adjustment to disability, been used to study processes of adjustment in diverse maintained emotional balance, and preservation of healthy chronic conditions including cancer, diabetes, HIV-infec-tion, asthma, and rheumatoid arthritis.8,9 We review prospective (observational) and experimental Search strategy and selection criteria
research in 1996–2005 on four innovative areas in adjustment to chronic illness. We focus on approaches We used the Web of Science (1996–2005) to search reviewed topics. General search terms that explain how patients can successfully adjust and referred to psychological adjustment, including: “adjust*”, “adapt*”, “distress”, “depress*”, review the physiological, emotional, behavioural, and and “anxi*”. Other searches included terms covering chronic disease (“chronic disease”, cognitive aspects of the process. First, we discuss “chronic illness”, or a speciﬁ c disease). For eﬀ ects of blockades of proinﬂ ammatory cytokines, pathophysiological factors focusing on the role of we used “rheumatoid arthritis” or “RA” in the title with one of the drugs (“inﬂ iximab”, cytokines, such as those that reduce activity and aﬀ ect “etanercept”, “adalimumab”, “remicade”, “enbrel”, “humira”); or other words referring to mood, and that have been shown to interfere with blockade with TNFα. For associations between emotion regulation and adjustment to attempts to engage in activities important to patients. As chronic illness, we combined “emotio*” with “control”, “repress*”, “suppress*”, “express*”, such, to deal with the consequences of cytokines and to “non-express*”, or “intens*”, or the terms “alexithymia”, “ambivalence”, or “aﬀ ect intens*”. remain active is of utmost importance for adjustment. For positive moods and self-management, we used “self-management”, “self-care”, “dietary Second, we address the role of dealing with emotions in behavi*”, or “exercise”. For relations between beneﬁ t ﬁ nding or growth and adjustment adjustment processes. For some time, the adaptive role beneﬁ t ﬁ nding, we used “positive emotion”, “beneﬁ t ﬁ nding”, “post-traumatic growth”, or of focusing on emotions has been regarded with “stress-related growth”. Full articles of studies published in English and that included suspicion, but a growing consensus has indicated that adolescents or adults were used. Abstracts and references of all identiﬁ ed articles were also the confrontation of negative emotions associated with examined for importance, relevance, and overlap.
chronic illness could contribute to adjustment. Third, we www.thelancet.com Vol 372 July 19, 2008
examine self-management in adjustment and highlight studies that indicate the adaptive beneﬁ ts of patients’ Panel 1: Eﬀ ects of blockade of proinﬂ ammatory cytokines* on psychological
willingness and ability to engage in self-management. adjustment in patients with rheumatoid arthritis, as shown in relevant studies
Finally, we discuss how chronic illnesses can have Disability in daily activities
positive consequences by showing that a crucial part of Disability scores have been shown to improve after the ﬁ rst week of medication.18–29 This adjustment could entail a process of patients ﬁ nding a improvement was sustained with prolonged drug use (up to 5 years).19 Eﬀ ect size was beneﬁ t from the condition. These ﬁ ndings could explain about 0·6 SD units,20,25 regarded as a moderate change; percentage change varied why people with chronic illnesses, despite the negative physical consequences of their disease, report a quality of life that is notably similar to that of healthy people.
Quality of life
Summary scores of the short form 36, measuring physical functioning, improved.18,20–22,24,25,28,29
The challenge of patients remaining active
Eﬀ ect size was more than 0·5 SD units,20,25 regarded as a moderate change; percentage despite cytokine activity
change was about 40%.22,25 Improvement on the summary score of the short form 36, Infectious and inﬂ ammatory processes can induce a measuring mental wellbeing (which did not diﬀ er greatly from the general population at constellation of non-speciﬁ c symptoms, often called baseline),21 was generally small (about 15%).20–22,24,25,28,29 sickness behaviour, including weakness, malaise, Fatigue and vitality
inability to concentrate, depressed mood, lethargy, anhe- Substantial improvement was seen on the fatigue scale of the Functional Assessment of donia, and anorexia.10 Therefore, in addition to dealing Chronic Illness Therapy questionnaire.29 Change on the vitality scale of the short form 36 with the behavioural, cognitive, and emotional challenges was as large as the change seen on physical functioning scales.18,20 of disease, patients must also cope with these physiologically-induced symptoms to preserve an active *TNFα was blocked with inﬂ iximab (remicade), etanercept (enbrel), or adalimumab (humira). Most studies were double-blinded clinical trials in which the eﬀ ect of conventional treatment with methotrexate only was compared with the eﬀ ect of treatment with methotrexate combined with TNFα blockade.
The psychological eﬀ ects of these pathophysiological processes are mediated by cytokines. Several studies have shown that proinﬂ ammatory cytokines such as tumour The malaise and behavioural inactivation associated necrosis factor α (TNFα) and interferon alfa seem to with illness is generally regarded as adaptive, especially promote the psychological symptoms seen with several during acute infection and inﬂ ammation. By inducing chronic diseases. Proinﬂ ammatory cytokines contribute rest, this response conserves energy and promotes to the vital exhaustion (loss of energy, increased irritability, healing, and thus stimulates adjustment similar to the and feelings of demoralisation) seen with acute myocardial desire for food in response to hunger, pain in response to infarction.11 In diabetes, increased concentrations of injury, and the ﬁ ght-or-ﬂ ight response to threat. However, proinﬂ ammatory cytokines are produced by adipose these adaptive mechanisms can also have adverse tissue, and by monocytes and macrophages seen with consequences in chronic conditions. In diabetes, hunger increasing age, and could contribute to depression and can make adjustment to a healthy diet diﬃ so-called sickness behaviour.12 In cancer, these cytokines pain due to rheumatic disease can inhibit healthy physical contribute to fatigue, memory and concentration activity, and the ﬁ ght-or-ﬂ ight response can endanger problems, depression, and anxiety.13 patients with cardiovascular disease. Thus, symptoms Immunotherapy with cytokines has also been shown to (such as fatigue and pain) that are beneﬁ cial during an promote these symptoms. In uncontrolled prospective acute illness can become obstacles to psychological trials with interferon-alfa infusions, patients frequently adjustment in chronic disease.
report fatigue (70–100%), depressive symptoms (21–58%), Chronic pain has been suggested not only to lead to and depression according to diagnostic criteria (9–45%) pain-avoidance behaviour but also to persistence or even as well as anorexia, pain, cognitive slowing, confusion, overuse of activities, both of which can lead to disability.30 lethargy, mania, inner tension, anxiety, and reduction in Furthermore, patients with other chronic diseases are goal-directed behaviour.14–17 faced with the challenge to pace their activity and ﬁ nd a Evidence suggests that cytokines mediate disease- new balance in their lives. Only a few decades ago, the induced inactivity and distress. In patients with common recommendation given to patients with chronic rheumatoid arthritis who do not respond to conventional inﬂ ammatory diseases such as rheumatoid arthritis was disease-modifying antirheumatic drugs, reduced disease to rest.31 Nowadays, graded exercise tailored to the activity can be achieved by blockade of proinﬂ ammatory patients’ abilities and disease severity is thought to lead cytokines. Immediately after blockade of TNFα, a to improved physical, functional, and emotional substantial improvement of physical functioning, quality outcomes.32,33 Inactivity in response to acute illness is of life, and fatigue can be seen (panel 1). The ﬁ nding that natural and often beneﬁ cial. But one of the challenges proinﬂ ammatory cytokines can promote—and by facing patients with chronic illness is to engage in those blockade reduce—these symptoms shows that physio- activities that can improve functional ability and logical factors are a real obstacle to the psychological emotional status in the face of real cytokine-related adjustment to chronic illness.
www.thelancet.com Vol 372 July 19, 2008
Emotion regulation: to feel or not to feel
occurrence and risk of disease progression, increasing Patients with chronic illness typically have anxiety, evidence has shown that the habitual acknowledgment depression, and other negative emotions.2 How these and expression of emotions can promote good individuals cope with these emotions can aﬀ ect how well they adjust to their illness. Emotion regulation is a term In cross-sectional studies, maladjustment to chronic encompassing several conscious or unconscious styles of illness is commonly related to styles of emotion experiencing, processing, and modulating emotions.34 regulation characterised by avoidance and non-expression. Two main categories of emotion regulation have been Examples include patients having diﬃ distinguished: avoidance and inhibition of emotions, and and describing emotions (alexithymia), being unaware expression and acknowledgment of emotions. Although of emotions (repression), avoiding the expression of the ﬁ rst category—when generally applied—is associated emotions (emotional control, suppression, anti- with maladaptive outcomes such as an increase in disease emotionality), and being ambivalent about expressing emotions.36 Although patients are often advised to face and express emotions, cross-sectional relations between Panel 2: Prospective and experimental studies of associations between emotion
adjustment and the acknowledgment and expression of regulation and adjustment to chronic illness
emotions have been inconsistent.37 However, these cross-sectional ﬁ ndings do not prove that emotion Prospective studies
regulation aﬀ ects adjustment; it is equally possible that the distressing emotions experienced during chronic • Emotional control before diagnosis of breast cancer predicted increased psychological illnesses aﬀ ect emotion regulation.
distress after diagnosis.39 Control did not predict increased distress 15 months later in Prospective studies examining which types of emotion regulation aﬀ ect adjustment show that, at least in the • Emotional processing and aﬀ ect intensity not only predicted positive aﬀ ect scores in North American and western European cultures, the rheumatoid arthritis,41 but also negative aﬀ ect41 and increased distress in patients with regular use of avoidant non-expressive styles of emotion breast cancer and rheumatoid arthritis after 3–15 months40,42 regulation is disadvantageous for psychological • Mood repair and mood clarity predicted reduced pain-related psychological distress in adjustment and survival. In less emotionally expressive rheumatoid arthritis and osteoarthritis41,43 Asian cultures, non-expressive emotion regulation styles • Expression of emotion predicted reduced distress after diagnosis of breast cancer and have proven advantageous, suggesting that the 3 months after diagnosis,39,42 and did not predict distress in rheumatoid arthritis after congruence between one’s general style to handle emotions and the style advocated in one’s cultural system determines whether the emotion regulation style is • Alexithymia and ambivalence over expression of emotions predicted an increase in adaptive or maladaptive.38 Acknowledgment and intense self-reported disease activity in rheumatoid arthritis after 15 months40 experience of emotions are suggested to be beneﬁ cial for • Non-expression of emotions predicted rapid disease progression in HIV after adjustment as long as those emotions are expressed and processed; the mere uncontrolled expression of emotions emotions45 and emotional control46,47 predicted increased mortality in without processing can be maladaptive (panel 2).
cancer, whereas other studies showed no association with survival,48–50 and one study Expression of emotions is often a component of in Japan showed moderate anti-emotionality to predict survival38 psychological interventions in chronically ill patients.65 • Emotional expression resulted in improved self-perceived health status and reduced Emotional disclosure interventions66 have provided the number of medical visits in breast cancer after 3 months,42 and no change in perceived most convincing evidence that expression can improve health in rheumatoid arthritis after 15 months40 psychological and physical adjustment, sometimes even • Emotional expression predicted survival in breast cancer46 on objective markers of disease activity (panel 2). Experimental studies
Beneﬁ cial eﬀ ects have been noted after disclosure (mostly written, but also oral) by participants from varying • Emotional expression in several chronic diseases led to decreased distress, mood cultural backgrounds and socioeconomic status, as well improvement, or reduced intrusions up to several months after the intervention,51–55 as in diverse chronic conditions, including cancer, HIV, or resulted in no change or change in only one minor outcome variable56–61 Physiological and psychological mechanisms have been proposed to explain the negative eﬀ ect of avoidant • Emotional expression in several chronic diseases led to a reduction in health-care use, and non-expressive emotion regulation styles on improved physical functioning, fewer symptoms reported, or reduced self-perceived adjustment. Although denial and non-expression of disease activity up to several months after the intervention,51–54,57,59,60 or resulted in emotions can be a useful initial coping strategy to deal with the stress that accompanies the diagnosis of a • Emotional expression led to improvements in clinical and laboratory observations chronic disease,67 failure to acknowledge and express (eg, pulmonary function in asthma, joint score in rheumatoid arthritis, emotions can leave these emotions unresolved. These CD4+ lymphocyte counts in HIV) up to several months after the intervention,51,58,62,63 unresolved emotions can aﬀ ect patients’ health negatively or resulted in no change53,54,56,59,60,64 by, for example, chronic raised activity of the sympathetic www.thelancet.com Vol 372 July 19, 2008
nervous system.68 The inhibition of emotions can also 15–25% of patients improve their health practices after delay help-seeking behaviour when it hampers symptom diagnosis,77 suggesting that they ﬁ nd disease management recognition and, when help is sought, compromise the diﬃ cult to integrate into their lives. Indeed, many communication with health-care providers. Such patients have a great fear of lifestyle changes78,79 and inhibition can also lead to patients failing to practice report more non-adherence to diet and exercise than to health-protective behaviours and adhere to treatment.67 medication use or check-up appointments and symptom erent mechanisms have been monitoring.79,80 An explanation for the non-use of proposed to explain why acknowledgment and expression self-management might be the large amount of time and of emotions are beneﬁ cial for patients.69 Although the eﬀ ort needed,81 and patients might not always have acknowledgment and experience of negative emotions immediate beneﬁ ts in terms of symptom improvement can be adaptive because they focus attention toward or a sense of improved wellbeing.76 The burden of threats, elicit action, and provide feedback on progress self-management could be the reason why patients who toward important goals,67 repeated reﬂ ection on or show signs of poor psychological adjustment face rumination about negative feelings without expressing particular diﬃ them is not deemed healthy.42,70 Some processing of Many studies on adjustment and self-management emotions is needed before being beneﬁ cial. Patients have highlighted the role of major depression as a risk thinking and talking or writing about emotions will make factor for non-adherence to self-management recom- their experience less intensive and invasive (habituation), mendations, with depressed patients frequently reporting whereas it can also increase insight into why emotions indecisiveness and reduced self-conﬁ dence about self-are experienced and how their eﬀ ect can be reduced management.82 The presence of clinical depression has (cognitive reappraisal). Furthermore, expression of been shown to disrupt adequate self-treatment in emotions can decrease emotional distress and restore diabetes,80,83 COPD,84 and HIV.85 Although depression is psychophysiological balance, and create opportunities thought to precede poor self-management instead of the for social support and enhanced closeness with others, other way around, the cross-sectional design used in beneﬁ t ﬁ nding, and improved self-regulation.35,70 such studies precludes conclusions about the causal link Overall, when confronted with chronic illness it seems between self-management and psychological adjustment. better for patients to generally express than to deny or Symptoms of depression, such as reduced energy or inhibit emotions, as long as this strategy surpasses the motivation, can clearly interfere with self-management, unbridled spouting of emotions and helps to achieve more but the inability to undertake self-management can also insight. Evidence on the role of emotion regulation in lead to feelings of helplessness and hopelessness.86 Major adjustment to chronic illness implies that patients depression and poor self-management can even be acknowledging and dealing with the negative emotions regarded as independent outcomes resulting from surrounding chronic illness is not necessarily bad for cytokines and other pathophysiological mechanisms.87 adjustment. Although styles of emotion regulation are a Clinical forms of anxiety have also been suggested to stable characteristic of a person and can be diﬃ cult to compromise self-management, but this association has change, interventions that aim to teach more eﬀ ective not been studied extensively.83styles to regulate emotions have proven beneﬁ cial for Even when patients do not meet criteria for clinical individuals who consistently use ineﬀ ective emotion diagnosis of depression (or anxiety), they can have some regulation styles in adjusting to their chronic condition.65 form of psychological distress,88 which could be regarded a signal of poor adjustment. Some of the most frequently Self-management: improvement of mood and
reported sources of distress include worries about health behaviour
long-term complications, guilt or anxiety when problems Management of chronic illness is characterised by many in self-management occur, and fear about other potential responsibilities regarding medication use, lifestyle negative eﬀ ects of the disease.89 Like major depression, changes, and behaviour to prevent long-term compli ca- mild forms of distress have been associated with reduced tions—generally referred to as self-management of self-management in cross-sectional studies of diﬀ erent disease.71 Many studies have shown that patients who chronic conditions, including COPD,90 diabetes,91 HIV,72 engage in healthy diet, exercise, or other aspects of and asthma.92 Notably, the few available prospective self-management have physical beneﬁ ts in terms of fewer studies of distress and self-management suggest a symptoms, better functional capability, and fewer diﬀ erent pathway than assumed in studies of depression complications than those who do not in various diseases and self-management, and lend support to the (eg, HIV/AIDS,72 rheumatoid arthritis,73 asthma or assumption that poor self-management could precede chronic obstructive pulmonary disease,74 diabetes,75 and decreased adjustment. For example, a cancer study heart failure76). However, the extent to which self- showed that patients with decreased self-management management can also aﬀ ect psychological adjustment is predicted a reduced quality of life and increased mood much less understood. Studies have shown a low disturbance after 8 months,93 whereas a study of adherence to self-management regimens; only about individuals with rheumatoid arthritis showed that a www.thelancet.com Vol 372 July 19, 2008
such as problem-solving and goal-setting.100 These Panel 3: Positive moods and self-management
self-management skills are recognised and appreciated by many patients, including those from ethnic groups,101 Not only can positive mood beneﬁ t self-management, but adequate self-management can suggesting that they are valuable ingredients of also promote wellbeing. In patients with diabetes who reported increased levels of perceived self-management interventions. However, although good competence and autonomous motivation for self-management, improved life satisfaction95 mood seems to promote engagement in self-management and self-management behaviour were reported, which in turn increased glycaemic control of illness, improvement of moods could prove valuable after 1 year.75 Engagement in self-management could also beneﬁ t psychological adjustment, to self-management interventions since many patients both in the short term and long term, as shown in several prospective studies in cancer. Such report feelings of discomfort about disease, sometimes results indicated that patients with head and neck cancer who took appropriate only after they have been dealing with disease for several self-management measures after surgery were less anxious the next day,96 and women with cancer who exercised at least 90 min per week on 3 or more days reported less fatigue and emotional distress as well as higher functional ability and quality of life than less active women during treatment.97 Similar eﬀ ects of self-management on psychological adjustment have Cognitive processing: beyond negative
been shown in prospective studies of patients with heart failure98 and patients who had had outcomes
Although health-related quality of life of patients with
cardiac surgery.99 Only a few self-management interventions have also examined adjustment; chronic conditions is generally lower than that of healthy although patients increase eﬀ orts in self-management when participating in the intervention, controls,1 this diﬀ erence is less pronounced or even they have mixed ﬁ ndings regarding the eﬀ ect on adjustment. Some studies show that self- absent in aspects of mental health.1,103 Individuals can use management does not necessarily beneﬁ t adjustment,76,98 whereas others report improved various cognitive strategies to counteract the negative quality of life and mood after some time.71,73,93 These ﬁ ndings suggest that patients can learn to eﬀ ect of illness on their wellbeing. Much research has appreciate the need of self-management as a result of participating in interventions, but that addressed Howard Leventhal’s model of illness such beneﬁ ts of improved wellbeing could take some time.
representations,104 showing that patients’ beliefs (eg, about the course and consequences of their illness) can decline in the ability to perform self-management aﬀ ect adjustment in chronic conditions such as diabetes.105 activities predicted the subsequent onset of depressed Only recently, attention has been paid to post-traumatic feelings.94 growth and beneﬁ t ﬁ nding,106–108 as well as response Most relevant studies have examined the association shift.109 between poor adjustment and poor self-management. The experience of dealing with illness is not all However, other studies have investigated the connection negative. Individuals have reported positive outcomes between good adjustment and engagement in from various diseases (eg, breast52,70,110–114 cancer,115,116 self-management practices. These studies are rare, rheumatoid arthritis,117 multiple sclerosis,118 myocardial although their prospective design allows for an infarction,112 HIV/AIDS,119 and ﬁ bromyalgia106), such as interpretation of the direction of the connection. an improved appreciation of life, enhanced sense of Importantly, these studies show evidence of a bidirectional purpose, changes in life priorities, and improved association between wellbeing and adherence to personal relationships. About 60–85% of patients with self-management regimens. Patients who can maintain breast cancer,112,113 83% of HIV-positive women,119 73% of good moods seem to be more willing to engage in lifestyle patients with rheumatoid arthritis,117 and 58% of changes, and those who practice self-management individuals with myocardial infarction112 have reported at behaviours also report improved wellbeing (panel 3).
least one positive change as a result of their illness. With These studies suggest a diﬀ erent connection between multi-item scales used to measure beneﬁ t, patients have self-management and adjustment than has been generally reported a small-to-moderate degree of assumed so far. Research on the association between perceived positive change.70,110,111,113,116,118 Moreover, survivors depression and self-management has been driven by the of breast cancer have reported more positive growth assumption that depression precedes poor self- experiences than matched controls (who reported on a management, but the available cross-sectional studies stressful event in the same period), even though the can neither support nor refute this assumption. survivors have reported either similar120,121 or increased Moreover, the role of mild forms of psychological levels of distress,115 worsened physical functioning,115,120 or discomfort needs more research since such low levels of more negative changes as a result of the experience.121 mood disturbance could impair self-management to the Some patients with chronic illness are more likely to same extent as clinical manifestations of poor adjustment report positive experiences than are other patients. in terms of (major) depression. Perhaps even more Reports of positive changes are correlated with important is the ﬁ nding that good adjustment predicts demographic variables such as young age70,111,116,122,123 and, increased participation in self-management and vice perhaps counter-intuitively, minority status,111,114 but versa. This association could have important implications generally not with sex,116–118,122,123 and inconsistently with for self-management interventions, which vary greatly in socioeconomic status and education.111,113,114,116 Consistent approach (from education to cognitive-behavioural with the theoretical assumption that an event should be treatment)73 but share an emphasis on improving skills intense to provoke growth or beneﬁ t ﬁ nding,107,108 some www.thelancet.com Vol 372 July 19, 2008
cancer studies have suggested that heightened physical stressful, traditional research focusing on the negative threat (ie, poor disease stage or increased physical aspects provides an incomplete picture since many symptoms)111,114 and raised perceived stress113 are related to patients can ﬁ nd a new equilibrium by focusing on the an increased report of positive changes. However, a study exploring the curvilinear association between cancer
stage and post-traumatic growth showed that very high Discussion
levels of threat (stage IV breast cancer) resulted in Psychological adjustment to chronic illness is tremen-
reduced perceived beneﬁ t.123 With respect to time since dously important. An estimated 50% of people have a
diagnosis, ﬁ ndings are inconsistent.111,117,123 Theoretically, a
chronic physical condition, needing some form of positive correlation would be expected because time is medical intervention.136 About 35% of young adults report needed to work through the event to experience at least one chronic condition2 and more chronic illnesses growth.113,118,122 One prospective study70 showed that occur in older adults. While the average age of the post-traumatic growth in patients with breast cancer population increases, so does the occurrence of chronic increased consistently during the ﬁ rst 18 months after diagnosis. Beneﬁ t ﬁ nding and growth have also been related to personality characteristics such as trait Panel 4: Prospective and experimental studies examining relations between beneﬁ t
optimism,113,122 dispositional hope,106,113 and extraversion.122 ﬁ nding or growth and adjustment
Prospective studies examining the relation between Prospective studies
growth or beneﬁ t ﬁ nding and psychological adjustment have shown mixed results (panel 4). Research suggests Beneﬁ t ﬁ nding in survivors with breast cancer (1–5 years after diagnosis)111 and rheumatoid that eﬀ ects could depend on the time of assessment and arthritis and multiple sclerosis (on average 10 years after diagnosis)122 predicted increased length of follow-up. Positive eﬀ ects on adjustment were positive aﬀ ect after 5 years and 1 year, respectively. Two studies in patients recently recorded in samples in which beneﬁ t ﬁ nding was assessed diagnosed with breast cancer (4 months post-diagnosis114 and post-treatment some time after diagnosis111,122 or with an extended completion113) showed no relation with positive aﬀ ect after 3–12 months. follow-up.124 Beneﬁ t ﬁ nding that is early in the adjustment Negative aﬀ ect, depression and mental functioning process could represent a form of avoidance,130 or early Beneﬁ t ﬁ nding in patients with breast cancer (3, 6, and 12 months after diagnosis) predicted beneﬁ t ﬁ nding could be qualitatively diﬀ erent from beneﬁ t decreased negative aﬀ ect and depression after 4–7 years;124 In patients recently diagnosed ﬁ nding later on.114 Research shows that beneﬁ t ﬁ nding with breast cancer (4 months after diagnosis),114 beneﬁ t ﬁ nding predicted increased negative that is induced52 or that is a result of an intervention110 aﬀ ect after 3–9 months and worsened mental functioning after 3 months for women with shortly after diagnosis does lead to positive outcomes, more severe stages of disease (relations were weak or absent for women with less severe including positive eﬀ ects on physical adjustment.
stages). Other studies of breast cancer (1–5 years after diagnosis111 and post-treatment Finding beneﬁ t or growth could be one of the cognitive completion,113 respectively) showed that rheumatoid arthritis117,122 and multiple sclerosis122 strategies used to oﬀ set the negative eﬀ ect of illness and showed no eﬀ ects on negative aﬀ ect,111,122 mental functioning,111 or psychological distress.117 could be viewed as part of a so-called response shift process.109 When diagnosed, individuals may change Disability, physiology, and mortality their internal standards of what constitutes health or In patients with rheumatoid arthritis (average 10–16 years after diagnosis) beneﬁ t ﬁ nding other aspects of quality of life (recalibration), adjust their was related to reduced disability in one study117 but not in another.122 Studies of breast values and priorities (reprioritisation), or redeﬁ ne what cancer did not ﬁ nd relations between beneﬁ t ﬁ nding and self-reported physical they think is important (reconceptualisation) to maintain functioning111,114 or perceived health.113 In HIV-positive men (on average 8 months after an acceptable quality of life in the face of declining bereavement), beneﬁ t ﬁ nding was related to a more favourable immune status (CD4 health.109 Most research has focused on recalibration and T cells) after 2–3 years and decreased AIDS-related mortality after a follow-up of supports the assumption that individuals change their 4–9 years.125 In the only prospective study before 1996, beneﬁ t ﬁ nding in patients with internal standards of aspects of quality of life over time heart attacks (7 weeks after the attack) was related to a reduced likelihood of heart attack or as a result of medical treatment.116,131–133 Evidence has recurrence and morbidity at 8 years of follow-up.126 also shown the occurrence of reconceptualisation132,134 and Experimental studies
• A cognitive-behavioural stress management intervention for recently diagnosed patients with breast cancer led to increased beneﬁ t ﬁ nding at 9-month follow-up.110 At interventions such as cognitive-behavioural therapy. 3-month follow-up, increased beneﬁ t ﬁ nding was related to improved immune status Cognitive-behavioural therapy includes various strate- (lymphocyte proliferation)127 and reduced concentration of testosterone128 and serum gies that promote a realistic but optimistic attitude to cholesterol129 immediately after intervention illness, but few attempts have incorporated elements of • Beneﬁ t ﬁ nding that is induced experimentally (ie, patients writing about positive response shift or beneﬁ t ﬁ nding into the approach. thoughts and feelings regarding the experience of having breast cancer) reduced Encourage ment for patients to identify advantages after medical visits for cancer-related morbidities at 3 months’ follow-up in patients recently the devel opment of illness or to shift from a state of diagnosed with breast cancer.52 Beneﬁ t ﬁ nding reduced psychological distress in compromised function to improved function could women with high cancer-related avoidance. No eﬀ ects were seen on perceived quality prove to be valuable ingredients of cognitive behavioural therapy.8 Although chronic illnesses are undoubtedly www.thelancet.com Vol 372 July 19, 2008
illnesses.137 Moreover, the rapid developments in medical Conﬂ ict of interest statement
knowledge have resulted in a growing number of chronic We declare that we have no conﬂ ict of interest.
diseases that previously were considered immediately References
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