Article
Reference
Distress and body image disturbances in women with breast cancer in the immediate postsurgical period: The influence of attachment
insecurity
FAVEZ, Nicolas, et al.
Abstract
The aim of this study was to assess, in the immediate postsurgical period, the influence of attachment avoidance and anxiety on distress and body image disturbances in women facing breast cancer. Seventyfive women participated in the study 3 weeks after surgery.
Questionnaires were used to assess study variables. To predict distress and body image disturbances, we controlled for several variables known to influence adjustment to the stress of breast cancer. The results of hierarchical regression analyses show that attachment explains the outcomes above and beyond other influential variables. Insecurely attached women are especially vulnerable to the stress of the disease.
FAVEZ, Nicolas, et al. Distress and body image disturbances in women with breast cancer in the immediate postsurgical period: The influence of attachment insecurity. Journal of Health Psychology, 2016, vol. 21, no. 12, p. 2994-3003
PMID : 26092841
DOI : 10.1177/1359105315589802
Available at:
http://archive-ouverte.unige.ch/unige:86143
Disclaimer: layout of this document may differ from the published version.
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Distress and body image disturbances in women with breast cancer in the immediate postsurgical period: The influence of attachment insecurity
Nicolas Favez1, 2, Sarah Cairo Notari1, Linda Charvoz1, Luca Notari1, Paolo Ghisletta1, 2, Bénédicte Panes Ruedin3 and Jean-François Delaloye3
1 Faculty of Psychology and Educational Sciences, University of Geneva, Switzerland
2 Distance Learning University, Switzerland
3 Unit of Senology, CHUV, University of Lausanne, Switzerland
Funding
This research is part of the National Center of Competence in Research LIVES - Overcoming Vulnerability: Life Course Perspectives, supported by the Swiss National Science Foundation.
Corresponding author
Nicolas Favez, Faculty of Psychology and Educational Sciences, University of Geneva, Boulevard du Pont d’Arve 40, 1211 Geneva 4, Switzerland. E-mail:
nicolas.favez@unige.ch. Tél: +41 22 3799403. Fax: +41 22 3790639.
Abstract
The aim of this study was to assess, in the immediate postsurgical period, the influence of attachment avoidance and anxiety on distress and body image disturbances in women facing breast cancer. Seventy-five women participated in the study 3 weeks after
surgery. Questionnaires were used to assess study variables. To predict distress and body image disturbances, we controlled for several variables known to influence adjustment to the stress of breast cancer. The results of hierarchical regression analyses show that attachment explains the outcomes above and beyond other influential
variables. Insecurely attached women are especially vulnerable to the stress of the disease.
Keywords
Breast cancer, immediate postsurgical period, attachment, distress, body image
Distress and body image disturbances in women with breast cancer in the immediate postsurgical period: The influence of attachment insecurity
Introduction
Psychological distress is one of the outcomes most often mentioned by breast cancer patients (Ando et al., 2011; Goldschmidt Mertz et al., 2012; Hegel et al., 2006). While distress is considered a transient state and a normative reaction to a highly stressful event, the inability to cope with distress at the beginning of treatment may be predictive of long-term depression and anxiety, which can develop as disease in their own right, independently of the evolution of the cancer (Bloom et al., 2004; Burgess et al., 2005;
Shimozuma et al., 1999). Another outcome, directly related to treatment, is related to body image. Most women report concerns about body image, especially after
mastectomy or chemotherapy, in the first weeks after surgery (Fobair et al., 2006;
Helms et al., 2008). Studies have shown links between dissatisfaction with postsurgical body image and the development of depressive symptoms in the following months (Härtl et al., 2003; Petronis et al., 2003).
The literature reports important individual variability among women in the ability to overcome the stress of breast cancer (Mancini et al., 2011). Several sociological and psychological variables have been reported to explain increased vulnerability to
negative outcomes: lack of a social network (Nordin et al., 2001), being in a relationship
(married women report more social support to buffer disease-related distress, but also show more distress related to body image after surgery; Fobair et al., 2006; Helms et al., 2008), reluctance to request support or inability to perceive the support provided (Arora et al., 2007), age (younger women report more negative body image and distress after surgery; Avis et al., 2004; Kornblith et al., 2007), and low financial resources (Uchino, 2004). Interestingly, although studies showed the influence of sociological and
psychological variables on the adjustment to the situation, evidence of the impact of cancer-related variables is weaker and findings are more controversial (Coyne et al., 2004; Reich et al., 2008). The literature thus suggests that distress is influenced more by individual features than by characteristics of the disease. As a consequence, identifying personality variables relevant to the adjustment to the stress of breast cancer in the immediate postsurgical period is crucial to screen for women more at risk of developing maladaptive psychological functioning.
In this regard, attachment theory provides an ideal framework, as it allows an understanding of the psychological processes related to differences in emotion
regulation among individuals when facing danger (Mikulincer and Shaver, 2007, 2008).
First developed to explain the emotional bond between infants and their caregivers (who provide protection against danger; Bowlby, 1969), attachment theory has been
generalized to adulthood, romantic partners becoming prominent sources of protection and reassurance (Hazan and Shaver, 1987). According to the theory, individuals build
cognitive models derived from their interpersonal attachment experiences, that is, from the extent to which their caregivers (and later, their partners) were responsive when they requested protection; these models then serve as templates for individual emotional regulation. Two dimensions have been described as underlying attachment models:
avoidance and anxiety. Avoidance refers to the tendency to repress emotional needs as a consequence of a history of attachment needs being rejected by the caregivers. Anxiety refers to the tendency to feel uncertainty and helplessness as a consequence of a history of unpredictability in the responses of the caregivers (Bartholomew and Horowitz, 1991).
People low on avoidance and anxiety dimensions have built a so-called secure model of the world and of the Self: they trust others, who were responsive to their needs, and they have a sense of self-worth, as the others paid attention to them. The relationship with their caregivers was an optimal context in which to learn about the regulation of negative emotions. In adulthood, a secure model is a “relationship-oriented inner resource” that helps individuals to cope with life adversities (Mikulincer and Florian, 1998). People who are high on avoidance and anxiety dimensions, on the other hand, have built insecure models. They tend to implement “secondary” attachment strategies as a defense against the negative emotions associated with activation of attachment needs (Shaver and Mikulincer, 2002). Avoidant individuals tend to use a strategy of “deactivation” of the attachment system, consisting of an attempt to block
emotional states associated with threat-related thoughts. These thoughts are likely to activate attachment-related needs that in themselves elicit negative emotions.
Consequently, avoidant individuals tend to see the expression of needs as a
manifestation of weakness and often have a high desire for self-reliance. They tend to not notice their own emotional reactions and so do not report distress when facing an unpleasant event. Anxious individuals, in contrast, use a strategy of “hyperactivation”
of the attachment system. They have low self-esteem; as a result, they overemphasize their helplessness and inability to cope with the threatening situation to “force” the social environment to provide protection. Attachment anxiety has been specifically related to higher dissatisfaction with body image, which is understood as a higher preoccupation with socially relevant cues such as body appearance, while avoidance of closeness may make avoidant people less likely to attend to their appearance (Cash et al., 2004; McKinley and Randa, 2005). Both avoidance and anxiety are related to higher levels of distress when individuals face an aversive event (Maunder et al., 2006;
Mikulincer and Shaver, 2008). Even when avoidant people report a low level of distress, physiological measures show a high level of activation (decreased heart variability, increased skin conductance), which indicates dissociation between felt distress (as reported by the people themselves) and physiological reactivity (Diamond et al., 2006).
To date, only a few studies have investigated the link between attachment and adjustment to the stress of cancer. One study dedicated to chronic disease included breast cancer patients (Schmidt et al., 2002). According to its results, attachment insecurity is related to lower psychological adaptation: anxiety is predictive of more negativity and implementation of multiple but uncoordinated coping efforts. In contrast, avoidance is linked to a more passive reaction. Studies on other types of cancer (e.g.
lung cancer) have shown that avoidance and anxiety are both linked to depressive symptoms (Kim and Carver, 2007; Rodin et al., 2007).
Following these results, our aim was to use attachment theory to understand psychological reactions in breast cancer patients in the immediate period after surgery.
As attachment models are mainly implemented in romantic relationships in adulthood, we assessed romantic attachment tendencies. In accordance with the literature in this domain, we hypothesized that the more women report attachment anxiety tendencies, the more they will report dissatisfaction with body image and psychological distress in the immediate postsurgical period. Likewise, we hypothesized that the more women report attachment avoidance tendencies, the less they will report psychological distress and dissatisfaction with body image. As attachment is related to personality features, we expected avoidance and anxiety to be linked to distress and body image over and above other variables of influence reported in the literature, such as demographic features, disease and treatment characteristics, and social support.
Materials and Methods
Sample
One hundred twenty-one women with breast cancer were contacted at the Breast Centre of the University Hospital of xxxx, xxxx. Participants had to be able to speak and read French. The exclusion criterion regarding the illness was having metastatic cancer.
Seventy-five women agreed to participate, a 62% acceptance rate. Among the reasons for refusal in the other 46 women were no desire to be part of research (31%), lots of stress and lack of energy (27%), no desire to talk about these difficult moments (22%), and various other reasons (20%).
The mean age of the women was 51.9 years (SD = 11.9), with a range of 31-77.
Fifty-eight women were in a relationship (30 married), while 17 were single. The socioeconomic levels were as follows (Hollingshead Two-Factor Index of Social Position): lower (10 women), lower-middle (11), middle (17), upper-middle (17), and upper (20). The cancer stages were 0 (11 women), I (34), II (21), and III (9). The
women underwent the following surgeries: mastectomy (33 women), tumorectomy (47), curettage (22), and sentinel node procedure (39). For 10 women, neoadjuvant treatment preceded surgery (chemotherapy or hormonal therapy). Time between diagnosis and surgery was 1.4 months on average (SD = 2.1), with a range of 0-13. Thirteen women took antidepressants.
Preliminary checks showed that women who underwent preliminary neoadjuvant treatment had a longer time between diagnosis and surgery than the other women (5.3 months versus 0.8 months on average), a difference that was significant t(9.07) = 4.00, p
< .01. There was also a difference in the stage of the illness: 10% of the women who underwent preliminary neoadjuvant treatment had stage I cancer (versus 49.2% of women without this treatment), 60% stage II (versus 23.1%), and 30% stage III (versus 9.2%).
Procedure
Women were asked to participate in the research by their referent nurse at the
presurgery consultation at the Breast Centre; documents on the research were provided and signed consent forms obtained. Women who agreed to participate were given a set of questionnaires at the first postsurgical consultation, with the instruction to bring them completed to the next meeting with the nurse. It was not possible to strictly standardize the time intervals between surgery and participation in the study, mainly because of practical constraints. On average, the interval was 3 weeks (range 2–5 weeks).
Participants received compensation of xxxx for their participation.
This procedure and its protocol received approval from the Ethical Committee of the xxxx, xxxx, where the University Hospital is located.
Self-reported questionnaires
The Revised Experiences in Close Relationships questionnaire (ECR-R; Fraley et al., 2000) was used to assess romantic attachment. This instrument consists of 36 items that assess on 7-point Likert scales the two dimensions of anxiety (fear of rejection and abandonment; e.g. “I'm afraid that I will lose my partner's love”) and avoidance (discomfort with closeness and dependence on others; e.g. “I find it difficult to allow myself to depend on romantic partners”). A total score was obtained for each dimension by computing the mean of the 18 items related to avoidance ( = .89) and to anxiety (
= .87).
The Brief Symptom Inventory (BSI-18; Derogatis, 2001) was used as an index of psychological distress. Eighteen items assess symptoms on 5-point Likert scales along three dimensions: somatization, depression, and anxiety (six items per dimension). A total score of psychological distress, the Global Severity Index (GSI), is computed as the sum of the 18 items ( = .91).
The Body Image Scale (BIS; Hopwood et al., 2001) is a questionnaire specifically designed to assess perceived negative body image modification in cancer patients. Ten items are assessed on 4-point Likert scales. A total score was computed by summing the scores of the 10 questions ( = .94). The higher the score, the more negative the body image.
The Social Support Questionnaire Short Form (SSQSF; Sarason et al., 1987) was used to assess satisfaction with social support. This questionnaire contains six questions about social support in diverse domains; women were asked to rate their satisfaction with the support received in each domain on 6-point Likert scales. A total score of satisfaction was computed by calculating the mean of the seven questions ( = .84). The higher the score, the more women are satisfied with social support.
A questionnaire specifically designed for the study was used to collect the demographic variables, medical data, and information about treatment.
Results
Descriptive statistics and preliminary analysis
The mean for attachment anxiety was 2.9 (SD = 1.0, range 1.0-5.8), slightly higher than that for attachment avoidance, which was 2.5 (SD = 1.0, range 1.0-4.8). The mean for the GSI was 8.5 (SD = 9.0, range 0-34) and the mean for the Body Image Scale was 9.8 (SD = 8.3, range 0-29). The mean for social support was 5.6 (SD = 0.6, range 3.4-6.0).
Correlation analysis showed that attachment avoidance and anxiety were both positively linked with the GSI (r = .25, p < .05 and r = .47, p < .001, respectively) and negative body image (r = .35, p < .01 and r = .45, p < .001, respectively). In all cases, the higher the insecurity of attachment, the worse the outcomes.
Control variables as predictors of outcomes
The impact of several control variables on the outcomes was first tested: demographic characteristics (age, being in a relationship versus being single, marital status,
socioeconomic level), cancer stage (0 to IV), cancer treatment (type of surgery, neoadjuvant treatment), and social support. Regression analyses showed that the only variables predictive of global distress were marital status (β = -.23, p < .05),
neoadjuvant treatment (β = .23, p < .05), and social support (β = -.22, p < .05). For negative body image, significant predictors were mastectomy (β =.34, p < .01), age (β = -.23, p < .05), and social support (β = -.36, p < .01).
Attachment as a predictor of outcomes
Using hierarchical regression analyses, we then tested the extent to which the two attachment dimensions were predictive of outcomes over and above the significant control variables (see Table 1).
- Insert Table 1 about here -
For each model, demographic variables were entered first. As a second step, we added cancer treatment variables. As a third step, we added social support and as a fourth step, we added attachment avoidance and anxiety. We also tested for interactions between attachment and other predictors, which were not significant, showing no moderation effects (the results of this last step are thus not provided in Table 1). The
final number of predictors entered in each model was acceptable with respect to the sample size (Pedhazur, 1997).Residual analyses revealed no outliers, homoskedasticity, and normality of residuals. Predictors were not multicollinear.
Global psychological distress was first predicted by marital status; when women were married, they reported less distress. Then, as a second step, while marital status remained significant, neoadjuvant treatment was added as a positive predictor: women who had such treatment reported more distress than did those who did not have
neoadjuvant treatment. Entered as a third step, social support was a significant
predictor: the more women were satisfied with the support they received, the less they reported distress. Finally, entered in a final step, attachment anxiety was a strong positive predictor of psychological distress, along with neoadjuvant treatment, while marital status and social support were no longer significant. The final model explained 32% of the variance.
Body image was first negatively predicted by age; the older women were, the less they reported negative body image. Then, as a second step, while age remained
significant, mastectomy was added as a positive predictor: women who underwent this type of surgery reported a more negative image than did those who did not have a mastectomy. Entered as a third step, social support was a significant negative predictor:
the more women were satisfied with social support, the less they reported negative body image. Finally, entered in a final step, attachment avoidance was a positive predictor of
negative body image; age, mastectomy, and social support were still significant. The final model explained 42% of the variance.
Discussion
Identifying personality variables that influence reaction to the stress of breast cancer in the immediate postsurgical period is of paramount importance to prevent the possible occurrence of comorbid psychological disturbances in the long run. Attachment constitutes a suitable theoretical framework to this aim, as on the one hand it specifies the psychological processes involved in facing emotional challenges, and on the other it connects stress adjustment strategies to individual differences. Our study shows that several variables are predictive of global distress and negative body image 3 weeks after surgery, attachment tendencies being significant predictors once the influence of the other variables has been taken into account.
Entered first in hierarchical regression analyses, several demographic variables were predictive of outcomes. Being married is a buffering factor, as married women report significantly less distress than single women do. This finding is consistent with the report of the importance of the couple relationship when a woman faces breast cancer (Kayser and Scott, 2008). However, of note is that being in a relationship is not in itself linked to distress in our sample: it is the specific fact of being married that is predictive of lower distress. This effect may be due to a lesser fear of abandonment in married women when they have to face a disease that is likely to hamper their intimate
relations with their partner (Uchino, 2000). On the other hand, being married is not related to a more negative body image, contrary to what has been reported in other studies (e.g. Helms et al., 2008). Another demographic variable related to outcomes is age, which is negatively related to negative body image; this finding is consistent with that in other studies showing that younger women are more concerned with their physical appearance than are older women (Schover, 1994; Tiggemann, 2004).
Variables directly related to treatment, entered in a second step, were also
predictive of outcomes. First, neoadjuvant treatment is associated with greater distress:
this may occur because this preliminary treatment may be indicative of a more
dangerous and life-threatening disease, as it was associated with a more advanced stage of cancer. As we have seen, the proportion of women with stage II and III cancer was indeed greater in those who had neoadjuvant treatment than in those who did not have this treatment. However, the status of the cancer itself, in terms of stages, is not related to distress. This result is surprising at first glance, as a more advanced or more
aggressive cancer, implying a worse prognosis, might be expected to be associated with greater distress. Other factors related to neoadjuvant treatment may thus explain
increased distress: there is, for example, a longer delay between the diagnosis and the surgery, with a period of uncertainty for women about the type of surgery to follow, which depends on the success of the neoadjuvant treatment. Second, mastectomy was predictive of negative body image, while other types of surgery were not. Although
there is no consensus in the literature about the impact of type of surgery (Avis et al., 2004; Goldberg et al., 1992), our data show that this operation, which has the most visible effect, is logically related to negative body image. Surprisingly, neoadjuvant treatment was not linked with negative body image, whereas its side effects (in
particular hair loss) could be expected to have a negative impact. As this treatment was given prior to surgery, by the time we assessed body image modification, the
aftereffects of the treatment had diminished or disappeared, which may explain why it was not predictive of negative body image.
Social support, entered as a third step in the analyses, proved to have a substantial effect, particularly on body image: women who are satisfied with the support they receive report less negative body image. This result is consistent with the widely documented effect of social support in breast cancer, in particular the perception that women must be emotionally supported by significant others who will accept them whatever the consequences of the disease (Leung et al., 2014).
Overall, our results are thus consistent with what has been described in the literature: demographic features, disease- and treatment-related variables, and social support already have an impact on distress and negative body image in the immediate postsurgical period.
In accordance with our hypotheses, entering romantic attachment dimensions as an additional set of predictors allowed us to explain a substantial amount of additional
variance for both outcomes. We expected avoidant individuals to use deactivating strategies and consequently to downplay distress and inconvenient outcomes due to the disease. On the other hand, we expected anxious individuals to use hyperactivating strategies and consequently to increase their reported outcomes. Our results show that avoidance, counter to our hypothesis, is related to an increase in negative outcomes, specifically regarding body image. This is in disagreement with the theory of avoidance and with previous studies linking attachment and body image in domains other than cancer, but in line with studies showing that avoidant defenses, or deactivating
strategies, can be sufficient for dealing with minor stressors—i.e. daily hassles—but can collapse when an individual is faced with severe stressors (Mikulincer and Shaver, 2007). The elevated report of negative outcomes felt by avoidant women in our sample might thus be the consequence of an “emotional breakthrough” and the unsuccessful attempt to regulate emotions via a deactivating strategy. Moreover, as avoidance is theoretically related to hypercontrol, this may explain why body image is the outcome of most concern, as the body will, so to speak, betray the fact that the woman had to face a disease. Anxiety was related to global distress in a mainly positive way; this finding is consistent with the theory and with our hypothesis, showing that anxiously attached individuals tend to report especially elevated distress when facing this negative event.
Our results clearly show the contribution of romantic attachment dimensions to psychological outcomes in the postsurgical period, over and above variables related to the individual’s status (demographic variables), to the disease itself and its treatment (neoadjuvant treatment, mastectomy), and to satisfaction with social support; it thus seems clear that personality features already play a role in the adjustment to the stress of breast cancer in the immediate postsurgical period. These results have direct clinical implications. First, they confirm that there is individual variability in the ability to cope with the stress of the disease. This must be taken into account, as the more distressed a woman is in the period immediately following surgery, the less positive the long-term outcomes (Burgess et al., 2005; Härtl et al., 2003; Petronis et al., 2003; Shimozuma et al., 1999). Women with avoidant or anxious attachment tendencies should thus be all the more supported in this period; questionnaires about romantic attachment tendencies could be used as part of the regular follow-up to screen for women at risk and to offer them (and their partner if they are in a committed relationship) support that is
specifically centered on relational needs. Second, these results imply that a program aiming to improve coping skills in women facing breast cancer should consider these individual differences in order to implement tailor-made interventions, as it has been shown in other domains (psychotherapy, dental surgery) that an intervention that aims to reduce stress and its consequences is all the more efficient if it matches the
personality of the patient and his or her way of regulating emotion; further, neglecting
these variables may result in increased distress felt by the patients (Auerbach et al., 1976).
The study has several limitations. First, our sample is small, and so the results need to be confirmed in a larger sample. In particular, this would allow testing of more comprehensive models, including other possible variables of influence. Second,
attachment models could be assessed in more detail to identify more precisely which processes explain the links between attachment dimensions and outcomes (an interview procedure would be warranted). This would allow researchers and practitioners to overcome the limitation of the ECR-R questionnaire, which is to a certain extent relationship specific. Although we asked single women (17 of 75) to complete the questionnaire in reference to previous romantic relationships, we cannot rule out the fact that this questionnaire did not have the same meaning for them as it did for women who were engaged in a relationship at that time (however, it is of note that being single was not related to different outcomes in our study). Third, breast reconstruction was not taken into account, as it is usually not proposed immediately after surgery in the xxxx Hospital where the study was conducted. Reconstruction will, of course, affect body image (but body image disturbance is one of the variables in the reconstruction decision). Fourth, information on the details of treatment for women who underwent neoadjuvant treatment was missing; this information would have allowed us to better understand why it was not linked to negative body image. Fifth, our study was focused
on one point in time only, on average 3 weeks after surgery. For the majority of women in our sample, further treatments will follow in the next 12 months (hormone treatment for 80% of the women, but also chemotherapy for 10% and radiotherapy for 5%) and anticipation of these treatments may cause anticipatory distress. It will be thus necessary to longitudinally assess the evolution of distress and negative body image in order to check the extent to which attachment explains outcomes across the illness trajectory.
Finally, studies on adjustment to the stress of breast cancer should take into account not only the relational status of the woman, but also the effective relationship she has with her partner. From this point of view, attachment theory is also the ideal framework to build a bridge between the study of individual processes of adjustment and their relational counterparts in effective relations. Several paths of future research linking attachment and breast cancer are thus opened; the results presented in this article are a first step in this direction.
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Declaration of Conflicting Interests
The authors have no conflicting interests to report.
Table 1. Demographics, treatment, social support, and attachment as predictors of outcomes (N = 75)
Outcome
Predictor Global Severity Index
(BSI)
Negative Body Image (BIS)
Demographic variables
Marital status -.23* -
Age - -.27*
ΔR2 .05* .07*
Adding cancer treatment
Marital status -.23* -
Age - -.24*
Neoadjuvant treatment .23* -
Mastectomy - .29*
ΔR2 (Total R2) .06* (.11) .08* (.15) Adding social support
Marital status -.22* -
Age - -.24*
Neoadjuvant treatment .23* -
Mastectomy - .32**
Social support -.21* -.39***
ΔR2 (Total R2) .04° (.15) .15*** (.30) Adding attachment
Marital status -.12 -
Age - -.24*
Neoadjuvant treatment .29** -
Mastectomy - .33**
Social support -.07 -.24*
Anxiety .45*** .16
Avoidance .00 .25*
ΔR2 (Total R2) .17*** (.32) .12** (.42) Final model F(5, 69) = 6.52*** F(5, 68) = 9.71***
Dashes represent variables not entered in the model. BSI, Brief Symptom Inventory; BIS, Body Image Scale. °p < .10. *p < .05. **p < .01. ***p < .001.
