Affective differentiation in breast cancer patients.

Abstract

Fifty-three breast cancer patients completed an Internet-based diary measuring daily negative affect and positive affect and daily negative and positive events for seven consecutive evenings shortly after surgery. The authors used Hierarchical Linear Modeling (Raudenbush and Bryk in Hierarchical linear models: applications and data analysis methods. Sage, Thousand Oaks, CA, 2002) to examine moderators of affective differentiation, or the daily relationship between the patients' negative affect and positive affect. Strong affective differentiation is characterized by the relative independence of negative and positive affect. There were no significant Level 1 (within-subject) moderators of affective differentiation. However, at Level 2 (between-subject), as predicted, increased age was associated with stronger affective differentiation, as was greater use of planning to cope with breast cancer. Also as predicted, increased anxiety and greater use of behavioral disengagement and denial coping were associated with weaker affective differentiation. The results suggest the value of the affective differentiation construct, and a daily diary methodology, for research on the daily lives of breast cancer patients.

Full text

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Affective differentiation in breast cancer patients
Kimberly B. Dasch•Lawrence H. Cohen•
Amber Belcher•Jean-Philippe Laurenceau•
Jeff Kendall•Scott Siegel•Brendt Parrish•
Elana Graber
Received: November 18, 2009/Accepted: June 11, 2010/Published online: June 29, 2010
? Springer Science+Business Media, LLC 2010
Abstract
Internet-based diary measuring daily negative affect and
positive affect and daily negative and positive events for
seven consecutive evenings shortly after surgery. The au-
thors used Hierarchical Linear Modeling (Raudenbush and
Bryk in Hierarchical linear models: applications and data
analysis methods. Sage, Thousand Oaks, CA, 2002) to
examine moderators of affective differentiation, or the
daily relationship between the patients’ negative affect and
positive affect. Strong affective differentiation is charac-
terized by the relative independence of negative and
positive affect. There were no significant Level 1 (within-
subject) moderators of affective differentiation. However,
at Level 2 (between-subject), as predicted, increased age
was associated with stronger affective differentiation, as
was greater use of planning to cope with breast cancer.
Also as predicted, increased anxiety and greater use of
behavioral disengagement and denial coping were associ-
ated with weaker affective differentiation. The results
suggest the value of the affective differentiation construct,
and a daily diary methodology, for research on the daily
lives of breast cancer patients.
Fifty-three breast cancer patients completed an
Keywords
Diary research
Breast cancer ? Affective differentiation ?
Introduction
Breast cancer is the most frequently diagnosed cancer in
women and is responsible for the second largest number of
cancer-related deaths in women (American Cancer Society
2009). Diagnosis and treatment for breast cancer are sig-
nificant life stressors for women affected by the disease,
often resulting in psychological distress (e.g., Hinnen et al.
2008). Many studies have evaluated predictors of the
psychological functioning of breast cancer patients,
including, for example, demographic variables, pre-cancer
psychiatric diagnosis, recent life events, and perceived
social support (Green et al. 2000).
Few studies, however, have examined the daily psy-
chological experiences of breast cancer patients, experi-
ences that are best studied with a daily assessment (diary)
methodology. Compared to a typical cross-sectional
methodology that relies on relatively long-term retrospec-
tive reports, a daily diary methodology can increase the
reliability and validity of self-reports, because in the latter
methodology, there is a shorter lag between the experience
and reporting of affect and life experiences (Bolger et al.
2003). At present, we are aware of only one published
study with breast cancer patients that used a daily diary
methodology (Badr et al. 2006). Badr et al. studied 23
breast cancer survivors several years post-treatment and
found that greater daily fatigue and pain were associated
with greater daily negative mood.
Affective differentiation
One way to study daily experiences is to evaluate the daily
relationship between positive affect and negative affect,
that is, the extent to which they operate independently or in
a dependent, inverse manner. The literature on the rela-
K. B. Dasch ? L. H. Cohen (&) ? A. Belcher ?
J.-P. Laurenceau ? B. Parrish ? E. Graber
Department of Psychology, University of Delaware, Newark,
DE 19716, USA
e-mail: lcohen@udel.edu
J. Kendall ? S. Siegel
Helen F. Graham Cancer Center, Newark, DE, USA
123
J Behav Med (2010) 33:441–453
DOI 10.1007/s10865-010-9274-8

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tionship between positive affect and negative affect is
extremely complex. Specifically, some studies suggest that
they operate independently, whereas other studies suggest
that they are inversely related (e.g., Reich et al. 2003). The
Dynamic Model of Affect (Reich et al. 2003) represents a
unique perspective on the relationship between positive
and negative affect because it is concerned with the per-
sonal and environmental determinants of the two affects’
interrelationship. In other words, the model does not ask
whether positive and negative affect are related, but instead
asks under what conditions are they related, and for which
individuals.
The Dynamic Model of Affect proposes that, in general,
the relative independence (separation) of positive and
negative affect is adaptive: When people keep separate
accounts of their positive and negative affect, they main-
tain maximum information about their affective experi-
ence, because the presence of one emotion is not affected
by the presence or absence of another emotion. Ordinarily,
people benefit from having independent experiences of
negative and positive affect, resulting in a low correlation
between the two.
However, the cognitive load is greater when affective
differentiation is greater because there is more information
to process (i.e., separate experiences of positive affect and
negative affect). During times of stress, the attentional
resources become focused on the more immediate
demands, which provide competition for the cognitive
resources needed for affective differentiation. Therefore,
during times of stress, the Dynamic Model of Affect pre-
dicts that positive affect and negative affect will collapse
into a single bipolar dimension, resulting in an inverse
correlation between the two, and consequently weaker
affective differentiation (Reich et al. 2003). Further, the
ability to achieve affective differentiation is likely linked to
emotion regulation skills because a number of aspects of
emotion regulation seem relevant, such as the ability to
identify, understand, process, and express emotions (Davis
et al. 2004).
The major goal of the current study was to apply the
Dynamic Model of Affect to research on the daily emo-
tional experiences of breast cancer patients. Assuming that
it is adaptive to have relative independent experiences of
positive and negative affect, an understanding of the factors
that promote this independence in breast cancer patients
might contribute to the design of relevant prevention and
intervention programs (Reich et al. 2003). Specifically,
most psychological interventions focus on alleviation of
negative affect, sometimes at the expense of attention to
positive affect (Reich et al. 2003). Even interventions that
have emanated from the recent popularity of positive
psychology, and that are designed to promote positive
affect, rarely address how negative and positive affect
operate together in an integrative model (Reich et al.
2003).
To date, most of the research on affective differentiation
has been conducted by Zautra et al. with chronic pain pa-
tients, specifically those with rheumatoid arthritis and
fibromyalgia, and has relied on repeated assessments over
several weeks. In general, this research has supported the
model described above and suggests the adaptive value of
affective differentiation.
Within-subject moderators of affective differentiation
Some studies have examined within-subject (situational)
moderators of affective differentiation. For example, dur-
ing times of high stress, as well as high pain, the rela-
tionship between negative affect and positive affect
becomes stronger compared to times of low stress and low
pain (e.g., Potter et al. 2000). The presence of positive
affect weakens the relationship between pain and negative
affect (e.g., Zautra et al. 2001). In addition, research on
adults with chronic pain has shown that affective differ-
entiation is weaker on days associated with a greater
number of negative events, and is stronger on days asso-
ciated with a greater number of positive events (Zautra
et al. 2005a).
Between-subject moderators of affective differentiation
Several between-subject moderators of affective differen-
tiation have also been studied. This research suggests that
stronger affective differentiation is associated with adap-
tive individual difference variables, specifically higher
mood clarity (Zautra et al. 2001), and higher levels of
dispositional resilience and lower levels of neuroticism and
perceived stress (Ong and Bergeman 2004).
Although affective differentiation has been studied in a
few medical populations, primarily with chronic pain, to
our knowledge, it has not been examined in a cancer
population. In addition to the variables previously cited
(e.g., neuroticism and perceived stress), there are other
potential moderators of affective differentiation that seem
particularly relevant to breast cancer patients. We discuss
these potential moderators in the sections below.
Age and breast cancer
Numerous studies have documented that, compared to
older breast cancer patients, younger patients have a more
difficult time adjusting to their illness and treatment (e.g.,
Stanton et al. 2002; Turner et al. 2005). One reason why
younger patients experience more distress is that some
concerns are specific to them, for example, feeling different
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than other woman their age and worrying that they will not
see their children grow up (Dunn and Steginga 2000). With
this in mind, we anticipated that in the current study,
affective differentiation would be positively related to pa-
tients’ age. In other words, we expected that, the younger
the patient, the more strongly daily negative affect and
positive affect would be inversely related.
Coping and breast cancer
Use of specific coping strategies influences adjustment to
breast cancer, and thus is another potential moderator of
patients’ affective differentiation. In general, active coping
is defined as taking concrete, active steps to solve a problem
or reduce its effects (Carver 1997). Overall, most active
types of coping are associated with positive psychological
outcomes in breast cancer patients (e.g., Bellizzi and Blank
2006; Epping-Jordan et al. 1999; Karanci and Erkam 2007).
Positive reframing coping is also associated with psycho-
logical adjustment in breast cancer patients (e.g., Karad-
emas et al. 2007; Reddick et al. 2005; Roussi et al. 2007;
Sears et al. 2003). Finally, several studies have also shown
that acceptance coping is associated with positive psycho-
logical outcomes in breast cancer patients (e.g., Culver et al.
2002; Roussi et al. 2007; Stanton et al. 2000).
Several types of coping strategies are consistently
associated with negative psychological outcomes in breast
cancer patients. These include disengagement forms of
coping (Compas et al. 2006; Culver et al. 2002; Epping-
Jordan et al. 1999), avoidant coping (Karademas et al.
2007; McCaul et al. 1999; Stanton et al. 2000; Stanton and
Snider 1993), and denial (Roussi et al. 2007).
In the current study, we measured patients’ coping with
their cancer experience and then related their coping
behavior with their daily affective differentiation. With the
aforementioned literature in mind, we expected that active
coping (including planning), positive reframing, and
acceptance coping would be associated with stronger
affective differentiation, whereas behavioral disengage-
ment, avoidance, and denial coping would be associated
with weaker affective differentiation. Our rationale for
these hypotheses is as follows: Because the former types of
coping (e.g., planning) have been shown to be adaptive for
cancer patients, their use should help patients successfully
navigate the daily stress associated with their illness and
treatment, and thus facilitate the daily availability of
attentional resources needed for affective differentiation.
On the other hand, because the latter types of coping (e.g.,
denial) have been shown to be maladaptive for cancer
patients, their use should be less helpful in managing pa-
tients’ daily stress, thus hindering the availability of
attentional resources needed for affective differentiation
(Reich et al. 2003).
Present study
Patients were recruited shortly after their breast cancer
surgery. They completed an initial packet of question-
naires, including a brief measure of demographic infor-
mation, as well as a measure of anxiety and a measure of
their use of coping strategies to deal with the cancer
experience. Following completion of this initial packet of
questionnaires, patients then completed an Internet-based
diary every night for seven consecutive nights, which
included items for daily negative affect and positive
affect and the daily occurrence of negative and positive
events.
We used Hierarchical Linear Modeling (Raudenbush
and Bryk 2002) to examine the moderators of affective
differentiation. On a daily within-subject level (Level 1),
we examined the moderating effects of daily number of
negative and positive events. On a between-subject level
(Level 2), we examined the moderating effects of anxiety,
age, and coping. Our major hypotheses for Level 1 mod-
erator variables were that: (a) affective differentiation will
become weaker when the number of negative events in-
creases on a given day; and (b) affective differentiation will
become stronger when the number of positive events in-
creases on a given day. Our major hypotheses for Level 2
variables were that affective differentiation will be stronger
in patients with individual difference scores indicative of
greater ‘‘adjustment,’’ specifically: (c) lower anxiety and
(d) and older age. We also predicted that affective differ-
entiation will be stronger in patients who use the following
coping strategies to deal with their breast cancer (e–h):
active coping, planning, positive reframing, and accep-
tance. Finally, we predicted that affective differentiation
will be weaker in patients who use (i-k): denial, behavioral
disengagement, and self-distraction (a form of avoidance)
to cope with their cancer.
Method
Participants
Participants were 53 breast cancer patients from the Breast
Center and Helen F. Graham Cancer Center at the Chris-
tiana Care Health System (Newark, Delaware). Inclusion
criteria were a diagnosis of breast cancer (any stage),
surgery within the past 7 months, and ability to speak and
read English. Exclusion criteria were lack of Internet
access at home. Seven participants were removed from the
original sample of 60 because of excessive missing data or
questionable study compliance. Fifty additional partici-
pants originally agreed to participate in the study, but did
not return the informed consent or questionnaire packets.
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Ten patients were screened out due to lack of Internet ac-
cess. Forty-one patients declined to participate. Thus, of the
161 eligible patients, 53 (33%) agreed to participate and
completed the study. This participation rate is comparable
to that obtained in other studies of breast cancer patients
(e.g., 37%: Bellizzi and Blank 2006; 24%: Hinnen et al.
2008).
The mean age of the participants was 53.34 years
(SD = 9.99; range = 31–70). Ninety-four percent of the
participants (n = 50) were Caucasian, 4% (n = 2) were
Black, and 2% (n = 1) were Hispanic. Forty-five percent
(n = 24) completed high school, while 36% (n = 19) had
a bachelors degree, 17% (n = 9) had an advanced degree,
and 2% (n = 1) did not answer. Eleven percent (n = 6)
reported a household income between $10,000 and
$40,000, 47% (n = 25) reported an income between
$40,001 and $100,000, 38% (n = 20) reported an income
over $100,000, and 4% (n = 2) did not report income.
Forty-three percent of the participants (n = 23) were
working full-time, 17% (n = 9) were working part-time,
and 40% (n = 21) were not working. Eighty-nine percent
of the women (n = 47) were married, and 11% (n = 6)
were single.
Eighty-three percent of the patients (n = 44) had
lumpectomies, 15% (n = 8) had mastectomies, and 2%
(n = 1) had a biopsy only. Twenty-one percent of the
patients (n = 11) were Stage 0 (noninvasive), 53%
(n = 28) were Stage 1 (invasive cancer up to 2 cm with no
lymph node involvement), 21% (n = 11) were Stage 2
(invasive cancer up to 5 cm with no lymph node involve-
ment or greater than 2 cm with lymph node involvement),
4% (n = 2) were Stage 3 (invasive cancer that has spread
to auxiliary lymph nodes that are clumping together, or that
has spread to chest wall, skin of breast, or lymph nodes
near the breastbone or collarbone), and 2% (n = 1) were
Stage 4 (invasive cancer which has spread to other organs
of the body). The mean time since surgery was 42 days
(SD = 49.09). Twenty-three percent of the patients
(n = 12) were receiving radiation and 21% (n = 11) were
receiving chemotherapy during their participation in the
study.
Initial measures
Participants completed questionnaires prior to their par-
ticipation in the daily diary component of the study. The
specific questionnaires are described below.
Anxiety
The 14-item Hospital Anxiety and Depression Scale (Zig-
mond and Snaith 1983) has seven items that assess anxiety
in a medical population, and was normed using medical
patients. A strength of this measure for use with medical
patients is that it does not include somatic symptoms,
preventing an overlap between medical and psychological
symptoms. Participants rated items on a 4-point Likert-type
scale ranging from 0 to 3, with a higher score indicating
more of the symptom described. The reliability and validity
of this measure have been demonstrated (Zigmond and
Snaith 1983), as has the stability of the factor structure
indicating separate anxiety and depression scales in cancer
patients (Moorey et al. 1991). In the current study, the
Cronbach’s alpha for Anxiety was .87.
Coping
Participants completed the 28-item Brief COPE question-
naire (Carver 1997) to indicate their past-week use of
various coping strategies to cope with their cancer. The
Brief COPE consists of 14 subscales with two items per
subscale: (a) Self-Distraction; (b) Active Coping; (c)
Denial; (d) Substance Use; (e) Use of Emotional Support;
(f) Behavioral Disengagement; (g) Venting; (h) Use of
Instrumental Support; (i) Positive Reframing; (j) Self-
Blame; (k) Planning; (l) Humor; (m) Acceptance; and (n)
Religion. Participants rated their use of each strategy on a
4-point Likert-type scale ranging from 1 (not at all) to 4 (a
lot). Carver (1997) documented the reliability and validity
of the Brief COPE. In addition, we added one item to
assess ‘‘Seeking Medical Advice’’. This item was worded
‘‘I’ve been seeking advice from my medical team,’’ and
relied on the same Likert-type scale used for the Brief
COPE items. In the current study, the Cronbach’s alphas
for each two-item scale were Self-Distraction = .43,
Active Coping = .75, Denial = .75, Substance Use = .49,
Use of Emotional Support = .87, Behavioral Disengage-
ment = .58, Venting = .45, Use of Instrumental Sup-
port = .76, Positive Reframing = .46, Self-Blame = .80,
Planning = .49, Humor = .90, Acceptance = .67, and
Religion = .91.
Daily diary measures
Participants completed the diary measures for seven con-
secutive nights approximately one week after their com-
pletion of the initial questionnaire packet. The diary took
approximately eight minutes to complete each night. On
average, participants completed 6.8 (out of 7) days of
diaries (SD = .40). This diary completion rate is superior
to that obtained by Badr et al. (2006) in their electronic
diary study of breast cancer survivors. The diary items are
described below.
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Daily affect
We used the Positive and Negative Affect Schedule—
Expanded Form (PANAS-X; Watson and Clark 1994) to
assess current (state) positive affect and negative affect.
For the purposes of this study, we administered seven items
with negative valence (i.e., sad, lonely, blue, angry, afraid,
scared, frightened) and five items with positive valence
(i.e., enthusiastic, excited, determined, interested, in-
spired). We chose these PANAS items to reflect a broad
range of negative and positive emotions. Participants rated
each item on a 5-point Likert-type scale ranging from 1
(very slightly or not at all) to 5 (extremely) based on how
they felt ‘‘at this moment’’. The PANAS-X is a widely used
measure of affect with convergent and discriminant valid-
ity (Watson and Clark 1994). In this study, between-person
reliabilities were calculated after aggregating each partic-
ipant’s items across all seven days. The between-person
Cronbach’s alphas for negative affect and positive affect
were .91 and .95, respectively. Within-person reliability
estimates were calculated by first transforming item scores
into z-scores within each participant. The within-person
Cronbach’s alphas for negative affect and positive affect
were .78 and .79, respectively.
Daily events
Participants then completed a 17-item negative events
checklist. Participants indicated whether or not each event
occurred that day. Items included daily work (e.g., too
much work to do) and relationship hassles (e.g., argument
or conflict with my spouse), as well as cancer-specific
stressors (e.g., saw self or scars in mirror; noticed hair
falling out).
Participants also completed an 11-item positive events
checklist, again indicating whether or not each event
occurred that day. Items included positive daily work (e.g.,
positive event at work) and relationship events (e.g., my
spouse/partner and I had a good laugh together), as well as
cancer-specific positive events (e.g., had a positive inter-
action with a medical professional).
The cancer-specific negative and positive events were
chosen after consultation with staff at the Helen F. Graham
Cancer Center. The other events were based in part on
previous daily event checklists used with adults (e.g.,
Bolger et al. 1989; Cohen et al. 2008).
Procedure
Patients were identified for potential participation in the
study by breast surgeons’ and oncologists’ staff, via breast
cancer multidisciplinary center appointments, and by
positive breast biopsy lists. After identification for the
study, participants were contacted in person or by phone as
soon as possible after surgery, were screened for study
inclusion, and were invited to participate in the study. If the
participant agreed, we gave or mailed her a questionnaire
packet with instructions to complete the informed consent
and questionnaires and mail them back to the research team
as soon as possible.
Upon receiving the completed questionnaire packet, the
investigator then called the participant to schedule a start
date at the participant’s earliest convenience for the Inter-
net-based daily diaries. The diaries were to be completed
each evening between 7 p.m. and 11 p.m. for seven con-
secutive nights. Entries completed between 4 p.m. and 1:30
a.m. were considered acceptable, to accommodate the fact
that many women did not feel well and had varying work
schedules and responsibilities. Of the 361 valid responses,
83.1% (n = 300) were completed between 7 p.m. and 11
p.m. The average time of diary completion was approxi-
mately 8:30 p.m. The study was conducted in compliance
with the Institutional Review Board of Christiana Care.
Overview of analyses
Our main analyses focused on the influence of daily neg-
ative and positive events, anxiety, age, and coping on
affective differentiation. Specifically, we examined the
moderating effects of these aforementioned variables on
the daily relationship between positive affect and negative
affect. Our data had a two-level structure: Level 1 is the
within-subject level (daily observations over several days
of negative and positive events and negative affect and
positive affect) and Level 2 is the between-subject level
(individual differences on anxiety, age, and coping). To
perform these analyses we used Hierarchical Linear Mod-
eling (Raudenbush and Bryk 2002), which accommodates
missing repeated data when data are missing at random, by
using full information maximum likelihood for parameter
estimation (Schafer and Graham 2002).
The Level 1 (within-subject) regression equation for the
relationship between positive affect (PA) and negative af-
fect (NA) is:
NAt¼ b0þ b1PAt
ð Þ þ et
where NAtis NA at the end of day t, PAtis PA at the end of
day t, b0is the intercept representing the level of NA at
average levels of PA for that individual (centered within
cluster), b1is the slope coefficient for PA (that is, the
number of units higher the NA score is for every additional
unit higher the PA score is on day t), and etis the error
term, or random component of NA on day t. Using Hier-
archical Linear Modeling, this regression equation was
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