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Stress and Posttraumatic Growth Among Survivors of Breast Cancer: A Test of Curvilinear Effects.

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Stress and Posttraumatic Growth Among Survivors of Breast Cancer: A Test of Curvilinear Effects.

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The purpose of the current study was to test the curvilinear associations between experiences of stress and posttraumatic growth among female breast cancer survivors. Participants (n = 193; 86% Caucasian; 80% diagnosed with Stage I or II cancer) completed self-report questionnaires assessing sociodemographic and medical information, perceived general stress, cancer- specific stress, and posttraumatic growth. Two hierarchical regression models tested the associations between general and cancer-specific stress and posttraumatic growth. After controlling for the effects of age, education, and time since diagnosis, there was a significant curvilinear effect of general stress on posttraumatic growth. Moderate levels of general stress were associated with the greatest posttraumatic growth. Cancer-specific stress was not associated with posttraumatic growth. These findings suggest that stress can be adaptive in the aftermath of cancer treatments, and different manifestations of stress may require individualized intervention. Future research studies are needed to better understand and contextualize these findings among other cancer populations.
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International Journal of Stress Management
Stress and Posttraumatic Growth Among Survivors of
Breast Cancer: A Test of Curvilinear Effects
Adina Coroiu, Annett Körner, Shaunna Burke, Sarkis Meterissian, and Catherine M. Sabiston
Online First Publication, May 11, 2015. http://dx.doi.org/10.1037/a0039247
CITATION
Coroiu, A., Körner, A., Burke, S., Meterissian, S., & Sabiston, C. M. (2015, May 11). Stress and
Posttraumatic Growth Among Survivors of Breast Cancer: A Test of Curvilinear Effects.
International Journal of Stress Management. Advance online publication.
http://dx.doi.org/10.1037/a0039247
Stress and Posttraumatic Growth Among Survivors
of Breast Cancer: A Test of Curvilinear Effects
Adina Coroiu and Annett Körner
McGill University
Shaunna Burke
University of Leeds
Sarkis Meterissian
McGill University
Catherine M. Sabiston
University of Toronto
The purpose of the current study was to test the curvilinear associations
between experiences of stress and posttraumatic growth among female breast
cancer survivors. Participants (n 193; 86% Caucasian; 80% diagnosed
with Stage I or II cancer) completed self-report questionnaires assessing
sociodemographic and medical information, perceived general stress, can-
cer-specific stress, and posttraumatic growth. Two hierarchical regression
models tested the associations between general and cancer-specific stress
and posttraumatic growth. After controlling for the effects of age, education,
and time since diagnosis, there was a significant curvilinear effect of general
stress on posttraumatic growth. Moderate levels of general stress were
associated with the greatest posttraumatic growth. Cancer-specific stress
was not associated with posttraumatic growth. These findings suggest that
stress can be adaptive in the aftermath of cancer treatments, and different
Adina Coroiu and Annett Körner, Department of Educational and Counselling Psychol-
ogy, McGill University; Shaunna Burke, School of Biomedical Sciences, University of Leeds;
Sarkis Meterissian, Department of Surgery and Oncology, McGill University; Catherine M.
Sabiston, Faculty of Kinesiology and Physical Education, University of Toronto.
Adina Coroiu held student fellowships from the Canadian Institutes of Health Research
(CIHR) and the Fonds de recherche en santé du Quebec (FRSQ). This research was funded by
an operating grant from CIHR awarded to Catherine M. Sabiston.
Correspondence concerning this article should be addressed to Catherine M. Sabiston,
Faculty of Kinesiology and Physical Education, University of Toronto, 55 Harbord Street,
Toronto, Ontario M5S 2W6, Canada. E-mail: catherine.sabiston@utoronto.ca
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
International Journal of Stress Management © 2015 American Psychological Association
2015, Vol. 22, No. 3, 000 1072-5245/15/$12.00 http://dx.doi.org/10.1037/a0039247
1
manifestations of stress may require individualized intervention. Future
research studies are needed to better understand and contextualize these
findings among other cancer populations.
Keywords: breast cancer, curvilinear effects, posttraumatic growth, stress
Breast cancer is the most frequently diagnosed cancer among women
worldwide (Jemal et al., 2011). Early detection and effective treatments have
led to an increased life expectancy for those diagnosed with the disease, with
a 5-year relative survival rate of approximately 90% in North America
(Canadian Cancer Society, 2011; National Cancer Institute, 2014). Although
promising, these figures do not entirely reflect the number of women who live
with the debilitating disease and treatment-related health outcomes that span
across physical, emotional, and social life domains beyond the phase of
active treatment. It is well-documented that survivors of cancer report various
negative outcomes of the illness (Deimling, Bowman, Sterns, Wagner, &
Kahana, 2006), yet cancer survivors also experience profound positive
changes throughout the illness trajectory (see Helgeson, Reynolds, & To-
mich, 2006 for a review). Specifically, between 53% to 84% of breast cancer
survivors report positive changes in the aftermath of their diagnosis (Collins,
Taylor, & Skokan, 1990; Sears, Stanton, & Danoff-Burg, 2003; Taylor,
Lichtman, & Wood, 1984). The experience of both positive and negative
challenges during cancer survivorship suggests that there may be unique
experiences requiring different interventions in cancer care.
The interplay of negative and positive experiences after a cancer diag-
nosis is best captured by concepts such as adversarial growth, benefit finding,
thriving, or posttraumatic growth. There are debates among researchers and
clinicians as to the distinctions among these concepts and the underlying
experiences. For a comprehensive overview of the aspects involved in the
aforementioned conceptual debate, the reader can refer to review articles
written by Coyne and Tennen (2010), Linley and Joseph (2004), and Park and
Helgeson (2006). Although these concepts are sometimes used interchange-
ably in spite of potential differences in the experiences, researchers are urged
to specify the concept under study and avoid conceptualizing the terms as
synonymous. The research in the current study focuses on posttraumatic
growth.
Posttraumatic growth (PTG; Tedeschi & Calhoun, 2004; Tedeschi, Park,
& Calhoun, 1998) is broadly defined as a positive psychological change that
is triggered by highly stressful events. More specifically, it refers to a
transformative positive experience from before to after the trauma, which
occurs as a direct result of struggling with challenging life circumstances.
The mechanism driving the growth is a process of cognitive restructuring of
one’s life and priorities, which could be regarded as adaptation to a new
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2 Coroiu, Körner, Burke, Meterissian, and Sabiston
reality, that is to life after the trauma (Calhoun & Tedeschi, 2006; Janoff-
Bulman, 1992). The theoretical model of PTG proposed by Tedeschi and
Calhoun posits that growth can manifest in a number of ways through
fostering new relationships with others, developing a new appreciation for
life, finding new meanings in life, discovering personal strength, experienc-
ing spiritual change, and the realization of new opportunities (e.g., Lelorain,
Tessier, Florin, & Bonnaud-Antignac, 2012; Sabiston, McDonough, &
Crocker, 2007). In most studies (see Koutrouli, Anagnostopoulos, & Pota-
mianos, 2012 for a systematic review), these different facets of PTG are
highly correlated and a more global concept of PTG has been studied.
Among cancer populations, reported prevalence rates of perceived PTG
range from 53% to 90% (Petrie, Buick, Weinman, & Booth, 1999; Rieker,
Edbril, & Garnick, 1985) and vary according to the type of cancer (Barskova
& Oesterreich, 2009), time since diagnosis, heterogeneity and ethnicity of the
sample (Helgeson et al., 2006), choice of measurement (Park & Helgeson,
2006; Sumalla, Ochoa, & Blanco, 2009), and many personal factors. For
example, younger age at diagnosis, lower socioeconomic status (e.g., income
and education), and belonging to a minority group (e.g., African American or
Hispanic) have been consistently associated with an increased likelihood of
PTG (Lechner & Antoni, 2004; Tomich & Helgeson, 2004; Weiss, 2004).
Within a meta-analysis encompassing 78 cross-sectional studies, Helgeson
and colleagues (2006) found associations between PTG and sociodemo-
graphic, psychological, and medical variables. Specifically, PTG was greater
for females, younger individuals, and people who self-identify as being of
minority status and it related to higher positive affect, optimism, religiosity,
and positive reappraisal, increased stress perceptions and intrusive-avoidant
thoughts, lower depression levels, and greater trauma severity (Helgeson et
al., 2006). A second meta-analysis including 38 studies with cancer and
HIV-positive populations (Sawyer, Ayers, & Field, 2010) generally con-
firmed the findings. These reviews offer support for the tenets of the PTG
model by highlighting the co-occurrence of both positive and negative health
outcomes and PTG and a heightened perception of stress in survivors who
also experience PTG.
According to Tedeschi and colleagues (Tedeschi & Calhoun, 2004;
Tedeschi et al., 1998), the experience of PTG is highly dependent on whether
a circumstance is appraised as stressful. Similarly, in the context of cancer,
PTG would be dependent on the degree of stress experienced in relationship
to the cancer diagnosis, cancer treatment, and/or cancer-related lifestyle
changes. In studies validating the PTG model, qualitative and quantitative
analyses, and reviews of the existing scholarship, researchers have suggested
a potential positive association between prolonged psychological stress and
increased PTG among survivors of cancer (Lelorain et al., 2012; Sabiston et
al., 2007). However, the nature and directionality of this relationship is still
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3Stress and Posttraumatic Growth
poorly understood in this population, with some studies reporting positive
(Lechner et al., 2003; Sears et al., 2003), negative (Love & Sabiston, 2011;
Tomich & Helgeson, 2004), or null (Manne et al., 2004; Weiss, 2004)
relationships between psychological stress and PTG. It is possible that a more
complex, nonlinear relationship between stress and PTG needs to be consid-
ered in the context of cancer (Helgeson et al., 2006; Lechner, Carver, Antoni,
Weaver, & Phillips, 2006), as different levels of stress and related processes
(i.e., coping, adjustment) may be differentially linked to experiences of PTG
(Lechner et al., 2006; Taku, 2013).
To date, only a few studies have explored curvilinear associations
between psychological stress and PTG. For example, Lechner et al. (2003)
investigated the link between objective threat, which was measured via stages
of cancer (e.g., stage 0-I lowest threat; stage IV highest threat), and PTG
in a sample of 83 patients diagnosed with various types of cancer. The
highest growth was found among individuals diagnosed with stage II cancer,
whereas those with stages I and IV experienced the least growth. Although
objective stress was correlated with perceived stress (measured via one item
asking about the likelihood of dying of cancer), no curvilinear relationship
was found between perceived stress and PTG. Further, Lechner et al. (2006)
found a curvilinear relationship between psychosocial outcomes (e.g., adjust-
ment, depression, state affectivity) and PTG such that the highest adjustment
was related to low and high levels of growth whereas moderate levels of
growth were associated with the least adjustment. Curvilinear effects have
been documented among survivors of terrorist attacks, whereby moderate
symptoms of posttraumatic stress disorder were related to highest PTG
(Butler et al., 2005) and in survivors of assault, where negative affective
experiences were also related to highest PTG (Kleim & Ehlers, 2009). As
such, a curvilinear relationship between stress and PTG may provide a more
comprehensive representation of adjustment to diagnosis and throughout the
cancer treatment trajectory. Furthermore, different stress manifestations have
not been examined in the relationship to PTG among cancer survivors.
Cancer-specific stress encompasses fears or worry about future cancer
recurrences, disease progression, and other health-related aspects associated
with a cancer diagnosis (Gotay & Pagano, 2007; Kornblith et al., 2007).
Among breast cancer survivors, worrying about cancer has been associated
with higher distress, and mental health such as increased anxiety and depres-
sion symptoms and lower quality of life (Deimling et al., 2006). Given that
up to 60% of survivors report heightened cancer worries after diagnosis and
treatment (Mehnert, Berg, Henrich, & Herschbach, 2009), it seems important
to investigate the role of cancer-specific stress on experiences of PTG to
provide an accurate and comprehensive picture of this relationship.
The objective of the current study was to test the curvilinear associations
between perceived general and cancer specific stress and PTG in a sample of
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4 Coroiu, Körner, Burke, Meterissian, and Sabiston
women who have recently completed breast cancer treatment. It was hypoth-
esized that a significant curvilinear association would be observed (i.e., an
inverted U relationship) such that moderate levels of stress, both general and
cancer-specific, would relate to the highest reports of PTG.
METHOD
Participants and Procedures
A convenience sample of 199 female survivors of breast cancer was
recruited via physician referral and advertisements in hospitals and medical
clinics in Montreal to participate in a cohort study entitled Life After Breast
Cancer: Moving On. The current study focuses on testing the associations
between stress and PTG at the first data collection. Eligibility criteria for
participation in this project included a first diagnosis of breast cancer,
completion of active treatment, ability to read and write in English or French,
and being 18 years of age or above. Participation was voluntary and was
initiated as soon as possible after the last scheduled primary/systemic treat-
ment for breast cancer. Approval for the study was obtained from the Ethics
Board of the McGill University Health Centre before study commencement.
All procedures followed were in accordance with the ethical standards of the
responsible committee on human experimentation (institutional and national)
and with the Helsinki Declaration of 1975, as revised in 2000. Informed
consent was obtained from all patients for being included in the study.
The analytical sample of the current study includes 193 women who pro-
vided complete data. Most women (86%) in the current sample identified as
Caucasian with ages between 28 to 79 years; 65% were married or in a common
law; and just over half (51%) had completed undergraduate or graduate studies.
The mean time since diagnosis was 10.6 months (SD 3.4), and the mean time
since treatment was 3.5 months (SD 2.4). Approximately 40% of the women
were diagnosed with stage I, 40% with stage II, and 20% with stage III breast
cancer. The most common treatments were lumpectomy (60%), chemotherapy
(65%), radiotherapy (89%), and hormonal therapy (55.3%). Some women had
single (28%) or double (17%) mastectomy.
Measures
Data were collected on sociodemographic (e.g., age) and medical infor-
mation (e.g., disease severity), as well as several psychological constructs
captured via validated self-report measures.
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5Stress and Posttraumatic Growth
Posttraumatic growth was assessed using the 21-item Posttraumatic
Growth Inventory (PTGI; Tedeschi & Calhoun, 1996). The PTGI is a 21-item
self-report measure assessing five separate domains of posttraumatic growth:
new possibilities (n
items
5, sample item: “I established a new path for my
life”), relating to others (n
items
7, sample item, “Putting effort into my
relationships”), personal strengths (n
items
4, sample item, “I discovered
that I am stronger than I thought I was”), spiritual change (n
items
2, sample
item, “A better understanding of spiritual matters”), and appreciation of life
(n
items
3, sample item, “Appreciating each day.”) Respondents were asked
to indicate the degree to which they had experienced positive changes in their
lives following the breast cancer diagnosis. The answers were rated on a
6-point Likert-type scale ranging from 0 (not at all)to5(a very great
degree), with higher scores indicating higher growth. A total PTGI score is
commonly used as a measure of PTG. Internal consistency reliability (Cron-
bach’s alpha) ranged from .90 to .95 for the total scale (Brunet, McDonough,
Hadd, Crocker, & Sabiston, 2010; Tedeschi & Calhoun, 1996). Two-month
test–retest reliability for PTGI has been reported as r.71 (Tedeschi &
Calhoun, 1996). In the current study, a total score reflecting the construct of
PTG was used in analyses. Reliability assessed as internal consistency
coefficient Cronbach’s alpha was ␣⫽.95.
Perceived general stress was assessed via the Perceived Stress Scale
(PSS; Cohen, Kamarck, & Mermelstein, 1983; Cohen & Williamson, 1988).
The PSS is a 10-item self-report instrument measuring the frequency of
stressful events experienced in the month before completing the question-
naire. Sample items include the following: “In the last month, how often have
you felt you were unable to control the important things in your life” and “. . .
found that you could not cope with all the things that you had to do.” The
items are rated on a 5-point Likert-type scale ranging from 0 (never)to4
(very often), with higher scores indicating higher stress. The internal consis-
tency reliability of the PSS ranged from .75 to .92 in the general population
(Cohen & Williamson, 1988) and from .75 to .91 among a breast cancer
sample (Golden-Kreutz et al., 2005). In the current sample, the internal
consistency reliability coefficient for the total scale was ␣⫽.78.
Cancer-specific stress was assessed via the Assessment of Survivors
Concerns (ACS; Gotay & Pagano, 2007). The ASC is a 6-item instrument
assessing cancer-related worries. Sample items include “I worry about my
cancer coming back” and “I worry about my death.” Items are rated on a
4-point Likert-type scale ranging from 1 (not at all)to4(very much), with
higher scores indicating more worry. In the development sample of 753
cancer survivors, the internal consistency reliability coefficients ranged from
␣⫽.72 to .92. A mean score across 5 items was used in the current analyses,
while excluding the item “I worry about my child’s health” because not all
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6 Coroiu, Körner, Burke, Meterissian, and Sabiston
women in the sample reported having children. The internal consistency
reliability coefficient for the five items was ␣⫽.85.
Data Analyses
After computing descriptive statistics (e.g., means, standard deviations,
frequencies, Pearson correlation coefficients), the linear and curvilinear as-
sociations between both perceived general stress and cancer-specific stress
and PTG were tested in separate hierarchical regression models, as per
guidelines developed by Aiken and West (1991). Consistent with previous
findings from Helgeson et al. (2006) and based on significant correlations
with PTG, women’s age, education, and time since diagnosis were entered as
covariates in the first step of the regression models. In step two, the mean-
centered stress variables (i.e., perceived general stress and cancer-specific
stress) were entered. In the final step, the quadratic terms (e.g., Centered
stress Centered stress) were added to the models. Significant effects on
step two reflect linear associations, whereas quadratic effects (step three)
illustrate curvilinear associations, specifically one bend in the regression line.
RESULTS
A Pearson correlation coefficient matrix, along with means, standard
deviation, and ranges for all study measures, is presented in Table 1. Of note,
the association between general and cancer-specific stress was moderate, r
.38, p.001, suggesting that the concepts are related yet the two scales tap
different facets of stress. Lastly, PTG was related to cancer-specific stress,
r.20, p.005, but not to general stress.
In the main analyses, the regression model predicting PTG from general
stress was significant, F(5, 187) 6.12, p.001 (see Table 2). In step 1,
Table 1. Correlation Matrix Between the Study Measures
Variable 1 2 3 4 5 6
1. Age
2. Education .17
*
3. Months since diagnosis .21
***
.06 —
4. General stress .24
***
.06 .07 —
5. Cancer-specific stress .17
*
.14 .15
*
.38
***
6. Posttraumatic growth .20
*
.18
*
.12
*
.02 .20
*
M55.01 10.64 15.79 12.85 62.95
SD 11.02 3.45 5.41 3.86 21.57
Range 28–79 2–20 4–30 5–20 1–101
*
p.05.
***
p.003, as per the Bonferroni correction.
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7Stress and Posttraumatic Growth
age, education, and time since diagnosis accounted for 9% of the variance in
the PTG. In step 2, general stress was entered into the equation, but ac-
counted for only a nonsignificant 1% in variance in PTG. This step assessed
the linear effect of PSS on PTG. Step 3 assessing the curvilinear effect of PSS
on PTG was significant and accounted for an additional 4% of the variance
in PTG. This curvilinear effect, which is graphed in Figure 1, shows that
moderate levels of general stress were associated with the highest PTG.
The final regression model predicting PTG from cancer-specific stress was
significant, F(5, 187) 4.65, p.001. However, after controlling for the effects
of age, education, and time since diagnosis, there was no significant linear or
curvilinear effect of cancer-specific stress on PTG (see Table 2).
Table 2. Hierarchical Multiple Regression Analyses Predicting PTG Among Female Breast
Cancer Survivors
Step and variable
PTG regressed on general
stress
PTG regressed on cancer-
specific stress
R
2
R
2
FR
2
R
2
F
1. Covariates .09 .09 5.98
**
.09 .09 5.98
**
Age .22
**
.22
**
Education .21
**
.21
**
Time since diagnosis .06 .06
2. Stress .10 .01 1.86 .10 .10 .01 1.69 .09
3. Stress Stress .14 .05 9.79
**
.22
**
.11 .02 3.31 .13
Overall F(5, 187) 6.12
**
Overall F(5, 187) 4.65
**
Note. PTG Posttraumatic growth.
**
p.01.
Figure 1. Curvilinear relationship between PTG and general stress. PTG posttraumatic
growth.
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8 Coroiu, Körner, Burke, Meterissian, and Sabiston
DISCUSSION
The purpose of the current study was to test the curvilinear associations
between general and cancer-specific stress and posttraumatic growth (PTG)
in a sample of female survivors of breast cancer. After controlling for
covariates, which have been found to contribute to the experiences of growth
(Helgeson et al., 2006), there was a significant curvilinear effect between
general stress and PTG, but no significant relationships between cancer-
related stress and PTG. The PTG levels reported in the current sample were
comparable with PTG reports from other studies with similar populations
(Cordova et al., 2007; Danhauer et al., 2013; Lelorain et al., 2012). These
findings may suggest that different manifestations of stress should be con-
sidered differently in cancer care, and tests of the PTG model (Tedeschi &
Calhoun, 2004; Tedeschi et al., 1998) should include assessments of both
linear and nonlinear associations between stress and challenges and PTG.
As hypothesized, general stress demonstrated a curvilinear association
with PTG. The significant curvilinear effect corroborates previous findings
about high levels of stress (O’Connor, Rasmussen, & Hawton, 2010) being
detrimental to one’s health. As shown in the current study, moderate levels
of stress were related to the most positive or desirable outcomes. These
findings complement previous literature, which reported on a curvilinear
association between objective threat (i.e., cancer stage, which can be con-
ceptualized as a proxy measure of stress) and PTG (Lechner et al., 2003).
This effect is also consistent with the inverted-U hypothesis (Yerkes &
Dodson, 1908), which posits that curvilinear associations exist between
arousal and performance whereby moderate levels of arousal predict better or
optimal performance (Gould & Krane, 1992). In the current study general
stress was found to relate to PTG much in the same way physiological arousal
related to physical performance (Arent & Landers, 2003).
The nonsignificant curvilinear relationship between cancer-specific stress
and PTG was contrary to hypothesis. In partial support of the PTG model
(Tedeschi & Calhoun, 2004; Tedeschi et al., 1998), a small positive bivariate
correlation was found between cancer-specific stress and PTG. However, in
multivariate models controlling for covariates, the linear and curvilinear
effect of cancer-related stress on PTG did not reach significance. It may be
that the pervasive nature of cancer worries (Janz et al., 2011) is not perceived
as a challenge that fosters PTG. Further, the measure used to assess cancer-
specific stress in the current study focuses on only a few of the many
cancer-related worries that are likely experienced among breast cancer sur-
vivors. For example, cancer stressors related to physical functioning, emo-
tional well-being, social relationships, body image and weight, and health
have been reported (Hadd, Sabiston, McDonough, & Crocker, 2010). Fur-
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9Stress and Posttraumatic Growth
thermore, these results are consistent with previous findings that global stress
predicted both positive (e.g., positive affect and positivity about the illness)
and negative adjustment outcomes (depression, anxiety; negative affect)
among breast cancer patients, whereas cancer-specific stress only predicted
negative affective outcomes (Groarke, Curtis, & Kerin, 2013). Based on their
findings, it can be inferred that perceived general stress might be of greater
importance to adaptation than cancer-specific stress. Stress at moderate levels
may be perceived as a challenge and could be related to adaptive outcomes,
such as higher PTG. Cancer stress on the other hand, if perceived as
threatening as opposed to challenging, would likely be related to higher
distress (Tedeschi & Calhoun, 2004). Although it is possible that different
appraisal processes occurred for stress (challenge) compared with cancer-
related stress (threat), the two measures were not specifically designed to
measure different stress appraisals, and this proposition requires further
research.
Notwithstanding the strengths and contributions of this study, there are
certain limitations that may impact the generalizability of the results. First,
given the cross-sectional design, the directionality of the effects could not be
empirically established and claims about cause-and-effect could not be made.
Second, this study used a convenience sample of volunteer participants,
which precludes generalizability of the results. Third, PTG was assessed via
a self report measure, the PTGI (Tedeschi & Calhoun, 1996), which although
widely used in psycho-social oncology, it subjectively and retrospectively
assesses the perceived experience of growth while also asking respondents to
assess the changes they had undergone from before to after their diagnosis:
this is in itself quite problematic, as it may yield unreliable reports of growth
(Coyne & Tennen, 2010). Further, the suitability of assessing growth in
cancer survivors via the PTGI is not well researched: the chronic type of
trauma that survivors endure is arguably different from the acute types of
traumas (e.g., university exams; failed romantic relationships) based on
which the PTGI items were developed (Sumalla et al., 2009).
Future studies should examine PTG among other cancer populations.
Studies with a longitudinal design are also needed to examine causal rela-
tionships between stress and PTG over time. Furthermore, future studies
should continue to challenge the existing linear PTG model (Tedeschi &
Calhoun, 2004) while highlighting the adaptive and maladaptive roles of
stress perceptions during the posttreatment cancer trajectory. To better un-
derstand the interplay of PTG and stress variables, further research will
benefit from exploring the effect of moderator variables, such as coping,
adjustment to cancer, and various personality traits. Deciphering the nature
and directionality of these relationships might provide critical insight for
clinicians who deliver psychosocial services to cancer patients. For example,
nurturing the experiences of PTG in patients with moderate levels of distress
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10 Coroiu, Körner, Burke, Meterissian, and Sabiston
may facilitate faster adaptation to day-to-day reality in cancer survivors and
decrease distress. It has been shown that patients who experience high levels
of stress benefit from psychosocial interventions targeting stress and distress
reduction (see Jacobsen & Jim, 2008 for a review). By reducing stress to
manageable levels, such interventions could simultaneously facilitate PTG.
To conclude, the current findings suggest that among female cancer
survivors who recently completed treatment for breast cancer, the association
between stress and PTG is not necessarily linear, as postulated in the PTG
model (Tedeschi & Calhoun, 2004). Instead, a curvilinear association be-
tween the two variables better explained the PTG experiences. More specif-
ically, moderate levels of general stress predicted the highest posttraumatic
growth. Interventions geared toward reducing stress levels in breast cancer
survivors who experience high levels of stress might indirectly facilitate
growth. Intervention strategies may be needed to target stress appraisals to
help breast cancer survivors appreciate stressors as challenges as opposed to
threats.
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Received August 27, 2014
Revision received March 18, 2015
Accepted March 23, 2015
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14 Coroiu, Körner, Burke, Meterissian, and Sabiston
... In addition, whereas previous studies have systematically found linear correlations between higher perceived stress and higher distress (Dunkel Schetter & Tanner, 2012;Goletzke et al., 2017), the findings concerning the connection between perceived stress and personal growth are equivocal. Some studies show that higher perceived stress is associated with higher growth (Koutrouli et al., 2012;Zoellner & Maercker, 2006), whereas others present curvilinear associations indicating that moderate levels of stress are associated with the greatest growth, whereas lower and higher levels of stress are related to lower personal growth (Coroiu et al., 2016;Rozen et al., 2018). ...
... In addition, the regression analysis revealed that curvilinear stress predicted personal growth above and beyond all other variables. This is consistent with previous studies examining the curvilinear association between perceived stress and posttraumatic growth following traumatic events (Coroiu et al., 2016;Shakespeare-Finch & Lurie-Beck, 2014;Tsai et al., 2015), as well as between perceived stress and personal growth among parents of preterm babies (Rozen et al., 2018). ...
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Objective: Coping with the stress aroused by early pregnancy can not only result in distress, but may constitute an opportunity to experience personal growth. Relying on the model of posttraumatic growth, this study examined the contribution of perceived stress and emotion regulation to women’s personal growth during the first trimester of pregnancy. Method: A convenience sample of Israeli women (n=170), who were during their first trimester of pregnancy (up to 13 weeks), over 18 years old, and capable to completing the instruments in Hebrew, were recruited through a women’s health clinic and through social media during the years 2017-2019. Results: The findings indicate that primiparous mothers report higher personal growth than multiparous. In addition, younger age, being primiparous, and higher cognitive-reappraisal contributed to greater personal growth. Moreover, a curvilinear association was found between perceived stress and personal growth, so that a medium level of stress was associated with the highest level of growth. Finally, cognitive-reappraisal fully mediated the relationship between perceived stress and personal growth. Conclusions: The findings add to the growing body of knowledge concerning the implications of early pregnancy in general, and personal growth as a result of dealing with the stress typical of this period in particular and highlight the role of the perceived stress as well as the woman’s personal characteristics and resources that contribute to this result.
... Furthermore, among the studies that do find a positive association between PTSD and PTG, there are contradictions regarding the nature of the relationship between stress and growth. Indeed, some studies suggest that the trauma must be "seismic" enough (extremely severe) in order to foster growth [33][34][35], while others support the idea that it is "moderate" levels of PTSD that will promote the highest levels of PTG [32,[36][37][38]. Indeed, McCaslin et al. [37] explain that "low levels of distress may be insufficient to stimulate growth, and that an overwhelming amount of distress-at the time of the event and following it-may impede the development of growth following traumatic events" (p. ...
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Studies show that experiencing traumatic events can lead to positive psychological change, or posttraumatic growth (PTG). In the hope of promoting PTG, authors have been focusing on identifying the factors that may foster PTG. Despite these attempts, the literature shows inconsistencies, making it difficult to know which variables may be involved in the process of growth. Indeed, authors seem to disagree on the nature of the relationship between PTSD and PTG, time since the event, social support, intrusive rumination, and sociodemographics. Thus, this study aims to clarify these discrepancies, and verify whether the processes involved are the same across two different cultural groups, both of which are confronted with traumatic events regularly: 409 American firefighters, and 407 French firefighters. Results indicate that, in both samples, PTG is positively related to PTSD, subjective perceptions of the event, stress during the event, disruption of core-beliefs, and deliberate rumination; and unrelated to social support, core-self evaluations, and socio-demographic variables (age, gender, relationship status, etc.). However, time since the event and the number of years on the job only predicted PTG in the American sample, while colleague and emotional support only predicted PTG in the French sample. Additionally, American firefighters reported more growth, more social support, more positive self-perceptions, more intrusive rumination, and more neuroticism than French firefighters. These results suggest that the process of growth, as defined by Tedeschi and Calhoun, is relatively stable among firefighters, but that some differences do exist between cultural groups.
... The relationship between perceived stress and posttraumatic growth has been analyzed in different contexts, such as breast cancer (Groarke et al., 2017;Yeung & Lu, 2018), earthquakes (Taku et al., 2015) and work satisfaction (Xu & Wu, 2014). In particular, Coroiu et al. (2016) found that moderate perceived stress levels may be linked to higher post-traumatic growth, which may reflect more adaptive outcomes. Regarding the relationship between post-traumatic growth and PTSD symptoms, higher levels of distress is not reflective of an absence of psychological growth and maturation (Solomon & Dekel, 2007). ...
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The present study investigates the mediating roles of psychological inflexibility and differential coping strategies on perceived stress and post-traumatic symptoms and growth in the context of COVID-19. Study one recruited 662 participants (54.8% women; Mage = 40.64 years, SD = 13.04) who completed a cross-sectional questionnaire. It was proposed that orientation to the problem, avoidance strategies, psychological inflexibility, and positive attitude were mediators for the positive association between perceived stress and PTSD symptoms. The fit indices for the path model were excellent: CFI = 0.977, TLI = 0.950, RMSEA = 0.057 [90%CI = 0.043–0.081], and SRMS = 0.042. Gender and stressful events encountered had indirect effects on the endogenous variables. In study two, 128 participants (57.8% women; Mage = 42.30, SD = 12.08) were assessed for post-traumatic growth one year later. Psychological inflexibility and orientation acted as mediators between perceived stress and PTSD symptoms. Furthermore, a novel path model was constructed in which psychological inflexibility and orientation to the problem as mediators for perceived stress and PTSD symptoms. The indices for the path model were excellent: CFI = 0.99, TLI = 0.97, RMSEA = 0.055 [90%CI = 0.001–0.144], and SRMS = 0.49. Furthermore, PTSD symptoms, psychological inflexibility, and orientation to the problem predicted post-traumatic growth. Specifically, both orientation to the problem (β = .06 [90%CI: .01;.13]) and psychological inflexibility (β = .14 [90%CI: .08;.26]) had an indirect effect on post-traumatic growth. Overall, these results significantly contribute to the literature as orientation to the problem positively predicted PTSD symptoms and post-traumatic growth one year later while psychological inflexibility predicted PTSD symptoms and less post-traumatic growth one year later. These results underline the importance of assessing both symptomology and psychological growth to determine adaptive coping strategies in specific contexts.
... Therefore, our study further supports the idea that high levels of traumatic stress may be necessary for individuals to experience the onset of positive change. Nevertheless, it is important to note that the literature suggests that "moderate" levels of PTSD will promote the highest levels of PTG (Coroiu et al., 2016;Manning-Jones et al., 2017;McCaslin et al., 2009;Mols et al., 2009). This may partly explain why anxiety was negatively correlated with growth. ...
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Purpose To validate a European French translation of the Posttraumatic Growth Inventory (PTGI). Methods This study examined the factorial and the convergent validity of the French version of the PTGI (PTGI-F). A first sample of 406 firefighters was used to test the psychometric structure of the PTGI. A second sample of 210 first responders was then used to test its convergent validity. Participants completed measures of growth, traumatic events, PTSD, anxiety and depression, and personality. Results The PTGI-F was unrelated to Anxiety, supporting the convergent validity of the PTGI-F. Additionally, there was a positive correlation between the PTGI-F and the PCL-C. Finally, the PTGI-F had the same five-factor structure as the PTGI. Discussion The PTGI-F appears to be a valid tool. However, the contradictions that were put froward by other translated versions suggest that the PTGI should be reconsidered and improved to better assess the growth process.
... They explain that such "growth" is born out of the crisis and the state of trauma, allowing the individuals to reexamine their values and way of life (Aflakseir et al. 2016). A reconstruction of values may also lead to changes in behavior that are appropriate to the individual's new reality posttrauma (Coroiu et al. 2016;Harding et al. 2014). ...
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The present study sheds light on the phenomenon whereby groups experience adversity, following which they show signs of growth. We propose the conceptualization of post-traumatic growth as a phenomenon that also exists at the group level, “community post-traumatic growth” (CPTG). The concept of CPTG is explained using a case study on the ultra-Orthodox Jewish community in Israel following the first wave of the coronavirus disease 2019 (COVID-19) pandemic. The study describes shared characteristics of Israeli ultra-Orthodox society and the crisis it experienced during the first wave of the COVID-19 pandemic, both in terms of physiological features such as the relatively high proportion of affected people and in terms of psychological characteristics such as the shut-down of synagogues and yeshivas, and the perceived discrimination they experienced from the general population in Israel. The present study views the sense of discrimination as a traumatic factor at the group level. In total, 256 participants completed online questionnaires examining three hypotheses: (1) sense of discrimination (trauma) will be correlated with level of CPTG; (2) the level of identification with the ultra-Orthodox culture will be positively related to CPTG, while the level of identification with Israeli culture will be negatively correlated with CPTG; (3) the level of life satisfaction of the individual will be predicted by CPTG. The results supported the hypotheses and are discussed at length in the discussion section.
... According to , PTG is defined as positive psychological changes that occur after the experience of highly challenging life situation. Cognitive reconstruction to formulate a new identity is assumed to be underlying the process of PTG [30]. People with mental health concerns, including experiences of psychosis, are known to experience PTG [12,31]. ...
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Background Delivery of recovery-oriented mental health practice is fundamental to personal recovery. Yet, there is lack of service users’ accounts on what constitutes mental health recovery in Egypt. Objectives The aim of this study was to explore mental health recovery meaning informed by people with personal experience of recovery. Methods A phenomenological research design was used. Semi-structured qualitative interviews were conducted with 17 adult community-dwelling individuals who identified as recovered/recovering from mental health issues. An inductive thematic analysis approach was used to analyses participants’ responses. Results Participants predominately reported personal and functional definitions of mental health recovery. Posttraumatic growth was the strongest theme comprising: relation to others, spirituality, new possibilities, identity & strengths, and appreciation of life. Themes of acceptance and forgiveness, functional and clinical recovery, and finding hope were also identified. Conclusions This is the first study to explore mental health recovery meaning among a sample of people with lived experience of mental health issues in Egypt. Findings suggest that developing and implementing psychosocial interventions to support posttraumatic growth among people with mental health issues is a priority.
... Various factors other than the trauma itself may affect people's reactions to trauma, e.g. stress levels before the trauma [8,16] and current stress [17]. Furthermore, relief, adaptability, what the person considers important, life-satisfaction and positivity are also key factors when it comes to individual response to trauma [17]. ...
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Background Many people experience psychological trauma during their lifetime, often negatively affecting their mental and physical health. Post-traumatic growth is a positive psychological change that may occur in an individual after having processed and coped with trauma. This journey, however, has not been studied enough. Aim The purpose of this phenomenological study was to explore people's experience of suffering psychological trauma, the personal effects of the trauma and the transition from trauma to post-traumatic growth. Methods A purposeful sample of seven women and five men, aged 34–52, were selected whose backgrounds and history of trauma varied, but who had all experienced post-traumatic growth. One to two interviews were conducted with each one, in all 14 interviews. Results This study introduces a unique mapping of the challenging journey from trauma to post-traumatic growth through lived experiences of people who have experienced trauma as well as post-traumatic growth. Participants had different trauma experience, but their suffering shaped them all as persons and influenced their wellbeing, health and view of life. Participants described post-traumatic growth as a journey, rather than a destination. There was a prologue to their journey which some described as a hindering factor while others felt it was a good preparation for post-traumatic growth, i.e. to overcome difficulties at an early age. Participants described six main influencing factors on their post-traumatic growth, both facilitating and hindering ones. They also described the positive personal changes they had undergone when experiencing post-traumatic growth even though the epilogue also included heavy days. A new theoretical definition of post-traumatic growth was constructed from the findings. Conclusion The results suggest that the journey to post-traumatic growth includes a recovery process and certain influencing factors that must be considered. This information has implications for professionals treating and supporting people who have suffered traumas.
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Suffering intimate partner violence (IPV) is a devastating personal experience and post-traumatic growth (PTG) is a positive, psychological change in a person, following trauma such as IPV. There is a gap in the literature when it comes to theories on PTG after surviving IPV. The aim of this theory development was to synthesize an approach to understanding the PTG journey of female IPV survivors. According to our theory, their PTG journey includes eight main components: 1. The women's early experience of trauma, 2. The consequences of that trauma, 3. Their experiences of IPV, 4. The consequences of IPV, 5. The facilitating factors to PTG, 6. The hindering factors to PTG, 7. Their experience of PTG, and 8. The lingering effects of IPV. According to our findings, PTG is a real possibility for female IPV survivors, and it is likely to improve their mental health, well-being, and quality of life, as well as that of their children, loved ones, and communities, thereby decreasing the damaging effects of IPV. The theory can be useful for professionals when guiding female survivors of IPV to promote their recovery and healing. Due to the lack of research in this field, additional research is needed to further develop this theory.
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Purpose Cancer is a stressful life event that can lead to specific posttraumatic reactions. Posttraumatic stress symptoms (PTSS) and posttraumatic growth (PTG) are two main posttraumatic reactions that are related to each other, and both have different correlates. Methods The linearity of the relationship between PTG and PTSS and the different socio-demographic, cancer-related, emotional, and psychological correlates were analyzed in patients with cancer (N = 126). Results The relationship between PTG and PTSS was found to be more curvilinear than linear. PTSS was more strongly related to psychological factors (e.g., anxious preoccupation, hope-helplessness, and resilience) while PTG was strongly related to existential factors (e.g., self-transcendence and religiosity). Conclusion The results show that cancer-related PTSS and PTG are specifically related constructs which are related differently to particular correlates. Specifically, the greatest differences were observed in the psychological variables. In the early phases, therapeutic interventions focused on variables related to PTSS can lead to the reduction of PTSS. In follow-up phases, the therapeutic intervention focused on the increase of the level of variables related to PTG can help the development of PTG.
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tdráttur Bakgrunnur rannsóknir á afleiðingum sálraenna áfalla hafa aðallega beinst að neikvaeðum afleiðingum þeirra. Tilgangur þessarar rannsóknar var að auka þekkingu og dýpka skilning á reynslu fólks af sálraenum áföllum og auknum þroska í kjölfar þeirra. Aðferð rannsóknaraðferðin var fyrirbaerafraeðileg og gögnum safnað með einu til tveimur viðtölum við 12 einstaklinga sem orðið höfðu fyrir sálraenu áfalli og náð auknum þroska í kjölfarið, samtals 14 viðtöl. Þátttakendur voru 34-52 ára, fimm karlar og sjö konur. Niðurstöður Titill rannsóknarinnar; "Eins og að fara niður svarta brekku og koma svo upp graena hlíðina," er orðrétt lýsing eins þátttakanda á þeirri lífs-reynslu að verða fyrir sálraenu áfalli og ná meiri þroska í kjölfar þess. Þetta lýsir vel þeirri erfiðu vegferð sem áfallið var upphafið að. Þátt-takendur misstu fótanna við áfallið en töldu innri þaetti á borð við þrautseigju, seiglu, og hugrekki til að horfast í augu við líðan sína, skipta mestu máli í úrvinnslu þess. Öll urðu þau fyrir frekari áföllum á vegferðinni, höfðu mikla þörf fyrir stuðning og umhyggju, og sögðu frá jákvaeðum áhrifum þess að takast á við ný verkefni. allir þátttak-endur töldu upphaf aukins þroska tilkomið vegna innri þarfar fyrir breytingar. Sá aukni þroski sem þau upplifðu fannst þeim einkennast af baettum og dýpri tengslum við aðra, meiri persónulegum þroska, jákvaeðari tilveru, aukinni sjálfsþekkingu og baettri sjálfsmynd. Þátt-takendur lýstu "þungum dögum" þrátt fyrir meiri þroska en fannst þau engu að síður standa uppi sem sigurvegarar. Ályktanir rannsóknarniðurstöður benda til þess að það að verða fyrir áfalli sé verulega krefjandi lífsreynsla en að tilteknir innri þaettir séu forsenda aukins þroska í kjölfar áfalls. Mikilvaegt er að hjúkrunarfraeðingar og annað fagfólk bregðist við áföllum skjólstaeðinga sinna með snemm-taekri greiningu og íhlutun, ásamt stuðningi, umhyggju og eftirfylgni. Lykilhugtök: geðhjúkrun, sálraent áfall, aukinn þroski í kjölfar áfalls, fyrirbaerafraeði, viðtöl. Inngangur Stór hluti fólks verður fyrir einhvers konar áföllum á lífsleiðinni og hafa rannsóknir sýnt að sálraen áföll geta átt stóran þátt í þróun ýmissa sálraenna vandamála (Boals o.fl., 2013; Brown o.fl., 2014; Dar o.fl., 2014). rannsóknir á afleiðingum sálraenna áfalla hafa að miklu leyti snúið að neikvaeðum afleiðingum þeirra en til að fá betri heildarmynd af því sem gerist í raun og veru eftir slíkt áfall er þörf á að rannsaka jákvaeðar afleiðingar þeirra nánar. Sálraent áfall (e. psychological trauma) er upplifun einstak-lings af atburði eða aðstaeðum þar sem hann naer ekki að sam-þaetta og höndla tilfinningalega reynslu sína eða upplifir ógn við líf, líkamlegt eða andlegt heilbrigði sitt (Pearlman og Saak-vitne, 1995). Við sálraent áfall geta ýmsar neikvaeðar tilfinningar kviknað, s.s. sektarkennd, skömm, kvíði, depurð eða þunglyndi (Beck o.fl., 2015; Boals o.fl., 2013) og haetta á tilfinningalegum skaða eykst eftir því sem áhrif atburðarins á líf viðkomandi eru 86 tímarit hjúkrunarfraeðinga • 1. tbl. 94. árg. 2018 hulda Saedís Bryngeirsdóttir, Starfsendurhaefingu norðurlands, aðjúnkt við heilbrigðisvísindasvið háskólans á akureyri Sigríður halldórsdóttir, Prófessor og deildarformaður framhaldsnámsdeildar, heilbrigðisvísindasvið háskólans á akureyri "Eins og að fara niður svarta brekku og koma svo upp graena hlíðina": Reynsla fólks af auknum þroska í kjölfar sálraenna áfalla Nýjungar: rannsóknarniðurstöðurnar auka þekkingu og dýpka skilning á þeirri vegferð að verða fyrir sálraenu áfalli og ná meiri þroska í kjölfar þess sem getur nýst hjúkrunarfraeð-ingum í starfi. Hagnýting: Mikilvaegt er að sýna þeim sem lent hafa í áföllum stuðning og umhyggju. Það getur haft jákvaeð áhrif á vegferð þeirra til þroska. Þekking: geðhjúkrunarfraeðingar og annað fagfólk geta notað niðurstöðurnar sem grunn að samraeðum við skjól staeðinga sem orðið hafa fyrir áfalli til að meta áhrif áfallsins og til að hjálpa viðkomandi að ná auknum þroska í kjölfar þess. Áhrif á störf hjúkunarfraeðinga: fraeðslu-og stuðningshlut-verk hjúkrunarfraeðinga er mikið gagnvart fólki sem lent hefur í sálraenum áföllum, t.d. í kjölfar skyndilegra veikinda og slysa. Baett þekking hjúkrunarfraeðinga á áhrifum sálraenna áfalla og hvernig einstaklingurinn getur náð auknum þroska í kjölfar þeirra er því mikilvaeg.
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