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fpsyg-10-00177 January 31, 2019 Time: 18:46 # 1
CONCEPTUAL ANALYSIS
published: 04 February 2019
doi: 10.3389/fpsyg.2019.00177
Edited by:
Changiz Mohiyeddini,
Northeastern University, United States
Reviewed by:
Valentina Tesio,
University of Turin, Italy
Josef Jenewein,
Psychiatric Clinic Zugersee,
Switzerland
*Correspondence:
Cristian Ochoa Arnedo
cochoa@iconcologia.net
Specialty section:
This article was submitted to
Clinical and Health Psychology,
a section of the journal
Frontiers in Psychology
Received: 02 July 2018
Accepted: 18 January 2019
Published: 04 February 2019
Citation:
Ochoa Arnedo C, Sánchez N,
Sumalla EC and Casellas-Grau A
(2019) Stress and Growth in Cancer:
Mechanisms and Psychotherapeutic
Interventions to Facilitate
a Constructive Balance.
Front. Psychol. 10:177.
doi: 10.3389/fpsyg.2019.00177
Stress and Growth in Cancer:
Mechanisms and Psychotherapeutic
Interventions to Facilitate a
Constructive Balance
Cristian Ochoa Arnedo1,2,3*, Nuria Sánchez4, Enric C. Sumalla1and
Anna Casellas-Grau1,2
1Psycho-oncology Unit, Institut Català d’Oncologia, L’Hospitalet de Llobregat, Barcelona, Spain, 2Institut d’Investigació
Biomèdica de Bellvitge, Barcelona, Spain, 3Clinical Psychology and Psychobiology Department, Universitat de Barcelona,
Barcelona, Spain, 4Hospital Clínic de Barcelona, Barcelona, Spain
Post-traumatic stress and growth are common responses to adverse life events such
as cancer. In this article, we establish how cancer becomes a “fertile land” for the
emergence of stress and growth responses and analyze the main mechanisms involved.
Stress-growth responses on adjusting to cancer is potentially determined by factors like
the phase of the illness (e.g., initial phases vs. period of survivorship), patient’s coping
strategies, meaning-making, and relationships with significant others. We also review the
mechanisms of constructive and adaptative stress-growth balances in cancer to study
the predictors, interrelated associations, triggering mechanisms, long-term results, and
specific trajectories of these two responses to cancer. Finally, we update the evidence
on the role of these stress-growth associations in psychologically adjusting to cancer.
Together with this evidence, we summarize preliminary results regarding the efficacy
of psychotherapeutic interventions that aim to facilitate a constructive psychological
balance between stress and growth in cancer patients. Recommendations for future
research and gaps in knowledge on stress-growth processes in this illness are
also highlighted. Researchers are encouraged to design and use psychotherapeutic
interventions according to the dynamic and changeable patients’ sources of stress and
growth along the illness. Relevant insights are proposed to understand the inconsistency
of stress-growth literature and to promote psychotherapeutic interventions to facilitate a
constructive balance between these key responses in cancer.
Keywords: cancer, post-traumatic growth, post-traumatic stress, oncology, vicarious growth, secondary growth,
psychotherapy
INTRODUCTION
Three stages can be identified in the history of research on psychological responses to
adverse/traumatic situations such as cancer (Vázquez et al., 2014). The first stage, which goes
from 1980 to the early 1990s, was lead by the trauma definition in DSM-III (American Psychiatric
Association, 1980) in relation to vulnerability to stressors. During this stage, most studies were
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focused on the negative effects of trauma (Bonanno et al., 2010).
The second stage took place during the mid-1980s, when it
was found that serious life events do not necessarily cause
mental disorders. For example, it was reported that despite
significant national differences being largely unexplained, most
participants (35–65%) showed being resilient when confronted
with adverse events (Bonanno et al., 2011). We are currently in
the third stage of research that focuses on positive aspects and
growth resulting from traumatic experiences. The culmination
of these changes is reflected in the profound transformation
of the psychopathological conceptualization of trauma response
in the fifth version of the “Diagnostic and Statistical Manual
of Mental Disorders” (2013). In DSM-V, the new diagnostic
category “Trauma and Stress-Related Disorders,” that includes
both “post-traumatic stress disorder” (PTSD) and “adaptive
disorder” (AD), redefines the concept of a traumatic event in a
more restrictive manner. Thus, the new definition emphasizes
that a traumatic event must refer directly to an exposure to a
near–death experience, serious injury or sexual violence.
Cancer diagnosis, first recorded as a trauma in DSM-IV
(American Psychiatric Association, 1994) is no longer considered
a traumatic event. Currently, a medical event has to be urgent
and catastrophic before it can be considered traumatic. Thus,
existing therapies in oncology that improve prognosis and
considerably increase survival rates make it difficult to define
cancer diagnosis as a trauma (Brewin et al., 2009). Cancer is
now redefined as a powerful stressor, but it does not have the
potential to generate PTSD, except in very specific cases. The
cancer patient’s own symptomatology, such as hyperactivation,
avoidance and intrusion that were previously linked to PTSD, is
now reconsidered under other diagnoses such as AD, generalized
anxiety or somatized stress, with PTSD relegated to the
background (Kangas, 2013). Moreover, the definition of trauma
in DSM-IV (1994) included the type of response generated by
the adverse event, requiring an emotional reaction of horror and
intense fear for an event to be considered traumatic. In the new
DSM-V (American Psychiatric Association, 2013), the subjective
response of the patient is explicitly denied as a defining element
of trauma, the objective characteristics of the event being the
central criteria in understanding the trauma. Thus, the frequently
catastrophic emotional experience in a patient diagnosed with
cancer is no longer a defining characteristic of trauma (Pai et al.,
2017).
The reformulation of criterion A in DSM-V (2013) could
have important repercussions in the field of psycho-oncology in
two different ways. First, it questions much of the theoretical
apparatus from which the response to cancer diagnosis
is addressed. According to Janoff-Bulman (1992), traumatic
experience is characterized by the destruction or alteration of a
whole series of basic beliefs about oneself, the world and others
that allow the subject to generate a sense of security and meaning
around their existence. Cancer diagnosis as a trauma, by affecting
these basic beliefs, could generate feelings of insecurity and fear
of the future, hinder interpersonal relationships or question one’s
own value as a person, among other responses. However, if
the cancer is stripped of its traumatic characteristics to become
a simple stressor or adverse event, as posited by the new
criterion A, the response associated with the trauma should be
reconsidered under the adaptative response parameters. Second,
all the reflections and practices focusing on the experience of
cancer as a post-traumatic response (Rustad et al., 2012) should
be reconsidered and reformulated as AD, as indicated by Kangas
(2013), including stress and growth experiences as a common and
clear moderator of psychological adaptation in cancer.
In this paper, we review the evidence to clarify and
understand stress/growth responses in psychological adaptation
during and after cancer treatment. First, we will perform
a contextual analysis of cancer as a stressor with common
factors that trigger trauma and growth. Second, we will
review the mechanisms of constructive and adaptative stress-
growth balances in cancer (cancer process, coping, meaning-
making and relational syntony). Finally, we will detail growing
evidence regarding psychotherapeutic interventions that facilate
constructive stress-growth balances in cancer patients.
CANCER AS A STRESSOR AND
COMMON FERTILE LAND FOR TRAUMA
AND GROWTH: A CONTEXTUAL
ANALYSIS
Within popular, mostly Western, culture, responses to adverse
events such as cancer are increasingly being simplified into
“being positive” or “being negative.” The scientific literature has
contributed to this simplification, attributing positive responses
to “growth” and negative ones to “stress-trauma.” The belief that
traumatic and growth responses are independent and opposite
to one another is a common error when interpreting outcome in
diverse cancer studies. In this section, we will review the elements
of cancer that help better understand the common and different
bases of stress and growth within the same framework of human
experience of the disease (Joseph and Linley, 2006).
In order to show a clear overview and analysis of stress-growth
processes we decided to use a dichotomic conceptualization
of these two extreme responses, to dilucidate their role in
psychological cancer adaptation. However, numerous cancer
survivors are resistant to or resilient against cancer related stress.
We have deliberately decided not include resilience responses in
cancer in part for the controversy over its meaning and overlap
with growth processes. Many studies on growth have equated
posttraumatic growth with resilience or considered growth a
superior psychological functioning (Sumalla et al., 2009). In
contrast, other authors suggested PTG and resilience should be
viewed as two independent constructs. Moreover they argued that
it is very unlikely for resilient persons to perform the meaning-
making narratives characteristics of growth processess (Westphal
and Bonanno, 2007).
Same Origin of Stress and Growth
Responses: Perception of
Threat/Vulnerability
The processes of post-traumatic stress and growth in cancer,
as well as in other extreme situations, have a common basis:
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the threat to one’s physical or psychological integrity (identity).
Disease severity does not show clear associations with post-
traumatic growth (PTG), however, the relationship between
stress and growth begins in the high subjective perception
of threat and vulnerability, which, in addition to an intense
emotional reaction to the severity of the event, is narrowly
associated with stress and growth in cancer patients (Cordova
et al., 2001). The degree of the threat and challenge to one’s
previous identity (basic beliefs about oneself, others and the
world) may affect the subsequent responses of stress and growth
in one’s search of a new balance and adjustment after the illness
(Janoff-Bulman, 1992).
The relationship between stress and growth is clearly
explained through the theory on the organismic valuing of
adaptation to threatening events (Joseph and Linley, 2006). In
their theory, the authors explain how both the emotional distress
(e.g., post-traumatic stress) and PTG could be integrated into
the same structure of human experience. They distinguished two
main procedures in adjusting to threatening events: assimilation
and accommodation. Assimilation focuses on the stressful event
management and the human willing to integrate this event into
one’s basic beliefs, in order to keep them from changing. This
occurs in the time around the traumatic event (peri-traumatic)
and generates appraisal meaning mechanisms that aim to control
or regulate intense emotional reactions after the event. The
maintenance of post-traumatic stress is a global indicator of
difficulties or dysfunction in the assimilation process, indicating
the need for cognitive elaboration of the information challenged
by the traumatic event (e.g., mortality). Often, to elaborate
this information, people must make changes to their basic
beliefs, which leads to the accommodation process that focuses
on creating new vital meanings. Accommodation is composed
of changes in identity that one performs when incorporating
their understanding of an extreme experience. This may either
generate meanings of chaos, absurdity or terror, resulting in
trauma (negative vital changes), or, on the contrary, generate
searches, deepening and endowing new vital meanings that result
in growth (positive life changes). However, in most cases, a
combination of both responses occurs together: trauma and
growth (Sumalla et al., 2009). The centrality that the event
has on one’s life is a triggering factor for the initiation of
these assimiliation and accommodation processes (Reiland and
Brendan Clark, 2017;Wamser-Nanney et al., 2018). As such,
the most central an event is in one’s life, the most these
processes are ought to emerge (Reiland and Brendan Clark,
2017;Wamser-Nanney et al., 2018). The next section and Table 1
clearly state cancer as an example of how these processes work in
the aftermath of trauma.
Characteristics of Cancer as a Stressor
in the Common Basis of Stress and
Growth Responses
Current and past debates about cancer as a potential traumatic
event have focused on the extent to how well cancer fits
in a biomedical model of trauma based on acute stressors.
Several authors (Smith et al., 1999;Kangas et al., 2002;Mehnert
and Koch, 2007;Sumalla et al., 2009) have emphasized the
distinctions between cancer diagnosis and treatment and other
acute adverse events. The differences between cancer and other
stressors have focused on the traumatic response, but not
on post-traumatic growth. In Table 1, we exemplify how the
characteristics of cancer could promote the usual stress-trauma
and growth responses in a common framework of human
experience. For example, the internal source of cancer (appears
in our body) partly explains hypervigilance and health anxiety
(stress response), which trigger self-care and the adoption of
healthy lifestyles (growth). Psycho-oncological treatments and
natural adaptation processes promote a balanced response of a
salutogenic consciousness of one’s body (alert) to promote better
self-care, without seeing the body in constant danger.
MECHANISMS OF CONSTRUCTIVE AND
ADAPTATIVE STRESS-GROWTH
BALANCES IN CANCER
The paradoxical coexistence of posttraumatic stress and PTG
in cancer is one of the most interesting areas with very few
substantial clinical investigations (Sumalla et al., 2009;Ochoa
et al., 2017). The first set of studies in this field explored the
association between stress and growth, finding significant and
positive associations between them (Bower et al., 2005;Kilmer
et al., 2009;Xu and Liao, 2011;Lowe et al., 2013;Liu et al., 2018).
The interpretation of this association remains unclear. For some
authors, this association indicates that the complex combination
of being conscious and having both negative and positive
experiences may represent evidence of real growth (Butler, 2007).
However, other authors doubt the adaptive value of growth and
consider its illusory face (Zoellner and Maercker, 2006). The
TABLE 1 | Cancer characteristics and stress-growth responses.
Cancer
characteristics/responses
Stress-Trauma response (negative changes) Growth response (positive changes)
Internal source (body) Body hypervigilance and alert (health anxiety). Self-care and adoption of healthy lifestyles.
Future perception of threat Feeling of limited future. Change of life priorities and greater appreciation for life.
Permanent, undefined threat
(complexity)
Ongoing threat, existential trouble and Sword of
Damocles syndrome.
Maintenance of structural identity changes.
Perceived control Guilt and shame. Responsibility and involvement in the process (adherence to treatment).
Invalidating sequels Incomprehension, loneliness, alienation. Need for others, gratitude, closeness and openness.
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second set of studies found no significant relationship between
the psychological responses of stress and growth (Cordova et al.,
2001). This has been interpreted as an indicator of the need
to view stress and growth as two separate processes (Salsman
et al., 2009;Shakespeare-Finch and Lurie-Beck, 2014). However,
the third set of studies and reviews showed a more negative
correlation between stress and growth (Frazier et al., 2001;Sawyer
et al., 2010;Hall et al., 2015). In general, these third set of studies
results highlighted the adaptive value of growth as a buffering and
direct effect in reducing stress and discomfort (Wang et al., 2014).
All these results demonstrate that a clearer conception on the
combination of stress and growth responses and the role they
play in the positive adjustment to cancer are needed. Zoellner
and Maercker (2006) introduced the distinction between the
constructive and illusory aspects of PTG, which other authors
have associated with positive real or illusory changes (Sumalla
et al., 2009). Constructive growth describes the functional aspects
of positive changes, while illusory growth defines dysfunctional
or self-deceptive growth. The model assumes that the two aspects
of PTG can simultaneously occur and are likely to involve
different paths and mechanisms. Constructive growth is more
probable to produce positive adaptation at long term, while
illusory PTG offers short-term relief that is likely to decrease over
time (Zoellner et al., 2008).
To explore the different adaptative significance of this
paradoxical coexistence and explain the relevant mechanisms and
factors associated with the constructive and adaptative stress-
growth balances in cancer, we analyzed the role of time and
the càncer process, coping and emotional regulation, continuity
and coherence of meaning-making, and relational stress-growth
syntony.
Time and the Cancer Process
Studies focusing on how stress and growth interact during the
cancer process report contradictory outcomes. The different
adaptive and dynamic meanings of the combination of stress and
growth during the entire cancer process can help us understand
and clarify their role in the process of facing and adapting to
cancer.
The coexistence of stress and growth in the initial stages
of cancer (diagnosis and treatment) has been linked to its
illusory nature, seen as cognitive avoidance and a short-term
palliative coping strategy that is lost over time (Sumalla et al.,
2009). A similar palliative or buffering effect has been found in
predictive studies. Although these studies found that growth is
more likely to produce long-term positive psychological effects
and less subsequent distress (Carver and Antoni, 2004), others
observed that growth predicted either higher distress or that it
was unrelated to future distress (Tomich and Helgeson, 2004;
Bower et al., 2005). In fact, a longitudinal study by Lechner
et al. (2006) showed that current growth (measured as a search
for benefits) did not indicate reduced current or future stress,
but the increase in growth over time was associated with a
decrease in stress. In other words, it is the dynamic process of
increasing growth throughout the illness (learning) that predicts
the decrease in stress and not the early willingness to change when
the threat is still current, this growth having a more defensive and
illusory role.
Wang et al. (2017) recently reported some results that
could explain the controversial results of Lechner et al. (2006)
involving a common moderator between the stress and growth
responses in cancer, perceived vulnerability. The authors referred
to vulnerability as negative changes in the perception of physical
vulnerability, which included the fear of cancer recurrence,
concerns about the side effects of cancer treatment concerns,
and feeling the world as a more unsafe place. In the study, the
only relationship between PTG and distress might have been
shadowed by the positive association between stress-growth and
vulnerability. Thus, extremely narrowing the focus on growth or
stress can channel to a misleading conclusion about adjusting
to the illness (Bellizzi et al., 2007;Park and Blank, 2012).
Wang et al. (2017) showed that growth independently predicted
lower distress or stress over time after having controlled for
vulnerability, confirming the adaptiveness of growth to reduce or
buffer against stress in cancer.
Based on the abovementioned data, psychological treatments
in cancer may need to be tailored according to stress-growth
and time (Ochoa et al., 2017). In the initial phases during
diagnosis and primary cancer treatment, vulnerability is linked
to the need to increase emotional awareness and regulation
with psychoeducation or stress management. In these stages,
stress management and psychoeducational therapies focused on
understanding and reducing the threat of the initial stressors
(surgical intervention, chemotherapy and radiotherapy) would
be suitable, as patients are in the assimiliation process. After
primary cancer treatment, it would be more relevant to provide
therapies facilitating growth such as meaning-making therapies,
as patients begin to accommodate their experience and become
open to considering vital changes.
Coping and Emotional Regulation
The numerous studies that link coping with stress and growth
in cancer reveal the importance of coping styles in cancer-
related stress and growth. These responses are triggered by
the self-assessment of cancer as a potential traumatic or
threatening stressor (Cordova et al., 2007;Andrykowski et al.,
2015), generating automatic rumination that increases stress.
Depending on the coping strategies used, this automatic
rumination can increase stress (trauma) or elicit deliberate
rumination that leads to a re-elaboration of the experience into
positive life changes (growth).
Post-traumatic stress symptoms and PTSD have been linked
to non-adjusted coping strategies (Jacobsen et al., 2002), such
as anxious worrying (Pérez et al., 2014), cognitive avoidance,
helplessness, fatalism (Pérez et al., 2014), self-blame, denial, and
behavioral disengagement (Richardson et al., 2016;Langford
et al., 2017). Furthermore, PTG has been directly linked to
the patient’s active coping strategy (Bellizzi and Blank, 2006;
Lelorain et al., 2012;Svetina and Nastran, 2012;Tong et al., 2012;
Danhauer et al., 2013) problem solving (Widows et al., 2005),
positive reappraisal (Sears et al., 2003;Carver and Antoni, 2004;
Urcuyo et al., 2005;Widows et al., 2005;Lechner et al., 2006),
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religious coping (Urcuyo et al., 2005;Jim et al., 2006;Lechner
et al., 2006;Gall et al., 2011), and acceptance (Urcuyo et al., 2005).
We therefore conclude that PTG could be linked to active
coping, focusing on both the problem and the emotion, while
PTSS/PTSD could be associated with dysfunctional avoidance
coping. There are few studies exploring the role of coping as a
mechanism to elucidate constructive/adaptive or illusory stress-
growth balances in cancer. Available data show that during the
initial assimilation process of adjustment, when coping strategies
focus on the emotion (stress), the coexistence of growth is
usually temporary and does not imply a change in one’s belief
system (Sumalla et al., 2009). This process could be related to
an illusory PTG, which is defensive and temporarily produces
a positive emotional state and reduces stress. However, these
emotional states are not maintained over time. Accommodation
and constructive growth are more likely to maintain meaning-
based coping processes, involving an active search for meaning
that would lead to more general, deep and stable changes in one’s
perception about oneself, others and the world. Accommodation
is fundamental in constructive PTG and is associated with
active coping that includes positive reappraisal, acceptance and
behavioral changes sustained over time (Pat-Horenczyk et al.,
2015). Furthermore, the flexibility of coping could also be
important in developing constructive PTG (Pat-Horenczyk et al.,
2016).
Some longitudinal data dispute these general processes of
assimilation and accommodation. For example, there are studies
showing that those who use coping styles that facilitate emotional
expression and communication in stressful events during the
early moments of diagnosis and treatment show better growth
and less stress later (Manne et al., 2004). Therefore, patients who
show high and rapid emotional re-elaboration, together with a
meaning-making coping style, tend to report high growth scores
that reflect an early and constructive growth as a result of deep
pre-conception and pre-cancer beliefs, which are praised and
prioritized after the disease. A sentence that exemplifies these
situations is: “I always thought that I had to prioritize the family
and now it has become a pressing vital change to do because of
the disease.” Moreover, Pat-Horenczyk et al. (2015) emphasized
the importance of the temporal dimension. PTG develops during
a process of dynamic and changing adjustment, with individuals
experiencing illusory and constructive PTG as subsequent steps
in the adjustment process.
Giving Meaning to the Experience:
Continuity and Coherence of
Meaning-Making Narratives
Stress and growth are responses that are closely linked to events
that psychologically challenge one’s basic beliefs. That is, they
question the basic psychological framework of understanding
and the meaning to life (Janoff-Bulman, 1992). Finding meaning
in life is one of the primary motivations of a human being.
Meaning-making is a process by which people create, understand
or give meaning to events in life, relationships and oneself.
It is considered essential in adjusting to stressful situations
(Gillies and Neimeyer, 2006). In her review of the studies
on meaning-making, Park (2010) synthesized the concept of
meaning as “meaning connects things.” Cancer survivors,
attempting to bring coherence and continuity to their life
experience, may look forward to integrating and giving answers
to the traits of their life that are challenged by their illness. Park
(2010) distinguished two components in the process of meaning-
making: (a) the meaning-making process, which includes coping
efforts to understand the stressor (appraised meaning) and
include it in the individual’s global belief system and (b) the
products of this process, the meaning made, which are the final
results of the search for meaning. The most important within
these meanings would be (1) the perception of PTG, (2) a sense
of meaning of the deeper life, and (3) the restoration or reduction
of the inconsistency of just-world beliefs.
Empirical studies on people with cancer show inconsistent
results regarding the role of meaning-making in the psychological
adjustment to cancer. In some papers, the search for meaning
has been related to better adjustment and quality of life (Davis
et al., 1998;Sears et al., 2003;Bower et al., 2005). However,
in other studies, searching for meaning has been associated
with higher levels of stress and a lack of adjustment. Other
studies show that meaning-making moderates the effects that
intrusive thoughts (Park et al., 2010) and social and physical
functioning (Jim and Andersen, 2007) have on stress. Some
researchers claim that people who do not try to find a meaning
are equal or even better than those who do (e.g., Bonanno et al.,
2005). Some theorists point out that meaning-making only favors
psychological adaptation and reduces stress when a meaning is
found (Segerstrom et al., 2003). While meaning-making does not
result in any change that reduces the inconsistency with global
meaning, it does positively correlate with stress. If results are
satisfactory (meaning made), the need to continue searching for
meaning ends and, so, the stress ends. Meaning-making may not
be adaptive if it is highly intensive and maintained over a long
period without any result (Joseph et al., 2005). In conclusion,
although the search for new meaning is the basis of PTG for
most patients, meaning-making could be more constructive and
adaptive if it solves and canalizes unproductive ruminations
about, for example, the fear of cancer recurrence or other threats
(cognitive post-traumatic stress symptoms) (Ochoa et al., 2017).
It is widely accepted in clinical settings that the way to reduce
post-traumatic stress and improve PTG in meaning-making
interventions is by creating sustainable continuity and coherence
with pre-cancer identity narratives, now enriched and integrated
with information on threat and mortality (Ochoa and Casellas-
Grau, 2015). New approaches, such as positive psychotherapy,
propose new strategies to work with in the search for meaning in
cancer. In positive psychotherapy, the construction of continuity
and biographical coherence is not only carried out by working
with traumatic memories, but through the recovery of positive
autobiographical memories and establishing patterns of personal
fulfillment (Serrano et al., 2004;Ochoa et al., 2010). These
patterns link relevant aspects from the past, present and future
(Guidelines of Personal Realization), reducing stress and favoring
PTG in cancer (Ochoa et al., 2010;Vázquez et al., 2014).
Some authors summarized the role of the search for meaning
in stress/growth responses in a comprehensive way (Bauer and
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McAdams, 2004). This search for meaning in situations that
promote stress/growth may be better understood as a process
during which a narrative that explains how the person has been
positively transformed by the traumatic event is constructed and
then integrated into an identity-defining life story. For them
Bauer and McAdams (2004) the life story about suffering should
not be “just one piece of the complex puzzle of posttraumatic
growth (. . .) but rather as the fundamental frame that holds the
entire puzzle together.”
Relational Stress-Growth Syntony
One of the foundations for our psychological life is the desire
for interpersonal relationships. Then, personal stress and growth
responses should be regarded as being linked to the deterioration
and optimization of interpersonal relationships. To understand
stress-growth responses, as well as their triggering mechanisms
and their balancing adaptive value during the cancer process, it is
necessary to know the relational impact of a patient’s significant
others. Cancer may constitute a stress/growth experience for
both patients and their significant others with whom share the
experience of the illness (Ochoa et al., 2013). An increasing
amount of research have reported the presence of distress or stress
among cancer patients’ significant others, especially partners
(Hodges et al., 2005) and the parents of children or teenagers
suffering from cancer (Landolt et al., 2003;Ozono et al., 2007).
Moreover, patients’ significant others and caregivers have also
been reported to experience growth and positive changes (Weiss,
2004a;Cadell, 2007;Zwahlen et al., 2010;Moore et al., 2011),
indicating that the effects of trauma and growth in the aftermath
of disease are not exclusive from survivors, as they also have
relevant effects on those accompanying or helping them, or
even those who simply witness their suffering. The relevant
factors in relational stress-growth responses between cancer
survivors and their significant others are: independent or shared
relational stress-growth responses, the direction of this influence,
and corroboration/congruence between them to discriminate
between constructive and adaptive relational combinations. In
Table 2, we have adapted and extended the contents of our
first review (Ochoa et al., 2013) on how cancer could become a
secondary traumatic stress/growth (independent of the trauma
or growth in the cancer patient) or a vicarious stress/growth
(transmitted and related to the trauma and growth in the cancer
patient) event in the significant others. Moreover, our adaptation
helps to elucidate some key points in relational stress/growth
responses between cancer survivors and their significant others to
discriminate between constructive stress/growth combinations.
Overall, Ochoa et al. (2013) reported significant correlations
between the stress/growth responses of cancer survivors and their
partners. However, a more detailed analysis revealed that the
mechanism of stress/growth “transmission” to the partner of a
cancer patient differed depending on gender. Growth in men
who had a female partner with cancer was lower than that in
the patient but was predicted by and depended more on the
growth of their female partner, suggesting vicarious learning or
transmission (Pakenham, 2005;Ackroyd et al., 2011). By contrast,
stress/growth in women who had a male partner with cancer
was similar to or greater than that in the patient, which could
emerge in different dimensions to that of their spouse (Thornton
and Perez, 2006;Ruf et al., 2009;Zwahlen et al., 2010). For
example, Ruf et al. (2009) found that, on the one hand, women
placed greater emphasis on the improvement of their marital
relationship (reporting increased intimacy and communication),
while, in the other hand, male patients focused the description
of positive changes in their family relationships and friendships,
rather than in their marital relationship. Other studies have
reinforced this gender effect, especially in growth responses.
Female cancer survivors can transmit more growth to their
partners and female partners of male cancer survivors can show
more growth than their partners. Moreover, growth in female
breast cancer survivors can be induced by other women with
breast cancer more than by their own husbands (Weiss, 2004a,b).
Studies on the predictors of stress/growth responses in couples
have only found two common shared factors: positive reframing
and age (Ochoa et al., 2013). Age may favor a shared stress/growth
response probably because, for both parties, cancer may be a
very disruptive unexpected event in young people (trauma) and
TABLE 2 | Distinction between secondary and vicarious stress/growth responses.
Cancer survivors/significant others Secondary posttraumatic stress/growth Vicarious posttraumatic stress/growth
Does the significant other’s stress/growth result
in definitive changes in their life?
This is a primary stress/growth and is more significant than
for the survivor.
The degree of stress/growth is the same as for the
survivor.
Who initiates and generates the stress/growth
responses?
They are initiated by the significant other and how the fact
challenges their identity.
They are initiated by the survivor’s PTG, which
predicts, drives or affects the significant other’s
PTG.
Are there asymmetrical processes of
stress/growth transmission?
Stress and growth are parallel or symmetrical. The
significant other’s stress and growth may be greater than
the survivor’s.
Asymmetrical. From the survivor to the significant
other, through observational, relational, modeling,
transmission or imitation learning.
Are the sources and dimensions of
stress/growth similar or different? Is there
harmony and synchrony within the answers?
No. As they are independent processes, stress and growth
may arise for different reasons and in non-shared
dimensions.
Yes. Stress/growth arises from similar sources and
dimensions. There is harmony and synchrony in the
answers.
Importance of relational and family variables They are not important. Stress/growth responses are
autonomous and independent, and so are essentially an
intrapersonal process.
They are the basis of the significant other’s
stress/growth. These variables predict and mediate
the changes in both the significant other and the
survivor, as growth is an essentially interpersonal
process.
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because younger people are prone to have a greater willingness
and capacity for change (growth). Positive reframing seems to be
a mediating coping style in common stress/growth responses in
partners. The focus of positive reframing on what was achieved
instead of what was not achieved in cancer could be related to
positive peri-traumatic meaning-making being closely linked to
the PTG accommodation process.
Similar results have been reported for other close
relationships, like the parents of children or teenagers suffering
from cancer. About the 50% of these parents report stress
symptoms, and 20–25% of them meet the PTSD diagnostic
criteria (Pelcovitz et al., 1996;Ozono et al., 2007). In a
similar way, however, parents of children with cancer do also
report positive psychological changes (Barakat et al., 2010;
Hungerbuehler et al., 2011). It is not well understood how
these stress/growth responses are transmitted or shared in
parental relationships. However, there is more evidence about
the traumatic effect (stress symptoms) that these experiences
have on parents than there is for growth transmission. Indeed,
parents (especially mothers) show a greater predisposition to
report high post-traumatic stress scores than their child, despite
it was this latter who suffered the disease. Further, mothers
tend to show a higher prevalence of stress symptoms than adult
survivors of cancer, what suggest the higher traumatic nature
of the experience of having a child with cancer than the direct
experience of the disease (Smith et al., 1999;Kissane et al.,
2003). Studies examining longitudinal stress/growth processes
in fathers, mothers, and children separately have reported
interesting results. Hungerbuehler et al. (2011) reported that
mothers experienced more psychological distress than fathers
1 month after the cancer diagnosis of their child, this distress
being associated with higher levels of growth three years later
in the mothers but not fathers. Again, it seems that synchronic
emotional distress (and their expression) at diagnosis could
promote growth over time. Since it is unclear whether growth
in the mother is associated with that in the child or father, only
speculative hypothesis about its vicarious or secondary nature
can emerge. However, some studies suggest that mothers play
an essential role in transmitting stress/growth responses to the
child (Pelcovitz et al., 1996) because their responses appear to
be higher and better predictors of stress/growth responses in
children and fathers (Barakat et al., 2006;Hungerbuehler et al.,
2011). To summarize, illness in a child or teenager is more likely
to produce initial stress/trauma and future growth in mothers
than in fathers.
Data on relational stress/growth responses in cancer have
also been used to assess the real, adaptive and constructive
nature of these responses in cancer. The transmission or
corroboration of growth in the significant others of patients
indicates “real, adaptative and constructive” relational syntony
(Shakespeare-Finch and Enders, 2008;Sumalla et al., 2009;
Moore et al., 2011;Ochoa et al., 2013). However, some studies
show that memories about interpersonal growth are far from
precise (Tennen and Affleck, 2009) and may be subject to bias.
Furthermore, agreement in couples regarding growth does not
ensure the presence of a real change (Kirkpatrick and Hazan,
1994). Couples may rewrite memories and show memory bias
when recalling their shared history, highlighting positive aspects
of their emotional life which had not been recounted before.
However, this positive memory bias could have a constructive
outcome. Positively remembered experiences have been shown to
be a better predictor of well-being than the veracity or accuracy
of these memories (Wirtz et al., 2003).
Some other important mediators of these real, adaptative
or constructive stress/growth relational combinations have been
found. For example, stress/growth concordance in couples (Ruf
et al., 2009) is linked to higher mutual future growth than
discordance in couples, which results in low satisfaction in their
relationship and more separations. Other variables like flexibility,
perceived family cohesion and quality of family relationships
correlate with lower stress symptoms in teenagers with cancer
(Pelcovitz et al., 1996) and predict more growth (Hungerbuehler
et al., 2011). All these relational/family mechanisms sustain
mutual vicarious learning and support, making cancer a “family
shared seismic event” that may buffer against stress and promote
relational growth (Ochoa et al., 2013).
Personal Characteristics and the
Stress-Growth Relationship
Personal charactesristics have also been explored as underlying
mechanisms of the stress/growth relationship. A recent
systematic review (Casellas-Grau et al., 2016) concluded
that, in breast cancer, the age of patients had a distinctive
role in triggering high levels of stress, but also, promoting
posttraumatic growth. The explanation that sustains this
paradoxical relationship is the perception of cancer as more
disruptive and aggressive among younger women than in their
older peers (Kangas et al., 2005;Ochoa et al., 2013;Sharp et al.,
2018).
Future prospective research on the mechanisms of
stress/growth among close relationships in cancer is required.
Correlational data still prevail, making some interpretations
speculative. However, available data suggest a clear effect of
gender and/or role (mother vs. father). Female cancer survivors
promote more vicarious stress/growth responses in their male
partners, while female partners of male cancer patients or
mothers of children or adolescents with cancer can show even
greater stress/growth than the patients themselves. This indicates
that for women, cancer in their significant others constitutes a
secondary stress/growth process (in this case, the response being
more independent from that of the patient) and for men, cancer
in their significant others, trigger stress/growth processes that
are more vicarious and dependent of their cancer survivors loved
one. These stress/growth responses are constrained by important
aspects linked to the synchronicity of their responses (Stanton
et al., 2000). Likewise, modulating variables, such as positive
reframing, or relational variables, like relational concordance
or family cohesion, show greater capacity to generate mutual
vicarious growth and could be important in the shared reduction
of stress in cancer (Pelcovitz et al., 1996;Ruf et al., 2009;Ochoa
et al., 2013). Also the marital status and the special and concrete
social support provide by one’s partner has been a focus of
exploration among the latest literature. Studies have found that
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Ochoa Arnedo et al. Stress and Growth in Cancer
this type of social support has a stress-absorbing function for
patients in two ways: on the one hand, it buffers the negative
effects of stress, especially in the first phases of the disease, and in
the other hand, it promotes the emergence of positive emotions
due to the closer and intimate relationships, deriving in stress
reduction and growth facilitation (Salovey et al., 2000;Cohen,
2004;Kangas et al., 2005;Shand et al., 2018).
PRELIMINARY EVIDENCE FROM
PSYCHOTHERAPEUTIC
INTERVENTIONS FACILITATING
CONSTRUCTIVE STRESS-GROWTH
BALANCE IN CANCER PATIENTS
In this paper, we have shown how research on the psychological
responses to traumatic or adverse events such as cancer has been
changing to incorporate the combination of stress and growth
responses in the adjustment process. Few (recent) studies have
clarified and contextualized this combination of responses in
such a complex disease as cancer. Moreover, few articles have
proposed psychological interventions to achieve a constructive
and adaptive balance of both responses (Pat-Horenczyk et al.,
2016;Ochoa et al., 2017).
In a recent review of interventions aimed at facilitating growth
(Roepke, 2014), the authors could not find good studies that used
treatments facilitating growth. In fact, the first interventions that
managed to promote growth in patients with cancer achieved
it as a side effect, since they were designed to focus on and
target stress management (Antoni et al., 2001, 2006;Bower and
Segerstrom, 2004;McGregor et al., 2004;Penedo et al., 2006). In
addition, these interventions are performed in the initial stages
(diagnosis and treatment) of the disease when cancer stressors
are present, using a measure of growth that is closely linked to
seeking benefits during coping. These results confirm what was
explained in the previous section. Soon after cancer diagnosis,
stress and growth tend to occur together, reflecting a reaction to
perceived vulnerability. Stress management in the initial phases of
cancer could promote constructive and adaptative stress-growth,
buffering against post-traumatic stress symptoms. However, what
happens when significant stress and distress remain? Would an
intervention facilitating PTG be more suitable in cancer survivors
after primary cancer treatment than an intervention targeting
stress management?
PTG facilitation is associated with the positive psychology
scientific movement. A recent systematic review (Casellas-Grau
et al., 2014), based on positive psychological interventions for
breast cancer survivors, concluded that these interventions can
result in an increase of PTG, well-being, meaning, quality of life,
hope, optimism, happiness, benefit-finding, and, life satisfaction.
Further, the most effective interventions are those performed
with samples coming from hospitals, those which have an
individual self-help style, and those that are longer (Bolier et al.,
2013). However, none of these studies designed the intervention
to understand stress and growth in cancer, with the mechanisms
underlying these positive effects remaining unclear.
The first intervention that focused on facilitating PTG to
reduce post-traumatic stress was Positive Psychotherapy in
Cancer (PPC) (Ochoa et al., 2010;Ochoa and Casellas-Grau,
2015). The intervention was designed after having extensively
reviewed the literature exploring trauma and growth processes
in the aftermath of cancer (Sumalla et al., 2009). PPC integrates
trauma and growth into the same framework of human
experience to obtain a stress-growth balance. The effectiveness
of PPC has been proved in pilot studies. It achieves greater
reductions in emotional distress and post-traumatic stress and
facilitates PTG compared to a waiting list group (Ochoa et al.,
2017) and another cognitive behavioral stress management
therapy that improves psychosocial adjustment (Antoni et al.,
2001). In the pilot study, PPC was superior to this latter
stress management therapy in reducing post-traumatic stress,
emotional distress, and facilitating PTG at 3- and 12-month
follow-ups (Ochoa, 2012). In studies with larger samples (Ochoa
et al., 2017), the significant reduction of post-traumatic stress
favored by PPC was related to an increase of PTG. Thus, as
reported in other studies, PTG predicts better adaptation after
the disease, showing better mental health and a better physical
health subjective state (Helgeson et al., 2006;Sawyer et al., 2010).
Further, there is an association between high levels of post-
traumatic stress and a loss in the quality of life in cancer patients
(Cordova et al., 1995) and this loss is lessened by experiencing
PTG (Morrill et al., 2006). In conclusion, growth can be a
therapeutic way to enhancing quality of life in survivors.
Another similar intervention (Pat-Horenczyk et al., 2015)
studied the illusory and constructive aspects of PTG in a group
of breast cancer survivors participating in a group intervention
that aimed to build resilience. During a 6-month period, more
than half of the participants reported PTG, and the intervention
group reported a higher increase in coping and PTG than
the control group. Moreover, participants in the intervention
group reported more constructive growth (improved coping and
increased PTG) and less illusory growth (increased PTG, but no
differences in coping improvement) than those in the control
group. This demonstrates the effectiveness of interventions
that enhance coping and promote PTG. This intervention
was specifically focused on promoting self-regulation strengths,
cognitive restructuring, and active coping, while discouraging
avoidance among breast cancer survivors.
To conclude, the few intervention studies that have been
carried out to achieve a better stress-growth balance indicate
the importance of the elements reviewed in this work. First,
cancer is a stressor with common precursors for trauma and
growth, especially perceived vulnerability. Psycho-oncological
interventions focused on stress-growth responses need to
facilitate growth in relation to vulnerability (emotional awareness
and expression), as well as better self-care behavior, changing
priorities and a need for others (openness and closeness). Second,
psychological adaptation has changing sources of stress/growth
during the cancer process that influence our targets and
psycho-oncological interventions. We have detailed the most
important mechanisms of constructive and adaptive stress-
growth balances in cancer: the role of time and the cancer process,
coping and emotional regulation, continuity and coherence of
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Ochoa Arnedo et al. Stress and Growth in Cancer
meaning-making narratives, and relational stress-growth
syntony. Third, recent innovative psychological interventions
have taken into account stress/growth procesess in cancer to
facilitate a constructive balance. It should be noted that the
interventions that facilitate PTG to reduce stress are more
recommendable after cancer treatment. Moreover, interventions
must promote assimilation first and then accommodation,
prioritizing self-regulation, active coping and cognitive
restructuring, while discouraging avoidance. Accommodation
and growth are promoted by meaning-making and greater
relational syntony with the significant others of cancer patients.
FUTURE RESEARCH
These conclusions lead us to encourage future research in
developing and promoting the use of psychological interventions
based on promoting growth, especially for those patients
reporting higher levels of stress. We suggest investigating how
to properly apply these psychological interventions, taking
into account the changeable sources of stress-growth during
the cancer process. Specifically, in the first phases of the
disease, -the diagnosis and first oncologocical treatment-, it
would be necessary to focus the intervention on the stress
reduction through more directive psychoeducational therapies
and emotional regulation interventions. However, future research
should address whether the interventions that facilitate growth
in these early stages can also reduce stress. To our knowledge,
there are no current studies exploring this field. On the other
hand, after having completed the primary cancer treatment,
psychological treatment could be better focused on growth
facilitation, where peritraumatic stress associated with threat and
vulnerability around treatments are further away. In addition,
as aforementioned, social support and relational growth are
also a relevant focus of interest, given the positive synergic
influence these have on cancer patient’s process of growth
facilitation and stress reduction. For this reason, future research
should not only focus on patient itself, but also on their
significant others, feeding a positive retroalimentary circle
between them.
AUTHOR CONTRIBUTIONS
COA was a clinical psychologist, an expert in psycho-oncology
and the principal investigator. As the first author, he has been
in charge of articulating and coordinating all the work of the
rest of the authors. He has reviewed, adapted and drafted most
of the contributions, with special emphasis on sections two,
three and four. NS is a clinical psychologist expert in psycho-
oncology. Her collaboration has been based on reviewing the
role of coping and the meaning-making processes on stress and
growth processes in cancer in section three. ES was a historian,
clinical psychologist and anthropologist. His collaboration has
focused on the history, conceptualization and phenomenology of
cancer as a stressor that facilitates trauma and growth processes
in cancer. He has collaborated mainly in the introduction and in
the two tables that clarify these processes. AC-G was a PhD in
psychology and an expert in positive psychology in cancer. His
collaboration has focused on the review of interventions based
on the positive psychology in section Preliminary Evidence From
Psychotherapeutic Interventions Facilitating Constructive Stress-
Growth Balance in Cancer Patients and has given methodological
support to all authors in the bibliographic and critical search of
the paper.
FUNDING
This study was supported by the Instituto de Salud Carlos III
(Grant/Award No. FIS PI15/01278), FEDER funds/European
Regional Development Fund (ERDF) “A Way to Build Europe,”
and the Fundación Científica Asociación Española Contra el
Cáncer (Grant/Award No. AECC_Catalunya2016). Grup de
recerca consolidat: Recerca en serveis sanitaris en càncer.2014
SGR0635.
REFERENCES
Ackroyd, K., Fortune, D. G., Price, S., Howell, S., Sharrack, B., and Isaac, C. L.
(2011). Adversarial growth in patients with multiple sclerosis and their partners:
relationships with illness perceptions, disability and distress. J. Clin. Psychol.
Med. Settings 18, 372–379. doi: 10.1007/s10880-011- 9265-0
American Psychiatric Association (1980). Diagnostic and Statistical Manual
of Mental Disorders: DSM-III. Wahsington, DC: American Psychiatric
Association.
American Psychiatric Association (1994). Diagnostic and Statistical Manual of
Mental Disorders: DSM-IV, 4th Edn. Wahsington, DC: American Psychiatric
Association.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of
Mental Disorders: DSM-5. Wahsington, DC: American Psychiatric Association.
doi: 10.1176/appi.books.9780890425596
Andrykowski, M. A., Steffens, R. F., Bush, H. M., and Tucker, T. C. (2015). Lung
cancer diagnosis and treatment as a traumatic stressor in DSM-IV and DSM-5:
prevalence and relationship to mental health outcomes and DSM-5: prevalence
and relationship to mental health outcomes. J. Trauma. Stress 28, 206–213.
doi: 10.1002/jts.22005
Antoni, M. H., Lechner, S. C., Kazi, A., Wimberly, S. R., Sifre, T., Urcuyo, K. R.,
et al. (2006). How stress management improves quality of life after treatment
for breast cancer. J. Consult. Clin. Psychol. 74, 1143–1152. doi: 10.1037/0022-
006X.74.6.1143
Antoni, M. H., Lehman, J. M., Kilbourn, K. M., Boyers, A. E., Culver, J. L.,
Alferi, S. M., et al. (2001). Cognitive-behavioral stress management intervention
decreases the prevalence of depression and enhances benefit finding among
women under treatment for early-stage breast cancer. Health Psychol. 20, 20–32.
doi: 10.1037/0278-6133.20.1.20
Barakat, L. P., Alderfer, M. A., and Kazak, A. E. (2006). Posttraumatic growth in
adolescent survivors of cancer and their mothers and fathers. J. Pediatr. Psychol.
31, 413–419. doi: 10.1093/jpepsy/jsj058
Barakat, L. P., Marmer, P. L., and Schwartz, L. A. (2010). Quality of life of
adolescents with cancer: family risks and resources. Health Qual. Life Outcomes
8:63. doi: 10.1186/1477-7525- 8-63
Bauer, J. J., and McAdams, D. P. (2004). Personal growth in adults’ stories
of life transitions. J. Pers. 72, 573–602. doi: 10.1111/j.0022-3506.2004.
00273.x
Bellizzi, K. M., and Blank, T. O. (2006). Predicting posttraumatic growth in breast
cancer survivors. Health Psychol. 25, 47–56. doi: 10.1037/0278-6133.25.1.47
Frontiers in Psychology | www.frontiersin.org 9February 2019 | Volume 10 | Article 177
fpsyg-10-00177 January 31, 2019 Time: 18:46 # 10
Ochoa Arnedo et al. Stress and Growth in Cancer
Bellizzi, K. M., Miller, M. F., Arora, N. K., and Rowland, J. H. (2007). Positive and
negative life changes experienced by survivors of non-Hodgkin’s lymphoma.
Ann. Behav. Med. 34, 188–199. doi: 10.1007/BF02872673
Bolier, L., Haverman, M., Westerhof, G. J., Riper, H., Smit, F., and Bohlmeijer, E.
(2013). Positive psychology interventions: a meta-analysis of randomized
controlled studies. BMC Public Health 13:119. doi: 10.1186/1471-2458-13- 119
Bonanno, G. A., Brewin, C. R., Kaniasty, K., and La Greca, A. M. (2010). Weighing
the costs of disaster: consequences, risks, and resilience in individuals,
families, and communities. Psychol. Sci. Public Interest. 11, 1–49. doi: 10.1177/
1529100610387086
Bonanno, G. A., Papa, A., Lalande, K., Zhang, N., and Noll, J. G. (2005). Grief
processing and deliberate grief avoidance: a prospective comparison of bereaved
spouses and parents in the United States and the People’s Republic of China. J.
Consult. Clin. Psychol. 73, 86–98. doi: 10.1037/0022-006X.73.1.86
Bonanno, G. A., Westphal, M., and Mancini, A. D. (2011). Resilience to loss and
potential trauma. Annu. Rev. Clin. Psychol. 7, 511–535. doi: 10.1146/annurev-
clinpsy-032210- 104526
Bower, J. E., Meyerowitz, B. E., Desmond, K. A., Bernaards, C. A., Rowland,
J. H., and Ganz, P. A. (2005). Perceptions of positive meaning and
vulnerability following breast cancer: predictors and outcomes among long-
term breast cancer survivors. Ann. Behav. Med. 29, 236–245. doi: 10.1207/
s15324796abm2903_10
Bower, J. E., and Segerstrom, S. C. (2004). Stress management, finding benefit, and
immune function: positive mechanisms for intervention effects on physiology.
J. Psychosom. Res. 59, 9–11. doi: 10.1016/S0022-3999(03)00120-X
Brewin, C. R., Lanius, R. A., Novac, A., Schnyder, U., and Galea, S. (2009).
Reformulating PTSD for DSM-V: life after criterion A. J. Trauma. Stress 22,
366–373. doi: 10.1002/jts.20443
Butler, L. D. (2007). Growing pains: commentary on the field of posttraumatic
growth and hobfoll and colleagues’ recent contributions to it: commentaries.
Appl. Psychol. 56, 367–378. doi: 10.1111/j.1464-0597.2007.00293.x
Cadell, S. (2007). The sun always comes out after it rains: understanding
posttraumatic growth in HIV caregivers. Health Soc. Work 32, 169–176.
doi: 10.1093/hsw/32.3.169
Carver, C. S., and Antoni, M. H. (2004). Finding benefit in breast cancer during
the year after diagnosis predicts better adjustment 5 to 8 years after diagnosis.
Health Psychol. 23, 595–598. doi: 10.1037/0278-6133.23.6.595
Casellas-Grau, A., Font, A., and Vives, J. (2014). Positive psychology interventions
in breast cancer. A systematic review. Psychooncology 23, 9–19. doi: 10.1002/
pon.3353
Casellas-Grau, A., Vives, J., Font, A., and Ochoa, C. (2016). Positive psychological
functioning in breast cancer. An integrative review. Breast 27, 136–168.
doi: 10.1016/j.breast.2016.04.001
Cohen, S. (2004). Social relationships and health. Am. Psychol. 59, 676–684.
doi: 10.1037/0003-066X.59.8.676
Cordova, M. J., Andrykowski, M. A., Kenady, D. E., McGrath, P. C., Sloan, D. A.,
and Redd, W. H. (1995). Frequency and correlates of posttraumatic-stress-
disorder-like symptoms after treatment for breast cancer. J. Consult. Clin.
Psychol. 63, 981–986. doi: 10.1037/0022-006X.63.6.981
Cordova, M. J., Cunningham, L. L., Carlson, C. R., and Andrykowski, M. A. (2001).
Posttraumatic growth following breast cancer: a controlled comparison study.
Health Psychol. 20, 176–185. doi: 10.1037/0278-6133.20.3.176
Cordova, M. J., Giese-Davis, J., Golant, M., Kronenwetter, C., Chang, V.,
and Spiegel, D. (2007). Breast cancer as trauma: posttraumatic stress and
posttraumatic growth. Jof Clin. Psychol. Med. Settings 14, 308–319. doi: 10.1007/
s10880-007- 9083-6
Danhauer, S. C., Case, L. D., Tedeschi, R., Russell, G., Vishnevsky, T., Triplett, K.,
et al. (2013). Predictors of posttraumatic growth in women with breast cancer.
Psychooncology 22, 2676–2683. doi: 10.1002/pon.3298
Davis, C. G., Nolen-Hoeksema, S., and Larson, J. (1998). Making sense of loss and
benefiting from the experience: two construals of meaning. J. Pers. Soc. Psychol.
75, 561–574. doi: 10.1037/0022-3514.75.2.561
Frazier, P., Conlon, A., and Glaser, T. (2001). Positive and negative life changes
following sexual assault. J. Consult. Clin. Psychol. 69, 1048–1055. doi: 10.1037/
0022-006X.69.6.1048
Gall, T. L., Charbonneau, C., and Florack, P. (2011). The relationship between
religious / spiritual factors and perceived growth following a diagnosis
of breast cancer. Psychol. Health 26, 287–305. doi: 10.1080/088704409034
11013
Gillies, J., and Neimeyer, R. A. (2006). Loss, grief, and the search for significance:
toward a model of meaning reconstruction in bereavement. J. Construct.
Psychol. 19, 31–65. doi: 10.1080/10720530500311182
Hall, B. J., Saltzman, L. Y., Canetti, D., and Hobfoll, S. E. (2015). A longitudinal
investigation of the relationship between posttraumatic stress symptoms
and posttraumatic growth in a cohort of Israeli Jews and Palestinians
during ongoing violence. PLoS One 10:e0124782. doi: 10.1371/journal.pone.012
4782
Helgeson, V. S., Reynolds, K. A., and Tomich, P. L. (2006). A meta-analytic
review of benefit finding and growth. J. Consult. Clin. Psychol. 74, 797–816.
doi: 10.1037/0022-006X.74.5.797
Hodges, L. J., Humphris, G. M., and Macfarlane, G. (2005). A meta-analytic
investigation of the relationship between the psychological distress of cancer
patients and their carers. Soc. Sci. Med. 60, 1–12. doi: 10.1016/j.socscimed.2004.
04.018
Hungerbuehler, I., Vollrath, M. E., and Landolt, M. A. (2011). Posttraumatic
growth in mothers and fathers of children with severe illnesses. J. Health
Psychol. 16, 1259–1267. doi: 10.1177/1359105311405872
Jacobsen, P. B., Sadler, I. J., Booth-Jones, M., Soety, E., Weitzner, M. A., and Fields,
K. K. (2002). Predictors of posttraumatic stress disorder symptomatology
following bone marrow transplantation for cancer. J. Consult. Clin. Psychol. 70,
235–240. doi: 10.1037/0022-006X.70.1.235
Janoff-Bulman, R. (1992). Shattered Assumptions. Towards a New Psychology of
Trauma. New York, NY: The Free Press.
Jim, H. S., and Andersen, B. L. (2007). Meaning in life mediates the relationship
between social and physical functioning and distress in cancer survivors. Br. J.
Health Psychol. 12, 363–381. doi: 10.1348/135910706X128278
Jim, H. S., Purnell, J. Q., Richardson, S. A., Golden-Kreutz, D., and Andersen,
B. L. (2006). Measuring meaning in life following cancer. Qual. Life Res. 15,
1355–1371. doi: 10.1007/s11136-006- 0028-6
Joseph, S., and Linley, P. A. (2006). Growth following adversity: theoretical
perspectives and implications for clinical practice. Clin. Psychol. Rev. 26,
1041–1053. doi: 10.1016/j.cpr.2005.12.006
Joseph, S., Linley, P. A., and Harris, G. J. (2005). Understanding positive change
following trauma and adversity: structural clarification. J. Loss Trauma. 10,
83–96. doi: 10.1080/15325020490890741
Kangas, M. (2013). DSM-5 trauma and stress-related disorders: implications for
screening for cancer-related stress. Front. Psychiatry 4:122. doi: 10.3389/fpsyt.
2013.00122
Kangas, M., Henry, J. L., and Bryant, R. A. (2002). Posttraumatic stress disorder
following cancer. A conceptual and empirical review. Clin. Psychol. Rev. 22,
499–524. doi: 10.1016/S0272-7358(01)00118- 0
Kangas, M., Henry, J. L., and Bryant, R. A. (2005). Predictors of posttraumatic stress
disorder following cancer. Clin. Psychol. Rev. 24, 579–585. doi: 10.1037/0278-
6133.24.6.579
Kilmer, R. P., Gil-Rivas, V., Tedeschi, R. G., Cann, A., Calhoun, L. G., Buchanan, T.,
et al. (2009). Use of the revised posttraumatic growth inventory for children.
J. Trauma. Stress 22, 248–253. doi: 10.1002/jts.20410
Kirkpatrick, L. A., and Hazan, C. (1994). Attachment styles and close relationships:
a four-year prospective study. Personal. Relat. 1, 123–142. doi: 10.1111/j.1475-
6811.1994.tb00058.x
Kissane, D., Bloch, S., Smith, G., Miach, P., Clarke, D., Ikin, J., et al. (2003).
Cognitive-existential group psychotherapy for women with primary breast
cancer: a randomised controlled trial. Psychooncology 12, 532–546. doi: 10.1002/
pon.683
Landolt, M. A., Vollrath, M., Ribi, K., Gnehm, H. E., and Sennhauser, F. H.
(2003). Incidence and associations of parental and child posttraumatic stress
symptoms in pediatric patients. J. Child Psychol. Psychiatry 44, 1199–1207.
doi: 10.1111/1469-7610.00201
Langford, D. J., Cooper, B., Paul, S., Humphreys, J., Keagy, C., Conley, Y. P.,
et al. (2017). Evaluation of coping as a mediator of the relationship between
stressful life events and cancer-related distress. Health Psychol. 36, 1147–1160.
doi: 10.1037/hea0000524
Lechner, S. C., Carver, C. S., Antoni, M. H., Weaver, K. E., and Phillips, K. M.
(2006). Curvilinear associations between benefit finding and psychosocial
Frontiers in Psychology | www.frontiersin.org 10 February 2019 | Volume 10 | Article 177
fpsyg-10-00177 January 31, 2019 Time: 18:46 # 11
Ochoa Arnedo et al. Stress and Growth in Cancer
adjustment to breast cancer. J. Consult. Clin. Psychol. 74, 828–840. doi: 10.1037/
0022-006X.74.5.828
Lelorain, S., Tessier, P., Florin, A., and Bonnaud-Antignac, A. (2012).
Posttraumatic growth in long term breast cancer survivors: relation to coping,
social support and cognitive processing. J. Health Psychol. 17, 627–639.
doi: 10.1177/1359105311427475
Liu, X. L., Wang, L., Zhang, Q., Wang, R., and Xu, W. (2018). Less mindful,
more struggle and growth: mindfulness, posttraumatic stress symptoms, and
posttraumatic growth of breast cancer suvivors. J. Nerv. Ment. Dis. 206,
621–627. doi: 10.1097/NMD.0000000000000854
Lowe, S. R., Manove, E. E., and Rhodes, J. E. (2013). Posttraumatic stress and
posttraumatic growth among low-income mothers who survived Hurricane
Katrina. J. Consult. Clin. Psychol. 81, 877–889. doi: 10.1037/a0033252
Manne, S. L., Ostroff, J., Winkel, G., Goldstein, L., Fox, K., and Grana, G.
(2004). Posttraumatic growth after breast cancer: patient, partner, and couple
perspectives. Psychosom. Med. 66, 442–454.
McGregor, B. A., Antoni, M. H., Boyers, A., Alferi, S. M., Blomberg, B. B., and
Carver, C. S. (2004). Cognitive-behavioral stress management increases benefit
finding and immune function among women with early-stage breast cancer.
J. Psychosom. Res. 56, 1–8. doi: 10.1016/S0022-3999(03)00036-9
Mehnert, A., and Koch, U. (2007). Prevalence of acute and post-traumatic
stress disorder and comorbid mental disorders in breast cancer patients
during primary cancer care: a prospective study. Psychooncology 16, 181–188.
doi: 10.1002/pon.1057
Moore, A. M., Gamblin, T. C., Geller, D. A., Youssef, M. N., Hoffman, K. E.,
Gemmell, L., et al. (2011). A prospective study of posttraumatic growth as
assessed by self-report and family caregiver in the context of advanced cancer.
Psychooncology 20, 479–487. doi: 10.1002/pon.1746
Morrill, E. F., Brewer, N. T., O’Neill, S. C., Lillie, S. E., Dees, E. C., Carey,
L. A., et al. (2006). The interaction of post-traumatic growth and post-
traumatic stress symptoms in predicting depressive symptoms and quality of
life. Psychooncology 17, 1093–1098. doi: 10.1002/pon.1313
Ochoa, C. (2012). “Psicoterapia positiva grupal en cáncer: la facilitación del
crecimiento como vía terapéutica,” in I Congreso Nacional de la Sociedad
Española de Psicologia positiva. Symposium, Madrid, 17.
Ochoa, C., and Casellas-Grau, A. (2015). “Positive psychotherapy in cancer:
facilitating posttraumatic growth in assimilation and accomodation of
traumatic experience,” in Comprehensive Guide to Post-Traumatic Stress
Disorder, eds C. R. Martin, V. R. Preedy, and V. B. Patel (Basel: Springer
International Publishing Switzerland), 2133–2149.
Ochoa, C., Casellas-Grau, A., Vives, J., Font, A., and Borràs, J. M. (2017). Positive
psychotherapy for distressed cancer survivors: posttraumatic growth facilitation
reduces posttraumatic stress. Int. J. Clin. Health Psychol. 17, 28–37. doi: 10.1016/
j.ijchp.2016.09.002
Ochoa, C., Castejon, V., Sumalla, E. C., and Blanco, I. (2013). Posttraumatic growth
in cancer survivors and their significant others: vicarious or secondary growth?
Ter. Psicol. 31, 81–92. doi: 10.4067/S0718-48082013000100008
Ochoa, C., Sumalla, E. C., Maté, J., Castejón, V., Rodríguez, A., Blanco, I., et al.
(2010). Psicoterapia positiva grupal en cáncer. Hacia una atención psicosocial
integral del superviviente de cáncer. Psicooncología 7, 7–34.
Ozono, S., Saeki, T., Mantani, T., Ogata, A., Okamura, H., and Yamawaki, S. (2007).
Factors related to posttraumatic stress in adolescent survivors of childhood
cancer and their parents. Support. Care Cancer 15, 309–317. doi: 10.1007/
s00520-006- 0139-1
Pai, A., Suris, A., and North, C. (2017). Posttraumatic stress disorder in the
DSM-5: controversy, change, and conceptual considerations. Behav. Sci. 13:7.
doi: 10.3390/bs7010007
Pakenham, K. I. (2005). Benefit finding in multiple sclerosis and associations with
positive and negative outcomes. Health Psychol. 24, 123–132. doi: 10.1037/
0278-6133.24.2.123
Park, C. L. (2010). Making sense of the meaning literature: an integrative review of
meaning making and its effects on adjustment to stressful life events. Psychol.
Bull. 136, 257–301. doi: 10.1037/a0018301
Park, C. L., and Blank, T. O. (2012). Associations of positive and negative life
changes with well-being in young and middle-aged adult cancer survivors.
Psychol. Health 4, 412–429. doi: 10.1080/08870446.2011.586033
Park, C. L., Chmielewski, J., and Blank, T. O. (2010). Post-traumatic growth:
finding positive meaning in cancer survivorship moderates the impact of
intrusive thoughts on adjustment in younger adults. Psychooncology 19,
1139–1147. doi: 10.1002/pon.1680
Pat-Horenczyk, R., Perry, S., Hamama-Raz, Y., Ziv, Y., Schramm-Yavin, S., and
Stemmer, S. M. (2015). Posttraumatic growth in breast cancer survivors:
constructive and illusory aspects. J. Trauma. Stress 28, 214–222. doi: 10.1002/
jts.22014
Pat-Horenczyk, R., Saltzman, L. Y., Hamama-Raz, Y., Perry, S., Ziv, Y., Ginat-
Frolich, R., et al. (2016). Stability and transitions in posttraumatic growth
trajectories among cancer patients: LCA and LTA analyses. Psychol. Trauma.
8, 541–549. doi: 10.1037/tra0000094
Pelcovitz, D., Goldenberg, B., Kaplan, S., Weinblatt, M., Mandel, F., Meyers, B.,
et al. (1996). Posttraumatic stress disorder in mothers of pediatric cancer
survivors. Psychosomatics 37, 116–126. doi: 10.1016/S0033-3182(96)71577-3
Penedo, F. J., Molton, I., Dahn, J. R., Shen, B. J., Kinsinger, D., Traeger, L., et al.
(2006). A randomized clinical trial of group-based cognitive-behavioral stress
management in localized prostate cancer: development of stress management
skills improves quality of life and benefit finding. Ann. Behav. Med. 31, 261–270.
doi: 10.1207/s15324796abm3103_8
Pérez, S., Galdón, M. J., Andreu, Y., Ibáñez, E., Durá, E., Conchado, A., et al. (2014).
Posttraumatic stress symptoms in breast cancer patients: temporal evolution,
predictors, and mediation. J. Trauma. Stress 27, 224–231. doi: 10.1002/jts.21901
Reiland, S. A., and Brendan Clark, C. (2017). Relationship between event type and
mental health outcomes: event centrality as mediator. Personal. Individ. Diff.
114, 155–159. doi: 10.1016/j.paid.2017.04.009
Richardson, A. E., Morton, R. P., and Broadbent, E. (2016). Coping strategies
predict post-traumatic stress in patients with head and neck cancer. Eur. Arch.
Otorhinolaryngol. 273, 3385–3391. doi: 10.1007/s00405-016-3960-2
Roepke, A. M. (2014). Psychosocial interventions and posttraumatic growth: a
meta-analysis. J. Consult. Clin. Psychol. 83, 129–142. doi: 10.1037/a0036872
Ruf, M., Büchi, S., Moergeli, H., Zwahlen, R. A., and Jenewein, J. (2009).
Positive personal changes in the aftermath of head and neck cancer diagnosis:
a qualitative study in patients and their spouses. Head Neck 31, 513–520.
doi: 10.1002/hed.21000
Rustad, J. K., David, D., and Currier, M. B. (2012). Cancer and post-traumatic
stress disorder: diagnosis, pathogenesis and treatment considerations. Palliat.
Support. Care 10, 213–223. doi: 10.1017/S1478951511000897
Salovey, P., Rothman, A., Detweiler, J., and Steward, W. (2000). Emotional states
and health. Am. Psychol. 55, 110–121. doi: 10.1037/0003-066X.55.1.110
Salsman, J. M., Segerstrom, S. C., Brechting, E. H., Carlson, C. R., and Michael, A.
(2009). Posttraumatic growth and PTSD symptomatology among colorectal
cancer survivors: a 3-month longitudinal examination of cognitive processing.
Psychooncology 41, 30–41. doi: 10.1002/pon.1367
Sawyer, A., Ayers, S., and Field, A. P. (2010). Posttraumatic growth and adjustment
among individuals with cancer or HIV/AIDS: a meta-analysis. Clin. Psychol.
Rev. 30, 436–447. doi: 10.1016/j.cpr.2010.02.004
Sears, S. R., Stanton, A. L., and Danoff-Burg, S. (2003). The yellow brick road and
the emerald city: benefit finding, positive reappraisal coping and posttraumatic
growth in women with early-stage breast cancer. Health Psychol. 22, 487–497.
doi: 10.1037/0278-6133.22.5.487
Segerstrom, S. C., Stanton, A. L., Alden, L. E., and Shortridge, B. E. (2003).
A multidimensional structure for repetitive thought: what’s on your mind, and
how, and how much? J. Pers. Soc. Psychol. 85, 909–921. doi: 10.1037/0022-3514.
85.5.909
Serrano, J. P., Latorre, J. M., Gatz, M., and Montanes, J. (2004). Life review therapy
using autobiographical retrieval practice for older adults with depressive
symptomatology. Psychol. Aging 19, 270–277. doi: 10.1037/0882-7974.19.2.272
Shakespeare-Finch, J., and Enders, T. (2008). Corroborating evidence of
posttraumatic growth. J. Trauma. Stress 21, 421–424. doi: 10.1002/jts.20347
Shakespeare-Finch, J., and Lurie-Beck, J. (2014). A meta-analytic clarification of
the relationship between posttraumatic growth and symptoms of posttraumatic
distress disorder. J. Anxiety Disord. 28, 223–229. doi: 10.1016/j.janxdis.2013.
10.005
Shand, L. K., Brooker, J. E., Burney, S., Fletcher, J., and Ricciardelli, L. A.
(2018). Psychosocial factors associated with posttraumatic stress and growth
in Australian women with ovarian cancer. J. Psychosoc. Oncol. 36, 470–483.
doi: 10.1080/07347332.2018.1461728
Sharp, L., Redfearn, D., Timmons, A., Balfe, M., and Patterson, J. (2018).
Posttraumatic growth in head and neck cnacer survivors: is it possible and
Frontiers in Psychology | www.frontiersin.org 11 February 2019 | Volume 10 | Article 177
fpsyg-10-00177 January 31, 2019 Time: 18:46 # 12
Ochoa Arnedo et al. Stress and Growth in Cancer
what are the correlates? Psychooncology 27, 1517–1523. doi: 10.1002/pon.
4682
Smith, M. Y., Redd, W. H., Peyser, C., and Vogl, D. (1999). Post-traumatic stress
disorder in cancer: a review. Psychooncology 8, 521–537. doi: 10.1002/(SICI)
1099-1611(199911/12)8:6< 521::AID-PON423> 3.0.CO;2-X
Stanton, A. L., Danoff-Burg, S., Cameron, C. L., Bishop, M., Collins, C. A., Kirk,
S. B., et al. (2000). Emotionally expressive coping predicts psychological and
physical adjustment to breast cancer. J. Consult. Clin. Psychol. 68, 875–882.
doi: 10.1037/0022-006X.68.5.875
Sumalla, E. C., Ochoa, C., and Blanco, I. (2009). Posttraumatic growth in cancer:
reality or illusion? Clin. Psychol. Rev. 29, 24–33. doi: 10.1016/j.cpr.2008.09.006
Svetina, M., and Nastran, K. (2012). Family relationships and posttraumatic growth
in breast cancer patients. Psychiatr. Danub. 24, 298–306.
Tennen, H., and Affleck, G. (2009). “Assessing positive life change: in search of
meticulous methods,” in Medical Illness and Positive Life Change: Can Crisis
Lead to Personal Transformation?, eds C. Park, S. Lechner, and A. L. Stanton
(Washington, DC: American Psychological Association), 31–49. doi: 10.1037/
11854-002
Thornton, A. A., and Perez, M. A. (2006). Posttraumatic growth in prostate cancer
survivors and their partners. Psychooncology 15, 285–296. doi: 10.1002/pon.953
Tomich, P. L., and Helgeson, V. S. (2004). Is finding something good in the bad
always good? Benefit finding among women with breast cancer. Health Psychol.
23, 16–23. doi: 10.1037/0278-6133.23.1.16
Tong, Y., Monahan, P. O., Rand, K. L., Cripe, L. D., Schmidt, K., and Rawl,
S. M. (2012). Illness appraisal, religious coping, and psychological responses in
men with advanced cancer. Support. Care Cancer 20, 1719–1728. doi: 10.1007/
s00520-011- 1265-y
Urcuyo, K. R., Boyers, A. E., Carver, C. S., and Antoni, M. H. (2005). Finding benefit
in breast cancer: relations with personality, coping, and concurrent well-being.
Psychol. Health 20, 175–192. doi: 10.1080/08870440512331317634
Vázquez, C., Pérez-Sales, P., and Ochoa, C. (2014). “Posttraumatic growth:
challenges from a cross-cultural viewpoint,” in Increasing Psychological Well-
Being in Clinical and Educational Settings, eds G. A. Fava and C. Ruini
(Dordrecht: Springer), 57–74. doi: 10.1007/978-94- 017-8669-0_4
Wamser-Nanney, R., Howell, K. H., Schwarts, L. E., and Hasselle, A. J. (2018). The
moderating role of trauma type on the relationship between event centrality
of the traumatic experience and mental health outcomes. Psychol. Trauma. 10,
499–507. doi: 10.1037/tra0000344
Wang, A. W., Chang, C., Chen, S., Chen, D., and Hsu, W. (2014). Identification of
posttraumatic growth trajectories in the fi rst year after breast cancer surgery.
Psychooncology 23, 1399–1405. doi: 10.1002/pon.3577
Wang, A. W. T., Chang, C. S., Chen, S. T., Chen, D. R., Fan, F., Carver, C. S., et al.
(2017). Buffering and direct effect of posttraumatic growth in predicting distress
following cancer. Health Psychol. 36, 549–559. doi: 10.1037/hea0000490
Weiss, T. (2004a). Correlates of posttraumatic growth in husbands of breast cancer
survivors. Psychooncology 13, 260–268.
Weiss, T. (2004b). Correlates of posttraumatic growth in married breast cancer
survivors. J. Soc. Clin. Psychol. 23, 733–746. doi: 10.1521/jscp.23.5.733.50750
Westphal, M., and Bonanno, G. A. (2007). Posttraumatic growth and resilience to
trauma: different sides of the same coin or different coins? Appl. Psychol. 56,
417–427. doi: 10.1111/j.1464-0597.2007.00298.x
Widows, M., Jacobsen, P., Booth-Jones, M., and Fields, K. (2005). Predictors
of posttraumatic growth following bone marrow transplantation for cancer.
Health Psychol. 24, 266–273. doi: 10.1037/0278-6133.24.3.266
Wirtz, D., Kruger, J., Scollon, C. N., and Diener, E. (2003). What to do on spring
break? Psychol. Sci. 14, 520–524. doi: 10.1111/1467-9280.03455
Xu, J., and Liao, Q. (2011). Prevalence and predictors of posttraumatic growth
among adult survivors one year following 2008 Sichuan earthquake. J. Affect.
Disord. 133, 274–280. doi: 10.1016/j.jad.2011.03.034
Zoellner, T., and Maercker, A. (2006). Posttraumatic growth in clinical
psychology – a critical review and introduction of a two component model. Clin.
Psychol. Rev. 26, 626–653. doi: 10.1016/j.cpr.2006.01.008
Zoellner, T., Rabe, S., Karl, A., and Maercker, A. (2008). Posttraumatic
growth in accident survivors: openness and optimism as predictors of its
constructive or illusory sides. J. Clin. Psychol. 64, 245–253. doi: 10.1002/jclp.
20441
Zwahlen, D., Hagenbuch, N., Carley, M. I., Jenewein, J., and Buchi, S. (2010).
Posttraumatic growth in cancer patients and partners–effects of role, gender
and the dyad on couples’ posttraumatic growth experience. Psychooncology 19,
12–20. doi: 10.1002/pon.1486
Conflict of Interest Statement: The authors declare that the research was
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