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Stress and Growth in Cancer: Mechanisms and Psychotherapeutic Interventions to Facilitate a Constructive Balance


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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.
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fpsyg-10-00177 January 31, 2019 Time: 18:46 # 1
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,
Cristian Ochoa Arnedo
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
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,
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.,
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.
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
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.
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.
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
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
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
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.,
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
Who initiates and generates the stress/growth
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
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
Yes. Stress/growth arises from similar sources and
dimensions. There is harmony and synchrony in the
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
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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.,
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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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).
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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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.
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.
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.
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
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
American Psychiatric Association (1994). Diagnostic and Statistical Manual of
Mental Disorders: DSM-IV, 4th Edn. Wahsington, DC: American Psychiatric
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-
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.
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 | 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/
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/
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/
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/
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
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
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.
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.
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-
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-
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/
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 | 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/
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/
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/
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/
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.
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.
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 | 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.
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/
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.
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
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Copyright © 2019 Ochoa Arnedo, Sánchez, Sumalla and Casellas-Grau. This is an
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Frontiers in Psychology | 12 February 2019 | Volume 10 | Article 177
... Although PTG and PTSD have both been frequently studied in cancer survivors, some authors have expressed the need to raise awareness of PTSD, because it can go undiagnosed and untreated in cancer patients [4]. In addition, the investigation of the relationship between PTSS and PTG, as well as the study of their correlates, can contribute to identifying adequate interventions which can help avoid the development of PTSS and aid the process of the development of the PTG that reduces the initial stress and sorrow [26]. Shared correlates could be an effective target for the intervention. ...
... PTSS was strongly related to psychological factors while PTG was strongly related to existential factors. Knowledge about the relationship between PTSS and PTG in addition to their shared and differentiating correlates can be helpful in preparing adaptive stress-growth balance interventions [26]. Specifically, psychological variables can play an important role in the context of PTSS and PTG. ...
Full-text available
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.
... Even though the association between benefit finding and well-being does not seem to be strong, increasing people's opportunities and abilities for experiencing benefits is likely to play a role in reducing stress and enhancing well-being. Some previous research has demonstrated that the experience of benefit finding can be increased, for example in response to workrelated traumas [52] and in response to cancer [53]. However, further research is needed to assess the effectiveness of strategies to enhance benefit finding in response to collective traumas. ...
Full-text available
This study focuses on understanding benefit finding, the process of deriving growth from adversity, and its relationship to well-being amidst the COVID-19 pandemic. Participants (n = 701) completed online surveys at 1, 3, 6, and 12 months after a shelter-in-place mandate was announced in California, USA. Identifying as female or of Asian descent, having a supportive social network, and reporting more distress were associated with higher levels of general benefit finding at all data collection points, while other demographics were not. Benefit finding exhibited small but statistically significant associations with two measures of well-being. Understanding the extent to which various groups of people experience benefit finding during ongoing adversity and how such benefit finding is associated with well-being may help to promote mental health during a collective trauma like the COVID-19 pandemic.
... It appears to researchers that their mind disturbances had indirectly triggered the negative emotions. These findings are in line with numerous literatures that claimed cancer as a powerful stressor and lead to catastrophic emotional experience in a cancer patient (Arnedo, Sánchez, Sumalla, & Casellas-Grau, 2019;Pai, Suris, & North, 2017). ...
Full-text available
This study explored cancer survivors’ life experiences in moving towards growth. Four Iban participants were interviewed and the data were thematically analysed. This paper concludes that the cancer diagnosis impacts participants mentally, emotionally, and physically. Spiritual strategy is the most used coping strategy, and participants were highly motivated by social support. Participants also reported to experience growth mostly in the area of relationship with others. It implies that the findings of this study are able to expand posttraumatic growth (PTG) among Asians literatures and contribute as references for counsellors and psychologists to develop appropriate psychological interventions that suit the patients’ culture. Further explorations on the spiritual and social elements for psychological interventions among Asian cancer patients are recommended.
... Thus, there is now an increased population of people living a long, productive life with a history of cancer. Nevertheless, the side effects of current treatments, as well as the stress associated with the diagnosis and fear of disease recurrence, pose a serious burden on patients' mental and physical well-being [4,5]. ...
Background Increasing evidence shows that lifestyle interventions can improve the symptoms, quality of life (QoL), and even overall survival of patients with cancer. Digital therapeutics (DTx) can help implement behavioral modifications and empower patients through education, lifestyle support, and remote symptom monitoring. Objective We aimed to test the feasibility of a DTx program for patients with cancer, as measured by engagement, retention, and acceptability. In addition, we explored the effects of the program on cancer-related QoL. Methods We conducted a 4-week single-arm trial in Iceland, where DTx was delivered through a smartphone app. The intervention consisted of patient education about mindfulness, sleep, stress, and nutrition; lifestyle coaching; and the completion of daily missions for tracking physical activity and exercise, reporting patient-reported outcomes (PROs), practicing mindfulness, and logging healthy food intake. Information on program engagement and retention, step goal attainment, as well as PROs were collected throughout the study. QoL was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 at baseline and follow-up. Results In total, 30 patients with cancer undergoing active therapy were enrolled, and 29 registered in the app (23 female, 18 with breast cancer; mean age 52.6, SD 11.5 years). Overall, 97% (28/29) of participants were active in 3 of the 4 weeks and completed the pre- and postprogram questionnaires. The weekly active days (median) were 6.8 (IQR 5.8-6.8), and 72% (21/29) of participants were active at least 5 days a week. Users interacted with the app on average 7.7 (SD 1.9) times per day. On week 1, all 29 participants used the step counter and logged an average of 20,306 steps; 21 (72%) participants reached their step goals of at least 3000 steps per day. On week 4, of the 28 active users, 27 (96%) were still logging their steps, with 19 (68%) reaching their step goals. Of the 28 participants who completed the satisfaction questionnaire, 25 (89%) were likely to recommend the program, 23 (82%) said the program helped them deal with the disease, and 24 (86%) said it helped them remember their medication. QoL assessment showed that the average global health status, functioning, and symptom burden remained stable from baseline to follow-up. In all, 50% (14/28) of participants reported less pain, and the average pain score decreased from 31 (SD 20.1) to 22.6 (SD 23.2; P=.16). There was no significant change in PROs on the quality of sleep, energy, and stress levels from the first to the last week. Conclusions The high retention, engagement, and acceptability found in this study demonstrate that multidisciplinary DTx is feasible for patients with cancer. A longer, full-scale randomized controlled trial is currently being planned to evaluate the efficacy of the intervention.
... When there is integration of the trauma-related information to facilitate the reconstruction of the new assumptive worldview on self, others and the surrounding environment, via the process of accommodation, search of meaning out of the trauma of living with cancer occurred. A successful search of meaning to solve unproductive ruminations such as cognitive posttraumatic stress symptoms and fear of cancer progression, and facilitate the reconstruction of the new assumptive worldview on self, others and the surrounding environment, will lead to development of PTG (Leong Abdullah et al., 2019;Ochoa Arnedo et al., 2019). ...
Full-text available
Despite head and neck cancer (HNC) association with various negative impacts, collective evidence is accumulating regarding the positive impacts of positive psychology on cancer survivors. However, data on how positive psychology is related to the psychological complications of HNC across time are lacking. This longitudinal study examined the trends of positive psychology (e.g., posttraumatic growth [PTG], hope, and optimism), perceived spousal support, and psychological complications (e.g., depression, anxiety, and posttraumatic stress symptoms) and determined the association between them, psychological complications, and PTG across two timelines among a cohort of HNC patients. A total of 175 HNC respondents exhibited an increasing trend of positive psychology and perceived spousal support while reporting a decreasing trend of psychological complications between baseline and follow-up assessments. A greater degree of hope and perceived spousal support contributed to a higher degree of PTG across time. Conversely, a higher severity of anxiety symptoms was associated with a lower degree of PTG over time. Female gender had a moderating effect on the association between severity of anxiety symptoms and PTG, but did not moderate the association between hope, perceived spousal support and PTG. This study indicates the pivotal role of incorporating psychosocial interventions into the treatment regimen to enhance the degree of hope and perceived spousal support and reduce the severity of anxiety symptoms, which, in turn, will facilitate the development of PTG in HNC patients.
This study assessed posttraumatic growth (PTG) across multiple trauma types and by demographic characteristics (i.e., sex, age, education). Moreover, we examined the association between PTG and posttraumatic stress disorder (PTSD) symptoms as well as the characteristics and predictors of PTG after sexual violence. A phone survey was conducted in a nationally representative sample of 1,766 Icelandic adults. In total, 1,528 individuals reported having experienced some form of trauma and were included in the analysis, and 563 reported experiencing sexual violence. Interpersonal trauma (e.g., sexual violence, emotional abuse, and domestic violence) was associated with the highest levels of PTG. Moderate levels of PTSD symptoms were associated with the highest levels of PTG, whereas high- or low-level PTSD symptoms were related to less PTG. Women reported significantly more PTG than men, d = 0.16 and survivors of sexual violence reported significantly more PTG than individuals who reported other forms of trauma exposure, d = 0.28. Among sexual violence survivors, no demographic factors were associated with PTG, but cumulative trauma and positive social reactions were significantly related to higher levels of PTG. This study highlights that personal growth can result from aversive experiences and suggests a curvilinear association between PTG and PTSD symptoms.
The detrimental effects of Post-Traumatic Stress Symptoms (PTSS) and Post-Traumatic Stress Disorder (PTSD) and the benefits of Post-Traumatic Growth (PTG) are well established for cancer survivors. Increased cancer survival rates necessitate an understanding of how these two paradoxical outcomes, PTSS/PTSD and PTG, are targeted through interventions. This systematic scoping review aims to (a) examine existing evidence on interventions targeting PTSS/PTSD and/or PTG among cancer survivors and (b) identify knowledge gaps to inform future research. Following the six steps of a scoping review, 76 articles met the inclusion criteria. Quantitative articles were examined using descriptive analysis. Frequency counts of the collated data were tabulated into summary tables. Qualitative articles were reviewed using meta-synthesis. Most articles were quantitative (n = 52) and targeted PTG (n = 68) through promising intervention approaches such as psychotherapy, mindfulness, physical activity, and psilocybin-assisted therapy. Three key implications for future research and practice were synthesized: (1) mechanistic considerations for intervention design that provide a roadmap for rigorous and theoretically-grounded research; (2) the need for improved representation of cancer survivors in trials; and (3) potential facilitators of intervention efficacy. Together, these findings can direct future research to optimize interventions to reduce PTSS/PTSD and promote PTG achievement among cancer survivors.
Objective: The objective of this study was to explore the experiences of head and neck cancer (HNC) survivors who returned to valued activities to understand how they reconstruct their lives following HNC diagnosis and treatment. Methods: A qualitative research approach based on social constructionist theory was used. A total of 21 in-depth semi-structured interviews were conducted with adults diagnosed with any type of HNC in the previous six years. Reflexive thematic analysis was used to identify themes. Results: HNC presents a unique trauma following which some survivors navigate paths back to meaningful activities. The experiences of HNC survivors who adapted to life after treatment described internal and external change and development, identified by three themes; Mindfulness; Gratitude; and Adaptation. Conclusion: People diagnosed with HNC frequently experience lasting effects and other survivorship issues, however some survivors were able to return to valued activities and recreate a meaningful lifestyle reflecting the possibility of post traumatic growth. This study provides insight into the experiences of head and neck cancer survivors who were able to make meaning and find internal and external growth following treatment. These findings can be used to inform advanced communication skills training for oncology health professionals and psychoeducational courses for people diagnosed with head and neck cancer in the future. This article is protected by copyright. All rights reserved.
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Introduction Childhood maltreatment is a highly prevalent traumatic experience, and its adverse psychological and behavioral consequences are well-documented. Notwithstanding these adverse outcomes, many individuals who suffered from traumatic experiences report post-traumatic growth, i.e., transformative positive changes resulting from their struggle to cope. Post-traumatic growth has been extensively explored among adult survivors of childhood maltreatment, with findings indicating both the previously recognized domains (personal strength, relating to others, appreciation of life, openness to new possibilities, and spiritual change) as well as abuse-specific domains of growth (e.g., increased ability to protect themselves from abuse). However, little attention has been given to vocational aspects of post-traumatic growth among survivors, despite the central role and importance of work in adulthood. Exploration of post-traumatic growth at work has focused on certain vocational traumatic experiences, such as those which occur in the military, or through secondary trauma. This exploratory qualitative study focuses on the question: What is the lived experience of work-related post-traumatic growth among high-functioning adult survivors of CM? Method Twenty in-depth interviews were held with high-functioning working adults who were maltreated as children. Phenomenological analysis was applied to the retrospective data reported in these interviews. Result Rich descriptions of work-related positive psychological changes were provided by all participants. Analysis revealed that survivors’ post-traumatic growth corresponded with all five previously recognized domains of growth: changes in self, relating to others, openness to new possibilities, finding meaning to the abuse, and appreciation of life. It also revealed that work is perceived as a form of resistance (a subtheme of changes in self), and that finding meaning entails three emerging subthemes: being a survivor and a role model, giving others what was needed and never received, and making a better world. Discussion While the vocational lives of survivors of childhood maltreatment have rarely been examined through the lens of post-traumatic growth, our results show this lens to be highly valuable. Work-related post-traumatic growth has relevance not only regarding vocational traumas occurring in adulthood as has been previously studied, but also in the context of childhood traumas. Moreover, our research broadens the understanding of the possible domains of work-related growth.
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Objective: Event centrality, or the extent to which traumatic events are perceived to be integral to one's life, has been found to be predictive of trauma-related symptoms, such as posttraumatic stress disorder (PTSD) and depression. Less research has been devoted to whether event centrality is related to adaptive outcomes, such as posttraumatic growth (PTG) and resiliency, and psychological well-being (PWB) has not been investigated. Given the unique circumstances of different types of traumas, the relationship between event centrality and posttrauma functioning may differ by the type of trauma experienced. Method: The present study investigated the direct relationships between event centrality and PTSD, depression, PTG, resiliency, and PWB, and then examined whether type of trauma (i.e., sexual victimization, death of a loved one, serious illness/injury, violence exposure) moderated the relationship between event centrality and mental health outcomes among 429 trauma-exposed college students (Mage = 19.66, SD = 1.65; 78.6% female; 49.9% White). Results: Event centrality was positively related to PTSD, depression, and PTG, inversely linked with multiple indices of PWB, and unrelated to resiliency. Type of traumatic event moderated the relationship between event centrality and PTSD, as well as 4 subscales of PWB. When sexual trauma was the index event, event centrality was more strongly associated with PTSD and aspects of PWB compared to death of a loved one. Conclusions: Findings indicate the importance of trauma type when disentangling the relationships between event centrality and negative and positive outcomes and demonstrate the relevance of event centrality in understanding posttrauma functioning. (PsycINFO Database Record
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Objective: Lifetime stressful life events (SLEs) may predispose oncology patients to cancer-related distress (i.e., intrusive thoughts, hyperarousal, avoidance). Coping may influence cancer-related distress by mediating this relationship. This study sought to (a) determine the prevalence and impact of lifetime SLEs among oncology outpatients receiving chemotherapy and (b) examine the relationship between SLEs and cancer-related distress and the mediating role of coping on this relationship. Method: Patients (n = 957), with breast, gastrointestinal, gynecologic or lung cancer, who were undergoing chemotherapy, completed the Life Stressor Checklist-Revised (LSC-R), a measure of lifetime SLEs. Cancer-related distress was assessed with the Impact of Event Scale-Revised. Coping strategies since beginning chemotherapy were assessed with the Brief COPE; 2 latent variables (engagement and disengagement coping) were identified based on these scores. LSC-R scores (number of SLEs and perceived impact during the prior year) were evaluated in relation to demographic and clinical characteristics. Structural equation modeling was used to evaluate the relationship between LSC-R and Impact of Event Scale-Revised scores and the mediating role of engagement and disengagement coping on this relationship. Results: On average, patients reported 6.1 (SD = 4.0; range = 0-23 out of 30) SLEs. Patients who were not married/partnered, had incomes <$30,000/year, or who had lower functional status or greater comorbidity had higher LSC-R scores. The relationship between more SLEs and more severe cancer-related distress was completely mediated by disengagement coping. Engagement coping did not mediate this relationship. Conclusions: Disengagement coping, including behavioral disengagement, avoidance, and denial, should be targeted to mitigate cancer-related distress. (PsycINFO Database Record
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The criteria for posttraumatic stress disorder PTSD have changed considerably with the newest edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Changes to the diagnostic criteria from the DSM-IV to DSM-5 include: the relocation of PTSD from the anxiety disorders category to a new diagnostic category named "Trauma and Stressor-related Disorders", the elimination of the subjective component to the definition of trauma, the explication and tightening of the definitions of trauma and exposure to it, the increase and rearrangement of the symptoms criteria, and changes in additional criteria and specifiers. This article will explore the nosology of the current diagnosis of PTSD by reviewing the changes made to the diagnostic criteria for PTSD in the DSM-5 and discuss how these changes influence the conceptualization of PTSD.
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Background/Objective There is increasing evidence that positive life changes, such as posttraumatic growth (PTG), can result from the experience of coping with cancer. However, no interventions have been specifically designed to facilitate the development of PTG in cancer. In this article, we describe and assess the results of Positive Psychotherapy for Cancer (PPC) survivors. It aims to facilitate PTG as a way of achieving significant reductions in the symptoms of emotional distress and posttraumatic stress. In addition, the corroboration of this PTG facilitation is assessed using interpersonal indicators. Method: We allocated 126 consecutive survivors of cancer with high levels of emotional distress and who were seeking psychological support to either an experimental group (PPC) or a waiting list group. Results: The PPC group obtained significantly better results after treatment than the control group, showing reduced distress, decreased posttraumatic symptoms, and increased PTG. The benefits were maintained at 3 and 12 months’ follow-up. Participants’ PTG was correlated to the PTG that their significant others attributed to them, corroborating PTG facilitation. Conclusions: PPC appears to promote significant long-term PTG and can reduce emotional distress and posttraumatic stress in cancer survivors. In addition, PTG facilitation induced by PPC is corroborated by significant others.
Treatment of posttraumatic stress symptoms (PTSSs) and facilitation of posttraumatic growth (PTG) are two encouraging areas of research, yet little is understood about the relationships between dispositional mindfulness, PTSSs, and PTG. The aim of the present study was to investigate whether PTSSs is correlated with PTG among breast cancer patients in China and explore the role of mindfulness in this relationship. A sample of 202 Chinese breast cancer patients voluntarily participated in the study by completing a set of questionnaires. The results revealed that PTSSs were significantly positively correlated with PTG. Structural equation modeling showed that mindfulness did not moderate but mediated the relation between PTSSs and PTG. These findings indicate that breast cancer patients with higher mindfulness may recover from PTSSs through a different process. Posttraumatic growth may not be the only positive indicator of posttraumatic individuals.
The study examined psychosocial factors (quality of life, depression, anxiety, optimism, coping, and social support) in relation to symptoms of posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG) in 108 women diagnosed with ovarian cancer. Canonical correlational analysis showed that both PTSD and PTG were related to poorer quality of life, lack of social supports, and avoidant coping styles. However, higher PTG was also associated with the use of meaning and social support to cope with their experience. The findings highlight both negative and positive posttraumatic outcomes but longitudinal studies are now needed to more fully evaluate these relationships.
Objectives: Posttraumatic growth (PTG) is a possible positive consequence of a traumatic event, such as cancer. Head and neck cancer (HNC) may be particularly traumatic, given its adverse effects on functional, psychological and social wellbeing. We investigated: extent of PTG; factors associated with PTG; and associations between PTG and health-related quality-of-life (HRQoL) in HNC survivors. Methods: HNC survivors (ICD10 C00-C14, C32), identified from the population-based National Cancer Registry Ireland, completed a postal survey. PTG was assessed using the Posttraumatic Growth Inventory (PTG-I) and HRQoL with FACT-G and FACT-HN. Associations between socio-economic characteristics, social support, and clinical variables and PTG were examined using multivariable linear regression. Total HRQoL scores were compared in those with none-low PTG vs moderate-high PTG. Results: 583 survivors participated (response rate=59%). The mean PTG score was 55.74 (95%CI 53.15-58.33); 60% had moderate-high PTG. Survivors scored highest in the PTG-I domain appreciation of life. In multivariable analysis, being female, being younger, having more social support and having cancer-related financial stress were significantly associated with more PTG. HRQoL was significantly higher in those with moderate-high than no-little PTG (p<0.01) CONCLUSION: A notable proportion of HNC survivors report PTG but growth is, on average, lower than reported for other cancers. Nonetheless, higher PTG appears related to better HRQoL. Further research would be valuable to understand the pathways by which HNC may lead to PTG and inform development of strategies to support and encourage PTG in this survivor population.
Objective: Evidence regarding post traumatic growth (PTG) as a predictor of future reductions in distress has been inconclusive. The purpose of this study was to examine this relationship in a multiple-observation prospective study, to provide a more rigorous test of prediction over time. This longitudinal study extended previous work by taking into account perceptions of vulnerability and explored the buffering role of PTG on the links between vulnerability and psychological distress. We also explored whether individual differences in demographic and medical characteristics moderate the relationship of interests. Method: Participants were 312 Taiwanese women (Mage = 46.7 years) who underwent surgery for breast cancer. Measures of PTG, perceived vulnerability, and distress were assessed at Day 1 and 3, 6, 12, and 24 months after surgery. Hierarchical linear modeling was used to investigate whether PTG and vulnerability and their interaction predicted distress over time. Results: A significant direct effect of PTG on distress was found: higher PTG was followed by lower distress. Analysis also yielded a significant buffering effect of PTG on vulnerability leading to distress. However, this effect was moderated by type of surgery. The buffering effect of PTG occurred only among women having mastectomy. Conclusions: We conclude that PTG tends to lead to less psychological distress overall but particularly so in a high impact context. (PsycINFO Database Record
Although stressful life events can trigger adverse mental health outcomes, many people will not develop symptoms of depression or Posttraumatic Stress Disorder (PTSD), leading researchers to seek out factors that influence the relationship between life events and emotional responses. PTSD appears to be more likely following interpersonal traumas compared to non-interpersonal traumas, but the reasons for this relationship are unclear. The current study examines whether event significance mediates the relationship between event type (interpersonal or non-interpersonal) and PTSD and depressive symptoms in a sample of 314 college students. Perceived importance was higher for interpersonal events, and we found support for a mediational role of event importance in the relationship between event type and mental health symptoms. Findings suggest that the importance of an event to one's identity might underlie the relationship between event characteristics and mental health outcomes and be a salient target for prevention and treatment efforts.