Psychosomatics 45:483-491, December 2004
© 2004 The Academy of Psychosomatic Medicine
Diagnostic Criteria for Psychosomatic Research and Psychosocial Variables in Breast Cancer Patients
Luigi Grassi, M.D.,
Elena Rossi, Ph.D.,
Silvana Sabato, Ph.D.,
Giorgio Cruciani, M.D., and
Maurizio Zambelli, M.D.
Received Oct. 1, 2003; revision received Jan. 21, 2004; accepted March 5, 2004. From the Section of Psychiatry, Department of Medical Sciences of Communication and Behavior, University of Ferrara, Ferrara, Italy; the Clinical Psychiatry Unit and the Rehabilitation Unit, S. Anna University Hospital, Ferrara, Italy; and the Division of Oncology, Lugo, Italy. Address reprint requests to Dr. Grassi, Clinica Psichiatrica Università di Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy; luigi.grassi{at}unife.it (e-mail).
|
ABSTRACT
|
The aim of the study was to examine the relationship of the Diagnostic Criteria for Psychosomatic Research (DCPR) with psychosocial variables and quality of life among cancer patients. Of 105 women with breast cancer who participated in the study, 40 (38.1%) had symptoms meeting the criteria for at least one DCPR syndrome, and 30 (28.6%) had more than one DCPR syndrome. Health anxiety, demoralization, and alexithymia were the most frequent DCPR syndromes. Patients who were diagnosed with DCPR syndromes reported higher levels of cancer-related worries and poorer quality of life than those without a DCPR diagnosis. Analysis of the single DCPR clusters and coping with cancer indicated that health anxiety was related to higher scores on the Mini-Mental Adjustment to Cancer (Mini-MAC) anxious preoccupation subscale, DCPR demoralization was related to higher scores on the Mini-MAC hopelessness subscale, and DCPR alexithymia was related to higher scores on the Mini-MAC avoidance subscale. The study indicates the usefulness of the application of the DCPR in breast cancer, although further research is needed to improve the feasibility and internal validity of DCPR constructs.
Key Words: gender • diagnostic criteria
|
INTRODUCTION
|
Over the last 20 years, an enormous amount of data has accumulated regarding the remarkable psychosocial consequences of breast cancer.1,2 Among the different areas of research, part of the studies aimed at examining the prevalence of psychiatric morbidity3 and its associated variables in order to identify risk factors for psychosocial maladjustment.4 Another part of the studies aimed at developing short screening instruments that patients attending busy oncology clinics can fill out in order to rapidly detect pathological symptoms of distress.5,6
Although this research has improved the knowledge and the quality of care in psycho-oncology incredibly, pitfalls and problems have been identified. On one hand, the use of formal nosographic systems to evaluate psychiatric morbidity has been questioned, with discordance between the authors about the need to modify DSM diagnostic criteria, such as including or excluding somatic symptoms for the diagnosis of major depression7–9 and improving the criteria of adjustment disorders.10 Furthermore, subsyndromal states and/or subthreshold situations that do not necessarily fit a DSM or ICD psychiatric diagnosis have been found to negatively influence the patients' quality of life.11,12 Most of these situations are generally referred to as "other conditions that may be a focus of clinical attention" (DSM-IV) or "factors influencing health status and contact with health system" (ICD-10, chapter 21, code Z00-Z99), but they are not often recognized in a proper way.
On the other hand, the use of screening instruments has been found helpful in efficiently evaluating large numbers of patients and in educating oncology about the problem of psychosocial dimensions of cancer and the need to recognize emotional distress.13,14 However, problems in the sensitivity/specificity of the most frequently used tools (e.g., the Hospital Anxiety Depression Scale) have been raised, and their application has been questioned, given the high percentage of misclassified cases.15,16
An interesting conceptual framework to be considered for evaluation of psychosocial dimensions of cancer patients can be derived from the work of an international group of researchers,17 who developed the Diagnostic Criteria for Psychosomatic Research (DCPR) system. The DCPR consists of 12 clinical categories or clusters, which, through a semistructured interview, explore a variety of possible psychological conditions and emotional responses to medical illness (e.g., demoralization, alexithymia, health anxiety, and thanatophobia).18,19 The most interesting feature of the DCPR is that it seems to increase the detection of psychosocial clinical conditions caused by medical illness and to better characterize their phenomenology. Data from different studies have, for example, indicated that the joint application of the DCPR and DSM-IV improved the identification of psychological problems by 30%–40% in subjects affected by gastrointestinal disorders,20 endocrine diseases,21 and myocardial disease.22,23 More specifically, 40% of the patients who underwent heart transplant surgery had a DCPR diagnosis but no DSM-IV diagnosis,22 and 30% of the patients in cardiac rehabilitation who did not receive any DSM psychiatric diagnoses met the criteria for psychosocial syndromes, according to the DCPR, namely type A behavior and irritable mood.23 In other words, it seems that the levels of sensitivity and specificity of the DCPR in the context of medical illness are better than what can be obtained by the application of a "pure" psychiatric nosographic system. In a recent preliminary study carried out on patients with cancer at different sites, we showed that 44.5% of the sample met the criteria for a DSM-IV diagnosis, but among those who did not meet DSM-IV criteria for any psychiatric diagnosis (55.5%), 40.4% had a DCPR syndrome and a further 30.8% had two or more DCPR syndromes.24
The aims of the present study were to examine in greater depth the application of the DCPR and the association between the DCPR and coping, quality of life, and illness-related worries among patients with breast cancer.
|
METHOD
|
Subjects
This study is part of a broader investigation examining the feasibility of the DCPR in patients with cancer in different sites. The details of the methods and the results of DSM-IV morbidity and overlap with the DCPR have been extensively reported elsewhere.24
Patients participating in the study presented here consisted of a convenience sample of women who had received a diagnosis of breast cancer within the past 18 months, who had a score of 80 or above on the Karnofsky Performance Status Scale,25 indicating a good level of functioning, who did not have cognitive impairment secondary to the effects of treatment, and who were followed by the outpatient oncology service and/or the physical rehabilitation unit of S. Anna University Hospital in Ferrara (Northern Italy) over 1 year. All of the patients were approached during one of their routine follow-up visits, were informed of the aim of the study, and gave written consent for participation as required by the institutional review board of the hospital.
The subjects were met individually and underwent a semistructured interview to evaluate the possible presence of potential psychological syndromes identified by the DCPR system.26 All the raters participated in a 1-day meeting to fulfill reliability criteria (kappa 0.75). As stated, the DCPR consists of 12 syndromes, namely, health anxiety, irritable mood, demoralization, illness denial, alexithymia, type A behavior, thanatophobia, disease phobia, functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion syndrome, and anniversary reaction. In consideration of the population examined, only the first seven clusters were explored. Disease phobia is not applicable if a definite medical diagnosis, such as cancer, has been given. Constellations dealing with somatoform disorders (functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion syndrome, and anniversary reaction) were excluded to avoid possible false positive cases due to cancer itself or treatment side effects. An example of a subgroup of DCPR clusters is provided in Appendix 1, while the semistructured interview and all DCPR syndromes are fully detailed elsewhere.17,26
Then the patients were asked to fill out a short booklet of questionnaires to assess the following areas: 1) coping with cancer (the Mini-MAC), 2) illness-related concerns (the Cancer Worries Inventory), and 3) quality of life dimensions (the Visual Analogue Quality of Life Scale). These three self-report instruments were given in this order to all of the patients.
The Mini-MAC27 is a 29-item scale that evaluates the cognitive and behavioral responses to cancer through four subscales, namely, fighting spirit (the tendency to confront and actively face the illness), hopelessness (the tendency to adopt a pessimistic attitude about the illness), anxious preoccupation (feelings of anxiety and tension concerning the illness), fatalism (resigned and fatalistic attitudes about the illness), and avoidance (tendency to avoid confrontation with the illness).
The Cancer Worries Inventory,28 in a shorter 13-item version, was given to investigate, on a 0–4-point Likert scale, the intensity of concerns caused by cancer and related problems (e.g., the illness itself, the effects of treatment, feeling different from others, the impact on sexual life, the future).
A visual analogue Quality of Life Scale29 was used to examine, on a 0–10 scale, six quality-of-life dimensions, namely, depressed mood, general well-being, physical symptoms (e.g., pain, nausea), the ability to participate in a leisure activity, adjustment to illness, and perceived support from interpersonal relationships. Lower scores in each domain corresponded to a worse condition.
Statistical Analysis
Statistical analysis was performed with the SPPS-10 package. Procedures included descriptive statistics to examine the general characteristics of the sample. Differences between groups were tested by means of the analysis of variance, Student's t test, and chi-square test. Reliability of the scales was evaluated by using Cronbach's alpha, when appropriate. Statistical significance was set at the 1% level.
|
RESULTS
|
Of 110 patients meeting the inclusion criteria, five (4.5%) refused to participate, leaving 105 women as the study group. Ages ranged from 27 to 70 years (mean=55.5 years, SD=10.4). Interventions were nodulectomy (N=1, 0.9%), quadrantectomy (N=99, 94.3%), and radical mastectomy (N=5, 4.8%). Fifty-one patients (48.6%) had a local disease, 48 (45.7%) had a local-regional disease, and 6 (5.7%) had a metastatic disease. Sociodemographic and clinical characteristics of the group are summarized in Table 1.
Prevalence of DCPR Syndromes and Differences on Psychosocial Measures
Forty patients (38.1%) had symptoms meeting criteria for at least one DCPR syndrome (DCPR=1), and 30 (28.6%) had more than one DCPR syndrome (DCPR cases >1) (total DCPR cases=70, 66.6%; total number of DCPR diagnoses=133; mean=1.26 per patient). The distribution of the DCPR constellations is shown in Table 2.
There was no difference between patients with DCPR diagnoses (DCPR=1 and DCPR >1) and those without any DCPR syndrome (N=35) in regard to age (F=1.12, df=1, 103, p=n.s.), education (F=0.99, df=1, 103, p=n.s.), and stage of illness ( 2=3.1, df=3, p=n.s.). The prevalence of DCPR was higher among patients who had had chemotherapy (76.4%) or radiotherapy (69.2%) than among patients who did not receive any adjuvant treatment (41.7%) (2=8.18, df=2, p=0.01).
With regard to psychological measures, Cronbach's alpha scores were acceptable for most of the psychometric instruments used, namely, Mini-MAC hopelessness ( = 0.88), anxious preoccupation (=0.82), avoidance (= 0.86), the Cancer Worries Inventory (=0.81), the Quality of Life Scale (=0.82), with the exception of Mini-MAC fighting spirit (=0.53), and fatalism (=0.53).
The comparison on the psychological measures between patients without DCPR diagnoses (N=35), with DCPR=1 (N=40), and DCPR >1 (N=30) are presented in Table 3. No difference was found on any Mini-MAC subscales. On the Quality of Life Scale, patients with DCPR syndromes showed scores indicating higher levels of depression (F=17.29, df=2, 103, p<0.001), more physical symptoms (F=6.30, df=2, 103, p<0.01), poorer well-being (F=11.17, df=2, 103, p<0.001), poorer leisure activity (F=10.40, df=2, 103, p<0.001), and lower support (F=6.14, df=2, 103, p<0.01). They also showed a higher score on the Cancer Worries Inventory (F=5.0, df=2, 103, p<0.01).
View this table:
[in this window]
[in a new window]
|
TABLE 3. Measures According to the Presence or Absence of Syndromes of Diagnostic Criteria for Psychosomatic Research (DCPR)
|
Single DCPR Syndromes and Psychological Measures
Student's t test was used to examine the differences between patients across single DCPR syndromes in comparison with patients without any DCPR syndrome (N= 35) (Table 4). Patients with a DCPR health anxiety reported higher scores on the Mini-MAC subscale anxious preoccupation (t=3.52, df=103, p<0.001) and, marginally, fatalism (t=2.55, df=103, p<0.02) than those not meeting the criteria for this syndrome. They also showed scores indicating poorer adjustment (t=2.92, df=103, p=0.005) and leisure activity (t=2.90, df=103, p=0.005) on the Quality of Life Scale.
View this table:
[in this window]
[in a new window]
|
TABLE 4. Comparison on the Psychosocial Measures Between Single Syndromes of Diagnostic Criteria for Psychsomatic Research (DCPR) and DCPR Noncases
|
DCPR demoralization was associated with higher scores on the Mini-MAC subscale for hopelessness (t=2.91, df=103, p=0.005). On the Quality of Life Scale, this group showed scores indicating higher levels of depression (t=5.91, df=103, p=0.001), poorer well-being (t=2.93, df=103, p<0.01), more physical symptoms (t=4.25, df=103, p<0.01), poorer leisure activity (t=3.79, df=103, p=0.001), poorer adjustment (t=5.53, df=103, p=0.001), and poorer social support (t=3.69, df=103, p<0.01). Cancer-related concerns (the Cancer Worries Inventory) were also higher in this group (t=4.54, df=103, p<0.001).
Patients meeting the DCPR cluster of alexithymia had higher scores on the Mini-MAC subscale avoidance (t=2.60, df=103, p=0.01). Scores on the Quality of Life Scale dimensions indicated more depression (t=5.58, df=103, p<0.001), poorer well-being (t=3.38, df=103, p<0.01), more physical symptoms (t=6.06, df=103, p< 0.01), poorer leisure activity (t=2.88, df=103, p=0.01), poorer adjustment (t=5.07, df=103, p<0.01), and lower interpersonal support (t=3.44, df=103, p=0.01). The mean score on the Cancer Worries Inventory was also higher (t=2.65, df=103, p=0.01).
Patients meeting the criteria for irritable mood had Quality of Life Scale scores indicating poorer quality of life (i.e., depression: t=6.01, df=103, p<0.001; leisure activity: t=6.26, df=103, p=0.001; adjustment: t=5.03, df=103, p<0.01; support: t=3.55, df=103, p=0.01) and higher scores on the Cancer Worries Inventory (t=3.17, df=103, p<0.01).
Analysis on the DCPR clusters type A behavior, illness denial, and thanatophobia was not carried out because of the small number of subjects in each of these categories.
|
DISCUSSION
|
This study examined the application of the DCPR in breast cancer patients and its association with a group of specific dimensions, such as styles of coping with cancer, cancer-related concerns, and physical and psychosocial dimensions of quality of life.
In agreement with a larger study in patients affected by cancer in different sites,24 two-thirds of breast cancer patients showed DCPR syndromes, especially health anxiety, demoralization, and alexithymia. Other research has also found these dimensions to be particularly frequent among patients with severe heart disease.22,23 This confirms the need for a broad investigation of psychological consequences of medical illness, specifically, as in this study, breast cancer. In fact, patients with DCPR syndromes reported a poorer quality of life, at least in the areas we have explored (e.g., leisure activity, general well-being, support from interpersonal ties, adjustment to illness). It also appeared that the patients with DCPR syndromes perceived higher levels of cancer-related concerns (e.g., sexual problems, uncertainty about the future, worry of recurrence). Although it is well known that worries about cancer and treatment have negative consequences at the individual psychological level,30 this is not necessarily expressed in the form of a formal psychiatric diagnosis but often in more subtle or subthreshold conditions that merit consideration. Patients with DCPR diagnoses did not show significant differences on the styles of coping with cancer that they adopted in comparison with patients without DCPR diagnoses. It is possible that the different clusters of DCPR, taken together, prevented discrimination between the specific cognitive and behavioral reaction to cancer, as measured by the Mini-MAC. In fact, significant differences emerged when the single DCPR syndromes were analyzed. In this case, a good correspondence was found between DCPR health anxiety and anxious preoccupation coping style (i.e., the tendency to constantly feel anxiety and tension about cancer), between DCPR demoralization and hopelessness (i.e., the tendency to adopt a helpless attitude and to give up), and between alexithymia and avoidance (i.e., the tendency to consciously avoid thinking about cancer). These results seem to validate the aforesaid DCPR constructs, although more research is necessary to clarify these aspects and to explore the parameters that were shown to be less reliable in this study (i.e., fighting spirit and fatalism). Most of the DCPR constructs (e.g., demoralization) were associated with poorer quality of life, indicating the role of this cluster in molding the patients' subjective experience.
An open question concerns the clinical implications of the DCPR over time. With respect to this, it has been found that clinical improvement in patients with gastrointestinal disorders was predicted both by a low prevalence of DCPR diagnoses, especially alexithymia and persistent somatization.31 In contrast, the development of coronary events (i.e., death, myocardial infarction, angina pectoris) over the long run (median 2 years) among patients with myocardial infarction was only weakly related to DCPR syndromes, as evaluated within 1 month from the diagnosis.32 On the basis of the cross-sectional study presented here, we do not have any element to hypothesize that DCPR syndromes can be risk factors for maladjustment to illness (e.g., poor quality of life, poor adherence to treatment) and negative events (e.g., recurrence or death) over the long run, although existing psycho-oncology data tend to suggest the role for psychological factors in both senses.33–37
The present study had several limitations. A first series of problems is relative to the DCPR clusters, as applied in oncology. A controversial point regards the concept of demoralization, which has been recently explored by both consultation-psychiatry38 and psycho-oncology.39 If the difference between major depression and demoralization is apparently clear,40,41 the nature and the implications of demoralization in medical illness remain an area of open discussion. In our study, demoralization was assessed according to the DCPR, and this does not allow us to make comparisons with other investigations that used other criteria. Kissane et al.,42 for example, proposed the following six criteria for the diagnosis of demoralization: 1) affective symptoms of existential distress, including hopelessness or loss of meaning and purpose in life; 2) cognitive attitudes of pessimism, helplessness, sense of being trapped, personal failure, or lacking a worthwhile future; 3) conative absence of drive or motivation to cope differently; 4) associated features of social alienation or isolation and lack of support; 5) allowing for fluctuation in emotional intensity, these phenomena persist across more than 2 weeks; 6) a major depressive or other psychiatric episode is not present as the primary condition. In this formulation, the authors consider that demoralization is a clinical situation that may frequently occur in cancer patients but that is not necessarily related to clinical depression. Similar indications were given by Clarke et al.43 who found that concepts of demoralization, anhedonia, and grief differed between important clinical syndromes among medically ill patients, leading the authors to propose the development of a new taxonomy of common distress syndromes to be used in medicine. Further research is necessary in this area.
A further caveat regards the DCPR cluster of alexithymia. Although it has been found that this cluster has adequate sensitivity, specificity, and accuracy compared to the Toronto Alexithymia Scale,44 more data are necessary to validate these findings in cancer patients and to examine the complex relationship between alexithymia and emotional repression (i.e., the tendency to control and block the expression of negative feelings), which has been shown to be a factor influencing adjustment in patients affected by breast cancer.45–47 More indications are also necessary with regard to the clusters of type A behavior, thanatophobia, and illness denial, which were found in a low percentage of patients and did not provide sufficient data to be discussed. Furthermore, since we decided to exclude the application of DCPR syndromes related to somatoform disorders (i.e., functional somatic symptoms secondary to a psychiatric disorder, persistent somatization, conversion syndrome, and anniversary reaction) in order to avoid the risk of overestimating these diagnoses, no comparison is possible with other studies pointing out the need for more attention to this underevaluated problem in oncology.48 The development of further DCPR clusters could also be helpful in the investigation of psychological consequences of specific medical illness. For example, body-image problems and sexuality, which have significant psychological impact in breast cancer patients' quality of life,49,50 should be taken into consideration by future DCPR research.
A further limitation regards the fact that all the patients were relatively homogeneous in terms of time since diagnosis, performance level, stage of illness, and type of surgery (i.e., quadrantectomy). These aspects do not allow us to generalize our findings on DCPR to other types of patients, such as those having a less recent diagnosis and a lower performance status, having received a different type of surgery (including breast reconstruction), or being in an advanced phase of illness. All these variables should be taken into account in future research. Related to this issue is the need for prospective studies that may clarify the effective role of DCPR syndromes over the long run. It has been reported that several variables, such as personality disposition,51 coping repertoire,52 spirituality,53 and social support54,55 influence adjustment to breast cancer, even though less data are available in long-term survivors of breast cancer.56,57 The role of DCPR in this complex and multi-deterministic58 area is not known and deserves to be examined. Finally, we have to mention the feasibility of the DCPR in cancer settings. As a preliminary result, the DCPR brought interesting data as far as the psychosocial clinical constellations that are detectable in cancer patients. However, it is also true that the system is still complex, and there is a strong need in clinical settings to have easy-to-administer instruments. In other words, we do not need further instruments showing reliable properties in comparison with other tested tools, but new instruments that can improve the understanding of the psychosocial consequences of medical illness, such as breast cancer. With respect to this, simpler versions (or modules) of the DCPR could be added to psychosocial investigation to better identify and detect the psychosocial sequelae of cancer and to tailor specific interventions according to the patient's individual needs.
To conclude, in the present study, the application of the DCPR provided promising findings in breast cancer patients, pointing out the role of DCPR constellations and their associations with cancer-related worries, coping strategies, and quality of life. Further research is in order to confirm the validity of the DCPR system and to improve its application in breast cancer patients.
|
ACKNOWLEDGMENTS
|
Funded in part by the Italian National Health Institute—National Mental Health Project (2000)—and in part by the Italian National Research Council (2000–2002).
The authors thank the colleagues who took part in the study and Paul Packer for revision of the manuscript.
|
REFERENCES
|
- Holland JC, Mastrovito R: Psychologic adaptation to breast cancer. Cancer 1980; 46:1045–1052[CrossRef][Medline]
- Psychological Aspects of Breast Cancer Study Group: Psychological response to mastectomy: a prospective comparison study. Cancer 1987; 59:189–196[CrossRef][Medline]
- Silberfarb PM: Psychiatric problems in breast cancer. Cancer 1984; 53:820–824[CrossRef][Medline]
- Coscarelli Schag CA, Ganz PA, Polinsky ML, Fred C, Hirji K, Petersen L: Characteristics of women at risk for psychosocial distress in the year after breast cancer. J Clin Oncol 1993; 11:783–793[Abstract]
- Zabora JR, Smith-Wilson R, Fetting JH, Enterline JP: An efficient method for psychosocial screening of cancer patients. Psychosomatics 1990; 31:192–196[Abstract/Free Full Text]
- Holland J: An algorithm for rapid assessment and referral of distressed patients, in American Society of Clinical Oncology Educational Book. Edited by Perry CM. Alexandria, Va, ASCO, 2000, pp 129–138
- Endicott J: Measurement of depression in patients with cancer. Cancer 1984; 53:2243–2248[CrossRef][Medline]
- Kathol RG, Mutgi A, Williams J, Clamon G, Noyes R: Diagnosis of major depression in cancer patients according to four sets of criteria. Am J Psychiatry 1990; 147:1021–1024[Abstract/Free Full Text]
- Akechi T, Nakano T, Akizuki N, Okamura M, Sakuma K, Nakanishi T, Yoshikawa E, Uchitomi Y: Somatic symptoms for diagnosing major depression in cancer patients. Psychosomatics 2003; 44:244–248 [Abstract/Free Full Text]
- Cavanaugh SV: Depression in the medically ill: critical issues in diagnostic assessment. Psychosomatics 1995; 36:48–59[Abstract/Free Full Text]
- Saleeba A, Weitzner MA, Meyers CA: Subclinical psychological distress in long-term survivors of breast cancer: a preliminary communication. J Psychosoc Oncol 1996; 14:83–93
- Holzner B, Kemmler G, Kopp M, Moschen R, Schweigkofler H, Dunser M, Margreiter R, Fleischhacker WW, Sperner-Unterweger B: Quality of life in breast cancer patients: not enough attention for long-term survivors? Psychosomatics 2001; 42:117–123[Abstract/Free Full Text]
- Payne DK, Hoffman RG, Theodulou M, Dosik M, Massie MJ: Screening for anxiety and depression in women with breast cancer. Psychosomatics 1999; 40:64–69[Abstract/Free Full Text]
- Zabora J, Brintzenhofe-Szoc K, Jacobsen P, Curbow B, Piantadosi S, Hooker C, Owens A, Derogatis L: A new psychosocial screening instrument for use with cancer patients. Psychosomatics 2001; 42:241–246[Abstract/Free Full Text]
- Hopwood P, Howell A, Maguire P: Psychiatric morbidity in patients with advanced cancer of the breast: prevalence measured by two self-rating questionnaires. Br J Cancer 1991; 64:349–352[Medline]
- Hall A, A'Hern R, Fallowfield L: Are we using appropriate self-report questionnaires for detecting anxiety and depression in women with early breast cancer? Eur J Cancer 1999; 35:79–85
- Fava GA, Freyberger HJ, Bech P, Christodoulou G, Sensky T, Theorell T, Wise TN: Diagnostic criteria for use in psychosomatic research. Psychother Psychosom 1995; 63:1–8[Medline]
- Fava GA: Beyond the biopsychosocial model: psychological characterization of medical illness. J Psychosom Res 1996; 40:117–120[CrossRef][Medline]
- Fava GA, Mangelli L, Ruini C: Assessment of psychological distress in the setting of medical disease. Psychother Psychosom 2001; 70:171–175 [CrossRef][Medline]
- Porcelli P, De Carne M, Fava GA: Assessing somatization in functional gastrointestinal disorders: integration of different criteria. Psychother Psychosom 2000; 69:198–204[CrossRef][Medline]
- Sonino N, Navarrini C, Ruini C, Ottolini F, Paoletta A, Fallo F, Boscaro M, Fava GA: Persistent psychological distress in patients treated for endocrine disease. Psychother Psychosom 2004; 73:78–83[CrossRef][Medline]
- Grandi S, Fabbri S, Tossani E, Mangelli L, Branzi A, Magelli C: Psychological evaluation after cardiac transplantation: the integration of different criteria. Psychother Psychosom 2001; 70:176–183[CrossRef][Medline]
- Rafanelli C, Roncuzzi R, Finos L, Tossani E, Tomba E, Mangelli L, Urbinati S, Pinelli G, Fava GA: Psychological assessment in cardiac rehabilitation. Psychother Psychosom 2003; 72:343–349[CrossRef][Medline]
- Grassi L, Rossi E, Sabato S, Gatti ME, Biancosino B, Marmai L: Use of the Diagnostic Criteria for Psychosomatic Research (DCPR) in oncology. Psychother Psychosom (in press)
- Karnofsky DA, Burchenal JH: The clinical evaluation of chemotherapeutic agents in cancer, in Evaluation of Chemotherapeutic Agents. Edited by MacLeod CM. New York, Columbia University Press, 1949, pp 191–205
- Mangelli L, Rafanelli C, Porcelli P, Fava GA: Interview for the Diagnostic Criteria of Psychosomatic Research (DCPR). Psychother Psychosom (in press)
- Watson M, Law M, dos Santos M, Greer S, Baruch J, Bliss J: The Mini-MAC: further development of the Mental Adjustment to Cancer Scale. J Psychosoc Oncol 1994; 12:33–46
- D'Errico GM, Galassi JP, Schanberg R, Ware WB: Development and validation of the Cancer Worries Inventory: a measure of illness-related cognitions. J Psychosoc Oncol 1999; 17:119–137
- Grassi L, Travado L, Gil Moncayo F, Sabato S, Rossi E: Psychosocial morbidity and its correlates in cancer patients of the Mediterranean area: findings from the Southern European Psycho-Oncology Study. J Affect Disord (in press)
- Spencer SM, Lehman JM, Wynings C, Arena P, Carver CS, Antoni MH, Derhagopian RP, Ironson G, Love N: Concerns about breast cancer and relations to psychosocial well-being in a multiethnic sample of early-stage patients. Health Psychol 1999; 18:159–168[CrossRef][Medline]
- Porcelli P, De Carne M, Todarello O: The prediction of treatment outcome of patients with functional gastrointestinal disorders by the diagnostic criteria for psychosomatic research (DCPR). Pychother Psychosom 2004; 73:166–173
- Rafanelli C, Roncuzzi R, Finos L, Tossani E, Tomba E, Mangelli L, Urbinati S, Pinelli G, Fava GA: Psychological assessment in cardiac rehabilitation. Psychother Psychosom 2003; 72:343–349
- Heim E, Valach L, Schaffner L: Coping and psychosocial adaptation: longitudinal effects over time and stages in breast cancer. Psychosom Med 1997; 59:408–418[Abstract/Free Full Text]
- Stanton AL, Danoff-Burg S, Huggins ME: The first year after breast cancer diagnosis: hope and coping strategies as predictors of adjustment. Psycho-Oncology 2002; 11:93–102[CrossRef][Medline]
- Watson M, Haviland JS, Greer S, Davidson J, Bliss JM: Influence of psychological response on survival in breast cancer: a population-based cohort study. Lancet 1999; 354:1331–1336[CrossRef][Medline]
- Brown KW, Levy AR, Rosberger Z, Edgar L: Psychological distress and cancer survival: a follow-up 10 years after diagnosis. Psychosom Med 2003; 65:636–643[Abstract/Free Full Text]
- Hjerl K, Andersen EW, Keiding N, Mouridsen HT, Mortensen PB, Jørgensen T: Depression as a prognostic factor for breast cancer mortality. Psychosomatics 2003; 44:24–30[Abstract/Free Full Text]
- Slavney PR: Diagnosing demoralization in consultation psychiatry. Psychosomatics 1999; 40:325–329[Abstract/Free Full Text]
- Clarke DM, Kissane DW: Demoralization: its phenomenology and importance. Aust N Z J Psychiatry 2002; 36:733–742[CrossRef][Medline]
- de Figuereido JM: Depression and demoralization: phenomenological differences and research perspectives. Comp Psychiatry 1993; 34:308–311
- Angelino AF, Treisman GJ: Major depression and demoralization in cancer patients: diagnostic and treatment considerations. Support Care Cancer 2001; 9:344–349[CrossRef][Medline]
- Kissane DW, Clarke DM, Street AF: Demoralization syndrome: a relevant psychiatric diagnosis for palliative care. J Palliat Care 2001; 17:12–21[Medline]
- Clarke DM, Smith GC, Dowe DL, McKenzie DP: An empirically derived taxonomy of common distress syndromes in the medically ill. J Psychosom Res 2003; 54:323–330[CrossRef][Medline]
- Porcelli P, De Carne M: Criterion-related validity of the diagnostic criteria for psychosomatic research for alexithymia in patients with functional gastrointestinal disorders. Psychother Psychosom 2001; 70:184–188[CrossRef][Medline]
- Stanton AL, Danoff-Burg S, Cameron CL, Bishop M, Collins CA, Kirk SB, Sworowski LA, Twillman R: Emotionally expressive coping predicts psychological and physical adjustment to breast cancer. J Consult Clin Psychol 2000; 68:875–882[CrossRef][Medline]
- Anagnostopoulos F, Vaslamatzis G, Markidis M, Katsouyanni K, Vassilaros S, Stefanis C: An investigation of hostile and alexithymic characteristics in breast cancer patients. Psychother Psychosom 1993; 59:179–189[CrossRef][Medline]
- Servaes P, Vingerhoets AJ, Vreugdenhil G, Keuning JJ, Broekhuijsen AM: Inhibition of emotional expression in breast cancer patients. Behav Med 1999; 25:23–27[Medline]
- Chaturvedi SK, Maguire GP: Persistent somatization in cancer: a controlled follow-up study. J Psychosom Res 1998; 45:249–256[CrossRef][Medline]
- Ganz PA, Rowland JH, Desmond K, Meyerowitz BE, Wyatt GE: Life after breast cancer: understanding women's health-related quality of life and sexual functioning. J Clin Oncol 1998; 16:501–514[Abstract]
- Shapiro SL, Lopez AM, Schwartz GE, Botzin R, Figueredo AJ, Braden CJ, Kurker S: Quality of life and breast cancer: relationship to psychosocial variables. J Clin Psychol 2001; 57:501–519[CrossRef][Medline]
- Carver CS, Pozo-Kanderman C, Harris SD, Noriega V, Scheier MF, Robinson DS, Ketcham AS, Moffat FL Jr, Clark KC: Optimism versus pessimism predicts the quality of women's adjustment to early stage breast cancer. Cancer 1994; 73:1213–1220[CrossRef][Medline]
- McCaul KD, Sandgren AK, King B, O'Donnell S, Branstetter A, Foreman G: Coping and adjustment to breast cancer. Psycho-Oncology 1999; 8:230–236[CrossRef][Medline]
- Cotton SP, Levine EG, Fitzpatrick CM, Dold KH, Targ E: Exploring the relationships among spiritual well-being, quality of life, and psychological adjustment in women with breast cancer. Psycho-Oncology 1999; 8:429–438[CrossRef][Medline]
- Grassi L, Rosti G, Lasalvia A, Marangolo M: Psychosocial variables associated with mental adjustment to cancer. Psycho-Oncology 1993; 2:11–20
- Koopman C, Hermanson K, Diamond S, Angell K, Spiegel D. Social support, life stress, pain and emotional adjustment to advanced breast cancer. Psycho-Oncology 1998; 7:101–111[CrossRef][Medline]
- Dorval M, Maunsell E, Deschenes L, Brisson J, Masse B. Long-term quality of life after breast cancer: comparison of 8-year survivors with population controls. J Clin Oncol 1998; 16:487–494[Abstract]
- Tomich PL, Helgrson VS: Five years later: a cross-sectional comparison of breast cancer survivors with healthy women. Psycho-Oncology 2002; 11:154–169[CrossRef][Medline]
- Irvine D, Brown B, Crooks D, Roberts J, Browne G: Psychosocial adjustment in women with breast cancer. Cancer 1991; 67:1097–1117[Medline]
This article has been cited by other articles:
|
|
|
|
 
A. Picardi, P. Porcelli, P. Pasquini, G. Fassone, E. Mazzotti, I. Lega, L. Ramieri, E. Sagoni, D. Abeni, A. Tiago, et al.
Integration of multiple criteria for psychosomatic assessment of dermatological patients.
Psychosomatics,
March 1, 2006;
47(2):
122 - 128.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Mangelli, F. Semprini, L. Sirri, G. A. Fava, and N. Sonino
Use of the Diagnostic Criteria for Psychosomatic Research (DCPR) in a Community Sample.
Psychosomatics,
March 1, 2006;
47(2):
143 - 146.
[Abstract]
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2004
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
