Psychological adjustment to chronic disease Denise de Ridder, Rinie Geenen, Roeline Kuijer, Henriët van MiddendorpLancet 2008; 372: 246–55 This Review discusses physiological, emotional, behavioural, and cognitive aspects of psychological adjustment to Department of Clinical & Health chronic illness. Reviewing the reports of the past decade, we identify four innovative and promising themes that are Psychology, Utrecht University, relevant for understanding and explaining psychological adjustment. In particular, the emphasis on the reasons why The Netherlands Research people fail to achieve a healthy adjustment has shifted to the identiﬁ cation of factors that help patients make that Institute for Psychology & adjustment. To promote psychological adjustment, patients should remain as active as is reasonably possible, Health, Utrecht, Netherlands acknowledge and express their emotions in a way that allows them to take control of their lives, engage in self-management, and try to focus on potential positive outcomes of their illness. Patients who can use these strategies have the best chance of successfully adjusting to the challenges posed by a chronic illness. Introduction
relationships),3 the absence of psychological disorders, the
Chronic illnesses are disorders that persist for an extended
presence of low negative aﬀ ect and high positive aﬀ ect,
period and aﬀ ect a person’s ability to function normally. adequate functional (eg, work) status, and the satisfaction
Some chronic diseases (eg, rheumatoid arthritis) need and wellbeing in various life domains.4 Several models
long-term pharmacological treatment and are often have been proposed on how patients could achieve these
characterised by progressive physical disability and pain. outcomes, including: the model of cognitive adaptation, Others (eg, diabetes) can be medically controlled, but only
which emphasises illness acceptance and perceptions of
at the cost of strict adherence to disease management control over illness;5 the personality model that emphasises regimens. Thus, a chronic illness has the potential to the role of personality factors (such as optimism or induce profound changes in a person’s life, resulting in neuroticism) in adjustment; and the stress and coping negative eﬀ ects on quality of life and wellbeing.1
model that emphasises strategies used by patients to deal
After the medical diagnosis of chronic illness, patients with adaptive tasks imposed by disease.6 The authoritative
are confronted with new situations that challenge their stress and coping model acknowledges that chronic illness habitual coping strategies. As a result, they must ﬁ nd consists of several challenges, but at the same time, it new ways of coping to adjust to their altered condition.2
highlights—more than other models of adjustment—
We use the terms adjustment and psychological processes of appraisal and coping that explain why some adjustment interchangeably to refer to the healthy patients successfully identify and act on opportunities to rebalancing by patients to their new circumstances. Most
manage these tasks whereas others might fail to do so.
patients eventually reach a state of good psychological More recently, the stress and coping model has been adjustment, but for about 30% of patients, the adjustment
extended with the model of self-regulation, which allows
phase is prolonged and sometimes unsuccessful.2
patients to deal with illness more proactively.7 Both models
At least ﬁ ve key elements of successful adjustment to a show the active role that patients may have in adjusting to
chronic illness have been identiﬁ ed: the successful the challenges posed by their condition, and they have performance of adaptive tasks (eg, adjustment to disability,
been used to study processes of adjustment in diverse
maintained emotional balance, and preservation of healthy
chronic conditions including cancer, diabetes, HIV-infec-tion, asthma, and rheumatoid arthritis.8,9
We review prospective (observational) and experimental
Search strategy and selection criteria
research in 1996–2005 on four innovative areas in adjustment to chronic illness. We focus on approaches
We used the Web of Science (1996–2005) to search reviewed topics. General search terms
that explain how patients can successfully adjust and
referred to psychological adjustment, including: “adjust*”, “adapt*”, “distress”, “depress*”,
review the physiological, emotional, behavioural, and
and “anxi*”. Other searches included terms covering chronic disease (“chronic disease”,
cognitive aspects of the process. First, we discuss
“chronic illness”, or a speciﬁ c disease). For eﬀ ects of blockades of proinﬂ ammatory cytokines,
pathophysiological factors focusing on the role of
we used “rheumatoid arthritis” or “RA” in the title with one of the drugs (“inﬂ iximab”,
cytokines, such as those that reduce activity and aﬀ ect
“etanercept”, “adalimumab”, “remicade”, “enbrel”, “humira”); or other words referring to
mood, and that have been shown to interfere with
blockade with TNFα. For associations between emotion regulation and adjustment to
attempts to engage in activities important to patients. As
chronic illness, we combined “emotio*” with “control”, “repress*”, “suppress*”, “express*”,
such, to deal with the consequences of cytokines and to
“non-express*”, or “intens*”, or the terms “alexithymia”, “ambivalence”, or “aﬀ ect intens*”.
remain active is of utmost importance for adjustment.
For positive moods and self-management, we used “self-management”, “self-care”, “dietary
Second, we address the role of dealing with emotions in
behavi*”, or “exercise”. For relations between beneﬁ t ﬁ nding or growth and adjustment
adjustment processes. For some time, the adaptive role
beneﬁ t ﬁ nding, we used “positive emotion”, “beneﬁ t ﬁ nding”, “post-traumatic growth”, or
of focusing on emotions has been regarded with
“stress-related growth”. Full articles of studies published in English and that included
suspicion, but a growing consensus has indicated that
adolescents or adults were used. Abstracts and references of all identiﬁ ed articles were also
the confrontation of negative emotions associated with
examined for importance, relevance, and overlap.
chronic illness could contribute to adjustment. Third, we
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examine self-management in adjustment and highlight studies that indicate the adaptive beneﬁ ts of patients’
Panel 1: Eﬀ ects of blockade of proinﬂ ammatory cytokines* on psychological
willingness and ability to engage in self-management.
adjustment in patients with rheumatoid arthritis, as shown in relevant studies
Finally, we discuss how chronic illnesses can have
Disability in daily activities
positive consequences by showing that a crucial part of
Disability scores have been shown to improve after the ﬁ rst week of medication.18–29 This
adjustment could entail a process of patients ﬁ nding a
improvement was sustained with prolonged drug use (up to 5 years).19 Eﬀ ect size was
beneﬁ t from the condition. These ﬁ ndings could explain
about 0·6 SD units,20,25 regarded as a moderate change; percentage change varied
why people with chronic illnesses, despite the negative
physical consequences of their disease, report a quality of life that is notably similar to that of healthy people. Quality of life Summary scores of the short form 36, measuring physical functioning, improved.18,20–22,24,25,28,29 The challenge of patients remaining active
Eﬀ ect size was more than 0·5 SD units,20,25 regarded as a moderate change; percentage
despite cytokine activity
change was about 40%.22,25 Improvement on the summary score of the short form 36,
Infectious and inﬂ ammatory processes can induce a
measuring mental wellbeing (which did not diﬀ er greatly from the general population at
constellation of non-speciﬁ c symptoms, often called
baseline),21 was generally small (about 15%).20–22,24,25,28,29
sickness behaviour, including weakness, malaise,
Fatigue and vitality
inability to concentrate, depressed mood, lethargy, anhe-
Substantial improvement was seen on the fatigue scale of the Functional Assessment of
donia, and anorexia.10 Therefore, in addition to dealing
Chronic Illness Therapy questionnaire.29 Change on the vitality scale of the short form 36
with the behavioural, cognitive, and emotional challenges
was as large as the change seen on physical functioning scales.18,20
of disease, patients must also cope with these physiologically-induced symptoms to preserve an active
*TNFα was blocked with inﬂ iximab (remicade), etanercept (enbrel), or adalimumab (humira). Most studies were double-blinded clinical trials in which the eﬀ ect of conventional treatment with methotrexate only was compared with the
eﬀ ect of treatment with methotrexate combined with TNFα blockade.
The psychological eﬀ ects of these pathophysiological
processes are mediated by cytokines. Several studies have shown that proinﬂ ammatory cytokines such as tumour
The malaise and behavioural inactivation associated
necrosis factor α (TNFα) and interferon alfa seem to with illness is generally regarded as adaptive, especially promote the psychological symptoms seen with several during acute infection and inﬂ ammation. By inducing chronic diseases. Proinﬂ ammatory cytokines contribute rest, this response conserves energy and promotes to the vital exhaustion (loss of energy, increased irritability,
healing, and thus stimulates adjustment similar to the
and feelings of demoralisation) seen with acute myocardial
desire for food in response to hunger, pain in response to
infarction.11 In diabetes, increased concentrations of injury, and the ﬁ ght-or-ﬂ ight response to threat. However, proinﬂ ammatory cytokines are produced by adipose these adaptive mechanisms can also have adverse tissue, and by monocytes and macrophages seen with consequences in chronic conditions. In diabetes, hunger increasing age, and could contribute to depression and can make adjustment to a healthy diet diﬃ
so-called sickness behaviour.12 In cancer, these cytokines pain due to rheumatic disease can inhibit healthy physical contribute to fatigue, memory and concentration activity, and the ﬁ ght-or-ﬂ ight response can endanger problems, depression, and anxiety.13
patients with cardiovascular disease. Thus, symptoms
Immunotherapy with cytokines has also been shown to
(such as fatigue and pain) that are beneﬁ cial during an
promote these symptoms. In uncontrolled prospective acute illness can become obstacles to psychological trials with interferon-alfa infusions, patients frequently adjustment in chronic disease. report fatigue (70–100%), depressive symptoms (21–58%),
Chronic pain has been suggested not only to lead to
and depression according to diagnostic criteria (9–45%) pain-avoidance behaviour but also to persistence or even as well as anorexia, pain, cognitive slowing, confusion, overuse of activities, both of which can lead to disability.30 lethargy, mania, inner tension, anxiety, and reduction in Furthermore, patients with other chronic diseases are goal-directed behaviour.14–17
faced with the challenge to pace their activity and ﬁ nd a
Evidence suggests that cytokines mediate disease-
new balance in their lives. Only a few decades ago, the
induced inactivity and distress. In patients with common recommendation given to patients with chronic rheumatoid arthritis who do not respond to conventional
inﬂ ammatory diseases such as rheumatoid arthritis was
disease-modifying antirheumatic drugs, reduced disease to rest.31 Nowadays, graded exercise tailored to the activity can be achieved by blockade of proinﬂ ammatory patients’ abilities and disease severity is thought to lead cytokines. Immediately after blockade of TNFα, a to improved physical, functional, and emotional substantial improvement of physical functioning, quality
outcomes.32,33 Inactivity in response to acute illness is
of life, and fatigue can be seen (panel 1). The ﬁ nding that natural and often beneﬁ cial. But one of the challenges proinﬂ
ammatory cytokines can promote—and by facing patients with chronic illness is to engage in those
blockade reduce—these symptoms shows that physio-
activities that can improve functional ability and
logical factors are a real obstacle to the psychological emotional status in the face of real cytokine-related adjustment to chronic illness.
www.thelancet.comVol 372 July 19, 2008 Emotion regulation: to feel or not to feel
occurrence and risk of disease progression, increasing
Patients with chronic illness typically have anxiety, evidence has shown that the habitual acknowledgment depression, and other negative emotions.2 How these and expression of emotions can promote good individuals cope with these emotions can aﬀ ect how well
they adjust to their illness. Emotion regulation is a term
In cross-sectional studies, maladjustment to chronic
encompassing several conscious or unconscious styles of
illness is commonly related to styles of emotion
experiencing, processing, and modulating emotions.34
regulation characterised by avoidance and non-expression.
Two main categories of emotion regulation have been Examples include patients having diﬃ
distinguished: avoidance and inhibition of emotions, and
and describing emotions (alexithymia), being unaware
expression and acknowledgment of emotions. Although of emotions (repression), avoiding the expression of the ﬁ rst category—when generally applied—is associated
emotions (emotional control, suppression, anti-
with maladaptive outcomes such as an increase in disease
emotionality), and being ambivalent about expressing emotions.36 Although patients are often advised to face and express emotions, cross-sectional relations between
Panel 2: Prospective and experimental studies of associations between emotion
adjustment and the acknowledgment and expression of
regulation and adjustment to chronic illness
emotions have been inconsistent.37 However, these cross-sectional ﬁ ndings do not prove that emotion
regulation aﬀ ects adjustment; it is equally possible that
the distressing emotions experienced during chronic
• Emotional control before diagnosis of breast cancer predicted increased psychological
illnesses aﬀ ect emotion regulation.
distress after diagnosis.39 Control did not predict increased distress 15 months later in
Prospective studies examining which types of emotion
regulation aﬀ ect adjustment show that, at least in the
• Emotional processing and aﬀ ect intensity not only predicted positive aﬀ ect scores in
North American and western European cultures, the
rheumatoid arthritis,41 but also negative aﬀ ect41 and increased distress in patients with
regular use of avoidant non-expressive styles of emotion
breast cancer and rheumatoid arthritis after 3–15 months40,42
regulation is disadvantageous for psychological
• Mood repair and mood clarity predicted reduced pain-related psychological distress in
adjustment and survival. In less emotionally expressive
rheumatoid arthritis and osteoarthritis41,43
Asian cultures, non-expressive emotion regulation styles
• Expression of emotion predicted reduced distress after diagnosis of breast cancer and
have proven advantageous, suggesting that the
3 months after diagnosis,39,42 and did not predict distress in rheumatoid arthritis after
congruence between one’s general style to handle
emotions and the style advocated in one’s cultural system
determines whether the emotion regulation style is
• Alexithymia and ambivalence over expression of emotions predicted an increase in
adaptive or maladaptive.38 Acknowledgment and intense
self-reported disease activity in rheumatoid arthritis after 15 months40
experience of emotions are suggested to be beneﬁ cial for
• Non-expression of emotions predicted rapid disease progression in HIV after
adjustment as long as those emotions are expressed and
processed; the mere uncontrolled expression of emotions
emotions45 and emotional control46,47 predicted increased mortality in
without processing can be maladaptive (panel 2).
cancer, whereas other studies showed no association with survival,48–50 and one study
Expression of emotions is often a component of
in Japan showed moderate anti-emotionality to predict survival38
psychological interventions in chronically ill patients.65
• Emotional expression resulted in improved self-perceived health status and reduced
Emotional disclosure interventions66 have provided the
number of medical visits in breast cancer after 3 months,42 and no change in perceived
most convincing evidence that expression can improve
health in rheumatoid arthritis after 15 months40
psychological and physical adjustment, sometimes even
• Emotional expression predicted survival in breast cancer46
on objective markers of disease activity (panel 2).
Beneﬁ cial eﬀ ects have been noted after disclosure (mostly
written, but also oral) by participants from varying
• Emotional expression in several chronic diseases led to decreased distress, mood
cultural backgrounds and socioeconomic status, as well
improvement, or reduced intrusions up to several months after the intervention,51–55
as in diverse chronic conditions, including cancer, HIV,
or resulted in no change or change in only one minor outcome variable56–61
Physiological and psychological mechanisms have
been proposed to explain the negative eﬀ ect of avoidant
• Emotional expression in several chronic diseases led to a reduction in health-care use,
and non-expressive emotion regulation styles on
improved physical functioning, fewer symptoms reported, or reduced self-perceived
adjustment. Although denial and non-expression of
disease activity up to several months after the intervention,51–54,57,59,60 or resulted in
emotions can be a useful initial coping strategy to deal
with the stress that accompanies the diagnosis of a
• Emotional expression led to improvements in clinical and laboratory observations
chronic disease,67 failure to acknowledge and express
(eg, pulmonary function in asthma, joint score in rheumatoid arthritis,
emotions can leave these emotions unresolved. These
CD4+ lymphocyte counts in HIV) up to several months after the intervention,51,58,62,63
unresolved emotions can aﬀ ect patients’ health negatively
or resulted in no change53,54,56,59,60,64
by, for example, chronic raised activity of the sympathetic
www.thelancet.comVol 372 July 19, 2008
nervous system.68 The inhibition of emotions can also 15–25% of patients improve their health practices after delay help-seeking behaviour when it hampers symptom
diagnosis,77 suggesting that they ﬁ nd disease management
recognition and, when help is sought, compromise the diﬃ
cult to integrate into their lives. Indeed, many
communication with health-care providers. Such patients have a great fear of lifestyle changes78,79 and inhibition can also lead to patients failing to practice report more non-adherence to diet and exercise than to health-protective behaviours and adhere to treatment.67
medication use or check-up appointments and symptom
erent mechanisms have been monitoring.79,80 An explanation for the non-use of
proposed to explain why acknowledgment and expression
self-management might be the large amount of time and
of emotions are beneﬁ cial for patients.69 Although the eﬀ ort needed,81 and patients might not always have acknowledgment and experience of negative emotions immediate beneﬁ ts in terms of symptom improvement can be adaptive because they focus attention toward or a sense of improved wellbeing.76 The burden of threats, elicit action, and provide feedback on progress self-management could be the reason why patients who toward important goals,67 repeated reﬂ ection on or show signs of poor psychological adjustment face rumination about negative feelings without expressing particular diﬃ
them is not deemed healthy.42,70 Some processing of
Many studies on adjustment and self-management
emotions is needed before being beneﬁ cial. Patients have highlighted the role of major depression as a risk thinking and talking or writing about emotions will make
factor for non-adherence to self-management recom-
their experience less intensive and invasive (habituation),
mendations, with depressed patients frequently reporting
whereas it can also increase insight into why emotions indecisiveness and reduced self-conﬁ dence about self-are experienced and how their eﬀ ect can be reduced management.82 The presence of clinical depression has (cognitive reappraisal). Furthermore, expression of been shown to disrupt adequate self-treatment in emotions can decrease emotional distress and restore diabetes,80,83 COPD,84 and HIV.85 Although depression is psychophysiological balance, and create opportunities thought to precede poor self-management instead of the for social support and enhanced closeness with others, other way around, the cross-sectional design used in beneﬁ t ﬁ nding, and improved self-regulation.35,70
such studies precludes conclusions about the causal link
Overall, when confronted with chronic illness it seems between self-management and psychological adjustment.
better for patients to generally express than to deny or Symptoms of depression, such as reduced energy or inhibit emotions, as long as this strategy surpasses the motivation, can clearly interfere with self-management, unbridled spouting of emotions and helps to achieve more
but the inability to undertake self-management can also
insight. Evidence on the role of emotion regulation in lead to feelings of helplessness and hopelessness.86 Major adjustment to chronic illness implies that patients depression and poor self-management can even be acknowledging and dealing with the negative emotions regarded as independent outcomes resulting from surrounding chronic illness is not necessarily bad for cytokines and other pathophysiological mechanisms.87 adjustment. Although styles of emotion regulation are a Clinical forms of anxiety have also been suggested to stable characteristic of a person and can be diﬃ
cult to compromise self-management, but this association has
change, interventions that aim to teach more eﬀ ective not been studied extensively.83styles to regulate emotions have proven beneﬁ cial for
Even when patients do not meet criteria for clinical
individuals who consistently use ineﬀ ective emotion diagnosis of depression (or anxiety), they can have some regulation styles in adjusting to their chronic condition.65
form of psychological distress,88 which could be regarded a signal of poor adjustment. Some of the most frequently
Self-management: improvement of mood and
reported sources of distress include worries about
long-term complications, guilt or anxiety when problems
Management of chronic illness is characterised by many in self-management occur, and fear about other potential responsibilities regarding medication use, lifestyle negative eﬀ ects of the disease.89 Like major depression, changes, and behaviour to prevent long-term compli ca-
mild forms of distress have been associated with reduced
tions—generally referred to as self-management of self-management in cross-sectional studies of diﬀ erent disease.71 Many studies have shown that patients who chronic conditions, including COPD,90 diabetes,91 HIV,72 engage in healthy diet, exercise, or other aspects of and asthma.92 Notably, the few available prospective self-management have physical beneﬁ ts in terms of fewer
studies of distress and self-management suggest a
symptoms, better functional capability, and fewer diﬀ erent pathway than assumed in studies of depression complications than those who do not in various diseases and self-management, and lend support to the (eg, HIV/AIDS,72 rheumatoid arthritis,73 asthma or assumption that poor self-management could precede chronic obstructive pulmonary disease,74 diabetes,75 and decreased adjustment. For example, a cancer study heart failure76). However, the extent to which self-
showed that patients with decreased self-management
management can also aﬀ ect psychological adjustment is predicted a reduced quality of life and increased mood much less understood. Studies have shown a low disturbance after 8 months,93 whereas a study of adherence to self-management regimens; only about individuals with rheumatoid arthritis showed that a
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such as problem-solving and goal-setting.100 These
Panel 3: Positive moods and self-management
self-management skills are recognised and appreciated by many patients, including those from ethnic groups,101
Not only can positive mood beneﬁ t self-management, but adequate self-management can
suggesting that they are valuable ingredients of
also promote wellbeing. In patients with diabetes who reported increased levels of perceived
self-management interventions. However, although good
competence and autonomous motivation for self-management, improved life satisfaction95
mood seems to promote engagement in self-management
and self-management behaviour were reported, which in turn increased glycaemic control
of illness, improvement of moods could prove valuable
after 1 year.75 Engagement in self-management could also beneﬁ t psychological adjustment,
to self-management interventions since many patients
both in the short term and long term, as shown in several prospective studies in cancer. Such
report feelings of discomfort about disease, sometimes
results indicated that patients with head and neck cancer who took appropriate
only after they have been dealing with disease for several
self-management measures after surgery were less anxious the next day,96 and women with
cancer who exercised at least 90 min per week on 3 or more days reported less fatigue and emotional distress as well as higher functional ability and quality of life than less active women during treatment.97 Similar eﬀ ects of self-management on psychological adjustment have
Cognitive processing: beyond negative
been shown in prospective studies of patients with heart failure98 and patients who had had
outcomes Although health-related quality of life of patients with
cardiac surgery.99 Only a few self-management interventions have also examined adjustment;
chronic conditions is generally lower than that of healthy
although patients increase eﬀ orts in self-management when participating in the intervention,
controls,1 this diﬀ erence is less pronounced or even
they have mixed ﬁ ndings regarding the eﬀ ect on adjustment. Some studies show that self-
absent in aspects of mental health.1,103 Individuals can use
management does not necessarily beneﬁ t adjustment,76,98 whereas others report improved
various cognitive strategies to counteract the negative
quality of life and mood after some time.71,73,93 These ﬁ ndings suggest that patients can learn to
eﬀ ect of illness on their wellbeing. Much research has
appreciate the need of self-management as a result of participating in interventions, but that
addressed Howard Leventhal’s model of illness
such beneﬁ ts of improved wellbeing could take some time.
representations,104 showing that patients’ beliefs (eg, about the course and consequences of their illness) can
decline in the ability to perform self-management aﬀ ect adjustment in chronic conditions such as diabetes.105 activities predicted the subsequent onset of depressed Only recently, attention has been paid to post-traumatic feelings.94
growth and beneﬁ t ﬁ nding,106–108 as well as response
Most relevant studies have examined the association shift.109
between poor adjustment and poor self-management.
The experience of dealing with illness is not all
However, other studies have investigated the connection negative. Individuals have reported positive outcomes between good adjustment and engagement in from various diseases (eg, breast52,70,110–114 cancer,115,116 self-management practices. These studies are rare, rheumatoid arthritis,117 multiple sclerosis,118 myocardial although their prospective design allows for an infarction,112 HIV/AIDS,119 and ﬁ bromyalgia106), such as interpretation of the direction of the connection. an improved appreciation of life, enhanced sense of Importantly, these studies show evidence of a bidirectional
purpose, changes in life priorities, and improved
association between wellbeing and adherence to personal relationships. About 60–85% of patients with self-management regimens. Patients who can maintain breast cancer,112,113 83% of HIV-positive women,119 73% of good moods seem to be more willing to engage in lifestyle
patients with rheumatoid arthritis,117 and 58% of
changes, and those who practice self-management individuals with myocardial infarction112 have reported at behaviours also report improved wellbeing (panel 3).
least one positive change as a result of their illness. With
These studies suggest a diﬀ erent connection between multi-item scales used to measure beneﬁ t, patients have
self-management and adjustment than has been generally reported a small-to-moderate degree of assumed so far. Research on the association between perceived positive change.70,110,111,113,116,118 Moreover, survivors depression and self-management has been driven by the
of breast cancer have reported more positive growth
assumption that depression precedes poor self-
experiences than matched controls (who reported on a
management, but the available cross-sectional studies stressful event in the same period), even though the can neither support nor refute this assumption. survivors have reported either similar120,121 or increased Moreover, the role of mild forms of psychological levels of distress,115 worsened physical functioning,115,120 or discomfort needs more research since such low levels of
more negative changes as a result of the experience.121
mood disturbance could impair self-management to the
Some patients with chronic illness are more likely to
same extent as clinical manifestations of poor adjustment
report positive experiences than are other patients.
in terms of (major) depression. Perhaps even more Reports of positive changes are correlated with important is the ﬁ nding that good adjustment predicts demographic variables such as young age70,111,116,122,123 and, increased participation in self-management and vice perhaps counter-intuitively, minority status,111,114 but versa. This association could have important implications
generally not with sex,116–118,122,123 and inconsistently with
for self-management interventions, which vary greatly in
socioeconomic status and education.111,113,114,116 Consistent
approach (from education to cognitive-behavioural with the theoretical assumption that an event should be treatment)73 but share an emphasis on improving skills intense to provoke growth or beneﬁ t ﬁ nding,107,108 some
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cancer studies have suggested that heightened physical stressful, traditional research focusing on the negative threat (ie, poor disease stage or increased physical aspects provides an incomplete picture since many symptoms)111,114 and raised perceived stress113 are related to
patients can ﬁ nd a new equilibrium by focusing on the
an increased report of positive changes. However, a study
exploring the curvilinear association between cancer stage and post-traumatic growth showed that very high Discussion levels of threat (stage IV breast cancer) resulted in Psychological adjustment to chronic illness is tremen- reduced perceived beneﬁ t.123 With respect to time since dously important. An estimated 50% of people have a diagnosis, ﬁ ndings are inconsistent.111,117,123 Theoretically, a
chronic physical condition, needing some form of
positive correlation would be expected because time is medical intervention.136 About 35% of young adults report needed to work through the event to experience at least one chronic condition2 and more chronic illnesses growth.113,118,122 One prospective study70 showed that occur in older adults. While the average age of the post-traumatic growth in patients with breast cancer population increases, so does the occurrence of chronic increased consistently during the ﬁ rst 18 months after diagnosis. Beneﬁ t ﬁ nding and growth have also been related to personality characteristics such as trait
Panel 4: Prospective and experimental studies examining relations between beneﬁ t
optimism,113,122 dispositional hope,106,113 and extraversion.122
ﬁ nding or growth and adjustment
Prospective studies examining the relation between
growth or beneﬁ t ﬁ nding and psychological adjustment
have shown mixed results (panel 4). Research suggests
Beneﬁ t ﬁ nding in survivors with breast cancer (1–5 years after diagnosis)111 and rheumatoid
that eﬀ ects could depend on the time of assessment and
arthritis and multiple sclerosis (on average 10 years after diagnosis)122 predicted increased
length of follow-up. Positive eﬀ ects on adjustment were
positive aﬀ ect after 5 years and 1 year, respectively. Two studies in patients recently
recorded in samples in which beneﬁ t ﬁ nding was assessed
diagnosed with breast cancer (4 months post-diagnosis114 and post-treatment
some time after diagnosis111,122 or with an extended
completion113) showed no relation with positive aﬀ ect after 3–12 months.
follow-up.124 Beneﬁ t ﬁ nding that is early in the adjustment
Negative aﬀ ect, depression and mental functioning
process could represent a form of avoidance,130 or early
Beneﬁ t ﬁ nding in patients with breast cancer (3, 6, and 12 months after diagnosis) predicted
beneﬁ t ﬁ nding could be qualitatively diﬀ erent from beneﬁ t
decreased negative aﬀ ect and depression after 4–7 years;124 In patients recently diagnosed
ﬁ nding later on.114 Research shows that beneﬁ t ﬁ nding
with breast cancer (4 months after diagnosis),114 beneﬁ t ﬁ nding predicted increased negative
that is induced52 or that is a result of an intervention110
aﬀ ect after 3–9 months and worsened mental functioning after 3 months for women with
shortly after diagnosis does lead to positive outcomes,
more severe stages of disease (relations were weak or absent for women with less severe
including positive eﬀ ects on physical adjustment.
stages). Other studies of breast cancer (1–5 years after diagnosis111 and post-treatment
Finding beneﬁ t or growth could be one of the cognitive
completion,113 respectively) showed that rheumatoid arthritis117,122 and multiple sclerosis122
strategies used to oﬀ set the negative eﬀ ect of illness and
showed no eﬀ ects on negative aﬀ ect,111,122 mental functioning,111 or psychological distress.117
could be viewed as part of a so-called response shift process.109 When diagnosed, individuals may change
Disability, physiology, and mortality
their internal standards of what constitutes health or
In patients with rheumatoid arthritis (average 10–16 years after diagnosis) beneﬁ t ﬁ nding
other aspects of quality of life (recalibration), adjust their
was related to reduced disability in one study117 but not in another.122 Studies of breast
values and priorities (reprioritisation), or redeﬁ ne what
cancer did not ﬁ nd relations between beneﬁ t ﬁ nding and self-reported physical
they think is important (reconceptualisation) to maintain
functioning111,114 or perceived health.113 In HIV-positive men (on average 8 months after
an acceptable quality of life in the face of declining
bereavement), beneﬁ t ﬁ nding was related to a more favourable immune status (CD4
health.109 Most research has focused on recalibration and
T cells) after 2–3 years and decreased AIDS-related mortality after a follow-up of
supports the assumption that individuals change their
4–9 years.125 In the only prospective study before 1996, beneﬁ t ﬁ nding in patients with
internal standards of aspects of quality of life over time
heart attacks (7 weeks after the attack) was related to a reduced likelihood of heart attack
or as a result of medical treatment.116,131–133 Evidence has
recurrence and morbidity at 8 years of follow-up.126
also shown the occurrence of reconceptualisation132,134 and
• A cognitive-behavioural stress management intervention for recently diagnosed
patients with breast cancer led to increased beneﬁ t ﬁ nding at 9-month follow-up.110 At
interventions such as cognitive-behavioural therapy.
3-month follow-up, increased beneﬁ t ﬁ nding was related to improved immune status
Cognitive-behavioural therapy includes various strate-
(lymphocyte proliferation)127 and reduced concentration of testosterone128 and serum
gies that promote a realistic but optimistic attitude to
cholesterol129 immediately after intervention
illness, but few attempts have incorporated elements of
• Beneﬁ t ﬁ nding that is induced experimentally (ie, patients writing about positive
response shift or beneﬁ t ﬁ nding into the approach.
thoughts and feelings regarding the experience of having breast cancer) reduced
Encourage ment for patients to identify advantages after
medical visits for cancer-related morbidities at 3 months’ follow-up in patients recently
the devel opment of illness or to shift from a state of
diagnosed with breast cancer.52 Beneﬁ t ﬁ nding reduced psychological distress in
compromised function to improved function could
women with high cancer-related avoidance. No eﬀ ects were seen on perceived quality
prove to be valuable ingredients of cognitive behavioural
therapy.8 Although chronic illnesses are undoubtedly
www.thelancet.comVol 372 July 19, 2008
illnesses.137 Moreover, the rapid developments in medical
Conﬂ ict of interest statement
knowledge have resulted in a growing number of chronic
We declare that we have no conﬂ ict of interest.
diseases that previously were considered immediately References life-threatening (cancer, AIDS) or characterised by rapid 1
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Young voices against poverty: What would you change? Have your say! Video Competition for Children and Young Adults European Development Days 2013 Official Contest Rules 1. To enter this contest you must be between the ages of 13 and 24 at the time of entry. All video entries must be submitted in one of the 5 official contest languages: English, French, German, Portuguese or
Medical abortion: A safe and effective alternative to surgical methods WRITER’S COMMENT: When I was first assigned to do a review paper I had no idea what I was going to write about. There were so many topics I was interested in that trying to decide on just one that was specific enough for the paper was tough. I was reading some old scientific news articles to see if anything appealed to