Center on Stress and Health

Stress and Trauma

Bergmark, B. A., C. H. Winograd and C. Koopman (2008). "Residence and quality of life determinants for adults with tetraplegia of traumatic spinal cord injury etiology." Spinal Cord.
Study design: Cross-sectional analysis of individual interviews with a convenience sample of persons living with tetraplegia.Objectives: To describe patterns of residence among persons living with tetraplegia following discharge from initial acute medical care after spinal cord injury, decision-making process for each residence move and quality of life determinants at different residence types.Setting: California and Minnesota, United States.Methods: A total of 22 adults with traumatic spinal cord injury tetraplegia were interviewed about their residence histories, the residence decision-making process for each move, and positive and negative features at each residence at which they had lived.Results: Information, money, insurance, accessibility, intimate relationships and personal assistants had the strongest influence over residence location, with insufficient information and finances demonstrating particularly strong influences. Participants frequently viewed parents' homes as an 'only option,' 'place of refuge' or 'stunting' environment. They viewed own homes as 'only options' or ways to achieve quality of life improvements, and other institutions as 'only options' or 'stepping-stones' to independent living.Conclusion: Further research is needed to examine decision-making across multiple moves over the course of the lives of persons living with tetraplegia, particularly examining the roles of inadequate information and finances as inhibitors of freedom of choice.Spinal Cord advance online publication, 4 March 2008; doi:10.1038/sc.2008.15.

Palesh, O., C. C. Classen, N. Field, H. C. Kraemer and D. Spiegel (2007). "The relationship of child maltreatment and self-capacities with distress when telling one's story of childhood sexual abuse." J Child Sex Abus 16(4): 63-80.
This study examined the impact of telling one's story of childhood sexual abuse and its relationship with the survivor's self-capacities and history of other child maltreatment. The baseline data were collected from 134 female CSA survivors who were participating in a large intervention study. Participants were given 10 minutes to describe their childhood sexual abuse and completed a post-interview questionnaire assessing post-traumatic stress symptoms and their emotional response. The distress in response to their narrative was both predicted and mediated by the survivors' self-capacities and other forms of child maltreatment beyond child sexual abuse.

Classen, C. C., H. C. Kraemer, C. Blasey, J. Giese-Davis, C. Koopman, O. G. Palesh, A. Atkinson, S. Dimiceli, G. Stonisch-Riggs, J. Westendorp, G. R. Morrow and D. Spiegel (2007). "Supportive-expressive group therapy for primary breast cancer patients: a randomized prospective multicenter trial." Psychooncology.
Objective: The aim is to evaluate the effectiveness of a manualized 12-week supportive-expressive group therapy program among primary breast cancer patients treated in community settings, to determine whether highly distressed patients were most likely to benefit and whether therapist's training or experience was related to outcome.Method: Three hundred and fifty-three women within one year of diagnosis with primary breast cancer were randomly assigned to receive supportive-expressive group therapy or to an education control condition. Participants were recruited from two academic centers and nine oncology practices, which were members of NCI's Community Clinical Oncology Program (CCOP) and were followed over 2 years.Results: A 2x2x19 analysis of variance was conducted with main effects of treatment condition, cohort, and baseline distress and their interactions. There was no main effect for treatment condition after removing one subject with an extreme score. Highly distressed women did not derive a greater benefit from treatment. Therapist training and psychotherapy experience were not associated with a treatment effect.Conclusions: This study provides no evidence of reduction in distress as the result of a brief supportive-expressive intervention for women with primary breast cancer. Future studies might productively focus on women with higher initial levels of distress. Copyright (c) 2007 John Wiley & Sons, Ltd.

Palesh, O., L. D. Butler, C. Koopman, J. Giese-Davis, R. Carlson and D. Spiegel (2007). "Stress history and breast cancer recurrence." J Psychosom Res 63(3): 233-9.
BACKGROUND: There is mixed evidence regarding the possible association between a history of stressful or traumatic life events and more rapid breast cancer progression. METHOD: Retrospective reports of past experiences of traumatic life events were assessed among 94 women with metastatic or recurrent breast cancer. A traumatic event assessment was conducted using the event-screening question from the posttraumatic stress disorder (PTSD) module of the Structured Clinical Interview for the DSM-IV-TR (SCID; 2002). Each reported event was judged by two independent raters to determine whether it met DSM-IV-TR PTSD A1 criteria for a traumatic event. Those events that did not meet such criteria were designated "stressful events." RESULTS: Nearly 42% of the women in the sample were judged to have experienced one or more traumatic events; 28.7% reported only stressful events. A Kruskal-Wallis test found significant differences in disease-free interval among the three groups [chi2 (2, N=94)=6.09, P<.05]. Planned comparisons revealed a significantly longer disease-free interval among women who had reported no traumatic or stressful life events (median=62 months) compared to those who had experienced one or more stressful or traumatic life events (combined median=31 months). CONCLUSIONS: A history of stressful or traumatic life events may reduce host resistance to tumor growth. These findings are consistent with a possible long-lasting effect of previous life stress on stress response systems such as the hypothalamic-pituitary-adrenal (HPA) axis.

Spiegel, D. and E. Vermetten (2007). "Post-traumatic stress disorder: medicine or politics (not both)." Lancet 369(9566): 992.

Strachowski, D., A. Khaylis, A. Conrad, E. Neri, D. Spiegel and C. B. Taylor (2007). "The effects of cognitive behavior therapy on depression in older patients with cardiovascular risk." Depress Anxiety.
This study examined the effect of a cognitive behavior therapy (CBT) therapy intervention designed to reduce depression in older patients with elevated cardiovascular disease (CVD) risk. Forty-eight depressed patients with elevated CVD were randomized to a 16-week individual CBT intervention (n = 23) or a wait-list control (WLC) group (n = 25). Pre- and post-treatment measures of depression were obtained during office visits, and measures of positive and negative affect were obtained during laboratory psychological stress testing and at five points during the day. At post-treatment, the CBT subjects were significantly less depressed than WLC subjects on the Hamilton Depression Inventory (F = 52.8, P<.001, ES = 1.85) and the Beck Depression Inventory (F = 17.1, P = <.001, ES = 0.85). Fifty-seven percent (13/23) of subjects in the CBT treatment were considered to be in remission (on the basis of a clinical interview) at post compared to only 4% (1/25) in the WLC (chi(2) = 9.0, P =.003). Treatment subjects reported significantly less stress on the Perceived Stress Scale (F = 23.2, P<.001). CBT significantly improved mean positive affect during the day (F = 12.7, P =.0001) but there were no significant differences in mean negative affect (F = 1.8, P =.19). CBT significantly reduced negative affect (F = 7.1, P =.01) during psychological stress testing but did not affect positive affect. CBT is an effective treatment for reducing depression and increasing positive affect in patients at risk for CVD, but the results vary by time of measurement and measurement setting. Depression and Anxiety 0:1-10, 2007. Published 2007 Wiley-Liss, Inc.

Vermetten, E., J. D. Bremner, L. Skelton and D. Spiegel (2007). "PTSD and Vietnam Veterans." Science 315(5809): 184-7; author reply 184-7.

Palesh, O. G., K. Collie, D. Batiuchok, J. Tilston, C. Koopman, M. L. Perlis, L. D. Butler, R. Carlson and D. Spiegel (2007). "A longitudinal study of depression, pain, and stress as predictors of sleep disturbance among women with metastatic breast cancer." Biol Psychol 75(1): 37-44.
OBJECTIVE: Sleep disturbances are common among women with breast cancer and can have serious consequences. The present study examined depression, pain, life stress, and participation in group therapy in relation to sleep disturbances in a sample of women with metastatic breast cancer. METHODS: Ninety-three women with metastatic breast cancer participated in a large intervention trial examining the effect of the group therapy on their symptoms. They completed measures of depression, pain, life stress, and sleep disturbance at baseline, 4, 8 and 12 months. RESULTS: The results showed that higher initial levels of depression at baseline predicted problems associated with getting up in the morning, waking up during the night, and daytime sleepiness. Increases in depression over the course of 12 months were associated with fewer hours of sleep, more problems with waking up during the night and more daytime sleepiness. Higher levels of pain at baseline predicted more problems getting to sleep. Increases in pain predicted more difficulty getting to sleep and more problems waking up during the night. Greater life stress at baseline predicted more problems getting to sleep and more daytime sleepiness. CONCLUSIONS: Depression, pain, and life stress scores were each associated with different types of negative change in self-reported sleep disturbances. Depression, especially worsening depression, was associated with the greatest number of types of negative change. The relationships found between sleep disturbance and depression, pain, and life stress suggest specific ways to address the problem of sleep disturbance for women with metastatic breast cancer and show how different types of disturbed sleep may be clinical markers for depression, pain, or life stress in this population.

Holmes, D., G. W. Alpers, T. Ismailji, C. Classen, T. Wales, V. Cheasty, A. Miller and C. Koopman (2007). "Cognitive and emotional processing in narratives of women abused by intimate partners." Violence Against Women 13(11): 1192-205.
This study examined relationships between cognitive and emotional processing with changes in pain and depression among intimate partner violence survivors. Twenty-five women who wrote about their most traumatic experiences completed measures of pain and depressive symptoms before the first writing session and again 4 months following the last writing session. Reduced pain was significantly associated with less use of positive and negative emotion words. Relationships between cognitive and emotional aspects of writing with changes in depressive symptoms fell short of statistical significance. The results suggest that emotional processing in narrative writing predicts changes in pain in intimate partner violence survivors.

Israelski, D. M., D. E. Prentiss, S. Lubega, G. Balmas, P. Garcia, M. Muhammad, S. Cummings and C. Koopman (2007). "Psychiatric co-morbidity in vulnerable populations receiving primary care for HIV/AIDS." AIDS Care 19(2): 220-5.
Considerable evidence suggests that people with HIV disease are significantly more distressed than the general population, yet psychiatric disorders are commonly under-detected in HIV care settings. This study examines the prevalence of three stress-related psychiatric diagnoses--depression, posttraumatic stress disorder (PTSD), and acute stress disorder (ASD), among a vulnerable population of HIV-infected patients. Among approximately 350 patients attending two county-based HIV primary care clinics, 210 participants were screened for diagnostic symptom criteria for depression, PTSD, and ASD. Standardized screening measures used to assess for these disorders included the Beck Depression Inventory, the Posttraumatic Stress Checklist, and the Stanford Acute Stress Questionnaire. High percentages of HIV-infected patients met screening criteria for depression (38 per cent), PTSD (34 per cent), and ASD (43 per cent). Thirty eight percent screened positively for two or more disorders. Women were more likely to meet symptom criteria for ASD than men (55 per cent vs. 38 per cent, OR=1.94, CI95 per cent=1.1-3.5). ASD was detected more commonly among African-American and white participants (51 per cent and 50 per cent respectively), compared with other ethnic groups. Latinos were least likely to express symptoms of ASD (OR=0.52, CI95 per cent=0.29-0.96). Of the 118 patients with at least one of these disorders, 51 (43 per cent) reported receiving no concurrent mental health treatment. Patients with HIV/AIDS who receive public healthcare are likely to have high rates of acute and posttraumatic stress disorders and depression. These data suggest that current clinical practices could be improved with the use of appropriate tools and procedures to screen and diagnose mental health disorders in populations with HIV/AIDS.

Steiner, H., S. J. Erickson, P. MacLean, S. Medic, B. Plattner and C. Koopman (2007). "Relationship between defenses, personality, and affect during a stress task in normal adolescents." Child Psychiatry Hum Dev 38(2): 107-19.
OBJECTIVE: Although there are extensive data on the relationship between personality and stress reactivity in adults, there is little comparable empirical research with adolescents. This study examines the simultaneous relationships between long term functioning (personality, defenses) and observed stress reactivity (affect) in adolescents. METHODS: High school students (N = 169; mean age 16; 73 girls) were asked to participate in two conditions of the Stress Induced Speech Task (SIST): Free Association and Stressful Situation. Immature and mature defenses, distress and restraint personality dimensions, and negative and positive affect were examined. RESULTS: Greater reported use of immature defenses was significantly associated with negative affect, whereas greater reported use of mature defenses was significantly associated with greater positive affect. Although personality style was also a significant predictor of negative affect across two out of three conditions, defenses were better overall predictors of affect than were personality dimensions. Gender was also a significant predictor of negative affect, wherein girls reported more negative affect than boys. DISCUSSION: Defenses and personality style predict affective response during a moderately stressful task. Immature defenses and, to a lesser extent, the distress personality dimension predict mobilization of negative affect, whereas mature defenses predict the reporting of positive affect. These results relate to processes central to psychotherapy: defensive responding, personality style, and affective reactivity during the recounting of stressful events.

Collie, K., M. A. Kreshka, S. Ferrier, R. Parsons, K. Graddy, S. Avram, P. Mannell, X. H. Chen, J. Perkins and C. Koopman (2007). "Videoconferencing for delivery of breast cancer support groups to women living in rural communities: a pilot study." Psychooncology 16(8): 778-82.
Women with breast cancer in rural areas are likely to exhaust their usual sources of psychosocial support while still facing challenges posed by breast cancer, but are unlikely to have access to professionally led support groups. In this community-based project, we assessed the feasibility and acceptability of providing support groups to women with breast cancer in a large rural area using videoconferencing and a workbook journal, and we assessed the intervention's potential to reduce distress and increase emotional expression and self-efficacy for coping with cancer. Twenty-seven women in the Intermountain Region of northeastern California participated in eight-session support groups led by an oncology social worker by going to nearby videoconferencing sites. Feasibility and acceptability were demonstrated. Older as well as younger women were comfortable using videoconferencing and said the groups were valuable because they promoted information sharing and emotional bonds with other women with breast cancer. They emphasized the importance of a professional facilitator and identified advantages of using videoconferencing for support groups. Pretest and posttest comparisons showed significant decreases in depression and posttraumatic stress disorder symptoms. The results suggest that the intervention has the potential to provide a valuable service that is not readily available in rural communities.

Matano, R. A., C. Koopman, S. F. Wanat, A. J. Winzelberg, S. D. Whitsell, D. Westrup, K. Futa, J. B. Clayton, L. Mussman and C. B. Taylor (2007). "A pilot study of an interactive web site in the workplace for reducing alcohol consumption." J Subst Abuse Treat 32(1): 71-80.
An interactive web-site-based intervention for reducing alcohol consumption was pilot tested. Participants were 145 employees of a work site in the Silicon Valley region of California, categorized as low or moderate risk for alcohol problems. All participants were given access to a web site that provided feedback on their levels of stress and use of coping strategies. Participants randomized to the full individualized feedback condition also received individualized feedback about their risk for alcohol-related problems. Some evidence was found for greater alcohol reduction among participants who received full individualized feedback, although due to difficulties in recruiting participants, the sample size was inadequate for evaluating treatment effects on drinking. The results provide preliminary support for using an interactive web site to provide individualized feedback for persons at risk for alcohol problems. However, the low participation rate (2.7%) suggests that such an intervention must address the challenges of recruiting employees through their work site.

Spiegel, D., J. Giese-Davis, C. B. Taylor and H. Kraemer (2006). "Stress sensitivity in metastatic breast cancer: analysis of hypothalamic-pituitary-adrenal axis function." Psychoneuroendocrinology 31(10): 1231-44.
The normal diurnal cortisol cycle has a peak in the morning, decreasing rapidly over the day, with low levels during the night, then rising rapidly again to the morning peak. A pattern of flatter daytime slopes has been associated with more rapid cancer progression in both animals and humans. We studied the relationship between the daytime slopes and other daytime cortisol responses to both pharmacological and psychosocial challenges of hypothalamic-pituitary-adrenal (HPA) axis function as well as DHEA in a sample of 99 women with metastatic breast cancer, in hopes of elucidating the dysregulatory process. We found that the different components of HPA regulation: the daytime cortisol slope, the rise in cortisol from waking to 30 min later, and cortisol response to various challenges, including dexamethasone (DEX) suppression, corticotrophin releasing factor (CRF) activation, and the Trier Social Stress Task, were at best modestly associated. Escape from suppression stimulated by 1mg of DEX administered the night before was moderately but significantly associated with flatter daytime cortisol slopes (r=0.28 to .30 at different times of the post DEX administration day, all p<.01). Daytime cortisol slopes were also moderately but significant associated with the rise in cortisol from waking to 30 min after awakening (r=.29, p=.004, N=96), but not with waking cortisol level (r=-0.13, p=.19). However, we could not detect any association between daytime cortisol slope and activation of cortisol secretion by either CRF infusion or the Trier Social Stress Task. The CRF activation test (following 1.5mg of DEX to assure that the effect was due to exogenous CRF) produced ACTH levels that were correlated (r=0.66, p<.0001, N=74) with serum cortisol levels, indicating adrenal responsiveness to ACTH stimulation. Daytime cortisol slopes were significantly correlated with the slope of DHEA (r=.21, p=.04, N=95). Our general findings suggest that flatter daytime cortisol slopes among metastatic breast cancer patients may be related to disrupted feedback inhibition rather than hypersensitivity in response to stimulation.

Giese-Davis, J., F. H. Wilhelm, A. Conrad, H. C. Abercrombie, S. Sephton, M. Yutsis, E. Neri, C. B. Taylor, H. C. Kraemer and D. Spiegel (2006). "Depression and stress reactivity in metastatic breast cancer." Psychosom Med 68(5): 675-83.
OBJECTIVE: Cancer-related distress due to the psychological and physical challenges of metastatic breast cancer (MBC) may result in symptoms of depression, which negatively affects quality and may influence quantity of life. This study investigated how depression affects MBC stress reactivity, including autonomic (ANS) and hypothalamic-pituitary-adrenal (HPA) axis function. METHOD: Forty-five nondepressed and 45 depressed patients with MBC underwent a modified Trier Social Stress Test (TSST) while affect, cardiovascular, respiratory, and cortisol responses were measured. RESULTS: At study entry, depressed compared with nondepressed patients had significantly lower log cortisol waking rise levels (p = .005) but no other HPA differences. Positive affect (p = .025) and high-frequency heart-rate variability (lnHF) (p = .002) were significantly lower at TSST baseline in depressed patients. In response to the TSST, depressed patients reported significantly lower positive (p = .050) and greater negative affect (p = .037) and had significantly reduced lnHF (p = .031). In secondary analyses, at TSST baseline both low-frequency (lnLF) (p = .002) and very-low-frequency (lnVLF) (p = .0001) heart rate variability were significantly lower in the depressed group. In secondary analyses during the TSST, those who were depressed had significantly lower lnVLF (p = .008) and did not increase aortic impedance reactivity as much as did the nondepressed during the stressor (p = .005). CONCLUSION: Depression in patients with MBC was associated with alterations in autonomic regulation, particularly reductions in respiratory sinus arrhythmia, a measure of cardiac vagal control, at baseline and during the TSST. In addition, depression was associated with blunted HPA response to awakening. Both MBC groups had relative cortisol hyporesponsiveness to acute stress.

Ginzburg, K., B. Arnow, S. Hart, W. Gardner, C. Koopman, C. C. Classen, J. Giese-Davis and D. Spiegel (2006). "The abuse-related beliefs questionnaire for survivors of childhood sexual abuse." Child Abuse Negl 30(8): 929-43.
OBJECTIVE: To evaluate the psychometric properties of a new measure, the Abuse-Related Beliefs Questionnaire (ARBQ), designed to assess abuse-related beliefs among adult survivors of childhood sexual abuse (CSA). Study 1 examined the structure of the scale, and Study 2 evaluated its reliability and validity. METHOD: One hundred and seventy female CSA survivors recruited into a group psychotherapy intervention study were administered the ARBQ in Study 1. A subsample of 45 women completed the ARBQ again 12 months later. In Study 2, 70 women from a health maintenance organization who identified themselves as survivors of CSA completed the ARBQ along with the Trauma Symptom Checklist-40 (TSC-40) and the Symptom Checklist 90R (SCL-90-R). RESULTS: Three reliable ARBQ subscales emerged in Study 1: Guilt, Shame, and Resilience. Twelve-month test-retest reliability was high (r=.60-.64). The internal consistency of the subscales was further supported in Study 2, and validity was demonstrated by moderate to high correlations with the distress measures. CONCLUSIONS: The results indicate that the ARBQ has good psychometric characteristics, supporting the feasibility of its use in measuring abuse-related beliefs in research on survivors of CSA. A next step for validation of the ARBQ would be to evaluate its sensitivity in measuring changes in studies of interventions for treating CSA survivors.

Gore-Felton, C., C. Koopman, D. Spiegel, M. Vosvick, M. Brondino and A. Winningham (2006). "Effects of quality of life and coping on depression among adults living with HIV/AIDS." J Health Psychol 11(5): 711-29.
This prospective study examined the effect of maladaptive coping strategies and psychological quality of life (QOL) on depression at two time points in a diverse sample of persons living with HIV/AIDS (N = 85). The use of maladaptive coping strategies to deal with the stress of living with HIV/AIDS, particularly engaging in various kinds of avoidant behaviors, was significantly associated with greater depression at baseline and increased depression at three months. QOL was the single most important predictor of depression. In an effort to develop effective clinical methods aimed at decreasing depression among adults living with HIV, future studies need to focus on improving quality of life and increasing adaptive coping strategies associated with the stress of living with HIV/AIDS.

Taylor, C. B., A. Conrad, F. H. Wilhelm, E. Neri, A. DeLorenzo, M. A. Kramer, J. Giese-Davis, W. T. Roth, R. Oka, J. P. Cooke, H. Kraemer and D. Spiegel (2006). "Psychophysiological and cortisol responses to psychological stress in depressed and nondepressed older men and women with elevated cardiovascular disease risk." Psychosom Med 68(4): 538-46.
OBJECTIVE: The objective of this study was to compare psychophysiological and cortisol reactions to psychological stress in older depressed and nondepressed patients at risk for cardiovascular disease (CVD). METHODS: Forty-eight depressed participants and 20 controls with elevated cardiovascular risk factors underwent a psychological stress test during which cardiovascular variables were measured. Salivary cortisol was collected after each test segment. Traditional (e.g., lipids) and atypical (e.g., C-reactive protein) CVD risk factors were also obtained. RESULTS: At baseline, the groups did not differ on lipid levels, flow-mediated vasodilation, body mass index, or asymmetric dimethylarginine. However, the depressed patients had significantly higher C-reactive protein levels. Contrary to our hypothesis, there were no differences in baseline cortisol levels or diurnal cortisol slopes, but depressed patients showed significantly lower cortisol levels during the stress test (p = .03) and less cortisol response to stress. Compared with nondepressed subjects, depressed subjects also showed lower levels of respiratory sinus arrhythmia (RSA(TF)) during the stress test (p = .02). CONCLUSIONS: In this sample, older depressed subjects with elevated risk for CVD exhibited a hypocortisol response to acute stress. This impaired cortisol response might contribute to chronic inflammation (as reflected in the elevated C-reactive proteins in depressed patients) and in other ways increase CVD risk. The reduced RSA(TF) activity may also increase CVD risk in depressed patients through impaired autonomic nervous system response to cardiophysiological demands.

Owen, J. E., J. Giese-Davis, M. Cordova, C. Kronenwetter, M. Golant and D. Spiegel (2006). "Self-report and linguistic indicators of emotional expression in narratives as predictors of adjustment to cancer." J Behav Med 29(4): 335-45.
Emotional expression and cognitive efforts to adapt to cancer have been linked to better psychological adjustment. However, little is known about the relationship between linguistic indicators of emotional and cognitive coping efforts and corresponding self-report measures of related constructs. In this study, we sought to evaluate the interrelationships between self-reports of emotional suppression and linguistic indicators of emotional and cognitive coping efforts in those living with cancer. Seventy-one individuals attending a community cancer support group completed measures of emotional suppression and mood disturbance and provided a written narrative describing their cancer experience. Self-reports of emotional suppression were associated with more rather than less distress. Although linguistic indicators of both emotional expression and cognitive processing were generally uncorrelated with self-report measures of emotional suppression and mood disturbance, a significant interaction was observed between emotional suppression and use of cognitive words on mood disturbance. Among those using higher levels of emotional suppression, increasing use of cognitive words was associated with greater levels of mood disturbance. These findings have implications for a) the therapeutic use of emotion in psychosocial interventions and b) the use of computer-assisted technologies to conduct content analysis.

Ginzburg, K., C. Koopman, L. D. Butler, O. Palesh, H. C. Kraemer, C. C. Classen and D. Spiegel (2006). "Evidence for a dissociative subtype of post-traumatic stress disorder among help-seeking childhood sexual abuse survivors." J Trauma Dissociation 7(2): 7-27.
This study examined evidence for a dissociative subtype of post-traumatic stress disorder (PTSD) among women seeking psychotherapy for childhood sexual abuse (CSA). One hundred and twenty-two women seeking treatment for CSA completed a battery of questionnaires assessing PTSD, dissociative symptoms, and child maltreatment. Using signal detection analysis, we identified high and low dissociation PTSD subgroups. A constellation of three PTSD symptoms-hypervigilance, sense of foreshortened future, and sleep difficulties-discriminated between these two subgroups (OR = 8.15). Further evidence was provided by the finding of a nonlinear relationship between severity of childhood maltreatment and dissociation in the women with PTSD. These results provide support for a dissociative subtype of PTSD that may stem from more severe childhood experiences of neglect and abuse.

Spiegel, D. (2006). "Recognizing traumatic dissociation." Am J Psychiatry 163(4): 566-8.

Kraemer, H. C., J. Giese-Davis, M. Yutsis, R. O'Hara, E. Neri, D. Gallagher-Thompson, C. B. Taylor and D. Spiegel (2006). "Design decisions to optimize reliability of daytime cortisol slopes in an older population." Am J Geriatr Psychiatry 14(4): 325-33.
OBJECTIVE: The daytime log-cortisol slope appears to be of growing importance in studying the relationship between stress and health. How best to estimate that slope with minimal burden to the participants and the cost of the study is a decision often made without empiric foundation. METHODS: In 50 older participants, the authors examined cortisol assay comparability across laboratories, assay reliability, test-retest reliability of slopes, and comparability of slope estimates for two, three, and four samples per day. RESULTS: The authors demonstrate in an older sample that 1) assay reliability is a relatively minor issue, that one assay per saliva sample suffices; 2) the use of a sample obtained at wake time for each participant appears to be a preferred anchor for the slope estimate in comparison to a sample 30 minutes postwake time; 3) self-reported times appear preferable to automatic time recording; and 4) test-retest reliability of slopes, however, is not sufficiently high to base a slope estimate on one day; minimally two days and preferably three should be required. CONCLUSIONS: Whether these conclusions apply to other populations, or using other protocols, is not assured, but the study itself provides a model that can be used to check research decisions. Unnecessarily imposing a burdensome protocol has both ethical and scientific ramifications and should be carefully avoided.

Giese-Davis, J., C. Bliss-Isberg, K. Carson, P. Star, J. Donaghy, M. J. Cordova, N. Stevens, L. Wittenberg, C. Batten and D. Spiegel (2006). "The effect of peer counseling on quality of life following diagnosis of breast cancer: an observational study." Psychooncology 15(11): 1014-22.
Women with breast cancer express the greatest need for counseling at the time of diagnosis and report that the intervention they want is to be able to speak with someone who has the same cancer, but has lived through the crisis of treatment and is leading a 'normal' life. We conducted an observational study of a 6-month peer-counseling intervention testing outcomes for both newly diagnosed women (Sojourners) and peer counselors (Navigators) as a first step toward the goal of validating a peer navigator program. Significant improvement in the Sojourners was observed in trauma symptoms, emotional well-being, cancer self-efficacy, and desire for information on breast cancer resources. Navigators maintained baseline levels of the outcome variables, but increased in dissatisfaction with their interactions with their medical team and increased emotional suppression. Our findings indicate that peer navigation may halt a decline in quality of life that is commonly found in the first year following breast cancer diagnosis. In addition, Navigators were not adversely affected by their experience; however, careful training and supervision of Navigators is crucial to overall success. Randomized clinical trials are needed to demonstrate the efficacy of peer navigator programs.

Turner-Cobb, J. M., L. E. Bloor, A. S. Whittemore, D. West and D. Spiegel (2006). "Disengagement and social support moderate distress among women with a family history of breast cancer." Breast J 12(1): 7-15.
Using a cross-sectional, exploratory design, this pilot study analyzed the relationships between familial history of breast cancer and psychological distress in order to evaluate who is more distressed and to assess the possible need for intervention. Coping style, social support, and family relations were investigated as potential moderators of these relationships. Participants were 45 women with a familial history of breast cancer recruited from the Family Registry for Breast Cancer (FRBC) at the Northern California Cancer Center (NCCC). Contrary to previous reports of similar cohorts, the overall level of psychological distress in this cohort was comparable to normative samples. The number of relatives with breast cancer was related to distress as measured by the State-Trait Anxiety Inventory (STAI) scale, but there was no significant differentiation in distress associated with the number of first-degree as compared to second- and third-degree relatives with breast cancer. Having more relatives that had died from breast cancer was associated with greater distress on a number of measures. The number of first-degree relative deaths, including maternal death, was also associated with distress. Positive and network support, disengagement coping responses, and family cohesion were each significant moderators of the impact of family history on distress. This association between distress and disengagement is similar to that found in metastatic breast cancer patients themselves, and the findings suggest a subgroup that merits and might respond to more intensive intervention to provide support and facilitate emotional expression.

Bowles, S. V., R. S. Bernard, T. Epperly, S. Woodward, K. Ginzburg, R. Folen, T. Perez and C. Koopman (2006). "Traumatic stress disorders following first-trimester spontaneous abortion." J Fam Pract 55(11): 969-73.
Provide counsel and support to women after a spontaneous abortion. Research indicates that many women will talk with their physician about their emotional distress and that physicians provide good information after the spontaneous abortion. Evaluate women for acute stress disorder (ASD) after a spontaneous abortion. Research found that women reporting physical, emotional, or sexual abuse are more likely to experience ASD. Patients should be assessed for post-traumatic stress disorder in follow-up visits 1 month after the initial visit. Research has found that up to 25% of women meet criteria for PTSD 1 month post the spontaneous abortion and 7% met criteria at 4 months. Physicians should refer women who are experiencing traumatic stress to a behavioral health professional.

Shaw, R. J., T. Deblois, L. Ikuta, K. Ginzburg, B. Fleisher and C. Koopman (2006). "Acute stress disorder among parents of infants in the neonatal intensive care nursery." Psychosomatics 47(3): 206-12.
The authors examined the prevalence of acute stress disorder (ASD) in parents of infants hospitalized in the neonatal intensive care unit (NICU). Forty parents were assessed after the birth of their infants. Parents completed self-report measures of ASD, parental stress, family environment, and coping style: 28% of parents developed symptoms of ASD. ASD was associated with female gender, alteration in parental role, family cohesiveness, and emotional restraint. Family environment and parental coping style are significantly associated with the development of trauma symptoms. Results from this study suggest potential interventions to help minimize psychological distress in parents.

Wong, M., E. Looney, J. Michaels, O. Palesh and C. Koopman (2006). "A preliminary study of peritraumatic dissociation, social support, and coping in relation to posttraumatic stress symptoms for a parent's cancer." Psychooncology 15(12): 1093-8.
This study examined predictors of posttraumatic stress disorder (PTSD) symptoms in adults who, as children, had a parent diagnosed with cancer. Possible predictors of adulthood PTSD examined were peritraumatic dissociation, satisfaction with social support, coping through denial, behavioral disengagement and self-distraction, and whether or not the parent died. Thirty research participants (20 women and 10 men, ages 18-38) were recruited who were 8-17-years old at the time of a parent's cancer diagnosis. Each participant completed measures of their current PTSD symptoms in response to their parent's cancer, peritraumatic dissociative experiences, demographic characteristics, and satisfaction with social support and use of coping strategies at the time of their parent's cancer diagnosis. Seventeen percent met screening criteria for likely PTSD. As hypothesized, PTSD symptoms were strongly and positively correlated with peritraumatic dissociation. Furthermore, PTSD symptoms were greater among females and were related to greater use of denial and behavioral disengagement and to less satisfaction with social support. These results suggest that health care providers need to recognize symptoms of peritraumatic dissociation in the children of parents who are diagnosed with cancer so that steps can be taken to minimize the children's development of PTSD that may extend into their adult lives.

Palesh, O. G., T. Shaffer, J. Larson, S. Edsall, X. H. Chen, C. Koopman, J. M. Turner-Cobb, M. A. Kreshka, K. Graddy and R. Parsons (2006). "Emotional self-efficacy, stressful life events, and satisfaction with social support in relation to mood disturbance among women living with breast cancer in rural communities." Breast J 12(2): 123-9.
This study evaluated the relationships of emotional self-efficacy, stressful life events, and social support with mood disturbance among women diagnosed with breast cancer who live in rural communities. Eighty-two women completed measures of demographic characteristics, medical status, and psychosocial variables. Using multiple regression analysis, we found that greater mood disturbance was related to having less emotional self-efficacy (p < 0.001) and to having experienced more stressful life events (p = 0.02), while satisfaction with social support was not significantly related to mood disturbance (adjusted R2 = 0.39). Women living with breast cancer in rural communities who have experienced multiple stressful life events may have an increased risk for mood disturbance, whereas having greater emotional self-efficacy may provide resilience against mood disturbance.

Remien, R. H., T. Exner, R. M. Kertzner, A. A. Ehrhardt, M. J. Rotheram-Borus, M. O. Johnson, L. S. Weinhardt, L. E. Kittel, R. B. Goldstein, R. M. Pinto, S. F. Morin, M. A. Chesney, M. Lightfoot, C. Gore-Felton, B. Dodge and J. A. Kelly (2006). "Depressive symptomatology among HIV-positive women in the era of HAART: a stress and coping model." Am J Community Psychol 38(3-4): 275-85.
OBJECTIVE: An enhanced stress and coping model was used to explain depression among HIV-positive women in healthcare and community settings where highly active anti-retroviral treatment (HAART) was commonplace. METHOD: HIV-infected women in four cities (N=978) were assessed, cross-sectionally, for mental and physical health, stress, social support, and other background factors. RESULTS: Self-reported level of depressive symptomatology was high. Number of physical symptoms, illness intrusiveness, and perceived stress were positively associated with depressed mood, while coping self-efficacy and social support were negatively associated. Stress mediated the effect of health status on depression and coping self-efficacy mediated the effect of psychosocial resources on depression. Our enhanced stress and coping model accounted for 52% of variance in depressive symtpomatology. CONCLUSIONS: Interventions focused on improving coping self-efficacy, bolstering social supports, and decreasing stress in the lives of HIV-positive women may help to reduce the negative effects of HIV disease on mood.

Ashton, E., M. Vosvick, M. Chesney, C. Gore-Felton, C. Koopman, K. O'Shea, J. Maldonado, M. H. Bachmann, D. Israelski, J. Flamm and D. Spiegel (2005). "Social support and maladaptive coping as predictors of the change in physical health symptoms among persons living with HIV/AIDS." AIDS Patient Care STDS 19(9): 587-98.
This study examined social support and maladaptive coping as predictors of HIV-related health symptoms. Sixty-five men and women living with HIV/AIDS completed baseline measures assessing coping strategies, social support, and HIV-related health symptoms. The sample was primarily low-income and diverse with respect to gender, ethnicity, and sexual orientation. Three, 6, and 12 months after completing baseline assessments, physical health symptoms associated with HIV disease were assessed. After controlling for demographic characteristics, CD4 T-cell count, and baseline HIV-related health symptoms, individuals reporting lower increase in HIV-related health symptoms used less venting (expressing emotional distress) as a strategy for coping with HIV. However, when satisfaction with social support was added to the model, the use of this coping strategy was no longer significant, and individuals reporting more satisfying social support were more likely to report lower increase in their HIV-related health symptoms, suggesting that social support is a robust predictor of health outcomes over time independent of coping style and baseline medical status. These findings provide further evidence that social support can buffer deleterious health outcomes among individuals with a chronic illness. Future research needs to examine mediating pathways that can explain this relationship.

Spiegel, D. (2005). "Treatment of acute traumatic stress reactions." J Trauma Dissociation 6(2): 101-8.
This paper calls for a broadening of the context within which we study responses to traumatic stress, the course of recovery, components of effective interventions, and assessments of outcome. Acute stress reactions to trauma as a spectrum include anxiety, dissociative, and depressive symptoms. The course of these symptoms may vary, with fluctuations between intrusion (positive) and avoidance/numbing/dissociative (negative) symptoms that may complicate assessment, treatment-seeking, and course of recovery. Components of effective treatments including affect management, cognitive restructuring, and social integration are discussed. Finally, a broader view of outcome assessment in such research is called for, including not just reduction in psychopathological symptoms but attention to coping styles, affect management, resilience, social reorganization, and sensitivity to subsequent trauma.

Butler, L. D., B. K. Symons, S. L. Henderson, L. D. Shortliffe and D. Spiegel (2005). "Hypnosis reduces distress and duration of an invasive medical procedure for children." Pediatrics 115(1): e77-85.
OBJECTIVE: Voiding cystourethrography (VCUG) is a commonly performed radiologic procedure in children that can be both painful and frightening. Given the distress that some children experience during the VCUG and the need for children to be alert and cooperative during the procedure, finding a psychological intervention that helps children to manage anxiety, distress, and pain is clearly desirable. This study was designed to examine whether relaxation and analgesia facilitated with hypnosis could reduce distress and procedure time for children who undergo this procedure. METHODS: Forty-four children who were scheduled for an upcoming VCUG were randomized to receive hypnosis (n = 21) or routine care (n = 23) while undergoing the procedure. The sample consisted of 29 (66%) girls and 15 (34%) boys with a mean age of 7.6 years (SD: 2.5; range: 4-15 years). Ethnic/racial backgrounds were 72.7% white, 18.2% Asian, 4.5% Latino, 2.3% black, and 2.3% Filipino. The mean number of previous VCUGs was 2.95 (SD: 2.51; mode: 2; range: 1-15). Potential participants were identified through computerized hospital records of upcoming VCUGs. Parents were contacted by telephone and invited to participate if their child was eligible. To be eligible for the study, the child must have undergone at least 1 previous VCUG, been at least 4 years of age at that time, and experienced distress during that procedure, and both the child and the participating parent had to be English speaking. Each eligible child and parent met with the research assistant (RA) before the day of the scheduled procedure for an initial assessment. Children were queried regarding the degree of crying, fear, and pain that they had experienced during their most recent VCUG. Parents completed a series of parallel questions. Immediately after this assessment, those who were randomized to the hypnosis condition were given a 1-hour training session in self-hypnotic visual imagery by a trained therapist. Parents and children were instructed to practice using the imaginative self-hypnosis procedure several times a day in preparation for the upcoming procedure. The therapist was also present during the procedure to conduct similar exercises with the child. The majority (83%) of those who were randomized to the routine care control group chose to participate in a hospital-provided recreation therapy program (offered as part of routine care). The program includes demonstration of the procedure with dolls, relaxation and breath work training, and assistance during the procedure. On the day of the VCUG, the RA met the family at the clinic before the procedure, and both the child and the parent rated the child's present level of fearfulness. During the procedure, the RA recorded observational ratings of the child's emotional tone and behavior and timed the overall procedure and its phases. Immediately after the VCUG, the child was asked how much crying, fear, and pain he or she had experienced during the procedure; the parent rated the child's experience on the same dimensions and also how traumatic the procedure had been (both generally and compared with their previous one), and the medical staff rated the degree of procedural difficulty. Outcomes included child reports of distress during the procedure, parent reports of how traumatic the present VCUG was compared with the previous one, observer ratings of distress during the procedure, medical staff reports of the difficulty of the procedure overall, and total procedural time. RESULTS: Results indicate significant benefits for the hypnosis group compared with the routine care group in the following 4 areas: (1) parents of children in the hypnosis group compared with those in the routine care group reported that the procedure was significantly less traumatic for their children compared with their previous VCUG procedure; (2) observational ratings of typical distress levels during the procedure were significantly lower for children in the hypnosis condition compared with those in the routine care condition; (3) medical staff reported a significant difference between groups in the overall difficulty of conducting the procedure, with less difficulty reported for the hypnosis group; and (4) total procedural time was significantly shorter-by almost 14 minutes-for the hypnosis group compared with the routine care group. Moderate to large effect sizes were obtained on each of these 4 outcomes. CONCLUSIONS: Hypnotic relaxation may provide a systematic method for improving the overall medical care of children with urinary tract abnormalities and may be beneficial for children who undergo other invasive medical procedures. Because the VCUG is an essential part of the evaluation of urinary tract infections and vesicoureteral reflux in children, lower distress during the procedure may improve patient and family compliance with initial as well as follow-up evaluations. These findings augment the accumulating literature demonstrating the benefits of using hypnosis to reduce distress in the pediatric setting. The present findings are noteworthy in that this study was a controlled, randomized trial conducted in a naturalistic medical setting. In this context, we achieved a convergence of subjective and objective outcomes with moderate to large effect sizes, including those that may have an impact on patient care and procedure cost, that were consistently supportive of the beneficial effects of hypnosis-a noninvasive intervention with minimal risk. The findings, therefore, have immediate implications for pediatric care. Limitations of this study include the lack of participant and staff blindness to the child's condition assignment, which could have introduced bias into reports. However, the objective procedural time differences between groups were consistent with the other, more subjective outcome findings. The sample was also small and primarily white in ethnic/racial makeup, which may have restricted our ability to detect some differences and may limit the generalizability of findings to more representative samples. In addition, the sample comprised children who had already undergone at least 1 VCUG during which they had had difficulty. Consequently, additional research is needed to determine whether hypnosis would be helpful to those who are undergoing their first VCUG. Additional limitations, clinical observations, and directions for future research are also discussed.

Butler, L. D., N. P. Field, A. L. Busch, J. E. Seplaki, T. A. Hastings and D. Spiegel (2005). "Anticipating loss and other temporal stressors predict traumatic stress symptoms among partners of metastatic/recurrent breast cancer patients." Psychooncology 14(6): 492-502.
This study examined pre- and post-loss levels of posttraumatic stress symptoms (intrusion and avoidance) in partners of metastatic/recurrent breast cancer patients, and the relationship of these symptoms to past, current, and anticipatory stressors. The results indicate that 34% (17/50) of the partners experienced clinically significant symptom levels prior to the patients' deaths. Prior to loss, partners' symptoms were positively associated with their current level of perceived stress and anticipated impact of the loss; whereas following loss, partners' symptoms were predicted by higher pre-loss levels of symptoms, past family deaths, and anticipated impact of the loss. Limitations and treatment implications of the present research and directions for future research are discussed.

Han, W. T., K. Collie, C. Koopman, J. Azarow, C. Classen, G. R. Morrow, B. Michel, E. Brennan-O'Neill and D. Spiegel (2005). "Breast cancer and problems with medical interactions: relationships with traumatic stress, emotional self-efficacy, and social support." Psychooncology 14(4): 318-30.
This investigation examined relationships between breast cancer patients' psychosocial characteristics (impact of the illness, traumatic stress symptoms, emotional self-efficacy, and social support) and problems they perceived in their medical interactions and their satisfaction with their physicians. Participants were 352 women enrolled in a multicenter trial of the effects of group therapy for women with recently diagnosed primary breast cancer. The findings reported here are from a cross-sectional analysis of baseline data gathered prior to randomization. Problems interacting with physicians and nurses were associated with greater levels of cancer-related traumatic stress (p < 0.01), less emotional self-efficacy for cancer (p < 0.05), less satisfaction with informational support from family, friends, and spouse, and a tendency to perceive those sources of support as more aversive (p < 0.05). Women who were less satisfied with emotional support from their family, friends and spouse were less likely to feel satisfied with their physicians (p < 0.05). These patient characteristics identify women with primary breast cancer who are likely to experience difficulty in their interactions with nurses and physicians and to be less satisfied with their physicians.

Collie, K., P. Wong, J. Tilston, L. D. Butler, J. Turner-Cobb, M. A. Kreshka, R. Parsons, K. Graddy, J. D. Cheasty and C. Koopman (2005). "Self-efficacy, coping, and difficulties interacting with health care professionals among women living with breast cancer in rural communities." Psychooncology 14(10): 901-12; discussion 913-4.
This study examined self-efficacy, coping, and social support in relation to difficulties interacting with physicians and nurses among women living with breast cancer. One hundred women living in rural, mountainous communities of northeastern California were recruited, with 89 providing complete data for this study. All women completed a battery of questionnaires that included the CARES--Medical Interaction Subscale and measures of self-efficacy, coping, satisfaction with social support, and demographic and medical characteristics. In a multiple regression analysis, difficulties interacting with medical professionals were found to be greater among women who were not married, who used more behavioral disengagement or less self-distraction to cope with breast cancer, and who reported less self-efficacy for affect regulation and for seeking and understanding medical information. Emotional venting and satisfaction with social support for dealing with cancer-related stress were not, however, significantly related to difficulties in interacting with the medical team. This model accounted for an adjusted value of 42% of the variance. Further research is needed to identify possible causal relationships related to these findings and to determine what interventions might be warranted to improve medical interactions for women with breast cancer living in rural areas.

Koopman, C., T. Ismailji, D. Holmes, C. C. Classen, O. Palesh and T. Wales (2005). "The effects of expressive writing on pain, depression and posttraumatic stress disorder symptoms in survivors of intimate partner violence." J Health Psychol 10(2): 211-21.
This study examined the effects of expressive writing on depression, posttraumatic stress disorder (PTSD) and pain symptoms among women who have survived intimate partner violence (IPV). Forty-seven women completed baseline and four-month follow-up assessments and were randomly assigned to four writing sessions of either expressive writing focused on traumatic life events or writing about a neutral topic. Main effects were not significant for changes in depression, pain or PTSD symptoms. However, among depressed women, those assigned to expressive writing showed a significantly greater drop in depression. For depressed women with IPV histories, expressive writing may lead to reduced depression.

Gore-Felton, C., M. J. Rotheram-Borus, L. S. Weinhardt, J. A. Kelly, M. Lightfoot, S. B. Kirshenbaum, M. O. Johnson, M. A. Chesney, S. L. Catz, A. A. Ehrhardt, R. H. Remien and S. F. Morin (2005). "The Healthy Living Project: an individually tailored, multidimensional intervention for HIV-infected persons." AIDS Educ Prev 17(1 Suppl A): 21-39.
The NIMH Healthy Living Project (HLP), a randomized behavioral intervention trial for people living with HIV, enrolled 943 individuals, including women, heterosexual men, injection drug users, and men who have sex with men from Los Angeles, Milwaukee, New York, and San Francisco. The intervention, which is based on qualitative formative research and Ewart's Social Action Theory, addresses three interrelated aspects of living with HIV: stress and coping, transmission risk behavior, and medication adherence. Fifteen 90-minute structured sessions, divided into 3 modules of five sessions each, are delivered to individuals. Sessions are tailored to individuals within a structure that uses role-plays, problem solving, and goal setting techniques. A 'Life Project'--or overarching goal related to personal striving-provides continuity throughout sessions. Because this is an ongoing project with efficacy yet to be established, we do not report intervention outcomes. However, the intervention was designed to be useful for prevention case management, settings where repeated one-on-one contact is possible, and where a structured but highly individualized intervention approach is desired.

Vosvick, M., C. Gore-Felton, E. Ashton, C. Koopman, T. Fluery, D. Israelski and D. Spiegel (2004). "Sleep disturbances among HIV-positive adults: the role of pain, stress, and social support." J Psychosom Res 57(5): 459-63.
OBJECTIVE: Investigate the relationships between pain, stress, social support, and sleep disturbance among a diverse sample of HIV-positive adults. METHOD: Participants (N = 146) completed self-report measures on pain, stress, social support, and sleep disturbance. CD4 T-cell count was obtained from medical records. RESULTS: Greater pain and stress were associated with greater sleep disturbance. Greater assistance from friends was associated with greater sleep disturbance, whereas greater understanding from friends regarding participants' HIV-related stress was associated with less sleep disturbance. CONCLUSION: As expected, pain was significantly associated with sleep disturbance. Additionally, psychosocial variables were strongly associated with sleep. The type of support from friends differentiated whether the support was positively or negatively associated with sleep problems. Social support, depending on the type, may not always be helpful for adults living with HIV/AIDS. Future studies need to examine factors that may mediate the relationship between psychosocial constructs and healthy sleep.

Turner-Cobb, J. M., C. Koopman, J. D. Rabinowitz, A. I. Terr, S. E. Sephton and D. Spiegel (2004). "The interaction of social network size and stressful life events predict delayed-type hypersensitivity among women with metastatic breast cancer." Int J Psychophysiol 54(3): 241-9.
This study examined relationships between social support, stressful life events and antigen-specific cell-mediated immunity. Participants were 72 women with documented metastatic breast carcinoma, who completed self-report measures of social support and life stress. Immune response was assessed using the delayed type hypersensitivity (DTH) skin test. Number of positive antigens was significantly related to the interaction of social network size and stressful life events (p<0.05). Number of positive antigens was greater for women who had experienced a high frequency of stressful life events but who reported a larger network of support. However, social network size was inversely related to DTH response among women who had experienced fewer stressful life events. Average induration size was not significantly related to the quality of social support, life stress per se, or their interactions. The relationship between social network size and immune response in women with metastatic breast cancer depends on prior stressful life experience.

Abercrombie, H. C., J. Giese-Davis, S. Sephton, E. S. Epel, J. M. Turner-Cobb and D. Spiegel (2004). "Flattened cortisol rhythms in metastatic breast cancer patients." Psychoneuroendocrinology 29(8): 1082-92.
Allostatic load, the physiological accumulation of the effects of chronic stressors, has been associated with multiple adverse health outcomes. Flattened diurnal cortisol rhythmicity is one of the prototypes of allostatic load, and has been shown to predict shorter survival among women with metastatic breast cancer. The current study compared diurnal cortisol slope in 17 breast cancer patients and 31 controls, and tested associations with variables previously found to be related to cortisol regulation, i.e, abdominal adiposity, perceived stress, social support, and explicit memory. Women with metastatic breast cancer had significantly flatter diurnal cortisol rhythms than did healthy controls. Patients with greater disease severity showed higher mean cortisol levels, smaller waist circumference, and a tendency toward flatter diurnal cortisol rhythms. There were no relations between cortisol slope and psychological or cognitive functioning among patients. In contrast, controls with flatter rhythms showed the expected allostatic load profile of larger waist circumference, poorer performance on explicit memory tasks, lower perceived social support, and a tendency toward higher perceived stress. These findings suggest that the cortisol diurnal slope may have important but different correlates in healthy women versus those with breast cancer.

Rosenbaum, E., H. Gautier, P. Fobair, E. Neri, B. Festa, M. Hawn, A. Andrews, N. Hirshberger, S. Selim and D. Spiegel (2004). "Cancer supportive care, improving the quality of life for cancer patients. A program evaluation report." Support Care Cancer 12(5): 293-301.
GOALS OF WORK: As medical care for cancer has become more specialized in diagnosis, treatment has become more technical and fragmented. In order to help cancer patients and their families, we developed a coordinated program called the Stanford Cancer Supportive Care Program (SCSCP) at the Center for Integrative Medicine at Stanford Hospital and Clinics. The Stanford Cancer Supportive Care Program was initiated in 1999 to provide support for cancer patients, addressing the need for improved physical and emotional well-being and quality of life. This paper is a program evaluation report. PATIENTS AND METHODS: The number of patient visits grew from 421 in 1999 to 6319 in 2002. This paper describes the utilization of the SCSCP program as assessed by 398 patient visit evaluations during a 9-week period, January 2002 to March 2002. During this time we collected attendance records with demographic data and anonymous questionnaires evaluating each program. Patients were asked to evaluate how the program helped them regarding increase of energy, reduction in stress, restful sleep, pain reduction, sense of hopefulness, and empowerment. MAIN RESULTS: Over 90% of the patients using the SCSCP felt there was benefit to the program. Programs were chosen based on a needs assessment by oncologists, nurse managers, social workers, and patients. Massage, yoga, and qigong classes had the highest number of participants. Qualitative data showed benefit for each program offered. CONCLUSIONS: This evaluation of a free cancer supportive care program initiated in a hospital outpatient setting provides initial evidence of patient satisfaction and improvement in quality of life.

Koopman, C., V. Carrion, L. D. Butler, S. Sudhakar, L. Palmer and H. Steiner (2004). "Relationships of dissociation and childhood abuse and neglect with heart rate in delinquent adolescents." J Trauma Stress 17(1): 47-54.
This study examined the relationship of dissociative symptoms, abuse and neglect, and gender to mean heart rate (HR) in two types of interviews. Participants were 25 female and 16 male delinquent adolescents. Dissociative symptoms and abuse and neglect were assessed by structured interviews. Participants were randomized to one of two conditions, to describe either their most stressful life experience or their free association thoughts. Greater dissociative symptoms were associated with lower mean HR, whereas abuse and neglect, being a girl, and participating in the free association task were associated with higher mean HR. The finding that high levels of dissociative symptoms may be related to a suppression of autonomic physiological responses to stress support Bremner's conceptualization (J. D. Bremner, 1999) that dissociative symptoms comprise one of two subtypes of the acute stress response, differing physiologically as well as subjectively from a predominantly hyperarousal or intrusive symptom response.

Kalichman, S. C., C. Gore-Felton, E. Benotsch, M. Cage and D. Rompa (2004). "Trauma symptoms, sexual behaviors, and substance abuse: correlates of childhood sexual abuse and HIV risks among men who have sex with men." J Child Sex Abus 13(1): 1-15.
Childhood sexual abuse is associated with high-risk sexual behavior in men who have sex with men. This study examined psychological and behavioral correlates of HIV risk behavior associated with childhood sexual abuse in a sample of men who have sex with men. Men attending a large gay pride event (N = 647) completed anonymous surveys that assessed demographic characteristics, childhood sexual abuse history, symptoms of dissociation and trauma-related anxiety, borderline personality characteristics, substance use, and sexual risk behavior. Results indicated that men who have a history of childhood sexual abuse were more likely to: engage in high-risk sexual behavior (i.e., unprotected receptive anal intercourse), trade sex for money or drugs, report being HIV positive, and experience non-sexual relationship violence. Results of this study extend previous research to show that men who have sex with men and who have a history of child sexual abuse are more likely to be at high risk for HIV infection.

Cordova, M. J., J. Giese-Davis, M. Golant, C. Kronnenwetter, V. Chang, S. McFarlin and D. Spiegel (2003). "Mood disturbance in community cancer support groups. The role of emotional suppression and fighting spirit." J Psychosom Res 55(5): 461-7.
OBJECTIVE: In this cross-sectional study, we tested whether the coping styles of emotional suppression and fighting spirit were associated with mood disturbance in cancer patients participating in professionally led community-based support groups even when demographic, medical, and group support variables were taken into account. METHODS: A heterogeneous sample of 121 cancer patients (71% female, 29% male) completed the Courtauld Emotional Control Scale (CECS), the Mini-Mental Adjustment to Cancer Scale (Mini-MAC), a measure of perceived group support, and the Profile of Mood States (POMS). RESULTS: Consistent with hypotheses, lower emotional suppression and greater adoption of a fighting spirit, in addition to older age and higher income, were associated with lower mood disturbance. Gender, time since diagnosis, presence of metastatic disease, time in the support group, perceived group support, cognitive avoidance, and fatalism were unrelated to mood disturbance. CONCLUSION: Expression of negative affect and an attitude of realistic optimism may enhance adjustment and reduce distress for cancer patients in support groups.

Sephton, S. and D. Spiegel (2003). "Circadian disruption in cancer: a neuroendocrine-immune pathway from stress to disease?" Brain Behav Immun 17(5): 321-8.
Psychosocial factors may modulate the course of cancer, but few data have been gathered on the biological mechanisms by which these effects may be mediated. We briefly review evidence of psychosocial effects on cancer progression and discuss one potential pathway that may underlie these effects: the disruption of neuroendocrine and immune circadian rhythms. Circadian system alterations occur in tumor tissue, tumor-bearing animals, and cancer patients with greater disruption seen in more advanced cases. Rhythm alterations include diminished amplitude, phase shifts, period changes, and erratic peaks and troughs in endocrine, metabolic, immunological, and rest- activity cycles. Psychosocial factors can engender dysregulation of circadian function. Cancer-related circadian dysregulation may also be driven by genetic factors, environmental and behavioral influences, and effects of the tumor on host clock regulation. There are several mechanisms by which circadian disruption might hasten tumor growth: via direct effects of altered hormone levels on tumor cells, effects on tumor versus host metabolism, neuroimmune effects resulting in cancer-relevant immunosuppression, or reduced efficacy and tolerability of cancer treatments for which the timing of administration is based upon the assumption of normal circadian rhythms. Emerging data in the human and animal literature suggest that circadian regulation may be an important prerequisite for the maintenance of host defenses against cancer. Thus, stress-related circadian disruption may have negative implications for cancer prognosis. Psychosocial effects on cancer progression may be measured, and possibly mediated, by disruption of circadian function.

Gore-Felton, C., M. Vosvick, T. Bendel, C. Koopman, B. Das, D. Israelski, M. Herrera, K. Litzenberg and D. Spiegel (2003). "Correlates of sexually transmitted disease infection among adults living with HIV." Int J STD AIDS 14(8): 539-46.
This study examined the prevalence of sexually transmitted diseases (STDs) as well as the relationships between STDs and coping strategies used to deal with the stress of living with HIV among adults. The sample comprised 179 men and women, 58% were Caucasian, 54% were male, more than half (61%) were diagnosed with AIDS, 43% were heterosexual, and 39% reported an STD post-HIV diagnosis. Logistic regression analysis indicated that individuals reporting longer time elapsed since HIV diagnosis and greater use of emotion-focused coping were more likely to report STDs. There was an interaction effect between time and coping such that the less time that elapsed since HIV diagnosis and the more an individual used emotion-focused coping, the more likely they were to report an STD. Tailoring interventions to address specific stressors associated with length of time living with HIV, may be a particularly effective prevention strategy.

Power, R., C. Koopman, J. Volk, D. M. Israelski, L. Stone, M. A. Chesney and D. Spiegel (2003). "Social support, substance use, and denial in relationship to antiretroviral treatment adherence among HIV-infected persons." AIDS Patient Care STDS 17(5): 245-52.
This study examined the relationship of adherence to antiretroviral treatment with three types of social support (partner, friends, and family) and use of two coping strategies (denial and substance use). Participants were 73 men and women with HIV infection drawn from a larger sample of 186 clinical trial patients. Based on inclusion criteria, parent trial participants taking antiretroviral therapies, and those with complete data on self-reported measures of adherence were considered eligible for the present study. Overall, 26% of participants were found to be nonadherent, which was defined as one or more missed doses of treatment in the prior 4-day period. Logistic regression analysis was conducted to determine associations of sociodemographic and psychosocial variables with adherence to antiretroviral regimen. Results indicated that heterosexual participants (p < 0.01) and participants of Latino ethnicity (p < 0.05) were significantly more likely to report missed medications. Perceived satisfaction with support from a partner was associated with taking antiretroviral therapy as prescribed, whereas satisfaction with support from friends and from family was not significantly related to adherence. Examination of coping strategies showed that participants reporting drug and alcohol use (p <.05) to cope with HIV-related stress were more likely to be nonadherent. These findings call for adherence interventions designed to address barriers and strengths, such as community norms or traditional cultural values, specific to certain populations. Furthermore, couple-based approaches enlisting partner support may help persons living with HIV to adhere to antiretroviral regimens.

Butler, L. D., C. Koopman, M. J. Cordova, R. W. Garlan, S. DiMiceli and D. Spiegel (2003). "Psychological distress and pain significantly increase before death in metastatic breast cancer patients." Psychosom Med 65(3): 416-26.
OBJECTIVE: This study was designed to examine the course of psychological distress and pain from study entry to death in 59 women with metastatic breast cancer participating in a randomized trial of the effects of group psychotherapy on psychosocial outcomes and survival. It was hypothesized that psychological distress would increase significantly before death independent of changes in pain. METHOD: Data were collected as part of a larger study (N = 125). Analyses were based on data from a subset of women who had died and for whom we had data from at least three assessments. Mean levels of mood, trauma symptoms, depression symptoms, well-being, and pain over three time points were examined: at baseline (T1), the second-to-last assessment before death (T2), and the last assessment before death (T3). RESULTS: Results indicate that while psychological distress remained relatively constant or declined from T1 to T2, means on all measures significantly changed in the hypothesized direction from T2 to T3. Neither self-reported pain, nor the passage of time, appeared to account for these changes. Additionally, participation in group psychotherapy did not have a significant impact on this change in distress proximal to death. CONCLUSIONS: Results suggest that specialized end-stage clinical interventions are particularly needed for cancer patients as they approach death. Moreover, intervention studies for patients with deteriorating illnesses may need to take this "spike" in psychological distress and pain proximal to death into account to avoid Type II errors in evaluations of psychological outcomes.

Lieberman, M. A., M. Golant, J. Giese-Davis, A. Winzlenberg, H. Benjamin, K. Humphreys, C. Kronenwetter, S. Russo and D. Spiegel (2003). "Electronic support groups for breast carcinoma: a clinical trial of effectiveness." Cancer 97(4): 920-5.
BACKGROUND: A recent Pew Charitable Trust study found that 52,000,000 individuals used the Internet to obtain health/medical information. Clinical trials of face-to-face breast carcinoma support groups show evidence of 1) improvement in quality of life, 2) reduction of psychologic symptoms, 3) improvement in coping responses, and 4) a reduction in pain. To the authors' knowledge, a few studies published to date have investigated Internet-delivered electronic support groups (ESGs) for cancer. The most sophisticated is the Comprehensive Health Enhancement Support System (CHESS) program, which provides integrated information, referral, and a newsgroup-based social support program. However, to the authors' knowledge, no studies published to date have examined the impact of a breast carcinoma ESG in a clinical trial. METHODS: Sixty-seven women completed the initial baseline questionnaires, 32 of whom accepted the authors' invitation and began the groups. With regard to geographic location, 49% lived in rural/small towns, 41% lived in medium-sized cities, and 10% lived in large cities. Diagnostic stages of disease were: Stage I, 22%; Stage II, 56%; Stage III, 12%; and other forms, 10%. There were 4 intervention groups, of which 8 participants led by trained Wellness Community (TWC) (a national agency) leaders met for 1.5 hours once a week for 16 weeks. Student t tests for paired outcome data were computed using baseline and postgroup scores. RESULTS: The results of the current study indicated that breast carcinoma patients significantly reduced depression (Center for Epidemiologic Studies-Depression [CES-D] scale) and Reactions to Pain. They also demonstrated a trend toward increases on The Posttraumatic Growth Inventory (PTGI) in two subscales: New Possibilities and Spirituality. Counterintuitively, breast carcinoma patients appeared to demonstrate an increase in emotional suppression. Postinterview results indicated that approximately 67% of patients found the group to be beneficial. Those who withdrew from the groups (20%) demonstrated low scores in their ability to contain anxiety and appeared to be more likely to suppress their thoughts and feelings regarding their illness. CONCLUSIONS: The findings of the current study are encouraging, particularly because it was conducted through TWC, a national agency willing to make this type of intervention readily available at no cost. A limitation of the current study was the lack of randomization and a control group comparison. Although the authors were not able to demonstrate effectiveness without the addition of a control condition, the analysis of pregroup and postgroup outcomes suggests that a randomized trial is worthwhile. Women with a devastating disease will join and commit themselves to an online support group. In addition, because a large percentage of these women were from rural locations, this type of intervention may hold promise for those who have limited access to support groups.

Vosvick, M., C. Koopman, C. Gore-Felton, C. Thoresen, J. Krumboltz and D. Spiegel (2003). "Relationship of functional quality of life to strategies for coping with the stress of living with HIV/AIDS." Psychosomatics 44(1): 51-8.
The authors examined factors associated with four dimensions of functional quality of life (physical functioning, energy/fatigue, social functioning, and role functioning) in 142 men and women living with HIV/AIDS. Participants completed the Brief COPE inventory and the Medical Outcomes Study Health Survey, with HIV-relevant items added. Greater use of maladaptive coping strategies was associated with lower levels of energy and social functioning. Pain severe enough to interfere with daily living tasks was associated with a lower level of functional quality of life on all four quality of life dimensions. Interventions aimed at developing adaptive coping strategies and improving pain management may improve functional aspects of quality of life in persons living with HIV/AIDS.

Matano, R. A., C. Koopman, S. F. Wanat, S. D. Whitsell, A. Borggrefe and D. Westrup (2003). "Assessment of binge drinking of alcohol in highly educated employees." Addict Behav 28(7): 1299-310.
This study evaluated the usefulness of the Alcohol Use Disorders Identification Test (AUDIT) and CAGE, a standardized screening instrument for detecting alcohol dependence in identifying binge drinking among highly educated employees. Brochures were mailed to an entire workforce inviting employees to learn about their coping strategies, stress levels, and risk for alcohol-related problems, with 228 employees providing complete data. Binge drinking in the previous 3 months was reported by 29% of the employees, with greater binge drinking reported by White employees, of mixed/other ethnic background, or younger. The AUDIT achieved a sensitivity of 35% in identifying respondents who reported binge drinking and a specificity of 98% in accurately identifying respondents who did not report binge drinking. Sensitivity using the cut-off of scoring one or more positive hits on the CAGE was 67%, and specificity was 84%. Therefore, neither the AUDIT nor the CAGE achieved adequate sensitivity, as well as specificity, as screening tools for assessing binge drinking. A more accurate method for assessing binge drinking appears to be by directly asking for the largest number of drinks consumed in a single drinking session.

Angell, K. L., M. A. Kreshka, R. McCoy, P. Donnelly, J. M. Turner-Cobb, K. Graddy, H. C. Kraemer and C. Koopman (2003). "Psychosocial intervention for rural women with breast cancer: The Sierra-Stanford Partnership." J Gen Intern Med 18(7): 499-507.
OBJECTIVE: This study was initiated by breast cancer survivors living in a rural community in California. They formed a partnership with academic researchers to develop and evaluate a low-cost, community-based Workbook-Journal (WBJ) for improving psychosocial functioning in geographically and economically isolated women with primary breast cancer. DESIGN: A randomized controlled trial was used to compare the WBJ intervention plus educational materials to educational materials alone (usual care). SETTING: One rural cancer center and several private medical, surgical, and radiation oncology practices in 7 rural counties in the Sierra Nevada Foothills of California. PARTICIPANTS: One hundred women with primary breast cancer who were either within 3 months of diagnosis or within 3 months of completing treatment. INTERVENTION: A community-initiated, theoretically-based Workbook-Journal, designed by rural breast cancer survivors and providers as a support group alternative. It included compelling personal stories, local rural resources, coping strategies, and messages of hope. RESULTS: Community recruiters enrolled 83% of the women referred to the study. Retention at 3-month follow-up was 98%. There were no main effects for the WBJ. However, 3 significant interactions suggested that women who were treated in rural practices reported decreased fighting spirit and increased emotional venting and posttraumatic stress disorder symptoms if they did not receive the WBJ. Among women who receive the WBJ, 74% felt emotionally supported. CONCLUSIONS: This community-based Workbook-Journal may be an effective psychosocial intervention for rural, isolated, and low-income women with breast cancer. Community involvement was essential to the success of this project.

Steiner, H., V. Carrion, B. Plattner and C. Koopman (2003). "Dissociative symptoms in posttraumatic stress disorder: diagnosis and treatment." Child Adolesc Psychiatr Clin N Am 12(2): 231-49, viii.
This article explores the complex relationship between dissociation and psychiatric trauma. Dissociation is described as a defense reaction, a risk factor for the development of posttraumatic stress disorder, and as a set of syndromal disturbances. The authors discuss various models proposed for the relationship between these. They outline developmental considerations in diagnosis and treatment and end by discussing further needed research.

Koopman, C., S. F. Wanat, S. Whitsell, D. Westrup and R. A. Matano (2003). "Relationships of alcohol use, stress, avoidance coping, and other factors with mental health in a highly educated workforce." Am J Health Promot 17(4): 259-68.
PURPOSE: The relationships of drinking, stress, life satisfaction, coping style, and antidepressant use to mental health were examined in a highly educated workforce. DESIGN: This study used a one-time mail-out, mail-back cross-sectional survey design to examine the relationships of mental health with three kinds of stress (life events, work stress, home stress); two kinds of life satisfaction (work and home); use of avoidance coping; and antidepressant use. SETTING: This study was conducted at a large worksite in northern California in which the workforce was comprised of predominantly highly educated employees. SUBJECTS: Questionnaires were mailed to a random sample of 10% of 8567 employees, and 504 were completed and returned by participants (59%). Complete data were provided by 460 participants (53%). MEASURES: Respondents completed the Mental Health Index, the Alcohol Use Disorders Identification Test (AUDIT), and measures of coping style, work and home stress and satisfaction, stressful life events, and antidepressant use. RESULTS: Mean Mental Health Index scores were at the 32nd percentile of the U.S. population-based norms, with low percentile values associated with worse mental health. Using multiple regression analysis, the factors examined in this study were significantly related to Mental Health Index scores as the dependent variable [F(16, 443) = 27.41, p < .001, adjusted overall R2 = .48]. Poor mental health scores were significantly related to the following: age (p < .05); screening positively for current harmful or hazardous drinking (p < .05); having high levels of stress at work (p < .05) or home (p < .01); experiencing dissatisfaction with work (p < .001) or home life (p = .01); engaging in avoidance coping (p < .001); and using antidepressants (p < .001). Employees currently using antidepressants had significantly more outpatient medical and mental health visits, indicating higher health costs. Furthermore, mental health status was also significantly related to the interactions between several pairs of these variables: education and gender, age and job stress, home satisfaction and work stress, home satisfaction and avoidance coping, and home satisfaction and use of antidepressants. CONCLUSION: Mental health status was poorer on average in a highly educated workforce compared with general U.S. norms. Most of the factors that were found to be associated with poorer mental health were ones that are potentially modifiable, such as experiencing more stress and less satisfaction in work and home life and engaging in current hazardous or harmful drinking. The findings that mental health is worse among individual employees who exhibit combinations of these factors suggest that we need to better understand possible effects of these factors in the context of one another. As interpretation of these results may be limited by the single worksite that participated in this study, future research should re-examine these relationships in other worksites varying from this one in geography and demographic characteristics.

Winzelberg, A. J., C. Classen, G. W. Alpers, H. Roberts, C. Koopman, R. E. Adams, H. Ernst, P. Dev and C. B. Taylor (2003). "Evaluation of an internet support group for women with primary breast cancer." Cancer 97(5): 1164-73.
BACKGROUND: Women with breast carcinoma commonly experience psychologic distress following their diagnosis. Women who participate in breast cancer support groups have reported significant reduction in their psychologic distress and pain and improvement in the quality of their lives. Web-based breast cancer social support groups are widely used, but little is known of their effectiveness. Preliminary evidence suggests that women benefit from their participation in web-based support groups. METHODS: Seventy-two women with primary breast carcinoma were assigned randomly to a 12-week, web-based, social support group (Bosom Buddies). The group was semistructured, moderated by a health care professional, and delivered in an asynchronous newsgroup format. RESULTS: The results indicate that a web-based support group can be useful in reducing depression and cancer-related trauma, as well as perceived stress, among women with primary breast carcinoma. The effect sizes ranged from 0.38 to 0.54. Participants perceived a variety of benefits and high satisfaction from their participation in the intervention CONCLUSIONS: This study demonstrated that the web-based program, Bosom Buddies, was effective in reducing participants' scores on depression, perceived stress, and cancer-related trauma measures. The effect size of the intervention was in the moderate range. Although web-based social support groups offer many advantages, this delivery mechanism presents a number of ethical issues that need to be addressed.

Koopman, C., C. Gore-Felton, N. Azimi, K. O'Shea, E. Ashton, R. Power, S. De Maria, D. Israelski and D. Spiegel (2002). "Acute stress reactions to recent life events among women and men living with HIV/AIDS." Int J Psychiatry Med 32(4): 361-78.
OBJECTIVE: This study examined the prevalence of acute stress reactions to recent life events among persons living with HIV/AIDS. A second aim was to investigate the relationship of acute stress reactions among HIV-infected men and women to posttraumatic stress disorder (PTSD) symptoms to previous traumatic life events. METHOD: Participants included 64 HIV-seropositive persons (33 men and 31 women) drawn from a larger study examining the effects of group therapy on quality of life and health behavior. These individuals were assessed at baseline on demographic and medical status characteristics and (PTSD) symptoms andthen randomly assigned to either receive group therapy plus education or education alone. Three months later they were assessed for acute stress reactions to recent life events. RESULTS: Nearly a third (31.3 percent) of the participants reported levels of acute stress reactions to recent life events that met all symptom criteria for the diagnosis of acute stress disorder. However, only 9.4 percent of the respondents described a recent stressful life event that was threatening to the life or physical integrity of themselves or others. Acute stress reactions to recent life events were significantly and positively related to experiencing PTSD symptoms to prior traumatic life events. Acute stress did not differ significantly by gender, AIDS status, or whether or not participants had received 12 weeks of group therapy. CONCLUSIONS: A subset of individuals with HIV/AIDS experience high levels of acute stress reactivity to life events considered non-traumatic. HIV-infected individuals who react strongly to ongoing life stressors are more likely to have developed PTSD symptoms in response to previous traumatic life events.

Maldonado, J. R., K. Page, C. Koopman, L. D. Butler, H. Stein and D. Spiegel (2002). "Acute stress reactions following the assassination of Mexican presidential candidate Colosio." J Trauma Stress 15(5): 401-5.
Considerable evidence suggests that exposure to traumatic events increases the risk of developing anxiety-spectrum disorders in response to later traumatization. We conducted a survey in Guadalajara, Mexico to assess factors associated with acute stress reactions to the assassination of a political figure. Participants included 86 adults who completed the Stanford Acute Stress Reaction Questionnaire (SASRQ) and measures of the perceived impact of the assassination, exhibited emotional behavior following the assassination, and had exposure to a specific prior disaster (a gas pipeline explosion). The results suggest that acute stress reactions can occur in response to an assassination, and that those most susceptible are those most emotionally invested, those who engage in emotional behavioral responses, and those whose lives have been affected by a previous potentially traumatic event.

Koopman, C., B. Nouriani, V. Erickson, R. Anupindi, L. D. Butler, M. H. Bachmann, S. E. Sephton and D. Spiegel (2002). "Sleep disturbances in women with metastatic breast cancer." Breast J 8(6): 362-70.
We examined sleeping problems in women with metastatic breast cancer in relation to depression, social support, and salivary cortisol. Ninety-seven women with metastatic breast cancer were drawn from a larger study on the effects of group therapy on quality of life and survival. This study is based on the baseline assessments conducted prior to randomization into treatment conditions. Sleep, depression symptoms, and social support were assessed by self-reporting. Cortisol was assessed from saliva samples taken over a 3-day period. Medical status and demographic characteristics were also examined in relation to each sleep variable in multiple regression analysis. Most women (63%) reported one or more types of sleep disturbance and 37% reported using sleeping pills in the previous 30 days. Problems with falling to sleep were significantly related to greater pain and depressive symptoms. Problems of waking during the night were significantly associated with greater depression and less education. Problems in waking/getting up were significantly associated with greater depressive symptoms and less social support. Sleepiness during the day was not significantly related to the variables in the regression model. Fewer hours of sleep were significantly associated with metastases to the bone, higher depressive symptoms, and more social support. Women who reported sleeping 9 or more hours per night, compared to those who reported a moderate amount of sleep (6.5-8.5 hours), had significantly lower 9 p.m. cortisol levels. Use of sleeping pills was more frequent among women reporting greater pain and depressive symptoms. These results suggest that women with metastatic breast cancer who are at higher risk for having sleeping problems are those who are less educated, in pain, depressed, have bony metastases, or lack social support.

Fobair, P., C. Koopman, S. DiMiceli, K. O'Hanlan, L. D. Butler, C. Classen, N. Drooker, H. R. Davids, J. Loulan, D. Wallsten and D. Spiegel (2002). "Psychosocial intervention for lesbians with primary breast cancer." Psychooncology 11(5): 427-38.
This study examined the effects of a Supportive-Expressive group therapy intervention offered to lesbians with early stage breast cancer. Twenty lesbians diagnosed with breast cancer in the previous 12-months were recruited and assessed at baseline, and at 3, 6, and 12 months after the group intervention. During the 12-week intervention, group members focused on the problems of a new diagnosis, coping with the illness and treatment, mood changes, coping responses and self-efficacy, improving relationships with family, friends and physicians, the impact of the illness on life, pain and sleep, and changes in body image and sexuality. A within-subject slopes analysis was conducted on data collected for each woman over the first year. As predicted, women reported reduced emotional distress, intrusiveness, and avoidance, and improved coping. There were significant changes in their social support, but in the unexpected direction. Instrumental support and informational support declined. However, conflict in family relations also declined, while trends were found towards more cohesiveness and expressiveness. Participants reported less pain and better sleep. There were no changes in body image, sexuality, or attitudes toward health-care providers. These results suggest that Supportive/Expressive group intervention appears to be helpful for lesbians with breast cancer.

Koopman, C., L. D. Butler, C. Classen, J. Giese-Davis, G. R. Morrow, J. Westendorf, T. Banerjee and D. Spiegel (2002). "Traumatic stress symptoms among women with recently diagnosed primary breast cancer." J Trauma Stress 15(4): 277-87.
This study examined the concurrent and longitudinal relationships between traumatic stress symptoms and demographic, medical, and psychosocial variables among women recently diagnosed with primary breast cancer. Participants were 117 women drawn from a parent study for women recently diagnosed with primary breast cancer. At baseline, the Impact of Event Scale (IES) total score was related to intensity of postsurgical treatment and lower emotional self-efficacy. At the 6-month follow-up, the IES total score was significantly related to younger age, to the increased impact of the illness on life, and to the baseline IES total score assessment. These results suggest that it is important to intervene for traumatic stress symptoms soon after the diagnosis of breast cancer. Furthermore, these results suggest women at greatest risk are those who are younger, who receive postsurgical cancer treatment, who are low in emotional self-efficacy and whose lives are most affected by having cancer.

Martinez, A., D. Israelski, C. Walker and C. Koopman (2002). "Posttraumatic stress disorder in women attending human immunodeficiency virus outpatient clinics." AIDS Patient Care STDS 16(6): 283-91.
This study examined posttraumatic stress disorder (PTSD) in human immunodeficiency virus (HIV)-positive women seeking medical care. Specifically, we examined traumatic life events, psychiatric treatment, social support, and demographic characteristics in relation to level of PTSD symptoms. We recruited and obtained informed consent from 47 ethnically diverse HIV-positive women from two HIV outpatient clinics in a county medical system. Forty-one of these women provided complete data on measures assessing demographics, traumatic life events, PTSD symptoms, social support, and psychotherapy/medical history. Analysis of the data demonstrated that a high percentage (42%) of the HIV-positive women were likely to meet criteria for full current PTSD, and an additional 22% for partial PTSD. Of the women likely with full PTSD, 59% were not receiving any psychiatric treatment, and of those likely with partial PTSD, 78% were not receiving any psychiatric treatment. Also, women reported having experienced a mean of 12 traumatic life events. As hypothesized, the level of PTSD was significantly related to the number of life events experienced (rs = 0.52, p < 0.001), and to perceived social support from friends (rs = - 0.34, p < 0.02) and family (rs = - 0.29, p < 0.05). Given the high percentages of women who were found to have experienced traumatic life events and high levels of PTSD symptoms, it seems important to assess and treat PTSD in women with HIV/acquired immune deficiency syndrome (AIDS).

Steiner, H., E. Ryst, J. Berkowitz, M. A. Gschwendt and C. Koopman (2002). "Boys' and girls' responses to stress: affect and heart rate during a speech task." J Adolesc Health 30(4 Suppl): 14-21.
PURPOSE: To examine gender differences in heart rate and reports of negative and positive affect among adolescents during a speech task. METHODS: Subjects were 133 adolescents, 73 girls and 60 boys, ages 14-18 years. Subjects were randomly assigned to speak for 10 minutes and asked either to free associate or to describe the most stressful event in their lives. Their heart rate was assessed at baseline and at 5 and 10 minutes after the task began. Self-ratings of negative and positive affect were assessed at baseline and at 10 minutes after the beginning of the task. Data were analyzed by Student's t-tests for independent samples, analyses of covariance, and Spearman rank-order correlation coefficients. RESULTS: Girls rated their negative affect significantly higher at baseline in comparison to boys. In addition, girls had a higher baseline heart rate. However, boys' increase in heart rate 5 minutes into the speech task was significantly greater than that of girls. Also, the free association task elicited significantly greater increases in heart rate compared to a task in which the adolescent described his or her most stressful life event. However, the stressful event task elicited greater negative and less positive affect. Significant relationships between change in heart rate and ratings of post-task affect were found among girls but not among boys, suggesting that the girls' ratings of their affect are more congruent with their physiological reactions to a stressful speech task. CONCLUSIONS: These results suggest that gender and task differences must be considered in assessing adolescents' stress.

Koopman, C., K. R. Pelletier, J. F. Murray, C. E. Sharda, M. L. Berger, R. S. Turpin, P. Hackleman, P. Gibson, D. M. Holmes and T. Bendel (2002). "Stanford presenteeism scale: health status and employee productivity." J Occup Environ Med 44(1): 14-20.
Workforce productivity has become a critical factor in the strength and sustainability of a company's overall business performance. Absenteeism affects productivity; however, even when employees are physically present at their jobs, they may experience decreased productivity and below-normal work quality--a concept known as decreased presenteeism. This article describes the creation and testing of a presenteeism scale evaluating the impact of health problems on individual performance and productivity. A total of 175 county health employees completed the 34-item Stanford Presenteeism Scale (SPS-34). Using these results, we identified six key items to describe presenteeism, resulting in the SPS-6. The SPS-6 has excellent psychometric characteristics, supporting the feasibility of its use in measuring health and productivity. Further validation of the SPS-6 on actual presenteeism (work loss data) or health status (health risk assessment or utilization data) is needed.

Catz, S. L., C. Gore-Felton and J. B. McClure (2002). "Psychological distress among minority and low-income women living with HIV." Behav Med 28(2): 53-60.
The growing incidence of HIV infection among low-income and minority women makes it important to investigate how these women adjust to living with HIV and AIDS. Psychological distress associated with HIV infection may compound the adjustment difficulties and increase the barriers to care associated with living in poverty. The authors surveyed 100 women who were receiving HIV care at a public hospital in the southeastern United States on measures of depression, anxiety, life stress, social support, and coping; they also assessed demographic and medical characteristics of the sample. Participants' annual incomes were low (87% < $10,000), and most participants were minorities (84% African American). Their levels of depression, stress, and anxiety symptoms were elevated relative to community norms. Greater anxiety and depression symptoms were associated with women who reported higher stress, using fewer active coping strategies, and perceiving less social support (ps < .001).

Otto-Salaj, L. L., C. Gore-Felton, E. McGarvey and R. J. Canterbury, 2nd (2002). "Psychiatric functioning and substance use: factors associated with HIV risk among incarcerated adolescents." Child Psychiatry Hum Dev 33(2): 91-106.
This study examined several types of psychiatric functioning (neuropsychiatric, emotional, and cognitive functioning) and substance use in relation to HIV risk behavior among 894 incarcerated girls and boys. Youth remanded to juvenile correctional facilities in a southern US state completed a structured interview regarding abuse history, emotional and behavioral difficulties, and demographics. Adolescents who experienced sullen affect were significantly more likely to engage in behaviors that put them at risk for HIV infection. Moreover, higher levels of alcohol use predicted HIV risk behavior. HIV prevention efforts need to address emotional distress as well as substance use among delinquent adolescents to reduce HIV risk behavior. Implications for treatment and future research are discussed.

Koopman, C., C. Gore-Felton, C. Classen, P. Kim and D. Spiegel (2001). "Acute stress reactions to everyday stressful life events among sexual abuse survivors with PTSD." J Child Sex Abus 10(2): 83-99.
This study examined symptoms of Acute Stress Disorder (ASD), which is often thought of as a precursor to PTSD, among 54 women who already had PTSD for childhood sexual abuse for which they were seeking treatment. We examined the prevalence of ASD symptoms as well as their relationships to trauma symptoms measured by the Trauma Symptom Checklist-40. The ASD diagnosis requires the occurrence of a traumatic life event as well as meeting specific symptoms criteria. We found that fourty-four percent of participants met all symptom criteria for ASD, but only three of these 24 participants described a traumatic life event. Moreover, ASD symptoms were significantly related to trauma symptom scores. These findings suggest that a significant proportion of women with PTSD for childhood sexual abuse may be highly symptomatic for everyday stressful events that would not be experienced as traumatizing to others. Thus, these individuals need assistance in coping with everyday life stressors that do not involve a serious threat or injury in addition to needing help to alleviate their trauma symptoms.

Spiegel, D. and S. E. Sephton (2001). "Psychoneuroimmune and endocrine pathways in cancer: effects of stress and support." Semin Clin Neuropsychiatry 6(4): 252-65.
The bulk of cancer research has productively focused on the pathophysiology of the disease, emphasizing tumor biology, especially tumor characteristics such as DNA ploidy and estrogen/progesterone receptor status as predictors of disease outcome, at the expense of studying the body's psychophysiological reactions to tumor invasion. These reactions are mediated by brain/body mechanisms, including the endocrine, neuroimmune, and autonomic nervous systems. Although a large portion of the variance in any disease outcome is accounted for by the specific local pathophysiology of that disease, some variability must also be explained by 'host resistance' factors, which include the manner of response to the stress of the illness. The evidence of links between social support, stress, emotional state, and immune and endocrine function is growing. Here we examine evidence that 2 especially promising mechanisms, one immune, one endocrine, may mediate the relationship between stress and social support on the one hand and cancer progression on the other. We chose natural killer (NK) cells and cortisol because they are particularly good examples of mediating mechanisms for which there is solid basic and clinical evidence. NK cells are of great interest because they are involved in tumor surveillance, and because their activity can be measured in vitro.

Field, N. P., C. Classen, L. D. Butler, C. Koopman, J. Zarcone and D. Spiegel (2001). "Revictimization and information processing in women survivors of childhood sexual abuse." J Anxiety Disord 15(5): 459-69.
This study examined the effect of sexual revictimization on information processing of trauma-related stimuli in a sample of child sexual abuse (CSA) survivors diagnosed with posttraumatic stress disorder (PTSD). Fifty-one treatment-seeking women participated in this study. Participants completed the Sexual Experiences Survey regarding sexual revictimization in the last 6 months and performed a modified emotional Stroop task in which they named the colors of neutral words (e.g., apple), general threat words (e.g., malignant and death), and sexual/victimization words (e.g., penis and abuser). As predicted, the revictimized participants (n = 16) took significantly longer to color-name sexual/victimization words than did the nonrevictimized participants. These results suggest that revictimization serves to prime preexisting "trauma" memory networks, thereby amplifying the impact of childhood sexual trauma on selective attention toward trauma-related stimuli.

Giese-Davis, J. and D. Spiegel (2001). "Suppression, repressive-defensiveness, restraint, and distress in metastatic breast cancer: separable or inseparable constructs?" J Pers 69(3): 417-49.
A longstanding hypothesis links affective and behavioral inhibition with cancer incidence and progression though it does not clarify psychometric distinctions among related constructs. We hypothesized that repressive-defensiveness, suppression, restraint, and distress would be separable factors in our sample of metastatic breast cancer patients. Our results support the discriminant validity of these constructs in our total sample, and the stability over 1 year in our control group. Using factor analysis, we found 4 separate factors at our prerandomization baseline corresponding closely to hypothesized constructs. Additionally, associations in a multi-trait, multi-occasion (baseline and 1 year) matrix met each of the 3 Campbell and Fiske (1959) criteria of convergent and discriminant validity. Future research testing the links between psychological, physiological, and survival outcomes with affective inhibition in cancer patients will be clearer when informed by these distinctions.

Spiegel, D. (2001). "Mind matters. Coping and cancer progression." J Psychosom Res 50(5): 287-90.
The idea that having an 'attitude' about cancer makes a difference in its course is a popular but controversial one. Most oncologists and surgeons believe that tumor type and stage, general health, and medical treatment are all that account for the variance in outcome. Many patients and their families believe that having the right attitude makes a difference in the course of disease. This leads us to two empirical questions: (1) Does coping make a difference in disease progression when medical prognostic variables are taken into account? and (2) What constitutes the 'right attitude'?

Classen, C., L. D. Butler, C. Koopman, E. Miller, S. DiMiceli, J. Giese-Davis, P. Fobair, R. W. Carlson, H. C. Kraemer and D. Spiegel (2001). "Supportive-expressive group therapy and distress in patients with metastatic breast cancer: a randomized clinical intervention trial." Arch Gen Psychiatry 58(5): 494-501.
BACKGROUND: Metastatic breast cancer carries with it considerable psychosocial morbidity. Studies have shown that some patients with metastatic breast cancer experience clinically significant anxiety and depression and traumatic stress symptoms. Supportive-expressive group psychotherapy was developed to help patients with cancer face and adjust to their existential concerns, express and manage disease-related emotions, increase social support, enhance relationships with family and physicians, and improve symptom control. METHODS: Of 125 women with metastatic breast cancer recruited into the study, 64 were randomized to the intervention and 61 to the control condition. Intervention women were offered 1 year of weekly supportive-expressive group therapy and educational materials. Control women received educational materials only. Participants were assessed at baseline and every 4 months during the first year. Data at baseline and from at least 1 assessment were collected from 102 participants during this 12-month period, and these participants compose the study population. RESULTS: Primary analyses based on all available data indicated that participants in the treatment condition showed a significantly greater decline in traumatic stress symptoms on the Impact of Event Scale (effect size, 0.25) compared with the control condition, but there was no difference in Profile of Mood States total mood disturbance. However, when the final assessment occurring within a year of death was removed, a secondary analysis showed a significantly greater decline in total mood disturbance (effect size, 0.25) and traumatic stress symptoms (effect size, 0.33) for the treatment condition compared with the control condition. CONCLUSION: Supportive-expressive therapy, with its emphasis on providing support and helping patients face and deal with their disease-related stress, can help reduce distress in patients with metastatic breast cancer.

Koopman, C., K. Angell, J. M. Turner-Cobb, M. A. Kreshka, P. Donnelly, R. McCoy, A. Turkseven, K. Graddy, J. Giese-Davis and D. Spiegel (2001). "Distress, coping, and social support among rural women recently diagnosed with primary breast cancer." Breast J 7(1): 25-33.
This study examined distress, coping, and group support among a sample of rural women who had been recently diagnosed with breast cancer. We recruited 100 women who had been diagnosed with primary breast cancer at one of two time points in their medical treatment: either within a window up to 3 months after their diagnosis of breast cancer, or within 6 months after completing medical treatment for breast cancer. Their mean age was 58.6 years (SD = 11.6), and 90% were of white/European American ethnicity. Women completed a battery of demographic and psychosocial measures prior to being randomized into a psychoeducational intervention study, and then again 3 months later at a follow-up assessment. The focus of this article is on the women's self-reported psychosocial status at baseline. Many of the women experienced considerable traumatic stress regarding their breast cancer. However, this distress was not reflected in a standard measure of mood disturbance that is frequently used in intervention research (the Profile of Mood States). The average woman considered her diagnosis of breast cancer to be among the four most stressful life events that she had ever experienced. Also, women on average reported a high level of helplessness/hopelessness in coping with their cancer. On average, women felt that they "often" (but not "very often") received instrumental assistance, emotional support, and informational support. Women varied considerably in which kind of social group provided them with the most support, with as many reporting that they found the greatest support in spiritual/church groups or within their family units as with breast or general cancer groups. These results suggest that among these rural women with breast cancer, distress with the diagnosis of breast cancer must be carefully assessed, as women who are highly distressed about their breast cancer may not report general mood disturbance. Furthermore, the kinds of groups that rural women with breast cancer experience as most supportive need to be identified so that psychosocial interventions can be matched to breast cancer patients' individual needs.

Fobair, P., K. O'Hanlan, C. Koopman, C. Classen, S. Dimiceli, N. Drooker, D. Warner, H. Davids, J. Loulan, D. Wallsten, D. Goffinet, G. Morrow and D. Spiegel (2001). "Comparison of lesbian and heterosexual women's response to newly diagnosed breast cancer." Psychooncology 10(1): 40-51.
In a study comparing lesbian and heterosexual women's response to newly diagnosed breast cancer, we compared data from 29 lesbians with 246 heterosexual women with breast cancer. Our hypotheses were that lesbian breast cancer patients would report higher scores of mood disturbance; suffer fewer problems with body image and sexual activity; show more expressiveness and cohesiveness and less conflict with their partners; would find social support from their partners and friends; and would have a poorer perception of the medical care system than heterosexual women. Our predictions regarding sexual orientation differences were supported for results regarding body image, social support, and medical care. There were no differences in mood, sexual activity or relational issues. Not predicted were differences in coping, indicating areas of emotional strength and vulnerability among the lesbian sample.

Gore-Felton, C., L. D. Butler and C. Koopman (2001). "HIV disease, violence, and post-traumatic stress." Focus 16(6): 5-6.

Koopman, C., C. Gore-Felton, F. Marouf, L. D. Butler, N. Field, M. Gill, X. H. Chen, D. Israelski and D. Spiegel (2000). "Relationships of perceived stress to coping, attachment and social support among HIV-positive persons." AIDS Care 12(5): 663-72.
The purpose of this study was to examine the relationships of coping, attachment style and perceived social support to perceived stress within a sample of HIV-positive persons. Participants were 147 HIV-positive persons (80 men and 67 women). Multiple regression analysis was used to examine the relationships of the demographic variables, AIDS status, three coping styles, three attachment styles and perceived quality of general social support with total score on the Perceived Stress Scale (PSS). PSS score was significantly associated with less income, greater use of behavioural and emotional disengagement in coping with HIV/AIDS, and less secure and more anxious attachment styles. These results indicate that HIV-positive persons who experience the greatest stress in their daily lives are those with lower incomes, those who disengage behaviourally/emotionally in coping with their illness, and those who approach their interpersonal relationships in a less secure or more anxious style.

Spiegel, D., C. Classen and E. Cardena (2000). "New DSM-IV diagnosis of acute stress disorder." Am J Psychiatry 157(11): 1890-1.

Giese-Davis, J., K. Hermanson, C. Koopman, D. Weibel and D. Spiegel (2000). "Quality of couples' relationship and adjustment to metastatic breast cancer." J Fam Psychol 14(2): 251-66.
This study examined mood disturbance among women with metastatic breast cancer in relationship to partnership status, relationship quality, and partner's coping and mood disturbance. These associations were examined within a total sample of 125 metastatic breast cancer patients and a subsample of 48 of these patients and their partners. Partnered and single women were indistinguishable in mood disturbance when household income was statistically controlled. Results also showed that patients were less distressed when they rated the relationship higher in Cohesion--Expression and in Conflict and when their partners reported lower mood disturbance. One possible implication of these results is that in relationships in which a woman has metastatic cancer, she may benefit from open engagement of difficulties and conflict. Furthermore, alleviating her distress may be better achieved by focus on the couple relationship rather than her individual coping.

Turner-Cobb, J. M., S. E. Sephton, C. Koopman, J. Blake-Mortimer and D. Spiegel (2000). "Social support and salivary cortisol in women with metastatic breast cancer." Psychosom Med 62(3): 337-45.
OBJECTIVE: This study used a cross-sectional design to examine the relationships between social support, both quantity (number of people) and quality (appraisal, belonging, tangible, and self-esteem), and neuroendocrine function (mean and slope of diurnal salivary cortisol) among women with metastatic breast cancer. METHODS: Participants (N = 103) were drawn from a study (N = 125) of the effects of group therapy on emotional adjustment and health in women with metastatic breast cancer. They completed the Interpersonal Support Evaluation List and the Yale Social Support Index and provided saliva samples for assessment of diurnal cortisol levels on each of 3 consecutive days. Diurnal mean levels were calculated using log-transformed cortisol concentrations, and the slope of diurnal cortisol variation was calculated by regression of log-transformed cortisol concentrations on sample collection time. RESULTS: Mean salivary cortisol was negatively related to the Interpersonal Support Evaluation List subscales of appraisal, belonging, and tangible social support. No association was found between quantitative support or the esteem subscale of the Interpersonal Support Evaluation List and mean salivary cortisol. Measures of qualitative and quantitative social support were not associated with the diurnal cortisol slope. CONCLUSIONS: Results show that greater quality of social support is associated with lower cortisol concentrations in women with metastatic breast cancer, which is indicative of healthier neuroendocrine functioning. These results may have clinical implications in the treatment of breast cancer.

Cardena, E., C. Koopman, C. Classen, L. C. Waelde and D. Spiegel (2000). "Psychometric properties of the Stanford Acute Stress Reaction Questionnaire (SASRQ): a valid and reliable measure of acute stress." J Trauma Stress 13(4): 719-34.
A reliable and valid measure is needed for assessing the psychological symptoms experienced in the aftermath of a traumatic event. Previous research suggests that trauma victims typically experience dissociative, anxiety and other symptoms, during or shortly after a traumatic event. Although some of these symptoms may protect the trauma victim from pain, they may also lead to acute stress, posttraumatic stress, or other disorders. The Stanford Acute Stress Reaction Questionnaire (SASRQ) was developed to evaluate anxiety and dissociation symptoms in the aftermath of traumatic events, following DSM-IV criteria for acute stress disorder. We present data from multiple datasets and analyses supporting the reliability and construct, convergent, discriminant, and predictive validity of the SASRQ.

Blake-Mortimer, J., C. Gore-Felton, R. Kimerling, J. M. Turner-Cobb and D. Spiegel (1999). "Improving the quality and quantity of life among patients with cancer: a review of the effectiveness of group psychotherapy." Eur J Cancer 35(11): 1581-6.
Cancer patients suffer from a number of psychosocial problems related to the progression of their disease as well as standard medical interventions. Fortunately, there is empirical evidence suggesting that group psychotherapy is effective at ameliorating psychological distress and in some cases improving survival. For this literature review we examined the psychological morbidity, particularly anxiety and depression, among cancer patients. Further, we conducted a critical examination of the current evidence regarding the effectiveness of group psychotherapy for improving the quality as well as the quantity of life in cancer patients. Finally, we explored the specific components of effective group psychotherapy, which has been associated with enhanced survival. We conclude that there is compelling evidence indicating that group psychotherapy improves the quality of life of cancer patients. Furthermore, there is a growing body of evidence suggesting that group psychotherapy improves survival of cancer patients.

Butler, L. D., C. Koopman, C. Classen and D. Spiegel (1999). "Traumatic stress, life events, and emotional support in women with metastatic breast cancer: cancer-related traumatic stress symptoms associated with past and current stressors." Health Psychol 18(6): 555-60.
This study examined levels of intrusion and avoidance symptoms and their relationships to past life stress, current emotional support, disease-related variables, and age in 125 women with metastatic breast cancer. The results indicate that a sizable proportion of these women experienced clinically significant levels of intrusion and avoidance symptoms related to their cancer, particularly those with both more stressful past life events and higher current levels of aversive emotional support. Additionally, both types of symptoms were associated with shorter time since recurrence, and avoidance symptoms were associated with smaller emotional support networks. These results indicate that metastatic breast cancer is an emotionally traumatic event for a significant proportion of women, particularly those with past life stressors and unsupportive social environments.

Spiegel, D., G. R. Morrow, C. Classen, R. Raubertas, P. B. Stott, N. Mudaliar, H. I. Pierce, P. J. Flynn, L. Heard and G. Riggs (1999). "Group psychotherapy for recently diagnosed breast cancer patients: a multicenter feasibility study." Psychooncology 8(6): 482-93.
As many as 80% of breast cancer patients report significant distress during initial treatment, yet there is little in the way of systematic psychotherapeutic interventions for women coping with the stress of a recent diagnosis of breast cancer. The literature on psychotherapeutic treatment of cancer patients provides uniform evidence for an improvement in mood, coping and adjustment as a result of group therapy. The present study examined the feasibility of implementing a manualized treatment, supportive-expressive group psychotherapy, in busy oncology practices across the US. This intervention was applied to women with primary breast cancer in a manner which tests not only the efficacy of the approach but also its accessibility to group therapists not previously experienced in its use. One hundred and eleven breast cancer patients within 1 year of diagnosis were recruited from ten geographically diverse sites of the National Cancer Institute's Community Clinical Oncology Program (CCOP) and two academic medical centers. Two therapists from each site were trained in supportive-expressive group psychotherapy. Training consisted of participation in a workshop, reading a treatment manual, and viewing explanatory videotapes. Each patient participated in a supportive-expressive group that met for 12 weekly sessions lasting 90 min. Assessment of mood disturbance was made at entry, 3, 6, and 12 months. Results indicated a significant 40% decrease in the Total Mood Disturbance (TMD) scores of the Profile of Mood States (POMS) (ANOVA F [2,174]=3.98, p<0.05). The total symptom score of the Hospital Anxiety and Depression Scale (HADS) was likewise significantly reduced over the 6-month period (F [2, 174]=5.2, p<0.01). Similarly, the total score of the Impact of Event Scale (IES) was significantly reduced (F [2,174]=4.0, p<0.05). There was substantial uniformity of treatment effect across sites. Outcome was independent of stage of disease (I vs. II). We conclude that this treatment program can be effectively implemented in a community setting and results in reduced distress among breast cancer patients.

Spiegel, D. (1999). "Embodying the mind in psychooncology research." Adv Mind Body Med 15(4): 267-73; discussion 275-81.

Spiegel, D. (1999). "Healing words: emotional expression and disease outcome." Jama 281(14): 1328-9.

McGarvey, E. L., L. A. Kryzhanovskaya, C. Koopman, D. Waite and R. J. Canterbury (1999). "Incarcerated adolescents' distress and suicidality in relation to parental bonding styles." Crisis 20(4): 164-70.
This study examines the relationships between the bonding style of an incarcerated adolescent with parents and his/her current feelings of self-esteem, hopelessness, and suicidal thoughts and attempts. It also investigates differences between bonding to mother and bonding to father. Some 296 incarcerated adolescents were interviewed using the Parental Bonding Instrument. Significant relationships were found between youths' self-esteem, hoplessness, and suicidal behavior and their bonding style. Youths whose parent(s) had a parental bonding style of affectionless control reported the greatest distress, and youths whose parent(s) had an optimal bonding style reported the least distress. Differences were found between bonding styles with the mother and with the father. Attachment theory may be useful in targeting incarcerated youths who have affectionless control bonding with parent(s) for special interventions since these youths are most at risk for psychosocial problems.

Classen, C., N. P. Field, A. Atkinson and D. Spiegel (1998). "Representations of self in women sexually abused in childhood." Child Abuse Negl 22(10): 997-1004.
OBJECTIVE: This exploratory study examined the self representations of 27 women sexually abused in childhood and their association with symptomatology. METHOD: Twenty-seven self-identified female survivors of childhood sexual abuse completed the Trauma Symptom Checklist-40, Beck Depression Inventory, State-Trait Anxiety Inventory and a measure designed to elicit subjects' self-generated descriptors of selves. RESULTS: Discrepancies in views of current self when compared to ideal or future selves were positively correlated with all symptom measures. Discrepancies in representations of current self compared to views of who they were when they were with their perpetrator were negatively correlated with trait anxiety. Self integration, as defined in this study, was negatively correlated with symptoms. CONCLUSIONS: This study suggests that cognitive representations of self are an important indicator of adjustment in survivors of childhood sexual abuse.

Spiegel, D. (1998). "Consistency of memory among veterans of Operation Desert Storm." Am J Psychiatry 155(9): 1301.

Spiegel, D., S. E. Sephton, A. I. Terr and D. P. Stites (1998). "Effects of psychosocial treatment in prolonging cancer survival may be mediated by neuroimmune pathways." Ann N Y Acad Sci 840: 674-83.
Research has provided growing evidence of links between the social environment and cancer progression. Indeed, social support in the form of marriage, frequent daily contact with others, and the presence of a confidant may all have protective value against cancer progression. Furthermore, retrospective data suggest that major stressful life events are more prevalent in patients with relapse or malignancy, and thus may contribute to cancer morbidity. Initial studies of the effects of psychosocial intervention with cancer patients have provided some promising results. In three randomized prospective trials, protective effects of psychosocial interventions on cancer progression have been confirmed, while one matching and one randomized study showed no survival effect after psychosocial treatment. Though more research is clearly needed in this area, this body of evidence suggests that psychosocial factors have potentially powerful modulating effects on the course of disease. Here we review evidence of one possible mechanism whereby psychosocial factors may influence disease-resistance capabilities: the neuroimmune connection. Suppressive effects of stress on immune function are well documented, and these effects have been shown to be modulated by social support. Thus, it is reasonable to hypothesize that supportive social relationships may buffer the effects of cancer-related stress on immunity, and thereby facilitate the recovery of immune mechanisms that may be important for cancer resistance. Data addressing this hypothesis are reviewed.

Koopman, C., K. Hermanson, S. Diamond, K. Angell and D. Spiegel (1998). "Social support, life stress, pain and emotional adjustment to advanced breast cancer." Psychooncology 7(2): 101-11.
The purpose of this study was to examine relationships between emotional adjustment to advanced breast cancer, pain, social support, and life stress. The cross-sectional sample was compromised of 102 women with metastatic and/or recurrent breast cancer who were recruited into a randomized psychosocial intervention study. All women completed baseline questionnaires assessing demographic and medical variables, social support, life stress, pain, and mood disturbance. Three types of social support were assessed: (1) number of persons in support system; (2) positive support; and (3) aversive support. On the Profile of Mood States (POMS) total score, we found significant interactions between life stress and social support; having more people in the patient's support system was associated with less mood disturbance, but only among patients who had undergone greater life stress. Also, aversive social contact was significantly related to total mood disturbance (POMS), and having more aversive social contact was particularly associated with total mood disturbance (POMS) among patients who had undergone greater life stress. Pain intensity was associated with greater total life stress, and was not significantly related to social support. These results are consistent with the 'buffering hypothesis' that social support may shield women with metastatic breast cancer from the effects of previous life stress on their emotional adjustment; however, aversive support may be an additional source of life stress associated with emotional distress. Also, pain is greater among women with greater life stress, regardless of social support.

Classen, C., C. Koopman, R. Hales and D. Spiegel (1998). "Acute stress disorder as a predictor of posttraumatic stress symptoms." Am J Psychiatry 155(5): 620-4.
OBJECTIVE: Using the DSM-IV diagnostic criteria for acute stress disorder, the authors examined whether the acute psychological effects of being a bystander to violence involving mass shootings in an office building predicted later posttraumatic stress symptoms. METHOD: The participants in this study were 36 employees working in an office building where a gunman shot 14 persons (eight fatally). The acute stress symptoms were assessed within 8 days of the event, and posttraumatic stress symptoms of 32 employees were assessed 7 to 10 months later. RESULTS: According to the Stanford Acute Stress Reaction Questionnaire, 12 (33%) of the employees met criteria for the diagnosis of acute stress disorder. Acute stress symptoms were found to be an excellent predictor of the subjects' posttraumatic stress symptoms 7-10 months after the traumatic event. CONCLUSIONS: These results suggest not only that being a bystander to violence is highly stressful in the short run, but that acute stress reactions to such an event further predict later posttraumatic stress symptoms.

Spiegel, D. and R. Moore (1997). "Imagery and hypnosis in the treatment of cancer patients." Oncology (Williston Park) 11(8): 1179-89; discussion 1189-95.
Many patients with cancer often seek some means of connecting their mental activity with the unwelcome events occurring in their bodies, via techniques such as imagery and hypnosis. Hypnosis has been shown to be an effective method for controlling cancer pain. The techniques most often employed involve physical relaxation coupled with imagery that provides a substitute focus of attention for the painful sensation. Other related imagery techniques, such as guided imagery, involve attention to internally generated mental images without the formal use of hypnosis. The most well-known of these techniques involves the use of "positive mental images" of a strong army of white blood cells killing cancer cells. Despite claims to the contrary, no reliable evidence has shown that this technique affects disease progression or survival. Studies evaluating more broadly defined forms psychosocial support have come to conflicting conclusions about whether or not these interventions affect survival of cancer patients. However, 10-year follow-up of a randomized trial involving 86 women with cancer showed that a year of weekly "supportive/expressive" group therapy significantly increased survival duration and time from recurrence to death. This intervention encourages patients to express and deal with strong emotions and also focuses on clarifying doctor-patient communication. Numerous other studies suggest that suppression of negative affect, excessive conformity, severe stress, and lack of social support predict a poorer medical outcome from cancer. Thus, further investigation into the interaction between body and mind in coping with cancer is warranted.

Spiegel, D. (1997). "Trauma, dissociation, and memory." Ann N Y Acad Sci 821: 225-37.

Spiegel, D. (1997). "Psychosocial aspects of breast cancer treatment." Semin Oncol 24(1 Suppl 1): S1-36-S1-47.
Social stress, psychological distress, and psychosocial support effect the adjustment of breast cancer patients, influence their experience of and adherence to medical treatment, and may effect the course of the disease. The literature indicates that levels of distress, depression, and anxiety are substantially elevated among patients with breast cancer. These problems persist in a sizable minority of patients even years after diagnosis. Coping styles are related to adjustment and, in some studies, survival time. The nature of the relationship with physicians affects adjustment to the illness, satisfaction with treatment outcome, and adherence to medical treatment protocols, which can influence relapse and survival. In many but not all studies, serious life stress adversely affects medical outcome. Social support in general and structured psychotherapy in particular have been shown to positively affect both adjustment and survival time. Clear and open communication, expression of appropriate emotion, and collaborative planning and problem-solving enhance adjustment and improve outcome. Conversely, influences that isolate breast cancer patients from others or undermine support can have adverse medical and psychological consequences.

Koopman, C., C. Classen and D. Spiegel (1996). "Dissociative responses in the immediate aftermath of the Oakland/Berkeley firestorm." J Trauma Stress 9(3): 521-40.
This study examined relationships between dissociative symptoms experienced in the immediate aftermath of the Oakland/Berkeley firestorm and contact with the fire, life events, demographic variables, and actions taken after learning about the fire. One hundred eighty-seven participants completed self-report measures about their experiences during and immediately following the fire. Dissociative symptoms were significantly related to contact with the fire, sex, and stressful life events. Also, dissociative symptoms were significantly related to engaging in certain activities, such as trying to get closer to the fire and going into blocked-off areas and crossing police barricades. These results suggest that dissociative symptoms may merit special attention in intervention focusing on the immediate aftermath of disaster.

Butler, L. D., R. E. Duran, P. Jasiukaitis, C. Koopman and D. Spiegel (1996). "Hypnotizability and traumatic experience: a diathesis-stress model of dissociative symptomatology." Am J Psychiatry 153(7 Suppl): 42-63.
OBJECTIVE: The authors propose a diathesis-stress model to describe how pathological dissociation may arise from an interaction between innate hypnotizability and traumatic experience. METHOD: To support the proposition that pathological dissociation may reflect autohypnotic process, the authors highlight clinical and research data indicating parallels between controlled hypnotic dissociative states and uncontrolled pathological dissociative symptoms and summarize evidence of hypnotizability in persons with psychiatric disorders that manifest these symptoms. The authors present this evidence by examining dissociative symptomatology in four psychological domains: perception, behavior and will, affect, and memory and identity. In addition, modern cognitive and neuropsychological models of dissociation are briefly reviewed. RESULTS: Several lines of evidence converge in support of the role of autohypnosis in pathological dissociation. There is considerable evidence that controlled formal hypnosis can produce a variety of dissociations of awareness and control that resemble many of the symptoms in uncontrolled pathological dissociative conditions; and it is possible to discern in dissociative pathology the features of absorption, dissociation, and suggestibility/automaticity that characterize formal hypnotic states. There is also accumulating evidence of high levels of hypnotic capacity in all groups with dissociative symptomatology that have been systematically assessed. In addition, the widespread and successful therapeutic use of hypnosis in the treatment of many dissociative symptoms and conditions (and the potential for hypnosis to induce dissociative symptomatology) also supports the assumption that hypnosis and pathological dissociation share an underlying process. CONCLUSIONS: High hypnotizability may be a diathesis for pathological dissociative states, particularly under conditions of acute traumatic stress.

Spiegel, D. (1996). "Cancer and depression." Br J Psychiatry Suppl(30): 109-16.
Half of all cancer patients have a psychiatric disorder, usually an adjustment disorder with depression. Anxiety about illness, such as cancer, often leads to delay in diagnosis, which has been estimated to reduce prospects of long-term cancer survival by 10% to 20%. Although earlier studies showed that depressed individuals were at higher risk for cancer incidence, later studies have not confirmed this predictive relationship. Nonetheless, effective psychotherapeutic treatment for depression has been found to affect the course of cancer. Psychotherapy for medically ill patients results in reduced anxiety and depression, and often pain reduction. In three randomised studies, psychotherapy resulted in longer survival time for patients with breast cancer (18 months), lymphoma, and malignant melanoma. The physiological mechanisms for these findings have not yet been determined, but four fundamental possibilities for psychotherapeutic effects on physiological change include health maintenance behaviour, health-care utilisation, endocrine environment, and immune function. Thus, effective treatment of depression in cancer patients results in better patient adjustment, reduced symptoms, reduced cost of care, and may influence disease course. The treatment of depression in these patients may be considered a part of medical as well as psychiatric treatment.

Spiegel, D. (1996). "Psychological distress and disease course for women with breast cancer: one answer, many questions." J Natl Cancer Inst 88(10): 629-31.

Spiegel, D. and P. M. Kato (1996). "Psychosocial influences on cancer incidence and progression." Harv Rev Psychiatry 4(1): 10-26.
The impact of psychosocial factors on the incidence and progression of cancer has become an area that demands attention. In this article recent evidence of psychosocial effects on cancer incidence and progression is reviewed in the context of past research. Psychosocial factors discussed include personality, depression, emotional expression, social support, and stress. Mechanisms that could mediate the relationship between psychosocial conditions and cancer incidence and progression are also reviewed. These include alterations in diet, exercise, and circadian cycles; variations in medical treatment received; and physiological mechanisms such as psychoendocrinologic and psychoneuroimmunologic effects. We conclude that there is a nonrandom relationship among various psychosocial factors and cancer incidence and progression that can only partially be explained by behavioral, structural, or biological factors. Suggestions for future research are discussed.

Rotheram-Borus, M. J., K. A. Mahler, C. Koopman and K. Langabeer (1996). "Sexual abuse history and associated multiple risk behavior in adolescent runaways." Am J Orthopsychiatry 66(3): 390-400.
Relationships between sexual abuse and sexual risk, substance use, emotional distress, and conduct problems were examined among 190 runaways. Those who had been abused were significantly more likely than nonabused peers to engage in unprotected sex, have more sexual partners, and use alcohol and drugs, but did not differ in emotional distress. Those abused after age 13 were more often engaged in sex work than nonabused peers. Males abused before age 13 had more sexual partners than those not abused, and runaway males were significantly more likely to have been sexually abused than has been reported in prior research.

Spiegel, D. (1995). "Psychiatry disabused." Nat Med 1(6): 490-1; author reply.

Koopman, C., C. Classen, E. Cardena and D. Spiegel (1995). "When disaster strikes, acute stress disorder may follow." J Trauma Stress 8(1): 29-46.
During and immediately following a traumatic event, people may manifest a pattern of dissociative and anxiety symptoms and other reactions, referred to as Acute Stress Disorder. A review of the empirical literature on psychological reactions to trauma suggest that this pattern of symptoms has often been identified across different kinds of traumatic events. It is likely to constitute a psychological adaptation to a stressful event, limiting painful thoughts and feelings associated with the event and allowing the person to function at least minimally. Continuation of these symptoms, however, may impair the person's quality of life and disrupt social and other functioning. If symptoms last beyond a month following the traumatic event, Post Traumatic Stress Disorder (PTSD) may ensue, continuing for months or even years after the precipitating event. Hence, it is important to be able to identify this pattern of reactions that may be manifested in reaction to trauma, so that appropriate intervention can be provided. Although it was not officially recognized in the 3rd edition Diagnostic and Statistical Manual (DSM-III-R), Acute Stress Disorder is included as a separate diagnosis in the DSM-IV.

Rotheram-Borus, M. J., M. Rosario, H. Reid and C. Koopman (1995). "Predicting patterns of sexual acts among homosexual and bisexual youths." Am J Psychiatry 152(4): 588-95.
OBJECTIVE: This longitudinal study examined predictors of patterns of change in HIV sexual risk acts among homosexual and bisexual adolescent males. METHOD: A consecutive series of 136 homosexual and bisexual males aged 14-19 years were recruited into the study. Subjects were predominantly Hispanic (51%) and African American (31%) and seeking services at a homosexual-identified community-based agency in New York City. All subjects participated in an intensive HIV intervention program. Patterns of change in HIV sexual risk acts were based on assessments at four points (intake and 3, 6, and 12 months later) and were used to classify youths as demonstrating one of five patterns of anal and oral sexual acts: protected (anal: 45%, oral: 25%), improved (32% and 28%, respectively), relapse (5% and 8%), variable (8% and 15%), and unprotected (10% and 24%). Components of the health belief, self-efficacy, peer influence, coping, and distress models were assessed as predictors of these patterns. RESULTS: Protected and improved patterns of sexual risk acts were associated with low levels of anxiety, depression, and substance use and high self-esteem. CONCLUSIONS: These data suggest that HIV interventions must address non-HIV-related issues confronting youths in difficult life circumstances, particularly emotional distress and the role of peer networks for homosexual and bisexual youths.

Spiegel, D., S. Sands and C. Koopman (1994). "Pain and depression in patients with cancer." Cancer 74(9): 2570-8.
BACKGROUND. Although the existence of a relationship between depression and pain in patients with cancer has been known for many years, the influence of one upon the other is still poorly understood. It has been thought that depressed individuals complain of pain more because of their psychiatric illness. Evidence from two studies indicate that pain may induce clinical depression. METHODS. In the first study, the authors examined both current and lifetime psychiatric diagnoses among patients with cancer who had high and low pain symptoms to examine the strength of the relationship between depression and cancer pain. The sample consisted of 72 women and 24 men, with 39 women and 9 men in the high pain group, and 33 women and 15 men in the low pain group. In the second study, 35 patients with metastatic carcinoma of the breast were examined for pain intensity and frequency and mood disturbance. RESULTS. The prevalence of depressive disorders of all types was found to be significantly higher in the high pain than in the low pain group across measures, 33 versus 13% (chi-square [degrees of freedom = 1] = 5.90, P < 0.05). Furthermore, there was a significantly higher history of major depression in the low pain group than in the high pain group (chi-square [degrees of freedom = 1] = 3.86, P < 0.05). Also, in comparison with patients in the low pain group, patients in the high pain group were significantly more anxious and emotionally distressed. In the second study, pain intensity correlated significantly with fatigue, vigor, and total mood disturbance, and pain frequency correlated significantly with fatigue, vigor, and depression. CONCLUSIONS. This study confirms the high concomitant occurrence of pain and psychiatric morbidity and suggests that pain may play a causal role in producing depression.

Spiegel, D. and A. W. Scheflin (1994). "Dissociated or fabricated? Psychiatric aspects of repressed memory in criminal and civil cases." Int J Clin Exp Hypn 42(4): 411-32.
During the last decade, clinicians, courts, and researchers have been faced with exceedingly difficult questions involving the crossroads where memory, traumatic memory, dissociation, repression, childhood sexual abuse, and suggestion all meet. In one criminal case, repressed memories served as the basis for a conviction of murder. In approximately 50 civil cases, courts have ruled on the issue of whether repressed memory for childhood sexual abuse may form the basis of a suit against the alleged perpetrators. Rulings that have upheld such use underscore the importance of the reliability of memory retrieval techniques. Hypnosis and other methodologies employed in psychotherapy may be beneficial in working through memories of trauma, but they may also distort memories or alter a subject's evaluation of their veracity. Because of the reconstructive nature of memory, caution must be taken to treat each case on its own merits and avoid global statements essentially proclaiming either that repressed memory is always right or that it is always wrong.

Spiegel, D. (1994). "Health caring. Psychosocial support for patients with cancer." Cancer 74(4 Suppl): 1453-7.
Psychosocial treatments, including group, individual, and family therapies, are of proven efficacy and deserve inclusion as standard components of biomedical treatment for patients with cancer. Four issues regarding such treatment are reviewed. The first is need. Significant anxiety and depression are common (and treatable) problems among the medically ill and represent a major aspect of the burden of illness. Even those with less severe emotional reactions need help coping with the stress of serious illness. The second is methods. Psychotherapy, both group and individual, provides valuable emotional and social support and teaches important symptom management skills. The third is outcome. Psychotherapy has been shown to be effective in improving quality of life and enhancing the ability of the medically ill to cope with their illness. Results of various psychotherapies include reducing depression and anxiety, improving coping skills, and in some cases, extending survival time. The fourth is cost offset. Appropriate psychotherapeutic intervention saves money by reducing unnecessary office visits, diagnostic tests, medical procedures, and hospital admittance.

Koopman, C., C. Classen and D. Spiegel (1994). "Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkeley, Calif., firestorm." Am J Psychiatry 151(6): 888-94.
OBJECTIVE: The purpose of this study was to examine factors predicting the development of posttraumatic stress symptoms after a traumatic event, the 1991 Oakland/Berkeley firestorm. The major predictive factors of interest were dissociative, anxiety, and loss of personal autonomy symptoms reported in the immediate aftermath of the fire; contact with the fire; and life stressors before and after the fire. METHOD: Subjects were recruited from several sources so that they would vary in their extent of contact with the fire. Of 187 participants who completed self-report measures about their experiences in the aftermath of the firestorm, 154 completed a follow-up assessment. Of these 154 subjects, 97% completed the follow-up questionnaires 7-9 months after the fire. The questionnaires included measures of posttraumatic stress and life events since the fire. RESULTS: Dissociative and loss of personal autonomy symptoms experienced in the fire's immediate aftermath, as well as stressful life experiences occurring later, significantly predicted posttraumatic stress symptoms measured 7-9 months after the firestorm by a civilian version of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder and the Impact of Event Scale. Dissociative symptoms more strongly predicted posttraumatic symptoms than did anxiety and loss of personal autonomy symptoms. Intrusive thinking differs from other kinds of posttraumatic symptoms in being related directly to the trauma and previous stressful life events. CONCLUSIONS: These findings suggest that dissociative symptoms experienced in the immediate aftermath of a traumatic experience and subsequent stressful experiences are indicative of risk for the later development of posttraumatic stress symptoms. Such measures may be useful as screening procedures for identifying those most likely to need clinical care to help them work through their reactions to the traumatic event and to subsequent stressful experiences.

Freinkel, A., C. Koopman and D. Spiegel (1994). "Dissociative symptoms in media eyewitnesses of an execution." Am J Psychiatry 151(9): 1335-9.
OBJECTIVE: The first execution in California since 1976 took place recently in the San Quentin Prison gas chamber. Eighteen journalists were invited as media eyewitnesses. The authors postulated that witnessing this execution was psychologically traumatic and that dissociative and anxiety symptoms would be experienced by the journalists. METHOD: To investigate the prevalence and specific nature of these symptoms, questionnaires were sent to all the journalists about a month after the execution. The questionnaire contained 17 items assessing dissociative symptoms from the authors' questionnaire of 35 highly intercorrelated acute stress items. Fifteen of 18 of the witnesses returned the questionnaire. Items were endorsed on a scale of 0 ("have not experienced") to 5 ("very often experienced") and analyzed as being dichotomously present or absent. The mean age of the respondents was 37.6 (SD = 8.6) and mean years as a journalist were 15.2 (SD = 9.0). Nine subjects were men and six were women. RESULTS: Journalists witnessing the execution endorsed an average of 5.0 dissociative items, ranging from "I saw, heard, or felt things that were not really there" (endorsed by no one) to "I felt estranged or detached from other people" (endorsed by 60%). This prevalence of reported dissociative symptoms is comparable to that seen among persons who endured the recent Oakland/Berkeley, Calif., firestorm. CONCLUSIONS: The experience of being an eyewitness to an execution was associated with the development of dissociative symptoms in several journalists.

van der Hart, O. and D. Spiegel (1993). "Hypnotic assessment and treatment of trauma-induced psychoses: the early psychotherapy of H. Breukink and modern views." Int J Clin Exp Hypn 41(3): 191-209.
The role of hypnotizability assessment in the differential diagnosis of psychotic patients is still unresolved. In this article, the pioneering work of Dutch psychiatrist H. Breukink (1860-1928) during the 1920s is used as early evidence that hypnotic capacity is clinically helpful in differentiating highly hypnotizable psychotic patients with dissociative symptomatology from schizophrenics. Furthermore, there is a long tradition of employing hypnotic capacity in the treatment of these dissociative psychoses. The ways in which Breukink used hypnosis for diagnostic, prognostic, and treatment purposes are summarized and discussed in light of both old and current views. He felt that hysterical psychosis was trauma-induced, certainly curable, and that psychotherapy using hypnosis was the treatment of choice. Hypnosis was used for symptom-oriented therapy, as a comfortable and supportive mental state, and for the uncovering and integrating of traumatic memories. For the latter purpose, Breukink emphasized a calm mental state, both in hypnosis and in the waking state, thereby discouraging emotional expression, which he considered dangerous in psychotic patients. In the discussion, special attention is paid to the role and dangers of the expression of trauma-related emotions.

Cardena, E. and D. Spiegel (1993). "Dissociative reactions to the San Francisco Bay Area earthquake of 1989." Am J Psychiatry 150(3): 474-8.
OBJECTIVE: This study systematically evaluated the psychological reactions of a nonclinical population to the October 1989 earthquake in the San Francisco Bay Area. METHOD: A representative group of about 100 graduate students from two different institutions in the Bay Area volunteered to participate in the study. Within 1 week of the earthquake, the authors administered a checklist of anxiety and dissociative symptoms to the subjects, and 4 months later they conducted a follow-up study with the same checklist. RESULTS: The participants reported significantly greater numbers and frequency of dissociative symptoms, including derealization and depersonalization, distortions of time, and alterations in cognition, memory and somatic sensations, during or shortly after the earthquake than after 4 months. To a lesser degree they also reported significantly more nonsomatic anxiety symptoms and Schneider's first-rank symptoms at the earlier testing time. CONCLUSIONS: These results suggest that among nonclinical populations, extreme distress may significantly increase the prevalence and severity of transient dissociative phenomena and anxiety. They provide further evidence of the role that dissociation plays in the response to trauma and are of considerable clinical and theoretical importance in view of the lifetime prevalence of traumatic experiences in the general population.

Classen, C., C. Koopman and D. Spiegel (1993). "Trauma and dissociation." Bull Menninger Clin 57(2): 178-94.
The stress associated with experiencing or witnessing physical trauma can cause abrupt and marked alterations in mental state, including anxiety and transient dissociative symptoms. Intense manifestations of this pattern of response to trauma are described in a new diagnostic category proposed for DSM-IV: acute stress disorder. Severe dissociative symptoms may predict subsequent posttraumatic stress disorder. Persons who experience a series of traumatic events may be especially vulnerable to a variety of dissociative states, including amnesia, fugue, depersonalization, and multiple personality disorder. Treatment for these symptoms emphasizes strengthening supportive interpersonal relationships and developing insight that reduces psychological pain by integrating the trauma into a meaningful, less self-blaming perspective.

Spiegel, D. (1992). "The use of hypnosis in the treatment of PTSD." Psychiatr Med 10(4): 21-30.

Koopman, C., M. J. Rotheram-Borus, L. Dobbs, M. Gwadz and J. Brown (1992). "Beliefs and behavioral intentions regarding human immunodeficiency virus testing among New York City runaways." J Adolesc Health 13(7): 576-81.
From 1988 to 1991, 139 runaways aged 11-19 years in the New York City area (n = 70 males, 69 females) were recruited from four shelters. Each runaway participated in a semistructured interview assessing beliefs and behavioral intentions regarding human immunodeficiency virus (HIV) testing. When asked how they would respond to being seropositive for HIV, 29% of runaways reported that they would engage in self-destructive acts and/or harm others (e.g., suicide, unprotected sex), 80% anticipated extreme distress, 47% expected difficulty securing housing and food, and 61% believed that friends were likely to avoid them. When presented with specific alternatives, fewer runaways anticipated self-destructive acts. Drug use, rather than sexual behaviors, would lead runaways to get tested for HIV. These results suggest that health-care providers must anticipate emotional distress and potential self-destructive behavior following receipt of documentation of HIV positive serostatus among runaways. Furthermore, prior to testing, youths' access to food, shelter, medical care, and social support must be secured.

Spiegel, D. and E. Cardena (1991). "Disintegrated experience: the dissociative disorders revisited." J Abnorm Psychol 100(3): 366-78.
We present proposed changes to the dissociative disorders section of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders and review the concept of pathological and nonpathological dissociation, including empirical findings on the relations between trauma and dissociative phenomenology and between dissociation and hypnosis. The most important proposals include the creation of two new diagnostic entities, brief reactive dissociative disorder and transient dissociative disturbance, and the readoption of the criterion of amnesia for a multiple personality disorder diagnosis. We conclude that further work on dissociative processes will provide an important link between clinical and experimental approaches to human cognition, emotion, and personality.

Spiegel, D. and F. Cardena (1991). "Comments on hypnotizability and dissociation." Am J Psychiatry 148(6): 813-5.

Spiegel, D. and E. Cardena (1990). "New uses of hypnosis in the treatment of posttraumatic stress disorder." J Clin Psychiatry 51 Suppl: 39-43; discussion 44-6.
Hypnosis is associated with the treatment of posttraumatic stress disorder (PTSD) for two reasons: (1) the similarity between hypnotic phenomena and the symptoms of PTSD, and (2) the utility of hypnosis as a tool in treatment. Physical trauma produces a sudden discontinuity in cognitive and emotional experience that often persists after the trauma is over. This results in symptoms such as psychogenic amnesia, intrusive reliving of the event as if it were recurring, numbing of responsiveness, and hypersensitivity to stimuli. Two studies have shown that Vietnam veterans with PTSD have higher than normal hypnotizability scores on standardized tests. Likewise, a history of physical abuse in childhood has been shown to be strongly associated with dissociative symptoms later in life. Furthermore, dissociative symptoms during and soon after traumatic experience predict later PTSD. Formal hypnotic procedures are especially helpful because this population is highly hypnotizable. Hypnosis provides controlled access to memories that may otherwise be kept out of consciousness. New uses of hypnosis in the psychotherapy of PTSD victims involve coupling access to the dissociated traumatic memories with positive restructuring of those memories. Hypnosis can be used to help patients face and bear a traumatic experience by embedding it in a new context, acknowledging helplessness during the event, and yet linking that experience with remoralizing memories such as efforts at self-protection, shared affection with friends who were killed, or the ability to control the environment at other times. In this way, hypnosis can be used to provide controlled access to memories that are then placed into a broader perspective. Patients can be taught self-hypnosis techniques that allow them to work through traumatic memories and thereby reduce spontaneous unbidden intrusive recollections.

Spiegel, D. (1989). "Hypnosis in the treatment of victims of sexual abuse." Psychiatr Clin North Am 12(2): 295-305.
The relevance of hypnosis to the treatment of sexual assault derives from two sources: the fact that hypnotic phenomena are mobilized spontaneously as defenses during assault, becoming part of the syndrome of posttraumatic stress disorder (PTSD) and the usefulness of formal hypnosis in treating PTSD. The role of dissociative defenses during and after traumatic experiences is reviewed; an analogy between the major elements of formally-induced hypnosis--absorption, dissociation, and suggestibility, and the major elements of PTSD--is drawn. Special problems relevant to sexual assault in childhood are discussed, including extreme self-blame and a profound sense of personality fragmentation. Uses of hypnosis in the treatment of sexual assault victims are reviewed, with an emphasis on helping such patients restructure their memories of the experience, both by reviewing them with greater control over their physical sense of comfort and safety and by balancing painful memories with recognition of their efforts to protect themselves or someone else who was endangered. The use of a split-screen technique in hypnosis is described with a clinical example. Special considerations in such treatment, including the traumatic transference and forensic complications of such psychotherapeutic work, are enumerated.

Spiegel, D. (1988). "Commentary. The treatment accorded those who treat patients with multiple personality disorder." J Nerv Ment Dis 176(9): 535-6.

Spiegel, D., T. Hunt and H. E. Dondershine (1988). "Dissociation and hypnotizability in posttraumatic stress disorder." Am J Psychiatry 145(3): 301-5.
The authors compared the hypnotizability of 65 Vietnam veteran patients with posttraumatic stress disorder (PTSD) to that of a normal control group and four patient samples using the Hypnotic Induction Profile. The patients with PTSD had significantly higher hypnotizability scores than patients with diagnoses of schizophrenia (N = 23); major depression, bipolar disorder--depressed, and dysthymic disorder (N = 56); and generalized anxiety disorder (N = 18) and the control sample (N = 83). This finding supports the hypothesis that dissociative phenomena are mobilized as defenses both during and after traumatic experiences. The literature suggests that spontaneous dissociation, imagery, and hypnotizability are important components of PTSD symptoms.

Spiegel, D. (1986). "Dissociating damage." Am J Clin Hypn 29(2): 123-31.

Spiegel, D. and A. Rosenfeld (1984). "Spontaneous hypnotic age regression: case report." J Clin Psychiatry 45(12): 522-4.
Age regression--reliving the past as though it were occurring in the present, with age appropriate vocabulary, mental content, and affect--can occur with instruction in highly hypnotizable individuals, but has rarely been reported to occur spontaneously, especially as a primary symptom. The psychiatric presentation and treatment of a 16-year-old girl with spontaneous age regressions accessible and controllable with hypnosis and psychotherapy are described. Areas of overlap and divergence between this patient's symptoms and those found in patients with hysterical fugue and multiple personality syndrome are also discussed.

Spiegel, D. (1984). "Multiple personality as a post-traumatic stress disorder." Psychiatr Clin North Am 7(1): 101-10.
This article examines multiple or dissociative personality syndrome as a multiple post-traumatic stress disorder, discussing these patient's developmental histories, their high hypnotizability, and their profound capacity to dissociate spontaneously to protect themselves from emotional and physical pain.

Bloom, J. R. and D. Spiegel (1984). "The relationship of two dimensions of social support to the psychological well-being and social functioning of women with advanced breast cancer." Soc Sci Med 19(8): 831-7.
Of interest to the field is the mechanism through which social support acts as a resistance resource for individuals undergoing stressful life circumstances. Women with advanced breast cancer (N = 86) were interviewed to determine how their outlook on life and social functioning were affected by the social support they received. Emotional support provided by the family was predicted to affect the woman's sense of well-being whereas the opportunities for social exchange provided by one's social activities were expected to effect the woman's social functioning. Consistent with the predictions, the data indicate that social support is multidimensional. Emotional support was strongly related to one's outlook. However, one's opportunities for social exchange affect not only one's social functioning, but also one's outlook on life, suggesting an interactive process whereby family support improves outlook, both outlook and opportunities for social exchange are related to one's sense of social functioning. These data explain the erosion of social support during life-threatening illness such as cancer as a result of the limitations imposed by the illness on one's opportunities for social exchange.

Koopman, C., S. Eisenthal and J. D. Stoeckle (1984). "Ethnicity in the reported pain, emotional distress and requests of medical outpatients." Soc Sci Med 18(6): 487-90.
Relationships of patients' ethnicity to their reported pain, emotional distress and requests were investigated. When patients aged over 60 years were compared. Italian-Americans were found to more frequently report pain than were Anglo-Americans; however, this difference was not replicated in the younger patients of Italian and Anglo backgrounds. In addition to patients' age, their sex also was found to mediate the relationship of ethnicity to the expression of pain. In particular, older female Italian-Americans were likely to report pain while, in contrast, older male Anglo-Americans were not. Age and sex may be important mediators of ethnic differences because older and female patients may carry on ethnic traditions more than do younger and male patients. Ethnicity was not found to be significantly related to emotional distress and requests.

Spiegel, D. and J. R. Bloom (1983). "Group therapy and hypnosis reduce metastatic breast carcinoma pain." Psychosom Med 45(4): 333-9.
The pain and mood disturbance of 54 women with metastatic carcinoma of the breast were studied over the course of one year. A random sample was offered weekly group therapy during the year, with or without self-hypnosis training directed toward enhancing their competence at mastering pain and stress related to cancer. Both treatment groups demonstrated significantly less self-rated pain sensation (t = 2.5 p less than 0.02) and suffering (t = 2.17, p less than 0.03) than the control sample. Those who were offered the self-hypnosis training as well as group therapy fared best in controlling the pain sensation (F = 3.1, p less than 0.05). Pain frequency and duration were not affected. Changes in pain measures were significantly correlated with changes in self-rated total mood disturbance on the Profile of Mood States and with its anxiety, depression, and fatigue subscales. Possible mechanisms for the effectiveness of these interventions are discussed.

Spiegel, D. (1981). "Vietnam grief work using hypnosis." Am J Clin Hypn 24(1): 33-40.

Spiegel, D. and R. A. Chase (1980). "The treatment of contractures of the hand using self-hypnosis." J Hand Surg [Am] 5(5): 428-32.
The successful treatment of a man with severe posttraumatic contractures of the hand using a combined psychological and physical rehabilitation approach is reported. The contractures had functional and organic components, as did the treatment, which involved teaching the patient self-hypnosis exercises and the use of a splint. The patient obtained virtually complete return of movement after 3 1/2 years of total disability. The importance of identifying and mobilizing rather than challenging the patient's motivation for recovery using a rehabilitation approach is discussed. Hypnosis can facilitate recovery in such psychosomatic disorders in patients with the requisite hypnotic capacity and motivation.

Spiegel, D. and R. Fink (1979). "Hysterical psychosis and hypnotizability." Am J Psychiatry 136(6): 777-81.
The very existence of hysterical psychosis as a diagnostic entity has been questioned as part of the general difficulty in defining both hysteria and psychosis. However, several recent investigations have documented a syndrome that usually involves brief and intense periods of psychotic behavior, generally with graphic decompensation, severe environmental stress, and rapid recompensation, in individuals with other hysterical features. The authors assert that such a syndrome does exist as a clinical entity and that the differential diagnosis can be facilitated by using a standardized measure of hypnotic trance capacity. They hypothesize that patients with hysterical psychosis are highly hypnotizable, while those who are schizophrenic and psychotic have low hypnotizability. The authors review the literature and present two case examples.

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