J. William Worden

The Existential Plight in Cancer: Significance of the First 100 Days

The Existential Plight in cancer is a poorly recognized but significant period. It starts with the definite diagnosis and continues for two to three months into the illness, approximately 100 days. The chief signs are the predominance of life/death concerns, even over worries about health or physical symptoms. One hundred and twenty newly diagnosed cancer patients were interviewed, tested, and followed from about ten days after diagnosis at four to six week intervals until three to four months had elapsed. Plight was analyzed from the viewpoint of coping strategies, resolution of problems, vulnerability, total mood disturbance, and predominant concerns. Patients who had higher emotional distress during this period had many regrets about the past, were pessimistic, came from a multiproblem family, and had marital problems. The widowed or divorced had higher vulnerability, as did patients who anticipated little or no support from significant others. Although vulnerability increased with advanced staging and many symptoms, at the time of diagnosis psychosocial distress crossed diagnostic and prognostic boundaries, enabling investigation to predict within limits those patients who will cope effectively or fail to cope with cancer and its ramifications.

Parental Death and the Adjustment of School-Age Children

Findings on the emotional impact of parental death for dependent children have not been consistent due to serious methodological limitations. The Child Bereavement Study investigated a community-based sample of parentally bereaved children and compared their responses to those from matched non-bereaved controls. Children and their surviving parent were assessed four months, one year, and two years after the death using standardized instrumentation. Most of the difference between the two groups was not obvious until two years after the death. The bereaved showed higher levels of social withdrawal, anxiety, and social problems as well as lower self-esteem and self-efficacy. Although most bereaved children do not show signs of serious emotional/behavioral disturbance, there is a significantly large group of bereaved children who show serious problems at one year (19%) and at two years (21%).

Psychosocial Analysis of Cancer Deaths

In addition to biological activity and cancer treatment, psychosocial considerations may influence both the quality of survival and its length. The investigators used information from psychological autopsies of cancer deaths, and correlated observed survival (measured in months beyond expected survival) with psychosocial findings. Patients who lived significantly longer tended to maintain cooperative and mutually responsive relationships, especially towards the end of their lives. Patients with death wishes, depression, apathy, and long-standing mutually destructive relationships survived for shorter periods than expectable. Why longevity occurs in some patients, but not in others, may be related to different traits which create alienation in personal life and in caretaking staff as life draws to a close. More assertive patients ask for and get better attention and services, and as a result, may live longer and die better deaths.

Preventive Psychosocial Intervention With Newly Diagnosed Cancer Patients

To study the effectiveness of preventive intervention in lowering emotional distress and improving coping, 381 newly diagnosed cancer patients were assessed shortly after the time of initial diagnosis. Subjects predicted by a screening instrument to be at risk for high levels of emotional distress and poor coping during the second through sixth months of their illness were randomly allocated to one of two short-term intervention programs (N = 59). Specific techniques to lower distress and improve coping were given during the four weeks following diagnosis. A control group (N = 58) received no intervention. All were followed at two-month to 6-month intervals by interview and testing. There was a significant lowering of emotional distress in the intervention group as compared to the control group (p less than 0.05). There was also a significant increase in the level of problem resolution in the intervention groups (p less than 0.01), although the numbers of problems experienced by both groups were no different.

Psychosocial components of lagtime in cancer diagnosis

Abstract General programs for prevention of cancer are largely based upon public information, early diagnosis and prompt treatment. Articles about delay in cancer diagnosis usually acknowledge that most patients see a doctor within three months of their original symptoms. Nevertheless, it is also presumed that beyond this arbitrary time, patients will significantly endanger their health. The concept of delay , set by custom at three months, tends to blame the patient or the doctor, without considering special characteristics of the cancer itself, and without correcting for clinical biological and psychosocial factors. This paper demonstrates that the designation, delay, should be dropped, and replaced with a less pejorative, but more scientific term, called Lagtime . Together with its logarithmic derivative(loglag), lagtime, which is not a redundant variable, can be used in conjunction with other variables to help establish the effectiveness of treatment in various kinds of tumors. 125 consecutive, newly diagnosed patients with cancer of the breast, lung, colon, Hodgkins disease, and malignant melanoma were interviewed and tested psychologically within 30 days of the original diagnosis. Individual assessment through interviews and inventories and multivariate analysis of psychosocial components, regressed against time intervals from initial symptoms to definitive examination, showed that only breast patients who delayed had cancer at a more advanced stage when diagnosed. However, while there were psychosocial correlates typical of the entire group of longer lagtime, some characteristics were found only in individual types of cancer, and were not shared by others.

The fallacy in postmastectomy depression

The prominence of postmastectomy depression and loss of self esteem, together with its reputed relation to symbolism or sexual significance of the breasts, has been investigated. Neither could be confirmed. Forty newly diagnosed breast cancer patients were compared with 50 women with other types of cancer. Only 20 per cent of breast patients and 18 per cent of others reported the syndrome of depression, lowered self esteem, increased health concerns, and loss of energy. Peak emotional distress did occur in breast patients about two to three months after mastectomy, a finding which may be influenced by the treatment, as well as by return to regular responsibilities. Few women ascribed psychosocial problems primarily to losing their breast. While the postmastectomy syndrome is not common, the frequency of breast cancer itself means that a substantial number of women may still be affected. But other variables are better predictors or concomitants of emotional distress than are problems about damaged body image.

Psychosocial effects of war experiences among displaced children in southern Darfur.

This study focused on assessing the psychosocial effects of the long standing, high intensity, and guerrilla-style of warfare among displaced children in Southern Darfur. The goal was to better understand the etiology, prognosis, and treatment implications for traumatic reactions, depression, and grief symptoms in this population. Three hundred thirty-one children aged 6–17 from three IDP Camps were selected using a quota sampling approach and were administered a Demographic Questionnaire, Child Post Traumatic Stress Reaction Index, Child Depression Inventory, and the Expanded Grief Inventory. Forty-three percent were girls and 57% were boys. The mean age of the children was 12 years. Results found that children were exposed to a very large number of war experiences with no significant differences between genders for types of exposure, including rape, but with older children (13–17 years) facing a larger number of exposures than younger children (6–12 years). Out of the 16 possible war experiences, the mean number was 8.94 (SD = 3.27). Seventy-five percent of the children met the DSM-IV criteria for PTSD, and 38% exhibited clinical symptoms of depression. The percentage of children endorsing significant levels of grief symptoms was 20%. Increased exposure to war experiences led to higher levels of: 1) traumatic reactions; 2) depression; and 3) grief symptoms. Of the 16 war experiences, abduction, hiding to protect oneself, being raped, and being forced to kill or hurt family members were most predictive of traumatic reactions. Being raped, seeing others raped, the death of a parent/s, being forced to fight, and having to hide to protect oneself were the strongest predictors of depressive symptoms. War experiences such as abduction, death of ones parent/s, being forced to fight, and having to hide to protect oneself were the most associated with the childs experience of grief. In addition to Total Grief, Traumatic Grief, Existential Grief, and Continuing Bonds were measured in these children. Although trauma, depression, and grief often exist as co-morbid disorders, the mechanisms and pathways of these is less understood. In this study we used Structural Equation Modeling to better understand the complex interaction and trajectories of these three symptoms evolving from war exposure and loss. This study is the first of its kind to assess the psychosocial effects of war experiences among children currently living in war zone areas within Sudan. It identifies some of the most prevalent war-related atrocities and their varying impact on the childrens psychological well-being and overall adjustment. Implications for planning mental health interventions are discussed.

Handbook of bereavement: Children's reactions to the death of a parent

There is general agreement that the death of a parent for school-age children is a very stressful experience (Antonovsky, 1979; Garmezy, 1987). Some researchers have shown that such a loss can lead to depression or other behavior problems in children and also later on as adults (Furman, 1974; Birtchnell, 1980; Bowlby, 1980; Brown, Harris, & Bifulco, 1986). In contrast, other studies have not been able to point to any consistent findings supporting the hypothesis that the death of a parent in childhood leads to an increase in problem behaviors or to an increased risk of subsequently developing psychological problems (Van Eerdewegh, Bieri, Parilla, & Clayton, 1982; Osterweis, Solomon, & Green, 1984). Berlinsky and Biller (1982), in an extensive review of the research literature, observed that this lack of consistent findings may be due to an oversimplification of outcome measures, such as the presence or absence of psychiatric symptoms or other problem behaviors. Also contributing to the confusion is the use of a singleevent model, which obscures the complexity of the situation. The death of a parent cannot be viewed as a single stressful event but as a series of events that occur before and after the death (Berlinsky & Biller, 1982; Norris & Murrell, 1987). Brown et al. (1986), in their study of depressed women who, as children, lost their mother, and Elizur and Kaffman (1983), who studied Israeli children who lost fathers in war, suggest that factors other than the loss need to be in place before a bereaved child can be considered at risk.

An Empirical Study of the Proposed Complicated Grief Disorder Criteria

Diagnostic criteria for complicated grief have been proposed as a pathological disorder for inclusion into the next edition of the DSM. However, to date, little empirical testing of the criteria to support or refute the diagnostic claims has been completed. Since the original criteria were developed based on work with widows and widowers, further testing with other bereft groups is needed before advancing complicated grief to a diagnosis worthy of inclusion in diagnostic systems. The present study was undertaken to empirically test the complicated grief disorder criteria. The basic criteria of the complicated grief disorder, formerly called traumatic grief, separation distress, and traumatic distress, were not isolated as distinct constructs in confirmatory factor analyses, and conceptualization as a unitary construct did not provide an adequate fit of the model to the data. Further analyses did not support the distinctness between complicated grief and depression, or complicated grief and normal grief. Based on these findings, both further investigation into the validity of complicated grief disorder as a diagnosis and verification of the validity of the diagnostic criteria is warranted before declaring this phenomenon appropriate for inclusion in diagnostic systems.

Children's Understanding of Funeral Ritual

One hundred-twenty children who experienced the death of one of their parents were interviewed about their view of the funeral ritual. Ninety-five percent of them attended the funeral. Shortly after the death they recalled little about the funeral. Two years later, children reported that it was important to them that they had attended. Attendance helped them to acknowledge the death, provided an occasion for honoring their deceased parent, and made it possible for them to receive support and comfort.