International Journal of Psychotherapy Practice and Research

International Journal of Psychotherapy Practice and Research

International Journal of Psychotherapy Practice and Research

Current Issue Volume No: 1 Issue No: 2

Research Article Open Access Available online freely Peer Reviewed Citation

Investigation and Analysis on Mental Health State of Breast Cancer Patients in China

Xiaoyan Liu 1,   Wei Xu 1  

1School of Psychology, Nanjing Normal University

Abstract

Purpose:

There are nearly 170,000 new cases of breast cancer in China every year, and this number is showing an increasing trend. Mental health plays an important role in promoting the physical rehabilitation of patients. Therefore, attention paid to their psychological problems needs to be reinforced. The current study aims to investigate the mental health states of the breast cancer patients and provides the references for their psychosomatic rehabilitation in the future work.

Methods:

A total of 643 breast cancer patients completed the whole study. A questionnaire survey on anxiety, depression, posttraumatic stress disorder (PTSD), and posttraumatic growth (PTG) was conducted in Jiangsu Women and Children Health Hospital.

Results:

13.53% breast cancer patients had anxiety; 21.5% had depression; the prevalence of PTSD was 7.15%, while the prevalence of PTG was 26.12%; Anxiety levels in older patients were significantly lower than those in the other two groups; PTG levels in older patients were significantly lower than those in the other two groups.

Conclusion:

Breast cancer patients have certain emotional distress and stress symptoms, but they also experience psychologically positive changes. And age shows various differences on anxiety and PTG. Clinical medical personnel should pay attention to the patient's psychological rehabilitation when concerning about the physical rehabilitation of patients. Patients in different ages have different mental health problems, thus the medical staff shall provide differential nursing plans for them.

Author Contributions
Received 2 May 2018; Accepted 11 Jun 2018; Published 20 Jun 2018;

Academic Editor: Shuai Li, University of Cambridge.

Checked for plagiarism: Yes

Review by: Single-blind

Copyright ©  2018 Xiaoyan Liu, et al

License
Creative Commons License     This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Competing interests

The authors have declared that no competing interests exist.

Citation:

Xiaoyan Liu, Wei Xu (2018) Investigation and Analysis on Mental Health State of Breast Cancer Patients in China. International Journal of Psychotherapy Practice and Research - 1(2):24-33. https://doi.org/10.14302/issn.2574-612X.ijpr-18-2110

Download as RIS, BibTeX, Text (Include abstract )

DOI 10.14302/issn.2574-612X.ijpr-18-2110

Introduction

According to statistics, there are about 1.4 million new cases of breast cancer every year all over the world 1. The incidence of breast cancer in China has surpassed the world and there are 170,000 newly diagnosed Chinese breast cancer patients each year 2. Furthermore, this number is showing an increasing trend 2. Of all cancers, breast cancer has become the most lethal disease with the exception of lung cancer among female 3.

Being diagnosed with breast cancer not only damages the physical function of the patients, but also has a negative impact on their mental health. They may experience a threat of physical integrity due to mastectomy and hair loss caused by chemotherapy. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), threats of physical integrity and life-threatening illnesses are events that may traumatize individuals 4. More than 75% patients with breast cancer were suffering from subclinical symptoms of posttraumatic stress disorder (PTSD) 5, 6. Patients with breast cancer may have persistent memory of surgical scars, avoid underwear advertisements, nightmares and other posttraumatic stress symptoms 7.

In addition, breast cancer patients are also suffering from different levels of negative emotions such as anxiety and depression. Fann et al. (2008) reviewed the evidence for the prevalence of depression in women with breast cancer from the last 20 years, and suggested that the incidence of depression is about 10% to 25% 8. Literature had indicated that anxiety, which varied from 10% to 30%, is more common than depression among breast cancer patients 9, 10. Burgess et al. (2005) pointed out that the number of patients with depression and anxiety reached the maximum value in the first year after breast cancer diagnosis 11.

However, despite the initial negative posttraumatic response, research had also reported that breast cancer patients will experience positive changes 12. One of the most typical positive changes is posttraumatic growth (PTG). Posttraumatic growth refers to a positive psychological change that occurs after individuals have fought against a disaster. It mainly includes changes in self-awareness, changes in interpersonal experience, and changes in life philosophy 13. In addition, the study by Manne et al. (2004) also found that breast cancer patients' posttraumatic growth scores increased with postoperative time 14.

With the increase in medical conditions and living standards, the survival rate of breast cancer has risen 3. The mental health of individuals after their illness may also change. Moreover，most epidemiological studies of breast cancer associated with mental disorder used tools such as screening scales to assess depressive symptoms rather than using diagnostic tools based on the DSM diagnostic criteria 15. Therefore, Re-investigating the level of mental health of breast cancer patients under different cultural background is necessary. Clinical scales were used to investigate the mental health status of breast cancer patients in this study. In addition, we explored the influence of factors such as age and social stimulations on their mental health states.

Experimental Procedure

Questionnaires and informed consent forms were sent to the hospital for investigation by the research personnels, mainly graduate students. Researchers conducted a short interview with the patients and then the patients began to fill out the questionnaires. If the patient (infusion or bedridden) couldn’t complete it by himself, the questionnaires will be read by the investigator and the patient gave the answers in oral. Most patients completed the questionnaires independently.

Materials and Methods

Participants

In this study, the participants were the hospitalized patients from the Mammary Department of Jiangsu Women and Children Health Hospital. A total of 643 patients were female patients. Inclusion criteria to the participants were: (1) voluntarily participated in the study and had signed the informed consent form; (2) had undergone breast cancer surgery and the clinical pathological diagnosis was Stage I-III breast cancer; (3) possessed no mental health problems, brain injuries and severe mental illness.

Measures

The Chinese version of Posttraumatic Stress Disorder Symptom Scale (PSS).

The applied questionnaire was the Chinese version of Posttraumatic Stress Disorder Symptom Scale, revised by Zhou et al. (2014) 16. The original scale is Posttraumatic Stress Disorder Symptom Scale 17. The scale contains 3 dimensions and 17-items, including Intrusion (5 items), Avoidance (7 items), and Hyper-arousal (5 items), which uses a 4-point Likert scoring of 0 (“Not a bit”) -3 (“Always”). In this sample, the scale has a good internal consistency coefficient (α=.906).

The Chinese version of Posttraumatic Growth Inventory (PTG)

PTG levels were assessed using the Posttraumatic Growth Inventory 18. The Chinese version of PTGI was revised and validated by Zhou et al. (2014) 16, and they added one item, “I have some more understanding of uncontrollable forces exist” on the basis of the original scale. The scale consists of 22-items evaluating three factors of PTG including Perceived Changes in Self (9 items), A Changed Sense of Relationships with Others (7 items) and Changed Philosophy of Life (6 items). Items were rated on a 4-point Likert scale ranging from 0 (“no change”) to 5 (“very great degree of change”). This scale exhibited good reliability and construct validity for this study (α =.933), and yielded consistent measures for each subscale (Perceived Changes in Self, α = .861; A Changed Sense of Relationships with Others, α = .854; Changed Philosophy of Life, α = .799).

The Chinese version of Patient Health Questionnaire (PHQ-9)

The scale was developed based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) standard for the diagnosis of the major depressive disorder, which was used to assess the depressive symptoms of the past two weeks 19. Yeung et al. (2008) translated the scale into Chinese and examined the reliability and validity 20. The PHQ-9 has a single-factor structure with 9 items rated from 0 (“almost never”) to 3 (“almost always”). Each item is a description of the symptoms of depression. The higher score reflects the severer depression tendency. The internal consistency was good for the present study (α = .853).

The Chinese version of General Anxiety Disorder Scale (GAD-7),

The Chinese version 21 of General Anxiety Disorder Scale 22 was adapted to measure the anxiety symptoms. The inventory consists of 7 items. All the items are rated on a 4-point Likert scale that ranges from 0 (“almost never”) to 3 (“almost always”). The overall scale score is the sum of the 7 items score, and the higher the score, the more anxiety symptoms. In this study, the internal reliability of the modified inventory was good (α = .912).

Statistical Analyses

Missing data across questionnaire items (< 4.5 % in overall data) were replaced by the series mean. Means, SDs, range, Cronbach’s alpha coefficients, correlations of the scales, and ANOVA analysis in the current study were computed using SPSS 21.0. We used Harman’s single factor test to examine common method bias 23. All items relevant to the study were subjected to an exploratory factor analysis. The results show that 8 factors can be obtained, while no single factor accounts for a majority of the covariance among the variables. Therefore, no significant common method bias existed in the current study.

Results

Descriptive Statistics

The demographic and clinical information of the current sample were listed in Table 1. A total of 643 females completed the research, and the ages ranged from 26 to 73.

Table 1. Demographic statistics of subjects (N = 643).
Variables M (SD) or N (%) Variables M (SD) or N (%)
Age(years) 48.78 (9.21) Household monthly income  
Marital Status   <500 RMB (～73USD) 28 (4.35%)
Single 12 (1.87%) 500 - 1,000 RMB 42 (6.53%)
Married 599 (93.16%) 1,000 - 3,000 RMB 146 (22.71%)
Divorced 20 (3.11%) 3,000 - 5,000 RMB 144 (22.40%)
Widowed 9 (1.40%) 5,000 - 10,000 RMB 177 (27.52%)
Education   >10,000 RMB 67 (10.41%)
Primary school 112 (17.41%) Medical history  
Middle school 174 (27.06%) No 166 (25.82%)
High/Secondary School 163 (25.35%) Yes 256 (39.81%)
Three -year college 89 (13.84%) Unknown 210 (32.66%)
University or above 75 (11.66%) Surgery history  
Number of children   Yes 279 (43.39%)
No children 28 (4.35%) No 292 (45.41%)
One child 421 (65.47%) Unknown 63 (9.80%)
Two children 162 (25.35%) Treatment type  
≥Three Children 26 (4.04%) Mastectomy 406 (63.14%)
Social stimulation   Breast Conservation Surgery 104 (16.17%)
Divorce 11 (1.71%) Mastectomy and reconstruction 96 (14.93%)
Work/ Study  pressure 102 (15.86%) No treatment yet 28 (4.35%)
Spouse death 11 (1.71%) Adjuvant therapy  
Family members’ health 83 (12.91%) Chemotherapy 547 (85.07%)
Marital Problems 23 (3.58%) Radiotherapy 41 (6.38%)
No 413 (64.23%) Endocrine therapy 32 (4.98%)

Negative Psychological Status in Breast Cancer Patients

The scores of the GAD-7 and PHQ-9 scale indicated that the total score was greater than 10 points for best specificity and sensitivity 20, 21. We selected scores above 10 as the clinical diagnostic criteria for anxiety and depression in this study. According to the standard, there were 13.53% of breast cancer patients had anxiety, 21.5% of breast cancer patients had depression. According to the PTSD diagnostic criteria of DSM-4, individuals who meet all of the following conditions are considered to have "high risk of having PTSD": firstly, at least 1 of the 5 items of Intrusion symptoms scores ≥ 2 points; secondly, at least 3 of the 7 items of Avoidance symptoms scores ≥ 2 points; thirdly, at least 2 of the 5 items of Hyper-arousal symptoms scores ≥ 2 points. The results suggested that the incidence of PTSD breast cancer patients in Jiangsu province was 7.15%. The specific results are shown in Table 2.

Table 2. Status of mental health among breast cancer patients.
  Incidence (%) M(SD)
Anxiety 13.53% 4.9 (4.24)
Depression 21.5% 6.5 (4.62)
Posttraumatic Stress Disorder 7.15% 12.1 (8.68)
Intrusion — 3.7 (3.02)
Avoidance — 4.5 (3.64)
Hyper-arousal — 3.9 (3.00)
Posttraumatic Growth 26.12% 48.6 (22.97)
Changed Philosophy of Life — 16.1 (8.15)
Perceived Changes in Self — 13.2 (8.37)
A Changed Sense of Relationships with Others — 12.8 (7.82)

Positive Psychological Status in Breast Cancer Patients

According to the studies of Tang (2006) and Xu et al. (2011), it was considered that individuals with a PTG score of ≥ 3 points had significant changes in this item 24, 25. The PTG questionnaire used in this study had a total of 22 items. Therefore, the PTG total score set ≥ 66 points as the critical value. According to the standard, the incidence of PTG in breast cancer patients was 26.12%. The ranking of average scores of each dimension of PTG from high to low was Changed Philosophy of Life, Perceived Changes in Self, A Changed Sense of Relationships with Others. The specific results are shown in Table 1.

The Comparison of Age and Social Stimulus of Mental Health of Patients with Breast Cancer

In this study, to investigate whether age differentiated of breast cancer patients' mental healths, patients were divided into three groups based on their ages, namely 26-40 years old, 41-60 years old, and 61-73 years old. The results suggested that anxiety scores were significantly different in three groups [F (2, 634) = 3.04, p < 0.05]. Further post hoc tests found that the anxiety scores between ages 26-40 and 41-60 were significantly higher than those between 61-73 years old in breast cancer patients [t26-40_61-73 (1, 184)=1.99, p < 0.05; t41-60_61-73 (1,522)=2.47, p < 0.05]. PTG levels were significantly different in age [F (2, 634) = 3.69, p < 0.05], and post hoc tests found that the PTG levels between ages 26-40 were significantly higher than those in other two older groups [t26-40_41-60 (1, 562) =2.37, p < 0.05; t26-40_61-73 (1,184) =2.31, P <0.05].

We used ANOVA to text the destructive factor of mental health, socially stimulations, including Divorce, Work / Study pressure, Spouse death, Family members’ health, Marital Problems, and None of them. A comparison of the effects of socially stimulating events on the mental health status of breast cancer patients revealed that anxiety scores were significantly affected by social stimulation [F (6, 636) = 4.64, p < 0.001]. Post hoc tests found that the anxiety scores of patients who had changes in Family members’ health were significantly higher than patients who divorced (p < 0.05) and patients who had work / study pressures (p < 0.05). Depression scores were significantly associated with social stimulation [F (6, 636) = 2.63, p < 0.05]. Post hoc tests found that the depression scores of patients who had changes in Family members’ health and experienced spouse death were significantly higher than patients who haven’t stimulations (p < 0.01; p < 0.05). PTSD scores were significantly associated with social stimulation [F (6, 636) = 4.77, p < 0.001]. Post hoc tests found that the PTSD scores of patients who had changes in Family members’ health, patients with work / study pressures and experienced spouse death were significantly higher than patients who haven’t stimulations (p < 0.001; p < 0.01; p < 0.05). (Table 3)

Table 3. Differences in ages and social stimulations for mental health status.
  Anxiety Depression PTSD PTG
  M (SD) F M (SD) F M (SD) F M (SD) F
Age   3.04*   0.01   1.11   3.69*
26-40 5.06 (4.48)   6.53 (5.05)   12.73 (9.73)   53.74 (25.67)  
41-60 5.09 (4.21)   6.51 (4.50)   12.24 (8.43)   47.94 (22.61)  
61-73 3.78 (4.00)   6.43 (4.89)   10.83 (8.70)   45.52 (20.05)  
Social stimulation   4.64***   2.63*   4.77***   1.73
Divorce 3.77 (2.98)   7.09 (5.47)   13.82 (9.35)   61.60 (30.48)  
Work / Study pressure 5.53 (4.46)   6.77 (4.60)   13.37 (9.16)   51.29 (23.79)  
Spouse death 5.16 (4.16)   9.45 (7.30)   17.09 (13.71)   52.89 (16.88)  
Family members’ health 7.12 (4.84)   7.95 (5.18)   15.93 (8.84)   49.63 (22.18)  
Marital Problems 5.65 (4.10)   7.16 (5.40)   12.21 (7.61)   56.48 (25.36)  
No 4.39 (3.95)   6.05 (4.62)   10.89 (8.09)   47.10 (22.52)  

Discussion

The current study aimed to investigate and analyses mental health for those who had been diagnosed with breast cancer. The incidence of anxiety and depression was 13.53% and 21.5% in breast cancer patients, which consist of previous research 8, 9, 10. Anxiety is a response to future stimuli, which is a strong, uncertainty, and excessive fear. Being diagnosed with breast cancer and undergoing various treatments are a series of unpleasant and negative stimuli to the patient. Under such stimuli, the patient will experience anxiety symptoms accordingly. What’s more, patients are often afraid of cancer recurrence even after the treatment. These persistent fears will stimulate anxiety among breast cancer patients also. Anxiety often coexists with depressive symptoms 26. Cognitive evaluation theory pointed out that when individuals are in a stressful environment for a long period, they will produce inconsistent assumptions and coping styles with the outside world 27. They may adopt negative cognitive methods, which to trigger depression. The treatment of breast cancer patients is a long-term process, and patients will continue to be stimulated by this source of stress. Breast cancer patients would catch in the whirlpool of negative emotions and produce depression in this long process of recovery.

The results showed that the incidence of PTSD was 7.15% in patients with breast cancer, which supported the previous studies 5, 28. Kangas et al. (2002) summarized 10 evaluations of the incidence of PTSD in breast cancer patients and found that the incidence of PTSD in patients was between 5% and 10% 29. Patients with breast cancer require the care of caregivers during a treatment process. The interactions with caregivers to help relieve their fears and obtain a lot of social support, which can alleviate the symptoms of PTSD 30, 31. On the other hand, the results of the study showed that the incidence of PTG reached 21.5%, and the number of breast cancer patients who had a positive psychological change after a traumatic stress event was relatively small. This is partly inconsistent with some previous findings, which may due to the time of this study that the patient who had just undergone surgery 32. Danhauer et al. (2015) extended the time range of previous studies and found an average change in the PTG of a breast cancer patient over time: the mean score increased within the first 18 months of diagnosis and subsequently tended to plateau 33. The current study was performed postoperatively, and patients may not have enough time to meaning searching and changed positively so that PTG levels may be lower.

This current study concluded that the anxiety scores of breast cancer patients are significantly different in ages. Anxiety levels of younger patients were significantly higher than those older patients. Younger breast cancer patients are faced with more unknown problems, such as fertility and marital crisis than older patients 34. The fear of possible future events is the source of anxiety 35, 36. At the same time, the cognitive development of young breast cancer patients is still unstable and vulnerable to external influences 37, 38. So they are more prone to posttraumatic cognitive changes caused by the disease than older patients, thereby helping them to generate more PTG 39, 40, 41. Negative psychological health status, including anxiety, depression, and PTSD were all significantly associated with social stimulations. What’s more, Post hoc tests found that the influence of changes in Family members’ health was significantly higher than other stimulations. This result reflected the characteristics of breast cancer patients themselves and indicated that the diagnosed with breast cancer is a deep damage to the individual's mental health.

The above conclusions enlighten that clinical staff need to provide different nursing plans for patients in different ages. For example, young breast cancer patients may need more proposals to release anxiety; older breast cancer patients may need more attention to their traumatic recovery. However, several design and measurement limitations must be acknowledged. This study is a cross-sectional study design and cannot clearly depict the trends of mental health in before-surgery after-surgery, chemotherapy, and recovery stage. Follow-up studies should focus on trajectories of mental health during long-term treatment, which based on a combination of longitudinal and cross-sectional studies. This study used only quantitative methods and did not describe the patient's mental health from an individual perspective. Future studies can be either qualitative or mixed studies 42. What’s more, the overall level and incidence are naturally different due to different research tools were used. China does not have a unified normative norm at present. Future researchers can use more advanced research methods which considered medicine 42, 43 to refine the research process, to fully investigate the symptoms of breast cancer in China and more realistically and specifically understand the status of breast cancer patients.

Conclusion

The current study investigated the mental health status of breast cancer patients. In addition, we explored the influence of factors such as age and social stimulations on their mental health states. Results suggest that 13.53% breast cancer patients had anxiety; 21.5% had depression; the prevalence of PTSD was 7.15%, while the prevalence of PTG was 26.12%. What’s more, the results suggested that anxiety scores and PTG level were significantly different in ages. Thus the medical staff shall provide differential nursing plans for differential age patients.

Acknowledgments

We gratefully thank the researchers of the Center of Trauma and Mindfulness Research and clinical staff at the Galactophore Dept, Jiangsu Province Hospital for their assistance and support.

References

  1. 1.Laudisio D, Muscogiuri G, Barrea L, Savastano S, Colao A.(March27,2018) Obesity and breast cancer in premenopausal women: current evidence and future perspectives. doi: 10.1016/j.ejogrb.2018.03.050. , European Journal of Obstetrics & Gynecology and Reproductive Biology
  1. 2.Fan L, Strasser-Weippl K, Li J J, D M Finkelstein, K D Yu. (2014) Breast cancer in China. , The Lancet Oncology; 15, 279-289.
  1. 3.R L Siegel, K D Miller, Jemal A. (2018) Cancer statistics,2018. , CA: A Cancer Journal for Clinicians; 68, 7-30.
  1. 4.American Psychiatric Association. (2013) . The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5) , Washington, DC:AmericanPsychiatricPublishing .
  1. 5.Arnaboldi P, Riva S, Crico C, Pravettoni G. (2017) A systematic literature review exploring the prevalence of post-traumatic stress disorder and the role played by stress and traumatic stress in breast cancer diagnosis and trajectory. , Breast cancer: Targets and Therapy;. 9, 473-485.
  1. 6.G A Bonanno, Galea S, Bucciarelli A, Vlahov D. (2006) Psychological resilience after disaster:NewYorkCity in the aftermath of the September 11th terrorist attack. , Psychological Science; 17, 181-186.
  1. 7.S B Thompson, Eccleston L, Tamas H. (2011) Post-traumatic stress disorder in cancer survivors: recognising and acknowledging the symptoms. , WebmedCentral; 2, 1-16.
  1. 8.J R Fann, A M Thomasrich, W J Katon, Cowley D, Pepping M. (2008) Major depression after breast cancer: a review of epidemiology and treatment. , General Hospital Psychiatry; 30, 112-126.
  1. 9.Saboonchi F, L M Petersson, Wennmanlarsen A, Alexanderson K, Brännström R. (2014) Changes in caseness of anxiety and depression in breast cancer patients during the first year following surgery: patterns of transiency and severity of the distress response. , European Journal of Oncology Nursing; 18, 598-604.
  1. 10.D P Stark, House A. (2000) Anxiety in cancer patients. , British Journal of Cancer; 83, 1261-1267.
  1. 11.Burgess C, Cornelius V, Love S, Graham J, Richards M. (2005) Depression and anxiety in women with early breast cancer: five year observational cohort study. , The British Medical Journal; 330, 702-705.
  1. 12.Bellur Z, Aydın A, E H Alpay. (2018) Mediating role of coping styles in personal, environmental and event related factors and posttraumatic growth relationships in women with breast cancer. , Klinik Psikiyatri Dergisi; 21, 38-51.
  1. 13.An Y, Ding X, Fu F. (2017) Personality and post-traumatic growth of adolescents 42 months after the Wenchuan earthquake: A mediated model. , Frontiers in Psychology; 8, 2152.
  1. 14.Manne S, Ostroff J, Winkel G, Goldstein L, Fox K. (2004) Posttraumatic growth after breast cancer: patient, partner, and couple perspectives. , Psychosomatic Medicine; 66, 442-454.
  1. 15.Wu L, Cui J. (2011) A review of studies on depression in breast cancer. , Chinese Medicine Modern Distance Education oh China; 9, 154-155.
  1. 16.Zhou X, Wu X, An Y, Chen J, S O Psychology. (2014) The roles of rumination and social support in the associations between core belief challenge and post-traumatic growth among adolescent survivors after the Wenchuan earthquake. , Acta Psychologica Sinica; 46, 1509-1520.
  1. 17.E B Foa, K M Johnson, N C Feeny, K R Treadwell. (2001) The Child PTSD symptom scale: A preliminary examination of its psychometric properties. , Journal of Clinical Child Psychology; 30, 376-384.
  1. 18.R G Tedeschi, L G Calhoun. (1996) The posttraumatic growth inventory: Measuring the positive legacy of trauma. , Journal of Traumatic Stress; 9, 455-471.
  1. 19.Kroenke K, R L Spitzer, J B Williams. (2010) The phq-9: validity of a brief depression severity measure. , Journal of General Internal Medicine; 16, 606-613.
  1. 20.Yeung A, Fung F, S C Yu, Vorono S, Ly M. (2008) Validation of the patient health questionnaire-9 for depression screening among Chinese Americans. , Comprehensiv Psychiatry; 49, 211-217.
  1. 21.He X, Li C, Qian J, Cui H, Wu W. (2010) Reliability and validity of a generalized anxiety disorder scale in general hospital outpatient. , Shanghai Archives of Psychiatry; 22, 200-203.
  1. 22.R L Spitzer, Kroenke K, J B Williams, Löwe B. (2006) A brief measure for assessing generalized anxiety disorder: the GAD-7. , Archives of Internal Medicine; 166, 1092-1097.
  1. 23.P M, S B Mackenzie, J Y Lee, N P Podsakoff. (2003) Common method biases in behavioral research: a critical review of the literature and recommended remedies. , Journal of Applied Psychology; 55, 879-903.
  1. 24.Tang C S K. (2006) Positive and negative postdisaster psychological adjustment among adult survivors of the Southeast Asian earthquake–tsunami. , Journal of Psychosomatic Research; 61, 699-705.
  1. 25.Xu J, Liao Q. (2011) Prevalence and predictors of posttraumatic growth among adult survivors one year following 2008 Sichuan earthquake. , Journal of Affective Disorders; 133, 274-280.
  1. 26.Song Y, Lindquist R. (2015) Effects of mindfulness-based stress reduction on depression, anxiety, stress and mindfulness in Korean nursing students. , Nurse Education Today; 35, 86-90.
  1. 27.A D Williams, Moulds M L. (2008) Negative appraisals and cognitive avoidance of intrusive memories in depression: a replication and extension. , Depression and Anxiety; 25, 26-33.
  1. 28.Wu X, Wang J, Cofie R, A C Kaminga, Liu A. (2016) Prevalence of posttraumatic stress disorder among breast cancer patients: a meta-analysis. , Iranian Journal of Public Health; 45, 1533-1544.
  1. 29.Kangas M, J L Henry, R A Bryant. (2002) Posttraumatic stress disorder following cancer: A conceptual and empirical review. , Clinical Psychology Review; 22, 499-524.
  1. 30.An Y, Wu X, Liu C, Lin C. (2013) Neuroticism personality and posttraumatic growth in adolescent: The moderating effect of coping style and mediating effect of social support. , Psychological Development and Education; 29, 657-663.
  1. 31.Scarpa A, S C Haden, Hurley J. (2006) Community violence victimization and symptoms of posttraumatic stress disorder: The moderating effects of coping and social support. , Journal of Interpersonal Violence; 21, 446-469.
  1. 32.M J Cordova, Giese-Davis J, Golant M, Kronenwetter C, Chang V. (2007) Breast cancer as trauma: Posttraumatic stress and posttraumatic growth. , Journal of Clinical Psychology in Medical Settings; 14, 308-319.
  1. 33.S C Danhauer, Russell G, L D Case, Sohl S J, R G Tedeschi. (2015) Trajectories of posttraumatic growth and associated characteristics in women with breast cancer. , Annals of Behavioral Medicine; 49, 650-659.
  1. 34.Yang L, Yu X. (2009) Advanced research of psychological status and related factors in breast cancer patients. , Contemporary Medicine; 15, 14-16.
  1. 35.C F Jehn, Flath B, Strux A, Krebs M, Possinger K. (2012) Influence of age, performance status, cancer activity, and IL-6 on anxiety and depression in patients with metastatic breast cancer. , Breast Cancer Research and Treatment; 136, 789-794.
  1. 36.V B Sheppard, Harper F W K, Davis K, Hirpa F, Makambi K. (2014) The importance of contextual factors and age in association with anxiety and depression in black breast cancer patients. , Psycho-Oncology; 23, 143-150.
  1. 37.Xu W, An Y, Ding X, Yuan G, Zhuang Y et al. (2017) Dispositional mindfulness, negative posttraumatic beliefs, and academic burnout among adolescents following the 2016 Yancheng tornado. , Personality and Individual Differences; 116, 405-409.
  1. 38.Yu M, Xu W, Xie Q, Zhu Y, G S Chasson. (2017) Automatic thoughts as a predictor of internalizing and externalizing problems in Chinese adolescents: a test of the cognitive content‐specificity hypothesis with age effects. , Scandinavian Journal of Psychology; 58, 351-358.
  1. 39.Fu Z, Xu W. (2017) Relationship between trauma-related psychotic reactions and Post-traumatic stress symptoms: the mediating role of alcohol use. , International Journal of Psychotherapy Practice and Research; 1, 45-51.
  1. 40.Kolokotroni P, Anagnostopoulos F, Tsikkinis A. (2014) Psychosocial factors related to posttraumatic growth in breast cancer survivors: a review. , Women and Health; 54, 569-592.
  1. 41.Xu W, Fu G, An Y, Yuan G, Ding X. (2018) Mindfulness, posttraumatic stress symptoms, depression, and social functioning impairment in Chinese adolescents following a tornado: Mediation of posttraumatic cognitive change. , Psychiatry Research; 259, 345-349.
  1. 42.Kar P, Li S, Narasimhan H, Chawla S, Sebastiani F.(August,2016) Online Optimization Methods for the Quantification Problem. In Proceedings of the 22nd ACM SIGKDD International Conference on Knowledge Discovery and Data Mining , San Francisco, USA 1625-1634.
  1. 43.Li S, Hao F, Li M, H C Kim.(May,2013) Medicine Rating Prediction and Recommendation in Mobile Social Networks. In International Conference on Grid and Pervasive Computing , Berlin, Germany 216-223.
  1. 44.Li S. (2016) The art of clustering bandits. Ph.D. thesis, Università degli Studi dell'Insubria .