|Ahead of print publication
Self-esteem, metacognition, and coping strategies in cancer patients: A case–control study
Habibe Inci1, Fatih Inci2, Süleyman Ersoy3, Fatih Karatas2, Didem Adahan1
1 Department of Family Medicine, Karabuk University, Karabuk, Turkey
2 Department of Medical Oncology, Faculty of Medicine, Karabuk University, Karabuk, Turkey
3 Department of Family Medicine, Ümraniye Education and Research Hospital, Istanbul, Turkey
|Date of Submission||18-Aug-2019|
|Date of Decision||09-Oct-2019|
|Date of Acceptance||30-Dec-2019|
|Date of Web Publication||22-Oct-2020|
Department of Medical Oncology, Faculty of Medicine, Karabuk University, Karabuk
Source of Support: None, Conflict of Interest: None
Background: Self-esteem refers to a person's positive and negative attitudes towards the self, and metacognition is an upper system providing awareness and direction of events and mental functions. Coping refers to the specific and psychological efforts used to deal with stressful events or the negative effects of the agents of these. The aim of this study was to evaluate self-esteem, metacognition status and coping attitudes in patients with cancer, which is known to have severely destructive psychological effects. Materials and Methods: Fifty adult cancer patients who were followed up in the medical oncology clinic between July 2018 and June 2019 and 50 age- and gender-matched healthy controls as control group were included in this study. All the participants were applied with a sociodemographic data form, the Rosenberg self-esteem scale, the Metacognition Assessment Scale, and the Copying Orientation to Problems Experienced (COPE) inventory, and their results were compared between the groups. Results: The groups comprised 50% females with a median age of 58 (33–82) years. The values related to the degree of participation in discussions, problem-focused coping, active coping, planning, and state of emotional vulnerability were low in the cancer patient group compared to the control group (P < 0.005 for all). The sustaining of their self-image, feeling threatened in interpersonal relationships, and degree of daydreaming were higher, and in the metacognition tests, the positive beliefs related to anxiety, uncontrolled or dangerous negative thoughts, nonfunctional coping, religious coping, joking, reckless behavior, substance use, denial, and mental disengagement scores were higher (P < 0.05 for all). Conclusion: Self-esteem was lower in cancer patients and upper level cognitive functions and problem-focused coping were determined to be worse compared to healthy controls. In the light of these results, psychosocial support given to cancer patients in this respect could contribute to quality of life and social conformity.
Keywords: Cancer, coping, metacognition, self-esteem, stress
| > Introduction|| |
As one of the most important health problems throughout the world, cancer is a chronic, psychosocially destructive disease, which causes pain, reminding the patient of death, and creates feelings of guilt and anxiety, panic, and confusion. The primary sources of stress for cancer patients are the knowledge that death could occur very soon, and the side-effects and the possibility of failure of the majority of known treatment methods., Just as behavioral factors have a role in the formation of cancer, psychiatric complications can develop in cancer patients because of various neurophysiological and perceived psychological effects. Starting from the stage of diagnosis, many different emotional and behavioral reactions can emerge at all stages of treatment in a cancer patient.
Cancer is perceived as destruction with thoughts of fear, hopelessness, guilt, desperation and abandonment and causes a crisis in the psychological balance of the individual. The psychological reactions and psychosocial environment of the patient experienced at all stages of the disease have been reported to affect patient compliance and the course of the treatment.,
Self-esteem is the positive or negative attitude of an individual to themself or the degree to which they perceive themselves as adequate, reliable and important. The concept of metacognition can be defined as upper level cognitive structure, information and processes, which control, organizes, and evaluate cognition. Metacognition is an upper system that includes awareness of events and functions in the mind, directing mental events and functions, in other words, an individual knowing what he knows, thinking what he thinks, and recognizing his own cognitive process. Coping attitudes include the specific and psychological efforts used to deal with stressful events or the negative effects of the agents of these.
Several studies have shown that when the self-esteem of cancer patients is reduced, the self-esteem points are lower than those accepted for the average individual., Upper cognitive functions can be seen to be deteriorated in cancer patients. Depression at a clinical level can develop because of the sadness felt at the loss of physical health over time and concerns related to death. Individuals experiencing stress such as life-threatening cancer and who have experienced mental problems may not be able to cope with new situations and therefore have difficulties in starting an adaptation process. This can indirectly affect treatment compliance and continuity after diagnosis and can result in a shorter survival period because of poor quality of life and possibly treatment non-compliance.
The aim of this study was to evaluate the self-esteem, metacognition and coping attitudes of cancer patients in comparison with a control group.
| > Materials and Methods|| |
This cross-sectional, case-control study included 50 adult cancer patients who were being treated and followed up in the Medical Oncology Clinic of Karabuk University Faculty of Medicine Training and Research Hospital between July 2017 and June 2019. A control group was formed of 50 age and gender-matched adults who presented at the Family Medicine Polyclinic for any reason, who had no chronic or psychiatric disease and no diagnosis of cancer. All the participants in both groups were evaluated with a data collection form in respect of age, gender, marital status, educational level, occupation, psychiatric history, and chronic disease history.
All the participants were administered the Rosenberg self-esteem scale (RSES), the Metacognition Assessment Scale (MAS), and the Coping Orientation to Problems Experienced (COPE). Written informed consent was obtained from all the participants. The RSES, developed by Rosenberg in 1965, is a scale consisting of 63 items in 12 subscales. The first 6 of these subscales comprise 10 items in each and measure self-esteem. Each item is answered with a Likert-type response of “absolutely agree,” “agree,” “disagree,” or “absolutely disagree.” Of the 10 items scored in each subscale, items 1, 2, 4, 6, and 7, are scored as 3: Absolutely agree, 2: agree, 1, disagree, and 0: Absolutely disagree, and items 3, 5, 8, 9, and 10 are scored in reverse. The total scale points can range from 0 to 30 with the maximum 30 points accepted as self-esteem.
The MAS was developed by Cartwright-Hatton and Wells in 1997, and then in 2004, it was modified by the same researchers to create a 30-item short form, the MAS-30. Each item in the MAS-30 is answered with 4-point Likert-type responses from 1 = absolutely disagree, to 4 = absolutely agree. The total points can range from 30 to 120, with higher points indicating an increase in metacognitive activities. The 30 items of the MAS-30 are distributed among 5 factors and this distribution is identical to the long form. The first factor of positive beliefs is formed of items 1, 7, 10, 20, 23 and 28, and includes positive beliefs about worry, related to planning or helping to solve the problem. At the same time, according to this factor, worry is a desirable personal characteristic. The second factor of uncontrollability and danger includes items 6, 13, 15, 21, 25, and 27 and is formed of two dimensions. The first is the belief that “it is necessary to control worries for a person to function and to remain safe”. The other is the belief that worry cannot be controlled. The third factor of cognitive trust includes items 8, 14, 18, 24, 26, and 29, and is related to the individual not trusting their own memory and attention capabilities. The fourth factor of the need for control includes items 2, 4, 9, 11, 16, and 22, and relates to the need to control negative beliefs, including superstition, punishment and themes of responsibility. These beliefs are related to the view that as they cannot be controlled by the individual, the person will be responsible and punished for the harmful outcomes that will emerge. The fifth factor of cognitive awareness is formed of items 3, 5, 12, 17, 19 and 30, and refers to the constant involvement of a person with their own thought processes. The MAS-30 has been adapted to Turkish and validity and reliability studies have been conducted.
The COPE scale was developed by Carver et al. to determine the coping strategies used in stressful situations. The validity and reliability analysis of the Turkish form was performed by Agargün et al. It consists of 60 items in 15 subscales answered with 4-point Likert-type responses: 1 = I never do that, 2 = I occasionally do that, 3 = I do that to a moderate degree, 4 = I usually do that. Each subscale is formed of 4 items, and each subscale provides information about a separate coping attitude. The total points for each subscale can range from 4 to 16 points. The total points of the first 5 of the subscales are the problem-focussed coping points, the total points of subscales 6–10 are the emotion-focused coping points, and the total points of the final five subscales are the non-functional coping points. Higher points obtained in any of these subscales show which coping attitude the individual uses more. These 15 coping attitudes or subscales are: Problem-focused coping (1: Active coping, 2: Stalling, 3: Planning, 4: Using beneficial social support, 5: Suppressing other activities, emotion-focused coping, 6: Positive re-interpretation and development, 7: Religious coping, 8: Joking, 9: using emotional social support, 10: Acceptance, and non-functional coping, 11: Cognitive disengagement, 12: Substance use, 13: Denial, 14: Mental disengagement, and 15: Focusing on the problem and showing emotion).
Data obtained in the study were analyzed statistically using IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. In the comparisons between groups, the Student's t-test was used for data showing normal distribution, and the Mann–Whitney U-test for nonparametric data. Categorical paired data were compared using the Chi-square test. P < 0.05 was accepted as statistically significant. Approval for the study was granted by the Non-Interventional Clinical Research Ethics Committee of Karabuk University with decision number 2/31, February 7, 2018.
| > Results|| |
Evaluation was made of 50 adult cancer patients (gastric, colon, cervical, rectum, breast, liver, ovarian, and nasopharyngeal cancers) and 50 age- and gender-matched controls with no cancer diagnosis and no chronic or psychiatric disease. The sociodemographic data of all the participants are presented in [Table 1].
The patients and control group comprised 50% males and 50% females with a median age of 58 (33–82) years, and the majority (94%) were married. The educational level and professional status were significantly lower in the cancer patient group than in the control group (P < 0.001). The rate of psychiatric disease diagnosis in the cancer patient group was low (12%). The sociodemographic features of all participants shown in the [Table 1].
In the evaluation of the groups according to the RSES, the degree of participation in discussions of the patients group was significantly low, and the rates of maintenance of the concept of the self, feeling threatened in interpersonal relationships, and daydreaming were significantly high (P < 0.05). In both groups, the values related to self-esteem, sensitivity to criticism, and parental interest were high, and the degree of psychological isolation and relationship with their father were determined to be low. No statistically significant difference was determined between the groups in respect of trust in other people, psychosomatic symptoms, and depressive feelings [Table 2].
In the MAS evaluation, the mean points of the positive beliefs related to worry and of the negative beliefs related to uncontrollability and danger were determined to be significantly higher in the patient group than in the control group (P < 0.05). No difference was determined between the groups in respect of total points and the points related to cognitive reliability, the need to control thoughts, and cognitive self-awareness [Table 3]. According to the COPE evaluation, no difference was determined between the groups in respect of problem-focused coping and total points, and the problem-focused, non-functional coping points were determined to be lower in the patient group than in the control group (P < 0.05) [Table 4].
In the comparisons of the groups according to the COPE subscales, no statistically significant difference was determined in respect of stalling, using beneficial social support and suppressing other activities, emotion-focused coping, positive re-interpretation and development, using emotional social support, acceptance and the total points (COPE-T). However, the points of problem-focused coping, active coping, planning, focusing on the problem, and showing emotion were lower in the patient group than in the control group and the points for religious coping, joking, functional-focused coping, cognitive disengagement, substance use, denial, and mental disengagement were found to be statistically significantly higher (P < 0.05) [Table 5].
| > Discussion|| |
Cancer is the one of the most important health problems worldwide. Many different emotional and behavioral reactions can be seen in cancer patients from the time of diagnosis, throughout treatment and in the subsequent period. A study has reported that psychiatric disorders are seen in approximately half of all cancer patients; the most frequently seen disorder is depression. Watson et al. determined mental disorders in cancer patients at the rates of 29%–47%. In the current study, the rate of diagnosis of psychiatric disease in cancer patients was low. This could be attributed to the patients not yet being at the terminal stage of the disease, that they were followed up in the polyclinic and were patients who were continuing treatment with a psychological status not deteriorated to an advanced degree that could be diagnosed as psychiatric disease. In the period of advanced disease, this rate can be seen to be higher. In a study by Cook et al., it was determined that while the anxiety and trauma symptoms seen after diagnosis regressed in the long-term evaluations, the depressive symptoms increased significantly.
In both groups of the current study, while self-esteem, the degree of sensitivity to criticism, and parental interest were high, the degree of psychological isolation and the relationship with their father were determined to be low. No statistically significant difference was determined between the groups in respect of feeling safe, psychosomatic symptoms, and depressive emotions. However, it was determined that cancer patients did not participate in discussions, the concept of self was high, and they felt threatened in interpersonal relationships and were daydreamers. Previous studies in literature have generally been conducted on patients with various cancer types, and to the best of our knowledge, there has been no comparative study with a healthy control group. Denizgil and Sönmez examined the effect of the type of surgical operation applied to women with a diagnosis of breast cancer on body perception, self-esteem, sexual satisfaction and experiences, and no difference was observed in self-esteeem. Wakimizuet al. reported that the mean self-esteem points of cancer patients were below the level accepted for a normal healthy person, and these patients experienced more intense depressive emotions compared to interpersonal sensitivity and anxiety. In a study by Al-Ghazal et al., the effects of cosmetic results on mental and social areas were examined in patients treated for primary breast cancer, and in the patient group with good cosmetic results from the operations applied, a significant relationship was observed between cosmetic results and anxiety, depression, body perception, self-esteem and sexuality. In patients treated for gynaecological cancers, Üstündaǧ et al. determined increased anxiety and depression symptoms, distorted body perception, and decreased self-esteem. In another study of women with breast cancer in Spain, self-esteem was low in 39% of the patients, and self-esteem was reported to be related to general, social and sexual quality of life. In the same study, a strong negative correlation was determined between self-esteem and depression.
In the current study, depression, anxiety and other psychiatric problems were not investigated, but the number of patients with a psychiatric diagnosis was found to be extremely low. According to the results of this study, the nonparticipation of cancer patients in discussions, and decrease in connections with the external world could be associated with the high concept of self, and tendency to turn towards their own internal world. Feeling threatened in interpersonal relationships may be the result of a tendency to feel that they could be harmed by society, and daydreaming shows that they still dream of things they could not do before the cancer.
In the evaluation of metacognition in this study, it was seen that the cancer patients were worried, and felt out of control and in danger. As a result of increasing loss of health, cancer patients can feel that they have lost control and are in danger. Cancer diagnosis and treatment is a stressful life event, and how the patient perceives this situation and how they cope with it are two important concepts. Managing, regulating, and controlling emotional responses and the coping strategies (the process of regulating emotions) have an effect on the biological and psychological well-being of the patient and on patient compliance. Cognitions play a critical role in the determination of human emotions, and are functional in the processes of identifying, regulating and controlling emotions. Several studies have shown a positive correlation between anxiety and depression and disrupted metacognitive beliefs.,,
In a study evaluating the relationship between anxiety and depression and metacognitions in cancer patients, Cook et al. reported that negative beliefs related to worry and cognitive reliability were independent predictive factors for anxiety and depression in the patients and a strong relationship was shown between anxiety and the subscale of negative beliefs related to uncontrollability and danger. The researchers suggested that correcting the metacognitive beliefs could change the problems associated with cancer. In a study by Thewes et al. of women with breast cancer, a significant relationship was determined between a negative metacognition status and a high fear of recurrence. When compared with the healthy control group in the current study, the mean points of positive beliefs related to worry and negative beliefs related to uncontrollability and danger of the cancer patients were determined to be significantly high.
Previous studies of cancer patients have shown that strategies that catastrophize and self-blame are negative when coping with the disease, whereas acceptance, positive refocusing and re-evaluation strategies have positive effects when coping with disease. Starting with the relationship between metacognitions and negative emotions, studies on this subject have reported that psychological interventions based on a metacognition approach could have positive effects on cancer patients.,
In the current study, it was determined that cancer patients coping with stress did not use problem-focused coping strategies, did not actively cope and did not plan. The cancer patients in this study were found to use strategies of religious coping, joking, function-focused coping, behavioral disengagement, substance use, denial, and mental disengagement. When cancer patients are faced with stress, they may not be able to find the strength within themselves to cope actively with problems because of the short survival time, cannot make plans for the future and thus cannot apply problem-focused coping. As a result of the severity of the disease and the short survival time, cancer patients may attempt to cope with stress by strengthening themselves religiously. Thus as a result of having a serious disease, they may joke about the less important and detailed events in life, may be in denial from time to time to forget about the disease and may show an increase in substance use. Individuals with a history of mental problems who encounter life-threatening stress such as cancer may find themselves unable to cope with the new situation and may experience difficulties in starting an adaptation process.
Five basic characteristics have emerged in the context of a coping strategy for cancer. These are the process of changing thoughts, the process of increasing and preserving belief, the interaction process, the acquisition of knowledge and skills process and the control process. In a study, which evaluated depression, anxiety and coping attitudes in cancer patients, a positive correlation was determined between the dysfunctional coping attitudes of focusing on the problem, showing emotions and behavioral disengagement and levels of depression and anxiety. From these results, the researchers suggested that as anxiety and depression increased, the patient maintained a destructive attitude to the functionality of their life, which was interpreted as the patient distancing themself from societal life as anxiety increased. Avci and Dogan showed that cancer patients were at risk of post-traumatic stress disorder and social support and coping strategies for stress were effective for the compliance and coping of cancer patients.
| > Conclusion|| |
The results of this study showed that the self-esteem of cancer patients is low, and metacognitive functions and problem-focused coping are impaired. If many paths are taken in the treatment of the cancer disease, there will be greater psychological effects. These results demonstrate the importance of detailed psychological and cognitive evaluation and the implementation of a biopsychosocial approach in addition to medical treatment for cancer patients from the time of diagnosis onward.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]