Relationships among Perceived Stress Management Skills and Sleep, Pain, and Mood in Women with Suspected Gynecologic Cancers

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Title:
Relationships among Perceived Stress Management Skills and Sleep, Pain, and Mood in Women with Suspected Gynecologic Cancers
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english
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Postupack, Rachel A
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Degree:
Master's ( M.S.)
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University of Florida
Degree Disciplines:
Psychology, Clinical and Health Psychology
Committee Chair:
Pereira, Deidre B
Committee Members:
Mccrae, Christina Smith
Boggs, Stephen R
Dotson, Vonetta M

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Subjects / Keywords:
cancer -- resilience -- stress -- women
Clinical and Health Psychology -- Dissertations, Academic -- UF
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Psychology thesis, M.S.
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theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
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Abstract:
Research on psychological resilience in adaptation to highly disruptive events, including cancer, has focused on a variety of individual psychosocial factors and less on perceived stress management skills (PSMS).  Results of improved psychosocial and health outcomes from Cognitive Behavioral Stress Management interventions (CBSM) in health populations are partially due to changes in perceptions of stress management ability. The current study examined the relationships between PSMS and (a) sleep quality, (b) pain disability, and (c)mood symptoms amongst women with suspected gynecologic cancer.  Participants were 25 women (M age = 58.4 yrs, SD = 11.8) who completed measures of perceived stress management skills (MOCS: Measure of Current Status), sleep quality (PSQI: Pittsburgh Sleep Quality Index), pain disability (PDI: Pain Disability Index), depression (BDI-II: Beck Depression Inventory), and anxiety (STAI: State-Trait Anxiety Inventory) during the pre-operative period.  Bivariate Pearson correlations revealed no significant relationship between PSMS and sleep disturbance (r = .12, p = 0.57), pain disability (r = -.184, p = 0.39) or depression (r =-.036, p = 0.87).  A marginally significant negative correlation with a moderate effect size was found between PSMS and state anxiety (r = - .342, p = 0.10) and a significant correlation with a large effect size emerged between PSMS and trait anxiety (r= - .617, p = 0.10).  After controlling for relevant demographic variables, PSMS remained a significant independent predictor of trait anxiety(ß = -.502, p = 0.009).  Despite the small sample size, the moderate to large effect sizes for the relationships between anxiety and PSMS findings suggest that while anxiety is a common experience in the pre-operative period,women with lower PSMS may be especially vulnerable to elevated trait anxiety.  Patients with low PSMS may experience greater benefit from CBSM interventions which target the augmentation of PSMSskills.  Future research should attempt to replicate these relationships in a larger sample, while evaluating the stability and impact of PSMS on psychosocial and health outcomes throughout the peri-operative period.
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In the series University of Florida Digital Collections.
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Includes vita.
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Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Rachel A Postupack.
Thesis:
Thesis (M.S.)--University of Florida, 2013.
Local:
Adviser: Pereira, Deidre B.
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RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-05-31

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1 RELATIONSHIPS AMONG PERCEI VED STRESS MANAGEMENT SKILLS AND SLEEP, PAIN, AND MOOD IN WOMEN WITH SUSPECTED GYNECOLOGIC CANCERS By RACHEL A. FOX POSTUPACK A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2013

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2 2013 Rachel A. Fox Postupack

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3 To my wonderful husband and family

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4 ACKNOWLEDGMENTS I would like to thank Deidre Pereira for her for her mentorship and guidance throughout this project. Her keen insight and enthusiasm continue to encourage my development as a scientist practitioner. I acknowledge the members of my supervisory committee, D r. Stephen Boggs, Dr. Christina, McCrae, and Dr. Vonetta Dotson. I would also like to thank my husband, family, and friends for their encouragement and support throughout my graduate school experience. Finally, I would like to thank the women who participated for their willingness to share their experiences and for making this project possible.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................. 4 LIST OF TABLES ............................................................................................................ 7 LIST OF FIGURES .......................................................................................................... 8 ABSTRACT ..................................................................................................................... 9 CHAPTER 1 INTRODUCTION .................................................................................................... 11 Epidemiology of Gynecologic Cancers ................................................................... 11 Impact of Cancer on Psychosocial Patient Centered Outcomes (PCOs) ................ 13 Sleep Quality Among Cancer Patients ............................................................. 13 Pain Among Cancer Patients ........................................................................... 16 Emotional Distress Among Cancer Patients ..................................................... 19 Resilience and Stress Management Skills in the Context of Cancer ....................... 21 Resilience and Cancer ..................................................................................... 21 Cognitive Behavioral Stress Management Skills and Intervention .................... 24 Current Study .......................................................................................................... 25 2 METHODS .............................................................................................................. 28 Design ..................................................................................................................... 28 Participants ............................................................................................................. 28 Procedures ............................................................................................................. 29 Psychosocial Assessment ...................................................................................... 30 Psychosocial Screening ................................................................................... 30 Sleep Quality .................................................................................................... 30 Perceived Stress Management Skills ............................................................... 31 Pain Disability ................................................................................................... 32 Mood ................................................................................................................ 32 Control Variables .............................................................................................. 33 Statistical Analyses ................................................................................................. 34 3 RESULTS ............................................................................................................... 36 Preliminary Analyses .............................................................................................. 36 Comparison to Parent Study Sample ............................................................... 36 Normality Assumptions ..................................................................................... 36 Descriptive Results ........................................................................................... 36 Associations among Control and Outcome Variables ....................................... 37 Participant Characteristics on Outcome Measures ........................................... 38

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6 Analyses of Specific Aims ....................................................................................... 38 Specific Aim 1: Relationships between PSMS and Sleep Quality .................... 38 Specific Aim 2: Relationships between PSMS and Pain Disability ................... 39 Specific Aim 3: Relationships between PSMS and Mood ................................. 39 4 DISCUSSION ......................................................................................................... 48 Study Limitations .................................................................................................... 50 Future Directions .................................................................................................... 51 APPENDIX A MEASURE OF CURRENT STATUS ....................................................................... 52 B PITTSBURG H SLEEP QUALITY INDEX ................................................................ 53 C PAIN DISABILITY INDEX ....................................................................................... 57 D STATETRAIT ANXIETY INVENTORY ................................................................... 59 E BECK DEPRESSION INVENTORY VERSION II ................................................. 61 LIST OF REFERENCES ............................................................................................... 66 BIOGRAPHICAL SKETCH ............................................................................................ 75

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7 LIST OF TABLES Table page 1 1 Prevalence of chronic insomnia comorbid with medical condition (Taylor et al., 2007) ............................................................................................................. 27 3 1 Comparison of categorical demographic variables for eligible study participants ......................................................................................................... 40 3 2 Comparison of continuous demographic variables ............................................. 41 3 3 Comparison of categorical demographic and disease variables ......................... 41 3 4 Characteristics of outcome measures ................................................................ 44 3 5 Correlations between PSMS and sleep quality ................................................... 44 3 6 Hierarchical regression controlling for demographic covariates between PSMS and pain disability .................................................................................... 45 3 7 Hierarchical regression controlling for demographic covariates between Awareness of Tension and Ability to Relax and pain disability ........................... 45 3 8 Correlations between PSMS and mood symptoms ............................................ 45 3 9 Hierarchical regression controlling for demographic covariates between PSMS and depressive symptoms ....................................................................... 46 3 10 Hierarchical regression controlling for demographic covariates between PSMS and Trait Anxiety ..................................................................................... 46

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8 LIST OF FIGURES Figure page 3 1 Relationship between PSMS and anxiety symptoms ( n = 25) ........................... 47

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9 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science RELATIONSHIPS AMONG PERC EI VED STRESS MANAGEMENT SKILLS AND SLEEP, PAIN, AND MOOD IN WOMEN WITH SUSPECTED GYNECOLOGIC CANCERS By Rachel A. Fox Postupack May 2013 Chair: Deidre B. Pereira Major: Psychology Research on psychological resilience in adaptation to highly disruptive events, including cancer, has focused on a variety of individual psychosocial factors and less on perceived stress management skills (PSMS). Results of improved psychosocial and health outcomes from Cognitive Behavioral St ress Management interventions (CBSM) in health populations are partially due to changes in perceptions of stress management ability. The current study examined the relationships between PSMS and (a) sleep quality, (b) pain disability, and (c) mood symptoms amongst women with suspected gynecologic cancer. Participants were 25 women ( M age = 58.4 yrs, SD = 11.8) who completed measures of perceived stress management skills (MOCS: Measure of Current Status), sleep quality (PSQI: Pittsburg h Sleep Quality Index) pain disability (PDI: Pain Disability Index), depression (BDI II : Beck Depression Inventory), and anxiety (STAI: State Trait Anxiety Inventory) during the pre operative period. Bivariate Pearson correlations revealed no significant relationship between PSMS and sleep disturbance ( r = .12, p = 0.57) pain disability ( r = .184, p = 0.39 ) or depression ( r = .036, p = 0.87) A marginally signi ficant negative correlation with a moderate effect size

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10 was found between PSMS and state anxiety ( r = .342 p = 0.10 ) and a significant correlation with a large effect size emerged between PSMS and trait anxiety ( r = .617, p = 0.10) After controlling for relevant demographic variables PSMS remained a .502 p = 0.009) Despite the small sample size, the moderate to large effect sizes for the relationships between anxiety and PSMS findings suggest that while anxiety is a common experience in the preoperative period, women with lower PSMS may be especially vulnerable to elevated trait anxiety Patients with low PSMS may experience greater benefit from CBSM interventions which target the augmentation of PSMS skills. Future research should attempt to replicate these relationships in a larger sample, while ev aluating the stability and impact of PSMS on psychosocial and health outcomes throughout the peri operative period.

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11 CHAPTER 1 INTRODUCTION Epidemiology of Gynecologic Cancers Gynecologic cancers originate in t he female reproductive organs and are differentiated into six main types : ovarian, fallopian tube, uterine or endometrial, cervical, vaginal, and vulvar. Approximately 71,500 women in the United States are diagnosed with a gynecologic cancer each year ( CDC, 2010 ) As of 2009, approximately 182,758 women in the United States had a history of ovarian cancer and 589,887 had a history of uterine cancer ( Howlander et al., 2012) The American Cancer Society estimated that in 2012 approximately 22,280 new cases of ovarian cancer and 47,130 cases of endometrial cancer would be diagnosed, while approximately 15,500 and 8 ,010 women would die of these diseases respectively ( ACS, 2012) In fact, among women both ovarian and endometrial cancers are ranked in the ten most commonly diagnosed cancers and the ten leading causes of cancer death making them a significant public health concern. These statistics suggest that gynecologic cancers are significant causes of both morbidity and mortality in women, and accordingly, represent a subs tantial public health burden. Therefore, the exploration of the influence of psychological factors on important health and quality of life related outcomes is an important adjunct to the standard medical care for women whose lives are affected by gynecologic cancers. Treatment of Ovarian and Endometrial Cancers Ovarian adenocarcinomas are mo re commonly diagnosed at an advanced stage and tend to have a poor prognosis due to risk for treatment resistance and recurrence / metastasis (spread of cancer to distant organs) within five years of diagnosis and initial

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12 treatment. In fact, less than 40% of women with ovarian cancer are cured ( Jemal, Siegel, Xu, & Ward, 2010) T reatment often requires both surgical debulking, or the removal of the affected organs and adjuvant chemotherapy even when diagnosed early According to the National Comprehens ive Cancer Network (NCCN) treatment guidelines only very early stage ovarian cancers (Stages I A/B; i.e., tumor is intact and confined to the ovaries ) may be observed following surgery without adjuvant therapy. However, once the lesion has ruptured (S tage IC ) the cancer may easily spread to the pelvic area (S tage II) or to surrounding/ distan t organs (S tages III / IV) adjuvant chemotherapy is the standard treatment ( NCCN, 2012a) Endometrial cancers are predominately adenocarcinomas and may have endometrioid, uterine papillary serous (UPS) clear cell, and/or mucinous histologic subtypes. Endometrioid adenocarcinoma, also referred to as Type I endometrial cancer, is the most common form of endometrial cancer. This subtype is often detected at an early stage and tends to have an excellent prognosis. At early stages, it can be treated primarily with bilateral salpingo oophorectomy (TAH BSO), or the surgical removal of the uterus, fallopian tubes, and ovaries ( ACS, 2012 ) Treatment guidelines published by the N CCN in 2012 recommend adjuvant vaginal brachytherapy or pelvic radi ation therapy for (a) women with early stage (Stage I ) endometrioid adenocarcinoma and comorbid adverse risk factors, and (b) women f or whom the cancer has spread from the uterus to the connective tissue (Stage II). Adjuvant c hemotherapy is recommended as the standard of care for advanced stage (Stages III IV) endometrioid adenocarcinomas ( NCCN, 2012b ) In contrast with endometrioid adenocarcinoma, UPS, clear cell, and mucinous adenocarcinomas tend to be detected at more advanced

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13 stages, are more resistant to treatment, recur more frequently, and have lower survival rate s. Referred to as the Type II endometrial c ancers they are commonly treated with TAH BSO followed by adjuvant therapy, such as chemotherapy and/ or radiation, even at early stages ( NCCN, 2012a ) Impact of Cancer on Psychosocial Patient Centered Outcomes (PCOs) Psychosocial PCOs associated with cancer and cancer treatment are experiences that are prevalent meaningful and clinically significant t o i ndividuals living with cancer ( Selby, Beal, & Frank, 2012) T hree of the most prevalent and clinically meaningful psychosocial PCOs in cancer are sleep quality, pain disability, and emotional well being; each of which are responsive to evidenced based psychosocial interventions. The prevalences, risk factors, and clinical significance of these PCOs in cancer are reviewed below. Sleep Quality A mong Cancer Patients Insomnia is defined by t he Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association [DSM IV TR], 2000) as difficulty initiating or maintaining sleep or nonrestorative sleep for a period of at least one month. Insomnia is a significant risk factor for a variety of health complications ; includ ing depression and anxiety disorders, alcohol/substance abuse/dependence, suicide, and immune dysregulation ( Taylor, Lichstein, & Durrence, 2003 ) Furthermore, s leep diary confirmed insomnia is commonly comorbid with a variety of chronic health conditions including cancer (Table 1 1 ; Taylor et al., 2007) It is worth noting that the assessment of insomnia and sleep difficulties varies widely within the literature. Research studi es of insomnia rely on self report data because insomnia is a subjective disorder. T he literature base supports a correlation between individuals with subjective sleep

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14 complaints and poorer health ( McCrae et al., 2005; Ohayon, 2002; Vitiello, Moe, & Prinz, 2002) A recent large cross sectional study of 11,445 patients with cancer were surveyed using the Patient Car e Monitor (PCM) a self report measure that surveys how problematic patients perceive different symptoms to be in daily life. Twenty six percent of patients reported that trouble sleeping was a moderate to severe problem ( Stepanski et al., 2009) Davidson and colleagues (2002) also observed that 30.5% of 982 cancer patients reported difficult y sleeping for at least 7 of the prior 28 nights and endorsed associated daytime dysfunction. Notably, 48.2% of those with sleep difficulties reported onset within the diagnostic and early survivorship phases (i.e., 6 months prediagnosis through 18 months post diagnosis ). Similarly, among women with breast cancer, 48% of 300 participants reported current sleep difficulties on the sleep impairment index (SII) 33% of which reported onset of these difficulties at the point of diagnosis ( Savard, Simard, Ivers, & Morin, 2005) In su mmary, while rates of insomnia in cancer vary by disease type and stage and treatment modality, ample evidence suggests that insomnia is frequently comorbid with cancer and the diagnostic/early survivorship phase of illness may be a frequent time of onset. Sleep difficulties have also been noted during and following cancer treatment. Studies that have focused on women with breast cancer during the active phase of adjuvant chemotherapy treatment compared to the rest period between cycles, demonstrated th at women report poorer overall sleep quality on sleepdiaries ( Kuo, Chiu, Liao, & Hwang, 2006 ) M ore symptoms of sleep disturbance were reported by women post treatment compared to pretreatment as measured by the Pittsburg h Sleep

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15 Quality Index ( PSQI ), a widely used screening measure for sleep difficulties ( Bower et al., 2011 ) In addition, sleep difficulties persist after the completion of treatment for 30% of cancer survivors, and this is 17% higher than the rates of insomnia reported by people with no history of cancer ( Mao et al., 2007) Although most of the research on sleep difficulties among women with cancer has been conducted in breast cancer, a handful of studies have been performed on sleep difficulties in gynecologic cancers. Of w omen with gynecologic cancers 29.4% of 180 women reported difficulty sleeping on at least 7 of the prior 28 nights and endorsed associated daytime dysfunction, while 22.8% indicated the use of sleep medication ( Davidson, 2002) Although Davidson and colleagues (2002) found lower rates of sleep difficulties in gynecologic cancer compared to breast cancer, Sandadi and colleagues (2011) reported that 6 7% of 86 w omen with ovarian, fallopian tube, or peritoneal cancer s, more specifically, had clinically significant sleep disturbance as assessed by the PSQI Furthermore, 43% of women with ovarian, fallopian tube, and peritoneal cance rs reported using sleep medications at least once in the prior month ( Sandadi et al., 2011 ) Th e higher prevalences of sleep disturbances in Sandadi and colleagues (2011) compared to Davidson and colleagues (2002) may be partially attributed to the fact that the former examined sleep in a homogeneous sample of women with the most aggressive and difficult to treat gynecologic malignancies, while the latter included women with various types and stages of gynecologic cancers Sleep difficulties reported by women with gy necologic cancers persist through treatment and into survivorship Christman and colleagues (2001) revealed that more than 50% of women with a gynecologic cancer who had received radiotherapy indicated difficulties falling

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16 asleep or waking multiple times at night dur ing weeks four and five of treatment using a self report symptom checklist The women in the post operative group reported a greater persistence of sleep disturbance symptoms at two weeks and one month after the completion of radiotherapy ( Christman, Oakley, & Cronin, 2001) Greimel et al. (2011 ) followed ovarian cancer pati ents health related quality of life from the pre operative period to 10 years post diagnosis using the EORTC QLQ C30, a widely used measure of health related quality of life in cancer in Europe. They discovered that, prior to surgery, insomnia was among the four most distressing sympt oms for patients ; furthermore, out of these four symptoms, only distress related to insomnia remained persistent ly high at one year post diagnosis. S leep difficulties are associated with poorer quality of life among individuals with cancer Across studies of women with cancer, sleep difficulties are associated with poorer physical functioning, emotional well being, stress tolerance, performance of daily activities, concentration, and social / functional well being ( Davidson, 2002; Enderlin et al., 2011; Sandadi et al., 2011) Notably, sleep difficulties may ( a) mediate the effect of depressed mood on fatigue and pain among individuals with cancer and (b) predict greater fatigue through its effects on higher pain (Stepaniski et al., 2009) As a whole, the research reveals an elevate d prevalence of insomnia among women with gynecologic cancers that persists post treatment and is associated with a diminished sense of well being. Pain A mong Cancer Patients Pain is one of the most common symptoms associated with cancer and unlike many individuals with chronic pain, patients with cancer require medical treatment that may create and intensify pain symptoms Previous research has documented high

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17 prevalence rates of acute and chronic pain among cancer patients that may be related to (a) di rect tumor involvement due to lesions and somatic visceral structures, (b) direct tumor involvement due to lesions of nervous tissue, (c) cancer treatments (e.g. surgical pain chemotherapy induced neuropathy, radiationinduced tissue necrosis/inflammation) and (d ) other/unknown causes ( Caraceni & Portenoy, 1999) A review of the literature on malignant diseases and pain symptoms by Svendensen et al. (2005) cited that a pproximately 30 40% of cancer patients report pain at the time of diagnosis; this figure rises to 50 70% during the course of treatment An even higher percentage, 70 80%, of i ndividuals with advanced stages of c ancer report pain symptoms ( Svendsen et al., 2005) Pain symptoms experienced by patients with cancer often fluctuate, consisting of basal levels of pa in with periodic breakthrough pain or flare s of moderate to intense pain that exceed basal levels A longitudinal study conducted by Green et al. (2009) recruited cancer patients on an analgesic medication regime who experienced breakthrough pain and assessed their symptoms by survey over a six month period. Ratings of consistent pain remained stable over time and averaged in the mild to moderate range (i.e., 3.5 to 4.5 on a 10 point scale ). In contrast, patients stated that breakthrough pain had greater variability an d the average severity did not change significantly across time points Green and colleagues (2009) highlight that ethnic minorities reported significantly more pain, greater interference in daily functioning, and more intense breakthrough pain compared to Caucasi a ns in this sample. Gynecologic cancers are often associated with symptoms of pelvic pain or pressure and low back pain prior to treatment ( CDC, 2010 ) Vaz et al (2007)

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18 conducted clin ical interviews with a group of 103 patients with gynecologic cancers, primarily cervical and endometrial, and found 50% endorsed pain symptoms prior to beginning radiotherapy Women who reported more symptoms also reported that pain negatively impacted o verall quality of life, physical functioning, and physical health on the WHOQOL BREF a self report measure of quality of life developed by the World Health Organization. A survey conducted by Rummans et al (1998) asked women with breast or gynecologic cancers across the treatment spectrum (i.e., newly diagnosed, undergoing adjuvant therapy, stable disease status, and recurrent disease) to rate the frequency, intensity, and interference of pain symptoms They found that 51% of women with gynecologic cancer endorsed a mild to moderate amount of pain in the previous month, and 62% of these indicat ed that the pain interfered with their ability to function. Portenoy and colleagues (1994) asked women with ovarian cancer to provide a detailed description of the location, frequency, and duration of pain symptoms for a two week period. Pain severity was further assessed using the Memorial Pain Assessment Cards (Fishman et al., 1987) and interference was evaluated with the Brief Pain Inventory (Cleeland & Ryan, 1994). A mong women with ovarian cancer primarily stages III and IV, 42% described frequent or persistent pain during the preceding two weeks ( Portenoy et al., 1994 ) Most patients (68%) also repor ted that pain interfered with their ability to be active, work mood, and overall enjoyment of life. Taken together, these data suggest that women with gynecologic cancers experience significant interference in daily functioning and physical/emotional wel l being due to pain symptoms arising from the disease and medical treatments.

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19 Emotional Distress A mong Cancer Patients Emotiona l distress is also prevalent among cancer patients and often includes mixed anxiety and depressed mood. Carroll et al. (1993) screened 809 Individuals with cancer in both inpatient and outpatient settings with the Hospital Anxiety and Depression Scale (HADS). Their results show ed that 18% of individuals surveyed reported elevate 11). Of note, women with gynecologic cancers reported elevated anxiet y. Boscaglia and colleagues (2005) demonstrated that women with gynecologic cancer endorsed higher than average symptoms of state anxiety on the StateTrait Anxiety Inventory (STAI) compared to women of the same age range in the general population ( Boscaglia et al., 2005) Another study reported that 29% of 246 women with ovarian cancer, who were evenly divided between active treatment and post treatment surveillance indicated anxiety symptoms greater tha n the 75th percentile on the STAI ( Bodurka Bevers et al., 2000 ) In addition, Costanzo and colleagues (2006) reported that significantly more anxiety was reported by w omen undergoing adjuvant treatment for gynecologic cancer compared to women treated with surgery alone on the Profile of Mood States (POMS ; McNair Droppleman, & Lorr, 1992) Similarly for p atients with ovarian cancer who had just finished a course of chemotherapy treatments 38% reported clinically significant anx iety on the HADS ( Hipkins, Whitworth, Tarrier, & Jayson, 2004) Prospective longitudinal studies with newly diagnosed cancer patients reveal an overall decrease in anxiety during the first year post treatment. Hou and colleagues (2010) found that 13% of patients with cancer will show a decrease in distr ess, including anxiety, as measured by the HADS over the course of a 12 month period from the time of diagnosis. Chan et al. (2001) also conducted a longitudinal study assessing

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20 psychological distress in women with gynecologic cancers before treatment, 6 months, and 18 months post treatment. Anxiety symptoms were evaluated using the Hamilton Anxiety Scale (HAM A) a validated semi structured clinical interview. Participants were diagnosed with cervical (50.0%), ovarian (17.6%), endometrial ( 14.9%), and gestational trophoblastic disease (GTD ; 17.6% ). Over time reported levels of anxiety remained stable for the majority of participants (approximately 80%) with 12.7% showing significant improvement at 6 months post treatment and 17.0% at the 18month follow up. In contrast, a mong women with ovarian cancer en rolled following chemotherapy rates of elevated anxiety on the HADS increased significantly from 38% of 63 participants to 47% of 27 participants at 3 months post treatment (Hipkins, 2004). Thus, while research suggests that clinically significant anxiety often decreases over the first year post treatment, anxiety remains a salient and distressing emo tional experience for a significant minority of women with gynecologic cancer. The prevalence of major depression in a general cancer population, based on a literature review of epidemiological data, is estimated at around 20 25% with the rates of clinica lly significant depressi ve symptoms having a similar range ( Carr et al., 2002 ) For wom en with gynecologi c cancers, a literature review estimated the prevalence of major depression ranges from approximately 1223% ( Massie, 2004) while clinically significant depressive symptoms reported by women diagnosed with ovarian cancer range from 2155% using valid ated self report measures such as the Centers for Epidemiological Studies Depression Scale (CES D) and the Beck Depression Inventory II (BDI II; BodurkaBevers et al., 2000 ; E. S. Costanzo et al., 2005; Norton et al., 2004)

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21 For women with ovarian cancer who had completed chemotherapy, 33% endorsed clinically significant levels of depressi ve symptoms on the HADS ( Hipkins et al., 2004 ) Prospective longitudinal studies of newly diagnosed cancer patients show that many experience reductions in depression symptoms ; however similar proportions of patients have depressive symptoms that remain clinically significant over time. Amongst women newl y diagnosed gynecologic cancer evaluated in a clinical interview, Chan and colleagues (2001) found that 18 .3% had a decrease in depressive symptoms six months post diag nosis and 14.7% at the 18 month follow up. In contrast, 7 12% of people with cancer will experience chronic depressive symptoms at a clinically significant level. Deshields and colleagues (2006) found that 12% of women with breast cancer continued to report clinically significant depressive symptoms on the CES D at 6 months post treatment. Hou et al. (2010) estimated that about 7% of individuals newly diagnosed with cancer will consistently report clinically elevated distress on the HADS for a 12 month period. Overall, these findings suggest that a significant minority of patients experience persistently elevated depressive symptoms over time. Resilience and Stress Management Skills in the Context of Cancer Resilience and Cancer Although the impact of cancer and cancer treatments on physical and emotional functioning has been well documented, a growing body of literature has begun to explore psychological resilience in adaptation to cancer to advance well being and reduce the risk of poor adjustment ( Aspinwall & MacNamara, 2005; Coughlin 2008 ) Broadly defined, resilience is the ability to maintain a stable equilibrium over time despite transient symptoms of distress when faced with highly stressful or lifealt ering situations ( Bonanno, 2004) Extensive research into psychological resilience outside of

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22 the cancer population has revealed four heterogeneous trajectories that develop in the first two years following diff icult or traumatic life events such as the death of a close friend/family member ( Bonanno et al., 2002; Bonanno, Wortman, & Nesse, 2004) a terrorist attack ( Bonanno, Galea, Bucciarelli, & Vlahov, 2006, 2007) natural disasters ( Norris, Tracy, & Galea, 2009 ) and spinal cord or multiple trauma injury ( Quale & Schanke, 2010 ) The majority of people among these groups approximately 3555%, follow a resilient trajectory, experiencing a normal psychological response t o the event with symptoms of distress quickly diminishing without reaching clinically significant levels. However, it is estimated 1035% of people experience either chronic distress or elevated distress for a sustained period of time with symptoms slowly decreasing over a one to two year period in the recovery trajectory. Lastly, less than 10% report delayed distress or an increase in distress overtime, rising to clinically significant levels ( Bonanno, 2008 ) Substantial evidence suggests that a cancer diagnosis and its sequela can be considered a traumatic life event ( Rustad, David, & Currier, 2012 ) suggesting that the concept of psychological resilience may be salient among this population. Although research is limited as to the trajectory of resiliency in this population, a few studies provide evidence that the trajectories are similar to those among individuals experienci ng other traumatic life events. A longitudinal study of women with breast ca ncer conducted by Deshields and colleagues (2002) reported five trajectories of psychological adaptation/resiliency, operationalized by the pattern of depressive symptoms over time. The first four groups followed the same trajectories found in the traumat ic event literature: resilient or no depression (61%), recovered or improved

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23 depression (1%), delayed depression onset (<1%), and chronic depression (12%). However, a fifth group emerged that vacillated between clinically significant and non significant depressi ve symptoms (14%) suggesting that symptoms of depression were fluid among a substantial minority of women. More recently Hou and colleagues (2010) used a growth mixture modeling approach to assess patterns of anxious and depressed symptomatology in colorectal cancer patients. Similar to the previous results, 6567% were resilient, 1316% recovered, 1013% had delayed distress, and 7 9% had chronic distress. The higher prevalence rate of delayed onset distress found in Hou and colleagues (2010) compared to Deshields and col l e agues (2002) highlights two concepts: (1) symptoms can be fluid over time, and (2) symptom level at diagnosis may not reliably predict the longterm course of symptoms. Independently, Helgeson and colleagues (2004) tracked t he psychological adjustment of women with breast cancer over a period of four years and discovered that 43% of women with the highest levels of mental health functioning and lowest distress levels at the start of chemotherapy maintained a high level of functioning throughout the four year follow up period. This stands in stark contrast to the 12% of women with lower levels of mental health functioning and higher distress who showed an immediate and sustai ned decline in functioning. Of the two other groups that started at moderate levels of mental health functioning and distress, 18% of the women experience minor mood fluctuations while 27% demonstrated an immediate improvement in functioning that began to decline towards the end of the study. This indicates that initial high and low levels of psychological functioning and distress may be useful indicator s for predicting long term outcomes while initial moderate levels may have a more variable

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24 trajectory Taken together, this body of research points to d ifferences that enable women to cope with the stress and physical changes associated with cancer, with a substanti a l group experiencing clinically significant difficulties. Cognitive Behavioral Stress Management Skills and Intervention Despite voluminous l iterature exploring protective factors (i.e., coping style, optimism, personality, perceived control, and positive emotions) that characterize resilient individuals responses to stressful events ( Aspinwall & MacNamara, 2005; Carver, 2005; Erin S. Costanzo et al., 2006; Helgeson et al., 2004; Hou et al., 2010; Mancini & Bonanno, 2009 ) little attention has been paid to the discrete behaviors that, when utilized, may foster and sustain resilient outcomes in the context of cancer Mancini and Bonanno (2009) conceptualize premorbid functioning, pragmatic coping, and flexible adaptation as key behavioral features of resilience in response to trauma. Notably, pragmatic coping and flexibility in response to stressors are also key behavioral targets of empirically supported Cognitive Behavioral Stress Management (CBSM) interventions for distressed individuals with chronic and lifelimiting illnesses, such and HIV and cancer ( Michael H. Antoni et al., 2001) Within this research, self report instruments have been developed to assess individuals perceived stress management skills (PSMS), including coping ability, awareness of tension, the ability to use relaxation strategies, communicating needs with others, and the abili ty to indentify/ reframe distorted cognitions. This research has demonstrated that increases in an individuals perceived ability to implement these skills or PSMS, mediates the relationship between intervention and increased benefit finding as well as i m proved quality of life in men with prostate cancer ( F. Penedo et al., 2006; F. J. Penedo et al., 2004) In women with breast cancer who participated in psychosocial treatment, a rise

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25 in PSMS was associated with greater quality of life ( Michael H. Antoni et al., 2006 ) CBSM interventions that increase PSMS have also been shown to reduce life stress and buffer the odds of cervical dysplasia amongst minority women with HIV and cervical cancer risk, a group typically exposed to more persistent and chronic stressors ( Michael H Antoni et al., 2008) There is also evidence that greater levels of PSMS are associated with greater functional well being and less sleep disturbance and daytime dysfunction, the latter of which is mediated by lower depressive symptoms in this population (Fox et al. 2013). In summary, the evidence suggest s that assessing PSMS may be a useful way to operationalize behaviors associated with short and long term resiliency/adaptation among individuals with cancer. For women with gynecologic cancers, sleep disturbance, pain, and emotional distress are significant patient reported outcomes that may comprise adaptation as a global construct This raises the possibility that t h e assessment of PSMS at the time of diagnosis may be a useful tool for evaluating the risk for sleep disturbance, pain symptoms, and mood disturbance and assist ing with identifying patients who may receive the most benefit from a CBSM intervention. Current Study The current study explored the relationships between perceived stress management skills (PSMS) and (a) sleep quality, (b) pain disability, and (c) anxious or depressed mood among women with suspected gynecologic cancer immediately prior to su rgical resection To this end, the following specific aims were pursued: Specific Aim 1 : To examine the relationship between PSMS and sleep quality among women with suspected gynecologic cancers immediately prior to surgical resection.

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26 Hypothesis 1a A si gnificant negative correlation with at least a moderate effect size will emerge between PSMS and sleep disturbance Hypothesis 1b A significant negative correlation with at least a moderate effect size will emerge between perceived abilities to manage sleep and pain, specifically sleep disturbance. Specific aim 2 : To examine the relationship between PSMS and pain disability among women with suspected gynecologic cancers immediately prior to surgical resection. Hypothesis 2a A significant negative correlation with at least a moderate effect size will emerge between PSMS and pain disability. Hypothesis 2b A significant negative correlation with at least a moderate effect size will emerge between perceived abilities to be aware of tension and relaxation, sp ecifically, pain disability Specific aim 3 : To examine the relationship between PSMS and depressed or anxious symptomatology among women with suspected gynecologic cancers immediately prior to surgical resection. Hypothesis 3a A significant negative correlation with at least a moderate effect size will emerge between PSMS and depressive symptomatology. Hypothesis 3b A significant negative correlation with at least a moderate effect size will emerge between PSMS and anxiety symptomatology.

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27 Table 1 1 Prevalence of chronic i nsomnia comorbid with medical condition ( Taylor et al., 2007 ) Prevalence of Chronic Insomnia (%) Among Individuals With Medical Condition Among Individuals Without Medical Condition Heart disease 44.1 22.8 Cancer 41.1 24.6 High blood pressure 44.0 19.3 Neurologic disease 66.7 24.3 Breathing problems 59.6 21.4 Urinary problems 41.5 23.3 Chronic Pain 48.6 17.2 Gastrointestinal problems 55.4 20.0

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28 CHAPTER 2 METHODS Design The current study utilized a nonexperimental, crosssectional design. Briefly, participants provided psychosocial data immediately prior to surgery for suspected gynecologic cancer. Data collection included self report measures of perceived stress management skills (PSMS), sleep quality, pain disabi lity, and mood symptoms. Participants Participants for the present study were 25 women drawn from a larger, ongoing parent study funded by the National Cancer Institute (PI: Deidre Pereira, Ph. D. R01 CA 138808). Participants were recruited and enrolled f rom October 2010 until present. Inclusion criteria for the parent study were women who were: (a) 18 or older with suspected primary adenocarcinoma or squamous cell cancers of gynecologic origin, (b) undergoing a surgical procedure such as a TAH BSO, tumor debulking, or surgical resection, (c) fluent in English, and (d) screened for sleep disturbance with a score greater than > 5 on the Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds Iii, Monk, Berman, & Kupfer, 1989) Exclusions criteria were: (a) diagnosis of recurrent primary adenocarcinoma or squamous cell cancers of gynecologic origin, (b) metastasis to the female genital tract from another site, (c) undergoing preoperative chemotherapy or radiotherapy, (d) history of chemotherapy in the past 5 years, (e) m edical record documented dementia or a score < 24 on the Mini Mental Status Exam (MMSE ; Folstein, Folstein, & McHugh, 1975) (f) seizure disorder, and (g) current psychotic disorder or B ipolar D isorder as assessed by the SCID a semi structured clinical interview for DSM IV disorders ( First, 2007 ) and/or current recurrent suicidal ideation or

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29 recent/current suicidal intent/plan as assessed by a score > 0 on the first five items of the Beck Scale for Suicide Ideation (BSS; A. Beck & Steer, 1991 ) Participants from the parent study were included in the present study if they had complete preoperative psychosocial data. Procedures Pa rticipants for this study were recruited from the Gynecologic Oncology Clinic at Shands at the University of Florida. Women who met preliminary inclusion/exclusion criteria (e.g., suspected primary, nonrecurrent gynecologic cancer) were identified by med ical staff during their initial consultation visit with Gynecologic Oncology Physicians/nurse practitioners notified potentially eligible patients of the opportunity to discuss the present study with a study representative. Patients who expressed interest in hearing more about the study then met with a trained member of the research team Patients interested in being screened for the study were then administered the PSQI ( Buysse et al., 1989 ) Patients who scored > 5 on this measure were notified of preliminary eligibility based on their score and p rovided an Institutional Review Board (IRB) approved Informed Consent Form (ICF) Study staff reviewed the ICF with patients, and patients choosing to continue with the study signed the ICF and underwent additional screening for uncontrolled psychopathology (i e. suicidal ideation/ intent, Bipolar Disorder, Psychotic disorders and dementia). Participants who continued to meet eligibility criteria were then given a set of self report questionnaires to complete prior to their next pre operativ e Gynecologic Oncology appointment approximately one week later At this pre operative visit, participants were administered an interview to assess current mood, and research st aff collected the self report questionnaires

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30 completed over the prior week A ll study procedures were conducted in accordance with the rules and regulations of the University of Florida IRB. Psychosocial Assessment Psychosocial Screening At study entry, research staff conducted a brief psychiatric interview using the SCID a sem i structured clinical interview for assessing DSM IV disorders ( First, 2007 ) The following modules were administered: Mood Episodes Manic Episode and the Psychotic Screening. The SCID is a widely used reliabl e/ valid assessment of psychopathology and has been cited as a gold standard for the clinical diagnosis of DSM IV disorder s in community samples ( Shear et al., 2000 ) To screen for dementia or severe cognitive impairment the Mini Mental Status Exam ( Folstein et al., 1975) was administered. MMSE reliability statistics in community samples are adequate and range from 0 .68 to 0 .77 ( Tombaugh & McIntyre, 1992) P articipants also completed the Beck Suicide Scale ( A. Beck & Steer, 1991) a self report measure that assess ed for suicidal ideation/ intent with a reported reliability (alpha) of 0 .90 ( Aaron T. Beck, Steer, & Ranieri, 1988) Participants who screened positive for untreated mania/hypomania, psychotic disorder, severe cognitive impairment, and/or suicidality were referred for urgent psychiatric/psychological evaluation and inf ormed of ineligibility. Sleep Quality As a part of study screening procedures, s leep disturbance was assessed using the Pittsburg h Sleep Quality Index (PSQI ; Buysse et al., 1989) which evaluated overall sleep quality in the past month. The PSQI is a 19item questionnaire that has been validated for use in cancer populations ( Carpenter & Andrykowski, 1998) It produces a global sleep quality score and seven component scores assessing sleep quality, sleep

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31 latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping medications, and daytime dysfunction. High scores on the global score represent poorer sleep quality and high component scores represent greater degrees of that component. The range of possible scores is 0 to 57 with scores greater than 5 considered clinically signif icant. The total scores were used as an outcome measure and the subscales were evaluated in exploratory analyses. Although the modest sample size in the current study did not allow for the evaluation of the PSQIs psychometric properties, the PSQI has ev idenced adequate internal consistency in cancer populations in prior published research 0; Carpenter & Andrykowski, 1998 ) Perceived Stress Management Skills Perceived stress management skills (PSMS) were assessed using a modified version of the Measure of Current Status (MOCS; Carver, 2006) This is a measure of a persons perceived ability to respond to the challenges and demands of everyday life. The ori ginal scale contained 17 items based on components of stress management interventions: awareness of tension, cognitive reframing, use of social support, and adaptive anger expression. In previous research with cancer populations, the MOCS has been associated with greater optimism and positive mood ( F. J. Penedo et al., 2003) as well as inversely related to anxiety and depression ( Faul, Jim, Williams, Loftus, & Jacobsen, 2010) It has also been associated with greater quality of life for women with breast cancer ( Michael H. Antoni et al., 2006) and men with prostate cancer ( F. J. Penedo et al., 2004 ) The MOCS was tailored for use in th is study ; specifically, items related to adaptive anger expression were removed while items related to behavioral sleep and pain management were added. Our modified scale contained 23 item rated

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32 on a scale ranging from 1 (I cannot do this at all) to 5 (I can do this extremely well) and assessed the following domains: awareness of tension and ability to relax, awareness of thoughts and ability to cognitively reframe, ability to cope effectively, and behavioral sleep and pain management. The minimum and maximum of possible scores range from 23 to 115, with elevated scores indicating greater PSMS. In previous research the MOCS A has demonstrated adequate internal consistency among women with breast cancer ( = 0.71 0.89 ; Michael H. Antoni et al., 2006 ) The total MOCS score was used as the predictor in all analyses. P ain Disability Pain disability was assessed using the Pain Disability Index ( Pollard, 1984) a measure of the degree to which pain interferes with daily activities; including family responsibilities, recreation, social activity, occupation, sexual behavior, self care, and life support activity. The PDI is a sevenitem questionnaire that has demonstrated reliability ( = 0.86) and validity with chronic pain patients ( Tait, Chibnall, & Krause, 1990) as well as women with breast cancer ( Bishop & Warr, 2003 ) Pain interference was rated for each daily activity domain on a scale ranging from 0 (no disability) to 10 (total disability). High scores indicate a greater degree of pain disability and interference with daily functioning. Scores can range from 0 to 70 on the pain disability scale. Reliability (alpha) of pain disability in the present study was 0. 89. The PDI was used as an outcome variable. Mood Severity of depressive symptomatology was assessed using the Beck Depress ion Inventory II ( Aaron T. Beck, Steer, & Brown, 1996) which evaluated the severity of depression symptoms during the past two weeks. The BDI II is a 21 item

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33 measure that evaluates the following symptoms and attitudes: mood, pessimism, sense of failure, lack of satisfaction, feelings of gui lt, sense of punishment, self dislike, self accusation, suicidal wishes, crying, irritability, social withdrawal, indecisiveness, distortion of body image, work inhibition, sleep disturbance, fatigue, loss of appetite, weight loss, somatic preoccupation, and loss of libido. It has been widely used in clinical research and validated with medical populations ( Arnau, Meagher, Norris, & Bramson, 2001) Symptoms of depression are rated on a scale ranging from 0 to 3, with a high score corresponding to greater intensity. Possible scores range from 0 to 63 on the depression scale. Among patients with a variety of medical conditions the reliability (alpha) was 0.94 ( Arnau et al., 2001) Depression symptoms were examined as a study outcome. Severity of anxi ous symptomatology was a ssessed using the Spielberger State Trait Anxiety Inventory ( Spielberger, Gorsuch, & Lushene, 1970) The STAI is a 4 0 item measure divided into two 20item subscales; stateanxiety which assesses symptoms at the cur rent moment and trait anxiety based on an individuals general level of anxiety. This measure has been widely used in research with clinical populations and demonstrated good reliability ; Barnes, Harp, & Jung, 2002) Feelings of anxiety were rated on a scale ranging from 0 (not at all) to 4 (very much so). Possible scores range from 20 to 80 on the state and trait anxiety sub scales, with high scores indicating greater anxiety. Symptoms of anxiety were evaluated as an outcome variable. Control Variables Demographic factors are significantly associated with health status ( Veenstra, 2000; Baum, Garofalo, & Yali, 1999) As a result information about participants age,

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34 race, ethnicity, work status, yearly income, years of education, marital status, housing, and the number of people in the household was collected using the MacArthur Sociodemographic Questionnaire (MASQ; N ancy E Adler, Epel, Castellazzo, & Ickovics, 2000) Post operative pathology was used to determine cancer diagnosis versus benign disease status These demographic and disease characteristics were evaluated as potential control variables. Statistical Analyses I ndividuals who were eligible consented, and enrolled in the parent study were compared with those who were eligible but declined to participate on age, race, and ethnicity using Chi square and t test statistics. Then, using the same statistics, the 25 participants in the current study (i.e., with complete psychosocial data) were compared with the remaining participants (i.e., with incomplete psychosocial data) on the above variables; as well as cancer diagnosis, work status, househol d income, marital status, housing type, and number of individuals living in household. Descriptive statistics were then calculated on all variables of interest. The distributions of the psychosocial variables were examined for normality and transformed, as needed, to allow for the use of parametric statistics. In order to identify demographic and health related factors that may confound the relationship between PSMS and psychosocial outcomes, the above potential control variables were evaluated using biva riate correlations and dummy coded regressions. Demographic or health related variables found to be significantly related ( p <0.05) to the outcome measures were then controlled for in subsequent hierarchical regression analyses.

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35 Bivariate correlations and hierarchical regression analyses were performed to estimate the relationships between PSMS and (a) sleep quality, (b) pain disability, and (c) mood.

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36 CHAPTER 3 RESULTS Preliminary Analyses Comparison to Parent Study Sample There were no significant differences on age, race, or ethnicity between individuals who consented to participate in the parent study compared ( n = 41) and those who were eligible but declined ( n = 33) (Table 3 1). Furthermore, there were no statisticall y significant differences between participants with complete psychosocial data ( n = 25) and those with incomplete psychosocial data ( n = 16) across age, race, ethnicity, cancer diagnosis, benign disease, education, income, work status, housing, number in household, and mari tal status (Tables 32, 3 3 ). Normality Assumptions Age was determined to be nonnormally distributed in this sample with the majority of women over 60 years of age (Skewness = 1.542; Kurtosis = 4.084). A s a result, a Blom transformation ( Blom, 1958) was used in order to normalize the data so general linear models could be utilized. All other variables were normally distributed. Descriptive Results A total of 41 women met eligibility requirements for participation and were enrolled in the parent study. A subset of 25 women had full psych o social data from the preoperative assessment including the MOCS a measure of PSMS. Participants who did not complete this psychosocial assessment included; 6 women enrolled before the MOCS was added, 3 individuals who had insufficient time to complete some of the psychosocial data because they were recruited at a preoperative appointment, 2 women withdrawn by the investigator based on exclusion criteria (e.g., passive suicidal

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37 ideation and plans to file a health related lawsuit) 3 participants who forgot to complete the measure, 1 participant who withdrew prior to t he preop appointment due t o transportation difficulties and 1 participant who did not complete a sufficient number of items on the MOCS to allow for valid scoring The 25 p articipants in the present study ranged in age from 19 78 years of age ( M = 58.35 years, SD = 11.79 years). The majority of participants identified as Caucasian (80%) and n onHispanic (76.0 %) ; 16.0 % identified as African American. Post operative pathology determined that 10 women had endometrial c ancer (40%), 4 had ovarian canc er (16 %), 2 had fallopian tube cancer (8%), and 1 had cancer of unknown origin (4%). The remaining 8 women were diagnosed with benign disease (32%) even though they were advised of the possibility/probability of cancer prior to surgery. Associations amon g Control and Outcome Variables Type of cancer diagnosis and presence of benign disease were not significantly related to any of the outcomes of interest (all p s > 0 .05) Sleep quality was not associated with any of the potential control variables examined. However, age and years of education were significantly correlated with reported levels of pain disability r = 0.56, p = 0.008 and r = 0.50, p = 0.01, respectively. In addition, being widowed was a significant predictor of greater depressive symptoms p = 0.01. Finally, greater number of years of formal education was significantly correlated with lower trait anxiety, r = 0.50, p = 0.01 A s a result the se demographic variables were controlled for in subsequent analyses.

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38 Participant Characteristics on Outcome Measures As per the inclusion criteria, all participants had clinically significant sleep disturbance (PSQI > 5) Mean PSQI global sleep quality scores were 10.69 ( SD = 3.48) Overall, participants reported mild to moderate interference in daily functioning from pain ( M = 2 1.72, SD = 15.43). Based on previously established clinical cut offs for depression symptoms ( Aaron T. Beck et al., 1996) 40% ( n = 10) of women reported m inimal depressive symptoms 32% ( n = 8) reported mild symptoms 24% ( n = 6) reported moderate symptoms and 4% ( n = 1) reported severe symptoms Average state and trait anxiety symptom scores were 44.19 ( SD = 12.41) and 39.62 ( SD = 9.51 ), respectively ( Table 3 4 ). Analyses of Specific Aims Specific Aim 1: Relationships between PSMS and Sleep Quality Relationships between PSMS and sleep quality were examined using b ivariate correlations (Table 3 5 ). Contrary to hypotheses, no significant relationships em erged ( r = 0.12, p = 0.57) and the effect size was small Exploratory analysis of correlations between PSMS and PSQI component scores assessing sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping me dications, and daytime dysfunction also revealed no significant relationships although the relationship between PSMS and daytime dysfunction had a medium effect size in the nonhypothesized direction (Table 35). In addition, exploratory analyses revealed no significant relationship between Behavioral Sleep and Pain Management Skills, specifically, and global sleep quality, also with a small effect size, r = 0.14 p = 0.51.

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39 Specific Aim 2: Relationships between PSMS and Pain Disability Contrary to hypot heses, PSMS was not associated with pain disability 0.06, p = 0.76) in a hierarchical regression controlling for age and years of education (Table 3 6) Awareness of T ension and the A bility to R elax specifically, was also not related to pain disability p = 0.69 ; Table 37). Specific Aim 3: Relationships between PSMS and Mood Relationships between PSMS and mood/anxiety symptoms were evaluated using bivariate P earson correlations (Table 3 8 ). Contrary to hypotheses, a significant relationship did not emerge between PSMS and depressi ve symptoms ( r = 0.04, p = 0.87) After controlling for widowed marital status, the relationship between depressive symptoms and PSMS remained nonsignificant p =0 36; Table 3 9 ) However, a significant negative correlation with a large effect size ( r = 0.62 p = 0.0 1) emerged between greater PSMS and lower trait anxiety (Table 38). This relationship 0.50, p =0.009), and the overall model accounted for 45% of the variance in trait anxiety (Table 310; Figure 3 1). A nonsignificant negative correlation with a medium effect size ( r = .34 p = 0.10 ) also emerged between greater PSMS and lower state anxiety (Table 38)

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40 Table 3 1 Comparison of categorical demographic variables for eligible study participants Participants Enrolled (N= 41 ) Patients who Declined to Participate ( N= 33 ) Variable name n % n % X 2 p Cramer s V Age 7.10 0.42 0.31 18 19 years 1 2.4 0 0.0 20 29 years 0 0.0 1 3.0 30 39 years 2 4.9 1 3.0 40 49 years 5 12.2 4 12.1 50 59 years 12 2 9.3 7 21.1 60 69 years 19 46.3 13 39.4 70 79 years 2 4.9 6 18.2 80 89 years 0 0.0 1 3.0 Race 2.93 0.40 0.20 Caucasian 30 73.2 27 81.8 African American 8 19.5 5 15.2 Native American 1 2.4 0 0.0 Unknown 2 4.9 0 0.0 Ethnicity 4.04 0.13 0.24 Hispanic or Latino 3 7.5 2 6.1 Not Hispanic or Latino 28 70.0 29 87.9 Unknown 9 22.5 2 6.1

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41 Table 3 2 Comparison of continuous demographic variables Participants with Complete Psychosocial Data (N= 25) Participants with Incomplete Psychosocial Data (N= 16) Variable name M SD M SD t df p Cohen s d Age 59.68 11.91 54.88 9.30 1.08 39 0.29 0.35 Years of Education 13.84 3.12 13.83 2.99 .005 29 1.00 0.002 Number of Individuals Living in Household 2.68 1.55 3.00 1.27 .469 29 0.64 0.17 Table 3 3. Comparison of categorical demographic and disease variables Participants with Complete Psychosocial Data (N= 25) Participants with Incomplete Psychosocial Data (N= 16) Variable name n % n % X 2 p Cramers V Race 4.58 0.21 0.33 Caucasian 20 80.0 10 62.5 African American 4 16.0 4 25.0 Native American 1 2.4 0 0.0 Unknown 0 0.0 2 12.5 Ethnicity 5.41 0.07 0.37 Hispanic or Latino 0 0.0 3 20.0 Not Hispanic or Latino 19 76.0 9 60.0 Unknown 6 24.0 3 20.0

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42 Table 3 3. Continued. Participants with Complete Psychosocial Data (N= 25) Participants with Incomplete Psychosocial Data (N= 16) Variable name n % n % X 2 p Cramers V Cancer diagnosis 4.51 0.48 0.33 Endometrial 10 40.0 4 25.0 Ovarian 4 16.0 2 12.5 Fallopian tube 2 8.0 1 6.3 Non GYN 0 0.0 1 6.3 Unknown 1 4.0 3 18.8 Benign disease 8 32.0 5 31.3 Work status 9.87 0.08 0.56 Full time 8 32.0 1 16.7 Part time 0 0.0 1 16.7 Unemployed 1 4.0 2 33.3 Looking for work 1 4.0 0 0.0 Homemaker 5 20.0 1 16.7 Retired 10 40.0 1 16.7 Family income 2.80 0.59 0. 31 0 24,999 9 37.5 4 66.7 25,000 49,999 4 16.7 0 0.0 50,000 74,999 3 12.5 1 16.7 75,000+ 5 20.8 1 16.7 Unknown 3 12.5 0 0.0 Marital status 2.73 0.44 0.30 Never married 1 4.0 1 16.7 Married 18 72.0 5 83.3 Divorced 3 12.0 0 0.0 Widowed 3 12.0 0 0.0

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43 Table 3 3. Continued. Participants with Complete Psychosocial Data (N= 25) Participants with Incomplete Psychosocial Data (N= 16) Variable name n % n % X 2 p Cramers V Housing 3.30 0.19 0.36 Owner 20 80.0 3 50.0 Rent for $ 4 16.0 3 50.0 Living with friends or family 1 4.0 0 0

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44 Table 3 4. Characteristics of outcome measures Outcome measure n % BDI Minimal (0 9) 10 40 Mild (10 18) 8 32 Moderate (19 29) 6 24 Severe (>30) 1 4 M SD PSQI 10.69 3.48 PDI 21.72 15.43 State anxiety 44.19 12.41 Trait anxiety 39.50 9.52 T able 3 5 Correlations between PSMS and sleep quality 1 2 3 4 5 6 7 8 1. PSMS 2. Global sleep quality .12 3. Sleep quality .13 .51** 4. Sleep latency .15 .65** .06 5 Sleep efficiency .19 .65** .02 .38 6 .Sleep disturbance .11 .36 .27 .29 .03 7 Use of sleep medication .15 .44* .09 .15 .27 .22 8 Daytime dysfunction .34 .12 .22 .21 .28 .39 .36

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45 Table 3 6. Hierarchical regression controlling for demographic covariates between PSMS and pain disability Variable B SE B R 2 2 p Step 1 0.38 0.38 0.01** Age 21.46 11.15 0.41 Years of Education 1.49 1.04 0.31 Step 2 0. 39 0.003 0.04* Age 22.20 11.68 0.42 Years of Education 1.31 1.21 0.27 PSMS 0.06 0.19 0.07 0.76 01 Table 3 7 Hierarchical regression controlling for demographic covariates between Awareness of Tension and A bility to Relax and pain disability Variable B SE B R 2 2 p Step 1 0.38 0.38 0.01** Age 21.46 11.15 0.41 Years of Education 1.49 1.04 0.31 Step 2 0. 39 0.006 0.03* Age 20.22 11.81 0.39 Years of Education 1.67 1.15 0.34 Awareness of Tension and Ability to R elax 0.34 0.82 0.08 0.69 Table 3 8. Correlations between PSMS and mood symptoms 1 2 3 4 1. PSMS 2. Depression symptoms .04 3. State anxiety .34 .15 4. Trait anxiety .62** .53** .56**

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46 Table 3 9 Hierarchical regression controlling for demographic covariates between PSMS and depressive symptoms Variable B SE B R 2 2 p Step 1 0.39 0.39 0.001*** Widowed Marital Status 13.99 3.66 0.62 Step 2 0.41 0.02 0.003** Widowed Marital Status 15.03 3.84 0.67 PSMS 0.07 0.08 0.16 0.36 ; 0 1 Table 3 10 Hierarchical regression controlling for demographic covariates between PSMS and Trait Anxiety Variable B SE B R 2 2 p Step 1 0.2 4 0.2 4 0.014 Years of Education 1.48 0.55 0.49 0.014 Step 2 0.4 5 0.21 0.001** Years of Education 0.86 0.53 0.28 PSMS 0.29 0.10 0.50 0.009*

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47 Figure 31. Relationship between PSMS and anxiety symptoms ( n = 25)

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48 CHAPTER 4 DISCUSSION C linically significant sleep disturbance ( Christman et al., 2001 ; Davidson, 2002; Greimel et al., 2011 ) pain that interferes with daily functioning ( Portenoy et al., 1994; Rummans et al., 1998; Vaz et al., 2007) and depressive or anxious symptamatology ( Bodurka Bevers et al., 2000; Hipkins et al., 2004; M assie, 2004 ; Stark et al., 2002) are prevalent and distressing experiences among women undergoing diagnosis and treatment for suspected gynecologic cancers Yet the literature also indicates that substantial individual differences enable many patients (>60%) to respond with resilient coping and maintenance of healthy levels of psychological functioning ( Deshields et al., 2006; Helgeson et al., 2004; Hou et al., 2010) L ittle attention has been paid to the role of specific and discrete behaviors that may foster and sustain resilient outcomes In the pres ent study, an individuals appraisal of their ability to engage in these specific behaviors in time of need has been conceptualized as perceived stress management skills (PSMS) The results of the current study did not support the hypotheses that PSMS wou ld be significantly associated with sleep disturbance, pain disability, or depressive symptoms among women preparing to undergo surgery f or suspected gynecologic cancer Several possibilities for this exist. Participants in t he current study sample had clinically significant sleep disturbance (PSQI >5) but minimal pain disability (M = 21.72, SD = 15.43) and mild depressive symptoms The range of responses on the PSQI, PDI, and BDI II were restricted, and as a result, there may have been low power to detect any true statistically significant relationships. Furthermore, depressed mood and distress related to pain may be less salient than anxiety to patients in the pre operative

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49 time period. Several studies have demonstrated that anxious symptomatology i s the most prevalent mental health concern during the pre operative period among women with breast cancer ( Millar, Jelicic, Bonke, & Asbury, 1995; zalp, Sarioglu, Tuncel, Aslan, & Kadiogullari, 2002) This suggests that predicting pain disability and depression prior to surgery for possible cancer may have less practical application than predicting anxiety. In contrast, the current study found that greater PSMS wa s significantly associated with lower trait anxiety and was trending toward significance with lower state anxiety Higher PSMS scores indicate greater perceived ability to cope with stressors and implement effec tive anxiety reducing strategies These perceptions are characteristic of adaptive secondary appraisals that buffer the development of anxious symptomatology in response to negative life stressors ( Folkman & Lazarus, 1988) Possessing adaptive secondary appraisals in response to stressful events, such as undergoing surgery for suspected cancer, may be key to maintaining psychological health and, therefore, may define resilience ( Bonanno et al., 2004) These findings also suggest that women with lower PSMS prior to surgery for suspected gynecologic cancer are more likely to experience elevated trait anxiety. As a result, these women may experience greater benefit from CBSM interventions that target adaptive secondary stress appraisals and related techniques. These findings are consistent with a large body of literature that demonstr ates that individuals with cancer who participate in an intervention that teaches these skills report decreases in anxiety symptoms ( Michael H Antoni et al., 2008; Loprinzi, Prasad, Schroeder, & Sood, 2011) as well as less perceived stress ( Cohen & Fried, 2007 ) Among cancer surv ivors the

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50 augmentation of cognitive behavioral skills reduces anxiety ( Osborn, Demoncada, & Feuerstein, 2006) thereby promoting improved quality of life. The importance of helping patients with cancer cope with anxiety has been well documented. Psychological distr ess, including anxiety, has been associated with decreased quality of life ( Skarstein, Aass, Foss, Skovlund, & Dahl, 2000) more pain symptoms ( Chen, Chang, & Yeh, 2000; Glover, Dibble, Dodd, & Miaskowski, 1995; Vahdaninia, Omidvari, & Montazeri, 2010) and insomnia ( Espie et al., 2008 ) However, developing effective mechanisms for screening of psychological distress and communication amongst multi disciplinary teams continues to be a challenge in many health care settings ( N.E. Adler & Page, 2008 ) By enhancing our understanding through clinical research of the active ingredients of CBSM that correlate with the promotion of resilient outcomes, PSMS may aide in determining who will benefit the most from intervention. Routinely evaluating PSMS in this population may allow for early intervention and effective buffering of anxious mood over time. Study Limitations The current study has several notable limitations. This is a preliminary analysis conducted on data being collected as a part of a larger intervention study that is still active ly recruiting. The small sample size ( n = 25) limits the s tatistical power to detect significant relationships between PSMS and sleep disturbance, pain disability, and mood outcomes This is highlighted by the moderate effect size, yet nonsignificant correlation, between PSMS and state anxiety ( r = 0.34, p = 0. 10) The moderate effect size suggests that it is likely the correlation would have reached significance with a larger sample size. This is noteworthy because for this group of participants, anxiety appeared to be the most salient emotional experience in the preoperative period.

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51 Another important consideration of this study is that only women who reported clinically significant sleep difficulties (PSQI > 5) were enrolled in the parent study. As a result the range of self reported sleep disturbance was r estricted further reducing statistical power. The current findings are also not generalizable to individuals preparing for surgery who deny sleep disturbance. Lastly, 32% of the sample was diagnosed with benign disease following a review of surgical pathology in spite of the fact that cancer was suspected prior to surgery. Therefore, the results of this study may not generalize to individuals whose diagnoses are known unequivocally prior to surgery. Future D irections Future directions include increasing the sample size in order to replicate and expand on these findings. Additional research is needed to establish the psychometric properties of the modified MOCS scale and the hypothesized subscales used to mea sure PSMS. A larger sample size would allow for a confirmatory factor analysis to be conducted to determine if the following latent constructs were assessed ; awareness of tension and ability to relax, awareness of thoughts and ability to cognitively reframe, ability to cope effectively, and behavioral sleep and pain management. The analysis of PSMS data collected at post op would allow for the exploration of PSMS in the peri operative time period more broadly and its relationship with health and psychosoc ial outcomes Lastly, psychosocial data collected from women who participated in the CBSM intervention would enable investigators to evaluate PSMS as a mediator of treatment outcomes.

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52 APPENDIX A MEASURE OF CURRENT STATUS Measure of Current Status Modified Version (MOCS) People have different levels of various skills for responding to the challenges and demands of everyday life. The following items list several things that people are able to do to a greater or lesser degree to deal with daily stresses. For each item, indicate how well you currently can do what it describes. Please dont indicate what you think you should be able to do, or what you wish you could do. Be as accurate as you can. Choose from the following responses: 1 = I cannot do this at all 2 = I can do this just a little bit 3 = I can do this a medium amount 4 = I can do this pretty well 5 = I can do this extremely well ____ 1. I am able to use muscle relaxation techniques to reduce any tension I experience. ____ 2. I become aware of any tightness in my body as soon as it develops. ____ 3. I can easily stop and re examine my thoughts to gain a new perspective. ____ 4. Its easy for me to decide how to cope with whatever problems arise. ____ 5. I can easily recognize situations that make me feel stressed or upset. ____ 6. When problems arise I know how to cope with them. ____ 7. I am aware of the stream of thoughts that pass through my mind as events occur. ____ 8. I am able to use mental imagery to reduce any tension I experience. ____ 9. I am confident about being able to choose the best coping responses for hard situations. ____ 10. I can come up with emotionally balanced thoughts even during negative times. ____ 11. I can modulate my activity level to help reduce pain and fatigue. ____ 12. I can easily recognize habits that interfere with my sleep. ____ 13. I am capable of managing my sleep problems by modifying my habits. ____ 14. I am able to discontinue my use of caffeine late in the day. ____ 15. I can refrain from napping all together. ____ 16. If I do need to nap, I can prevent myself from doing so late in the day. ____ 17. I am able to use my bed for sleep (and sex) only. ____ 18. I am able to engage in activities I enjoy. ____ 19. I am able to use deep breathing to reduce any tension I experience. ____ 20. I can adjust how much time I spend in bed in order to get the right amount of sleep. ____ 21. I can easily maintain a regular sleep schedule. ____ 22. I am able to use mindfulness to focus on the moment and reduce any tension I experience. ____ 23. When I have difficulty falling asleep I can get out of bed and do something else until I am tired.

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53 APPENDIX B PITTSBURG H SLEEP QUALITY INDEX Pitt sburg h Sleep Quality Index (PSQI) INSTRUCTIONS: The following questions relate to your usual sleep habits during the past month only Your answers should indicate the most accurate reply for the majority of days and nights in the past month. Please answer all questions. 1. During the past month, what time have you usually gone to bed at night? BED TIME ___________ 2. During the past month, how long (in minutes) has it usually taken you to fall asleep each night? NUMBER OF MINUTES ___________ 3. During the past month, what time have you usually gotten up in the morning? GETTING UP TIME ___________ 4. During the past month, how many hours of actual sleep did you get at night? (This may be different than the number of hours you spent in bed.) HOURS OF SLEEP PER NIGHT ___________ For each of the remaining questions (5a 5j; 10b) check the one best response. Please answer all questions. 5. During the past month, how often have you had trouble sleeping because you a) Cannot get to sleep with in 30 minutes Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ b) Wake up in the middle of the night or early morning Not during the Less t han Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ c) Have to get up to use the bathroom

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54 Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ d) Cannot breathe comfortably Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ e) Cough or snore loudly Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ f) Feel too cold Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ g) Feel too hot Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ h) Had bad dreams Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ i) Have pain Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ j) Other reason(s), please describe_______________________________________________________________ _____________________________________________________ _____ How often during the past month have you had trouble sleeping because of this? Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____

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55 6. During the past month, how would you rate your sleep quality overall? Very good ____________ Fairly good ____________ Fairly bad _____________ Very bad ____________ 7. During the past month, how often have you taken medicine to help you sleep (prescribed or "over the counter")? Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ 8. During the past month, how often have you had trouble staying awake while dri ving, eating meals, or engaging in social activity? Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ 9. During the past month, how much of a problem has it been for you to keep up enough enthusiasm to get things done? No problem at all __________ Only a very slight problem __________ Somewhat of a problem __________ A very big problem __________ 10a Do you have a bed partner or room mate? No bed partner or room mate __________ Partn er/room mate in other room __________ Partner in same room, but not same bed __________ Partner in same bed __________

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56 10b.If you have a room mate or bed partner, ask him/her how often in the past month you have had a) Loud snoring Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ b) Long pauses between breaths while asleep Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ c) Legs twitching or jerking while you sleep Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ d) Episodes of disorientation or confusion during sleep Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____ e) Other restlessness while you sleep; please describe____________________ ________________________________________________________________ Not during the Less than Once or twice Three or more past month_____ once a week_____ a week_____ times a week_____

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57 APPENDIX C PAIN DISABILITY INDEX Pain Disability Index (PDI) The rating scales below are designed to measure the degree to which several aspects of your life are presently disrupted by chronic pain. In other words, we would like to know how much your pain is preventing you from doing what you normally do, or from d oing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when the pain is at its worst. For each of the 7 categories of life activity listed, please circle the number on the scale wh ich describes the level of disability you typically experience. A score of 0 means no disability at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain. (1) Family / home responsibilities This category refers to activities related to the home or family. It includes chores or duties performed around the house (e.g., yard work) and errands or favors for other family members (e.g., driving the children to school). 0 1 2 3 4 5 6 7 8 9 10 no total disability disability (2) Recreation This category includes hobbies, sports, and other similar leisure time activities. 0 1 2 3 4 5 6 7 8 9 10 no total disability disability (3) Social activity This category refers to activities which involve participation with friends and acquaintances other than family members. It includes parties, theater, concerts, dining out, and other social functions. 0 1 2 3 4 5 6 7 8 9 10 no total disability disability

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58 (4) Occupation This category refers to activities that are a part of or directl y related to ones job. This includes non paying jobs as well, such as that of a housewife or volunteer worker. 0 1 2 3 4 5 6 7 8 9 10 no total disability disability (5) Sexual behavior This category refers to the frequency and quality of ones sex life. 0 1 2 3 4 5 6 7 8 9 10 no total disability disability (6) Self care This category includes activities which involve personal maintenance and independent daily living (e.g., taking a shower, driving, getting dressed, etc.). 0 1 2 3 4 5 6 7 8 9 10 no total disability disability (7) Life support activity This cat egory refers to basic life supporting behaviors such as eating, sleeping, and breathing. 0 1 2 3 4 5 6 7 8 9 10 no total disability disability

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59 APPENDIX D STATETRAIT ANXIETY INVENTORY State trait Anxiety Inventory (STAI FORM 1) I nstructions : Read each statement and mark the number to the right to indicate how you feel RIGHT NOW, AT THIS MOMENT. There are no right or wrong answers. Dont spend too much time on any one statement. Giv e the answer that seems to describe your present feelings. NOT AT ALL SOMEWHAT MODERATELY VERY MUCH 1. I feel calm 1 2 3 4 2. I feel s ecure 1 2 3 4 3. I am tens e 1 2 3 4 4. I feel st rained 1 2 3 4 5. I feel at ease 1 2 3 4 6. I f eel upset 1 2 3 4 7. I am presently wor rying over possible 1 2 3 4 misfortunes 8. I feel satisfied. 1 2 3 4 9. I feel frightened 1 2 3 4 10. I feel comfortable. 1 2 3 4 11. I feel s elf confident. 1 2 3 4 12. I fe el nervous. 1 2 3 4 13. I am jittery. 1 2 3 4 14. I feel indecisive 1 2 3 4 15. I am relaxed. 1 2 3 4 16. I fee l content. 1 2 3 4 1 7. I am w orried. 1 2 3 4 18. I feel confused 1 2 3 4 19. I fee l steady. 1 2 3 4 20. I feel pleasant. 1 2 3 4

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60 STAI FORM Y 2 Instructions: Read each statement and mark the number to the right to indicate how you GENERALLY FEEL There are no right or wrong answe rs. Dont spend too much time on any one statement. Give the answer that seems to describe your present feelings. ALMOST NEVER SOME TIMES OFTEN ALMOST ALWAYS 21. I feel pleasant 1 2 3 4 22. I ner vous and restless 1 2 3 4 23. I feel satis fied with myself 1 2 3 4 24. I wish I could be as happy as 1 2 3 4 0thers seem to be 25. I fee l like a failure 1 2 3 4 26. I feel rested .. 1 2 3 4 27. I am cool, calm, and collected.. 1 2 3 4 28. I feel difficulties ar e piling up 1 2 3 4 so that I cannot overcome them. 29. I worry too much over something 1 2 3 4 that really doesnt matter. 30. I am happy. 1 2 3 4 31. I have dis turbing thoughts. 1 2 3 4 32. I lack confidence. 1 2 3 4 33. I fee l secure. 1 2 3 4 34. I make deci sions easily 1 2 3 4 35. I feel inadequate 1 2 3 4 36. I am c ontent. 1 2 3 4 37. Some unimport ant thought runs 1 2 3 4 through my mind and bo thers me. 38. I take disappointme nts so keenly 1 2 3 4 that I cant put them out of my mind. 39. I am a steady person. 1 2 3 4 40. I get in a state of tensi on or 1 2 3 4 t urmoil as I think over my recent concerns and interests.

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61 APPENDIX E BECK DEPRESSION INVENTORY VERSION II Beck Depression Inventory Version II (BDI II) This questionnaire consists of 21 groups of statements. Please read each group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today Circle t he number beside the statement you have picked. If several statements in the group seem to apply equally well, circle the highest number for that group. Be sure that you do not choose more than one statement for any group, including item 16 or item 18: _____ 1. Sadness 0 I do not feel sad 1 I feel sad much of the time 2 I am sad all the time 3 I am so sad or unhappy that I cant stand it _____ 2. Pessimism 0 I am not discouraged about my future 1 I feel more discouraged about my future than I used to be 2 I do not expect things to work out for me 3 I feel my future is hopeless and will only get worse _____ 3. Past Failure 0 I do not feel like a failure 1 I have failed more than I should have 2 As I look back, I see a lot of failures 3 I feel I am a total failure as a person _____ 4. Loss of Pleasure 0 I get as much pleasure as I ever did from the things I really enjoy 1 I dont enjoy things as much as I used to 2 I get very little pleasure from the things I used to enjoy

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62 3 I cant get any pleasure from the things I used to enjoy _____ 5. Guilty Feelings 0 I dont feel particularly guilty 1 I feel guilty over many things I have done or should have done 2 I feel quite guilty most of the time 3 I feel guilty all of the time _____ 6. Pun ishment Feelings 0 I dont feel I am being punished 1 I feel I may be punished 2 I expect to be punished 3 I feel I am being punished _____ 7. Self Dislike 0 I feel the same about myself as ever 1 I have lost confidence in myself 2 I am disappointed in myself 3 I dislike myself _____ 8. Self Criticalness 0 I dont criticize or blame myself more than usual 1 I am more critical of myself than I used to be 2 I criticize myself for all of my faults 3 I blame myself for everything bad that happens _____ 9. Suicidal Thoughts or Wishes 0 I dont have any thoughts of killing myself 1 I have thoughts of killing myself, but I would not carry them out 2 I would like to kill myself 3 I would kill myself if I had the chance

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63 _____ 10. Crying 0 I dont cry anymore than I used to 1 I cry more than I used to 2 I cry over every little thing 3 I feel like crying, but I cant _____ 11. Agitation 0 I am no more restless or wound up than usual 1 I feel more restless or wound up than usual 2 I am so restless or agitated that its hard to stay still 3 I am so restless or agitated that I have to keep moving or doing something _____ 12. Loss of Interest 0 I have not lost interest in other people or activities 1 I am less interested in other people or things than before 2 I have lost most of my interest in other people or things 3 Its hard to get interested in anything _____ 13. Indecisiveness 0 I make decisions about as well as ever 1 I find it more difficult to make decisions than usual 2 I have much greater difficulty in making decisions than I used to 3 I have trouble making any decisions _____ 14. Worthlessness 0 I do not feel I am worthless 1 I dont consider myself as worthwhile and useful as I used to 2 I feel more worthless as compared to other peopl e 3 I feel utterly worthless

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64 _____ 15. Loss of Energy 0 I have as much energy as ever 1 I have less energy than I used to have 2 I dont have enough energy to do very much 3 I dont have enough energy to do anything _____ 16. Changes in Sleeping Patt ern 0 I have not experienced any change in my sleeping pattern 1a I sleep somewhat more than usual 1b I sleep somewhat less than usual 2a I sleep a lot more than usual 2b I sleep a lot less than usual 3a I sleep most of the day 3b I wake up 12 hours early and cant get back to sleep _____ 17. Irritability 0 I am no more irritable than usual 1 I am more irritable than usual 2 I am much more irritable than usual 3 I am irritable all the time _____ 18. Changes in Appetite 0 have not experienced any change in my appetite 1a My appetite is somewhat less than usual 1b My appetite is somewhat greater than usual 2a My appetite is much less than before 2b My appetite is much greater than usual 3a I have no appetite at all 3b I crave food all the time

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65 _____ 19. Concentration Difficulty 0 I can concentrate as well as ever 1 I cant concentrate as well as usual 2 Its very hard to keep my mind on anything for very long 3 I find I cant concentrate on anything _____ 20. Tiredness or Fatigue 0 I am no more tired or fatigued than usual 1 I get more tired or fatigued more easily than usual 2 I am too tired or fatigued to do a lot of the things I used to do 3 I am too tired or fatigued to do most of the things I used to do _____ 21. Loss of Interest in Sex 0 I have not noticed any recent change in my interest in sex 1 I am less interested in sex than I used to be 2 I am much less interested in sex now 3 I have lost interest in sex completely

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69 Longitudinal Study on Risk Factors for Maladjustment. Gynecologic Oncology, 80(3), 387394. Chen, M. L., Chang, H. K., & Yeh, C. H. (2000). Anxiety and depression in Taiwanese cancer patients with and without pain. Journal of Advanced Nursing, 32(4), 944 951. Christman, N. J., Oakley, M. G., & Cronin, S. N. (2001). Developing and Using Preparatory Information for Women Undergoing Radiation Therapy for Cervical or Uterine Cancer. [Article]. Oncology Nursing Forum, 28 (1), 9398. Cleeland, C., & Ryan, K. (1994). Pain assessment: global use of the Brief Pain Inventory. Annals of the Academy of Medicine, Singapore, 23(2), 1 29. Cohen, M., & Fried, G. (2007). Comparing relaxation training and cognitive behavioral group therapy for women with breast cancer. Research on Social Work Practice, 17(3), 313 323. Costanzo, E. S., Lutgendorf, S. K., Rothrock, N. E., & Anderson, B. (2006). Coping and quality of life among women extensively treated for gynecologic cancer. Psycho Oncology, 15 (2), 132142. doi: 10.1002/pon.930 Costanzo, E. S., Susan, K., Lutgendorf, S. K., Bradley, S. L., Rose, S. L., & Anderson, B. (2005). Cancer attributions, distress, and health practices among gynecologic cancer. Psychosomatic Medicine, 67, 972980. Coughlin, S. S. (2008). Surviving Cancer or Other Serious Illness: A Review of Individual and Community Resources. CA: A Cancer Journal for Clinicians, 58(1), 6064. doi: 10.3322/ca.2007.0001 Davidson, J. R. (2002). Sleep disturbance in cancer patients. Social Science & Medicine, 54, 1309 1321. Deshields, T., Tibbs, T., Fan, M.Y., & Taylor, M. (2006). Differences in patterns of depression after treatment for breast cancer. Psycho Oncology, 15(5), 398 406. doi: 10.1002/pon.962 Enderlin, C. A., Coleman, E. A., Cole, C., Richards, K. C., Kennedy, R. L., Goodwin, J. A., Mack, K. (2011). Subjective sleep quality, objective sleep characteristics, insomnia symptom severity, and daytime sleepiness in women aged 50 and older with nonmetastatic breast cancer. Paper presented at the Oncology Nursing Forum. Espie, C. A., Fleming, L., Cassidy, J., Samuel, L., Taylor, L. M., White, C. A., Paul, J. (2008). Randomized controlled clinical effectiveness trial of cognitive behavior

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75 BIOGRAPHICAL S KETCH Rachel Fox Postupack graduated with honors from Nyack College and attended Columbia University Teachers Coll ege where she earned her Master of Arts in p sychology in e ducation. While completing her studies, Rachel interned with the American Red Cros s in Disaster Services assisting families forced to evacuate their homes due to fire, flood, or vacate order. She participated in Dr. George Bonannos research laboratory and developed research interests in loss, trauma, and resilience. In addition, she completed an internship at the Anxiety Disorders Clinic of the New York State Psychiatric Institute (NYSPI) and assisted with a pilot study of Complicated Grief Treatment (CGT) for 9/11 bereaved. After graduation, she accepted a full time project coordinator and clinic manager position for Dr. M. Katherine Shear at Columbia University School of Social Work (CUSSW). During her tenure, she was responsible for the management of a large randomized psychotherapy study of Complicated Grief Treatment in Older Adults (CGTOA; 1R01MH07074101A2 ) and assisted with the start up of a multi site combined medication/ psychotherapy efficacy study for complicated grief (HEAL; R01MH060783) In addition, she taught Research Methods as an adjunct professor at Nyack College. Rachel is currently attending gr aduate school at the University of Florida in the Department of Clinical and Health Psychology. She began her graduate studies in 2011 and was awarded a Graduate Fellowship. Rachel obtained her Master of Science in 2013 and is presently working towards he r doctorate. Her current research focuses on psycho oncology, psychoneuroimmunology, and womens health as a member of Dr. Deidre Pereiras research lab.