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Table of contents
1. Applying a cognitive behavioral model of health anxiety in a cancer genetics service................................ 1
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Applying a cognitive behavioral model of health anxiety in a cancer genetics service.
Author: Rimes, Katharine A.;
1
; Salkovskis, Paul M.;
2
; Jones, Linda;
3
; Lucassen, Anneke M.;
4
;
1
Department
of Psychological Medicine, King's College London, nstitute of Psychiatry, London, United Kingdom
k.rimes@iop.kcl.ac.uk;
2
Department of Psychology, King's College London, nstitute of Psychiatry, London,
United Kingdom;
3
Genetics Service, Carmarthenshire National Health Service Trust, United Kingdom;
4
Wessex Clinical Genetics Service, Southampton, United Kingdom
Publication info: Health Psychology 25. 2 (Mar 2006): 171-180.
ProQuest document link
Abstract: A cognitive-behavioral model of health anxiety was used to investigate reactions to genetic counseling
for cancer. Participants (N = 218) were asked to complete a questionnaire beforehand and 6 months later.
There was an overall decrease in levels of cancer-related anxiety, although 24% of participants showed
increased cancer-related anxiety at follow-up. People who had a general tendency to worry about their health
reported more cancer-related anxiety than those who did not at both time points. This health-anxious group also
showed a postcounseling anxiety reduction, whereas the others showed no significant change. Participants with
breast or ovarian cancer in their family were more anxious than participants with colon cancer in their family.
Preexisting beliefs were significant predictors of anxiety, consistent with a cognitive-behavioral approach.
(PsycNFO Database Record (c) 2012 APA, all rights reserved)(journal abstract)
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Contents
Abstract
Methods
Participants
Procedure
Measures
Beliefs and feelings about cancer
General mood ratings
Demographic and medical/family history
Additional postcounseling measures
Statistical Analysis
Results
Sociodemographic and Clinical Characteristics of the Sample
Characteristics of People Who Did Not Return the Follow-up Questionnaire
mpact of Genetic Counseling
Accuracy of risk perceptions
Anxiety about developing cancer
Comparison of Anxiety and Beliefs About Cancer in People With Family Histories of Breast and/or Ovarian or
Colon Cancer
General group differences
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Did people who tended to worry about their health report more negative cancer-related beliefs and anxiety and
respond particularly negatively to "increased risk information?
Prediction of Anxiety and Beliefs
Prediction of anxiety and beliefs from medical/family history variables
Prediction of beliefs and anxiety from variables derived from the CB model
Discussion
Show less
Figures and Tables
Figure 1
Table 1
Table 2
Table 3
Table 4
Table 5
Table 6
Show less AbstractA cognitive-behavioral model of health anxiety was used to investigate reactions to genetic
counseling for cancer. Participants (N = 218) were asked to complete a questionnaire beforehand and 6
months later. There was an overall decrease in levels of cancer-related anxiety, although 24% of participants
showed increased cancer-related anxiety at follow-up. People who had a general tendency to worry about their
health reported more cancer-related anxiety than those who did not at both time points. This health-anxious
group also showed a postcounseling anxiety reduction, whereas the others showed no significant change.
Participants with breast or ovarian cancer in their family were more anxious than participants with colon cancer
in their family. Preexisting beliefs were significant predictors of anxiety, consistent with a cognitive-behavioral
approach. The importance of genetic susceptibility to certain cancers has led to an increase in the demand for
genetic counseling by specialist genetic services, particularly from members of families with a history of breast
and/or ovarian cancer or colon cancer (Ravine &Sampson, 2001). Genetic counseling is "the process by which
patients or relatives at risk of a disorder that may be hereditary are advised of the consequences of the
disorder, the probability of developing or transmitting it and of the ways in which this may be prevented, avoided
or ameliorated (Harper, 1998, p. 3). However, providing patients with such information does not necessarily
ensure that they will interpret or recall it correctly (Watson et al., 1998). Furthermore, although genetic
counseling may bring reassurance to some individuals, it also has the potential to cause psychological distress.
Therefore, the U.K. Department of Health (1996) has recommended that psychological support be part of the
genetic counseling process, and assessment of the psychological impact of these services has been advocated.
Relatively little is known about how different people react to genetic counseling or how adverse reactions should
be handled.There is evidence that a significant minority of individuals with a family history of cancer experience
high levels of psychological distress (e.g., Kash, Holland, Halper, &Miller, 1992; Lerman et al., 1993). Some
studies have found that genetic counseling is associated with decreases in overall levels of distress (e.g., Keller
et al., 2002), whereas others have found no significant change (e.g., Hopwood, Shenton, Lalloo, Evans,
&Howell, 2001). Prospective studies have found some evidence that individuals' risk perceptions tend to
become somewhat more accurate after genetic counseling although this has not been confirmed in randomized
controlled trials (Braithwaite, Emery, Walter, Provost, &Sutton, 2004; Meiser &Halliday, 2002). Those
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conducting previous research have generally failed to examine the impact of genetic counseling on other
cancer-related beliefs or to compare reactions of people being counseled for different types of cancer.Even if a
sample as a whole shows a decrease or no significant change on measures of distress after genetic counseling,
particular individuals may experience substantial increases in distress. As the demand for genetic counseling
and testing increases, psychological support will need to be focused on those at high risk for experiencing
adverse psychological effects (Grosfeld, Lips, Beemer, &ten Kroode, 2000). A few researchers have conducted
studies on precounseling predictors of postcounseling distress. They have generally found that scores on a
precounseling measure of distress can predict postcounseling scores on the same measure (Cull et al., 1999;
Lerman et al., 1996). Precounseling risk perceptions can also predict postcounseling distress (Ritvo et al., 2000
). Sociodemographic variables generally predict little or no variance in postcounseling distress.Few authors of
published studies have reported using a psychological model to guide their search for precounseling predictors
of distress or risk perceptions in people undergoing genetic counseling. A notable exception is the use of
Miller's (1987) monitoring/blunting model. One study (Lerman et al., 1996) found that women with a family
history of breast cancer who had a monitoring coping style showed increases in general distress from baseline
to follow-up, although there was no impact on cancer-specific distress. However, a number of studies have
failed to find any association between scores on the monitoring scale and risk perceptions or distress (e.g.,
Audrain et al., 1997; Cull et al., 1999).t has been suggested that applying a cognitive-behavioral (CB) approach
to the understanding of reactions to genetic screening may be fruitful (Salkovskis &Rimes, 1997). One of the
most commonly observed psychological problems is anxiety about developing the condition in question. A CB
approach to health anxiety (Warwick &Salkovskis, 1990) suggests that the extent to which people are likely to
make particularly negative interpretations of health information, and therefore to experience excessive anxiety,
is determined partly by their preexisting general beliefs about health, their specific beliefs about the disease in
question, and the extent to which their interpretations trigger maintaining factors such as checking or
reassurance-seeking behaviors. At least four aspects of their specific beliefs about the illness are thought to be
central to the perception of threat and hence to the anxiety reaction: (a) how likely they perceive the illness to
be, (b) how severe the negative consequences of the illness would be, (c) how well they think they would cope if
they developed the illness, and (d) how much external help might be available (e.g., how treatable a condition
might be). This CB model of health anxiety has been successfully applied to the prediction of individual
differences in psychological reactions to a nongenetic type of health assessmentbone density screening for
osteoporosis (Rimes &Salkovskis, 2002). For example, it was found that greater anxiety about osteoporosis
after bone density screening was associated with more negative prescanning beliefs about the likelihood of
developing osteoporosis, how serious it is to have low bone density, how well one would cope if one had
osteoporosis, the likelihood of successful treatment, and preexisting tendencies to worry about one's health and
to avoid illness-related matters. Several of these factors were stronger predictors of anxiety than the scanning
result itself.The main aims of the present study were
to investigate the impact of genetic counseling on anxiety about cancer and cancer-related beliefs 6 months
after counseling,
to investigate whether people who tended to worry about their health would show greater distress and more
negative cancer-related beliefs before counseling and would show more negative reactions to the information
they received, and
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to investigate whether precounseling beliefs about the cancer, derived from a CB approach to health anxiety,
would be predictive of anxiety about cancer. t was hypothesized that preexisting beliefs would be a better
predictor of postcounseling anxiety about cancer than participants' calculated lifetime risk of cancer.
A further aim was to compare the psychological effects of genetic counseling on participants from families with
breast and/or ovarian cancer with people from families with colon cancer. Previously published studies have not
compared the effects of genetic counseling on patients with different types of familial cancer. People have
different beliefs and levels of anxiety about the various types of cancer (e.g., Wroe, Salkovskis &Rimes, 1998),
and the CB model would suggest that the impact of genetic counseling would therefore also vary in relation to
these preexisting beliefs and anxiety. Thus, it would not be appropriate to simply assume that reactions to
genetic counseling for different forms of cancer are similar. f group differences were found, this information may
also be helpful for genetic counselors, who often have to counsel people with different types of cancer in their
family backgrounds. Therefore, in the present study, we compared the reactions of people with family histories
of colon or breast and/or ovarian cancer, which were the two most common types of family cancer history in this
sample. Methods ParticipantsParticipants were 218 people referred to the Oxford Regional Genetics Service,
Churchill Hospital, Oxford, United Kingdom. All patients referred to the clinic were sent the psychological
questions together with the standard preclinic-visit questionnaire, so everyone who pursued their referral
participated in at least the first part of this study. Participants were included if they were 18 years or older and
had a family history but not personal history of cancer. ProcedureEveryone referred to the clinic was sent a
preclinic-visit questionnaire about family/medical history in order for us to calculate their lifetime risk of cancer.
For those from families with breast and/or ovarian cancer, the risk figures were derived by interpolating the
Claus data set (Claus, Risch, &Thompson, 1994) using the program Cyrillic (version 2.1; Cyrillic Software,
Oxfordshire, United Kingdom, 1999). For those from families with colon cancer, the probability of a dominantly
inherited cancer-predisposing gene was calculated using Bayes's theorem. The probability of developing cancer
was calculated using the population prevalence of cancer and the penetrance of known hereditary nonpolyposis
colorectal cancer (HNPCC) genes.People who were calculated to have a "low additional risk (i.e., at or near
population risk) were sent a letter informing them that their risk had been calculated and that the chances of the
cancers in their family being determined by a major inherited genetic component were very low. These letters
contained information about genetic influences on cancer; population rates of cancer; recommendations, where
appropriate, regarding health behaviors; and an explanation of why frequent screening was not necessary in
their case. Patients were told that they could contact the service if they had further questions. n this sample,
28% (n = 61) were sent a letter rather than being seen in clinic. ndividuals were seen in clinic by a specialist
genetics nurse or physician if their calculated risk was not low or if further information was needed. For those
who were seen in clinic (n = 157; 72%), the genetic consultation included information about genetic influences
on cancer; population rates of cancer; and recommendations regarding health behaviors, surveillance
measures, and genetic testing, as appropriate. For both the individuals seen in clinic and those receiving the
"low-risk letter, sometimes an absolute risk figure (e.g., lifetime risk of 20%) was provided, but more commonly
their risk was discussed in relation to the general population risk. A letter summarizing the content of the
consultation was sent afterward. (When discussing the present study, we will use the phrase "genetic
counseling to refer to both the face-to-face consultation and the letter sent to some of those at low risk).Follow-
up questionnaires were posted 6 months after the time when the participants was either seen in clinic or sent
the letter providing their risk information. One reminder was sent to those who did not reply (n = 106, 48.6%).
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Of those participants who were sent reminders, 46 subsequently returned their questionnaires. These
individuals did not report significantly different levels of postcounseling anxiety than those who returned their
questionnaire unprompted, t (150) = 0.6. Measures Beliefs and feelings about cancerVisual analogue scales
(0100) were used, similar to those used in a study of the prediction of responses to bone density screening (
Rimes &Salkovskis, 2002). The scales are used to assess feelings and beliefs about the type of cancer that
occurred in the participants' families: anxiety about this cancer, need for reassurance and beliefs about their risk
for this type of cancer, likelihood that they would be able to prevent it, how bad it would be if they developed this
cancer, how well they would cope if they developed this cancer, and how likely it is that the cancer would be
successfully treated if they were to develop it. For ratings of the likelihood of developing cancer, participants
were asked to report their "feelings rather than what [they thought] a 'rational' or 'correct' response would be.
This question was based on the assumption that people's feelings about their risk would show a greater
association to their anxiety than what they might regard as a "rational response in which they did not really
believe. Risk perceptions assessed in this way had been found to be highly predictive of reactions to a different
type of health screening in a previous study (Rimes &Salkovskis, 2002). For all the scales, a higher score
indicated greater concern or more negative beliefs. General mood ratingsParticipants were asked to rate how
much they worry about their health in general and their current mood (sadness/low mood, anxiety) using visual
analogue scales as described earlier. The current mood measures have been used in previous research into
psychological aspects of health screening (e.g., Rimes &Salkovskis, 2002; Rimes, Salkovskis, &Shipman, 1999
; Wroe, Salkovskis, &Rimes, 2000). They have shown good sensitivity to change in mood over time; for
example, ratings on these measures increase immediately after a "high-risk result from bone mineral density
screening for osteoporosis (Rimes et al., 1999). The measure of a tendency to worry about one's health in
general was devised for this study because there was no space to include the full health anxiety questionnaire
used in our previous research. Demographic and medical/family historyDemographic and medical/family history
information was taken from the standard clinical questionnaire that participants were asked to complete by the
genetics clinic. Additional postcounseling measuresTwo additional questions were asked at follow-up: The first
was "Do you feel more or less worried about developing this condition since being referred to the genetics
clinic? Responses on a 7-point scale ranged from much less worried to much more worried . The second
question was "Compared with the 'average person,' how much 'at risk' do you feel for developing this condition
in the future? Responses on the 7-point scale ranged from much less at risk to much more at risk . Statistical
AnalysisChi-square analyses and independent t tests were used to compare the characteristics of participants
from families with breast and/or ovarian or colon cancer. People from families with histories of breast or ovarian
cancer were combined because some genes (breast cancer genes 1 and 2, or BRCA1 and BRCA2) have been
identified as ones that increase one's vulnerability to both these forms of cancer. People were excluded if they
had both colon cancer and breast or ovarian cancer in their family. Repeated measures analyses of variance
(ANOVAs) were used to compare the two groups in terms of the psychological variables before and after
counseling.To investigate responses of those with high and low levels of preexisting general health worry, we
created two dichotomous variables to represent high and low levels of general health worry and high and low
calculated risk of cancer. Cutoff scores (general worry <25 vs. general worry 30; calculated risk <11.9% vs.
calculated risk >12) were chosen to give similar sized groups. ANOVAs were used to examine change over time
in the psychological variables, with health worry and calculated risk as grouping variables.Multiple regression
analyses were performed to investigate predictors of anxiety and cancer-related beliefs. n cases in which
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variables were selected according to the CB model, standard (simultaneous) multiple regression analysis was
used. For exploratory analyses looking at whether medical/family history variables were associated with anxiety
and beliefs, stepwise regression methods were used. A variable was entered if the significance level of its F
was less than 0.05 and was removed if the significance level of F was greater than 0.1. For a number of the
participants, a full family history was not available, so analyses involving these variables typically involved a
smaller number of participants. Gender was not included in these analyses because it would be confounded
with a history of breast and/or ovarian cancer. Results Sociodemographic and Clinical Characteristics of the
SampleThe sample contained 189 women (86.7%) and 29 men (13.3%). The mean age of the participants was
39.4 years (SD = 9.9). Participants were not routinely questioned about ethnicity except whether they or
members of their immediate family were Jewish, because Jews of Ashkenazi descent may have elevated risk
for certain types of cancers. Of the 147 participants for whom data was available, 3 (2.0%) said that they or
someone in their immediate family was Jewish. n keeping with the community that the genetics clinic serves,
the majority of the participants were of Caucasian origin.Of those participants for whom the data were available,
the family histories were as follows: 68.8% with breast and/or ovarian cancer, 24.2% with colon cancer, 2.5%
with both breast and/or ovarian and colon cancer, <1% with prostate cancer, <1% with lung cancer, and 3.2%
with three or more different cancers. For some of the analyses described below, participants with family
histories of breast and/or ovarian cancer were compared with participants with colon cancer in their family.
Participants with family histories of breast and/or ovarian cancer were all women, whereas 45% of those with
colon cancer family histories were women. The participants in the breast and/or ovarian group were significantly
younger, t (144) = ~2.7, p <.05, than those in the colon cancer group, (M = 39.4, SD = 9.0, and M = 44.2,
SD = 10.9, respectively). There was no significant difference, t (142) = 0.3, in the calculated lifetime risk of
cancer for the individuals with breast and/or ovarian or colon cancer family histories (M = 16.2, SD = 9.7, and
M = 14.3, SD = 10.7, respectively). As would be expected, people from families with breast cancer were
significantly more likely to have a same-gender parent who had had cancer,
2
(1, N = 155) = 3.9, p <.05, had
more relatives of the same gender as themselves with cancer, t (153) = 2.4, p <.05, and had a greater
proportion of same-gender relatives with cancer, t (153) = 2.9, p <.005. There were no significant differences
between the two groups regarding the number or proportion of relatives who had had cancer, the number or
proportion of cancers on the most affected side of the family, the number of parents who had had cancer,
whether they had had a parent with cancer who had died, the number of siblings who had had cancer, the
youngest age of cancer onset in the family, or whether they had had a previous major illness. Characteristics of
People Who Did Not Return the Follow-up QuestionnaireCompared with those who returned the follow-up
questionnaire, people who did not return the questionnaire (29.8%) were significantly younger and had
significantly higher precounseling ratings of anxiety about cancer, belief in the likelihood that they would develop
cancer, need for reassurance, and general anxiety; see Table 1. There was a nonsignificant trend for them to
have a higher calculated lifetime risk of cancer, t (213) = 2.0, p = .084.
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Characteristics of Participants Who Did and Did Not Return the Follow-Up Questionnaire mpact of Genetic
Counseling Accuracy of risk perceptionsCorrelations between risk beliefs and calculated risk were r = .15 (p =
.064) before counseling and r = .23 (p <.05) 6 months afterward for the 150 participants who reported their risk
perceptions at both time points. Using Williams's (1959) revision of Hotelling's formula for testing the difference
between two nonindependent correlations, it was found that there was no significant difference between the
correlations for perceived risk and calculated risk before and after genetic counseling, t (147) = ~0.735. The
extent to which participants under- or overestimated their risk is shown in Table 2. The mean amount of
discrepancy (in either direction) between risk beliefs and calculated risk before the counseling was 41.2 (SD =
22.5) and 6 months after the counseling was 34.3 (SD = 22.1). A paired t test indicated that this represented a
significant improvement in accuracy of risk beliefs after counseling, t (152) = 4.0, p <.0005.

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Accuracy of Risk Perceptions Before and After Counseling (n = 150) Anxiety about developing cancerThose
who completed questionnaires at both points showed an overall decrease in anxiety about developing cancer,
t (148) = 4.8, p <.0005, Cohen's d = 0.33, with a precounseling mean of 48.2 (SD = 25.9) and a
postcounseling mean of 39.8 (SD = 25.6). However, 24.2% (36/149) of the sample had higher ratings of
cancer-related anxiety after counseling than before counseling (increase ranging from 5 to 45 points).
Comparison of Anxiety and Beliefs About Cancer in People With Family Histories of Breast and/or Ovarian or
Colon Cancer General group differencesFor most variables, there was a main effect of cancer type, with the
colon cancer group reporting lower levels of anxiety about cancer (Cohen's d = 0.43), general anxiety (Cohen's
d = 0.48), sadness/low mood (Cohen's d = 0.47), and need for reassurance (Cohen's d = 0.42). n addition,
the colon cancer group reported less negative beliefs about the likelihood of developing cancer in the near
future (Cohen's d = 0.53), likelihood of developing cancer at any point in the future (Cohen's d = 0.63), how
bad it would be to develop cancer (Cohen's d = 0.53), how well they would cope if they developed cancer
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(Cohen's d = 0.41), and the likelihood of successful treatment (Cohen's d = 0.42). There were main effects of
time for several variables, with participants reporting lower levels of anxiety about developing cancer (Cohen's
d = 0.34) and general anxiety (Cohen's d = 0.30), lower perceived likelihood of developing cancer in the near
future (Cohen's d = 0.22) and at any point in the future (Cohen's d = 0.29), and lower need for reassurance
(Cohen's d = 0.63) at the 6-month follow-up (see Table 3 for means, standard deviations, and F values).
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Changes in Beliefs and Distress Levels in People With Family Histories of Breast and/or Ovarian and Colon
CancerTo check that the group differences were not simply a result of the significant difference in age between
the two groups, we removed the 21 youngest participants from the breast cancer families and the two oldest
participants from the colon cancer families so that the two groups were matched for age (n = 87 and n = 36,
respectively). The ANOVAs were repeated, and the same patterns of results were found, although some effects
were slightly weaker or stronger than in the original analyses.Because the group differences may have resulted
from the fact that all participants in the breast cancer group were women whereas participants in the colon
cancer group were both men and women, we conducted exploratory analyses in which the ANOVAs were
repeated using only the 16 female colon cancer participants. Still significant group differences were found on
feelings concerning the likelihood of developing cancer and how bad it would be if one developed cancer, and
there were nonsignificant trends (.05 <p <.125) in the same direction for anxiety about cancer and the likelihood
of treatment success. The group differences concerning the need for reassurance or one's ability to cope if one
developed cancer were no longer significant. However, these results should be viewed with caution because of
the small number of female participants in the colon cancer group (n = 16) compared with the number in the
breast and/or ovarian group (n = 107). Did people who tended to worry about their health report more negative
cancer-related beliefs and anxiety and respond particularly negatively to "increased risk information?Contrary
to the prediction that people with a general tendency to worry about their health (high health-anxiety group)
would react particularly negatively to being told that they were at increased risk for cancer, there were no
significant Health Anxiety Risk Time interactions (all F s <2.5; see Table 4 for means, standard deviations,
and significant effects for all analyses in this section). There were significant Health Anxiety Time interactions
for anxiety about developing cancer, likelihood of developing cancer in the near future, need for reassurance,
how bad it would be if one developed cancer, and general state anxiety as well as a nonsignificant trend for
likelihood of developing cancer at any point in the future, F (1, 142) = 2.9, p = .089). Paired and independent t
tests were used to investigate these effects further, with alpha levels set at p <.025. These indicated that the
high health-anxiety group showed a significant reduction in anxiety about cancer after counseling (Cohen's d =
0.56), whereas the low health-anxiety group showed no significant change (Cohen's d = 0.13); see Figure 1a.
However, participants in the high health-anxiety group were significantly more anxious than the low health-
anxiety group at both time points (Cohen's d = 1.10 before counseling and 0.62 afterward). The same pattern
of results was shown for general state anxiety (Cohen's d = 0.50 for the change in the high health-anxiety
group, 0.14 for the change in the low health-anxiety group, 1.07 for group differences before counseling, and
0.73 afterward), perceived likelihood of developing cancer in the near future (Cohen's d = 0.39, 0.02, 0.74, and
0.35, respectively), and perceived likelihood of developing cancer at any point in the future (Cohen's d = 0.44,
0.18, 0.73, and 0.43, respectively; see Figure 1b). The high health-anxiety group had higher ratings of need for
reassurance both time points (Cohen's d = 1.08 before counseling and 0.59 afterward); both groups showed a
significant decrease by the follow-up (Cohen's d = 0.92 for the high health-anxiety group and 0.40 for the low
health-anxiety group), although the decrease was significantly larger in the high health-anxiety group.
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Graphs depicting (a) anxiety about developing cancer in people with high and low levels of health anxiety and
calculated risk, measured before genetic counseling and 6 months later and (b) perceived likelihood of
developing cancer at any point in the future in people with high and low levels of health anxiety and calculated
risk
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Graphs depicting (a) anxiety about developing cancer in people with high and low levels of health anxiety and
calculated risk, measured before genetic counseling and 6 months later and (b) perceived likelihood of
developing cancer at any point in the future in people with high and low levels of health anxiety and calculated
risk
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Distress and Beliefs in People With Low and High Levels of Health Anxiety and Low and High Calculated Risk
for CancerFor beliefs about how bad it would be if they developed cancer, the high health-anxiety group had
more negative ratings at both time points (Cohen's d = 0.89 before counseling, 0.54 after), although the low
health-anxiety group's ratings became significantly more negative by the 6-month follow-up (Cohen's d = 0.24)
whereas the high health-anxiety group showed no significant change over time (Cohen's d = 0.07). The high
health-anxiety group also reported greater sadness/low mood (Cohen's d = 1.01) and more negative beliefs
about how they would cope if they developed cancer (Cohen's d = 0.60), but there was no interaction with time
for these variables.There were main effects of risk group for perceived likelihood of developing cancer at any
point in time (Cohen's d = 0.35) and for perceived risk compared with "the average person (Cohen's d = 0.47),
indicating that those with greater calculated lifetime risk had higher risk perceptions. No interactions between
risk group and time were found, indicating that those with lower and higher risk did not respond significantly
differently to genetic counseling. Prediction of Anxiety and Beliefs Prediction of anxiety and beliefs from
medical/family history variablesHigher pre- and postcounseling ratings of the likelihood developing of cancer at
any point in the future were predicted by younger age but by no other medical/family history variables.
Significant predictors of more negative beliefs about how bad it would be to develop cancer were having had a
parent dying of cancer, which entered the regression equation first, followed by having had a previous major
illness. None of the medical/family history variables were significant of predictors of pre- or postcounseling
anxiety about developing cancer. See Table 5 for details of these results.
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Stepwise Multiple Regression Analyses Predicting Anxiety and Beliefs by Medical and Family History Variables
Prediction of beliefs and anxiety from variables derived from the CB modelPostcounseling beliefs about the
likelihood of cancer at any point in the future were significantly predicted by precounseling likelihood beliefs. n
the prediction of precounseling levels of anxiety about developing cancer, the following precounseling beliefs
entered as significant predictors: beliefs about the likelihood of developing cancer at any point in the future, the
likelihood of developing cancer in the near future, how bad it would be if one developed cancer, and the general
tendency to worry about one's health. Greater postcounseling anxiety about developing cancer was predicted
by higher precounseling ratings of the likelihood of developing cancer at any point in the future, more negative
beliefs about one's ability to cope if one developed cancer, and a general tendency to worry about one's health.
See Table 6 for details of these results.
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Multiple Regression Analyses Predicting Anxiety and Beliefs From Other Psychological Variables Discussion
Six months after genetic counseling, there was an overall decrease in anxiety about cancer, although a
significant minority of participants showed higher levels of anxiety afterward. Factors influencing the impact of
the counseling included beliefs about cancer, a preexisting tendency to worry about one's health, and the type
of cancer in the family. As predicted, participants' precounseling beliefs were more important predictors of
distress after genetic counseling than the individuals' calculated risk of cancer. Precounseling beliefs were
influenced in part by the participants' previous experiences of illness.The reduction in anxiety about developing
cancer found in the present study is consistent with the findings of some previous studies of cancer-specific
distress (e.g., Bish et al., 2002) although most have found that postcounseling changes are not significant,
especially in the longer term (Braithwaite et al., 2004). Overall group changes can conceal important individual
variations, and in this case, 24% showed an increase in anxiety about developing cancer at the 6-month point
after counseling. The clinical significance of this level of increase is not known, but the issue requires further
investigation in case some individuals require further advice or help.The extent to which medical/family history
variables were predictive of beliefs and anxiety about cancer were investigated in exploratory analyses. These
showed that having had a parent who had died of cancer and having had a previous major illness were both
significant predictors of beliefs about how bad it would be to develop cancer. This indicates that people's
previous experience of illness, either in themselves and others, seems to affect their beliefs about the
consequences that cancer would have for them. (However, the findings of these exploratory analyses require
replication because stepwise multiple regression methods were used, which are more likely to be affected by
chance differences within a single sample). n contrast, beliefs about the likelihood of developing cancer were
not predicted by any of the medical/family history variables that might be expected to influence risk perceptions,
such as the person's "actual (calculated) risk, the number of people in one's family who have had cancer, the
proportion of relatives on the affected side of the family who have had cancer, or having had a sibling with
cancer. Only younger age predicted higher pre- and postcounseling ratings of the likelihood of developing
cancer at any point in the future. Furthermore, none of the medical/family history variables were predictors of
pre- or postcounseling anxiety about developing cancer. This finding may be important information for people
who are training to become genetic counselors to bear in mind. t suggests that one should not make any
assumptions about patients' risk perceptions or the level of anxiety about cancer on the basis of their actual risk
or the facts about their family history.The finding that perceived risk before genetic counseling was significantly
associated with anxiety is consistent with the results of previous studies (e.g., Hopwood et al., 2001; Julian-
Reynier et al., 1999). n the present study, we also examined other beliefs as predictors of anxiety, derived from
a CB model of health anxiety. As expected, beliefs about how negative the consequences of cancer would be
and how well one would cope with cancer were both significant predictors of anxiety. However, relatively
positive beliefs about the likelihood of successful prevention and treatment were not predictive of lower levels of
anxiety, perhaps because the prevention and treatment of cancer can involve methods that are themselves
anxiety-provoking.People with family histories of colon cancer reported significantly lower levels of distress than
people with family histories of breast and/or ovarian cancer, despite no significant group difference in objective
risk. According to cognitive models of anxiety, this is because the colon cancer group had less negative cancer-
related beliefs (i.e., about likelihood, negative consequences, coping ability, and treatment). Factors that may
02 May 2013 Page 19 of 25 ProQuest
contribute to the group differences in such beliefs are the higher level of mass media attention to breast cancer
or the fact that people are more likely to have known people outside their family with breast cancer because it is
more common in the general population.Participants' general tendency to worry about their health also
predicted cancer-related anxiety before and after counseling. However, contrary to expectations, the more
highly health-anxious individuals showed a significant decrease in anxiety at follow-up, whereas those who did
not tend to worry about their health showed no significant change over time. This finding is probably due to the
fact that risk perceptions were reduced significantly in the high health-anxiety group but not in the low health-
anxiety group, perhaps because the high health-anxiety group had previously been overestimating their risk to a
much greater degree.One possible reason for the difference in these findings from those in a previous study of
bone density screening for osteoporosis (Rimes &Salkovskis, 2002), in which health-anxious individuals showed
an increase in anxiety after a high-risk result, is that many of the participants in the osteoporosis study were
volunteering for screening not because they already perceived themselves to be at risk but simply in order to
help research. When those participants were given high-risk information, it was often a surprise and resulted in
an increase in their risk perceptions. n contrast, participants in the present study were already aware of their
increased risk because of their family history and generally overestimated their risk beforehand. Here, they
received new information showing that their risk was usually much lower than their preexisting risk beliefs.
Furthermore, these patients were already in a state of uncertainty about their risk, and the genetic counseling
may have helped to reduce the ambiguity. This point highlights the importance of taking into account the
person's preexisting risk perceptions and state of uncertainty when attempting to understand reactions to health
screening. These factors are likely to differ in population-based screening compared with high-risk population
screening.Although the accuracy of risk perceptions increased slightly, both groups were still generally
overestimating their risk of cancer after counseling, as has been found in other studies. Participants' actual risk
status was not predictive of how they respondedthere was no evidence of greater reductions in risk
perceptions in those who were told that they were at lower risk. n contrast, precounseling risk perceptions were
a strong predictor of postcounseling risk perceptions. This finding indicates that to achieve more accurate risk
perceptions after genetic counseling, it may be necessary to identify and correct the bases for individuals'
preexisting idiosyncratic beliefs, in addition to providing information about their calculated risk. Similarly, to
reduce anxiety about cancer, it may be helpful to address other negative idiosyncratic beliefs, for example,
about one's ability to cope if one developed cancer. Questionnaires such as the one used in the present study
could be used to identify which individuals may be vulnerable to experiencing persistent distress and which of
their beliefs are particularly negative (e.g., risk of cancer, consequences, treatment, one's coping ability, and so
on). The genetic counselor would then need to elicit the precise content and reasons for the individual's beliefs
within the session in order to modify them effectively.An important previous study identifying precounseling
predictors of postcounseling cancer-specific distress found that postcounseling scores on the mpact of Event
Scale (ES; Horowitz, Wilner, &Alvarez, 1979) were predicted by baseline ES scores and that only the less
educated women showed a significant decrease in ES scores (Lerman et al., 1996). Using measures of
precounseling beliefs as predictors of distress, as we did in the present study, means that elevated scores
indicate not only that intervention may be required but the nature of that interventionthat is, which
dysfunctional beliefs need to be addressed. Future studies should combine these approaches, using belief
questionnaires together with well-validated measures of symptoms and sociodemographic variables.
Participants who returned their follow-up questionnaires were less anxious and felt less at risk of cancer before
02 May 2013 Page 20 of 25 ProQuest
counseling than those who did not return the second questionnaire. This finding means that the negative effects
of genetic counseling were probably underestimated in the study. A further limitation is that postcounseling
assessments were only taken at 6 months, and immediate or longer term reactions may have shown a different
pattern of results. The fact that the patients were all seen within a single clinic may also limit the generalizability
of the results. Furthermore, the ethnicity, education level, and social class of the participants were not
assessed, which makes it more difficult to compare these results with those of other studies that may have had
different participant profiles.The questionnaire measures were adapted from measures in a previous study
examining responses to health screening (Rimes &Salkovskis, 2002). Although it would have been preferable to
use well-validated measures, no such measures were available at the time of the study that were brief enough
for use in that context. Similar measures have been shown to be predictive of responses to health screening
and have good correlations with longer measures of health anxiety (Rimes &Salkovskis, 2002). However, in
future research, it will be important to replicate the findings using better validated questionnaires.n services
such as the one studied in the present study, genetic information is offered in a range of ways, varying from
letters about genetic risk and other relevant issues sent to those at obviously low risk to face-to-face counseling
provided to those at ambiguous or high risk. n the present study, we wished to evaluate all of those referred to
the service, that is, those at all levels of risk, so the intervention inevitably contained this range of components.
The applicability of this research to routine clinical practice is strengthened by the study's setting and
methodology.The CB model of health anxiety focuses primarily on the perception of threat (including but not
confined to risk) and the associated emotional responses. ntegral to this theory are behavioral responses in the
form of safety-seeking behaviors, ranging from avoidance of threatening medical information to excessive
reassurance-seeking behaviors. However, the specific prediction of medically important behaviors (e.g.,
preventive and surveillance behaviors) is outside the focus of this model and may well be best viewed from
another perspective. For example, the association between anxiety and health-related behavior change has
been found to be weak and inconsistent in the context of health screening decision-making research (e.g.,
Wroe et al., 1998, 2000), in which another cognitive theory (the modified subjective expected utility theory) may
provide a better account of behavior change.n conclusion, although genetic counseling was associated with an
overall decrease in anxiety about developing cancer, most people continued to overestimate their risk for the
disease and some became more distressed. As predicted by a CB model of health anxiety, individuals'
preexisting beliefs about cancer were significant predictors of distress and risk perceptions after genetic
counseling. t is possible that genetic counseling would result in a greater accuracy in risk perceptions and
larger reductions in anxiety if the bases for these idiosyncratic beliefs were addressed within the consultation. A
CB model of health anxiety has now been shown to be useful in understanding and predicting reactions to two
types of health screeningbone density screening for osteoporosis and genetic counseling for cancer. Further
research is needed to investigate whether it is also useful in predicting reactions to other types of health
screening.

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Show less

Address for Correspondence:Katharine Rimes, Department of Psychological Medicine, Section of General
Hospital Psychiatry (P062), King's College London, nstitute of Psychiatry, Weston Education Centre (3rd
Floor), 10 Cutcombe Road, London, United Kingdom SE5 9RJ
Email:k.rimes@iop.kcl.ac.uk

2006 American Psychological Association
02 May 2013 Page 22 of 25 ProQuest

Subject: Anxiety (major); Cognitive Therapy (major); Genetic Counseling (major); Neoplasms (major); Risk
Perception (major); Genetics; Health
Classification: 3293: Cancer; 3311: Cognitive Therapy
Age: Adulthood (18 yrs & older)
Population: Human, Male, Female
Location: United Kingdom
dentifier (keyword): cognitive-behavioral model, health anxiety, risk perceptions, genetic counseling, cancer
Test and measure: Visual Analogue Scale
Methodology: Empirical Study, Followup Study, Quantitative Study
Author e-mail address: k.rimes@iop.kcl.ac.uk
Contact individual: Rimes, Katharine A., Department of Psychological Medicine, Section of General Hospital
Psychiatry (P062), King's College London, nstitute of Psychiatry, Weston Education Centre, 10 Cutcombe
Road,; (3rd Floor), London, SE5 9RJ, United Kingdom,; k.rimes@iop.kcl.ac.uk
Publication title: Health Psychology
Volume: 25
ssue: 2
Pages: 171-180
Publication date: Mar 2006
Format covered: Electronic
Publisher: American Psychological Association
Country of publication: United States
SSN: 0278-6133
eSSN: 1930-7810
Peer reviewed: Yes
Language: English
Document type: Journal, Journal Article, Peer Reviewed Journal
Number of references: 27
DO: http://dx.doi.org/10.1037/0278-6133.25.2.171
Release date: 27 Mar 2006 (PsycNFO); 10 Jul 2006 (PsycARTCLES)
Correction date: 02 Nov 2009 (PsycNFO)
Accession number: 2006-03515-005
PubMed D: 16569108
ProQuest document D: 614445369
Document URL:
https://fgul.idm.oclc.org/login?url=http://search.proquest.com/docview/614445369?accountid=10868
02 May 2013 Page 23 of 25 ProQuest
Copyright: American Psychological Association 2006
Database: PsycARTCLES
02 May 2013 Page 24 of 25 ProQuest
Bibliography
Citation style: APA 6th - American Psychological Association, 6th Edition
Rimes, K. A., Salkovskis, P. M., Jones, L., & Lucassen, A. M. (2006). Applying a cognitive behavioral model of
health anxiety in a cancer genetics service. Health Psychology, 25(2), 171-180.
doi:http://dx.doi.org/10.1037/0278-6133.25.2.171

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