DYSFUNCTIONALATTITUDES,DEPRESSIONANDQUALITY

OFLIFEINASAMPLEOFROMANIANHUNGARIANCANCER
PATIENTS

Brief Research Report

va KLLAY* 1 , Csaba L. DEGI 2 , Anna E. VINCZE 1

1 Department of Psychology, Babe-Bolyai University, Cluj-Napoca, Romania
2 Semmelweis University, Faculty of Medicine, Budapest, Hungary

ABSTRACT
The main objective of this exploratory study was to investigate the relationship
between depression, dysfunctional attitudes (DA), and their effect on quality of
life (QoL) in a sample of Romanian Hungarian cancer patients. Our sample
consisted of 376 patients hospitalized with different types and grades of cancer,
and was assessed with the Beck Depression Inventory, the Dysfunctional
Attitudes Scale, and the Functional Quality of Life Scale. We have found
significant differences in depression only between age groups; significant
differences in quality of life between age groups and different levels of
education; significant differences of dysfunctional attitudes have been found
between rural and urban patients. As our data have revealed, in the assessed
population one of the most disturbing psychological changes that may
accompany this life threatening illness consists in the heightened levels of
depression. Taking into consideration the specificities of the traditional rural
Romanian Hungarian culture, the reasons for these differences in depression
and QoL may be induced or catalyzed by other mechanisms as well. The
significant, though weak correlation between DA and depression supports this
presumption. We believe that cancer patients may need more individual-tailored
and culture specific interventions (CBT, social, emotional support,
pharmaceutical treatment or combined), nevertheless, we are conscious that
future, more thorough investigations are needed.

KEYWORDS: psycho-oncology, depressive symptoms, dysfunctional attitudes,

quality of life

*
Corresponding author:
E-mail: evakallay@psychology.ro
INTRODUCTION

The diagnosis with cancer, its prolonged treatment and physical side effects
can have a profound impact on the patients life.
Approximately 25% of the patients diagnosed with cancer report
considerable levels of distress around the event (McDaniel, Musselman, Porter,
Reed, & Nemeroff, 1995). This first stage is characterized by intense symptoms of
anxiety, depression, cognitive, and behavioral impairments in functioning. Usually,
after approximately 2-3 weeks, the levels of distress seem to decrease (Chaturvedi
& Maguire, 1998; Nordin & Glimelius, 1999), the person bouncing back to an
acceptable level of functioning, while trying to incorporate the event in an
accommodating way into his/her life narrative. Nevertheless, a significant part of
research has not found any kind of decrease in the levels of distress (Omne-Ponten,
Holmberg, & Sjoden, 1992; Vinokur, Threatt, Vinokur-Caplan, & Satariano, 1990),
patients experiencing anxiety and depression even years after diagnosis and
cessation of treatment.
As concerning the relationship between cancer and dysfunctional attitudes,
long-term cancer survivors may have recurrent thoughts about the diagnosis and
experience a greater sense of uncertainty about their health, about their future, and
fears regarding the recurrence of the cancer (Tross & Holland, 1989).
Severe, life-threatening illness does not only affect a persons organism; it
affects his/her entire life on all its dimensions, exerting physical, psychological,
behavioral, social, and sexual changes. The study, diagnosis, and treatment of
severe illness has until recently been interested mostly in length of survival,
physical and psychological changes, taking little account of the way patients
perceived themselves in the particular situation. Nevertheless, most recent
approaches have taken seriously into consideration this aspect as well, within the
concept of quality of life (QoL) after diagnosis and/or installation of illness. The
issue of QoL becomes even more stringent in clinical oncology, where both
diagnosis and treatment are severely debilitating (Fayers & Bottomley, 2002). In
this specific situation where the changes produced by surgical and/or non-surgical
interventions (radio-therapy, chemotherapy, etc.), the implications of the highly
charged psychological nature of the diagnosis itself, become decisive factors that
increasingly participate in treatment decisions. Consequently, the investigation of
the factors implied in QoL along other parameters of the illness is strongly
supported by the actual health policy targeting the prevention of premature
mortality and morbidity, and simultaneously enhancing QoL itself (Pojoga, 2001).
The World Health Organization defines QoL as an individuals perception of
his/her position in life in the context of culture and value systems in which he/she
lives and in relation to his/her goals, expectations, standards and concerns
(WHOQOL, 1994, p. 25). Most frequently, QoL is defined as the subjective
perception the patient has about his health status, as well as the changes within
his/her health status that may be affecting his/her daily functioning (Spilker, 1990;
Pojoga, 2001).

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 A considerable number of studies have found a significant relationship
between dysfunctional attitudes and depressive symptoms (Marton, Churchard, &
Kutcher, 1993; Weich, Churchill, & Lewis, 2003). Dysfunctional attitudes are
negatively biased assumptions and beliefs regarding oneself, the world, and the
future (Beck, 1976). They contain and reflect the content of stable cognitive
schemata (Beck, Brown, Steer, & Weissman, 1991; Macavei, 2006), thus becoming
a central issue in depression has been strongly supported by cognitive behavioral
theories (Beck, 1979). Dysfunctional attitudes may reflect negative maladaptive
cognitive biases in which, compared to positively valenced information, the
importance of negatively valenced information is exaggerated (Beck, 1976). The
level of dysfunctional attitudes usually increases beyond the healthy range in case
of depression (Beck, 1976). Several findings suggest that dysfunctional attitudes
impair spontaneous recovery from depression and that the effects of antidepressant
drug treatment may obscure this effect (Lam, Green, Power, & Checkley, 1999).
Other findings have confirmed a positive, direct association between the level of
dysfunctional attitudes and level of depression. The presence and persistence of
these dysfunctional attitudes evidently heightened the development of symptoms
associated with depression.

A considerable amount of research has dealt with investigating the

relationship between depression and dysfunctional attitudes. Similarly, the relation
between depression and quality of life has also been thoroughly studied.
Nevertheless, to our knowledge, the relationship between dysfunctional attitudes
and quality of life in cancer patients has not been addressed.
Moreover, as a recent research targeting differences in levels of depression
in Romanian cancer patients has revealed (Degi, Kallay, Vincze, & Kopp, in press),
the Romanian Hungarian cancer populations has proved to be significantly more
depressed than their Romanian counterpart. Consequently, we consider very
important to investigate the possible relationship between depression,
dysfunctional attitudes and quality of life in this sample. This aspect is extremely
important, since this particular population has scarce access to specialized
intervention.

OBJECTIVES

The major objective of our exploratory study is to investigate the

relationship between depression, dysfunctional attitudes, and their possible effect
on quality of life in this special cultural environment. The impact of some
demographic factors previously investigated in relationship to these constructs
(Degi et al., in press) will also be explored.

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METHOD

Participants

The patients included in this study were all diagnosed with different types
and grades of cancer (34 % breast cancer, 19 % cervical cancer, 17 % prostrate
cancer, 30% lung cancer). All patients were hospitalized at the time of assessment.
The sample consisted of 375 patients hospitalized at the County Hospitals in
Miercurea Ciuc (Oncology Department) and Trgu Mure (Oncology Department),
with ages ranging from 18 to 80 years, coming from both rural (66) and urban
(277) environments. 207 of the participants were female patients and 168 male
patients. All patients were assessed 12 to 14 months after being diagnosed.

Materials

1. Depression and depressive symptoms

Depression and depressive symptoms were assessed by the shortened,

nine-item version of the Beck Depression Inventory (BDI). This inventory has
been found to be a reliable measure of depressive symptoms, and symptom
severity both on Hungarian and Romanian populations (Kopp & Skrabski, 1996;
Rozsa, Szadoczky, & Furedi, 2001). In this study the internal consistency for the
scale was .87 (0 = lowest score, 27 = maximal score) (see scale in Appendix 1).

2. Dysfunctional attitudes

Generally dysfunctional attitudes are assessed with Dysfunctional

Attitudes Scale (DAS) developed by Weissman and Beck (Weismann & Beck,
1979) and used in many studies in relationship with assessment of depression
either directly or as a vulnerability factor (Beck, Rush, Shaw, & Emery 1979). In
our study we used the shortened, 8-item version of the original scale. The internal
consistency of the scale for our population was .62 (8 = lowest score, 32 =
maximal score) (see scale in Appendix 2).

3. Quality of life

One of the most appropriate assessment tools used to assess QoL in cancer
patients is the FACT-G (Functional Assessment of Cancer Therapy General,
assessing four dimensions of QoL in cancer patients: physical well-being,
social/family well being, emotional well-being and functional well-being. Our
study has focused on the 7-item functional well-being subscale, which in our
population had an internal consistency of .79 (see scale in Appendix 3).

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Procedure

All participants were asked whether they agree to participate in the study
or not. After receiving their verbal agreement, the participants were asked to
complete a demographic questionnaire, requiring data about age, level of
education, provenience (rural vs. urban), and ethnicity. After completing this, they
were asked to complete the nine-item version of the BDI, the DAS and the FACT-
G described above.

RESULTS

In Table 1 we present the descriptive statistics for the demographic variables

Table 1. Descriptive statistics for the demographic variables

Study variables Cancer patients

(n=375)
Gender n (%)
Women 207 (55.2)
Men 168 (44.8)
Age Mean
51.33
n (%)
18 35 age group 50 (13.6)
36 65 age group 271 (73.4)
66 and over age group 48 (13)
Education level n (%)
Mandatory or less 57 (15.3)
High school 247 (66.4)
College / University 68 (18.3)
Environment n (%)
Rural 96 (25.7)
Urban 277 (74.3)

In Table 2 presents the Impact of demographic data on depression,

dysfunctional attitudes and quality of life.

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 Table 2.
Impact of demographic data on depression, dysfunctional attitudes and
quality of life.

Study Depression p Dysfunctional p Functional p

variables (BDI score) attitudes quality of life
(DAS score) (FACT score)
Gender Mean (SE) Mean (SE) Mean (SE)

Women 20.12 (1.07) 10.81 (0.28) 16.16 (0.47)

Men 19.61 (1.20) p >.05 10.81 (0.33) p >.05 15.21 (0.54) p >.05
Age Mean (SE) Mean (SE) Mean (SE)

18 35 age
group 13.26* (2.09) 9.97 (0.57) 18.57 (0.92) p <.01
36 65 age p <.01 p >.05
group 19.53* (0.96) 10.88 (0.25) 15.97 (0.41) p <.05
66 and over
age group 28.62* (2.14) 11.41 (0.60) 11.29 (0.98)
Education Mean (SE) Mean (SE) Mean (SE)
level

Mandatory or 25.46* (2.08) p <.05 10.80 (0.59) 12.87* (0.96) p <.01

less
High school 19.13 (1.00) 11.04 (0.27) p >.05
College / p >.05 16.19* (0.43)
University 18.31 (1.78) 10.06 (0.48) 16.48* (0.79) p >.05
Environment Mean (SE) Mean (SE) Mean (SE)

Rural 20.35 (1.56) p >.05 11.55 (0.43) p <.05 15.87 (0.69) p >.05
Urban 19.71 (0.94) 10.54 (0.25) 15.71 (0.41)

SE = standard error; Covariates = age, gender

Probability value for Bonferroni test for continuous variables (covariates age and gender)
were calculated.

As the results in Table 2 indicate, we have found significant differences in

levels of depression between all age groups (p <.01), meaning that the most
depressed are the patients over 66 years of age, and least depressed are individuals
belonging to the younger generations. By the same token, depression varies
significantly depending on the level of education (p <.05). The most depressed are
those who have fulfilled only mandatory education. We have found no significant
differences in the level of depression between high-school and university
graduates.

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 Interestingly, we have found no significant differences within the group
depending on gender, age, and level of education regarding the level of
dysfunctional attitudes (DA). Nevertheless, our data have revealed significant
differences depending on environment (rural-urban), meaning that cancer patients
coming from rural areas have significantly more dysfunctional attitudes ( p <.05)
than urban cancer patients (see table 2).
Regarding QoL, we have found significant differences between age groups
(p <.01, p <.05). More specifically, older patients relate significantly the lowest
quality of life, while the younger cancer patients do relate significantly higher
quality of life. By the same token, there are significant differences depending on
levels of education; those who have fulfilled only mandatory education report a
lower quality of life than those with higher levels of education.

Table 3 presents correlations between depression, DA and QoL.

Table 3.
Correlation between BDI, DAS, FACT

Depression Dysfunctional Functional

(BDI score) attitudes quality
(DAS score) of life
(FACT score)
Pearson r= .152* r= -.561**
correlation p= .010 p= .000
* Correlation is significant at the 0.05 level (2-tailed)
** Correlation is significant at the 0.01 level (2-tailed)

As the results in Table 3 reveal, there are significant, nevertheless modest

relationship between depression scores and DA (r=.155*), while significant and
strong relationship between depression and QoL (r=.561**).

DISCUSSIONS AND CONCLUSIONS

Based on our previous research (Degi et al., in press), and present data, in
the assessed Romanian Hungarian cancer population one of the most disturbing
psychological changes that may accompany this life threatening illness consists in
the heightened levels of depression. The more depressed the patient is the lower
his/her quality of life is. These results were consistent along age groups and
different levels of education: older patients were found to be significantly more
depressed than younger patients, and their quality of life was also significantly
lower that that of younger patients. The same results have been found across levels
of education. Those with lower education are significantly more depressed and
have a lower quality of life compared to their more educated counterparts.

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 We have found no significant differences neither in levels of depression
and quality of life between patients coming from rural and urban areas. However,
we have found significant differences of Dysfunctional Attitudes between these
groups; namely, rural patients have a significantly higher level of DA than do urban
patients. These results may hint at the possibility that in the case of rural
population, dysfunctional attitudes may not directly lead to the development of
high levels of depression, and low levels of QoL.
Taking into consideration the specificities of the traditional rural Romanian
Hungarian culture, the reasons for these differences in depression and QoL may be
induced or catalyzed by other mechanisms as well. The significant, though weak
correlation between DA and depression supports this presumption.
Accordingly, in order to enhance Romanian Hungarian cancer patients
quality of life may be done through the reduction of the levels of depression but
not necessarily through intervention only on DA. It is possible that more complex
intervention, involving other aspects of life and illness would be welcome.
As presented above, in many cases dysfunctional attitudes regarding the
illness, the physical and psychological changes produced by it, the uncertainty of
future, etc. may lead or exacerbate the distress and depression. This heightened
level of depression may change the patients quality of life in a negative direction,
thus forming a vicious circle: the dysfunctional attitudes leading to, maintaining
and/or aggravating depression; high levels of depression deteriorating quality of
life; low quality of life sustaining and aggravating depression and so on. One of the
most efficient ways to break this circle up might be the direct intervention targeting
the change of dysfunctional attitudes, thus reducing depression, which at its turn
may improve the patients quality of life. This improved quality of life may further
on exert its effect by providing the patient emotional comfort in this delicate state,
which hopefully may in the long run beneficially influence the unfolding of the
event.

We hope that our results will help specialists identify factors important in
the development of more individual-tailored and culture specific interventions
(CBT, social, emotional support, pharmaceutical treatment or combined),
nevertheless, we are conscious that future, more thorough investigations are
needed.

REFERENCES
Beck, A. (1976). Cognitive Therapy and the Emotional Disorders. NewYork, International
Universities Press.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
New York: Guilford.

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Beck, A.T., Brown, G., Steer, R.A., & Weissman, A.N. (1991). Factor Analysis of the
Dysfunctional Attitude Scale in a Clinical Population. Psychological Assessment:
A Journal of Consulting and Clinical Psychology, 3, 478-483.
Burns, D.D., & Spangler, L.D. (2001). Do Changes in Dysfunctional Attitudes Mediate
Changes in Depression and Anxiety in Cognitive Behavioral Therapy ? Behavior
Therapy, 32, 337-369.
Chaturvedi S.K., Maguire G.P. (1998). Persistent somatisation in cancer: a follow up study.
Journal of Psychosomatic Research. 45. 249-56.
Degi, Cs. L., Kallay, E., Vincze, A. E., & Kopp, M. (in press). A cross-cultural study on
cancer related depression: in Hungarian, Romanian, and Romanian Hungarian
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EORTC QLO-C30. European Journal of Cancer. 38. 125-133.
Kopp, M. S.,& Skrabski, . (1996). Behavioural sciences applied to a changing society.
Budapest, Hungary: Biblioteca Septem Artium Liberalium.
Lam, D. H., Green, B., Power, M. J., & Checkley, S. (1996). Do levels of dysfunctional
attitudes predict recovery in major depression? Clinical Psychology &
Psychotherapy, 4 (4), 246 250.
Macavei, B. (2006).Dysfunctional Attitudes Scale, Form A; Norms for the Romanian
population. Journal of Cognitive and Behavioral Psychotherapies, 6(2), 157-173.
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women with breast cancer stages I and II: six-year follow-up of consecutive
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Pojoga, C. (2001). Quality of Life and Breast Cancer: A Review from a Behavioral
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Reuter, K., & Hrter, M. (2004). The concepts of fatigue and depression in cancer.
European Journal of Cancer Care, 13, 127134.
Rzsa, S., Szdczky, E., & Fredi, J. (2001). Psychometric properties of the Hungarian
version of the shortened Beck Depression Inventory. Psychiatria Hungarica, 16,
384402. (in Hungarian)
Spilker, B. (1990). Quality of life assessments in clinical trials. Raven Press: New York.
Tross, S. & Holland, C.J. (1989). Psychological Sequelae In Cancer Survivors. In Holland,
J.C. & Rowland, J.H. (Eds.). Handbook of Psychooncology. New York. Oxford
University Press. pp. 101-116.
Vinokur, A.D., Threatt, B.A., Vinokur-Caplan, D., & Satariano, W.A. (1990). The process
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Weismann, A.N., Beck, A.T. (1979) The dysfunctional attitude scale Thesis, University,
Philadelphia. (translation by Kopp Maria, 1985, in Klinikai pszichofiziolgia,
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International Journal of Mental Health, 23. 24-56.

APPENDIX

Appendix 1
Shortened 9-item Beck Depression Inventory

1. Not characteristic at all

2. Scarcely characteristic
3. Characteristic
4. Fully characteristic

1. I have lost all of my interest in other people.

2. I can't make decisions at all any more.
3. I wake up several hours earlier than I used to and cannot get back to sleep.
4. I am too tired to do anything.
5. I am so worried about my physical problems that I cannot think about anything
else.
6. I can't do any work at all.
7. I feel that the future is hopeless and things cannot improve.
8. I am dissatisfied or bored with everything.
9. I feel guilty all of the time.

Appendix 2
Dysfunctional Attitude Scale

1. Disagree very much

2. Disagree slightly
3. Agree slightly
4. Agree strongly

1 My value as a person depends greatly on what others think of me.

2 If a person I love does not love me, it means I am unlovable.
3 If I fail at my work, then I am a failure as a person.
4 I should be upset if I make a mistake.
5 If I do nice things for someone, I can anticipate that they will respect me and

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 treat me just as well as I treat them.
6 I must try to help everyone who needs it.
7 My happiness is largely dependent on what happens to me.
8 People are generally dishonest and selfish and they want to take advantage of
others.

Appendix 3
FACT-G

Below is a list of statements that other people with your illness have said are important. By
circling one (1) number per line, please indicate how true each statement has been for you
during the past 7 days.

PHYSICAL WELL-BEING

Not A Some Quite Very

at little what a bit much
all bit
1 I have a lack of energy 0 1 2 3 4
2 I have nausea 0 1 2 3 4
3 Because of my physical condition, I have 0 1 2 3 4
trouble meeting the needs of my family
4 I have pain 0 1 2 3 4
5 I am bothered by side effects of treatment 0 1 2 3 4
6 I feel ill 0 1 2 3 4
7 I am forced to spend time in bed 0 1 2 3 4

SOCIAL/FAMILY WELL-BEING

Not A Some Quite Very

at little what a bit much
all bit
1 I feel close to my friends 0 1 2 3 4
2 I get emotional support from my family 0 1 2 3 4
3 I get support from my friends 0 1 2 3 4
4 My family has accepted my illness 0 1 2 3 4
5 I am satisfied with family communication 0 1 2 3 4
about my illness
6 I feel close to my partner (or the person who 0 1 2 3 4
is my main support)
Regardless of your current level of sexual
activity, please answer the following
question. If you prefer not to answer it,
please check this box and go to the next
section.
7 I am satisfied with my sex life 0 1 2 3 4

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EMOTIONAL WELL-BEING

Not A Some Quite Very

at little what a bit much
all bit
1 I feel sad 0 1 2 3 4

2 I am satisfied with how I am coping with 0 1 2 3 4

my illness
3 I am losing hope in the fight against my 0 1 2 3 4
illness
4 I feel nervous 0 1 2 3 4
5 I worry about dying 0 1 2 3 4
6 I worry that my condition will get worse 0 1 2 3 4

FUNCTIONAL WELL-BEING

Not A Some Quite Very

at little what a bit much
all bit
1 I am able to work (include work at home) 0 1 2 3 4
2 My work (include work at home) is 0 1 2 3 4
fulfilling
3 I am able to enjoy life 0 1 2 3 4
4 I have accepted my illness 0 1 2 3 4
5 I am sleeping well 0 1 2 3 4
6 I am enjoying the things I usually do for fun 0 1 2 3 4
7 I am content with the quality of my life right 0 1 2 3 4
now

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