Introduction

Breast cancer accounts for 31% of all women’s cancers in the United States [1]. Feeling of pain is common in breast cancer [3]. Pain-related anxiety refers to the combination of cognitive, psychological, and behavioral reposnses to pain or pain-related events [4]. In patients with cancer, emotion regulation are impaired [6]. Emotional regulation refers to actions that are used to modify an emotional state [7]. In the context of chronic pain, Acceptance and Commitment Therapy (ACT) targets ineffective control and avoidance strategies by fostering techniques that lead to psychological resilience [11]. It helps people to accept pain (to experience pain or unpleasant events without trying to control them) or pain-related thoughts, promote meaningful aspects of life, and increase valuable activities [12]. In this method, the patient is taught that any action to avoid or control these unwanted mental experiences is ineffective or has adverse effects, and that the experiences must be fully accepted without any attempt to eliminate them [15, 16]. The aim of this study is to examine the effect of group therapy based on ACT method on pain-related anxiety and cognitive emotion regulation in patients with breast cancer.

Materials and Methods

 This is a quasi-experimental study with pretest/postest design. The study population consists of all patients with a diagnosis of breast cancer referred to Shahid Ghazi Hospital in Tabriz, Iran. of these, 68 eligible patients were selected using a convenience sampling method and randomly divided into two groups of intervention (n=34) and control (n=34). The intervention group received 8 weeks of ACT, while controls recived 8 weeks of routine training with no ACT content. Treatment sessions were conducted by an expert in psychology. Data collection tools were: (a) Pain Anxiety Symptom Scale-Short Form (PASS) developed by McCracken and Dhingra [22] which has 20 items and 4 subscales of cognitive, escape/avoidance, fear, and physiological anxiety symtomps; and (b) Cognitive Emotion Regulation Questionnaire (CERQ) developed by Garnefski et al. [23] which has 36 items measuring two negative and postive affects. Their validity and reliability have been already confirmed in different studies. 

Results

Subjects in the experimental and control groups were homogenous in terms of age (t=-2, P=0.6) and marital status (x2=0.4, P=0.7). Analysis of the main and interaction effects of the factors using Wilks’ lambda statistic showed that the ACT intervention has made a significant difference in the cognitive emotion regulation model (F=47.5, P=0.001). The results of Levene’s test used for testing the equality of variances of pain-related anxiety and cognitive emotion regulation, was not significant (P>0.05). Table 1 presents the results of comparing the mean scores of pain-related anxiety and cognitive emotion regulation for the two study groups.

In order to investigate the differences between the mean scores of the two groups, after controling the effects of the pretest scores, one-way ANOVA was used for pain-related anxiety and MANCOVA was used for cognitive emotion regulation variables. Results presented in Table 2 showed that ACT reduced pain-related anxiety and cognitive regulation of negative affect, and increased cognitive regulation of positive affect.

Discussion

ACT reduced pain-related anxiety and cognitive regulation of negative affect, and increased cognitive regulation of positive affect. This is consistent with the results of Fish et al. and Cho et al. [24, 25]. The use of some adaptive emotion regulation strategies, such as cognitive reappraisal, to cope with stress, can increase positive emotions by reducing negative emotions [26]. Due to the effect of ACT on different dimensions of pain, it is a suitable alternative to other treatment methods [27]. With its techniques, ACT aims to accept the present conditions and take active and committed actions. Techniques such as considering thoughts as an imaginary thing, not real [28], reducing experiential avoidance and increasing flexibility [25], correction and strengthening of self-compassion, reduction of misplaced judgments [29], increasing the acceptance of existing conditions and the commitment to action, observing life events and seeing oneself as part of it [30] are some techniques used in this method. In other words, it helps patient accept pain-related anxiety as part of his/her life by accepting pain and related thoughts [15].

The limitations of this study was the absence of some patients in some treatment sessions, difficulty in selecting subjects with the disease knowledge and finding a standard location. In future studies, the case study method should be used to investigate the trend of changes based on treatment techniques. The ACT is recommended for patients with mastectomy due to their tangible physical changes.

Conclsuion

ACT allows patients to become familiar with their feelings and thoughts and to be able to observe and identify their negative emotions, and learn ways to reduce judgmental look to these thoughts.

Ethical Considerations

Compliance with ethical guidelines

The participants were informed about the purpose of the research and its implementation stages; they were also assured about the confidentiality of their information; Moreover, They were allowed to leave the study whenever they wish. This study ethically approved by the Medical Ethics Committee of Tabriz University of Medical Sciences (Code: 1397.287 IR.TBZMED.REC) and registered in Iranian Registry of Clinical Trials (IRCT2017100615590N5).

Funding

This research was conducted with the financial support of the Hematology and Oncology Research Center of Tabriz University of Medical Science.

Authors' contributions

All authors contributed in preparing this article.

Conflicts of interest

The authors declared no conflict of interest.

Acknowledgements

The authors would like to thank the esteemed colleagues and staff of Shahid Ghazi Hospital in Tabriz, as well as the management of the Aramesh Andisheh Counseling Center in Tabriz, who cooperated in the implementation of this project

References

1.Kolden GG, Strauman TJ, Ward A, kata J, woods TE, Schneider KL, et al. A pilot study of Group Exercise Training (GET) for women with primary breast cancer: Feasibility and healed benefits. Psychooncology. 2002; 11(5): 447-56. [DOI:10.1002/pon.591] [PMID]

2.Ake chi T, Nakano T, okamura H, etal. Psychiatric disorders in cancer patients: Descriptive analysis of 1721 Psychiatric referrals at two Japanese cancer hospitals. Jpn J Clin Oncol. 2001; 31(5):188-94. [DOI:10.1093/jjco/hye039] [PMID]

3.Wang K, Yee C, Tam S, Drost L, Chan S, Zaki P, Rico V & et al. Prevalence of pain in patients with breast cancer post-treatment: A systematic review. Breast. 2018; 42:113-27 [DOI:10.1016/j.breast.2018.08.105] [PMID]

4.Asmundson G, Vlaeyen JWS, GC. Understanding and treating fear of pain. Oxford, UK: Oxford University Press; 2004.

5.Schreier AM, Johnson LA, Vohra NA, Muzaffar M, Kyle B. Post-treatment symptoms of pain anxiety, sleep disturbance, and fatigue in breast cancer survivors. Pain Manag Nurs. 2018; 20(2). [DOI:10.1016/j.pmn.2018.09.005]

6.Moskowitz JT. Emotion and coping. In: Tugade MM, Shiota MN, Fredrickson BL, Kirby LD, editors. Handbook of Positive Emotions: Guilford Publications; 2016.

7.Amstadter A. Emotion regulation and anxietydisorders. Anxiety Disord. 2008; 22(2):211-21. [DOI:10.1016/j.janxdis.2007.02.004] [PMID] [PMCID]

8.Garnefski N. Van den Kommer T. Kraaij V. Teerds J. Legerstee J. Onstein E. The relationshipbetween cognitive emotion regulation strategies andemotional problems: Comparison between clinical and anonclinical sample. Eur J Pers. 2002; 16(5):403-20. [DOI:10.1002/per.458]

9.Folkman S, Moskowitz JT. Coping: Pitfalls and promise. Annu Rev Psychol. 2004; 55:745-74. [DOI:10.1146/annurev.psych.55.090902.141456] [PMID]

10.Vowles K, McNeil D, Gross R, McDaniel M, Mouse A. Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain. Behav Ther. 2007; 38(4):412-25. [DOI:10.1016/j.beth.2007.02.001] [PMID]

11.Bogduk N. Psychology and low back pain. J Osteopath Med. 2006; 9(2):49-53 [DOI:10.1016/j.ijosm.2005.11.005]

12.Vowles KE, McCracken LM. Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process. J Consult Clin Psychol. 2008; 76(3):397-407. [DOI:10.1037/0022-006X.76.3.397] [PMID]

13.Blarrina M, Luciano C, Martinez O, Valdivia S, Valverde M, Ortega J. Coping with pain in the motivational context of values comparison between an acceptance-based and cognitive control based protocol behavior modification. Behav Modif. 2008; 32(3):403-22. [DOI:10.1177/0145445507309029] [PMID]

14.Zettle R, Rains J, Hayes S. Processes of change in acceptance and commitment therapy and cognitive therapy for depression: A mediation reanalysis of Zettle and Rains. Behav Modif. 2011; 35(3): 265-83. [DOI:10.1177/0145445511398344] [PMID]

15.Powers MB, Vording M, Emmelkamp PM. Acceptance and commitment therapy: A meta-analytic review. Psychother Psychosom. 2009; 78(2):73-80. [DOI:10.1159/000190790] [PMID]

16.Smout M. Acceptance and commitment therapy: Pathways for general practitioners. Psychol Strateg. 2012; 41(9):672-6.

17.Cosio D. Practice-based evidence for outpatient, acceptance & commitment therapy for veterans with chronic, non-cancer pain. Contextual Behav Sci. 2016; 5(1):23-32. [DOI:10.1016/j.jcbs.2015.12.002]

18.Mohabbat-Bahar S, Akbari ME, Maleki F, Moradijoo M. [The effectiveness of group psychotherapy based on acceptance and commitment on quality of life in women with breast cancer (Persian)]. Thought Behav Clin Psychol. 2015; 8(2):71-6. https://jtbcp.riau.ac.ir/article_104.html

19.Wicksell RK, Ahlqvist J, Bring A, Melin L, Olsson GL. Can exposure strategies improve functioning and life satisfaction in people with chronic pain and Whiplash-Associated Disorders [WAD]? A randomized controlled trial. Cogn Behav Ther. 2008; 37(3):169-82. [DOI:10.1177/0960327107083411] [PMID]

20.Johnston M, Foster M, Shennan J, Starkey N, Johnson A. The effectiveness of an acceptance and commitment therapy self-help intervention for chronic pain. Clin J Pain. 2010; 26(5):393-402. [DOI:10.1097/AJP.0b013e3181cf59ce] [PMID]

21.Irandoost F, Neshat-Doost HT, Nadi MA, Safary S. [The effectiveness of Acceptance And Commitment Therapy (ACT) on the rate of pain intensity in women with chronic low back pain (Persian)]. J Clin Psychol. 2014; 8(3):31-40. [DOI: 10.22075/JCP.2017.2165]

22.Davoodi I, Zargar Y, Mozafaripour Sisakht E, Nargesi F, Mola K. [The relationship between pain catastrophizing, social support, pain-related anxiety, coping strategies and neuroticism, with functional disability in rheumatic patients (Persian)]. J Health Psychol. 2012; 1(1):59-67. http://hpj.journals.pnu.ac.ir/article_141.html

23.Abdi S, Babapoor J, Fathi H. [Relationship between cognitive emotion regulation styles and general health among university students (Persian)]. Ann Mil Health Sci Res. 2011; 8(4):258-64. https://www.sid.ir/Fa/Journal/ViewPaper.aspx?ID=129986

24.Fish JA, Ettridge K, Sharplin GR, Hancock B, Knott VE. Mindfulness‐based cancer stress management: Impact of a mindfulness‐based programmer on psychological distress and quality of life. Eur J Cancer Care (Engl). 2014; 23(3):413-21. [DOI:10.1111/ecc.12136] [PMID]

25.Cho S, Heiby EM, McCracken LM, Lee SM, Moon DE. Pain-related anxiety as a mediator of the effects of mindfulness on physical and psychosocial functioning in chronic pain patients in Korea. Pain. 2010; 11(8):789-97. [DOI:10.1016/j.jpain.2009.12.006] [PMID]

26.McCracken LM, Velleman SC. Psychological flexibility in adults with chronic pain: A study of acceptance, mindfulness, and values-based action in primary care. Pain. 2010; 148(1):141-7. [DOI:10.1016/j.pain.2009.10.034] [PMID]

27.Veehof MM, Oskam MJ, Schreurs KM, Bohlmeijer ET. Acceptance-based interventions for the treatment of chronic pain: A systematic review and meta-analysis. Pain. 2011; 152(3):533-42. [DOI:10.1016/j.pain.2010.11.002] [PMID]

28.Peterson BD, Eifert GH, Feingold T, Davidson S. Using acceptance and commitment therapy to treat distressed couples: A case study with two couples. Cogn Behav Pract. 2009; 16(4):430-42. [DOI:10.1016/j.cbpra.2008.12.009]

29.Hayes-Skelton SA, Orsillo SM, Roemer L. An acceptance-based behavioral therapy for individuals with generalized anxiety disorder. J Cogn Behav Pract. 2013; 20(3):264-81. [DOI:10.1016/j.cbpra.2011.02.005] [PMID] [PMCID]

30.Wells A, Fisher P, Myers S, Wheatley J, Patel T, Brewin C. Metacognitive therapy in treatment-resistant depression: A platform trial. Journal of Behav Res Ther. 2012; 50(6):367-73. [DOI:10.1016/j.brat.2012.02.004] [PMID]

31.Lauwerier E, Caes L, Van Damme S, Goubert L. Acceptanc: What’s in a name? A content analysis of acceptacne instruments in individuals with chronic pain. J Pain. 2015; 16(4):306-17. [DOI:10.1016/j.jpain.2015.01.001] [PMID]