Personality, social relationships and depression in post menopause women with early stage breast cancer: a pilot study for a secondary prevention towards a positive aging.

Purpose: The aim of our study is to establish whether a difference exists in the personality intrapsychic processes, SN and SS, ASQ-anxiety, and CDQ-depression of fty-eight breast cancer(BC) women(W) and seventy-four healthy-women, all in post menopause. Methods: Tests: SASB Form-A intrapsychic behavior, Social Network List (SN), and Social support evaluation (SS). Statistical analysis: Variance analysis (ANOVA) was applied to evaluate the SASB clusters differences between the two groups; Pearson’s R coecient was used to compare SASB, SN, SS dimensions, ASQ, and CDQ. Results: BC women showed a smaller size of SN (fewer social relationships), with ties stronger than healthy women. SASB Prole BC-W (comparison with healthy-women).” Not aliation and Autonomy”: medium low value of autonomy, low self-appreciation and self-esteem, low expression of emotions and needs, diculties in being able to achieve emotional and psychic equilibrium in presence of stress because of their control and self-critical behavior, depression, stress; diculties in asking helps to family members. They invest in limited bonds for leisure, considered important but without fall into intimacy: they may be not always satised of their relationships. The depression is directly linked to these intrapsychic behaviors. Conclusions: Patients with “not Aliation and Autonomy” SASB prole should be regarded as having a high risk of worse social support and depression, and could be followed up and screened, in order to plan the multidimensional and psychotherapeutic intervention specic to the single patient, aimed at modifying the problematic and unhealthy intrapsychic experience and promoting the development of a better quality of life.


Background
Breast cancer (BC) it is the most common cause of cancer death for women worldwide. Approximately 70% of breast cancers occur after menopause. The postmenopausal period is often a very di cult one for women in association with cancer diagnosis [2]. Menopausal symptoms have been shown to trigger or intensify depression among women with coexisting stressors, a previous history of depression, or a negative attitude towards menopause [1]. Many postmenopausal patients reported a decrease in social and family well-being, endocrine symptoms and neurotoxicity symptoms [3], affecting quality of life (QoL) [4,5].
Thus, it is important to have a greater knowledge of the problems and depression related to the onset of breast cancer(BC) in post menopause women. A high percentage of postmenopausal women reports endocrine symptoms, fatigue intensity and anxiety three years after starting of cancer treatment [6]. The age of diagnosis is important to implement targeted preventive intervention for elderly and postmenopausal patients with different needs [3]. Multidimensional interventions implemented on the basis of knowledge of the speci c di culties of BC-patients in post menopause may play a role in restoring bio-psycho-social QoL, especially after an incisive diagnosis [7]. Secondary prevention is important for a good aging process, on the basis of theories of stress and coping, self-regulation, personality, and social processes, which have shaped the theoretical framework for identifying determinants of psychosocial adjustment to cancer [8,9]. In this perspective, QoL outcomes are associated with psycho-social factors, including personality [10][11] and depression [5]the last largely under diagnosed and undertreated in cancer patients, even if it may impact the disease progression, being associated with health complications [12]. Other studies about associations between psychological functioning and cancer, showed a tendency to be emotionally constricted and depressed with inappropriate and often destructively blame [13,14]. Inhibition of emotional expression and depression are associated with the incidence and progression of BC and other chronic illnesses [12,15].
Personality traits, stress and low social support (SS) may in uence the individual's ability to cope, which mediates breast cancer risk via alterations in neuroendocrine and immune functioning [2,16]. Personality traits such as neuroticism was associated with high levels of negative psychological symptoms [17].
Type D distressed personality in this patients includes dimensions of negative affect and social inhibition and is associated with poor adherence to treatment and poorer health [18]. Lydia Temoshok [19] stated that the suppression of emotions characterized by a tendency to defer one's own needs to the needs of others contributes to the hypothesis of the existence of a personality that carries these aspects. Most studies focused on single personality traits, thus covering only a part of the personality structure, even if through analysis of traits it is possible to study combination personality pro les that may increase risk for depression, and physical symptoms among patients undergoing cancer treatment [5,15,20,21].
Person centered approaches to examining personality traits enable the identi cation of latent classes (subgroups) of individuals with distinct pro les of personality dimensions [22]. Some of such approaches include cluster analysis, complementary variable centered approaches by conceptualizing personality as an interrelated system of several traits. To our knowledge, few studies have utilized the SASB-Structural-Analysis-Social-Behavior by L.S. Benjamin [23,24] to examine the relationship between personality pro les and depression in BC women. For this reason, in this study we have implemented the SASB circumplex-model to describe personality from normal to pathology and de ne intrapsychic behaviors by three underlying dimensions: focus (other-self-introject), a liationhostility (love-hate), and interdependence-independence (enmeshment-differentiation). SASB applications extend from research to practice: diagnosis of personality, planning and veri cation of psychotherapeutic intervention.
The importance of social relationship for health is supported by several studies [25,26]. Epidemiological studies evidenced that social isolation is often associated with unhealthy lifestyles and behaviors, that in time can lead to poor health outcomes [27]. Conversely, social relationships seem to exert a e stress management and a protective in uence on health, for the adjustment to illness and in adaptation to the progression of many clinical conditions as, i.e. BC [26,28,29]. Socially isolated women report more problems in vitality [30]. Individual relationships are often explored by Social Network Analysis (SNA).
Social Network (SN)mapping techniques have been applied with a growing in uence in the area of health and illness [26,28]. SNA has been also applied to explore the relation between personal network structure and its association to personality traits [31]. Some studies con rmed a correlation between Type D and SS in patients with breast cancer, analyzing single aspects i.e. neuroticism [20]. Individuals with low neuroticism are likely to be in uential person in a friendship network[32], while extraversion positively predicts social network characteristics such as the network size and proportion of new contacts [33]. The link between personality, SS and SN is very important for the emotional and social inhibition of personality in BC women, but to our knowledge few research have deepen this issue [26,34]. Instead, it was emphasized that this knowledge may allow the implementation of multidimensional and psychotherapeutic interventions, also considering that the age of menopause might be the beginning of a possible path of decline in going towards the third age, requiring speci c interventions [35,36].
The aim of our study is to establish whether a difference exists in the personality intrapsychic traits, SN and SS, depression of healthy and post-menopausal BC women at rst diagnosis [33]. We hypothesize that the presence of depression and negative intrapsychic traits are correlated with the SN and SS in BC postmenopausal women at rst diagnosis.

Methods
This study was approved by Bioethical Advisory Committee of IRCCS-INRCA, Italy: code no. 19019. The SASB-Form-A questionnaire administration took place in the context of clinical interviews conducted by a single psychotherapist trained in the SASB administration. The administration of the network analysis was conducted by an experienced sociologist. Given the complexity of the administration, the sample is of fty-eight subjects. The same psychotherapist and sociologist administrated the tests to the control group (Cg). Inclusion criteria: signing informed consent; age >= fty years); post menopause; BC rst time diagnosis (biopsy) (57% rst-stage, 43%second-stage). Exclusion criteria: refusing to participate; being unable to provide informed consent; having other forms of cancer; using any type of psychotropic drugs (including antidepressants); having adrenal disorders; having a previous history of malignancy, with exception of non melanomatous skin cancers.
Ninety-two patients in post menopause were approached in the Oncology Clinic of INRCA-Hospital by the physician and asked to participate in the study. Seventy-two decided to participate and signed a consensus form after detailed explanation by the physician. Fourteen patients who did not complete the questionnaires were excluded. The study group was composed of fty-eight BC women.
The Cg was composed of seventy-four healthy women in post menopause, with the same distribution of age, education, marital status, working situation of the BCg, recruited from several social centers in the city.
All the subjects of the study and control group completed the following questionnaires: 1. Socio-demographic characteristics 2. SASB-Form-A-Questionnaire by L.S. Benjamin [23,24] describes the intrapsychic behaviors of the personality structure from normal to pathological, by three underlying dimensions: focus (other,self,introject), a liation-hostility(love-hate), interdependence-independence (enmeshmentdifferentiation). It has the appropriate reliability and validity to evaluate intrapsychic dimensions and is validated on the basis of DSMIV and on the Italian population. Interviewed subjects had to respond to 36 items rating on a ten-point scale ranging from zero to ten describing the intrapsychic behaviors during the last year (e.g. 'I neglect myself, don't try to develop good skills, ways of being'; 'I practice and work on developing worthwhile skills, ways of being'; 'I think up ways to hurt and destroy myself. I am my own worst enemy'). SASB applications extend from research to practice: assessment, treatment of psychopathology and veri cation of psychotherapeutic intervention. [23,36].
The thirty-six questions of Form A are grouped by a speci c score correction in eight clusters (Cl) of intrapsychic "Oneself" and interpersonal "Other" experience.
The eight clusters (Cl) of "Onself" and "Other" are both complementary and opposite (Appendix A).
The eight Cl of "Oneself" Intrapsychic experience are the following: SASB-Cl1=Autonomy:Assertive and separating.
SASB-Cl4=Love and Control:Self-care and development.

Social network characteristics
The Social Network List[37] was used for network evaluation. Respondents were asked about size, typology and subjective perception of their social network by means of an Ego centred matrix, aimed to identify the system of relationships. The size was obtained by asking to respondents to list people important to them, also including acquaintances outside the inner circle of intimates, i.e. co-workers and neighbors. The structure of the network is de ned by the SNA measures: density, (the extent to which network members know each other), multiplexity (the number of types of support that each network member provides), reciprocity (the extent to which support is mutually exchanged). Density was calculated as the ratio between the effective number of ties among all the important persons and the maximum number of ties of each network, except the interviewed. Multiplexity was calculated as the ratio between the absolute number of multidimensional persons (persons who provided several kinds of support) and the total number of important persons. Reciprocity was calculated as the ratio between the absolute number of persons with a reciprocal relationship and total of important persons.

Statistical Methods
The data were analyzed using SPSS 11.5 software (SPSS Inc. Chicago, Illinois). Descriptive analysis was performed to check the distribution and the quality of the data. Differences between the two groups were tested through chi square and t test or ANOVA. Variance analysis (ANOVA) was applied to evaluate the differences between the two groups of subjects (case and control groups) on the Scales SASB, ASQ, and CDQ.

Results
BCg and Cg Differences.
The demographic characteristics are described in coworkers (p<.001); the level of reciprocity in the relationships was signi cant higher for the Cg (p=.034) ( Table 2); ASQ(p=.038) and CDQ (p=.022) were higher in BCg.
BC women were less likely to show self-esteem and to care for themselves (Cl2,Cl3), are less prone to protect and take care of themselves (Cl4), exercised more control(Cl5) and more self-critical behaviours than Cg.
BCg:SASB Pro le "Not A liation and Autonomy" BC women are less prone to be satis ed with themselves, their lives and their entourages and to cope with stress. They manifest medium low value of autonomy, low self-appreciation and self-esteem, low expression of emotions and needs, control towards themselves. They may have di culties in being able to achieve emotional and psychic equilibrium in presence of stressful situations. They are less likely to protect themselves and to utilize crisis and stress for their own emotional development. Because of this poor coping they may be more subject to depression (as the distribution of SASB-ranges in the different clusters shows). These patients displayed a low assertiveness and low ability to accept themselves and support themselves (to treat, care for, console and consolidate). Moreover, they may be oppressive towards themselves and may accuse themselves of inadequacy, evoking feelings of guilt and shame, which purport low self-esteem and, a may incur in self-punitive behavior. They may neglect their needs at emotional and physical levels especially in presence of stressful situations. The medium low SASB-Cl2-"Self-accepting and exploring" is correlated with high density relations with leisure companions, characterized by behavior patterns which include treating the other justly, listening to him|her attentively even if there are differences of opinion.

BCg-Correlation
However, the proportion of friends on important persons is inversely correlated with self-acceptance. We can argue that patients with low self-acceptance need to look for cultivating few and dense relations with leisure companions.
BC woman who are not completely able to treat, care for themselves and show low capacity for selfesteem, low contact with their needs and emotion, are depressed (negative correlation) and tend to establish bonds with a multiple kinds of exchanges with single persons. Since the multidimensionality is an indicator of strength, the links tend to be strong.
BC women show low self-care and more depression. They may have problem in being positively selfconstructive, not actively developing their abilities and other important qualities for self-growth and all these intrapsychic behaviors are correlated with depression. They invest especially in family ties for their well-being. In the work area they tend not to establish relations of mutual exchange that it may result in situation of a lower wellbeing, low self-care and di culties in developing their qualities.
SASB-Cl5=Control-is correlated with: BC women exercise control on themselves in the context of close relationships with friends and multidimensional relations at work. In the context of work each colleague has many de ned roles and these is correlated with SASB-Cl5-self-control exercised by BC women. Reciprocity at works shows, in fact, a control exercised in the context of exchanging help in work activity. These patient are dependent in their choices from a network of few important persons with a large range of roles. BC women are able to be in touch with their needs at emotional and physical levels but in presence of stressful situation they may incur in neglecting behaviors and may become depressed (Cl7-medium low level) investing in especially in leisure relationships considered important without, however, fall into intimacy, which they need.
BC women in presence of stress may tend to become disoriented and may be more subject to anxiety.

Discussion
In this study the correlations between SASB personality traits and SN and SS characteristics in BC women in post menopause were evaluated [38] with differences in SN and SS structures between the BCg and Cg. Anxiety, depression and intrapsychic traits of personality are associated to different dimensions of SN and SS.
BC patients have a smaller size network, with fewer social relationships, stronger ties than healthy women (36), characterized by family ties, few other types of bonds, while the healthy women show a greater presence of friends and coworkers. The BC women receiving support only from the family, do not ask help to friends (higher density relationships between family network members), in agreement with other studies showing that severity of chronic illnesses may limits SN and negatively impact the BC women health (25,27,28,36). The patient invests in leisure companionships creating dense bonds, and in multiple roles relations at work, conditioned by reciprocal exchange with the same people, and by established goals. This aspect of SN can be con rmed by the correlations with the following intrapsychic traits emerged in this study: low assertiveness (Cl1), di culties in accepting and supporting themselves (to treat, care for, console and consolidate) with low self-esteem (Cl2, Cl3) low ability to actively develop abilities and other qualities for self-growth, (Cl4), self-control Cl5), self-critical behavior (Cl6), and feelings of inadequacy (Cl7).
The accumulated stress is due to adaptation to the roles because of control and self-criticism (Cl5, Cl6). In this particular context they search for emotional and informational support from leisure companions and invest especially in limited bonds, both in private and leisure activities. The attitude of self-control is related to strong bonds and a dense social network. Even if they consider their relationships important, they may experiment di culties in asking for help and in falling into intimacy because of control in expressing emotion and di culties and self-critical behaviors (Cl2,Cl5, Cl6) [25,28]. The same considerations, made above, are applied to the workplace relationships where they tend to establish reciprocal links.
So all these modalities of SS are correlated to intrapsychic control, (Cl5), low self-esteem, medium low self-care, passive adaptation (Cl2,Cl3,Cl4) and anxiety and depression, the last two linked to the di culty of being in intimate relation with others and themselves, with the consequence of having di culty in getting the emotional interpersonal support they need [19].
The high levels of anxiety and depression suggest that the period after diagnosis is particularly di cult for these women. Depression can be not only a reaction to the stressful events (onset of the disease, restructuring of life to follow medical therapy), but we can hypothesize that BC women were predisposed to depression even before the disease onset as the SASB "not-A liation and Autonomy pro le" indicates. Studies showed an association between anxiety, depression and self-blame and shame behaviors (SASB-Cl6, Cl7) during the rst year after breast cancer diagnosis, associations that can often be markers of the recurrence and previous psychological disorders [7,9]. For all these reasons we hypothesize that problematic personality traits and limitation in social relationships linked to them may hamper the patient's ability to receive the needed helps and cure, and the adaptation to the disease condition and to the medical treatment and its side effects [21].
Our conclusion is that patients with di culties in interpersonal relationships and problematic intrapsychic traits should undergo closer cancer surveillance. The ability to deal with relationships, even problematic ones, may be a resource for reducing vulnerability to distress or buffering the adverse psychological effects of illness. Studies showed the amount of social support available reducing negative health outcome [31. So patients with "not A liation and Autonomy" SASB-pro le should be regarded as having an high risk of worse social support and depression and could be followed up and screened [35].

Clinical implication
Multidimensional and psychotherapeutic interventions should be based on the screening of these problematic behaviors with the aim of modifying unhealthy intrapsychic experience and promoting the development of a better quality of life [30,36]. Psychotherapeutic interventions should focus on changing the intrapsychic modalities of low autonomy, low self-acceptance, high control, high self-critical behavior by developing a better contact with the patient emotions and needs [23,35].

Study limitations
The small sample is not representative of breast cancer patients in general. Second, all the subjects in this study were BC patients, and care is needed when extrapolating these results to other diseases.

Declarations
Funding: This work was partially supported by Ricerca Corrente funding from Italian Ministry of Health to IRCCS INRCA. This funding body did not play any role in designing the study nor in data collection, analysis and interpretation, nor in writing this paper.
Con icts of interest/Competing interests The authors declare no con ict of interest.
Availability of data and material: Not applicable Code availability: Not applicable Authors' contributions: All authors contributed to the study conception and design. Material preparation,  Note: Signi cant level: * p< 0.05. ** p< 0.01. *** p< 0.001 Table 3. Correlation between ASQ, CDQ, SASB (Intrapsychic levels) and Social Network-Social Support characteristics in the Breast cancer group