Currently, in Romania, there are up-to-date treatments that support people diagnosed with breast cancer to maintain an adequate quality of life and global functioning in accordance with their age. One of these treatments is represented by breast reconstruction following mastectomy, a procedure that is available for all Romanian women, via a national program that was started in 2014. However, the number of cases benefiting from this intervention in 2016 in Romania was of only 176 women (25). Therefore, the following question arises: why is it that certain women diagnosed with breast cancer refuse to benefit from reconstructive procedures following a mastectomy? What lies behind this decision?
In this study, we have attempted to evaluate the relationship between cognitive schemas and the presence of anxiety and depression in women diagnosed with breast cancer, who have either accepted or refused to benefit from breast reconstruction surgery following a mastectomy. The correct identification of maladaptive cognitive schemas, as well as that of comorbid symptoms of anxiety and depression in this group of people, helps design specific psychotherapeutic interventions that aim to reduce mental health difficulties, by supporting patients when choosing the most appropriate individual treatment, as well as by helping to increase their overall quality of life (26-27).
To date, the literature has focused on highlighting the clinical symptoms of depression and anxiety, and evaluating the role that these symptoms play in the evolution and prognosis of women with breast cancer. The maladaptive cognitive schemas proposed by Young have not been explored in women with breast cancer, although these are some of the key points from which the psychotherapeutic intervention is built.
The two patient groups that we evaluated in this study were reasonably homogenous, in terms of socio-demographic data; however, there were notable age differences between the two samples: the group with mastectomy and reconstruction surgery had an average age of 49 years compared to the other group of women, with an average age of 61.5 years. The other socio-demographic parameters were relatively similar, without significant differences.
The presence of clinical symptoms of anxiety, depression, and stress was identified by using the DASS-21 self-evaluation scale that performs an assessment based more on the dimensional, than on the categorical concept. The level of depression was noted to be similar in both groups, occurring in about one-quarter of all subjects and without any statistically significant differences. The same aspect was present when assessing levels of stress, even though some of these patients underwent reconstructive breast surgery. Differences only occurred in terms of anxiety levels, with higher scores found in group II, a fact that we correlated with the difficult decision process to not undergo reconstruction intervention. In general, decision-making is correlated with the frontal lobe and amygdala, from an anatomic viewpoint, but also with individual cognitive patterns (28-30).
The assessment of cognitive schemas was achieved by using the YSQ self-evaluation questionnaire - short form that showed that the group with mastectomy and reconstruction had lower values than the other group, and this while taking into account that we must have at least three responses with high scores (replies of 5 or 6) in order to conclude that there is a cognitive schema employed by the person. Even though this is a self-assessment questionnaire, it is essential that the results are discussed with the patients, which helps to practically connect their cognitive patterns to their current life problems. Results from this questionnaire showed significant differences between the two groups at the ‘enmeshment / undeveloped self' (8.50 vs. 11.50, Mann-Whitney U test, p = 0.019) and ‘punitiveness' (31.00 vs. 37.00, Mann-Whitney U test, p = 0.009) level, meaning that they were prominent in the group of patients who have not opted for reconstructive surgery. The ‘enmeshment / undeveloped self' cognitive schema encompasses emotional involvement and excessive attachment to their significant others and is usually experienced as a sense of emptiness or a lack of direction, of existential meaninglessness. In a similar vein, the 'punitiveness' schema involves difficulties forgiving personal or others' mistakes, as well as difficulties when faced with having to accept imperfections, and is experienced as a general sense of anger and intolerance. Both schemas can be correlated with the decision of mastectomy without reconstruction through a lack of existential purpose and the tendency to care for oneself in a harsh, punitive manner.
The dominant schemas for the group of participants with breast reconstruction were ‘vulnerability to harm or illness’, ‘subjugation’, ‘self-sacrifice’ and ‘approval-seeking’/’recognition-seeking’.
The ‘vulnerability to harm or illness’ schema falls in the domain of ‘autonomy and poor performance’, while the other three types are in the field of ‘orientation towards others’. The domain of ‘autonomy and poor performance’ implies a lower ability to function independently, which translates into difficulties of leaving the family of origin and, also, of setting personal goals. The domain of ‘focusing on others’ involves maintaining emotional ties with other people and making efforts to avoid upsetting other people. Very often, these individuals will tend to focus more on social appearances than on their individual needs.
Another notable aspect from this study is that most of the schemas that we identified belong to the area of conditioned cognitive schemas that frequently develop in order to reduce the suffering caused by unconditioned schemas and to, somehow, help people cope with their life struggles (21).
The dominant schemas identified in the group of participants without breast reconstruction were: ‘emotional deprivation’, ‘mistrust/abuse’, ‘failure’, ‘enmeshment/undeveloped self’, ‘self-sacrifice’, ‘unrelenting standards’, ‘negativity/pessimism’ and ‘punitiveness’. The ‘unrelenting standards’, ‘negativity/pessimism’ and ‘punitiveness’ cognitive schemas belong to the category of ‘hypervigilance and inhibition’, while ‘emotional deprivation’, ‘mistrust/abuse’ and ‘enmeshment/undeveloped self’ are in the grouping of ‘separation and rejection’. The ‘failure’ schema is related to ‘autonomy and poor performance’. The existence of ‘hyper-vigilance' schemas leads to the suppression of feelings, but also to a decrease in spontaneity and adherence to rigid internal rules. The domain of ‘separation and rejection' includes cognitive schemas that cause the person to believe that fundamental needs, such as love, safety, and stability, will not be met.
It is also noteworthy that most of the schemas that we identified in this group of patients are unconditioned schemas, which, by definition, determine the person to believe that, no matter their choice, the end result will be the same.
Anyone who is faced with an adverse life event (e.g., receiving a diagnosis of breast cancer), which subsequently causes numerous unfavorable consequences, should contemplate all possible solutions and choose the one that they consider to be the best for their individual circumstances and needs. When making a decision, there are many factors involved, including the cognitive schemas described above. By analyzing the two samples of patients, we noticed some clear differences that could explain their opposite decisions regarding reconstructive surgery following a mastectomy. Cognitive schemas that focus on others are connected to the idea of maintaining an adequate emotional relationship with those around us and, as a result, the predominant idea is that everything should remain unchanged. For this category of patients, this goal was thought to be achievable by accepting to undergo reconstructive breast surgery.
Another aspect that we sought to analyze was the correlation of the five cognitive schema areas with clinical elements of depression, anxiety, and stress, and we attempted to achieve this by assessing all patients a few weeks after receiving the diagnosis, and also immediately after surgery. For the group of patients with mastectomy and no reconstructive surgery, there was a correlation between the early maladaptive schemas of ‘emotional deprivation', ‘mistrust/abuse' and ‘enmeshment/undeveloped self' and anxiety and depressive symptoms (Spearman's r = 0.598, p < 0.001). A potential explanation for this finding is that when someone experiences a significant or life-threatening illness and is faced with making critical decisions, the presence of these schemas, along with other factors, favors the occurrence of comorbid clinical depression and anxiety. However, in the group of patients who opted for breast reconstruction surgery, there were no correlations, and the clinical psychopathological symptoms were notably less prominent.
Schemas belonging to the area of ‘separation and rejection' (‘defectiveness/shame', ‘emotional deprivation' and ‘social isolation') that develop during childhood appear to be correlated with depressive elements in adult life. These models were found in the group of women who refused reconstructive surgery and were correlated with the presence of comorbid depressive and anxiety elements.
Cognitive schemas belonging to “impaired autonomy and performance” were correlated with anxiety and stress in the group of patients with mastectomy and reconstructive surgery, and with depression in the group of patients with mastectomy without reconstruction. Interestingly, we observed that patients with mastectomy and reconstructive surgery showed both anxiety and stress regarding vulnerability to harm or illness. An explanation is that the patients who opted for reconstruction are also exposed to human vulnerability. The patients with mastectomy and without reconstruction presented depressive elements regarding vulnerability to harm or illness, dependence/incompetence, enmeshment/undeveloped self and failure.
Another maladaptive schema that we identified was that of ‘subjugation', by which a person conforms to the wishes of others, while repressing their own needs and desires. Surprisingly, this schema failed to correlate with any depressive elements, having only been identified and employed in the group of patients with mastectomy and reconstructive breast surgery. This result contradicts findings from other studies that describe an association of this schema with depression (31).
The 'unrelenting standards/hyper-criticalness' schema belongs to the ‘hypervigilance and inhibition' area and consists of the belief that the person must meet high standards, in order to avoid criticism or punishment, thus being usually correlated with depressive clinical elements. This pattern was identified in the group of patients with mastectomy, without reconstructive breast surgery, and was significantly correlated with the presence of comorbid depression. Additionally, in the same sample of patients, the 'negativity/pessimism' schema was very significantly correlated with depression, anxiety, and stress; however, it is a well-known fact that this schema predisposes the person towards a constant focus on the negative aspects of life (death, negative things, unresolved problems, loss) and it is only natural to expect that a critical illness will re-activate it.
The anxious-depressive symptomatology correlates with certain cognitive schemas in the group of patients that refused reconstructive breast surgery; however, the issue that arises is related to the role they play in the onset of this symptomatology, but also to the role in the decisional process, namely whether or not to accept the second surgical intervention. Therefore, we suggest that it is essential to offer a psychiatric evaluation to all breast cancer patients, in order to exclude depressive and anxiety symptoms that may negatively influence the individual treatment choice, but also to identify early maladaptive cognitive schemas, so that a more adequate psychotherapeutic approach may be developed. We should also mention that, after receiving a diagnosis of breast cancer, patients are informed of their therapeutic options, thus having the possibility of individual choice. There were several limitations to this study, including the small sample size and the fact that we were only able to use self-assessment scales, which meant that these could have easily been influenced by the patients' personality traits, their educational level or their family situation.