Dispositional mindfulness as a moderator between perceived stress and psychological symptoms in Chinese digestive tract cancer patients

Abstract

Mindfulness has been garnering increased attention within the area of clinical psychology due to its theorized and empirical associations with psychological well-being. Using a sample of patients diagnosed with digestive tract cancer (N = 292), we examined the relationship between perceived stress and psychological symptoms at varying levels of dispositional mindfulness. Results showed significant associations between perceived stress and psychological symptoms. More importantly, the relationship between perceived stress and psychological symptoms was only significant for patients with low, but not high, levels of dispositional mindfulness. Implications and future research directions were discussed.

Keywords

digestive tract cancer dispositional mindfulness moderation perceived stress psychological symptoms

Introduction

Recent estimations put cancer deaths in China at approximately 2,814,000 in the year 2015, corresponding to over 7500 deaths per day (Chen et al., 2016), compared to about 1600 deaths per day in the United States (Siegel et al., 2015). According to Chen and colleagues, one of the leading contributors of cancer death among Chinese men and women was digestive tract cancer, with a mortality rate of 33.9 percent in males and 15.9 percent in females for stomach cancer, 25.4 percent in males and 12.1 percent in females for esophageal cancer, and 11.1 percent in males and 8 percent in females for colorectal cancer. In the United States, esophageal (mortality rate of 4% in males) and colorectal (mortality rate of 8% in males and 9% in females) cancers, but not stomach cancer, were among the top 10 most common forms of cancer (Siegel et al., 2015). Given the severity of the cancer crisis in China, it is important to study the psychological well-being of cancer patients within the Chinese context.

Indeed, Malalur et al. (2016) have shown that the prevalence of depressive disorders in patients with cancer is estimated at 20–50 percent, which is significantly higher than the general population. Moreover, the prevalence of anxiety and depression is higher among Chinese patients with digestive tract cancer than those with other forms of cancer. Specifically, between 50 and 80 percent of Chinese with digestive tract cancer reports depressive symptoms (Hong and Tian, 2014). Such evidence suggests that digestive tract cancer is a chronic disease, which threatens not only the physical but also the mental health of humans.

One possible predictor of psychological well-being in cancer patients is perceived stress (Iwata et al., 2013). For instance, cancer patients undergoing surgery may be burdened by psychological stress stemming from the surgery, as well as from the cancer diagnosis itself (Matsushita et al., 2005). Past research has shown that cancer patients’ state of mental health can vary (Applebaum et al., 2014). According to stress and coping theory (Folkman et al., 1986), stress does not always lead to adverse consequences because individuals may have access to a variety of flexible coping resources, which may aid stress regulation at various levels of the stress process. Appraisal and coping are two important processes in this framework: (1) Individuals may differ in their experience of stress despite exposure to the same stressor because of differences in their appraisal of the stressor. (2) People may also experience the stress appraised from the stressor differently due to variability in access to or availability of coping resources, which could comprise of psychological or environmental resources (Folkman, 2013). Taken together, this model suggests that while perceived stress could predict negative psychological outcomes or psychological symptoms, this relationship is likely dependent on one’s access to coping resources.

More recent evidence have highlighted the effectiveness of mindfulness in stress regulation (e.g. Arch and Craske, 2006), and also in predicting of general psychological well-being ( ; Keng et al., 2011). With roots in the practice of Buddhism, mindfulness or mindful awareness can be defined as a psychological process that involves the “self-regulation of awareness towards present mental states and processes,” and “a non-evaluative openness and acceptance towards those moment-to-moment experiences” (Bränström et al., 2011: 301). By bringing non-elaborative awareness to current experiences and being fully present in the moment, individuals may attend to their thoughts, feelings, and sensations in an accepting manner, and neither over-identify nor react to them in an automatic, habitual pattern (Bishop et al., 2004). Mindfulness may therefore represent a form of coping resource, which could moderate the relationship between perceived stress and psychological symptoms. Indeed, mindfulness has been proposed to be one form of a stress buffer (Mindfulness stress buffering hypothesis), with considerable support for this proposition among individuals under high stress (see Creswell, 2015 for review). For instance, Moskowitz et al. (2015) have shown that mindfulness was inversely related to stress appraisal. Mindful individuals tend to report more benign stress appraisals, report less frequent use of avoidant coping strategies, and demonstrate more adaptive stress responses (Donald et al., 2016; Weinstein et al., 2009)—all of which could result in improved psychological well-being.

Furthermore, a dispositional tendency to be mindful in daily life has been linked to good physical and psychological health in both non-clinical (Arch and Craske, 2010; Bowlin and Baer, 2012; Smith et al., 2011; Tamagawa et al., 2013) and clinical populations (Walach et al., 2006). Mindfulness has been shown to be associated with less sleeping problems among 111 cancer patients under medical treatment (Garland et al., 2013), as well as a general reduction in depression (Brown and Ryan, 2003; Cash and Whittingham, 2010) and other psychological symptoms (Baer et al., 2006; Garland et al., 2013). While individuals with low dispositional mindfulness tend to be more depressed, anxious, and stressed out, those with high dispositional mindfulness tend to report more positive well-being and mood (Brown and Ryan, 2003; Carlson and Brown, 2005). Given the lack of research on the protective factors of psychological well-being among digestive tract cancer patients, the aim of this study was to examine whether dispositional mindfulness moderated the relationship between perceived stress and psychological symptoms within a sample of Chinese digestive tract cancer patients.

This study hypothesized that (1) as digestive tract cancer patients perceive more stress, they report higher degree of psychological symptoms. More importantly, we expected (2) the positive relationship between perceived stress and psychological symptoms of patients with digestive tract cancer to be conditional on one’s dispositional level of mindfulness. Specifically, the relationship between perceived stress and psychological symptoms is expected to be stronger among cancer patients who report lower rather than higher levels of dispositional mindfulness.

Methods

Participants

In all, 292 patients (101 males and 191 females) recruited from one hospital in Tianjin, China participated in this investigation. Participants had (1) to be over 18 years old, (2) to be currently receiving treatment, and (3) not, till the commencement of the study, accepted any psychological intervention. All participants provided informed consent prior to commencement of the study.

The average age of the final sample was 52.2 years old (SD = 11.8). In all, 45 of participants were diagnosed with stage I cancer, 48 patients with stage II, 113 patients with stage III, and 86 patients with stage IV. The major types of cancer in our sample were stomach, colon, and esophagus cancer. In all, 97 (33.2%) participants reported a total household income below ¥2000, 139 (46.6%) made between ¥2100 and ¥5000, 39 (13.4%) made between ¥5001 and ¥10,000, with the remaining 17 (5.8%) making over ¥10,000 a month. In all, 36 (12.3%) participants completed primary school education, 169 (57.9%) completed middle or high school education, 74 (25.3%) held a college degree, and 13 (4.5%) held a graduate’s or higher degree. In terms of marital status, 5 (1.7%) participants were unmarried at the time of the study, 275 (94.2%) were married, 9 (3.1%) were divorced, and 3 (1.0%) were widowed.

Measures

Chinese Perceived Stress Scale

This 14-item Chinese Perceived Stress Scale (CPSS) was used to assess globally perceived stress (Wang et al., 2016). The Perceived Stress Scale was developed by Cohen et al. (1983). Item-level scores range from 1 = never to 5 = very often. Higher total scores indicate higher perceived stress. In this study, Cronbach’s alpha coefficient for this scale was 0.78.

Mindful Attention Awareness Scale

This 15-item of Mindful Attention Awareness Scale (MAAS) measured the frequency of mindful states in day-to-day life, using both general and situation-specific statements (Brown and Ryan, 2003). Item-level scores range from 1 = very often to 6 = never. The MAAS has been validated for both non-clinical and clinical populations, including cancer patients (Carlson and Brown, 2005). MAAS scores were obtained by reversing the scores on all items, and then summing across all 15 items. Higher scores indicate greater mindfulness. Chinese version of the MAAS was revised and validated by Deng et al. (2012). In this study, Cronbach’s alpha coefficient for this scale was 0.81.

General Health Questionnaire-12

The General Health Questionnaire-12 (GHQ-12) has been validated for using in China (Wang et al., 2004). In our study, the Chinese Version (Pan and Goldberg, 1990) of the 12-item GHQ-12 rated on a 4-point Likert scale (0 = never, 3 = much more than usual) was used (Gao et al., 2004; Li and Li, 2015). Thus, the total score ranged from 0 to 36, with higher scores representing higher levels of mental distress. There are three dimensions of GHQ-12: anxiety/depression, social dysfunction, and loss of confidence (Ip and Martin, 2006). In this study, Cronbach’s alpha coefficient for this scale was 0.84, with dimension-specific alphas of 0.74 for anxiety/depression, 0.76 for social dysfunction, and 0.66 for loss of confidence.

Procedure

Participants were recruited through advertisements in the consultation room of the hospital. Patients interested in the study were asked to complete the questionnaire package. The surveys were completed in a quiet room under the instruction of a clinician. Upon completing the questionnaire package, each patient received monetary compensation for their time and effort. All participants completed the study anonymously and voluntarily. This study was approved by the Ethics Committee of Nanjing Normal University.

Statistical analysis

All data analyses were conducted with SPSS 16.0 statistic software. Pearson correlation was used to measure the relationship between the variables of interest. Multiple regression was used to examine the moderating role of mindfulness on the relationship between perceived stress and psychological outcomes.

Results

The descriptive statistics and zero-order correlations between variables are provided in Table 1. Mindfulness was negatively associated with perceived stress, anxiety and depression, loss of confidence as well as the total score of GHQ. Perceived stress was positively associated with all the subscales as well as the total score of GHQ.

Table 1.

Means, standard deviations, and correlations of CPSS, MAAS, and GHQ.

	1	2	3	4	5	6
1. CPSS	1
2. MAAS	−0.22***	1
3. GHQ_T	0.38***	−0.20***	1
4. GHQ_AD	0.36***	−0.19***	0.82***	1
5. GHQ_SD	0.28***	−0.11	0.86***	0.46***	1
6. GHQ_LC	0.30***	−0.23***	0.76***	0.61***	0.47***	1
M	36.82	63.63	15.34	6.57	6.47	2.31
SD	8.15	10.55	7.38	3.03	4.07	1.86

CPSS: Chinese Perceived Stress Scale; MAAS: Mindful Attention Awareness Scale; GHQ_T: General Health Questionnaire-12 total score; GHQ_AD: General Health Questionnaire-12 Anxiety and Depression score; GHQ_SD: General Health Questionnaire-12 Social Dysfunction; GHQ_LC: General Health Questionnaire-12 Loss of Confidence; M: mean; SD: standard deviation.

***

p < 0.001.

Table 2 shows the results of the regression analysis. There was a significant positive relationship between perceived stress and psychological symptoms (β = 0.34, p < 0.001). However, this relationship was significantly moderated by dispositional mindfulness (β = −0.24, p < 0.001). Simple slopes analysis was further conducted to understand the direction of the moderation and the results are graphically depicted in Figure 1(a). Simple slopes analysis revealed that perceived stress was associated with psychological symptoms for patients with low (1 SD below mean) levels of dispositional mindfulness (B = 0.563, SE = 0.074, t = 7.625, p < 0.001, 95% CI = 0.418–0.708), but was not associated with psychological symptoms for patients with high (1 SD above mean) levels of dispositional mindfulness (B = 0.071, SE = 0.074, t = 0.952, p = 0.342, 95% CI = −0.076 to 0.217).

Table 2.

Hierarchical regression analysis predicting psychological symptoms outcomes.

	Psychological symptoms (β)	Anxiety and depression (β)	Social dysfunction (β)	Loss of confidence (β)
Step 1	ΔR² = 0.221	ΔR² = 0.152	ΔR² = 0.183	ΔR² = 0.100
Gender	−0.32***	−0.25***	−0.31***	−0.20***
Age	−0.26***	−0.23***	−0.22***	−0.16**
Clinical stage	0.15**	0.14**	0.10	0.16**
Step 2	ΔR² = 0.141	ΔR² = 0.128	ΔR² = 0.075	ΔR² = 0.103
Perceived stress	0.34***	0.32***	0.26***	0.26***
Dispositional mindfulness	−0.11*	−0.11*	−0.04	−0.15**
Step 3	ΔR² = 0.052	ΔR² = 0.027	ΔR² = 0.034	ΔR² = 0.054
Perceived stress × dispositional mindfulness	−0.24***	−0.17***	−0.20***	−0.25***

p < 0.05, **p < 0.01, ***p < 0.001.

Figure 1.

Interaction between perceived stress and dispositional mindfulness on (a) psychological symptoms, (b) anxiety and depression, (c) social dysfunction, and (d) loss of confidence.

We reran the model using the three dimensions of psychological symptoms as outcomes, and found significant associations between perceived stress and all the subscales of GHQ (Anxiety and Depression: β = 0.32, p < 0.001; Social Dysfunction: β = 0.26, p < 0.001; Loss of Confidence: β = 0.26, p < 0.001). Similarly, the interactions between perceived stress and dispositional mindfulness on all the subscales of GHQ were also significant (Anxiety and Depression: β = −0.17, p < 0.001; Social Dysfunction: β = −0.20, p < 0.001; Loss of Confidence: β = −0.25, p < 0.001). Results of simple slopes analyses are presented in Figure 1(b) to (d), which showed that the associations between perceived stress and all three subscales of the GHQ were qualified by individual levels of dispositional mindfulness. Among patients with low dispositional mindfulness, perceived stress was associated with anxiety and depression (B = 0.196, SE = 0.031, t = 6.314, p < 0.001, 95% CI = 0.135–0.257), social dysfunction (B = 0.243, SE = 0.043, t = 5.643, p < 0.001, 95% CI = 0.158–0.328), and loss of confidence (B = 0.124, SE = 0.019, t = 6.545, p = 0.000, 95% CI = 0.087–0.161). These associations, however, were not significant among those with high dispositional mindfulness, ps > 0.10.

Discussion

The goal of this study was to investigate the moderating role of dispositional mindfulness in the relationship between perceived stress and psychological symptoms among digestive tract cancer patients in China. Overall, our findings support our hypotheses: (1) patients who perceive higher rather than lower stress generally reported more psychological symptoms but more specifically, (2) perceived stress was not significantly related to psychological symptoms among patients who endorsed high levels of dispositional mindfulness. This association(s) was only significant among those who reported low levels of dispositional mindfulness.

Partly consistent with previous research, we found significant associations between perceived stress and anxiety and depression (Chang, 1998), social dysfunction, and loss of confidence. These findings support the notion that perceived stress is not only an outcome, but also a meaningful predictor of psychological symptoms among cancer patients (Golden-Kreutz et al., 2004). This finding, on its own, highlights the importance of stress management in improving the psychological well-being and morale of cancer patients who are already experiencing physical discomfort from their cancer treatment programs.

Moreover, our findings of a significant moderation of dispositional mindfulness on the relationship between perceived stress and various psychological symptoms parallel previous findings on the effectiveness of mindfulness-based stress reduction (MBSR) training or techniques among individuals with anxiety disorders (Goldin et al., 2016). For example, individuals who have undergone mindfulness training were more likely to report reductions in state and trait anxiety as well as psychological distress (Shapiro et al., 1998). In addition to anxiety symptoms, MBSR completers have also shown improvements in depressive symptoms and self-esteem relative to levels at baseline (Goldin and Gross, 2010). Moreover, there is evidence that long-term mindfulness practice can lead to decreases in ruminative thinking (Ramel et al., 2004), increases in self-esteem and positive self-endorsement (Goldin et al., 2009), and cognitive improvements in focusing attention (Goldin and Gross, 2010; Jha et al., 2007) and receptivity to new incoming information (Slagter et al., 2009).

Within the context of this study, dispositional mindfulness may function as an effective coping resource when dealing with appraised stress (Tamagawa et al., 2013) through the tendency to respond to negative emotions with a more accepting and non-defensive attitude. With such response styles, cancer patients who are high in dispositional mindfulness may cope more effectively with the appraised stress, thus reducing the detriment to their psychological well-being. That is, mindfulness may promote psychological well-being through active cognitive, emotional, and behavioral regulation. Because individuals with high dispositional mindfulness may be better able to, or more automatically attend to emotional experiences, put their experiences into practices, take a non-judgmental stance, and consciously respond to emotion-provoking situations, these individuals may actively respond to appraised stress or other difficulties. Those with low levels of dispositional mindfulness, on the other hand, may find it more difficult to effectively regulate emotion and therefore may not easily or automatically cope with negative feelings or thoughts in the face of stress (Liu et al., 2016).

The current findings highlight the utility of MBSR interventions and its application in boosting the psychological well-being of high-stress populations, such as patients with digestive tract cancer in China. In particular, our findings suggest that the cultivation of mindfulness in these populations can significantly improve their quality of life despite their experience of high stress levels. Despite these implications, this study has some limitations, which future studies should address. First, as the moderation hypothesis was tested in a cross-sectional sample, the temporal relationships between the variables were unknown. Second, we only considered the stress buffering role of mindfulness in this work when, in fact, there may be other moderating variables in play.

Conclusion

In sum, this work provided evidence for the role of dispositional mindfulness as a moderator or buffer of the relationship between perceived stress and psychological well-being among digestive tract cancer patients. Our findings lend support to the mindfulness stress buffering hypothesis (Creswell, 2015) and also offer preliminary support for the consideration of mindfulness-based interventions to improve the psychological well-being of digestive tract cancer patients in China.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Applebaum

Stein

Lord-Bessen

, et al. (2014) Optimism, social support, and mental health outcomes in patients with advanced cancer. Psycho-Oncology 23(3): 299–306.

Arch

Craske

(2006) Mechanisms of mindfulness: Emotion regulation following a focused breathing induction. Behaviour Research and Therapy 44(12): 1849–1858.

Arch

Craske

(2010) Laboratory stressors in clinically anxious and non-anxious individuals: The moderating role of mindfulness. Behaviour Research and Therapy 48(6): 495–505.

Baer

Smith

Hopkins

, et al. (2006) Using self-report assessment methods to explore facets of mindfulness. Assessment 13(1): 27–45.

Bishop

Lau

Shapiro

, et al. (2004) Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice 11(3): 230–241.

Bowlin

Baer

(2012) Relationships between mindfulness, self-control, and psychological functioning. Personality and Individual Differences 52(3): 411–415.

Bränström

Duncan

Moskowitz

(2011) The association between dispositional mindfulness, psychological well-being, and perceived health in a Swedish population-based sample. British Journal of Health Psychology 16(2): 300–316.

Brown

Ryan

(2003) The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology 84(4): 822–848.

Carlson

Brown

(2005) Validation of the Mindful Attention Awareness Scale in a cancer population. Journal of Psychosomatic Research 58(1): 29–33.

10.

Cash

Whittingham

(2010) What facets of mindfulness contribute to psychological well-being and depressive, anxious, and stress-related symptomatology? Mindfulness 1(3): 177–182.

11.

Chang

(1998) Does dispositional optimism moderate the relation between perceived stress and psychological well-being?: A preliminary investigation. Personality and Individual Differences 25(2): 233–240.

12.

Chen

Zheng

Baade

, et al. (2016) Cancer statistics in China, 2015. CA: A Cancer Journal for Clinicians 66(2): 115–132.

13.

Cohen

Kamarck

Mermelstein

(1983) A global measure of perceived stress. Journal of Health and Social Behavior 24: 385–396.

14.

Creswell

(2015) Biological pathways linking mindfulness with health. In: Brown

Creswell

Ryan

(eds) Handbook of Mindfulness: Theory, Research, and Practice. New York: Guilford Press, pp. 426–440.

15.

Deng

Tang

, et al. (2012) Psychometric properties of the Chinese translation of the mindful attention awareness scale (MAAS). Mindfulness 3(1): 10–14.

16.

Donald

Atkins

Parker

, et al. (2016) Daily stress and the benefits of mindfulness: Examining the daily and longitudinal relations between present-moment awareness and stress responses. Journal of Research in Personality 65: 30–37.

17.

Folkman

(2013) Stress: Appraisal and Coping (ed Gellman

Turner

; Practitioner, vol. 251). New York: Springer.

18.

Folkman

Lazarus

Dunkel-Schetter

, et al. (1986). Dynamics of a stressful encounter: Cognitive appraisal, coping, and encounter outcomes. Journal of Personality and Social Psychology 50(5): 992–1003.

19.

Gao

Luo

Thumboo

, et al. (2004) Does the 12-item General Health Questionnaire contain multiple factors and do we need them? Health and Quality of Life Outcomes 2: 63.

20.

Garland

Campbell

Samuels

, et al. (2013) Dispositional mindfulness, insomnia, sleep quality and dysfunctional sleep beliefs in post-treatment cancer patients. Personality and Individual Differences 55(3): 306–311.

21.

Golden-Kreutz

Browne

Frierson

, et al. (2004) Assessing stress in cancer patients a second-order factor analysis model for the Perceived Stress Scale. Assessment 11(3): 216–223.

22.

Goldin

Gross

(2010) Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Emotion 10(1): 83–91.

23.

Goldin

Morrison

Jazaieri

, et al. (2016) Group CBT versus MBSR for social anxiety disorder: A randomized controlled trial. Journal of Consulting and Clinical Psychology 84(5): 427–437.

24.

Goldin

Ramel

Gross

(2009) Mindfulness meditation training and self-referential processing in social anxiety disorder: Behavioral and neural effects. Journal of Cognitive Psychotherapy 23(3): 242–257.

25.

Hong

Tian

(2014) Prevalence of anxiety and depression and their risk factors in Chinese cancer patients. Supportive Care in Cancer 22(2): 453–459.

26.

Martin

(2006) Psychometric properties of the 12-item General Health Questionnaire (GHQ-12) in Chinese women during pregnancy and in the postnatal period. Psychology, Health & Medicine 11(1): 60–69.

27.

Iwata

Ota

Duman

(2013) The inflammasome: Pathways linking psychological stress, depression, and systemic illnesses. Brain, Behavior, and Immunity 31: 105–114.

28.

Jha

Krompinger

Baime

(2007) Mindfulness training modifies subsystems of attention. Cognitive, Affective & Behavioral Neuroscience 7(2): 109–119.

29.

Keng

Smoski

Robins

(2011) Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review 31(6): 1041–1056.

30.

(2015) The factor structure of the 12-item General Health Questionnaire: The multi-group analyses. Psychological Exploration 35(4): 355–359.

31.

Liu

Hou

(2016) Effect of perceived stress on depression of Chinese “Ant Tribe” and the moderating role of dispositional optimism. Journal of Health Psychology 21(11): 2725–2731.

32.

Malalur

Agastya

Dawod

, et al. (2016) Cancer, depression, and health care coverage in the state of Nevada: A retrospective cross-sectional study. Journal of Clinical Oncology 34(7): 42.

33.

Matsushita

Matsushima

Maruyama

(2005) Anxiety and depression of patients with digestive cancer. Psychiatry and Clinical Neurosciences 59(5): 576–583.

34.

Moskowitz

Duncan

Moran

, et al. (2015) Dispositional mindfulness in people with HIV: Associations with psychological and physical health. Personality and Individual Differences 86: 88–93.

35.

Pan

P-C

Goldberg

(1990) A comparison of the validity of GHQ-12 and CHQ-12 in Chinese primary care patients in Manchester. Psychological Medicine 20(4): 931–940.

36.

Ramel

Goldin

Carmona

, et al. (2004) The effects of mindfulness meditation on cognitive processes and affect in patients with past depression. Cognitive Therapy and Research 28(4): 433–455.

37.

Shapiro

Schwartz

Bonner

(1998) Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine 21(6): 581–599.

38.

Siegel

Miller

Jemal

(2015) Cancer statistics, 2015. CA: A Cancer Journal for Clinicians 65(1): 5–29.

39.

Slagter

Lutz

Greischar

, et al. (2009) Theta phase synchrony and conscious target perception: Impact of intensive mental training. Journal of Cognitive Neuroscience 21(8): 1536–1549.

40.

Smith

Ortiz

Steffen

, et al. (2011) Mindfulness is associated with fewer PTSD symptoms, depressive symptoms, physical symptoms, and alcohol problems in urban firefighters. Journal of Consulting and Clinical Psychology 79(5): 613–617.

41.

Tamagawa

Giese-Davis

Speca

, et al. (2013) Trait mindfulness, repression, suppression, and self-reported mood and stress symptoms among women with breast cancer. Journal of Clinical Psychology 69(3): 264–277.

42.

Walach

Buchheld

Buttenmüller

, et al. (2006) Measuring mindfulness: The Freiburg Mindfulness Inventory (FMI). Personality and Individual Differences 40(8): 1543–1555.

43.

Wang

, et al. (2016) Psychometric properties of the Chinese version of the Affective Style Questionnaire and its role as a moderator of the relationship between stress and negative affect. Journal of Health Psychology. DOI: 10.1177/1359105316679722.

44.

Wang

Chen

, et al. (2004) The attitude toward truth telling of cancer in Taiwan. Journal of Psychosomatic Research 57(1): 53–58.

45.

Weinstein

Brown

Ryan

(2009) A multi-method examination of the effects of mindfulness on stress attribution, coping, and emotional well-being. Journal of Research in Personality 43(3): 374–385.