Looming threat-processing style in a cancer cohort

Abstract

Objective

Looming threat-processing style, where threats are perceived to be progressing (looming) at a frightening velocity, is implicated in anxiety vulnerability. This study aims to validate a new measure of looming, the looming cancer, and explore its clinical correlates in a chronic lymphocytic leukemia (CLL) cohort.

Methods

In a cross-sectional design, 105 CLL patients completed the Looming Cancer Scale, Looming Cognitive Style Questionnaire (LCSQ), SF-36, Beck Anxiety Inventory (BAI) and Beck Depression Inventory II (BDI-II).

Results

Exploratory factor analysis reduced the 20-item Looming Cancer Scale to a 10-item version, which demonstrated good psychometric properties (Cronbach's α=.926). Convergent validity was demonstrated by Pearson correlation with the LCSQ (0.418), BAI (0.380), BDI-II (0.336) and the mental component score of the SF-36 (−0.434) (all P<.001). Divergent validity was demonstrated by a lack of correlation with the SF-36 physical component score and cross tabulation frequencies of high and low loomers. High vs. low loomers showed significantly more anxiety (31% vs. 13%), depression (23% vs. 2%) and mixed anxiety–depression (18% vs. 2%). An area under the receiver operating characteristic curve analysis revealed high sensitivity (82%) and specificity (69%) in detecting mixed anxiety–depression using a cutoff score of ≥20/30.

Conclusions

The Looming Cancer Scale is a valid measurement of looming cognitive style and is the first time that the looming construct has been studied in a cancer cohort. The importance of this research lies in its potential to identify populations vulnerable to developing anxiety, depression and mixed anxiety–depression symptoms.

Introduction

Looming cognitive styles are considered to cognitively bias processing of threat-related information so that the threat is seen as rapidly escalating both temporally and spatially. Central to the looming concept is the perceived velocity of the threat. Often, relatively mundane or ambiguous situations are perceived as intensifying and progressing at a frightening velocity [1], [2].

People with a looming threat-processing bias (loomers) are more likely to see a spider as moving toward them with greater velocity or acceleration than others [3]. They are more likely to interpret chest pain as pathological and ambiguous words as more menacing (e.g., sleigh vs. slay) [2]. They have a greater tendency to remember threatening visual images (e.g., of surgery rather than furniture) and rate threatening images as more threatening than people who rate low in looming [2].

Looming is conceptualized as an upstream vulnerability to anxiety — people with this diathesis may not necessarily be anxious but are more liable to develop anxiety given the correct environmental context [1], [2], such as the threat of cancer.

Looming correlates with anxiety, worry, thought suppression and depression [2]. Furthermore, it predicts shared variance with anxiety disorders [obsessive–compulsive disorder (OCD), posttraumatic stress disorder, generalized anxiety disorder (GAD), social phobia and specific phobia], supporting the concept of an overarching dimension of vulnerability to anxiety. Although it correlates with both anxiety and depression, one study found high levels in GAD but not in pure unipolar depression [4]. It is also correlated with insecure adult attachment (preoccupied, fearful and dismissive) [5], fear of acquiring HIV [6] and fear of contamination in subclinical OCD [7].

Looming is an independent predictor of current catastrophizing (even when controlling for worry) and predicts future level of catastrophizing [1]. Although the “ing” suffix of catastrophizing is, prima facie, suggestive of velocity, catastrophizing involves imagined static outcomes rather than perceived velocity of threats. Turner and Aaron [8], in their commentary on the difficulties with the catastrophizing construct, note that, in current iterations of measures, areas such as rumination, helplessness, magnification and even suicidality are examined, and they question what catastrophizing scales really measure. To contrast the two, catastrophizing may involve missing a mortgage payment inducing a static image of being homeless. Looming involves the perceived speed at which missing a mortgage payment might cascade into homelessness. In a similar manner, the velocity-dependent function also differentiates looming from interpretive biases that focus on outcomes alone [9].

Looming is of interest to psycho-oncology because of the high prevalence of anxiety and depression in cancer patients. Twenty-four percent of cancer patients screened for distress have anxiety symptoms, and 18.7% have depressive symptoms [10]. Although there is little data on the prevalence of mixed anxiety–depression symptoms in cancer cohorts, epidemiological catchment area data suggest that 47.2% of those meeting a lifetime criteria for major depression have also met criteria for a comorbid anxiety disorder [11]. Another large study found that the lifetime prevalence of mood and anxiety disorder is 8.36% (S.D.=0.26); mood without anxiety, 11.18% (S.D.=0.23); and anxiety without mood, 8.78% (S.D.=0.26) [12]. Many more patients have subthreshold anxiety and depression symptoms, and DSM-IV has research criteria for mixed anxiety depressive disorder [13]. Moreover, both anxiety and depression respond to antidepressants [14], and adding benzodiazepines to an antidepressant results in a lesser chance of treatment discontinuation and a greater response to antidepressants [15].

Identifying overarching vulnerability factors for anxiety and depression is of great importance to psycho-oncology. The protean manifestations of the fear phenotype often mean that one cancer patient is labeled distressed, another anxious, a third depressed, a fourth as desiring physician-assisted suicide, a fifth “difficult” and so on.

If the acute and chronic manifestations of the fear phenotype could be defined more accurately, it might be possible to improve the prediction of who is at risk for developing distress, depression and anxiety at the start of an arduous process of cancer treatment. It is conceivable that psychological interventions could be targeted more precisely, earlier and possibly even prophylactically.

In this regard, the looming concept could be considered in the light of two hypotheses linking anxiety with depression:

• Recursive neural circuits (such as a fear circuit that involves the amygdala, activating psychiatric symptoms), suggesting that depression and anxiety are epiphenomena of each other modulated by serotonergic, noradrenergic, dopaminergic and gabaminergic neurotransmitter systems [16], [17], [18].

• A shared upstream genetic vulnerability[16], [19]. Multivariate twin modeling data suggest that anxiety and depression are influenced by a common genetic factor [20] and within anxiety disorders; two genetic influences could account for comorbidity — one shared by GAD, panic and agoraphobia, and the second by the specific phobias (including social) [21]. Different environmental triggers may predispose to activation of either a depressive or anxious phenotype. For example, in another twin study, pure major depression and mixed depression–generalized anxiety were predicted by higher loss and humiliation ratings. Pure generalized anxiety was predicted by higher loss and danger ratings. High ratings of entrapment predicted only onsets of mixed episodes. The loss categories of death and respondent-initiated separation predicted pure major depression but not pure generalized anxiety. Events with a combination of humiliation and loss were more depressogenic than pure loss events, including death [22].

Taken together, genetic and neural circuitry data seem to suggest that shared factors may influence the phenotypic development of depression and anxiety. Threat-processing factors (such as looming cognitive styles) and environmental factors (such as a cancer setting) may further influence the development of distinctive anxiety and depression phenotypes. This data supports the development of instruments that measure overarching vulnerability to anxiety and depression in the context of threat appraisal.

The aim of this study, therefore, was to validate a measure of looming designed for a cancer population, the Looming Cancer Scale, and to explore its clinical correlates. We modeled the Looming Cancer Scale on a well-validated looming instrument [the Looming Cognitive Style Questionnaire (LCSQ)], originally designed for use in college-aged students, and structured it around themes of escalating physical loss and danger, decreasing self-efficacy, escalating social loss and danger, escalating risk of humiliation, escalating risk of contamination and escalating entrapment. We hypothesized that the looming cancer will significantly correlate with LCSQ, anxiety, and the mental component of quality of life.