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UBC Theses and Dissertations

Relationships between appraisal and coping strategies used over time by myocardial infarction patients Béchard, Pâquerette 1988

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RELATIONSHIPS BETWEEN STRATEGIES USED OVER INFARCTION APPRAISAL AND COPING TIME BY MYOCARDIAL PATIENTS By LIEUTENANT COMMANDER PAQUERETTE BECHARD B.Sc.N., The U n i v e r s i t y of Ottawa, 1977 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i i n THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA August 1988 © Paquerette Bechard, 1988 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of NOfcSfMXr The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date DE-6(3/81) i i . ABSTRACT Thi s d e s c r i p t i v e c o r r e l a t i o n a l and l o n g i t u d i n a l study was designed to a s s e s s the changes i n c o g n i t i v e a p p r a i s a l of emotions and cop i n g s t r a t e g i e s which myocardial i n f a r c t i o n (Ml) p a t i e n t s used a t two p o i n t s i n time. A d d i t i o n a l l y , the v a r i a b l e s of c o g n i t i v e a p p r a i s a l of emotions were i n v e s t i g a t e d f o r t h e i r r e l a t i o n s h i p s to copi n g s t r a t e g i e s . A convenience sample of 21 confirmed f i r s t MI p a t i e n t s was s e l e c t e d from coronary care u n i t s (CCU) of four h o s p i t a l s i n western Canada. P a r t i c i p a n t s completed the Emotion A p p r a i s a l S c a l e , the Revised Ways of Coping c h e c k l i s t as w e l l as an i n f o r m a t i o n sheet. O v e r a l l , the p a r t i c i p a n t s e x p e r i e n c e d a wide range of the four a p p r a i s a l types of t h r e a t , harm, c h a l l e n g e and b e n e f i t . Challenge emotions were the most frequent a p p r a i s a l type at both i n t e r v i e w s . I n i t i a l l y - , b e n e f i t emotions were the l e a s t frequent a p p r a i s a l type, while harm emotions were the l e a s t f r e q u e n t a t the second p e r i o d . While r e s u l t s i n d i c a t e d changes, no s i g n i f i c a n t changes were found i n the four emotion a p p r a i s a l s of t h r e a t , harm, c h a l l e n g e and b e n e f i t over time. The co m p l e x i t y of emotions e x p e r i e n c e d r e f l e c t s the m u l t i f a c a t e d nature of the MI s i t u a t i o n i n f l u e n c i n g p a t i e n t s i n e a r l y phases of r e c o v e r y . H i . The p a r t i c i p a n t s used a v a r i e t y of coping s t r a t e g i e s which are r e l a t e d to emotion-focused and problem-focused c o p i n g to manage the demands of t h e i r MI. Most of the p a r t i c i p a n t s used a l l e i g h t a v a i l a b l e types of c o p i n g . The s t r a t e g i e s of s e e k i n g s o c i a l support, d i s t a n c i n g and p o s i t i v e r e a p p r a i s a l were the most predominant types of c o p i n g a t both i n t e r v i e w s . The s t r a t e g i e s of s e l f - c o n t r o l l i n g , p l a n f u l p r o b l e m - s o l v i n g and a c c e p t i n g r e s p o n s i b i l i t y were moderately used, while escape-avoidance and c o n f r o n t i v e coping were the l e a s t used types of coping a t both times. The f i n d i n g s suggest t h a t c o p i n g with a c a r d i a c event i s a complex p r o c e s s . The MI c r i s i s p resent the p a t i e n t s with m u l t i p l e t a s k s which r e q u i r e a combination of c o p i n g s t r a t e g i e s . At the i n i t i a l p e r i o d , a s i g n i f i c a n t r e l a t i o n s h i p was found between t h r e a t emotions and p l a n f u l p r o b l e m - s o l v i n g c o p i n g . Harm emotions were s i g n i f i c a n t l y and p o s i t i v e l y c o r r e l a t e d with a c c e p t i n g r e s p o n s i b i l i t y , p l a n f u l p r o b l e m - s o l v i n g and c o n f r o n t i v e c o p i n g . S i m i l a r l y , c h a l l e n g e emotions c o r r e l a t e d with s e e k i n g s o c i a l support and p o s i t i v e r e a p p r a i s a l c o p i n g . S i g n i f i c a n t r e l a t i o n s h i p s were found between b e n e f i t emotions and two forms of c o p i n g : c o n f r o n t i v e and s e e k i n g s o c i a l support c o p i n g . At the second p e r i o d , o n l y two s i g n i f i c a n t c o r r e l a t i o n s were i v . found: b e n e f i t emotions s i g n i f i c a n t l y c o r r e l a t e d with s e l f - c o n t r o l l i n g and a c c e p t i n g r e s p o n s i b i l i t y . The f i n d i n g s suggest t h a t a h eart a t t a c k i s a p p r a i s e d as moderately s t r e s s f u l by f i r s t MI p a t i e n t s In e a r l y phases of r e c o v e r y . The MI p a t i e n t s ' p e r c e p t i o n or u n d erstanding of the c o n t e x t u a l f a c t o r s a f f e c t a p p r a i s a l of harm, t h r e a t , b e n e f i t and c h a l l e n g e emotions which i n t u r n i n f l u e n c e the c h o i c e of coping s t r a t e g i e s . TABLE OF CONTENTS Page A b s t r a c t i i T a b l e o f C o n t e n t s v L i s t o f T a b l e s v i i i L i s t o f F i g u r e s i x A c k n o w l e d g e m e n t s x CHAPTER ONE INTRODUCTION 1 B a c k g r o u n d t o t h e P r o b l e m 1 S t a t e m e n t o f t h e P r o b l e m 3 P u r p o s e o f t h i s S t u d y 4 T h e o r e t i c a l F r a m e w o r k 4 H y p o t h e s e s 10 D e f i n i t i o n o f Terms 10 A s s u m p t i o n s 12 L i m i t a t i o n s 12 O v e r v i e w o f t h e T h e s i s C o n t e n t 12 CHAPTER TWO REVIEW OF SELECTED LITERATURE 14 I n t r o d u c t i o n . 14 C o g n i t i v e A p p r a i s a l 14 P a t i e n t s ' A p p r a i s a l o f I l l n e s s 15 H a r m / l o s s 16 C h a l l e n g e 17 G a i n / b e n e f i t 17 T h r e a t 18 P a t i e n t s ' A p p r a i s a l o f M y o c a r d i a l I n f a r c t i o n 21 C o p i n g S t r a t e g i e s 28 C o p i n g W i t h S t r e s s f u l E n c o u n t e r s 28 C o p i n g W i t h M y o c a r d i a l I n f a r c t i o n 29 v i C o p i n g a s a P r o c e s s 37 C h a n g e s i n E m o t i o n s a n d C o p i n g S t r a t e g i e s . . 37 R e l a t i o n s h i p B e t w e e n C o g n i t i v e A p p r a i s a l a n d C o p i n g S t r a t e g i e s 41 Summary 47 CHAPTER THREE METHODOLOGY 53 Sample 53 S e t t i n g 54 Human R i g h t s a n d E t h i c a l C o n s i d e r a t i o n s 54 D a t a C o l l e c t i o n P r o c e d u r e 55 D a t a C o l l e c t i o n I n s t r u m e n t s 56 E m o t i o n A p p r a i s a l S c a l e 57 The R e v i s e d Ways o£ C o p i n g S c a l e 58 P a t i e n t I n f o r m a t i o n S h e e t 63 D a t a A n a l y s i s 63 CHAPTER FOUR PRESENTATION AND DISCUSSION OF RESULTS 6 4 C h a r a c t e r i s t i c s o f t h e Sample 64 D e m o g r a p h i c C h a r a c t e r i s t i c s o f t h e Sample 64 Age, M a r i t a l , E d u c a t i o n a l a n d O c c u p a t i o n a l S t a t u s 64 I l l n e s s - R e l a t e d C h a r a c t e r i s t i c s . o f t h e Sample 66 F i n d i n g s 70 H y p o t h e s i s One: C h a n g e s i n E m o t i o n s 70 H y p o t h e s i s Two: C h a n g e s i n C o p i n g S t r a t e g i e s 73 H y p o t h e s i s T h r e e : R e l a t i o n s h i p s B e t w e e n C o g n i t i v e A p p r a i s a l a n d C o p i n g S t r a t e g i e s . . 77 D i s c u s s i o n o f R e s u l t s 80 C h a r a c t e r i s t i c s o f t h e Sa m p l e 81 C h a n g e s i n E m o t i o n s 81 C h a n g e s i n C o p i n g S t r a t e g i e s 96 R e l a t i o n s h i p s B e t w e e n C o g n i t i v e A p p r a i s a l a n d C o p i n g S t r a t e g i e s 104 Summary 115 v i i CHAPTER F I V E SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS 121 Summary 121 C o n c l u s i o n s 129 I m p l i c a t i o n s 131 R e c o m m e n d a t i o s f o r F u r t h e r R e s e a r c h 134 REFERENCES 137 APPENDICES 141 A p p e n d i x A: E m o t i o n A p p r a i s a l S c a l e 141 A p p e n d i x B: The R e v i s e d Ways o f C o p i n g S c a l e 143 A p p e n d i x C: P a t i e n t I n - H o s p i t a l I n f o r m a t i o n S h e e t 149 A p p e n d i x D: P a t i e n t At-Home I n f o r m a t i o n S h e e t 151 A p p e n d i x E: I n f o r m a t i o n - C o n s e n t L e t t e r . . . . 153 v i i i L I S T OF TABLES T a b l e P age I . Age o f t h e Sample 65 I I . O c c u p a t i o n a l S t a t u s o f t h e Sample 66 I I I . Number o f Symptoms 67 I V . Symptoms R e p o r t e d B e t w e e n t h e F i f t h a n d t h e S e v e n Days a n d E i g h t Weeks P o s t M I . . . . 68 V. C o g n i t i v e A p p r a i s a l T y p e s and C h a n g e s O v e r Time 71 V I . C h a n g e s i n C o g n i t i v e A p p r a i s a l B e t w e e n t h e F i f t h a n d t h e S e v e n t h Days a n d E i g h t Weeks P o s t M I . . . . 72 V I I . c o p i n g S t r a t e g i e s T y p e s a n d C h a n g e s Over Time 74-75 V I I I . C h a n g e s i n C o p i n g S t r a t e g i e s B e t w e e n t h e F i f t h a n d t h e S e v e n t h Days and E i g h t Weeks P o s t MI 78 I X . R e l a t i o n s h i p s B e t w e e n C o g n i t i v e A p p r a i s a l a n d C o p i n g S t r a t e g i e s B e t w e e n t h e F i f t h a n d t h e S e v e n t h Days and E i g h t Weeks P o s t MI 79 i x L I S T OF FIGURES F i g u r e P a ge 1. C o n c e p t u a l Framework 6 The S t r e s s , A p p r a i s a l a n d C o p i n g T h e o r y ( L a z a r u s & F o l k m a n , 1 9 8 4 ) . X ACKNOWLEDGEMENTS I would l i k e to express my g r a t i t u d e to those who have helped me throughout the r e s e a r c h p r o j e c t . I would l i k e to thank the members of my t h e s i s committee, Dr. Ann H i l t o n ( c h a i r p e r s o n ) and C a r o l J i l l i n g s . I am ve r y g r a t e f u l f o r the guidance and a s s i s t a n c e they have p r o v i d e d me throughout t h i s r e s e a r c h p r o c e s s . I would l i k e to extend my thanks to the h o s p i t a l s and n u r s i n g s t a f f who p a r t i c i p a t e d and gave so ge n e r o u s l y of t h e i r time. I a l s o would l i k e to thank each of the 21 p a r t i c i p a n t s who shared t h e i r e x p e r i e n c e s with me. I wish to express my a p p r e c i a t i o n to the Canadian Armed F o r c e s , Department of N a t i o n a l Defence f o r g i v i n g me the p r i v i l e g e to pursue my s t u d i e s . F i n a l l y , I would l i k e to thank my mother, Madame Yvonne Bechard f o r her support and her p r a y e r s . 1 CHAPTER ONE Background t o the Problem C a r d i o v a s c u l a r d i s e a s e has been d e s c r i b e d as the worst epidemic ever to s t r i k e Canadians, a c c o u n t i n g f o r c l o s e to h a l f of a l l deaths each year, and i n 1 9 8 2 , i t s major sub-component, ischemic h e a r t d i s e a s e , was r e s p o n s i b l e f o r almost a t h i r d of a l l deaths ( N i c h o l l s et a l . , 1 9 8 6 ) . Furthermore, i t i s estimated t h a t about 8 0 0 , 0 0 0 Canadians e x p e r i e n c e d h e a r t problems i n 1979 ( S t a t i s t i c s Canada, 1 9 8 5 ) . T h e r e f o r e , a sudden i l l n e s s such as a myocardial i n f a r c t i o n (MI) a s s o c i a t e d with a high death r i s k understandably arouses many e m o t i o n a l - s t r e s s r e a c t i o n s (Gulledge, 1 9 7 9 ; Burgess & Hartman, 1 9 8 6 ) . A d d i t i o n a l l y , l i f e s t y l e changes, t h r e a t to s e l f - e s t e e m and f e a r of r e c u r r i n g h e a r t a t t a c k may f u r t h e r s t r e s s the i n d i v i d u a l (Wishnie, Hackett & Cassem, 1 9 7 1 ; G u l l e d g e , 1 9 7 9 ; Burgess & Hartman, 1 9 8 6 ) . Emotional r e a c t i o n s e x p e r i e n c e d by p a t i e n t s d u r i n g the v a r i o u s stages of r e c o v e r y have been r e p o r t e d (Cassem & Hackett, 1 9 7 1 ; Wiklund et a l . , 1 9 8 5 ) . D i s b e l i e f , anger, d e n i a l , a n x i e t y and d e p r e s s i o n c o n s t i t u t e normal responses (Cassem & Hackett, 1 9 7 1 ) . Although the event of Ml i t s e l f i s o f t e n a s i n g l e e p i s o d e , I n d i v i d u a l s must cont i n u e f o r the remainder of t h e i r l i v e s to adapt t o the p s y c h o l o g i c a l e f f e c t s of the MI. "Recovery from a 2 m y o c a r d i a l i n f a r c t i o n i s more t h a n j u s t a m e d i c a l p r o b l e m " ( B u r i s h & B r a d l e y , 1 9 8 3 , p. 8 5 ) . P a t i e n t s must a d j u s t p h y s i c a l l y a n d p s y c h o l o g i c a l l y i n o r d e r t o c o p e w i t h a l l a s p e c t s o f t h e i r s i t u a t i o n s , a n d "many s u c h p a t i e n t s a f t e r l e a v i n g t h e h o s p i t a l h a v e y e t t o f e e l a n d c o m p r e h e n d t h e c o m p l e t e e f f e c t s o f t h e i r i l l n e s s " ( G u l l e d g e , 1 9 7 9 , p. 114) . P s y c h o l o g i c a l d i s t r e s s i s d e s t r u c t i v e t o l o n g t e r m r e c o v e r y f o l l o w i n g a m y o c a r d i a l i n f a r c t i o n ( W i s h n i e , H a c k e t t & C a s s e m , 1 9 7 1 ; W i k l u n d e t a l . , 1 9 8 4 ) . T h e s e r e s e a r c h e r s r e m a r k t h a t o t h e r t h a n t h e e x p e c t e d t e m p o r a r y p s y c h o l o g i c a l r e a c t i o n s , l o n g - l a s t i n g e m o t i o n a l d i s t u r b a n c e s a f t e r a h e a r t a t t a c k a r e c o n s i d e r a b l e . T h e y f u r t h e r e x p l a i n t h a t many p a t i e n t s who r e c o v e r p h y s i o l o g i c a l l y f r o m t h e i r m y o c a r d i a l i n f a r c t i o n l a t e r s u ccumb t o p s y c h o l o g i c a l s t r e s s e s a s s o c i a t e d w i t h t h e e v e n t . A h i g h i n c i d e n c e o f a n x i e t y a n d d e p r e s s i o n h a s b e e n r e p o r t e d ( W i s h n i e , H a c k e t t & C a s s e m , 1971 ; W i k l u n d e t a l . , 1 9 8 4 ) . B a s e d on t h e i r f i n d i n g s , t h e y c o n c l u d e d t h a t e m o t i o n a l d i s t r e s s a n d s e r i o u s n e s s o f a MI do n o t a l w a y s c o r r e l a t e , a n d t h a t some MI p a t i e n t s become c a r d i a c c r i p p l e s w i t h o u t o f t e n s u f f i c i e n t c a r d i a c damage o r symptoms t o w a r r a n t s u c h a s t a t e o f i n v a l i d i s m . C o h e n and L a z a r u s ( 1 9 7 9 ) s t a t e t h a t c o g n i t i v e f a c t o r s p l a y a m a j o r r o l e i n e m o t i o n s a n d c o p i n g . The way a n i n d i v i d u a l a p p r a i s e s a n e v e n t i n f l u e n c e s c o p i n g a n d t h e 3 e m o t i o n a l a n d t h e b e h a v i o r a l r e a c t i o n s t o t h e s t r e s s f u l e x p e r i e n c e ( C o h e n & L a z a r u s , 1 9 7 9 ) . A c c o r d i n g t o L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) , e m o t i o n s e x p e r i e n c e d i n s t r e s s f u l s i t u a t i o n s c o n t i n u a l l y c h a n g e . A p a t i e n t may f e e l a n x i o u s , g u i l t y o r a n g r y a s t h e s i t u a t i o n p r o g r e s s e s . As t h e m e a n i n g o f a s i t u a t i o n c h a n g e s , s o d o e s t h e i n d i v i d u a l ' s ways o f c o p i n g . A s s e s s i n g t h e c o p i n g s t r a t e g i e s u s e d o v e r t i m e t o manage t h e s t r e s s e s o f s e v e r e i l l n e s s e s i s t h e r e f o r e i m p o r t a n t . S u c h i n f o r m a t i o n may e x p l a i n why p a t i e n t s s u c c e e d o r f a i l I n a d j u s t i n g d u r i n g t h e i r r e c o v e r y p e r i o d ( C o h e n & L a z a r u s , 1 9 7 9 ) . A c c o r d i n g t o F o l k m a n e t a l . ( 1 9 8 6 ) , t h e r e l a t i o n b e t w e e n s t r e s s a n d c o p i n g i s c o m p l e x a n d p o o r l y u n d e r s t o o d , a n d " d e s p i t e t h e i m p o r t a n c e t h a t i s a t t r i b u t e d t o c o p i n g a s a f a c t o r i n p s y c h o l o g i c a l a n d s o m a t i c h e a l t h o u t c o m e s , l i t t l e i s known a b o u t a c t u a l c o p i n g p r o c e s s e s " ( p . 9 9 2 ) . No s t u d i e s were f o u n d w h i c h c o m p r e h e n s i v e l y a s s e s s e d e m o t i o n a p p r a i s a l s and c o p i n g s t r a t e g i e s i n MI p a t i e n t s . F u r t h e r m o r e , no M l - l i n k e d r e s e a r c h s h o w i n g how a p p r a i s a l s a n d c o p i n g s t r a t e g i e s a r e r e l a t e d , a n d how e a c h c h a n g e o v e r t i m e was f o u n d . S t a t e m e n t o f t h e P r o b l e m F o r t h e i n d i v i d u a l , a m y o c a r d i a l i n f a r c t i o n r e p r e s e n t s a s t r e s s f u l e v e n t b e g i n n i n g w i t h t h e o n s e t o f t h e i l l n e s s a n d c o n t i n u i n g t h r o u g h o u t t h e r e c o v e r y p e r i o d . To manage t h e s t r e s s e s o f a M I , p a t i e n t s u s e c o p i n g s t r a t e g i e s b a s e d on t h e i r a p p r a i s a l o f t h e s i t u a t i o n . The n a t u r e o f t h e a p p r a i s a l s made o r t h e c o p i n g s t r a t e g i e s u s e d b y t h e s e p a t i e n t s i s n o t c l e a r . H o w e v e r , no r e s e a r c h was f o u n d w h i c h has s t u d i e d t h e l i n k b e t w e e n a p p r a i s a l a n d c o p i n g s t r a t e g i e s , and how t h e y c h a n g e f r o m t h e a c u t e t o t h e c o n v a l e s c e n t p h a s e s o f r e h a b i l i t a t i o n , i n p a t i e n t s d i a g n o s e d w i t h a MI. Purpose of t h i s s t u d y The p u r p o s e o f t h i s s t u d y i s t w o f o l d : f i r s t , t o d e s c r i b e a n d c o m p a r e t h e c o g n i t i v e a p p r a i s a l a n d c o p i n g s t r a t e g i e s u s e d b y MI p a t i e n t s b e t w e e n t h e e a r l y MI p e r i o d a n d e i g h t weeks l a t e r ; a n d s e c o n d , t o e x a m i n e t h e r e l a t i o n s h i p s b e t w e e n c o g n i t i v e a p p r a i s a l a n d c o p i n g s t r a t e g i e s u s e d . T h e o r e t i c a l F r a m e w o r k The t h e o r e t i c a l f r a m e w o r k u s e d i n t h i s s t u d y w i l l be L a z a r u s a n d F o l k m a n ' s ( 1 9 8 4 ) t h e o r y o f s t r e s s a n d c o p i n g ( s e e F i g u r e 1 ) . I n t h e m o d e l , c o g n i t i v e a p p r a i s a l r e f e r s t o t h e e v a l u a t i v e c o g n i t i v e p r o c e s s e s w h i c h m e d i a t e b e t w e e n t h e p e r s o n a n d t h e e n v i r o n m e n t i n a n y s i t u a t i o n . T h a t i s , t h e i n d i v i d u a l e v a l u a t e s a s i t u a t i o n a n d d e f i n e s h a r m s , t h r e a t s a n d c h a l l e n g e s i n v o l v e d , a s w e l l a s t h e r e s o u r c e s r e q u i r e d t o manage t h e demands. A p p r a i s a l s g i v e 5 r i s e t o t h o u g h t s a nd a c t i o n s . The way a n i n d i v i d u a l a p p r a i s e s a s i t u a t i o n i s t h e b a s i s f o r u n d e r s t a n d i n g e m o t i o n a l r e a c t i o n s a n d c o p i n g s i t u a t i o n c h a n g e s . T h i s t h e o r y v i e w s c o p i n g a s a p r o c e s s w i t h m u l t i p l e f u n c t i o n s t o h e l p p e o p l e d e a l w i t h t h e demands o f s t r e s s f u l e n c o u n t e r s . C o g n i t i v e A p p r a i s a l A c c o r d i n g t o L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) , what a s i t u a t i o n means t o a n i n d i v i d u a l d e t e r m i n e s t h e e m o t i o n a l a n d b e h a v i o r a l r e s p o n s e s . C o g n i t i v e a p p r a i s a l may be d e f i n e d a s t h e e v a l u a t i v e c o g n i t i v e p r o c e s s e s t h a t m e d i a t e b e t w e e n t h e s i t u a t i o n a n d t h e f a c t o r s w i t h i n t h e p e r s o n . C o g n i t i v e a p p r a i s a l p r o c e s s e s a l l o w i n d i v i d u a l s t o e v a l u a t e t h e s i t u a t i o n ' s r e l e v a n c e t o t h e i r w e l l - b e i n g a n d s h a p e t h e i r r e s p o n s e s t o a n y e n c o u n t e r . P e r s o n - f a c t o r s s u c h a s b e l i e f s a n d c o m m i t m e n t s , a n d s i t u a t i o n - f a c t o r s s u c h a s n o v e l t y , u n c e r t a i n t y a n d p r e d i c t a b i l i t y , i n f l u e n c e p e r c e p t i o n s a n d a p p r a i s a l s . L a z a r u s a n d F o l k m a n ' s ( 1 9 8 4 ) s t r e s s a p p r a i s a l a n d c o p i n g t h e o r y e m p h a s i z e s t h e r e l a t i o n s h i p b e t w e e n t h e p e r s o n a n d t h e e n v i r o n m e n t , a n d t a k e s i n t o a c c o u n t t h e s p e c i f i c c h a r a c t e r i s t i c s o f a n i n d i v i d u a l a s w e l l a s t h e e n v i r o n m e n t a l s i t u a t i o n . P s y c h o l o g i c a l s t r e s s i s d e f i n e d a s " t h e r e l a t i o n s h i p b e t w e e n t h e i n d i v i d u a l a n d t h e e n v i r o n m e n t t h a t i s a p p r a i s e d b y t h e i n d i v i d u a l a s r e l e v a n t t o h i s / h e r w e l l - b e i n g a n d i n w h i c h t h e 6 PERSON Commitments B e l i e f s ENVIRONMENT I MI H o s p i t a l Home COGNITIVE APPRAISAL P r i m a r y A p p r a i s a l ( w hat i s a t s t a k e ) B e n i g n -I r r e l e v a n t S t r e s s f u l P o s i t i v e H a r m / l o s s C h a l l e n g e T h r e a t S e c o n d a r y A p p r a i s a l ( c o p i n g o p t i o n s ) R e a p p r a i s a l O utcomes C o p i n g S t r a t e g i e s r COPING PROCESS OVER TIME C o g n i t i v e A p p r a i s a l R e a p p r a i s a l t C o p i n g S t r a t e g i e s Outcome F i g u r e 1. T h e o r e t i c a l Framework f o r A p p r a i s a l a n d C o p i n g S t r a t e g i e s . N o t e . A d a p t e d w i t h p e r m i s s i o n f r o m C o p i n g w i t h t h e U n c e r t a i n t i e s o f B r e a s t C a n c e r : A p p r a i s a l a n d C o p i n g S t r a t e g i e s ( p . 7 ) , by B.A. H i l t o n , 1 9 8 7 . Ann A r b o r , MI: U n i v e r s i t y M i c r o f i l m s I n t e r n a t i o n a l , No. 8 7 - 0 0 , 2 0 5 . 7 i n d i v i d u a l ' s r e s o u r c e s a r e t a x e d o r e x c e e d e d " ( p . 1 9 ) . L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) c l a i m t h a t a p p r a i s a l h a s t h r e e c o g n i t i v e p r o c e s s e s : p r i m a r y a p p r a i s a l , s e c o n d a r y a p p r a i s a l a n d r e a p p r a i s a l . I n p r i m a r y a p p r a i s a l , t h e p e r s o n j u d g e s t h e r e l e v a n c e o f t h e s i t u a t i o n t o h i s / h e r w e l l - b e i n g . The p e r s o n may u s e t h r e e k i n d s o f p r i m a r y a p p r a i s a l . F i r s t , when a s i t u a t i o n w i t h i n t h e e n v i r o n m e n t d o e s n o t r e l a t e t o a n I n d i v i d u a l ' s w e l l - b e i n g , t h e p e r s o n p e r c e i v e s t h a t s i t u a t i o n a s i r r e l e v a n t . S e c o n d , t h e I n d i v i d u a l a p p r a i s e s a s b e n i g n - p o s i t i v e a s i t u a t i o n w h i c h seems t o h a v e p o t e n t i a l a d v a n t a g e s f o r p e r s o n a l w e l l - b e i n g . S t r e s s - a p p r a i s a l s s u c h a s h a r m / l o s s , t h r e a t a n d c h a l l e n g e r e p r e s e n t t h e t h i r d k i n d . I n h a r m / l o s s , t h e i n d i v i d u a l h a s a l r e a d y r e c o g n i z e d t h e damage s u s t a i n e d t o s e l f o r a l o v e d o n e . I n t h r e a t , t h e i n d i v i d u a l a n t i c i p a t e s harm o r l o s s e s . W i t h c h a l l e n g e , t h e i n d i v i d u a l p e r c e i v e s a g a i n o r a p o t e n t i a l g a i n . I n t h e s e c o n d p a r t o f t h i s p r o c e s s , t h r o u g h s e c o n d a r y a p p r a i s a l , t h e i n d i v i d u a l e v a l u a t e s t h e r e s o u r c e s r e q u i r e d t o c o p e w i t h t h e e n c o u n t e r . The i n d i v i d u a l a s s e s s e s what c a n be done t o s u c c e e d , p r e v e n t harm, o r i m p r o v e c h a n c e s o f s u c c e s s . The I n d i v i d u a l d e t e r m i n e s n o t o n l y w h i c h c o p i n g o p t i o n s a r e a v a i l a b l e , b u t a l s o what t h e p o t e n t i a l c o n s e q u e n c e s o f u s i n g s u c h s t r a t e g i e s a r e . R e a p p r a i s a l r e f e r s t o a m o d i f i e d a p p r a i s a l on t h e b a s i s o f new i n f o r m a t i o n o r f e e d b a c k f r o m t h e e n v i r o n m e n t 8 a n d / o r t h e p e r s o n . The r e a p p r a i s a l may c h a n g e a n e a r l i e r a p p r a i s a l i n t h e same s i t u a t i o n . R e a p p r a i s a l r e f e r s t o b o t h t h e a s s e s s m e n t o f harm, t h r e a t , o r r e s o u r c e s a n d t h e c h o i c e s o f a c t i o n s a n d a n t i c i p a t e d o u t c o m e s . P r i m a r y a n d s e c o n d a r y a p p r a i s a l s a r e i n t e r d e p e n d e n t . F o r e x a m p l e , i f t h e c o p i n g r e s o u r c e s a r e j u d g e d a s a d e q u a t e t o meet t h e demands o f a s t r e s s f u l s i t u a t i o n , t h e d e g r e e o f t h r e a t i s d e c r e a s e d . On t h e o t h e r h a n d , a s i t u a t i o n r e g a r d e d b y a n i n d i v i d u a l a s i n s i g n i f i c a n t may become t h r e a t e n i n g i f c o p i n g r e s o u r c e s a r e i n a d e q u a t e t o o v e r c o m e t h e s i t u a t i o n . A l t h o u g h p r i m a r y a p p r a i s a l u s u a l l y p r e c e d e s s e c o n d a r y a p p r a i s a l , t h e i r r e l a t i o n s h i p i s n o t n e c e s s a r i l y s e q u e n t i a l . C o p i n g S t r a t e g i e s B a s e d on t h e p r i m a r y a n d s e c o n d a r y a p p r a i s a l s , t h e i n d i v i d u a l s e l e c t s p a r t i c u l a r c o p i n g s t r a t e g i e s t o manage t h e demands o f t h e s i t u a t i o n . C o p i n g i s d e f i n e d a s " c o n s t a n t l y c h a n g i n g c o g n i t i v e a n d b e h a v i o r a l e f f o r t s t o manage s p e c i f i c e x t e r n a l a n d / o r i n t e r n a l demands t h a t a r e a p p r a i s e d a s t a x i n g o r e x c e e d i n g t h e r e s o u r c e s o f t h e p e r s o n " ( L a z a r u s & F o l k m a n , 1984, p. 141). C o p i n g s t r a t e g i e s a r e e f f o r t s t h e p e r s o n g e n e r a t e s a s a r e s u l t o f c o g n i t i v e a p p r a i s a l , i n o r d e r t o m o d i f y t h e e n v i r o n m e n t o r t o c h a n g e t h e m e a n i n g o f t h e s i t u a t i o n . T h e s e c o p i n g e f f o r t s o r i g i n a t e i n t e r n a l l y o r e x t e r n a l l y , a n d may be c o n s c i o u s o r u n c o n s c i o u s . L a z a r u s a n d F o l k m a n (1984) 9 f u r t h e r s u g g e s t t h a t c o p i n g s t r a t e g i e s s e r v e two m a j o r f u n c t i o n s . P r o b l e m - f o c u s e d c o p i n g s t r a t e g i e s d e a l w i t h t h e t h r e a t I t s e l f , o r w i t h t h e o b s t a c l e s p r e s e n t i n t h e e n v i r o n m e n t o r i n o n e s e l f . T h e s e s t r a t e g i e s s e r v e a p r o b l e m - s o l v i n g f u n c t i o n . E m o t i o n - f o c u s e d c o p i n g s t r a t e g i e s a t t e m p t t o d e a l w i t h s t r e s s f u l e m o t i o n s c a u s e d by t h e s i t u a t i o n a n d t o r e g u l a t e t h e e m o t i o n a l d i s t r e s s , t h e r e b y s e r v i n g a p a l l i a t i v e f u n c t i o n . C o p i n g a s a P r o c e s s C o p i n g when v i e w e d i n t h i s manner i s a p r o c e s s w i t h t h r e e m a i n c h a r a c t e r i s t i c s . F i r s t , c o p i n g i s c o n c e r n e d w i t h what t h e I n d i v i d u a l a c t u a l l y t h i n k s o r d o e s . S e c o n d , what t h e p e r s o n t h i n k s o r d o e s i s e x a m i n e d i n a p a r t i c u l a r c o n t e x t . T h i r d , t h i s a p p r o a c h c o n s i d e r s t h e c h a n g e s i n a p e r s o n ' s t h o u g h t s a n d a c t i o n s a s t h e s t r e s s f u l e n c o u n t e r e v o l v e s . As t h e s i t u a t i o n c h a n g e s , t h e p e r s o n a p p r a i s e s a n d r e a p p r a i s e s t h e s i t u a t i o n , a n d a c c o r d i n g l y a d j u s t s t h e c o p i n g e f f o r t s t o meet t h e new demands. The p r e s e n t s t u d y i s d e s i g n e d t o e x a m i n e t h e c h a n g e s and t h e r e l a t i o n s h i p s b e t w e e n t h e c o g n i t i v e a p p r a i s a l and c o p i n g s t r a t e g i e s u s e d b y m y o c a r d i a l I n f a r c t i o n p a t i e n t s a t two p o i n t s i n t i m e . A c c o r d i n g t o F o l k m a n a n d L a z a r u s ( 1 9 8 5 ) , s t u d y o f t h e n a t u r e a n d c o n t e n t o f i n d i v i d u a l s ' c o p i n g s t r a t e g i e s i n s t r e s s f u l s i t u a t i o n s i s c r u c i a l . "The e s s e n c e o f s t r e s s , c o p i n g , a n d a d a p t a t i o n i s c h a n g e . . . a n d u n l e s s we f o c u s on c h a n g e , we c a n n o t l e a r n how p e o p l e come to manage s t r e s s f u l events and c o n d i t i o n s " (p. 1 5 0 ) . Hypotheses 1. There i s a change i n c o g n i t i v e a p p r a i s a l used by p a t i e n t s diagnosed with m y o c a r d i a l i n f a r c t i o n a t two p o i n t s i n time, between the f i f t h and the seventh days post MI and e i g h t weeks a f t e r the MI. 2. There i s a change i n c o p i n g s t r a t e g i e s used by p a t i e n t s diagnosed with m y o c a r d i a l i n f a r c t i o n at two points, i n time, between the f i f t h and the seventh days post MI and e i g h t weeks a f t e r the MI. 3. There i s a r e l a t i o n s h i p between c o g n i t i v e a p p r a i s a l and coping s t r a t e g i e s t h a t p a t i e n t s use d u r i n g the process of r e c o v e r y from a m y o c a r d i a l i n f a r c t i o n . D e f i n i t i o n s of Terms M y o c a r d i a l i n f a r c t i o n : n e c r o s i s of the c e l l s of an area of the h e a r t muscle (myocardium) o c c u r r i n g as a r e s u l t of oxygen d e p r i v a t i o n , which i n t u r n i s caused by the o b s t r u c t i o n of blood s u p p l y from i t s coronary a r t e r i e s ( M i l l e r & Keane, 1987) . C o g n i t i v e a p p r a i s a l : c o g n i t i v e e v a l u a t i v e processes which mediate between the person and the s i t u a t i o n i n terms of i t s s i g n i f i c a n c e f o r a person's w e l l - b e i n g (Lazarus & Folkman, 1984) . Primary a p p r a i s a l : c o g n i t i v e processes i n which the person e v a l u a t e s w h e t h e r a n e v e n t I s i r r e l e v a n t , b e n i g n - p o s i t i v e , o r s t r e s s f u l ( L a z a r u s & F o l k m a n , 1 9 8 4 ) . An i r r e l e v a n t a p p r a i s a l r e f e r s t o a n e n c o u n t e r w h i c h c a r r i e s no i m p l i c a t i o n t o t h e p e r s o n ' s w e l l - b e i n g ; i n a b e n i g n - p o s i t i v e a p p r a i s a l t h e o u t c o m e s o f a n e n c o u n t e r i s c o n s t r u e d a s p o s i t i v e ; s t r e s s a p p r a i s a l s a r e c h a r a c t e r i z e d b y t h r e a t , c h a l l e n g e , o r h a r m / l o s s . H a r m / l o s s r e f e r s t o damage t h a t h a s a l r e a d y o c c u r r e d ; t h r e a t c o n c e r n s a n t i c i p a t e d o r f u t u r e harm; c h a l l e n g e f o c u s e s on t h e p o t e n t i a l f o r g a i n o r g r o w t h i n h e r e n t i n a n e n c o u n t e r . S t r e s s : t h e r e l a t i o n s h i p b e t w e e n t h e p e r s o n a n d t h e e n v i r o n m e n t t h a t i s a p p r a i s e d b y t h e p e r s o n a s r e l e v a n t t o h i s / h e r w e l l b e i n g a nd i n w h i c h t h e p e r s o n ' s r e s o u r c e s a r e t a x e d o r e x c e e d e d ( L a z a r u s & F o l k m a n , 1 9 8 4 ) . C o p i n g : t h e c o n s t a n t l y c h a n g i n g c o g n i t i v e a n d b e h a v i o r a l e f f o r t s t o manage s p e c i f i c e x t e r n a l a n d / o r i n t e r n a l demands t h a t a r e a p p r a i s e d a s t a x i n g o r e x c e e d i n g t h e r e s o u r c e s o f t h e p e r s o n ( L a z a r u s & F o l k m a n , 1 9 8 4 ) . C o p i n g S t r a t e g i e s ; t h o s e c o p i n g e f f o r t s t h a t o r i g i n a t e f r o m t h e p e r s o n ' s i n t e r n a l o r e x t e r n a l e n v i r o n m e n t t o meet t h e demands i m p o s e d b y a s t r e s s f u l e v e n t ( L a z a r u s & F o l k m a n 1 9 8 4 ) . The s t r e s s , a p p r a i s a l a n d c o p i n g t h e o r y i d e n t i f i e s two f o r m s o f c o p i n g : p r o b l e m - f o c u s e d a n d e m o t i o n - f o c u s e d c o p i n g . P r o b l e m - f o c u s e d c o p i n g s t r a t e g i e s d e a l w i t h t h e t h r e a t i t s e l f , or with the o b s t a c l e s present i n the environment or i n o n e s e l f . These s t r a t e g i e s serve a p r o b l e m - s o l v i n g f u n c t i o n . Emotion-focused c o p i n g s t r a t e g i e s attempt to d e a l with s t r e s s f u l emotions caused by the s i t u a t i o n , and r e g u l a t e the emotional d i s t r e s s , and thus serve a p a l l i a t i v e f u n c t i o n . Assumption. 1. There are no good or bad, r i g h t or wrong ways of c o p i n g . 2. The p a r t i c i p a n t s w i l l be a b l e to i d e n t i f y the emotions p e r c e i v e d and c o p i n g s t r a t e g i e s used. 3. The p a r t i c i p a n t s w i l l respond h o n e s t l y to the q u e s t i o n n a i r e . L i m i t a t i o n s G e n e r a l i z a t i o n s from t h i s study's f i n d i n g s cannot be a p p l i e d t o other groups of p a t i e n t s and/or to other groups of c a r d i a c p a t i e n t s because of the s m a l l sample s i z e and the convenience sampling technique used. Overview of the T h e s i s Content T h i s t h e s i s i s comprised of f i v e c h a p t e r s . Chapter One reviews the background to the problem, e x p l a i n s the c o n c e p t u a l framework and o u t l i n e s the purpose of the study. In Chapter Two, s e l e c t e d l i t e r a t u r e i s reviewed under t h r e e h e a d i n g s : c o g n i t i v e a p p r a i s a l , c o p i n g s t r a t e g i e s and c o p i n g as a p r o c e s s . Chapter Three d e s c r i b e s the r e s e a r c h methodo logy , i n c l u d i n g a d e s c r i p t i o n of the s a m p l i n g p r o c e d u r e s d e s i g n , i n s t r u m e n t s , d a t a c o l l e c t i o n methods and s t a t i s t i c a l p r o c e d u r e s . The d e s c r i p t i o n of the s a m p l e , r e s u l t s of the d a t a a n a l y s i s and the d i s c u s s i o n of the f i n d i n g s c o n s t i t u t e s the f o u r t h c h a p t e r . The f i n a l c h a p t e r p r e s e n t s a summary of the s t u d y and c o n c l u s i o n s and a d i s c u s s i o n on i m p l i c a t i o n s f o r n u r s i n g and recommendat ions f o r f u t u r e r e s e a r c h . CHAPTER TWO R e v i e w o f S e l e c t e d L i t e r a t u r e i n t r o d u c t i o n The r e v i e w o f l i t e r a t u r e i s d i v i d e d i n t o t h r e e s e c t i o n s . The f i r s t s e c t i o n p r e s e n t s a d i s c u s s i o n o f l i t e r a t u r e a n d r e s e a r c h on a p p r a i s a l o f i l l n e s s r e l a t e d t o h a r m / l o s s , c h a l l e n g e , g a i n / b e n e f i t , a n d t h r e a t . The s e c o n d s e c t i o n f o c u s e s on c o p i n g s t r a t e g i e s . The f i n a l s e c t i o n e x a m i n e s c o p i n g a s a p r o c e s s . C h a n g e s o v e r t i m e i n e m o t i o n a p p r a i s a l s a n d c o p i n g s t r a t e g i e s , a s w e l l a s r e l a t i o n s h i p s b e t w e e n c o g n i t i v e a p p r a i s a l a n d c o p i n g a r e d i s c u s s e d . C o g n i t i v e A p p r a i s a l A c c o r d i n g t o L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) , t h e a i m o f a p p r a i s a l i s t o e v a l u a t e t h e e n c o u n t e r i n t e r m s o f h a r m s , t h r e a t s a n d i t s p o t e n t i a l c h a l l e n g e o r b e n e f i t , a s w e l l a s t h e r e s o u r c e s r e q u i r e d t o t o l e r a t e , m i n i m i z e a n d / o r t o m a s t e r t h e e n v i r o n m e n t . T h r o u g h p r i m a r y a p p r a i s a l , a n i n d i v i d u a l j u d g e s w h e t h e r a s i t u a t i o n i s i r r e l e v a n t , b e n i g n - p o s i t i v e o r s t r e s s f u l . T h r e e f o r m s o f s t r e s s f u l a p p r a i s a l e x i s t : h a r m / l o s s , t h r e a t a n d c h a l l e n g e . T h e s e r e s e a r c h e r s s t a t e t h a t t h e d e g r e e o f s t r e s s a p e r s o n e x p e r i e n c e s d e p e n d s on what i s a t s t a k e i n a s i t u a t i o n . The s t a k e s i n v o l v e c o n c e r n s o r t h r e a t s r e l a t e d t o s e l f - e s t e e m , g o a l a t work o r harm t o o n e ' s w e l l - b e i n g . I f 15 the s i t u a t i o n seems to have relevance for the person's well-being, the cognitive appraisal of emotions w i l l be that i t poses threats, has done harm, or has p o t e n t i a l for benefit or challenge. Patients' Appraisal of I l l n e s s Lazarus ( 1 9 8 4 ) states that patients view or appraise th e i r i l l n e s s in several ways. The degree of stress a patient experiences strongly depends on i n d i v i d u a l meaning or appraisal of the I l l n e s s . Individual meaning or s i g n i f i c a n c e of an i l l n e s s strongly influences both the patient's emotional response and the coping strategies which aim at dealing with the demands of the i l l n e s s (Llpowski, 1 9 7 0 - 1 9 7 1 ; Lazarus, 1 9 8 4 ) . These authors believe that the s p e c i f i c meaning indivi d u a l s attach to th e i r i l l n e s s may be conscious or unconscious, and may be influenced by past experiences and b e l i e f s . Several categories of personal meaning related to i l l n e s s have been described in the l i t e r a t u r e . I l l n e s s may be perceived as a strategy, a challenge, an enemy, a loss or damage, or weakness, a r e l i e f , a punishment, a value {Llpowski, 1 9 7 0 - 1 9 7 1 ; Cohen & Lazarus, 1979) or a threat (Cohen & Lazarus, 1 9 7 9 ) . Since these categories have s i m i l a r i t i e s , they may be further regrouped into 4 broader categories: harm/loss, challenge, gain/benefits, and threat. The categories coincide with the stress appraisals i d e n t i f i e d by Lazarus and Folkman ( 1 9 8 4 ) . H_____. L a z a r u s a n d F o l k m a n (1984 ) s t a t e t h a t I n h a r m / l o s s , damage t o t h e i n d i v i d u a l h a s a l r e a d y o c c u r r e d . Harm a p p r a i s a l i s c h a r a c t e r i z e d b y n e g a t i v e e m o t i o n s . Monat a n d L a z a r u s ( 1 9 8 5 ) p o i n t o u t t h a t i n harm a p p r a i s a l , p a s t o r p r e s e n t damage c a n n o t be p r e v e n t e d , a n d t h a t t h e p e r s o n c o p e s w i t h h a r m / l o s s i n much t h e same manner a s i n t h e r e a d j u s t m e n t s t a k i n g p l a c e i n g r i e f . The p e r s o n t r i e s t o c o m p e n s a t e f o r t h e l o s s , a c c e p t i t o r a b a n d o n v a l u e d c o m m i t m e n t s . L i p o w s k i ( 1 9 7 0 - 1 9 7 1 ) s u g g e s t s t h a t i l l n e s s may be p e r c e i v e d a s a n enemy. P a t i e n t s v i e w t h e m s e l v e s a s v i c t i m s o f d e s t r u c t i v e o r h a r m f u l f o r c e s . T h e y may e x p e r i e n c e e m o t i o n a l r e a c t i o n s s u c h a s a n x i e t y , f e a r , h o s t i l i t y a n d / o r a n g e r . I l l n e s s may a l s o be s e e n a s a w e a k n e s s . P a t i e n t s who h o l d t h i s v i e w l o o k a t t h e i r d i s e a s e a s a s i g n o f f a i l u r e a n d l o s s o f c o n t r o l . T h e y may f e e l ashamed an d h u m i l i a t e d . A c c o r d i n g t o L i p o w s k i ( 1 9 7 0 - 1 9 7 1 ) , i l l n e s s s e e n a s a p u n i s h m e n t i s common an d t h i s v i e w may t a k e s e v e r a l f o r m s . P a t i e n t s may r e g a r d t h e i r i l l n e s s a s a f a i r p u n i s h m e n t a n d a c h a n c e f o r r e d e m p t i o n . D u r i n g t h e i r r e c o v e r y , p a t i e n t s show g r e a t e n e r g y , o p t i m i s m , a n d i n i t i a t i v e . H o w e v e r , i f p a t i e n t s v i e w t h e i r i l l n e s s a s j u s t a n d f i n a l , t h e y w i l l become p a s s i v e a n d w i l l show l i t t l e r e s i s t a n c e . F i n a l l y , p a t i e n t s who d i s p l a y s i g n s o f d e p r e s s i o n u s u a l l y p e r c e i v e t h e i r i l l n e s s a s a n u n j u s t p u n i s h m e n t . E m o t i o n a l r e a c t i o n s 17 such as anger, a n x i e t y , and d e p r e s s i o n are common r e a c t i o n s . P a t i e n t s may a l s o r e g a r d t h e i r i l l n e s s as an I r r e p a r a b l e l o s s or damage ( L i p o v s k i , 1970-1971). For some p a t i e n t s even a minor l o s s of f u n c t i o n , e s p e c i a l l y one f o r which the i n d i v i d u a l h e l d a s p e c i a l v a l u e , may be so d e v a s t a t i n g t h a t n o t h i n g can be done t o compensate f o r the l o s s . Such p a t i e n t s may be depressed, h o s t i l e , non-compliant or even s u i c i d a l . "The most damaging l i f e events are those i n which c e n t r a l and e x t e n s i v e commitments are l o s t " (Lazarus & Folkman, 1984, p. 32). Ch a l l e n g e . I l l n e s s , a c c o r d i n g to Llpowski (1970-1971) and Lazarus and Folkman (1984) may f r e q u e n t l y be viewed as a c h a l l e n g e . I l l i n d i v i d u a l s attempt to d e a l with the demands of t h e i r i l l n e s s as they would with any other s t r e s s f u l event. Lazarus and Folkman (1984) p o i n t out t h a t an i n d i v i d u a l ' s sense of c o n t r o l i n c r i s i s s i t u a t i o n s r e p r e s e n t s a form of c h a l l e n g e . T h i s a p p r a i s a l Is accompanied by p l e a s u r a b l e emotions. The p a t i e n t maintains a p o s i t i v e o u t l o o k , f e e l s c o n f i d e n t , t o l e r a t e s p a i n and d i s t r e s s . Here, c h a l l e n g e means t h a t p a t i e n t s can c o n t r o l themselves and t h e i r emotions. G a i n / b e n e f i t . Secondary b e n e f i t may be obtained from i l l n e s s ( L l p o w s k i , 1970-1971; Lazarus & Folkman, 1984). In t h i s p e r s p e c t i v e , Lipowski s t a t e s t h a t i l l n e s s may be p e r c e i v e d as a r e l i e f , a value or a s t r a t e g y . . Some p a t i e n t s r e g a r d i l l n e s s a s a r e l i e f . T h e y may welcome t h e i r s i c k r o l e t o g e t away f r o m t h e s t r e s s e s o f t h e i r d a i l y l i v e s . I n i t s e x t r e m e f o r m , i l l n e s s may r e v e a l i n t r a p s y c h i c c o n f l i c t s . A c c o r d i n g t o L i p o w s k i ( 1 9 7 0 - 1 9 7 1 ) i l l n e s may a l s o be r e g a r d e d a s a s t r a t e g y . I n t h i s way, p a t i e n t s u s e t h e i r i l l n e s s a s a t e c h n i q u e t o g a i n p e r s o n a l b e n e f i t s I n t h e i r r e l a t i o n s h i p s . I n some c a s e s , i l l n e s s may be p e r c e i v e d a s a v a l u e . L i p o w s k i ( 1 9 7 0 - 1 9 7 1 ) p o i n t s o u t t h a t t h i s v i e w i s uncommon i n o u r s o c i e t y w h e r e i l l n e s s h a s a n e g a t i v e v a l u e a n d i s t o be a v o i d e d a t a n y c o s t . F o r some p e o p l e h o w e v e r , i l l n e s s may be a means t o g r o w , t o e n h a n c e t h e i r p e r s o n a l i t i e s . T h r e a t . A c c o r d i n g t o L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) , t h r e a t r e f e r s t o harms o r l o s s e s t h a t h a v e n o t y e t o c c u r r e d , b u t a r e a n t i c i p a t e d . N e g a t i v e e m o t i o n s s u c h a s f e a r , w o r r y a n d / o r a n x i e t y c h a r a c t e r i z e t h r e a t a p p r a i s a l . B a s e d on p r e s e n t c u e s , t h e i n d i v i d u a l r e c o g n i z e s o r p r e d i c t s f u t u r e h a r m s . The r e s e a r c h e r s f u r t h e r e x p l a i n t h a t i t I s i m p o r t a n t t o d i s t i n g u i s h b e t w e e n p a s t o r p r e s e n t harm, a n d a n t i c i p a t e d harm. T h r e a t a n d harm a p p r a i s a l s d i f f e r i n t h e i r c o g n i t i v e c o m p o n e n t s : t h e j u d g m e n t o f p a s t / p r e s e n t harms v e r s u s p o t e n t i a l harm. B o t h r e q u i r e d i f f e r e n t c o p i n g e f f o r t s . C o m m e n t i n g on t h e d i f f e r e n t a p p r a i s a l t y p e s p r e v i o u s l y d i s c u s s e d , C o h en a n d L a z a r u s ( 1 9 7 9 ) a d d t h a t t h r e a t may be i n v o l v e d i n e a c h o n e , a n d t h a t t h e s e v a r i o u s m e a n i n g s may h e l p t o u n d e r s t a n d t h r e a t a p p r a i s a l . D e p e n d i n g on t h e p e r s o n ' s a p p r a i s a l o f t h e i l l n e s s , t h r e a t may i n c r e a s e o r d e c r e a s e . F o r e x a m p l e , t h r e a t may I n c r e a s e f o r a p e r s o n who s e e s i l l n e s s a s a p u n i s h m e n t b u t d o e s n o t p e r c e i v e t h e i l l n e s s a s g i v i n g o p p o r t u n i t y f o r r e d e m p t i o n . On t h e c o n t r a r y , t h r e a t may be r e d u c e d , i f t h e i l l n e s s i s p e r c e i v e d a s a r e l i e f f r o m s o c i a l demands a n d o b l i g a t i o n s . A d d i t i o n a l l y , Cohen a n d L a z a r u s ( 1 9 7 9 ) s t a t e t h a t i t i s i m p o r t a n t t o u n d e r s t a n d t h e v a r i o u s t h r e a t s a n d c o n c e r n s o f p a t i e n t s w i t h s e v e r e i l l n e s s . A t h r e a t g e n e r a t e s a s p e c i f i c e m o t i o n . I n t u r n , t h i s e m o t i o n r e q u i r e s a p a r t i c u l a r c o p i n g e f f o r t w h i c h r e g u l a t e s t h e e m o t i o n a l r e s p o n s e . Cohen a n d L a z a r u s ( 1 9 7 9 ) h a v e c a t e g o r i z e d t h e d i f f e r e n t t h r e a t s t h a t may o c c u r i n t h e c o n t e x t o f p h y s i c a l i l l n e s s . T h e y s t a t e t h a t t h e s e c a t e g o r i e s o f t h r e a t s h a v e b e e n s y n t h e s i z e d f r o m t h e work o f s e v e r a l r e s e a r c h e r s : 1. T h r e a t s t o l i f e a n d f e a r s o f d y i n g i t s e l f ; 2. T h r e a t s t o b o d i l y I n t e g r i t y a n d c o m f o r t ( f r o m I l l n e s s , t h e d i a g n o s t i c p r o c e d u r e s , o r t h e m e d i c a l t r e a t m e n t i t s e l f ) ; 3. T h r e a t s t o o n e ' s s e l f - c o n c e p t a n d f u t u r e p l a n s ; 4. T h r e a t s t o o n e ' s e m o t i o n a l e q u i l i b r i u m ; t h a t i s , t h e n e c e s s i t y t o d e a l w i t h f e e l i n g s o f a n x i e t y , a n g e r , a n d o t h e r e m o t i o n s t h a t come a b o u t a s a r e s u l t o f o t h e r s t r e s s e s d e s c r i b e d ; 5. T h r e a t s t o t h e f u l f i l l m e n t o f c u s t o m a r y s o c i a l r o l e s a n d a c t i v i t i e s ; 6. T h r e a t s i n v o l v i n g t h e n e e d t o a d j u s t t o a new p h y s i c a l o r s o c i a l e n v i r o n m e n t . L a z a r u s ( 1 9 8 4 ) u s e s t h e c o n c e p t o f c o g n i t i v e a p p r a i s a l t o u n d e r s t a n d e m o t i o n a l r e s p o n s e s t o s e v e r e i l l n e s s . A c c o r d i n g t o t h e s t r e s s , a p p r a i s a l and c o p i n g t h e o r y , f o r e a c h e m o t i o n e x p e r i e n c e d , t h e i n t e n s i t y a n d q u a l i t y o f s u c h e m o t i o n s t e m f r o m t h e way p e o p l e e v a l u a t e t h e s i g n i f i c a n c e o f what i s h a p p e n i n g t o t h e i r w e l l - b e i n g . L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) e m p h a s i z e t h a t t h r e a t a n d c h a l l e n g e a p p r a i s a l s , o r harm a n d b e n e f i t a p p r a i s a l s , a r e r e l a t e d c o n c e p t s . T h e y a r e n o t p o l e s on a s i n g l e c o n t i n u u m , a n d t h e r e f o r e c a n o c c u r s i m u l t a n e o u s l y . A c c o r d i n g t o L a z a r u s ( 1 9 8 4 ) , i l l n e s s e s a r e c o m p l e x s i t u a t i o n s a n d c a n i n v o l v e b o t h p o s i t i v e a n d n e g a t i v e e m o t i o n s . T h e s e e m o t i o n s c a n o c c u r s i m u l t a n e o u s l y b e c a u s e e a c h r e f e r s t o o r r e p r e s e n t s a n e v a l u a t i v e r e s p o n s e t o a s p e c i f i c a s p e c t o f a s t r e s s f u l s i t u a t i o n . T h e r e f o r e , t h e t y p e s a n d t h e I n t e n s i t y o f e m o t i o n s p a t i e n t s e x p e r i e n c e r e p r e s e n t s how t h e y i n t e r p r e t what i s h a p p e n i n g i n r e l a t i o n t o t h e i r v a l u e s a n d c o m m i t m e n t s . I n t h e i r e a r l i e r s t u d i e s F o l k m a n a n d L a z a r u s ( 1 9 8 5 ) e x p l o r e c o g n i t i v e a p p r a i s a l o f e m o t i o n s among c o l l e g e s t u d e n t s p r e p a r i n g f o r a m i d t e r m e x a m i n a t i o n . T h i s s t u d y p r o v i d e s e v i d e n c e t h a t a p p r a i s a l - r e l a t e d p r o c e s s e s s h a p e e m o t i o n a l r e s p o n s e s . T h e y f o u n d t h a t t h e r e i s a r e l a t i o n s h i p b e t w e e n a p p r a i s a l a n d e m o t i o n . A m i d t e r m c o l l e g e e x a m i n a t i o n was s e l e c t e d a s t h e s t r e s s f u l e n c o u n t e r f o r t h e s t u d y . As p a r t o f a s t u d y a b o u t s t r e s s a s s e s s m e n t , s t u d e n t s w e re a s k e d t o i n d i c a t e t h e e x t e n t t o w h i c h t h e y e x p e r i e n c e d e a c h o f a number o f e m o t i o n s r e l a t e d t o t h r e a t , harm, c h a l l e n g e a n d b e n e f i t a p p r i a s a l s . On t h r e e o c c a s i o n s i n c l a s s t h e y c o m p l e t e d t h e L a z a r u s & F o l k m a n ' s S t r e s s Q u e s t i o n n a i r e : two d a y s b e f o r e t h e m i d t e r m exam ( a n t i c i p a t o r y s t a g e ) , f i v e d a y s a f t e r t h e m i d t e r m exam a n d two d a y s b e f o r e g r a d e s w e re a n n o u n c e d ( w a i t i n g s t a g e ) , a n d f i v e d a y s a f t e r g r a d e s were a n n o u n c e d ( o u t c o m e s t a g e ) . The d a t a o b t a i n e d r e f l e c t e d t h e e m o t i o n s t h e s t u d e n t s e x p e r i e n c e d a t e a c h s t a g e . F o r e x a m p l e , a t t i m e o n e , b o t h t h r e a t a n d c h a l l e n g e e m o t i o n s were e l e v a t e d , a n d were e x p e r i e n c e d b y 9 4 % o f t h e s t u d e n t s ; w h e r e a s harm a n d b e n e f i t e m o t i o n s were more e l e v a t e d a t t i m e t w o . T h e s e f i n d i n g s c o n f i r m e d t h a t d i f f e r e n t t y p e s o f a p p r a i s a l e m o t i o n s c a n be e x p e r i e n c e d s i m u l t a n e o u s l y , d e p e n d i n g how t h e s i t u a t i o n i s p e r c e i v e d . P a t i e n t s ' A p p r a i s a l o f M y o c a r d i a l I n f a r c t i o n L i t e r a t u r e f i n d i n g s r e p o r t t h a t a h e a r t a t t a c k may be p e r c e i v e d a s a n e x p e r i e n c e w h i c h c a r r i e s p o t e n t i a l f o r t h r e a t , h a r m / l o s s , c h a l l e n g e a n d b e n e f i t . M y o c a r d i a l i n f a r c t i o n I s a s t r e s s f u l e v e n t i n w h i c h t h e p a t i e n t i s c o n f r o n t e d w i t h a t h r e a t t o h e a l t h and l i f e , a n d a l l t h e v a l u e d o b j e c t s a n d c o m m i t m e n t s t h a t t h e s e e n t a i l ( G a r r i t y , 1 9 7 5 ) . I n a t t e m p t i n g t o u n d e r s t a n d MI p a t i e n t s ' e m o t i o n a l r e a c t i o n s , one must remember t h a t s e v e r a l f a c t o r s may a f f e c t t h e i r r e a c t i o n s a n d r e s p o n s e s , s u c h a s t h e p e r c e p t i o n o f t h e i r i l l n e s s ( P r a n u l i s , 1 9 7 5 ) . B u r g e s s a n d H a r t m a n ( 1 9 8 6 ) c o n d u c t e d a s t u d y on how p a t i e n t s ' p e r c e i v e t h e i r c a r d i a c c r i s i s . T h e s e r e s e a r c h e r s h y p o t h e s i z e d t h a t t h e p a t i e n t s ' b e l i e f s a b o u t t h e MI i t s e l f w i l l s h a p e w h a t e v e r m e a n i n g t h e MI w i l l h a v e f o r t h e p e r s o n ' s i m m e d i a t e a n d f u t u r e l i f e . The f i n d i n g s r e v e a l e d t h a t t h e p a t i e n t s ' p e r c e p t i o n s i n f l u e n c e d p s y c h o l o g i c a l d i s t r e s s . S p e c i f i c a l l y , t h e f i n d i n g s i n d i c a t e d t h a t 9 4 . 4 % o f p a t i e n t s v i e w e d t h e i r h e a r t a t t a c k a s a s e r i o u s i l l n e s s ; 8 2 % f e l t t h a t t h e y were h i g h l y s u s c e p t i b l e t o h e a r t a t t a c k s w h i l e 5 2 % f e a r e d t h e t h r e a t o f a f u r t h e r M l ; a l m o s t h a l f o f t h e p a t i e n t s v i e w e d t h e M l a s l e t h a l ; 6 3 % o f p a t i e n t s a s s o c i a t e d t h e h e a r t a t t a c k w i t h s e v e r e p a i n a n d 3 1 % w i t h s t i g m a . More t h a n 9 0 % p e r c e i v e d a h e a r t a t t a c k t o be m o d e r a t e l y t o h i g h l y l i f e - t h r e a t e n i n g . C a ssem a n d H a c k e t t ( 1 9 7 3 ) , r e p o r t i n g t h e f i n d i n g s o f t h e i r e a r l i e r s t u d i e s , i n d i c a t e d t h a t a n x i e t y and d e p r e s s i o n w e r e common among MI p a t i e n t s d u r i n g t h e a c u t e a n d t h e r e h a b i l i t a t i v e p h a s e s . I n 5 0 % o f MI p a t i e n t s s e l e c t e d a t random f r o m a c o r o n a r y c a r e u n i t , 7 6 % o f p a t i e n t s showed o b j e c t i v e s i g n s o f d e p r e s s i o n . I n a n o t h e r f o l l o w - u p s t u d y o f home v i s i t s t o t w e n t y MI p a t i e n t s , t h e s e r e s e a r c h e r s f o u n d t h a t 8 0 % o f t h e p a t i e n t s r e p o r t e d s i g n s o f a n x i e t y a n d / o r d e p r e s s i o n . F i f t y - f i v e p e r c e n t h a d s l e e p d i s t u r b a n c e s , a n d 3 8 % f a i l e d t o r e t u r n t o work f o r p s y c h o l o g i c a l r e a s o n s . C a s s e m a n d H a c k e t t ( 1 9 7 7 ) p o i n t o u t t h a t o u t o f 445 MI p a t i e n t s s u r v e y e d o v e r a f i f t e e n month p e r i o d , 145 ( 3 3 % ) r e q u i r e d p s y c h i a t r i c c o n s u l t a t i o n . A n x i e t y a n d d e p r e s s i o n w e r e t h e most f r e q u e n t l y r e p o r t e d p r o b l e m s . B a s e d on t h e s t u d y d a t a , C a s s e m a n d H a c k e t t ( 1 9 7 7 ) h a v e c o n c l u d e d t h a t e m o t i o n a l r e a c t i o n s s u c h a s a n x i e t y a n d d e p r e s s i o n seem t o be t y p i c a l o f MI p a t i e n t s . A h e a r t a t t a c k may be p e r c e i v e d a s a t h r e a t . I n t h i s c a s e t h e p a t i e n t i s more l i k e l y t o e x p e r i e n c e a n x i e t y . S c a l z i ( 1 9 7 3 ) a n d Cassem a n d H a c k e t t ( 1 9 7 7 ) h a v e d e s c r i b e d t h e a n x i e t y r e a c t i o n . When a h e a r t a t t a c k s t r i k e s , p a t i e n t s s u d d e n l y r e a l i z e t h a t t h e i r l i f e i s i n i m m e d i a t e d a n g e r . D u r i n g t h e f i r s t f e w d a y s o f h o s p i t a l i z a t i o n , a n x i e t y a p p e a r s t o be a t i t s peak a n d d e c r e a s e s o v e r t h e n e x t s e v e r a l d a y s . The p a t i e n t I s o v e r w h e l m e d a n d f r i g h t e n e d b y t h e t h r e a t e n i n g e v e n t . C r u s h i n g p a i n a n d s h o r t n e s s o f b r e a t h a r e a c o n s t a n t r e m i n d e r o f t h e i m m i n e n c e o f d e a t h . G e n t r y a n d Haney ( 1 9 7 5 ) r e p o r t e d t h a t p a t i e n t s who d i s p l a y e d more c o n c e r n s a b o u t i m m i n e n t d e a t h a l s o showed more s i g n s o f s u b j e c t i v e a n x i e t y i n CCU. A n x i e t y i s a n i m p o r t a n t e m o t i o n a l r e s p o n s e b e c a u s e many o t h e r r e a c t i o n s , s u c h a s d e n i a l a n d d e p r e s s i o n o r i g i n a t e f r o m a n x i e t y ( S c a l z i , 1 9 7 3 ; G r a n g e r , 1 9 7 4 ) . F o r e x a m p l e , t h r e a t s t o o n e ' s l i f e , s e l f - c o n c e p t o r h e a l t h p r o v o k e a n x i e t y ; a n d p a t i e n t s manage t h e i r a n x i e t y r e a c t i o n s d i f f e r e n t l y d e p e n d i n g on t h e i r c a u s e . C o n t r a r y t o Cassem a n d H a c k e t t , S h i n e ( 1 9 8 4 ) b e l i e v e s t h a t a n x i e t y r e a c t i o n s a r e n o t l i m i t e d t o t h e f i r s t few d a y s o f h o s p i t a l i z a t i o n , b u t f l u c t u a t e t h r o u g h o u t t h e r e c o v e r y p e r i o d . I n a c l i n i c a l l y - o r i e n t e d a r t i c l e , S h i n e r e m a r k s t h a t a n x i e t y i s due t o f e a r o f d e a t h . The f i r s t a n x i e t y peak i s o b s e r v e d d u r i n g t h e i n i t i a l p e r i o d o f h o s p i t a l i z a t i o n , a n d i s due t o f e a r o f d e a t h . A s e c o n d a n x i e t y r e a c t i o n may be o b s e r v e d a t t h e t i m e o f t r a n s f e r f r o m t h e CCU. T h i s s e c o n d e p i s o d e i s r e f e r r e d t o a s s e p a r a t i o n a n x i e t y . F i n a l l y , t h e l e v e l o f a n x i e t y w i l l r e c u r j u s t p r i o r t o d i s c h a r g e , a n d r e a p p e a r a g a i n when t h e p a t i e n t t r i e s t o resume n o r m a l a c t i v i t i e s a f t e r l e a v i n g t h e h o s p i t a l . When a h e a r t a t t a c k i s a p p r a i s e d a s a l o s s / h a r m , d e p r e s s i o n f e e l i n g s may be m a r k e d . D e p r e s s i o n i s a common r e a c t i o n t o t h e e x p e r i e n c e o f h a v i n g a h e a r t a t t a c k ( S c a l z i , 1 9 7 3 ; Cassem & H a c k e t t , 1 9 7 7 ) . A f t e r a p e r i o d o f s h o c k a n d d i s b e l i e f , t h e p a t i e n t f i n a l l y f a c e s t h e r e a l i t i e s o f t h e M I , "The more d e v a s t a t i n g t h e e f f e c t s o f t h e i n f a r c t , t h e more p r o f o u n d t h e d e p r e s s i o n i s l i k e l y t o b e " ( C a s s e m & H a c k e t t , 1 9 7 7 , p. 7 1 5 ) . A c c o r d i n g t o Cassem an d H a c k e t t ( 1 9 7 8 ) , t h e d e p r e s s i o n b e g i n s i n t h e CCU a n d o f t e n becomes e v i d e n t a g a i n a f t e r d i s c h a r g e a t home. D e p r e s s i o n r e s u l t s f r o m a l o s s o f h e a l t h a n d f e a r o f d e a t h ; a n d i s c h a r a c t e r i z e d b y f e e l i n g s o f s a d n e s s , h e l p l e s s n e s s a n d h o p e l e s s n e s s . E v e n t h o u g h a p a t i e n t s u r v i v e s t h e h e a r t a t t a c k , h e / s h e h a s t o c o p e w i t h a s e r i e s o f l e s s e r harms a nd l o s s e s r e l a t e d t o p h y s i c a l l i m i t a t i o n s a n d s o c i a l r o l e s , " F o l l o w i n g a M I , one a l m o s t I n v a r i a b l y f e e l s a s t h o u g h one h a s l o s t a p a r t o f o n e s e l f ... u s u a l l y i t i s a v a l u e d p a r t : s t r e n g t h , e n e r g y , I n d e p e n d e n c e " ( C a s s e m & H a c k e t t , 1 9 7 8 , p. 2 4 3 ) . S c a l z i ( 1 9 7 3 ) e x p l a i n s t h a t d e p r e s s i o n may s t e m f r o m a n g e r a n d g u i l t : a n g e r a t b e i n g t h e v i c t i m a n d g u i l t f r o m s e l f - i m p o s e d l i f e s t y l e h a b i t s . The c o n c e p t o f d e n i a l a s a p p l i e d t o a t y p e o f c h a l l e n g e a p p r a i s a l made f o l l o w i n g m y o c a r d i a l i n f a r c t i o n h a s a l s o b e e n d i s c u s s e d i n t h e l i t e r a t u r e . H a c k e t t a n d Ca s s e m ( 1 9 7 8 ) d e s c r i b e d t h e most common p s y c h o l o g i c a l f a c t o r s r e l a t e d t o c a r d i a c r e h a b i l i t a t i o n . I n a d d i t i o n t o a n x i e t y a n d d e p r e s s i o n , t h e y r e m a r k t h a t , b a s e d on i n f o r m a t i o n o b t a i n e d f r o m p a t i e n t s ' c a s e h i s t o r i e s a n d o t h e r a n e c d o t a l r e c o r d s , t h e a p p r a i s a l o f a h e a r t a t t a c k may a l s o be one o f o p t i m i s m . I n t h i s c a s e , a c c o r d i n g t o H a c k e t t a n d Cassem ( 1 9 7 8 ) , o p t i m i s m i s p r e s e n t I n t h e f o r m s o f hope a n d c o n f i d e n c e , w i k l u n d e t a l . ( 1 9 8 4 ) e x a m i n e d t h e p a t i e n t s ' a t t i t u d e s t o w a r d s t h e f u t u r e a t two months p o s t MI. F i f t y - f i v e p e r c e n t o f t h e p a t i e n t s r e p o r t e d m a i n t a i n i n g a p o s i t i v e o u t l o o k on l i f e , 3 9 % were i n d i f f e r e n t , a n d o n l y 6% w e re p e s s i m i s t i c . E m p i r i c a l f i n d i n g s a l s o r e p o r t a h e a r t a t t a c k a s h a v i n g p o t e n t i a l b e n e f i t s . G e n e r a l l y , p o s i t i v e c o n s e q u e n c e s f r o m a n e v e n t a s s t r e s s f u l a s a MI a r e n o t e x p e c t e d . N e v e r t h e l e s s , t h e e x p e r i e n c e o f h e a r t a t t a c k may a l s o b r i n g u n e x p e c t e d b e n e f i t s . U s i n g f i v e c o u p l e s , M e d d i n a n d B r e l j e ( 1 9 8 3 ) c o n d u c t e d a s m a l l - s c a l e s t u d y a f t e r t h e h u s b a n d s h a d r e c o v e r e d f r o m MI. A c c o r d i n g t o t h e f i n d i n g s , two o f t h e f i v e c o u p l e s h a v e d e s c r i b e d t h e r e c o v e r y p e r i o d a s a p o s i t i v e e x p e r i e n c e i n t e r m s o f i m p r o v e d m a r i t a l r e l a t i o n s h i p s a n d l i f e s t y l e c h a n g e s . D e s p i t e t h e s m a l l s a m p l e s t u d i e d , t h e r e s e a r c h e r s c o n c l u d e d t h a t s u c h u n e x p e c t e d p o s i t i v e c o n s e q u e n c e s o f MI a d d a p o s i t i v e d i m e n s i o n t o what w o u l d o t h e r w i s e be a s t r e s s f u l a n d l i f e - t h r e a t e n i n g e x p e r i e n c e . Summary. A c c o r d i n g t o t h e s t r e s s , a p p r a i s a l a n d c o p i n g t h e o r y , c o g n i t i v e a p p r a i s a l p r o c e s s e s a r e u s e d t o e v a l u a t e a s i t u a t i o n , w i t h r e s p e c t t o i t s s i g n i f i c a n c e f o r a n I n d i v i d u a l ' s w e l l - b e i n g . T h r o u g h s t r e s s f u l a p p r a i s a l s o f harm a n d t h r e a t , t h e f o c u s i s p l a c e d n e g a t i v e l y on p o s s i b l e r i s k s , w h i l e c h a l l e n g e a n d b e n e f i t a p p r a i s a l s p l a c e t h e e m p h a s i s p o s i t i v e l y on p o t e n t i a l g a i n a n d g r o w t h . R e s e a r c h e r s h a v e d e s c r i b e d t h e d i f f e r e n t ways i n d i v i d u a l s r e g a r d t h e i r i l l n e s s , a n d how t h i s m e a n i n g c a n i n f l u e n c e e m o t i o n a l r e a c t i o n s . T h e y s u g g e s t t h a t i l l n e s s may be p e r c e i v e d a s a c h a l l e n g e , h arm, t h r e a t a n d b e n e f i t . E a c h o f t h e s e a p p r a i s a l t y p e s a r e c h a r a c t e r i z e d b y p a r t i c u l a r p o s i t i v e o r n e g a t i v e e m o t i o n s . R e s e a r c h f i n d i n g s p r o v i d e e v i d e n c e t h a t a p p r a i s a l - r e l a t e d p r o c e s s e s s h a p e e m o t i o n a l r e a c t i o n s . D i f f e r e n t t y p e s a n d i n t e n s i t y o f e m o t i o n s a r e e x p e r i e n c e d d e p e n d i n g on t h e demands o f a s i t u a t i o n . C o n s e q u e n t l y , d i f f e r e n t a p p r a i s a l s may be e x p e r i e n c e d s i m u l t a n e o u s l y . S i m i l a r l y , l i t e r a t u r e f i n d i n g s r e p o r t a h e a r t a t t a c k a s h a v i n g p o t e n t i a l f o r t h r e a t , h a r m , c h a l l e n g e a n d b e n e f i t . A m y o c a r d i a l i n f a r c t i o n was d e s c r i b e d a s a m o d e r a t e t o h i g h l y s t r e s s f u l e x p e r i e n c e d e p e n d i n g on what a s p e c t s o f t h e s i t u a t i o n t h e p e r s o n i s e v a l u a t i n g . E m p i r i c a l f i n d i n g s s u g g e s t t h a t a n x i e t y a n d d e p r e s s i o n a r e t h e most common t y p e s o f e m o t i o n s p a t i e n t s e x p e r i e n c e d f o l l o w i n g a h e a r t a t t a c k . C o n v e r s e l y , many p a t i e n t s w e r e f o u n d t o h a v e a p o s i t i v e o u t l o o k f o l l o w i n g a m y o c a r d i a l i n f a r c t i o n . O t h e r f i n d i n g s r e p o r t t h a t a l t h o u g h l i f e - t h r e a t e n i n g , a h e a r t a t t a c k may be a p o s i t i v e e x p e r i e n c e i n t e r m s o f p e r s o n a l a n d s o c i a l b e n e f i t s . C o p i n g S t r a t e g i e s C o p i n g W i t h S t r e s s f u l E n c o u n t e r s A c c o r d i n g t o L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) , c o p i n g i s d e f i n e d a s a c o n s t a n t l y c h a n g i n g p r o c e s s o f p s y c h o l o g i c a l a n d b e h a v i o r a l e f f o r t s t o manage s p e c i f i c e x t e r n a l a n d I n t e r n a l demands t h a t one j u d g e s a s e x c e e d i n g o n e ' s r e s o u r c e s . W i t h i n t h i s f r a m e w o r k , c o p i n g e f f o r t s a n d a u t o m a t i z e d a d a p t i v e b e h a v i o r s d i f f e r i n t h e f o l l o w i n g way. A u t o m a t i z e d a d a p t i v e b e h a v i o r s r e f e r t o s k i l l s t h a t a n i n d i v i d u a l p e r f o r m s a u t o m a t i c a l l y t o manage e n v i r o n m e n t a l demands. C o n v e r s e l y , c o p i n g r e f e r s t o e v e r y t h i n g a n i n d i v i d u a l d o e s a n d t h i n k s , a n d i n v o l v e s a l l e f f o r t s r e g a r d l e s s o f t h e i r o u t c o m e s . D i s c u s s i n g t h e f u n c t i o n s o f c o p i n g , C o b u r n a nd L a z a r u s ( 1 9 7 9 ) d i s t i n g u i s h b e t w e e n p r o b l e m - f o c u s e d a n d e m o t i o n - f o c u s e d s t r a t e g i e s . P r o b l e m - f o c u s e d s t r a t e g i e s r e f e r t o e f f o r t s made t o manage t h e s t r e s s i t s e l f , o r t o d e a l d i r e c t l y w i t h t h e i n t e r n a l demands o r e x t e r n a l p r o b l e m s , a n d i m p l y a p r o b l e m - s o l v i n g f u n c t i o n . E m o t i o n - f o c u s e d s t r a t e g i e s h a v e a p a l l i a t i v e f u n c t i o n , a n d r e p r e s e n t e f f o r t s t o c o n t r o l o r c o p e w i t h s o m a t i c a n d e m o t i o n a l r e s p o n s e s s u c h a s d e n i a l o r a v o i d a n c e . F u r t h e r m o r e , L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) s t a t e t h a t some e m o t i o n - f o c u s e d c o p i n g s t r a t e g i e s , s u c h a s s e l f - b l a m e a n d s e l f - p u n i s h m e n t , may i n c r e a s e e m o t i o n a l d i s t r e s s , "Some i n d i v i d u a l s n e e d t o f e e l w o r s e b e f o r e t h e y c a n f e e l b e t t e r " ( p . 1 5 0 ) . Cohen a n d L a z a r u s (1979) a l s o s t a t e t h a t t h e s e two t y p e s o f c o p i n g s t r a t e g i e s c a n e n h a n c e o r c o m p l e m e n t one a n o t h e r ; o r t h e y may h i n d e r o r work a g a i n s t e a c h o t h e r . A d d i t i o n a l l y , a c c o r d i n g t o t h e s t r e s s , a p p r a i s a l a n d c o p i n g t h e o r y , t h e s e two f o r m s o f c o p i n g w i l l be u s e d d i f f e r e n t l y , d e p e n d i n g on t h e i n d i v i d u a l ' s a p p r a i s a l o f t h e s t r e s s f u l e n c o u n t e r . B o t h t y p e s o f c o p i n g c a n be s i m u l t a n e o u s l y u s e d i n t h e same s i t u a t i o n . E m o t i o n - f o c u s e d c o p i n g s t r a t e g i e s a r e u s e d when t h e p e r s o n f e e l s p o w e r l e s s t o c h a n g e a n y t h i n g , a n d i s f o r c e d t o a c c e p t t h e s i t u a t i o n . C o n v e r s e l y , t h e p e r s o n who p e r c e i v e s t h a t t h e s i t u a t i o n I s c h a n g e a b l e o r t h a t t h e p r o b l e m c a n be a l l e v i a t e d i s more l i k e l y t o u s e p r o b l e m - f o c u s e d c o p i n g s t r a t e g i e s . I n some s i t u a t i o n s f e w , i f a n y , o p t i o n s f o r p r o b l e m - s o l v i n g e x i s t . I n t h e s e c a s e s , t h e a b s e n c e o f p r o b l e m - f o c u s e d c o p i n g s t r a t e g i e s s h o u l d be i n t e r p r e t e d a s a f u n c t i o n o f t h e s i t u a t i o n . C o p i n g W i t h M y o c a r d i a l I n f a r c t i o n A m y o c a r d i a l i n f a r c t i o n i m p o s e s many p o t e n t i a l t h r e a t s f o r t h e p a t i e n t a n d r e q u i r e s a w i d e v a r i e t y o f c o m p l e x c o p i n g s t r a t e g i e s . An i n d i v i d u a l f u n c t i o n s a s a n i n t e g r a t e d w h o l e , a n d w h e n e v e r a m a j o r d i s r u p t i o n t a k e s p l a c e , a l l a s p e c t s o f t h e p e r s o n a r e a f f e c t e d . The p a t i e n t ' s t a s k d u r i n g t h i s t r a n s i t i o n a l p e r i o d i s t o m o b i l i z e a l l c o p i n g r e s o u r c e s t o manage t h e p h y s i c a l a n d 30 p s y c h o l o g i c a l demands o f t h e MI ( C o o k , 1 9 7 9 ) . C ohen a n d L a z a r u s ( 1 9 7 9 ) h a v e i d e n t i f i e d f i v e m a i n modes o f c o p i n g : d i r e c t a c t i o n , i n h i b i t i o n o f a c t i o n , i n t r a p s y c h i c p r o c e s s e s , i n f o r m a t i o n - s e e k i n g a n d t u r n i n g t o o t h e r s f o r h e l p . E a c h mode s e r v e s b o t h p r o b l e m - s o l v i n g a n d e m o t i o n - r e g u l a t i o n f u n c t i o n s . The f o l l o w i n g s e c t i o n w i l l p r e s e n t how, a c c o r d i n g t o v a r i o u s r e s e a r c h e r s , MI p a t i e n t s u s e e a c h o f t h e s e c o p i n g modes. B e c a u s e most l i t e r a t u r e p r o v i d e s no s y s t e m f o r d e f i n i n g c o p i n g s t r a t e g i e s , one mode may o v e r l a p w i t h a n o t h e r . D i r e c t a c t i o n r e f e r s t o a n y t h i n g a n i n d i v i d u a l d o e s t o d e a l w i t h a s t r e s s f u l e v e n t , s u c h a s a d h e r i n g t o t h e t h e r a p e u t i c r e g i m e n , a r g u i n g o r r u n n i n g away ( C o h e n & L a z a r u s , 1 9 7 9 ) . T h e s e d i r e c t a c t i o n s a t t e m p t t o c h a n g e t h e d i s t u r b e d p e r s o n - e n v i r o n m e n t r e l a t i o n s h i p . C o n v e r s e l y , r e f r a i n i n g f r o m a c t i o n s w h i c h a r e i m p u l s i v e , e m b a r a s s i n g o r d a n g e r o u s may be v i e w e d a s i n h i b i t i o n o f a c t i o n . M i l l e r e t a l . ( 1 9 8 5 ) h a v e s t u d i e d c o p i n g s t r a t e g i e s u s e d i n 480 c a r d i a c p a t i e n t s . F i f t y p e r c e n t had p r e v i o u s l y e x p e r i e n c e d a m y o c a r d i a l i n f a r c t i o n . A c t u a l c o p i n g s t r a t e g i e s m o s t f r e q u e n t l y u s e d b y p e o p l e t o h a n d l e s t r e s s f u l e v e n t s w e re g r o u p e d i n t o two m a i n c a t e g o r i e s : e n g a g i n g i n e n e r g y - g e n e r a t i n g a c t i v i t i e s ( 6 8 % ) , a n d d e c r e a s i n g e n v i r o n m e n t a l s t r e s s o r s ( 2 1 % ) . E n g a g i n g i n e n e r g y g e n e r a t i n g a c t i v i t i e s i n c l u d e d c o p i n g s t r a t e g i e s s u c h a s p r a y i n g ( 3 6 . 5 % ) , e x p r e s s i n g f e e l i n g s ( 3 4 . 4 % ) , e x e r c i s i n g ( 3 1 . 5 % ) , u s i n g r e l a x a t i o n t e c h n i q u e s ( 2 2 . 3 % ) , t a k i n g m e d i c a t i o n ( 1 8 % ) , d e v e l o p i n g h o b b i e s ( 1 4 . 2 % ) , a n d t a k i n g n a p s ( 0 % ) . D e c r e a s i n g e n v i r o n m e n t a l s t r e s s o r s i n c l u d e d a v o i d i n g s t r e s s f u l s i t u a t i o n s ( 4 5 % ) a n d r e t i r i n g ( 4 . 2 % ) a s c o p i n g s t r a t e g i e s . I n a n o t h e r r e p o r t , s i c k - r o l e b e h a v i o r s a n d a t t i t u d e t o w a r d s I l l n e s s a n d work were s t u d i e d i n 201 c o n s e c u t i v e m a l e p a t i e n t s a t two mo n t h s p o s t MI ( W i k l u n d e t a l . , 1 9 8 4 ) . T h i s i n f o r m a t i o n was t h e n e x a m i n e d i n r e l a t i o n t o s o m a t i c , s o c i a l , a n d p s y c h o l o g i c a l f a c t o r s p r i o r t o t h e MI. A v o i d a n c e b e h a v i o r was one o f t h e s t r a t e g i e s s t u d i e d . P a t i e n t s w e r e a s k e d what f a c t o r s t h e y a v o i d e d t h e most t o c o p e w i t h t h e i r M I. The r e s e a r c h e r s s t a t e t h a t a f t e r t h e p a t i e n t ' s M l , two o u t o f t h r e e p a t i e n t s d i s p l a y e d a v o i d a n c e b e h a v i o r s . A l c o h o l was a v o i d e d , v e r y m u c h / t o some e x t e n t b y 7 7 % o f t h e p a t i e n t s , a s was d r i v i n g a c a r by 6 8 % . G o i n g t o t h e c o u n t r y s i d e , w a l k i n g I n t h e woods, an d t r a v e l l i n g b y a i r were e a c h a v o i d e d b y 5 3 % o f t h e p a t i e n t s . I n t r a p s y c h i c modes o f c o p i n g r e f e r t o c o g n i t i v e p r o c e s s e s s u c h a s d e n i a l , r e p r e s s i o n , m i n i m i z a t i o n a n d o t h e r d e f e n s e s ( C o h e n & L a z a r u s , 1 9 7 9 ) . Cohen a n d L a z a r u s f u r t h e r e m p h a s i z e t h a t I n t r a p s y c h i c modes a r e " p a r t i c u l a r l y i m p o r t a n t i n t h e c o n t e x t o f i l l n e s s b e c a u s e s o o f t e n , l i t t l e c a n be done d i r e c t l y b y t h e p a t i e n t ... e x c e p t t o f i n d some s e r v i c e a b l e way t o t h i n k a b o u t what i h a p p e n i n g " ( p . 2 2 1 ) . The more h e l p l e s s t h e i n d i v i d u a l i s , t h e g r e a t e r t h e r e l i a n c e on i n t r a p s y c h i c modes o f c o p i n g . The c o n c e p t o f d e n i a l a s a p p l i e d t o a c o p i n g s t r a t e g y u s e d b y MI p a t i e n t s h a s b e e n g i v e n much e m p h a s i s i n t h e l i t e r a t u r e . As t h e p h y s i c a l symptoms s u b s i d e a n d t h e p a t i e n t f e e l s b e t t e r , a n x i e t y l e v e l s t e n d t o d e c r e a s e a n d d e n i a l becomes t h e p r e d o m i n a n t p a t t e r n o f c o p i n g ( S c a l z i , 1 9 7 3 ; C a s s e m & H a c k e t t , 1 9 7 7 ) . A c c o r d i n g t o S c a l z i ( 1 9 7 3 ) , t h e p a t i e n t i s s u d d e n l y c o n f r o n t e d w i t h t h e I m p l i c a t i o n s o f a h e a r t a t t a c k . A p e r i o d o f d e n i a l may be a common r e a c t i o n b e c a u s e p a t i e n t s a r e n o t a d e q u a t e l y p r e p a r e d t o h a n d l e o r c o p e w i t h t h e s t r e s s f u l demands i m p o s e d by t h e i l l n e s s . L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) e x p l a i n t h a t i n some c a s e s , some f o r m o f d e n i a l may be b e n e f i c i a l t o p a t i e n t s i n t h e e a r l y s t a g e o f t h e i r i l l n e s s . B u t , i f t h e p a t i e n t s u s e d e n i a l f o r a n e x t e n d e d p e r i o d o f t i m e , t h e d e n i a l may become h a r m f u l t o them. Cassem a n d H a c k e t t ( 1 9 7 7 ) c l a i m t h a t a p p r o x i m a t e l y 5 0 % o f MI p a t i e n t s w i l l e x p e r i e n c e some f o r m o f d e n i a l . D e n i a l may t a k e d i f f e r e n t f o r m s , d e p e n d i n g on what a s p e c t s o f t h e i l l n e s s t h e p a t i e n t s a r e a c t u a l l y d e n y i n g ( C a s s e m & H a c k e t t , 1 9 7 7 ; C o o k , 1 9 7 9 ) . A c c o r d i n g t o Cook ( 1 9 7 9 ) , p a t i e n t s may r e f u s e t o b e l i e v e t h a t t h e y h a v e had a h e a r t a t t a c k ; o r may d e n y t h e f e e l i n g s o f f e a r , a n g e r o r a n x i e t y a s s o c i a t e d w i t h t h e I l l n e s s . C assem a n d H a c k e t t ( 1 9 7 7 ) p o i n t o u t t h a t a t t h e t i m e o f d i s c h a r g e a f t e r a h e a r t 33 a t t a c k , o n e - t h i r d o f t h e p a t i e n t s do n o t u n d e r s t a n d t h e i r i l l n e s s . T h i s l a c k o f u n d e r s t a n d i n g " a p p e a r s t o be r e l a t e d t o t h e n a t u r a l p r o c e s s by w h i c h p e o p l e p r o t e c t t h e m s e l v e s f r o m t h i n k i n g a b o u t t h e t h r e a t e n i n g i m p l i c a t i o n s o f t h e d i s e a s e " ( p . 7 1 6 ) . D e g r e - C o u s t r y a n d G r e v i s s e ( 1 9 8 2 ) i n t e r v i e w e d 304 m a l e p a t i e n t s o f w o r k i n g age o v e r a t h r e e y e a r p e r i o d t o d e t e r m i n e t h e i r b e h a v i o r a l r e a c t i o n s p o s t MI w h i l e i n t h e CCU. B a s e d on t h e i r b e h a v i o r a l r e a c t i o n s t o t h e i r i l l n e s s , p a t i e n t s ' b e h a v i o r s were c l a s s i f i e d i n t h r e e b r o a d c a t e g o r i e s : I m p u l s i v e , a d a p t i v e a n d a g g r e s s i v e b e h a v i o r s . I n t h e f i r s t c a t e g o r y , t h e i m p u l s i v e b e h a v i o r i s c h a r a c t e r i z e d b y r e j e c t i o n a n d m i n i m i z a t i o n . T h e s e p a t i e n t s r e j e c t t h e i d e a t h a t t h e y h a v e had a h e a r t a t t a c k , a n d t r y t o m i n i m i z e t h e i r symptoms. T h e y may be a g g r e s s i v e a n d h y p e r a c t i v e . T h e s e p a t i e n t s may r e f u s e t o f o l l o w p r o f e s s i o n a l a d v i c e , may I g n o r e t h e r e s t r i c t i o n s i m p o s e d b y t h e i r i l l n e s s , e v e n i n t h e CCU, o r may r e f u s e t o c h a n g e t h e i r l i f e s t y l e . The a u t h o r s r e m a r k , h o w e v e r , t h a t t h e s e p a t i e n t s ' m o t i v a t i o n f o r work i s g o o d . The s e c o n d c a t e g o r y , t h e a d a p t i v e b e h a v i o r , i s c h a r a c t e r i z e d by s e l f - c o n t r o l . H e r e p a t i e n t s c o n t r o l t h e i r e m o t i o n a l r e a c t i o n s . T h e y makes p l a n s t o o b j e c t i v e l y r e o r g a n i z e t h e i r l i v e s , t a k i n g i n t o a c c o u n t t h e Imposed r e s t r i c t i o n s . M o t i v a t i o n f o r work r e m a i n s e x c e l l e n t . M i l l e r e t a l . ( 1 9 8 5 ) r e p o r t e d t h a t i n t h e i r s t u d y , o n l y 1 1 % o f c a r d i a c p a t i e n t s u s e d s t r a t e g i e s i n t h e c a t e g o r y o f c o n t r o l l i n g f e e l i n g s . C o n t r o l l i n g f e e l i n g s I n c l u d e d c o p i n g s t r a t e g i e s s u c h a s n o t g e t t i n g u p s e t o r e x c i t e d , a v o i d i n g m e n t a l s t r e s s , s t a y i n g c a l m a n d i g n o r i n g s i t u a t i o n s . I n t h e t h i r d c a t e g o r y , t h e a g g r e s s i v e b e h a v i o r , t h e p a t i e n t i s d e s c r i b e d a s p o o r l y a d a p t e d . The p a t i e n t s ' r e s p o n s e s a r e c h a r a c t e r i z e d b y i n c r e a s e d c o n c e r n s a b o u t t h e i r symptoms a n d t h e i r d i s a b i l i t y . H e r e , t h e p a t i e n t s a r e o v e r w h e l m e d b y t h e s i t u a t i o n , a n d c o n s e q u e n t l y f a i l t o a d e q u a t e l y c o n t r o l t h e i r e m o t i o n a l r e s p o n s e s . T h e i r b e h a v i o r i s m a r k e d b y p a s s i v i t y , d e p e n d e n c y and l o w e r e d work m o t i v a t i o n . Some o f t h e l i t e r a t u r e a l s o e x p l a i n s where t h e p a t i e n t s p l a c e t h e b l ame f o r t h e i r MI ( W i k l u n d e t a l . , 1 9 8 4 ; B u r g e s s & H a r t m a n , 1 9 8 6 ) . A c c o r d i n g t o W i k l u n d e t a l . , MI p a t i e n t s t e n d e d t o b l a m e s o u r c e s o t h e r t h a n t h e m s e l v e s . P a t i e n t s most o f t e n b e l i e v e d work r e l a t e d f a c t o r s c a u s e d t h e i r MI. T h e s e same p a t i e n t s p l a c e d l e s s e m p h a s i s on s m o k i n g a s a r i s k f a c t o r , d e s p i t e t h e f a c t t h a t t h e m a j o r i t y o f t h e p a t i e n t s were s m o k e r s p r i o r t o t h e MI. B u r g e s s a n d H a r t m a n ( 1 9 8 6 ) r e p o r t e d s i m i l a r f i n d i n g s . More t h a n 1 5 % p e r c e i v e d s m o k i n g t o be t h e c a u s e o f t h e i r h e a r t a t t a c k s . T h e y a l s o f o u n d t h a t 3 3 % o f t h e p a t i e n t s b l a m e d t h e i r j o b s f o r t h e M I , y e t more t h a n 9 0 % o f t h e p a t i e n t s r e p o r t e d j o b s t r e s s . I n f o r m a t i o n s e e k i n g r e p r e s e n t s t h e f o u r t h mode o f c o p i n g ( C o h e n & L a z a r u s , 1 9 7 9 ) . Cohen & L a z a r u s ( 1 9 7 9 ) r e m a r k t h a t i n f o r m a t i o n s e e k i n g I s one o f t h e most b a s i c f o r m s o f c o p i n g u s e d b y p a t i e n t s i n new s i t u a t i o n s . M i l l e r e t a l . ( 1 9 8 5 ) s t u d i e d how c a r d i a c p a t i e n t s u s e d i n f o r m a t i o n r e l a t e d t o s t r e s s management t o e n h a n c e t h e i r c o p i n g e f f o r t s . F o r t h i s p u r p o s e , t h e s t u d y c o m p a r e d t h e c o p i n g s t r a t e g i e s p a t i e n t s u s e d , a n d t h e a d v i c e h e a l t h p r o f e s s i o n a l s p r o v i d e d . The most f r e q u e n t l y u s e d a d v i c e was t h e a v o i d a n c e o f s t r e s s f u l s i t u a t i o n s ( 1 8 % ) ; h o w e v e r , 4 3 % o f t h e p a t i e n t s r e p o r t e d r e c e i v i n g no a d v i c e f r o m h e a l t h p r o f e s s i o n a l s a b o u t s t r e s s management; a n d t h e r e m a i n i n g 5 7 % were n o t u s i n g t h e m a j o r i t y o f a d v i c e t h e y a c k n o w l e d g e d r e c e i v i n g . B e c a u s e p a t i e n t s u s e o n l y i n f o r m a t i o n t h e y p e r c e i v e a s r e l e v a n t t o t h e i r h e a l t h p r o b l e m s , t h e y may w e l l i g n o r e much o f t h e i n f o r m a t i o n t h e y r e c e i v e . D i s c u s s i n g c o p i n g s t r a t e g i e s o f t h e c h r o n i c a l l y i l l , B u r c k h a r d t ( 1 9 8 7 ) p o i n t s o u t t h a t " p a t i e n t s t e n d t o f o c u s n a r r o w l y on what t h e y s e e a s most p r o b l e m a t i c a n d a r e most r e c e p t i v e t o l e a r n i n g i n f o r m a t i o n t h a t e n a b l e s them t o make s o u n d d e c i s i o n s " ( p . 5 4 5 ) . The f i f t h a n d l a s t c o p i n g mode i s t u r n i n g t o o t h e r s f o r h e l p . T h i s mode I s d e f i n e d a s t h e p e r s o n ' s s o c i a l s u p p o r t s y s t e m , o r a l l f o r m s o f a s s i s t a n c e a v a i l a b l e t h a t may e n h a n c e c o p i n g s t r a t e g i e s . T u r n i n g t o o t h e r s f o r h e l p i n c l u d e s e m o t i o n a l s u p p o r t , d i r e c t a s s i s t a n c e a n d i n f o r m a t i o n s u p p o r t ( F o l k m a n & L a z a r u s , 1 9 8 5 ) . I n t h e s t u d y o f t h e p a t i e n t s ' s i c k - r o l e a n d a t t i t u d e s t o w a r d s t h e i r i l l n e s s a t two months ( W i k l u n d e t a l . , 1984) d i s c u s s e d e a r l i e r , s o c i a l s u p p o r t was e x a m i n e d . P a t i e n t s w e r e a s k e d how much t h e c o n t a c t t h e y h ad w i t h t h e i r s i g n i f i c a n t o t h e r s c h a n g e d i n c o m p a r i s o n t o t h e c o n t a c t t h e y e x p e r i e n c e d b e f o r e t h e o n s e t o f t h e M I . F o r t y - s i x p e r c e n t o f p a t i e n t s r e p o r t e d a n i n c r e a s e d c o n t a c t w i t h t h e i r f a m i l y ; 2 0 % r e p o r t e d a d e c r e a s e d c o n t a c t w i t h c l o s e f r i e n d s a n d 3 1 % w i t h o t h e r f r i e n d s . F u r t h e r m o r e , 5 0 % o f p a t i e n t s a v o i d e d v e r y m u c h / t o some e x t e n t b e i n g a l o n e . I n t h e same s t u d y , p a t i e n t s w e re a l s o a s k e d how t h e y w e r e t r e a t e d b y t h e i r f a m i l i e s . E i g h t y p e r c e n t o f p a t i e n t s r e p o r t e d b e i n g p r o t e c t e d f r o m p h y s i c a l e x e r t i o n , 6 8 % t r e a t e d w i t h u n d e r s t a n d i n g , 6 7 % shown c o n s i d e r a t i o n , 6 2 % g i v e n p r a c t i c a l h e l p , 4 7 % r e s p o n s i b i l i t y t a k e n away, 3 6 % shown c o m p a s s i o n , a n d 1 4 % i n i t i a t i v e t a k e n away. S u p p o r t f r o m s i g n i f i c a n t o t h e r s i n t h e s e c a s e s s u g g e s t s o v e r p r o t e c t i o n . Summary. W i t h i n t h e s t r e s s , a p p r a i s a l a nd c o p i n g f r a m e w o r k , c o p i n g r e p r e s e n t s a l l c o g n i t i v e a n d b e h a v i o r a l e f f o r t s u s e d t o d e a l w i t h s p e c i f i c i n t e r n a l a n d e x t e r n a l demands. C o p i n g e f f o r t s s e r v e two f u n c t i o n s : t o manage t h e p r o b l e m i t s e l f ( p r o b l e m - s o l v i n g c o p i n g ) , o r t o r e g u l a t e e m o t i o n a l d i s t r e s s ( e m o t i o n - f o c u s e d c o p i n g ) . Some f o r m s o f e m o t i o n - f o c u s e d s t r a t e g i e s p r o m o t e p r o b l e m - f o c u s e d coping, while others seem to increase emotional distress. Both forms of coping may be used differently and simultaneously, depending on the individual's appraisal of the stressful situation. Research findings show that patients use a wide variety of coping strategies to manage their myocardial infarction. More specifically, most coping strategies Ml patients used were related to the five main modes of coping suggested by the stress, appraisal and coping theory: direct action, inhibition of action, intrapsychic processes, information-seeking and turning to others for help. C o p i n g a s a P r o c e s s C h a n g e s i n E m o t i o n s a n d C o p i n g S t r a t e g i e s Lazarus and Folkman's (1984) stress, appraisal and coping theory defines coping as the constantly changing cognitive and behavioral efforts to manage the demands that are appraised as exceeding the resources of the Individual. Within this framework, coping is viewed as a process rather than trait-oriented coping. The trait-oriented approach defines coping as the characteristics of individuals used to predict what they would do in a particular situation, but not what they are actually doing; and does not consider the contextual changes. According to Lazarus and Folkman (1984), the changes 38 t h a t c h a r a c t e r i z e c o p i n g a s a p r o c e s s a r e a f u n c t i o n o f c o n t i n u o u s a p p r a i s a l s and r e a p p r a i s a l s o f t h e s h i f t i n g p e r s o n - e n v i r o n m e n t r e l a t i o n s h i p . I n F o l k m a n a n d L a z a r u s ' ( 1 9 8 5 ) m i d t e r m e x a m i n a t i o n s t u d y m e n t i o n e d e a r l i e r , c h a n g e s i n t h e f o u r t y p e s o f e m o t i o n s were e x a m i n e d . T h r e a t and c h a l l e n g e e m o t i o n s w h i c h r e f l e c t e d a n t i c i p a t o r y a p p r a i s a l s were e l e v a t e d a t t i m e one a n d two a n d d i d n o t c h a n g e s i g n i f i c a n t l y f r o m t i m e one t o t i m e t w o , b u t d e c r e a s e d s i g n i f i c a n t l y f r o m t i m e two t o t i m e t h r e e . Harm a n d b e n e f i t e m o t i o n s w h i c h r e p r e s e n t e d o utcome a p p r a i s a l s r o s e s i g n i f i c a n t l y f r o m t i m e one t o t i m e t w o , b u t d i d n o t c h a n g e f r o m t i m e two t o t i m e t h r e e . The f i n d i n g s a l s o s u p p o r t L a z a r u s and F o l k m a n ' s t h e s i s t h a t t h r e a t a n d c h a l l e n g e e m o t i o n s , o r harm a n d b e n e f i t e m o t i o n s , c a n o c c u r s i m u l t a n e o u s l y . D u r i n g t h e a n t i c i p a t o r y s t a t e ( t i m e o n e ) , 9 4 % o f t h e s t u d e n t s e x p e r i e n c e d b o t h t h r e a t a n d c h a l l e n g e e m o t i o n s a t t h e same t i m e ; w h i l e a t t i m e t w o , t h e w a i t i n g s t a g e , harm a n d b e n e f i t e m o t i o n s were e l e v a t e d . T h e s e r e s u l t s c o n f i r m e d t h e h y p o t h e s i s t h a t u n d e r c o n d i t i o n s o f maximum a m b i g u i t y , i n d i v i d u a l s a r e l i k e l y t o e x p e r i e n c e b o t h t h r e a t a n d c h a l l e n g e e m o t i o n s . As t h e e n c o u n t e r u n f o l d s and i n f o r m a t i o n I s a d d e d , a m b i g u i t y d e c r e a s e s a n d t h e s i t u a t i o n becomes l e s s s i g n i f i c a n t f o r a n i n d i v i d u a l ' s w e l l - b e i n g . M c C o r k l e a n d Q u l n t - B e n o l i e l ( 1 9 8 3 ) h a v e i n v e s t i g a t e d t h e c o p i n g p r o c e s s i n c a n c e r a n d MI p a t i e n t s . T h e y have c o n d u c t e d a s t u d y w h i c h c o m p a r e d t h e d i f f e r e n c e s o f symptom d i s t r e s s , c u r r e n t c o n c e r n s , a n d mood d i s t u r b a n c e a s s o c i a t e d w i t h c a n c e r a n d m y o c a r d i a l i n f a r c t i o n a t two d i f f e r e n t p o i n t s i n t i m e . The s t u d y ' s p u r p o s e was t o u n d e r s t a n d how p e o p l e c o p e w i t h t h e c h a n g e s Imposed b y s e v e r e i l l n e s s . The s t u d y ' s m o s t s i g n i f i c a n t f i n d i n g was t h a t a l t h o u g h symptom d i s t r e s s r e m a i n e d u n c h a n g e d b e t w e e n o c c a s i o n s f o r b o t h g r o u p s , b o t h g r o u p s o f p a t i e n t s * c o n c e r n s a n d moods I m p r o v e d s i g n i f i c a n t l y b y t h e s e c o n d o c c a s i o n . F u r t h e r m o r e , t h i s c h a n g e i n p a t i e n t s o c c u r r e d w i t h o u t a n y d e s i g n e d n u r s i n g a n d m e d i c a l i n t e r v e n t i o n s t o r e d u c e t h e c o n c e r n s a n d d e c r e a s e mood d i s t u r b a n c e . The r e s e a r c h e r s c o n c l u d e d t h a t t h e p a t i e n t s a d j u s t e d i n t e r n a l l y b e c a u s e o f how d i f f e r e n t l y , b e t w e e n t h e f i r s t a n d s e c o n d m o n t h s p o s t - d i a g n o s i s , t h e y a p p r a i s e d t h e i r i l l n e s s . L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) e x p l a i n t h a t t h e c o p i n g p r o c e s s a l s o I m p l i e s c h a n g e s I n t h o u g h t s a n d a c t i o n s a s a s t r e s s f u l s i t u a t i o n u n f o l d s . The way p e o p l e c o p e a s a s i t u a t i o n e v o l v e s i s i l l u s t r a t e d I n two s t u d i e s . I n t h e m i d t e r m e x a m i n a t i o n s t u d y ( F o l k m a n & L a z a r u s , 1 9 8 5 ) , t h e s t u d e n t s were a s k e d a t e a c h s t a g e t o i n d i c a t e on t h e Ways o f C o p i n g Q u e s t i o n n a i r e t h e c o p i n g s t r a t e g i e s t h e y h a d u s e d i n r e l a t i o n t o t h e e x a m i n a t i o n . The f i n d i n g s showed t h a t s t u d e n t s u s e d c o m b i n a t i o n s o f p r o b l e m - f o c u s e d a n d e m o t i o n - f o c u s e d c o p i n g s t r a t e g i e s a t e v e r y s t a g e . D i f f e r e n t f o r m s o f c o p i n g were u s e d d u r i n g t h e a n t i c i p a t i o n a n d w a i t i n g s t a g e s . P r o b l e m - f o c u s e d f o r m s o f c o p i n g s u c h a s t r y i n g t o c o n t r o l o n e s e l f , t r y i n g t o a n a l y z e t h e p r o b l e m a n d m a k i n g a p l a n o f a c t i o n were more f r e q u e n t l y u s e d d u r i n g t h e a n t i c i p a t i o n s t a g e . D u r i n g t h e w a i t i n g s t a g e , a p a r t i c u l a r f o r m o f e m o t i o n - f o c u s e d c o p i n g , d i s t a n c i n g , was more p r o m i n e n t . D i s t a n c i n g I n c l u d e d s t r a t e g i e s s u c h a s " t r y t o f o r g e t t h e w h o l e t h i n g " a n d "I'm w a i t i n g t o s e e what w i l l h a p p e n b e f o r e d o i n g a n y t h i n g " . A c c o r d i n g t o F o l k m a n a n d L a z a r u s ( 1 9 8 5 ) , d i s t a n c i n g may be a n a p p r o p r i a t e f o r m o f c o p i n g f o r w a i t i n g , s i n c e n o t h i n g b u t w a i t i n g i s p o s s i b l e . O t h e r t y p e s o f c o p i n g s t r a t e g i e s s u c h a s e m p h a s i z i n g t h e p o s i t i v e a s p e c t s o f a s t r e s s f u l e v e n t , s e e k i n g s o c i a l s u p p o r t , a n d w i s h f u l t h i n k i n g a l s o c h a n g e d f r o m s t a g e t o s t a g e . W i k l u n d e t a l . ( 1 9 8 5 ) h a v e u s e d t h e c r i s i s t h e o r y c o p i n g m o d e l t o d e s c r i b e t h e c o p i n g p r o c e s s f o l l o w i n g a MI. T h e y h a v e i d e n t i f i e d f o u r m a i n p h a s e s : t h e s h o c k p h a s e , t h e r e a c t i o n p h a s e , t h e r e c o n s t r u c t i o n p h a s e , a nd t h e r e o r i e n t a t i o n p h a s e . The s h o c k p h a s e b e g i n s i m m e d i a t e l y f o l l o w i n g t h e h e a r t a t t a c k . T h i s p e r i o d l a s t s f r o m a s h o r t moment t o a few d a y s . D u r i n g t h i s p e r i o d , p a t i e n t s f i n d i t d i f f i c u l t t o come t o t e r m s w i t h r e a l i t y b e c a u s e o f t h e s i t u a t i o n ' s n o v e l t y . T h i s p h a s e i s c h a r a c t e r i z e d b y e m o t i o n a l i n s t a b i l i t y . A n x i e t y , c o n f u s i o n , d e n i a l a n d / o r a s s e r t i o n may o c c u r . The r e a c t i o n p h a s e u s u a l l y b e g i n s a f t e r a few d a y s a n d l a s t s up t o two mon t h s a f t e r t h e h e a r t a t t a c k . D u r i n g t h i s p e r i o d , p a t i e n t s f o c u s on t h e i r c a r d i a c a n d e m o t i o n a l symptoms; t h e y w o r r y a b o u t t h e i r f u t u r e , t h e y f i n d l i f e m e a n i n g l e s s , a n d t h e y l o s e s e l f - c o n f i d e n c e . E m o t i o n a l I n s t a b i l i t y s t i l l p e r s i s t s , a n d may be c h a r a c t e r i z e d b y d e p r e s s i o n , i r r i t a b i l i t y , a v o i d a n c e , d e p e n d e n c y a n d / o r p a s s i v i t y . The r e c o n s t r u c t i o n p h a s e b e g i n s a t a p p r o x i m a t e l y t h e s e c o n d month a n d may l a s t up t o t w e l v e m o n t h s . D u r i n g t h i s p h a s e , t h e e m o t i o n a l r e a c t i o n s d e c l i n e , p a t i e n t s f a c e r e a l i t y a n d a t t e m p t t o r e o r g a n i z e t h e i r l i f e . T h i s p h a s e I s c h a r a c t e r i z e d b y m i l d a n x i e t y a n d t e n s i o n , b u t t h e r e s p o n s e s e x p e r i e n c e d I n p r e v i o u s p h a s e s may a l s o o c c u r . The l a s t p h a s e , r e o r i e n t a t i o n , b e g i n s a f t e r t w e l v e m o n t h s , a n d I s c o m p l e t e when t h e p a t i e n t h a s come t o t e r m s w i t h t h e c r i s i s . The a u t h o r s r e m a r k t h a t o n l y f ew p a t i e n t s w i l l e v e n t u a l l y a c h i e v e t h e i d e a l s t a t e o f e m o t i o n a l s t a b i l i t y . I n some c a s e s , e m o t i o n a l a n d b e h a v i o r a l r e s p o n s e s become p a t h o l o g i c a l a n d may i n t e r f e r e w i t h t h e n o r m a l r e c o v e r y p r o c e s s . R e l a t i o n s h i p B e t w e e n C o g n i t i v e A p p r a i s a l and C o p i n g s t r a t e g i e s A c c o r d i n g t o t h e s t r e s s , a p p r a i s a l a n d c o p i n g t h e o r y , t h e way a n i n d i v i d u a l a p p r a i s e s a s i t u a t i o n i n f l u e n c e s t h e c o p i n g s t r a t e g i e s u s e d t o manage i n t e r n a l and e x t e r n a l demands. F o l k m a n e t a l . ( 1 9 8 6 ) e x a m i n e d t h e r e l a t i o n s h i p s b e t w e e n c o g n i t i v e a p p r a i s a l , c o p i n g a n d i m m e d i a t e e n c o u n t e r o u t c o m e s . T h e y u s e d a n l n t r a i n d i v i d u a l ( i p s a t i v e ) a n a l y s i s i n o r d e r t o c o m p a r e t h e same p e r s o n w i t h h i m s e l f o r h e r s e l f a c r o s s s e v e r a l s t r e s s f u l s i t u a t i o n s , a n d t o u n d e r s t a n d t h e i n t e r r e l a t i o n s among t h e v a r i a b l e s . The f i n a l s a m p l e c o n s i s t e d o f 75 m a r r i e d c o u p l e s , a n d t h e p a r t i c i p a n t s were i n t e r v i e w e d o n c e a m o nth f o r s i x m o n t h s . P a r t i c i p a n t s were a s k e d t o d e s c r i b e t h e most s t r e s s f u l e v e n t t h e y had e x p e r i e n c e d d u r i n g t h e p r e v i o u s week. The f i n d i n g s i n d i c a t e d t h a t a s t r o n g r e l a t i o n s h i p e x i s t s b e t w e e n p r i m a r y a p p r a i s a l a n d c o p i n g , a n d t h a t t y p e s o f c o p i n g d i f f e r e d d e p e n d i n g on what was a t s t a k e ( p r i m a r y a p p r a i s a l ) . P r o b l e m - f o c u s e d c o p i n g s t r a t e g i e s w e r e u s e d i n s i t u a t i o n s w h ere a p p r a i s a l p r o v e d t o h a v e p o t e n t i a l f o r I m p r o v e m e n t . F o r e x a m p l e , p e o p l e u s e d p l a n f u l p r o b l e m s o l v i n g and s e l f c o n t r o l i n s i t u a t i o n s w here a g o a l a t work was a t s t a k e . E m o t i o n - f o c u s e d c o p i n g -s t r a t e g i e s were more f r e q u e n t l y u s e d i n s i t u a t i o n s r e q u i r i n g more a c c e p t a n c e . C o n f r o n t i v e c o p i n g , s e l f - c o n t r o l , e s c a p e - a v o i d a n c e , a n d a c c e p t i n g r e s p o n s i b i l i t y c o p i n g were u s e d more f r e q u e n t l y when 43 p e o p l e ' s s e l f - e s t e e m was a t s t a k e . C o n f r o n t i v e c o p i n g a n d e s c a p e - a v o i d a n c e c o p i n g w e re u s e d more when a l o v e d o n e ' s w e l l - b e i n g was a t s t a k e . P e o p l e u s e d c o n f r o n t i v e c o p i n g a n d s e l f - c o n t r o l when l o s s o f r e s p e c t f o r someone e l s e was t h r e a t e n e d . P e o p l e u s e d c o n f r o n t i v e c o p i n g a n d s e e k i n g s o c i a l s u p p o r t more h e a v i l y when f i n a n c i a l r e s o u r c e s were a t s t a k e . When t h e s i t u a t i o n i n v o l v e d o n e ' s own p h y s i c a l h e a l t h , s e e k i n g o f s o c i a l s u p p o r t a n d e s c a p e - a v o i d a n c e w e r e u s e d more. O t h e r w r i t e r s o r r e s e a r c h e r s d e s c r i b e how a p p r a i s a l p r o c e s s e s a r e r e l a t e d t o c o p i n g s t r a t e g i e s i n d i v i d u a l s u s e t o manage t h e i r i l l n e s s . L l p o w s k i ( 1 9 7 0 - 1 9 7 1 ) s t a t e s t h a t d i f f e r e n t m e a n i n g s a t t r i b u t e d t o I l l n e s s c a n I n f l u e n c e c o p i n g s t r a t e g i e s p a t i e n t s u s e . He e x p l a i n s t h a t p a r t i c u l a r f o r m s o f c o p i n g may be a s s o c i a t e d w i t h harm a p p r a i s a l . I n t h i s c a s e , t h e p e s o n who p e r c e i v e s i l l n e s s a s a n enemy may p l a c e t h e b l a m e on o t h e r s , a n d u s e o t h e r f o r m s o f c o p i n g r e l a t e d t o d e n i a l , p r o j e c t i o n , d e p e n d e n c y a nd p a s s i v i t y . The p e r s o n who r e g a r d s I l l n e s s a s a w e a k n e s s may t r y t o e s c a p e r e a l i t y b y d e n y i n g t h e I l l n e s s o r may engage i n a v a r i e t y o f a c t i v i t i e s s u c h a s a t t e m p t i n g e i t h e r t o l o o k h e a l t h y o r t o be o v e r - c o m p l i a n t . L l p o w s k i ( 1 9 7 0 - 1 9 7 1 ) f u r t h e r e x p l a i n s t h a t when i l l n e s s i s p e r c e i v e d a s a c h a l l e n g e , p a t i e n t s t r y t o m a s t e r t h e s i t u a t i o n u s i n g t h e a v a i l a b l e r e s o u r c e s . T h e y t a k e a n a c t i v e r o l e i n t h e i r i l l n e s s a n d d i s p l a y a d a p t i v e c o p i n g p a t t e r n s s u c h a s o b t a i n i n g p r o f e s s i o n a l a d v i c e a n d i n f o r m a t i o n . P a r t i c u l a r f o r m s o f c o p i n g s t r a t e g i e s may be a s s o c i a t e d w i t h d i f f e r e n t t y p e s o f b e n e f i t a p p r a i s a l s ( L i p o w s k i , 1 9 7 0 - 1 9 7 1 ) . F o r e x a m p l e , i n d i v i d u a l s who p e r c e i v e t h e i r i l l n e s s a s a s t r a t e g y may u s e i t a s a t e c h n i q u e i n t h e i r i n t e r p e r s o n a l r e l a t i o n s h i p s . I n t h i s c a s e , i l l n e s s i s a means o f g e t t i n g a t t e n t i o n , s u p p o r t a n d c o m p l i a n c e f r o m o t h e r s . I l l n e s s p e r c e i v e d a s a r e l i e f may be a means o f p r o l o n g i n g d i s a b i l i t y a n d m a i n t a i n i n g t h e s i c k r o l e b e y o n d t h e n o r m a l r e c o v e r y p e r i o d . T h e s e p a t i e n t s may e x c e s s i v e l y u s e m e d i c a l r e s o u r c e s a n d have numerous s o m a t i c c o m p l a i n t s . M c N e t t ( 1 9 8 7 ) s t u d i e d t h e e f f e c t s o f s o c i a l s u p p o r t , t h r e a t a p p r a i s a l a n d c o p i n g r e s p o n s e s on c o p i n g e f f e c t i v e n e s s i n 50 f u n c t i o n a l l y d i s a b l e d w h e e l c h a i r - b o u n d s u b j e c t s . She f o u n d t h a t a v a i l a b i l i t y o f s o c i a l s u p p o r t was s i g n i f i c a n t l y r e l a t e d t o r e d u c e d t h r e a t a p p r a i s a l (r_ = 0 . 2 9 ) . A d d i t i o n a l l y , t h r e a t a p p r a i s a l was a l s o s i g n i f i c a n t l y r e l a t e d t o e m o t i o n - f o c u s e d c o p i n g (r_ = 0.23) . R e s e a r c h f i n d i n g s i n d i c a t e t h a t t h e way p a t i e n t s a p p r a i s e t h e h e a r t a t t a c k w i l l i n f l u e n c e c o p i n g s t r a t e g i e s u s e d . G a r r i t y ( 1 9 7 5 ) d i s c u s s e s t h e r e s u l t s o f two e a r l i e r 45 s t u d i e s on p a t i e n t s * p e r c e p t i o n s o f t h e i r h e a r t a t t a c k s . The s t u d i e s s e a r c h e d f o r f a c t o r s t h a t c o u l d e x p l a i n t h e MI p a t i e n t s ' s u c c e s s o r f a i l u r e t o a d j u s t p h y s i c a l l y and p s y c h o l o g i c a l l y . C l i n i c a l , s o c i a l a nd p s y c h o l o g i c a l v a r i a b l e s w e r e s e l e c t e d a s p r e d i c t o r s o f a d j u s t m e n t . The f i n d i n g s showed s t r i k i n g e v i d e n c e t h a t p a t i e n t s ' p e r c e p t i o n o f t h e i r h e a l t h s t a t u s was t h e most u s e f u l p r e d i c t o r o f r e t u r n t o work and l e i s u r e a c t i v i t i e s , a s w e l l a s p o s i t i v e a t t i t u d e . G e n t r y a n d Haney ( 1 9 7 5 ) h a v e I n v e s t i g a t e d t h e r e l a t i o n s h i p s w i t h i n a n d b e t w e e n v a r i o u s d i m e n s i o n s o f p a t i e n t s ' c h a r a c t e r i s t i c s , p r e - h o s p i t a l b e h a v i o r s , c o r o n a r y c a r e u n i t b e h a v i o r s a n d o u t c o m e s i n p a t i e n t s h o s p i t a l i z e d f o r a c u t e MI. P r e - h o s p i t a l and CCU b e h a v i o r s I n c l u d e d v a r i a b l e s s u c h a s symptoms a t t r i b u t i o n , d e l a y , d e c i s i o n - m a k i n g , p e r c e i v e d i l l n e s s , a n d f e a r o f p a i n a n d d e a t h . The most s i g n i f i c a n t f i n d i n g r e p o r t e d was t h e c l o s e r e l a t i o n s h i p b e t w e e n d e a t h c o n c e r n a n d o t h e r p a t i e n t s ' b e h a v i o r s . P a t i e n t s who w e r e h i g h l y c o n c e r n e d a b o u t d e a t h v i e w e d t h e m s e l v e s a s s i c k e r , a n d r e p o r t e d a g r e a t e r d e g r e e o f p a i n a n d d i s c o m f o r t . The f i n d i n g s a l s o i n d i c a t e d t h a t y o u n g e r p a t i e n t s were more o p t i m i s t i c a b o u t t h e i r f u t u r e t h a n o l d e r p a t i e n t s . A d d i t i o n a l l y , y o u n g e r p a t i e n t s were l e s s c o n c e r n e d a b o u t f i n a n c e s . D e c i s i o n - m a k i n g a n d d e l a y i n s e e k i n g m e d i c a l h e l p were r e l a t e d t o p a t i e n t s ' s u b j e c t i v e a p p r a i s a l o f t h e i r i l l n e s s , how s i c k t h e y p e r c e i v e d t h e m s e l v e s , a n d how w o r r i e d t h e y were a b o u t d e a t h . P a t i e n t s who showed l e s s d e l a y i n s e e k i n g m e d i c a l h e l p r e p o r t e d more d e a t h c o n c e r n s a n d v i e w e d t h e m s e l v e s a s s i c k e r , b u t i n d i c a t e d f e w e r c o n c e r n s r e l a t e d t o f i n a n c e s . P a t i e n t s who t h o u g h t t h e y had s u s t a i n e d a MI a t t h e t i m e o f a d m i s s i o n t e n d e d t o h a v e d e c i d e d t o s e e k m e d i c a l a t t e n t i o n , r a t h e r t h a n t o r e l y on s o c i a l s u p p o r t . H o w e v e r , f o r p a t i e n t s who r e l i e d on s o c i a l s u p p o r t , t h e i r r e s p o n s e s w e r e c a t e g o r i z e d b y d e n i a l . Summary. W i t h i n t h e s t r e s s , a p p r a i s a l a n d c o p i n g f r a m e w o r k , c o p i n g I s d e f i n e d a s a p r o c e s s . T h a t i s , c o g n i t i v e a n d b e h a v i o r a l e f f o r t s c o n t i n u a l l y c h a n g e t o meet t h e s t r e s s e s o f t h e s i t u a t i o n . R e s e a r c h f i n d i n g s s u p p o r t t h e s t r e s s , a p p r a i s a l a n d c o p i n g t h e o r y ' s f o r m u l a t i o n t h a t t h e c h a n g e s i n c o p i n g a r e a f u n c t i o n o f c o n t i n u o u s a p p r a i s a l s a n d r e a p p r a i s a l s o f t h e s h i f t i n g p e r s o n - e n v i r o n m e n t r e l a t i o n s h i p . The d e f i n i t i o n o f c o p i n g i s c o n c e p t u a l i z e d a s o c c u r r i n g i n s t a g e s , w i t h c h a n g e s i n t h o u g h t s a n d a c t i o n e f f o r t s a s t h e e n c o u n t e r u n f o l d s . S u p p o r t f o r t h i s t h e o r e t i c a l t e n e t was f o u n d i n r e s e a r c h i n v e s t i g a t i n g c o p i n g s t a g e s r e l e v a n t t o r e c o v e r y f o l l o w i n g a h e a r t a t t a c k . W i t h i n t h e f r a m e w o r k o f c r i s i s t h e o r y , a d o m i n a n t p a t t e r n o f e m o t i o n a l r e a c t i o n s a n d c o p i n g s t r a t e g i e s i s a d o p t e d by MI p a t i e n t s i n e a c h o f t h e f o u r c o p i n g s t a g e s . R e s e a r c h f i n d i n g s p r o v i d e e v i d e n c e t h a t a p p r a i s a l - r e l a t e d processes i n f l u e n c e coping s t r a t e g i e s people used to manage the s p e c i f i c demands of a s i t u a t i o n . S t u d i e s I n v e s t i g a t e d p a t i e n t s * coping f o l l o w i n g a h e a r t a t t a c k . F i n d i n g s i n d i c a t e t h a t p e r c e p t i o n of i l l n e s s i s the most u s e f u l determinant of b e h a v i o r a l ajustment outcomes. A p p r a i s a l s r e l a t e d to r e c o g n i t i o n of c a r d i a c symptoms or f e a r of death were a s s o c i a t e d with p r e - h o s p i t a l and CCU b e h a v i o r s i n c l u d i n g v a r i a b l e s such as symptoms a t t r i b u t i o n and d e l a y i n s e e k i n g p r o f e s s i o n a l h e l p . Summary of the L i t e r a t u r e Review A review of l i t e r a t u r e suggests t h a t a p p r a i s a l - r e l a t e d processes h e l p e x p l a i n emotional r e a c t i o n s and c o p i n g s t r a t e g i e s used i n s t r e s s f u l s i t u a t i o n s , and how they change over time. A c c o r d i n g to s t r e s s , a p p r a i s a l and coping t h e o r y , s t r e s s a p p r a i s a l s are of three t y p e s : harm, t h r e a t , and c h a l l e n g e . These s t r e s s a p p r a i s a l s determine to what degree people e v a l u a t e a s i t u a t i o n as damaging or p o t e n t i a l l y damaging based on t h e i r u n d erstanding of the power of the s i t u a t i o n to cause harm. S i m i l a r l y , r e s e a r c h e r s have d e s c r i b e d the d i f f e r e n t ways i n d i v i d u a l s regard t h e i r I l l n e s s e s , and how t h i s meaning can i n f l u e n c e emotional r e a c t i o n s and the coping s t r a t e g i e s used. They suggest t h a t I l l n e s s may be p e r c e i v e d a s c h a l l e n g e , h arm, t h r e a t o r b e n e f i t . P e r s o n - c h a r a c t e r i s t i c s s u c h a s a t t i t u d e s , b e l i e f s a n d p e r s o n a l r e s o u r c e s i n f l u e n c e t h e a p p r a i s a l s o f harm, t h r e a t , c h a l l e n g e a n d b e n e f i t t h a t a r e made. I l l n e s s p e r c e i v e d a s a harm may t a k e s e v e r a l f o r m s : a s a n enemy, i n d i v i d u a l s v i e w t h e m s e l v e s a s v i c t i m s o f d e s t r u c t i v e f o r c e s ; a s a w e a k n e s s , p a t i e n t s r e g a r d t h e i r i l l n e s s e s a s a s i g n o f f a i l u r e ; a s a f a i r o r u n f a i r p u n i s h m e n t ; o r a s i r r e p a r a b l e l o s s o r damage. E m o t i o n s s u c h a s a n g e r , d e p r e s s i o n , h u m i l i a t i o n a n d h o s t i l i t y c h a r a c t e r i z e harm a p p r a i s a l . I f i l l n e s s i s p e r c e i v e d a s a c h a l l e n g e , p a t i e n t s w i l l d e a l w i t h t h e i l l n e s s a s t h e y w o u l d i n a n y o t h e r s t r e s s f u l s i t u a t i o n s where p a r t i c u l a r t a s k s h a v e t o be m a s t e r e d . C h a l l e n g e a p p r a i s a l i s c h a r a c t e r i z e d b y e m o t i o n s s u c h a s hope a n d c o n f i d e n c e . I f i l l n e s s i s p e r c e i v e d a s g a i n / b e n e f i t , t h i s a p p r a i s a l may t a k e t h e f o r m o f r e l i e f , v a l u e o r s t r a t e g y . D i f f e r e n t t h r e a t s may be i n v o l v e d i n e a c h t y p e o f a p p r a i s a l . I l l n e s s p e r c e i v e d a s a t h r e a t , i m p l i e s a n t i c i p a t e d h a r m s / l o s s e s o f d i f f e r e n t k i n d s . F e a r , w o r r y a n d a n x i e t y a r e common r e a c t i o n s . S t u d i e s ' f i n d i n g s s u p p o r t t h e s t r e s s , a p p r a i s a l a n d c o p i n g p r e m i s e t h a t t h e s e t y p e s o f a p p r a i s a l s s h a p e e m o t i o n a l r e a c t i o n s , a n d c a n o c c u r s i m u l t a n e o u s l y . R e l e v a n t l i t e r a t u r e I n d i c a t e s t h a t a s t r e s s f u l e x p e r i e n c e s u c h a s a h e a r t a t t a c k c a r r i e s p o s s i b l e r i s k s a s w e l l a s p o t e n t i a l b e n e f i t s . A h e a r t a t t a c k g i v e s r i s e t o v a r i o u s f e a r s a n d c o n c e r n s , and g e n e r a t e s m o d e r a t e t o h i g h l e v e l s o f s t r e s s d e p e n d i n g on what a s p e c t s o f t h e M l s i t u a t i o n t h e p e r s o n i s e v a l u a t i n g . T h e s e p e r c e p t i o n s o f t h e h e a r t a t t a c k a r e i n f l u e n c e d p r i m a r i l y b y p e r s o n a l b e l i e f s . F o l l o w i n g a MI, most i n d i v i d u a l s e x p e r i e n c e two t y p e s o f e m o t i o n s : a n x i e t y a n d d e p r e s s i o n . T h e s e e m o t i o n s o c c u r s i m u l t a n e o u s l y , a n d t h e i r i n t e n s i t y may f l u c t u a t e d u r i n g t h e p r o c e s s o f c o n v a l e s c e n c e d e p e n d i n g on t h e demands o f t h e s i t u a t i o n . C o n v e r s e l y , many i n d i v i d u a l s were f o u n d t o h a v e a p o s i t i v e o u t l o o k r e g a r d i n g t h e i r h e a r t a t t a c k s . P o s s i b l e b e n e f i t s may a l s o be g a i n e d a s a r e s u l t o f t h e s t r e s s f u l e x p e r i e n c e . W i t h i n t h e s t r e s s , a p p r a i s a l and c o p i n g t h e o r y , c o p i n g i s d e f i n e d a s a l l c o g n i t i v e a n d b e h a v i o r a l e f f o r t s t o manage s p e c i f i c e x t e r n a l a n d i n t e r n a l demands. C o p i n g s t r a t e g i e s s e r v e two b r o a d f u n c t i o n s . F i r s t , t h e p u r p o s e o f t h e p r o b l e m - s o l v i n g f u n c t i o n s i s t o a l t e r t h e t r o u b l e d p e r s o n - e n v i r o n m e n t r e l a t i o n s h i p ; a n d s e c o n d , t h e e m o t i o n - r e g u l a t i n g f u n c t i o n s may be d i r e c t e d a t t h e s e l f o r t h e e n v i r o n m e n t i n o r d e r t o r e g u l a t e t h e p a t i e n t ' s e m o t i o n s . To manage t h e v a r i o u s e x i g e n c i e s i m p o s e d b y t h e MI s i t u a t i o n , p a t i e n t s u s e a w i d e v a r i e t y o f c o p i n g s t r a t e g i e s . T h e s e c o p i n g s t r a t e g i e s a r e c a t e g o r i z e d u n d e r f i v e m a i n c a t e g o r i e s s u g g e s t e d by t h e s t r e s s , a p p r a i s a l a n d c o p i n g f r a m e w o r k : d i r e c t a c t i o n , i n h i b i t i o n o f a c t i o n , I n t r a p s y c h i c p r o c e s s e s , i n f o r m a t i o n s e e k i n g and t u r n i n g t o o t h e r s f o r h e l p . C o p i n g s t r a t e g i e s i n c l u d e d i n e a c h mode may s e r v e b o t h p u r p o s e s o f e m o t i o n - f o c u s e d and p r o b l e m - f o c u s e d c o p i n g . R e s e a r c h f i n d i n g s i n d i c a t e d t h a t a l a r g e p e r c e n t a g e o f MI p a t i e n t s were e n g a g e d I n d i r e c t a c t i o n and i n h i b i t i o n o f a c t i o n f o r m s o f c o p i n g d u r i n g t h e r e c o v e r y p e r i o d . T h e s e two f o r m s o f c o p i n g m a i n l y a i m a t m a n a g i n g p e r s o n a l a n d e n v i r o n m e n t a l demands f o l l o w i n g a h e a r t a t t a c k . T y p e s o f i n t r a p s y c h i c modes o f c o p i n g i n c l u d e d e n i a l , r e j e c t i o n , m i n i m i z a t i o n , s e l f - c o n t r o l f o r m s o f c o p i n g a n d b l a m i n g s o u r c e s o t h e r t h a n s e l f . T h e s e modes o f c o p i n g seem t o be u s e d m a i n l y d u r i n g t h e i n i t i a l p e r i o d f o l l o w i n g a h e a r t a t t a c k . Some f o r m s o f I n t r a p s y c h i c c o p i n g s u c h a s d e n i a l a r e f r e q u e n t l y u s e d , a n d may be b e n e f i c i a l t o p a t i e n t s i n t h e e a r l y s t a g e s o f r e c o v e r y . I n f o r m a t i o n s e e k i n g I s one o f t h e most b a s i c f o r m s o f c o p i n g i n new s i t u a t i o n s . P a t i e n t s seem t o f o c u s o n l y on w hat t h e y s e e a s r e l e v a n t t o t h e i r h e a l t h p r o b l e m s . R e s e a r c h f i n d i n g s r e p o r t t h a t t u r n i n g t o o t h e r s f o r h e l p a s a f o r m o f c o p i n g i s i n c r e a s e d d u r i n g t h e r e c o v e r y f r o m a h e a r t a t t a c k . W i t h i n t h e s t r e s s , a p p r a i s a l a n d c o p i n g f r a m e w o r k , c o p i n g i s v i e w e d a s a p r o c e s s . T h a t i s , a s t h e c o n s t a n t l y c h a n g i n g c o g n i t i v e and b e h a v i o r a l e f f o r t s t o manage t h e demands o f a s i t u a t i o n . R e s e a r c h f i n d i n g s s u p p o r t t h e t h e o r e t i c a l p r e m i s e t h a t c o n t i n u o u s a p p r a i s a l s a n d r e a p p r a i s a l s a r e d e t e r m i n a n t s o f t h e c h a n g e s t h a t c h a r a c t e r i z e c o p i n g a s a p r o c e s s f o l l o w i n g a h e a r t a t t a c k . D i f f e r e n t t y p e s o f s t r e s s f u l a p p r a i s a l s a r e made d e p e n d i n g on demands o f t h e s i t u a t i o n . The c o p i n g p r o c e s s a l s o i n v o l v e s c h a n g e s i n c o p i n g e f f o r t s a s t h e s i t u a t i o n e v o l v e s . S t u d i e s ' f i n d i n g s s u g g e s t t h a t p e o p l e u s e v a r i o u s f o r m s o f e m o t i o n - f o c u s e d a n d p r o b l e m - f o c u s e d c o p i n g a t e v e r y s t a g e o f a s t r e s s f u l e n c o u n t e r . C r i s i s - o r i e n t e d a s p e c t s a r e e s p e c i a l l y r e l e v a n t w i t h r e g a r d t o a c u t e i l l n e s s s u c h a s a h e a r t a t t a c k . W i t h i n t h e c r i s i s t h e o r y , f o u r m a i n c o p i n g s t a g e s h a v e b e e n d e s c r i b e d f o l l o w i n g a m y o c a r d i a l i n f a r c t i o n : t h e s h o c k p h a s e , t h e r e a c t i o n p h a s e , t h e r e c o n s t r u c t i o n p h a s e , a n d t h e r e o r i e n t a t i o n p h a s e . E a c h p h a s e i s c h a r a c t e r i z e d b y s p e c i f i c e m o t i o n a l r e a c t i o n s a n d c o p i n g s t r a t e g i e s . E m o t i o n a l s t a b i l i t y i s r e a c h e d when t h e p a t i e n t h a s s u c c e s s f u l l y w o r k e d t h r o u g h e a c h p h a s e . S t u d i e s w h i c h i n v e s t i g a t e d t h e r e l a t i o n s h i p b e t w e e n a p p r a i s a l a n d c o p i n g s u g g e s t t h a t p a r t i c u l a r f o r m s o f c o p i n g a r e a s s o c i a t e d w i t h s p e c i f i c s t r e s s f u l e n c o u n t e r s . A l t h o u g h b o t h f o r m s a r e u s e d , c o p i n g e f f o r t s r e l a t e d t o e m o t i o n - f o c u s e d c o p i n g a r e u s e d more f r e q u e n t l y i n h e a l t h - r e l a t e d s i t u a t i o n s ; w h e r e a s p r o b l e m - f o c u s e d c o p i n g e f f o r t s a r e u s e d more i n w o r k - r e l a t e d s i t u a t i o n s . R e s e a r c h f i n d i n g s i n d i c a t e t h a t t h e c o p i n g s t r a t e g i e s p a t i e n t s u s e d are l a r g e l y determined by the type of a p p r a i s a l s made. P e r c e p t i o n s of the MI s i t u a t i o n proved to be the most s u c c e s s f u l determinants of b e h a v i o r a l adjustment p a t t e r n s , such as r e t u r n to work and l e i s u r e a c t i v i t i e s . Threat r e l a t e d a p p r a i s a l s such as r e c o g n i t i o n of c a r d i a c symptoms and f e a r of death were a l s o a s s o c i a t e d with p r e - h o s p i t a l and CCU be h a v i o r s and outcome i n c l u d i n g v a r i a b l e s such as symptoms a t t r i b u t i o n , d e l a y i n s e e k i n g p r o f e s s i o n a l h e l p and f u n c t i o n a l s t a t u s . 53 CHAPTER THREE M e t h o d o l o g y T h i s c h a p t e r w i l l d e s c r i b e t h e d e s i g n s a m p l e , s e t t i n g s f o r t h e s t u d y a n d d a t a c o l l e c t i o n i n s t r u m e n t s . A d d i t i o n a l l y , human r i g h t s a n d e t h i c a l c o n s i d e r a t i o n s , d a t a c o l l e c t i o n a n d d a t a a n a l y s i s p r o c e d u r e s w i l l be r e v i e w e d . T h i s s t u d y u s e d a d e s c r i p t i v e c o r r e l a t i o n a l a n d a l o n g i t u d i n a l d e s i g n w i t h m e a s u r e s o b t a i n e d a t two p o i n t s I n t i m e . A l l d a t a were g a t h e r e d b y t h e I n v e s t i g a t o r b y means o f q u e s t i o n n a i r e s a n d p a t i e n t I n f o r m a t i o n s h e e t s . S a m p l e A c o n v e n i e n c e s a m p l e o f 21 p a r t i c i p a n t s was o b t a i n e d i n a c c o r d a n c e w i t h t h e I n c l u s i o n c r i t e r i a : 1. The p a r t i c i p a n t s were a d u l t s b e t w e e n t h e a g e s o f 41 and 73 . 2. The p a r t i c i p a n t s w e r e a d m i t t e d t o a c r i t i c a l c a r e u n i t w i t h a c o n f i r m e d f i r s t m y o c a r d i a l i n f a r c t i o n d i a g n o s e d b y t h e u s u a l c r i t e r i a o f c l i n i c a l h i s t o r y , enzyme a n d / o r e l e c t r o c a r d i o g r a p h i c c h a n g e s . 3. The p a r t i c i p a n t s w e r e a b l e t o u n d e r s t a n d , r e a d a n d s p e a k E n g l i s h . 4. The p a r t i c i p a n t s l i v e d i n m e t r o p o l i t a n V a n c o u v e r . 5. No o t h e r m a j o r i l l n e s s e s were i n d i c a t e d f r o m t h e p a t i e n t s ' m e d i c a l h i s t o r y . 6 . A l l p a r t i c i p a n t s had exp e r i e n c e d t h e i r MI no more than seven days p r i o r to t h i s study. Seven days and e i g h t weeks post-MI were chosen as c r i t i c a l p o i n t s i n the MI r e h a b i l i t a t i o n process because the process of co p i n g , a c c o r d i n g to c r i s i s t h e o r y , appears to be r e l e v a n t f o r the study. The shock phase and the r e a c t i o n phase begin immediately f o l l o w i n g the MI, and may l a s t a few weeks (Wiklund et a l . , 1 9 8 5 ) . The r e c o n s t r u c t i o n phase begins a t ap p r o x i m a t e l y e i g h t weeks a f t e r the acute e p i s o d e . A c c o r d i n g t o Wenger and H e l l e r s t e i n ( 1 9 7 8 ) , w i t h i n e i g h t to twelve weeks, most p a t i e n t s are expected t o resume t h e i r normal a c t i v i t i e s f o l l o w i n g an uncomplicated MI. Setting P a r t i c i p a n t s were r e c r u i t e d from four h o s p i t a l s i n western Canada. The i n i t i a l data were c o l l e c t e d i n the acute or subacute c o r o n a r y care u n i t s . The second q u e s t i o n n a i r e was answered a t e i g h t weeks at the p a r t i c i p a n t s ' home or o f f i c e , whichever was convenient to them. Human Ri g h t s and E t h i c a l C o n s i d e r a t i o n s P e r m i s s i o n t o conduct the study was obt a i n e d from the U n i v e r s i t y of B r i t i s h Columbia B e h a v i o r a l S c i e n c e s Screening committee. P e r m i s s i o n to implement the study was a l s o o b t a i n e d from the H o s p i t a l and Nursing Research Committee and H o s p i t a l Research Committees. A d d i t i o n a l l y , the four s e l e c t e d h o s p i t a l s r e c e i v e d a l e t t e r e x p l a i n i n g the study. N u r s i n g s t a f f a s s i s t e d i n the s e l e c t i o n of p o t e n t i a l s u b j e c t s a c c o r d i n g to the sample c r i t e r i a . A c o n t a c t person who was e i t h e r a c l i n i c a l nurse s p e c i a l i s t , I.C.U. c o o r d i n a t o r or head nurse i d e n t i f i e d p o t e n t i a l s u b j e c t s and d e s c r i b e d the study to them. The i n v e s t i g a t o r then approached a l l i d e n t i f i e d p a t i e n t s between the f i f t h and seventh days post MI t o d i s c u s s the study w i t h them. In a d d i t i o n to a v e r b a l e x p l a n a t i o n of the study, the p a t i e n t s r e c e i v e d an i n f o r m a t i o n - c o n s e n t l e t t e r (Appendix E) which e x p l a i n e d the nature, the purpose and the i m p l i c a t i o n s of the study. Any q u e s t i o n s r a i s e d about the study or the q u e s t i o n n a i r e s were answered and those p a t i e n t s who agreed to p a r t i c i p a t e s i g n e d the consent. The p a t i e n t s r e t a i n e d a copy of the i n f o r m a t i o n - c o n s e n t form. A f t e r consent was o b t a i n e d , the p a r t i c i p a n t s completed the q u e s t i o n n a i r e i n the presence of the i n v e s t i g a t o r . Measures were taken to p r o t e c t the p a r t i c i p a n t s ' c o n f i d e n t i a l i t y with the use of code numbers. Data C o l l e c t i o n Procedure Data were c o l l e c t e d a t two d i f f e r e n t p o i n t s In time. The f i r s t time was between the f i f t h and the seventh days post MI; the second time was a t e i g h t weeks post MI. The i n v e s t i g a t o r a r r a n g e d t o meet i n d i v i d u a l l y w i t h t h e p a r t i c i p a n t i n t h e a c u t e o r s u b a c u t e c a r e u n i t s a t a c o n v e n i e n t t i m e b e t w e e n t h e f i f t h a n d t h e s e v e n t h d a y s p o s t MI t o c o m p l e t e t h e q u e s t i o n n a i r e . The n u r s i n g s t a f f s c r e e n e d a l l f i r s t MI p a t i e n t s a d m i t t e d t o t h e c r i t i c a l c a r e u n i t s t o d e t e r m i n e i f t h e y met t h e s a m p l i n g c r i t e r i a . A t o t a l o f 21 c o n s e c u t i v e n e w l y d i a g n o s e d MI p a t i e n t s c o m p r i s e d t h e s a m p l e f o r t h e f i r s t i n t e r v i e w . I n t h e o r i g i n a l p r o p o s a l t h e age l i m i t was s e t a t 70 y e a r s o f a g e . B e c a u s e o f t h e d i f f i c u l t y i n o b t a i n i n g p a r t i c i p a n t s , h o w e v e r , two s u b j e c t s o f 71 a n d two o f 73 y e a r s o f age were i n c l u d e d i n t h e s t u d y . P a t i e n t s were v i s i t e d i n e i t h e r t h e a c u t e o r s u b a c u t e CCU. The i n v e s t i g a t o r a r r a n g e d f o r a c o n v e n i e n t t i m e a n d p l a c e f o r t h e f o l l o w - u p q u e s t i o n n a i r e . A phone number a n d a d d r e s s t o p e r m i t f u r t h e r c o n t a c t w i t h t h e i n d i v i d u a l was o b t a i n e d . The i n v e s t i g a t o r p h o n e d t h e s u b j e c t s s e v e n weeks p o s t MI a t t h e i r home o r o f f i c e a s a g r e e d , a n d t h e I n t e r v i e w s were h e l d i n l o c a t i o n s s e l e c t e d b y t h e p a r t i c i p a n t s . D a t a C o l l e c t i o n I n s t r u m e n t s The f o l l o w i n g i n s t r u m e n t s were u s e d i n t h e s t u d y : The E m o t i o n A p p r a i s a l S c a l e ( F o l k m a n & L a z a r u s , 1 9 8 5 ) , The R e v i s e d Ways o f C o p i n g ( L a z a r u s & F o l k m a n , 1 9 8 4 ) , a n d a p a t i e n t i n f o r m a t i o n s h e e t . 57 Emotion A p p r a i s a l Scale The Emotion A p p r a i s a l S c a l e (Appendix A) was used to measure c o g n i t i v e a p p r a i s a l . The instrument i s a 24-item c h e c k l i s t with a 5-point L i k e r t S c a l e (0 = not a t a l l ; 4 = a g r e a t d e a l ) . The 24 items are c l a s s i f i e d i n t o 4 emotion s c a l e s : t h r e a t emotions, c h a l l e n g e emotions, harm emotions and b e n e f i t emotions. Threat a p p r a i s a l focuses on p o t e n t i a l harm and i s c h a r a c t e r i z e d by emotions such as f e a r , a n x i e t y and worry; c h a l l e n g e a p p r a i s a l i s c h a r a c t e r i z e d by p l e a s u r a b l e emotions such as eagerness, excitement and e x h i l a r a t i o n ; anger, sadness, g u i l t and d i s g u s t r e f e r to harm a p p r a i s a l ; while emotions such as p l e a s u r e , happiness and r e l i e f r e f l e c t b e n e f i t a p p r a i s a l . Evidence i s a v a i l a b l e t o support content v a l i d i t y . The Instrument was developed from the f i n d i n g s of a p r e v i o u s l y formulated c o g n i t l v e - p h e n o m e n o l o g i c a l t h e o r y of emotion. Examining the r e l a t i o n s h i p s based on the t h e o r e t i c a l p r e d i c t i o n s p r o v i d e s evidence of c o n s t r u c t v a l i d i t y ( P o l i t & Hungler, 1983). In the study of the s t u d e n t s ' midterm examination, Folkman and Lazarus (1985) h y p o t h e s i z e d t h a t a person s i m u l t a n e o u s l y e x p e r i e n c e d p o s i t i v e and n e g a t i v e emotions. T h i s h y p o t h e s i s was supported by the f i n d i n g s . As expected, students r e p o r t e d f e e l i n g both t h r e a t and c h a l l e n g e emotions, as w e l l as harm and b e n e f i t emotions a t each stage of the event. The i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y f o r each of t h e s e s c a l e s f o r t h e s t u d e n t s ' m i d t e r m e x a m i n a t i o n s t u d y ( F o l k m a n & L a z a r u s , 1985) r e v e a l s a mean a l p h a f o r t h e t h r e a t e m o t i o n s s c a l e o f .80; .59 f o r t h e c h a l l e n g e e m o t i o n s s c a l e ; .84 f o r t h e harm e m o t i o n s s c a l e ; a n d .78 f o r t h e b e n e f i t e m o t i o n s s c a l e . A c c o r d i n g t o F o l k m a n a n d L a z a r u s , t h e r e l a t i v e l y l o w r e l i a b i l i t y o f t h e c h a l l e n g e s c a l e s u g g e s t s t h a t t h e r e s u l t s b a s e d on c h a l l e n g e s h o u l d be i n t e r p r e t e d w i t h c a u t i o n . I n t h e p r e s e n t s t u d y , t h e i n t e r n a l c o n s i s t e n c y r e l i a b i l i t y ( C r o n b a c h ' s A l p h a ) f o r t h e f o u r s c a l e s was c a l c u l a t e d f o r e a c h o f t h e two a d m i n i s t r a t i o n s . A t t h e i n i t i a l p e r i o d , t h e T h r e a t E m o t i o n S c a l e r e l i a b i l i t y was .75; .58 f o r t h e Harm E m o t i o n S c a l e ; .73 f o r t h e C h a l l e n g e E m o t i o n S c a l e ; a n d .66 f o r t h e B e n e f i t E m o t i o n S c a l e . A t t h e s e c o n d p e r i o d , t h e I n t e r n a l c o n s i s t e n c y r e l i a b i l i t y f o r t h e f o u r s c a l e s was a s f o l l o w s : T h r e a t .44, Harm .77, C h a l l e n g e .64, a n d B e n e f i t .82. T h i s I n d i c a t e s t h a t r e s u l t s must be i n t e r p r e t e d w i t h c a u t i o n f o r t h e harm s c a l e a t t i m e o n e , a n d t h e t h r e a t s c a l e a t t h e s e c o n d i n t e r v i e w . R e v i s e d Ways o f C o p i n g S c a l e The R e v i s e d Ways o f C o p i n g S c a l e ( A p p e n d i x B) d e s i g n e d b y L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) was u s e d t o m e a s u r e c o p i n g s t r a t e g i e s . The r e v i s e d v e r s i o n I s a 6 7 - i t e m c h e c k l i s t w i t h a 4 - p o i n t L i k e r t s c a l e (0 = d o e s n o t a p p l y ; 3 = u s e d a g r e a t d e a l ) , a n d m e a s u r e s a w i d e r a n g e o f c o g n i t i v e a n d b e h a v i o r a l c o p i n g s t r a t e g i e s p e o p l e u s e t o manage t h e demands o f a s t r e s s f u l s i t u a t i o n . The i t e m s on t h e c h e c k l i s t c o v e r t h e two b r o a d f u n c t i o n s o f e m o t i o n - f o c u s e d a n d p r o b l e m - f o c u s e d c o p i n g . E v i d e n c e i s a v a i l a b l e t o s u p p o r t c o n t e n t v a l i d i t y o f t h e R e v i s e d Ways o f C o p i n g S c a l e . C o p i n g s t r a t e g y i t e m s were d e r i v e d f r o m t h e i r own t h e o r e t i c a l f r a m e w o r k , a s w e l l a s f r o m r e l e v a n t l i t e r a t u r e . The Ways o f C o p i n g S c a l e h a s b e e n a d m i n i s t e r e d t o s e v e r a l s a m p l e s o f p e o p l e , w i t h r e v i s i o n s i n c o r p o r a t e d i n t o t h e I n s t r u m e n t b a s e d on t h e r e s u l t s . F a c t o r i a l v a l i d i t y i s one method f o r e s t a b l i s h i n g c o n s t r u c t v a l i d i t y . F u r t h e r m o r e , B u r n s a nd G r o v e ( 1 9 8 7 ) p o i n t o u t t h a t f a c t o r a n a l y s i s i s t h e most i m p o r t a n t s t a t i s t i c a l t e c h n i q u e f o r v a l i d a t i n g t h e s t r u c t u r e o f a n i n s t r u m e n t , b e c a u s e t h i s m e t hod o r g a n i z e s i t e m s i n t o f a c t o r s w h i c h g r o u p i t e m s t h a t h a v e a s i m i l a r u n d e r l y i n g t h e m e . F a c t o r a n a l y s i s o f t h e Ways o f C o p i n g S c a l e was p e r f o r m e d u s i n g p r i n c i p a l f a c t o r i n g a n d o b l i q u e r o t a t i o n . O b l i q u e r o t a t i o n was s e l e c t e d b e c a u s e f r o m a t h e o r e t i c a l p e r s p e c t i v e , p e o p l e a r e e x p e c t e d t o c h o o s e f r o m a w i d e v a r i e t y o f c o p i n g s t r a t e g i e s , r a t h e r t h a n t o u s e one t y p e o f s t r a t e g y t o t h e e x c l u s i o n o f a n o t h e r . T h r e e f a c t o r s t r u c t u r e s h a v e b e e n i d e n t i f i e d f o r t h e Ways o f C o p i n g S c a l e . F o l k m a n e t a l . ( 1 9 8 6 ) r e p o r t e d a 6 f a c t o r s o l u t i o n f o r t h e c o l l e g e s t u d e n t s ' m i d t e r m e x a m i n a t i o n s t u d y ; H i l t o n ( 1 9 8 7 ) f o u n d a 5 f a c t o r s o l u t i o n i n h e r s t u d y o f women w i t h b r e a s t c a n c e r ; a n d I n t h e s t u d y o f c o m m u n i t y m i d d l e - a g e d m a r r i e d c o u p l e s , a n 8 f a c t o r s o l u t i o n was f o u n d ( F o l k m a n e t a l . , 1 9 8 6 ) . F o r t h e p r e s e n t s t u d y , t h e f a c t o r s t r u c t u r e f r o m t h e m i d d l e - a g e d c o m m u n i t y s a m p l e s t u d y was u s e d b e c a u s e t h e f a c t o r s t r u c t u r e was b a s e d on a b r o a d s a m p l i n g o f p a r t i c i p a n t s a n d s t r e s s f u l s i t u a t i o n s . The 8 f a c t o r s a r e t h e f o l l o w i n g : c o n f r o n t i v e c o p i n g , d i s t a n c i n g , s e l f - c o n t r o l l i n g , s e e k i n g s o c i a l s u p p o r t , a c c e p t i n g r e s p o n s i b i l i t y , e s c a p e - a v o i d a n c e , p l a n f u l p r o b l e m - s o l v i n g a n d p o s i t i v e r e a p p r a i s a l . C o n f r o n t i v e c o p i n g d e s c r i b e s a g g r e s s i v e e f f o r t s t o a l t e r t h e s i t u a t i o n ( e . g . , " t r y t o g e t t h e p e r s o n r e s p o n s i b l e t o c h a n g e h i s / h e r m i n d " ) , a n d i t e m s w h i c h s u g g e s t a d e g r e e o f h o s t i l i t y ( e . g . , " I e x p r e s s a n g e r t o t h e p e r s o n who c a u s e d t h e p r o b l e m " ) , a n d r i s k - t a k i n g ( e . g . , " I t a k e a b i g c h a n c e o r do s o m e t h i n g r i s k y " ) . D i s t a n c i n g d e s c r i b e s e f f o r t s t o d e t a c h o n e s e l f ( e . g . , " I r e f u s e t o b e l i e v e i t h a s h a p p e n e d " ) , a n d e f f o r t s t o c r e a t e a p o s i t i v e o u t l o o k ( e . g . , " I make l i g h t o f t h e s i t u a t i o n ; I r e f u s e t o g e t t o s e r i o u s a b o u t i t " ) . S e l f - c o n t r o l l i n g d e s c r i b e s e f f o r t s t o r e g u l a t e o n e ' s own f e e l i n g s ( e . g . , " I t r y t o k e e p my f e e l i n g s t o m y s e l f " ) , a n d a c t i o n s ("I t r y n o t t o b u r n my b r i d g e s , b u t l e a v e t h i n g s o p e n s o m e w h a t " ) . A c c e p t i n g r e s p o n s i b i l i t y acknowledges one's own r o l e In the problem (e.g., "I r e a l i z e I brought the problem on m y s e l f " ) , or t r y i n g to put t h i n g s r i g h t (e.g., "I a p o l o g i z e or do something to make up f o r i t " ) . Escape-avoidance d e s c r i b e s w i s h f u l t h i n k i n g (e.g., "I wish the s i t u a t i o n would go away or somehow be over w i t h " ) , and other e f f o r t s to escape or a v o i d (e.g., "I a v o i d being with people i n g e n e r a l " ) . P l a n f u l p r o b l e m - s o l v i n g d e s c r i b e s d e l i b e r a t e p r o b l e m - s o l v i n g e f f o r t s t o a l t e r the s i t u a t i o n (e.g., "I know what has to be done, so I double my e f f o r t s to make t h i n g s work"), combined with an a n a l y t i c approach to p r o b l e m - s o l v i n g (e.g., "I make a p l a n of a c t i o n and f o l l o w i t " ) . P o s i t i v e r e a p p r a i s a l d e s c r i b e s e f f o r t s to c r e a t e p o s i t i v e meaning by f o c u s i n g on p e r s o n a l growth (e.g., "I have found new f a i t h " ) . L a s t l y , s e e k i n g s o c i a l support d e s c r i b e s e f f o r t s to seek emotional support (e.g., "I accept sympathy and understanding from someone"), and i n f o r m a t i o n a l support (e.g., "I t a l k to someone to f i n d out more about the s i t u a t i o n " ) . F u r t h e r evidence of c o n s t r u c t v a l i d i t y was obtained on the ways of Coping S c a l e by examining the expected r e l a t i o n s h i p s based on t h e o r e t i c a l c o n s i d e r a t i o n s . The c o g n i t i v e a p p r a i s a l t h e o r y p r e d i c t s a r e l a t i o n s h i p between primary a p p r a i s a l ( v a r i o u s s t a k e s ) and c o p i n g . The r e s u l t s o b t ained from the study of the middle-aged married c o u p l e s , as d i s c u s s e d e a r l i e r , supported t h i s h y p o t h e s i s . I n t h e s t u d y o f t h e m i d d l e - a g e d m a r r i e d c o u p l e s , r e l i a b i l i t y a l p h a c o e f f i c i e n t s p r o v i d e d e v i d e n c e o f t h e I n s t r u m e n t ' s i n t e r n a l c o n s i s t e n c y . The r e l i a b i l i t y a l p h a c o e f f i c i e n t s f o r t h e c o n f r o n t i v e c o p i n g s c a l e was .70; .61 f o r t h e d i s t a n c i n g s c a l e ; .76 f o r t h e s e e k i n g s o c i a l s u p p o r t S c a l e ; .66 f o r t h e a c c e p t i n g r e s p o n s i b i l i t y s c a l e ; .72 f o r t h e e s c a p e - a v o i d a n c e s c a l e ; .68 f o r t h e p l a n f u l p r o b l e m - s o l v i n g s c a l e ; .79 f o r t h e p o s i t i v e r e a p p r a i s a l s c a l e ; a n d , .70 f o r t h e s e l f - c o n t r o l l i n g s c a l e . I n t h e p r e s e n t s t u d y , r e l i a b i l i t y a l p h a c o e f f i c i e n t s f o r t h e 8 s c a l e s a t t h e i n i t i a l p e r i o d were c o n f r o n t i v e c o p i n g .44, d i s t a n c i n g .47, s e l f - c o n t r o l l i n g .35, s e e k i n g s o c i a l s u p p o r t .68, a c c e p t i n g r e s p o n s i b i l i t y .53, e s c a p e - a v o i d a n c e .74, p l a n f u l p r o b l e m - s o l v i n g .59, a n d p o s i t i v e r e a p p r a i s a l .85. A t t h e s e c o n d i n t e r v i e w , r e l i a b i l i t y a l p h a c o e f f i c i e n t s w e r e c o n f r o n t i v e c o p i n g .55, d i s t a n c i n g .76, s e l f - c o n t r o l l i n g .69, s e e k i n g s o c i a l s u p p o r t .86, a c c e p t i n g r e s p o n s i l i t y .46, e s c a p e - a v o i d a n c e .68, p l a n f u l p r o b l e m - s o l v i n g .56, a n d p o s i t i v e r e a p p r a i s a l .86. A t b o t h t e s t i n g s c o n f r o n t i v e c o p i n g , p l a n f u l p r o b l e m - s o l v i n g a n d a c c e p t i n g r e s p o n s i b i l i t y h a d l o w r e l i a b i l i t i e s . A d d i t i o n a l l y , a t t h e i n i t i a l p e r i o d d i s t a n c i n g a n d s e l f - c o n t r o l l i n g a l s o had a l o w r e l i a b i l i t y . R e s u l t s m u s t , t h e r e f o r e , be i n t e r p r e t e d c a u t i o u s l y . P a t i e n t I n f o r m a t i o n S h e e t The i n v e s t i g a t o r developed a p a t i e n t i n f o r m a t i o n sheet a t each p o i n t i n time (Appendices C & D) to r e c o r d p e r t i n e n t demographic d a t a , and r e l e v a n t i l l n e s s - r e l a t e d i n f o r m a t i o n . D a t a A n a l y s i s Data obtained were a n a l y s e d u s i n g d e s c r i p t i v e s t a t i s t i c s and nonparametr1c s t a t i s t i c s . Nonparametric t e s t s were s e l e c t e d because, a s m a l l sample s i z e and a convenience sampling technique were used. N o r m a l i t y c o u l d not be assumed. The Wilcoxon matched-pairs signed-ranks t e s t and the Spearman rank c o r r e l a t i o n were used f o r the comparative and c o r r e l a t i o n a l d ata a n a l y s i s . A t w o - t a i l e d l e v e l of s i g n i f i c a n c e was used to t e s t the hypotheses because the i n v e s t i g a t o r had not p r e d i c t e d the d i r e c t i o n of a r e l a t i o n s h i p . The l e v e l of s i g n i f i c a n c e was e s t a b l i s h e d a t 0.05 f o r the study. Data obtained from the q u e s t i o n n a i r e s were coded and analyzed u s i n g the SPSS-X computer program. CHAPTER FOUR P r e s e n t a t i o n and D i s c u s s i o n of R e s u l t s T h i s chapter i s d i v i d e d i n t o three s e c t i o n s . The f i r s t s e c t i o n r e p o r t s the demographic and h e a l t h - r e l a t e d c h a r a c t e r i s t i c s of the sample. The r e s u l t s r e l a t e d to each of the t h r e e hypotheses are o u t l i n e d i n s e c t i o n two. A d i s c u s s i o n of the f i n d i n g s i s presented i n s e c t i o n t h r e e . C h a r a c t e r i s t i c s of the Sample Twenty one newly diagnosed MI p a t i e n t s comprised the sample f o r the f i r s t I n t e r v i e w . Nineteen of these s u b j e c t s p a r t i c i p a t e d i n the second i n t e r v i e w . Of the two s u b j e c t s who d i d not p a r t i c i p a t e i n the second i n t e r v i e w , one had d i e d , and the other r e f u s e d to p a r t i c i p a t e because he f e l t e m o t i o n a l l y overwhelmed. A f u r t h e r s u b j e c t who was v i s i t e d a t e i g h t weeks had a second MI. He d i d not complete the second q u e s t i o n n a i r e s u f f i c i e n t l y enough f o r i t to be i n c l u d e d i n the data a n a l y s i s p r o c e s s . At the f i r s t i n t e r v i e w , the p a t i e n t s were 5 to 9 days post MI, with 90% (H = 5.7) between the f i f t h and seventh days post MI. At the second i n t e r v i e w , p a t i e n t s were v i s i t e d 8 to 9 weeks post MI (H = 8.1). Demographic C h a r a c t e r i s t i c s of the Sample The sample w i l l be d i s c u s s e d i n terms of age, sex, m a r i t a l , o c c u p a t i o n a l and e d u c a t i o n a l s t a t u s . The sample c o n s i s t e d o f 16 m a l e s ( 7 6 . 2 % ) a n d 5 f e m a l e s ( 2 3 . 8 % ) . Ages r a n g e d f r o m 41 t o 73 y e a r s w i t h a mean o f 6 2 . 3 % y e a r s ( s e e T a b l e I ) . S e v e n t e e n were m a r r i e d , 2 were d i v o r c e d , a n d 1 e a c h was s i n g l e , a n d w i d o w e d . P a r t i c i p a n t s ' o c c u p a t i o n s w e re c a t e g o r i z e d b y t h e i n v e s t i g a t o r ( s e e T a b l e I I ) . o v e r h a l f o f t h e s u b j e c t s w e r e r e t i r e d ( 1 1 ) , p r o f e s s i o n a l s / m a n a g e r s ( 3 ) , t e c h n i c i a n s ( 3 ) , s e c r e t a r i e s / o f f i c e w o r k e r s ( 2 ) , m a n u a l l a b o u r e r s ( 1 ) o r homemakers ( 1 ) . I n t e r m s o f e d u c a t i o n , 4 p a r t i c i p a n t s had c o m p l e t e d a c o l l e g e o r u n i v e r s i t y p r o g r a m ( 1 9 % ) , 8 p a r t i c i p a n t s h a d c o m p l e t e d h i g h s c h o o l ( 3 8 . 1 % ) , 6 p a r t i c i p a n t s h a d some s e c o n d a r y e d u c a t i o n ( 2 8 . 6 % ) , a n d t h e r e m a i n i n g 3 had a c h i e v e d a t l e a s t a g r a d e 8 e d u c a t i o n ( 1 4 . 3 % ) . T a b l e I Age of t h e Sample Age F r e q u e n c y P e r c e n t 40-44 1 4.8 45-49 0 0.0 50-54 2 9.5 55-59 3 14.4 60-64 6 28.6 65-69 5 24.0 70-74 4 19.0 T o t a l 21 100. 0 T a b l e I I o c c u p a t i o n a l s t a t u s o f s a m p l e s O c c u p a t i o n S t a t u s F r e q u e n c y P e r c e n t R e t i r e d 11 52.4 P r o f e s s i o n a l / m a n a g e r 3 14.3 T e c h n i c i a n 3 14.3 S e c r e t a r y / o f f i c e w o r k e r 2 9.5 M a n u a l l a b o u r e r 1 4.8 Homemaker 1 4.8 T o t a l 21 100.0 I l l n e s s - R e l a t e d C h a r a c t e r i s t i c s o f t h e Sam p l e I l l n e s s - r e l a t e d v a r i a b l e s w i l l be d i s c u s s e d a s f o l l o w s : t i m e t h a t e l a p s e d f r o m s u s p e c t e d symptoms t o a d m i s s i o n t o h o s p i t a l , number o f symptoms a n d o t h e r m e d i c a l / h e a l t h p r o b l e m s r e p o r t e d , l e n g t h o f s t a y i n t h e CCU a n d t h e h o s p i t a l , a n d p r e v i o u s k n o w l e d g e o f h e a r t a t t a c k s . P a t i e n t s r e p o r t e d a p e r i o d o f d e l a y r a n g i n g f r o m z e r o t o two d a y s (_ = 7 h o u r s ) b e t w e e n t h e o n s e t o f symptoms an d t h e i r a d m i s s i o n t o h o s p i t a l s . S i x t e e n p a t i e n t s ( 7 6 . 2 % ) were a d m i t t e d t o h o s p i t a l s on t h e same d a y t h a t symptoms a p p e a r e d . Of t h e f i v e r e m a i n i n g p a t i e n t s who r e p o r t e d a p e r i o d o f d e l a y r a n g i n g f r o m one t o two d a y s , t h r e e p a t i e n t s h a d s o u g h t m e d i c a l a s s i s t a n c e b u t were t r e a t e d f o r c o n d i t i o n s o t h e r t h a n a n MI. Two o t h e r p a t i e n t s d e c i d e d t o s e e k m e d i c a l h e l p a f t e r t h e i r u n s u c c e s s f u l a t t e m p t s t o r e l i e v e what t h e y had a p p r a i s e d a s " s t o m a c h p r o b l e m s " . A t t h e f i r s t I n t e r v i e w , t h e number o f symptoms p a t i e n t s r e p o r t e d r a n g e d f r o m z e r o t o t h r e e , w i t h 12 p a t i e n t s ( 5 7 . 1 % ) r e p o r t i n g one symptom ( T a b l e I I I ) . A t t h e s e c o n d i n t e r v i e w , t h e number o f symptoms p a t i e n t s r e p o r t e d r a n g e d f r o m z e r o t o f o u r , w i t h h a l f r e p o r t i n g one symptom. The number o f p a t i e n t s r e p o r t i n g h a v i n g no symptoms d e c r e a s e d f r o m f o u r t o o n e ; a l l f o u r p a t i e n t s who r e p o r t e d h a v i n g no symptoms a t t h e f i r s t i n t e r v i e w h a d d e v e l o p e d symptoms d u r i n g t h e i r c o n v a l e s c e n c e . T a b l e I I I Number of Symptoms Number o f F i r s t I n t e r v i e w S e c o n d i n t e r v i e w symptoms F r e q u e n c y P e r c e n t F r e q u e n c y P e r c e n t 0 4 19 .0 1 5.3 1 12 57.1 10 52.6 2 4 19.0 4 21.0 3 1 4.8 2 10.5 4 0 0.0 1 5.3 T o t a l 21 100.0 19 100.0 F a t i g u e was t h e most f r e q u e n t l y r e p o r t e d symptom a t b o t h t i m e p e r i o d s b y a t l e a s t 10 s u b j e c t s ( T a b l e I V ) . Of t h e 10 p a t i e n t s who c o m p l a i n e d o f f a t i g u e a t t h e s e c o n d i n t e r v i e w , t h r e e p a t i e n t s r e p o r t e d f a t i g u e f o r a s e c o n d t i m e , a n d t h e r e m a i n i n g s e v e n p a t i e n t s s t a t e d t h a t t h e y had d e v e l o p e d t h i s symptom s i n c e d i s c h a r g e f r o m t h e h o s p i t a l . The number o f p a t i e n t s who r e p o r t e d h a v i n g c h e s t p a i n i n c r e a s e d f r o m two ( 9 . 5 % ) t o e i g h t ( 4 2 . 1 % ) . Two o f t h e s e p a t i e n t s h a d r e p o r t e d h a v i n g m i l d c h e s t p a i n a t t h e f i r s t i n t e r v i e w ; a n d t h e s i x o t h e r p a t i e n t s c o m p l a i n e d o f m i l d t o s e v e r e c h e s t p a i n . F i v e p a t i e n t s r e p o r t e d e x p e r i e n c i n g s h o r t n e s s o f b r e a t h a t b o t h i n t e r v i e w s . A t t h e s e c o n d i n t e r v i e w , o n l y one p a t i e n t r e p o r t e d s h o r t n e s s o f b r e a t h a s a p e r s i s t i n g symptom. A l t h o u g h s h o r t n e s s o f b r e a t h h ad s u b s i d e d i n f o u r p a t i e n t s , f o u r o t h e r p a t i e n t s h a d d e v e l o p e d s h o r t n e s s o f b r e a t h f o l l o w i n g d i s c h a r g e f r o m T a b l e I V S y m p t o m s R e p o r t e d B e t w e e n t h e F i f t h a n d t h e S e v e n t h D a v s a n d E i g h t W e e k s P o s t MT Symptoms F i r s t i n t e r v i e w F r e q u e n c y P e r c e n t S e c o n d F r e q u e n c y i n t e r v i e w P e r c e n t C h e s t p a i n 2 9.5 8 42.1 S h o r t n e s s o f b r e a t h 5 23.8 5 26.3 F a t i g u e 11 52.4 10 52.6 O t h e r symptoms 5 23.8 4 21.1 t h e h o s p i t a l . A t t h e f i r s t I n t e r v i e w , o t h e r symptoms r e p o r t e d b y f i v e p a t i e n t s w e r e l o n e l i n e s s ( 3 ) , t e a r f u l n e s s ( 1 ) , a n d p a i n due t o a f r a c t u r e d arm ( 1 ) . A t t h e s e c o n d I n t e r v i e w , o t h e r symptoms were r e p o r t e d by t h r e e p a t i e n t s : one p a t i e n t c o n t i n u e d t o r e p o r t l o n e l i n e s s ; a n o t h e r r e p o r t e d s l e e p d i s t u r b a n c e s ; a t h i r d p a t i e n t , who had u n d e r g o n e a c o r o n a r y b y p a s s g r a f t s u r g e r y s i x weeks p r i o r t o t h e s e c o n d i n t e r v i e w , c o m p l a i n e d o f i n c i s i o n a l t e n d e r n e s s a n d s w e l l i n g o f a n k l e s . O t h e r m e d i c a l o r h e a l t h p r o b l e m s r e p o r t e d b y s e v e n p a t i e n t s w e r e d i a b e t e s ( 2 ) , h y p e r t e n t l o n ( 2 ) , m i l d a r t h r i t i s ( 1 ) , g l a u c o m a ( 1 ) , u p p e r r e s p i r a t o r y t r a c t i n f e c t i o n ( 1 ) a n d h i a t u s h e r n i a ( 1 ) . L e n g t h o f s t a y I n t h e c o r o n a r y c a r e u n i t s r a n g e d f r o m t h r e e t o f i f t e e n d a y s ( t l = 6.8; SD = 3 . 4 ) . The m a j o r i t y o f p a t i e n t s ( 7 6 . 2 % ) r e m a i n e d i n t h e a c u t e c o r o n a r y c a r e u n i t s f r o m t h r e e t o e i g h t d a y s . The l e n g t h o f h o s p i t a l i z a t i o n r a n g e d f r o m s i x t o t w e n t y - t w o d a y s (H = 1 2 . 3 , SD = 4 . 2 ) , w i t h most p a t i e n t s ( 9 0 . 4 % ) h o s p i t a l i z e d f r o m s i x t o s e v e n t e e n d a y s . A l l p a t i e n t s w e r e d i s c h a r g e d f r o m s u b a c u t e c a r e u n i t s . D u r i n g t h e e i g h t week p e r i o d b e t w e e n i n t e r v i e w s , two p a t i e n t s had c o r o n a r y a n g i o g r a p h y a n d a t l e a s t f o u r p a t i e n t s w e r e w a i t i n g t o g e t a f i r m d a t e f o r e i t h e r t r e a d m i l l t e s t o r a n g i o g r a p h y . One p a t i e n t had b e e n r e a d m i t t e d f o r a m e d i c a t i o n r e a c t i o n , w h i l e a n o t h e r had undergone c o r o n a r y bypass g r a f t s u r g e r y . P a t i e n t s were a l s o asked i f they knew of other people who had a h e a r t a t t a c k . Most had known someone, whether f r i e n d or r e l a t i v e , yet o n l y 2 of s u b j e c t s s a i d t h a t the Information was h e l p f u l to them now. F i n d i n g s The f i n d i n g s of the study w i l l be presented i n r e l a t i o n to each of the t h r e e hypotheses. Hypothesis 1; Changes i n C o g n i t i v e A p p r a i s a l Data are presented u s i n g the s c o r e r e s u l t s o b t a i n e d on the four emotion s c a l e s of t h r e a t , harm, c h a l l e n g e and b e n e f i t a t two d i f f e r e n t p o i n t s i n time. A d e s c r i p t i o n of the frequency of each a p p r a i s a l w i l l be p r o v i d e d b e f o r e a d d r e s s i n g h y p o t h e s i s 1 r e l a t e d to changes i n c o g n i t i v e a p p r a i s a l In p a t i e n t s a t two p o i n t s i n time (see Table V ) . A d d i t i o n a l l y , s c a l e means and s c a l e item means are presented i n Table VI. In the immediate post MI p e r i o d , t h r e a t emotions ranged from 0 to 10 (M_ = 4.0, SD = 2 . 8 ) , harm emotions ranged from 0 to 15 (tt = 6.4, SD = 4 . 2 ) , c h a l l e n g e emotions ranged from 2 to 12 (M. = 6.1, SD = 3 . 5 ) , and b e n e f i t emotions ranged from 0 to 12 (ft = 3.3, SD = 3 . 5 ) . At e i g h t weeks post MI, t h r e a t emotions ranged from 1 to 9 (H = 3.7, SD = 2 . 1 ) , harm emotions ranged from 0 to 17 ( H = 5.6, SD = 4 . 6 ) , c h a l l e n g e emotions ranged from 2 to 11 Table V C o g n i t i v e A p p r a i s a l Types and Changes Over Time 5 and 7 Days Post MI 8 Weeks Post MI T o t a l s c o r e Frequency Percent Frequency Percent T h r e a t A p p r a i s a l (a ) 0-2 8 3 8 . 1 7 3 8 . 9 3 - 5 6 2 8 . 6 8 4 4 . 5 6-8 5 2 3 . 8 2 1 1 . 2 9 - 1 1 2 9 . 6 1 5 . 6 T o t a l 21 1 0 0 . 0 18 1 0 0 . 0 Harm A p p r a i s a l ( M 0-3 7 3 3 . 4 8 4 4 . 6 4-7 6 2 8 . 5 5 2 7 . 8 8 -11 6 2 8 . 6 2 1 1 . 2 1 2 - 1 5 2 9 . 6 2 1 1 . 2 1 6 - 1 9 0 0 . 0 1 5 . 6 T o t a l 21 1 0 0 . 0 18 1 0 0 . 0 Challenge A p p r a i s a l (a) 2-4 9 4 2 . 8 5 2 7 . 8 5 -7 6 2 8 . 6 6 3 3 . 4 8 -10 2 9 . 6 5 2 7 . 9 1 1 - 1 3 4 1 9 . 1 2 1 1 . 1 T o t a l 21 1 0 0 . 0 18 1 0 0 . 0 B e n e f i t A p p r a i s a l (c) 0-3 12 57 .1 7 3 9 . 0 4 -7 6 2 8 . 6 7 3 9 . 0 8 -11 2 9 . 6 2 1 1 . 2 1 2 - 1 5 1 4 . 8 1 5 . 6 1 6 - 1 9 0 0 . 0 1 5 . 6 T o t a l 21 1 0 0 . 0 18 1 0 0 . 0 Note. (a) Maximum score p o s s i b l e = 12 (3 items x 4 ) . (b) Maximum score p o s s i b l e = 20 (5 items x 4 ) . (c) Maximum score p o s s i b l e = 16 (4 items x 4 ) . ( H = 6.3, SD = 2 . 9 ) , and b e n e f i t e m o t i o n s r a n g e d f r o m 0 t o 16 (ft = 5.3, SD = 4.4). E a c h a p p r a i s a l r e f l e c t e d a w i d e r a n g e o f s c o r e s . A t f i v e t o s e v e n d a y s p o s t M I , s c a l e i t e m means i n d i c a t e t h a t c h a l l e n g e e m o t i o n s were most f r e q u e n t , f o l l o w e d b y t h r e a t , harm and t h e n b e n e f i t e m o t i o n s . A t e i g h t weeks p o s t M l , c h a l l e n g e e m o t i o n s p r e d o m i n a t e d . H o w e v e r , b e n e f i t e m o t i o n s i n c r e a s e d c o n s i d e r a b l y a n d were s e c o n d i n f r e q u e n c y , f o l l o w e d b y t h r e a t a n d harm e m o t i o n s . To a d d r e s s t h e h y p o t h e s i s p r e d i c t i n g s i g n i c a n t c h a n g e s i n e a c h c o g n i t i v e a p p r a i s a l o v e r t i m e , t h e W l l c o x o n m a t c h e d - p a i r s s l g n e d - r a n k s t e s t was u s e d . No s i g n i f i c a n t d i f f e r e n c e s were f o u n d i n a l l c o g n i t i v e T a b l e VI C h a n g e s i n C o g n i t i v e A p p r a i s a l B e t w e e n t h e F i f t h a n d t h e S e v e n t h D a y s a n d E i g h t W e e k s P o s t MI E m o t i o n a l n Time M. Number I tern Z. D. A p p r a i s a l s o f i t e m s mean T h r e a t 21 1 4.1 (3) 1.37 e m o t i o n s -.63 NS 18 2 3.7 (3) 1.23 H a r m / l o s s 21 1 6.4 (5) 1.28 e m o t i o n s -.97 NS 18 2 5.6 (5 ) 1.12 C h a l l e n g e 21 1 6.1 (3) 2 .03 e m o t i o n s -.44 NS 18 2 6.3 (3) 2.10 B e n e f i t 21 1 3.3 (4) 0.83 e m o t i o n s -1.39 NS 18 2 5.3 (4) 1.33 a p p r a i s a l e m o t i o n s b e t w e e n t h e i n i t i a l p e r i o d , a n d e i g h t weeks p o s t MI. T h e r e f o r e , t h e r e s u l t s do n o t s u p p o r t h y p o t h e s i s 1. T h e r e were no s i g n i f i c a n t c h a n g e s i n c o g n i t i v e a p p r a i s a l o v e r t i m e . Hypothesis 2; C h a n g e s i n C o p i n g S t r a t e g i e s D a t a a r e p r e s e n t e d u s i n g t h e r e s u l t s o b t a i n e d on e a c h o f t h e e i g h t c o p i n g s t r a t e g i e s a t two d i f f e r e n t p o i n t s I n t i m e . A d e s c r i p t i o n o f t h e f r e q u e n c y o f e a c h c o p i n g s t r a t e g y w i l l be p r o v i d e d b e f o r e a d d r e s s i n g h y p o t h e s i s 2 r e l a t e d t o c h a n g e s i n t h e c o p i n g s t r a t e g i e s u s e d a t two p o i n t s i n t i m e ( s e e T a b l e V I I ) . A d d i t i o n a l l y , s c a l e means a n d s c a l e i t e m means a r e p r e s e n t e d i n T a b l e V I I I . A t t h e f i r s t i n t e r v i e w , c o n f r o n t i v e s t r a t e g i e s r a n g e d f r o m 1 t o 10 ( H = 4.7, SD = 2 . 6 ) , d i s t a n c i n g s t r a t e g i e s r a n g e d f r o m 3 t o 16 ( t i = 8.91, SD = 3 . 2 ) , s e l f - c o n t r o l l i n g s t r a t e g i e s r a n g e d f r o m 3 t o 15 (M_ = 9.9, SD = 3 . 1 ) , s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s r a n g e d f r o m 4 t o 18 ( t l = 1 0 . 7 , SD = 4 . 0 ) , a c c e p t i n g r e s p o n s i b i l i t y s t r a t e g i e s r a n g e d f r o m 1 t o 10 (11= 6.0, SD = 3 . 2 ) , e s c a p e - a v o i d a n c e s t r a t e g i e s r a n g e d f r o m 1 t o 20 ( H = 7.7, SD = 5 . 4 ) , . p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s r a n g e d f r o m 2 t o 15 ( H = 8.3, SD = 3 . 7 ) , a n d p o s i t i v e r e a p p r a i s a l s t r a t e g i e s r a n g e d f r o m 1 t o 21 ( t l = 1 1 . 4 8 , SD = 5 . 8 ) . A t e i g h t weeks p o s t M I , c o n f r o n t i v e s t r a t e g i e s r a n g e d f r o m 0 t o 11 ( t l = 4.4, SD = 3 . 2 ) , d i s t a n c i n g s t r a t e g i e s r a n g e d f r o m 2 t o 17 ( t l = 9.4, SD = 4 . 2 ) , s e l f - c o n t r o l l i n g T a b l e V I I C o p i n g S t r a t e g i e s T y p e s a n d c h a n g e s O v e r Time 5 a n d 7 Days P o s t MI 8 Weeks P o s t MI T o t a l s c o r e F r e q u e n c y P e r c e n t F r e q u e n c y P e r c e n t C o n f r o n t i v e C o p i n a lb) 0-2 4 1 9 . 1 5 2 7 . 8 3 - 5 11 5 2 . 4 7 3 9 . 0 6 -8 3 1 4 . 3 4 2 2 . 3 9 - 1 1 3 1 4 . 3 2 1 1 . 2 T o t a l 21 1 0 0 . 0 18 1 0 0 . 0 D i s t a n c i n g C o p i n a ( b ) 2-5 3 1 4 . 3 4 2 2 . 4 6-9 9 4 2 . 8 5 2 7 . 8 1 0 - 1 3 8 3 8 . 2 6 3 3 . 4 1 4 - 1 7 1 4 . 8 3 1 6 . 8 T o t a l 21 1 0 0 . 0 18 1 0 0 . 0 s e l f - c o n t r o l l i n a C o D i n a ( c ) 0-3 l 4 . 8 3 1 6 . 7 4 -7 3 14 .3 3 1 6 . 7 8 - 1 1 11 5 2 . 4 9 5 0 . 0 1 2 - 1 5 6 2 8 . 6 2 1 1 . 2 1 6 - 1 9 0 0 . 0 1 5 . 6 T o t a l 21 1 0 0 . 0 18 1 0 0 . 0 5 . _ K i n q S o c i a l S u p p o r t C o D i n a (b) 0-3 0 0 . 0 6 3 3 . 3 4 -7 5 2 3 . 8 4 2 2 . 3 8 - 1 1 5 2 3 . 8 5 2 7 . 9 1 2 - 1 5 8 3 8 . 1 2 1 1 . 2 1 6 - 1 9 3 1 4 . 3 1 5 . 6 T o t a l 21 1 0 0 . 0 18 1 0 0 . 0 A c c e p t i n g R e s p o n s i b i l i t y C o p i n q ( a ) 0-2 4 1 9 . 0 6 3 3 . 3 3 - 5 4 19 .0 6 3 3 . 3 6-8 7 3 3 . 3 5 2 7 . 8 9 - 1 1 6 2 8 . 6 .1 5 . 6 T o t a l 21 1 0 0 . 0 18 1 0 0 . 0 T a b l e V I I ( c o n t i n u e d ) 5 a n d 7 Days P o s t MI 8 Weeks P o s t MI T o t a l s c o r e F r e q u e n c y P e r c e n t F r e q u e n c y P e r c e n t E s c a p e - a v o i d a n c e C o p i n a ( d ) 0-4 6 28.6 8 44.5 5-9 7 33.4 7 39.0 10-14 5 23.8 1 5.6 15-19 2 9.6 2 11.1 20-24 1 4.8 0 0.0 T o t a l 21 100.0 18 100.0 P l a n f u l P r o b l e m - s o l v i n g C o D i n a ( b ) 0-3 3 14 .3 3 16.7 4-7 6 28.7 5 27.9 8-11 ' 8 38.2 10 55.6 12-15 4 19.1 0 0.0 T o t a l 21 100.0 18 100.0 P o s i t i v e R e a D D r a i s a l C o D i n a le) 0-4 3 14.4 3 16.8 5-9 4 19.1 7 39.0 10-14 6 28.6 1 5.6 15-19 7 33 . 4 6 33. 4 20-24 1 4.8 1 5.6 T o t a l 21 100.0 18 100.0 N o t e . ( a ) Maximum s c o r e p o s s i b l e = 12 (4 i t e m s x 3) . (b) Maximum s c o r e p o s s i b l e = 18 (6 i t e m s x 3) . ( c ) Maximum s c o r e p o s s i b l e = 21 (7 i t e m s x 3 ) . (d) Maximum s c o r e p o s s i b l e = 24 (8 i t e m s x 3 ) . s t r a t e g i e s r a n g e d f r o m 1 t o 16 (H =8.7, SD = 4 . 3 ) , s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s r a n g e d f r o m 1 t o 18 (fci = 7.1, SD = 5 . 2 ) , a c c e p t i n g r e s p o n s i b i l i t y s t r a t e g i e s r a n g e d f r o m 1 t o 9 (_ = 4.6, SD = 2 . 7 ) , e s c a p e - a v o i d a n c e s t r a t e g i e s r a n g e d f r o m 0 t o 15 (fci = 6.3, SD = 4 . 6 ) , p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s r a n g e d f r o m 1 t o 11 (_. = 7.1, SD = 2 . 9 ) , a n d p o s i t i v e r e a p p r a i s a l s t r a t e g i e s r a n g e d f r o m 2 t o 20 (_ = 1 0 . 3 , SD = 5 . 7 ) . I n c o m p a r i n g s c a l e i t e m means f o r e a c h t i m e p e r i o d , a t f i v e t o e i g h t d a y s , t h e s t r a t e g i e s o f d i s t a n c i n g , s e e k i n g s o c i a l s u p p o r t , a c c e p t i n g r e s p o n s i b i l i t y a n d p o s i t i v e r e a p p r a i s a l w e r e u s e d most f r e q u e n t l y ; w i t h c o n f r o n t i v e c o p i n g , s e l f - c o n t r o l l i n g , e s c a p e - a v o i d a n c e a n d p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s u s e d l e s s . A t e i g h t weeks p o s t MI, t h e s t r a t e g i e s o f d i s t a n c i n g , p o s i t i v e r e a p p r a i s a l a n d s e l f - c o n t r o l l i n g w e r e u s e d t h e most w i t h c o n f r o n t i v e c o p i n g , e s c a p e - a v o i d a n c e , a c c e p t i n g r e s p o n s i b i l i t y , p l a n f u l p r o b l e m - s o l v i n g a n d s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s u s e d l e s s f r e q u e n t l y . C o n s i d e r a b l e v a r i a b i l i t y was n o t e d i n t h e u s e o f d i s t a n c i n g , s e e k i n g s o c i a l s u p p o r t , a c c e p t i n g r e s p o n s i b i l i t y , e s c a p e - a v o i d a n c e a n d p o s i t i v e r e a p p r a i s a l s t r a t e g i e s , w i t h l e s s v a r i a b i l i t y n o t e d f o r c o n f r o n t i v e , s e l f - c o n t r o l l i n g a n d p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s . The W l l c o x o n m a t c h e d - p a i r s s l g n e d - r a n k s t e s t was u s e d t o e x a m i n e w h e t h e r o r n o t t h e r e were s i g n i f i c a n t c h a n g e s f o r e a c h s t r a t e g y a t two p o i n t s i n t i m e ( s e e t a b l e V I I I ) . S i g n i f i c a n t d i f f e r e n c e s were f o u n d i n s e e k i n g s o c i a l s u p p o r t , p l a n f u l p r o b l e m - s o l v i n g , a n d p o s i t i v e r e a p p r a i s a l s t r a t e g i e s . No s i g n i f i c a n t c h a n g e s were f o u n d f o r a c c e p t i n g r e s p o n s i b i l i t y , c o n f r o n t i v e c o p i n g , e s c a p e - a v o i d a n c e , d i s t a n c i n g , a n d s e l f - c o n t r o l l i n g s t r a t e g i e s . A l t h o u g h n o t s i g n i f i c a n t , a c c e p t i n g r e s p o n s i b i l i t y s t r a t e g i e s had a p r o b a b i l i t y l e v e l o f 0.07. T h e r e f o r e , t h e f i n d i n g s o f t h i s s t u d y o n l y p a r t i a l l y s u p p o r t h y p o t h e s i s 2 r e l a t e d t o c h a n g e s i n c o p i n g s t r a t e g i e s o v e r t i m e . T h e r e were s i g n i f i c a n t c h a n g e s I n t h r e e c o p i n g s t r a t e g i e s b u t t h e r e m a i n i n g f i v e d i d n o t c h a n g e . Hypothesis 3; Relationships Between Cognitive Appraisal and Coping Strategies A Spearm a n r a n k c o r r e l a t i o n was p e r f o r m e d t o e x a m i n e t h e r e l a t i o n s h i p b e t w e e n e a c h o f t h e f o u r e m o t i o n a p p r a i s a l s c a l e s a n d t h e e i g h t c o p i n g s t r a t e g i e s a t e a c h o f t h e two t i m e p e r i o d s ( s e e T a b l e I X ) . Some s i g n i f i c a n t r e l a t i o n s h i p s were n o t e d b e t w e e n c o g n i t i v e a p p r a i s a l o f e m o t i o n s a n d c o p i n g s t r a t e g i e s . B e t w e e n t h e f i f t h a n d s e v e n t h d a y s p o s t M I , t h r e a t e m o t i o n s were p o s i t i v e l y r e l a t e d o n l y t o t h e u s e o f p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s . A l t h o u g h harm e m o t i o n s were n o t r e l a t e d t o t h e use o f a n y c o p i n g s t r a t e g i e s a t t h e s e c o n d p e r i o d , t h e y w e r e p o s i t i v e l y r e l a t e d t o c o n f r o n t i v e , a c c e p t i n g T a b l e V I I I C h a n g e s I n C o p i n g S t r a t e g i e s B e t w e e n t h e F i f t h a n d t h e S e v e n t h Days a n d E i g h t Weeks P o s t MI C o p i n g n Time t l Number I tern Z. EL S t r a t e g i e s o f i t e m s mean C o n f r o n t i v e 21 1 4.67 (6 ) 0.78 c o p i n g -.14 NS 18 2 4.44 (6) 0.74 D i s t a n c i n g 21 1 8.91 (6 ) 1.49 -.50 NS 18 2 9.44 (6) 1.57 S e l f - c o n t r o l l i n g 21 1 9 .86 (7) 1.41 -1.22 NS 18 2 8.72 (7 ) 1.25 S e e k i n g S o c i a l 21 1 10.71 (6) 1.79 S u p p o r t -2.74 .01 18 2 7.11 (6 ) 1.19 A c c e p t i n g 21 1 6 .00 (4) 1.50 R e s p o n s i b i l i t y -1.82 .07 18 2 4.56 ( 4 ) 1.14 E s c a p e - a v o i d a n c e 21 1 7.71 (8 ) 0.96 -1 . 1 1 NS 18 2 6.33 (8) 0.79 P l a n f u l 21 1 8.29 (6 ) 1.38 P r o b l e m - s o l v i n g -1.92 .055 18 2 7 .06 (6) 1.18 P o s i t i v e 21 1 11.48 (7) 1.64 R e a p p r a i s a l -2.15 .03 18 2 10.33 (7) 1.48 79 Table IX R e l a t i o n s h i p - B e t w e e n c o g n i t i v e A p p r a i s a l a n d c o p i n g S t r a t e g i e s Between the F i f t h and the Seventh Days and E i g h t Weeks post MI 1 2 Coping S t r a t e g i e s (a) 3 4 5 6 7 8 Threat Time 1 . rho P-. 28 NS . 13 NS .19 NS . 3 5 NS Time 2 . .28 NS ,34 NS , 49 . 026 .08 NS Kho P. . 1 1 NS . 0 1 NS . 03 NS . 1 5 NS . 13 NS . 27 NS .19 NS .19 NS Harm Time 1 . rho P. .49 .03 .18 NS . 18 NS . 13 NS Time 2 . . 62 .00 .34 NS . 4 7 .03 . 37 NS rho P. . 23 NS . 27 NS . 21 NS . 05 NS - . 1 2 NS .04 NS . 056 NS . 05 NS Challenge Time 1 . rho P-. 37 NS . 42 . 0 5 7 . 1 1 NS . 73 . 00 Time 2 . .13 NS . 16 NS . 29 NS . 4 5 .04 rho P. .19 NS .04 NS - . 1 1 NS . 1 1 NS . 23 NS . 17 NS - . 0 2 NS . 18 NS B e n e f i t Time 1 . rho P-. 44 .05 . 1 7 NS .09 NS . 54 . 01 Time 2 . - . 3 2 NS . 2 5 NS . 18 NS . 30 NS rho P. .02 NS . 38 .06 .50 .02 .09 NS .42 .04 - . 0 5 NS . 21 NS . 00 NS (a) Note. l = c o n f r o n t i v e coping; 2 = d i s t a n c i n g ; 3 = s e l f - c o n t r o l l i n g ; 4=seeking s o c i a l support; 5=accepting r e s p o n s i b i l i t y ; 6=escape-avoldance; 7 = p l a n f u l p r o b l e m - s o l v i n g ; 8 = p o s i t i v e r e a p p r a i s a l . r e s p o n s i b i l i t y a n d p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s a t a t t h e i n i t i a l p e r i o d . S i m i l a r l y , c h a l l e n g e e m o t i o n s w ere n o t r e l a t e d t o t h e u s e o f a n y c o p i n g s t r a t e g i e s a t t h e s e c o n d t i m e , b u t w e r e p o s i t i v e l y r e l a t e d t o s e e k i n g s o c i a l s u p p o r t a n d p o s i t i v e r e a p p r a i s a l s t r a t e g i e s a t t h e I n i t i a l I n t e r v i e w . B e n e f i t e m o t i o n s were r e l a t e d t o d i f f e r e n t s t r a t e g i e s a t e a c h p o i n t i n t i m e . I n i t i a l l y , b e n e f i t e m o t i o n s w ere p o s i t i v e l y r e l a t e d t o t h e u s e o f c o n f r o n t i v e and s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s , a n d t o t h e u s e o f s e l f - c o n t r o l l i n g a n d a c c e p t i n g r e s p o n s i b i l i t y s t r a t e g i e s a t t h e s e c o n d i n t e r v i e w . O n l y one f o r m o f c o p i n g s t r a t e g y , e s c a p e - a v o i d a n c e , was n o t r e l a t e d t o a n y o f t h e a s s e s s e d t y p e s o f e m o t i o n s . No o t h e r s i g n i f i c a n t c o r r e l a t i o n s w e r e f o u n d . T h e r e f o r e , t h e f i n d i n g s s u p p o r t i n p a r t h y p o t h e s i s 3 r e l a t e d t o r e l a t i o n s h i p s b e t w e e n c o g n i t i v e a p p r a i s a l and c o p i n g s t r a t e g i e s . The m a j o r i t y o f c o r r e l a t i o n s were n o t s i g n i f i c a n t . A t t h e i n i t i a l I n t e r v i e w , o n l y e i g h t s i g n i f i c a n t c o r r e l a t i o n s w e r e f o u n d b e t w e e n v a r i o u s e m o t i o n a p p r a i s a l s a n d c o p i n g s t r a t e g i e s , a n d two a t t h e s e c o n d i n t e r v i e w . D i s c u s s i o n o f R e s u l t s The r e s u l t s w i l l be d i s c u s s e d u n d e r t h e f o l l o w i n g f o u r h e a d i n g s : s a m p l e c h a r a c t e r i s t i c s , c h a n g e s i n e m o t i o n s , c h a n g e s i n c o p i n g s t r a t e g i e s , a n d r e l a t i o n s h i p s 81 b e t w e e n c o g n i t i v e a p p r a i s a l a n d c o p i n g s t r a t e g i e s . The r e s u l t s o f t h i s s t u d y w i l l be e x a m i n e d i n l i g h t o f t h e o r e t i c a l f o r m u l a t i o n s , o t h e r e m p i r i c a l f i n d i n g s , a n d t h e m e t h o d o l o g i c a l p r o b l e m s r e l a t e d t o t h e s t u d y . C h a r a c t e r i s t i c s o f t h e Sample No s p e c i f i c s t a t i s t i c a l d a t a a r e c u r r e n t l y a v a i l a b l e w i t h w h i c h t o d e t e r m i n e how r e p r e s e n t a t i v e t h e s a m p l e I s i n t e r m s o f d e m o g r a p h i c c h a r a c t e r i s t i c s ( S t a t i s t i c s C a n a d a , p e r s o n a l c o m m u n i c a t i o n , J u l y 26, 1 9 8 8 ) , h o w e v e r , g e n e r a l t r e n d s w e re I n d i c a t e d . H e a r t a t t a c k s a p p e a r p r e d o m i n a n t l y I n p e r s o n s o v e r 40 y e a r s o f a g e , a n d i n t h i s s t u d y , a ge r a n g e d f r o m 41 t o 73 y e a r s . As a g r o u p , men r e p r e s e n t a l a r g e p e r c e n t a g e o f t h o s e e x p e r i e n c i n g MI. I n t h i s s t u d y , 7 6 % were men w h i c h r e f l e c t s t h i s h i g h e r i n c i d e n c e . A c c o r d i n g t o S t a t i s t i c s C a n a d a ( 1 9 8 7 ) , 5 0 % o f MI v i c t i m s a r e o f w o r k i n g a g e . I n t h e p r e s e n t s t u d y ' s s a m p l e , 4 3 % were o f w o r k i n g a g e . T h e r e f o r e , w i t h r e s p e c t t o s e x , age i n g e n e r a l , a n d w o r k i n g a g e , t h e s a m p l e o f t h i s s t u d y a p p e a r s t o r e f l e c t t h e s e b r o a d n a t i o n a l t r e n d s . C h a n g e s i n E m o t i o n s The f r e q u e n c y o f t h e f o u r t y p e s o f e m o t i o n a l a p p r a i s a l s w i l l be d i s c u s s e d b e f o r e a d d r e s s i n g c h a n g e s i n t h e s e e m o t i o n s . A t b o t h t i m e s , p a r t i c i p a n t s r e p o r t e d more t h a n one a p p r a i s a l t y p e . M o s t p a r t i c i p a n t s c o n c u r r e n t l y e x p e r i e n c e d a l l f o u r t y p e s o f e m o t i o n s t o some d e g r e e . The d e g r e e o f v a r i a b i l i t y i n t h e f o u r e m o t i o n s r e m a i n e d p r a c t i c a l l y t h e same, e x c e p t f o r b e n e f i t e m o t i o n a p p r a i s a l s w h i c h r e v e a l e d a h i g h e r d e g r e e o f v a r i a b i l i t y . P o s s i b l y , a l o w e r d e g r e e o f v a r i a b i l i t y w o u l d h a v e b e e n n o t e d i n t h e s c o r e s a t t h e s e c o n d m e a s u r e m e n t I f t h e i n t e r v i e w had b e e n c o n d u c t e d a t s i x o r t w e l v e months p o s t M I , o r w i t h a l a r g e r number o f s u b j e c t s e x p e r i e n c i n g a n u n e v e n t f u l r e c o v e r y . The i t e m means i n d i c a t e d t h a t c h a l l e n g e e m o t i o n s were t h e most f r e q u e n t a p p r a i s a l t y p e , w i t h m o d e r a t e l e v e l s r e p o r t e d a t b o t h i n t e r v i e w s . M o d e r a t e t o m o d e r a t e l y l o w l e v e l s o f harm a n d t h r e a t e m o t i o n s were n o t e d a t b o t h t i m e s . Harm e m o t i o n s w ere a l s o t h e l e a s t f r e q u e n t a p p r a i s a l t y p e a t t h e s e c o n d i n t e r v i e w . W h i l e b e n e f i t e m o t i o n s w ere t h e l e a s t f r e q u e n t a p p r a i s a l t y p e a t t h e I n i t i a l I n t e r v i e w , m o d e r a t e l y l o w l e v e l s o f b e n e f i t e m o t i o n s w ere r e p o r t e d a t t h e s e c o n d i n t e r v i e w . I n t h i s s t u d y , m o d e r a t e t o m o d e r a t e l y l o w l e v e l s o f t h r e a t e m o t i o n s were, r e p o r t e d a t b o t h m e a s u r e m e n t s . No s t u d y was f o u n d I n t h e l i t e r a t u r e t h a t a s s e s s e d e m o t i o n a p p r a i s a l s i n a s a m p l e t h a t i s c o m p a r a b l e t o t h e MI p a t i e n t s . H o w e v e r , B u r g e s s a n d H a r t m a n ( 1 9 8 6 ) s t u d i e d p e r c e p t i o n s o f c a r d i a c c r i s i s i n MI p a t i e n t s d u r i n g t h e f i n a l week o f t h e i r h o s p i t a l i z a t i o n . A l t h o u g h t h e y f o u n d t h a t 9 4 % o f MI p a t i e n t s r e g a r d e d t h e i r h e a r t a t t a c k a s a s e r i o u s i l l n e s s , h a l f r e p o r t e d b e i n g m o d e r a t e l y s t r e s s e d by t h e h e a r t a t t a c k c r i s i s . F i f t y - t w o p e r c e n t r e p o r t e d f e a r of r e c u r r i n g h e a r t a t t a c k , and 5 0 % r e p o r t e d moderate t h r e a t to t h e i r l i v e s . I t appears t h a t MI p a t i e n t s do not a p p r a i s e t h e i r f u t u r e as b e i n g b l e a k . That t h e y d o n ' t would e x p l a i n the m o d e r a t e l y low l e v e l s of t h r e a t r e p o r t e d i n t h i s s t u d y . S i m i l a r l y , low to m o d e r a t e l y low l e v e l s of harm emot ions were r e p o r t e d a t bo th measurements. One p l a u s i b l e e x p l a n a t i o n may be t h a t the MI p a t i e n t s had j u s t begun to d i s c o v e r the r e a l i t i e s of what happened. As L a z a r u s and Folkman (1984) remark , i n some s t r e s s f u l s i t u a t i o n s i n d i v i d u a l s may be so c o g n i t i v e l y f o c u s e d on a c t i n g and r e a c t i n g t h a t t h e y may r e q u i r e c o n s i d e r a b l e t ime to s o r t out the event and a s s e s s i t s s i g n i f i c a n c e . In o t h e r words , I n i t i a l l y , MI p a t i e n t s may not u n d e r s t a n d the f u l l i m p l i c a t i o n s of t h e i r i l l n e s or have the n e c e s s a r y i n f o r m a t i o n to make an a c c u r a t e a p p r a i s a l . T h e r e f o r e , t h e y may not r e a l i z e the e x t e n t of the damage d o n e . C o n s e q u e n t l y , i n t h i s s i t u a t i o n p a t i e n t s are not l i k e l y to p e r c e i v e the new demands or t h r e a t s t h a t a re imposed. V e r b a l comments o f f e r e d by one p a t i e n t a t the i n i t i a l i n t e r v i e w s u p p o r t s t h i s t e n t a t i v e h y p o t h e s i s . He p u r p o s e f u l l y d i d not comple te the i tem r e l a t e d to " g u i l t y " , which i s one of the harm e m o t i o n s . T h i s p a t i e n t s t a t e d , "I c a n ' t complete t h i s i tem because I d o n ' t know what caused my h e a r t a t t a c k ; and i n any c a s e , I have enough on my mind r i g h t now, I ' l l worry about t h i s l a t e r " . I n t e r e s t i n g l y , a t t h e s e c o n d i n t e r v i e w , t h e p a t i e n t g a v e a s c o r e o£ 1 on t h e g u i l t e m o t i o n i t e m . T h i s s t a t e m e n t i n d i c a t e s t h a t d i f f e r e n c e s i n a p p r a i s a l s o v e r t h e u n f o l d i n g e v e n t may mean t h a t p a r t i c i p a n t s must h a v e r e a s s e s s e d i t s s i g n i f i c a n c e . A n o t h e r p o s s i b l e e x p l a n a t i o n f o r t h e m o d e r a t e l y l o w l e v e l s o f t h r e a t a n d harm e m o t i o n s a t t h e i n i t i a l p e r i o d may a l s o be r e l a t e d t o t h e p a t i e n t s ' u s e o f d e n i a l w h i l e I n CCU. F o r e x a m p l e , two p a t i e n t s commented on t h e i r s i t u a t i o n w h i l e t h e y w e re i n t h e CCU. One p a t i e n t s a i d , " I s t i l l t h i n k t h a t I h a v e s t o m a c h p r o b l e m s . . . I'm c o n v i n c e d i t w a s n ' t a h e a r t a t t a c k " . D u r i n g t h e s e c o n d v i s i t , t h e s e c o n d p a t i e n t s t a t e d t h a t s h e was a f r a i d w h i l e i n t h e CCU. " I knew t h i s was h a p p e n i n g t o me, b u t I t r i e d t o c o n v i n c e m y s e l f i t was h a p p e n i n g t o somebody e l s e . T h a t ' s what g o t me t h r o u g h " . Cassem a n d H a c k e t t ( 1 9 7 3 ) s t a t e t h a t d e n i a l i s u s e d a s a d e f e n c e m e c h a n i s m . T h e y f o u n d t h a t d e n i e r s t e n d t o be l e s s a n x i o u s t h a n n o n - d e n i e r s . T h e y f u r t h e r p o i n t o u t t h a t I n t h e e a r l y i l l n e s s p h a s e t h e use o f d e n i a l may be b e n e f i c i a l . C o n s e q u e n t l y , i f p a t i e n t s p e r c e i v e a s i t u a t i o n a s l e s s t h r e a t e n i n g , t h e y a r e more l i k e l y t o make p o s i t i v e a p p r a i s a l s . The f a c t t h a t c h a l l e n g e e m o t i o n s were t h e most f r e q u e n t a p p r a i s a l t y p e a t b o t h t i m e s may be t h a t some p a r t i c i p a n t s d i d n o t a p p r a i s e t h e w h o l e s i t u a t i o n o r t h e h e a r t a t t a c k I t s e l f , b u t i n s t e a d c o n s i d e r e d t h e p o s i t i v e a s p e c t s o f t h e i r s i t u a t i o n . O b s e r v a t i o n s t h a t p a t i e n t s made d u r i n g t h e i n t e r v i e w s e x e m p l i f y t h i s p o i n t . F o r some p a r t i c i p a n t s , e s p e c i a l l y t h o s e who e x p e r i e n c e d a c a r d i a c a r r e s t o r o t h e r s e r i o u s c o m p l i c a t i o n s , c h a l l e n g e a p p r a i s a l s a p p e a r e d t o be b a s e d on p r o g r e s s made d u r i n g t h e i r r e c o v e r y p r o c e s s . P o s s i b l y , b y f o c u s i n g on p o s i t i v e a s p e c t s , t h e p a r t i c i p a n t s a p p r a i s e d t h e s i t u a t i o n a s more c h a l l e n g i n g , a n d t h e r e f o r e may h a v e m i n i m i z e d i t s n e g a t i v e o r t h r e a t e n i n g a s p e c t s . L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) e x p l a i n t h a t i f . a p e r s o n ' s a p p r a i s a l s h i f t s f r o m a n x i e t y o r w o r r y t o f i n d i n g r e a s o n s f o r h o p e , t h e a p p r a i s a l t h a t e m e r g e s i s more one o f c h a l l e n g e t h a n t h r e a t . One p o s s i b l e e x p l a n a t i o n f o r t h e i n i t i a l l o w l e v e l o f b e n e f i t e m o t i o n s may be t h a t i t was t o o e a r l y i n t h e r e c o v e r y p r o c e s s f o r t h e p a r t i c i p a n t s t o make s u c h p o s i t i v e a p p r a i s a l s . T h i s a r g u m e n t may f u r t h e r e x p l a i n t h e m o d e r a t e l y l o w l e v e l o f b e n e f i t e m o t i o n s r e p o r t e d a f t e r e i g h t w e e k s , and may r e f l e c t t h e s u c c e s s p a t i e n t s had i n m a n a g i n g t h e demands o f t h e s t r e s s f u l s i t u a t i o n . W h i l e t h e r e s u l t s i n d i c a t e d c h a n g e s i n c o g n i t i v e a p p r a i s a l o f e m o t i o n s o v e r t i m e , no s i g n i f i c a n t c h a n g e s w ere f o u n d i n t h e f o u r e m o t i o n t y p e s o f h arm, t h r e a t , c h a l l e n g e a n d b e n e f i t . H o w e v e r , some g e n e r a l t r e n d s were o b s e r v e d . B o t h t h e p o s i t i v e e m o t i o n s o f c h a l l e n g e and b e n e f i t i n c r e a s e d o v e r t i m e . The most i m p o r t a n t c h a n g e was o b s e r v e d i n b e n e f i t e m o t i o n s w h i c h i n c r e a s e d , a l t h o u g h n o t s i g n i f i c a n t l y . The n e g a t i v e e m o t i o n s o f t h r e a t and harm d e c r e a s e d s l i g h t l y o v e r t i m e . I n a d d i t i o n t o t h e s m a l l s a m p l e s i z e a nd t h e c o n v e n i e n c e s a m p l i n g m e t h o d , s e v e r a l o t h e r f a c t o r s may h a v e c o n t r i b u t e d t o t h e l a c k o f s i g n i f i c a n t c h a n g e s i n e m o t i o n s o v e r t i m e . U s i n g t h e s t r e s s , a p p r a i s a l a n d c o p i n g t h e o r y ( L a z a r u s & F o l k m a n , 1 9 8 4 ) , t h e a b s e n c e o f s i g n i f i c a n t c h a n g e s may be e x p l a i n e d i n t e r m s o f p e r s o n a l , s i t u a t i o n a l a n d e n v i r o n m e n t a l f a c t o r s . A c c o r d i n g t o L a z a r u s and F o l k m a n ( 1 9 8 4 ) , p e r s o n a l f a c t o r s r e f e r t o t h e p e r s o n - c h a r a c t e r i s t i c s o f c o m m i t m e n t s a n d b e l i e f s w h i c h a r e i m p o r t a n t d e t e r m i n a n t s o f t h e s i t u a t i o n a p p r a i s a l s o f t h r e a t , h arm, c h a l l e n g e o r b e n e f i t . E n v i r o n m e n t a l f a c t o r s r e f e r t o t h e c h a r a c t e r i s t i c s o f t h e s i t u a t i o n a n d t h e human and m a t e r i a l r e s o u r c e s w h i c h a r e r e l e v a n t t o a p e r s o n a c c o r d i n g t o t h e demands o f a s t r e s s f u l s i t u a t i o n . The p e r s o n - and s i t u a t i o n - f a c t o r s w i l l be d i s c u s s e d s e p a r a t e l y h o w e v e r , b e c a u s e t h e f a c t o r s a r e i n t e r d e p e n d e n t , a t t i m e s t h e d i s c u s s i o n w i l l s i m u l t a n e o u s l y r e f e r t o t h e o t h e r f a c t o r . P e r s o n a l f a c t o r s w i l l be c o n s i d e r e d f o r t h e i r i n f l u e n c e on c h a l l e n g e e m o t i o n s , and e n v i r o n m e n t a l c h a r a c t e r i s t i c s a s c o n t r i b u t i n g f a c t o r s t o t h e l a c k o f c h a n g e i n t h r e a t e m o t i o n a p p r a i s a l . S i t u a t i o n a l f a c t o r s w i l l i n c l u d e t h e n o v e l t y , t h e a m b i g u i t y a n d t h e c h a n g i n g n a t u r e o f t h e s i t u a t i o n . The n o v e l t y o£ t h e s i t u a t i o n w i l l be u s e d t o e x p l a i n t h e l a c k o f c h a n g e i n t h r e a t e m o t i o n s ; w h i l e a m b i g u i t y o f t h e s i t u a t i o n w i l l be c o n s i d e r e d f o r i t s e f f e c t on t h r e a t and b e n e f i t e m o t i o n s . F i n a l l y , t h e c h a n g i n g n a t u r e o f t h e s i t u a t i o n w i l l be u s e d t o e x p l a i n t h e l a c k o f s i g n i f i c a n t c h a n g e i n harm e m o t i o n s . L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) e x p l a i n t h a t harm a n d b e n e f i t a r e o utcome a p p r a i s a l s o r e v a l u a t i o n s o f w h a t h a s a l r e a d y h a p p e n e d . C o n v e r s e l y , t h r e a t a n d c h a l l e n g e a r e a n t i c i p a t o r y a p p r a i s a l s . T h e y a r e e v a l u a t i o n s o f p o t e n t i a l harm a n d b e n e f i t d e a l i n g w i t h f u t u r e e v e n t s . A l t h o u g h n o t s i g n i f i c a n t , a s h i f t i n a n t i c i p a t o r y a n d o u t c o m e s e m o t i o n s r e p o r t e d b y MI p a t i e n t s was o b s e r v e d o v e r t i m e . The i n t e n s i t y o f harm e m o t i o n s d e c r e a s e d s l i g h t l y , w h i l e t h e r e was a s l i g h t I n c r e a s e i n b e n e f i t e m o t i o n s . A c c o r d i n g t o L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) , t h r e a t a n d c h a l l e n g e a p p r a i s a l c a n s h i f t a s a s i t u a t i o n u n f o l d s . The i n v e s t i g a t o r f o u n d a s l i g h t c h a n g e i n t h e s e a n t i c i p a t o r y a p p r a i s a l s o f t h r e a t and c h a l l e n g e , w i t h t h r e a t e m o t i o n s d e c r e a s i n g s l i g h t l y , w h i l e c h a l l e n g e e m o t i o n s i n c r e a s e d s l i g h t l y . The o n l y s t u d y i n t h e l i t e r a t u r e t o d e a l w i t h e m o t i o n a p p r a i s a l c h a n g e s i s F o l k m a n a n d L a z a r u s ' ( 1 9 8 5 ) s t u d y o f t h e c o l l e g e s t u d e n t s i n a m i d t e r m e x a m i n a t i o n s i t u a t i o n . T h e y f o u n d t h a t t h r e a t a n d c h a l l e n g e e m o t i o n s w h i c h r e f l e c t e d a n t i c i p a t o r y a p p r a i s a l s were e l e v a t e d a t t i m e 88 one a n d two a n d d i d n o t c h a n g e s i g n i f i c a n t l y f r o m t i m e one t o t i m e t w o , b u t d e c r e a s e d s i g n i f i c a n t l y f r o m t i m e two t o t i m e t h r e e . Harm a n d b e n e f i t e m o t i o n s w h i c h r e p r e s e n t e d o u tcome a p p r a i s a l s r o s e s i g n i f i c a n t l y f r o m t i m e one t o t i m e t w o , b u t d i d n o t c h a n g e f r o m t i m e two t o t i m e t h r e e . I t i s d i f f i c u l t t o compare r e s u l t s t o t h e s t u d e n t s ' m i d t e r m exam b e c a u s e o f d i f f e r e n c e s i n s a m p l e c h a r a c t e r i s t i c s a n d t h e c o n t e x t o f t h e s t u d y . An e x a m i n a t i o n I s a d i f f e r e n t t y p e o f s t r e s s t h a n a l i f e t h r e a t e n i n g i l l n e s s e v e n t . T h a t t h e p a r t i c i p a n t s h a d a p p r a i s e d t h e s i t u a t i o n a s b e i n g more c h a l l e n g i n g t h a n t h r e a t e n i n g on b o t h o c c a s i o n s may be r e l a t e d t o t h e p e r s o n a l f a c t o r s o f c o m m i t m e n t s and b e l i e f s , L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) e x p l a i n t h a t t h e s e two m a i n p e r s o n - f a c t o r s c o n t r i b u t e t o a p p r a i s a l . T h e y g e n e r a t e c o n f i d e n c e a n d h o p e , a n d t h e r e f o r e r e g u l a t e e m o t i o n s . I n t h i s way, p e r h a p s p a t i e n t s t r i e d t o c o p e w i t h t h e i r f u t u r e I n a n a n t i c i p a t o r y p o s i t i v e manner. L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) e x p l a i n t h a t c o m m i t m e n t d e t e r m i n e s a p p r a i s a l t h r o u g h n u m e r o u s m e c h a n i s m s w h i c h p e o p l e may r e f l e c t i n d i f f e r e n t w a y s . Commitment r e p r e s e n t s n o t o n l y what i s i m p o r t a n t t o a p e r s o n , b u t a l s o what m o t i v a t e s and h e l p s t h e p e r s o n m a i n t a i n h o p e . S u c h a p a t t e r n o f commitment may be r e f l e c t e d i n Type A p e r s o n a l i t y b e h a v i o r s o r i n t h e u s e o f d e n i a l - l i k e p r o c e s s e s . A 3 Lazarus and Folkman ( 1984) remark, the Type A p e r s o n a l i t y may be regarded not o n l y as a coping s t y l e , but a l s o as a s t a b l e p a t t e r n of commitments and b e l i e f s . A c c o r d i n g to Jen k i n s ( 1 9 7 5 ) , a coronary-prone i n d i v i d u a l i s p r e d i s p o s e d to p e r c e i v e elements of c h a l l e n g e i n any s t r e s s f u l s i t u a t i o n , a l b e i t p l e a s a n t or t r o u b l i n g . McCorkle and Q u i n t - B e n o l i e l ( 1983) found t h a t MI p a t i e n t s had a more p o s i t i v e outlook r e g a r d i n g t h e i r i l l n e s s than d i d cancer p a t i e n t s . Furthermore, Lazarus and Folkman (1984) s t a t e t h a t some i n d i v i d u a l s may attempt to d e a l with t h e i r i l l n e s s demands as they would i n any other s t r e s s f u l s i t u a t i o n . They a l s o e x p l a i n t h a t i n t h i s case, the person would t r y to master the s i t u a t i o n u s i n g a v a i l a b l e r e s o u r c e s . Hackett and Cassem ( 1978) e l a b o r a t e on an asp e c t of commitment i n t h e i r d i s c u s s i o n of d e n i a l . They remark t h a t t h e r e are s e v e r a l dimensions t o the concept of d e n i a l . In some i n s t a n c e s , the use of d e n i a l i m p l i e s optimism or hope. In t h i s view, s u c c e s s f u l d e n i a l a l l e v i a t e s a n x i e t i e s . Here, the person i s not negating the he a r t a t t a c k i t s e l f , but r a t h e r a c c e n t u a t i n g i t s p o s i t i v e a s p e c t s . The p a r t i c i p a n t s v e r b a l l y made t h i s p o i n t d u r i n g the i n t e r v i e w s . Many p a r t i c i p a n t s made t h e i r a p p r a i s a l s based on s p e c i f i c a s p e c t s of the s i t u a t i o n , whether an i n c r e a s e i n a c t i v i t y l e v e l , p o s i t i v e t e s t r e s u l t s or the s t a f f ' s encouraging e x p l a n a t i o n s . In t h i s way, not o n l y was d a n g e r m i n i m i z e d , b u t o p t i m i s m was p r e s e n t i n a l l a s p e c t s o f t h e s i t u a t i o n , n o t j u s t f o r s u r v i v a l b u t f o r g o od f u t u r e . The a p p r a i s a l o f f e a r becomes one o f hope and c o n f i d e n c e r e p l a c e s w o r r y . L i k e c o m m i t m e n t s , b e l i e f s a l s o h e l p p e o p l e c r e a t e m e a n i n g a n d m a i n t a i n hope i n d i f f i c u l t s i t u a t i o n s ( L a z a r u s & F o l k m a n , 1 9 8 4 ) . Some a s p e c t s o f b e l i e f s , s u c h a s p e r s o n a l c o n t r o l a r e p a r t i c u l a r l y i m p o r t a n t i n s u c h s i t u a t i o n s . L a z a r u s and F o l k m a n ( 1 9 8 4 ) s t a t e t h a t a p p r a i s i n g a s i t u a t i o n a s c o n t r o l l a b l e i s s t r e s s - r e d u c i n g . I n B u r g e s s a n d H a r t m a n ' s ( 1 9 8 6 ) s t u d y , t h e y f o u n d t h e m a j o r i t y o f MI p a t i e n t s p e r c e i v e d t h e i r h e a r t a t t a c k s a s p r e v e n t a b l e ( 6 6 % ) , a n d a l s o c o n t r o l l a b l e ( 7 1 % ) . T h e s e f a c t s may e x p l a i n t h a t a l t h o u g h a h e a r t a t t a c k i s l i f e t h r e a t e n i n g , o t h e r f a c t o r s i n t h e s i t u a t i o n may h e l p t h e i n d i v i d u a l m a i n t a i n h o p e , t h e r e b y r e d u c i n g s t r e s s . The r e s u l t s I n d i c a t e t h a t t h e i n t e n s i t y o f t h r e a t e m o t i o n s d i d n o t s i g n i f i c a n t l y c h a n g e o v e r t i m e . H o w e v e r , e n v i r o n m e n t a l a n d s i t u a t i o n a l f a c t o r s may h a v e c o n t r i b u t e d t o t h i s l a c k o f s i g n i f i c a n t c h a n g e . E n v i r o n m e n t a l f a c t o r s may be r e l a t e d t o t h e m o d e r a t e l y l o w l e v e l o f t h r e a t e m o t i o n s a t t h e i n i t i a l I n t e r v i e w . F o r t h e p a t i e n t s , t h e p r e s e n c e o f h i g h l y s k i l l e d n u r s e s and m o n i t o r i n g e q u i p m e n t may have r e d u c e d some o f t h e f e a r s . A f t e r a few d a y s i n a CCU, p a t i e n t s may h a v e a d j u s t e d t o t h i s s e c u r e e n v i r o n m e n t . S h i n e ( 1 9 8 4 ) r e m a r k s t h a t t h e c o n s t a n t m o n i t o r i n g o f v i t a l s i g n s may h e l p t o a l l e v i a t e some f e a r s and a n x i e t i e s . D u r i n g h o s p i t a l i z a t i o n , m o r e o v e r , p a t i e n t s may h a v e r e s p o n d e d p o s i t i v e l y t o t h e f e e d b a c k o r s u p p o r t t h e s t a f f p r o v i d e d . I t i s n o t u n r e a s o n a b l e t o assume t h a t t h e p a t i e n t s d e r i v e d f e e l i n g s o f s e c u r i t y f r o m t h e p r e s e n c e a n d f u n c t i o n i n g o f t h e s t a f f a n d t h e e q u i p m e n t . The n o v e l t y o f t h e s i t u a t i o n may h ave i n i t i a l l y i n f l u e n c e d t h r e a t a p p r a i s a l . A c c o r d i n g t o L a z a r u s and F o l k m a n ( 1 9 8 4 ) , a n o v e l s i t u a t i o n i s s t r e s s f u l t o t h e e x t e n t t h a t p e o p l e p r e v i o u s l y a s s o c i a t e d i t w i t h harm o r t h r e a t . One p l a u s i b l e e x p l a n a t i o n may be t h a t t h e p a r t i c i p a n t s were a l l f i r s t MI p a t i e n t s who had n e v e r b e e n p r e v i o u s l y t r e a t e d f o r c o r o n a r y symptoms. G e n t r y a n d H aney ( 1 9 7 5 ) s t u d i e d e m o t i o n a l a n d b e h a v i o r a l r e a c t i o n t o m y o c a r d i a l i n f a r c t i o n , a n d f o u n d t h a t p a t i e n t s e x p e r i e n c i n g a f i r s t MI w e r e l e s s a n x i o u s t h a n t h o s e w i t h a p r i o r c a r d i a c h i s t o r y . F u r t h e r m o r e , a s p r e v i o u s l y e x p l a i n e d , t h e m a j o r i t y o f t h e p a r t i c i p a n t s had known someone who had had a h e a r t a t t a c k . O n l y 2 o f t h e s u b j e c t s i n t h e s t u d y s a i d t h e i n f o r m a t i o n was h e l p f u l t o them. P o s s i b l y , a l a c k o f i n f o r m a t i o n r e g a r d i n g t h e r e h a b i l i t a t i o n p r o c e s s may h a v e p l a y e d a r o l e i n a p p r a i s a l o f i l l n e s s . A s e c o n d s i t u a t i o n a l c h a r a c t e r i s t i c , t h e a m b i g u i t y o f t h e s i t u a t i o n , may h ave a l s o c o n t r i b u t e d t o t h e l a c k o f s i g n i f i c a n t c h a n g e i n t h r e a t e m o t i o n s . I f a p e r s o n i s u n a w a r e o f t h e r i s k s I n v o l v e d i n a s t r e s s f u l s i t u a t i o n , t h a t p e r s o n w i l l u n l i k e l y e x p e r i e n c e a h i g h d e g r e e o f t h r e a t . As L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) r e m a r k , e v e n i n s i t u a t i o n s w h ere t h e r e a r e c u e s s i g n a l l i n g h arm, a m b i g u i t y c a n be u s e d t o r e d u c e t h r e a t b y a l l o w i n g r e a s s u r i n g a l t e r n a t i v e i n t e r p r e t a t i o n s . S u c h may be t h e c a s e h e r e . A t t h e f i r s t i n t e r v i e w , p a r t i c i p a n t s were o v e r t h e i r i n i t i a l c r i s i s a n d symptoms I n i t i a l l y r e p o r t e d had s u b s i d e d . The f a c t t h a t t h e p a r t i c i p a n t s w e r e i n a l e s s p r e c a r i o u s p o s i t i o n may h a v e i n f l u e n c e d t h e i r t h r e a t a p p r a i s a l . C o n s e q u e n t l y , c u e s p r e s e n t i n t h e s i t u a t i o n d i d n o t l e a d t h e p a t i e n t s t o a n t i c i p a t e f u r t h e r harm o r t h r e a t . As M c C o r k l e a n d Q u i n t - B e n o l i e l ( 1 9 8 3 ) p o i n t o u t , a h e a r t a t t a c k c a u s e s f e a r a n d u n c e r t a i n t y , b u t when p a t i e n t s do n o t p e r c e i v e t h e i r symptoms a s w o r s e n i n g , some e a r l i e r a n x i e t i e s a r e r e l i e v e d . I n t h i s s t u d y , t h e most i m p o r t a n t a p p r a i s a l c h a n g e was a n i n c r e a s e I n b e n e f i t e m o t i o n s o v e r t i m e . S i n c e t h e t h e a m b i g u i t y o f t h e s i t u a t i o n a l l o w s o p t i m i s m , i t may a l s o e x p l a i n t h i s i n c r e a s e i n b e n e f i t e m o t i o n s . D u r i n g t h e i r s e c o n d i n t e r v i e w , some p a r t i c i p a n t s commented on how much w o r s e t h e s i t u a t i o n c o u l d h a v e b e e n . Some f o c u s e d on t h e i r p r o g r e s s a n d were e n c o u r a g e d b y t h e i r t e s t r e s u l t s . O t h e r s h ad a l r e a d y b e g u n t o p l a n t h e i r r e h a b i l i t a t i o n p r o g r a m s . I f t h e p a t i e n t s p e r c e i v e d t h a t t h e y h a v e p r o g r e s s e d , t h e i r g a i n was l i k e l y t o r e m i n d them t h a t p o s i t i v e o u t c o m e s were p o s s i b l e . F o l k m a n a n d L a z a r u s ( 1 9 8 5 ) s t a t e t h a t a s t h e s i t u a t i o n e v o l v e s a n d i n f o r m a t i o n i s a d d e d , a m b i g u i t y d e c r e a s e s . T h e r e f o r e , s u c h r e a s s u r i n g i n t e r p r e t a t i o n s may h a v e c o n t r i b u t e d t o t h e i n c r e a s e i n b e n e f i t e m o t i o n s a t t h e s e c o n d i n t e r v i e w . W h i l e t h e r e was a n i n c r e a s e i n b e n e f i t e m o t i o n s , t h e i n t e n s i t y o f harm e m o t i o n s d e c r e a s e d o n l y s l i g h t l y . The c h a n g i n g n a t u r e o f t h e s i t u a t i o n may e x p l a i n why harm ( o u t c o m e ) e m o t i o n s d i d n o t s i g n i f i c a n t l y c h a n g e o v e r t i m e . A c c o r d i n g t o L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) , t h e s i t u a t i o n i s a p p r a i s e d d i f f e r e n t l y a t d i f f e r e n t s t a g e s , d e p e n d i n g on t h e demands i m p o s e d . T h e y f u r t h e r r e m a r k t h a t d u r i n g t h e p o s t I m p a c t p e r i o d , t h e p e r s o n c o n t i n u e s t o r e a s s e s s t h e s i g n i f i c a n c e o f t h e s t r e s s f u l s i t u a t i o n f o r h i s / h e r w e l l - b e i n g i n t e r m s o f t h r e a t and c h a l l e n g e . F o l l o w i n g a h e a r t a t t a c k , r e s i d u a l symptoms a r e l i k e l y t o r e m i n d p a t i e n t s o f p o s s i b l e n e g a t i v e o u t c o m e s . I n t h e p r e s e n t s i t u a t i o n , a l t h o u g h damage h a s o c c u r r e d , s u c h a l i f e t h r e a t e n i n g e v e n t c a r r i e s w i t h i t o t h e r t h r e a t s s u c h a s f e a r o f a f u r t h e r h e a r t a t t a c k o r d e a t h . T h e s e t h r e a t s may be r e f l e c t e d i n t h e i r harm e m o t i o n s a t t h e s e c o n d i n t e r v i e w . D a t a o b t a i n e d a t t h e s e c o n d t e s t i n g r e v e a l e d t h a t a l t h o u g h some p a t i e n t s had made p r o g r e s s , f o r most p a t i e n t s , many o f t h e i s s u e s r e l a t e d t o t h e i r i l l n e s s r e m a i n e d u n r e s o l v e d . P a t i e n t s r e p o r t e d symptoms i n c r e a s i n g both i n numbers and s e v e r i t y , as w e l l as concerns r e l a t e d to ongoing t e s t s and changes i n l i f e s t y l e . Furthermore, a l l except one s u b j e c t had not r e t u r n e d to t h e i r p r e - i n f a r c t a c t i v i t y l e v e l . Based on these o b s e r v a t i o n s , one can h a r d l y say th a t the post impact stage was over or t h a t the event was concluded. Lazarus and Folkman ( 1 9 8 4 ) remark t h a t i n r e a l - l i f e s i t u a t i o n s , i t i s almost i m p o s s i b l e to d i f f e r e n t i a t e the c o g n i t i v e p r o c e s s e s a s s o c i a t e d w i t h each s t a g e . Damage t h a t happened c a r r i e s with i t elements of t h r e a t t h a t w i l l c o n t i n u e to s t r e s s the person d u r i n g the post i n f a r c t s t a g e . The pr e c e e d i n g p o i n t s would e x p l a i n why harm emotions d i d not s i g n i f i c a n t l y change over time. In some cases, a c c o r d i n g to c r i s i s t h e o r y , a p e r i o d of r e c o n s t r u c t i o n may l a s t up to a year f o l l o w i n g trauma, bef o r e emotional s t a b i l i t y can be reached (Wiklund et a l . , 1985) . M e t h o d o l o g i c a l problems may f u r t h e r e x p l a i n the lack of s i g n i f i c a n t changes i n emotions over time. The absence of s i g n i f i c a n t changes i n emotions may be r e l a t e d to problems with the low i n t e r n a l c o n s i s t e n c y of the harm and t h r e a t s c a l e s . At the f i r s t i n t e r v i e w , the r e l i a b i l i t y alpha c o e f f i c i e n t f o r the harm emotion s c a l e was 0.58. At the second i n t e r v i e w , the r e l i a b i l i t y alpha c o e f f i c i e n t f o r the t h r e a t emotion s c a l e was 0.44. R e s u l t s must t h e r e f o r e be i n t e r p r e t e d c a u t i o u s l y . The s m a l l sample s i z e may be i n f l u e n t i a l i n c a u s i n g the n o n - s i g n i f i c a n t r e s u l t s . Since some s u b j e c t s e l e c t e d not to p a r t i c i p a t e who may have pr o v i d e d a wider v a r i a n c e i n the sample. T h e r e f o r e , data such as these must be c o n s i d e r e d i n i n t e r p r e t i n g the f i n d i n g s . Another e x p l a n a t i o n f o r the l a c k of s i g n i f i c a n t r e s u l t s i n emotion a p p r a i s a l s c o u l d be t h a t p a r t i c i p a t i o n i n t h i s study was v o l u n t a r y . Only those p a t i e n t s the n u r s i n g s t a f f judged a b l e to complete the q u e s t i o n n a i r e were i d e n t i f i e d and approached. Some p a t i e n t s , however, r e f u s e d to p a r t i c i p a t e because they were too e m o t i o n a l l y d i s t r a u g h t . Those who r e f u s e d may have responded d i f f e r e n t l y ; thus, the sample may have been skewed i n terms of those not d i s p l a y i n g unusual s t r e s s . Another e x p l a n a t i o n f o r the l a c k of s i g n i f i c a n t changes i n emotions may be t h a t a nonparametric t e s t was used. Some of the f i n d i n g s may have been s i g n i f i c a n t ; but because of the weak s t a t i s t i c a l t e s t used, s i g n i f i c a n t changes i n emotions may not have been d e t e c t e d . Absence of s i g n i f i c a n t changes can a l s o r e f l e c t r e a l i t y . Emotion a p p r a i s a l s may not change i n e i g h t weeks f o l l o w i n g a myocardial i n f a r c t i o n . A c c o r d i n g to c r i s i s t h e o r y , the person a t t h i s time i s merely a t the end of the r e a c t i o n phase (Wiklund et a l . , 1985). F u r t h e r measurements are needed to determine whether changes occur at s i x or twelve months f o l l o w i n g a myocardial i n f a r c t i o n . P o s s i b l y , as one p a t i e n t s t a t e d a t the second i n t e r v i e w , emotion a p p r a i s a l s may never s i g n i f i c a n t l y change i n a s t r e s s f u l s i t u a t i o n such a he a r t a t t a c k : "Sure, I can change something to prevent a second heart a t t a c k , but one t h i n g t h a t w i l l never change... t h i s p s y c h o l o g i c a l s c a r e w i l l always be t h e r e " . C h a n g e s i n c o p i n g s t r a t e g i e s The frequency of the e i g h t types of copi n g w i l l be d i s c u s s e d b e f o r e a d d r e s s i n g changes i n coping s t r a t e g i e s . In comparing mean s c o r e s of each s t r a t e g y a t each time p e r i o d , c o n s i d e r a b l e v a r i a b i l i t y was noted i n the use of d i s t a n c i n g , s e e k i n g s o c i a l s upport, a c c e p t i n g r e s p o n s i b i l i t y , escape-avoidance and p o s i t i v e r e a p p r a i s a l s t r a t e g i e s . Less v a r i a b i l i t y was noted f o r c o n f r o n t i v e , s e l f - c o n t r o l l i n g and p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s . Item mean sco r e s r e v e a l e d t h a t a l l types of copi n g s t r a t e g i e s were used l e s s f r e q u e n t l y a t the second p e r i o d , except f o r d i s t a n c i n g which i n c r e a s e d s l i g h t l y . At the i n i t i a l p e r i o d , the Item mean s c o r e s i n d i c a t e d t h a t s e e k i n g s o c i a l support was the most f r q u e n t l y used s t r a t e g y , with moderately hi g h to moderately low l e v e l s r e p o r t e d a t both times. P o s i t i v e r e a p p r a i s a l was the second most f r e q u e n t l y used type of s t r a t e g y a t both times, with item mean sco r e s d e c r e a s i n g from moderately high to moderate l e v e l s . Scores on a c c e p t i n g r e s p o n s i b i l i t y decreased from moderate to moderately low l e v e l s . D i s t a n c i n g was the most used type of s t r a t e g y a t the second time. Scores on the d i s t a n c i n g s c a l e o n l y i n c r e a s e d s l i g h t l y from moderate to moderately high l e v e l s . Scores on the s e l f - c o n t r o l l i n g s c a l e were higher a t the I n i t i a l p e r i o d but remained moderately e l e v a t e d at both times. P l a n f u l p r o b l e m - s o l v i n g s c o r e s decreased from moderate to moderately low l e v e l s . The escape-avoidance s c a l e i n d i c a t e d low l e v e l s a t both times, with a s l i g h t l y h i gher s c o r e a t the i n i t i a l p e r i o d . C o n f r o n t i v e c o p i n g , the l e a s t used type of c o p i n g , r e f l e c t e d low l e v e l s a t both times, with o n l y a s l i g h t decrease a t the second p e r i o d . The study demonstrates t h a t the s u b j e c t s used a wide range of c o p i n g s t r a t e g i e s to d e a l with the s t r e s s e s of t h e i r h e a r t a t t a c k . At f i v e and seven days post MI, a l t h o u g h some forms of s t r a t e g i e s were used more f r e q u e n t l y , a l l p a t i e n t s ( 1 0 0 % ) used the e i g h t a v a i l a b l e types of c o p i n g s t r a t e g i e s . S i m i l a r l y , at e i g h t weeks post MI, a l l p a t i e n t s used the e i g h t a v a i l a b l e types of coping s t r a t e g i e s , but a t t h i s time, 8 8 . 9 % of p a t i e n t s used c o n f r o n t i v e c o p i n g s t r a t e g i e s , and 9 4 . 4 % of p a t i e n t s used escape-avoidance s t r a t e g i e s . That they used a v a r i e t y of coping s t r a t e g i e s may mean t h a t they respond to d i f f e r e n t a s p e c t s a t each stage of an encounter; and/or t h a t they are experimenting with a v a r i e t y of s t r a t e g i e s to manage j u s t one a s p e c t of the s i t u a t i o n (Folkman & Lazarus, 1985) . The r e s u l t s o f t h e p r e s e n t s t u d y s u p p o r t t h e s t r e s s a p p r a i s a l t h e o r y w h i c h h y p o t h e s i z e s t h a t i n s t r e s s f u l s i t u a t i o n s , p e o p l e t y p i c a l l y u s e b o t h p r o b l e m - f o c u s e d a nd e m o t i o n - f o c u s e d f o r m s o f c o p i n g . A t t h e i n i t i a l p e r i o d o f t h e p r e s e n t s t u d y , t h e s t r a t e g i e s o f s e e k i n g s o c i a l s u p p o r t , p o s i t i v e r e a p p r a i s a l , a c c e p t i n g r e s p o n s i b i l i t y a n d d i s t a n c i n g were u s e d most f r e q u e n t l y ; s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s were u s e d t h e m o s t . A t t h e s e c o n d t i m e , d i s t a n c i n g , p o s i t i v e r e a p p r a i s a l , s e l f - c o n t r o l l i n g a n d s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s were u s e d more f r e q u e n t l y , d i s t a n c i n g s t r a t e g i e s b e i n g u s e d t h e m o s t . Two p l a u s i b l e r e a s o n s c o u l d e x p l a i n why s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s were f r e q u e n t l y u s e d . S e e k i n g s o c i a l s u p p o r t d e s c r i b e s t h e e f f o r t s t o s e e k e m o t i o n a l , i n f o r m a t i o n a l a n d t a n g i b l e s u p p o r t . The f i r s t r e a s o n r e l a t e s t o s i t u a t i o n a l f a c t o r s : t h e n o v e l t y a n d t h e a m b i g u i t y o f t h e s i t u a t i o n . A l l p a r t i c i p a n t s were f i r s t MI p a t i e n t s , a n d c o n s e q u e n t l y h ad l i m i t e d k n o w l e d g e r e g a r d i n g t h e i r i l l n e s s e s . A c c o r d i n g t o . C o h e n a n d L a z a r u s ( 1 9 7 9 ) , i n f o r m a t i o n s e e k i n g i s one o f t h e m o s t b a s i c f o r m s o f c o p i n g i n new s i t u a t i o n s w h ere p e o p l e have l i t t l e k n o w l e d g e o r i n a m b i g u o u s s i t u a t i o n s . P e r h a p s t h e p a r t i c i p a n t s s o u g h t i n f o r m a t i o n a s a way t o f i n d o u t more a b o u t t h e p r o b l e m , w h e t h e r i t e x i s t e d , a n d i f s o what c o u l d be done a b o u t i t . S e e k i n g s o c i a l s u p p o r t m i g h t a l s o have b e e n u s e d b e c a u s e o f t h e n a t u r e o f t h e r e s o u r c e s a v a i l a b l e . E s p e c i a l l y a t t h e i n i t i a l p e r i o d t h i s o b s e r v a t i o n c o u l d e x p l a i n why s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s were w i d e l y u s e d . B e i n g i n a c a r i n g e n v i r o n m e n t where i n d i v i d u a l i z e d c a r e was g i v e n may have a l l o w e d t h e p a t i e n t s t o p e r c e i v e t h e a v a i l a b l e r e s o u r c e s a s r e l e v a n t t o t h e i r p r o b l e m s . T h i s a r g u m e n t c o u l d a l s o e x p l a i n why p e o p l e u s e d p o s i t i v e r e a p p r a i s a l , d i s t a n c i n g , s e l f - c o n t r o l l i n g a n d a c c e p t i n g r e s p o n s i b i l i t y s t r a t e g i e s . T h e s e f o r m s o f c o p i n g s h a r e common t h e m e s . P o s i t i v e r e a p p r a i s a l a n d d i s t a n c i n g h e l p c r e a t e p o s i t i v e m e a n i n g , w h i l e a c c e p t i n g r e s p o n s i b i l i t y a n d s e l f - c o n t r o l h a v e a c o n c o m i t t a n t theme o f w a n t i n g t o p u t t h i n g s r i g h t ( D e g r e - C o u s t r y & G r e v i s s e ( 1 9 8 2 ; F o l k m a n e t a l . ( 1 9 8 6 ) . L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) s t a t e t h a t t h e u s e o f s o c i a l r e s o u r c e s a l s o h e l p p e o p l e m a i n t a i n a p o s i t i v e o u t l o o k i f p e o p l e b e l i e v e t h e y r e c e i v e t h e s u p p o r t t h a t i s n e e d e d . I n t h i s way, s o c i a l s u p p o r t may o v e r l a p o r may i n f l u e n c e t h e u s e o f o t h e r t y p e s o f c o p i n g . A d d i t i o n a l l y , i n t h e c a s e o f d i s t a n c i n g , i t may be t h a t i n s t r e s s f u l s i t u a t i o n s s u c h a s a h e a r t a t t a c k , p a t i e n t s w i s h t o be be e m o t i o n a l l y d e t a c h e d w i t h o u t d e n y i n g i t s o c c u r r e n c e ( L a z a r u s & F o l k m a n , 1 9 8 4 ) . I n t h i s s t u d y , t h e p a r t i c i p a n t s made m o d e r a t e . u s e o f p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s . T h i s c h o i c e may r e f l e c t t h e f a c t t h a t w h i l e some a s p e c t s o f t h e MI s i t u a t i o n were a m e n a b l e t o r a t i o n a l p r o b l e m - s o l v i n g , o t h e r s w e re p e r c e i v e d a s u n c h a n g e a b l e . T h a t t h e p a t i e n t s u s e d some f o r m s o f p r o b l e m - s o l v i n g s t r a t e g i e s l e s s f r e q u e n t l y t h a n e m o t i o n - f o c u s e d c o p i n g s u c h a s s e l f - c o n t r o l , p o s i t i v e r e a p p r a i s a l a n d d i s t a n c i n g i s c o n s i s t e n t w i t h t h e f i n d i n g s o f F o l k m a n and L a z a r u s ' ( 1 9 8 0 ) m i d d l e - a g e d c o m m u n i t y s a m p l e s t u d y . T h e y r e m a r k t h a t w h i l e b o t h f o r m s o f c o p i n g a r e u s e d i n s t r e s s f u l s i t u a t i o n s , h e a l t h c o n t e x t s f a v o r e m o t i o n - f o c u s e d c o p i n g . E s c a p e - a v o i d a n c e a n d c o n f r o n t i v e c o p i n g s t r a t e g i e s w ere t h e l e a s t u s e d c o p i n g s t r a t e g i e s a t b o t h t i m e s . S i t u a t i o n a l a nd e n v i r o n m e n t a l f a c t o r s may e x p l a i n t h e l a c k o f u s e o f t h e s e c o p i n g s t r a t e g i e s . The f i r s t r e a s o n r e f e r s t o s i t u a t i o n a l f a c t o r s . P e r h a p s d e a l i n g w i t h a l i f e - t h r e a t e n i n g s i t u a t i o n s u c h a s a h e a r t a t t a c k , made I t d i f f i c u l t t o u s e t h e d e n i a l e f f o r t s i n c l u d e d i n t h e e s c a p e - a v o i d a n c e s c a l e , o r a g g r e s s i v e a n d r i s k - t a k i n g e f f o r t s c o n t a i n e d i n c o n f r o n t i v e c o p i n g . A n o t h e r e x p l a n a t i o n i s r e l a t e d t o e n v l r o m e n t a l f a c t o r s . C h r i s t m a n e t a l . ( 1 9 8 8 ) s t u d i e d u n c e r t a i n t y , c o p i n g and d i s t r e s s f o l l o w i n g m y o c a r d i a l I n f a r c t i o n . D i s c u s s i n g t h e u s e o f c o n f r o n t i v e c o p i n g , t h e y r e m a r k t h a t h o s p i t a l e n v i r o n m e n t s may l i m i t a p a t i e n t ' s c o p i n g s t r a t e g i e s , e s p e c i a l l y i n p a t i e n t s e x p e r i e n c i n g h i g h l e v e l s o f s t r e s s . T h i s may be t h e c a s e i n t h e p r e s e n t s t u d y . M e t h o d o l o g i c a l p r o b l e m s may f u r t h e r e x p l a i n t h e l a c k of use of escape-avoidance c o p i n g s t r a t e g i e s . Many p a r t i c i p a n t s gave a score of "0" on coping items which they thought c o n t a i n e d two d i f f e r e n t a c t i o n s . The escape-avoidance coping s c a l e c o n t a i n s two such items: "wish the s i t u a t i o n would go away or somehow be over w i t h " , and " t r y to make myself f e e l b e t t e r by e a t i n g , d r i n k i n g , smoking, u s i n g drugs or m e d i c a t i o n s " . Semantic problems l i k e these may have a f f e c t e d the r e c o g n i t i o n of p a r t i c u l a r c o p i n g s t r a t e g i e s . R e s u l t s demonstrate t h a t c o p i n g changes as a s t r e s s f u l event u n f o l d s . Such i s the c l a i m of Lazarus and Folkman's s t r e s s , a p p r a i s a l and cop i n g t h e o r y . Examining the changes i n the e i g h t types of coping s t r a t e g i e s r e v e a l e d t h a t three forms of cop i n g have s i g n i f i c a n t l y d e creased: p o s i t i v e r e a p p r a i s a l c o p i n g (emotion-focused), p l a n f u l p r o b l e m - s o l v i n g (problem-focused), and see k i n g s o c i a l support (mixed emotion- and problem-focused). No study was found i n the l i t e r a t u r e t h a t assessed changes i n copi n g s t r a t e g i e s i n a sample t h a t was comparable to t h a t of these MI p a r t i c i p a n t s . However, i n the midterm exam study, Folkman and Lazarus (1985) noted s i m i l a r changes i n co p i n g s t r a t e g i e s used by students to d e a l with the s t r e s s e s of a midterm exam: these three forms of coping s t r a t e g i e s decreased s i g n i f i c a n t l y over time as the t h r e a t of the s i t u a t i o n decreased. In the prese n t study, p o s i t i v e r e a p p r a i s a l decreased s i g n i f i c a n t l y o v e r t i m e . F o l k m a n a n d L a z a r u s ( 1 9 8 5 ) a r g u e t h a t some f o r m s o f e m o t i o n - f o c u s e d c o p i n g , s u c h a s e m p h a s i z i n g t h e p o s i t i v e , c a n f a c i l i t a t e p r o b l e m - f o c u s e d c o p i n g i f t h e y a r e u s e d t o manage e m o t i o n s t h a t w o u l d Impede p r o b l e m - f o c u s e d a c t i v i t i e s . I t may be t h a t s o m e t h i n g i n t h e e n v i r o n m e n t s u c h a s r e s o u r c e s , t h e e x i g e n c i e s o f t h e s i t u a t i o n , o r c o p i n g o p t i o n s a v a i l a b l e w i t h i n i t , may a f f e c t p a r t i c u l a r f o r m s o f c o p i n g . T h e s e c o n t e x t u a l e l e m e n t s may h a v e p r o m o t e d p o s i t i v e r e a p p r a i s a l w h i c h I n t u r n have i n f l u e n c e d t h e u s e o f p l a n f u l p r o b l e m - s o l v i n g a n d s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s . A c c o r d i n g t o F o l k m a n a n d L a z a r u s ( 1 9 8 5 ) , one p o s s i b l e e x p l a n a t i o n f o r t h e d e c r e a s e i n p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s may be t h a t p e o p l e f e e l t h a t n o t h i n g c a n be done t o c h a n g e t h e t r o u b l e d s i t u a t i o n . C o n v e r s e l y , when t h e e v e n t i s a p p r a i s e d a s c h a n g e a b l e , p e o p l e u s e d c o p i n g s t r a t e g i e s , s u c h a s p l a n f u l p r o b l e m - s o l v i n g c o p i n g t h a t a l l o w them t o f o c u s on t h e t r o u b l i n g s i t u a t i o n . M i l l e r e t a l . ( 1 9 8 5 ) s t u d i e d c o p i n g s t r a t e g i e s u s e d b y 480 c a r d i a c p a t i e n t s , h a l f o f whom were MI p a t i e n t s . T h e y f o u n d t h a t t h e m a j o r i t y ( 6 8 % ) o f s t r a t e g i e s p a t i e n t s u s e d were r e l a t e d t o p r o b l e m - s o l v i n g a c t i v i t i e s , s u c h a s e n g a g i n g i n e n e r g y g e n e r a t i n g a c t i v i t i e s a n d d e c r e a s i n g e n v i r o n m e n t a l s t r e s s o r s . O n l y 1 1 % o f c o p i n g s t r a t e g i e s were i n t h e c a t e g o r y o f s e l f - c o n t r o l , a l t h o u g h 4 2 % o f method s a d v i s e d b y h e a l t h p r o f e s s i o n a l s were o f t h a t n a t u r e . I n t h e p r e s e n t study, although other forms of coping were used, problem-focused coping were used more f r e q u e n t l y a t the I n i t i a l p e r i o d than a t the second p e r i o d . P o s s i b l y , the p a r t i c i p a n t s had a p p r a i s e d the MI s i t u a t i o n as being under c o n t r o l . There was a l s o a s i g n i f i c a n t decrease i n the use of s e e k i n g s o c i a l support s t r a t e g i e s between the f i r s t and the second p e r i o d s . Lazarus and Folkman (1984) e x p l a i n t h a t the use of c o p i n g s t r a t e g i e s may be determined by the r e s o u r c e s a v a i l a b l e , the demands of the s i t u a t i o n , and the changes i n these demands. T h e r e f o r e , i t makes l o g i c a l sense t h a t i n the immediate post MI p e r i o d , p a t i e n t s i n t e r a c t i n g with h e a l t h p r o f e s s i o n a l s who o f f e r e d t a n g i b l e support ( i n f o r m a t i o n , a d v i c e , emotional support) would use such coping s t r a t e g i e s . Other p l a u s i b l e e x p l a n a t i o n s f o r the l a c k of s i g n i f i c a n t changes i n d i s t a n c i n g , c o n f r o n t i v e c o p i n g , escape-avoidance, s e l f - c o n t r o l l i n g and a c c e p t i n g r e s p o n s i b i l i t y s t r a t e g i e s may be r e l a t e d to m e t h o d o l o g i c a l problems r e f e r r e d to e a r l i e r . The absence of s i g n i f i c a n t changes i n the types of s t r a t e g i e s p r e v i o u s l y mentioned may be r e l a t e d to problems with measurement t o o l s . At both t e s t i n g s c o n f r o n t i v e c o p i n g , p l a n f u l p r o b l e m - s o l v i n g and a c c e p t i n g r e s p o n s i b i l i t y coping had low r e l i a b i l i t y a l p h a c o e f f i c i e n t s below .60. A d d i t i o n a l l y , at the i n i t i a l p e r i o d , s e l f - c o n t r o l l i n g and d i s t a n c i n g coping a l s o had low r e l i a b i l i t y . R e s u l t s must t h e r e f o r e be i n t e r p r e t e d c a u t i o u s l y . The l a c k of change In some cop i n g s t r a t e g i e s r a i s e s some q u e s t i o n s r e g a r d i n g the v a l i d i t y of the coping s t r a t e g i e s . In a d d i t i o n t o the semantic problems mentioned e a r l i e r , the lack of s i g n i f i c a n t r e s u l t s may be due to the nature of the items on the cop i n g s c a l e s . Perhaps some of the s t r a t e g i e s a v a i l a b l e d i d not lend themselves to be used, and t h e r e f o r e coping was not a c c u r a t e l y measured. Regardless of the nature of the items, i t may a l s o be t h a t some forms of cop i n g are not t y p i c a l of MI p a t i e n t s ' ways of c o p i n g . T h i s study's r e s u l t s may r e p r e s e n t MI p a t i e n t s ' c o p i n g p a t t e r n s , a l t h o u g h f u r t h e r r e s e a r c h i n t h i s area i s necessar y . Another e x p l a n a t i o n f o r the r e s u l t s may be r e l a t e d to the nonparametr1c t e s t used. Some of the f i n d i n g s may have been s i g n i f i c a n t ; but because of the weak s t a t i s t i c a l t e s t used, s i g n i f i c a n t changes i n some forms of coping may not have been d e t e c t e d . The o p p o s i t e may a l s o be t r u e . With d i f f e r e n t s t a t i s t i c a l t e s t s , some s i g n i f i c a n t r e s u l t s may prove otherwise. R e l a t i o n s h i p s between C o g n i t i v e A p p r a i s a l and Coping S t r a t e g i e s In t h i s study, s i g n i f i c a n t c o r r e l a t i o n s were found between the four types of emotion a p p r a i s a l s and p a r t i c u l a r f o r m s o f c o p i n g . I n t h e i m m e d i a t e p o s t MI p e r i o d , t h r e a t e m o t i o n s were p o s i t i v e l y r e l a t e d o n l y t o t h e u s e o f p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s . Harm e m o t i o n s were p o s i t i v e l y r e l a t e d t o c o n f r o n t i v e , a c c e p t i n g r e s p o n s i b i l i t y a n d p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s a t t h e i n i t i a l p e r i o d . S i m i l a r l y , c h a l l e n g e e m o t i o n s w ere r e l a t e d t o s e e k i n g s o c i a l s u p p o r t a n d p o s i t i v e r e a p p r a i s a l s t r a t e g i e s a t t h e e a r l y p e r i o d . B e n e f i t e m o t i o n s w ere r e l a t e d t o d i f f e r e n t s t r a t e g i e s a t b o t h p o i n t s i n t i m e . I n i t i a l l y , b e n e f i t e m o t i o n s were p o s i t i v e l y r e l a t e d t o t h e u s e o f c o n f r o n t i v e a n d s e e k i n g s o c i a l s u p p o r t s t r a t e g i e s , and t o t h e u s e o f s e l f - c o n t r o l l i n g and a c c e p t i n g r e s p o n s i b i l i t y s t r a t e g i e s . O n l y one t y p e o f c o p i n g , e s c a p e - a v o i d a n c e , was n o t r e l a t e d t o a n y o f t h e a p p r a i s a l t y p e s a s s e s s e d . The s t r e s s , a p p r a i s a l a n d c o p i n g t h e o r y h e l p s t o e x p l a i n t h e r e l a t i o n s h i p s b e t w e e n c o g n i t i v e a p p r a i s a l and c o p i n g s t r a t e g i e s u s e d b y MI p a t i e n t s . L a z a r u s and F o l k m a n ( 1 9 8 4 ) s t a t e t h a t how a p e r s o n a p p r a i s e s t h e s i t u a t i o n i n f l u e n c e s t h e c h o i c e o f c o p i n g s t r a t e g i e s . The s t r e s s , a p p r a i s a l , a n d c o p i n g t h e o r y p r e d i c t s a r e l a t i o n s h i p b e t w e e n c o g n i t i v e a p p r a i s a l o f e m o t i o n s and c o p i n g s t r a t e g i e s , b u t i t d o e s n o t make s p e c i f i c p r e d i c t i o n s a b o u t t h e r e l a t i o n s h i p s b e t w e e n p a r t i c u l a r e m o t i o n a p p r a i s a l t y p e s a n d p a r t i c u l a r f o r m s o f c o p i n g ( L a z a r u s & F o l k m a n , 1 9 8 4 ) . A d d i t i o n a l l y , no r e s e a r c h was f o u n d w h i c h 106 s y s t e m a t i c a l l y a s s e s s e d t h e r e l a t i o n s h i p b e t w e e n c o g n i t i v e a p p r a i s a l o f e m o t i o n s and c o p i n g s t r a t e g i e s . A t t h e i n i t i a l p e r i o d , a s i g n i f i c a n t r e l a t i o n s h i p was f o u n d b e t w e e n t h r e a t e m o t i o n s a n d p l a n f u l p r o b l e m - s o l v i n g c o p i n g . I n t h e M c N e t t ' s ( 1 9 8 7 ) s t u d y o f f u n c t i o n a l l y d i s a b l e d s u b j e c t s , t h r e a t a p p r a i s a l was s i g n i f i c a n t l y r e l a t e d t o e m o t i o n - f o c u s e d c o p i n g (r_ = 0 . 2 3 ) . H o w e v e r , f i n d i n g s f r o m o t h e r s t u d i e s o f c o p i n g w i t h i l l n e s s i n d i c a t e t h a t a l t h o u g h e m o t i o n - f o c u s e d c o p i n g seemed t o be a s s o c i a t e d more w i t h h e a l t h - r e l a t e d s i t u a t i o n s , p r o b l e m - s o l v i n g c o p i n g was a l s o u s e d i n t h e s e s i t u a t i o n s ( L l p o w s k i , 1 9 7 0 - 1 9 7 1 ; Cohen & L a z a r u s , 1 9 7 9 ; F o l k m a n e t a l , 1 9 8 6 ) . T h e r e f o r e , t h e r e s u l t s o f t h i s s t u d y seem t o be c o n g r u e n t w i t h o t h e r r e s e a r c h f i n d i n g s . F u r t h e r m o r e , L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) s t a t e t h a t c o p i n g i s b e s t u n d e r s t o o d b y e x a m i n i n g t h e r e l a t i o n s h i p b e t w e e n t h e p e r s o n a n d t h e e n v i r o n m e n t a s w e l l a s t h e c o p i n g o p t i o n s and t h e c o p i n g r e s o u r c e s a v a i l a b l e . A p o s s i b l e e x p l a n a t i o n f o r t h e r e l a t i o n s h i p b e t w e e n t h r e a t e m o t i o n s a n d p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s may be t h a t , a l t h o u g h t h r e a t e n e d b y t h e s i t u a t i o n , t h e p a t i e n t s a p p r a i s e d I t a s a m e n a b l e t o r a t i o n a l p r o b l e m - s o l v i n g b e c a u s e o f t h e c o p i n g r e s o u r c e s a v a i l a b l e . A d d i t i o n a l l y , t h e s h o r t p e r i o d o f d e l a y b e t w e e n o n s e t o f symptoms and t h e p a t i e n t s * a d m i s s i o n t o h o s p i t a l s u g g e s t s t h a t t h e y were a l r e a d y e n g a g e d i n some f o r m s o f p r o b l e m - s o l v i n g . A c c o r d i n g to Gentry and Haney ( 1 9 7 5 ) , MI p a t i e n t s who d e c i d e to admit themselves to h o s p i t a l are a l r e a d y more committed than are those who r e l y on other forms of c o p i n g , such as d e n i a l . Although environmental f a c t o r s are important, Lazarus and Folkman ( 1 9 8 4 ) f u r t h e r e x p l a i n t h a t the l e v e l of t h r e a t a person e x p e r i e n c e s may i n f l u e n c e the use of c o p i n g s t r a t e g i e s . They a l s o s t a t e t h a t high l e v e l s of t h r e a t r e s u l t i n emotion-focused c o p i n g , while moderate l e v e l s r e s u l t i n problem-focused c o p i n g . In t h i s study, p a r t i c i p a n t s experienced moderate l e v e l s of t h r e a t emotions. T h e r e f o r e , t h i s o b s e r v a t i o n may e x p l a i n the c o r r e l a t i o n between t h r e a t emotions and p l a n f u l problem-focused c o p i n g . I t may be t h a t a moderate l e v e l of t h r e a t promotes the use of p r o b l e m - s o l v i n g a c t i v i t i e s . C o n v e r s e l y , h i g h l e v e l s of t h r e a t may I n t e r f e r e with an i n d i v i d u a l ' s a b i l i t y to make r a t i o n a l d e c i s i o n s . S i m i l a r l y , a t the i n i t i a l p e r i o d , harm emotions were s i g n i f i c a n t l y and p o s i t i v e l y c o r r e l a t e d with p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s . P a r t i c i p a n t s a l s o experienced moderate l e v e l s of harm emotions. L e v e l of t h r e a t as a d e t e r m i n i n g f a c t o r i n the use of p r o b l e m - s o l v i n g coping may a l s o help e x p l a i n the c o r r e l a t i o n . A c c o r d i n g to Lazarus and Folkman ( 1 9 8 4 ) , d i f f e r e n t t h r e a t s are i n v o l v e d i n harm a p p r a i s a l s . In t h i s study, harm and t h r e a t a p p r a i s a l s may be r e l a t e d i n some ways. MI p a t i e n t s may have b e e n u s i n g p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s t o manage s i m i l a r a s p e c t s o f t h e s i t u a t i o n . Harm e m o t i o n s were s i g n i f i c a n t l y c o r r e l a t e d w i t h a c c e p t i n g r e s p o n s i b i l i t y . A c c o r d i n g t o F o l k m a n e t a l . ( 1 9 8 6 ) , a n I n d i v i d u a l who u s e s t h i s f o r m o f c o p i n g a nd a c c e p t s r e s p o n s i b i l i t y o r b l a m e a l s o knows what t o do t o c h a n g e t h e s i t u a t i o n . T h e y f u r t h e r s a y t h a t I n t h i s way a c c e p t i n g r e s p o n s i b i t y p r o m o t e s t h e u s e o f p r o b l e m - s o l v i n g c o p i n g . T h i s p o i n t may e x p l a i n why harm e m o t i o n s were p o s i t i v e l y r e l a t e d t o p r o b l e m - s o l v i n g s t r a t e g i e s . An i n t e r e s t i n g q u e s t i o n , h o w e v e r , i s why a c c e p t i n g r e s p o n s i b i l i t y c o p i n g c o r r e l a t e s w i t h harm e m o t i o n s a t t h e i n i t i a l p e r i o d , b u t w i t h b e n e f i t e m o t i o n s a t t h e s e c o n d . One c o u l d assume t h a t d u r i n g t h e e i g h t week p e r i o d , t h e p a t i e n t s w o u l d l i k e l y h a v e r e a s s e s s e d t h e s i t u a t i o n w i t h a d i f f e r e n t p e r s p e c t i v e . W ould new i n f o r m a t i o n a c q u i r e d d u r i n g t h i s t i m e p e r i o d i n f l u e n c e t h e r e a p p r a i s a l s , o r i s i t t h e c h a n g e d c o n t e x t o f t h e s i t u a t i o n t h a t a l l o w s t h e p a t i e n t s t o make d i f f e r e n t a p p r a i s a l s ? N u r s i n g a nd m e d i c a l i n t e r v e n t i o n s m i g h t e x p l a i n t h i s c h a n g e i n t h e p a r t i c i p a n t s ' b e l i e f s w h i c h may h a v e i n t u r n I n f l u e n c e d t h e c o r r e l a t i o n s o f harm e m o t i o n s w i t h a c c e p t i n g r e s p o n s i b i l i t y t o b e n e f i t e m o t i o n s . I n t h e i r s t u d y o f p a t i e n t s ' p e r c e p t i o n s o f t h e c a r d i a c c r i s i s , B u r g e s s a n d H a r t m a n ( 1 9 8 6 ) s t u d i e d t h e e f f e c t o f n u r s i n g i n t e r v e n t i o n s b a s e d on t h e way i n d i v i d u a l s p r o c e s s i n f o r m a t i o n . Over a three month p e r i o d , most heart a t t a c k v i c t i m s a l t e r e d t h e i r b e l i e f s about the causes of t h e i r h e a r t a t t a c k , and t h e i r a b i l i t y to resume p r e - i l l n e s s a c t i v i t i e s . Instead of blaming sources other than themselves, people accepted r e s p o n s i b i l i t y f o r t h e i r d i s e a s e . The r e s e a r c h e r s b e l i e v e t h a t i n t e r v e n t i o n s which o f f e r e d a l t e r n a t i v e b e l i e f s helped people reframe i n f o r m a t i o n . For example, i f the p a t i e n t b e l i e v e d the heart a t t a c k was "the worst t h i n g t h a t c o u l d have happened", the a l t e r n a t i v e would be "how can the h e a r t a t t a c k be u s e f u l ? " . In t h i s study, most MI p a t i e n t s were i n v o l v e d i n r e h a b i l i t a t i o n programs d u r i n g the e i g h t week time p e r i o d . As a r e s u l t , these i n t e r v e n t i o n s may have i n f l u e n c e d t h i s change i n harm and b e n e f i t a p p r a i s a l s with r e s p e c t t o s e l f - b l a m e . Lazarus and Folkman (1984) remark t h a t outcome a p p r a i s a l s of harm and b e n e f i t can change as a s i t u a t i o n u n f o l d s . At the i n i t i a l p e r i o d , both outcome a p p r a i s a l s of harm and b e n e f i t emotions were s i g n i f i c a n t l y and p o s i t i v e l y c o r r e l a t e d with c o n f r o n t i v e c o p i n g . C o n f r o n t i v e c o p i n g d e s c r i b e s r i s k - t a k i n g and a g g r e s s i v e e f f o r t s to a l t e r the s i t u a t i o n ; whereas p l a n f u l p r o b l e m - s o l v i n g i n c l u d e s r a t i o n a l p r o b l e m - s o l v i n g e f f o r t s . I t seems c o n t r a d i c t o r y t h a t the p a t i e n t s would use both forms of copi n g s i m u l t a n e o u s l y . However, a c c o r d i n g to Folkman et a l . ( 1 9 8 6 ) , on o c c a s i o n s c o n f r o n t i v e c o p i n g may be a n a d a p t i v e f o r m o f c o p i n g . H e r e , i n t h i s s t u d y t h e MI p a t i e n t s may h a v e u s e d b o t h f o r m s o f c o p i n g t o manage d i f f e r e n t f a c e t s o f t h e s i t u a t i o n . D e p e n d i n g on t h e n a t u r e o f t h e t h r e a t s , c o n t r a d i c t o r y f o r m s o f c o p i n g may be m u t u a l l y f a c i l i t a t i v e ( F o l k m a n e t a l . , 1 9 8 6 ) . B e c a u s e t h e o t h e r c o r r e l a t e s r e f l e c t more m a t u r e o r a d a p t i v e f o r m s o f c o p i n g , t h e i n v e s t i g a t o r b e l i e v e s t h a t MI p a t i e n t s u s e d c o n f r o n t i v e c o p i n g t o c o n t r o l t h e s o u r c e s o f harm. I n t h i s way, c o n f r o n t i v e c o p i n g m i g h t have f a c i l i t a t e d a p p r o p r i a t e a c t i o n s a s s o c i a t e d w i t h b e n e f i t a p p r a i s a l . I n t h e s t u d y o f t h e c o m m u n i t y - r e s i d i n g a d u l t s , F o l k m a n e t a l . ( 1 9 8 6 ) f o u n d t h a t p l a n f u l p r o b l e m - s o l v i n g a n d c o n f r o n t i v e c o p i n g w e r e a s s o c i a t e d w i t h s a t i s f a c t o r y a n d u n s a t i s f a c t o r y e n c o u n t e r s . R e s u l t s o b t a i n e d i n t h e p r e s e n t s t u d y s u g g e s t e i t h e r t h a t a t t h e i n i t i a l p e r i o d , t h e MI s i t u a t i o n was p e r c e i v e d a s h o l d i n g b o t h p o s i t i v e a n d n e g a t i v e o u t c o m e s , o r t h a t t h e p a t i e n t s t r i e d t o d e a l w i t h v a r i o u s demands o f t h e s i t u a t i o n . No s i g n i f i c a n t c o r r e l a t i o n s w e r e o b t a i n e d b e t w e e n t h e f o u r t y p e s o f e m o t i o n s a n d c o n f r o n t i v e c o p i n g a t t h e s e c o n d m e a s u r e m e n t t i m e . One p o s s i b l e e x p l a n a t i o n i s t h a t , g i v e n t h e i n c r e a s e i n b o t h c h a l l e n g e a n d b e n e f i t e m o t i o n s , t h e p a t i e n t s may ha v e more p o s i t i v e l y a p p r a i s e d t h e s i t u a t i o n . I n t h e p r e s e n t s t u d y , a t t h e s e c o n d m e a s u r e m e n t t i m e , a s i g n i f i c a n t c o r r e l a t i o n was f o u n d b e t w e e n b e n e f i t e m o t i o n s a n d s e l f - c o n t r o l l i n g c o p i n g . A c c o r d i n g t o D e g r e - C o u s t r y a n d G r e v i s s e ( 1 9 8 2 ) , s e l f - c o n t r o l r e p r e s e n t s a n a d a p t i v e f o r m o f b e h a v i o r . I n t h i s c a s e , p a t i e n t s t r y t o c o n t r o l t h e i r e m o t i o n a l r e a c t i o n s . T h e y make p l a n s t o o b j e c t i v e l y r e o r g a n i z e t h e i r l i v e s , t a k i n g i n t o a c c o u n t t h e i m p o s e d r e s t r i c t i o n s . I n t h i s s t u d y , s e l f - c o n t r o l l i n g i s a c c o m p a n i e d b y a c c e p t i n g r e s p o n s i b i l i t y . T h i s a s s o c i a t i o n makes l o g i c a l s e n s e , s i n c e b o t h f o r m s o f c o p i n g s h a r e s i m i l a r t hemes o f " w a n t i n g t o p u t t h i n g s r i g h t o r t r y i n g t o r e o r g a n i z e o n e ' s l i f e " . A t t h e f i r s t m e a s u r e m e n t t i m e , a s i g n i f i c a n t r e l a t i o n s h i p was f o u n d b e t w e e n b e n e f i t e m o t i o n s a n d s e e k i n g s o c i a l s u p p o r t c o p i n g . A d d i t i o n a l l y , c h a l l e n g e e m o t i o n s w ere s i g n i f i c a n t l y c o r r e l a t e d w i t h s e e k i n g s o c i a l s u p p o r t c o p i n g , a n d w i t h p o s i t i v e r e a p p r a i s a l c o p i n g . I n t e r p r e t a t i o n s o f t h e c o r r e l a t e s c a n be made i n r e l a t i o n t o p e r s o n a l a n d e n v i r o n m e n t a l f a c t o r s e x p l a i n e d e a r l i e r . P e r s o n a l f a c t o r s r e l a t e d t o b e l i e f s a b o u t p e r s o n a l c o n t r o l may h a v e i n f l u e n c e d c h a l l e n g e a n d b e n e f i t a p p r a i s a l s . P e r s o n - f a c t o r s a r e more l i k e l y t o i n f l u e n c e a p p r a i s a l s i n a m b i g u o u s s i t u a t i o n s . ( L a z u r u s & F o l k m a n , 1 9 8 4 ) . L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) s t a t e t h a t c h a l l e n g e a p p r a i s a l s o c c u r when a n i n d i v i d u a l h a s a s e n s e o f c o n t r o l o v e r t h e t r o u b l e d p e r s o n - e n v i r o n m e n t r e l a t i o n s h i p . T h e y f u r t h e r s a y t h a t c h a l l e n g e w i l l o c c u r o n l y i f t h e s i t u a t i o n r e q u i r e s s u b s t a n t i a l e f f o r t s . A c c o r d i n g t o L l p o w s k i ( 1 9 7 0 - 1 9 7 1 ) , c o p i n g s t r a t e g i e s r e f l e c t a c c e p t a n c e o f i l l n e s s . P a t i e n t s a r e more l i k e l y t o use e f f e c t i v e o r more m a t u r e f o r m s o f c o p i n g , s u c h a s s e e k i n g p r o f e s s i o n a l a d v i c e , m a k i n g p o s i t i v e p l a n s a nd s e e k i n g I n f o r m a t i o n ( L l p o w s k i , 1 9 7 0 - 1 9 7 1 ; H a c k e t t & C a s s e m , 1 9 7 8 ) . I n t h e p r e s e n t s t u d y , i t i s p o s s i b l e t h a t MI p a t i e n t s p e r c e i v e d t h e s i t u a t i o n a s c o n t r o l l a b l e , a n d t h a t t h e y b e l i e v e d t h e y c o u l d do s o m e t h i n g t o manage t h e h a r m f u l s i t u a t i o n . A n o t h e r r e a s o n t h e s e r e l a t i o n s h i p s were f o u n d may a l s o be due t o t h e p a r t i c i p a n t s ' p e r c e p t i o n o f s o c i a l s u p p o r t . S o c i a l s u p p o r t i s d e f i n e d a s t h e n a t u r e o f t h e i n t e r a c t i o n s t a k i n g p l a c e i n s o c i a l r e l a t i o n s h i p s , a n d how t h e y a r e s u b j e c t i v e l y a s s e s s e d w i t h r e s p e c t t o t h e i r s u p p o r t i v e n e s s ( L a z a r u s a n d F o l k m a n , 1 9 8 4 ) . T h e y e x p l a i n t h a t p e o p l e h a v e a b e t t e r m o r a l e i f t h e y b e l i e v e t h a t t h e y w i l l r e c e i v e s o c i a l s u p p o r t when i t i s n e e d e d . A c c o r d i n g t o Cohen a n d L a z a r u s ( 1 9 7 9 ) , s o c i a l s u p p o r t e n h a n c e s t h e p o s s i b i l i t i e s f o r e f f e c t i v e c o p i n g . T h e r e f o r e , t h e p r e s e n c e o f w o r k a b l e a l t e r n a t i v e s f o r c o p i n g e n c o u r a g e d t h e p a r t i c i p a n t s t o i m p l e m e n t more m a t u r e f o r m s o f c o p i n g . The f a c t t h a t s e e k i n g s o c i a l s u p p o r t was a c c o m p a n i e d by p o s i t i v e r e a p p r a i s a l a p p e a r s l o g i c a l . S i n c e p o s i t i v e r e a p p r a i s a l d e s c r i b e s e f f o r t s t o c r e a t e p o s i t i v e m e a n i n g , p e o p l e a r e more l i k e l y t o u s e e f f e c t i v e f o r m s o f c o p i n g . F o l k m a n e t a l . ( 1 9 8 6 ) s u g g e s t t h a t p o s i t i v e r e a p p r a i s a l f a c i l i t a t e s problem-focused c o p i n g . They p o i n t out t h a t p o s i t i v e r e a p p r a i s a l c o u l d a l s o i n d i c a t e the r e a p p r a i s a l of a s i t u a t i o n i n which problem-focused coping had been e f f e c t i v e . Such may be the case i n the present study. The p a r t i c i p a n t s ' use of p l a n f u l p r o b l e m - s o l v i n g s t r a t e g i e s to reduce harm and t h r e a t may have produced p o s i t i v e r e s u l t s . In t u r n , these f a v o r a b l e outcomes may have i n f l u e n c e d p o s i t i v e r e a p p r a i s a l . Based on the s t r e s s , a p p r a i s a l and c o p i n g t h e o r y ' s f o r m u l a t i o n s and the study's r e s u l t s , the i n v e s t i g a t o r b e l i e v e s t h a t the coping process i n p a t i e n t s e x p e r i e n c i n g a f i r s t Ml i s determined through a s p e c i f i c p a t t e r n . I t i s now r e c o g n i z e d t h a t s i t u a t i o n a l f a c t o r s are the determinants of emotion a p p r a i s a l s , and these emotions are I n d i c a t o r s of what i s Important to a person's w e l l - b e i n g (Lazarus and Folkman, 1984). In t h i s study, major s i t u a t i o n a l f a c t o r s were i d e n t i f i e d as the n o v e l t y , the ambiguity, the changing demands of the s i t u a t i o n and the environmental r e s o u r c e s a v a i l a b l e . The p e r c e p t i o n or the u nderstanding of these c o n t e x t u a l f a c t o r s may have a l t e r e d the p a r t i c i p a n t s ' b e l i e f s with r e s p e c t to c o n t r o l and r e s p o n s i b i l i t y f o r t h e i r i l l n e s s . These b e l i e f s appeared r e l e v a n t to the p a r t i c i p a n t s ' a p p r a i s a l s made i n t h a t they p r o b a b l y i n f l u e n c e d the e x t e n t to to which harm, t h r e a t , c h a l l e n g e and b e n e f i t emotions were e x p e r i e n c e d . In other words, the p a r t i c i p a n t s ' b e l i e f s r e g u l a t e d the l e v e l s of e m o t i o n s . T h e s e l e v e l s o f e m o t i o n s r e f l e c t t h e s t r e s s e x p e r i e n c e d by MI p a t i e n t s i n e a r l y p h a s e s o f t h e i r i l l n e s s . L a z a r u s a n d F o l k m a n ( 1 9 8 4 ) f u r t h e r e x p l a i n t h a t c o p i n g s t r a t e g i e s a r e m u l t i d e t e r m i n e d and t h a t t h e l e v e l o f t h r e a t i s one o f t h e d e t e r m i n i n g f a c t o r s . The same a p p e a r s t o h o l d t r u e f o r t h e e m o t i o n s o f harm, b e n e f i t and c h a l l e n g e . The r e s u l t s r e v e a l e d t h a t l o w t o m o d e r a t e l e v e l s o f e m o t i o n s were a s s o c i a t e d w i t h a s e t o f c o r r e l a t e s r e f l e c t i v e o f w hat L a z a r u s and F o l k m a n ( 1 9 8 4 ) c o n s i d e r m a t u r e f o r m s o f c o p i n g . The r e s u l t s s u g g e s t t h a t t h e t y p e s a n d t h e l e v e l s ( i n t e n s i t y ) o f e m o t i o n s d e t e r m i n e d t h e c o p i n g s t r a t e g i e s u s e d by f i r s t MI p a t i e n t s a t f i v e t o s e v e n d a y s a n d e i g h t weeks p o s t MI. F u r t h e r r e s e a r c h i n t h i s a r e a m i g h t be p r o d u c t i v e . M e t h o d o l o g i c a l p r o b l e m s may h e l p e x p l a i n t h e l a c k o f s i g n i f i c a n t c o r r e l a t i o n s . One p l a u s i b l e e x p l a n a t i o n may be r e l a t e d t o t h e p r o b l e m s w i t h m e a s u r e m e n t t o o l s r e p o r t e d e a r l i e r . F i v e c o p i n g s c a l e s and two a p p r a i s a l s c a l e s I n d i c a t e d l o w i n t e r n a l c o n s i s t e n c y . A t b o t h t i m e s , p l a n f u l p r o b l e m - s o l v i n g a c c e p t i n g r e s p o n s i b i l i t y a n d c o n f r o n t i v e c o p i n g had a r e l i a b i l i t y a l p h a c o e f f i c i e n t b e l o w .60. A d d i t i o n a l l y , a t t h e i n i t i a l p e r i o d , s e l f - c o n t r o l l i n g and d i s t a n c i n g c o p i n g I n d i c a t e d l o w r e l i a b i l i t y a l p h a c o e f f i c i e n t s . S i m i l a r l y , a t t h e i n i t i a l p e r i o d , harm a p p r a i s a l s c a l e i n d i c a t e d l o w r e l i a b i l i t y a l p h a c o e f f i c i e n t s , a s d i d t h r e a t a p p r a i s a l s c a l e a t t h e s e c o n d p e r i o d . T h e r e f o r e , the r e s u l t s must be c a u t i o u s l y i n t e r p r e t e d . The f i n d i n g s of the study may be r e l a t e d to the v a l i d i t y of p a r t i c u l a r c o p i n g s t r a t e g i e s p r e v i o u s l y d i s c u s s e d and to the use of a nonparametrlc t e s t to measure the r e l a t i o n s h i p s . D i f f e r e n t c o r r e l a t i o n s may have been o b t a i n e d w i t h the use of p a r a m e t r i c t e s t . For these reasons, a d d i t i o n a l r e s e a r c h should be c a r r i e d out with a l a r g e r sample s i z e . Summary In t h i s c h a p t e r , the sample c h a r a c t e r i s t i c s have been d e s c r i b e d i n terms of the p a r t i c i p a n t s ' age, m a r i t a l , e d u c a t i o n a l and o c c u p a t i o n a l s t a t u s . In a d d i t i o n to demographic d a t a , i l l n e s s - r e l a t e d data were d i s c u s s e d . Scores obtained on the four types of emotion a p p r a i s a l s of t h r e a t , harm, c h a l l e n g e and b e n e f i t i n d i c a t e d t h a t most s u b j e c t s experienced moderate to low l e v e l s of the four emotion types a t both times. Only b e n e f i t emotions r e v e a l e d a higher degree of v a r i a b i l i t y . C hallenge emotions were the most frequent a p p r a i s a l type a t both I n t e r v i e w s . I n i t i a l l y , b e n e f i t emotions were the l e a s t f requent a p p r a i s a l type, while harm emotions were the l e a s t f requent a t the second p e r i o d . The t r e n d found i n emotion a p p r a i s a l s suggests t h a t , although s t r e s s f u l , a f i r s t MI i s a s s o c i a t e d with an o p t i m i s t i c outlook and p o s i t i v e a p p r a i s a l i n p a t i e n t s who are f i v e to seven days and e i g h t weeks post MI. S i t u a t i o n a l f a c t o r s t h a t r e l a t e d to the p a r t i c i p a n t s ' l a c k of knowledge r e g a r d i n g the demands of a c h r o n i c i l l n e s s as w e l l as the p e r c e i v e d c h a n g e a b i l i t y of the MI s i t u a t i o n may have c o n t r i b u t e d to the r e s u l t s . Although changes were observed, no s i g n i f i c a n t changes were noted i n the four types of emotions a p p r a i s a l of harm, t h r e a t , c h a l l e n g e and b e n e f i t i n an e i g h t week time p e r i o d . Challenge emotions r e v e a l e d the l e a s t change with o n l y a s l i g h t i n c r e a s e ; whereas a g r e a t e r change was noted i n the b e n e f i t emotions. Both harm and t h r e a t emotions decreased but remained at moderate l e v e l s . The l a c k of s i g n i f i c a n t changes i n emotions p a r t i c i p a n t s e x p e r i e n c e d suggests t h a t having a f i r s t MI i s a s t r e s s f u l e x p e r i e n c e , and t h a t p e r s o n a l and c o n t e x t u a l f a c t o r s i n f l u e n c e s t r e s s a p p r a i s a l s i n f i r s t MI p a t i e n t s i n the stages s t u d i e d . The study's r e s u l t s i n d i c a t e d t h a t s u b j e c t s have used a wide range of c o p i n g s t r a t e g i e s to manage the s t r e s s e s of t h e i r MI. On both o c c a s i o n s , most p a t i e n t s used the e i g h t a v a i l a b l e types of c o p i n g . A l l forms of coping except d i s t a n c i n g were used l e s s f r e q u e n t l y at the second p e r i o d . O v e r a l l , the coping s c a l e s r e p o r t e d moderately low to moderately high score l e v e l s , except f o r d i s t a n c i n g and c o n f r o n t i v e coping which r e v e a l e d low s c o r e s at both times. At both i n t e r v i e w s , the s t r a t e g i e s of s e e k i n g s o c i a l s upport, p o s i t i v e r e a p p r a i s a l and d i s t a n c i n g coping were the most f r e q u e n t l y used; whereas escape-avoidance and c o n f r o n t i v e coping were the l e a s t used types of c o p i n g . The r e s u l t s are c o n s i s t e n t with p r e v i o u s r e s e a r c h f i n d i n g s (Cohen & Lazarus, 1979; Folkman & Lazarus, 1980). These r e s e a r c h e r s e x p l a i n t h a t a l t h o u g h h e a l t h - r e l a t e d s i t u a t i o n s favor emotion-focused coping, both forms of emotion-focused and problem-focused coping are used. In t h i s study, p a r t i c i p a n t s drew on forms of emotion-focused and problem-focused coping, p o s s i b l y to d e a l with d i f f e r e n t a s p e c t s of t h e i r i l l n e s s , or v a r i o u s forms of c o p i n g to manage j u s t one a s p e c t . The MI p a t i e n t s ' coping p a t t e r n s r e f l e c t e d mature or a c t i v e forms of coping which were i n f l u e n c e d by the s i t u a t i o n a l v a r i a b l e s . The ambiguity of the s i t u a t i o n , the p e r c e i v e d s u p p o r t i v e n e s s of s o c i a l supports and c o p i n g o p t i o n s a v a i l a b l e helped determine the coping p a t t e r n of a f i r s t Ml p a t i e n t a t f i v e to seven days and e i g h t weeks post MI. More s p e c i f i c a l l y , these c o n t e x t u a l f a c t o r s may have a f f e c t e d the use of p a r t i c u l a r forms of coping such as p o s i t i v e r e a p p r a i s a l and d i s t a n c i n g to c r e a t e p o s i t i v e meaning. In t u r n , these types of c o p i n g promoted the use of coping s t r a t e g i e s r e l a t e d to p r o b l e m - s o l v i n g a c t i v i t i e s . C o n v e r s e l y , other s i t u a t i o n a l f a c t o r s r e l a t e d to the demands of the i l l n e s s and the nature of the acute care s e t t i n g may have I n h i b i t e d the escape-avoidance and c o n f r o n t i v e c o p i n g . Examining the changes over time i n the e i g h t forms of c o p i n g r e v e a l e d t h a t three c o p i n g s t r a t e g i e s s i g n i f i c a n t l y d ecreased: p o s i t i v e r e a p p r a i s a l , p l a n f u l p r o b l e m - s o l v i n g and s e e k i n g s o c i a l s u pport. The r e s u l t s support p r e v i o u s r e s e a r c h f i n d i n g s (Folkman & L a z a r u s , 1985) which r e p o r t e d s i m i l a r changes i n c o p i n g . The changes i n s i t u a t i o n a l demands as w e l l as environmental r e s o u r c e s a v a i l a b l e I n f l u e n c e d the c o p i n g s t r a t e g i e s MI p a t i e n t s used, p r i m a r i l y i n the e a r l y phases of r e c o v e r y . The r e s u l t s i n d i c a t e d s i g n i f i c a n t r e l a t i o n s h i p s between p a r t i c u l a r types of emotions and v a r i o u s c o p i n g s t r a t e g i e s . At the i n i t i a l p e r i o d , a s i g n i f i c a n t r e l a t i o n s h i p was found between t h r e a t emotions and p l a n f u l p r o b l e m - s o l v i n g c o p i n g . Harm emotions were s i g n i f i c a n t l y and p o s i t i v e l y c o r r e l a t e d with a c c e p t i n g r e s p o n s i b i l i t y , p l a n f u l p r o b l e m - s o l v i n g and c o n f r o n t i v e c o p i n g . S i m i l a r l y , c h a l l e n g e emotions c o r r e l a t e d with s e e k i n g s o c i a l support and p o s i t i v e r e a p p r a i s a l c o p i n g . S i g n i f i c a n t r e l a t i o n s h i p s were found between b e n e f i t emotions and two forms of c o p i n g : c o n f r o n t i v e and s e e k i n g s o c i a l support c o p i n g . At the second p e r i o d , o n l y two s i g n i f i c a n t c o r r e l a t i o n s were found: b e n e f i t emotions s i g n i c a n t l y c o r r e l a t e d with s e l f - c o n t r o l l i n g and a c c e p t i n g r e s p o n s i b i l i t y . The p o s i t i v e a s s o c i a t i o n s of the assessed emotion types and the v a r i o u s forms of coping suggest t h a t a heart a t t a c k Is a p p r a i s e d as moderately s t r e s s f u l by f i r s t MI p a t i e n t s who are a t f i v e to seven days and e i g h t weeks post MI. The study's r e s u l t s f u r t h e r suggest t h a t the MI p a t i e n t s ' p e r c e p t i o n or u n derstanding of the c o n t e x t u a l f a c t o r s may i n f l u e n c e t h e i r b e l i e f s which i n t u r n a f f e c t s a p p r a i s a l of harm, t h r e a t , b e n e f i t and c h a l l e n g e emotions. The l e v e l s of emotions seem to determine the c h o i c e of c o p i n g s t r a t e g i e s p a t i e n t s use to d e a l with the s t r e s s e s of a f i r s t MI at f i v e to seven days and e i g h t weeks post MI. The c o p i n g s t r a t e g i e s used r e f l e c t a more mature form of c o p i n g which enables the p a r t i c i p a n t s to m a i n t a i n hope and i n i t i a t e p r o b l e m - s o l v i n g a c t i v i t i e s . The l a c k of s i g n i f i c a n t r e s u l t s i n some areas may be r e l a t e d to m e t h o d o l o g i c a l problems. The s m a l l sample s i z e and the convenience method of sampling may have r e s u l t e d i n a sample t h a t was not r e p r e s e n t a t i v e of the p o p u l a t i o n of f i r s t MI p a t i e n t s . Measurements of emotions and c o p i n g were conducted o n l y d u r i n g the e a r l y stages of the MI r e c o v e r y process where the p a r t i c i p a n t s * understanding of the demands of t h e i r I l l n e s s i s s t i l l v e r y b a s i c . Measurement t o o l s may have a l s o caused problems. F i v e c o p i n g s c a l e s and two a p p r a i s a l s c a l e s r e p o r t e d r e l i a b i l i t y alpha c o e f f i c i e n t s below .60. The use of nonparametric t e s t s to measure changes and r e l a t i o n s h i p s In emotions and coping may have a f f e c t e d the r e s u l t s . The v a l i d i t y of the c o p i n g s t r a t e g i e s may be q u e s t i o n a b l e . Perhaps p a r t i c u l a r c o p i n g s t r a t e g i e s were not t y p i c a l of MI p a t i e n t s * ways of c o p ing, or c o u l d not be used, and t h e r e f o r e coping was not a c c u r a t e l y measured. The s t r e s s , a p p r a i s a l and c o p i n g t h e o r y p r o v i d e d a t h e o r e t i c a l b a s i s f o r e x p l a i n i n g changes and r e l a t i o n s h i p s between c o g n i t i v e a p p r a i s a l of emotions and coping s t r a t e g i e s used over time by MI p a t i e n t s . CHAPTER FIVE Summary, C o n c l u s i o n s , I m p l i c a t i o n s and Recommendations I n t r o d u c t i o n T h i s study was designed to d e s c r i b e and compare the c o g n i t i v e a p p r a i s a l and copi n g s t r a t e g i e s used by myoc a r d i a l i n f a r c t i o n p a t i e n t s a t two p o i n t s i n time, i n the i n i t i a l p e r i o d and e i g h t weeks l a t e r . A d d i t i o n a l l y , the v a r i a b l e s o£ t h r e a t , harm, c h a l l e n g e and b e n e f i t were i n v e s t i g a t e d f o r t h e i r r e l a t i o n s h i p s to the copi n g s t r a t e g i e s p a t i e n t s used d u r i n g the r e c o v e r y p r o c e s s . T h i s chapter p r e s e n t s an overview of the study, f o l l o w e d by c o n c l u s i o n s , i m p l i c a t i o n s f o r t h e o r y and n u r s i n g p r a c t i c e and recommendations f o r r e s e a r c h . Summary A review of l i t e r a t u r e suggests t h a t processes which r e l a t e to p a t i e n t s ' a p p r a i s a l s of an event h e l p e x p l a i n emotional r e a c t i o n s and copi n g s t r a t e g i e s used i n s t r e s s f u l s i t u a t i o n s . No r e s e a r c h has been found which comprehensively measures emotion a p p r a i s a l s made by p a t i e n t s r e c o v e r i n g from a MI, and how these a p p r a i s a l s change over time. Although emotion a p p r a i s a l s have not been measured, r e s e a r c h f i n d i n g s have found t h a t most MI p a t i e n t s experienced a n x i e t y and d e p r e s s i o n i n e a r l y c o n v a l e s c e n c e . A c c o r d i n g to the s t r e s s , a p p r a i s a l and c o p i n g t h e o r y , negative emotions such as these are i n d i c a t o r s of harm and t h r e a t a p p r a i s a l s . A d d i t i o n a l l y , s t u d i e s suggest t h a t a heart a t t a c k i s a l s o a s s o c i a t e d with the occurrence of p o s i t i v e emotions of hope and c o n f i d e n c e r e f l e c t i v e of c h a l l e n g e and b e n e f i t a p p r a i s a l s (Lazarus and Folkman, 1 9 8 4 ) . While r e s e a r c h f i n d i n g s have d e s c r i b e d p a r t i c u l a r forms of coping p a t i e n t s used d u r i n g the v a r i o u s coping s t a g e s , no s t u d i e s were found which I n v e s t i g a t e d how c o p i n g s t r a t e g i e s change over time. Furthermore, no r e s e a r c h s t u d i e s were found which have s y s t e m a t i c a l l y assessed the r e l a t i o n s h i p between emotions and c o p i n g In MI p a t i e n t s a t v a r i o u s stages of t h e i r i l l n e s s . T h e r e f o r e , t h i s study was designed to a s s e s s the changes and the r e l a t i o n s h i p s between c o g n i t i v e a p p r a i s a l of emotions and coping s t r a t e g i e s MI p a t i e n t s used over time . T h i s d e s c r i p t i v e c o r r e l a t i o n a l and l o n g i t u d i n a l study was i n i t i a l l y conducted i n the c r i t i c a l care f a c i l i t i e s of four h o s p i t a l s i n western Canada. Twenty-one MI p a t i e n t s who met the sampling c r i t e r i a comprised the sample. The i n v e s t i g a t o r i n t e r v i e w e d the p a r t i c i p a n t s between the f i f t h and the seventh days post MI while i n the CCU, and then i n e i g h t weeks. They completed a q u e s t i o n n a i r e which Included the Emotion A p p r a i s a l Scale (Folkman & Lazarus, 1 9 8 5 ) , the Revised Ways of Coping C h e c k l i s t (Lazarus & F o l k m a n , 1 9 8 4 ) , a s w e l l a s a n i n f o r m a t i o n s h e e t . The d a t a w e r e a n a l y s e d u s i n g d e s c r i p t i v e a nd n o n p a r a m e t r i c t e s t s . The s a m p l e c o n s i s t e d o f 5 f e m a l e s a nd 16 m a l e s . The mean age f o r t h e p a r t i c i p a n t s was 62.3 y e a r s . E i g h t y one p e r c e n t o f t h e p a r t i c i p a n t s were m a r r i e d , a nd 8 5 % had a t t a i n e d a t l e a s t a h i g h s c h o o l e d u c a t i o n . The m a j o r i t y o f p a r t i c i p a n t s w e r e r e t i r e d ( 5 2 % ) ; 2 9 % were e m p l o y e d i n t h e work f o r c e . The s a m p l e was c o m p r i s e d o f c o n f i r m e d MI p a t i e n t s w i t h no p r i o r c a r d i a c h i s t o r y , e x c e p t f o r two p a t i e n t s who ha d a h i s t o r y o f h y p e r t e n s i o n . P h y s i c a l a nd p s y c h o l o g i c a l symptoms I n c r e a s e d i n number a n d s e v e r i t y d u r i n g t h e e i g h t week p e r i o d o f t h e s t u d y . A t t h e i n i t i a l p e r i o d , 8 1 % o f t h e s u b j e c t s e x p e r i e n c e d some p h y s i c a l o r p s y c h o l o g i c a l s ymptoms; w h i l e 9 5 % r e p o r t e d v a r i o u s symptoms a t t h e s e c o n d p e r i o d . I n a d d i t i o n t o c h e s t p a i n , s h o r t n e s s o f b r e a t h a nd f a t i g u e , symptoms s u c h a s l o n e l i n e s s , t e a r f u l n e s s a n d p a i n r e l a t e d t o o t h e r m e d i c a l p r o b l e m s were a l s o r e p o r t e d . A t b o t h I n t e r v i e w s , o v e r h a l f o f t h e p a t i e n t s r e p o r t e d f a t i g u e a s t h e most f r e q u e n t symptom. The p a t i e n t s ( 1 9 % ) who were a s y m p t o m a t i c a t t h e f i r s t I n t e r v i e w had d e v e l o p e d symptoms d u r i n g t h e i r c o n v a l e s c e n c e . I n i t i a l l y , 9% o f p a t i e n t s r e p o r t e d m i l d c h e s t p a i n ; w h e r e a s 4 2 % c o m p l a i n e d o f m i l d t o s e v e r e c h e s t p a i n a t t h e s e c o n d i n t e r v i e w . A d d i t i o n a l l y , 1 9 % o f p a t i e n t s r e p o r t e d s h o r t n e s s o f b r e a t h a s a new symptom. T h i r t y - t h r e e percent of p a t i e n t s r e p o r t e d having other h e a l t h or medical problems such as d i a b e t e s and h y p e r t e n s i o n . The m a j o r i t y of p a r t i c i p a n t s (76%) were admitted to h o s p i t a l on the same day as the symptoms appeared. The l e n g t h of s t a y i n CCU ranged from 3 to 15 (M. =6.8) days. The l e n g t h of h o s p i t a l i z a t i o n ranged from 6 to 22 (H = 12.3) days. Although the m a j o r i t y of p a r t i c i p a n t s had known someone who s u f f e r e d a MI, o n l y 10% of the p a t i e n t s s t a t e d t h a t such p r e v i o u s knowledge of h e a r t a t t a c k was h e l p f u l . At both i n t e r v i e w s , the MI p a t i e n t s e x p e r i e n c e d a wide range of emotions, with moderate to low l e v e l s of the four emotion a p p r a i s a l s types of t h r e a t , harm, c h a l l e n g e and b e n e f i t . There was some v a r i a b i l i t y i n the emotions experi e n c e d by the p a t i e n t s but o n l y b e n e f i t emotions r e v e a l e d a higher degree of v a r i a b i l i t y . Challenge emotions were the most fre q u e n t a p p r a i s a l type a t both i n t e r v i e w s . I n i t i a l l y , b e n e f i t emotions were the l e a s t frequent a p p r a i s a l type, while harm emotions were the l e a s t frequent a t the second p e r i o d . The r e s u l t s suggest t h a t emotion a p p r a i s a l s may have been i n f l u e n c e d by the s i t u a t i o n a l f a c t o r s of the p e r c e i v e d c h a n g e a b i l i t y of the MI s i t u a t i o n and l a c k of knowledge r e g a r d i n g the i l l n e s s . While r e s u l t s i n d i c a t e d changes, no s i g n i f i c a n t changes were found i n the four emotion a p p r a i s a l s o f t h r e a t , harm, c h a l l e n g e and b e n e f i t . Threat emotions d e c r e a s e d s l i g h t l y o v e r t i m e (_ = 4.1, _ = 3 . 7 ) . S i m i l a r l y , harm e m o t i o n s s l i g h t l y d e c r e a s e d (M = 6.4, M = 5 . 6 ) . C h a l l e n g e e m o t i o n s i n c r e a s e d v e r y s l i g h t l y (_ = 6.1, _ = 6 . 3 ) . The g r e a t e s t c h a n g e was o b s e r v e d i n b e n e f i t e m o t i o n s , w h i c h i n c r e a s e d b u t t h e i n c r e a s e was n o t s i g n i f i c a n t (_ = 3.3, _ = 5 . 3 ) . The l a c k o f s i g n i f i c a n t c h a n g e i n e m o t i o n s p a r t i c i p a n t s e x p e r i e n c e d s u g g e s t s t h a t h a v i n g a f i r s t MI i s a s t r e s s f u l e x p e r i e n c e , a n d t h a t p e r s o n a l a n d c o n t e x t u a l f a c t o r s i n f l u e n c e s t r e s s a p p r a i s a l s i n f i r s t MI p a t i e n t s who a r e f i v e t o s e v e n d a y s a n d e i g h t weeks p o s t M I. The p a r t i c i p a n t s u s e d v a r i o u s c o p i n g s t r a t e g i e s t o manage t h e demands o f t h e i r MI. C o n s i d e r a b l e v a r i a b i l i t y was n o t e d I n t h e u s e o f p o s i t i v e r e a p p r a i s a l , s e e k i n g s o c i a l s u p p o r t , d i s t a n c i n g , e s c a p e - a v o i d a n c e a nd a c c e p t i n g r e s p o n s i b i l i t y . P l a n f u l p r o b l e m - s o l v i n g , s e l f - c o n t r o l l i n g a n d c o n f r o n t i v e c o p i n g r e v e a l e d l e s s v a r i a b i l i t y . M o s t p a r t i c i p a n t s u s e d t h e e i g h t t y p e s o f c o p i n g a t b o t h t i m e s . A l l e i g h t a v a i l a b l e t y p e s o f c o p i n g were u s e d l e s s f r e q u e n t l y a t t h e s e c o n d i n t e r v i e w , e x c e p t d i s t a n c i n g c o p i n g w h i c h I n c r e a s e d s l i g h t l y . C e r t a i n s t r a t e g i e s were s t r o n g l y i n e v i d e n c e a t b o t h p e r i o d s . The s t r a t e g i e s o f s e e k i n g s o c i a l s u p p o r t , d i s t a n c i n g a n d p o s i t i v e r e a p p r a i s a l were t h e most f r e q u e n t l y u s e d . A t t h e f i r s t i n t e r v i e w , s e e k i n g s o c i a l 126 s u p p o r t was t h e most u s e d t y p e o f s t r a t e g y , w i t h m o d e r a t e l y h i g h t o m o d e r a t e l y l o w l e v e l s r e p o r t e d a t b o t h t i m e s ( H = 1 0 . 7 , 7 . 1 ) . D i s t a n c i n g was t h e most u s e d t y p e o f s t r a t e g y a t t h e s e c o n d p e r i o d , w i t h s c o r e s i n c r e a s i n g o n l y s l i g h t l y ( H = 8.91, 9 . 4 ) . P o s i t i v e r e a p p r a i s a l was t h e s e c o n d most f r e q u e n t l y u s e d t y p e o f s t r a t e g y w i t h s c o r e s d e c r e a s i n g f r o m m o d e r a t e l y h i g h t o m o d e r a t e l e v e l s (M. = 1 1 . 4 8 , 1 0 . 3 ) . S i t u a t i o n a l f a c t o r s r e l a t i n g t o t h e a v a i l a b i l i t y o f e n v i r o n m e n t a l r e s o u r c e s , a s w e l l a s t h e n o v e l t y and t h e a m b i g u i t y o f t h e s i t u a t i o n may h a v e I n f l u e n c e d t h e u s e o f s e e k i n g s o c i a l s u p p o r t . I n t u r n , s e e k i n g s o c i a l s u p p o r t may h a v e a f f e c t e d t h e u s e o f d i s t a n c i n g a n d p o s i t i v e r e a p p r a i s a l s i n c e t h e s e s t r a t e g i e s a l l s h a r e common themes o f c r e a t i n g p o s i t i v e m e a n i n g . The s t r a t e g i e s o f a c c e p t i n g r e s p o n s i b i l i t y , p l a n f u l p r o b l e m - s o l v i n g and s e l f - c o n t r o l l i n g were m o d e r a t e l y u s e d a t b o t h t i m e s . P l a n f u l p r o b l e m - s o l v i n g d e c r e a s e d f r o m m o d e r a t e t o m o d e r a t e l y l o w l e v e l s ( H = 8.3, 7 . 1 ) . T h i s t r e n d r e f l e c t s t h a t f o u n d i n e a r l i e r r e s e a r c h s t u d i e s ( C o h e n & L a z a r u s , 1 9 7 9 ; F o l k m a n & L a z a r u s , 1980) w h i c h I n d i c a t e d t h a t i n h e a l t h - r e l a t e d s i t u a t i o n s s t r a t e g i e s r e l a t e d t o b o t h e m o t i o n - f o c u s e d and p r o b l e m - s o l v i n g c o p i n g a r e u s e d , a l t h o u g h e m o t i o n - f o c u s e d c o p i n g may be t h e p r e f e r r e d t y p e . S c o r e s on a c c e p t i n g r e s p o n s i b i l i t y d e c r e a s e d f r o m m o d e r a t e t o m o d e r a t e l y l o w l e v e l s ( H = 6.0, 4 . 6 ) . S c o r e s on s e l f - c o n t r o l l i n g r e m a i n e d m o d e r a t e l y e l e v a t e d a t both times (_ = 9.9, 8.7). A c c e p t i n g r e s p o n s i b i l i t y and s e l f - c o n t r o l l i n g which share common themes of wanting to put t h i n g s r i g h t may have i n f l u e n c e d the use of r a t i o n a l p r o b l e m - s o l v i n g . The l e a s t used s t r a t e g i e s at both times were escape-avoidance and c o n f r o n t i v e c o p i n g . Escape-avoidance i n d i c a t e d low s c o r e s a t both times (_ = 7.7, 6.3). C o n f r o n t i v e c o p i n g , the l e a s t used s t r a t e g y at both times i n d i c a t e d low s c o r e s with o n l y a s l i g h t decrease over time (_ = 4.7, 4.4). The r e s u l t s suggest t h a t s i t u a t i o n a l f a c t o r s r e l a t e d t o the demands of the i l l n e s s and h o s p i t a l environment may have prevented the p a t i e n t s from u s i n g these s t r a t e g i e s . S i g n i f i c a n t changes were noted In three forms of c o p i n g : p o s i t i v e r e a p p r a i s a l c o p i n g (_ = -2.15, p_ = .03), p l a n f u l p r o b l e m - s o l v i n g coping (_ = -1.92, p. = .055), and s e e k i n g s o c i a l support c o p i n g (_ = -2.74, p_ = .01). The r e s u l t s are c o n s i s t e n t w i t h Folkman & Lazarus' (1985) pr e v i o u s r e s e a r c h f i n d i n g s which found s i m i l a r changes i n c o p i n g . The r e s u l t s suggest t h a t changes i n s i t u a t i o n a l demands as w e l l as environmental r e s o u r c e s a v a i l a b l e may have i n f l u e n c e d the coping s t r a t e g i e s MI p a t i e n t s used i n the e a r l y phases of r e c o v e r y . At the i n i t i a l I nterview, a s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p was found between t h r e a t emotions and p l a n f u l p r o b l e m - s o l v i n g coping (rho = .49, p_ = .03). Harm emotions were s i g n i f i c a n t l y a n d p o s i t i v e l y c o r r e l a t e d w i t h t h r e e c o p i n g s c a l e s : c o n f r o n t i v e c o p i n g ( r h o = .49, p_ = . 0 3 ) , a c c e p t i n g r e s p o n s i b i l i t y c o p i n g ( r h o = .62, p_ = . 0 0 ) , a n d p l a n f u l p r o b l e m - s o l v i n g c o p i n g ( r h o = .47, p_ = . 0 3 ) . S i g n i f i c a n t p o s i t i v e c o r r e l a t i o n s w e r e f o u n d b e t w e e n c h a l l e n g e e m o t i o n s a n d t h r e e c o p i n g s c a l e s : d i s t a n c i n g c o p i n g ( r h o = .42, p_ = . 0 6 ) , s e e k i n g s o c i a l s u p p o r t c o p i n g ( r h o = .73, p_ = . 0 0 ) , and p o s i t i v e r e a p p r a i s a l c o p i n g ( r h o = .45, p_ = . 0 4 ) . S i m i l a r l y , b e n e f i t e m o t i o n s were c o r r e l a t e d w i t h two c o p i n g s c a l e s : c o n f r o n t i v e c o p i n g ( r h o = .44, p_ = .05) a n d s e e k i n g s o c i a l s u p p o r t c o p i n g ( r h o = .54, p. = .01) . A t t h e s e c o n d i n t e r v i e w , b e n e f i t e m o t i o n s s i g n i f i c a n t l y a n d p o s i t i v e l y c o r r e l a t e d w i t h two c o p i n g s c a l e s : s e l f - c o n t r o l l i n g c o p i n g ( r h o = .50, p_ = . 0 2 ) , a n d a c c e p t i n g r e s p o n s i b i l i t y c o p i n g ( r h o = .42, p_ = . 0 4 ) . The f i n d i n g s s u g g e s t t h a t p a t i e n t s ' p e r c e p t i o n o r u n d e r s t a n d i n g o f p a r t i c u l a r c o n t e x t u a l f a c t o r s i n f l u e n c e t h e i r b e l i e f s w h i c h i n t u r n a f f e c t t h e l e v e l s o f e m o t i o n s . M o d e r a t e l e v e l s o f e m o t i o n s a r e a p p r a i s e d a s s t r e s s f u l by f i r s t MI p a t i e n t s i n t h e e a r l y s t a g e s o f t h e i r I l l n e s s . T h e r e f o r e , l e v e l s o f e m o t i o n s r e p r e s e n t t h e s t r e s s e x p e r i e n c e d by p a t i e n t s , and i t i s t h i s l e v e l o f s t r e s s w h i c h d e t e r m i n e s t h e c h o i c e o f c o p i n g s t r a t e g i e s o r m e d i a t e s t h e a s s o c i a t i o n b e t w e e n e m o t i o n a p p r a i s a l s a n d t y p e s o f c o p i n g . C o n c l u s i o n s Because of the s m a l l sample s i z e and the convenience nature of the sampling procedure, the f i n d i n g s of t h i s study cannot be g e n e r a l i z e d . Despite i t s l i m i t a t i o n s , however, the the study's f i n d i n g s suggest some g e n e r a l t r e n d s and d i r e c t i o n s . O v e r a l l , i n the e a r l y stages of a f i r s t MI, c h a l l e n g e a p p r a i s a l s predominate with low to moderate l e v e l s of harm, t h r e a t , c h a l l e n g e and b e n e f i t emotions e x p e r i e n c e d . While i t i s s t r e s s f u l , a f i r s t MI i s a s s o c i a t e d with an o p t i m i s t i c outlook and a p o s i t i v e a p p r a i s a l i n p a t i e n t s who are f i v e to seven days and e i g h t weeks p o s t - i n f a r c t . T h i s predominance of c h a l l e n g e emotions suggests t h a t a l t h o u g h a h e a r t a t t a c k i s l i f e t h r e a t e n i n g , the p e r s o n a l f a c t o r s of b e l i e f s and commitments may help the i n d i v i d u a l make more f a v o r a b l e a p p r a i s a l s , m a i n t a i n hope, and t h e r e b y reduce s t r e s s . S i t u a t i o n a l f a c t o r s r e l a t i n g to the ambiguity, the n o v e l t y , the changing demands of the s i t u a t i o n as w e l l as environmental r e s o u r c e s may a f f e c t t h r e a t , harm and b e n e f i t a p p r a i s a l s . The moderate l e v e l s of t h r e a t emotions p a t i e n t s experience suggest t h a t new s i t u a t i o n s where Information i s l a c k i n g , or ambiguous s i t u a t i o n s appear to reduce t h r e a t a s s o c i a t e d with a f i r s t heart a t t a c k . Ambiguity which a l l o w s the maintenance of hope may a l s o be a m e d i a t i n g f a c t o r which c o n t r i b u t e s to the i n c r e a s i n g l e v e l s o£ b e n e f i t emotions. Moderate l e v e l s of harm emotions which p e r s i s t over time suggest t h a t the t h r e a t s and demands imposed i n the e a r l y stage by the MI c o n t i n u e to s t r e s s p a t i e n t s who are two months post MI. In the e a r l y stages of r e c o v e r y , p a t i e n t s used v a r i o u s c o p i n g s t r a t e g i e s to manage the e x i g e n c i e s of a f i r s t MI. P a t i e n t s use types of s t r a t e g i e s r e l a t e d to both emotion-focused and problem-focused coping, which are r e f l e c t i v e of mature forms of c o p i n g . The f i n d i n g s suggest t h a t p a t i e n t s w i l l use a v a r i e t y of s t r a t e g i e s to manage d i f f e r e n t f a c e t s of t h e i r i l l n e s s or t r y p a r t i c u l a r s t r a t e g i e s t o d e a l with j u s t one a s p e c t . The s t r a t e g i e s of s e e k i n g s o c i a l support, p o s i t i v e r e a p p r a i s a l and d i s t a n c i n g appear to be used the most by MI p a t i e n t s . New and ambiguous s i t u a t i o n s and the p e r c e i v e d supportIveness of environmental r e s o u r c e s may i n f l u e n c e the use of s e e k i n g s o c i a l support which promotes cop i n g s t r a t e g i e s to c r e a t e p o s i t i v e meaning such as p o s i t i v e r e a p p r a i s a l and d i s t a n c i n g . C o n v e r s e l y , the t h r e a t e n i n g nature of the i l l n e s s and h o s p i t a l environment may prevent p a t i e n t s from u s i n g s t r a t e g i e s such as escape-avoidance and c o n f r o n t i v e c o p i n g . S i g n i f i c a n t changes noted i n p o s i t i v e r e a p p r a i s a l , p l a n f u l p r o b l e m - s o l v i n g coping and s e e k i n g s o c i a l support suggest t h a t c o n t e x t u a l f a c t o r s r e l a t e d to the a v a i l a b i l i t y of environmental r e s o u r c e s and the changing s i t u a t i o n a l demands may a f f e c t coping s t r a t e g i e s p a t i e n t s use i n the e a r l y stages of r e c o v e r y f o l l o w i n g a MI. Threats and demands imposed i n the e a r l y stage by the MI c o n t i n u e to s t r e s s p a t i e n t s who are a t two months post MI. The r e s u l t s suggest t h a t MI p a t i e n t s e x p e r i e n c i n g moderate l e v e l s of harm and t h r e a t are most l i k e l y to use p l a n f u l p r o b l e m - s o l v i n g , a c c e p t i n g r e s p o n s i b i l i t y and c o n f r o n t i v e c o p i n g , a l l c o p i n g s t r a t e g i e s designed to c r e a t e p o s i t i v e meaning and manage s i t u a t i o n a l problems. Moderate to low l e v e l s of c h a l l e n g e and b e n e f i t e l i c i t v a r i o u s forms of c o p i n g r e l a t e d to s e e k i n g s o c i a l s upport, p o s i t i v e r e a p p r a i s a l , s e l f - c o n t r o l l i n g and a c c e p t i n g r e s p o n s i b i l i t y . These a s s o c i a t i o n s suggest t h a t p o s i t i v e emotions enable MI p a t i e n t s to choose types of s t r a t e g i e s which enhance the p o s s l b l i t i e s f o r e f f e c t i v e c o p i n g . The f i n d i n g s suggest t h a t MI p a t i e n t s ' p e r c e p t i o n of c o n t e x t u a l f a c t o r s a f f e c t t h e i r b e l i e f s over time which i n t u r n i n f l u e n c e l e v e l s of emotions. L e v e l s of emotions which r e f l e c t the s t r e s s e x p e r i e n c e d by MI p a t i e n t s appear to be the determinants of coping s t r a t e g i e s used i n e a r l y phases of r e c o v e r y . I m p l i c a t i o n s While t h i s study's r e s u l t s are t e n t a t i v e , they would suggest i m p l i c a t i o n s f o r both n u r s i n g t h e o r y and p r a c t i c e i f the f i n d i n g s here are confirmed i n subsequent s t u d i e s . During a c r i t i c a l i l l n e s s such as a c a r d i a c event, nurses who are i n v o l v e d i n c a r d i a c r e h a b i l i t a t i o n programs have a s u p p o r t i v e and e d u c a t i o n a l r o l e i n working with MI p a t i e n t s . A c a r d i a c event generates negative emotions such f e a r , a n x i e t y and anger but i t a l s o generates the p o s i t i v e f e e l i n g s of hope and c o n f i d e n c e . T h i s response suggests t h a t p a t i e n t s c o g n i t i v e l y a p p r a i s e the impact of the c a r d i a c event as a t h r e a t , a harm, a c h a l l e n g e and a b e n e f i t . In other words, MI p a t i e n t s can a p p r a i s e t h e i r i l l n e s s from a p o s i t i v e v i e w p o i n t , and/or i n a more s t r e s s - p r o d u c i n g negative way. The a p p r a i s a l s made by p a t i e n t s r e g a r d i n g t h e i r i l l n e s s p r o v i d e s nurses with a u s e f u l framework with which to d e s i g n e f f e c t i v e n u r s i n g i n t e r v e n t i o n s s p e c i f i c a l l y r e l a t e d to t e a c h i n g and support. An i n t e g r a l p a r t of the assessment and i n t e r v e n t i o n s n e c e s s a r y to meet p a t i e n t s ' needs i s the r e c o g n i t i o n of t h e i r emotional response to the c a r d i a c c r i s i s . Nursing I n t e r v e n t i o n s t h a t are d i r e c t e d toward a s s i s t i n g p a t i e n t s a t the a p p r a i s a l l e v e l should a l l o w them to focus on the p o s i t i v e components of the event. T h i s type of i n t e r v e n t i o n can he l p p a t i e n t s make more o p t i m i s t i c a p p r a i s a l of t h e i r i l l n e s s . In working with MI p a t i e n t s , i t i s important to h e l p them see how they p e r c e i v e t h e i r i l l n e s s , and help them make a l t e r n a t i v e a p p r a i s a l s . A d d i t i o n a l l y , n u r s i n g i n t e r v e n t i o n s should a s s i s t the p a t i e n t to manage the t h r e a t e n i n g a s p e c t s o£ the i l l n e s s and s u b s e q u e n t l y c r e a t e a l e s s s t r e s s - p r o d u c i n g response. Secondly, coping with a c a r d i a c event i s a complex p r o c e s s . MI p a t i e n t s use a v a r i e t y of coping s t r a t e g i e s r e l a t e d to both emotion-focused and problem-focused c o p i n g . The MI c r i s i s p r e s e n t s the p a t i e n t with p a r t i c u l a r demands or ta s k s which r e q u i r e a combination of coping s t r a t e g i e s . Nurses working w i t h MI p a t i e n t s need to understand the d i f f e r e n t c o p i n g s t r a t e g i e s used i n the r e c o v e r y p r o c e s s , and how through n u r s i n g i n t e r v e n t i o n s they can f a c i l i t a t e t h i s p r o c e s s . The use of emotional, i n f o r m a t i o n a l and t a n g i b l e support may be an important source of s t r e n g t h i n times of c r i s i s . O f f e r i n g emotional support means encouraging p a t i e n t s to express t h e i r f e e l i n g s i n those acute care environments t h a t o f t e n r e s t r i c t p a t i e n t s from doing so. Timely i n f o r m a t i o n can a l l e v i a t e f e a r s and a n x i e t i e s generated by a lack of knowledge of the i l l n e s s . Nurses should a l s o h elp p a t i e n t s a s sess the v a r i o u s p r o b l e m - s o l v i n g s t r a t e g i e s i n terms of s h o r t - and long-term outcomes. When p a t i e n t s l e a r n t h a t they can do something to a l t e r or minimize the ne g a t i v e e f f e c t s of t h e i r i l l n e s s t h i s may f o s t e r a sense of hope and c o n t r o l . I t i s important t h a t nurses understand how the v a r i o u s a p p r a i s a l s MI p a t i e n t s make i n f l u e n c e the c h o i c e of c o p i n g s t r a t e g i e s and u l t i m a t e l y outcomes. MI p a t i e n t s f a c i n g t h r e a t and harm may choose, at l e a s t f o r a time, s t r a t e g i e s such as escape-avoidance and c o n f r o n t i v e c o p i n g . Nurses need to be aware of the r o l e they p l a y i n c o n t r o l l i n g harm and t h r e a t emotions, and need to implement s u p p o r t i v e n u r s i n g I n t e r v e n t i o n s to a l l o w the p a t i e n t t o use such forms of c o p i n g . A d d i t i o n a l l y , nurses need to take i n t o account c e r t a i n f a c t o r s r e l a t e d to the i l l n e s s and h o s p i t a l environment t h a t can both f a c i l i t a t e or hinder v a r i o u s coping s t r a t e g i e s . The s t r e s s , a p p r a i s a l and copi n g t h e o r y i s a u s e f u l framework with which to as s e s s c o g n i t i v e a p p r a i s a l and copin g s t r a t e g i e s MI p a t i e n t s use i n the e a r l y phases of t h e i r i l l n e s s . The framework i s c l i n i c a l l y r e l e v a n t to determine the type of emotional r e a c t i o n s r e l a t e d t o harm, t h r e a t , c h a l l e n g e and b e n e f i t a p p r a i s a l s , and to I d e n t i f y forms of copi n g used to c o u n t e r a c t or enhance t h e i r e f f e c t s . R e c o m m e n d a t i o n s f o r F u r t h e r R e s e a r c h The r e s u l t s of t h i s study are i n c o n c l u s i v e and t h e r e f o r e cannot be g e n e r a l i z e d . Although the sample was s m a l l , the study f i n d i n g s i n d i c a t e d some g e n e r a l trends t h a t warrant a d d i t i o n a l r e s e a r c h . T h i s study should be r e p l i c a t e d u s i n g a l a r g e r sample. The l a c k of s i g n i f i c a n t r e s u l t s may be r e l a t e d to the time p e r i o d s choosen f o r assessment. The present study a s s e s s e d emotion a p p r a i s a l s and coping o n l y d u r i n g the e a r l y stages of the i l l n e s s . The demands of a c h r o n i c I l l n e s s may p l a y a more or l e s s important r o l e f u r t h e r a l o n g i n the course of t h i s i l l n e s s , when demands begin to be e x p e r i e n c e d . Follow-up s t u d i e s on measurements of c o g n i t i v e a p p r a i s a l and coping are needed to determine whether the p a t t e r n of r e s u l t s o b t a i n e d a t the i n i t i a l p e r i o d s remains the same over time. Repeated measure designs would p r o v i d e a more e x p l i c i t u nderstanding of the usu a l responses to a MI s i t u a t i o n , and the sequence of stages i n emotional r e a c t i o n s and coping p r o c e s s e s . I l l n e s s - r e l a t e d data suggest t h a t MI p a t i e n t s ' r e h a b i l i t a t i o n process i s i d i o s y n c r a t i c . While some p a t i e n t s e x p e r i e n c e an u n e v e n t f u l r e c o v e r y , others face a d d i t i o n a l trauma, such as a p r o g r e s s i o n i n symptoms which may le a d t o coro n a r y bypass g r a f t s u r g e r y . Assuming the d i v e r g e n t types of emotions and coping s t r a t e g i e s which are a p p r o p r i a t e f o r the demands or s t r e s s o r s , p a t i e n t s should be d i v i d e d i n t o f u r t h e r subgroups. Comparative designs would produce more a c c u r a t e measurements of emotions and coping processes i n MI p a t i e n t s e x p e r i e n c i n g a c o m p l i c a t e d or an uncomplicated r e c o v e r y . Environmental f a c t o r s r e l a t e d to the nature of the s e t t i n g a l s o appear to I n f l u e n c e emotions and coping over time. Since the con t e x t of the s i t u a t i o n i s a c r i t i c a l element, a d d i t i o n a l measurements should be obtained i n the same s e t t i n g . Future I n v e s t i g a t i o n s should focus on det e r m i n i n g the f a c t o r s w i t h i n the h o s p i t a l environment more s y s t e m a t i c a l l y . The f i r s t measurement c o u l d be taken i n CCU and the second i n a subacute u n i t p r i o r to h o s p i t a l d i s c h a r g e . In many ways t h i s study i s o n l y a b e g i n n i n g . F u r t h e r r e s e a r c h should e x p l o r e how c u l t u r a l and e d u c a t i o n a l v a r i a b l e s I n f l u e n c e p a t i e n t s ' response t o t h e i r i l l n e s s . The v a l i d i t y of the measuring t o o l s may have i n f l u e n c e d the f i n d i n g s of t h i s study. They might have i n f l a t e d or underscored the r e s u l t s . The Ways of Coping c h e c k l i s t should be r e v i s e d , and those items which perhaps c o n t a i n m u l t i p l e a c t i o n s and thoughts should be r e f i n e d before a d m i n i s t e r i n g the q u e s t i o n n a i r e i n f u t u r e r e s e a r c h . REFERENCES Burckhardt, C.S. ( 1 9 8 7 ) . Coping s t r a t e g i e s of the c h r o n i c a l l y i l l . N ursing C l i n i c s of North America, 2 2 ( 3 ) , 5 4 3 - 5 5 0 . B u r i s h , T. & B r a d l e y , L. ( 1 9 8 3 ) . Coping with c h r o n i c d i s e a s e . Research and a p p l i c a t i o n s . San F r a n c i s c o : Academic P r e s s , Inc. Burgess, W.A. & Hartman, C.R. ( 1 9 8 6 ) . P a t i e n t s p e r c e p t i o n s of the c a r d i a c c r i s e s . American J o u r n a l of  Nursing, 5_, 4 5 - 7 1 . Burns, N. & Grove, S.K. ( 1 9 8 7 ) . The p r a c t i c e of n u r s i n g r e s e a r c h : conduct, c r i t i q u e and u t i l i z a t i o n . P h i l a d e l p h i a : W.B. Saunders Co. Canada. ( 1 9 8 5 ) . Canada year book. Ottawa: M i n i s t r y of Supply and S e r v i c e s Canada. Cassem, N.H. & Hackett, T.P. ( 1 9 7 1 ) . P s y c h i a t r i c c o n s u l t a t i o n i n a c o r o n a r y care u n i t . Annals of I n t e r n a l  M e dicine, 75. ( 9 ) , 9-14. Cassem, N.H. & Hackett, T.P. ( 1 9 7 3 ) . P s y c h o l o g i c a l r e h a b i l i t a t i o n of m y o c a r d i a l i n f a r c t i o n p a t i e n t s i n acute phase. Heart and Lung. 2. ( 3 ) , 3 8 2 - 3 8 8 . Cassem, N.H. & Hackett, T.P. ( 1 9 7 7 ) . P s y c h o l o g i c a l a s p e c t s of myocardial i n f a r c t i o n . M e d i c a l C l i n i c s of North A m e r c U , £ 1 ( 4 ) , 7 1 1 - 7 2 1 . Cassem, N.H. & Hackett, T.P. ( 1 9 7 9 ) . P s y c h o l o g i c a l I n t e r v e n t i o n In myocardial i n f a r c t i o n . In W.D. Gentry and R.B. W i l l i a m s ( E d s . ) . P s y c h o l o g i c a l a s p e c t s of myocardial i n f a r c t i o n and c o r o n a r y care (2nd ed.) (pp. 1 4 9 - 1 6 1 ) . S t . L o u i s : C.V. Mosby Co. Christman, N.J., McConnell, E.A., P f e i f f e r , C , Webster, K.K., Scchmitt & R i e s , J . ( 1 9 8 8 ) . U n c e r t a i n t y , c o p i n g , and d i s t r e s s f o l l o w i n g myocardial i n f a r c t i o n : t r a n s i t i o n from h o s p i t a l t o home. Research In Nursing & H e a l t h , 11, 7 1 - 8 2 . Cohen, F. & Lazarus, R. ( 1 9 7 9 ) . Coping with the s t r e s s e s of i l l n e s s . In G.C. Stone, F. Cohen, N.E. A d l e r . Health psychology - A handbook, (pp. 2 1 7 - 2 5 4 ) . San F r a n c i s c o : Jossey-Brass P u b l i s h e r s . Cook, R.L. ( 1 9 7 9 ) . P s y c h o l o g i c a l responses to m y o c a r d i a l i n f a r c t i o n . Heart & Lung, 8. ( 1 ) , 1 3 0 - 1 3 5 . Degr6-Coustry, C. & Gr<Wisse, M. (1982). P s y c h o l o g i c a l problems In r e h a b i l i t a t i o n a f t e r m y o c a r d i a l i n f a r c t i o n : n o n - i n s t i t u t i o n a l approach. Advances i n  C a r d i o l o g y , 2__, 126-131. Folkman, S. & Lazarus, R.S. (1980). An a n a l y s i s of coping i n a middle-aged community sample. J o u r n a l of  Heal t h and S o c i a l Behavior, 21 , 219-239. Folkman, S. & Lazarus, R. (1985). I f i t changes i t must be a p r o c e s s : study of emotion and coping d u r i n g three stages of a c o l l e g e examination. J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology. 45. (1), 150-170. Folkman, S., Lazarus, R.S., Gruen, R.J., & DeLongis, A., (1986). A p p r a i s a l , c o p i n g , h e a l t h s t a t u s , and p s y c h o l o g i c a l symptoms. J o u r n a l of P e r s o n a l i t y and S o c i a l Psychology. 5_p_ (3), 571-579. Folkman, S., Lazarus, R.S., Dunkel-Schetter, C , DeLonges, A., & Green, R.J. (1986). Dynamics of a s t r e s s f u l encounter: c o g n i t i v e a p p r a i s a l , c o p i n g , and encounter outcomes. J o u r n a l of P e r s o n a l i t y and S o c i a l  Psychology. 5_ (5), 992-1003. G a r r i t y , T.F. (1975). M o r b i d i t y , m o r t a l i t y , and r e h a b i l i t a t i o n . In .W.D. Gentry and R.B. W i l l i a m s ( E d s . ) . P s y c h o l o g i c a l a s p e c t s o f m y o c a r d i a l I n f a r c t i o n a n d c o r o n a r y c a r e , (pp. 124-133). S t . L o u i s : C.V. Mosby Co. Gentry, W.D. & Haney, T. (1975). Emotional and b e h a v i o r a l r e a c t i o n s to acute myocardial i n f a r c t i o n . Heart & Lung, 1 (5), 738-745. Granger, J.W. (1974). F u l l r e c o v e r y from myocardial i n f a r c t i o n : p s y c h o s o c i a l f a c t o r s . Heart & Lung, 2 (4), (pp. 600-610). G u l l e d g e , A.D. (1979). P s y c h o l o g i c a l a f t e r maths of myocardial i n f a r c t i o n . In W.D. Gentry and R.B. W i l l i a m s ( E d s . ) . P s y c h o l o g i c a l a s p e c t s of myocardial i n f a r c t i o n and corona r y care (2nd ed. ), (pp 113-130). St. L o u i s : C.V. Mosby Co. Hackett, T.P. & Cassem, N.H. (1978). P s y c h o l o g i c a l a s p e c t s of r e h a b i l i t a t i o n a f t e r myocardial i n f a r c t i o n . In N.K. Wenger and H.K. H e l l e r s t e i n ( E d s . ) . R e h a b i l i t a t i o n of  the co r o n a r y p a t i e n t , (pp. 243-253). New York: John Wiley & Sons. H i j e c k , T.W. (1984). The h e a l t h b e l i e f model and c a r d i a c r e h a b i l i t a t i o n . Nursing C l i n i c s of North America, 11 (3), 449-457. 139 H i l t o n , B.A. ( 1 9 8 7 ) . Coping with the u n c e r t a i n t i e s of br e a s t c ancer: a p p r a i s a l and coping s t r a t e g i e s . Ann Arbor, MI: U n i v e r s i t y M i c r o f i l m s I n t e r n a t i o n a l , No. 8 7 - 0 0 , 2 0 5 . J e n k i n s , C D . ( 1 9 7 5 ) . Coping with an acute myocardial i n f a r c t i o n . In W.D. Gentry and R.B. W i l l i a m s ( E d s . ) , P s y c h o l o g i c a l a s p e c t s of myocardial i n f a r c t i o n and coron a r y c a r e , (pp 5 - 2 3 ) . S t . L o u i s : C.V. Mosby Co. Lazarus, R. ( 1 9 8 0 ) . Emotions: A c o g n i t i v e phenomenologlcal a n a l y s i s , i n R. P l u t c h i k and H. Kellerman ( E d s . ) , E m o t i o n , Theory, R e s e a r c h and E x p e r i e n c e , (pp. 1 8 9 - 2 0 7 ) New York: Academic P r e s s . L a z a r u s , R. ( 1 9 8 4 ) . The t r i v i a l i z a t i o n of d i s t r e s s . In B.L. Hammonds and C.J. S c h e i r e r ( E d s . ) . Psychology and  Hea l t h , (pp. 1 2 5 - 1 4 4 ) . Washington, DC: American P s y c h o l o g i c a l A s s o c i a t i o n . L a z a r u s , R. & Folkman, S. ( 1 9 8 4 ) . S t r e s s , a p p r a i s a l  and c o p i n g . New York: S p r i n g e r P u b l i s h i n g Co. L l p o w s k i , Z.J. ( 1 9 7 0 - 1 , 9 7 1 ) . P h y s i c a l i l l n e s s , the I n d i v i d u a l and the coping p r o c e s s e s . I n t e r n a t i o n a l J o u r n a l of P s y c h i a t r y i n Medicine, 1, 9 1 - 1 0 2 . Meddin, J . & B r e l j e , M. ( 1 9 8 3 ) . Unexpected p o s i t i v e e f f e c t s of myo c a r d i a l i n f a r c t i o n on c o u p l e s . H e a l t h and S o c i a l Work. S p r i n g . 8_ ( 2 ) , 43 -46 . McCorkle, R. & Q u i n t - B e n o l i e l , J . ( 1 9 8 3 ) . Symptom d i s t r e s s , c u r r e n t concerns and mood d i s t u r b a n c e a f t e r d i a g n o s i s of l i f e - t h r e a t e n i n g d i s e a s e . S o c i a l Science and  Med i c i n e . H ( 7 ) , 4 3 1 - 4 3 8 . McNett, S. ( 1 9 8 7 ) . S o c i a l support, t h r e a t , and e f f e c t i v e n e s s i n f u n c t i o n a l l y d i s a b l e d . Nursing Reseach, 16_ ( 2 ) , 9 8 - 1 0 3 . M i l l e r , P., G a r r e t t , M.J. McMatton, M., Johnson, N.L. & Wlkoff, R. ( 1 9 8 5 ) . Coping methods and s o c i e t a l adjustments of c a r d i o v a s c u l a r c l i e n t s . H e a l t h V a l u e s , 9_ ( 4 ) , 1 0 - 1 3 . M i l l e r , B.F. & Keane, C.B. ( 1 9 8 7 ) . E n c y c l o p e d i a and d i c t i o n a r y of medicine, n u r s i n g , and a l l i e d h e a l t h . ( 4 t h e d . ) . P h i l a d e l p h i a : W.B. Saunders Co. Monat, A. & Lazarus, R. ( 1 9 8 5 ) , S t r e s s and c o p i n g : some c u r r e n t i s s u e s and c o n t r a v e r s i e s . In A. Monat and R. Lazarus ( E d s . ) , s t r e s s and c o p i n g ; a n a n t h o l o g y . New York: Columbia U n i v e r s i t y P r e s s . N l c h o l l s , E., N a i r , C , MacWilliam, L., Moen, J . & Mao, Y. ( 1 9 8 6 ) . C a r d l o - v a s c u l a r d i s e a s e In Canada. (Catalogue 82-544) Ottawa: S t a t i s t i c s Canada, He a l t h and Welfare Canada P o l i t , D. & Hungler, B. ( 1 9 8 3 ) . Nursing r e s e a r c h  p r i n c i p l e s and methods. ( 2 n d ed. ) . P h i l a d e l p h i a : J.B. L i p p i n c o t t Co. P r a n u l i s , M.F. ( 1 9 7 5 ) . Coping with an acute m y o c a r d i a l i n f a r c t i o n . In W.D. Gentry and R.B. W i l l i a m s ( E d s . ) , P s y c h o l o g i c a l a s p e c t s of myocardial i n f a r c t i o n and c o r o n a r y c a r e . (pp 6 5 - 7 5 ) . St. L o u i s : C.V. Mosby Co. R o s s i , L. ( 1 9 8 5 ) . N u r s i n g care f o r s u r v i v o r s of sudden c a r d i a c death. N u r s i n g c l i n i c s o f N o r t h A m e r i c a , 11 ( 3 ) , 4 1 1 - 4 2 5 . S c a l z i , C.C. ( 1 9 7 3 ) . Nursing management of b e h a v i o r a l responses f o l l o w i n g an acute m y o c a r d i a l i n f a r c t i o n . Heart  & Lung. 1 ( 1 ) , 6 2 - 6 9 . Shine, K.J. ( 1 9 8 4 ) . A n x i e t y i n p a t i e n t s P s y c h o s o m a t i c s , 21 ( 1 8 ) , 2 7 - 3 1 . Wenger, N.K. ( 1 9 7 8 ) . E a r l y ambulation a f t e r m yocardial i n f a r c t i o n : r a t i o n a l e , program components, and r e s u l t s . In N.K. Wenger and H.K. H e l l e r s t e i n ( E d s . ) , R e h a b i l i t a t i o n of the c o r o n a r y p a t i e n t , (pp., 5 3 - 6 3 ) . New York: John Wiley & Sons. Wiklund, I . , Sanne, H., Vedin, A. & Wilhermsson, C. ( 1 9 8 4 ) . S i c k - r o l e and a t t i t u d e towards d i s e a s e and working l i f e two months a f t e r a m y o c a r d i a l i n f a r c t i o n , S c a n d i n a v i a n J o u r n a l R e h a b i l i t a t i o n Medicine. L i , 57-64. Wiklund, I., Sanne, H., Vedin, A. & Wilhermsson, C. ( 1 9 8 5 ) . Coping with m y o c a r d i a l i n f a r c t i o n : a model with a p p l i c a t i o n s , a l i t e r a t u r e review. I n t e r n a t i o n a l  R e h a b i l i t a t i o n Medicine. 2 ( 4 ) , 1 6 7 - 1 7 5 . Wishnie, H.A., Hackett, T.P. & Cassem, N.H. ( 1 9 7 1 ) . P s y c h o l o g i c a l hazards of convalescence f o l l o w i n g m y o c a r d i a l i n f a r c t i o n . J o u r n a l of American M e d i c a l  A s s o c i a t i o n , 2_5_ ( 8 ) , 1 2 9 2 - 1 2 9 6 . 141 Appendix A: Emotion A p p r a i s a l S c a l e Emotion A p p r a i s a l Scale 142 1. As best you can, t e l l us how you f e e l about your heart a t t a c k today. To do t h i s , p lease c i r c l e f o r each item the number t h a t best d e s c r i b e s the extent of t h a t f e e l i n g . Not a t A Some- Quite A Great a l l l i t t l e what a b i t d e a l a. t anary 0 1 2 3 4 b, l e a l o u s 0 1 2 3 4 c. w o r r i e d 0 1 2 3 4 d, c h a l l e n g e d 0 1 2 3 4 e. e x h i l a r a t e d 0 1 2 3 4 t, sad 0 1 2 3 4 q, threatened 0 1 2 3 4 h , d i s a p p o i n t e d 0 1 2 3 4 1 , secure 0 1 2 3 4 1 , harmed 0 1 2 3 4 k, c o n f i d e n t 0 1 2 3 4 1, i n c o n t r o l 0 1 2 3 4 f e a r f u l 0 1 2 3 4 n. ple a s e d 0 1 2 3 4 0 t g u i l t y 0 1 2 3 4 P, h o p e f u l 0 1 2 3 4 q, d i s g u s t e d 0 1 2 3 4 E , eaaer 0 1 2 3 4 s. f r u s t r a t e d 0 1 2 3 4 t , embarrassed 0 1 2 3 4 U t anxious 0 1 2 3 4 y, happy 0 1 2 3 4 w. envious 0 1 2 3 4 X t r e l i e v e d 0 1 2 3 4 V. other (Dlease 0 1 2 3 4 s p e c i f y ) : Appendix B: The Revised Ways of Copi The Revised Ways of Coping Scale For each item, p l e a s e i n d i c a t e , by c i r c l i n g the a p p r o p r i a t e number, to what extent you are us i n g these s t r a t e g i e s a t the present time to d e a l with your h e a r t a t t a c k s i t u a t i o n . Used Used Use Not some- q u i t e g r e a t used what a b i t a d e a l 1. I j u s t c o n c e n t r a t e on what I have to do next — t h e next s t e D 0 1 2 3 2. I t r y to analyze the problem i n order to understand i t b e t t e r 0 1 2 3 3 . I t u r n to work or s u b s t i t u t e a c t i v i t y to take my mind o f f t h i n g s 0 1 2 3 4. I f e e l t h a t time w i l l make a d i f f e r e n c e — the o n l y t h i n g to do i s to wait 0 1 2 3 5. I b a r g a i n or compromise to get something p o s i t i v e from the s i t u a t i o n 0 1 2 3 6 . I do something which I don't t h i n k w i l l work, but a t l e a s t I am doing something 0 1 2 3 7. I t r y to get the person r e s p o n s i b l e to change h i s or her mind 0 1 2 3 8. I t a l k to someone to f i n d out more about the s i t u a t i o n 0 1 2 3 9 . I c r i t i c i z e or l e c t u r e myself 0 1 2 3 10. I t r y not to burn my b r i d g e s , but leave t h i n g s open somewhat 0 1 2 3 11. I hope a m i r a c l e w i l l happen 0 1 2 3 12. I go al o n g with f a t e ; sometimes I j u s t have bad luck 0 I I 3 Used Used Used Not some- q u i t e g r e a t used what a b i t a d e a l 1 3 . I go on as i f nothing has happened 0 1 2 3 1 4 . I t r y to keep my f e e l i n a s to myself 0 1 2 3 1 5 . I look f o r the s i l v e r l i n i n g , so to speak; I t r y to look on the b r i g h t s i d e of t h i n g s 0 1 2 3 I S , I s l e e p more than u s u a l o 1. 2 3 1 7 . I express anger to the person(s) who caused the problem 0 1 2 3 1 8 . I accept sympathy and understanding from someone 0 1 2 3 1 9 . I t e l l myself t h i n g s t h a t h e l p me to f e e l b e t t e r 0 1 2 3 2 0 . I am i n s p i r e d to do soraethina c r e a t i v e 0 1 2 3 2 1 . I t r y to f o r g e t the whole t h i n g o 1 2 3 2 2 . I'm g e t t i n g p r o f e s s i o n a l h e l p o 1 2 3 2 3 . I change or grow as a person i n a good way 0 1 2 3 2 4 . I wait to see what w i l l happen before d o i n a a n y t h i n q 0 1 2 3 2 5 . I a p o l o g i z e or do something to make up for i t o 1 2 3 2 6 . I make a p l a n of a c t i o n and f o l l o w i t o 1 2 3 27 . I accept the next best t h i n g to what I want o 1 2 3 2 8 . I l e t my f e e l i n g s out somehow o 1 2 3 29 . I r e a l i z e I brought the problem on myself o 1 2 3 3 0 . I am coming out of the experience b e t t e r than when I went i n 0 1 2 3 3 1 . I t a l k to someone who c o u l d do something c o n c r e t e about the p r o b l e m 0 1 2 3 U s e d U s e d U s e d N o t some- q u i t e g r e a t u s e d what a b i t a d e a l 32. I g e t away f r o m i t f o r a w h i l e ; I t r y t o r e s t o r t a k e a v a c a t i o n 0 1 2 3 33. I t r y t o make m y s e l f f e e l b e t t e r b y e a t i n g , d r i n k i n g , s m o k i n g , u s i n g d r u g s o r m e d i c a t i o n , e t c . 0 1 2 3 34. I t a k e a b i g c h a n c e o r do s o m e t h i n g r i s k y 0 1 2 3 35. I t r y n o t t o a c t t o o h a s t i l y o r f o l l o w my f i r s t h u n c h 0 1 2 3 36, I h a v e f o u n d new f a i t h 0 2 3 37. I m a i n t a i n my p r i d e a n d k e e p a s t i f f u p p e r l i p . 0 1 2 3 38. I r e d i s c o v e r what i s i m p o r t a n t i n l i f e 0 1 2 3 39 . I c h a n g e s o m e t h i n g s o t h i n a s w i l l t u r n o u t 0 1 2 3 40. I a v o i d b e i n g w i t h p e o p l e i n g e n e r a l 0 1 2 3 4 1 . I d o n ' t l e t i t g e t t o me; I r e f u s e t o t h i n k t o o much a b o u t i t 0 1 2 3 42. I a s k a r e l a t i v e o r f r i e n d I r e s p e c t f o r a d v i c e 0 1 2 3 43 . I k e e p o t h e r s f r o m k n o w i n g how b a d t h i n a s a r e 0 1 2 3 44. I make l i g h t o f t h e s i t u a t i o n ; I r e f u s e t o a e t t o o s e r i o u s a b o u t i t 0 1 2 3 45. I t a l k t o someone a b o u t how I am f e e l i n a 0 1 2 3 46. I s t a n d my g r o u n d and f i g h t f o r what I want 0 1 2 3 47 . I t a k e i t o u t on o t h e r p e o p l e 0 1 2 3 48 . I d r a w on my p a s t e x p e r i e n c e s ; I was i n a s i m i l a r s i t u a t i o n b e f o r e 0 1 2 3 147 U s e d U s e d Used N o t some- q u i t e g r e a t u s e d what a b i t a d e a l 49. I know what h a s t o be d o n e , s o I d o u b l e my e f f o r t s t o make t h i n g s work 0 1 2 3 50. I r e f u s e t o b e l i e v e t h a t i t h a s h a p p e n e d 0 1 2 3 5 1 . I make a p r o m i s e t o m y s e l f t h a t t h i n g s w i l l be d i f f e r e n t n e x t t i m e . 0 1 2 3 52. I h a v e come up w i t h a c o u p l e o f d i f f e r e n t s o l u t i o n s t o t h e p r o b l e m Q 1 2 3 53. I a c c e p t i t , s i n c e n o t h i n a c a n be done 0 1 2 3 54. I t r y t o k e e p my f e e l i n g s f r o m i n t e r -f e r i n g w i t h o t h e r t h i n c t s t o o much 0 1 2 3 55. I w i s h t h a t I c o u l d c h a n g e w h a t h a s h a p p e n e d o r how I f e e l 0 1 2 3 56. I c h a n g e s o m e t h i n g a b o u t m y s e l f 0 1 2 3 57. I d a y d r e a m o r i m a g i n e a b e t t e r t i m e o r p l a c e t h a n t h e one I am i n 0 1 2 3 58. I w i s h t h a t t h e s i t u a t i o n w o u l d go away o r somehow be o v e r w i t h 0 1 2 3 59. I h a v e f a n t a s i e s o r w i s h e s a b o u t how t h i n g s may t u r n o u t 0 1 2 3 60, I p r a y 0 1 2 3 61. I p r e p a r e m y s e l f f o r t h e w o r s t 0 1 2 3 62. I go o v e r i n my m i n d what I w i l l s a y o r do 0 1 2 3 63 . I t h i n k a b o u t how a p e r s o n I a d m i r e w o u l d h a n d l e t h i s s i t u a t i o n a n d u s e t h a t a s a m o d e l 0 1 2 3 64. I t r y t o s e e t h i n g s f r o m t h e o t h e r p e r s o n ' s p o i n t o f v i e w 0 1 2 3 Used Used Used Not some- q u i t e g r e a t used what a b i t a d e a l 65. I remind myself how much worse t h i n g s C Q u l d be Q 1 2 1 66. T i o a or e x e r c i s e : Q 1 2 1 67. I t r y something e n t i r e l y d i f f e r e n t from any of the above (please d e s c r i b e ) 0 1 2 3 Appendix C: P a t i e n t I n - H o s p i t a l I n f o r m a t i o n Sheet 150 P a t i e n t I n - H o s p i t a l Information Sheet Age Sex M a r i t a l S t a t u s : M a r r i e d D i v o r c e d Separated Widowed S i n g l e Occupation E d u c a t i o n Date of your heart a t t a c k Date o£ admission to CCU Are you e x p e r i e n c i n g any of the f o l l o w i n g symptoms? Chest p a i n Shortness of b r e a t h F a t i g u e Other Appendix D: P a t i e n t At-Home Information Sheet 152 P a t i e n t At-Home Information Sheet Number of days spent i n CCU Date of d i s c h a r g e from h o s p i t a l Are you e x p e r i e n c i n g any of the f o l l o w i n g symptoms? Chest p a i n Shortness of b r e a t h F a t i g u e Other Do you have any other h e a l t h problems? Do you know other people who have had a heart a t t a c k ? Appendix E: Information-Consent L e t t e r Form P a t i e n t Information-Consent Form 154 My name i s Peggy Bechard. I am a R e g i s t e r e d Nurse and a student i n the Master of Science i n Nursing Program a t the U n i v e r s i t y of B r i t i s h Columbia. I am i n t e r e s t e d i n l e a r n i n g how c a r d i a c p a t i e n t s p e r c e i v e and cope with t h e i r h e a r t a t t a c k s . I am i n v i t i n g you to p a r t i c i p a t e i n t h i s study. You w i l l be asked to complete a q u e s t i o n n a i r e between the f i f t h and seventh days a f t e r your heart a t t a c k , and ag a i n e i g h t weeks f o l l o w i n g your heart a t t a c k . Each q u e s t i o n n a i r e w i l l take about 45 minutes t o complete. I c o u l d come to your home when the second q u e s t i o n n a i r e r e q u i r e s completion or any p l a c e which i s convenient to you. Although there i s .no d i r e c t b e n e f i t to you, such i n f o r m a t i o n w i l l be u s e f u l t o nurses to b e t t e r understand s t r e s s and coping behaviors used by c a r d i a c p a t i e n t s so t h a t nurses can g i v e b e t t e r c a r e . I b e l i e v e t h a t nurses need to know more about the way c a r d i a c p a t i e n t s cope, not on l y i n h o s p i t a l , but a l s o a t home d u r i n g r e c o v e r y . A l l i n f o r m a t i o n you pr o v i d e w i l l be c o n f i d e n t i a l . To p r o t e c t c o n f i d e n t i a l i t y , a code number i n s t e a d of your name w i l l be used on the q u e s t i o n n a i r e . Your p a r t i c i p a t i o n i n the study w i l l not a f f e c t your medical or n u r s i n g care while i n or a f t e r d i s c h a r g e from 

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