13 066644 PANAGOPOULOU (bc-t) 15/6/06 3:26 pm Page 809

Social Sharing of
Emotion in
Anticipation of Journal of Health Psychology
Copyright 2006 SAGE Publications
Cardiac Surgery London, Thousand Oaks and New Delhi,
www.sagepublications.com
Vol 11(5) 809820
Effects on Preoperative DOI: 10.1177/1359105306066644

Distress

EFHARIS PANAGOPOULOU
Aristotle University, Thessaloniki, Greece Abstract
This study examined associations
STAN MAES between social sharing of
Leiden University, The Netherlands
emotions, social support and
preoperative psychological distress.
BERNARD RIM
Social sharing was operationalized
University of Louvain La Neuve, Belgium
in terms of quantity and quality.
Quantity of social sharing was
ANTHONY MONTGOMERY
Royal College of Surgeons in IrelandMedical University measured daily using a diary
of Bahrain, Kingdom of Bahrain method. Quality of social sharing
was measured with the Quality of
Sharing Inventory. Participants
were 157 hospitalized Greek
patients. Hierarchical regression
analysis showed that controlling
for distress on admission, quality of
social sharing was negatively
related to distress one day before
surgery (p < .01). No effects were
found for quantity of social
sharing. Results emphasize the
importance of studying qualitative
aspects of emotional disclosure.

COMPETING INTERESTS: None declared.

Keywords
ADDRESS. Correspondence should be directed to:
E F H A R I S PA NAG O P O U L O U , Medical School, Aristotle University of
cardiac surgery
Thessaloniki, A. Svolou, 2, 54622, Thessaloniki, Greece. emotional disclosure
[email: EFHARIS@the.forthnet.gr] social sharing
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JOURNAL OF HEALTH PSYCHOLOGY 11(5)
P S Y C H O L O G I C A L research over the past
decades has attempted to establish a link
between verbal emotional disclosure and
health. Studies based on Pennebakers (1989)
writing paradigm have consistently shown the
beneficial effects of writing about emotional
upheavals in a systematic way (Smyth, 1998).
Writing about personal experiences in three or
four consecutive lab sessions resulted in more
changes in autonomic and muscular activity
(Francis & Pennebaker, 1992; Pennebaker,
Hughes, & OHeeron, 1987), enhanced immune
functioning (Pennebaker, Kiecolt-Glaser, &
Glaser, 1988; Petrie, Booth, Pennebaker,
Davison, & Thomas, 1995), fewer visits to
medical centers (Pennebaker & Hoover, 1986)
and fewer self-reports of physical symptoms
(Greenberg & Stone, 1992), as compared to
writing about trivial topics or not writing at all.
However, studies exploring the impact of
disclosure developed spontaneously after an
emotional experience, and not induced in a lab
setting, have shown a different pattern of results:
in a series of recall and diary studies, Rim and
colleagues (Rim, Finkenauer, Luminet, Zech,
& Philippot, 1998; Rim, Philippot, Boca, &
Mesquita, 1992) have examined whether social
sharing of an emotional experience leads to
emotional recovery. Social sharing was defined as
the telling of an emotional event in a socially
shared language, while emotional recovery was
defined as the difference between the initial and
the residual intensity of the emotion elicited by
the event (Rim, Mesquita, Philippot, & Boca,
1991). No significant associations were found
between social sharing of emotion and indices of
emotional recovery (Rim et al., 1992, 1998).
Such a discrepancy between studies conducted
in the lab and studies conducted in the field
highlights the need to examine more closely the
assumptions underlying the study of emotional
disclosure and health. Indeed the majority of
studies exploring spontaneous or induced
emotional disclosure have been characterized
by three limitations.
The first limitation concerns the fact that
studies have overemphasized the quantitative
aspects of emotional disclosure, and have not
sufficiently addressed issues concerning quality
(Kennedy-Moore & Watson, 1999; Rim, 1995).
Empirical evidence so far is based on how much
people share their feelings, rather than on the
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Page 810
way they share them. Yet quality of emotional
disclosure might be equally or more important
than the extent of emotional disclosure
(Kosmicki & Glickauf-Hughes, 1997). Quali-
tative issues have been partially addressed only
in relation to the content of disclosure. For
example, Pennebaker and Beall (1986) have
examined the differential effects of writing
about factual aspects of the emotional episode
as compared to writing about feeling aspects.
Greenberg and Stone (1992) have explored the
impact of disclosing traumas of different sever-
ity. However, no systematic attempt has been
made to theoretically address and empirically
assess quality of emotional disclosure as a deter-
minant of physical health and well-being.
Yet, psychological well-being is inextricably
linked to the quality of social interactions
(Nwesom, Nishishiba, Morgan, & Rook, 2003).
While a wide range of studies has demonstrated
the benefits of positive social interactions,
several studies have also examined a series of
negative social interactions that have detri-
mental effects on psychological adjustment
(Berkman, Glass, Brissette, & Seeman, 2000;
Kiekolt-Glaser, Glaser, Cacioppo, & Malarkey,
1998; Rook, 1992). Indeed, studies show that
negative interactions have a greater impact on
well-being than positive interactions (Rook,
1990). In these studies positive interactions
referred to acceptance, understanding, sympa-
thy or caring, while negative interactions
referred to criticism, rejection, violation of
privacy, failure to provide help or lack of reci-
procity (Krause & Jay, 1991; Krause & Rook,
2003; Nwesom et al., 2003; Okun & Keith, 1998;
Smith & Ingram, 2004). Based on the differen-
tial impact of quality of social exchanges on
psychological adjustment, it is important to
explore the extent to which quality of emotional
disclosure influences psychological adjustment.
The second limitation concerns the fact that
studies have not sufficiently explored the associ-
ation of emotional disclosure to availability of
social support. Social support has been favorably
associated with various health outcomes (Cohen
& Wills, 1985; Hobfoll & Vaux, 1993; Sarason,
Sarason, & Pierce, 1988). However studies have
not yet examined whether the impact of
emotional disclosure on health and well-being is
dependent on the social support available to the
individual. Studies on social interactions show
13 066644 PANAGOPOULOU (bc-t) 15/6/06 3:26 pm
PANAGOPOULOU ET AL.: SOCIAL SHARING AND PREOPERATIVE DISTRESS
that the impact of negative social interactions on
well-being does not depend on the level of social
support (Rook, 1992; Siegel, Raveis, & Karus,
1994). In other words, negative social inter-
actions may have a detrimental effect on psycho-
logical adjustment independent of the positive
effects of social support (Ingram, Jones, Fass,
Neidig, & Song, 1999; Mindes, Ingram, Kliewer,
& James, 2003). It is therefore important to
explore the extent to which the influence of
quality of emotional disclosure on well-being
depends on availability of social support.
The third limitation concerns the fact that
studies have mostly focused on healthy indi-
viduals. Indeed, studies focusing on patients,
using emotional disclosure as an independent
predictor of health improvement, have been
rare. In a recent meta-analysis exploring the
independent effects of emotional disclosure, or
emotional inhibition on health, only 15 out of
171 studies published between 1980 and 1999,
were conducted in patient populations
(Panagopoulou, Kersbergen, & Maes, 2002). The
meta-analysis highlighted the need to explore
the implication of emotional disclosure in
improving the course of a chronic disease, or
facilitating the outcome of a medical treatment.
Based on the limitations reviewed with regard
to the study of emotional disclosure and health,
the present study had two goals: the first goal
was to investigate the effects of quantity and
quality of emotional disclosure on psychological
distress before cardiac surgery, and addressed
the first limitation. Previous studies have
systematically linked preoperative distress to
postoperative recovery, adaptation and quality
of life (Andrew, Baker, Kneebone, & Knight,
2000; Bruin, Schaefer, Krohne, & Dreyer, 2001;
Kain, Sevarino, Alexander, Pincus, & Mayes,
2000; van der Zee, Huet, Gallandat, & Evers,
2002). Identifying factors influencing pre-
operative distress could help us design inter-
ventions enhancing patient adjustment before
and after surgery. The second goal of the study
was to explore associations of quality of
emotional disclosure to availability of social
support and addressed the second limitation.
Both research goals concerned psychosocial
adjustment of cardiac patients and addressed
the third limitation.
In the present study, emotional disclosure was
operationalized as the social sharing of an
Page 811
emotion, involving the telling of an emotional
experience to some addressee in a socially
shared language (Rim et al., 1991). For the
purposes of the study, we focused on the social
sharing of emotions related to the forthcoming
operation, and distinguished between quantity
and quality of social sharing. Quantity of social
sharing was defined as the extent to which
patients shared their feelings in regard to the
forthcoming operation. Quality of sharing
assessed the extent to which patients reported
intrapersonal (ventilation, relief), and interper-
sonal (receiving understanding, support, being
listened to) benefits to the sharing situation
(Zech & Rim, 2003). Thus high-quality sharing
involved the disclosure of emotional material in
a private, pleasant and understanding context,
evoking supportive reactions and reassuring
feedback. Low-quality sharing involved
disclosure of more superficial topics in a more
judgmental, less private and tenser context,
initiating reactions that were perceived to be
inappropriate, negative or repetitive.
Three hypotheses were examined in this
study: the first hypothesis was based on studies
showing no associations between quantity of
social sharing and emotional recovery (Rim
et al., 1998) and predicted that quantity of social
sharing would have no influence on preopera-
tive distress. Based on the differential impact of
negative and positive social exchanges on
psychological adjustment (Krause & Rook,
2003), the second hypothesis predicted that
quality of social sharing would be negatively
associated to preoperative distress. Finally,
based on evidence suggesting that the extent to
which negative social interactions predict
psychological adjustment does not depend on
availability of social support (Ingram et al.,
1999), the third hypothesis predicted that the
effects of quality of sharing on preoperative
distress would be independent to availability of
social support. Emotional expressiveness as a
personality trait, and clinical severity were also
included in the study as control variables.
Method
Participants
All consecutive patients admitted for non-
urgent coronary artery bypass grafting (CABG)
in the cardio thoracic surgery unit of a city
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JOURNAL OF HEALTH PSYCHOLOGY 11(5)

hospital in Greece, between January 1998 and Table 1. Demographic and medical characteristics of
February 1999 were considered potentially the sample of the study (%) N = 157
eligible for the study. Inclusion criteria were (a)
fluency in Greek, (b) physical mobility, (c) Characteristics %
ability to complete psychological question-
Gender
naires, and respond to an interview situation and Male 91.7
(d) minimum scheduled preoperative stay of Female 8.3
two days. Patients using psychoactive medi-
cation were excluded. During the period of data Age
<30 2.0
collection 256 patients were admitted for non-
3140 2.0
urgent CABG in the clinic. Ten patients refused 4150 11.2
to participate; 16 were excluded due to inability 5160 24.5
to understand Greek, or complete the question- 6170 47.7
naires; 27 were scheduled for operation the day >71 12.6
after admission; 12 left the hospital without
Occupational status
undergoing the operation; 12 could not complete Working 40.1
the first interview due to physical pain, tiredness Non-working 7.7
or severe stress symptoms; 4 patients were Retired 52.2
excluded due to hearing problems and 1 due to
Marital status
medication for psychotic episodes. Finally due
Married 87.8
to hospital administration procedures, 17 Single 2.6
patients who were admitted for operation were Divorced 3.8
not contactable. Widowed 5.8
The final sample was composed of 157 patients
New York Heart Association
representing a completion rate of 64 percent.
classification (NYHA)
The participants were predominantly male (n = I 17.5
144), and married (n = 137). Sixty percent of the II 26.5
participants (n = 94) were 60 years old or older. III 35.0
Table 1 shows a detailed description of the IV 21.0
sample.
Grafts
1 10.9
Materials 2 24.6
Quantity of sharing was measured daily, with 3 43.5
one item from the Social Sharing Diary 4 21.10
(Panagopoulou & Maes, 2003). The Social
Previous MI
Sharing Diary (SSD) was constructed based on Yes 46.8
the diary method employed by Rim and No 53.2
colleagues (1998). It comprises of one page for
each preoperative day. Patients rated on a
5-point Likert scale (1 = not at all, 5 = very much associated with one-time retrospective state-
so) the extent to which they had shared their ments (for further information on the psycho-
feelings about the surgery on that particular metric properties of the SSD see Panagopoulou
day. The final score for each patient was & Maes, 2003). The internal consistency co-
obtained by dividing the sum of the daily scores efficient for the sample of this study was satis-
by the number of preoperative days (range: factory (
= 0.93).
15). Ethical and practical considerations Quality of sharing was measured on the day
arising from the severity of the situation faced before surgery with the Quality of Sharing
by the patients prohibited the assessment of Inventory (QSI), which was constructed for the
quantity of sharing using more than one item. purposes of the study. Items for the QSI were
However, the use of multiple, daily assessments, generated by patients, through open-ended
was expected to increase the reliability of the interviews with 10 hospitalized heart-patients
instrument, by avoiding memory biases often who were asked the following question: During
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PANAGOPOULOU ET AL.: SOCIAL SHARING AND PREOPERATIVE DISTRESS
your stay in the hospital, under what circum-
stances did talking with other people make you
feel better/worse? An additional sample of 10
healthy people were asked to indicate under
what circumstances did talking with other
people in general, made them feel better/worse.
Based on the distinction made by Zech and
Rim (2003) between intrapersonal and inter-
personal benefits of social sharing, responses
were coded into two categories: the QSI-
Interpersonal category included responses
referring to the appropriateness, understanding
and supportiveness of the sharing listener (The
persons I share my thoughts and feelings with,
understand exactly what I mean), as well as to
perceptions of privacy, and comfort of the
sharing context, i.e. (During the conversation
I feel comfortable). The QSI-Intrapersonal
category included responses referring to how
personal, and emotional the content of sharing
was (During the conversation, I reveal lots of
things about myself), and the extent to which
social sharing interfered with participants
thoughts, feelings and behavior (The discussions
I am having influence the way I feel for the
better). One item was then constructed for each
response in each coding category. An equal
number of positively and negatively worded
items were constructed. Items were reviewed
for their relevance, clarity and conciseness by
four experts, and four heart-patients. The final
scale comprised of 23 items: 15 items referred
to interpersonal characteristics and 8 items
referred to intrapersonal characteristics of
quality of sharing. Respondents rated on a
5-point Likert scale the extent to which they
agreed with each statement (1 = totally disagree,
5 = totally agree).
Social support was assessed on admission day
with the social support subscale of the Leiden
Screening Questionnaire for Heart patients
(van Elderen, Chatrou, Weeda, & Maes, 1997).
The scale measures perceived availability of
emotional, instrumental, informational and
esteem support. For the purposes of the study
only the subscale on perceived emotional
support was used (
= 0.70). The respondents
received a list of 8 possible support providers
and rated on a 3-point Likert scale (0 = not at
all, 1 = partially, 2 = completely) the extent to
which they could rely on each of them every
time they faced personal problems or emotional
Page 813
difficulties. The final score for each patient
consisted of the sum of all answers (range:
016).
Preoperative distress was measured twice, on
admission day (
= 0.78), and on the day before
surgery (
= 0.80), with the negative affect
subscale of the Positive Affect Negative Affect
Scale (PANAS; Watson & Clark, 1994). The NA
scale includes 10 items measuring negative
emotions (e.g. sad; nervous). Patients rated
on a 5-point Likert scale, the intensity they had
experienced each emotion on the day of the
interview. The total score on negative affect for
each patient consisted of the sum of all items
(range: 1050).
Clinical severity of the cardiac condition was
assessed independently by a cardiologist, and
the interviewer, using the New York Heart
Association classification (NYHA). A second
cardiologist was consulted in case of disagree-
ment. Patients were classified in four categories
(I, II, III, IV), based on the severity and
frequency of symptoms and restrictions, experi-
enced as a result of anginal pain. The least
severely ill patients were classified in category I,
whereas the most severely ill patients were clas-
sified in category IV.
Emotional expressiveness as an individual
difference was assessed on admission day, using
the Emotional Expressiveness Questionnaire
(EEQ; King & Emmons, 1990). The EEQ
measures the disposition to be generally
emotionally expressive (verbally and non-
verbally), and not the disclosure of specific
emotions. It comprised of 16 items (e.g. I often
tell people I care for them; When I really like
someone, I show it). The ) level for the EEQ
scale was less than satisfactory (
= 0.60).
Removal of items did not influence the
level,
so it was decided to use the 16-item scale while
accepting that the internal consistency was less
than good (range: 1680).
Procedure
Interviews were conducted in a private room by
two trained postgraduate clinical psychology
students. Patients were approached in their
wards by one of the interviewers between 18:00
and 20:00 on admission day. They were asked to
participate in a research project investigating
the way patients deal with the experience of
cardiac surgery. After informed consent was
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JOURNAL OF HEALTH PSYCHOLOGY 11(5)
obtained from them, patients were administered
the psychological distress and emotional
support scales under the form of a structured
interview. At the end of this interview, patients
were also given the social sharing diary with the
appropriate instructions. To make sure patients
understood the questions, they were asked to
complete the first (admission) day with the
interviewer. A second interview took place on
the day before surgery. Due to hospital adminis-
tration procedures, the length of preoperative
waiting was different for each patient. Conse-
quently, the second interview took place between
the third and the tenth day of preoperative
hospitalization. Patients completed the last
preoperative day of the diary with the inter-
viewer during the second interview, and they
were also administered the Quality of Sharing
Inventory, and the psychological distress scale.
Results
Out of 157 participants interviewed on admis-
sion day, 9 had to be urgently re-scheduled for
an operation on the day following admission,
and 6 refused to continue with the study on the
second interview. In total 142 patients partici-
pated in the second interview. Data on the
Social Sharing diary were available from 152
participants. Results showed that 91 percent of
patients shared their feelings to some extent,
while 15 percent did so to a moderate or large
extent. No significant differences in quantity of
social sharing were found between the first and
last preoperative day.
Psychometric properties of the
QSI
Using principal component analysis, a 2-factor
solution was extracted (rotated using Varimax)
and accounted for 30.7 percent of the explained
variance. Three items (2, 20, 17) did not load on
any of the two factors, and were omitted from
the scale. Based on our operationalization of
quality of sharing, it was expected that items
referring to interpersonal attributes of sharing
would load onto one factor (QSI-Interper-
sonal), while items referring to intrapersonal
attributes of sharing would load onto the second
factor (QSI-intrapersonal).
Using the criterion of factor loadings >.35, 20
items loaded significantly onto the two factors.
814
Page 814
One item (8) loaded on both factors and was
also omitted from the scale. The analysis was re-
run after the exclusion of the four items. The
loadings of the final 19 items are displayed in
Table 2.
Consistent with our prediction, all items refer-
ring to interpersonal attributes of sharing,
loaded on factor QSI-interpersonal (QSI-inter),
accounting for 16.52 percent of the explained
variance, while all items referring to intra-
personal attributes of sharing loaded on the
second factor, QSI-intrapersonal (QSI-intra). In
addition to the factor analysis, confirmatory
factor analysis (CFA) was conducted using
structural equation modeling (SEM) analysis,
AMOS (Arbuckle, 1997). The maximum likeli-
hood method was used to examine the covari-
ance matrices of the items. In addition to
exploratory factor analysis, confirmatory factor
analysis (CFA) was conducted to test the factor
structure of the QSI. This involved comparing
the two-factor solution with the one-factor solu-
tion, as per the methodology recommended by
Byrne (2001). Results indicated that the two-
factor model indicated a much better fit than the
one-factor solution, (2(1) = 108.95, p < .001).
Therefore, the results indicate that the two-
factor solution represents the best fit to the data.
Two subscales for the Quality of Sharing
Inventory were then computed based on the two
factors: the subscale of interpersonal quality of
sharing consisted of 9 items (
= .70), and the
subscale of intrapersonal quality of sharing
consisted of 10 items (
=.76). Similar internal
consistency coefficients were found, when the
sample was split in two subsamples of different
clinical severity. The correlation of the two
subscales for the total sample was r = .30, p < .01.
Table 3 reveals further information on the
psychometric properties of the two subscales.
No association was found between quantity of
sharing and interpersonal quality of sharing,
while a small positive association was found
between quantity of sharing and intrapersonal
quality of sharing (r = .23, p < .01). Interpersonal
quality of sharing was not related to emotional
support, or emotional expressiveness. A small
positive association was observed between
intrapersonal quality of sharing and emotional
support (r = .31, p < .01), and between intra-
personal quality of sharing and emotional
expressiveness (r = .19, p < .05). None of the
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PANAGOPOULOU ET AL.: SOCIAL SHARING AND PREOPERATIVE DISTRESS

Table 2. Factor loadings of QSI items after orthogonal rotation with two factors

Item QSI-intrapersonal QSI-interpersonal

18. In the conversations Im having I share interesting things .72 .17

about myself
4. During the conversation, I reveal lots of things about myself .67 .29
3. After talking to somebody, I feel relieved .61 .15
7. I feel that peoples reactions every time I talk about my .61 .22
thoughts and feelings help me a lot
13. My conversations are rather superficial .54 .01
24. The conversations I am having influence the way I feel for .52 .29
the better
9. I feel that people think highly of me every time I share my .51 .01
thoughts and feelings
21. The conversations I am having are very personal .47 .09
1. Every time I feel the need to talk to somebody, there is .40 .08
always the right person around
11. Most of the times I am the one who initiates the conversations .39 .08
5. I feel that people misunderstand me when I share my thoughts .01 .75
and feelings
12. The persons I share my thoughts and feelings with, understand .23 .66
exactly what I mean
10. During the conversations I feel comfortable .11 .56
23. When I talk with other people I feel as if there is a distance .27 .54
between them
16. During the conversation there are lots of arguments .28 .53
14. People always say the same things every time I talk about my .21 .51
thoughts and feelings
19. I feel that people get the wrong idea about me every time I .04 .44
talk about my thoughts and feelings
15. During the conversations I find myself in an awkward .03 .41
position, as if I dont know what to say
6. I would have preferred to share my thoughts and feelings with .08 .36
other persons, than the ones I share them with now

Note: Items 2, 5, 6, 13, 14, 15, 16, 19, 23 are to be reversed scored

correlations were high enough to suggest multi-
collinearity (Tabachnik & Fidel, 1996).
Associations with preoperative
distress
The mean score for distress one day before
surgery was 14.66 (SD = 5.05). Paired samples
t-test showed a small significant decrease of
distress from admission day to the day before
surgery: t(140) = 2.994, p < .01.
Results showed no association between
preoperative distress and emotional expressive-
ness, severity of heart disease or intrapersonal
quality of sharing, and therefore these variables
were not included in further analyses. Addition-
ally, although the number of preoperative days
was different for each patient, number of preop-
erative days was not related to any other vari-
able included in the study. Therefore, it was
excluded from further analyses.
As shown in Table 3, distress one day before
surgery was positively related to quantity of
sharing (r = .23, p < .01), and negatively related
to interpersonal quality of sharing (r = .47,
p < .01). No associations were found between
emotional support and preoperative distress.
In order to test the three hypotheses, hier-
archical regression analysis was performed.
Step one tested for the independent effect of
distress on admission. In step two, interpersonal
quality of sharing, quantity of sharing and
emotional support were included. In step three
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JOURNAL OF HEALTH PSYCHOLOGY 11(5)

Table 3. Means, standard deviations and correlations (Pearsons r) with preoperative distress (N = 142)

Mean
(SD) 1 2 3 4 5 6 7 8

1. Quality of sharing-intrapersonal 32.33 .30** .23** .31** .19* NS NS

(7.91)
2. Quality of sharing-interpersonal 34.95 NS NS NS .37** .47**
(6.45)
3. Quantity of social sharing 2.39 .20* .17* .25** .23**
(.82)
4. Emotional support 4.82 .19* NS NS
(2.29)
5. Emotional expressiveness 55.72 NS NS NS
(8.82)
6. Distress on admission 15.85 .64** NS
(5.59)
7. Distress on day before surgery 14.66
(5.05) NS

Note: *p < .05; **p < .01; NS = non significant

the interaction term of interpersonal quality of
sharing and emotional support (emotional
support x quality) was added in order to test for
interaction effects (Aiken & West, 1991). An
interaction effect was considered present only if
the F change of the step including the inter-
action term was significant (Holmbeck, 1997).
As shown in Table 4, controlling for the effects
of distress on admission day, the only predictor
of distress one day before surgery was interper-
sonal quality of sharing: the more patients
perceived that the interpersonal quality of their
sharing was high, the less distressed they felt one
day before surgery.
Table 4. Hierarchical regression analysis for distress
one day before surgery
Standardized
coefficients
(Beta) of step 2
Distress on admission .506**
Interpersonal quality of sharing .275**
Quantity of sharing .037
Emotional support .047
Note: Step 1: Distress on admission (R2 = .396).
Step 2: Distress on admission, total quality of sharing,
quantity of sharing (R2 = .453, R2 change = .065,
F change (2,132) = 8.025, p = < .01)
*p < .05; **p < .01
816
Results showed no significant F change for
the third step, indicating no interaction between
emotional support and interpersonal quality of
sharing.
Discussion
Overall, the study indicated support for the
three hypotheses postulated. Concerning our
first hypothesis, results confirmed the prediction
that the extent to which patients share their
emotions in regard to the forthcoming opera-
tion does not influence how distressed they feel
one day before surgery. This finding is in agree-
ment with previous studies showing no signifi-
cant associations between spontaneous social
sharing and emotional recovery (Rim et al.,
1992). Results also confirmed our second
hypothesis, the prediction that high-quality
sharing of emotions is associated with reduced
distress on the day before surgery. Overall, the
study suggests that when it comes to feeling
distressed, the extent to which people share
their feelings is not as influential as the way they
do it. Along the same lines Rim (1995) has
suggested that the critical factor in the study of
sharing of emotions lies less in quantitative
aspects of sharing and more in qualitative. For
example, in a study by Zech and Rim (2003) it
was shown that perceived intrapersonal and
interpersonal benefits of social sharing were
13 066644 PANAGOPOULOU (bc-t) 15/6/06 3:26 pm
PANAGOPOULOU ET AL.: SOCIAL SHARING AND PREOPERATIVE DISTRESS
able to discriminate between sharing and
control conditions, while emotional recovery
was not. In addition it has been shown that
expressing skills, social feedback and empathy
shown by the listeners, might be more important
than the extent to which someone expresses
his/her feelings (Kosmicki & Glickauf-Hughes,
1997). In regard to the third hypothesis results
supported the prediction that the association
between quality of social sharing and preopera-
tive distress was not dependent on perceived
availability of emotional support. Results
confirm previous findings showing that the
extent to which negative social interactions
predict psychological well-being is not depen-
dent on the individuals level of social support
(Ingram et al., 1999; Mindes et al., 2003).
This study presents an attempt to theoreti-
cally address and empirically assess quality of
sharing of emotions as a determinant of psycho-
logical adjustment. In order to assess quality of
social sharing, the Quality of Sharing Inventory
was developed. Results showed that quality and
quantity are independent and unrelated aspects
of social sharing. They also suggest that quality
of social sharing is considerably different from
external and internal resources (emotional
support, and emotional expressiveness). Psycho-
metric analysis of the new instrument revealed
two underlying factors, confirming the assump-
tion that quality of social sharing refers to inter-
personal as well as intrapersonal characteristics
(Zech & Rim, 2003).
With regard to the interpersonal attributes of
quality of sharing the study showed that social-
contextual characteristics of sharing predicted
psychological distress one day before surgery:
sharing emotions in a pleasant, understanding
context, evoking supportive reactions and reas-
suring feedback was associated with decreased
distress one day before surgery. On the contrary
sharing emotions in a tense, unsupportive
context evoking repetitive or unhelpful reactions
was associated with increased distress one day
before surgery. Similarly, studies on negative
social interactions have shown the detrimental
impact of unsupportive social responses on
psychological well-being (Smith & Ingram,
2004).
Alternatively, with regard to intrapersonal
attributes of quality of sharing the study shows
that characteristics of the content of sharing
Page 817
were not related to psychological distress one
day before surgery. However, previous studies
have shown that the impact of emotional
disclosure on health and well-being depends
also on how emotional, personal or stressful the
content of the disclosure is (Greenberg & Stone,
1992; Pennebaker & Beall, 1986). However in
these studies the content of disclosure was
either controlled, or qualitatively assessed by
the researcher, while in the present study it was
participants who evaluated how personal or
revealing the content of their sharing was. It is
possible that the influence of the content of
emotional disclosure depends on the method
used to assess it.
The observed difference between quantity
and quality of social sharing in this study could
explain some of the discrepancies reported in
previous studies, between spontaneous and
induced emotional disclosure (Rim, 1995;
Rim et al., 1998). Writing about emotional
experiences in a lab setting, controls for the
influence of social and contextual character-
istics. However, social and contextual character-
istics can influence the impact of emotional
disclosure occurring spontaneously in real
settings.
In contrast to previous studies showing the
benefits of social support, results of this study
showed no associations between emotional
support and preoperative distress. This could be
attributed to the fact that emotional support was
assessed in terms of a general context, and not
in terms of a hospital-specific setting. Previous
studies have shown the beneficial effects of
social support when assessed in terms of hospi-
tal visits or support received by other patients
(Kulik & Mahler, 1989; Kulik, Mahler, & Moore,
1996). An alternative explanation for the lack of
direct effects of emotional support could be that
the scale used in the study assesses quantitative
aspects of social support rather than qualitative
aspects. Previous studies have shown that it is
not the availability (actual, or perceived) of
social resources that influences peoples psycho-
logical state, but whether and how people make
use of them, when they share their feelings
(Costanza, Derlega, & Winstead, 1988; Derlega,
Metts, Petronio, & Margulis, 1993).
The difference between quantitative and
qualitative aspects of social sharing as well as
the lack of influence of emotional support in this
817
13 066644 PANAGOPOULOU (bc-t) 15/6/06 3:26 pm
JOURNAL OF HEALTH PSYCHOLOGY 11(5)
study could be attributed to the context in which
they were measured. When in hospital people
can count on high levels of social support and
opportunities to share. It is possible that quan-
tity or emotional support might emerge as
relevant factors in other settings (e.g. when
dealing when a personal loss, or a disease diag-
nosis at home).
Given the role of preoperative distress in
influencing intra- and postoperative adaptation,
findings of this study can be used for the design
of effective interventions aiming at reducing
preoperative distress (Salmon, 1992). In-hospital
interventions, could focus on promoting success-
ful processing of surgery-related emotions, by
creating the conditions for patients to disclose
their feelings in a safe, understanding environ-
ment, or by educating support systems about
appropriate, stress-reducing responses, and
supportive feedback.
The results of the present study should be
treated with caution due to several limitations.
Quality of social sharing was measured with a
newly constructed instrument (QSI). Although
the initial psychometric properties of the instru-
ment were satisfactory, more research is needed
in order to test its convergent and discriminant
validity, and the underlying factor structure
identified in this study. In addition interpret-
ation of findings could be potentially under-
mined by the fact that quantity of sharing was
measured on a daily basis, while quality of
sharing were measured only once. Consequently
quality of sharing was not measured for the
specific interactions the sharing diary referred
to. In addition, although the study tested for the
effects of distress on admission day, a longitudi-
nal design can further examine the identified
pattern of associations.
Due to the nature of heart disease and the
consecutive sampling procedure, women were
underrepresented in the sample of this study.1
Therefore, results of the study can be general-
ized mainly to male populations. Future
research should also try to explore the effects of
other types of sharing, such as sharing about
topics irrelevant to the surgery, as well as the
differential effects of sharing with different
people. Finally, the relationships identified in
the study should be tested for positive preoper-
ative emotions and extended for postoperative
physical and psychological outcomes.
818
Page 818
This study was the first attempt to systemati-
cally explore the link between quality of social
sharing of emotions and psychological well-
being. Further analysis is needed to confirm the
underlying structure of the new concept as a
combination of social-contextual and individ-
ual-personal characteristics, and explore their
differential impact on psychological adjustment.
Note
1. Due to the small number of female participants, no
separate analyses were conducted for male and
female participants. When the analyses were re-
run including only male participants no differences
were found in the structure and strength of the
emerged relationships.
References
Aiken, L. S., & West, S. G. (1991). Multiple regression:
Testing and interpreting interactions. Newbury Park,
CA: Sage.
Andrew, M. J., Baker, R. A., Kneebone, A. C., &
Knight, J. L. (2000). Mood state as a predictor of
neuropsychological deficits following cardiac
surgery. Journal of Psychosomatic Research, 48,
537546.
Arbuckle, J. L. (1997). Amos users guide version 3.6.
Chicago, IL: Smallwaters Corporation.
Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E.
(2000). From social interaction to health: Durkheim
in the new millennium. Social Science and Medicine,
51, 843857.
Bruin, J. T., Schaefer, M. K., Krohne, H. W., & Dreyer,
A. (2001). Preoperative anxiety, coping, and intra-
operative adjustment: Are there mediating effects
of stress-induced analgesia? Psychology & Health,
16, 253271.
Byrne, B. M. (2001). Structural equation modeling
with AMOS, EQS, and LISREL: Comparative
approaches to testing for the factorial validity of a
measuring instrument. International Journal of
Testing, 1, 5586.
Cohen, S., & Wills, T. A. (1985). Stress, social support,
and the buffering hypothesis. Psychological Bulletin,
98, 310357.
Costanza, R. S., Derlega, V. J., & Winstead, B. A.
(1988). Positive and negative forms of social
support: Effects of conversational topics on coping
with stress among same-sex friends. Journal of
Experimental Social Psychology, 24, 182193.
Derlega, V. J., Metts, S., Petronio, S., & Margulis, S. T.
(1993). Coping with stress and social support. In Self-
disclosure (pp. 89109). Newbury Park, CA: Sage.
Francis, M. E., & Pennebaker, J. W. (1992). Putting
13 066644 PANAGOPOULOU (bc-t) 15/6/06 3:26 pm
PANAGOPOULOU ET AL.: SOCIAL SHARING AND PREOPERATIVE DISTRESS
stress into words: The impact of writing on physio-
logical, absentee, and self-reported emotional
well-being measures. American Journal of Health
Promotion, 6, 280287.
Greenberg, M. A., & Stone, A. A. (1992). Emotional
disclosure about traumas and its relation to health:
Effects of previous disclosure and trauma severity.
Journal of Personality and Social Psychology, 63,
7584.
Hobfoll, S. E., & Vaux,A. (1993). Social support: Social
resources and social context. In L. Goldbergen &
S. Breznitz (Eds.), Handbook of stress: Theoretical
and clinical aspects (pp. 685705). New York: The
Free Press.
Holmbeck, G. N. (1997). Toward terminological,
conceptual, and statistical clarity in the study of
mediators and moderators: Examples from the
child-clinical and paediatric psychology literatures.
Journal of Consulting and Clinical Psychology, 65,
599610.
Ingram, K. M., Jones, D. A., Fass, R. J., Neidig, J. L., &
Song, Y. S. (1999). Social support and unsupportive
social interactions: Their association and with
depression among people living with HIV. AIDS
Care, 11, 313329.
Kain, Z. N., Sevarino, F., Alexander, G. M., Pincus, S.,
& Mayes, L. C. (2000). Preoperative anxiety and
postoperative pain in women undergoing hyster-
ectomy: A repeated-measure design. Journal of
Psychosomatic Research, 49, 417422.
Kennedy-Moore, E., & Watson, J. C. (1999). Express-
ing emotions: Myths, realities, and therapeutic strat-
egies. New York: Guilford Press.
Kiecolt-Glaser, J. K., Glaser, R., Cacioppo, J. T., &
Malarkey, W. B. (1998). Marital stress: Immuno-
logic, neuroendocrine, and autonomic correlates. In
S. M. McCann & J. M. Lipton (Eds.), Annals of the
New York Academy of Sciences: Vol. 840. Neuro-
immunomodulation: Molecular aspects, integrated
systems, and clinical advances (pp. 656663). New
York: New York Academy of Sciences.
King, L. A., & Emmons, R. A. (1990). Conflict over
emotional expression: Psychological and physical
correlates. Journal of Personality and Social
Psychology, 58, 864877.
Kosmicki, F. X., & Glickauf-Hughes, C. (1997). Cathar-
sis in psychotherapy. Psychotherapy, 341, 54159.
Krause, N., & Jay, G. (1991). Stress, social support, and
negative interaction in later life. Research on Aging,
13, 333363.
Krause, N., & Rook, K. S. (2003). Negative interaction
in late life: Issues in the stability and generalizability
of conflict across relationships. Journal of Gerontol-
ogy: Psychological Science, 58B, P88P99.
Kulik, J. A., & Mahler, H. I. M. (1989). Social support
and recovery from surgery. Health Psychology, 8,
221238.
Page 819
Kulik, J. A., Mahler, H. I. M., & Moore, P. J. (1996).
Social comparison and affiliation under threat:
Effects from recovery from major surgery. Journal
of Personality and Social Psychology, 71, 967979.
Mindes, E. J., Ingram, K. M., Kliewer, W., & James,
C. A. (2003). Longitudinal analyses of the relation-
ship between unsupportive social interactions and
psychological adjustment among women with
fertility problems. Social Science & Medicine, 56,
21652180.
Nwesom, J. T., Nishishiba, M., Morgan, D. L., & Rook,
K. (2003). The relative importance of three domains
of positive and negative social exchanges: A longi-
tudinal model with comparable measures. Psychol-
ogy and Aging, 18, 746754.
Okun, M. A., & Keith, V. M. (1998). Effects of positive
and negative social exchanges with various sources
of depressive symptoms in younger and older adults.
Journal of Gerontology: Psychological Sciences,
53B, P4P20.
Panagopoulou, E., Kersbergen, B., & Maes, S. (2002).
Sick people, healthy patients: The effects of
emotional (non-) expression in (chronic) disease. A
meta-analytic review. Psychology and Health, 17,
528545.
Panagopoulou, E., & Maes, S. (2003). Social sharing in
anticipation of cardiac surgery: Who talks more and
why. Anxiety Stress, and Coping: An international
Journal, 16, 417430.
Pennebaker, J. W. (1989). Confession, inhibition, and
disease. In L. Berkowitz (Ed.), Advances in experi-
mental social psychology (vol. 22, pp. 211244). New
York: Academic Press.
Pennebaker, J. W., & Beall, S. (1986). Confronting a
traumatic event: Toward an understanding of
inhibition and disease. Journal of Abnormal Psychol-
ogy, 95, 274281.
Pennebaker, J. W., & Hoover, C. W. (1986). Inhibition
and cognition: Towards an understanding of trauma
and disease. In R. J. Davison, G. E. Schwartz, &
D. Shapiro (Eds.), Consciousness and self-regulation
(vol. 4, pp. 107136). New York: Plenum Press.
Pennebaker, J. W., Hughes, C. F., & OHeeron, R. C.
(1987). The psychophysiology of confession:
Linking inhibitory and psychosomatic processes.
Journal of Personality and Social Psychology, 52,
781793.
Pennebaker, J. W., Kiecolt-Glaser, J. K., & Glaser, R.
(1988). Disclosure of traumas and immune function:
Health implications for psychotherapy. Journal of
Consulting and Clinical Psychology, 56, 239245.
Petrie, K. J., Booth, R. J., Pennebaker, J. W., Davison,
K. P., & Thomas, M. G. (1995). Disclosure of trauma
and immune response to a hepatitis B vaccination
program. Journal of Consulting and Clinical
Psychology, 63, 787792.
Rim, B. (1995). Mental rumination, social sharing,
819
13 066644 PANAGOPOULOU (bc-t) 15/6/06 3:26 pm
JOURNAL OF HEALTH PSYCHOLOGY 11(5)
and the recovery from emotional exposure. In
J. W. Pennebaker (Ed.), Emotion, disclosure, &
health (pp. 2546). Washington, DC: American
Psychological Association.
Rim, B., Finkenauer, C., Luminet, O., Zech, E., &
Philippot, P. (1998). Social sharing of emotion: New
evidence and new questions. In W. Stroebe &
M. Hewstone (Eds.), European review of social
psychology (vol. 9., pp. 145189). Chichester: Wiley.
Rim, B., Mesquita, B., Philippot, P., & Boca, S. (1991).
Beyond the emotional event: Six studies on the
social sharing of emotion. Cognition and Emotion,
5, 435465.
Rim, B., Philippot, P., Boca, S., & Mesquita, B. (1992).
Long-lasting cognitive and social consequences of
emotion: Social sharing and rumination. European
Review of Social Psychology, 3, 225258.
Rook, K. S. (1990). Parallels in the study of social
support and social strain. Journal of Social and
Clinical Psychology, 9, 118132.
Rook, K. S. (1992). Detrimental aspects of social
relationships: Taking stock of an emerging litera-
ture. In H. O. F. Veiel & U. Baumann (Eds.), The
meaning and measurement of social support
(pp. 157169). Washington, DC: Hemisphere.
Salmon, P. (1992). Psychological factors in surgical
stress: Implications for management. Clinical
Psychology Review, 12, 681704.
Sarason, I. G., Sarason, B. R., & Pierce, G. R. (1988).
Social support, personality and health. In S. Maes &
C. D. Spielberger (Eds.), Topics in health psychology
(pp. 245256). Chichester: John Wiley & Sons.
Siegel, K., Raveis, V. H., & Karus, D. (1994). Psycho-
Author biographies
E F H A R I S PA NAG O P O U L O U is a health
psychologist. She is currently the director the
communication skills training program of the
Medical School of the Aristotle University of
Thessaloniki.
S TA N M A E Sis a health psychologist
specializing in health behavior change. He is
currently a professor of Clinical and Health
Psychology in Leiden University in The
Netherlands.
820
Page 820
logical well-being of gay men with AIDS: Contri-
bution of positive and negative illness-related
network interactions to depressive mood. Social
Science & Medicine, 39, 15551563.
Smith, N. G., & Ingram, K. M. (2004). Workplace
heterosexism and adjustment among lesbian, gay,
and bisexual individuals: The role of unsupportive
social interactions. Journal of Counselling Psychol-
ogy, 51, 5767.
Smyth, J. M. (1998). Written emotional expression:
Effect sizes, outcome types, and moderating vari-
ables. Journal of Consulting and Clinical Psychol-
ogy, 66, 174184.
Tabachnick, B. G., & Fidel, A. S. (1996). Using multi-
variate statistics. New York: HarperCollins College
Publishers.
Van der Zee, K. I., Huet, R. C., Gallandat, C. C., &
Evers, K. (2002). The influence of the premedication
consult and preparatory information about anes-
thesia on anxiety among patients undergoing
cardiac surgery. Anxiety, Stress & Coping: An Inter-
national Journal, 15, 123133.
Van Elderen, T., Chatrou, M., Weeda, H., & Maes, S.
(1997). Leidse screening vragenlijst voor hartpa-
tientenII. Leiden University, unpublished manu-
script.
Watson, D., & Clark, L. A. (1994). Manual for the
positive and negative affect scheduleexpanded
form. University of Iowa, unpublished manuscript.
Zech, E. & Rim, B. (2003). Is talking about an
emotional experience helpful? Effects on emotional
recovery and perceived benefits. Manuscript
submitted for publication.
is a social psychologist
B E R NA R D R I M
specializing in emotions. He is currently
professor of Social Psychology in the Catholic
University of Louvain La Neuve in Belgium.
A N T H O N Y M O N T G O M E RY is an
organizational health psychologist. He is
currently a senior lecturer in behavioral
sciences in The Royal College of Surgeons in
IrelandMedical University of Bahrain.