10 Psycho-oncology
Introduction
Psycho-oncology is not a self-contained medical subject. It attempts to offer a concept of coping with disease through therapeutic conversation and psychotherapies, in order to elicit a change in the meaning of life through an integration of the disease. The treating physician must recognize the reactive psychogenic processes in the patient and also within himself or herself.
It is not only the patient who needs psycho-oncological support; the assisting therapist also needs to possess the knowledge-based tools. The therapist needs supervision to prevent himself or herself from losing sight of the healing mission in the face of the demands placed on him or her through burnout.
According to a poll, 72 % of the German population believes that physical illnesses, such as cancer, can have psychological causes and 83 % of people desire an increased use of complementary–alternative and naturopathic healing methods.
The majority of the medical profession rejects complementary cancer therapy and sometimes even acts with open hostility toward it—at least when it comes to their own patients. They only open themselves up to the possibility of alternative therapies if the physician himself or herself, or a family member is affected by cancer.
The theoretical and practical basic instructional principles are the same in the conventional as in complementary medicine. Medical education is generally based on the rational scientific insights of accepted conventional medicine. Despite sharing a common foundation of knowledge, two schools of thought have developed in the field of oncology that are not only oriented according to different interests, but also represent different and occasionally opposing points of view in terms of philosophy.
The field of psycho-oncology can help patients, doctors, and therapists to overcome conflicts and crises by employing cognitive processes, self-reflection, and psychosomatic insights. It describes psychological phenomena in persons with malignant diseases as well as the interactions with the therapist and the social environment.
In many medical fields catalogued knowledge is organized and offered in a very dogmatic manner. This may be appropriate for technical issues, but it is unsuitable for the purpose of describing the psyche, since psychological processes cannot be classified into subject areas and fields of reference. Mental events display framework and textural characteristics. A specific dynamic of processes exists that is directed intrapersonally as well as interpersonally toward the conditions of the environment.
The necessary scientific analysis of singular phenomena, as we know from broad areas of medicine, is required for didactic reasons, but must not lead to the loss of awareness for the interrelatedness and uncontrollable interactions of psychological processes. The subdivision into various areas and subject areas suggests an underlying order to the psychological system. The completeness and simultaneousness of psychological issues are analyzed into their one-dimensional components, where a multidimensional approach within the time axis of anteprojection and retroprojection would be appropriate. Psychological events do not take place in the abstract realm, but in concrete persons in concrete situations (50).
The Term “Health”
This contentious definition allows normal deviations and places the power of decision on the subjective level of the individual. Freud similarly defined the goal of psychoanalysis as having been achieved once a patient attained a full ability for love, pleasure, and work. In psychoanalysis one does not differentiate between norm and neurosis in a quantitative fashion, since a conflict-free normality does not correlate with reality or real-life experiences. Psychological health equates to the competence to lead one’s life and an ability to deal with life’s daily conflicts, fears, and troubles. A conflict-free life is considered an illusion, and not the norm.
In the world of employment, the health standard is defined as the fulfillment of a function, while society, through peer pressure, subliminally demands a willingness to adapt and perform as the norm.
In the natural sciences the distribution of the norm is simply determined by quantifiable values (for example through Gaussian normal distribution curves). Psychosocial data, such as intensity of fear, pain, depressive mood, or ability to perceive enjoyment, are, in contrast, difficult to measure and always require a frame of reference as well as an interpretation. The fear of cancer can be pathological in the sense of hypochondria, but fear can also be adequate, rational, and functionally correct when cancer is actually suspected.
The Cancer Diagnosis as Psychological Trauma
The classic, reductionist world perception of conventional medicine observes the patient only as a carrier of symptoms with organic disturbances, and not as a person who suffers from a disease (26).
Kreibich-Fischer (39) showed that the reactions of the doctors, patients, and nurses to the disease entity “cancer” was responsible for disrupting the therapeutic relationship itself. Doctors and patients know about the possibility of death as a likely outcome, but find themselves bound within a therapeutic community of fate, that extends beyond the normal communication relationship between doctor and patient. The imbalance between the demands of the medical community and the powerlessness of the patient occasionally makes this relationship unbearably strenuous.
Every physician who treats cancer patients must be aware of the psychological processes that humans have at their disposal when coping with crises. Processes for overcoming crises are dependent on the concentrated life experiences of the individual and his or her level of maturity, so that each oncology patient brings his or her own strategies for coping with disease.
The direct confrontation with the often deadly disease and the not infrequently crippling therapies generally present a psychological trauma for patients. The diagnosis of cancer is experienced as a personal catastrophe and immediate threat to the patient’s existence. The patient is fundamentally and effectively rendered insecure in his psychological and social identity, and these fears become conscious. Social relationships and the patient’s orientation toward life are often newly evaluated, and future perspectives are questioned.
Every physician knows that feelings and physical functions are inextricably linked. The interactions between a mental crisis and physical reactive well-being are caused by the simultaneousness of mental–physical experience: humans cry when they are sad, and shiver when they are scared, not the other way around. The physical processes are not an expression of an individual organ, but are triggered and influenced through experience, sadness, or fear. Experienced affects of emotion are inextricably linked with concurrent physical events (44).
Coping Mechanisms and Defense Mechanisms
Defense mechanisms should not be seen as pathological but should be considered as a means of self-protection. They can be life saving and are utilized subconsciously by most people. A life without a defense system, be it on a physical, immunological, or psychological level, is plainly inconceivable. This defense system must, however, be adapted to the real situation.
Oncology patients do not want to accept the reality of their cancer and the threat to life, and they often repress this. The denial of a malignant disease can initially protect from a flood of affect that could lead to panic reaction. In order to develop targeted coping strategies, it is necessary to accept the diagnosis of cancer over the course of time, in order to be able to achieve the capacity to make therapeutic choices.
The treating physician must recognize and take into account the defense mechanisms of the patient vs. the diagnosis with respect to his diagnostic and therapeutic approach strategy.
One must differentiate between a whole slew of defense mechanisms (37):
Repression—the Basic Mechanism
The ambivalent “mercy” of an inability to remember can be conscious or unconscious.
Not everything that appears to the conscious mind is stored in the memory, and even what is stored in the memory cannot be entirely recalled over the course of time. Repression protects from traumatic memories that bring out unpleasant feelings. These feelings are neutralized and exposed to the process of forgetting. Freud called these repressions during childhood “primordial repression.” The contents thereby displaced into the subconscious mind have an effect in the later adult lifetime, not only content—related, but also in terms of repressing similar episodes, situations, and feelings.
Suppression
Suppression is a conscious activity that is closely related to the unconsciously triggered repression.
Modern, legally required informed consent of patients before diagnostic or therapeutic procedures must include statistical reporting of the risk of death before an operative procedure. This can lead to considerable fear and insecurity that are not repressed but consciously suppressed. In this way, the threatening tension of operative risk can be tolerated. The same holds true for daily risks, such as the participation in city traffic with permanent risk suppression.
Case report A 43-year-old physician erroneously misdiagnose a rapidly growing melanoma of his left groin area with lymph node involvement, as a birthmark. Only after appearance of multiple chicken egg-sized metastases did he agree to a biopsy that confirmed melanoma. He did not survive the first chemotherapy cycle. Retrospectively, it has been shown that he was very much aware of the correct diagnosis, but had totally negated and suppressed this.
Introjection and Identification
Introjection refers to the construction of an inner representative of a person, who can desert someone, or whom one decides to keep at a distance.
In contrast to the interaction with actual persons, which are also represented as a notion, the inner representation is based upon memories and not the actual experience. During introjection, the internal representation of persons—from whom one is actually separate—can be questioned. “What would dad have to say about that?” Introjection is a normal process. Through introjection, a so-called object constancy is preserved, because these persons are represented internally and the relationship with them is upheld.
If the representation with the object is positive, one can speak about an identification with the object. Identification makes the object into an idealized person. The pathological step is characterized when attributes of the idealized person are not only assumed (“I would like to be like Elvis”), but when there is an attempt to actually be the other person (“I am Elvis”).
Identification as a defense mechanism ultimately means giving up one’s own identity and neglecting the ego functionality.
Case report A patient with a kidney tumor consistently rejected nephrectomy, referring to his father, who, despite a tumor growth (benign cyst) of the left kidney, lived to be over 80 years old. The patient died four years after the diagnosis due to a metastasizing kidney tumor.
Reaction Formation
Under the term “reaction formation” one understands the phenomenon of taking feelings and turning them into their opposite.
Aggressions that are not permitted can turn into feelings of particular affection or strong pity. On the other hand, reaction formation can also hinder a necessary aggressiveness and thus inhibit necessary action, if highly valued life is at stake and needs to be saved or protected, as in an emergency, for instance.
In addition, the aggressive and partially painful tumor therapy often creates aggression in patients, causing them to appear especially submissive in their behavior through reaction formation.
Reaction formation can also be seen in the physician, when affection is presented as narcissistic aggressiveness.
Case report An engaged 40-year-old surgeon greeted his especially attractive patient: “Dear Mrs. Meier, I have both bad and good news for you. First the bad news: You have breast cancer—now the good news: I will personally be operating on you.”
Negation
Negation—like reaction formation—entails a non-recognition of reality, whereby reaction formation refers to emotion that is reverted to its opposite, while negation actually refuses to recognize the actual situation (“I do not have cancer”).
Autoaggression
When aggressions cannot be tolerated in the social environment or in the interpersonal argument, aggression can be applied against oneself as a form of defense mechanism. This can happen through self-accusations, when a person cannot disassociate himself from other aggressive people, since he or she is dependent on these and the loss would be more painful than the self-accusation. The self-accusation of guilt of depressed subjects (“I alone am to blame for everything”) simultaneously discloses fantasies of omnipotence, since nobody can possibly be the one to blame for everything (self-aggrandizement).
Denial
A fact cannot be refuted, but its meaning can be rejected.
Denial, which is similar to repression or suppression, means that the knowledge of the malignancy of the disease is concealed from oneself and others. Denial implies phenomenological perception and makes the selective derangement of interpretation become apparent. An unwillingness to recognize is often unconscious and protects the patient from the pain of the acknowledgement, for example, the fact that he or she is suffering from an untreatable disease. The occasionally experienced misunderstood therapeutic aim of forced confrontational intervention toward the patient by the therapist may lead to an increase in denial, or the intervention may succeed—albeit with severely destructive potential.
Only an empathetic systematic intervention may offer hope and alternatives and may attempt to establish the necessary correlation to reality as a basis for deciding on therapeutic measures. It is to be noted that denial as a form of defense mechanism acts to stabilize the ego, similarly to other defense mechanisms. The big difference between suppression and denial lies with the fact that suppression is a conscious action while denial is a totally subliminal process. By contrast, repression tampers with the process of forgetting and of not remembering.
Case report A 25-year-old student presented himself to his urologist with a testicular tumor twice the size of an egg. The palpated diagnosis of testicular cancer was supported both by ultrasound and through elevated levels of tumor markers such as β-HCG and PLAP. Family history was reported as negative. Despite being given thorough information on the diagnosis and treatment, the patient rejected surgery on the affected testicle, giving the argument that he banged his testicle and therefore it swelled up. He even strictly rejected an initial impulse chemotherapy (without histology, only marker directed).
Six months later, the clinic was informed of his death and of the fact that his younger brother died six years ago due to a metastasizing chemotherapy-resistant testicular cancer.
Projection
Projection relegates one’s own psychological contents, evaluations, and effects to other persons.
One reason for this is to expel something from the internal world that is bothersome and that creates conflicts. Those who do not want to experience themselves as being weak, sick, and helpless, project the moods, affects, and impulses associated with this on to others. With projection, distance is not only initiated, but the opposite can also be encouraged; intimacy and a feeling of closeness can be established. The patient projects his own feelings on to others and thereby seeks a companion in misfortune, a fellow sufferer.
A projection can proceed more unrestricted the more unrealistic and fantastic the cover is, so that it cannot be refuted and endangered by realistic circumstantial evidence.
Case report A 16-year-old woman, who suffered under a strict regime of a compulsive father (a Prussian official), fell in love with a married chief surgeon 40 years older than herself during an inpatient sojourn at a surgical clinic due to an appendectomy. She ordered flowers to her bedside as an indication of apparent gifts from the doctor. Her desire for love and affection lead to self-mutilation requiring multiple operative procedures.
Selective Perception
One does not acknowledge unpleasant things, or through simultaneous denial the significance of the perception changes (for example, skin metastases are explained by a traumatic impact).
Rationalization
Logically deducible explanations are to distract from the emotionally directed decision or action, whereby the actual feelings are subliminal.
Case report A 61-year-old man suffered from obstructive disuria with excessive nocturia. The clinical examination resulted in a 30 g prostate adenoma with slight hardening of the right lobe, upon which a fine-needle biopsy was recommended. The patient rejected the extraction of tissue, since the tumor “would explode” through the entering of air. The patient refused an operation, the radiologist refused radiation therapy without histology. After an immediate therapy with antiandrogens the symptoms improved remarkably, so that the patient only appeared in the clinic after two years, now with PSA values around 40 ng/mL. Bone scintigraphy that was previously negative, now showed multiple metastases.
The pleading of pseudorational reasons for rejection alleviated the patient from the danger to divulge his deep-seated fears. His action appeared to be well-founded to the outsider: the temporarily introduced therapy fatally supported the disease construct, since symptomatic improvement was achieved initially.
Coping
In contrast to the described psychological phenomena, coping is the ability of a human being to come to terms with his or her disease in the sense of an adaptation. The disease is overcome or accepted. The evaluation scales for surveying the “cancer personality” measure the coping disposition in order to achieve control with future-oriented data.
A further measurement instrument is the vulnerability scale as well as the questioning about stressful situations (losses), risky behavior (alcohol, nicotine etc.), and various other parameters such as, for example, social adaptation, denial, despair, alienation, and dysphoria (74).
Clinical Studies
This describes the dilemma of cancer research very well. Healthy and diseased states lie close to one another. In the past decades, an endless amount of information was gathered on cancer, its genetic causes, and the psychological interactions. Cancer cannot be understood as a simple technical problem that can simply be solved with sufficient efforts. The disappointment regarding numerous failed cancer programs has been great, not only for those affected, but also with doctors, scientists, and sponsors.
Cancer Personality
Whether or not there actually is a “type-C patient” (typus carcinomatosus) who projects psychological conflicts within the context of somatic phenomena on to a visible physical level in the form of tumor growths is still debatable.
The term “cancer personality” has established itself in the literature to a great extent, but is still a speculative empirical term and not a scientific designation. According to phenomena, he is described as friendly, with an outwardly optimistic, cheerful façade, not complaining, not aggressive, and incapable of dealing with anger in an appropriate fashion (Table 10.1) (2).
A premanifest classification of a person as a type C would entail a considerable psychological strain and stigmatization and equate to a social-medical “preconviction.”
Table 10.1 Apparent characteristics of cancer patients—psychological test outcome (64)
| Lung cancer | Breast cancer | |
| Denial and repression | +/+ | +/− |
| Reduced emotional release | +/− | ++/−/−/− |
| Rigid, conventional life-style | +/+ | 0 |
| Inhibited sexuality | + | ++++ |
| Problems of dependency | + | ++++ (on the mother) |
| Anal psychological level | +/− | 0 |
| Submissiveness | +/− | + |
| High level of assertiveness | +/− | +/− |
| High moral self-concept | +/− | + |
| Increased fear | +/+ | + |
| Reduced expression of rage | 0 | ++ |
| Readiness to make sacrifices | 0 | + |
| Masochistic character structure | +/− | ++ |
| +, confirmed; –, not confirmed; 0, no data available. |
Genetic influences, environmental conditions, malnutrition, and abuse of nicotine are considered to be more severe criteria for estimation of risk.
While the psychogenesis of cancer remains largely in the dark, the defense mechanisms and coping mechanisms are recognized as “self-defense” of the soul. Even though patients occasionally experience their disease in a skewed fashion, depending on their personality, with partially strange accusations and explanations, the psychological defense phenomena are uniform. These can become chronic and display a pathological pattern through unopposed self-enhancement.
Case report A 53-year-old bank manager who was suffering from a prostate carcinoma for eight months, reports that he “contracted” the disease during an accidental homoerotic episode with anal sex while drunk. The single episode had caused much shame and considerable feelings of guilt, so that he experienced the diagnosed prostate cancer six weeks later as a fatalistic penalization and initially rejected further (antiandrogen) treatment. Only after overcoming the pain of feeling lost and the depressive somatization (after eight months), causal therapy (radical prostatectomy) was successfully completed.
• While various authors support the correlation based on individual observations and statistical examinations ( 3, 4, 38, 41, 67), some authors accuse the supporters of these theories as lacking scientific rigor in their textbooks (75).
However, epidemiological studies prove a correlation between crisis situations and the frequency or course of disease, not only with respect to cancer (75).
• Kissen (33) tried to prove the following hypothesis: the relation between lung cancer and emotional suppression. Using the study of Le Shan (42) as a point of reference, he conducted a double-blinded study. Additionally, he chose an accepted control group, used objective instruments for measurement and put the results through excellent statistical analysis. This procedure, which nowadays is generally accepted, was completely new at that time, especially in the realm of psychosomatics.
• Kissen (33) tried to prove the following hypothesis: the relation between lung cancer and emotional suppression. Using the study of Le Shan (42) as a point of reference, he conducted a double-blinded study. Additionally, he chose an accepted control group, used objective instruments for measurement and put the results through excellent statistical analysis. This procedure, which nowadays is generally accepted, was completely new at that time, especially in the realm of psychosomatics.
Patients with a low emotionality score (Maudsley Personality Inventory) as an expression of their suppression of feelings, would, according to the hypothesis, get lung cancer at a higher rate than those in a collective control group with normal emotionality scores. The examiners did not know to which group the participants (healthy vs. diseased) belonged.
The study showed that a much higher emotionality score was achieved in the study group compared with the control group (level of significance P < 0.01).
The study was repeated several times with similar results. The probability of a person with a low emotionality score suffering from lung cancer was found to be six times higher than for persons with a normal emotionality score. This estimate, relying as it does on several observed studies, seems to indicate that even a single personality factor (emotional suppression) can demonstrate a strong correlation to lung cancer (15).
• Schmähl and Habs (60) proposed using a so-called “cancer equation,” a type of operationalization of the construct “cancer personality” (61): Probability of getting cancer = f (disposition, exposure, time/age).
• Additional studies, specifically in reference to breast cancer, also showed a positive outcome and supported the hypothesis. The cautious summarization of these studies indicates that there is a substantial connection between the development of cancer and the suppression of emotions (8).
• Tumor patients showed a reduced reaction to evoked potentials at the level of the cortex, whereby the fact that these effects appeared 200 milliseconds after stimulation seems to indicate that suppression of potentials occurred involuntarily (34).
• Type-C cancer patients were compared with type-A patients with coronary cardiac disease, who are better able to verbalize anger, aggression, and aggressive behavior as compared with the former. Additionally, a control group with type B persons (healthy) was conducted alongside this study.
The participants were exposed to stressful situations in order to trigger anger, rage, sorrow, fear, and disturbed self-esteem as well as interpersonal stress. At the same time, vegetative reactions were measured.
The participants were asked to what degree they felt disturbed by the testing conditions. The patients were also classified as emotionally repressed if they gave no verbal indication of being affected but showed strong autonomous vegetative reactions. According to the hypothesis, cancer patients displayed emotional repression the most, while coronary heart patients (type A) were the lowest, type B (normal healthy) were found to be between the two groups (35).
• An older study by Schmähl and Habs took up apparent personality characteristics of cancer patients: inability to react appropriately to stressful situations, low endurance tolerance, and the development of helplessness and hopelessness (62).
The group was made up of women who were to undergo conization due to suspicious cervical smears. Of 68 women who received conization, 28 had cervical cancer, and 40 were tumor negative. Interviews conducted before conization diagnosis were intended to offer a measure of the predictability of pathological results. The objective was to estimate the degree of hopelessness and helplessness experienced at six month before the first suspicions cervical smear.
Of the 28 tumor-positive women (proof through conization) the tumor-positive result was correctly predicted in 19 women, nine were categorized as false-negative, while 31 of the 40 tumor-negative women were correctly predicted as such. Nine women in the group were estimated as false-positive. In conclusion, the outcome was correctly predicted in 50 of 68 women, which corresponds to 74 % (level of significance of P< 0.01).
Subsequent studies have validated this outcome for the most part with other histological tumor entities as well (59, 76, 21, 28, 30). Nonetheless, these studies are not easy to interpret, since even simple rolling of dice (negative–positive) would have led to a 50 % chance of correct predictability. In combination with preselection of the group (suspect cervical smears), for both patients and interviewers an attitude of expectancy was produced—albeit subconsciously—that was essential for evaluation.
This underlines the methodological difficulties in trying to prove the intuitively perceived possibility of a psychogenesis of cancer with statistical methods. The type C, who is at risk for cancer, is more of a retrospective emotional construct, based on the emotional constellation of patients already afflicted with cancer. The truth of the matter is that, independently of any such constructs, everyone may be affected by cancer, but that psychological traumas and life crises, and the resulting changes in behavior, are able to activate a latent tumor and lead to its dissemination.
• The Heidelberg Working Group Schwarz (64) demystified the myth of the type-C cancer personality in breast and lung cancer.
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