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The Psychological Aspects of Cancer in Man
The Psychological Aspects of Cancer in Man JUDITH
BRONNER-HuSZAR, M.D.
• A better understanding of the psychiatric aspects of work with cancer patients and their relatives can enable the profession to more effectively deal with the emotional turmoil and the dire anticipations of the afflicted and their families. 1 shall concentrate on exploring the effects of physical illness and its consequences upon the previously healthy or upon the sick mind. 1 shall not attempt to deal with the question: Can emotional disturbances or grave psychological shocks-such as the loss of a beloved spouse, for instance-cause cancer, predispose towards cancer, or even influence the clinical course of neoplastic disease. To my knowledge, this has never been adequately proven as yet-nor, for that matter-has it been scientifically refuted. More, truly scientific work is needed in this area. What does illness, especially chronic, debilitating, life-endangering illness, mean to the patient? It interferes with his daily activities, earning capacity, his social and familial relationships and his sexual activities. It makes him unable to take care of himself and, therefore, delivers him to the mercy of an often merciless environment; it wracks his body with pain, a body he is compelled to watch wasting away and, ultimately, it delivers him to helpless agony and to death. And the picture is in no way overdrawn. How does the patient react to all of this special and severe form of stress? Such stress does threaten or disrupt important defense mechanisms which the patient has evolved to bring his physical and emotional needs into harmony with the demands of his environment. It follows that, whenever such defense mechanisms are threatened or disrupted, a Presented at the Seventeenth Annual Meeting of the Academy of Psychosomatic Medicine. BermUda, November 16, 1970. Dr. Bronner-Huszar is a Psychiatrist, at Memorial Hospital for Cancer and Allied Diseases. New York City, New York. March-April 1971
considerable amount of anxiety is generated as the individual feels unable to fulfill his own emotional needs or cope with his environment. He loses self-esteem and becomes vulnerable to rejection from others. The behavior of the cancer patient is designed to prevent, minimize or repair injury-not only to his body but also to his basic defense mechanisms, as well as to his interpersonal relationships. If significant defense mechanisms are not disrupted or if the individual can develop other compensatory mechanisms, then emotional difficulties are greatly lessened. What happens when the patients first discover that something is wrong? Realistic patients will seek help as soon as possible, from the best available source. But, how will the others deal with anxiety aroused by the discovery? Some will at first be overwhelmed by it, but will eventually end up seeking treatment-which mayor may not be too late to bring cure or palliation. Very much akin to delay is the denial of the need for treatment, or even of the very existence of the signs or the symptoms of the disease. The threat to integrity is perceived as so great that it must be excluded from consciousness and/or it is hoped that by ignoring it, by not doing anything about it, it will magically go away all by itself. Of course, there are patients to whom the prospect of a mutilating operation is more threatening than the disease itself. This is especially true when the loss of valued organs is involved, such as the breast, anal sphincter, eye or testes. The rationalization here is that, "1 am going to die anyway so why die mutilated?" The threat of dying, frightening as it might be, seems yet a long-range prospect, whereas the operation would be immediate, drastic, irreversible. Here, too, the mechanisms of denial and of magical thinking are part of the picture. Besides, there is always the hope of a sudden break-through in cancer research. Failing that, the "magic" of quacks or of 133
PSYCHOSOMATICS
mystics may be called upon. What happens when the patient is admitted to the hospital? He surrenders his independence, his accustomed way of life; also, he must face mysterious diagnostic procedures, the threat of surgery and possible loss of parts of his body, disability and even death. Anxiety ensues, quite naturally. Anxiety may often be revealed only by such somatic manifestations as tachycardia, anorexia and insomnia. Occasionally, the anxiety may be so great as to cause long-deceased parents to be resurrected in dreams to reassure patients and to protect them. Individuals who have emotional problems involving self-destructiveness are particularly prone to acute preoperative anxiety concerned with death or mutilation in surgery. Thus, some patients likened the operating room to "a slaughter house." One patient said that he "felt guilty, like I lost a case and had to go to the electric chair. I felt that there was no hope left for me." Nightmares often are of hallucinatory vividness. Patients dreamt of being attacked by wild animals, or of seeing their own graves with their very names on the tombstones. One patient, prior to mastectomy, saw female breasts suspended from the meathooks in a butcher shop. When patients do not have specific knowledge of the operation and its residual effects preoperatively, acute anxiety usually predominates over depression. Acute depressions are very frequent, sometimes accompanied by marked suicidal trends. When valued defenses and behavior patterns, basic to the maintenance of self-respect, are threatened or disrupted by the illness itself, by treatment or its sequelae, depression occurs in addition to anxiety. When the patient is not able to call upon compensatory defenses, depression persists. Obviously, the loss of a valued organ in itself can produce depression, again when the loss interferes with the basic character defenses of the individual. The woman whose value and acceptability to others is predicated on her appearance will feel lost should one of her breasts be removed. She will feel worthless, ugly, defeminized, socially and sexually inacceptable. 134
In the patient whose adaptation centered around compulsive cleanliness and control, the destruction of the anal sphincter is even more of a tragedy than in others. Rejection is feared from the entire world as it was once feared from the toilet-training mother. In the case of colostomy, the expulsion of gas which is uncontrollable and often very noisy; the everpresent fear of embarrassing spillage, engender self-hatred, depression and withdrawal, turning the patient away from other human beings. Quite obviously the impotent male, castrated for carcinoma of the prostate, or the frigid female, having undergone oophorectomy combined with adrenalectomy for carcinoma of the breast, have ample reasons for becoming depressed and usually do so. Depression may be increased by the attitudes of significant people in the environment. Thus, the marital partner may be unable to accept the illness and its consequences, reject the patient and intensify depression. Following surgery and / or other drastic forms of therapy, in addition to anxiety, depression, withdrawal, loss of self-esteem and feelings of rejection, such reactions as denial, regression, hypochondriasis, exaggerated dependency or rage and resentment towards the environment-be it family or medical personnel-are fairly common. Obsessive-compulsive reactions are usually seen in patients who have had operations on sphincters: thus, the bathroom-addict colostomy patient is well known to the abdominal surgeon. Even more serious psychological complications of cancer and its treatment are occasionally encountered. Besides suicidal tendencies, serious paranoid and delusional reactions or acute schizophrenic reactions can sometimes occur. It goes without saying that the etiology of these complications has to be carefully investigated in order to differentiate purely psychogenic reactions from brain metastases, from electrolyte imbalance and from metabolic or pharmacologically induced reactions. Any postoperative complication, such as infection, phlebothrombosis or bronchopneumonia, may reinforce beliefs of irreversible bodily injury. Wound dehiscence after masVolume XII
PSYCHOLOGICAL ASPECTS OF CANCER-BRONNER-HUSZAR
tectomy rather regularly intensifies such responses. Complications then may be ascribed to surgical incompetence or to uncontrollable or recurrent cancer. Obviously the cancer patient lives with the constant fear of recurrences and of metastases. That this fear is realistic in many cases was dramatically brought home to me the day I saw a woman with a recurrence on the site of a mastectomy for cancer performed about thirty years previously. Remission or recovery after treatment for neoplastic disease can only be considered complete when the patient is able to fully resume work and all significant premorbid pursuits, such as social, recreational and sexual activities. "In the case of protracted invalidism after antineoplastic therapeutics, when the patient's apparent physical condition would in no way warrant such invalidism, psychological factors are as responsible for the situation as cryptic infections or the classic sponge left in the wound,"-says Sutherland, past leader of the pioneering Memorial Hospital team. The incidence of psychogenic invalidism in the cancer patient can only be decreased in one way: the establishment of proper communication in order to decrease anxieties and to avoid creating new ones. Few people realize the extent of the repercussions that inadequate or inappropriate communications can have upon the patient. Let me illustrate this with a case from my OWl"'. experience: A sedate. middle-class patient--Iet us call her Jane-was referred to the Psychiatric Out-Patient Clinic of Memorial Hospital for intractable chest pain. A thorough investigation revealed no organic etiology that could account for the pa'n nor did it respond to any somatic therapy, be it medication, radiat'on or even nerve block. She related the following to me: "After I had discovered a lump in my left breast I went to see mv family doctor, Dr. Smith (the names are fictitious), who referred me to Dr. Jones, a surgeon. Dr. Jones told Dr. Smith that he wanted to take out the growth; Dr. Smith encouraged me to let him do it. I said 'all right but under no circumstances do I want him to remove the whole breast.' Dr. Smith assured me that my wish would certainly be respected. So I entered the hospital the day before the operation was to be performed. March-April 1971
In the evening I was given some pills that made me very groggy. Then I vaguely remember that I was given a piece of paper that I had to sign. I don't know who gave it to me nor what it was all about. I was too dopey to realize anything. In the morning I was taken to the operation room and put to sleep. The next thing I remember is finding myself in a hospital bed; Dr. Jones was just coming in the door. 'Well beautifUl,' he greeted me, 'now you can't become a Copacabana girl any longer.' I didn't know what he was talking about except that I found his language insulting. Then he examined me and the realization came to me that my left breast had been removed. I was very angry and I tried to tell him so, much as I could. I was still groggy from the anesthesia and I couldn't very well find the words. He never again came back to see me while I was at the hospital." Jane decided not to sue Dr. Jones--which sre very possibly could have. Instead, she haunted him with her complaints of chest pain localized-I am sure you have guessed where-in the area of her mastectomy scar. It is also obvious that nothing Dr. Jones, or Dr. Smith for that matter, could do would alleviate Jane's pain.
jane's case is an extreme example of mismanagement. But even lesser, more subtle, psychological insults or lack of communication can result in troublesome, organic, inexplicable postoperative difficulties. What to do to avoid them? The patient will tell you. If you watch him and listen to him carefully, he wiII tell you about his doubts and anxieties, his attitudes and misconceptions about his illness; he will give you an idea of his personality and of the cultural influences that shaped it. This information should give you a very good idea of what, how much and how to tell him. The first problem, of course, IS to decide whether or not to tell him the diagnosis. Physicians manifest a wide variety of attitudes about cancer. Thus, some physicians go to great lengths to "protect" their patients from this knowledge, whereas others inform them of their diagnosis, no matter what, in precise medical and/or lay terms. In the past, several surveys of physicians' opinions have been made about the problem of whether or not to inform cancer patients of their diagnoses. Surveys have also been made of patients' opinions about being informed of their diagnoses. It seems that most physicians don't want to tell, 135
PSYCHOSOMATICS
whereas a large majority of patients at least say that they want to be informed. More confusion is added when we learn from Oken's study that, while the physicians at Michael Reese Hospital would themselves want to be told of their diagnoses, they are no more likely to tell a physician colleague his diagnosis than they are to tell it to a layman. Vernick and Karon in their study, "Who's Afraid of Death on a Leukemia Ward?" came to the conclusion that most children studied had some knowledge of the seriousness of their illness, that some even knew exactly what was wrong and that all worried. These hospitalwise children quickly learned to interpret the sudden absence of a playmate, the removal of the oxygen tent, the room change in the middle of the night and even the disconnection of the Bird respirator. Children are very acutely attuned to the wave lengths of their environment. When the physician gives the fateful news to the parents, the child immediately "knows" that he has something very serious because his entire environment changes. His parents, no matter how hard they try, cannot conceal their own grave concerns. The child quickly senses that the people whom he had come to trust and love are now keeping something from him, something frightening. All the children studied by Vernick and Karon were worried by the erection of a wall of secrecy. These authors also found that failure to discuss the diagnosis with the child could lead to behavior problems which disappeared once the wall of secrecy was removed and the child was allowed to discuss his feelings freely. Vernick and Karon attempted to meet the emotional needs of the seriously ill child by providing an atmosphere in which such children could feel completely free to express their concerns-an atmosphere which always provided an honest answer to any question. The diagnosis and its implications were freely shared with all members of the immediate family, especially with the siblings, in order to avoid jealousies arising from the special treatment the sick child invariably receives from the family. As for the results of this policy, Vernick and Karon reported that all children studied 136
by them were able to function normallywithin the physical limitations permitted by their illness. The withdrawal and depression so often observed by others even in the presence of a parent participation program occurred very infrequently and was always transient. I cannot resist reporting how Vernick, and Karon's policy of thorough discussion of the diagnosis with the patient enabled a child to protect himself against the thoughtless barbs of his peers. Upon his return from the hospital, patient "G" was greeted by one of his chums by, "You've got leukemia. You're supposed to be dead." He quickly snapped back, "Dead, hell. I'm here, ain't I?" Once more the question is, to what extent this atmosphere of candidness and trust can be instituted elsewhere, not only on children's but also on adult wards. Sutherland provides an answer. "The question of whether or not the doctor should tell the patient he has cancer cannot be answered because it presupposes a standard doctor, a standard patient and a standard cancer, none of which exists." In the pretreatment phase of cancer therapy, no matter what is done to minimize, avoid or to prevent injury, there is mounting anxiety. Anxiety may even disrupt communications and cause some patients to distort the physician's statements; this, in turn, will further increase anxiety. Obviously, it is vitally important that the physician do his best to relieve anxiety and fear. If the patient can see him as a kindly, protective and healing figure, intent on preventing damage to the cancer victim, anxiety can be considerably diminished and treatment will be better accepted. Later, the physician should be able to capitalize on good preoperative rapport in minimizing crippling notions of bodily injury and in encouraging the patient to resume normal, everyday activities. If, on the other hand, the physician remains distant or is otherwise unable to manage the patient's anxieties, then he may be seen unconsciously or even consciously by the patient as an injuring figure, identified with punitive, internalized conscience figures. The patient will then have difficulty in believing that anything done by the Volume XII
PSYCHOLOGICAL ASPECTS OF CANCER-BRONNER-HUSZAR
physician can be curative or therapeutic. Time spent in diminishing anxiety and building good rapport between the patient and his doctor does pay great dividends in the post-treatment course. This is especially true for ward and clinic patients. Some of these speak of being "guinea pigs," treated for research purposes only, of being operated on by "student surgeons," or "cut up by strangers," and approach any treatment with considerable amounts of anxiety. Much of how the hospitalized patient feels and reacts will also depend on the attitudes of the nonmedical-the administrative, the dietary and, especially, the ward personnel. The threats facing these patients and their anxities must be acknowledged by staff personnel and effectively managed. The cancer patient is not easy to handle. Forced to helplessly view his own deterioration, he will often be irritable, demanding or suspicious, to the point of suspecting the ward personnel of discriminating against him when his wishes or needs aren't immediately met. His withdrawal or maybe his all too frequent bids for attention will not endear him to the nursing staff either. Should his needs for reassurance, underlying much of his acting out, be met with hostility-which they often are-his anxiety and his sense of isolation will further increase, deepening his withdrawal or enhancing his acting out. In and out of the hospital, much will depend on the attitude of the family toward the patient. The nature of the relationship prior to the illness will almost always determine the relationship during any phase of the illness. Where there was genuine warmth previously, effective support can be expected. In purely facade relationships, ambivalent or indifferent facade support will prevail. As to previously hostile relationships, they will remain overtly or covertly hostile, retreating possibly under the mask of hypocritical, superficial pseudosupport. In any event, the family's attitude will help or sabotage attempts at rehabilitating the patient. There is hardly any need to discuss the disruptions caused in any family by nursing at home an invalid who is deteriorating, terMarch-April 1971
minaI, and fully aware of the disruptions he is causing, the hostilities he is engendering and cognizant of his total physical incapacity to do anything about the situation. How can the psychological difficulties of the cancer patient be lessened? Of course, there are the psychopharmacological drugs. Tranquilizers such as Thorazine, Mellaril, Stelazine and antidepressants, such as Tofranil and Elavil are among the most effective and the relatively least troublesome, when judiciously used. Physicians should familiarize themselves with the indications, contraindications and dosages of these drugs and not restrict themselves to the omnibus use of minor and often inadequate preparations. Pills are important, but as important and more important is the physician's own attitude. (Not the facade he presents to the patient, but his true attitude.) A forced posture of benevolence may be more tolerable than crudeness and outright cruelty-such as Dr. Jones' attitude toward Jane-but it is not good enough. The doctor's real feeling are not adequately proved, neither by himself nor by systematic scientific research. How many of us are aware of our frustrations and resentments of the chronically ill cancer patient who not only challenges us by refusing to get well, but inflicts upon us the ultimate affront by dying in spite of our care, leaving us not only angry with him but guilty and enraged with ourselves because of our inability to rescue him. Aren't we as doctors supposed to cure people? More research is needed, obviously, to help us to better understand our own complex feelings towards life and death, towards health and disease, towards the patient who gets well and the patient who does not. A better understanding of ourselves will also help us to promote a better understanding in the staff dealing with the dying and the chronically disabled. All of this cannot help but result in better communication and improved care. We owe it to the patient as long as there is a cancer patient. There is a lot more to do until the day 137
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comes when cancer has become a mere part of medical history. 823 Park Avenue New York, New York 10021. The author wishes to express her gratitude for the inspiration received from the Memorial Hospital Team. REFERENCES
1. Vernick, T. and Karon, M.: Who is Afraid of Death on a Leukemia ward? Amer. J. of Diseases of Children, 109: 393-397. 1965. 2. Oken, D. : What to tell Cancer Patients, JAMA, 175: 1120-1128. 1961. 3. Sutherland. A. et al: The Psychological Impact of Cancer and Cancer Surgery, I-VII. Cancer, 5. 857-872. 1952-Cancer 13. 528-531, 1960. 4. Fitts. W.T. Jr. and Ravdin. I.S.: What Philadelphia Physicians Tell Patients With Cancer. JAMA 1953: 901-904. 1953. 5. Mastrovito. RC.: Acute Psychiatric Problems and the Use of Psychotropic Medication in the Treatment of the Cancer Patient. Annals of the N.Y. Academy of Sciences, 125. Article 3.
1006-1010, 1966. 6. Perrin. G.M. and Pierce. I.R: Psychosomatic Aspects of Cancer: A review. Psychosom. Med. 21 :397, 1959. 7. Payne, E. and Krant, M.: The Psychosocial Aspects of Advanced Cancer. JAMA 210, 1238-1247. 1969. 8. Drellich, M.G. and Bieber.!.: The Psychological Importance of the Uterus and its Functions. J. Nerv. and Ment. Dis., 126: 322-336. 1958. 9. Renneker. R and Cutler. M.: Psychological Problems of Adjustment to Cancer of the Breast. JAMA 148: 833-838. 1952. 10. Paterson. R.: Why Do Cancer Patients Delay? Canad. Med. Assoc. J. 73:936. 1955. 11. Samp, RJ. and Curreri. A.R.: Questionnaire Survey on Public Cancer Educ.ation Obtained from Cancer Patients and Their Families. Cancer 10: 382-384. 19'57. 12. Stehlin. J.S. Jr. and Beach. K.H.: Psychological Aspects of Cancer Therapy. JAMA 197. 100-104. 1966. 13. Standard. S. and Nathan. H.: Eds. 1955. Should
The
Patient
Know
The
Truth
r
Springer. New York.
Experience is the name everyone g"ives to their mistakes. Oscar Wilde
138
Volume XII
BRONNER-HuSZAR, M.D.
• A better understanding of the psychiatric aspects of work with cancer patients and their relatives can enable the profession to more effectively deal with the emotional turmoil and the dire anticipations of the afflicted and their families. 1 shall concentrate on exploring the effects of physical illness and its consequences upon the previously healthy or upon the sick mind. 1 shall not attempt to deal with the question: Can emotional disturbances or grave psychological shocks-such as the loss of a beloved spouse, for instance-cause cancer, predispose towards cancer, or even influence the clinical course of neoplastic disease. To my knowledge, this has never been adequately proven as yet-nor, for that matter-has it been scientifically refuted. More, truly scientific work is needed in this area. What does illness, especially chronic, debilitating, life-endangering illness, mean to the patient? It interferes with his daily activities, earning capacity, his social and familial relationships and his sexual activities. It makes him unable to take care of himself and, therefore, delivers him to the mercy of an often merciless environment; it wracks his body with pain, a body he is compelled to watch wasting away and, ultimately, it delivers him to helpless agony and to death. And the picture is in no way overdrawn. How does the patient react to all of this special and severe form of stress? Such stress does threaten or disrupt important defense mechanisms which the patient has evolved to bring his physical and emotional needs into harmony with the demands of his environment. It follows that, whenever such defense mechanisms are threatened or disrupted, a Presented at the Seventeenth Annual Meeting of the Academy of Psychosomatic Medicine. BermUda, November 16, 1970. Dr. Bronner-Huszar is a Psychiatrist, at Memorial Hospital for Cancer and Allied Diseases. New York City, New York. March-April 1971
considerable amount of anxiety is generated as the individual feels unable to fulfill his own emotional needs or cope with his environment. He loses self-esteem and becomes vulnerable to rejection from others. The behavior of the cancer patient is designed to prevent, minimize or repair injury-not only to his body but also to his basic defense mechanisms, as well as to his interpersonal relationships. If significant defense mechanisms are not disrupted or if the individual can develop other compensatory mechanisms, then emotional difficulties are greatly lessened. What happens when the patients first discover that something is wrong? Realistic patients will seek help as soon as possible, from the best available source. But, how will the others deal with anxiety aroused by the discovery? Some will at first be overwhelmed by it, but will eventually end up seeking treatment-which mayor may not be too late to bring cure or palliation. Very much akin to delay is the denial of the need for treatment, or even of the very existence of the signs or the symptoms of the disease. The threat to integrity is perceived as so great that it must be excluded from consciousness and/or it is hoped that by ignoring it, by not doing anything about it, it will magically go away all by itself. Of course, there are patients to whom the prospect of a mutilating operation is more threatening than the disease itself. This is especially true when the loss of valued organs is involved, such as the breast, anal sphincter, eye or testes. The rationalization here is that, "1 am going to die anyway so why die mutilated?" The threat of dying, frightening as it might be, seems yet a long-range prospect, whereas the operation would be immediate, drastic, irreversible. Here, too, the mechanisms of denial and of magical thinking are part of the picture. Besides, there is always the hope of a sudden break-through in cancer research. Failing that, the "magic" of quacks or of 133
PSYCHOSOMATICS
mystics may be called upon. What happens when the patient is admitted to the hospital? He surrenders his independence, his accustomed way of life; also, he must face mysterious diagnostic procedures, the threat of surgery and possible loss of parts of his body, disability and even death. Anxiety ensues, quite naturally. Anxiety may often be revealed only by such somatic manifestations as tachycardia, anorexia and insomnia. Occasionally, the anxiety may be so great as to cause long-deceased parents to be resurrected in dreams to reassure patients and to protect them. Individuals who have emotional problems involving self-destructiveness are particularly prone to acute preoperative anxiety concerned with death or mutilation in surgery. Thus, some patients likened the operating room to "a slaughter house." One patient said that he "felt guilty, like I lost a case and had to go to the electric chair. I felt that there was no hope left for me." Nightmares often are of hallucinatory vividness. Patients dreamt of being attacked by wild animals, or of seeing their own graves with their very names on the tombstones. One patient, prior to mastectomy, saw female breasts suspended from the meathooks in a butcher shop. When patients do not have specific knowledge of the operation and its residual effects preoperatively, acute anxiety usually predominates over depression. Acute depressions are very frequent, sometimes accompanied by marked suicidal trends. When valued defenses and behavior patterns, basic to the maintenance of self-respect, are threatened or disrupted by the illness itself, by treatment or its sequelae, depression occurs in addition to anxiety. When the patient is not able to call upon compensatory defenses, depression persists. Obviously, the loss of a valued organ in itself can produce depression, again when the loss interferes with the basic character defenses of the individual. The woman whose value and acceptability to others is predicated on her appearance will feel lost should one of her breasts be removed. She will feel worthless, ugly, defeminized, socially and sexually inacceptable. 134
In the patient whose adaptation centered around compulsive cleanliness and control, the destruction of the anal sphincter is even more of a tragedy than in others. Rejection is feared from the entire world as it was once feared from the toilet-training mother. In the case of colostomy, the expulsion of gas which is uncontrollable and often very noisy; the everpresent fear of embarrassing spillage, engender self-hatred, depression and withdrawal, turning the patient away from other human beings. Quite obviously the impotent male, castrated for carcinoma of the prostate, or the frigid female, having undergone oophorectomy combined with adrenalectomy for carcinoma of the breast, have ample reasons for becoming depressed and usually do so. Depression may be increased by the attitudes of significant people in the environment. Thus, the marital partner may be unable to accept the illness and its consequences, reject the patient and intensify depression. Following surgery and / or other drastic forms of therapy, in addition to anxiety, depression, withdrawal, loss of self-esteem and feelings of rejection, such reactions as denial, regression, hypochondriasis, exaggerated dependency or rage and resentment towards the environment-be it family or medical personnel-are fairly common. Obsessive-compulsive reactions are usually seen in patients who have had operations on sphincters: thus, the bathroom-addict colostomy patient is well known to the abdominal surgeon. Even more serious psychological complications of cancer and its treatment are occasionally encountered. Besides suicidal tendencies, serious paranoid and delusional reactions or acute schizophrenic reactions can sometimes occur. It goes without saying that the etiology of these complications has to be carefully investigated in order to differentiate purely psychogenic reactions from brain metastases, from electrolyte imbalance and from metabolic or pharmacologically induced reactions. Any postoperative complication, such as infection, phlebothrombosis or bronchopneumonia, may reinforce beliefs of irreversible bodily injury. Wound dehiscence after masVolume XII
PSYCHOLOGICAL ASPECTS OF CANCER-BRONNER-HUSZAR
tectomy rather regularly intensifies such responses. Complications then may be ascribed to surgical incompetence or to uncontrollable or recurrent cancer. Obviously the cancer patient lives with the constant fear of recurrences and of metastases. That this fear is realistic in many cases was dramatically brought home to me the day I saw a woman with a recurrence on the site of a mastectomy for cancer performed about thirty years previously. Remission or recovery after treatment for neoplastic disease can only be considered complete when the patient is able to fully resume work and all significant premorbid pursuits, such as social, recreational and sexual activities. "In the case of protracted invalidism after antineoplastic therapeutics, when the patient's apparent physical condition would in no way warrant such invalidism, psychological factors are as responsible for the situation as cryptic infections or the classic sponge left in the wound,"-says Sutherland, past leader of the pioneering Memorial Hospital team. The incidence of psychogenic invalidism in the cancer patient can only be decreased in one way: the establishment of proper communication in order to decrease anxieties and to avoid creating new ones. Few people realize the extent of the repercussions that inadequate or inappropriate communications can have upon the patient. Let me illustrate this with a case from my OWl"'. experience: A sedate. middle-class patient--Iet us call her Jane-was referred to the Psychiatric Out-Patient Clinic of Memorial Hospital for intractable chest pain. A thorough investigation revealed no organic etiology that could account for the pa'n nor did it respond to any somatic therapy, be it medication, radiat'on or even nerve block. She related the following to me: "After I had discovered a lump in my left breast I went to see mv family doctor, Dr. Smith (the names are fictitious), who referred me to Dr. Jones, a surgeon. Dr. Jones told Dr. Smith that he wanted to take out the growth; Dr. Smith encouraged me to let him do it. I said 'all right but under no circumstances do I want him to remove the whole breast.' Dr. Smith assured me that my wish would certainly be respected. So I entered the hospital the day before the operation was to be performed. March-April 1971
In the evening I was given some pills that made me very groggy. Then I vaguely remember that I was given a piece of paper that I had to sign. I don't know who gave it to me nor what it was all about. I was too dopey to realize anything. In the morning I was taken to the operation room and put to sleep. The next thing I remember is finding myself in a hospital bed; Dr. Jones was just coming in the door. 'Well beautifUl,' he greeted me, 'now you can't become a Copacabana girl any longer.' I didn't know what he was talking about except that I found his language insulting. Then he examined me and the realization came to me that my left breast had been removed. I was very angry and I tried to tell him so, much as I could. I was still groggy from the anesthesia and I couldn't very well find the words. He never again came back to see me while I was at the hospital." Jane decided not to sue Dr. Jones--which sre very possibly could have. Instead, she haunted him with her complaints of chest pain localized-I am sure you have guessed where-in the area of her mastectomy scar. It is also obvious that nothing Dr. Jones, or Dr. Smith for that matter, could do would alleviate Jane's pain.
jane's case is an extreme example of mismanagement. But even lesser, more subtle, psychological insults or lack of communication can result in troublesome, organic, inexplicable postoperative difficulties. What to do to avoid them? The patient will tell you. If you watch him and listen to him carefully, he wiII tell you about his doubts and anxieties, his attitudes and misconceptions about his illness; he will give you an idea of his personality and of the cultural influences that shaped it. This information should give you a very good idea of what, how much and how to tell him. The first problem, of course, IS to decide whether or not to tell him the diagnosis. Physicians manifest a wide variety of attitudes about cancer. Thus, some physicians go to great lengths to "protect" their patients from this knowledge, whereas others inform them of their diagnosis, no matter what, in precise medical and/or lay terms. In the past, several surveys of physicians' opinions have been made about the problem of whether or not to inform cancer patients of their diagnoses. Surveys have also been made of patients' opinions about being informed of their diagnoses. It seems that most physicians don't want to tell, 135
PSYCHOSOMATICS
whereas a large majority of patients at least say that they want to be informed. More confusion is added when we learn from Oken's study that, while the physicians at Michael Reese Hospital would themselves want to be told of their diagnoses, they are no more likely to tell a physician colleague his diagnosis than they are to tell it to a layman. Vernick and Karon in their study, "Who's Afraid of Death on a Leukemia Ward?" came to the conclusion that most children studied had some knowledge of the seriousness of their illness, that some even knew exactly what was wrong and that all worried. These hospitalwise children quickly learned to interpret the sudden absence of a playmate, the removal of the oxygen tent, the room change in the middle of the night and even the disconnection of the Bird respirator. Children are very acutely attuned to the wave lengths of their environment. When the physician gives the fateful news to the parents, the child immediately "knows" that he has something very serious because his entire environment changes. His parents, no matter how hard they try, cannot conceal their own grave concerns. The child quickly senses that the people whom he had come to trust and love are now keeping something from him, something frightening. All the children studied by Vernick and Karon were worried by the erection of a wall of secrecy. These authors also found that failure to discuss the diagnosis with the child could lead to behavior problems which disappeared once the wall of secrecy was removed and the child was allowed to discuss his feelings freely. Vernick and Karon attempted to meet the emotional needs of the seriously ill child by providing an atmosphere in which such children could feel completely free to express their concerns-an atmosphere which always provided an honest answer to any question. The diagnosis and its implications were freely shared with all members of the immediate family, especially with the siblings, in order to avoid jealousies arising from the special treatment the sick child invariably receives from the family. As for the results of this policy, Vernick and Karon reported that all children studied 136
by them were able to function normallywithin the physical limitations permitted by their illness. The withdrawal and depression so often observed by others even in the presence of a parent participation program occurred very infrequently and was always transient. I cannot resist reporting how Vernick, and Karon's policy of thorough discussion of the diagnosis with the patient enabled a child to protect himself against the thoughtless barbs of his peers. Upon his return from the hospital, patient "G" was greeted by one of his chums by, "You've got leukemia. You're supposed to be dead." He quickly snapped back, "Dead, hell. I'm here, ain't I?" Once more the question is, to what extent this atmosphere of candidness and trust can be instituted elsewhere, not only on children's but also on adult wards. Sutherland provides an answer. "The question of whether or not the doctor should tell the patient he has cancer cannot be answered because it presupposes a standard doctor, a standard patient and a standard cancer, none of which exists." In the pretreatment phase of cancer therapy, no matter what is done to minimize, avoid or to prevent injury, there is mounting anxiety. Anxiety may even disrupt communications and cause some patients to distort the physician's statements; this, in turn, will further increase anxiety. Obviously, it is vitally important that the physician do his best to relieve anxiety and fear. If the patient can see him as a kindly, protective and healing figure, intent on preventing damage to the cancer victim, anxiety can be considerably diminished and treatment will be better accepted. Later, the physician should be able to capitalize on good preoperative rapport in minimizing crippling notions of bodily injury and in encouraging the patient to resume normal, everyday activities. If, on the other hand, the physician remains distant or is otherwise unable to manage the patient's anxieties, then he may be seen unconsciously or even consciously by the patient as an injuring figure, identified with punitive, internalized conscience figures. The patient will then have difficulty in believing that anything done by the Volume XII
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physician can be curative or therapeutic. Time spent in diminishing anxiety and building good rapport between the patient and his doctor does pay great dividends in the post-treatment course. This is especially true for ward and clinic patients. Some of these speak of being "guinea pigs," treated for research purposes only, of being operated on by "student surgeons," or "cut up by strangers," and approach any treatment with considerable amounts of anxiety. Much of how the hospitalized patient feels and reacts will also depend on the attitudes of the nonmedical-the administrative, the dietary and, especially, the ward personnel. The threats facing these patients and their anxities must be acknowledged by staff personnel and effectively managed. The cancer patient is not easy to handle. Forced to helplessly view his own deterioration, he will often be irritable, demanding or suspicious, to the point of suspecting the ward personnel of discriminating against him when his wishes or needs aren't immediately met. His withdrawal or maybe his all too frequent bids for attention will not endear him to the nursing staff either. Should his needs for reassurance, underlying much of his acting out, be met with hostility-which they often are-his anxiety and his sense of isolation will further increase, deepening his withdrawal or enhancing his acting out. In and out of the hospital, much will depend on the attitude of the family toward the patient. The nature of the relationship prior to the illness will almost always determine the relationship during any phase of the illness. Where there was genuine warmth previously, effective support can be expected. In purely facade relationships, ambivalent or indifferent facade support will prevail. As to previously hostile relationships, they will remain overtly or covertly hostile, retreating possibly under the mask of hypocritical, superficial pseudosupport. In any event, the family's attitude will help or sabotage attempts at rehabilitating the patient. There is hardly any need to discuss the disruptions caused in any family by nursing at home an invalid who is deteriorating, terMarch-April 1971
minaI, and fully aware of the disruptions he is causing, the hostilities he is engendering and cognizant of his total physical incapacity to do anything about the situation. How can the psychological difficulties of the cancer patient be lessened? Of course, there are the psychopharmacological drugs. Tranquilizers such as Thorazine, Mellaril, Stelazine and antidepressants, such as Tofranil and Elavil are among the most effective and the relatively least troublesome, when judiciously used. Physicians should familiarize themselves with the indications, contraindications and dosages of these drugs and not restrict themselves to the omnibus use of minor and often inadequate preparations. Pills are important, but as important and more important is the physician's own attitude. (Not the facade he presents to the patient, but his true attitude.) A forced posture of benevolence may be more tolerable than crudeness and outright cruelty-such as Dr. Jones' attitude toward Jane-but it is not good enough. The doctor's real feeling are not adequately proved, neither by himself nor by systematic scientific research. How many of us are aware of our frustrations and resentments of the chronically ill cancer patient who not only challenges us by refusing to get well, but inflicts upon us the ultimate affront by dying in spite of our care, leaving us not only angry with him but guilty and enraged with ourselves because of our inability to rescue him. Aren't we as doctors supposed to cure people? More research is needed, obviously, to help us to better understand our own complex feelings towards life and death, towards health and disease, towards the patient who gets well and the patient who does not. A better understanding of ourselves will also help us to promote a better understanding in the staff dealing with the dying and the chronically disabled. All of this cannot help but result in better communication and improved care. We owe it to the patient as long as there is a cancer patient. There is a lot more to do until the day 137
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comes when cancer has become a mere part of medical history. 823 Park Avenue New York, New York 10021. The author wishes to express her gratitude for the inspiration received from the Memorial Hospital Team. REFERENCES
1. Vernick, T. and Karon, M.: Who is Afraid of Death on a Leukemia ward? Amer. J. of Diseases of Children, 109: 393-397. 1965. 2. Oken, D. : What to tell Cancer Patients, JAMA, 175: 1120-1128. 1961. 3. Sutherland. A. et al: The Psychological Impact of Cancer and Cancer Surgery, I-VII. Cancer, 5. 857-872. 1952-Cancer 13. 528-531, 1960. 4. Fitts. W.T. Jr. and Ravdin. I.S.: What Philadelphia Physicians Tell Patients With Cancer. JAMA 1953: 901-904. 1953. 5. Mastrovito. RC.: Acute Psychiatric Problems and the Use of Psychotropic Medication in the Treatment of the Cancer Patient. Annals of the N.Y. Academy of Sciences, 125. Article 3.
1006-1010, 1966. 6. Perrin. G.M. and Pierce. I.R: Psychosomatic Aspects of Cancer: A review. Psychosom. Med. 21 :397, 1959. 7. Payne, E. and Krant, M.: The Psychosocial Aspects of Advanced Cancer. JAMA 210, 1238-1247. 1969. 8. Drellich, M.G. and Bieber.!.: The Psychological Importance of the Uterus and its Functions. J. Nerv. and Ment. Dis., 126: 322-336. 1958. 9. Renneker. R and Cutler. M.: Psychological Problems of Adjustment to Cancer of the Breast. JAMA 148: 833-838. 1952. 10. Paterson. R.: Why Do Cancer Patients Delay? Canad. Med. Assoc. J. 73:936. 1955. 11. Samp, RJ. and Curreri. A.R.: Questionnaire Survey on Public Cancer Educ.ation Obtained from Cancer Patients and Their Families. Cancer 10: 382-384. 19'57. 12. Stehlin. J.S. Jr. and Beach. K.H.: Psychological Aspects of Cancer Therapy. JAMA 197. 100-104. 1966. 13. Standard. S. and Nathan. H.: Eds. 1955. Should
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Experience is the name everyone g"ives to their mistakes. Oscar Wilde
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