Avery D. Weisman

The Existential Plight in Cancer: Significance of the First 100 Days

The Existential Plight in cancer is a poorly recognized but significant period. It starts with the definite diagnosis and continues for two to three months into the illness, approximately 100 days. The chief signs are the predominance of life/death concerns, even over worries about health or physical symptoms. One hundred and twenty newly diagnosed cancer patients were interviewed, tested, and followed from about ten days after diagnosis at four to six week intervals until three to four months had elapsed. Plight was analyzed from the viewpoint of coping strategies, resolution of problems, vulnerability, total mood disturbance, and predominant concerns. Patients who had higher emotional distress during this period had many regrets about the past, were pessimistic, came from a multiproblem family, and had marital problems. The widowed or divorced had higher vulnerability, as did patients who anticipated little or no support from significant others. Although vulnerability increased with advanced staging and many symptoms, at the time of diagnosis psychosocial distress crossed diagnostic and prognostic boundaries, enabling investigation to predict within limits those patients who will cope effectively or fail to cope with cancer and its ramifications.

Predilection to death. Death and dying as a psychiatric problem.

&NA; A series of five unusual surgical patients is reported in which “predilection” to death was a prominent part of the clinical picture. The common characteristic of these predilection patients is that each anticipated his death at the time of admission. With the exception of a mentally ill woman, they were neither anxious nor significantly depressed. All expressed the conviction that death would occur within a short time, except for a young girl who serenely anticipated death without openly referring to it. The conviction of death was invariably accompanied by an expectation of being killed by another. Predilection patients may be readily distinguished from preoperative patients with high anticipatory anxiety, depressed patients, suicidal patients, and those rare patients who correctly prognosticate their own deaths and demonstrate no significant lesions at autopsy. Two men died unexpectedly in the course of convalescence. Three women patients were not only expecting to die but were expected to die because of malignant disease. However, in one woman, the disease had apparently been arrested for 28 yr. Relapse and metastatic lesions did not occur in another patient until after a young man with the same disease had succumbed. A third woman, suffering both from severe mental illness and incurable cancer, became alarmed shortly before death when a palliative procedure threatened to prolong her unhappy life. Death held more appeal for these patients than did life because it promised either reunion with lost love, resolution of long conflict, or respite from anguish. Each patient was emotionally isolated during the final admission. Their “loneliness” was of several different kinds; one man was a semi‐vagrant who had never known emotional intimacy; another man had exiled himself from his family; one woman had suffered successive deaths of her husband and members of her family; another woman had repudiated all but the most formal relationships throughout her life; a young girl had not only lost a close friend by death but was deserted by her physicians and family, who were so concerned that they could not come to terms with her certain death. Study of the predilection patients has led to an evaluation of the care of the dying patient in general, particularly from the viewpoint of the paradoxical attitudes towards death that are conventionally assumed. The application of psychodynamic principles to the concept of death and the process of dying is based on the hypothesis of the appropriate death. An appropriate death is one that recognizes the inevitability of personal death as a fulfillment of life. It satisfies four conditions: conflict reduction, compatibility with ego ideals; continuity of personal relations with the living and the already dead; and consummation of phantasies. In short, the circumstances of an appropriate death are the opposite of those in which a patient would commit suicide. The conditions of an appropriate death have been derived from the distinction between impersonal, interpersonal, and intrapersonal death. The fear of dying is not the same as the fear of death. The dying process has psychological counterparts in primary anxiety, the sense of imminent disintegration; the fear of death. it has been shown, is a death phobia, indirectly related to “rational” fears. Appropriate death is an aspect of euthanasia‐‐death without suffering‐‐for patients whose death is imminent. However, the conventional concept of euthanasia as the hastening of the death of incurably ill patients is the antithesis of the appropriate attitude towards death which psychiatric intervention advocates. In conventional euthanasia, the patients personality is ignored; in the proposal of therapeutic dissociation of the patient from the disease, the personality in its unique dignity is enhanced. Various practical recommendations for implementing the appropriate death are presented, but no intervention is possible without frankly facing the imminence of death with the patient. Evidence has been presented to indicate that this is usually more difficult for the doctor than for the patient. Tacitly to impose silence, denial, deception, and isolation upon the dying patient may itself cause suffering and bring about bereavement of the dying, a state of premortem loneliness, emotional abandonment, and withdrawn interest that the survivors impose upon the dying. Examples are cited in which altered interpersonal relationships provide the prodromal intimations of approaching death. Instead of viewing death as a failure beyond his competence, the physician can extend his care and help his dying patient to achieve an appropriate emotional world in which to die.

Early diagnosis of vulnerability in cancer patients.

Abstract:The newly diagnosed CA patient faces psychosocial as well as physical problems. To assess the impact of diagnosis, and to find significant clues for later emotional distress, 163 new patients with CA of the breast, colon, lung, Hodgkins disease, and malignant melanoma were evaluated by interviews, psychological testing, and personality inventories, then followed regularly for six months. Vulnerability was but one parameter that measured emotional distress and faltering capacity to cope with concurrent problems. It was found that the more vulnerable patients had more symptoms when first diagnosed, and that systemic symptoms were more significant than the type of CA or the staging. High vulnerability patients were generally pessimistic, anticipating little recovery and practically no support from significant others. They had more marital problems, tended to suppress feelings, but often had a history of depression. Denial in itself did not mean vulnerability. Indecision about treatment and regrets about the past were more indicative of future emotional problems than was delay. Most patients showed little denial throughout the period of observation, but more vulnerable patients tended to vacillate between denial and acceptance. By learning to listen and ask tactful questions, this information can be elicited by the physician who can then intervene effectively.

Psychosocial Analysis of Cancer Deaths

In addition to biological activity and cancer treatment, psychosocial considerations may influence both the quality of survival and its length. The investigators used information from psychological autopsies of cancer deaths, and correlated observed survival (measured in months beyond expected survival) with psychosocial findings. Patients who lived significantly longer tended to maintain cooperative and mutually responsive relationships, especially towards the end of their lives. Patients with death wishes, depression, apathy, and long-standing mutually destructive relationships survived for shorter periods than expectable. Why longevity occurs in some patients, but not in others, may be related to different traits which create alienation in personal life and in caretaking staff as life draws to a close. More assertive patients ask for and get better attention and services, and as a result, may live longer and die better deaths.

Preventive Psychosocial Intervention With Newly Diagnosed Cancer Patients

To study the effectiveness of preventive intervention in lowering emotional distress and improving coping, 381 newly diagnosed cancer patients were assessed shortly after the time of initial diagnosis. Subjects predicted by a screening instrument to be at risk for high levels of emotional distress and poor coping during the second through sixth months of their illness were randomly allocated to one of two short-term intervention programs (N = 59). Specific techniques to lower distress and improve coping were given during the four weeks following diagnosis. A control group (N = 58) received no intervention. All were followed at two-month to 6-month intervals by interview and testing. There was a significant lowering of emotional distress in the intervention group as compared to the control group (p less than 0.05). There was also a significant increase in the level of problem resolution in the intervention groups (p less than 0.01), although the numbers of problems experienced by both groups were no different.

Psychosocial components of lagtime in cancer diagnosis

Abstract General programs for prevention of cancer are largely based upon public information, early diagnosis and prompt treatment. Articles about delay in cancer diagnosis usually acknowledge that most patients see a doctor within three months of their original symptoms. Nevertheless, it is also presumed that beyond this arbitrary time, patients will significantly endanger their health. The concept of delay , set by custom at three months, tends to blame the patient or the doctor, without considering special characteristics of the cancer itself, and without correcting for clinical biological and psychosocial factors. This paper demonstrates that the designation, delay, should be dropped, and replaced with a less pejorative, but more scientific term, called Lagtime . Together with its logarithmic derivative(loglag), lagtime, which is not a redundant variable, can be used in conjunction with other variables to help establish the effectiveness of treatment in various kinds of tumors. 125 consecutive, newly diagnosed patients with cancer of the breast, lung, colon, Hodgkins disease, and malignant melanoma were interviewed and tested psychologically within 30 days of the original diagnosis. Individual assessment through interviews and inventories and multivariate analysis of psychosocial components, regressed against time intervals from initial symptoms to definitive examination, showed that only breast patients who delayed had cancer at a more advanced stage when diagnosed. However, while there were psychosocial correlates typical of the entire group of longer lagtime, some characteristics were found only in individual types of cancer, and were not shared by others.

The fallacy in postmastectomy depression

The prominence of postmastectomy depression and loss of self esteem, together with its reputed relation to symbolism or sexual significance of the breasts, has been investigated. Neither could be confirmed. Forty newly diagnosed breast cancer patients were compared with 50 women with other types of cancer. Only 20 per cent of breast patients and 18 per cent of others reported the syndrome of depression, lowered self esteem, increased health concerns, and loss of energy. Peak emotional distress did occur in breast patients about two to three months after mastectomy, a finding which may be influenced by the treatment, as well as by return to regular responsibilities. Few women ascribed psychosocial problems primarily to losing their breast. While the postmastectomy syndrome is not common, the frequency of breast cancer itself means that a substantial number of women may still be affected. But other variables are better predictors or concomitants of emotional distress than are problems about damaged body image.

A model for psychosocial phasing in cancer

The way in which patients cope with cancer throughout the course of treatment and illness can be demonstrated by correlating levels and types of vulnerability with different psychosocial phases. The concept of psychosocial phasing is a hypothesis, the aim of which is to integrate typical problems, concerns, and distress with clinical staging, treatment, and disease progression. Expectations differ at each phase. Accordingly, different problems may arise which clinicians can anticipate and relieve through appropriate interventions.

Bereavement and Companion Animals.

Loss of a companion animal accompanied by intense grief and mourning is seldom recognized as an important and authentic occasion for bereavement. While pet ownership is praised and its virtues celebrated, corresponding grief is often trivialized and not recognized as truly significant. The author established a bereavement counseling program at a humane society and reports findings that confirm parallels between human and animal bonding and bereavements. The act of consenting to euthanasia was particularly disturbing, as if the owner had betrayed a trust by opting for death over life. Most of the bereaved owners reported depths of feeling that were unique and in most cases beyond those experienced in other deaths.

A study of the psychodynamics of duodenal ulcer exacerbations; with special reference to treatment and the problem of specificity.

Summary Six male patients with exacerbations of chronic duodenal ulcer have been studied in order to elicit the concomitant psychological factors. The major symptom was essentially similar in all patients: epigastric pain, usually nocturnal, relieved by ingestion of food, but reappearing within several hours. The investigative method included psychoanalysis and psychoanalytic psychotherapy. The formulation of the emotional state at the time of relapse includes both descriptive and psychodynamic observations regarding the nuclear conflict, predominant affects, ego defenses, and transference situation. In all 6 patients the nuclear conflict consisted of variations in the passive/active antinomy. Struggle over dependence/independence, however frequent, was regarded as a special case of the larger problem of passivity/ activity. The ulcer recurrence invariably developed in an atmosphere in which the patient vacillated between active seeking and passive yielding. The stress of the conflict could be brought about in three ways: by a lack of fulfillment of passive‐receptive wishes, by a transgression of the exaggerated ego ideal, and by fear of passivity itself. The basic affects were restrained resentment, angry guilt, and guilty fear. The patients were afraid of becoming helpless and submissive through a narcissistic injury, by depleting demands, or by loss of a source of strength or support. Ego defenses included compliance and defiance; inhibition and suppression; denial by word, act, or phantasy; avoidance and social isolation; phantasy formation; bisexual identification; and the secondary adaptive measures of various neurotic symptoms. Phobic and obsessional symptoms were frequent, but depression was strikingly absent during the ulcer exacerbations. The transference relationship to the doctor was distinguished by its excessive ambivalence. The therapist represented either an ideal, beneficent parent, or a demanding, exploiting, relentless, coercive force. In many respects the transference neurosis reflected the patients relationship with the significant figures in his life. The ego ideal was excessive in that the patients expected more from themselves than they were capable of fulfilling. It represented the ideal parent in the superego and the wish for complete identification with this parent. Fundamentally the underlying motivation of these patients was for the right to be passively loved and sustained with a unique, noncompetitive, inexhaustible devotion. Ulcer symptoms recurred most often when the threat of depletion exceeded the promise of replenishment and the resulting angry protest was restrained. The ulcer exacerbation was associated with no single factor operating alone, but required the integrated presence of the nuclear conflict, basic fear, special ego defenses, and ambivalent interpersonal relationships. The meaning of specificity is discussed. The logical requirements for specificity are described in terms of equivalent and conditional forms and a distinction is made between disorder specificity and stress specificity. The specific psychosomatic formulation of the various categories of psychological factors is regarded as conditional stress specificity because a similar formulation may exist without necessarily entailing the development of duodenal ulcer. It is therefore to be differentiated from equivalent stress specificity where a specific psychosomatic formulation may be applied if, and only if, a duodenal ulcer is present. Parallel psychological observations in other diseases are necessary in order to determine disorder specificity, which similarly may be either conditional or equivalent. The application of these observations to the management of ulcer recurrences has been discussed.