EFFECT OF EMOTIONS
Undoubtedly, no single factor is responsible for cancer. Recently, however, psychological factors have been considered in the causation, pathogenesis, and prognosis of neoplasms.40 In a Presidential address to the American Cancer Society in 1959, Pendergrass stated:
I personally have observed cancer patients who have undergone successful treatment and were living and well for years. … There is solid evidence that the course of disease in general is affected by emotional distress. … We may learn how to influence general body systems and through them modify the neoplasm which resides within the body. … As we go forward … searching for new means of controlling growth both within the cell and through systematic influences … we can widen the quest to include the distinct possibility that within one's mind is a power capable of exerting forces which can either enhance or inhibit the progress of this disease.
It also has been observed that the empathic physician who establishes good rapport is an important factor; that patients treated by one physician tended to have a smoother course than those treated by another; and that patients seem to do better if informed of the nature of their condition.
PERSONALITY FACTORS AND EMOTIONAL REACTIONS
The author has reviewed the extensive literature on the effect of personality patterns on cancer growth, personality profiles, and psychometric evaluation of patients known to have cancer.32The effect of cancer, emotions, and mental illness have recently been studied by Surawicz and co-workers.51 They analyzed the relationship between psychological factors and cancer, assaying the role of personality patterns and stress on development, site, and course of the cancer. Handling the psychiatric sequelae and awareness of death also are fully discussed.
Bahnson implicates despair, object loss, depression, and hopelessness as etiologic factors.2 Other researchers have also studied personality patterns associated with cancer.21,23,37,44 Maladaptive coping mechanisms, such as denial and repression of the illness, have been assayed extensively.3,15,25,29,30,31 Unfortunately, the investigations and the findings are subject to rather generalized interpretations. The studies of withdrawn schizophrenics, for instance, show that the death rate for carcinoma is half that for the population at large; however, for paranoid schizophrenics with overt hostility, it is four times the normal rate. The personality patterns responsible for the development of cancer vary from grief over deprivation, inhibited rage, sexuality and masochism,1 inability to tolerate emotional stress, constitutional inadequacy, and marital status (higher rate among widowed),39 to overcompliance, sincerity, and dependability.
The investigative procedures used included anecdotal collations, interviews, sociologic and demographic analyses, and psychological testing. In spite of faulty design, inadequate controls, and statistical evaluation, there is a general consistency in the surveys (i.e., cancer patients are immature, depressed, fearful, full of self-recrimination, have suffered a loss of some type, are sexually maladjusted, and are incapable of expressing anger). Patients with rapidly growing tumors appear to be more defensive, anxious, and inhibited than those with slow-growing malignancies. Of course, many of the emotional reactions cited above are similar to those noted in psychoneurotics and are not specific for cancer. It may be an injustice to infer that patients develop cancer because of an immature personality development or that a real or symbolic loss precipitated their malignant illness. However, it may be that specific personality factors become operative in the presence of other variables—the correct combination resulting in carcinoma.
Methodological Considerations
On a related issue, any efforts made with correlational designs to distinguish psychological reactions from psychological predispositions to cancer were completely arbitrary. Virtually every study published had taken dependent measures from patients where carcinoma had already been detected. This procedure only allows for a post hoc personality assessment, hardly a suitable design for the valid measurement of causal factors. Granted, there are numerous practical and ethical problems involved when doing cancer research. It would hardly be defensible to create cancer in a group of individuals as a means of determining the cause of the disease. But too often researchers have made assumptions far beyond their collected data. Future researchers may develop solutions to these formidable obstacles.
PSYCHOPHYSIOLOGIC AND BIOCHEMICAL FACTORS
According to Potter, the key role in the formation of neoplasms may be played by the enzyme-forming systems controlled by the deoxyribonucleic acid (DNA) pattern and molecules in a metabolic pool. He states:
The successive mutations that produce cancer cells may be due to inherent errors in nucleic acid replication, to errors induced by carcinogens, or to loss by segregation of enzyme-forming systems that fail to replicate fast enough during cell division.40
This theory hypothesizes that “certain viruses might substitute for endogenously altered nucleoproteins.” More specifically the DNA of the viruses may replace the mechanisms controlling the enzyme-forming systems, while the ribonucleic acid (RNA) of viruses would substitute for the enzyme-forming systems themselves. Certain protein molecules are remarkable in that they can reproduce like living things.
There is an assumption that there exists—in DNA to RNA to DNA information transfer—a process that can generate new nucleic acid sequences. It is posited that human cancer is a result of formation of the genes for neoplastic transformation by “misevolution of a normal cellular information transferring process.53 Such misevolution is caused by chemicals, physical agents or viruses.” It is hoped that recent advances in immunology will ultimately solve the baffling problem of cancer.41 A review of this area now seems to confirm that the body does indeed have natural or immunocompetent defenses against cancer.27 A speculative hypothesis has been advanced to the effect that psychological variables could interfere with the body's natural defenses and, in this way, affect the cancerous process. Current research has yielded interesting and significant data.4,50 In summing up this evidence, Bahnson concluded: “Thus, hard-nosed data from the neurological and endocrinological fields corroborate the notion that psychological events mediated by the nervous system may influence endocrine and immune reactions related to malignancies.”2
The fascinating work of Black, though not involved with cancer, points up that direct suggestions under hypnosis (DSUH) have an effect on the immune system.9 His formulations should be consulted by the reader interested in the control of the immune response by imagery conditioning (see p. 248). Barrios and Kroger state:
If such is the case then it seems a logical conclusion that if we had some effective tool for reversing these negative psychological factors, we should in turn revive the defense mechanisms. This, in turn, might lead to the body's natural rejection of the cancer. Thus, we should no longer fear proposing the hypothesis that one means of facilitating the cure of cancer may very well be through ‘the mind.’8
The hormonal mechanisms implicated in the growth or arrest of certain tumors are those involving the breast22,41,50,55 and the prostate. These, in part, are dependent on the extent of hormonal activity and, to a degree, are mediated through corticohypothalamic impulses.
SPONTANEOUS REMISSION AND THE ADAPTIVE RESPONSES
As pertinent as the changes in the cell is the kind of person who has the cancer. Host resistance appears to be affected, in part, in those who have the “will to live.” They often survive longer than others with similar degrees of cancer involvement.54 The phenomenon of “voodoo death” is illustrative. Stress has been held responsible for rapid metastases and recurrences of cancer after surgery.
Spontaneous remissions of neoplasms have been reported.16,20 Though rare, and inexplicable, the possibility of spontaneous regression of cancer may be of some psychotherapeutic value in offering hope to sufferers and relatives of patients with “incurable” cancer. Often, indeed, the mere thought that regression might possibly take place changes their attitude from complete despair to hopeful toleration.10,28,47
It has long been recognized that wart tumors, even though benign, are due to a viral involvement and often respond to suggestion and/or hypnosis (see Chap. 38).32,52 This noteworthy example of alteration in tissue pathology is pertinent to our discussion.
HYPNOTHERAPEUTIC MANAGEMENT OF THE CANCER PATIENT
There are several reports indicating that hypnosis diminishes the need for narcotic drugs,11 lessens the ill effects of x-rays, and reduces discomfort following radiation therapy.19 Together with empathy and positive reinforcing suggestions, it decreases the patient's shock upon learning that he has cancer. Improved mental attitudes, motivation, and relaxation in cancer patients have been attributed to hypnosis.21 Successful management of pain and suffering often depends more on the rapport and reduction of anxiety than on the hypnotic depth.37 These factors raise the pain threshold. Other investigators have described effective use of hypnosis in relieving cancer pain.8,12,13,14,17,18,24,26,35,45 La Baw advises hypnosis in lieu of hospitalization for the terminal cancer patient.41 He and his associates have also obtained good results using self-hypnosis in children with cancer.
The author has used hypnosis as an adjunct for the management of intractable pain in terminal cancer patients. Many were considering lobotomy, posterior rhizotomy, alcohol block, dorsal column stimulation, or chordotomy for pain relief. All were on high doses of opiates. After these patients learned how to induce glove anesthesia under autohypnosis, the dosage of narcotics was drastically decreased in over 60 per cent of them.
Hypnosis apparently blocks the perception of pain—it is a sort of “psychological” lobotomy. When it is used individually for direct symptom relief, the procedure is tedious and the results are often disappointing. One investigator has had only indifferent success with direct hypnosis.37 Group hypnosis (1 hour per week) is preferable, as faith, hope, and confidence are mobilized more readily; susceptibility to posthypnotic suggestions is increased when the readiness to respond to painful stimuli is minimized by misdirection of attention.5
As a consultant to the City of Hope Medical Center and the Pain Clinic at U.C.L.A., the author has treated a number of cancer patients in various stages using hypnosis. He has noted that about 20 per cent can control their discomfort and another 40 per cent can drastically reduce the need for narcotic drugs. Another advantage is that narcotic drugs can be held in abeyance. Even when the disease progresses, there often is no need for addictive pain-killing drugs. Since the tolerance for such drugs has not been increased, smaller doses, if necessary, can be employed. Many patients can live in relative comfort and peace of mind until the disease becomes terminal.
In an excellent review of the control of cancer pain by hypnosis, Hilgard and Hilgard point out that ego-strength is provided, pain is reduced by relief of anxiety, insomnia is mitigated, interests are broadened, and the dependence on the hypnotherapist is diminished through self-hypnosis.26 They also mention the various strategies that can be employed, such as symptom transference, glove anesthesia, time distortion, disassociation, age regression, and amnesia for the pain.
One of the first studies on the use of hypnosis in cancer was done by Hedge.24 The shortcomings of Hedge's study have been noted by Barrios.6 Hedge used only one standard hypnotic induction. More effective and varied hypnotic induction technics, such as those used by Hilgards, might have increased the effectiveness of the hypnotherapy. Moreover, Hedge did not make full use of the hypnosis. Often the success of hypnosis depends on how it is used. Apparently, Hedge used it primarily to instill a positive attitude regarding one's own ability to fight off the disease. This is definitely an important part of the therapy, but, in addition, the negative attitudes, beliefs, and habits that might be precipitating factors in causing the host's natural defenses to malfunction must be permanently eliminated. A holistic approach must be followed. One that will ensure more joy and happiness as opposed to despair and hopelessness.56 A more recent and ongoing study seems to be proceeding in this direction.
Simonton's technics are used to improve mental attitudes in his radiation therapy patients.48 In addition to pointing out to the patient, in a manner similar to Hedge, that the body has natural defenses against cancer, Simonton has also incorporated technics aimed at inculcating positive attitudes and bolstering the will to live. His basic tools are meditation or self-hypnosis exercises (suggesting relaxation to oneself with every breath exhaled), which give the patient greater control over the ability to relax. He also shows the patient how to use the meditative state for instilling positive suggestions via positive imagery. Thus far the results are quite encouraging. In a study involving 134 patients treated with meditation and visualization since 1972, 100 are still alive—and these survivors have lived longer than those similarly afflicted. Even the 34 who died lived longer than expected. Simonton concedes the importance of scientific proof to validate his approach. However, Simonton and Tatera found a strong correlation between positive mental attitudes and progress of the disease.49 Simonton maintains that the cancer patient should grasp the concept that he can influence the immune mechanisms and realize that the mind can powerfully alter the development and course of the disease.48 The Simontons47 report remissions in far-advanced metastatic cancers. However, they need 5-year follow-up data before publishing further results.
A major shortcoming of the Simonton approach, however, is how does one get the person really to believe in positive thinking? This shortcoming is similar to the one mentioned in regard to Hedge's study, namely, that only hypnotic relaxation was used. By using more varied technics, the physician or therapist can increase the belief factor which is so important if one wants one's words to have an effect.
SELF-PROGRAMMED CONTROL
Self-programmed control (SPC)7,8 has two major components: First there are the SPC technics—seven highly effective self-hypnosis* technics, which, in combination with the use of biofeedback as a reinforcer, give a person greater control over his involuntary functions (his habits, attitudes, emotions, and tensions) and make the possibility of a positive change really believable. This makes the patient receptive to the second component of the program—a positive philosophy which helps the individual to develop new attitudes toward life and himself, and often can provide the solutions to many personal problems plaguing the anxiety-ridden cancer patient.
The combination of these two components is effective for eliminating the negative psychological factors which have been posited as interfering with the natural defenses of the body. It is especially effective in eliminating the feeling of despair which has been felt by many to be the major culprit.
The program has many advantages. It is simply structured and easy to teach to physicians and paramedics, as well as to patients. As with most forms of hypnotherapy, it takes considerably less time than conventional forms of therapy. It was designed specifically for working with groups, thereby also cutting down on costs. And since the technics are aimed at self-control, much less dependency is created.
To test the hypothesis that such an approach can improve a person's ability to raise host resistance to cancer (it should be stressed that at the present time it is still just a hypothesis), the following initial study is proposed, using SPC in conjunction with any ongoing medical therapy (surgery, radiation therapy, chemotherapy, immunotherapy, etc.). As comparison controls, one could use statistical expectations or, if necessary, a matched control group. Tests for the immunological response55 as well as measurement of mental attitudes could be run concurrently to test the hypothesis that these factors are all correlated with the course of the disease.
As pointed out by Sacerdote, it is important to convince anyone in contact with the patient of the feasibility of any program, especially attending physicians and nurses.44 Negative attitudes can adversely affect or “contaminate” motivations of the patient. The study should not be limited to terminal cancer patients.
With ever-increasing reports of effectiveness, the author strongly feels that hypnosis should be the first method used to control pain in the cancer patient. It should not be used as a last resort, as is so often the case, particularly after surgery has been attempted for pain relief. Kroger and Fezler have combined hypnosis with operant conditioning, behavior modification, and imagery.33 The specifically constructed images have a potent effect on pain relief and also inculcate motivation and faith to fight the disease. A physician using hypnosis in these kinds of cases can expect a high failure rate. However, he should realize that he is doing the best he can under the circumstances.
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