Patricia Norris PhDIs there such a thing as a cancer personality? Is there a cluster of cancer personalities for different types of cancer? The evidence, though vast and multidimensional, is not yet considered to be conclusive.
For nearly two thousand years, since Galen’s observation in the second century that cancer accompanied melancholic personalities, observers have likened personality, or aspects of personality, to malignancy. The difficulty, in terms of the kind of hard scientific proof that is considered desirable, is the fact that most of these observations are ex post facto. Until very recently, few prospective studies have been done. Those that do exist, as well as all the many retrospective studies and observations, confirm a predisposing set of personality factors, attitudes, and beliefs.
Steven Locke and Mady Hornig-Rohan have edited a recent comprehensive annotated bibliography linking immune competence with the mind. Mind and Immunity: Behavioral Immunology contains 1304 articles and nearly 150 books, book chapters, and review articles dealing with the relationship of mind and immunity. In it, forty-nine papers on the topic of Personality and Cancer are cited. Most of these support a relationship between cancer and personality factors, with the predominant factor being depression and the helplessness/hopelessness syndrome. In many studies significant loss, in childhood or shortly predating the onset of illness or both, was also found.
One of the most interesting, and conclusive, evidences of the effect of personality on physiology comes from recent studies of people with multiple personalities. People with multiple personalities, like those made well known in books and movies such as The Three Faces of Eve and Sybil, have always created interest because of their strange switches in behavioral characteristics. The changes in behavior have included different body language, sometimes accents, speech mannerisms, handwriting, hobbies and skills, and different phobias and memories.
New interest is being generated by the fact that these people not only change behavior, but their brains and their bodies also change. Different personalities within one person have different brain wave patterns, different handedness, and different allergies. Eyeglass prescriptions and such objective measures as eye pressure and corneal curvature differ. A person may be nearsighted or farsighted in different personalities or even be colorblind in one but not another. As they change from personality to personality, these people experience dramatic physical characteristic changes as well.
Bennett Braun, a Chicago psychiatrist who has studied a number of persons with multiple personality disorder, notes that these changes in physiology are not greater than those that can be achieved through hypnosis. And this implies, in turn, at least theoretically, that there are no changes achieved through hypnosis that could not also be achieved through voluntary control. After all, the hypnotist holds no strings within the body of his subject. The person with multiple personality is controlling all the changes in physiology made, albeit unconsciously. Conscious control of the unconscious can be learned, perhaps of any system over time and surely over any system that can be affected by personality shifts or by hypnosis.
Early in their work connected with the psychological management of malignancy, Carl and Stephanie Simonton compiled an annotated bibliography. They reviewed the medical literature concerned with the etiology of cancer, and in more than two hundred articles they found a relationship between personality factors, emotional factors, and cancer. They found the most prevalent predisposing condition to be the loss of an important love object or relationship six to eighteen months prior to the diagnosis of malignancy. According to the authors, these losses create hopelessness because they recapitulate lack of closeness, loss, or rejection experienced in childhood.
The most common personality characteristics they found were a tendency to hold resentments, difficulty in forgiving others, a tendency toward self-pity, poor ability to develop and maintain long-term relationships, a poor self-image, and feelings of rejection in general.
Claus Bahnson, in his overviews, “Stress and Cancer: The State of the Art,” Parts 1 and 2, finds recurring themes of loneliness and hopelessness stemming from lack of a loving, protected childhood. Personality characteristics of inhibition, rigidity, repression and denial, when combined with the stress of loss and depression, seem to increase vulnerability to clinical cancer.
Lawrence LeShan, during the first five years of his research into personality and cancer, tested and interviewed over 450 patients and found that 72% of them had particular life-history events and personality characteristics that occurred in only 10% of a non-cancer control group. As he explored their case histories, he determined that these personality characteristics preceded the onset of cancer by many years and generally developed in childhood, when the patients often felt rejected and unloved and were constantly searching for ways to please others, inhibiting expression of their own feelings of anger and hostility in order to gain acceptance. They were generally thought by others to be fine, gentle, and uncomplaining people.
In discussing how personality might affect the genesis of cancer, there are two major theories. By far the most prevalent is the theory that the immunologic defenses are weakened, and hormonal and endocrine balances are upset by the biochemical changes that accompany depression, repressed hostility, and feelings of helplessness. If immunologic defenses are weakened, this leads to a sort of “double whammy.” The body is more vulnerable to the various carcinogens present in the environment, and it is more likely to produce cancerous cells. Also, cancer cells, once present, have a greater chance to multiply unchallenged.
The other theory, born out in part by observations and research on types of cancer related to specific experiences or personality configurations, is that psychic energy from frustrated desires or subjective losses can appear somatically as an attempt on the part of the unconscious–the lower brain centers–to replace the lost object or object of desire biologically. In the latter, the type and location of the tumor symbolically match the psychological experience of loss.
In either case, stress can deter the elimination of tumor and cancer cells by impairing immune surveillance. Stress can facilitate an increase in the growth of tumors by neuroendocrine changes, mediated by the autonomic nervous system through the limbic-hypothalamic-pituitary axis. Corticosteroids associated with stress inhibit lymphocyte proliferation and metabolism.
In “A Biopsychosocial Approach to Immune Function and Medical Disorders,” Marvin Stein suggests that as evidence is accumulating and knowledge unfolding of the various ways that psychosocial factors are related to immune functions, predisposing risk factors are being discovered which can provide a means for studying individuals prior to the onset of disease.
The common underlying factor in personality and stress seems to be a lack of coping ability in some way. Studies linking cancer and personality, and cancer and stress, are increasing all the time. In spite of this, there is no absolute evidence that stress causes cancer, but that it is a predisposing risk factor, there can be no doubt. However, cancer is not just one, but more than a hundred diseases. Factors influencing cancer and predisposing to cancer include genetics, diet and nutritional status, carcinogens present in the environment, radiation and excess sunlight, as well as factors stemming from mind and behavior. But regardless of whether or not stress causes cancer, there is general agreement that the body’s ability to fight cancer is hindered by stress and that the body’s immune defenses are compromised by stress.
For a cancer patient, there is a triple stress to deal with. There is the stress which predated the cancer and which seems always to have been present prior to diagnosis. There is the stress of having cancer and dealing with the threat to self-identify and personal security. And there is the stress of a treatment that can be uncomfortable, frightening, and depleting.
Learning to Choose Our Responses
Fortunately, humans are learners. We can change how we perceive stress and how our bodies respond to the stressors in our lives. We can acquire the skills and resources for dealing with stress as a challenge and as a learning opportunity. Learning self-regulation of responses to stress gradually leads the learner to meet change with a sense of energy and exhilaration rather than worry and despair, and this can have a powerful healing effect.
The idea that we can assume responsibility for the course of our illness suggests to some people that patients are being accused of causing their cancer, that guilt might be aroused by such an idea. Of course no one chooses to have cancer or causes their body to become cancerous in any conscious way. But the way our bodies unconsciously respond to stress may be, and probably is, a contributing factor in every stress-related illness. This is good news. It means there is something we can do to affect it in a positive manner.
There are other studies which look at the characteristics of survivors of cancer. There are also personal characteristics which increase the chance of survival, and these can be actively acquired.
The Simontons, together with Jeanne Achterberg, made a study of survivors, examining the characteristics of their own patients who outlived predicted life expectancies. All of the patients who choose their program are screened on the basis of a stated willingness to cooperate with their medical treatment and assume a responsibility for their own return to health. The exceptional patients refuse to give up, rate higher than average in nonconformity and ego strength, and have an inner-directed locus of control.
Kenneth Pelletier cited four significant factors present in those who survived cancer against the odds. Each of the patients had gone through some profound intrapsychic changes; their sense of self and innermost being had been changed, whether by a revelatory experience, meditation and prayer, or spiritual insight. They made important interpersonal changes, improving their relations with others. All had made major changes in their diet and nutrition and in the ways they cared for their bodies. And every one, without exception, looked upon their recovery not as a gift or a miracle, and not as a spontaneous remission, but as a long, hard struggle that they had won!
While a graduate student at New York University, Erik Peper compiled a list of so-called spontaneous remissions from cancer. A computer search of the medical literature from the Library of Congress and the medical libraries at Harvard and MIT yielded about four hundred articles which comprised his annotated bibliography. The circumstances surrounding the remissions were as varied as can be imagined; people used all their favorite methods, from religious sojourns to nutritional approaches, fasts, and lifestyle changes. The common ground among all these cases of remission lies in the assumption of self-regulation, the assumption of responsibility in some way, and a change of attitude involving hope, personal effort, determination, and other positive feelings.
Placebo or Visualization? The Case for Positive Thinking
The effect of belief and expectation has never been more clearly or dramatically illustrated than in the case of the man with cancer who believed in Krebiozen. This case is very famous in certain medical circles and is worth mentioning.
This is a true story about a man who had advanced cancer (lymphosarcoma) and was lingering very near death. Every possible medical treatment had been tried. His body was filled with huge tumor masses, the size of oranges, and his liver and spleen were enormous. He required oxygen most of the time, and every other day one or two quarts of fluid had to be removed from his chest because his thoracic duct was obstructed. He was in a terminal state, but he was filled with hope even though his doctors were not.
The reason this man was so filled with hope was that he had been waiting for medical science to discover a cure, and now he believed that this was accomplished. He had read about Krebiozen, and now he knew that the hospital where he lay dying had been chosen to test it. He wasn’t really eligible to be included in the research, since one of the requirements was that patients on whom Krebiozen was tried must have a life expectancy of at least three, and preferably six, months. But he was so enthusiastic and begged his physician for what he called a “golden opportunity,” that the physician felt he had to include him.
The first injection of Krebiozen was given to him on a Friday, and on the following Monday, the physician thought that his patient might be dead, and his supply of Krebiozen could be transferred to someone else. When the patient had received the injection, he was completely bedridden, gasping for air. On this Monday morning, he was walking around the ward, happily showing everyone he could find how wonderfully well he was doing with this new miracle drug.
The tumor masses had “melted like snowballs on a stove” and were less than half their size already. His physicians said that this was a more dramatic change than could be expected from radiation treatment given each of these three days. Very excited, the doctor rushed to see the other patients who had received Krebiozen injections, but none of them had changed. Very soon, the man was recovered completely, left the hospital, and even resumed flying his airplane with no discomfort, even though only a few short weeks before he had been gasping in an oxygen mask.
He continued to do just fine until controversy about the drug’s usefulness began to appear in the papers, as clinic after clinic was finding no results. He began to lose faith in his last hope, and in spite of two months of practically perfect health, he became gloomy and miserable. At this point his tumors came back with full force, and he again appeared before his physician in almost the same terminal condition.
As if this was not amazing enough, the second chapter of this story is even more amazing His physician, seizing upon a golden opportunity of his own, told this patient that it had just been discovered that the reason Krebiozen had been failing to achieve its initial promise was that it had a very short shelf life, quickly losing potency. He said that now there was available some Krebiozen that was very new and potent and that a shipment was expected in the next day or two. The man’s faith was restored, and he was very excited and hopeful. A couple of days later, when his expectancy was very high, the doctor administered an injection of sterile water.
The man’s recovery was even more dramatic than the first time. His tumors melted, his chest fluid vanished, and he went back to flying once more. As long as the water injections continued, he remained symptom-free. When the final judgment of Krebiozen by the American Medical Association appeared in the press, finding the drug worthless in treating cancer, he was readmitted to the hospital and soon died.
How are we to understand this? Did the man have two “spontaneous remissions”? This case clearly demonstrates the wondrous power of the mind when, bolstered by faith and expectation, it visualizes an outcome. That is exactly what the placebo effect is–the effect of a visualization, one that is thoroughly believed in. Isn’t this what we should be trying to engender in all patients and in ourselves as well? The placebo effect as a visualization was discussed by Elmer Green in his Presidential Address to the Biofeedback Society of America titled, “Psychophysiologic Correlates of Expectancy.” In the paper, he brought together converging information from ethology, psychodynamic theory, autogenic training theory, the psychology of perception, and neuroanatomy and the neuropysiologic correlates of sensory discrimination. Speaking of the placebo effect, he said,
It is now clear, at least to me, that what is called the placebo effect is a subdivision of the self-regulation effect.
Humans, through visualization are able to self-trigger physiological behaviors that in animals are associated, as far as we know, only with external perceptions of some kind. It is this fact in humans, of course, which gives rise to the placebo effect. The placebo, by definition, is something false by means of which a patient is tricked into using his or her own visualization powers for physiological manipulation. Not everyone has yet thought of it this way, I know, but if a placebo is put into a cup of coffee with instruction to a patient, “Drink this and it will slow your heart rate, ” it can happen. If the same sugar pill is slipped into the coffee unknown to the patient, however, nothing happens. This is because the visualization and the expectancy associated with that visualization are not triggered off.
As a species, we have probably been using this general effect since we differentiated from the animals, but now, for the first time in the history of humanity, it has become possible to get the information from inside the skin. Information before biofeedback was normally fed back only to subcortical brain centers for unconscious autonomic and homeostatic regulation. Now, for the first time in human history, this information is coming back to the cortex, and because we can visualize changes in the body, biofeedback is making it quite easy to regulate many heretofore involuntary processes.
The Vital Role of Biofeedback in Self-Regulation
In the Cancer Journal for Clinicians, Norman Cousins wrote a guest editorial titled, “Cancer and Placebos.” Because of his own experiences in self-healing, Cousins was appointed Adjunct Professor in the Department of Psychiatry and Behavioral Medicine in the U.C.L.A. School of Medicine. In the editorial, he examines the role of mind in healing and the relationship between mind and medicine in every way.
Cousins noted that recently the placebo is being studied in terms of its ability to change human chemistry. A bibliography of placebo research by three of his colleagues in the Neuropsychiatric Institute at U.C.L.A. listed 674 studies, many of which showed that people who respond to placebos release secretions in their brains that in turn produce specific physiological effects in their bodies. What Norman Cousins wanted to share with doctors was this: if a placebo is an emotional experience that can trigger a biochemical response, there is an important therapeutic value in a patient’s belief in the healing power of the physician. What a physician communicates to a patient and how he communicates it can have a powerful impact on the treatment outcome.
Perhaps every illness we ever have is in response to a problem of some type and is an attempt at a solution. A life-threatening illness like cancer may be a response to loss and despair, or it may be an unconscious attempt to replace something or to escape from some perceived or imagined inadequacy. Human reactions to stress and loss can cause cancer. This should not be interpreted as saying, “I caused this cancer”; however, the illness can act like an attention getter. Something internal needs to be dealt with.
Faced with a diagnosis of cancer, patients react in a number of different ways. Many patients would like to get well but want the doctor to invest all the energy and effort, seeing themselves as passive recipients of treatment. To a large extent, our culture fosters this. We are taught to believe that everything–or almost everything–can be resolved by popping a pill or by having something taken out. In fact, there is a tendency to be insulted and outraged when we discover that there is no easy cure for something that we have. Often physicians encourage us to take a passive role, follow instructions, and be compliant.
In fact, patient compliance is a very large issue in both psychiatric and physical medicine. So the patient may expect to be cured, or hope to be cured, but wants the doctor to take all the responsibility. Physicians often don’t know how, or are afraid, to tap patient potential for self-healing and encourage patient participation in the healing process.
A much smaller percentage of people seem quite ready to give up the moment the diagnosis is delivered, if not before. Once they discover they have cancer, it becomes the central focus of their lives. All their plans are organized around having cancer, and consciously or unconsciously they think of themselves almost as though they were already in the grave. Their self-image is that they are dying, and as if following a script they act out this role to the finish.
Another group of patients is willing to do anything to get well. No effort seems too great. This is a characteristic shared by survivors of catastrophic and life-threatening illness. Most importantly, it is an attitude that can be acquired. One thing that survivors have in common is a practice of envisioning themselves getting well.
A young man who experienced this type of change in a dramatic way told of his experience to a national audience on the television program “Good Morning America.” He was a graduate student at Harvard when he was diagnosed as having cancer and began treatment with chemotherapy. After a few months, he felt he could no longer go on with the treatments. He felt tired, weak, and depressed, and he told his physician he was withdrawing from chemotherapy. His doctor told him he would be signing his own death warrant, and he said he did not care. He went home and, feeling entirely frustrated and angry, put on a pair of running shorts and went for a run. Then he exercised, swam, and finally returned home, exhausted but happier than he had been for some time.
He became aware that he felt better for the first time in a long time and decided it was because he had taken charge of his life. During the ensuing months, he took up rowing, boxing, running, racquetball, and swimming, and he filled his life with taking care of his body and building strength. When he felt strong and positive and wanting to live, when he could envision himself getting well, he returned to chemotherapy and this time completed it with very little difficulty, maintaining his active life. That was more than six years ago, and he has been free of cancer ever since.
As beliefs and expectations have biological consequences, so do attitudes. There are definite neuroendocrine and neurohormone accompaniments to a good mood, to a strong positive attitude.
Lisa is one of the people who illustrates this power of attitude. She is one of the most lively, fun and laughter loving, vivacious people I know. She is also a person with strong values and beliefs, and her life and her profession give her ample opportunity to put them into practice. She has defied all the odds and is considered by some to be a medical miracle.
In the fall of 1972, just after she turned seventeen, Lisa was diagnosed as having acute myeloblastic or myelocytic leukemia. Her older brother had been killed in an automobile accident sixteen months earlier, and the stresses and pain in her family had been considerable ever since. Her parents were told that she had only three weeks to live, but she was treated with chemotherapy and gained a long remission. When she began to recover, they were told that the first relapse would mean an automatic death sentence, but she was not told this.
She entered college in Des Moines and made arrangements to continue her chemotherapy treatments there. She was told by a physician there, when she had been in remission for over four years, that she was almost to the point of five year’s remission, which was a good thing since if she had a relapse, she could not live through it. At the time, she believed this pronouncement totally.
In the fall of 1978, she had that first relapse. She was in the second year of law school. She had had a close group of friends as an undergraduate, everything had gone well for her, and she began to think of herself as invulnerable. When she went to law school, she left these friends behind and got into a round of very hard work. As she became somewhat tired and lonely, she began to think the cancer could come back. She came down with a fever and sore throat, and she knew immediately what it was. She went back and started chemotherapy all over again and achieved a substantial remission for about nine months. In her words, this was the first medically impossible thing that happened. At the time, she remembered that she had been told she could not survive a relapse, but once she had relapsed, she didn’t believe it and felt inside that she did not have to accept that outcome.
Many professional therapists and physicians feel that such a strong will to live represents denial. It appears that if the person does not conform to the conventional and expected idea of the course of their illness, then they are suffering from denial–denial of what? Steven Appelbaum, in discussing the topic of denial and the failure to adequately study the psychological effects on cancer, has this to say:
. . . the options are few and clear. One can assume that one has a hopeless disease, that one’s chances for survival are dictated irrevocably by the statistics attached to one’s disease and its treatment. Or one can embrace the assumption that control can be asserted over the disease, that its development and maintenance can be understood according to psychological dimensions, and that if one works at it one may create a new set of statistics. It is a choice that the therapist as well as the patient has to make.
Six months after her husband of only four days was killed in an automobile accident, Lisa had another relapse. Her subsequent medical history has been a continuous round of full and partial remissions and relapses. Her physicians are continuously amazed that she continues to rebound.
Lisa has the office across the hall from mine, where she is an attorney for Legal Services for Prisoners. When I first knew her, she did not tell anyone that she had leukemia. As she puts it, other people’s reactions are often less than helpful. However, she had the Simontons’ book, Getting Well Again, and was doing visualization and following their guidelines on her own.
Because she has not encountered all the other illnesses that generally accompany acute leukemia of her type, the original diagnosis is now being questioned. Nevertheless, she has had a number of complications, one of which was a myeloblastoma on her leg.
This myeloblastoma, a tumor made of live leukemic cells, was growing and was occasionally painful. Worse, it compromised her circulation and was a cause of great concern. A number of X-rays were taken of it, and it was also biopsied. Her physicians were contemplating amputation of her leg, since there was no other treatment considered feasible. Lisa began working on the tumor with visualization, and she and I also did a visualization session. Once she began visualizing her white cells attacking it and eliminating it totally, as a blueprint signaling her intentions to her body, it disappeared in a very short time. It remains absent to this date, more than a year later. Interestingly, in spite of the biopsy and all the X-rays, her physicians now deny that this tumor was ever there. It simply does not fit their belief system of what can happen.
Lisa is in remission again and happily married. Her energy, her strong positivity in every aspect of her life, and her unique blend of compassion and humor unleash a life force and energy that sustain her through everything. Her story represents a constancy of healing.
It was certainly in recognition of the role of attitude in healing that caused Jerry Jampolsky to choose the name, “The Center for Attitudinal Healing.” The center is founded on the idea that the most powerful healing force in the world is love. As Jerry said on the award-winning film, Donahue and Kids, “We believe the mind does control the body, and we do have a will to live; what we have done is give the added ingredient of love. The love and unity is the healing experience.”
The psychological effect of cancer or other life-threatening and catastrophic illness on people can go one of two ways. Either they identify themselves as very sick, dying, and that becomes the organizing principle of their lives, or they begin to experience every moment as precious and to reconstruct their priorities and become more open in their relationships, more consciously aware of love and warmth that they previously took for granted.
The children in the center help teach each other that they can choose one thought over another, they can choose peace instead of worry, love instead of fear. In Donahue and Kids, a number of the children state that the experience of having cancer contributed something very important to them. They have learned that in helping each other, they help themselves. They have learned that they can experience one day at a time and not live in regret over the past or worry about the future. They have learned that they have the power of choice. In combating their illness, these children have learned the greatest lessons of life.
Martin L. Rossman MD
