When the Body Says No: The Cost of Hidden Stress (20 page)

Donna called me back a few days later. Our conversation had brought to the forefront many memories. She needed to talk.

“After you and I spoke, I just went on about my day. I went to bed at night. About four o’clock in the morning I woke up. It was just incredible how many things came out and just kept going through my mind.

“You had mentioned Linda saying that Jimmy had a lot of sadness in him, maybe to do with his dad. I knew Jimmy really, really well, and yes, there was a lot of sadness. I can go way back to the beginning, remembering when he was little. The only time I can recall my dad doing anything with my brother was a little bit of roughhousing on the
carpet in the living room. And I see a bunch of smiles and laughs. But other than that, there was never any participation in Jimmy’s life. Never went to the hockey games. Never played with him.

“The crazy thing is that our father always said that he loved us, but he could be so hurtful. I have a brother who is quite heavy, and he’d ridicule him in front of people. He’d say some terrible things to him. And to Jimmy, too.

“I was never angry with my father—I’ve always covered up for him, maybe knowingly, maybe in an unknowing way. That night, all of a sudden, I got so angry. I started to think of Jimmy and all the things that happened as he was growing up and throughout his life. I kept thinking of all the times my father raised his voice. If he was trying to fix something and he didn’t have the right tools, or the screws fell on the floor, or if something didn’t happen exactly the way it was supposed to happen, he would scream and yell, and we were scared. We just fled. All of a sudden I remembered his voice and the screaming and the yelling, and I thought, This is not how you should live. This is not what we should have experienced.

“Even at the end … My father came out to see Jimmy—they drove from Halifax. Actually, my sister and her husband did all the driving; my father drank all the way. They arrived a couple of weeks before Jimmy had to go into palliative care. My father walked into the apartment and sat there sipping his beer, not wanting even to go into the bedroom to see his son, to see Jim.

“We were trying to cover up. We didn’t want Jimmy to realize that his father couldn’t face seeing him—was afraid to see what he was going to look like. Finally, Dad built up enough courage and went into the room, and asked, ‘Jimmy, can I get you anything? Is there something that you want?’

“My father came out, went to the fridge, and all of a sudden he said, ‘How come there’s no apple juice here? I don’t believe this!’ And he started ranting and raving at all of us in the apartment. We were stunned. Got his coat on and stomped off to the store and came back with apple juice for Jimmy.

“Then my father went home, and that was it. He never saw Jimmy in the hospital. He went back to Halifax and never saw him again. And the funny thing is, well … you know Linda was pregnant with Estelle and they got married five days before Jimmy died.

“He was semi-comatose that day.”

“Yes, he was drowsy. We’d had to increase his pain medication rapidly.”

“Well, one of the things I keep remembering is this…. After the wedding, he was weak, but he held his hand up and said, ‘Look, look,
just like Dad’s ring.’
And his wedding band was identical to my father’s. It’s funny, those were the words that came out of Jimmy’s mouth.
Just like Dad’s ring
.”

Jimmy’s mode of emotional coping has been extensively documented among melanoma patients. An elegant study in 1984 measured the physiological responses to stressful stimuli of three groups: melanoma patients, people with heart disease and a control cohort with no medical illness. Each person was connected to a dermograph, a device that recorded the body’s electrical reactions in the skin as the subject looked at a series of slides designed to elicit psychological distress. The slides displayed statements of an insulting, unpleasant or depressing nature, such as “You’re ugly,” or “You have only yourself to blame.” As their physiological responses were being registered, the participants were asked to record their subjective awareness of how calm or disturbed they felt on reading each statement. The researchers thus secured a printout of the actual level of distress experienced by the nervous system of each subject and simultaneously a report of the subjects’ conscious perception of emotional stress.

The physiological responses of the three groups were identical, but the melanoma group proved most likely to deny any awareness of being anxious or of being upset by the messages on the slides. “This study found that patients with malignant melanoma displayed coping reactions and tendencies that could be described as indicating ‘repressiveness.’ These reactions were significantly different from patients with cardiovascular disease, who could be said to manifest the opposite pattern of coping.”
²

The melanoma group was the most repressed among the three groups; the cardiac patients appeared to be the least inhibited. (It is not, as it may seem, that the reactivity of the cardiac patients is healthy. In between repression and hyper-reactiveness is a healthy median.) This study demonstrated that people can experience emotional stresses with measurable physical effects on their systems—while managing to sequester their feelings in a place completely beyond conscious awareness.

It was in relationship to melanoma that the notion of a “Type C” personality was first proposed, a combination of character traits more likely to be found in those who develop cancer than in people who remain free of it. Type A individuals are seen as “angry, tense, fast, aggressive, in control”—and more prone to heart disease. Type B represents the balanced, moderate human being who can feel and express emotion without being driven and without losing himself in uncontrolled emotional outbreaks. Type C personalities have been described as “extremely cooperative, patient, passive, lacking assertiveness and accepting…. The Type C individual may resemble Type B, since both may appear easygoing and pleasant, but … while the Type B easily expresses anger, fear, sadness and other emotions, the Type C individual, in our view, suppresses or represses ‘negative’ emotions, particularly anger, while struggling to maintain a strong and happy facade.”
³

Could it be disease itself that changes someone’s personality, affecting his coping style in a way that may not reflect how he had functioned in life before the onset of illness? Jimmy’s story, related by his wife and sister, illustrates that repression, “niceness” and lack of aggression are lifelong patterns, having their origins in early childhood. As the researchers who studied physiological stress responses in melanoma patients noted, “When people are diagnosed with a disease—whether cancer or cardiovascular—they do not precipitously change their usual ways of coping with stress or suddenly develop new patterns…. Under stress, people usually mobilize their existing resources and defences.”

How do psychological stresses translate into malignant skin lesions? Hormonal factors likely account for the fact that the number of melanoma tumours is increasing in bodily sites not exposed to sunlight. Researchers have suggested that hormones may be overstimulating the pigment-producing cells.
⁴

The Type C personality traits associated with melanoma have been found in studies of many other cancers as well. In 1991 researchers in Melbourne, Australia, investigated whether any personality traits were a risk factor in cancer of the colon or the rectum. Over six hundred people, newly diagnosed, were compared with a matched group of controls. Cancer patients, to a statistically significant degree, were more likely to demonstrate the following traits: “the elements of denial and repression of anger and of other negative emotions … the external
appearance of a ‘nice’ or ‘good’ person, a suppression of reactions which may offend others, and the avoidance of conflict…. The risk of colorectal cancer with respect to this model was independent of the previously found risk factors of diet, beer intake, and family history.”
⁵
Self-reported childhood or adult unhappiness was also more common among the bowel cancer cases. We have already noted similar traits among patients with breast cancer, melanoma, prostate cancer, leukemias and lymphomas, and lung cancer.

In 1946 researchers at Johns Hopkins University began a long-term prospective study to establish whether there are psychobiological characteristics in young people that could help predict susceptibility to future disease states. In the course of the subsequent eighteen years, 1,130 white male students enrolled in medical school underwent psychological testing. They were questioned regarding their emotional coping styles and childhood relationships with parents. Biological data—pulse, blood pressure, weight and cholesterol levels—were also recorded, as were habits such as smoking, coffee drinking and alcohol intake. At study’s end, nearly all the subjects had graduated and most were doctors, their ages ranging from thirty to over sixty. At this point, their health status was reviewed; the majority were healthy, but in about equal numbers some had developed heart disease, high blood pressure, mental illness, cancer or had committed suicide.

When the researchers conceived of the project, they had not expected to find that cancer would be associated with any pre-existing psychological factors. However, their data showed just such a connection. There were striking similarities between those who had been diagnosed with cancer and the suicide group: “Our results appear to agree with findings that cancer patients ‘tend to deny and repress conflictual impulses and emotions to a higher degree than do other people.’”
⁶

The researchers found that both for the healthy majority and for each disease category there was a distinctive set of psychological traits. The lowest scores for depression, anxiety and anger had been originally recorded for the medical students who later developed cancer. They had also reported being the most distant from their parents. Of all the groups, the cancer subjects were the least able to express emotion. Does that mean there is a “cancer personality”? The answer is neither a simple yes nor a no.

Melanoma illustrates the futility of simplistic reductions to a single origin. Fair skin alone cannot be the cause of this cancer, since not everyone with fair skin will develop melanoma. Ultraviolet damage to the skin by itself cannot be sufficient, since only a minority of light-complexioned persons who suffer sunburns will end up with skin cancer. Emotional repression by itself also cannot account for all cases of malignant melanoma, since not all people who are emotionally repressed will develop either melanoma or any other cancer. A combination of these three circumstances is potentially lethal.

While we cannot say that any personality type
causes
cancer, certain personality features definitely increase the risk because they are more likely to generate physiological stress. Repression, the inability to say no and a lack of awareness of one’s anger make it much more likely that a person will find herself in situations where her emotions are unexpressed, her needs are ignored and her gentleness is exploited. Those situations are stress inducing, whether or not the person is conscious of being stressed. Repeated and multiplied over the years, they have the potential of harming homeostasis and the immune system. It is stress—not personality per se—that undermines a body’s physiological balance and immune defences, predisposing to disease or reducing the resistance to it.

Physiological stress, then, is the link between personality traits and disease. Certain traits—otherwise known as coping styles—magnify the risk for illness by increasing the likelihood of chronic stress. Common to them all is a diminished capacity for emotional communication. Emotional experiences are translated into potentially damaging biological events when human beings are prevented from learning how to express their feelings effectively. That learning occurs—or fails to occur—during childhood.

The way people grow up shapes their relationship with their own bodies and psyches. The emotional contexts of childhood interact with inborn temperament to give rise to personality traits. Much of what we call personality is not a fixed set of traits, only coping mechanisms a person acquired in childhood. There is an important distinction between an inherent
characteristic
, rooted in an individual without regard to his environment, and a
response to the environment
, a pattern of behaviours developed to ensure survival.

What we see as indelible traits may be no more than habitual defensive techniques, unconsciously adopted. People often identify with these habituated patterns, believing them to be an indispensable part of the self. They may even harbour self-loathing for certain traits—for example, when a person describes herself as “a control freak.” In reality, there is no innate human inclination to be controlling. What there is in a “controlling” personality is deep anxiety. The infant and child who perceives that his needs are unmet may develop an obsessive coping style, anxious about each detail. When such a person fears that he is unable to control events, he experiences great stress. Unconsciously he believes that only by controlling every aspect of his life and environment will he be able to ensure the satisfaction of his needs. As he grows older, others will resent him and he will come to dislike himself for what was originally a desperate response to emotional deprivation. The drive to control is not an innate
trait
but a
coping style
.

Emotional repression is also a coping style rather than a personality trait set in stone. Not one of the many adults interviewed for this book could answer in the affirmative when asked the following: When, as a child, you felt sad, upset or angry, was there anyone you could talk to—even when he or she was the one who had triggered your negative emotions? In a quarter century of clinical practice, including a decade of palliative work, I have never heard anyone with cancer or with any chronic illness or condition say yes to that question. Many children are conditioned in this manner not because of any intended harm or abuse, but because the parents themselves are too threatened by the anxiety, anger or sadness they sense in their child—or are simply too busy or too harassed themselves to pay attention. “My mother or father needed me to be happy” is the simple formula that trained many a child—later a stressed and depressed or physically ill adult—into lifelong patterns of repression.