By Thomas P. Beresford, M.D.
Psychological treatment studies that did not measure the maturity of psychological adaptive mechanisms in cancer patients have reported conflicting cancer survival results. Widely publicized studies noted increased survival rates among cancer patients who underwent psychotherapeutic treatment. However, more recent multicenter study could not replicate improved survival after behavioral treatment, and other studies have reported similarly conflicting results. Since published reports suggest that patients likely to benefit from psychotherapies are generally those with the most psychological maturity, it seems possible that the underlying health of psychological adaptive mechanisms may be related to cancer survival.
To our knowledge, prior to our 2006 report, psychological adaptive mechanism maturity had not been considered as affecting cancer survival either in behavioral-treatment studies or in trials of antidepressants. In that report we used measures of both depression symptom frequency and psychological adaptive mechanism maturity to assess what, if any, relationship each bore on survival probability in cancer patients. On the basis of previous studies of depression and ego-adaptation, we believed that “Immature” adaptive styles and frequent depression symptoms would independently predict lower survival rates. Then we studied 86 consecutive, mostly late-stage, cancer outpatients for up to 5 years; their survival data were analyzed in relation to the Beck Depression Inventory (BDI) and the Defense Style Questionnaire (DSQ) scores at study entry. Cumulative survival probability curves contrasted the extreme cases: the most (N = 15) to the least (N = 21) depressed, and the “immature” (N = 14) to the “mature” (N = 16) adaptors. Depression did not separate the groups until 30 months after diagnosis. (Figure 1)
Psychological adaptive mechanism (ego defense) style separated them at 8 months; by 18 months, the Immature survival probability had dropped to 50%, versus 87% for the Mature. At 36 months, survival probabilities were 19% and 57%, respectively. This study suggested further clinical attention toward psychological adaptive mechanism maturity and immaturity as a potentially strong indicator of distress and lowered survival in cancer patients. It also indicated that the maturity of adaptive mechanisms must be taken into account in both medicinal and behavioral treatment trials of cancer patients since underlying difficulty may be more related to poor adaptation rather than traditional psychopathological constructs like depression.While human psychological adaptation has been studied in various forms, including such terms as coping or ego defense mechanisms, this concept has yet to reach clinical use owing largely to the absence of a replicable clinical format that can allow reliable recognition of psychological adaptive mechanisms in the clinical, one-on-one setting. The Principal Investigator (PI) has developed a decision tree recognition algorithm for the purpose of assessing individual adaptive behaviors in the diagnostic and treatment settings. (Figure 2)
While previous methods, such as the DSQ, offer a relative convenience, they are crude measures of these complex phenomena and can only be used in studies that compare groups of individuals in contrast to each other. The recognition algorithm approach aims at a specific assessment of respective individuals in a here-and-now setting. This approach can be used both in clinical assessment and treatment as well as in research studies that seek to characterize groups of patients, such as those presenting with use of Immature adaptive mechanisms who present with much lower likelihoods of cancer survival.
Other research indicates that psychological adaptive mechanisms occur naturally in graded steps that reflect increasing brain development from birth through early adulthood. Conversely, however, complex behaviors of this kind that utilize many brain tracts, including frontal lobe functions, may theoretically be lost when brain function decreases or when stress is overwhelming, as may be the case of the stress of cancer illness in the setting of the less flexible mechanisms. Neurodegenerative changes following radiation treatment of neoplasms in the brain, for example, may result in impaired functioning modulated by the fronto-subcortical tracts, including judgment, motivation, and executive planning functions. Alternatively, overwhelming stress reactions can result in lowered adaptive mechanism maturity, such as that seen in some cases of Post-Traumatic Stress Disorder. Much remains to be learned in the interaction between humans and the illnesses that they encounter; the psychological adaptation model offers one new approach to both clinical and empirical understanding.
Dr. Thomas P. Beresford is Professor of Psychiatry at the University of Colorado School of Medicine and the author of Psychological Adaptive Mechanisms: Ego Defense Recognition in Practice and Research. Trained in psychiatry at The Cambridge Hospital/Harvard Medical School, he has focused his clinical and scientific career on the psychiatric problems that medical and surgical patients encounter, whether in adjusting to illness or in returning to normal brain functioning.