CHAPTER I

Introduction

Medical professionals have concentrated their research on understanding the nature

and management of the organic factors in a disease, whereas, psychologists are interested
primarily in uncovering the psychological factors that may help in the management or cure
of that disease. However, there is growing interest among researchers that a disease may be
primarily physical or psychological, it is a disorder of whole person, not just of body or
psyche (American Psychiatric Association, 1994).

The idea that mind and body together determine health and illness demands a
model for studying these issues. Biopsychosocial model, as its name implies, its
fundamental assumption is that illness out come is consequence of the interplay of
biological, psychological, and social factors (Engel & Schawrtz, as cited in Taylor, 1995, p.
12). This model maintains that health and illness are caused by multiple factors and
produce multiple effects. The model further maintains that the mind and body can not be
distinguished in matters of health or illness because both so clearly influence an
individual's state of health. On the other hand biomedical model is a single factor model of
illness. It explains illness in terms of biological malfunction rather than recognizing that a
variety of factors only some of which are biological may be responsible for the
development of illness. This model follows the assumption of mind body dualism. The
biomedical model has proven to be scientifically and clinically inadequate in explaining
the disease processes (Taylor, p. 12). The Biopsychosocial model suggests the practitioners
to understand the social and psychological factors that contribute to an illness in order to
treat it appropriately. Biological psychological and social factors all contribute to recovery.

This more holistic concept of body and mind has led to the development of new
research discipline, health psychology also called psychosomatic and behavioral medicine.
Three major trends are dominant in behavioral medicine: (1) holistic thinking: the
recognition that our way of living and state of mind affects our physical well-being,
(2) acknowledgement that science of psychology has much to contribute to the study and
cure of physical illness, (3) discovery that certain treatments pioneered by behavioral
psychologist such as bio-feedback and relaxation training, can help to relieve stress related
physical ailment (Bootzin & Accocella, 1988).

Cancer
Cancer is a term for diseases in which abnormal cells divide uncontrollably, invading
nearby tissues and spreading to other parts of the body via the bloodstream or lymphatic
system. Whether you’ve been newly diagnosed, are an existing patient, or would like to
gain a better understanding about cancer, in this section you’ll find general cancer
information, as well as a thorough resource for many different types of cancers.

Although facing a diagnosis of cancer can be frightening, resources are available to help
you. Keep in mind that there as many myths and misconceptions about cancer. At the
present time, over half the people who are diagnosed with cancer have a good chance of
long-term survival.

New treatments are developed every day.

Cancer is not one disease, but a large group of almost one hundred diseases. Its two main
characteristics are uncontrolled growth of the cells in the human body and the ability of
these cells to migrate from the original site and spread to distant sites. If the spread is not
controlled, cancer can result in death1.

Types of Cancer

Carcinomas are cancers that arise in the epithelium (the layers of cells covering the body’s
surface and lining the internal organs and various glands). 90% of human cancers fall into
this category. Carcinomas can be subdivided into two types:

Aden carcinomas are cancers that develop in an organ or a gland, while squalors cell
carcinomas refer to cancers that originate in the skin.
1
  Melanomas also originate in the skin, usually in the pigment cells (melanocytes).

 Sarcomas are cancers of the supporting tissues of the body, such as bone, muscle
and blood vessels.

Cancer is amongst those diseases whose life threatening diagnosis and long
uncertain treatment course is a source of extreme uncomfort, leading to several
associated psychological problems including depression, learned helplessness and
anxiety. It is the disease, which not only affects the physical health of patient but it also has
a negative impact on the mental health of the patient. The possibility that psychological
factors play important role in the onset and progression of illness has developed the
thinking that awareness and information about mental health of such patients can play an
important role in the cancer prognosis Cunnigham (as cited in Firshen, 1999) studied 22
women with various form of incurable cancer. After asking experts to predict each person's
life span, Cunnigham gathered data on each patient's attitudes and behaviors as they
participated in an intervention. Interventions include weekly group therapies, attending
religious services and relaxation and mental images. He found that people, who
worked the hardest at transforming themselves psychologically, lived at least three
times longer than predicted. It makes sense that people who live longer are those who
make substantial psychological changes.

Cancer as ailment

Cancer is a disease, more feared than any other ailment. It materializes many
devastating images and beliefs. Many people still associate cancer with death, suffering or
disfigurement. It is a life threatening disease and used as an indirect word for death. The
incidence of cancer is increasing, next to heart disease it is the leading cause of death. Each
year in United States more than 1.4 million individuals are diagnosed, and an other half
million people, one person every 90 second, die of the disease (Parker, Tong, Bolden &
Wingo, 1997). Although increase in the incidences of cancer and mortality rate appear to
be related to the advances in early detection. Though the incidence of cancer is increasing,
the survival or cure rate of cancer patient is also increasing. Cancer Vary in their
prevalence and mortality. The most common diagnosis for women is breast cancer and for
men is prostate cancer but lung cancer is number one killer for both (Parker et. al.).

Medically defined cancer is not just one disease, but a large group of almost 100
diseases, with its two main characteristics is uncontrolled growth of the cells in the human
body and the ability of these cells to migrate from the originahsite and spread to distant
sites (Fischer, 1982, p. 3). Cancer, by definition, is a disease of the genes. A gene is a small
part of DNA, which is the master molecule of the cell. Genes make proteins, which are the
ultimate workhorses of the cells. These proteins, along with other substances, that allow
our bodies to carry out the many processes that permit people to breathe, think, move, etc
(Dupler, 2001 a). Many genes produce proteins that are involved in controlling the
processes of cell growth and division. An alteration, or mutation, to the DNA molecule can
disrupt the genes and produce faulty proteins. Such an alteration can take place when a
gene is exposed to radiation or particular drug or chemicals, or when unexplained internal
signal occurs. This causes the cell to become abnormal and lose its restraints on growth.
The abnormal cell begins to divide uncontrollably and eventually forms a new growth
known as a tumor or neoplasm (medical term for cancer meaning "new growth"). In a
healthy individual, the immune system can recognize the neoplastic cells and destroy them
before they get a chance to divide. However, some mutant cells may escape immune
detection and survive to become tumors or cancers (The Cancer Research Institute, 2002).

The cells of the tumor then push outward from their boundaries, infiltrating
surrounding normal tissues. Small clumps of cells may then dislodge from the tumor and
migrate to distant sites, often by invading the circulatory system of the blood or lymph.
After traveling to a new organ, the cancer cells burrow out of the blood or lymph vessels
and invade the surrounding tissues. There they continue to multiply, forming secondary
tumors. This process of spreading to a distant site is called metastasis. Cancer metastasis is
responsible for most therapeutic failure as patient succumbs to the multiple tumor growth
(Fielder, 1975, p. 101). Eventually, either local invasion or metastasis disrupts the body's
normal functions and often leads to death.
 Tumors are of two types, benign or malignant. A benign tumor is slow growing,
does not spread or invade surrounding tissue, and once removed, it does not usually recur.
A malignant tumor, on the other hand, contains fast growing cells that may have variety of
abnormal chromosomes. Malignant tumors invade surrounding tissue and has the capacity
to spread to other parts of the body (Fielder, 1975). If the cancer cells have spread to the
surrounding tissues, then, even after the primary malignant tumor is removed, it generally
recurs either locally or to a distant site. A majority of cancers are caused by changes in the
cell's DNA because of damage due to the cell's environment. Environmental factors that
are responsible for causing the initial mutation in the DNA are called carcinogens, and they
are of many types. Some cancers also have a genetic basis. In other words, an individual
could inherit faulty DNA from parents, which could predispose the patient to getting
cancer (Southani & Tabias, 1987, p. 23,29).

There are several different types of cancer. Carcinomas are cancers that arise in the
epithelium (the layers of cells covering the body's surface and lining the internal organ and
various glands). Ninety percent of human cancers fall into this category. Melanomas are
cancers that originate in skin, usually in the pigment cells. Sarcomas are cancers of the
supporting tissues of the body, such as bone, muscle and blood vessels. Cancer of blood
and lymph glands are called Leukemia and Lymphomas respectively. Gilomas are cancers
of the nerve tissue (The Cancer Research Institute, 2002).

Cancer is a progressive disease and goes through several stages: Stage I, the
simplest fqrm, indicates that tumor is small and confined to the organ or tissue where it
began. The best chance of cure is when the tumor is still in stage I. Stage II means the
tumor has spread to surrounding tissues. Stage III means that tumor has spread into
surrounding tissues and lymph nodes. Stage IV signifies more extensive spread, often to
many organ or parts of the body.

Cancer produces varying symptoms. Some symptoms are produced early and may
occur due to a tumor that is growing within an organ or gland. As the tumor grows, it may
press on the nearby nerves, organs and blood vessels. This cause pain and some pressure
that may be the earliest warning sign of the cancer. Despite the fact that there are several
hundred different type of cancer, producing very different symptoms, following seven
symptoms are possible warning sign of cancer (The Cancer Research Institute, 2002):

• Changes in the size, color, or shape of a wart or a mole

• A sore that does not heal

• Persistent cough, hoarseness, or sore throat

• A lump or thickening in the breast or else where ^

• Unusual bleeding or discharge

• Chronic indigestion or difficulty in swallowing

• Any change in bowel or bladder habits

Many other diseases, besides cancer, could produce same symptoms. However it is
important to have these symptoms checked because the earlier a cancer is diagnosed and
treated, there are better chances for its cure.

Treatment Modes of Cancer (Medical, Physical, Psychological)

There are number of treatments available to help the person with cancer.
Chemotherapy and radiation treatments are one of the more toxic of conventional
treatments and often have unpredictable results. Radiation therapy can cause violent
nausea, drowsiness and fatigue, thus affecting the normal daily functioning. Surgery can
result in amputation, paralysis, sensory deficit, and language and memory problems.
Chaturvedi et. al. (1996) studied the effects of radiotherapy; anxiety and depression were
detected frequently in patients receiving radiotherapy both prior to treatment and later
during follow up. Frequency of anxiety increased significantly after initiating radiotherapy,
but later reduced during the follow up assessment.

Alternative treatments which seek to help patients with mental and spiritual
challenges that cancer poses include psychotherapy support groups guided imagery,
meditation, biofeedback and hypnosis Alternative treatments are less toxic and have
minimal side effects. When used as adjuncts to the conventional treatment, some
alternative treatment have been shown to decrease pain and side effects, aid in recovery
process, and improve the quality of life of cancer patients.

Psychological approaches work with the idea that mind and emotions can
profoundly influence the health of the body and disease like cancer. Many studies have
acknowledged that mind and emotions play a key role in cancer and immune functioning.
A new field of academic medicine called psychoneuroimmunology has begun, that studies
the interaction between mental state and immune responses. Studies have shown that
patients that approach their cancer with positive attitude and peaceful acceptance have
higher survival rates than those patients who react with negative emotions like depression,
cynicism or helplessness (Dupler, 200la). Physical approaches to cancer include exercise,
massage, therapies, and movement therapies, like yoga, breathing technique and relaxation
technique. These therapies strive to increase immune system response, promote relaxation
and stress reduction, and reduce the side effects of conventional treatments such as pain,
nausea, weakness and physical immobility.

The aim of allopathic (conventional) cancer treatment is to remove all or as much

of the tumor as possible and to prevent the reoccurrence or the spread of the primary
tumor. The major type of allopathic treatments is: surgery, radiation, chemotherapy,
hormone therapy and bone marrow transplantation (Dupler, 200 Ib).

Surgery is the removal of a visible tumor and is a most frequently used cancer
treatment. It is most effective when a cancer is small and confined to one area of the body.
Surgery can be used for many purposes. Treatment of cancer by surgery involves removal
of tumor to cure the disease. This is typically done when tumor is localized to discrete area.
Along with cancer some part of the normal surrounding tissue is also removed to ensure
that no cancer cell remains in that area. Since cancer usually spread via the lymphatic
system, adjoining lymph nodes may be examined and some time removed, as well.
 Radiation kills tumor cells. Radiation is used alone in cases where tumor is
unsuitable for surgery. More often it is used in conjunction with surgery and chemotherapy.
Radiation can be either internal or external. In the external form, the radiation is aimed at
the tumor from outside the body. In internal form, a radioactive substance, in the form of
pellets or liquid is placed at the cancerous site by means of a pill, injecting or insertion in a
sealed container.

Chemotherapy is the use of drugs to kill cancer cells, tt destroys the hard to detect
cancer cells that have spread and are circulating in the body. Chemotherapeutic drugs can
be taken orally or intravenously and may be given alone or in conjunction with surgery,
radiation or both (Lane, 1985, p.93). The toxic effect of chemotherapy is
severe. In addition, it may make body less tolerant to the side effects of other treatment
that follow, such as radiation therapy.

Hormone therapy is standard treatment for some type of cancers that are hormone
dependent and grow faster in the presence of particular hormones. These include cancer of
prostate, breast and uterus. Hormone therapy involves blocking the production or action of
these hormones. As a result, the growth of the tumor slows down and survival may be
extended for several months or years.

Another technique is bone marrow transplantation. The bone marrow is tissue

within the bone cavities that contains blood-forming cells. Healthy bone marrow tissue
constantly replenishes the blood supply and is essential to life. Sometime the amount of
drug or radiation needed to destroy cancer cells also destroys bone marrow. Replacing the
bone marrow with healthy cells counteract this adverse effect. A bone marrow transplant is
the removal of the marrow from one person and the transplant of the blood-forming cell
either to the same person or some one else. It is used to rescue a patient. Bone marrow
transplant is used when conventional chemotherapy has failed (Wingard, 1985, p.554).

Many cancers are curable if detected and treated at their early stages. A cancer
patient's prognosis is affected by many factors, particularly the type of cancer the patient
has, the stage of the cancer, the extent to which it has metastasized, and the aggressiveness
of the cancer. In addition, the patient's age, general health status, and the effectiveness of
the treatment being pursued are also important factors.

The Role of Psychological Factors In Cancer Treatment

Cancer is a chronic disease with a remitting and relapsing course. The diagnosis is a
traumatic experience for individuals, because the person diagnosed with cancer faces the
danger of losing his economic power, job, organs and even his or her life. Diagnosis of
cancer implies weakening of all normal adaptation mechanism, frustration of plans and
expectations, and incapacity. Cancer significantly affects the quality of life. Isikhan et. a I.
(2001) in their study with cancer patients found that several disease features, including
treatment, early diagnosis, disease acceptance, pain, psychological distress has affect on
patient's quality of life.

Both layperson and medical professionals hold strongly negative attitude

towards cancer. In a nation wide survey of 1,553 adults, half of the respondent agreed with
the statement, that word cancer itself scares. Over a third reported that having cancer
would be the worst thing that could happen to a person (Meyerowitz, Williams & Gessner,
1987, p. 471). Elkind (1982) carried out a research on 785 nurses that which of the serious
diseases they perceived is most alarming, cancer was chosen most frequently.

Other chronic diseases share many medical aspects of cancer. For example
cardiovascular diseases, kidney diseases or stroke are even worse than cancer in life style
disruption, mortality, extent of disability and prevalence (Naheed, 2000). Thus it is
unlikely that specific medical factors are responsible for the negativity of attitudes towards
cancer. Literature review suggests that cancer is indeed perceived as uncontrollable. Image
of cancer is a disease out of control, spreading through the population unimpeded by the
treatment. No doubt there is some truth to the image of cancer. Cancer is one of those
diseases to which no one is immune. However cancer is not entirely uncontrollable. Cullen
(1982) has claimed that cancer is preventable disease, 130,000 cancer deaths are estimated
to have been preventable through early diagnosis and treatment. These numbers indicate
that at least half of deaths are preventable and cancer is not itself entirely uncontrollable.

Negative attitudes towards cancer are largely responsible for people's failure to
adopt preventive and early diagnostic behavior. Clearly believing that a disease cannot be
controlled reduces a person's effort to exercise control. A study was carried out by
Meyerowitz, et al. (1987) results shows that when a disease is perceived as controllable it
is evaluated less negatively than when it is perceived uncontrollable. Cancer was described
significantly more negatively than other fictitious diseases.

An important aspect of cancer is that the stage of the illness can have an important
influence on the mental health status. In various stages cancer patients can experience a
sequence of symptoms and psychosocial problems (Knob, 1990). With regard to
psychological problems cancer is a disease, which disturbs the psychic balance from the
beginning of the disease. The patient can be overwhelmed by the feelings of despair,
panic and other emotions, and experience severe feelings of depression and apathy.
Feeling of uncertainty about the future is common among cancer patients. Cancer patients
some time under go stressful medical treatment like chemotherapy or radiotherapy, which
can have severe side effects (Holland & Lesko, 1988).

A cancer patient has a whole life behind him, populated by thoughts, actions and
emotions that no other person shares exactly. The fact that emotions lie so deep does not
mean that patients cannot alter them. People can be rescued from their feelings of
helplessness and despair by doing through a still deeper level (Chopra, 1990).

Cancer is a very complex disease and a positive attitude may improve the quality
of one's life. One of the positive attitudes which is proposed is "will to live". Patients who
react with helplessness and depression to there cancer are more likely to die from the
disease then those patients who have a strong component in their personalities called the
"will to live". A person afflicted with cancer naturally goes through cycles of emotion^ his
will to live is susceptible to wild swings from one extreme to the other. Their "will to live"
means that they really want to live, whether or not they are afraid to die. They want to
enjoy life, they want to get more out of life, they believe that their life is not over and they
are willing to do whatever they can to squeeze more out of it. The threat of death often
renews appreciation of the importance of life, love, friendship and all there is to enjoy.
Patient open ups to new possibilities and begins taking risks, which he/she didn't have, the
courage to take before. Many patients say that facing the uncertainties of living with an
illness makes life more meaningful. In oncology practice, it is affirmed that the expressions
not only have meaning and that it can vastly improve the quality of life but also even
prolong the life of a cancer survivor. Like all creatures in the animal world, human beings
have a fierce instinct for survival. The will to live is a force within all human beings to
fight for survival when a disease such as cancer threatens their lives. Yet this force is
stronger in some people than in others (Rosenbaum & Rosenbaum, 1999).

Sometimes the biology of a cancer will dictate the course of events regardless of
the patient's attitude and fighting spirit. These events are often beyond control. But patients
with positive attitudes are better able to cope with disease-related problems. Many
physicians have noticed how two patients of same age group and having the same
diagnosis, degree of illness and treatment program, experience vastly different results. One
of the few apparent differences was that one patient was pessimistic and the other
optimistic (Kneier, Rosenbaum, Rosenbaum & Behar, 1999).

Researchers are now experimenting with methods of actively enlisting the mind in
the body's combat with cancer, using techniques such as meditation, biofeedback and
visualization (creating in the mind positive images about what is occurring in the body).
Some doctors and psychologists now believe that the positive attitude towards ailment may
even have a direct effect on cell function and consequently may be used to arrest, if not
cure, cancer. Psychoneuroimmunology focuses on the effect that how mental and
emotional activity on physical well-being of patients can play a much larger role in their
recovery (Kneier et. al., 1999). Unfortunately, many patients react to the diagnosis of
cancer in the same way that people in primitive cultures used to react to the imposition of a
curse or spell as a sentence to a ghastly death. This result in a paralytic fears, which causes
the victim to simply withdraw from the world and awaits the inevitable end. In modern
medical practice a similar phenomenon may occur when, out of ignorance or superstition, a
patient believes the diagnosis of cancer to be a death sentence.

Rosenbaum and Rosenbaum (1999) have proposed some strategies to have a more
positive attitude towards cancer:

• Those who must live with cancer can live to the maximum of their capacity by
living in the present, not the past

• Setting realistic goals and being willing to compromise

• Regaining control of their lives and maintaining a sense of independence and

self-esteem

• Trying to resolve negative emotions and depression by actively doing things to

help themselves and others

• Following an improved diet and exercising regularly

Psychological Well-being

The concept of well-being initially emerged in the discipline of health. The World
Health Organization (WHO) defined health as. ... "Positive state of physical, mental and
social well-being, not merely the absence of disease or infirmity" (WHO, 1958). The term
mental health is used to include emotional and social well-being as well as the mental state
of the individual. We all agree that no one lives perfectly efficiently, and no one ever
attains and maintain a continual high level of enjoyment.

Mental health can be defined as (Anderson, 1969):

 • More than just the absence of illness, disease or disfunctioning Psychological
well-being

• Maximum effectiveness and happiness

• Growth of creativity

• Positive and realistic self-concept

Psychological well-being is an important part of mental health. In fact it means

ones positive sense of subjective well-being i.e. a person who thinks positively about
himself and about his/her life and reports positively, is thought to have positive
psychological well-being. Andrew and Robinson (1991) termed well-being as "a positive
attitude towards one's self and life".

In an important review of researchers Myers and Diener (as cited in Zimbordo &
Weber, 1997, p.373) concluded that despite many and important individual differences in
the causes and expression of subjective well-being can be defined by three central
components:

• Satisfaction with present life: people who are high in subjective well-being like their
work and are satisfied with their current personal relationship.

• Relative presence of positive affect: Individuals with high subjective well-

being, more frequently feel pleasant emotions, mainly because they tend to
evaluate the world around them in generally positive way.

• Relative absence of negative affect: individual with a strong sense of

subjective well-being experience fewer and less severe episodes of negative
emotions such as anxiety, depression, and anger.^

In this context Myers and Diener (as cited in Zimbordo & Weber, 1997) point out
positive and negative emotions are not correlated. People may feel happy yet still feel
angry or sad, and it is possible for individual to be neither happy nor sad. The presence of
one type of mood does not guarantee the absence of other because they are not opposites.
Thus subjective well-being depends on complex of experiences and perspectives, not a
single dimension of mood.

Different theoretical models are proposed to explain the psychological well-being.

Ryff and Keys (1995) presented a Multidimensional Model, which explains six distinct
components of positive psychological functioning. They argue that we must define mental
health in terms of the positive. Based upon the knowledge of developmental and clinical
psychology, she identifies six core dimensions of well-being: (1) Self-acceptance: A person
not only has a positive attitude toward the self but also acknowledges and accepts multiple
aspects of the self, including good and bad qualities. A person feels, positive about his or
her past life. (2) Positive relations with other people: Healthy people have warm,
satisfying, and trusting interpersonal relationships. They are capable of empathy, affection,
and intimacy, and are concerned about the welfare of others. (3) Autonomy: The person is
independent, self-determining, and self-controlled. He or she is able to resist social
pressures to think and act in specific ways. (4) Environmental mastery: The healthy have a
sense of mastery and competence in managing the environment and make good use of the
available opportunities. They are able to choose or create contexts that are supportive of
their personal needs or values. (5) Purpose in life: The person has both goals and a sense of
directedness. He or she feels that there is meaning to present and past life and holds beliefs
that life must be purposeful. (6) Personal growth: Healthy people see themselves as
growing and expanding. They are open to new experiences and have a sense of realizing
their potential. They change in ways that reflect improved self-knowledge and
effectiveness.

Bottom up model of well being suggests that happiness is derived from summation
of pleasurable and unpleasurable moments or experiences, satisfaction and happiness
results from having many specific moments of happiness in life. This approach follows the
notion that nothing is in the mind except what was first in the senses (Brief, Butcher,
George & Link, 1993). In other words mind is Tabularasa or a blank sheet on which our
experiences are written

The Top-down Model assumes that people have a predisposition to interpret life
experiences in either positive or negative ways and this predisposition effect the
satisfaction in particular domains. Experience is not so much objectively good or bad but
rather is interpreted in that way. This view was derived from Kantian philosophical model
that holds the view that mind is active interpreter and organizer of sensory experiences
(Kant, 1958). The mind does not simply accept incoming sensation, but rather filters and
select only those sensations that are congruent with one's belief and attitudes.

Any single model is not sufficient to explain the individuals perception of well-
being rather application of both bottom-up and top-down models play a tangible role, in
which personality and as well as objective life events influence the way of ones perception.
Feist, Bonder, Jacobs, Miles and Tan (1995) conducted a longitudinal study in order to
compare bottom-up and top-down model of well-being. Results showed the application of
both bottom-up and top-down models. It proves that personality as well as objective life
events influence the way of one's perception. Brief, Butcher, George and Link (1993)
conducted another study as a mean of integrating bottom up and top down theories of Well-
being. They proposed that objective life circumstances and global personality dimensions
indirectly affect subjective well-being through their effects on the interpretation of life
circumstances.

Cancer and Psychological Well-being

Growing incidence of cancer has led the realization among medical practitioners
and psychologists to explore the possible relationships between psychological well-being
and physical health. It is believed that different kinds of psychological stressors are risk
factors for different types of physical ailments and diseases. Physically healthy person is
assumed to be satisfied with life and has a positive sense of psychological well- being,
whereas, the well-being of ailing person will be markedly low. It has been supported well
through empirical researches, which have provided ample support for the relationship
between psychological well-being and physical heajth (Diener, 1984; Larson, 1978; Veroff,
Feld, & Gurin, 1962). Zautra and Hampel (1984) observed that perceived health shows a
strong relation to subjective well-being. Health perhaps is one of the single most important
influences on subjective well-being (Larson, 1978).

Cancer is a serious physical illness, and its diagnoses warrant serious threats to life,
which has negative impact on the psychological well-being of patient in many ways. The
cancer diagnosis introduces quite drastic changes into a person's way of life. The disease
not only affects the feelings of wellness regarding general health and well-being, but it also
disrupts daily schedules and routines. It creates strain on one's relationship with friends and
family. These changes may initiate a variety of intense emotions as the patient passes
through various stages of cancer, their perception of interpersonal and family relationship
changes. Changes occur within the family e.g. relationship with spouse, significant other,
and children tend to be markedly changed. We all argue that positive relations with other
are very important issue for the wellness of an individual. Many researches emphasize
the importance of warm, trusting interpersonal relations. The ability to love is viewed as
a central component of mental health (Ryff, 1989).

Importance of positive relations and support of others is repeatedly stressed in the

concept of psychological well-being. Compared with those having few social ties, people
supported by close relationships with friends, family, or by fellow members of work
groups, church, etc., are less vulnerable to ill health and premature death. When afflicted
with leukemia or heart disease those people surrounded by extensive support systems have
higher survival rates. A large amount of data reveals that.... "people are happier when
attached then when unattached" (Physical Health and Emotional Health, 2002). Thus
family support can be important both for promoting health and in recovery from illness.
Berkman and Syme (1979) found that single persons, widowed persons, persons with few
friends and family died at a rate two to five times grater than those with extensive ties.

Social support is known to be associated with better emotional adaptation to cancer.

Emotional support of the individuals who interact with the patients have a profound
influence on the emotional state of the patients. Therefore, social support in the form of
calmness, caring and reassurance may operate to reduce anxiety. When a person is
physically ill or disfigured, the reaction of the others to the patients can have an important
effect on his or her self -image and feeling of self-esteem (Moos & Tsu, 1977)

Kleman (1994) found out that high social support is related to positive adjustment
in lung cancer patients. Another study aimed to assess important needs of cancer patients.
Social support was reported as the most important (Bateman, 1994). A study conducted by
Chandra et. al. (1998) about the impact of cancer on the psychological well-being of newly
diagnosed cancer patients indicated that there was a decrease in the well-being scores on
some dimensions such as perceived family and primary group support.

Individual's sense of self-acceptance is also very important for the psychological

wellness. Thus, holding positive attitudes towards oneself emerges as a central
characteristic of positive psychological functioning. For cancer patients acceptance of
illness and physical conditions are very important issues (Ryff, 1989).

Feelings of helplessness are another important factor that affects the well-being of
cancer patients. Seligman (2002) found that...."learned helplessness tends to be associated
with certain ways of thinking about events that form a person's explanatory style. Three
major components of explanatory style are associated with learned helplessness. These are
permanence, pervasiveness, and personalization. Permanence refers to the belief that
negative events and/or their causes are permanent, even when evidence, logic, and past
experience indicate that they are probably temporary. Pervasiveness refers to the tendency
to generalize so that negative features of one situation are thought to extend to others as
well. Personalization, the third component of explanatory style, refers to whether one tends
to attribute negative events to one's own flaws or to outside circumstances or other people.
Persons suffering from learned helplessness tend to blame themselves for everything, a
tendency associated with low self-esteem and depression. Feeling of helplessness develops
negative attitude in patients and is largely responsible for people's failure to adopt
preventive and early diagnostic behavior".

Diagnosis of cancer disrupts the psychological well-being many ways. It develops

feelings of anxiety, loneliness, and depression; Psycho-social distress; changes in sexuality
and body image (factors affecting sexuality include age, type of surgery, breast
reconstruction, hormone therapy, and hair loss), feelings of shock, anger, renewed fear of
death and dying, spiritual crisis, loss of hope and uncertainty over the future all these
experiences can disturb the psychological well-being of cancer victim (Williams, 2002).

Depression and Cancer

A depressive disorder is a "whole body" illness, involving body, mood and

thoughts. It affects the way we eat, sleep, the way we feel about ourselves, and the way one
feels about things. In any event when a person complains of feeling inordinately dejected,
hopeless or unhappy, the term depressed is used to label this subjective state (Beck, 1998,
p.6).

Beck (1998, p.255) had described three major cognitive patterns that force the
individual to view himself, his world and his future in idiosyncratic way. These cognitive
patterns lead to the other phenomena that are associated with depressive state. The first
component is constructing the experiences in negative way. The patient consistently
interprets his or her interaction with environment as representing defeat, deprivation, or
disparagement. He or she sees his or her life as filled with succession of burdens, obstacles,
or traumatic situations. The second component is the pattern of viewing himself or herself
in a negative way. Patients regard themselves as deficient, inadequate or unworthy, and
tend to attribute their unpleasant experiences to a physical, mental or moral defect in them.
The third component consists of viewing the future in a negative way. Patient anticipates
that his current difficulties or sufferings will continue indefinitely. As he looks ahead, he
sees a life of unremitting hardship, frustration and deprivation.
 A depressive disorder is not a passing blue mood. It is not a sign of personal
weakness or condition that can be willed or wished away. People with a depressive illness
cannot merely "pull themselves together" and get better. Without treatment, symptoms can
last for weeks, months, or years. Appropriate treatment, however, can help over 80% of
those who suffer from depression. All the people who are manic or depressed do not
experiences every symptom. Some people experience few symptoms some many; severity
of symptoms also varies with individuals. Symptoms of depression may include: persistent
sad, anxious or empty mood; feelings of hopelessness; feeling of guilt, worthlessness; loss
of interest in pleasure activities, insomnia; difficulty in concentrating, remembering and
making decision; persistent physical problems that do not respond to treatment e.g.
headaches, digestive disorder and chronic pain. A striking feature of depression is the
tendency to generalize from a particular behavior to a character trait. Any single deviation
from a high level of performance is assumed to represent a major shortcoming (Beck, 1998
p.259)

Immediately after a chronic illness is diagnosed, patients are often in a state of

crisis marked by physical, social and psychological disequlibrium (Moss, 1977). Anxiety
depression is common reaction. These reactions might be usual, and beneficial at certain
stages of adjustment to chronic illness, they may also impede recovery or treatment. The
possibility that mental factors may influence the onset and progress of cancer, has been
given more credibility by recent research in three separate areas: (1) there is clear evidence
from experiments with animals that stress and mental state can modulate the growth of
neoplasm. It is also well established in both animals and humans that mental factors can
affect the function of the immune system, a pathway through which mind may influence
cancer growth. (2) A number of prospective studies have been published to supplement the
large existing literature correlating human personality factors with risk of developing the
disease. It is suggested that depression and repressive tendencies are among those
characteristics favoring cancer, although there is great variation in results between studies.
(3) A number of large but uncontrolled clinical studies imply that various psychological
interventions may increase longevity of cancer patients (Cunningham, 1985).
 Depression is a common reaction to chronic illness. Bukberg, Penman and Holland
(1984) examined the prevalence of depression in hospitalized cancer patients. These
authors found that 24% of these patients were severely depressed 18% were moderately
depressed and 14% has depressive symptom of sadness. The factors most significantly
related to sever depression was physical functions. Seventy seven percent of those who
were most depressed were also most physically impaired. Plumb and Holland (1977) in
their study found that 23% of cancer patients were significantly depressed. Two studies of
patients on general medical floor found a similar prevalence of depression, supporting the
belief that patients with malignancies are no more or less depressed than patients with
equally physically debilitating illness. In short, approximately 2.5% of a\\ cancer
patients, "irrespective of their hospital and physical status, may be experiencing significant
depression (Moffic & Pykel, 1975).

There are many myths about the psychological state of cancer patients. There is
assumption that all patients are depressed and need psychiatric intervention contrary to this
there is another assumption that patients manage well and few need help. Prevalence
studies counter these attitudes. The Psychological Collaborative Oncology Group reported
a study of 215 randomly selected hospitalized and ambulatory patients at three major
cancer centers, 47% of patients met criteria for a psychiatric disorder and 53% did not. Of
47% who have a recognizable psychiatric disorder, 68% had an adjustment disorder with
depressed, anxious, or mixed mood; 13% had major depression; 8% had an organic mental
disorder; 7% had a personality disorder; and 4% had an anxiety disorder. Nearly 90% of
disorders observed were either reaction to a manifestation of disease or treatment. Only
11% represented prior psychiatric problems, such as personality and anxiety disorders
(Derogatis, Marrow & Petting, 1983). According to these findings patients with cancer are
thus largely psychologically healthy individuals whom emotional distress is related to
illness.

Studies reveal that depression may also have part in the onset of cancer. To explore
the hypothesis that depression is an etiological factor in the development of cancer, a study
indicates a small but statistically significant association between depression and the later
development of cancer (McGee, Williams & Elwood, 1994). These findings are consistent
with previously reported results suggesting that psychological depression might promote
the development and spread of malignant neoplasm (Persky, Kempthorne & Shekelle,
1987).

Depression and anxiety can increase the risk of cancer. National Cancer Institute
(1999) published a study of 4,825 healthy individuals, 146 of whom were chronically
depressed. Those who had been depressed for at least six years were more likely to develop
cancer. Another study, from Ohio State University, found that breast cancer patients who
reported high levels of anxiety about their disease showed a major reduction in the
effectiveness of their natural killer cells. That doesn't mean that mood
can cause cancer, but it does imply that depression and anxiety lower immunity-and
that can be a risk factor for cancer (Firshein, 1999).

Individuals suffer from high levels of anxiety and depression before they reach the
terminal phase of their illness. William (2002) in his study found the prevalence of
depression, 25 percent of patients admitted to palliative care unit. The symptom of
depression significantly impairs quality of life and can make the palliation of pain and
other symptoms difficult to achieve. All patients at the end of life can be expected to
express the feelings of sadness and grief for a life that is ending, but such patients are able
to express joy and hope for the time they have left. Patients who are depressed feel the loss
of all hope, feel worthless, and see no point in living and are not able to enjoy any aspect
of their life.

Some studies however, suggest that treatment such as radiotherapy, chemotherapy

actually cause this emotional disturbance. . For example Peck and Boland (1977) reported
a !ii .;her incidence of anxiety and depression in 50 patients following radiotherapy than
with pretreatment measures. Greer (1984) studied the effect of cancer treatment on the
quality of patient's life. He attributed it to be the main source of emotional disturbance.
Palmer, Walsh, MacKinna and Greening (1980) looked at the impact of chemotherapy on
cancer patients, and found physical side effects but also severe anxiety, depression and
sexual difficulties. Duration of cancer diagnosis and chemotherapy completion is also
directly related with greater depressive symptomatology (Broeckel, Jacobsen, Baldccii,
Horton & Layman, 2000)

Anxiety is also a commonly found reaction among the terminally ill. Rees (1972)
found in his study 13 out of 15 community patients were anxious, and in the hospital group
26 out of 50 were anxious. In a study of hospitalized patient anxiety and depression both
were found frequently present in the terminally ill (Hinton, 1976).

To examine the prevalence of depressive symptoms and its relationship with

quality-of-life domains in home care cancer patients, 86 patients were given psychological
tests one week after admission to the program. Depressive symptoms were reported by
45% of the subjects. The quality of life of depressed versus nondepressed was more
affected in the social, emotional, cognitive, and physical domains. Significant correlations
were found between depression scores and impairment in most quality-of-life areas (Grass!
et. al., 1996).

For cancer patient's depression means much more than just a dark mood. The
depression can drain a person's immune system, weakening the body's ability to cope with
disease. Orse, McCorkle, Tax and Barsevick (1996) carried out a study on colorectal
cancer patients. Research has demonstrated an association among depression, depressive
symptoms and certain component of immune system. Researches have also revealed that
women with breast cancer have an increased incidence of depression and anxiety than
women without the disease (Brown & Paraskeves, 1982).

A study was carried out on the incidence and etiology of major life difficulties for
women with survivable cancer. They were assessed after their diagnosis but prior to
treatment and then reassessed at 4, 8 and 12 months post treatment. The emotional
response to cancer diagnosis and treatment was a depressed, anxious and confused mood
(Anderson, Anderson & DeProsse, 1989). These data are consistent with surveys
suggesting that depression is the most prevalent affective problem for cancer patients
(Derogatis et al., 1983).

Investigations in the last few decades regarding the effect of psychological factors
related to cancer suggest a prevalence of depressive symptoms in the cancer patient. In an
attempt to put into perspective the prevalence of depression in cancer patients, Massie (as
cited in Covich, 2002) compared the occurrence of depression in the cancer population
with that of depression in the general population. Massie found that the prevalence of
depression in the general population was only 6%. Therefore, only a small number (about
6%) of cancer patients would be expected to have a preexisting affective disorder, which
would place them at an increased risk of depression during the course of cancer. However,
the frequency of depression occurring in cancer patients after diagnosis is 58%, there
apparently is a strong relationship that exists between the diagnosis of cancer and the onset
of depression.

Suppression of one's emotions and fears may also be related to the onset of cancer
and its progression (Greer, Cox & MacKay, as cited in Covich, 2002). However, years of
interest in this area have resulted in contradictory empirical evidence as to the importance
of psychological factors in the onset and progression of cancer. Although investigations
have not yet provided conclusive evidence for the association of psychological factors in
cancer progression, research does support the commonly held belief that individuals
diagnosed with cancer are likely to be psychologically devastated as a consequence.
Furthermore, numerous studies have found that depression appears to be the primary
psychological factor that substantially affects cancer patients.

Medically ill cancer patients with borderline personality disorder face formidable
emotional challenges as they cope with cancer diagnoses and treatment. The anxiety and
discomfort associated with medical treatment can lead them to have difficulties with
medical caregivers, distort reality for emotional protection, or exhibit outright aggression
and self destructiveness (Hay & Passik, 2000).

Depression and anxiety varies along the type of cancer. A study was conducted to
determine the prevalence of psychological distress among large sample of cancer patients
(7V=4496). The overall prevalence rate for this sample was reported 35.1%. The rate
varied from 43.4% for lung cancer to 29.6% for gynecological cancer. Pancreatic cancer
patients produced the highest mean score for symptoms such as anxiety and depression
(Zobara, BrintzenhofeSzoc, Curbow, Hooker & Paintadosi, 2001).

Psychological Interventions

Cancer affects feelings of overall health and well-being. It disrupts daily schedules
and routines as well as creating strain on personal relationships with friends and family.
These changes may initiate a variety of intense emotions as the patient travels through
various stages. Sadness, anxiety, fearfulness and anger represent a few of the many
emotions experienced by a cancer victim. Fortunately, these feelings are very normal and
there are ways in which a patient can receive the support needed to cope with these new
feelings. Psychologists can help patients and families reduce emotional distress, enhance
communication among patients, families and oncologists, reduce treatment's side effects
and improve patients' quality of life and as result can affect psychological well-being of
patient. There's even evidence that psychological interventions may strengthen patients'
immune systems, perhaps even helping them live longer (Clay, 2000).