Breast cancer and suppressing emotions
Every year there are 1.677 million new diagnosis of breast cancer (International Agency for Research on Cancer Globocan, 2012). Breast cancer is the most common form of cancer by women worldwide (World Health Organisation, z.j.). Through early diagnosis and improvement of therapy, the rate of survival has increased in almost a continuous trend over the past decade. Significant proportions of women survive five years after their diagnosis of breast cancer (International Agency for Research on Cancer Globocan, 2012). Beside the early diagnosis and improvement of therapy, other factors can play a role to improve this positive trend furthermore. Such as the biopsychological approach, which directs attention to the social, psychological, and behavioral dimensions of illness. A consensus of studies has occurred which shows that several emotional clusters of psychology factors warrant further investigation, for instance emotion.
Patients who are diagnosed with life-threatening illness, like breast cancer, have emotional distress. Distress, such as depression, anxiety and anger, seem to have a negative effect on the prognosis of the disease (Hann, Winter, & Jacobsen, 1999). The feelings of emotional distress is different between patients. Research has investigated these differences in patients and suggested that psychosocial aspects such as personality traits and coping styles can play a role in these differences (Burgess, Morris, & Pettingale, 1987). An example of a coping style seen in breast cancer patients is suppressing one’s negative emotions, which is linked to psychological maladjustment and stress (Iwamitsu et al., 2005). In this paper suppressing emotions can be read as suppressing negative emotions. Gross (1989) found that emotional inhibition might contribute the cancer prognosis. In contrast to suppressing emotions, expressing emotions had positive effects on physical and mental health, including function of autonomic nervous and endocrine systems (Pennebaker, 1999). Suppressing negative emotions might have been an effective coping style before these patients had breast cancer, but under the extreme stress of having breast cancer, it is no longer an effective coping style (Iwamitsu et al., 2005).
Problem definition
The question that arises from previously named studies is why do cancer patients suppress their negative emotions? Despite earlier, but minimal research, there is still not yet a consensus about the reason of suppressing emotions in the specific population of breast cancer patients. The gap in the literature is a knowledge gap about the reason of suppressing emotions in breast cancer patients. This makes it impossible to prevent or resolve the negative consequences of suppressing emotions in this specific population. In order to find solutions to minimize the suppression of emotions and negative consequences in breast cancer patients, the reason must be clear. Which can help to develop patients specific therapy, adequate psychological support or prevention. Whereas the aim is; an increase in life expectations, a decrease in breast cancer incidence and morality.
Theoretical background
Suppressing emotions
Gross and Levenson (1993) defined emotion regulation as “the manipulation of emotion antecedents or one or more physiological, subjective, or behavioral components of the emotional response” (p. 970). Suppressing emotions can be seen as a form of intrapersonal emotion regulation, the persons conscious inhibition of one’s own emotional expressive behavior while emotionally aroused (Gross & Levenson, 1993). Research has shown that emotionally unexpressive adults are more physiologically reactive to emotional stimuli than are expressive adults. This negative correlation between behavioral and physiological responses can be explained by a hydraulic model. Gross and Levenson (1993) clarified the hydraulic model as “when expressive signs of emotion are inhibited they are discharged through other channels” (p.971). Gross (2002) suggest that emotional suppression increases sympathetic activation of the cardiovascular system. Some literature suggested that people who suppress their emotions chronically may be more prone to diseases, than those who express their emotions (Gross, 1989; Temoshok, 1987). This can be explained due to the heightened physiological reactivity (Gross & Levenson, 1993).
Suppressing emotions has also been linked to stress. Stress, mediated by the central nervous system may cause progress through cancer stages of tumor induction, growth and metastatic spread (Gross, 1989). Beside the physical changes due to suppressing emotions, suppression decreased expressive behavior, with little or no change in ongoing emotion experience (Gross, 2002). Thus, emotion suppression decreases the outward signs of emotions, but has a little effect on the emotion experience itself. Nakatani et al. (2014) revealed that breast cancer patients with emotional suppression felt higher levels of psychological distress. This suggests that successful suppression may be achieved in emotionally challenging situations, however there is a downside. Namely, continued activation may be physiologically taxing and lead to disturbances in psychological and physical functioning (Gross, 2002; Abelson, Libezon, Young, & Khan, 2005).
Type C personality
Considering it has become clear what the consequences of suppressing emotions are, this paper will focus on the different reasons of suppressing emotions in breast cancer patients. There are several theories about the reason of suppressing emotions by breast cancer patients, one of them is the “Type C” patients’ theory introduced by Temoshok (1987). Temoshok suggested that emotional suppression is a common characteristic of many cancer patients. Type C can be seen as a coping style, these people have difficulties in expressing emotions and an attitude or tendency toward helplessness/hopelessness (Temoshok, 1987). According to Gross (1989) type C is characterized as “being cooperative and appeasing, unassertive, patient, unexpressive of negative emotions (particularly anger) and compliant with external authorities” (p.1239). Serveas, Vingerhoets, Vreugdehil, Keuning, and Broekhuijsen (1999) also found characteristics of breast cancer patients which correspond nicely with the type C personality. This type C coping style can be adaptive at first, but has negative consequences later on. Iwanitsu et al. (2005) found that emotional-suppressive patients already felt increased emotional distress at the first visit. Which supports the view of suppressing emotions as a personality component, because of the presence of suppressing emotions before the diagnosis.
Alexithymia
Besides seeing emotion suppressing as a personality, alexithymia is named as a cause. Alexithymia is a disturbance in the capacity to verbalize expression of emotions and to elaborate fantasies (Lesser, 1981). Distinctions have been made between primary and secondary alexithymia. Secondary alexithymia can play a role in the suppressing emotions of breast cancer patients. Secondary alexithymia refers to emotional inhibition in reaction to a traumatic experience (Lesser, 1981). A cancer diagnosis can be experienced as threatening and traumatic and cause alexithymia (Vries, Forni, Voellinger, & Stiefel, 2012). Although, Serveas et al. (1999) disagree, they found no significant difference between the healthy group and the group of breast cancer patients in the general tendency to express emotions. As concluded in the review of the Vries et al. (2012), none of the studies supported the existence of secondary alexithymia in cancer patients. All in all the literature on this subject is still very scarce and there is still no consensus about the existing of alexithymia in breast in cancer patients (Vries et al., 2012).
Reaction to the disease
Besides the suggestion of emotional suppression as personality trait or as a consequence or secondary alexithymia, research of Serveas et al. (1999) suggested something else. Serveas et al. (1999) found that the cancer patients showed more ambivalence to expressing emotions than the healthy controls did. When the patients expressed their emotions, they did not want to show their weakness. This results in not expressing their emotions, which is in conflict with their feelings. They also found no significant difference in assertiveness between cancer patients and controls, which suggests that it is a consideration to not express emotions.
However, they also found typical type C characteristics. Serveas et al. (1999) concluded that these cancer- prone characteristics are a consequence of confronting the disease of breast cancer rather than premorbid personality components. It is possible that the patients cope with breast cancer and controlling their feelings by displaying emotional repression. This can be explained by hedonic considerations, in which people avoid pain (Gross, 2008).
Importance for emotional studies
As mentioned before the medical techniques are becoming better and better. However, in the emotional field in physical disease there is more profit to achieve. Studying the current topic of emotional suppression in other physical diseases can determine if suppressing emotions is contemporary in other patient populations. If the reason of suppressing emotions in breast cancer patients is defined, emotional studies can focus on researching the generalizability. Maybe this reason is valid in other patient populations who also suppress their emotions. To focus on this current topic much progress can be made in the study of emotions and subsequent opportunities in the field of support or therapy concerning emotional suppression and its consequences.
Discussion
It can be concluded that it is still not clear if suppressing emotions is a consequence of suffering from breast cancer, secondary alexithymia or if it is a personality trait which may play a part in the cancer onset and progression. There has been an inability to consistently replicate earlier findings. In this selective paper there are a few solutions to discuss.
More awareness for this problem in the field of emotion is desired to stimulate more research. Furthermore, future research should focus on providing an unequivocal answer to the question why breast cancer patients suppress their emotions. A longitudinal quasi study can be a method to give this unequivocal answer in future research. At this study type C personality can be measured multiple times, for example each year. Because of the high incidence of breast cancer, there is a reliable chance that some of the woman in the study will be diagnosed with breast cancer in the time of the study. This gives insight in the people who are diagnoses with breast cancer and their personality before and after the diagnoses and therapies. Researchers can look at the amount of people with suppressing emotions who get diagnosed with breast cancer later on. Researchers can also look if people who are becoming breast cancer patients will suppress their emotions. With the purpose of a clear unambiguously answer of the reason of suppressing emotions in breast cancer patients. Apparently replication of this study is needed to make meaningful statements.
In future research operationalization of emotional suppression must also be considered. The definition of suppressing emotions is now unclear in most studies, which can mean that different studies have used different definitions of emotional suppression. This can cause contradicting results and an impossibility to replicate studies. Thus, the researchers must be transparent about their operationalization of emotional suppression.
All in all there is a lot to do in the field of emotions in breast cancer patients, starting with a longitudinal quasi study and a clear operationalization of suppressing emotions. However, this stresses the need to understand if suppressing emotions is a consequence of suffering from breast cancer, secondary alexithymia or if it is a personality trait to develop specific therapy, adequate psychological support and prevention.