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Guest Editorial
Highlighting Bipolar II Disorder
Gordon Parker, MD, PhD, DSc, FRANZCP
(PDF)

In Review
Neurobiological Findings in Bipolar II Disorder Compared With Findings in Bipolar I Disorder
Brent M McGrath, BSc, MSc, Phillip H Wessels, MD, FRCPC, Emily C Bell, BSc, MSc, Michele Ulrich, BSc, Peter H Silverstone, MB, BS, MD, MRCPsych, FRCPC
(PDF)

Bipolar II Disorder: An Overview of Recent Developments
George Hadjipavlou, MA, MD, Hiram Mok, MA, MB, BCh, BAO, FRCPC, Lakshmi N Yatham, MBBS, MRCPsych, FRCPC3 (PDF)

Review Paper
Bipolar Disorder: It’s All in Your Mind? The Neuropsychological Profile of a Biological Disorder
Gin S Malhi, BSc, MB, ChB, MRCPsych, FRANZCP, Belinda Ivanovski, Ssc Psychol, M Clin Psychol, Viktoria Szekeres, BSc,Psychol
(PDF)

Original Research
Impact of Culture on Depressive Symptoms of Elderly Chinese Immigrants
Glenda MacQueen, MD, PhD, FRCPC
Daniel WL Lai, PhD
(PDF)

Development and Reliability of a Pictorial Mental Disorders Screen for Young Adolescents
Nicole Smolla, PhD, Jean-Pierre Valla, MD, MSc, Lise Bergeron, PhD, Claude Berthiaume, MSc, Marie St-Georges, MPs
(PDF)

Command Hallucinations Among Asian Patients With Schizophrenia
Theresa MY Lee, MBBS, MMed, Siow Ann Chong, MBBS, MMed, Yiong Huat Chan, PhD, Gangaharan Sathyadevan, MBBS, MRCPsych
(PDF)

The Centre for Addiction and Mental Health Concurrent Disorders Screener
Juan C Negrete, MD, FRCPC, Jane Collins, MSc, Nigel E Turner, PhD, Wayne Skinner, MSW
(PDF)

Validation de la version française du questionnaire de Sociotropie-Autonomie de Beck et collègues
Mathilde M Husky, MSc, Olivier S Grondin, MSc, Philippe D Compagnone, PhD
(PDF)

Brief Communication
Depressive Symptoms and Alcohol Consumption Among Nonalcoholic Depression Patients Treated With Desipramine
Benjamin I Goldstein, MD, PhD, Ayal Schaffer, MD, FRCPC, Anthony Levitt, MD, FRCPC, Ari Zaretsky, MD, FRCPC, Russell T Joffe, MD, FRCPC, Virginia Wesson, MD, R Michael Bagby, PhD
Pierre Bleau, MD, FRCPC
(PDF)

Letters to the Editor
(PDF)

Safety of Clozapine in 2 Successive Pregnancies

Revisiting the Diagnostic Challenges of Secondary Mania and Bipolar Disorder in a Patient With Borderline Hyperthyroidism

Dyslipidaemia and Psychiatric Patients

Dream Contents in Patients With Major Depressive Disorder

Sensory Deprivation and Disorders of Perception

Re: The Internet’s Impact on the Practice of Psychiatry

Response: The Internet’s Impact on the Practice of Psychiatry

Denial and Avoidance in an Unusual Case of Death From Breast Cancer

Interferon-Induced Mania

Drug-Induced Psychosis After Long-Term Treatment With Levetiracetam

Priapism

An Ounce of Prevention: “COPEing with Toddler Behaviour”

Internet Gaming Addiction

Letters to the Editor

Denial and Avoidance in an Unusual Case of Death From Breast Cancer

Dear Editor:
We recently encountered the case of a woman who died in an atypical way as a result of coping with a breast mass by denial and avoidance. The patient, aged 48 years and white, lived at home with her husband and 2 young children. For 4 to 6 weeks preceding her death, she isolated herself from her family in the basement, explaining that she had personal issues that she was handling alone. She continued to work at her job, where her coworkers noted that she had become withdrawn. She was later found dead in the basement, surrounded by blood-soaked, foul- smelling clothing and gauze. There was a penetrating injury of the right breast and chest wall. An autopsy revealed that the injury was from a large ulcerated breast carcinoma, which eroded the chest wall and opened a large artery. There was no evidence of metastasis, which is the most common cause of death from breast cancer (1,2). Death owing to hemorrhage occurs in only approximately 9% of breast cancer patients (1,2) and is usually a complication of progressive disease. Death from a localized and usually curable primary tumor such as this one is most unusual.

We believe the patient’s denial and avoidance of her disease were psychosocial factors leading to this atypical mechanism of death from breast cancer. Denial can impede a woman’s willingness to undergo screening examination (3). A substantial number of women may not recognize a breast abnormality on their own, before it is found by screening (4,5). They may use avoidant coping mechanisms that prevent them from checking for potential disease (4). Women who experience denial prior to disease identification are also more likely to maintain that denial later in the course of disease (5).

After a diagnosis of breast cancer, a woman may experience denial based on fear of changes in self-image or sexuality or on concerns about the effect of the disease on her relationships with her partner or children (6). Coping strategies after diagnosis tend to assume a proactive character (3,7,8), however, and may include such activities as acceptance, positive reframing, use of religion, expressing emotion, adopting a fighting spirit, seeking support, asserting self-control, or diverting energy to other matters (7–9).

While proactive coping strategies may seem to caregivers to be more productive in dealing with a serious disease, denial is not inherently a poor coping strategy. It can provide relief of psychological distress during difficult periods of treatment (3,7) and may be associated with remaining recurrence-free or experiencing prolonged duration of survival in women with local disease (3,10,11). Denial does not necessarily lead to a mood disturbance or to poor adjustment to treatment (9). However, relying on denial as a significant coping strategy has disadvantages. Women who use denial or avoidance tend to experience more distress and poorer adjustment than do women who use proactive coping strategies (7,8,12). Of course, as this patient illustrates, denial and avoidance may impart a risk of missing a diagnosis and foregoing potentially lifesaving treatment.

References

1. Hagemeister FB Jr, Buzdar AU, Luna MA, Blumenschein GR. Causes of death in breast cancer: a clinicopathologic study. Cancer 1980;46:162–7.

2. Cho SY, Choi HY. Causes of death and metastatic patterns in patients with mammary cancer. Ten-year autopsy study. Am J Clin Pathol 1980;73:232–4.

3. Greer S. The management of denial in cancer patients. Oncology (Huntingt) 1992;6:33–6; discussion 39–40.

4. Styra R, Sakinofsky I, Mahoney L, Colapinto ND, Currie DJ. Coping styles in identifiers and nonidentifiers of a breast lump as a problem. Psychosomatics 1993;34:53–60.

5. Charavel M, Bremond A. Problem of perception and denial of illness in women who had breast cancer. Bull Cancer 1994;81:638–44.

6. Oktay JS. Psychosocial aspects of breast cancer. Lippincotts Prim Care Pract 1998;2:149–59.

7. Heim E, Valach L, Schaffner L. Coping and psychosocial adaptation: longitudinal effects over time and stages in breast cancer. Psychosom Med 1997;59:408–18.

8. Carver CS, Pozo C, Harris SD, Noriega V, Scheier MF, Robinson DS, and others. How coping mediates the effect of optimism on distress: a study of women with early stage breast cancer. J Pers Soc Psychol 1993;65:375–90.

9. Classen C, Koopman C, Angell K, Spiegel D. Coping styles associated with psychological adjustment to advanced breast cancer. Health Psychol 1996;15:434–7.

10. Dean C, Surtees PG. Do psychological factors predict survival in breast cancer? J Psychosom Res 1989;33:561–9.

11. Nelson DV, Friedman LC, Baer PE, Lane M, Smith FE. Attitudes of cancer: psychometric properties of fighting spirit and denial. J Behav Med 1989;12:341–55.

12. McCaul KD, Sandgren AK, King B, O’Donnell S, Branstetter A, Foreman G. Coping and adjustment to breast cancer. Psychooncology 1999;8:230–6.

Henry J Carson, MD; Richard Fiester, MD
Cedar Rapids, Iowa