Oncological Distress: Coping Styles in the Face of Suffering

Abstract

Psycho-oncology explores some complex dimensions like emotions, feelings, and relationships of oncological patients. Cross-sectional studies have found that anxiety is a common reaction among cancer patients; it manifests itself with both mental (psychological) and physical (somatic) symptoms. As a matter of fact, many anxious patients suffer from a combination of mental and physical symptoms, with one aggravating the other, creating a vicious circle. Mental symptoms are worry, irritability, restlessness, insomnia, and nightmares. Physical symptoms consist of respiratory breathlessness, hyperactivity of the autonomic nervous system, or muscle tension. Depression is also very common as a reaction. In this regard, we must specify that coping styles act as early modulators of adaptation responses to the disease, and their advance knowledge can predict the person’s response to the disease, and this can help to think about the most appropriate type of support to offer to the patient. It would be desirable to inform patients more frequently about the psychological consequences of cancer, about the psychological support available and its benefits, and about psychological interventions that can promote more suitable and effective coping.

1. Introduction

Psycho-oncology presents itself as a practice of care, in the light of a range of complex dimensions—emotions, feelings, gestures, postures, behaviors, relationships, and spiritual dynamics in relation to cancer patients [1]. Illness is always configured as the irruption of an extraordinary event into the ordinary, into everyday life, disrupting arrangements and experiences and reorienting priorities and values. Pain bears witness to the fact that man is not a machine and the doctor the one who repairs a fault in the system, but neither is pain a simple mechanism. If anything, pain refers to the complex relationship between man and the world and, at the same time, to a possible shattering, or at least a reorientation, of one’s being, of one’s way of opening up to life [2].

Man is open to a broad bundle of possibilities, as Heidegger writes in his Being most precisely this entity “The Dasein, the Being, the human” has the character of non-closure […] The Being is its openness [3].

The irruption of pain undermines the openness of the human being, its being an ever-open possibility, by shrinking or amputating these very possibilities and by disproportionately expanding the boundaries of anguish and despair.

Not only that, pain, for example cancer, often breaks in silently, and Leriche writes in this regard:

that in truth, most serious illnesses - - settle in without warning […] When the pain arrives, it is too late. The end is virtually already there. It is imminent. The pain has only made an already compromised situation more painful and sadder. Defensive reaction against whom? Against what? Against cancer that usually only hurts when it kills? [4].

Faced with the shrinking of life, of a pain that becomes lacerating after having been silent, one understands how what is at stake is the relational rupture between complex and closely linked worlds:

• Umwelt, the world of life cycles, of the law of nature;

• Uberwelt, the meaning we attribute to existence, its spiritual value;

• Eigenwelt, the world of the self and individual identity or ‘me’;

• Mitwelt, our being narrative, story, conversation with others, and the world (social relations) [5, 6].

The human complexity coagulated around pain, especially in the terminal phase, ends up, after all, by seeking an answer to the value of life, to its meaning if everything ends [3, 7, 8].

One understands therefore how approaching the suffering of the other requires extreme delicacy, a knowing how to live up to human experience. Therefore, in the practice of care, the physician is called to see in every suffering an unforeseeable event, an innumerable anthropological density. In the caring relationship, we are indeed called to see in the other, in every frailty, in every suffering. The flesh in which the scalpel sinks and the blood in which the drug flows are unique, unrepeatable; they are flesh and blood of a face that does not simply rely on the healer, on the doctor, on the clinical gaze; if anything, it requires that the doctor’s expertise never forgets, not even for a single moment, that what I have in front of me has an inextinguishable dignity. The principle of fragility, in this sense, is the only one capable of binding human beings together: the sick person, in the full unfolding of his fragility, offers himself to the doctor, to his competent fragility, to his knowledge that is rooted in the hand that palpates, in the eye that scrutinizes, in the scalpel that incises and dissects, knowing, or at least trying to know, that they are fragile, fallible hands and eyes, at least not omnipotent [9, 10].

In order for the doctor to exercise the art of healing starting from the awareness of the uniqueness of each individual human being, it is necessary, especially in the case of oncological pathologies, to have a knowledge of the anthropological and psychological dynamics, of the languages, gestures, psychological traces, and defensive mechanisms that the sick person puts on stage.

2. Anxiety and illness

In a passage from Cicero, he specifies that there is a difference between anxiety and anguish [11] and emphasizes how anxiety is different from anguish, since those who are anxious sometimes are not necessarily anxious, nor are those who are anxious always anxious. The passage is culturally interesting, since it refers, in our context, to a certain psychiatry that considers anxiety to be more related to the psychic contents of this emotion, to a circumscribed preoccupation, whereas it considers anguish to be more generalized and pervasive, less related to a single causal factor.

Anguish is a complex word, with a dense etymological and semantic track, the subject of a conspicuous philosophical tradition (think, just to name a few, of S. Kierkegaard, M. Heidegger, K. Jaspers, and J.-P. Sartre).

Anguish from a philosophical point of view is connected to the inevitability of pain in life; from an etymological point of view, we see that in the Greek language, the term refers back to the term Anánke, also connected to the Greek word anchein, ‘to strangle’ (see also the German Angst, ‘anguish’).

This etymological and semantic tracing refers, in turn, to the consonantal radical hnk: in the ancient Egyptian language, it includes meanings such as “cramped”, “throat” (hng); in Coptic, we find it in the word “ring” (chalak), in Syriac in hnk, “chain”, with the idea of suffocation implied [12, 13].

It is not by chance that Freud links the original sense of anguish (Angst, Enge) with the narrowing of breath experienced by the newborn at birth, to which it reacts with its first wailing, almost as if to indicate, already in coming into the world, a response of anguish to the danger underlying living itself [14].

Net of this pathway, then, anguish is constitutive of the human being and indicates a sense of suffocation, especially when pain breaks through, a narrowing of vital possibilities.

During illness, the sick person feels metaphorically suffocated; he feels that the bundle of possibilities that life has handed over to him is shrinking, that his existential path is increasingly narrow.

Great literature, whose purpose is to give voice to human experience, can never evade the discourse on illness, the burden of anguish it entails. Woolf rightly writes that considering the proportions of the spiritual change that illness produces, the virgin territories that it then opens up, it seems strange indeed that it does not figure, along with love, battles, jealousy, among the main themes of literature [15].

Thomas Mann, in The Magic Mountain, acutely notes how illness disrupts space and time, almost devouring them, and our very body, filled with anguish and suffering, produces a profound change in our place in the world [16].

We find this lacerating experience in an emblematic clinical case [17]: Paul was a 37-year-old single Caucasian graphic designer who was dying of acute lymphoblastic leukemia after two failed attempts at allogeneic bone marrow transplants (from identical nonfamily donors). He presented with acute pain and amplified anxiety, with chronic rejection disease affecting most of her body, accompanied by painful bloody sores. His steady gaze, like that of a deer dazzled by headlights, indicated that he was deathly afraid of his impending terminal condition. His tone of voice revealed an inner knowledge that the end was near but also the fact that he would have to suffer from this knowledge for days and weeks to come. Having to live with the thought of imminent death, alone in his hospital bed and covered in painful sores, triggered an unrelenting existential angst. Like many bone marrow transplant patients, Paul began to suffer from claustrophobia and panic attacks when he felt a strong sense of being ‘trapped’ and ‘suffocated’. It became increasingly evident that this had less to do with being confined in isolation in his hospital room than with the overwhelming anguish he experienced when consciously confronted with his death. Paul referred to his terminal condition as ‘a runaway train… heading off the track and towards a precipice!’ His intense death anxiety could barely be sedated by lorazepam or olanzapine. Paul finally found moments of respite by meaningfully exploring events in his life and sharing loose ends related to unfulfilled goals as a graphic designer or unrealized dreams such as finding love, getting married, and having children. It was as if meaningful dialogue and authentic self-expression allowed him to momentarily escape from his existential crisis of impending death and take part in a nostalgic and quiet space for a while [17].

In this context, psycho-oncology plays an important role.

3. Psycho-oncology: a complex discipline

The official history of psycho-oncology began in the mid-1970s in the United States. During this period, there was a decrease in the stigma associated with cancer, and more and more patients were being told directly about their diagnosis; thus began the study of emotional reactions to this event. Whereas initially the psychological problems of cancer patients and their families were addressed to nurses and social workers, the early research in this field led to an increasing referral to specialists such as psychiatrists, health psychologists (who focused on theoretical models of coping and cognitive-behavioral interventions), behavioral psychologists (who studied lifestyle changes, such as quitting smoking and diet modification to reduce the risk of cancer), and researchers in the nursing field (who dealt with symptom and pain management and control). Psycho-Oncology was immediately characterized as multidisciplinary [18]; the last few decades have seen its progressive affirmation and evolution. Today, Psycho-Oncology constitutes in the health field a reference for all those who, in the treatment of neoplastic disease, have a holistic vision of the patient, aimed at protecting and promoting a better quality of life for the patient, considering him/her in his/her complexity, given the inseparability in human beings of the biological component from the emotional one [19]. Currently, this discipline explores the psychological consequences of cancer for patients, their families, and carers; a further sphere of action concerns research aimed at elucidating the possible relationships between psyche and soma with regard to the pathogenesis of tumors, their evolution, perhaps even some possible ‘spontaneous cures’ or, conversely, dramatic worsening [20]. It therefore stands as an important link in the integration of the psychic and somatic disciplines in dealing with a pathology that is so vast, multifactorial, and, in some ways, so obscure. This integration is also intrinsic in the etymology of the term: ‘Psycho’ derives from the Greek word ‘psyche’, meaning mind or soul, while ‘Oncology’ derives from the Greek word ‘Onkos’, meaning mass, and means the study of tumors. ‘Psycho-Oncology’ therefore has to do with the relationship between the tumor, the body, and the mind. An important part of ‘Psycho-Oncology’ today is ‘Social Psycho-Oncology,’ which also includes the broader idea that cancer affects not only individuals but also their families, friends, and colleagues, as well as the society in which they live. The psycho-social implications of the disease are therefore also fundamental [20]. The main objectives of this discipline are respect for life and the human person and the family and cohabiting units, the right to the protection of relationships and affections, the consideration and treatment of pain, and psychological support in the different stages of the illness [19]. Specifically, the central themes in patient care focus on existential anxieties and anxieties, such as the concern to maintain one’s own identity, to find meaning in one’s own life experience, to respond to transcendent and spiritual themes, and to maintain hope [21]; thus, both the assistance to the person affected by cancer and the care pathways must be articulated taking into account, in a comprehensive manner, all the dimensions of human existence. This perspective is rooted far back in the history of medicine; in this perspective, George Engel introduced the term ‘Biopsychosocial Approach’ as a privileged modality both to decode and understand health and disease processes along the entire existential pathway and to articulate forms of care and taking charge. The biopsychosocial model is inspired by the complexity paradigm, in clear opposition to biomedical reductionism, as well as to the hierarchization of sciences. It adopts the perspective of the general systems theory developed by Von Bertalanffy, which considers a set of interrelated events as a system, which manifests specific functions and properties depending on the level at which it is placed in relation to a broader system comprising it. Systems theory argues that all levels of the organization are connected to each other so that a change in one affects change in the other, mitigating the dichotomy between holism and reductionism [22]. Overall, the model refers to three basic principles: dialogue-connection, relationship, and humility. In other words, it aspires to look at the person as a ‘whole’ as a genetic heir (bio), a subject of reflection and decision (psycho), as well as a cultural-historical and family (social) subject. The axioms of the model are inclusive (understanding of diversity) and nonexclusive (setting aside what is deemed as not being one’s own competence), whose responses are comprehensive and global whatever the point of entry into the system (now biological, now psychological, now social). In Psycho-Oncology, the centrality of this model has been confirmed and validated by a scientific literature, now boundless, which marks the transition from a traditional medical model centered on the body (and on the disease as a purely biological event) to a person-centered medicine [23], and it is now a widespread awareness that a biopsychosocial screening, rather than a compartmentalized approach of medical and psychosocial models, can help the planning of a more effective treatment and help an early and useful management of distress [24, 25].

4. Eustress and distress

The term stress was introduced into the field of psychology by Seyle. He was the first to use the term stress to describe a range of physical and psychological responses to adverse conditions or influences [26]. Originally, ‘just being sick’ syndrome covered an organism’s stereotypical response to a wide range of physical, biological, or chemical stimuli. Later, looking for a term to represent this response, Seyle used the word ‘stress’. Stress is an English term meaning ‘pressure’ and was introduced by analogy with engineering, where it is used to refer to any force that is applied to a body to test its endurance under stress. With time, this term was then also used to indicate more specifically ‘a state of non-specific tension in living matter, manifested by tangible morphological transformations in various organs, and particularly in the endocrine glands that are under the control of the pituitary gland’ [27]. The term stress, which describes the reaction on the part of the organism, is distinguished from stressor (stressful event, or stressor), a term that describes the stimulus factors that cause the aforementioned reaction on the part of the organism. Stressors can be serious factors (the death of a loved one or a serious illness), minor factors (minor facts of everyday life), acute factors (accidents), and chronic factors (e.g. a highly competitive work environment) [28]. Seyle also distinguished between eustress (or good stress) and distress; they were originally included in the broader definition of stress but were immediately referred to as distinct from each other. Seyle asserted that stress is an inevitable consequence of living, but distress appears when the demands made on a person (in both their psychological and physiological aspects) overwhelm the capacities and energies the person can and believes he or she can expend in maintaining homeostasis. The stimulus-demand may therefore have a more or less welcome meaning [29]. This idea was well illustrated by Holmes and Rahe [30] in their construction of the “Social Readjustment Rating Scale”: every stress can be classified into eustress and distress, the former is caused by a demand considered disproportionate in magnitude, while eustress is caused by a demand considered acceptable, which creates a moderate and not excessive level of tension that allows one to cope successfully with demands. This, however, is only one aspect of eustress. The concept of an optimal stress level derives from the studies of Yerkes and Dodson [31] who explained how increasing stress is beneficial for performance as long as it is moderate, after which performance will deteriorate. In order to clarify the connection between Yerkes and Dodson’s theory and Seyle’s, it must be explained that the nature of each stimulus depends on how each individual interprets it and chooses to react to it. It depends on the individual whether a stress will be eustress or distress. Eustress is the primary result of a positive perception of the stressor, whereas distress is the result of a negative perception. The classification therefore depends on what the stressor represents to the individual, what value is attached to it. Seyle suggested that learning to respond to stressful stimuli with positive emotions, such as hope, maximizes eustress and minimizes distress, while responding with negative emotions, such as despair, greatly increases distress [29]. In the perception of the stressor, and the attribution of meaning to it, the characteristics of the individual intervene: presenting an internal locus of control (and self-efficacy) has quite different implications than an external locus of control. Self-efficacy is the belief that one is able to control environmental challenges by taking adaptive action, and in accordance with social cognitive theory [32], self-efficacy in the case of cancer strongly influences behavior and is positively associated with adaptation [33]; it correlates with active coping and negatively with passive coping [34]. It is Seyle himself who also introduced the notion of the ‘general adaptation syndrome’ to describe the way in which the organism copes with stressful events; he distinguishes three phases that follow one another in this order:

1. Alarm phase: the autonomic nervous system is activated in the face of intense stressful events;

2. Resistance phase: the organism adapts to stress, and, if the stress is too intense, there are transitory manifestations such as enlarged adrenal glands, gastrointestinal ulcers, etc.;

3. Exhaustion phase: if the stressor persists, or if the organism is unable to mount adequate responses, the organism goes into irreversible responses, including death.

On the other hand, it is to the credit of the scientist Lazarus that he has integrated Seyle’s model with the more purely cognitive aspects connected to the subjective processing carried out by the person regarding the specific stressors, creating a more complex model. As a matter of fact, the same event, as already mentioned, may have different meanings for different individuals, and when faced with unequivocally stressful factors, different people react in different ways and with different outcomes. Optimal adaptation requires reaction strategies that are active as well as multiple, flexible, and calibrated to the specifics of the stressful factors or events at play. The stress response is thus modulated in two ways by the psychological characteristics of the person: in the phase of perception and processing of stressful factors and in the phase of coping with these factors. The characteristics that intervene at this second level and modulate stress reaction strategies are called coping Skills, and the entire process of reacting to and coping with stress is referred to by the term coping [35], an English-speaking term that literally means ‘holding one’s own,’ ‘fighting successfully’. Awareness has grown since the 1960s that while stress is an inevitable aspect of the human condition, coping makes a big difference to the outcome of coping with it [36]. Today, referring to the Psycho-Oncological context, for coping, we globally mean the cognitive and behavioral style of an individual in dealing with the pathology, that is, the ability to face problems and their emotional consequences, and refer to the adaptation of individual [37]. This construct has proved to be truly fundamental in complex disease situations such as cancer. Among its various meanings, it is considered as a sequential series of stressful events: diagnosis, aggressive treatments, fear of death, and changes in social and physical context. Each of these events already represents severe stress in itself [38]. In this context, the concept of coping represents a parameter capable of exerting a considerable influence on the different modes of psychological reaction and psychosocial adaptation to the disease, on possible psychopathological complications, on the quality of life following diagnosis, on compliance with antineoplastic treatments, and on the biological course of the disease. The patient’s ability to face a possible situation of existential crisis, triggered by the neoplasm, depends on a well-codified series of factors. According to Lazarus and Folkman [35], the psychological impact of a stressor is influenced both by the characteristics of the individual and by the characteristics of the stressor. With regard to the characteristics of the stressor, we must therefore take into account the type of pathology (symptomatology, course, therapy, collaterals); regarding the characteristics of the individual, they turn out to be complex, multiple, and strongly intertwined with each other: the level of adaptation prior to the neoplasm (for example, in relation to previous situations of illness); the meaning attributed to the disease, which in turn depends on self-efficacy, the history of the subject, his personality, and cultural and religious factors; the psychological attitude of the patient (age, degree of psychological maturation, introspective ability, education, any psychiatric disorders); and, above all, the coping style [34]. Also important is the type and extent of social support that the person can take advantage of [39]. For prognostic purposes, the personal meaning that each patient attributes to the disease is of particular importance, and according to Lipowsky, there would be eight different possible meanings attributable to the diagnosis of cancer: disease understood as punishment, as an enemy to fight against, as loss of one’s sexual identity or professional value, as a challenge to one’s own mental resources, as a strategy, as a relief in patients who had already reduced their expectations toward life, and as organ weakness [40]. The consequences of this attribution of meanings are decisive: if the disease is perceived and interpreted as a punishment, reaction models in which guilt prevails can be activated, with consequent behaviors of fatalism and resignation; if the perception prevails that cancer is an unwelcome guest or an enemy not to be given space because life is very important, the modalities that emerge will be characterized by acceptance of the challenge, open struggle, and will not to give up; if the perception prevails that the illness will lead to estrangement from loved ones, dependency behaviors and the need for continuous reassurance may be put in place [19]. Weisman [41] discussed the two main aspects of experiencing cancer in the 1970s: coping and vulnerability. In his studies, the so-called “Good Copers” have the persistent belief that they will be able to deal with the disease, are practical, and directly address the issues; the “Bad Copers” are characterized by regret and pessimism. Vulnerability is divided into dysphoric and dispositional types. The first is based on patients who report current experiences and depressive symptoms; the second reflects underlying character dynamics, which lead to alienation, annihilation, and despair [25]; therefore, there is a coping model toward oncological disease that takes into account the existential vulnerabilities associated with the diagnosis. He identified four phases:

1. Life Situation: This includes the impact of diagnosis, dealing with death, and anxieties about the future. There is hope for a cure in this phase.

2. Adaptation and Mitigation: There are varying levels of impairment, and the focus is on the pragmatic aspects of the treatment and its effects. At this point, the sense of having changed becomes stronger. The characteristic activity of this stage is vigilance. Patients who are being treated may not continue after this stage.

3. Relapse and Recurrence: At this point, existential concerns are evoked, and it may be more difficult to express optimism. The patient’s goal is often to maintain control.

4. Deterioration and Decline: This involves a consistent deterioration in functional abilities, a sense of time being limited, and variable attitudes, but often, there is a tendency to stop dwelling on details and focus on palliative care [25, 41].

5. Coping styles and adaptation to illness

Coping styles have been classified hierarchically by Greer according to their influence on the survival of cancer patients: on the basis of the results obtained, the author placed the combative coping style in the first position, in second, the avoidance-denial; instead, the effects of fatalism turned out to be worse, and those of anxious concern and despair proved to be worst [42, 43, 44, 45].

We will therefore present them in this order:

• Combativeness: This style is characterized by the patient’s acceptance of the challenge of defeating the disease; in the words of the creators of this dimension, Greer and Moorey, ‘the patient sees the diagnosis as a challenge, has an optimistic view of the future, believes that it is possible to exert control over the disease.’ The patient manifests coping responses aimed at direct confrontation; those who adopt this strategy therefore have an internal locus of control and want to know as much as possible about their disease, ask for input in the choice of therapies, adhere to the proposed treatments, participate in the proposed complementary interventions, and make changes to their lifestyle in order to preserve their health, for example, by changing their diet and exercising [20]; this strategy can be defined as active, positive coping, as it represents the tendency to actively confront and face the disease [20, 46]. It can also be associated both in the short and in the long term with adaptation denial, which protects against anxiety and depression and is expressed in the tendency to minimize the seriousness of the situation and in the lively hope of success in the battle against cancer [20, 47]. The optimism that characterizes this coping style has beneficial effects on the health, well-being, and quality of life of those who adopt it. Importantly, the coping style itself mediates the positive effect of optimism on quality of life and emotional, cognitive, and social functioning. Combative coping mediates these effects positively while fatalism, anxious concern, and despair, negatively: it is therefore not enough to be optimistic if you do not adopt a combative coping style. Combativity brings with it lower levels of anxiety and demoralization and responses of confrontation and conviction of at least partial control over events [19]. To refer to the construct “Mental Adjustment to Cancer,” patients who face the unfortunate event with a fighting spirit use comparison responses that can be summarized with the statements: “I see this disease as a challenge,” “I am determined to defeat the tumor,” “I am very optimistic;” they adopt more flexible and differentiated cognitive and behavioral strategies, “I am actively trying to improve my health,” which favor a more positive view of the event, without reducing its potential danger, even leading to grasping a deeper meaning of existence. As a result, as already introduced, this style is associated with less psychological morbidity, a feeling of greater personal control over the state of one’s health, and a more favorable course of the disease, therefore a greater survival from it [25].

• Avoidance-Denial: This strategy is very complex and is generally characterized by the tendency to avoid dealing directly with all issues related to the illness, the use of euphemisms to talk about it, and is linked to the use of the denial defense mechanism (avoidance of seeing unpleasant aspects of the illness). This is very common and often has a useful effect in protecting against anxiety but can cause problems if used as the only form of defense and if taken to extremes. A high level of avoidance, used as the sole coping strategy, can also lead to unrealistic self-efficacy perceptions and alexithymia [25]. Avoidance has however been found to be correlated with poor adaptation to the illness [48].

• Fatalism: This is a strategy characterized by a fatalistic attitude of resignation and passive acceptance of the illness, a belief in a lack of control over events and resigned acceptance of what fate has determined: those who adopt this strategy recognize the seriousness of the situation but accept it as their fate. We must therefore point out that the tendency to perceive external events as being linked to fate, to destiny, is typical of those who have an external locus of control, and this encourages poor adaptation to illness and a lack of responsibility for one’s own state of health [19]. Recent research has shown that it correlates with higher levels of distress 1 year after surgery; it has also been shown that fatalism particularly correlates with despair and has negative psychological effects throughout the course of the disease: it correlates negatively with optimism at the time of diagnosis, mediating negatively its effect on Global Heath Quality of Life (GHQOL), with GHQOL before and after surgery, and with emotional functioning before surgery. The resignation that fatalism entails is positively correlated with high levels of anxiety and depression; they were also found to be positively correlated with feelings of hopelessness, characteristic of the ‘coping style’ hopelessness [25].

• Anxious preoccupation: This is a strategy characterized by constant worry about illness and feelings of danger, a high proportion of anxiety and depression, and the placing of illness at the center of one’s existence. It was found to be negatively correlated with social and emotional functioning. Those who adopt this coping style are constantly seeking reassurance, requesting visits, or, on the contrary, escaping from the care setting because it is too distressing [19]. In this regard, it has been particularly highlighted how the continuation of this coping style negatively affects patients’ survival time, even 10 years after diagnosis. It was then shown how this strategy fortunately decreases after the first few months after diagnosis. It was finally found to be positively correlated with the coping style despair and fatalism [25].

• Hopelessness: This is characterized by feelings of defeat and the feeling of being overwhelmed by the diagnosis, a pessimistic attitude toward the disease [46, 49]; it is related to high levels of anxiety and depression, poor cognitive strategies, and the belief that one has little control about events. There is also poor therapeutic adherence and an attitude of renunciation: the arrival of the disease is proposed as an event that leaves no way out, impeding the search for help and the planning of any intervention [19]; as a matter of fact, there is a correspondence between despair and demoralization: affective symptoms of existential distress, loss of meaning and life goals, cognitive propensity to pessimism, sense of personal failure, lack of motivation to face the event differently, sense of social isolation, and alienation [25].

6. Dyadic coping

Starting from the evidence that patients with cancer and their loved ones (particularly the companion) are hit jointly by the stress of this disease, several researches about coping have investigated how partners can cope together with stress and how the dyads attempt to cope mutually influence each other [50, 51]. An evolution coping research us the focus on concept of dyadic coping [52], which is the way to deal together with the disease; it considers the stress experience at a dyadic couple level and the mutual influence process, in which one partner’s stress can influence the other one. This concept emphasizes that there is an interdependence between social support and coping styles: the coping success is strongly linked to other significant ones responses [52]. Bodenmann studied dyadic stress and created a specific dyadic coping process theory. He defined dyadic stress as a distinct form of social stress, which includes common concerns and emotional intimacy between two persons. Specifically, it is relevant that a stressful event always affects both partners indirectly and directly. The dyadic coping is part of an interpersonal process that involves both partners [53, 54, 55, 56], and it is rooted on Lazarus and Folkman transactional stress theory [35, 36] but expands it with some process-oriented and systemic dimensions. Starting from the question “How does stress affect marriage? How does dyadic coping can influence the relationship between stress and the quality of married life?,” Bodenmann has distinguished between negative and positive dyadic coping. Among the positive dyadic forms, there are:

1. Delegate Dyadic Coping: One of the partners is asked to assume more responsibility for trying to reduce the tension of the other, and the partner accepts.

2. Supportive Dyadic Coping: One partner supports the other in her/his attempts to cope. It can be expressed through acts such as assisting others, solidarity, empathic listening, and the purpose of reducing partner’s stress.

3. Common Dyadic Coping: Both partners participate in the coping process more or less in a complementary way, implementing common problem solving and common research for information.

Among the negative forms of dyadic coping, we can find:

1. Ambivalent Dyadic Coping: A partner provides unwilling support or a support with the belief that it will be useless.

2. Superficial Dyadic Coping: It is not sincere support (for example, it is expressed as trying to support the partner without empathy).

3. Hostile Dyadic Coping: The support is provided accompanied by minimization, sarcasm, and interpersonal distance [25].

Specifically, Acitelli and Badr [57] studied dyadic coping in the cases of chronic illness, such as oncologic pathology; they investigated the difference in the behavior of men and women and different expectations (depending on the gender) toward the partner. The data obtained from these researches show that the chronic disease should not be interpreted as an individual challenge but as a relational challenge; as a matter of fact, it emerged that if the partners communicate appropriately about their relationship, their health will hardly affect their marital satisfaction, especially for women: specifically, the more husbands are involved in a dialogue with the sick wives, the more satisfaction there will be for their relationship with their wives. Women, with their interdependent approach to relationships, are more likely to pay attention to these elements and derive good consequences for their relationship satisfaction.

On the contrary, it has been noted that if the oncological partner has great emotional needs and the healthy partner acts in accordance with the traditional gender role, sick women suffer more than men in the same conditions. Female subjects, on the other hand, in the role of the healthy partner tend more to give emotional support through dialogue, and it has been verified that the more husbands talk about their relationship, the more this generates support and favors a positive outcome. Acitelli and Badr [57] have also highlighted how perceiving the disease as “our disease,” rather than “my illness,” has significant implications on perceived social support and coping: it is better for the couple’s well-being to understand oncologic situation as a topic of the relationship, rather than as a purely individual matter; this leads to approach the situation like a team that solves the problems together, thus reporting a better adaptation [25, 57].

7. Conclusion

Fear of suffering, death, and the unknown are just some of the many experiences that the cancer patient has to deal with on a day-to-day basis, and many of the psychological effects of cancer must be considered, indeed, in terms of a reaction to the loss or the risk of the future loss of health and its implications. What consequences does this have for the cancer patient’s mind? Cross-sectional studies have found that anxiety is a common reaction among cancer patients; it manifests itself with both mental (psychological) and physical (somatic) symptoms. As a matter of fact, many anxious patients suffer from a combination of mental and physical symptoms, with one aggravating the other, creating a vicious circle. Mental symptoms are worry, irritability, restlessness, insomnia, and nightmares. Physical symptoms consist of respiratory breathlessness, hyperactivity of the autonomic nervous system, or muscle tension. Depression is also very common as a reaction [19, 25]. In this regard, we must specify that coping styles act as early modulators of adaptation responses to the disease, and their advance knowledge can predict the person’s response to the disease [58] and help think about the most appropriate type of support to offer. Patients at “high risk” of emotional distress do not show more problems than others but more inadequate ways of dealing with them (such as anxiety and resignation) and an inability to produce an alternative set of coping strategies. “Low risk” patients have an active, flexible, and differentiated coping style, characterized by methods of confrontation, redefinition of problems, and compliance with authority. In general, strategies characterized by a more efficient and diversified way of coping with problems, compared to those that are more passive and characterized by feelings of hopelessness and helplessness, are more effective for better adaptation [19]. In particular, subjects who face the unfortunate event with a fighting spirit use comparison responses that can be summarized with the statement “I see this disease as a challenge” and adopt more flexible and differentiated cognitive and behavioral strategies (“I am actively trying to improve my health”), which favor a more positive vision of the event, without reducing its potential danger, even leading to grasping a deeper meaning of existence. As a result, this style is associated with less psychological morbidity, a feeling of greater personal control over one’s health, a greater quality of life, and, according to some authors, a more favorable course of the disease [49, 59]. Understanding the type and effectiveness of the individual and dyadic coping styles with which one deals with the disease takes on particular importance in this perspective: if they are functional and effective, then adaptation to the disease can also turn into personal growth. On the contrary, if the type of situation is interpreted as too stressful, there are too high levels of anxiety, and therefore, the onset of psychopathological reactions and a state of intense subjective suffering are possible [38]. Personality variables (such as dominance and interpersonal trust) and the related processes of appraisal and coping have, in turn, a significant relationship with psychological symptoms and adaptation [25]. Among the psychological aspects that influence the coping style, there are aspects relating to individual history and personality characteristics. As already anticipated, the tendency to perceive external events as ineluctably linked to destiny (external locus of control) tends to favor maladaptive ways of approaching the disease, while the tendency to perceive events as at least partially controllable (internal locus of control) facilitates more adaptive ways. Furthermore, people with personality disorders or with inflexible psychological defenses and rigid ways of relating to reality are patients at risk of psychopathological complications. In this regard, the patient’s previous level of adaptation (depending on the number and severity of previous life events, negative or positive family, or personal experiences) is also significantly associated with the cancer coping style. The moment in the patient’s life when the disease appears also obviously plays an important role as it modulates the degree to which the disease interferes with developmental goals [19]. Upstream knowledge of individual and dyadic coping styles is very important in oncological clinical practice, for example, the relational implications and the ways of relating that the professional figure should adopt in the case of a patient who wishes to have detailed information in order to deal with these, compared with one who prefers to leave the management of his problems to the other. It should be pointed out that given that cancer patients experience significant levels of anxiety and depression, it is to be hoped that in the future, there will be an increasing emphasis on the need to screen patients’ emotional functioning, distress, and their desire to receive psychological support [25]. It would also be desirable to inform patients and caregivers more frequently about the psychological consequences of cancer, about the psychological support available and its benefits, and about psychological interventions that can promote more suitable and effective coping, since resilience in the case of cancer pathology can be improved through psychological intervention [60]. Finally, it should be remembered once again that oncological pathology can have relational repercussions, and therefore, stress can occur both for the patient’s caregivers and for those who have a medical role in the treatment; therefore, specific support interventions can be appropriately proposed not only for the oncological patient but also for his family and for the care team; the latter can also be negatively influenced by a possible death of the patient; and therefore, it makes sense to propose specific interventions in these cases.