Cancer and psyche: between scientific intervention and position of omnipotence *
18th January 2006
In the last decades there has been a lot of talk about the possible psychosomatic origin of many morbid forms and, among them, some authors have also inserted the oncologic process. In particular the frequent observation of the repeating of a determined psychic typification, also observed by myself 1 , let some researchers hypothesize the possibility of a remarkable influence of psychism on the structuration of illness. Furthermore some psychotherapists have even proposed to face the oncologic illness with psychotherapeutic treatments. What can be the scientific justifications for trying to treat a biological alteration with a psychological methodology?
A lot of psychoanalytic schools have elaborated models that postulate a deep body-mind synergy, some coming to theorize a genesis of conflict, and therefore an origin of somatopsychic pathologies, at a pre-psychic and pre-somatic level, substantially energetic.
I will immediately say that such a vision of phenomena, though supported in some cases with an elegant and coherent theoretical model of reference, doesn't satisfy my deep convictions.
Firstly since I believe that the adhesion to a metapsychological model is a remarkable danger for the scientific nature of conceptualizations.
I would immediately like to specify: I don't deny that, for minds using them with the due detachment and the necessary caution, the metapsychological hypotheses can be fertile associative inductors for the study in depth of new hypotheses of work, but we always ought to remember that models are just models, therefore instruments of reasoning, organizers of hypotheses, and they must never be confused with the reality of phenomena. From the dawning of science up to today every interpretative model has always sustained deep revisions, especially thanks to the acquisition of new and more powerful instruments of investigation, as the basic knowledge has been increased.
The readers who follow my contributions know that part of my training hinges on the clinical experience deriving from my practice, throughout twenty-five years of micropsychoanalysis. Even still today I consider the micropsychoanalytic technique of enormous therapeutic effectiveness in psychopathology, also heralding further and deeper theoretical elaborations, that I hope to be more and more linked with interdisciplinary verifications, but in the last years I have completely abandoned the use of the micropsychoanalytic formalism denominated dnv-ide (neutral dynamism of the void - instinct of attempt). The reason is that the existence of a failing of classical laws and the emerging of a quantum-like phenomenology in microscopic dimension (I translate that which Fanti has defined "Neutral Dynamism of the Void" as a physical language that is comprehensible to the majority) is already explainable in a simple and exhaustive way with the knowledge of the basic features of the quantum physics and it seems unsuitable to me to introduce lexical elements that can’t be shared, instead of easily understandable concepts by the scholars of the various disciplines (in all of my life I have always kept my distance from initiatory convictions, whether or not evident). Not to mention that, people who do not have enough cultural solidity, can be inclined to attribute, to a model currently bordering on philosophical abstraction, a scientifically corroborated value.
Obviously such considerations don't embrace the Freudian metapsychology since the hypotheses that Freud inserted in what he himself defined metapsychology (which seemed so audacious at the time of their formulation) have been widely verified and proved for over one century of experimental verifications and continue to be confirmed by other sciences. We could say with a paradox that the whole Freudian metapsychology has entered psychology by right. The term “metapsychology” is met first of all in the numerous letters that Freud addressed to his colleague and friend Fliess. It was used by Freud to define the originality of his attempt to build a psychology "... that leads behind the conscience" in comparison with the former psychologies, a psychology by then proven even by neuroscientific researches.
The Freudian theme that mostly bridges psyche and soma, which is subject that interests us, is the one related to the etiopathogenesis of hysteria, a psychic affection with somatic symptoms. Obviously I don't deny that a sinergy between psyche and soma exists, but my clinical experience makes me doubt the possibility that organic damages (to be precise the ones characterized by structural alterations, and not functional, of the cells) can be made reversible by a psychic treatment: software modifications don't repair hardware damages. I am fully satisfied with Nicola Peluffo’s definition of psycheas "representation of the somatic processes" published in the seventies. Hysteria, as everyone knows, is an affection, to use a rather obsolete, but precise terminology, "sine materia", that is characterized by the absence of organic damages; it shows itself with functional troubles, that can easily regress, in a way substantially definitive, with psychoanalytic treatment. Classical and definitive about its psychogenic origin it is the observation that the hysterical paralyses frequently strike territories that don't correspond in a logical way to the territories of innervation (one of the semiologic signs that is helpful to us in the differential diagnosis with the organic paralyses). Hysteria is a symbolic performance of a traumatic past, a performance not only unconscious, but even preconscious: according to my opinion the hysteric knows, in a part of his psychism, that he is playing a role, except that he is in perfect good faith, since he is subjected to the splitting mechanism that isolates the awareness in islands that are removed from the egoic integration. Cancer is a completely different matter: it’s an eminently organic process, showing itself with macroscopic devastations in the soma.
What does psychology have to say about cancer?
Finally I formulate the necessary question: "What does psychology, and one of its more fertile branches, psychoanalysis, have to say about a pathology such as cancer, in other words a phenomenology expressing itself inside organic structures both macroscopic and microscopic?".
Remaining for thousands of years a true mystery, in the last decades, thanks to the development of innovative branches of science such as the molecular genetics and the proteomics, great strides have been made in the definition of its pathogenetic mechanisms.
Scheme of the Hypotheses on the pathogenesis of cancer
Standard theory: Carcinogens directly alter the genic sequences in the Dna of the genes correlated to cancer. Mutations in the oncosuppressor genes make decrease or disappear the cell growth inhibitory proteins, which they normally codify, allowing the cells to survive and to keep on being reproduced unlimitedly. At the same time the mutations of the oncogenes induce an hyperactivity of the oncoproteins that function as activators of the cellular growth. Accordingly, a concomitant excess of oncoproteins and a lack of inhibitory proteins occurs which facilitates the growth and expansion of a cellular clone without inhibitions to the growth, until the colony invades the tissue surrounding the organ from which it has originated and goes on spreading.
Modified theory: Various factors can inactivate one or more genes necessary for the synthesis and the reparation of the Dna. When the altered cell divides, casual mutations are introduced in its genome and therefore they are no longer repaired and thousands of genic alterations accumulate. As in the standard theory, the activation of the oncoproteins and the elimination of the oncosuppression proteins short-circuit the mechanisms of self-destruction of the cell, preventing it from resorting to programmed suicide.
Theory of precocious instability: Some factors inactivate one or more "key" genes necessary for the correct cellular division. When the chromosomes are duplicated mistakes in transcription occur: some daughter cells acquire a wrong number of chromosomes, or chromosomes devoid of determined segments, or contrarily endowed with segments in excess. Aberrations become worse from generation to generation. After some time, because of such alterations, the quantity of proteins endowed with the oncosuppression function falls below a critical threshold and extra copies of oncogenes can determine an increase in the concentration of oncoproteins rising to dangerous levels.
Theory of aneuploidy: An anomaly occurring during the cellular division produces daughter cells aneuploid (the term initially referring specifically to an abnormal number of chromosomes, recently is used in wider acceptation, also including chromosomes with deletions or additions of fragments or chromosomes in which there are alterations in the order of the genetic code). The altered chromosome modifies the relative quantities of thousands of genes and entire squads of enzymes, which normally cooperate in copying or repairing the Dna, stop working. Most of the altered cells die but some survive and produce daughter cells in their turn aneuploid, until an aberrant cell-matrix imposes itself and acquires the so-called superpowers of cancer: loss of contact inhibition, inhibition of cellular self-destruction mechanisms, ability to encourage the growth of blood vessels and to invade other tissues. 2
As shown above in each of the four hypotheses an important alteration of the molecular hardware is admitted, which determines a disorder in the mechanisms of the cellular division and in the extracellular and intracellular signals responsible for its control.
In this perspective where can the psyche be placed? It’s obvious that, in order to carry on the legitimacy of this reasoning, it is necessary to find a bridge, a contact point, an intersection, between the psychic and the organic. The only reasonable hypothesis that can be put forward nowadays, is the influence of psychism on the epigenetic mechanisms, which has never been directly proved, but, using caution, it can be postulated by inference: in present literature scientists are proving that deep modifications of liberation and reabsorption mechanisms of the chemical mediators at the base of the functioning of nervous system (serotonin, adrenalin, noradrenalin) that some last generation psychodrugs produce, can provoke a fall of events determining real epigenetic modifications. On the other hand, the studies of the Nobel Prize winner Eric R. Kandel have theorized the possibility that deep psychotherapy can also produce stable modifications of the epigenetic mechanisms in the human being (as regards to this I recommend reading of the article of A. Mura “Biologia e psicoanalisi: Leggendo Kandel” _ [Biology and psychoanalysis: Reading Kandel] _ appearing in this same magazine).
The problem is that, when a somatopsychic modification has come to determine an alteration of the genic expression as deep and diffused as the one verified in the neoplastic process, we have passed, (to use a cybernetic metaphor which I love very much), from software faults (always potentially repairable) to hardware alterations (no longer repairable by the resetting of the software code, but by interventions on the cellular structure). This is the true problem of the matter, which anyone who attends to neoplastic patients in psychoanalysis or in other kinds of psychotherapy, should not scotomize. Therefore, it could be a particularly misleading conception of phenomena that puts, as equivalent and transitory states, on the same level the somatic and the psychic; in other words, it could lead to the illusion that psychic elaboration can determine deep modifications in the somatopsychic structure of the human being able to repair widespread genomic damages. It is worthwhile remembering that, even if a potential state of transition matter-energy exists at the quantum level, it disappears at the level of the macroscopic objects.
In addition to this, we must not forget that the atomic dimension is not the kingdom of "everything is possible" as some wrongly believes: Erwin Schrödinger reminds us: "… we must admit that a small system (of the size order of the atomic scale – (editor’s note)) is able, for reason of principle concerning its own nature, to possess only certain discrete quantities of energy, that go under the name of energetic level of the system … if a certain number of atomic nuclei, with all their bodyguard electrons come to be joined to form a 'system' they cannot assume, according to their nature, any arbitrary configuration among all those that can be imagined. Their nature allows themselves to choose only within a very numerous but always discrete series of states. 3
And even the quantic void suffers the influence of some constants of the universe: the constant of Planck, the speed of light, the gravitational constant.
Therefore, what contribution can psychoanalysis give to people suffering from cancer? I believe that the founding nucleus of any psychopathological form is the impact and the elaboration of death anxiety. Thus is comprehensible why in a subject affected by a neoplastic malignant disease, a massive activation of psychic mechanisms of defence occurs, above all the ones near to psychosis: the denial and the negation. Denial of desease is always a serious problem, most of all in a pathological form as cancer, in which early diagnosis and the beginning of appropriate therapies, are very important for the possibilities of stopping the process.
Therefore the psychotherapist who follows oncologic patients should be free from omnipotence desires and remind himself that he can do very much for the patients (to reduce and calm their death anxiety), but the organic illness does not concern his interest. First of all the intervention must be directed in facing and trying to resolve, as soon as possible, the opposition of the patients into recognition of their own state and the refusal of offered treatments, although not yet perfect and surely still painful and disabling.
The therapeutic effect of psychoanalysis consists in the clarification of the information inside the somatopsychic unit: elimination of aberrant information originating from lack of acknowledgements due to the immaturity of the developing psychic apparatus, release of energetic accumulations that haven’t found physiological discharge, reduction of narcissistic omnipotence feelings. The decomposition of psychic components is completed with a superior synthesis of the representational-affective contents. Psychoanalytic intervention will be likewise precious to eliminate the hysterical investments on the source-aim organs. These are truly eliminable, in order to avoid further suffering and worsening of the symptomatologic picture. In my opinion its field of investigation remains exclusively the psychicone4 : I truly hope, as Freud frequently affirmed , that psychoanalysis trusts medicine with the interest for the organic diseases and the relative therapeutic attempts. This doesn't mean that it cannot give a valid therapeutic contribution to the psychopathological manifestations that often go side by side with a multifactorial illness as cancer is.
1“The psychic typification of subjects with neoplastic affections and the marked familiarity of the forms not due to external inductions (radiations, chemical agents, etc.) in fact shows subjects with affective symbiotic-like relationships that, before developing the illness, or its clinical appearing, have had experience of an important loss (psychic or somatic)” (from: : “La vita: involucro vuoto” _ (Life: empty involucre) _, Borla, Rome, 1994)
2 W. Wayt Gibbs, Untangling the Roots of Cancer, Scientific American, 2003.
3 Erwin Schrödinger, What is life?, Cambridge University Press, 1944
4According to the evident synergies between psychic and somatic level, put in relationship and in feedback by the Psychoimmunoneuroendocrin system, it is obvious that there will always be outcomes in the soma, but these cannot be directly the object of psychoanalytic acting.