Let’s review several case scenarios that are common in medical practice and see if we can identify a common theme.

Case No. 1: A 73-year-old woman was brought in by her family because of weight loss. She had been a cigarette smoker for many years and over the past six months, her weight had dropped from 160 pounds to 130 pounds. Her appetite was diminished. She felt weak and tired. She agreed to have several diagnostic tests performed. She underwent a chest X-ray, which showed a large mass in her left upper lung. I had several conversations with her, during which I told her of my concern that she could have lung cancer.  Despite my recommendations to her, as well as the recommendations of family members, she declined to have further testing or consultations. She declined to have treatments. She said over and over there was nothing wrong with her and she refused to come back for follow-up. She passed away about three years later of lung cancer.

Case No. 2: An intelligent, 64-year-old man developed symptoms of excessive thirst and frequent urination. He went to his physician’s office and had laboratory testing that showed a high glucose level of 564. He was diagnosed with new onset diabetes mellitus. He started medication to lower his blood glucose level, but did not agree to start on insulin injections, which was the first line recommendation of his physician. He did not want to meet with a dietitian and he was not interested in changing his eating habits, which consisted of high levels of consumption of sugary foods. His blood glucose level remained elevated, until he had to be admitted to the hospital for intensification of his therapy.  He eventually agreed to start on insulin injections and a proper diabetic diet, following which his blood sugar levels went into the normal range. 

Case No. 3: A college educated 56-year-old woman went to see her physician because of pain in her breast. She had an examination, as well as X-rays, which confirmed the diagnosis of breast cancer.  Unfortunately the type of breast cancer that she was diagnosed with had an aggressive course, for which very strong treatment options were recommended. She underwent chemotherapy and radiation therapy, which did not slow the growth of her cancer. Eventually, she developed metastasis and her overall condition declined. She subsequently was referred for palliative care. At no time during her illness when her health was declining was she willing to talk openly to her family and friends about what she was experiencing. It appeared to be easier for her to keep her feelings, fears and wishes to herself.

All three of these scenarios demonstrate the power of denial. Denial is a defense mechanism we all have, which can protect our mind against psychological pain, by refusing to accept a present reality in our lives. Denial can be both good and bad. On the good side, it is a very effective way for us to shield ourselves from painful issues that arise in our lives. On the bad side, refusal to accept a reality can prevent one from seeking possible treatments or solutions. Denial can also prevent us from exploring end of life issues with loved ones. Through avoidance and denial, we lose the opportunity to help family members come to terms with their possible loss of a loved one and everything that involves. Individuals have different capabilities accepting illness and disease, and it is a delicate balancing act to maintain one’s self-awareness in the face of illness or mortality.

Dr. Mark Roth writes about internal medicine for the Cleveland Jewish News. He is an internal medicine physician with University Hospitals. 

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