Denial consists of acting and thinking as if a part of reality is not true. Denial is one of the most common psychological mechanisms of defense and can occur in both patients and health-care providers. Denial is often an emotional response to inner tension and prevents a painful conflict from producing overt anxiety. It is actually a form of self-deception. Denial is often observed in patients with terminal illnesses or with chronic, incurable diseases. In general, the more acute the illness, the greater is the patient's acceptance; the more insidious, the greater the denial.
A patient dying slowly from cancer can observe his or her weight decreasing and the side effects of medications. Frequent visits to the hospital for chemotherapy or radiation therapy confirm the severity of the illness; yet, in spite of all this, the patient may continue to deny the illness. He or she makes plans for the future and talks about the time when he or she will be cured. Denial is the psychological mechanism that keeps this patient going. The interviewer should not confront the patient's denial despite its apparent absurdity. Telling such a patient to ''face the facts'' is cruel. Breaking down denial in such a patient serves only to add to the dying patient's misery. However, the patient's family must understand and accept the poor prognosis.
Denial can sometimes obstruct proper medical care. A woman presents to a breast clinic with an orange-sized mass in one breast. The mass has already started to ulcerate, with a resultant foul-smelling infection. When asked how long she has had the mass, she responds that she noticed it ''just yesterday.'' It is often best to interview a reliable informant when the patient with denial is recognized.
Figure 2-1 illustrates another example of the tragic sequelae of denial. This man has a basal cell carcinoma of the face. As is discussed in Chapter 8, The Skin, basal cell carcinomas are very slow growing and rarely metastasize; they are locally invasive. Had the patient sought medical attention when the lesion first appeared (and was very small), he would have been totally cured. A person's denial can be so deep that it prevents him or her from seeing reality and seeking medical attention. It is therefore important for the health-care provider to be sensitive to this very powerful psychological mechanism. For another example of denial, see the unfortunate patient depicted in Figure 16-8.
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