SON CHOCOANO El Maquerule

I strongly wish for what I faintly hope: Like the day-dreams of melancholy men, I think and think on things impossible, yet love to wander in that golden maze.

(John Dryden, 1631-1700) DAYDREAMS OF MEDICAL PATIENTS

Patients in General Practice

There have been few studies of the daydreams of patients in general practice. Kreitler et al. (1990) studied the cognitive orientation of female patients in general practice (n = 210) for routine breast screening. Patients favoured a concrete form of thinking focussed on realism, which corresponded with an imbalance in the experience of emotion. Patients were unable to experience positive emotions defined to include elation, love, gratitude, and contentment. They were, however, more prone to negative emotions like sadness, anxiety, hostility and fear. Kreitler, et al. (1990) reported that previous research had found that these negative emotions coincided with a greater likelihood of affective disturbance, particularly symptoms of depression.

Most female patients reported a dramatic reduction in daydreaming as indicated by ‘better’ attentional control (as measured by the SIPI). Kreitler et al. (1990) argued that the reduction was due to limited boredom, since the preference for events in the external environment meant patients had fewer opportunities for mindwandering. It was proposed that patients preferred to concentrate on achieving success in concrete tasks rather than maintaining a ‘fantasy life’. Patients were also unable to maintain an inner-orientation without distraction from the external environment. When patients did daydream, they reported fewer affective daydreams measured by combining scores for positive constructive daydreaming and guilt and fear of failure daydreaming (of the SIPI). It was argued that the reduction in affective daydreams was indicative of the inability of patients to moderate intense emotion (Kreitler et al. 1990).

Kreitler et al. (1990) argued that the decision to see a general practitioner is incompatible with the need to withdraw from reality. On the other hand, their review of previous research indicated that limiting the spontaneous expression of emotion increases the likelihood of psychosomatic symptoms. Kreitler et al. (1990) also argued that frequent daydreaming limits the use of effective coping strategies needed for

long-term health. They proposed that patients denying the reality of the situation might disregard medical opinion. They suggested, nevertheless, that affective daydreams regulate intense dysphoric emotions, which is important for mental health. However, Kreitler et al. (1990) did not measure the health status of patients. Their study was unable to determine if limited daydreaming was related to patient health.

A more recent study by Kreitler, Kreitler, Chaitchik, Shaked, and Shaked (1997) investigated the psychological characteristics of females diagnosed with breast cancer. It was found that survival rates of patients five years post-surgery were predicted (more than 30 percent better than by chance) by psychological (and medical) factors. The most important psychological factor was psychological adjustment to the disease. Female patients reporting lower adjustment (measured one-year post-surgery) had the worse states of health (and lower survival rates) in the long-term (measured at three and five years post-surgery). An unexpected finding was that emotional distress was not related to reports of worse states of long-term health (or lower survival). On the contrary, distressed patients were in a better state of health and survived longer (than did patients reporting less distress). Kreitler et al. (1997, p. 396) suggested “distress reflects an active attempt to cope with psychological problems, being upset by them, perhaps trying to solve them.

These findings (Kreitler et al. 1997) confirmed an earlier report of Kreitler et al. (1993) that repressiveness (defined in the study as ‘low anxiety’) was related to shorter survival rates in female patients with breast cancer. The indirect inference of this study (Kreitler et al. 1993) was that the experience of anxiety indicated the potential for longer survival. It was found that patients tended to become low in emotional expression in response to the threat posed by the cancer diagnosis. That is, the capacity of patients to moderate emotion declined substantially from pre-to-post surgery, namely for patients diagnosed with malignant cancer. Prior to receiving the cancer diagnosis, patients did not differ from controls (non-cancer patients) in their reported experience of negative emotions such as anxiety. Kreitler et al. (1993) concluded that the decrease in anxiety (and presumably mental processes such as negative daydreams that reinforce, and arouse more, negative emotions) post-surgery reflected attempts to cope with the overwhelming stress of the diagnoses of cancer. These findings (Kreitler et al. 1993) provide indirect support for the finding of Kreitler et al. (1990) that the regulation of intense dysphoric emotions (via thought

processes such as affective daydreams) is important for the long-term health (in particular, the mental health) of medical patients with serious health concerns”.

An extensive literature search found no published studies in the past 30 years on the daydreams of patients in general practice for the management of physical disease. An early study by Streissuth et al. (1969) investigated medical patients (n = 80) with physical disease deemed by a general practitioner to warrant medical intervention. Half of these patients had been admitted to hospital, mostly for non-life threatening conditions. All patients completed a 262-item version of the IPI.

Patients reported an impoverished capacity for imaginal activities as indicated by a significant reduction in frequency of daydreaming. They reported fewer affective daydreams, particularly those containing anxiety, aggression, hostility, achievement, and heroism. Patients also reported fewer ‘fanciful’ daydreams defined to include wishful actions that could not be satisfied by the external environment. This included a noticeable absence of sexual daydreams (when compared to college students). Patients did report more unpleasant daydreams, which Streissuth et al. (1969) argued heightened the experience of negative emotion. These daydreams were ruminative with patients unable to ‘turn them off’. Patients reported being frightened by the contents of these unwanted daydreams, which were followed by negative reactions.

Patients also had more daydreams of realistic problem solving such as planning for future actions that may, or may not have occurred (Streissuth et al. 1969). It was feasible that these daydreams outlined the possible implications of physical disease for the daily living of the patient. Even though participants in the study were medical patients with health concerns the study did not include a measure of health status. The relationships between patterns of daydreaming and the health of patients remained unknown. It was recommended, nevertheless, that further research investigate this interaction. Despite this recommendation there has been little subsequent research.

Patients with Life-Threatening Health Conditions

A small volume of research has recognised the potential importance of daydreaming to the health outcomes of patients with life-altering medical conditions. Jensen (1987) investigated factors that determine the progression of malignant breast cancer. He argued that inattention to imaginal activities is an important characteristic of a ‘repressive’ personality, defined as a deficiency in the experience of emotion. He further argued that patients unable to experience emotion sometimes underestimate the seriousness of their medical condition. Jensen (1987) proposed that repressive

characteristics would hinder the recovery of patients from malignant breast cancer (n = 52). He followed patients over a two-year period. Patients were asked to complete subjective measures of health behaviours, as well as the SIPI. They also underwent blood chemistry analysis to determine the progression of cancer.

It was found that psychological factors were responsible for almost 50 percent of the health outcomes of female patients with malignant breast cancer. The most pronounced factor was the ‘inability to express’ negative emotions, which was characterised in part by fewer unpleasant daydreams. Patients unable to regulate negative emotions had the greatest likelihood of metastatic progression. There was also a noticeable reduction of involvement in health-related behaviours. These patients were more likely to have died from their cancer during the two-year study.

Jensen (1987) assumed that patients would focus on enhancing positive emotion. He argued that patients would use these daydreams to interpret life events in a positive manner and that this might foster an optimistic outlook on prognosis of cancer. He found, however, that patients reporting more positive daydreams also recorded the worse health outcomes. Despite medical intervention these patients had the most rapid neoplastic progression. They also spent less time in remission. The adverse implications of positive daydreams were observed even for patients considered not to have a ‘repressive personality’. Jensen (1987) concluded that the health of cancer patients might be improved if they focus on the expression of negative emotion. He argued that negative daydreams are important to the spontaneous expression of upsetting emotions that accompany the fears of being diagnosed with serious disease. He also argued that reducing positive daydreams would contribute to favourable health states, since pleasant daydreams minimise negative affect. These daydreams ‘allow’ patients to escape from fearful thoughts of disease into comforting fantasy. Thus, patients indulging in positive fantasy often underestimated the seriousness of the situation. The findings of Jensen (1987) implied that this underestimation might have negative effects for the progression of cancer including more metastatic development.

The findings reported by Jensen (1987) have been supported by a more recent study of the personality characteristics of patients with paraplegia due to traumatic spinal cord injury (n =83; Mattlar, Tarkkanen, Carlsson, Aaltonen, & Helenius, 1993). Mattlar et al. (1993) found that most patients reported the ‘regressive tendency’ of not being able to moderate the experience of emotion, particularly negative emotion. They favoured ‘improbable fantasy’ (as measured by the Rorschach method) that allowed

them to temporarily ‘escape’ from the negative emotion about the unexpected disability. It was likely that fanciful fantasy provided a peaceful sanctuary from feelings that were intolerable. Mattlar et al. (1993) implied that these comforting daydreams hindered patient rehabilitation, since patients often relied upon them to mentally disengage from the reality of their unchangeable situation.

It was also found that most patients had ‘unrealistic ambitions about their own resources’ (Mattlar et al. 1993). It was likely that they underestimated the functional limitations imposed by their injury. Mattlar et al. (1993) inferred that unrealistic thoughts were used to imagine that the disability would somehow be over, or that it was not as serious as forecast. They argued that thought patterns (including daydreams) would be beneficial to health outcomes if channelled towards planning realistic goals for rehabilitation, rather than fanciful ones. The findings of Mattlar et al. (1993) supported the conclusion of Jensen (1987) that patients should be encouraged to confront negative emotions as this might benefit their adjustment to life-changing events. Mattlar et al. (1993) also suggested that wishful daydreams might function as a defensive manoeuvre in response to the stressful demands of living with a chronic condition (such as its adverse affect on functional health).

Spiegel, Bloom, Kraemer, and Gottheil (1989) had earlier found that female breast cancer patients assigned to a support group to express negative feelings about their disease survived twice as long (than did control patients). It was argued that patients in the support group ‘achieved happiness’ not by eliminating (or avoiding) negative emotions but by confronting and accepting them. Spiegel et al. (1989) concluded that it is important for the wellbeing of medical patients with severe health concerns that they are encouraged to experience (and express) negative emotions in addition to those that are positive.

A series of recent studies sought to confirm whether the experience of positive and negative emotions could be separated. Larsen, McGraw, and Cacioppo (2001) investigated if people could feel happy and sad at the same time. They found, in contrast to the view of others (for example, Russell & Carroll, 1999) that positive affect and negative affect are polar opposites, that the experience of positive and negative emotions can be separated: that is, mixed feelings of happiness and sadness can co-occur. The experience of mixed feelings (at the same time) was most noticeable in ‘complex situations’ that were not typical-everyday experiences for most of the population. Larsen et al. (2001) reported that coping with severe stressors (such

as serious health concerns) requires not only positive emotions, but also the experience of, and dealing with, negative emotions attached to the stressor. They noted that it was necessary for individuals to experience and confront negative emotions while being comforted by positive emotions.

Cacioppo and Gardner (1999) studied the activation functions for positivity and negativity, which they are argued are separate affective systems. They reported that negative affect is most likely to be experienced when information is perceived as threat-related while positive affect is experienced when information indicates safety. They argued that negative affective dimensions were more influential than positive dimensions on cognitive activity (and behaviour) with a propensity to act more strongly to negative stimuli. They termed this heightened sensitivity to negative information ‘negativity bias’. Cacioppo and Gardner (1999) observed, nevertheless, that most people are at least moderately motivated to act when confronted with neutral or unfamiliar stimuli. They termed the tendency to respond in a positive manner to situations affectively neutral as ‘positive offset’. It is possible that negative affective dimensions such as negativity bias are more relevant to the wellbeing of medical patients. Some patients might become so overwhelmed with negativity that it hinders recovery (and health outcomes).

Patients with Chronic Health Conditions

Most measures of coping strategies designed for medical patients include a subscale of wishful daydreams (Felton, 1984; Folkman & Lazarus, 1985). These daydreams include I ‘daydreamed of a better time or place than the one I was in’, ‘had fantasies about how things might turn out’, and ‘thought about fantastic things like winning a million dollars that made me feel better’. The use of these daydreams as a coping strategy has been researched in patients diagnosed with chronic conditions such as hypertension, diabetes mellitus, cancer, and rheumatoid arthritis (Feifel, Strack, & Nagy, 1987; Felton, Revenson, & Hinrichsen, 1984). Felton and Revenson (1987) argued that these daydreams represent a passive adaptation to the stress of chronic disease, as they do not lead to direct action in the real world. Patients are more likely to adopt this form of emotion-focussed coping when the situation is considered unchangeable (Folkman & Lazarus, 1988), one that must be endured (Carver, Scheier, & Weintraub, 1989), or when relinquishing control to others (Brown & Nicassio, 1987). Felton and Revenson (1987) found patients who perceived their condition as serious coped by engaging in wishful daydreams at the expense of

seeking information about their condition. These patients were the least likely to adopt coping strategies that encourage them to search for realistic options in managing the stressful demands of their chronic condition (Folkman & Lazarus, 1988).

Revenson and Felton (1989) argued that wishful daydreams alleviate the emotional strain of disease by allowing patients to escape into comforting fantasy. These daydreams provide the opportunity for patients to modify the reality of the situation as desired (Felton & Revenson, 1987). These patients often indulge in daydreams that ‘long for the disease to disappear’. Felton and Revenson (1984) found that these daydreams sometimes comprised ‘what might have been’ and ‘memories of better times’. They reported that despite the cognitive effort to escape into pleasant fantasy, negative thoughts resurface through the thought patterns of medical patients.

Commerford, Gular, Orr, Reznikoff, and O’ Dowd (1994) found that patients reliant upon wishful daydreams to disengage from the external environment were the most likely to be diagnosed with affective disorders like depression. These patients also reported more psychosomatic symptoms (Vingerhoets & Menges, 1989), in addition to ‘feelings of helplessness’ regarding the side effects of chronic disease like pain management (Brown & Nicassio, 1987). Felton and Revenson (1984) found that patients engaging in fanciful daydreams reported more intense negative emotion. This included a more pessimistic outlook on life and the self, both of which hinder patient self-esteem. Felton and Revenson (1984) suggested that fanciful daydreams often entail ruminations of ‘self-pity for better times’ that provide little relief from the emotional stress of disease. These patients, they argued, manifest unhappy feelings about being chronically ill and often refer to themselves as feeling sad or depressed.

The daydreaming of ‘better times’ reduces patient acceptance of chronic conditions as requiring consistent medical supervision (Felton & Revenson, 1984). Such patients are often unwilling to accept the limitations imposed by chronic disease on their participation in the physical activities of everyday living. Even so, they are more likely to report severe functional incapacitation in routine activities like walking, washing floors, and carrying groceries. These patients also report a marked decline in the capacity for social participation in valued activities with family and friends (Brown & Nicassio, 1987). Quinn, Fontana, and Reznikoff (1987) argued that the failure of patients to adjust to these functional limitations coincides with an increased likelihood of affective disturbance. This deterioration in affective state

occurs despite wishful daydreams being initiated by the patient in an attempt to improve mental health by denying the presence of negative affect (Quinn et al. 1987).

The use of coping strategies that encourage realistic goals for rehabilitation, rather than fanciful ones, has been found to be beneficial to health outcomes (Felton & Revenson, 1984; Felton & Revenson, 1987). Folkman and Lazarus (1988) found that planful problem solving such as ‘I made a plan of action and followed it’ and ‘I came up with a couple of different solutions to the problem’ helped to improve the emotional state of patients with chronic conditions. These patients, taking an active role to improve the situation, were less likely to report being depressed or to feeling helpless, since they felt in more control of the situation (Brown & Nicassio, 1987).

Oettingen and Mayer (2002) and Oettingen et al. (2001) studied the role of positive fantasies (about desired future events) in setting and committing to goals. They found that individuals reporting frequent positive fantasies had fewer future goals and were also less successful in accomplishing goals. These individuals displayed less purposeful action, which increased the likelihood of less successful performance (compared to those reporting fewer positive daydreams). It was argued that positive fantasies provide little motivation to act: they embellish future events (and the probability of these occurring) and thereby prevent the individual from preparing for potential obstacles and from planning how to overcome them. The absence of sufficient preparation further compromised success in obtaining desired goals. Oettingen and Mayer (2002) noted that the experience (and enjoyment) of positive daydreams in the ‘here and now’ provided limited motivation to implement desired goals in real life. The adverse effects of positive daydreams on goal commitment and goal attainment were found for a number of life domains (professional, interpersonal, academic, and health).

The study by Oettingen and Mayer (2002) comprised medical patients (n = 67) preparing to undergo hip-replacement surgery. It found participants with frequent positive fantasies recorded the poorest recovery measured in terms of joint mobility, the functional capacity to walk up a set of stairs, and a general questionnaire on pain, muscular strength, and patient wellbeing. It was proposed that patients who mentally face the possibility of painful future events have a ‘better’ recovery than do avoidant patients Even so, Oettingen et al (2001) argued that sometimes fantasising about a desired future is experienced as welcome relief (even if temporary) from a harsh reality that manifests unwanted negative emotions.

The research on medical patients with chronic conditions appears to support the argument that patients should be encouraged to communicate negative emotions, rather than retreating into comforting fantasy. It is possible that a mutual reinforcing relationship exists for some patients: that ill health brings about negative emotion that leads to wishful ruminations, which in turn reinforces negative emotion and non- acceptance of the health concern. The research also implies that practical problem solving is central to patient adjustment to the stressful demands of chronic ill health.