Is emotional avoidance or disengagement from care denial?

Generally, the term denial refers to a largely unconscious defensive process in which the patient does not integrate, or rejects, the reality or implications of the diagnosis. Some patients might appear in denial because they show avoidance, which refers to a more conscious, effortful turning away from distressing information or affect while awareness is preserved. In clinical settings, denial or even avoidance can manifest themselves as disengagement in care, which could be seen as an umbrella, descriptive term for observable withdrawal from one or more domains of care, i.e., information (e.g., prognostic discussion), treatment (e.g., analgesia, palliative care), relationships (e.g., family notification), or the healthcare system. Disengagement behavior can occur with insight fully intact but is, for providers, observable withdrawal from care, rather than unawareness.

This case illustrates a clinical presentation initially interpreted as denial by the treating team yet resisting simple categorization. Denial is one of many psychological responses in patients with life-threatening illness. Despite its clinical relevance, no consensual definition exists. Its reported prevalence among cancer patients ranges from 4.3% to 46.7%, manifesting as minimization of symptoms, treatment refusal, or rejection of prognosis (Vos and de Haes Reference Vos and de Haes2007; Vos et al. Reference Vos, Putter and Leurs2007). It is typically phase-based, peaking at diagnosis and re-emerging as disease advances (Brock et al. Reference Brock, Gurekas and Deom1993).

Our patient explicitly acknowledged her diagnosis and its severity yet initially declined palliative care referral and opioid analgesics. This underscores the importance of not conflating apparent disengagement with true unawareness. Denial may be transient or persistent and can be understood through various theoretical lenses (see Table 1). It is shaped by interacting factors including cultural norms around discussing life-threatening illness, individual coping styles, family dynamics, and mistrust of healthcare systems (Vos and de Haes Reference Vos and de Haes2007; Vos et al. Reference Vos, Putter and Leurs2007). Reactions to bad news may reflect shock, emotional avoidance, or individual psychological responses to adversity. Family members may also engage in denial, complicating shared decision-making. Personality factors play a role, as some distressed individuals tend to use more dysfunctional coping (Langford et al. Reference Langford, Morgan and Cooper2020). In cancer patients, denial manifests in various ways across clinical contexts and settings (see Table 2).

Table 1.

Theoretical frameworks for understanding denial in advanced cancer

Table 1 Long description

Two columns list theoretical framework and key concept for denial in advanced cancer. Psychoanalytic theory, Vos and de Haes 2007, describes denial as a primitive defense mechanism that distorts reality to shield against overwhelming anxiety, preventing appropriate processing and fostering disconnection from reality. Transactional model, Lazarus 1993, describes denial as a potentially functional, flexible coping response to unmanageable stress, appropriate if it reduces distress in the short term, and evolving as the person adapts. Kubler Ross model, Kubler Ross et al. 1972, describes denial as the first stage of grief, acting as an emotional gatekeeper that buffers shock and breaks down reality into manageable steps during early adjustment. Cognitive social theory, Brennan 2001, describes denial as a delay in processing traumatic information, with the diagnosis held in active memory until the individual is emotionally ready, and oscillation between facing and denying reality. Neurobiological models, Gainotti 2018, Gainotti 2021, and Gallingani et al. 2025, describe anosognosia and neglect syndromes as distinct from denial but suggesting brain lesions may impair illness awareness, and note that no definitive neurobiological explanation for denial currently exists.

Table 2.

Clinical manifestations of denial in patients with advanced cancer

Table 2 Long description

Two columns list type of denial and clinical examples in patients with advanced cancer. Explicit refusal of diagnosis includes denying being informed of the illness or questioning the accuracy of the diagnosis. Minimization of severity includes claiming the cancer has been removed or using euphemisms, lump instead of tumor. Avoidance of discussion includes changing the subject, deflecting attention, or refusing to discuss the illness openly. Non-compliance with treatment includes missing follow-up appointments or discontinuing treatment without medical justification. Maintaining normality includes continuing daily activities as if unaffected and ignoring illness-related limitations. Displacement of concern includes focusing excessively on minor symptoms or routine tests while avoiding the central problem.

Whereas the treating team initially labeled the presentation as denial, our formulation was that her behavior represented selective, value-driven avoidance with preserved insight: an active coping strategy rather than a failure to apprehend reality. In fact, not all patients who appear unaware of their illness or disengaged with care are in denial. Apparent disengagement may stem from untreated psychiatric disorders, neurocognitive deficits, lack of social support, financial insecurity, or even caregiving responsibilities. Distrust of the healthcare system, often rooted in prior negative experiences, and ineffective communication, whether in word choice, language level, or cultural sensitivity, can erode a fragile therapeutic alliance. In our case, the patient’s choice not to discuss her terminal illness reflected a conscious effort to maintain composure in front of her daughters. Recognizing these overlapping barriers is essential to delivering compassionate interventions grounded in the patient’s lived experience.

How to distinguish maladaptive denial from adaptive coping?

Denial is one of several coping or defense mechanisms used to manage stress (Muskin et al. Reference Muskin, Feldhammer and Gelfand1998; Groves and Muskin Reference Groves, Muskin and Levenson2018). In the short term, it may be protective, allowing patients to gradually process their situation and adapt to new existential challenges (Vos and de Haes Reference Vos and de Haes2011; Vos et al. Reference Vos, Putter and van Houwelingen2011). When prolonged or rigid, it may interfere with treatment adherence, delay decision-making, and hinder psychological adjustment (see Table 3). A recent study of 399 patients with advanced cancer identified acceptance, emotional support, and active coping as adaptive, while distraction, venting, and denial were maladaptive (Dev et al. Reference Dev, Agosta and Fellman2024). For our patient, emotional distancing may have enabled her to preserve the role most meaningful to her: being an attentive mother.

Table 3.

Potential benefits and drawbacks of denial as defense mechanism in advanced cancer

Table 3 Long description

Benefits and drawbacks are listed in two columns. Benefits include reduction of anxiety and depressive symptoms, improved perceived quality of life and physical comfort, more stable social functioning, and enhanced optimism and resilience. Drawbacks include delay in medical consultation or non-adherence to treatment, refusal to make key decisions such as wills and advance directives, complicated bereavement for family members, and deterioration of health outcomes due to avoidance.

From traditional frameworks used to describe apparent denial in end-of-life contexts, some map particularly well onto our case. Through the lens of Lazarus’s transactional model, her selective non-disclosure and deferral of analgesia can, for example, be read as a flexible, appraisal-driven coping response that reduced distress in the short term and remained open to revision, as it was abruptly, in her final hours. Brennan’s cognitive-social model similarly frames such behavior as delayed processing, with information held until the person is emotionally ready and oscillation between facing and not facing reality. Her late acceptance illustrates the crossing of that readiness threshold. By contrast, her course challenges simple stage-based readings (according to the Kübler–Ross model). She acknowledged her diagnosis from the outset and her shift was not gradual progression through fixed stages but an almost sudden, values- and pain-driven reappraisal.

In a societal perspective, in Western healthcare contexts, death has become medicalized and marginalized, potentially delaying palliative care access and extending futile interventions (Zimmermann and Rodin Reference Zimmermann and Rodin2004; Zimmermann Reference Zimmermann2007). The clinical paradigm has shifted historically from paternalistic therapeutic non-disclosure to a shared approach where the patient is a partner to the physician (Novack et al. Reference Novack, Plumer and Smith1979; Karazivan et al. Reference Karazivan, Dumez and Flora2015). Acceptance, articulated in the concept of a “good death,” emphasizes minimal suffering and alignment of care with personal values (Zimmermann Reference Zimmermann2012; Meier et al. Reference Meier, Gallegos and Thomas2016).

When should psychiatric or neurocognitive disorders be suspected?

A thorough assessment of apparent denial requires ruling out neuropsychiatric conditions that may compromise insight (Kunkel et al. Reference Kunkel, Woods and Rodgers1997). Severe psychiatric disorders, including psychotic, bipolar, depressive, and anxiety disorders, can each impair awareness and self-reflection, ranging from reality distortion to avoidance and helplessness (Shad et al. Reference Shad, Tamminga and Cullum2006; Belzung et al. Reference Belzung, Willner and Philippot2015; Arnaudova et al. Reference Arnaudova, Kindt and Fanselow2017; Curran et al. Reference Curran, Sharpe and Butow2017; Fiorentino et al. Reference Fiorentino, Lo Buglio and Morelli2024). Substance use disorders may also be mistaken for denial due to impaired self-regulation (Schuckit et al. Reference Schuckit, Clarke and Smith2020).

From a neurocognitive standpoint, brain tumors or metastases can cause various manifestations (anosognosia, hemineglect, anosodiaphoria, hemiasomatognosia) arising from lesions in various regions. Those affecting the frontal or right non-dominant hemisphere can impair social cues, emotional regulation, and illness awareness (Gainotti Reference Gainotti2018, Reference Gainotti2021; Langer and Bogousslavsky Reference Langer and Bogousslavsky2020; Barrash et al. Reference Barrash, Bruss and Anderson2022; Schaff and Mellinghoff Reference Schaff and Mellinghoff2023). These impairments may affect illness awareness. Major neurocognitive disorders and delirium, highly prevalent in terminally ill patients, can further complicate the picture. The hypoactive subtype of delirium especially is often mistaken for voluntary psychological withdrawal or depression (Boettger et al. Reference Boettger, Jenewein and Breitbart2015; Hishikawa et al. Reference Hishikawa, Fukui and Nakano2017; Boyd et al. Reference Boyd, Naasan and Harrison2022; Gallingani et al. Reference Gallingani, Tondelli and Vannini2025). In our case, none of these conditions were identified; her choices reflected deliberate, value-driven decisions rather than impaired awareness.

How to approach apparent denial in everyday practice?

This case highlights the importance of a nuanced, non-confrontational therapeutic stance. The aim is not to force acceptance, but to create a “holding space” where patients can engage at their own pace. Clinicians must remain mindful of potentially problematic countertransference, which can lead to distancing from patients perceived as resistant to care. Establishing trust is foundational, particularly with patients from cultural backgrounds where direct communication about death may feel harmful or threatening (Chammas et al. Reference Chammas, Moment and Rosenberg2025). For our patient, a meaningful opening occurred in her final hours. Clinicians should remain attentive to such shifts, responding with humility and rigor. Effective end-of-life communication can reduce treatment aggressiveness and promote earlier palliative care referrals (Onishi Reference Onishi2021).

Cultural and migration-related factors warrant individualized consideration. In many cultural contexts, serious-illness communication is often family-centered rather than patient-centered. Protective non-disclosure toward relatives may in fact be normative, and stoicism in adversity is valued. For a patient who had migrated and worked within the healthcare system herself, these personal experiences might have shaped how she makes meaning out of her illness and the dying process (Kagawa-Singer and Blackhall Reference Kagawa-Singer and Blackhall2001; Searight and Gafford Reference Searight and Gafford2005). Recent research on culture and end-of-life care shows varied responses to pain and suffering and experts emphasize the need for personalization of care, considering unique life histories and the avoidance of stereotyping beliefs with every patient (Cain et al. Reference Cain, Surbone and Elk2018).

In terms of therapeutic approach, a recent case report also suggested that patients with serious illness and emotional avoidance may benefit from core principles of exposure therapy, involving progressive exposure to emotional content and enhancement of coping mechanisms to support engagement and resilience (Chammas et al. Reference Chammas, Jackson and Brenner2026). In our case, psycho-oncology consultation helped the team reframe the patient’s behavior as a culturally inflected response to an unimaginable situation.

Several practical principles could, in summary, be considered for managing apparent denial in advanced cancer. First, assess before labeling the problem: evaluate the patient’s insight and the meaning of the behavior rather than equating disengagement with unawareness. Second, explore the values (ex. dignity) and roles (ex. parenting) that may drive the patient’s choices. Third, rule out treatable or reversible factors, screening for psychiatric disorders and for neurocognitive impairment and delirium. Fourth, adopt a non-confrontational stance that works at the patient’s pace and remains alert to team countertransference. Finally, draw on multidisciplinary input from psycho-oncology consultants, palliative care specialists, and consider cultural perspectives, while staying attentive to shifts in readiness, which may come only in the patient’s final hours.