Yeah.
Mm.
A.
United States Army Medical Department Continuing
education program,
psychosocial aspects of hemodialysis
and kidney transplantation with Peter
Bridge,
Captain,
United States Army Medical Corps Department of
psychiatry,
NP Division walter reed,
Army Institute of Research walter reed Army Medical center
Washington,
D.
C.
What I want to speak about this morning
is to give you an overview of a
psychosocial model of the functioning of people under
stress,
which I think has direct applicability
to patients and the patients
families who undergo transplant experience.
Psychiatry's early involvement in the
clinical field of transplantation
was as a consultant who offered his
or her services and evaluating the potential
transplant recipient and his or her
family.
These evaluations usually centered upon the
relationships within the family and how the individuals
concerned had adapted to stress in the past
Because of the limitations of both funds and personnel.
During the 1960s,
selection of potential transplant recipients as well
as those who were placed on maintenance to analysis presented
unique problems to those involved in the care of
these patients.
Every effort was made to maximize the effective use
of the limited resources.
The result of this was that committees of physicians found
themselves in the unenviable position of deciding
whether or not patients would be admitted
to these limited facilities and realizing
that these decisions were ones of life and death,
Fortunately expanded federal funding funding since
1972 has saved physicians whose
primary commitment is to saving lives from having
to decide whose life is more worth saving.
The need for psychiatric involvement with
transplant patients has not ended.
Despite efforts to select out of population
of transplant candidates who were not psychiatrically
diagnosable,
the clinical material that has accumulated from
these patients indicates that they do produce a
wide range of psychiatric symptoms.
It's not difficult to imagine that this
population might have some difficulty
adjusting to the transplant experience.
It is difficult to imagine.
Let us consider for a moment the experience of the
transplant recipient.
Prior to transplantation,
the recipient is in a 10uous emotional state and may have been
exposed to disturbing neurological or
psychological manifestations of your premium.
He's been medically subjected to diets,
drugs,
regimens,
or the cramps and penetration of peritoneal dialysis.
The discomfort of cancellations is followed by the visible
external shunt which serves as a reminder of
his disorder,
with ensuing fears of infection and our
exsanguination.
By the time the patient is ready for transplant,
he or she may be disheartened by the duration,
repetitive nature of the hemodialysis,
by the restriction of physical activities,
weakness,
or by complications such as peripheral
neuropathy,
renal osteo dystrophy,
organic brain syndrome.
He may have had to relocate his residents,
changed jobs,
adjust to a lower income,
altered the basic routines of his life.
Diet malaise may arise from his
general physical condition,
yuri mia treatment and its
complications and psychological
innovation.
We can also imagine that many
of the adaptations that the recipient must make to his
life can also be applied to the recipients
family,
such as the often necessitated change of residence,
change of jobs,
decreased income,
major illness and member of the family and
change in contact with social support systems such
as family,
friends and organizations.
When an adult is the affected member of the family,
These families often operate as one parent
families.
And furthermore,
I believe that we really cannot expect that as routine Ization
transplantation occurs,
that this will automatically decrease the stressful effects
of these events upon the recipient and his family.
Okay,
Given we have made efforts in the past to select out
a population of candidates who are quote
psychiatrically normal,
which I believe in essence means that evaluation of
them did not produce a diagnosis.
This has failed to prevent the development of
psychiatric symptoms among this population undergoing
this experience.
Are we like to conclude then,
that the experience of transplantation was productive of the symptom
Atallah gee.
There's no direct answer for this in the transplant
literature.
If,
however,
we turn to the literature on stress and particularly that
literature,
which is related to recent life events,
we can find suggestions of an association
between stressful events and later symptom.
Atallah Gee Homes and Ray at
Washington University of Washington began their work by
studying a wide variety of
physiologic and psychiatric
patients in a retrospective fashion,
they found a very significant portion of them had a
clustering Stressful life events
which occurred during the 12 months prior to the
onset of their illness.
Now,
I've passed out a handout,
which,
if you look over briefly,
um,
is one of the instruments developed by Homes and
Ray and I think you'll see when
you look at it,
that it refers to
relatively universally understood series of
events that may happen
to any of us,
even when Homes and Ray controlled for
socio economic status,
race,
multinational effects,
they were still able to show a remarkable consistency and the
amount of stress that people perceive these events is
causing.
They've empirically assigned values to them as a
result of their research.
And you can note that these values are on the left
hand column beside the events.
Uhh,
They've also used this instrument to prospectively
study a wide variety of
populations and patients,
including cardiac patients,
cancer patients,
diabetics,
and normal populations such as college students and
naval personnel.
What the results demonstrate is that for
individuals who accumulate 200 or more
points,
Uh,
during any 12-month period is significantly greater
proportion of the population will develop an illness
than when you compare it to populations who don't have
this clustering of events.
Why do some people develop illnesses a response to
stress and others don't?
I'll return to this in a minute.
But I think it might be helpful if we briefly
consider our potential transplant
recipient and his family history
that's not untypical for a military family would
be that the mother would develop chronic renal failure,
leading to the decision to place her on
dialysis while awaiting transplant.
She's transferred to a regional medical center and initially she
and her family are separated.
But finally,
her husband arranges a transfer.
The wife who was formerly employed is no longer able to
work.
The family is contacted about the possibility of donating
screening proceeds and one sibling volunteers.
after considerable discussion with his wife but
nonetheless remains steadfast in his decision to donate
his time away from his business,
both for testing and finally,
for the donut effectively means a loss of income for
him.
The recipient following transplant,
which goes successfully reports upon her return home
of fear and avoidance of sexual intercourse.
Well,
if you look at the recent life change questionnaire,
I've noted down a code beside these events,
which is fairly simple.
Mind that are is for recipient Fs for the
family members of the recipient and ideas for the donor.
The events and just the events surrounding the
transplant experience in the lives of these people
Has already given both the recipient and the
members of that family more than their quote
necessary,
unquote 200 points.
The donor himself has also managed to accumulate almost
2/3 of the necessary points.
What I believe is clear,
then,
is that our hypothetical family
does endure a stress that is real,
and one that can legitimately concern us
to return them to the earlier question of why do some
people show an association between this
clustering of events and the disease onset and
others do not?
Again,
we can't answer this directly from the transplant literature.
We can look elsewhere,
though,
and,
for example,
to the work of George Engel and his group at Rochester,
who have described the complex of
affects which precede the
onset of illness,
which they described as the given up giving
up syndrome.
The essential point of this concept is that in
a wide variety of patients that they
interviewed after the illness experience,
they found that
by and large the majority of these patients had an
experience which was characterized by a significant loss in their
life,
which was described to the feeling of being given up
upon or hopelessness and that was
followed by a feeling of helplessness or
having or they themselves giving up.
They point out that this is neither necessary nor sufficient
condition for illness onset,
but it is significantly associated with it.
Another study by knuckles at all at
UNC looked at the complications of
pregnancy,
they administered a life change questionnaire similar to the
one I've passed out and found that
it of itself was not predictive of
who would and would not
suffer from complications of pregnancy.
However,
when it was combined with another instrument,
which measured the social assets
of the individuals in the study,
the two instruments together combined to
achieve significant predictive value.
In other words,
if we look at both the events which occur in a person's life,
which require adaptation to cope successfully with
them,
and we look at the assets that a person has in the social,
in social terms,
uh,
that they can rely upon for support in these
situations,
we begin to have a handle upon who might and who
might not develop illness as a response to these
events.
What is meant by social assets or social supports or
social adjustment or social networks
in brief and simply these terms are used to
describe the adequacy of various
fears of a person's social world
means work.
It means that social leisure life and his
family means his marriage,
sexuality and furthermore,
these are areas of a person's life that we are
able to assess with instruments that are currently available.
So given this assemblage of research findings,
what clinical applications can we make from them?
Well,
one view might be to simply
to develop a massive federal program
to remove all the stressful events from a person's life.
Obviously that's impractical.
2nd view might be to ask
if it's possible for us to provide
temporarily increased social support for
people undergoing stressful situations.
Uh,
for example,
the death of a spouse on the homes and Ray
questionnaire is the most stressful event
to occur to an individual that
widows and widowers often die shortly after the
death of their spouses.
Well known folklore,
I believe that the death rate among
widows and widowers uh
rises far above that of a comparable non
widowed population is a demonstrated research
finding that widows and widowers who adapt
badly to the death of their spouse
have perceived their environment.
And I think what we can do here is read social supports
as unsatisfactory as another demonstrated
finding in response to these facts,
Widow the widow programs have been developed to provide increased
social support to this group.
Simply,
they provide contact with a wide range of
services for the newly widowed by previously widowed
women who have successfully adapted to this
experience.
Do we know that such programs make a demonstrable difference?
Well,
anecdotally we do,
but not in a rigorously tested fashion as of yet.
Similar anecdotal evidence is reported for supportive
programs for a variety of patients,
including transplant and dialysis
patients.
Um The critical element though appears to
be that the support is obtained from a
person who is newly undergoing this stressful
event from someone who has successfully
adapted or coped with the situation.
In the past we cannot provide families,
marriages etcetera for our patients in order,
they particularly require that.
But what we can provide them with is a social support of these
self help groups.
While we await more vigorous testing of such services.
Do we have any indication that providing social supports
for transplant patients?
Matters Well,
perhaps we do.
A study by Kaplan d'Honneur of seven
rental units showed that even when a
research team and the clinical teams
agreed about the criteria for evaluating the
adjustment of their patients,
which were essentially three criteria compliance
with diet,
rehabilitation and emotional condition.
There was a considerable discrepancy between groups about the
actual evaluation.
one Group of clinicians and the research group
fairly closely agreed about their evaluations of the
patients.
However,
another clinical group um
rated their patients as doing far better
than the research group did.
And furthermore there,
their patients were rated as not doing as well
as when there was a matchup
between the research and the clinical
groups.
So in other words,
to state that again,
when it appears that the clinical team
was evaluating uh
adequately and realistically the adjustment of their
patients,
their patients seem to do better than when there was an
unrealistic evaluation by the clinical
team and those patients did not do as
well.
What explanation for this are we left with there to
basically one of which is that
one set of clinical teams had bad patients
and the fact that their patients didn't do well lead to a
development of denial among the staff members.
The other explanation and the one I think is more accurate
is that the denial by the staff members of the
accurate adjustment that their
patients were making led to the patients not
doing as well as they might.
And it's not proven which is really the case.
But other studies of the same group of patients shows that
denial by the staff of their condition
leads to delivery by the
staff to the patients of pat reassurance and
everything's gonna be okay.
You don't have anything to worry about.
Which in turn leads to a decreased reporting
of symptoms by the patients to their doctors.
This is in essence,
as I see it are closing off of an important social support for these
patients.
In summary,
I believe they have demonstrated that we have accumulated.
Clinical evidence suggested that the stressful event of
transplantation and lives of non psychiatric
population often produces psychiatric
symptom,
Atallah gee.
Furthermore,
the stress of this event is not only isolated to the
potential recipient but also includes his
family.
Because we,
as physicians,
have control of this massive intervention in the lives of our
patients.
It is reasonable that we assume responsibilities for
Ameliorating the deleterious effects of this event as
best we can to accomplish this,
we can provide for our patients what they need,
which in almost all cases is not massive,
personality modification,
but rather temporarily increased social supports to
them and to their families in order to help them adapt
to the stress of this series of events.
Such services are easily within the means
of any center providing transplant facilities.
These programs do not need to be slavishly forced upon the
patient's,
but rather utilized as the model present in the widow.
The widow programs in which a wide range of services
and contact is offered to the individual,
but participation and utilization is then
determined by the individuals concerned
psychosocial aspects of hemodialysis and
kidney transplantation
with peter bridge,
Captain,
United States,
Army Medical Corps,
Department of psychiatry,
Np Division walter reed,
Army Institute of Research walter reed Army Medical Center
Washington D.
C.
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