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. Was produced through the mobile facilities of the television division, Academy of Health Sciences, United States Army Fort Sam Houston texas.