WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:03.140 --> 00:03.340 Yeah. 00:03.940 --> 00:04.450 Mm. 00:13.440 --> 00:13.700 A. 00:13.700 --> 00:16.440 United States Army Medical Department Continuing 00:16.440 --> 00:17.850 education program, 00:19.440 --> 00:22.220 psychosocial aspects of hemodialysis 00:22.230 --> 00:25.110 and kidney transplantation with Peter 00:25.110 --> 00:25.620 Bridge, 00:25.620 --> 00:26.070 Captain, 00:26.070 --> 00:28.470 United States Army Medical Corps Department of 00:28.470 --> 00:29.260 psychiatry, 00:29.260 --> 00:31.050 NP Division walter reed, 00:31.050 --> 00:33.940 Army Institute of Research walter reed Army Medical center 00:33.940 --> 00:34.550 Washington, 00:34.550 --> 00:34.770 D. 00:34.770 --> 00:35.150 C. 00:36.140 --> 00:38.060 What I want to speak about this morning 00:38.640 --> 00:41.610 is to give you an overview of a 00:41.610 --> 00:44.440 psychosocial model of the functioning of people under 00:44.440 --> 00:45.060 stress, 00:45.540 --> 00:47.960 which I think has direct applicability 00:48.640 --> 00:51.470 to patients and the patients 00:51.470 --> 00:54.210 families who undergo transplant experience. 00:54.940 --> 00:57.630 Psychiatry's early involvement in the 00:57.640 --> 00:59.860 clinical field of transplantation 01:00.340 --> 01:03.220 was as a consultant who offered his 01:03.220 --> 01:06.020 or her services and evaluating the potential 01:06.020 --> 01:08.790 transplant recipient and his or her 01:08.790 --> 01:09.360 family. 01:10.010 --> 01:12.960 These evaluations usually centered upon the 01:12.970 --> 01:15.610 relationships within the family and how the individuals 01:15.610 --> 01:18.160 concerned had adapted to stress in the past 01:18.640 --> 01:21.310 Because of the limitations of both funds and personnel. 01:21.310 --> 01:22.760 During the 1960s, 01:23.110 --> 01:26.080 selection of potential transplant recipients as well 01:26.080 --> 01:28.820 as those who were placed on maintenance to analysis presented 01:28.820 --> 01:31.640 unique problems to those involved in the care of 01:31.640 --> 01:32.500 these patients. 01:32.890 --> 01:35.730 Every effort was made to maximize the effective use 01:35.740 --> 01:37.360 of the limited resources. 01:37.840 --> 01:40.560 The result of this was that committees of physicians found 01:40.560 --> 01:43.510 themselves in the unenviable position of deciding 01:43.510 --> 01:45.650 whether or not patients would be admitted 01:46.240 --> 01:49.240 to these limited facilities and realizing 01:49.240 --> 01:51.760 that these decisions were ones of life and death, 01:52.540 --> 01:55.500 Fortunately expanded federal funding funding since 01:55.500 --> 01:58.190 1972 has saved physicians whose 01:58.190 --> 02:01.150 primary commitment is to saving lives from having 02:01.150 --> 02:03.360 to decide whose life is more worth saving. 02:04.640 --> 02:07.630 The need for psychiatric involvement with 02:07.630 --> 02:09.660 transplant patients has not ended. 02:10.340 --> 02:12.860 Despite efforts to select out of population 02:13.240 --> 02:15.890 of transplant candidates who were not psychiatrically 02:15.890 --> 02:16.960 diagnosable, 02:17.540 --> 02:20.380 the clinical material that has accumulated from 02:20.380 --> 02:22.990 these patients indicates that they do produce a 02:22.990 --> 02:25.160 wide range of psychiatric symptoms. 02:25.820 --> 02:28.290 It's not difficult to imagine that this 02:28.290 --> 02:30.790 population might have some difficulty 02:30.800 --> 02:32.960 adjusting to the transplant experience. 02:33.640 --> 02:35.110 It is difficult to imagine. 02:35.110 --> 02:38.000 Let us consider for a moment the experience of the 02:38.000 --> 02:39.160 transplant recipient. 02:39.740 --> 02:41.110 Prior to transplantation, 02:41.110 --> 02:44.080 the recipient is in a 10uous emotional state and may have been 02:44.080 --> 02:46.980 exposed to disturbing neurological or 02:46.980 --> 02:49.260 psychological manifestations of your premium. 02:49.940 --> 02:51.950 He's been medically subjected to diets, 02:51.960 --> 02:52.850 drugs, 02:52.860 --> 02:53.780 regimens, 02:53.980 --> 02:56.960 or the cramps and penetration of peritoneal dialysis. 02:57.540 --> 03:00.290 The discomfort of cancellations is followed by the visible 03:00.290 --> 03:03.210 external shunt which serves as a reminder of 03:03.210 --> 03:04.090 his disorder, 03:04.090 --> 03:06.810 with ensuing fears of infection and our 03:06.810 --> 03:07.760 exsanguination. 03:08.540 --> 03:10.520 By the time the patient is ready for transplant, 03:10.540 --> 03:12.800 he or she may be disheartened by the duration, 03:12.810 --> 03:15.020 repetitive nature of the hemodialysis, 03:15.030 --> 03:17.080 by the restriction of physical activities, 03:17.640 --> 03:18.300 weakness, 03:18.300 --> 03:20.410 or by complications such as peripheral 03:20.410 --> 03:21.310 neuropathy, 03:21.320 --> 03:22.680 renal osteo dystrophy, 03:22.680 --> 03:24.360 organic brain syndrome. 03:25.240 --> 03:27.880 He may have had to relocate his residents, 03:27.890 --> 03:28.940 changed jobs, 03:28.950 --> 03:30.400 adjust to a lower income, 03:30.410 --> 03:32.560 altered the basic routines of his life. 03:32.570 --> 03:35.510 Diet malaise may arise from his 03:35.520 --> 03:36.750 general physical condition, 03:37.140 --> 03:39.250 yuri mia treatment and its 03:39.250 --> 03:41.770 complications and psychological 03:41.770 --> 03:42.450 innovation. 03:43.940 --> 03:46.730 We can also imagine that many 03:46.730 --> 03:49.730 of the adaptations that the recipient must make to his 03:49.730 --> 03:52.560 life can also be applied to the recipients 03:52.560 --> 03:53.160 family, 03:53.840 --> 03:56.630 such as the often necessitated change of residence, 03:56.640 --> 03:57.710 change of jobs, 03:57.720 --> 03:58.850 decreased income, 03:59.540 --> 04:02.320 major illness and member of the family and 04:02.320 --> 04:05.210 change in contact with social support systems such 04:05.210 --> 04:05.990 as family, 04:06.000 --> 04:07.600 friends and organizations. 04:08.340 --> 04:10.860 When an adult is the affected member of the family, 04:11.340 --> 04:14.100 These families often operate as one parent 04:14.110 --> 04:14.710 families. 04:15.820 --> 04:17.060 And furthermore, 04:17.060 --> 04:20.060 I believe that we really cannot expect that as routine Ization 04:20.740 --> 04:23.010 transplantation occurs, 04:23.230 --> 04:26.140 that this will automatically decrease the stressful effects 04:26.510 --> 04:28.860 of these events upon the recipient and his family. 04:30.340 --> 04:30.620 Okay, 04:30.630 --> 04:33.580 Given we have made efforts in the past to select out 04:33.590 --> 04:36.040 a population of candidates who are quote 04:36.040 --> 04:37.360 psychiatrically normal, 04:37.840 --> 04:40.800 which I believe in essence means that evaluation of 04:40.800 --> 04:42.850 them did not produce a diagnosis. 04:43.520 --> 04:46.110 This has failed to prevent the development of 04:46.110 --> 04:49.000 psychiatric symptoms among this population undergoing 04:49.000 --> 04:49.890 this experience. 04:50.640 --> 04:52.100 Are we like to conclude then, 04:52.110 --> 04:55.080 that the experience of transplantation was productive of the symptom 04:55.080 --> 04:55.760 Atallah gee. 04:56.440 --> 04:59.350 There's no direct answer for this in the transplant 04:59.350 --> 04:59.860 literature. 05:00.940 --> 05:01.400 If, 05:01.400 --> 05:01.730 however, 05:01.730 --> 05:04.260 we turn to the literature on stress and particularly that 05:04.740 --> 05:05.670 literature, 05:05.670 --> 05:07.680 which is related to recent life events, 05:08.130 --> 05:11.130 we can find suggestions of an association 05:11.130 --> 05:13.000 between stressful events and later symptom. 05:13.000 --> 05:15.960 Atallah Gee Homes and Ray at 05:15.960 --> 05:18.570 Washington University of Washington began their work by 05:18.570 --> 05:20.760 studying a wide variety of 05:20.770 --> 05:23.040 physiologic and psychiatric 05:23.170 --> 05:25.450 patients in a retrospective fashion, 05:26.140 --> 05:28.360 they found a very significant portion of them had a 05:28.360 --> 05:30.920 clustering Stressful life events 05:31.070 --> 05:33.730 which occurred during the 12 months prior to the 05:33.730 --> 05:34.960 onset of their illness. 05:35.440 --> 05:35.640 Now, 05:35.640 --> 05:37.240 I've passed out a handout, 05:37.240 --> 05:37.490 which, 05:37.490 --> 05:38.950 if you look over briefly, 05:39.340 --> 05:40.410 um, 05:40.550 --> 05:43.330 is one of the instruments developed by Homes and 05:43.330 --> 05:46.150 Ray and I think you'll see when 05:46.150 --> 05:47.070 you look at it, 05:47.080 --> 05:49.160 that it refers to 05:49.170 --> 05:51.820 relatively universally understood series of 05:51.820 --> 05:53.160 events that may happen 05:54.020 --> 05:55.620 to any of us, 05:56.440 --> 05:59.190 even when Homes and Ray controlled for 05:59.190 --> 06:00.530 socio economic status, 06:00.540 --> 06:01.090 race, 06:01.090 --> 06:03.210 multinational effects, 06:03.640 --> 06:06.480 they were still able to show a remarkable consistency and the 06:06.480 --> 06:09.190 amount of stress that people perceive these events is 06:09.190 --> 06:09.760 causing. 06:10.540 --> 06:13.390 They've empirically assigned values to them as a 06:13.390 --> 06:14.630 result of their research. 06:14.640 --> 06:17.490 And you can note that these values are on the left 06:17.490 --> 06:19.230 hand column beside the events. 06:20.940 --> 06:21.770 Uhh, 06:21.780 --> 06:24.340 They've also used this instrument to prospectively 06:24.340 --> 06:26.930 study a wide variety of 06:26.930 --> 06:28.540 populations and patients, 06:28.540 --> 06:29.900 including cardiac patients, 06:29.900 --> 06:30.870 cancer patients, 06:30.880 --> 06:31.650 diabetics, 06:32.040 --> 06:34.860 and normal populations such as college students and 06:34.860 --> 06:35.850 naval personnel. 06:36.340 --> 06:39.120 What the results demonstrate is that for 06:39.410 --> 06:42.020 individuals who accumulate 200 or more 06:42.020 --> 06:42.610 points, 06:43.140 --> 06:43.690 Uh, 06:43.700 --> 06:46.450 during any 12-month period is significantly greater 06:46.450 --> 06:49.330 proportion of the population will develop an illness 06:49.340 --> 06:52.280 than when you compare it to populations who don't have 06:52.280 --> 06:53.580 this clustering of events. 06:54.240 --> 06:56.880 Why do some people develop illnesses a response to 06:56.880 --> 06:58.170 stress and others don't? 06:58.260 --> 06:59.660 I'll return to this in a minute. 06:59.670 --> 07:02.510 But I think it might be helpful if we briefly 07:02.510 --> 07:05.000 consider our potential transplant 07:05.000 --> 07:07.890 recipient and his family history 07:07.890 --> 07:10.860 that's not untypical for a military family would 07:10.870 --> 07:13.830 be that the mother would develop chronic renal failure, 07:13.830 --> 07:16.710 leading to the decision to place her on 07:16.710 --> 07:18.660 dialysis while awaiting transplant. 07:19.140 --> 07:22.140 She's transferred to a regional medical center and initially she 07:22.140 --> 07:23.530 and her family are separated. 07:23.540 --> 07:24.130 But finally, 07:24.140 --> 07:25.860 her husband arranges a transfer. 07:26.340 --> 07:29.000 The wife who was formerly employed is no longer able to 07:29.010 --> 07:29.360 work. 07:30.040 --> 07:32.980 The family is contacted about the possibility of donating 07:32.980 --> 07:35.830 screening proceeds and one sibling volunteers. 07:35.830 --> 07:38.460 after considerable discussion with his wife but 07:38.460 --> 07:41.460 nonetheless remains steadfast in his decision to donate 07:42.040 --> 07:43.510 his time away from his business, 07:43.510 --> 07:44.930 both for testing and finally, 07:44.930 --> 07:47.800 for the donut effectively means a loss of income for 07:47.800 --> 07:47.950 him. 07:48.840 --> 07:50.540 The recipient following transplant, 07:50.540 --> 07:53.370 which goes successfully reports upon her return home 07:53.370 --> 07:55.980 of fear and avoidance of sexual intercourse. 07:56.740 --> 07:56.970 Well, 07:56.970 --> 07:59.100 if you look at the recent life change questionnaire, 07:59.100 --> 08:01.490 I've noted down a code beside these events, 08:01.500 --> 08:02.670 which is fairly simple. 08:02.670 --> 08:05.330 Mind that are is for recipient Fs for the 08:05.330 --> 08:08.210 family members of the recipient and ideas for the donor. 08:08.940 --> 08:11.530 The events and just the events surrounding the 08:11.530 --> 08:13.950 transplant experience in the lives of these people 08:14.340 --> 08:17.050 Has already given both the recipient and the 08:17.060 --> 08:19.400 members of that family more than their quote 08:19.400 --> 08:20.120 necessary, 08:20.120 --> 08:21.520 unquote 200 points. 08:22.140 --> 08:24.780 The donor himself has also managed to accumulate almost 08:24.790 --> 08:26.790 2/3 of the necessary points. 08:28.040 --> 08:29.020 What I believe is clear, 08:29.020 --> 08:29.240 then, 08:29.240 --> 08:31.550 is that our hypothetical family 08:31.940 --> 08:34.390 does endure a stress that is real, 08:34.390 --> 08:36.440 and one that can legitimately concern us 08:37.540 --> 08:40.170 to return them to the earlier question of why do some 08:40.170 --> 08:42.890 people show an association between this 08:42.890 --> 08:45.740 clustering of events and the disease onset and 08:45.740 --> 08:46.550 others do not? 08:47.140 --> 08:47.680 Again, 08:47.680 --> 08:50.400 we can't answer this directly from the transplant literature. 08:51.340 --> 08:52.540 We can look elsewhere, 08:52.540 --> 08:52.870 though, 08:52.870 --> 08:53.030 and, 08:53.030 --> 08:53.490 for example, 08:53.490 --> 08:56.280 to the work of George Engel and his group at Rochester, 08:56.840 --> 08:59.370 who have described the complex of 08:59.370 --> 09:01.870 affects which precede the 09:01.870 --> 09:03.590 onset of illness, 09:03.880 --> 09:06.600 which they described as the given up giving 09:06.600 --> 09:08.160 up syndrome. 09:08.940 --> 09:11.870 The essential point of this concept is that in 09:11.870 --> 09:14.320 a wide variety of patients that they 09:14.320 --> 09:17.160 interviewed after the illness experience, 09:17.840 --> 09:20.060 they found that 09:21.140 --> 09:23.820 by and large the majority of these patients had an 09:23.820 --> 09:26.550 experience which was characterized by a significant loss in their 09:26.550 --> 09:26.860 life, 09:27.340 --> 09:30.230 which was described to the feeling of being given up 09:30.240 --> 09:33.190 upon or hopelessness and that was 09:33.190 --> 09:36.160 followed by a feeling of helplessness or 09:36.170 --> 09:39.150 having or they themselves giving up. 09:39.940 --> 09:42.770 They point out that this is neither necessary nor sufficient 09:42.960 --> 09:44.650 condition for illness onset, 09:45.140 --> 09:47.260 but it is significantly associated with it. 09:48.440 --> 09:50.630 Another study by knuckles at all at 09:50.640 --> 09:53.290 UNC looked at the complications of 09:53.290 --> 09:53.960 pregnancy, 09:54.840 --> 09:57.820 they administered a life change questionnaire similar to the 09:57.820 --> 10:00.450 one I've passed out and found that 10:01.000 --> 10:03.660 it of itself was not predictive of 10:03.670 --> 10:05.280 who would and would not 10:06.540 --> 10:08.550 suffer from complications of pregnancy. 10:09.140 --> 10:09.510 However, 10:09.510 --> 10:11.110 when it was combined with another instrument, 10:11.120 --> 10:14.020 which measured the social assets 10:14.030 --> 10:16.250 of the individuals in the study, 10:16.810 --> 10:19.430 the two instruments together combined to 10:19.430 --> 10:21.450 achieve significant predictive value. 10:22.140 --> 10:22.770 In other words, 10:22.770 --> 10:25.410 if we look at both the events which occur in a person's life, 10:25.410 --> 10:28.340 which require adaptation to cope successfully with 10:28.340 --> 10:28.560 them, 10:29.240 --> 10:32.190 and we look at the assets that a person has in the social, 10:32.190 --> 10:33.260 in social terms, 10:33.840 --> 10:34.670 uh, 10:34.680 --> 10:37.000 that they can rely upon for support in these 10:37.000 --> 10:37.690 situations, 10:37.690 --> 10:40.530 we begin to have a handle upon who might and who 10:40.530 --> 10:42.970 might not develop illness as a response to these 10:42.970 --> 10:43.550 events. 10:43.560 --> 10:46.550 What is meant by social assets or social supports or 10:46.550 --> 10:49.320 social adjustment or social networks 10:49.830 --> 10:52.060 in brief and simply these terms are used to 10:52.060 --> 10:54.680 describe the adequacy of various 10:54.680 --> 10:57.060 fears of a person's social world 10:57.540 --> 10:58.300 means work. 10:58.300 --> 11:01.280 It means that social leisure life and his 11:01.280 --> 11:03.050 family means his marriage, 11:03.060 --> 11:05.380 sexuality and furthermore, 11:05.380 --> 11:08.210 these are areas of a person's life that we are 11:08.210 --> 11:10.860 able to assess with instruments that are currently available. 11:11.540 --> 11:13.890 So given this assemblage of research findings, 11:13.890 --> 11:16.660 what clinical applications can we make from them? 11:17.040 --> 11:17.390 Well, 11:17.390 --> 11:19.160 one view might be to simply 11:20.040 --> 11:22.560 to develop a massive federal program 11:22.940 --> 11:25.660 to remove all the stressful events from a person's life. 11:26.340 --> 11:28.160 Obviously that's impractical. 11:28.940 --> 11:31.160 2nd view might be to ask 11:31.840 --> 11:34.330 if it's possible for us to provide 11:34.340 --> 11:37.180 temporarily increased social support for 11:37.180 --> 11:39.380 people undergoing stressful situations. 11:40.240 --> 11:40.780 Uh, 11:40.790 --> 11:41.520 for example, 11:41.620 --> 11:44.480 the death of a spouse on the homes and Ray 11:44.490 --> 11:46.860 questionnaire is the most stressful event 11:47.340 --> 11:49.870 to occur to an individual that 11:49.870 --> 11:52.810 widows and widowers often die shortly after the 11:52.820 --> 11:54.370 death of their spouses. 11:54.380 --> 11:55.360 Well known folklore, 11:55.360 --> 11:58.040 I believe that the death rate among 11:58.040 --> 12:00.550 widows and widowers uh 12:01.640 --> 12:04.570 rises far above that of a comparable non 12:04.570 --> 12:07.210 widowed population is a demonstrated research 12:07.210 --> 12:10.150 finding that widows and widowers who adapt 12:10.160 --> 12:12.770 badly to the death of their spouse 12:12.780 --> 12:14.700 have perceived their environment. 12:14.710 --> 12:17.380 And I think what we can do here is read social supports 12:17.480 --> 12:20.100 as unsatisfactory as another demonstrated 12:20.110 --> 12:22.970 finding in response to these facts, 12:22.970 --> 12:25.750 Widow the widow programs have been developed to provide increased 12:25.750 --> 12:27.060 social support to this group. 12:27.640 --> 12:28.110 Simply, 12:28.110 --> 12:30.540 they provide contact with a wide range of 12:30.540 --> 12:33.450 services for the newly widowed by previously widowed 12:33.450 --> 12:35.900 women who have successfully adapted to this 12:35.900 --> 12:36.690 experience. 12:37.240 --> 12:40.060 Do we know that such programs make a demonstrable difference? 12:40.070 --> 12:40.330 Well, 12:40.330 --> 12:41.480 anecdotally we do, 12:41.490 --> 12:44.350 but not in a rigorously tested fashion as of yet. 12:45.240 --> 12:48.200 Similar anecdotal evidence is reported for supportive 12:48.200 --> 12:50.820 programs for a variety of patients, 12:50.820 --> 12:53.170 including transplant and dialysis 12:53.170 --> 12:53.960 patients. 12:54.340 --> 12:57.330 Um The critical element though appears to 12:57.330 --> 12:59.980 be that the support is obtained from a 12:59.990 --> 13:02.810 person who is newly undergoing this stressful 13:02.810 --> 13:05.760 event from someone who has successfully 13:05.850 --> 13:08.060 adapted or coped with the situation. 13:08.060 --> 13:11.020 In the past we cannot provide families, 13:11.020 --> 13:13.290 marriages etcetera for our patients in order, 13:13.290 --> 13:14.650 they particularly require that. 13:15.340 --> 13:18.220 But what we can provide them with is a social support of these 13:18.220 --> 13:19.290 self help groups. 13:21.040 --> 13:23.780 While we await more vigorous testing of such services. 13:23.780 --> 13:26.550 Do we have any indication that providing social supports 13:26.550 --> 13:27.920 for transplant patients? 13:27.920 --> 13:29.260 Matters Well, 13:29.260 --> 13:30.160 perhaps we do. 13:30.940 --> 13:33.660 A study by Kaplan d'Honneur of seven 13:33.660 --> 13:36.180 rental units showed that even when a 13:36.180 --> 13:39.030 research team and the clinical teams 13:39.040 --> 13:41.480 agreed about the criteria for evaluating the 13:41.480 --> 13:43.430 adjustment of their patients, 13:43.440 --> 13:46.310 which were essentially three criteria compliance 13:46.310 --> 13:46.970 with diet, 13:47.290 --> 13:50.150 rehabilitation and emotional condition. 13:50.830 --> 13:53.690 There was a considerable discrepancy between groups about the 13:53.690 --> 13:54.960 actual evaluation. 13:55.440 --> 13:57.960 one Group of clinicians and the research group 13:58.640 --> 14:01.550 fairly closely agreed about their evaluations of the 14:01.560 --> 14:02.180 patients. 14:02.450 --> 14:02.970 However, 14:02.970 --> 14:05.640 another clinical group um 14:05.650 --> 14:08.320 rated their patients as doing far better 14:08.370 --> 14:10.920 than the research group did. 14:11.230 --> 14:12.360 And furthermore there, 14:12.370 --> 14:14.840 their patients were rated as not doing as well 14:15.180 --> 14:16.750 as when there was a matchup 14:17.340 --> 14:20.320 between the research and the clinical 14:20.330 --> 14:20.850 groups. 14:21.740 --> 14:22.490 So in other words, 14:22.500 --> 14:24.550 to state that again, 14:25.240 --> 14:28.230 when it appears that the clinical team 14:28.270 --> 14:30.850 was evaluating uh 14:30.860 --> 14:33.530 adequately and realistically the adjustment of their 14:33.530 --> 14:34.100 patients, 14:34.100 --> 14:36.920 their patients seem to do better than when there was an 14:36.920 --> 14:39.740 unrealistic evaluation by the clinical 14:39.740 --> 14:42.540 team and those patients did not do as 14:42.540 --> 14:42.950 well. 14:43.440 --> 14:46.430 What explanation for this are we left with there to 14:46.430 --> 14:49.020 basically one of which is that 14:49.030 --> 14:51.500 one set of clinical teams had bad patients 14:52.040 --> 14:54.870 and the fact that their patients didn't do well lead to a 14:54.870 --> 14:57.260 development of denial among the staff members. 14:58.140 --> 15:00.990 The other explanation and the one I think is more accurate 15:01.000 --> 15:03.960 is that the denial by the staff members of the 15:04.340 --> 15:06.920 accurate adjustment that their 15:06.920 --> 15:09.900 patients were making led to the patients not 15:09.900 --> 15:11.160 doing as well as they might. 15:11.840 --> 15:13.850 And it's not proven which is really the case. 15:14.160 --> 15:16.880 But other studies of the same group of patients shows that 15:16.880 --> 15:19.620 denial by the staff of their condition 15:19.620 --> 15:22.440 leads to delivery by the 15:22.440 --> 15:25.270 staff to the patients of pat reassurance and 15:25.270 --> 15:26.260 everything's gonna be okay. 15:26.260 --> 15:27.360 You don't have anything to worry about. 15:28.240 --> 15:31.140 Which in turn leads to a decreased reporting 15:31.140 --> 15:33.550 of symptoms by the patients to their doctors. 15:34.340 --> 15:35.390 This is in essence, 15:35.390 --> 15:38.210 as I see it are closing off of an important social support for these 15:38.220 --> 15:38.810 patients. 15:40.040 --> 15:40.860 In summary, 15:40.870 --> 15:43.000 I believe they have demonstrated that we have accumulated. 15:43.000 --> 15:45.510 Clinical evidence suggested that the stressful event of 15:45.520 --> 15:48.320 transplantation and lives of non psychiatric 15:48.330 --> 15:51.050 population often produces psychiatric 15:51.050 --> 15:51.360 symptom, 15:51.360 --> 15:52.050 Atallah gee. 15:52.060 --> 15:52.850 Furthermore, 15:52.850 --> 15:55.540 the stress of this event is not only isolated to the 15:55.550 --> 15:58.060 potential recipient but also includes his 15:58.060 --> 15:58.660 family. 15:59.440 --> 16:00.010 Because we, 16:00.010 --> 16:00.700 as physicians, 16:00.700 --> 16:03.180 have control of this massive intervention in the lives of our 16:03.180 --> 16:03.720 patients. 16:03.730 --> 16:06.670 It is reasonable that we assume responsibilities for 16:06.670 --> 16:09.600 Ameliorating the deleterious effects of this event as 16:09.610 --> 16:12.260 best we can to accomplish this, 16:12.260 --> 16:14.470 we can provide for our patients what they need, 16:14.480 --> 16:17.220 which in almost all cases is not massive, 16:17.230 --> 16:18.860 personality modification, 16:19.340 --> 16:22.220 but rather temporarily increased social supports to 16:22.220 --> 16:24.760 them and to their families in order to help them adapt 16:25.140 --> 16:27.010 to the stress of this series of events. 16:27.440 --> 16:30.280 Such services are easily within the means 16:30.290 --> 16:32.980 of any center providing transplant facilities. 16:33.540 --> 16:36.180 These programs do not need to be slavishly forced upon the 16:36.180 --> 16:36.750 patient's, 16:37.030 --> 16:39.840 but rather utilized as the model present in the widow. 16:39.840 --> 16:42.640 The widow programs in which a wide range of services 16:42.640 --> 16:45.350 and contact is offered to the individual, 16:45.840 --> 16:48.570 but participation and utilization is then 16:48.570 --> 16:50.460 determined by the individuals concerned 16:51.640 --> 16:54.600 psychosocial aspects of hemodialysis and 16:54.600 --> 16:56.070 kidney transplantation 16:57.940 --> 16:58.890 with peter bridge, 16:58.890 --> 16:59.280 Captain, 16:59.280 --> 16:59.970 United States, 16:59.970 --> 17:00.950 Army Medical Corps, 17:00.950 --> 17:02.300 Department of psychiatry, 17:02.300 --> 17:04.080 Np Division walter reed, 17:04.080 --> 17:07.000 Army Institute of Research walter reed Army Medical Center 17:07.000 --> 17:07.730 Washington D. 17:07.730 --> 17:08.350 C. 17:10.140 --> 17:13.020 Was produced through the mobile facilities of the television 17:13.020 --> 17:13.590 division, 17:13.760 --> 17:15.270 Academy of Health Sciences, 17:15.270 --> 17:17.810 United States Army Fort Sam Houston 17:17.810 --> 17:18.490 texas.