Patients With Terminal Chronic Liver Pathology Faced With This Disease A. López-Navas, A. Ríos, L. Martínez-Alarcón, B. Febrero, J.A. Pons, M. Miras, G. Ramis, P. Ramírez, and P. Parrilla ABSTRACT Background. “Anxious preoccupation” is a maladaptive coping strategy for patients with terminal chronic liver pathology causing psychopathologic emotional responses. The aim of this study was to identify “anxious preoccupation” as a coping strategy when faced with this disease and to investigate its relationship with emotional-type psychopathologic symptoms in patients awaiting a liver transplant (LT). Methods. A total of 63 patients awaiting an LT were evaluated. The instrument used to evaluate coping style was the Mental Adjustment to Cancer questionnaire. One of the coping scales of this questionnaire is “anxious preoccupation” (9 items). An Instrument for psychopathologic assessment was used, the SA-45 questionnaire, which assessed 9 psychopathologic dimensions: somatizations, obsessions-compulsions, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Results. “Anxious preoccupation” was used as an inadequate coping style by 51% of patients when faced with the disease. Five psychopathologic dimensions were associated with this coping strategy: 1) obsessive-compulsivity: 75% of patients with “anxious preoccupation” had obsessive-compulsivity symptoms compared with 29% of patients with other coping strategies (P < .001); 2) interpersonal sensitivity: 25% vs 6%, respectively (P ¼ .044); 3) depression: 59% vs 29% (P ¼ .015); 4) anxiety: 75% vs 32% (P ¼ .001); and 5) phobic anxiety: 19% vs 3% (P ¼ .050). Conclusions. More than one-half of the patients on the LT waiting list used “anxious preoccupation” as a coping style for this disease. This strategy was associated with a greater presence of emotional-type psychopathologic symptoms in these patients.

C

OPING STRATEGIES are “constantly changing cognitive and behavioral efforts that are developed to manage the specific external and internal demands that are assessed as being too overwhelming for the resources of an individual.”1 A coping strategy causes a specific emotional response. Faced with disease, the type of coping strategy used is crucial for the patient’s psychiatric morbidity. Therefore, it is important to evaluate and identify the different coping strategies as the disease evolves to determine the emotional alterations in patients.2 In patients with terminal chronic hepatopathies, “anxious preoccupation” is an inadequate coping strategy for the disease, which could lead to the development of psychopathologic emotional responses. The objectives of the present study were: 1) to identify “anxious preoccupation” as a coping strategy when faced with disease;

and 2) to determine its relationship with emotional type psychopathologic symptoms in patients awaiting a liver transplant (LT).

From the Department of Psychology, Catholic University of San Antonio (A.L.-N.); International Collaborative Donor Project (A.L.-N., A.R., L.M.-A., B.F., G.R., P.R.); Regional Transplant Center, Consejería de Sanidad y Consumo de la Región de Murcia (A.L.-N., A.R., L.M.-A., B.F., G.R., P.R.), Murcia, Spain; Transplant Unit, General Surgery, Virgen de la Arrixaca Universitary Hospital (A.L.-N., A.R., L.M.-A., B.F., J.A.P., M.M., P.R., P.P.); Department of Surgery (A.R., L.M.-A., B.F., P.R., P.P.), University of Murcia (G.R.), Murcia, Spain. Address reprint requests to Dr Antonio Ríos Zambudio, Avenida de la Libertad n 208, Casillas, 30007, Murcia, Spain. E-mail: [email protected]

0041-1345/13/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.11.005

ª 2013 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710

3630

Transplantation Proceedings, 45, 3630e3632 (2013)

ANXIOUS PREOCCUPATION WHILE AWAITING LIVER TRANSPLANT

MATERIAL AND METHODS Study Population The patients included in this study were on the waiting list for a LT in a transplant hospital in the southeast of Spain, with a living and deceased LT donor program.

Assessment Instrument The coping strategies questionnaire “Mental Adjustment to Cancer” (MAC) was used. It is a version adapted for the Spanish population by Ferrero et al in.1994,3,4 in which one of the scales identified is “anxious preoccupation.” This scale is measured with the use of 9 items, with 4 response options: the first 2 correspond to a negative response (disagree [1] or slightly agree [2]) and the second 2 are positive (agree [3] or strongly agree [4]). On this scale, the maximum score is 36, the minimum 9, and the cutoff point is 26 (0e26 points: no “anxious preoccupation”; 27e36: “anxious preoccupation”). The psychopathologic symptoms were assessed with the use of the SA-45 questionnaire (Derogatis, 1975),5 a Spanish version adapted by González Rivera and de las Cuevas in 19886 consisting of 45 items. Both questionnaires are self-reporting tests. However, owing to the clinical features of the patients, it was applied by a professional psychologist.

Statistical Analysis A descriptive statistical analysis (SPSS 21.0) was carried out on each of the variables, and the Student t test and c2 test were applied along with an analysis of remainders and a multivariate analysis.

RESULTS

Of the 63 patients evaluated, 78% were male, 70% had a partner, and 78% had children. Regarding educational level, 30% had no education, 41% had high school, and 29% had higher education. Thirteen percent had some form of psychopathology. The etiology of liver disease was ethanol cirrhosis in 43%, hepatitis C virus cirrhosis in 16%, ethanol with hepatocellular cirrhosis in 10%, hepatocarcinoma with hepatitis C in virus 8%; and other etiologies in 23%. Of the patients included on the LT waiting list, 51% used anxiety as a coping strategy when faced with the disease. These patients agreed with the statements of the “anxious preoccupation” dimension as follows: 1) “I am worried that the disease will come back or that the one I have will get worse”: 91%; 2) “I would like to get in contact with people who are in the same situation”: 83%; 3) “I have been doing things that I believe will improve my health (not drinking or smoking”: 75%; 4) “I have been doing things that I believe will improve my health (diet, rest, etc”: 71%; 5) “I feel a lot of anxiety due to the disease”: 59%; 6) “My health problems stop me from making plans for the future”: 54%; 7) “I find it difficult to believe that this has happened to me”: 44%; 8) “I try to obtain all the information I can about my disease”: 41%; and 9) “I am very angry about what has happened to me”: 27%. Psychopathologic alterations such as obsessivecompulsivity, interpersonal sensitivity, depression, anxiety, and phobic anxiety are associated with this coping strategy.

3631 Table 1. “Anxious Preoccupation” as a Coping Strategy in Patients on the Liver Transplant Waiting List

Age (55  9 y) Sex Male (n ¼ 49) Female (n ¼ 14) Marital status Single (n ¼ 19) Married (n ¼ 44) Have children Yes (n ¼ 49) No (n ¼ 14) Liver disease diagnosis Ethanol cirrhosis (n ¼ 27) Hepatitis C virus cirrhosis (n ¼ 16) Ethanol with hepatocellular cirrosis (n ¼ 6) Hepatocarcinoma with hepatitis C virus (n ¼ 5) Other (n ¼ 15) Alcohol abuse Yes (n ¼ 41) No (n ¼ 22) Education Without studies (n ¼ 19) Primary School (n ¼ 26) Secondary School (n ¼ 9) University studies (n ¼ 9)

No Anxious Preoccupation (49%)

Anxious Preoccupation (51%)

55  1

54  1

24 (49%) 7 (50%)

25 (51%) 7 (50%)

7 (37%) 24 (55%)

12 (63%) 20 (45%)

27 (55%) 4 (29%)

22 (45%) 10 (71%)

13 (48%) 7 (70%)

14 (52%) 3 (30%)

3 (50%)

3 (50%)

2 (40%)

3 (60%)

6 (40%)

9 (60%)

19 (46%) 12 (55%)

22 (54%) 10 (45%)

6 17 6 7

13 9 3 2

P Value

.353 .946

.197

.080

.659

.535

.032* (32%) (65%) (67%) (78%)

(68%) (35%) (33%) (22%)

*P < .05.

Seventy-five percent of patients with “anxious preoccupation” had obsessive-compulsivity symptoms compared with 29% of patients with other coping strategies (P < .001). The characteristic psychopathologic symptom of interpersonal sensitivity was present in 25% of those who used “anxious preoccupation” compared with 6% of those who did not (P ¼ .044). The same occurred with depressive (59% vs 29%; P ¼ .015) and anxious (75% vs 32%; P ¼ .001) type emotional clinical symptoms. Finally, phobic symptoms were also associated with patients who used “anxious preoccupation” as a maladaptive means of coping with the disease (19% vs 3%; P ¼ .050). Regarding age, sex, marital status, having children, liver disease diagnosis, and alcohol abuse, there were no significant differences (P > .005; Table 1). Participants whose educational level was lower than primary school showed higher anxious preoccupation than those with high level education (68% vs 22%; P ¼ .032; Table 1). In the multivariate analysis of the results, significant association was maintained between an “anxious preoccupation” type of coping strategy and the presence of obsessive-compulsivee type psychopathologic symptoms, with an odds ratio of 5.020 (P ¼ .008) and the presence of anxious-type psychopathologic symptoms, with an odds ratio of 4.094 (P ¼ .020; Table 2).

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LÓPEZ-NAVAS, RÍOS, MARTÍNEZ-ALARCÓN ET AL

Table 2. Multivariate Study: Relationship Between an “Anxious Preoccupation” Type of Coping Strategy and the Presence of Psychopathologic-Type Symptoms Variable

Regression Standard Coefficient (b) Error

Obsessive-compulsive No (n ¼ 30) Yes (n ¼ 33) 1.614 Anxious No (n ¼ 29) Yes (n ¼ 34) 1.410

Odds Ratio (9%% CI)

P Value

.008 0.604

1 5.020 (1.537e16.402)

0.606

1 4.094 (1.248e13.427)

.020

To summarize, we find ourselves with patients who, after being included on the transplant waiting list, will face stressful situations that will affect their emotional state. Faced with this situation, the assessment of emotional aspects should be an integral part of the psychologic care protocol. Therefore, we highlight the need for specific psychologic care programs for patients on the transplant waiting list with coping strategy problems.2,8e10 In conclusion, more than one-half of the patients on the LT waiting list used an “anxious preoccupation” coping strategy for dealing with the disease. This strategy is associated with a greater presence of emotional-type psychopathologic symptoms among these patients.

DISCUSSION

The coping strategy used when faced with disease determines the patient’s psychologic morbidity with psychopathologic reactions that could trigger behavioral and psychologic alterations.7,8 Therefore, an increasing number of medical teams, including transplant units, are concerned about the psychologic assessment of patients. Accordingly, the psychologic situation of the patient in the pretransplantation phase will have repercussions for the posttransplantation phase.9e11 It is well known that there is a relationship between coping strategies and psychologic morbidity and that this relationship has implications for disease prognosis, indicating the importance of evaluating the coping strategy process to identify those ways of coping that could be harmful for the patient’s clinical evolution.7 The “anxious preoccupation” coping style is characterized by being an inadequate strategy generating a negative emotional tone in the patient, especially of a depressive and anxious nature, as we observed. There is a notable association between this coping style and obsessive-compulsivee type emotional clinical symptoms, interpersonal sensitivity, depression, anxiety, and phobic anxiety. These results were consistent with the definition of “anxious preoccupation” by Watson et al,7 in which the patient reports being constantly worried about the disease, reflecting the pain or suffering, and frequently looks for relief, at the same time assessing the disease prognosis as uncertain and regarding the control of the situation with great uncertainty. In addition, it is common for patients to compulsively seek tranquilization.6

REFERENCES 1. Lazarus R, Folkman S. Stress, appraisal and coping. Martínez Roca; 1986:164e168. 2. López-Navas A, Rios A, Riquelme A, et al. Importance of introduction of a psychological care unit in a liver transplantation unit. Transplant Proc. 2010;42:302e305. 3. Greer S, Moorey S, Watson M. Patients’ adjustment to cancer: the Mental Adjustment to Cancer (MAC) scale vs clinical ratings. J Psychosom Res. 1989;33:373e377. 4. Costa-Requena G, Gil F. The Mental Adjustment to Cancer scale: a psychometric analysis in Spanish cancer patients. Psychooncology. 2009;18:984e991. 5. Derogatis, LR. Brief Symptom Inventory. Clinical Psychometric Research. 1975. Baltimore. 6. Gonzalez de Rivera JL, de las Cuevas C. Versión española del cuestionario SCL-90-R. Tenerife: Universidad de la Laguna; 1988. 7. Watson HJ, Swan A, Nathan PR. Psychiatric diagnosis and quality of life: the additional burden of psychiatric comorbidity. Compr Psychiatry. 2011;52:265e272. 8. Sandín B, Valiente R, Chorot P, et al. SA-45: forma abreviada del SCL-90. Psicothema. 2008;20:290e296. 9. Mejías D, Ramírez P, Ríos A, et al. Recurrence of alcoholism and quality of life in patients with alcoholic cirrhosis following liver transplantation. Transplant Proc. 1999;31:2472e2474. 10. Ríos A, Ramírez P, Rodríguez MM, et al. Attitude of hospital personnel faced with living liver donation in a Spanish center with a living donor liver transplant program. Liver Transplant. 2007;13:1049e1056. 11. PérezeSan Gregorio MA, Martín-Rodriguez A, AsiánChávez E, et al. Psychopathological features in transplant patients. Transplant Proc. 2003;35:744e755.

Patients with terminal chronic liver pathology faced with this disease.

"Anxious preoccupation" is a maladaptive coping strategy for patients with terminal chronic liver pathology causing psychopathologic emotional respons...
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