Brit. 3. Psychiat. (ig@), 127, 588—90
Psychological
Aspects of Isolator By ALISTAIR
Summary.
Treatment
under
the stress of adaptation
Therapy
in Acute Leukaemia
M. GORDON
conditions
of gnotobiotic
to a diagnosis of leukaemia.
isolation
can augment
Identification
of the psycho
logical problems experienced in isolator treatment can contribute to the effective maintenance of therapy. Individual patterns of adjustment to treatment relate to
the psychological
defence mechanisms
position
by isolation.
enforced
employed to contend with the dependent
Psychiatric
and nursing staff with the management familiar
treatment
situation.
assessment
can assist both
of their separate
Psychological
features
of isolator
treatment
patients with acute leukaemia are described and suggestions psychological management of patients under isolator conditions.
INTRODUCTION
reversed
AND METHOD
Isolation systems which provide a protected environment reduce the incidence of exogenous infection
in various
medical
situations
: cytotoxic
therapy, organ transplants, burns, immune disease and radiation injury. The two basic designs
are
the
cubicle
isolator
plastic
tent
with
laminar
isolator
and
airflow.
the
Such
systems can create problems for patients in adaptation to a complex mechanical environ
ment. This study examines psychological of gnotobiotic
isolation
treatment
aspects
in patients
barrier
nursing.
patients
by
means
of
articles
anxiety on entry, strictures of barrier resolved quickly,
though two patients experienced panic reac tions with feelings of claustrophobia. Anxiety tended to recur at times of physical deteriora
diagnosis
assessed
for
All food and
munication. All patients expressed aggravated by the preceding nursing. Anxiety usually
ton. Women adapted routine which accorded
were
in ten
proposed
are gamma-irradiated. The patient has a regular daily programme, including physio therapy. Flexible visiting arrangements and a private telephone encourage external corn
with acute leukaemia. Over a two year period, TO patients with acute leukaemia (@ men and 7 women, age range 20—58years) were treated in isolators in 12 treatment periods totalling 516 days (range 21—99days). All patients knew their and
patients
difficulties in this un
activities. Restriction
more easily to the daily more with their habitual
in mobility limited physi
cal release of tension. The predominant com plaints concerned the monotony of the routine
and the unpalatability could sustain
of irradiated sufficient
food. Few
stimulation
from
psychiatric interview at regular intervals throughout treatment. Objective psychometric measures that might reinforce the experimental impression of isolator treatment were not attempted.
their own interests to relieve boredom, and the taste of favourite foods was distorted. However, no patient requested termination of treatment, and all expressed willingness to accept future readmission if necessary.
R@suL1's Effects of isolator routine
Effects of isolation
tent
Despite physical barriers no patient described increased social isolation during treatment, and
enclosing a bed and service hatch. Entry to the isolator is preceded by a 72-hour period of
social rapport with staff and relatives was maintained. Four patients expressed awareness
The
isolator
is an impervious
plastic
@88
BY ALISTAIR
of their use of isolation to withdraw from corn munication, a familiar psychological feature in fatal illness. Alteration in sensory input in the isolator was not associated with any consistent reaction, such as the ‘¿hypnoid' syndrome,
589
M. GORDON
DIscussIoN
Patients
found isolator treatment
less daunt
ing than they had anticipated. Fears of social isolation were not realized, staff contact could
be maintained
and controlled
though ‘¿touching' behaviour commonly followed
and the burdens
ofmonotony,
discharge.
and loss offamiliar pleasures could be tolerated. Despite overall acceptance, psychological equa
Confusional
states
occurred
only
in
the terminal stages of illness in three patients. Patients' attitudes toward the significance of isolator therapy shifted from pessimism before entry to optimism during treatment. All patients briefly experienced renewed anxiety on discharge, most marked in patients with the longest treatment. Increasing length of treatment was associated with increasing tolerance of isolation. Psychological patterns of rm@ction Psychological
reactions
to the combined
ofpotentiallyfatalillness
stress
and isolation fluctuated
nimity
was
often
tenuously
vioural disturbances, emotional withdrawal, criticisms
of
to some degree, restricted
preserved.
such brief
treatment
Beha
as social and mood changes,
and
antagonism
staff indicated
the stress of adaptation
and
Previous
isolation.
mobility
patterns
to
to illness
of reaction
to
stress were helpful predictors of response to isolation. A tendency to strive for autonomy characterized the manic defence group but not the regressive group. Complex apparatus which alters staff-patient contact can augment the tension experienced by
throughout treatment, but major defence mechanisms used to preserve equanimity emerged in every patient. Seven manifested a
staff in a unit for serious illness. Nurses
variety of manic defence, acknowledging
patients who test staff involvement by striving for independence or withdrawing co-operation. Staffwho meet patients' demands with reasoned consideration establish easier rapport than those who rely on isolator routine to defend them selves from anxiety. Psychiatric assessment can help to identify patients who might tolerate isolation poorly.
diagnosis,
attempting
to master
and
their control
the outcome of illness and expressing omni potent beliefs in survival. Three manifested a regressional defence, denying their diagnosis, complying passively with therapy and retreating from social contact and emotional expression. Successful
adaptation
patients yielding
to
isolation
to sustain active co-operation independence. The regressive
requires
while group
adapted more readily to the dependent position, proved less challenging in nursing management
and were able to maintain bility
for self care.
The
the required responsi manic
defence
group,
initially appreciative of the opportunity for participation in treatment, soon recognized their limited independence, struggled with stafffor controlof treatment,and were vulner
able to paranoid feelings and inclined to project their hostility. Sustained disturbances of mood were not apparent, and no patient developed affective disturbance
requiring
pharmacological
treat
ment or disrupting therapy. Two patients had a history of neurotic illness, but previous psy chiatric
illness did not emerge
tion to isolator therapy.
as a contraindica
a familiar patient,
Although
role with
but
are
vulnerable
previous
establish
the dependent
isolated
to criticism
psychological
from
disturbance
would not appear to contraindicate isolator therapy, the practical difficulties of managing psychotic illness could disrupt treatment. The patient with a manic defence to illness has an understandable appeal to many physicians. A psychiatrist can alert staff to the problems of managing
the
manic
defended
patient
and
indicate that the apathetic withdrawal of the regressed patient may prove less problematical. Discussion
with
medical
and
nursing
staff can
increase awareness of adaptive behaviour and assist with fluctuations in staff-patient rapport. Supportive psychotherapy appears more valuable than psychotropic drugs in improving patients' capacity to cope with both illness and treatment, but anxiolytic drugs can be beneficial on entry, on discharge and at times of physical deterioration. It is important for the psychiatrist
59°
PSYCHOLOGICAL
ASPECTS
OF ISOLATOR
to encourage the counselling skills of team members in closest contact with the patient and
to avoid
assuming
dominance
in psycho
logical support. Psychological difficulties in leukaemia patients during isolator therapy relate primarily to the stress of adjustment to their diagnosis but the isolator situation can accentuate disturbance. Effective management involves consideration of the psychological challenges which isolator therapy creates.
THERAPY
IN ACUTE
HOLLAND, J., HARRIS, S., PLUMB, M. et al. (@7o) Psycho
logical aspects ofphysical barrier isolation. Proceedings ofthe XIII Inter,mtionalCongressofHaematolog@,Munich. JAMESON,B., G@ssLE, D. R., LYNCH, J. & KAY, H. E. M. (‘97') Five-year analysis of protective isolation. Lancet, i, 1034. K0ISLE, K., SwoNs, C., WEmucIs, S. et al. (1971) Psycho logical aspects in the treatment of leukaemia patients in
the
isolated-bed
The author is indebted to Dr. John Goldman and the staff
of
the
M.R.C.
Leukaemia
Unit,
‘¿LifeIsland'.
P@ychother.
LEVINE, A. S., SIEGEL,J. E., SCHREIBER, A. D. et al. (i@7@) Protected environments and prophylactic anti
biotics. NewEng.J. Med., 288, 477. M. & TowREs,
(laminar) flow ventilation Lancet, i, 347. PLANr@,
Hamxnersmith
system
Psychosom.,19, 85.
LIDWELL, 0. ACKNOWLEDGEMENTS
LEUKAEMIA
W.
Z.
& PERRY,
A. G. (1972)
Unindirectional
system for patient 5.
(i@7o)
isolation.
Portable
laminar
air-flow isolator. Lancet, i, 174.
Hospital for their assistance.
ROBERTSON,
A.
C.,
Lv@cu,J.,
KAY,
H.
E.
M.
et al.
(i968)
Design and use of plastic tents for isolation of patients REFERENCES
prone to infection.
FIME, L., WACHSPRESS,M., GRAUBERT, D. et al. (ig6g) Psychological adaptation of patients during treat
ment of acute leukaemia in life island isolator. In Advances in Experithental Medicine and Biology, Vol.
Plenum Press.
Alistair M. Gordon,
3.
Lancet, ii, 1376.
TREXLER, P. C. (i97@) An isolator
system
for the mainte
nanceofaseptic environments. Lancet, i,9!. Zisiwm,E. (ig6@)An explanation ofmentalsymptoms found in acute sensory deprivation. Amer.J. Psychiat., 121, 939.
M.PhII., M.R.C.P., M.R.C.PSyCh.,Department of Psychological Medicine, Royal Post
graduateMedicalSchool;now SeniorLecturer, DepartmentofPsychiatry, St.Mary's Hospital, Harrow
Road, London, W.9 (Received i8 February 1975)
Psychological Aspects of Isolator Therapy in Acute Leukaemia ALISTAIR M. GORDON BJP 1975, 127:588-590. Access the most recent version at DOI: 10.1192/bjp.127.6.588
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/127/6/588#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;127/6/588 http://bjp.rcpsych.org/ on May 18, 2017 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
Psychological
Aspects of Isolator By ALISTAIR
Summary.
Treatment
under
the stress of adaptation
Therapy
in Acute Leukaemia
M. GORDON
conditions
of gnotobiotic
to a diagnosis of leukaemia.
isolation
can augment
Identification
of the psycho
logical problems experienced in isolator treatment can contribute to the effective maintenance of therapy. Individual patterns of adjustment to treatment relate to
the psychological
defence mechanisms
position
by isolation.
enforced
employed to contend with the dependent
Psychiatric
and nursing staff with the management familiar
treatment
situation.
assessment
can assist both
of their separate
Psychological
features
of isolator
treatment
patients with acute leukaemia are described and suggestions psychological management of patients under isolator conditions.
INTRODUCTION
reversed
AND METHOD
Isolation systems which provide a protected environment reduce the incidence of exogenous infection
in various
medical
situations
: cytotoxic
therapy, organ transplants, burns, immune disease and radiation injury. The two basic designs
are
the
cubicle
isolator
plastic
tent
with
laminar
isolator
and
airflow.
the
Such
systems can create problems for patients in adaptation to a complex mechanical environ
ment. This study examines psychological of gnotobiotic
isolation
treatment
aspects
in patients
barrier
nursing.
patients
by
means
of
articles
anxiety on entry, strictures of barrier resolved quickly,
though two patients experienced panic reac tions with feelings of claustrophobia. Anxiety tended to recur at times of physical deteriora
diagnosis
assessed
for
All food and
munication. All patients expressed aggravated by the preceding nursing. Anxiety usually
ton. Women adapted routine which accorded
were
in ten
proposed
are gamma-irradiated. The patient has a regular daily programme, including physio therapy. Flexible visiting arrangements and a private telephone encourage external corn
with acute leukaemia. Over a two year period, TO patients with acute leukaemia (@ men and 7 women, age range 20—58years) were treated in isolators in 12 treatment periods totalling 516 days (range 21—99days). All patients knew their and
patients
difficulties in this un
activities. Restriction
more easily to the daily more with their habitual
in mobility limited physi
cal release of tension. The predominant com plaints concerned the monotony of the routine
and the unpalatability could sustain
of irradiated sufficient
food. Few
stimulation
from
psychiatric interview at regular intervals throughout treatment. Objective psychometric measures that might reinforce the experimental impression of isolator treatment were not attempted.
their own interests to relieve boredom, and the taste of favourite foods was distorted. However, no patient requested termination of treatment, and all expressed willingness to accept future readmission if necessary.
R@suL1's Effects of isolator routine
Effects of isolation
tent
Despite physical barriers no patient described increased social isolation during treatment, and
enclosing a bed and service hatch. Entry to the isolator is preceded by a 72-hour period of
social rapport with staff and relatives was maintained. Four patients expressed awareness
The
isolator
is an impervious
plastic
@88
BY ALISTAIR
of their use of isolation to withdraw from corn munication, a familiar psychological feature in fatal illness. Alteration in sensory input in the isolator was not associated with any consistent reaction, such as the ‘¿hypnoid' syndrome,
589
M. GORDON
DIscussIoN
Patients
found isolator treatment
less daunt
ing than they had anticipated. Fears of social isolation were not realized, staff contact could
be maintained
and controlled
though ‘¿touching' behaviour commonly followed
and the burdens
ofmonotony,
discharge.
and loss offamiliar pleasures could be tolerated. Despite overall acceptance, psychological equa
Confusional
states
occurred
only
in
the terminal stages of illness in three patients. Patients' attitudes toward the significance of isolator therapy shifted from pessimism before entry to optimism during treatment. All patients briefly experienced renewed anxiety on discharge, most marked in patients with the longest treatment. Increasing length of treatment was associated with increasing tolerance of isolation. Psychological patterns of rm@ction Psychological
reactions
to the combined
ofpotentiallyfatalillness
stress
and isolation fluctuated
nimity
was
often
tenuously
vioural disturbances, emotional withdrawal, criticisms
of
to some degree, restricted
preserved.
such brief
treatment
Beha
as social and mood changes,
and
antagonism
staff indicated
the stress of adaptation
and
Previous
isolation.
mobility
patterns
to
to illness
of reaction
to
stress were helpful predictors of response to isolation. A tendency to strive for autonomy characterized the manic defence group but not the regressive group. Complex apparatus which alters staff-patient contact can augment the tension experienced by
throughout treatment, but major defence mechanisms used to preserve equanimity emerged in every patient. Seven manifested a
staff in a unit for serious illness. Nurses
variety of manic defence, acknowledging
patients who test staff involvement by striving for independence or withdrawing co-operation. Staffwho meet patients' demands with reasoned consideration establish easier rapport than those who rely on isolator routine to defend them selves from anxiety. Psychiatric assessment can help to identify patients who might tolerate isolation poorly.
diagnosis,
attempting
to master
and
their control
the outcome of illness and expressing omni potent beliefs in survival. Three manifested a regressional defence, denying their diagnosis, complying passively with therapy and retreating from social contact and emotional expression. Successful
adaptation
patients yielding
to
isolation
to sustain active co-operation independence. The regressive
requires
while group
adapted more readily to the dependent position, proved less challenging in nursing management
and were able to maintain bility
for self care.
The
the required responsi manic
defence
group,
initially appreciative of the opportunity for participation in treatment, soon recognized their limited independence, struggled with stafffor controlof treatment,and were vulner
able to paranoid feelings and inclined to project their hostility. Sustained disturbances of mood were not apparent, and no patient developed affective disturbance
requiring
pharmacological
treat
ment or disrupting therapy. Two patients had a history of neurotic illness, but previous psy chiatric
illness did not emerge
tion to isolator therapy.
as a contraindica
a familiar patient,
Although
role with
but
are
vulnerable
previous
establish
the dependent
isolated
to criticism
psychological
from
disturbance
would not appear to contraindicate isolator therapy, the practical difficulties of managing psychotic illness could disrupt treatment. The patient with a manic defence to illness has an understandable appeal to many physicians. A psychiatrist can alert staff to the problems of managing
the
manic
defended
patient
and
indicate that the apathetic withdrawal of the regressed patient may prove less problematical. Discussion
with
medical
and
nursing
staff can
increase awareness of adaptive behaviour and assist with fluctuations in staff-patient rapport. Supportive psychotherapy appears more valuable than psychotropic drugs in improving patients' capacity to cope with both illness and treatment, but anxiolytic drugs can be beneficial on entry, on discharge and at times of physical deterioration. It is important for the psychiatrist
59°
PSYCHOLOGICAL
ASPECTS
OF ISOLATOR
to encourage the counselling skills of team members in closest contact with the patient and
to avoid
assuming
dominance
in psycho
logical support. Psychological difficulties in leukaemia patients during isolator therapy relate primarily to the stress of adjustment to their diagnosis but the isolator situation can accentuate disturbance. Effective management involves consideration of the psychological challenges which isolator therapy creates.
THERAPY
IN ACUTE
HOLLAND, J., HARRIS, S., PLUMB, M. et al. (@7o) Psycho
logical aspects ofphysical barrier isolation. Proceedings ofthe XIII Inter,mtionalCongressofHaematolog@,Munich. JAMESON,B., G@ssLE, D. R., LYNCH, J. & KAY, H. E. M. (‘97') Five-year analysis of protective isolation. Lancet, i, 1034. K0ISLE, K., SwoNs, C., WEmucIs, S. et al. (1971) Psycho logical aspects in the treatment of leukaemia patients in
the
isolated-bed
The author is indebted to Dr. John Goldman and the staff
of
the
M.R.C.
Leukaemia
Unit,
‘¿LifeIsland'.
P@ychother.
LEVINE, A. S., SIEGEL,J. E., SCHREIBER, A. D. et al. (i@7@) Protected environments and prophylactic anti
biotics. NewEng.J. Med., 288, 477. M. & TowREs,
(laminar) flow ventilation Lancet, i, 347. PLANr@,
Hamxnersmith
system
Psychosom.,19, 85.
LIDWELL, 0. ACKNOWLEDGEMENTS
LEUKAEMIA
W.
Z.
& PERRY,
A. G. (1972)
Unindirectional
system for patient 5.
(i@7o)
isolation.
Portable
laminar
air-flow isolator. Lancet, i, 174.
Hospital for their assistance.
ROBERTSON,
A.
C.,
Lv@cu,J.,
KAY,
H.
E.
M.
et al.
(i968)
Design and use of plastic tents for isolation of patients REFERENCES
prone to infection.
FIME, L., WACHSPRESS,M., GRAUBERT, D. et al. (ig6g) Psychological adaptation of patients during treat
ment of acute leukaemia in life island isolator. In Advances in Experithental Medicine and Biology, Vol.
Plenum Press.
Alistair M. Gordon,
3.
Lancet, ii, 1376.
TREXLER, P. C. (i97@) An isolator
system
for the mainte
nanceofaseptic environments. Lancet, i,9!. Zisiwm,E. (ig6@)An explanation ofmentalsymptoms found in acute sensory deprivation. Amer.J. Psychiat., 121, 939.
M.PhII., M.R.C.P., M.R.C.PSyCh.,Department of Psychological Medicine, Royal Post
graduateMedicalSchool;now SeniorLecturer, DepartmentofPsychiatry, St.Mary's Hospital, Harrow
Road, London, W.9 (Received i8 February 1975)
Psychological Aspects of Isolator Therapy in Acute Leukaemia ALISTAIR M. GORDON BJP 1975, 127:588-590. Access the most recent version at DOI: 10.1192/bjp.127.6.588
References Reprints/ permissions You can respond to this article at Downloaded from
This article cites 0 articles, 0 of which you can access for free at: http://bjp.rcpsych.org/content/127/6/588#BIBL To obtain reprints or permission to reproduce material from this paper, please write to [email protected] /letters/submit/bjprcpsych;127/6/588 http://bjp.rcpsych.org/ on May 18, 2017 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/site/subscriptions/
