EDITORIAL
NORMAN B. LEVY, M.D.
Psychological sequelae to hemodialysis The patient maintained on hemodialysis is in an unusual position. Resuscitated from being near-death, the patient feels gratitude, but that feeling often gives way to dissatisfaction. In addition to the stress of chronic illness, hemodialysis patients have additional ones associated with this unusual therapy. Physically, they are never the same as they were prior to their illness and its treatment. They are intermittently uremic and prone to many complications such as secondary hyperparathyroidism; and they are chronically anemic with hematocrits in the range of 18 to 23. In the words of a physician-patient, "I cannot remember the last time ... that I felt really fit. There are definite limitations imposed on me, either by treatment itself, or by the state of my health: I cannot function as well as I would like to. My fatigue threshold, although not as low as that of some other dialysis patients, is lower than I would wish."1 Unlike most patients with chronic illnesses, patients undergoing hemodialysis have unique stresses that concern problems of dependency. In no other treatment development since that of the artificial external resspirator for bulbar poliomyelitis has such a large group of people been so abjectly dependent upon a procedure, a machine, and a group of professional personnel. Patients who have been very independent prior to their illness must accede to a treatment that runs counter to their personality; and at the other extreme of the dependency-independency spectrum are those who are very dependent, who find "enjoyment" in regressiveness, making rehabilitation difficult. JUNE 1978 • VOL 19 • NO 6
The treatment itself is unique; the patient's blood flows continually for a six-hour period, three times a week, through a complicated set of tubes and gauges, with bells monitoring leakage and other potential complications. Nurses and other professional staff scurry around answering alarms, doing venipunctures, hanging bottles of blood or other fluids, and monitoring for and rectifying mishaps. Although home dialysis usually occurs in a more tranquil setting than that of a medical center, the patient is constantly aware there that an unattended blood line disconnection or other mishap could result in death or varying degrees of morbidity. Illustrative of one person's response to this stress is this patient: "A 21-year-old college student showed all behavioral signs of anxiety by having in operation his radio and television set and by writing letters, all at the same time."2 In response to these multiple stresses, there are many psychologic complications, as well, among patients maintained on hemodialysis. Depression Depression is a response to loss-real, threatened, or fantasied. Patients maintained on hemodialysis have usually suffered a job loss or marked reduction in work, household, or school activity, often connected to a loss of financial security as well. There is usually a major loss of strength and stamina, and a loss in sexual activity, personal freedom and, most importantly, a reduction in life expectancy. It is therefore not surprising that depression has been termed "the most frequent 329
EDITORIAL psychological complication of hemodialysis.") It is often seen in these patients in association with a wide variety of problems, among which are medical complications and problems relating to work, as well as sexual and marital difficulties. Suicidal behavior Suicide is not uncommon among patients on hemodialysis, either by overt act, covertly through dietary indiscretion, or by voluntary withdrawal from hemodialysis programs. In.a study of personality characteristics of deceased patients contrasted with those of 21 survivors, a 42% incidence of suicidal threats was found in both groupS.4 However, among the survivors only 7% had made suicide attempts, whereas 42% of the deceased patients had made them. The most definitive study of suicidal behavior remains that of Abram and his associates,S who sent questionnaires to 201 dialysis centers throughout the United States. Their results, based on 3,478 patients living or dead, showed that the incidence of suicide is 100 times that of the national suicide rate of to per 100,000. When they included deaths due to abandonment of treatment regimen as suicide, the rate was 400 times greater. However, since the national suicide statistics are inaccurate and incorrectly low, the figures of 100 and 400 times are also incorrect. But ~t is safe to conclude from these data that suicide is much greater in hemodialysis patients than in the general population, a conclusion that is probably also true for other groups of patients with chronic illnesses. Unfortunately, there is little data with which to compare tttese statistics. Uncooperativeness Adhering tQ the medical regimen, in which there is strict dietary and fluid restriction, is an arduous task. For the very independent patient there may be great need to deny dependency upon machine, personnel, and procedure. Such denial may take the form of failure to adhere to t~e medical regimen, especially the diet, or missed dialysis runs, both ways of refuting this dependency. These patients see themselves in sharp contrast not only with physically normal people but also with ~he way they were prior to becoming ill. The resulting anger and dissatisfaction they often feel may be directed toward available medical personnel, espe3JO
cially hemodialysis nurses, who frequently end up bearing the brunt of such frustrations. 6,7 Sexual problems Patients maintained on hemodialysis have, in general, marked reduction in interest and ability to perform sexual intercourse. This conclusion has been documented by a number ofstudies.4.8.9 Among men, sexual difficulties reflect themselves chiefly in impotence, the inability to get or maintain an erection. Among women there is disinterest in having, and diminution in frequency of, orgasm during sexual intercourse.9 Although some of the reasons for this dysfunction are apparent, others remain uncertain. There are, of course, physical reasons for sexual dysfunction: these are patients who are chronically anemic and sick, and the diminution of sexual interest and ability may reflect simply that. In addition, there are endocrinologic changes that may, in part, explain some of the sexual dysfunction, especially in men. Low blood zinc,1O low testosterone levels,1I and elevated parathormone levels l2 seem to be implicated, as are antihypertensive medications that may cause impotence. Psychologically, there are many reasons why these patients may have sexual dysfunction. End-stage kidney disease, which strikes twice as many men as it does women, often results in its victims' being considered permanently disabled, for two disparate reasons: the harsh realities of their condition, and the benefits accruing from Social Security payments. In a household in which the male is unable to work and therefore is home most of the day, with the woman of the house often assuming some financial responsibility by working, the male patient often participates more in household activity. Among men whose masculine identity is tenuous, such role reversal may produce sexual dysfunction. The process of urination in the male involves his use of his sex organ for this activity a few times a day. With uremia, there is usually complete cessation of urination. The disuse of the male sex organ for its urinary activity may be confused intrapsychically with its sexual function, especially in those men whose masculinity is not firmly established. 13•14 Depression, the most common psychologic difficulty of these patients, may also have sexual dysfunction as a physical concomitant. PSYCHOSOMATICS
Therapeutic considerations The liaison physician has a potentially important role in the care of patients maintained on hemodialysis. These people need counseling prior to acceptance in the program in order to prepare them for the psychologic problems that may ensue. For example, because impotence is present in about 70% of male patients, defining it prior to the patient's even starting hemodialysis as a possible complication may have therapeutic value. Having already learned the possibility of this problem, the patient will usually feel freer to discuss it with his physician should it occur. The liaison physician also has an important role in monitoring psychologic complications and treating them. Although psychotherapy, in the usual use of the term, is rarely an acceptable form of treatment among these patients, who already feel "over-doctored," at times it may be feasible. 14 Psychotropic medication often has a role in therapy. However, drugs that are excreted by the kidney or which are dialyzable should
not be used. Fortunately, most of the psychologically active medications do not fall into this prohibited area: significant exceptions are lithium and the minor tranquilizers. The phenothiazines and tricyclic antidepressants can be used. With depression as common as it is, the antidepressants have a potentially important role and should probably be used more widely. For sexual dysfunctions, in addition to therapy for the depression, consideration should be given to the new behavioral techniques such as those described by Masters and Johnson. Their potential usefulness for hemodialysis patients is currently being explored}S Thus, the psychologically attuned professional person can playa major therapeutic role that may notably improve the quality of life for these patients. 16•'7 0 Dr. Levy is an associate professor of psychiatry at the State University ofNew York Downstate Medical Center, Brooklyn, New York. Reprint requests to him, Box 127, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY H203.
REFERENCES 1. Eady RAJ: Why I have not had a kidney transplant after nine and ona-ha~ years as a hemodialysis patient. Transplant Proc 5: 115,
7.
1973. 2. Reichsrnan F, Levy NB: Problems in adaptation to hemodialysis: A four-year study of 25 patients. Arch Intern Med 130:859.1972. 3. Lefebre P. Nobert A, Crombez JC: Psychological and psychopathological reactions in relation to chronic hemodialysis. Can Psychiat Assoc J 17:9, 1972. 4. Foster FG, Cohn GL, McKegney FP: Psychobiologic factors and individual survival on chronic renal hemodialysis: A two-year follow-up, part 1. Psychosom Med 35:64, 1973. 5. Abram HS. Moore GI. Westervelt FB Jr: Suicidal behavior in chronic dialysis patients. Am J Psychiatry 127:1199,1971. 6. Levy NB: The role of the hemodialysis nurses
JUNE 1978 • VOL 19 • NO 6
8. 9.
10.
in patients' psychological adjustment. JAANNT1:13,1973. Levy NB: The psychology and care 01 the center hemodialysis patient. Heart and Lung: J Crit Care 2:400.1973. Abram HS, Hester LR, Epstein BA, et al: Sexual functioning in patients with chronic renal failure. J Nerv Ment Dis 110:220, 1975. Levy NB: Sexual adjustment to maintenance hemodialysis and renal transplantation: National survey by questionnaire. Trens Am Soc Artif Intern Organs 11:138, 1973. Antoniou LO, Sudhakar I. Shalhoub RJ. et al: Reversal of uremic impotence by zinc. Lancet
2:895. 1977. 11. Lim SI/. Auletta F, Kathpolia S: Gonadal dysfunction in chronic renal failure: An endocrinologic review. Dialysis and Transplantation, in press.
12. Massry 00, Goldstein OA, Procci WR, et al: Impotence in patients with uramia: A possible role for parathyroid hormone. Nephron
11:305. 1977. 13. Kaplan De-Nour A: Some notes on the pS\Ichological significance of urination. J Nerv Ment Dis 148:615,1969. 14. Levy NB: Psychological studies at the Downstate Medical Center of patients on hemodialysis. Med Clin North Am 11: 759. 1977. 15. McKevitt P: Treating ~xual dysfunctions in dialysis and transplant patients. Health Soc Work 1:133,1976. 16. Levy NB. Wynbrandt GO: The quality of life on maintenance hemodialysis. Lancet 1: 1328.
1975. 17. Levy NB (ad): Living or Dying: Adaptation to Hemodialysis. Springfield. III, Charles C
Thomas. 1974.
331
NORMAN B. LEVY, M.D.
Psychological sequelae to hemodialysis The patient maintained on hemodialysis is in an unusual position. Resuscitated from being near-death, the patient feels gratitude, but that feeling often gives way to dissatisfaction. In addition to the stress of chronic illness, hemodialysis patients have additional ones associated with this unusual therapy. Physically, they are never the same as they were prior to their illness and its treatment. They are intermittently uremic and prone to many complications such as secondary hyperparathyroidism; and they are chronically anemic with hematocrits in the range of 18 to 23. In the words of a physician-patient, "I cannot remember the last time ... that I felt really fit. There are definite limitations imposed on me, either by treatment itself, or by the state of my health: I cannot function as well as I would like to. My fatigue threshold, although not as low as that of some other dialysis patients, is lower than I would wish."1 Unlike most patients with chronic illnesses, patients undergoing hemodialysis have unique stresses that concern problems of dependency. In no other treatment development since that of the artificial external resspirator for bulbar poliomyelitis has such a large group of people been so abjectly dependent upon a procedure, a machine, and a group of professional personnel. Patients who have been very independent prior to their illness must accede to a treatment that runs counter to their personality; and at the other extreme of the dependency-independency spectrum are those who are very dependent, who find "enjoyment" in regressiveness, making rehabilitation difficult. JUNE 1978 • VOL 19 • NO 6
The treatment itself is unique; the patient's blood flows continually for a six-hour period, three times a week, through a complicated set of tubes and gauges, with bells monitoring leakage and other potential complications. Nurses and other professional staff scurry around answering alarms, doing venipunctures, hanging bottles of blood or other fluids, and monitoring for and rectifying mishaps. Although home dialysis usually occurs in a more tranquil setting than that of a medical center, the patient is constantly aware there that an unattended blood line disconnection or other mishap could result in death or varying degrees of morbidity. Illustrative of one person's response to this stress is this patient: "A 21-year-old college student showed all behavioral signs of anxiety by having in operation his radio and television set and by writing letters, all at the same time."2 In response to these multiple stresses, there are many psychologic complications, as well, among patients maintained on hemodialysis. Depression Depression is a response to loss-real, threatened, or fantasied. Patients maintained on hemodialysis have usually suffered a job loss or marked reduction in work, household, or school activity, often connected to a loss of financial security as well. There is usually a major loss of strength and stamina, and a loss in sexual activity, personal freedom and, most importantly, a reduction in life expectancy. It is therefore not surprising that depression has been termed "the most frequent 329
EDITORIAL psychological complication of hemodialysis.") It is often seen in these patients in association with a wide variety of problems, among which are medical complications and problems relating to work, as well as sexual and marital difficulties. Suicidal behavior Suicide is not uncommon among patients on hemodialysis, either by overt act, covertly through dietary indiscretion, or by voluntary withdrawal from hemodialysis programs. In.a study of personality characteristics of deceased patients contrasted with those of 21 survivors, a 42% incidence of suicidal threats was found in both groupS.4 However, among the survivors only 7% had made suicide attempts, whereas 42% of the deceased patients had made them. The most definitive study of suicidal behavior remains that of Abram and his associates,S who sent questionnaires to 201 dialysis centers throughout the United States. Their results, based on 3,478 patients living or dead, showed that the incidence of suicide is 100 times that of the national suicide rate of to per 100,000. When they included deaths due to abandonment of treatment regimen as suicide, the rate was 400 times greater. However, since the national suicide statistics are inaccurate and incorrectly low, the figures of 100 and 400 times are also incorrect. But ~t is safe to conclude from these data that suicide is much greater in hemodialysis patients than in the general population, a conclusion that is probably also true for other groups of patients with chronic illnesses. Unfortunately, there is little data with which to compare tttese statistics. Uncooperativeness Adhering tQ the medical regimen, in which there is strict dietary and fluid restriction, is an arduous task. For the very independent patient there may be great need to deny dependency upon machine, personnel, and procedure. Such denial may take the form of failure to adhere to t~e medical regimen, especially the diet, or missed dialysis runs, both ways of refuting this dependency. These patients see themselves in sharp contrast not only with physically normal people but also with ~he way they were prior to becoming ill. The resulting anger and dissatisfaction they often feel may be directed toward available medical personnel, espe3JO
cially hemodialysis nurses, who frequently end up bearing the brunt of such frustrations. 6,7 Sexual problems Patients maintained on hemodialysis have, in general, marked reduction in interest and ability to perform sexual intercourse. This conclusion has been documented by a number ofstudies.4.8.9 Among men, sexual difficulties reflect themselves chiefly in impotence, the inability to get or maintain an erection. Among women there is disinterest in having, and diminution in frequency of, orgasm during sexual intercourse.9 Although some of the reasons for this dysfunction are apparent, others remain uncertain. There are, of course, physical reasons for sexual dysfunction: these are patients who are chronically anemic and sick, and the diminution of sexual interest and ability may reflect simply that. In addition, there are endocrinologic changes that may, in part, explain some of the sexual dysfunction, especially in men. Low blood zinc,1O low testosterone levels,1I and elevated parathormone levels l2 seem to be implicated, as are antihypertensive medications that may cause impotence. Psychologically, there are many reasons why these patients may have sexual dysfunction. End-stage kidney disease, which strikes twice as many men as it does women, often results in its victims' being considered permanently disabled, for two disparate reasons: the harsh realities of their condition, and the benefits accruing from Social Security payments. In a household in which the male is unable to work and therefore is home most of the day, with the woman of the house often assuming some financial responsibility by working, the male patient often participates more in household activity. Among men whose masculine identity is tenuous, such role reversal may produce sexual dysfunction. The process of urination in the male involves his use of his sex organ for this activity a few times a day. With uremia, there is usually complete cessation of urination. The disuse of the male sex organ for its urinary activity may be confused intrapsychically with its sexual function, especially in those men whose masculinity is not firmly established. 13•14 Depression, the most common psychologic difficulty of these patients, may also have sexual dysfunction as a physical concomitant. PSYCHOSOMATICS
Therapeutic considerations The liaison physician has a potentially important role in the care of patients maintained on hemodialysis. These people need counseling prior to acceptance in the program in order to prepare them for the psychologic problems that may ensue. For example, because impotence is present in about 70% of male patients, defining it prior to the patient's even starting hemodialysis as a possible complication may have therapeutic value. Having already learned the possibility of this problem, the patient will usually feel freer to discuss it with his physician should it occur. The liaison physician also has an important role in monitoring psychologic complications and treating them. Although psychotherapy, in the usual use of the term, is rarely an acceptable form of treatment among these patients, who already feel "over-doctored," at times it may be feasible. 14 Psychotropic medication often has a role in therapy. However, drugs that are excreted by the kidney or which are dialyzable should
not be used. Fortunately, most of the psychologically active medications do not fall into this prohibited area: significant exceptions are lithium and the minor tranquilizers. The phenothiazines and tricyclic antidepressants can be used. With depression as common as it is, the antidepressants have a potentially important role and should probably be used more widely. For sexual dysfunctions, in addition to therapy for the depression, consideration should be given to the new behavioral techniques such as those described by Masters and Johnson. Their potential usefulness for hemodialysis patients is currently being explored}S Thus, the psychologically attuned professional person can playa major therapeutic role that may notably improve the quality of life for these patients. 16•'7 0 Dr. Levy is an associate professor of psychiatry at the State University ofNew York Downstate Medical Center, Brooklyn, New York. Reprint requests to him, Box 127, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY H203.
REFERENCES 1. Eady RAJ: Why I have not had a kidney transplant after nine and ona-ha~ years as a hemodialysis patient. Transplant Proc 5: 115,
7.
1973. 2. Reichsrnan F, Levy NB: Problems in adaptation to hemodialysis: A four-year study of 25 patients. Arch Intern Med 130:859.1972. 3. Lefebre P. Nobert A, Crombez JC: Psychological and psychopathological reactions in relation to chronic hemodialysis. Can Psychiat Assoc J 17:9, 1972. 4. Foster FG, Cohn GL, McKegney FP: Psychobiologic factors and individual survival on chronic renal hemodialysis: A two-year follow-up, part 1. Psychosom Med 35:64, 1973. 5. Abram HS. Moore GI. Westervelt FB Jr: Suicidal behavior in chronic dialysis patients. Am J Psychiatry 127:1199,1971. 6. Levy NB: The role of the hemodialysis nurses
JUNE 1978 • VOL 19 • NO 6
8. 9.
10.
in patients' psychological adjustment. JAANNT1:13,1973. Levy NB: The psychology and care 01 the center hemodialysis patient. Heart and Lung: J Crit Care 2:400.1973. Abram HS, Hester LR, Epstein BA, et al: Sexual functioning in patients with chronic renal failure. J Nerv Ment Dis 110:220, 1975. Levy NB: Sexual adjustment to maintenance hemodialysis and renal transplantation: National survey by questionnaire. Trens Am Soc Artif Intern Organs 11:138, 1973. Antoniou LO, Sudhakar I. Shalhoub RJ. et al: Reversal of uremic impotence by zinc. Lancet
2:895. 1977. 11. Lim SI/. Auletta F, Kathpolia S: Gonadal dysfunction in chronic renal failure: An endocrinologic review. Dialysis and Transplantation, in press.
12. Massry 00, Goldstein OA, Procci WR, et al: Impotence in patients with uramia: A possible role for parathyroid hormone. Nephron
11:305. 1977. 13. Kaplan De-Nour A: Some notes on the pS\Ichological significance of urination. J Nerv Ment Dis 148:615,1969. 14. Levy NB: Psychological studies at the Downstate Medical Center of patients on hemodialysis. Med Clin North Am 11: 759. 1977. 15. McKevitt P: Treating ~xual dysfunctions in dialysis and transplant patients. Health Soc Work 1:133,1976. 16. Levy NB. Wynbrandt GO: The quality of life on maintenance hemodialysis. Lancet 1: 1328.
1975. 17. Levy NB (ad): Living or Dying: Adaptation to Hemodialysis. Springfield. III, Charles C
Thomas. 1974.
331
