The Review THE PSYCHOLOGICAL ASPECTS OF CHRONIC HEMODIALYSIS*
Introduction It has been almost fifteen years since Scribner and his associates (31) introduced the permanent arteriovenous shunt. This has made maintenance hemodialysis a practical possibility for the long-term care of patients with terminal renal disease. Increased technological sophistication has greatly improved the medical management of these patients over these years. This paper reviews the available psychological literature on chronic hemodialysis. In the early years hemodialysis was not universally available, and where available was very costly. It soon became apparent that some patients adapted more readily to its stresses than did others. In order to administer realistically and effectively to the needs of hemodialysis patients, efforts were made to find effective methods of patient selection. In 1964 Gombos (12) reported on a one-year study of the relative psychological adjustments of five dialysis patients - one committed' suicide and two adapted poorly to the treatment. In 1965 Shea et al. (32) concluded that nine patients followed over two and a half years manifested significant adverse psychological reactions while under the dialysis program and they exhibited poor acceptance and adjustment. Glassman (11) in 1970 attributed the poor treatment 'results in these 'Manuscript received November 1974. 'Department of Psychiatry, Ottawa Civic Hospital, Ottawa, Ontario. Can. Psychiatr. Assoc. J. Vol. 20 (1975)
studies to the lack of application of discriminating criteria for the selection of patients. Abram (1) also stressed the importance of psychiatric aspects in the selection process and cited Kolff (20), Sand et al. (30) and Johnson (13) who reported generally good psychological adjustment and adaptation to chronic dialysis. Abram contrasted these findings with the results obtained by Retan and Lewis (29) and Gombos who found a high incidence of poor adaptation and inadequate cooperation among patients who were accepted on a first come, first served basis, and again it was concluded that the different results were attributable to the patient selection process. In a later paper Abram (2) in referring to patient elimination criteria stated, "I believe that the only psychiatric contraindications per se are psychosis . . . and the mental defective patient. Patients should be rejected only on medical grounds." Several authors have attempted to identify personality characteristics which would predict good adjustment to hemodialysis. Sand et al, and Gombos felt that average or above average intelligence was necessary for good adjustment. Winokur, Czaczkes and Kaplan DeNour (36), using diet adherence and vocational rehabilitation as measures of adjustment, concluded that intelligence is on the whole a poor predictor of these two aspects of adjustment. Sand (30) and Malmquist et al . (25) felt that psychometric tests were of little use in predicting adjustment, but they noted that
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poor adjusters tended to be more defensive. Sand found that good adjustment was associated with supportive family attitudes and Malmquist found that patients who reported themselves to be closer to their mothers tended toward better adjustment but that closeness with their fathers was associated with poor adjustment. Both Sand and Malmquist concluded that a history of good adjustment to previous major life changes was a predictor of good adjustment to dialysis. Fishman and Snider (6) studied factors which predicted adjustment to home dialysis, and found that good adjustment after one year was predicted by good adjustment at the end of the home dialysis training program. Many authors (6, 7, 25, 30) have reported that emotional adjustment was not differentially predictive of survival. Foster et al. (7) compared fourteen survivors with seven patients who expired while on chronic hemodialysis. No psychological differences were observed with respect to age, sex, education or duration of employment, diagnosis, signs of organicity on mental status examinations or psychometric test results. They did find in their small sample that affiliation with the Roman Catholic church was associated with survival. On the Miller Fusion Boundary Test a high 'constraint' score (indicating an "abdication of the responsibility for members of the group") was associated with survival.
Problems in Adaptation Authors reported repeatedly (I, 8, 11, 16, 18, 24, 28, 32, 34) that the major adaptational problem in hemodialysis lies in the area of emotional dependency. Dependence on the dialysis machine for survival is a reality, and it has been suggested that psychological dependency needs expand to the point where staff are unable to gratify them. Kaplan DeNour (16) believes that acting-out behaviour in the form of noncompliance with medical" regime is attributable to a striving for independence. Abram (3), writing on suicidal behaviour in chronic dialysis patients, suggested that the high incidence of suicide is related to the emotional consequences - the difficulty in
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accepting dependency generated by passivity and inactivity. Depression has been noted by many authors (1, 2, 8, 10, 11, 17, 18, 24, 28, 32-34) to be a major problem. Reichman and Levy (28) found that all their twenty-five patients were significantly depressed before acceptance into the dialysis program. Most authors related depression to stresses induced by the mechanical difficulties and to the stresses of living with dialysis as a requisite for life maintenance. Glassman (11), using the Shipman Anxiety Depression Scale, and Gentry and Davis (10), using the Zung Self-Rating Depression Scale, found a discrepancy between the low level of depression and anxiety reported by the patients and their appearance as lethargic, depressed, and suffering from generalized pruritis.
Defence Mechanisms Denial is seen as the most commonly used defence mechanism of dialysis patients. Its adaptive value is frequently debated. Sand reported that" ... in general the patients who are later seen as making a poor adjustment tended to be more defensive in all tests and to deny even normal amounts of adjustive difficulty and anxiety." Kemp (18) reporting on the psychiatric correlates of renal failure noted a remarkable increase in the degree to which denial and projection were used as defences. Short and Wilson (33) found that MMPI changes reflected increasing denial and repression. Coincident with this was a lowering in the anxiety scale. They stated that, " ... the capacity for denial in these patients is phenomenal. " Freyberger (8) identified the defence mechanisms used by his patients as denial, infantile regression, secondary hypochondria, turning against the self, reaction formation, projection, displacement and intellectualization. Kaplan DeNour (15) noted the main defences used by nine dialysis patients to include denial, displacement, isolation, projection and reaction formation. He was impressed by the superficial appearance of well-being of his patients. Glassman, noting the disparity between his patients' appearance as lethargic and depressed, and the reporting of little
or no anxiety or depression on the Shipman Anxiety Depression Scale, concluded that patients cope with the stress of this program by massive use of denial as an adaptive mechanism. Kaplan DeNour (16) held that " . . . removal of this denial would make the patient on the one hand comply more but on the other hand become less adjusted to the other aspects of his life on dialysis." Reichman and Levy (28) felt that denial often seemed to serve a useful adaptive function. During some periods of depression it apparently protected patients from experiencing more intense helplessness, and during some periods of contentment it preserved their sense of well-being. Viederman (35) saw regression to a level of functioning reminiscent of infantile dependency as an adaptive mechanism, allowing the patient to accept the dependency that dialysis requires.
Stages of Adaptation to Dialysis There have been two attempts to classify the stages the patient must go through to adapt to chronic hemodialysis. Abram (2) suggested that adaptation occurs in four stages: • The Uremic Syndrome Prior to the beginning of dialysis the patient suffers from severe uremia, characterized by fatigue, apathy, drowsiness, inability to concentrate, depression and instability. • The Shift to Physiological Equilibrium This is characterized by a return from the dead type of revitalization. Abram further subdivides this into three substages; apathy - occurring as the patient approaches physiologic equilibrium; euphoria - the patient realizes he is not at death' s door; anxiety - this is transient and lasting only one or two dialyses. • Convalescence - The Return to the Living Depression often appears as the problem of living with dialysis becomes apparent. •
The Struggle/or Normalcy The problem of living rather than dying.
Reichman and Levy (28) classify the stages of adaptation in a similar way: • The Honeymoon Characterized by improvement of both physical and emotional state. • Disenchantment This stage usually shows a relationship with some external event (usually the planning or resumption of an active role in society). • Long-term Adaption Characterized by the patients arriving at some degree of acceptance of their own limitations.
Family Problems Short and Wilson (33) noted that families initially make adjustmental changes in good faith and with sincere motivation. However, demands for continuing changes necessitated by dialysis complications continue and family concessions necessarily occur over a period of many months to several years. Generally a progressive process of interactional decay between the patient and his home situation is observed. Continual uncertainty of the future distresses the spouse, and the roles previously established in their marriage change. "The hemodialysis patient, chronically anemic, intermittently uremic, and prone to many medical complications, usually cannot assume his previous emotional involvement with the spouse and children." (24) Sexual Problems Levy's (23) national survey showed that hemodialysis patients of both sexes (but particularly men) reported substantial deterioration in sexual functioning and, citing Abram's unpublished study of thirty-two patients, he reported that the frequency of sexual intercourse per month was 10.4 before developing uremia, 5.7 after uremia and before hemodialysis, and 4.0 while on hemodialysis. Lefebvre, Nobert and Crombez (22) attributed impotence directly to the dialysis, which they observed had an emasculating effect on many patients. In contrast, Elstein, Smith and Curtis (5) reported that pregnancy occurred in wives of three of
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their twenty-five male patients and most of them reported that libido returned to a premorbid level (that which was recognized as normal before uremia). Phadke et at. (27) studied eight patients on dialysis and eleven transplant patients. In the former they found a generally diminished sexual desire, and testicular biopsy on five dialysis patients showed gross abnormality of spermatogenesis. In their eleven transplant patients sexual desire had reverted to the pre-uremic level and three wives had become pregnant. Also all testicular biopsies on transplantation patients proved to be normal. Although one report (5) suggests that sexual functioning returns to premorbid levels, the majority of the reports support the observation that there is an increase in sexual dysfunction in dialysis patients, and that emotional factors playa role in this.
Special Problems of Children on Dialysis Early in the history of dialysis treatment children were not considered as candidates, but technical problems related to this have been overcome and children and adolescents are now considered to be eligible. Viederman (35) had" ... seen no adolescent who could be considered a welladapted one to dialysis." He attributed this difficulty in adaptation to their already difficult situation of struggling for independence from their parents. Korsh et at. (21) studied children who had had successful transplants, and felt that while in most areas they did not differ significantly from normals, they did appear to have suffered damage to their self-esteem. They noted that there was a considerable initial upheaval in the families of such recipients, but normal family equilibrium was usually restored within a year after a successful transplant. Khan et at. (19) studied the social and emotional adaptations of fourteen children; five with successful transplants, two with unsuccessful transplants and seven on chronic hemodialysis. They found that girls reported more handicap in social life than boys, and substantial dependency was found to be fostered by their families. It was rare to see normal supportive relationships maintained between parents and chil-
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dren, and most families reported psychological difficulties with other offspring, which was attributed to the greater amount of time spent with the sick children. Nordan et at. (26) observed that the emotional problems characteristic of children on dialysis were compounded by the effects of this treatment upon their unresolved body images, and therefore their problems are greater than those of adults.
The Role of the Psychiatrist in the Dialysis Unit In a report on one hundred and seventeen dialysis patients observed over five years it was stated that " . . . to date no major psychiatric problems requiring formal therapy have occurred" (4). Nevertheless, Abram (2) suggested that a role for the psychiatrist on the dialysis team should be considered for three reasons - selection of patients, evaluation and treatment of patients, and working with related medical staff and the patients' families. He suggested that psychotherapy was essential for a successful adaptation to dialysis. Kaye et at. (17) felt that the role of the psychiatrist in dialysis units was primarily supportive. According to Gelfman and Wilson (9), " . . . fear of death may be a stronger dynamic factor in the patient's family and those of us responsible for his care than it actually is in the patient." The potential value of psychiatrists in helping to clarify and work through transference and countertransference difficulties between patients and dialysis team members becomes clear in Short and Wilson's findings (33), that dialysands and nurses frequently build relationships which reflect dependency and counter-dependency dynamics. Often the point is reached where nurses can no longer satisfy patients' demands, and at this point they witt either unrealistically attempt to cater to the dialysands' every beck and call, or will ignore them. In either case guilt may attend their actions and anger arise. Kaplan DeNour (14) noted that possessiveness and over-protectiveness of the treating staff may well be one of the major obstacles to having the patient accept home dialysis. These findings further clarify the role of the
psychiatrist on the dialysis team, as he can help to identify and rectify counterproductive staff-patient interactions.
Although there have been some studies of the family problems which result from chronic dialysis, there have been few attempts to determine actual changes which occur in the quality of a patient's home life. The spouse of the dialysis patient has been portrayed as initially making many sincere efforts to accommodate to the patient's limitations, but a continuous process of decay is nonetheless described. It is reasonable to suspect that the spouse, who has a considerable emotional investment in the patient and whose life-style is interdependent with that ofthe patient, must be greatly affected by the new situation. The literature has presented no reports of the effect upon the children of dialysis patients. Reports on the observed effects of dialysis on siblings of child patients suggest that future investigations may reveal intra-familial problems as when adult patients are similarly observed. Attempts to classify stages of adaptation of hemodialysis suggest that adjustment is independent of the premorbid personality of the patient. What is lacking in the literature is a study of patients' adjustments, starting before the onset of uremia. Most people who receive dialysis are afflicted with chronic renal diseases, such as glomerulonephritis, chronic pyelonephritis or polycystic kidney disease. When these patients' problems progress to a known point, hemodialysis is imminently required, and this may be predicted six months to one year ahead. At this time the patient does not feel severely ill and could well be considered to be in a premorbid state. Personality assessments before severe uremia, subsequently upon initiation to dialysis, adjustment to its occurrence and to transplantation, appear to be desirable.
Discussion and Conclusions Many efforts have been made to ascertain the personality characteristics which distinguish good adjusters from bad. Since the primary conflict of the patient on dialysis revolves around the issue of dependenceindependence it is reasonable to believe that those who have few difficulties in this area will adjust better - they are dependent and passive individuals, whose past life history reflects little evidence of self-assertive and independent traits. Although this description may apply to the dialysis patients who adjust well to treatment, a paradoxical situation arises when professional rehabilitation is considered, as this requires the presence of some self-assertive and independent characteristics. It would appear then that the independent patient would be the better adjuster to rehabilitation. The significance for those who are treating dialysis patients is that there are two patient populations. In the initial stages of hemodialysis the independent patient will suffer the greatest psychological difficulties, and these derive primarily from the feeling that he is losing control over his life and will require support. In the later stages of treatment when professional rehabilitation becomes a goal, the more passive and dependent patient will encounter difficulties. These are the patients who fit into Reichman and Levy's classical second stage where depression was often associated with the planning or resumption of an active role in society. In his description of patients in his third stage Abram also stated that depression often appears as the problems of. living with dialysis become apparent. The difficulties at this stage may also partly relate to certain personality characteristics of the treating Acknowledgement staff. Professional personnel in dialysis The author wishes to thank K. E. Breitman units have frequently been described as highly motivated individuals, who project Ph.D. for his assistance in the preparation of their wish to rehabilitate their patients by this paper. pushing dependent people into active roles. References The dependent patients may perceive this as an unreasonable demand and consequently 1. Abram, H. S.: The psychiatrist, the treatment of chronic renal failure and the probecome depressed.
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longation of life. Part 1. Am. J. Psychiatry 124: 10,45-52, 1968. 2. Abram, H. S.: The psychiatrist, the treatment of chronic renal failure and the prolongation of life. Part II. Am. J. Psychiatry 126: 2,157-166,1969. 3. Abram, H. S., Moore, G. L., Wastervelt, F. B.: Suicidal behaviour in chronic dialysis patients. Am. J. Psychiatry, 127: 9, 11991204,1971. J 4. Baillod, R. A., Crockett, R. E., Ross, A.: Social and psychological aspects of regular hemodialysis treatment. Proc. Europ. Dialysis and Transplant Assoc. V, 97, 1968. 5. Elstein, M., Smith, E. K. M., Curtis, J. R.: Reproductive potential of patients treated by maintenance hemodialysis. Br. Med. J. 2,734-736,1969. 6. Fishman, D. B., Schneider, C. J.: Predicting emotional adjustment in home dialysis patients and their relatives. J. Chron. Dis. 25,99-109,1972. 7. Foster, F. G., Cohn, G. L., McKegney, F. P.: Psychological factors and individual survival on chronic renal hemodialysis, a two year follow-up, Part I. Psychosom. Med.35: I, January-February, 1973. 8. Freyberger, H.: Six years experience as a psychosomaticist in a hemodialysis unit. Psychiatr. Psychosom. 22,226-232,1973. 9. Gelfman, M., Wilson, E. S.: Emotional reactions in a renal unit. Compr. Psychiatry 13:3,283-290,1972. 10. Gentry, W. D., Davis, G. C.: Cross sectional analysis of psychological adaptation to chronic hemodialysis. J. Chronic Dis. 25,545-550, 1972. 11. Glassman, B. M.: Personality correlates of survival in a long term hemodialysis program. Arch. Gen. Psychiatry 22, 1970. 12. Gombos, E. A., Lee, T. H., Harton, M. R., and Cummings, 1. W.: One year's experience with an intermittent dialysis program. Ann. Int. Med. 61,462-469,1964. 13. Johnson, W. 1., Wagoner, R. D., Hunt, 1. C., Mueller, G. 1., Hallenback, G. A.: Long-term intermittent hemodialysis for chronic renal failure. Mayo Clinic Proc. 41, 73-94, 1966. 14. Kaplan DeNour, A., Czaczkes, J. W.: Resistance to home dialysis. Psychiatry Med. 1,207-221,1970. 15. Kaplan DeNour, A., Shaltiel, 1., Czaczkes, J. W.: Emotional reactions of patients on chronic hemodialysis. Psychosom. Med. 1211,1351-1357,1968.
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16. Kaplan DeNour, A.: Personality factors in chronic hemodialysis patients causing noncompliance with medical regimen. Psychosom. Med. 34: 4,1972. 17. Kaye, R., Hoyle, L., Stanch, B.: The role of the liaison psychiatrist in a hemodialysis program. Psychiatry Med. 4, 3313-3321, 1973. 18. Kemph, J. P.: Renal failure, artificial kidney and kidney transplant. Am. J. Psychiatry 122, 1270, 1966. 19. Khan, A. D., Herdon, C. H., Atemadian, S. Y.: Social and emotional adaptations of children with transplanted kidneys and chronic hemodialysis. Am. J. Psychiatry 127: 9, 1194-1198, 1971. 20. Kolff, W. S., Nakamoto, S., Scudder, J. P.: Experience with long-term intermittent dialysis. Trans. Am. Soc. Artif. Intern. Organs 8, 292-299, 1962. 21. Korsh, B. M., Gardner, J. E., Pine, R. N., Negrete, V. F.: Long-term follow-up on kidney transplant patients and their families. Proc. Europ. Dialysis and Transplant Assoc. IX, 359,1972. 22. Lefebvre, P., Nobert, A., Crombez, J. C.: Psychological and psychopathological reactions to chronic hemodialysis. Can. Psychiatr. Assoc. J. 17: SSII-9, 1972. 23. Levy, N. B.: Sexual adjustment to maintenance hemodialysis and renal transplantation. Trans. Am. Soc. Artif. Int. Organs XIX, 1973. 24. Levy, N. B.: The psychology and care of the maintenance hemodialysis patient. Heart and Lung 2: 3,1973. 25. Malmquist, A., Kapfstein, S., Frank, E. T.: Factors in psychiatric prediction of patients beginning hemodialysis: A follow-up of 13 patients. J. Psychosom. Res. /6, 19-23, 1972. 26. Nordan, R., Ostendorf, R., Naughton, 1. P.: Return to the land of the living, an approach to the problem of chronic hemodialysis. Pediatrics 48: 6, 939-945, 1971. 27. Phadke, A. G., MacKinnon, K. 1., Dossetor, J. B.: Male fertility in uremia restoration by renal allograft. Can. Med. Assoc. J. /02,607-608, 1970. 28. Reichman, F., Levy, N. B.: Problems in adaptation to maintenance hemodialysis. Arch. Int. Med. 130,859-865,1972. 29. Retan, S. W., Lewis, H. Y.: Repeated dialysis of indigent patients for chronic renal failure. Am. Int. Med. 64, 284-292, 1966.
30. Sand, P., Goodhue, L., Wright, R. G.: Psychological assessment of candidates for a hemodialysis program. Am. Int. Med. 64: 3,1966. 31. Scribner, B. H., Burl, R., Caner, J-E.Z., Hegstrom, R., and Burnell, J. M.: The treatment of chronic uremia by means of intermittent hemodialysis, a preliminary report. Trans. Am. Soc. Artif. Intern. Organs 6,114-121,1960. 32. Shea, E. 1., Bogdan, D., Freeman, R., Schriener, G.: Hemodialysis for chronic renal failure-psychological considerations. Ann. Int. Med. 62: 3, 558-563,1965. 33. Short, M. J., Wilson, W. P.: Roles of denial in chronic hemodialysis. Arch. Gen. Psychiatry20,433-437,1969. 34. Taylor, G. J.: Chronic renal failure, hemodialysis and the liaison psychiatrist. Can. Med. Assoc. J. 106, 1318-1323, 1972. 35. Viederman, M.: Adaptive and maladaptive regression in hemodialysis. Psychiatry 37, 68-77, 1974. 36. Winokur, M. Z., Czaczkes, 1. W., Kaplan DeNour, A.: Intelligence and adjustment to chronic hemodialysis. J. Psychosom. Res. 17,29-34,1973.
Resume Depuis pres de quinze ans, les patients souffrant de malfonction chronique du rein peuvent recourir a I'hemodialyse. L'article passe en revue la documentation traitant des aspects psychologiques de I'hemodialyse. Le premier probleme dans I' adaptation a ce traitement se trouve dans Ia depression provoquee par Ie conflit qui surgit de la dependance ernotionelle. Le refus est Ie mecanisme de defense Ie plus commun. II semble que les patients de nature passive et dependante s' adaptent facilement a la dialyse, mais eprouvent des difficultes a s' adapter plus tard a la rehabilitation professionnelle. Alors que les patients de caractere autonome acceptent malla dependance requise par la dyalise, ils s'adapteront plus facilement a la rehabilitation professionnelle. Comme on peut diagnostiquer Ie besoin ala dialyse de six mois 11 un an l'avance, on retient la possibilite de faire une etude prospective des patients destines a subir l'hemodialyse ainsi que de leurs familles.
Courage is the thing. All goes if courage goes. The Admirable Crichton Sir James Barrie 1860-1937