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The Review

THE PSYCHOLOGICAL ASPECTS


OF CHRONIC HEMODIALYSIS*

K. ANDERSON, M.D.l

Introduction studies to the lack of application of dis-


It has been almost fifteen years since criminating criteria for the selection of pa-
Scribner and his associates (31) introduced tients. Abram (1) also stressed the impor-
the permanent arteriovenous shunt. This tance of psychiatric aspects in the selection
has made maintenance hemodialysis a prac- process and cited Kolff (20), Sand et al.
tical possibility for the long-term care of (30) and Johnson (13) who reported gener-
patients with terminal renal disease. In- ally good psychological adjustment and
creased technological sophistication has adaptation to chronic dialysis. Abram con-
greatly improved the medical management trasted these findings with the results ob-
of these patients over these years. This tained by Retan and Lewis (29) and Gom-
paper reviews the available psychological bos who found a high incidence of poor
literature on chronic hemodialysis. adaptation and inadequate cooperation
In the early years hemodialysis was not among patients who were accepted on a first
universally available, and where available come, first served basis, and again it was
was very costly. It soon became apparent concluded that the different results were
that some patients adapted more readily to attributable to the patient selection process.
its stresses than did others. In order to In a later paper Abram (2) in referring to
administer realistically and effectively to patient elimination criteria stated, "I be-
the needs of hemodialysis patients, efforts lieve that the only psychiatric contraindica-
were made to find effective methods of tions per se are psychosis . . . and the
patient selection. In 1964 Gombos (12) mental defective patient. Patients should be
reported on a one-year study of the relative rejected only on medical grounds."
psychological adjustments of five dialysis Several authors have attempted to iden-
patients - one committed' suicide and two tify personality characteristics which would
adapted poorly to the treatment. In 1965 predict good adjustment to hemodialysis.
Shea et al. (32) concluded that nine patients Sand et al, and Gombos felt that average or
followed over two and a half years man- above average intelligence was necessary
ifested significant adverse psychological for good adjustment. Winokur, Czaczkes
reactions while under the dialysis program and Kaplan DeNour (36), using diet adher-
and they exhibited poor acceptance and ence and vocational rehabilitation as meas-
adjustment. Glassman (11) in 1970 attri- ures of adjustment, concluded that intelli-
buted the poor treatment 'results in these gence is on the whole a poor predictor of
these two aspects of adjustment. Sand (30)
'Manuscript received November 1974.
'Department of Psychiatry, Ottawa Civic Hospital, Ottawa,
and Malmquist et al . (25) felt that
Ontario. psychometric tests were of little use in
Can. Psychiatr. Assoc. J. Vol. 20 (1975) predicting adjustment, but they noted that

385
386 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol. 20, No.5

poor adjusters tended to be more defensive. accepting dependency generated by passiv-


Sand found that good adjustment was as- ity and inactivity. Depression has been
sociated with supportive family attitudes noted by many authors (1, 2, 8, 10, 11, 17,
and Malmquist found that patients who 18, 24, 28, 32-34) to be a major problem.
reported themselves to be closer to their Reichman and Levy (28) found that all their
mothers tended toward better adjustment twenty-five patients were significantly de-
but that closeness with their fathers was pressed before acceptance into the dialysis
associated with poor adjustment. Both Sand program. Most authors related depression
and Malmquist concluded that a history of to stresses induced by the mechanical dif-
good adjustment to previous major life ficulties and to the stresses of living with
changes was a predictor of good adjustment dialysis as a requisite for life maintenance.
to dialysis. Fishman and Snider (6) studied Glassman (11), using the Shipman Anxiety
factors which predicted adjustment to home Depression Scale, and Gentry and Davis
dialysis, and found that good adjustment (10), using the Zung Self-Rating Depres-
after one year was predicted by good ad- sion Scale, found a discrepancy between
justment at the end of the home dialysis the low level of depression and anxiety
training program. Many authors (6, 7, 25, reported by the patients and their appear-
30) have reported that emotional adjustment ance as lethargic, depressed, and suffering
was not differentially predictive of survival. from generalized pruritis.
Foster et al. (7) compared fourteen sur-
vivors with seven patients who expired Defence Mechanisms
while on chronic hemodialysis. No Denial is seen as the most commonly
psychological differences were observed used defence mechanism of dialysis pa-
with respect to age, sex, education or dura- tients. Its adaptive value is frequently de-
tion of employment, diagnosis, signs of bated. Sand reported that" ... in general
organicity on mental status examinations or the patients who are later seen as making a
psychometric test results. They did find in poor adjustment tended to be more defen-
their small sample that affiliation with the sive in all tests and to deny even normal
Roman Catholic church was associated with amounts of adjustive difficulty and anxie-
survival. On the Miller Fusion Boundary ty." Kemp (18) reporting on the psychiatric
Test a high 'constraint' score (indicating an correlates of renal failure noted a remarka-
"abdication of the responsibility for mem- ble increase in the degree to which denial
bers of the group") was associated with and projection were used as defences. Short
survival. and Wilson (33) found that MMPI changes
reflected increasing denial and repression.
Problems in Adaptation Coincident with this was a lowering in the
Authors reported repeatedly (I, 8, 11, anxiety scale. They stated that, " ... the
16, 18, 24, 28, 32, 34) that the major capacity for denial in these patients is
adaptational problem in hemodialysis lies in phenomenal. " Freyberger (8) identified the
the area of emotional dependency. Depen- defence mechanisms used by his patients as
dence on the dialysis machine for survival denial, infantile regression, secondary
is a reality, and it has been suggested that hypochondria, turning against the self,
psychological dependency needs expand to reaction formation, projection, displace-
the point where staff are unable to gratify ment and intellectualization. Kaplan De-
them. Kaplan DeNour (16) believes that Nour (15) noted the main defences used by
acting-out behaviour in the form of non- nine dialysis patients to include denial,
compliance with medical" regime is attribut- displacement, isolation, projection and
able to a striving for independence. Abram reaction formation. He was impressed by
(3), writing on suicidal behaviour in the superficial appearance of well-being of
chronic dialysis patients, suggested that the his patients. Glassman, noting the disparity
high incidence of suicide is related to the between his patients' appearance as lethar-
emotional consequences - the difficulty in gic and depressed, and the reporting of little
August, 1975 CHRONIC HEMODIALYSIS 387

or no anxiety or depression on the Shipman Reichman and Levy (28) classify the
Anxiety Depression Scale, concluded that stages of adaptation in a similar way:
patients cope with the stress of this program • The Honeymoon
by massive use of denial as an adaptive Characterized by improvement of both
mechanism. Kaplan DeNour (16) held that physical and emotional state.
" . . . removal of this denial would make
the patient on the one hand comply more • Disenchantment
but on the other hand become less adjusted This stage usually shows a relationship
to the other aspects of his life on dialysis." with some external event (usually the plan-
Reichman and Levy (28) felt that denial ning or resumption of an active role in
often seemed to serve a useful adaptive society).
function. During some periods of depres- • Long-term Adaption
sion it apparently protected patients from Characterized by the patients arriving at
experiencing more intense helplessness, some degree of acceptance of their own
and during some periods of contentment it limitations.
preserved their sense of well-being. Vie-
derman (35) saw regression to a level of Family Problems
functioning reminiscent of infantile depen- Short and Wilson (33) noted that families
dency as an adaptive mechanism, allowing initially make adjustmental changes in good
the patient to accept the dependency that faith and with sincere motivation. How-
dialysis requires. ever, demands for continuing changes
necessitated by dialysis complications con-
Stages of Adaptation to Dialysis tinue and family concessions necessarily
There have been two attempts to classify occur over a period of many months to
the stages the patient must go through to several years. Generally a progressive pro-
adapt to chronic hemodialysis. Abram (2) cess of interactional decay between the
suggested that adaptation occurs in four patient and his home situation is observed.
stages: Continual uncertainty of the future distres-
ses the spouse, and the roles previously
• The Uremic Syndrome established in their marriage change. "The
Prior to the beginning of dialysis the hemodialysis patient, chronically anemic,
patient suffers from severe uremia, charac- intermittently uremic, and prone to many
terized by fatigue, apathy, drowsiness, ina- medical complications, usually cannot as-
bility to concentrate, depression and insta- sume his previous emotional involvement
bility. with the spouse and children." (24)

• The Shift to Physiological Equilibrium Sexual Problems


This is characterized by a return from the Levy's (23) national survey showed that
dead type of revitalization. Abram further hemodialysis patients of both sexes (but
subdivides this into three substages; apathy particularly men) reported substantial de-
- occurring as the patient approaches terioration in sexual functioning and, citing
physiologic equilibrium; euphoria - the Abram's unpublished study of thirty-two
patient realizes he is not at death' s door; patients, he reported that the frequency of
anxiety - this is transient and lasting only sexual intercourse per month was 10.4 be-
one or two dialyses. fore developing uremia, 5.7 after uremia
and before hemodialysis, and 4.0 while on
• Convalescence - The Return to the Living hemodialysis. Lefebvre, Nobert and Crom-
Depression often appears as the problem bez (22) attributed impotence directly to the
of living with dialysis becomes apparent. dialysis, which they observed had an emas-
culating effect on many patients. In con-
• The Struggle/or Normalcy trast, Elstein, Smith and Curtis (5) reported
The problem of living rather than dying. that pregnancy occurred in wives of three of
388 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol. 20, No.5

their twenty-five male patients and most of dren, and most families reported psycholog-
them reported that libido returned to a ical difficulties with other offspring, which
premorbid level (that which was recognized was attributed to the greater amount of time
as normal before uremia). Phadke et at. spent with the sick children. Nordan et at.
(27) studied eight patients on dialysis and (26) observed that the emotional problems
eleven transplant patients. In the former characteristic of children on dialysis were
they found a generally diminished sexual compounded by the effects of this treatment
desire, and testicular biopsy on five dialysis upon their unresolved body images, and
patients showed gross abnormality of sper- therefore their problems are greater than
matogenesis. In their eleven transplant pa- those of adults.
tients sexual desire had reverted to the
pre-uremic level and three wives had be- The Role of the Psychiatrist in the
come pregnant. Also all testicular biopsies Dialysis Unit
on transplantation patients proved to be In a report on one hundred and seventeen
normal. Although one report (5) suggests dialysis patients observed over five years it
that sexual functioning returns to premorbid was stated that " . . . to date no major
levels, the majority of the reports support psychiatric problems requiring formal
the observation that there is an increase in therapy have occurred" (4). Nevertheless,
sexual dysfunction in dialysis patients, and Abram (2) suggested that a role for the
that emotional factors playa role in this. psychiatrist on the dialysis team should be
considered for three reasons - selection of
Special Problems of Children on Dialysis patients, evaluation and treatment of pa-
Early in the history of dialysis treatment tients, and working with related medical
children were not considered as candidates, staff and the patients' families. He
but technical problems related to this have suggested that psychotherapy was essential
been overcome and children and adoles- for a successful adaptation to dialysis. Kaye
cents are now considered to be eligible. et at. (17) felt that the role of the psychia-
Viederman (35) had" ... seen no adoles- trist in dialysis units was primarily suppor-
cent who could be considered a well- tive. According to Gelfman and Wilson (9),
adapted one to dialysis." He attributed this " . . . fear of death may be a stronger
difficulty in adaptation to their already dif- dynamic factor in the patient's family and
ficult situation of struggling for indepen- those of us responsible for his care than it
dence from their parents. Korsh et at. (21) actually is in the patient." The potential
studied children who had had successful value of psychiatrists in helping to clarify
transplants, and felt that while in most areas and work through transference and counter-
they did not differ significantly from nor- transference difficulties between patients
mals, they did appear to have suffered and dialysis team members becomes clear
damage to their self-esteem. They noted in Short and Wilson's findings (33), that
that there was a considerable initial up- dialysands and nurses frequently build rela-
heaval in the families of such recipients, but tionships which reflect dependency and
normal family equilibrium was usually re- counter-dependency dynamics. Often the
stored within a year after a successful trans- point is reached where nurses can no longer
plant. Khan et at. (19) studied the social satisfy patients' demands, and at this point
and emotional adaptations of fourteen chil- they witt either unrealistically attempt to
dren; five with successful transplants, two cater to the dialysands' every beck and call,
with unsuccessful transplants and seven on or will ignore them. In either case guilt may
chronic hemodialysis. They found that girls attend their actions and anger arise. Kaplan
reported more handicap in social life than DeNour (14) noted that possessiveness and
boys, and substantial dependency was over-protectiveness of the treating staff may
found to be fostered by their families. It well be one of the major obstacles to having
was rare to see normal supportive relation- the patient accept home dialysis. These
ships maintained between parents and chil- findings further clarify the role of the
August, 1975 CHRONIC HEMODIALYSIS 389

psychiatrist on the dialysis team, as he can Although there have been some studies of
help to identify and rectify counter- the family problems which result from
productive staff-patient interactions. chronic dialysis, there have been few at-
tempts to determine actual changes which
Discussion and Conclusions
occur in the quality of a patient's home life.
Many efforts have been made to ascertain The spouse of the dialysis patient has been
the personality characteristics which distin- portrayed as initially making many sincere
guish good adjusters from bad. Since the efforts to accommodate to the patient's
primary conflict of the patient on dialysis limitations, but a continuous process of
revolves around the issue of dependence- decay is nonetheless described. It is reason-
independence it is reasonable to believe that able to suspect that the spouse, who has a
those who have few difficulties in this area considerable emotional investment in the
will adjust better - they are dependent and patient and whose life-style is interdepen-
passive individuals, whose past life history dent with that ofthe patient, must be greatly
reflects little evidence of self-assertive and affected by the new situation. The literature
independent traits. Although this descrip- has presented no reports of the effect upon
tion may apply to the dialysis patients who the children of dialysis patients. Reports on
adjust well to treatment, a paradoxical situ- the observed effects of dialysis on siblings
ation arises when professional rehabilitation of child patients suggest that future investi-
is considered, as this requires the presence gations may reveal intra-familial problems
of some self-assertive and independent as when adult patients are similarly ob-
characteristics. It would appear then that served.
the independent patient would be the better Attempts to classify stages of adaptation
adjuster to rehabilitation. The significance of hemodialysis suggest that adjustment is
for those who are treating dialysis patients independent of the premorbid personality of
is that there are two patient populations. In the patient. What is lacking in the literature
the initial stages of hemodialysis the inde- is a study of patients' adjustments, starting
pendent patient will suffer the greatest before the onset of uremia. Most people
psychological difficulties, and these derive who receive dialysis are afflicted with
primarily from the feeling that he is losing chronic renal diseases, such as
control over his life and will require sup- glomerulonephritis, chronic pyelonephritis
port. In the later stages of treatment when or polycystic kidney disease. When these
professional rehabilitation becomes a goal, patients' problems progress to a known
the more passive and dependent patient will point, hemodialysis is imminently required,
encounter difficulties. These are the pa- and this may be predicted six months to one
tients who fit into Reichman and Levy's year ahead. At this time the patient does not
classical second stage where depression feel severely ill and could well be consid-
was often associated with the planning or ered to be in a premorbid state. Personality
resumption of an active role in society. In assessments before severe uremia, sub-
his description of patients in his third stage sequently upon initiation to dialysis, ad-
Abram also stated that depression often justment to its occurrence and to transplan-
appears as the problems of. living with tation, appear to be desirable.
dialysis become apparent. The difficulties
at this stage may also partly relate to certain
personality characteristics of the treating
staff. Professional personnel in dialysis Acknowledgement
units have frequently been described as The author wishes to thank K. E. Breitman
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.
The dependent patients may perceive this as References
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390 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol. 20, No.5

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August, 1975 CHRONIC HEMODIALYSIS 391

30. Sand, P., Goodhue, L., Wright, R. G.: Resume


Psychological assessment of candidates for
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3,1966. souffrant de malfonction chronique du rein
31. Scribner, B. H., Burl, R., Caner, J-E.Z., peuvent recourir a I'hemodialyse. L'article
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Schriener, G.: Hemodialysis for chronic
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semble que les patients de nature passive et
33. Short, M. J., Wilson, W. P.: Roles of dependante s' adaptent facilement a la
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Psychiatry20,433-437,1969. s' adapter plus tard a la rehabilitation pro-
34. Taylor, G. J.: Chronic renal failure, fessionnelle. Alors que les patients de
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1972. ont plus facilement a la rehabilitation pro-
35. Viederman, M.: Adaptive and maladaptive fessionnelle.
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Comme on peut diagnostiquer Ie besoin
68-77, 1974.
36. Winokur, M. Z., Czaczkes, 1. W., Kaplan
ala dialyse de six mois 11 un an l'avance, on
DeNour, A.: Intelligence and adjustment to retient la possibilite de faire une etude
chronic hemodialysis. J. Psychosom. Res. prospective des patients destines a subir
17,29-34,1973. l'hemodialyse ainsi que de leurs familles.

Courage is the thing.


All goes if courage goes.

The Admirable Crichton

Sir James Barrie


1860-1937