Personality Factors in Chronic Hemodialysis Patients Causing Noncompliance With Medical Regimen

A. Kaplan De-Nour, MD and J. W. Czaczkes, PhD, MD Forty-three patients on chronic hemodialysis were observed in a prospective study on the effects of a number of personality factors on noncompliance with a medical regimen (diet). It was found that low frustration tolerance and gains (primary and secondary) from the sick role were the most frequent causes for noncompliance, and these differentiated significantly between compilers and noncompliers, while "acting out" was frequent in both groups though more severe in the noncompliers. Other factors such as denial of sick role and suicidal behavior were also found, although more rarely. The importance of identifying the specific factors in each individual patient was stressed as it would dictate the strategy of the psychotherapeutic intervention. Although only dialysis patients were included in this study, it was suggested that the personality factors described can be identified in other patients and other medical setups as well. In many areas of medicine, the patient's wellbeing, his health and, at times, his life greatly depend on his active participation in a treatment program and on his compliance with the medical recommendationseg, taking medicines, adhering to a diet or undergoing surgery. Since abuse of medical recommendations often ' threatens the patient's health and life, there exists a tendency to regard noncompliance as expressing suicidal intentions (conscious or unconscious) and to regard it as suicidal behavior(l). The chronic hemodialysis setup (studied also in the above-mentioned report) is ideal for studying the problems of noncompliance and abuse of medical regimen. The treatment is chronic and the contact with the patients both prolonged and intensive. They cannot switch places or simply go to another physician. The problem (common at least in our country) that a patient consults three or more physicians, gets a variety of recommendations and becomes "mixed up" and does not comply with any of them, exists only to a very small extent in dialysis patients. The medical regimen of dialysis is usually very clear-cut. Furthermore, patients' adherence to or abuse of many of its aspects is easily measured; if a patient drinks too much, he gains weight; if he abuses the fruit restrictions, his blood potassium goes up. Therefore, at least some aspects of compliance, often the most important ones for the physical well-being of a dialysis patient, can be checked by objective methods, while for other aspects one has to accept, at least to some extent, the patient's description of his behavioreg, taking the prescribed amount of some medication.
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From the Department of Psychiatry and the Nephrological Service, Hadassah University Hospital and Medical School, Jerusalem, Israel. Supported by Grant 06-823-2 from the US Department of Health, Education, and Welfare, Public Health Service. Received for publication July 22, 1971; final revision received Jan 5, 1972. Address for reprint requests: A. Kaplan De-Nour, MD, Department of Psychiatry, Hadassah University Hospital, PO Box 499, Jerusalem, Israel.

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It is not surprising, therefore, that recent reports concerned with the determinants of compliance, like the present one, deal with dialysis patients. Borkman (2) noticed that a patient may comply with some, and at the same time abuse other, aspects of one and the same program, and she proceeded to study compliance with seven aspects of dialysis. In the same study it was found that intelligence has little influence on compliance with three aspects concerned with keeping the diet, but that it does affect other aspectseg, rehabilitation. Borkman also found a strong relationship between patients' understanding of the restrictions (as assessed by team members) and their compliance. To quote that report, however, "the majority' of noncompliers with any restriction has an adequate or excellent understanding of that restriction. Only one-third or less of non-compliers with a dietary restriction have poor understanding of that restriction." We feel that her comment, "The extent to which a patient's ratings on understanding and complying . . . are not independent, cannot be ascertained" should be stressed. Goldstein and Reznikoff (3) recently suggested that one should regard abuse of the diet by dialysis patients not as suicidal behavior but rather as an attempt to adjust to the stress. "As an attempt to cope with the continuous responsibility and anxiety of keeping oneself alive by following a rigid treatment regimen, the hemodialysis patient adopts an external locus of control with the result that his behavior is no longer perceived as life sustaining and a threatening area of responsibility is avoided." Working with chronic hemodialysis patients for a number of years has brought us to the conclusion that a patient's abuse of a medical regimen cannot be ascribed to one factor only. The medical team can affect the compliance or noncompliance of some patients. For other medical setups, a number of studies (4-7) include reports on the effects of doctor-patient relations on compliance. Families' attitudes influence the patient's behavior, and a number
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of personality factors can result in abuse of the medical regimen. In the present report we would like to concentrate mostly on the personality factors which, we suggest, are the determinants of noncompliance with the medical regimen of chronic hemodialysis.
METHOD AND PROCEDURE The Patients
Forty-three patients were observed in six different dialysis units in the country. Twenty-eight of these patients were men and 15 women. The majority of the group (25) were in the age group of 20 to 39. Five patients were under 20, and 13 patients were over 40. Fourteen were single, 28 were married and 1 was divorced. The group as a whole were at a low educational level; a third of the patients (14) had either no education at all or had not completed elementary school. Only 10 patients had high school educations and few of them higher educations. Most of the patients were also at a low socioeconomic level (Table 1). Patients who had started dialysis during the last 6 months only were excluded from this report, except for 3 patients who died on dialysis. The duration on dialysis of the 43 patients studied is presented in Table 2. Table 1. Socioeconomic Condition of Patients Examined No. of patients 9 9 9 7 6 3

Occupation None Housewives Unskilled workers Skilled workers High school and college students Professionals

Table 2. Length of Time on Dialysis for the Patients Examined Time on dialysis Under 6 months* 7-12 months 13-24 months Over 2 years No. of patients

3 17 14
9

*These patients died after 2, 3 1/2 and 4 months on dialysis, respectively.

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Psychiatric Observations
All the psychiatric observations were carried out by one of the authors. After the initial psychiatric examination,.the assessment of the studied personality traits was recorded. The amount and depth of the observations varied from patient to patient. One group (15 out of the 43 patients examined) was on dialysis in the Hadassah University Hospital and had all received individual psychotherapy of varying intensity as described elsewhere (8, 9). These patients had been on dialysis from 1 to 5 years. The other 28 patients were studied in five other centers as part of a study on prediction of adjustment to dialysis, and they all underwent a psychiatric evaluation before the beginning of dialysis, as well as follow-up examinations at 6-month intervals.

Assessment of Compliance or Noncompliance With the Medical Regimen

This assessment was done at 6-month intervals, beginning half a year.after the start of dialytic treatment. All the patients were assessed in a similar way by one of the authors. The patients underwent a physical checkup, and their biochemical data was taken from the medical chart. Compliance to the dietary regimeie, compliance to water, potassium and salt restrictions, as well as the total caloric and protein intake, was evaluated. As protein restriction and, therefore, caloric intake is not so much of a problem in this country (compared to normal dietary habits), compliance with the diet was determined by compliance with the restrictions on the first three items. Adherence to the restricted fluid intake was mainly determined by the weight gain between two dialyses over the last 3 months. Similarly, the predialysis potassium level gave us a measurement of adherence to potassium restriction. Success in keeping to sodium restriction was estimated mainly by observing prc- and postdialysis blood pressure measurements together with the weight gain. The overall compliance to diet was determined according to a quite accurately defined five-point scale ranging from excellent adherence to great abuse. Except for adherence to diet, we had to rely mainly on patients' reports on compliance with their regimen, such as taking or not taking medicines or refusing surgical intervention. Some such examples will be brought up here, but as there are no objective quantitative methods for measuring compliance in these areas, no statistical information will be reported. Grading of compliance with the diet was according to the following definitions. Excellent. Weight gain between dialyses is never above 500 g. Predialysis serum potassium levels are never

above 6 mEq/liter and most of the time less. Predialysis BUN levels are steady. Good. Weight gain between dialyses is from 500 to 1000 g. Predialysis potassium levels are usually 6 mEq/ liter or less, occasionally going up to 6.5 mEq/liter. Predialysis BUN levels are usually steady but may show occasionaljumps. Fair. Weight gain between dialyses is mostly 1000 to 1500 g, rarely going up to 2000 g. Predialysis potassium levels arc from 6.0 to 6.8 mEq/liter. Some abuse. Weight gain between dialyses is from 1500 to 2000 g, occasionally going up to 2500 or even 3000 g. Predialysis potassium levels are most of the time near 7.0 mEq/liter. Great abuse. Weight gain between dialyses is always above 2000 g, or most of the time above 2500 g. Predialysis potassium levels are frequently above 7.0 mEq/liter.

RESULTS

On the whole, adherence to the diet seemed to be rather poor; about half of the patients could be regarded as abusers of this aspect of the medical regimen. In assessing the 43 patients' adherence to the diet, 5 were regarded as excellent adherers, 10 were good, 8 were fair, 13 indicated some abuse, and 7 indicated great abuse. Because of the small number of patients, they were divided into two subgroups for all further analysis. The patients classified in the first three categoriesexcellent, good and fair were referred to as good adherers, and those in the other two categories were regarded as abusers of the diet. Of the 10 patients who died, 8 were abusers. The diet is a continuous source of frustration to the patients; the fluid restriction is the hardest for them. They often report trying to keep occupied all day long in order to avoid drinking, and they day-dream about the "Coke in the fridge." Even the patients who do adhere well to this restriction say that it is difficult and that they are thirsty most of the time. Some patients develop ingenious methods to conceal weight increase caused by overdrinking. Patients also complain about the salt restrictions, although those who adhere well report that they got used to saltless food. The neces335

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sary low potassium intake is difficult for only a few patients. It is suggested that the following factors, either alone or in combination with other factors, lead to the abuse of diet and other medical recommendations: a) low frustration tolerance or little ability to delay gratification; b) acting out (usually of hostility); c) denial of sick role; d) excessive gain from sick role; e) suicidal behavior; f) homicidal behavior (usually by family); g) superstition, prejudices and body image problems. In the present study these factors were selected for further observation on the basis of information and impressions gathered from regular psychotherapy with a few patients, as partly reported in earlier studies (8-10). Low Frustration Tolerance Patients with low frustration tolerance usually claim that they know and understand the restrictions but that they simply cannot keep to them. They swear that they try very hard but just cannot, and their behavior on dialysis is characterized by brief periods of fair to good adherence, which usually occur after a warning from the physician or after ill health resulting from their abuse of the diet. This fear, however, is not strong enough to balance their low frustration tolerance for an extended period of time, and they go back to abuse of the diet. These patients are usually preoccupied with food and drink and try to make dialysis hours into orgies of drinking and eating forbidden foods. They are also the patients who are most inclined to cheat and try to hide their abuse of the diet. This low frustration tolerance can be seen also in other areas of their lifethey are impatient, they get angry when they have to wait. Their (predialysis) work history often shows troubles like coming irregularly to work or going off in the afternoon because they "had to go to the movies." Except for their difficulties with the diet, many of these patients are quite happy on dialysis. Their functioning, however, is usually
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poor. From the material collected so far, low frustration tolerance seems to be a most common factor. It was found in 17 of the 20 abusers of the diet, and to a milder degree in only 8 of the 23 nonabusers. Acting Out The term "acting out" is used here to describe behavior expressing an unconscious psychic conditioneg, emotions, memories. The patient does not realize and has no insight into the fact that this behavior is caused by unconscious factors. Furthermore, in psychiatry of today, acting out is regarded as a common method of reducing anxiety and/or guilt which would have been felt if the emotions were to become conscious. In the present group of dialysis patients two "kinds" of acting out were observed, one of which expressed unconscious hostility and aggression. In some of the patients with this kind of acting out, it appeared only in flare-ups, while in others it was more repetitious and chronic. Less common was behavior expressing unconscious striving for independence. This second type of acting out did not, on the whole, come in outbursts but was chronic. Acting out of aggression, often directed against the team and at times against the family, can also cause abuse of the diet. One of our best patients has always had an "irresistible impulse" to take salty foods when eating with his motherthe mother who had refused to cooperate with a home dialysis program which the patient badly wanted. Frequently one sees patients who, when coming for dialysis and being told that there has been a technical hitch and that they have to wait for a couple of hours, are later found in the cafeteria on a "drinking spree"; or the patients who find that their "special nurse" cannot connect them to the machine on that same day and who suddenly become terribly thirsty; or the patients who become abusers of the diet when their physician goes on a vacation. The characteristic pattern of the acting-out

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patients is that at least some of them adhere in general rather well to the diet, but they have occasional periods of abuse. Most of the time something has happened before such an attack, to which other people would react with overt anger and aggression. Some, however, continue with this acting out for prolonged periods of time. These are usually people with a high level of aggression and little ability to express it verbally, often with marked passive-aggressive traits. Much less common is abuse of the diet as a result of acting out of independence problems. One young patient, for whom the dependency of dialysis was very difficult, refused to report on his weight before and after dialysis. As long as he was pressed to give this information, he not only abused the diet but also reported on even greater abuse than the actual one. Once the fight around that issue was stopped he seemed to keep better to his diet and has been doing extremely well on dialysis for a number of years already. Another patient declared, "I am not going to be ruled by this monster." As this patient had an obsessive compulsive personality, he decided for himself on a given degree of abuse of the fluid restriction, and he religiously adhered to it. The acting-out patients may at times reach the extreme of not coming to dialysis, as happened with 1 patient who will be described briefly later on in this report. Acting out seems to be a frequent phenomenon in dialysis patients and was found in 24 of the 43 patients studied. Denial of Sick Role Naturally, patients on dialysis realize that their lives depend on this treatment. Some of them, however, deny the severity of their condition. For these patients it is hard to accept not merely the dependency of dialysis but also the fact that they are ill. This denial may lead to abuse of the medical regimen and is often most pronounced in the area of taking medicines eg, not taking (or taking irregularly) prescribed

antihypertensive drugs. They are also inclined to argue that they do not need such prolonged dialysis and ask to have it reduced. These patients are rather easy to identify by their history. They have usually avoided going to physicians and tried to dissimulate and carry on even when feeling quite ill. They have thought that "half the dose of antibiotics is more than enough" and often have the attitude that physicians and medications should be avoided altogether. On dialysis they often continue dissimulating and, when asked about how they feel, reply "fine, fine." As part of their denial of being ill they are often "ideal patients." They ask for little attention from the nursing staff and continue to function in everyday life on a very high level. Excessive Gain From Sick Role The group of patients described here is the exact opposite of the one described above. Some dialysis patients get, or try to get, secondary gain from their conditionmore attention, social benefits from society, etc. This tendency for secondary gain, which is rather common in chronic patients, may cause or increase abuse of the medical regimen. There are some patients for whom dialysis does not create problems but for whom it solves predialysis conflicts. These patients do not want, usually unconsciously, to "get well" and thus have to face their problems again, and this might lead to their abuse of the medical regimen. An example of this is the patient who has been frigid all her married life and for whom this frigidity turned into active disgust of sexual relations after the birth of her second child, followed by many guilt feelings towards her devoted and considerate husband. On dialysis she complained of being unable to resume "normal family relations." From the above it is clear that every effort to convince her to increase her caloric intake would be in vain. Another form of primary gain is seen in patients who use their "sick condition" to solve, to a certain degree, their dependency-independ337

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ency problems. It can be said, therefore, that for some patients being ill has the primary gain of solving conflicts and reducing anxiety. They therefore ensure their state by a continuous, steady abuse of the medical regimen, usually of the diet.

Suicidal Behavior

Some patients, though not many, according to our findings, abuse the medical regimen as a result of suicidal tendencies. They drink too much, they eat forbidden foods and often say they are "fed up." In our opinion, in order to say that a patient's behavior is suicidal by intention (and not merely harmful in its results) there should be additional signs or symptoms that the patient is "fed up"eg, narrowing of interests, withdrawal from interpersonal relations, decrease in future planning, depressive affect or its equivalent in increased physical complaints or its projection to "others suffer so much from me, others are fed up with me." We believe that abuse of diet only should not be regarded as suicidal behavior if there is no concomitant reduction in other areas of self-care. Among the 43 patients included in this study there have been a number with verbalized suicidal thoughts. These usually took the form of, "I do not think such a life is worth living; if X happens (eg, inability to work, rejection by partner, etc.) I will kill myself," or inquiry into how many sleeping pills are necessary "to make it foolproof." Some of these patients were among the best in their compliance with the medical regimen. The only case of death we believed to be suicide (slipped shunt) was that of a woman who was perfect in her adherence to the medical regimen. The treating physician in that unit is of the opinion that it was an accidentwe are of the opinion that it was suicide as she had voiced her intentions"One day I will find the courage"and because some of the other manifestations described before were present. We realize that we are describing here an
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extreme contradiction: good or excellent adherence to a medical regimen in patients expressing suicidal thoughts. Though not very frequent, we found it often enough to motivate the present study, feeling that not all abuse of a medical regimen can be regarded as suicidal. We have therefore limited the term "suicidal" to those patients whose behavior shows conscious or unconscious death wishes. Excluded, therefore, was the so-called demonstrative suicidal behavior which is manipulation of the surrounding. These patients were included in the excessive (secondary) gain group.
Homicidal Behavior Against the Patient

It has been said already that when a patient attempts or commits suicide the question should not only be, "Whom did the patient want to punish?" or "Whom did the patient want to kill?" but sometimes we should also ask the question, "Who wanted the patient dead?" We believe this to be true in psychiatric patients and often striking in dialysis patients, as in the following examples.
An adolescent daughter of a divorced man on dialysis came in for a consultation about her father. She described her father's physical suffering (caused by his abuse of the water restriction and being on and over the verge of pulmonary edema) and his being unhappy, hopeless and depressed. She continued by describing her devotion to him. When asked what she does when her father does not feel well she described giving him big glasses of the lemonade that he likes, fixing him his favorite dinner of a large steak and trying to cheer him up. We asked if she realized the damage of such a treatment and her answer was, "He must have some pleasure in lifemaybe he would be better off dead." A more extreme example is that of a 21-year-old patient who was seen before start of dialysis. The prediction was that there would be many troubles on dialysis because of the miserable combination of extremely low frustration tolerance and very high tendencies for acting out, which would result in extreme abuse of the medical regimen. Transplantation was therefore preferred (also by the patient) and as there are few cadaver transplantations in our hospital, the patient's family, a widowed mother and an older brother, were interviewed. After some discussion each one was ready to admit that he/she really did not want to donate a kidney, but they objected even more strongly to the other one's giving a kidney. The summary of the mother

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Table 3. Profiles of Abusers of Diet Den~al of sick role F a ~to r mild abuse Mild chronic abuse Primarysecondary gain Suicidal behavior Severe abuse

Mechanism Acting out Fair t o good, with attacks of abuse Noncompliance Usually good

Low frustration tolerance

Compliance with diet

Abuse with short per~ods of efforts at adherence Good compliance

Severe abuse

Compliance with other medical recommendations Behavior o n dialysis Usually attacks of noncompliance Variable Variable; often relaxed

Cheating

Predialysis behavior

Irregular functioning

Diss~mulation of suffering; often high anxiety Dissimulation of physical problems Variable Very h g h

Withdrawn; physical complaints; depressed Variable

Functioning

Usually poor

H~story of problems i n handling aggression Variable

Decreases

Declines

DE-NOUR & CZACZKES was, "I am really scared of giving a kidney, but I naturally want to save my son and of course I do not want two crippled boys, so it should be my kidney." The older brother stated the same opinion, though in a more sophisticated way. They were therefore not accepted as potential donors. At the end the patient was accepted for dialysis in another unit. His abuse of the diet was extreme and his physical condition, as a result, was very bad. He continued to exert pressure on his family that he needed a transplantation. The team tried very hard to convince him to adhere to the diet and the other patients joined in their efforts. After a stormy argument"You must keep the diet""I just cannot keep the diet, I must have a transplantation"he left the hospital and did not come back for his next dialysis. The family was called in, and at first they disclaimed knowledge of his whereabouts but later explained that they had found a physician who could cure him without dialysis. Some 12 days later the patient came to the emergency ward of another hospital in severe pulmonary edema and died before dialysis could be started.

phenomena well but suspect that they are related to body image problems and to the psychologic significance of urination, for men especially.
Comments

From these, as well as from other less extreme and clear-cut examples, it seems that the families can promote severe abuse of the medical regimen out of their conscious, or more often unconscious, hostility against the patient. This, we believe, is the main reason why some families just cannot understand the importance of the diet. The family's abuse of the diet can be a very important factor in the patient's abuse of the medical regimen. So far, however, we have not seen a patient whose abuse of the medical regimen could be attributed only to the family.
Beliefs

Under this heading we include a variety of illogical and emotional attitudes that may result in abuse of the medical regimen. Often these attitudes seem to be connected with problems of body image. Two excessively hypertensive patients refused nephrectomy point-blank. Though no additional relevant information was received from them, this noncompliance was probably caused by their inability to face life without urination, as described elsewhere (10). Another, not psychotic, patient connected ejaculation difficulties with dehydration and "found out" that some overdrinking helped his potency and ejaculation. We do not feel that we understand the psychodynamics of these
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Table 3 summarizes the profiles of the patients in the first five groups, which are more homogeneous. (In some of the subgroups "variable" was put in to describe behavior, meaning that no clear pattern of behavior was found.) Often, of course, a patient's noncompliance with the medical regimen is not a result of one factor but a combination of a number of factors. The most common factor causing abuse of the diet seems to be low frustration tolerance. This was found to some extent in 25 of the 43 patients studied and seems to differentiate clearly between good and bad compliers (the difference is statistically significant at the .01 level). Acting out is another common factor and was found in 27 of the 43 patients. It differentiated less well between compliers and noncompliers, except that in the second group when acting out was found it was severe, while in the good compliers we often observed mild acting out. We would like to stress the importance of the factor named "primary gain." Most reports on dialysis patients concentrate on the stresses of dialysis and the emotional problems created by dialysis, which is true for many patients. There are, however, patients for whom dialysis is a solution for a long-standing conflict, often in the area of dependency-independency or activity-passivity. In our group of 43 patients we found that dialysis to some extent solved emotional conflicts for 21, of whom 14 were abusers of the diet. It seems, therefore, that when dialysis solves preexisting conflicts, the patient tends to abuse the diet. Denial of sick role was not a common finding in this group of patients. It was found in 10 patients only, and in most of them it was not severe enough to cause abuse of the diet.

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Suicidal thoughts were expressed by 11 patients and in only 4 of them did we gain the impression that the abuse of the diet was also influenced by suicidal behavior. As described previously, some of the patients expressing suicidal thoughts were among the best adherers to the diet. No statistical information on the frequency of the effects of the family on abuse of the diet can be presented, as we do not know enough about the families of the 28 patients not on psychotherapy. About the other 15 patients it can be said that in 3 of them the abuse of the diet was to some extent influenced by their families' homicidal wishes. The families of 3 other patients were also loud and clear in their wish to get rid of the patient, but those patients adhered well to the diet. It therefore seems that a negative, rejecting attitude of the family may be important if and when the patient is ready to act out accordingly, while in other patients the hostility of the family will not influence adherence to the diet. The three more common factors that may cause abuse of the diet are summarized in Table 4.
DISCUSSION

We have described the factors that can result

in abuse of the medical regimen of chronic hemodialysis, consisting mainly of a rather strict diet and, for some patients, of other medical recommendations such as various medications. No clinical signs of gross brain damage were found in any of the patients. Signs of organic damage in psychologic tests were found in some of the patients, but there was no correlation between abuse of the diet and signs of organicity. On the other hand, severe and prolonged abuse of the diet seems to be caused most frequently by low frustration tolerance as well as by continuous severe acting out. Patients for whom the sick role is problem solving are also likely to abuse the diet. Like most reports on adjustment to dialysis, those on compliance with the medical regimen of dialysis patients are often contradictory. To mention two, Bor.kman (2) reported that 32% of patients did not adhere to one or more aspects of the regimen, while Curtis et al (11) are of the opinion that, on the whole, the majority of patients gradually come to accept the dietary restrictions. In the present study about 45% of the patients were rated as abusers of the diet. Studies dealing with other patients (usually ambulatory patients) report on one-third of noncompliers. Davis and Eichorn (4) in their summary of the literature found the reported range of noncom-

Table 4. Three Common Factors That May Cause Abuse of the Diet No. of patients Total Abusers 17 3 Nonabusers 8 15

Low frustration tolerance Normal frustration tolerance Acting out No acting out Primary gain No primary gain

25 18 x 2 = 11.06 c.01 P < 27 16 ns 21 22

12 8 14 6

15 8 7 16

= 11.34

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pliance to extend from 15 to 93% of the patients. In another study (5) Davis reported that "patients with less severe medical problems were more likely to follow through with medical advice than those with more severe illness" and that "the greater the effect of the illness on performing daily activities the less likely was the patient to follow doctors' advice." Dialysis patients, therefore, can be expected to be noncompliers. We regard the rate of abusers in the present study as high, and this not merely because it is higher than the accepted third of the patients. Those classified as abusers of the diet were noncompliers in a striking way. Their noncompliance not only endangered their lives in the long run but also made them feel physically bad in the short run. In this aspect dialysis patients are different from most patients studied so far. Usually the physician tells the patient that "it is not good for you to . . . ," but the patient does not actually feel the harm. The dialysis patient, however, does feel it within a day or two. Theoretically, therefore, the immediate results of dietary noncompliance should have acted as repeated negative reinforcement and reduced the rate of noncompliance. This, however, has not been found, and we therefore regard the rate of noncompliers found in this group of patients as high. We believe that this high rate of noncompliance can be partially attributed to a high level of aggression. We have repeatedly expressed our opinion that in some or many patients (no statistical information yet) the dependency of dialysis and the loss of mastery causes an increase in hostility and aggression (8, 9). Few of them can express this hostility openly as it is quite difficult to be aggressive to those on whom one's life depends, irrespective of basic personality. Other patients repress this aggression but act it out, while still others introject it and develop depression with suicidal behavior, all cumulating in abuse of the medical regimen. Though often more than one factor was causing the patients' noncompliance with the
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regimen, we suggest that identifying the factor(s) in each individual patient is of utmost importance, as it should dictate the psychotherapeutic intervention with each patient, as well as the expectations from such an intervention. Low Frustration Tolerance Our experience of trying to influence this factor by psychotherapy has been very poor. Individual supportive psychotherapy, psychoanalytic oriented psychotherapy and mobilizing other patients in a sort of group psychotherapy, not to mention pleas and threats, have not helped. It seems that none of these methods is effective in either increasing the patient's frustration tolerance or decreasing his abuse of the diet. Lately we had the idea that hypnotic treatment with posthypnotic suggestion might be effective in these patients, but we have not had a chance to try it out yet. Acting Out This factor seems more amenable to psychotherapy, specially in the majority of patients who act out hostility and aggression. In psychodynamic psychotherapy the patient can be helped to understand the aggression underlying his behavior and find new methods for handling and expressing it. The work is somewhat more difficult with those patients who act out their intolerance of their dependent situation. In these cases it might be helpful to add work with the team to the orthodox psychotherapy and to find ways and means to decrease the patient's actual dependency (12). The main problem for this whole group is the one described previously (9) of establishing a psychotherapeutic relationship with dialysis (chronic) patients. When and where this can be achieved, there seems to be a good chance that the patient's abuse of the medical regimen would decrease and gradually stop within a few months.

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Denial of Sick Role

When this rather uncommon mechanism causes abuse of the medical regimen, it creates a problem because this denial has "positive" aspectsie, high functioning and few or no psychiatric symptoms. We have been afraid, therefore, 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 life on dialysis. Our policy has therefore been that as long as the noncompliance does not endanger the patient's life, nor is likely to damage his physical condition seriously, we should leave well enough alone. In such cases some work with the team should be done to enable the team to accept this noncompliance as a method of adjustment and not as symptoms of foolishness or manipulation or plain stubborness (12, 13).
Excessive Gain From Sick Role

behavior, and if he is not supportive the patient might see it as rejection with the same outcome. Another problem is the time elementthe psychotherapeutic work should progress fast enough to prevent actual suicide. All this is even more true of dialysis patients with suicidal behavior causing abuse of the medical regimen. The difficulties of establishing a relationship with dialysis patients in general have been described elsewhere (9), and to achieve it with a withdrawn, depressed patient is even harder. Finding the correct approach with these patients is very difficult because of the patient's suspicion that the psychiatrist, like the rest of the team, will be angry at his behavior. Nevertheless, it can be done, and intensive focused psychotherapy is recommended, together with maximal manipulation of environmentgetting the team, family and work place to participate.
Homicidal Behavior

As described, these patients have a good amount of primary gain as well as secondary gain from being ill. Their motivation for change is therefore very limited. To some extent they could be compared to psychophysiologic patients who also are often resistant to psychotherapy. Theoretically, long-term intensive psychotherapy should be able to help them solve the basic problems now solved by their sick condition, but so far our limited experience with psychotherapy has not proved this to be true.
Suicidal Behavior

From regular psychotherapy it is well known that work with suicidal patients, even when they are not psychotic, is often difficult. It is hard for the therapist to find a balanced attitude. If he is scared of the suicidal potential, the patient loses all confidence in his ability to control his behavior. If the therapist is not frightened at all, the patient might be provoked "to teach him a lesson." If the therapist is very "good and supportive," it might increase the patient's guilt feelings and promote the suicidal

In these cases it is useless to work only with the patient. It seems that working individually with the "homicidal family" is also often fruitless, while family psychotherapy may produce the wished-for results. In any family therapy it might be difficult for the therapist to remain neutral and avoid taking sides. It is even harder to achieve and retain this neutrality with dialysis patients and their families and to avoid blaming the family for their "inconsiderate, nonunderstanding behavior toward the unhappy and ill patient" and to refrain from taking sides with the family against the "demanding, egocentric patient." Our feeling, however, is that such family therapy can be done and that it would be helpful to many dialysis families and not only to the few "homicidal" ones. We would like to suggest that if a patient's noncompliance with a medical regimen could be diagnosed according to an outline such as the one presented here, the psychiatrist's interventions would be much more rationalmore
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fruitful with some of the patients and less frustrating in others. The outline presented is probably incomplete and does not cover all cases and mechanisms of nonpsychotic patients, yet it seems adequate for diagnosis and treatment of the majority of patients. We would like to suggest that such mechanisms cause abuse and noncompliance in any medical setup and not exclusively in chronic hemodialysis as described in this report, though, naturally, some of these factors may be more or less important according to the specific demands and stresses of the various medical treatments. This suggestion is now under further study. One problem seems to have been left unanswered: Most of the patients, irrespective of their adherence to the diet, complain bitterly of being thirsty all the time. Only some of the excellent adherers say that they "got used to it" and that the fluid restriction is not a problem any more. The question remainswhy are most of the patients thirsty even though they get enough water for their physiologic needs? Many say that drinking (like eating) is a habit. Then why cannot these patients develop new drinking habits? Does this continuous thirst have a special deep psychologic meaning, is it caused only by wanting the forbidden, or is it a nonspecific way of expressing their unhappiness with life on dialysis? At the present time we do not have adequate answers to these questions. We would like to stress this problem as the patients' misery is often related (at least superficially) to their being thirsty.
REFERENCES 1. Abram HS, Moore GL, Westervelt FB: Suicidal behavior in chronic dialysis patients. Am J Psy-

chiatry 127:1199, 1971 2. Borkman T: Patient compliance with hemodialysis regimen: study relating selected factors to patient compliance. Unpublished report, 1969 3. Goldstein AM, ReznikoffM: Suicide in chronic hemodialysis patients from an external focus of control framework. Am J Psychiatry 127:1204, 1971 4. Davis MS, Eichorn RL: Compliance with medical regimens: A panel study. J Health Hum Behav 4:240, 1963 5. Davis MS: Variations in patients' compliance with doctors' advice: An empirical analysis of pattern of communication. Am J Public Health 58:274, 1968 6. Davis MS: Physiological, psychological and demographic factors in patient compliance with doctors' orders. Med Care 6:115, 1968 7. Davis MS: Variation in patients' compliance with doctors' orders: Medical practice and doctor-patient interaction. Psychiatry In Med 2:31, 1971 8. Kaplan De-Nour A, Shaltiel J, Czaczkes JW: Emotional reactions of patients on chronic hemodialysis. Psychosom Med 30:521, 1968 9. Kaplan De-Nour A: Psychotherapy with patients on chronic haemodialysis. Br J Psychiatry 116:207,1970 10. Kaplan De-Nour A: Some notes on the psychological significance of urination. J Nerv Ment Dis 148:615, 1969 11. Curtis JR, Eastwood JB, Smith EKM, et al: Maintenance haemodialysis. Q J Med 38:49, 1969 12. Kaplan De-Nour A, Czaczkes JW: Emotional problems and reactions of the medical team in a chronic haemodialysis unit. Lancet 11:987, 1968 13. Kaplan De-Nour A, Czaczkes JW: Professional team opinion and personal bias: A study of a chronic hemodialysis unit team. J Chronic Dis 24:533, 1971

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