JOHN G. FLANNERY, M.B.
Adaptation to chronic renal failure The author's clinical experience in a large dialysis unit over a five-year period is described, with emphasis on the psychiatric aspects of long-term adaptation. Because the inevitable stresses of renal failure tend to restrict the patient's communication with other people, emotional difficulties can remain hidden in patients who appear to be coping well.
This article is meant to provide a tentative map of the altered psychologic terrain in patients maintained on renal dialysis (hemo- or peritoneal). Such patients lead a tidal life, the dialysis procedure washing away the accumulated noxious metabolites every two or three days, much as the ocean tide cleanses the beach of debris. Perhaps the map will enable people working with dialysis patients to get their bearings a little better in a confusing field. Confusing aptly describes the psychiatric literature that has emerged in the past 20 years about the psychologic responses to dialysis. 1 Many causes have been suggested for the high incidence of psychiatric morbidity and suicidal tendencies, although there is no real agreement on the kind of mor784
bidity to be expected in such patients. There is some agreement, however, that the psychiatric morbidity does not appear as an increased incidence of recognizable neurotic or psychotic syndromes, although many neurotic defense mechanisms are thought to be intensified in the coping process. Background The clinical material of this presentation is drawn from five years of close experience in a large dialysis unit within the department of nephrology in a metropolitan university teaching hospital. The author, who is a psychoanalyst and liaison psychiatrist, together with a senior psychiatric resident, were associated with this unit at all levels-medical, nursing-technical, and social work. While formal re-
quests for consultations were made frequently, and usually attended to on the same day, there were informal discussions on patient care almost every week. Consequently, the liaison team often knew a good deal about the patient's emotional reactions and adjustment weeks or months before meeting the patient personally. The unit social worker and nursing-technical staff often brought a patient's behavior to consultation even before the formal referral was made. Sometimes, such a consultation sufficed to resolve the difficulty. Many patients received individual short-term therapy, sometimes with drugs. Some received long-term therapy, and several required hospitalization and were followed by the liaison team for weeks or months while in the hospital psychiatric unit. In contrast to Baillod and associates,2 who found in 117 patients observed over five years that" ... to date no major psychiatric problems requiring formal therapy have occurred," our liaison team was clinically busy, although intermittently so. On this service, whether the paPSYCHOSOMATICS
tients are being seen or not, psychiatric involvement with the renal team is by necessity continuous, rather than occasional. Patients with renal failure do not get "well," and therefore remain in the care of the renal team, receiving one form of therapy or another, until death supervenes. Thus, a patient may be seen for an initial consultation, followed by several sessions of psychotherapy, then discussed with the renal team from time to time, only to be referred for further therapy months or even years later. Adaptation Abram) outlined four stages in adaptation to dialysis: I. The uremic syndrome 2. The shift to physiologic equilibrium 3. Convalescence-the return to the living 4. The struggle for normalcy. Reichsman and Levy4 describe three stages: I. The honeymoon (the initial improvement with dialysis) 2. Disenchantment 3. Long-term adaptation. It is the last stage in each series-the struggle for normalcy and longterm adaptation-that this paper attempts to describe. Long-term adaptation to dialysis has been described mainly in terms of the organism's ability to deal with serious threat. The model is that of neurosis: instinctual impulse perceived as a threat to the ego is responded to with signal anxiety, which evokes defensive maneuvers. The limits to this comparison need to be stressed. An intrapsychic threat is not the same as a perception that life is really in danger, and the fear, despondency, and brooding that the latter perception gives rise to are not necesDECEMBER 1978 • VOL 19· NO 12
sarily the same affect as signal anxiety. The dilemma of the dialysis patient remains centrally an existential one, although unconscious defenses may serve to make this less painfully visible to him or her. In contrast to neurosis, resolving the coping defenses may not always be helpful, unless these defenses have become counterproductive and hinder coping. Viedermans took the view that observations of the physically ill could be useful in confirming some of the developmental aspects of analytic theory. Extending this, it appears that the dialysis situation provides a partial working model of
The helpful technical organ, the dialysis apparatus, is ambivalence reified. some of our notions of dynamic psychology, making visible that which is usually presented only through concept and metaphor. In fact, metaphors become actual and literal in the situation of the patient connected to the dialysis machine: regression to an oral level; dependence; fusion with the nurturing object; blurring of body image and fluctuation in ego boundaries; incorporation by the nurturing object; alternating attachment and separation; persecution by dangerous internal objects; and projection and introjection (via the arterial and venous lines, respectively). The patient knows that he or she physically contains and has produced "bad" objects (nitrogenous wastes and increasing serum potassium); these can be removed if he or she regresses to a helpless, infantile state, dependent on the renal team as well as on an inanimate external
object; and "goodness" returns as the bad objects are removed-but this proves temporary. So the rhythmically applied machine becomes not only a feature of everyday life, but a part of the patient's body, a new external organ, also perceived as an incorporating device. To get free, the dialysis patient must accept a new form of internal organ, or object, in the form of a renal homograft. Yet the helpful technical organ, the dialysis apparatus, is ambivalence reified. Usually it is benign and lifesaving, but it is always liable to faults, and these can mean death. It cannot be viewed with comfortable complacency like that other familiar extension of the body image, the automobile, and it is never to be completely trusted.' To see how this obtrudes itself on psychic life, it is helpful to take an analogy from surgical anatomy, the pleural space. Normally the pleural space is not a space at all, but only potentially so, having a slight negative pressure. If air enters the pleural space, as in pneumothorax, it compresses and displaces the neighboring lung. The air in the pleural space is valueless to the body for it is static and not involved in the dynamic blood gas exchange mechanisms of the alveolar capillaries; as it compresses the lung it interferes with this ongoing exchange and the body's oxygen supply is depleted. Now the actualization of psychic process, the factual part-repetition of early developmental critical stages, that occurred before words, in a reality situation governed by the issues of life and death, has something of the same effect on the psyche as admitting air into the pleural space. What hap'Not all of this applies strictly to peritoneal dialysis. but the general circumstance is the same.
pens-or more exactly what can happen-is that there is a reduction of symbolic exchange with the environment, a reduced play of interpersonal communication. while the previously silent area is now taken up by the dialysis situation and all its vicissitudes displacing the more elastic and expressive aspects of the premorbid personality. An example may make this more clear. Case 1 A 30-year-old woman. in dialysis for one year. had a severe phobia of flying insects and a history of repeated slave-like involvement with exploitive men. alternating with bouts of more energetic and independent behavior. In the first year of dialysis, she had constant nausea, worse during dialysis, and she developed recurring nightmares of a rat attempting to bite her buttocks as she sat on the toilet. At psychiatric consultation. she flatly disclaimed any primary emotional difficulty over the enforced dependence, attributing her unhappiness to the difficulty of the dialysis. The consultation report recommended that she receive an early transplant, which she did. Immediately after the transplant. she lost her nausea entirely. Her nightmare also disappeared. but it was replaced by a recurring dream in which her nephrologist mildly rebuked her for continuing to smoke. Now free to move about once more, she became increasingly terrified of flying insects. She received behavior therapy for this, with successful modification of the symptom. This case shows how dialysis exacerbated an older emotional conflict over orality and dependency (biting and being bitten. smoking and being forbidden). that appeared clearly enough in symbolic form in her dreams, but-as long as she was on dialysis-was expressed as a chronic psychophysiologic symptom. The SUbjective distress of this symptom and the thoughts about the dialysis that caused it had estab-
lished themselves at the expense of more free-ranging communication and waking fantasy. In the words of Lefebvre and associates.6 the above patient had become psychologically opaque. a state that closely resem bles alexithymia 7-a composite trait thought to be associated with psychosomatic disorder and characterized by literal-mindedness and absence of imaginative thought and fantasy, concern only with the utilitarian and practical. and confusion over identifying emotional and physical states. This alexithymiclike state is only a potential sequela, however, since not all dialysis patients show these traits. Case 2 An example of a very successful adjustment is a 48-year-old business man who was initially seen in a state of despair. alternating with rage at his business partners and physicians. He had been on dialysis for five years. quite uneventfully until. after jogging one day, he developed a massive retroperitoneal hemorrhage from his left polycystic kidney. This first major setback caused a prolonged absence from work. He had displaced the internal threat onto his doctors (who had failed to foresee this) and his partners (who were questioning his long absence and his future ability to contribute). He was very fortunate in that he was comfortably off and dialysis had made less difference to his life than it does for many others. Vascular access was easy, his wife was skillful and supportive. and (being able to retain his kidneys because of polycystic disease) he had a relatively high hemoglobin and thus did not suffer from much loss of energy. He was able to attend psychotherapy sessions and work on his existential dilemma. as well as on his relationships with the significant others in his life.
For a psychologically opaque. literal-minded patient, on the other hand. dynamic psychotherapy is not possible to this degree because the preoccupation with dialysis becomes a fixed resistance and reconstructions seem irrelevant beside the actual oral-dependent situation. Every dysphoric state tends to be attributed to the patient's being at some point in the dialysis cycle, and as a result, introspection becomes impossible. As with every serious resistance, there is an admixture of reality because the unstable internal milieu and changing plasma volumes of these patients give rise to unpleasant feeling states, where the psychologic and physical are inextricably combined.
Clinical impressions These findings shed light on the diverse c1in ical im pressions so many observers have reported in studies of patients on maintenance dialysis. Kaplan De-Nour and associates. s for instance, studied nine patients extensively for a year and noted that they were nearly free of psychiatric symptoms. They reported several neurotic defenses that were used extensively. although they could not be sure to what extent the dialysis situation had mobilized these. Whether because of these defenses or not. they felt that the patients' personalities were impoverished, and that emotional involvement was merely superficial. Abram,9 in studying selfreports from dialysis pa tien ts, found that many patients see themselves as not entirely human, as a result of incorporating the machine into their body image. Moreover, this corresponded to some of his own fantasies about them. Litin,1O too, reports dialysis patients having Frankenstein fantasies.
My own experience is that for many of these patients, such fantasies are overdetermined and also represent the loss of imaginative play and emotional range (equated with humanness), as the dialysis situation preoccupies the personality in a static, rigid way. While the restriction of psychic interest to the utilitarian features of life on dialysis and all that follows (overt normality, compliance, uncomplaining and almost stoic perseverance) is only a potential sequela of dialysis, it is possibly the only specific one, and is wholly iatrogenic or, better, regarded as adventitious. 11 Of course it also serves the purpose of defense in a broad sense (that is, against both intrapsychic and external dangers), since attention is deflected from psychologic concerns and interpersonal issues, while dysphoric affects are easily rationalized as having physiologic causes. As a defense, it somewhat resembles ego restriction, but this term does not do justice to the resulting complex psychophysiologic and psychologic states. Accordingly, signs of emotional disequilibrium do not appear as in an ordinary population, but either as altered dialysis behavior (such as difficulty cannulating) or as unexplained physical symptoms (such as increased fatigue, impotence, difficulty in walking), while the facade of the compliant, uncomplaining, not very emotional patient is kept up. Because of this, the nursing and technical staff tend to spot trouble before the medical resident or nephrologist. If the presenting symptom is a physical one, a considerable time is often spent with
multiple investigations before a psychiatric referral is made. Delay in psychiatric referral was a frequent subject of unit conferences, where the nursing staff in particular would feel they were not being listened to, and the medical staff's absorption in physiologic indices would become very apparent, often with a defensive aspect. Residents beginning their term with the psychiatric liaison team at first tend to see these patients as emotionally dull and indifferent to a psychologic approach, finding, as Lefebvre and associates say, ..... a poverty of dialogue with the external object, an apparent sparseness of inner life, and a certain clinical inertia." This tends to be considered a sign of depression. Some residents, because of the depression evoked at seeing the patient's plight, diagnose it by projective identification. Others tend to identify with the patient and attribute the psychologic difficulties to the life style and vicissitudes ofdialysis. All these approaches can lead to an early therapeutic impasse. In fact, very few patients wholly reject a psychologic approach, and there is almost always some degree of egoawareness that can be co-opted into a therapeutic, rather than a purely defensive, alliance. A steady empathic presence is required of the therapist if the patient is to make his or her own terms with the primary existential dilemma of leading a tidal, uncertain life. Summary
Maintenance renal dialysis means that a technologic artifact is grafted onto human existence, creating, in
Dr. Flannery is coordinator ofthe consultation and liaison service at Toronto General Hospital and assistant professor ofpsychiatry at the University of Toronto. Reprint requests to him at Toronto General Hospital, Toronto, Ontario M5G JL7. DECEMBER 1978 • VOL 19 • NO 12
part, a reality facsimile of early, preverbal development. Under the inevitable stresses of renal failure, the thoughts and concerns evoked by dialysis impede the flow of imaginative process, tending to restrict communication with other people to the necessary and utilitarian. While this potential sequela is avoided by some patients, it appears at varying times and with varying severity in others. This change in expressive style explains why serious emotional difficulties can be present in patients who overtly seem to be coping very well. It also explains delays in referral, as well as the apparent indifference of patients to a psychologic approach, with its interest in a range of feelings no longer available to them. 0 REFERENCES 1. Anderson K: The psychological aspects of chronic haemodialysis. Can Psychiatr Assoc J 20:385·391. 1975. 2. Baillod RA. Crocke" RE. Ross A: Social and psychological aspects of regular hemodialysis treatment. Proc fur Dial Transplant Assoc 5:97. 1968. 3. Abram HS: The psychiatrist, the treatment of chronic renal failure and the prolongation of life. I. Am J Psychiatry 124:10, 45-52.1968. 4. Reichsman F. Levy NB: Problems in adaptation to maintenance hemodialysis. Arch Intern Med 130:859-865. 1972. 5. Viederman M: Adaptive and maladaptive regression in hemodialysis. Psychiatry 37:6877, 1974. 6. Lefebvre P, Norbert N, Crombez JG: Psychological & psychopathological reactions in reo lation to chronic hemodialysis. Can Psychiatr Assoc J 17:SSIi. 1972. 7. Nemiah J. Freyberger H. Sifneos P: Alexithymia: A view of the psychosomatic process, in Hill OW (ed): Modern Trends in Psychosomatic Medicine. London, Bu"erworths. 1976, vol 3. 8. Kaplan De-Nour A. Shaltiel J. Czaczkes JW: Emotional reactions of patients on chronic hemodialysis. Psychosom Med 30:521-533. 1968. 9. Abram HS: The psychiatrist. the treatment of chronic renal failure and the prolongation of life. II. Am J Psychiatry 128:43. 157-167, 1969. 10. Litin EM: Discussion of three papers on man and the artificial organ. read at the 123rd meeting of the American Psychiatric Association. Detroit. Mich, May 8·12.1967. 11. Flannery JG: Psychosomatic medicine in a general hospital: Some dilemmas. Can Med Assoc J 114:665-666, 1976.