The Review
THE PSYCHOLOGICAL ASPECTS
Introduction
It has been almost fifteen years since
Scribner and his associates (31) introduced
the permanent arteriovenous shunt. This
has made maintenance hemodialysis a prac-
tical possibility for the long-term care of
patients with terminal renal disease. In-
creased 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 man-
ifested significant adverse psychological
reactions while under the dialysis program
and they exhibited poor acceptance and
adjustment. Glassman (11) in 1970 attri-
buted 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)
385
OF CHRONIC HEMODIALYSIS*
K. ANDERSON, M.D.l
studies to the lack of application of dis-
criminating criteria for the selection of pa-
tients. Abram (1) also stressed the impor-
tance of psychiatric aspects in the selection
process and cited Kolff (20), Sand et al.
(30) and Johnson (13) who reported gener-
ally good psychological adjustment and
adaptation to chronic dialysis. Abram con-
trasted these findings with the results ob-
tained by Retan and Lewis (29) and Gom-
bos 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 be-
lieve that the only psychiatric contraindica-
tions per se are psychosis . . . and the
mental defective patient. Patients should be
rejected only on medical grounds."
Several authors have attempted to iden-
tify 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 adher-
ence and vocational rehabilitation as meas-
ures of adjustment, concluded that intelli-
gence 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
386 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
poor adjusters tended to be more defensive.
Sand found that good adjustment was as-
sociated 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 ad-
justment 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 sur-
vivors with seven patients who expired
while on chronic hemodialysis. No
psychological differences were observed
with respect to age, sex, education or dura-
tion 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 mem-
bers 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. Depen-
dence 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 non-
compliance with medical" regime is attribut-
able 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
Vol. 20, No.5
accepting dependency generated by passiv-
ity 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 de-
pressed before acceptance into the dialysis
program. Most authors related depression
to stresses induced by the mechanical dif-
ficulties 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 Depres-
sion Scale, found a discrepancy between
the low level of depression and anxiety
reported by the patients and their appear-
ance as lethargic, depressed, and suffering
from generalized pruritis.
Defence Mechanisms
Denial is seen as the most commonly
used defence mechanism of dialysis pa-
tients. Its adaptive value is frequently de-
bated. Sand reported that" ... in general
the patients who are later seen as making a
poor adjustment tended to be more defen-
sive in all tests and to deny even normal
amounts of adjustive difficulty and anxie-
ty." Kemp (18) reporting on the psychiatric
correlates of renal failure noted a remarka-
ble 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, displace-
ment and intellectualization. Kaplan De-
Nour (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 lethar-
gic and depressed, and the reporting of little
August, 1975 CHRONIC HEMODIALYSIS
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 depres-
sion it apparently protected patients from
experiencing more intense helplessness,
and during some periods of contentment it
preserved their sense of well-being. Vie-
derman (35) saw regression to a level of
functioning reminiscent of infantile depen-
dency 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, charac-
terized by fatigue, apathy, drowsiness, ina-
bility to concentrate, depression and insta-
bility.
• 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.
387
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 plan-
ning 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. How-
ever, demands for continuing changes
necessitated by dialysis complications con-
tinue and family concessions necessarily
occur over a period of many months to
several years. Generally a progressive pro-
cess of interactional decay between the
patient and his home situation is observed.
Continual uncertainty of the future distres-
ses 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 as-
sume 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 de-
terioration 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 be-
fore developing uremia, 5.7 after uremia
and before hemodialysis, and 4.0 while on
hemodialysis. Lefebvre, Nobert and Crom-
bez (22) attributed impotence directly to the
dialysis, which they observed had an emas-
culating effect on many patients. In con-
trast, Elstein, Smith and Curtis (5) reported
that pregnancy occurred in wives of three of
388 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL
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 sper-
matogenesis. In their eleven transplant pa-
tients sexual desire had reverted to the
pre-uremic level and three wives had be-
come 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 adoles-
cents are now considered to be eligible.
Viederman (35) had" ... seen no adoles-
cent who could be considered a well-
adapted one to dialysis." He attributed this
difficulty in adaptation to their already dif-
ficult situation of struggling for indepen-
dence 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 nor-
mals, they did appear to have suffered
damage to their self-esteem. They noted
that there was a considerable initial up-
heaval in the families of such recipients, but
normal family equilibrium was usually re-
stored within a year after a successful trans-
plant. Khan et at. (19) studied the social
and emotional adaptations of fourteen chil-
dren; 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 relation-
ships maintained between parents and chil-
Vol. 20, No.5
dren, and most families reported psycholog-
ical 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 pa-
tients, 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 psychia-
trist in dialysis units was primarily suppor-
tive. 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 counter-
transference difficulties between patients
and dialysis team members becomes clear
in Short and Wilson's findings (33), that
dialysands and nurses frequently build rela-
tionships 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
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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3. Abram, H. S., Moore, G. L., Wastervelt,
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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 pro-
voquee par Ie conflit qui surgit de la depen-
dance 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 pro-
fessionnelle. Alors que les patients de
caractere autonome acceptent malla depen-
dance requise par la dyalise, ils s'adapter-
ont plus facilement a la rehabilitation pro-
fessionnelle.
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