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Psychiatric problems in living-related transplantation (II): the association between paradoxical psychiatric syndrome and guilt feelings in adult recipients after living donor liver transplantation
Psychiatric Problems in Living-Related Transplantation (II): The Association Between Paradoxical Psychiatric Syndrome and Guilt Feelings in Adult Recipients After Living Donor Liver Transplantation I. Fukunishi, Y. Sugawara, T. Takayama, M. Makuuchi, H. Kawarasaki, Y. Kita, A. Aikawa, and A. Hasegawa
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SYCHIATRIC follow-up studies are available for recipients and donors after transplantation.1 Recent reports have established the occurrence of psychiatric symptoms among successful adult liver transplant recipients.2,3 Psychiatric symptoms manifested despite favorable operative outcome have been referred to as the Paradoxical Psychiatric Syndrome (PPS).3 We hypothesized that PPS is closely related to recipient guilt feelings toward a living donor. Before LDLT, recipients’ desire to escape from approaching death supersedes their conflicted feelings related to the prospect of living organ donation. Following LDLT, the fear of death subsides and concern for the donor becomes more pronounced. This psychological process may be relatively specific to LDLT because of its attendant risk of postoperative donor morbidity. We examined the relationship between guilt feelings and PPS. PATIENTS AND METHODS The subjects consisted of 53 Japanese adult recipients who underwent LDLT in Japan. The mean age of recipients and donors was 44.1 (18 to 64) and 39.1 (20 to 61) years at the time of transplantation. There were 23 males and 30 females who underwent LDLT. Donors for recipients undergoing LDLT were the recipients’ children (n ⫽ 18), brothers/sisters (n ⫽ 13), parents (n ⫽ 11), spouses (n ⫽ 8), and nephews (n ⫽ 3). After providing informed consent, all the recipients were interviewed by two mental health professionals, a psychiatrist and a psychologist. Diagnosis of psychiatric disorders was made based on the DSM-IV criteria. The presence or absence of PPS was evaluated on the basis of diagnostic criteria for PPS (Table 1). When all four elements existed, psychiatric symptoms were judged as PPS. We also assessed the level of guilt feelings using an item on guilt feelings of the Hamilton Depression Rating Scale (HRS).4
Table 1. Diagnostic Criteria for PPS 1. Prominent conflicts associated with transplantation (for example, guilt regarding the donor’s welfare) 2. Situational reaction such as depression, anxiety, conversion, somatization, and adjustment disorder, and/or psychosis 3. The reaction occurs as a late complication following liver transplantation (within the first year following transplant) 4. Favorable medical status of donor and recipient, without tissue rejection or other major medical complication.
Among the 31 recipients who met for the DSM-IV psychiatric disorders, 16 met the diagnostic criteria for PPS. The PPS diagnosis was seen in 51.6% (16 of 32 recipients with psychiatric disorders) and 30.2% (16 of 53 recipients). The PPS diagnosis occurred in 13 (72.2%) of 18 recipients who received a donor liver from one of their children, in 1 of 13 with a graft from brothers/sisters, in none of 11 with parental donors, in 1 of 8 with spousal donation, and in 1 of 3 with a graft from a nephew. Among 53 adult recipients who underwent LDLT, 18 donors were adult children (13 sons and 5 daughters) of the recipients. The 1-year incidence rate of PPS was significantly higher for child-to-parent (adult child to adult) LDLT than for other types of adult LDLT (df ⫽ 1, chi-square ⫽ 22.9, P ⬍ .05). According to the (HRS), the mean score on guilt feelings of the HRS was 1.3 (SD ⫽ 0.8). As shown in Table 2, multivariate analysis of variance for two factors (the presence or absence of PPS and adult child-to-adult type) revealed that recipients of child-to-parent (adult child-toadult) type who exhibited PPS had significantly higher scores on guilt feelings of the HRS (P ⬍ .05).
RESULTS
The 1-year incidence rate of the DSM-IV psychiatric disorders was 31 (58.5%) of 53 recipients who underwent LDLT. The diagnosis consisted of delirium (n ⫽ 9), major depression (n ⫽ 8), dysthymic disorder (n ⫽ 6), adjustment disorder (n ⫽ 4), brief psychotic disorder (n ⫽ 2), posttraumatic stress disorder (n ⫽ 1), and substance-induced disorder (n ⫽ 1).
From the Tokyo Institute of Psychiatry, Tokyo Metropolitan Organization for Medical Research, and Faculty of Medicine, University of Tokyo, Tokyo, Japan; and Department of Nephrology, Toho University School of Medicine, Tokyo, Japan. Address reprint requests to Isao Fukunishi, MD, Tokyo Institute of Psychiatry, Tokyo Metropolitan Organization for Medical Research, 2-1-8 Kamikitazawa, Setagaya-ku, Tokyo 156-8585, Japan.
0041-1345/02/$–see front matter PII S0041-1345(02)03455-3
© 2002 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710
2632
Transplantation Proceedings, 34, 2632–2633 (2002)
GUILT FEELINGS IN LIVER TRANSPLANT
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Table 2. Scores on Guilt Feelings of the HRS (Results Were Shown in Mean ⴞ SD)
PPS (⫹) (n ⫽ 16) PPS (⫺) (n ⫽ 37)
Adult child-to-adult Type (n ⫽ 18)
Others (n ⫽ 35)
2.6 ⫾ 0.7 (n ⫽ 13) 2.1 ⫾ 0.6 (n ⫽ 5)
2.0 ⫾ 0.6 (n ⫽ 3) 0.5 ⫾ 0.5 (n ⫽ 32)
events as Paradoxical Psychiatric Syndromes (PPS).5 The results of the present study suggest that this syndrome is related to guilt feelings of adult recipients who apparently develop increased concern for their donor offspring once the threat of death from end-stage liver disease has subsided.
DISCUSSION
REFERENCES
In this study, psychiatric disorders were most prevalent: 58.5% of cases among adult LDLT recipients. One reason for the observed high incidence rate is that PPS appears to be relatively specific for LDLT. After the exclusion of cases with PPS, the incidence of psychiatric disorders decreased from 58.5% to 28.3%. We have previously reported the occurrence of reactive psychiatric disorders among successful liver transplant recipients.2,3 We categorized these
1. Surman OS: Transplantation. Mass.: Blackwell Science; 1999, p 709 2. Fukunishi I: Psychiatr Times 15:48, 1998 3. Fukunishi I: Cutting-Edge Medicine and Liaison Psychiatry— Psychiatric Problems of Organ Transplantation, Cancer, HIV, and Genetic Therapy. Amsterdam, The Netherlands: Elsevier Science Publishers; 1999, p 85 4. Hamilton M: J Neurol Neurosurg Psychiat 23:56, 1960 5. Fukunishi I, Sugawara Y, Takayama T, et al: Psychosomatics 42:163, 2001
P
SYCHIATRIC follow-up studies are available for recipients and donors after transplantation.1 Recent reports have established the occurrence of psychiatric symptoms among successful adult liver transplant recipients.2,3 Psychiatric symptoms manifested despite favorable operative outcome have been referred to as the Paradoxical Psychiatric Syndrome (PPS).3 We hypothesized that PPS is closely related to recipient guilt feelings toward a living donor. Before LDLT, recipients’ desire to escape from approaching death supersedes their conflicted feelings related to the prospect of living organ donation. Following LDLT, the fear of death subsides and concern for the donor becomes more pronounced. This psychological process may be relatively specific to LDLT because of its attendant risk of postoperative donor morbidity. We examined the relationship between guilt feelings and PPS. PATIENTS AND METHODS The subjects consisted of 53 Japanese adult recipients who underwent LDLT in Japan. The mean age of recipients and donors was 44.1 (18 to 64) and 39.1 (20 to 61) years at the time of transplantation. There were 23 males and 30 females who underwent LDLT. Donors for recipients undergoing LDLT were the recipients’ children (n ⫽ 18), brothers/sisters (n ⫽ 13), parents (n ⫽ 11), spouses (n ⫽ 8), and nephews (n ⫽ 3). After providing informed consent, all the recipients were interviewed by two mental health professionals, a psychiatrist and a psychologist. Diagnosis of psychiatric disorders was made based on the DSM-IV criteria. The presence or absence of PPS was evaluated on the basis of diagnostic criteria for PPS (Table 1). When all four elements existed, psychiatric symptoms were judged as PPS. We also assessed the level of guilt feelings using an item on guilt feelings of the Hamilton Depression Rating Scale (HRS).4
Table 1. Diagnostic Criteria for PPS 1. Prominent conflicts associated with transplantation (for example, guilt regarding the donor’s welfare) 2. Situational reaction such as depression, anxiety, conversion, somatization, and adjustment disorder, and/or psychosis 3. The reaction occurs as a late complication following liver transplantation (within the first year following transplant) 4. Favorable medical status of donor and recipient, without tissue rejection or other major medical complication.
Among the 31 recipients who met for the DSM-IV psychiatric disorders, 16 met the diagnostic criteria for PPS. The PPS diagnosis was seen in 51.6% (16 of 32 recipients with psychiatric disorders) and 30.2% (16 of 53 recipients). The PPS diagnosis occurred in 13 (72.2%) of 18 recipients who received a donor liver from one of their children, in 1 of 13 with a graft from brothers/sisters, in none of 11 with parental donors, in 1 of 8 with spousal donation, and in 1 of 3 with a graft from a nephew. Among 53 adult recipients who underwent LDLT, 18 donors were adult children (13 sons and 5 daughters) of the recipients. The 1-year incidence rate of PPS was significantly higher for child-to-parent (adult child to adult) LDLT than for other types of adult LDLT (df ⫽ 1, chi-square ⫽ 22.9, P ⬍ .05). According to the (HRS), the mean score on guilt feelings of the HRS was 1.3 (SD ⫽ 0.8). As shown in Table 2, multivariate analysis of variance for two factors (the presence or absence of PPS and adult child-to-adult type) revealed that recipients of child-to-parent (adult child-toadult) type who exhibited PPS had significantly higher scores on guilt feelings of the HRS (P ⬍ .05).
RESULTS
The 1-year incidence rate of the DSM-IV psychiatric disorders was 31 (58.5%) of 53 recipients who underwent LDLT. The diagnosis consisted of delirium (n ⫽ 9), major depression (n ⫽ 8), dysthymic disorder (n ⫽ 6), adjustment disorder (n ⫽ 4), brief psychotic disorder (n ⫽ 2), posttraumatic stress disorder (n ⫽ 1), and substance-induced disorder (n ⫽ 1).
From the Tokyo Institute of Psychiatry, Tokyo Metropolitan Organization for Medical Research, and Faculty of Medicine, University of Tokyo, Tokyo, Japan; and Department of Nephrology, Toho University School of Medicine, Tokyo, Japan. Address reprint requests to Isao Fukunishi, MD, Tokyo Institute of Psychiatry, Tokyo Metropolitan Organization for Medical Research, 2-1-8 Kamikitazawa, Setagaya-ku, Tokyo 156-8585, Japan.
0041-1345/02/$–see front matter PII S0041-1345(02)03455-3
© 2002 by Elsevier Science Inc. 360 Park Avenue South, New York, NY 10010-1710
2632
Transplantation Proceedings, 34, 2632–2633 (2002)
GUILT FEELINGS IN LIVER TRANSPLANT
2633
Table 2. Scores on Guilt Feelings of the HRS (Results Were Shown in Mean ⴞ SD)
PPS (⫹) (n ⫽ 16) PPS (⫺) (n ⫽ 37)
Adult child-to-adult Type (n ⫽ 18)
Others (n ⫽ 35)
2.6 ⫾ 0.7 (n ⫽ 13) 2.1 ⫾ 0.6 (n ⫽ 5)
2.0 ⫾ 0.6 (n ⫽ 3) 0.5 ⫾ 0.5 (n ⫽ 32)
events as Paradoxical Psychiatric Syndromes (PPS).5 The results of the present study suggest that this syndrome is related to guilt feelings of adult recipients who apparently develop increased concern for their donor offspring once the threat of death from end-stage liver disease has subsided.
DISCUSSION
REFERENCES
In this study, psychiatric disorders were most prevalent: 58.5% of cases among adult LDLT recipients. One reason for the observed high incidence rate is that PPS appears to be relatively specific for LDLT. After the exclusion of cases with PPS, the incidence of psychiatric disorders decreased from 58.5% to 28.3%. We have previously reported the occurrence of reactive psychiatric disorders among successful liver transplant recipients.2,3 We categorized these
1. Surman OS: Transplantation. Mass.: Blackwell Science; 1999, p 709 2. Fukunishi I: Psychiatr Times 15:48, 1998 3. Fukunishi I: Cutting-Edge Medicine and Liaison Psychiatry— Psychiatric Problems of Organ Transplantation, Cancer, HIV, and Genetic Therapy. Amsterdam, The Netherlands: Elsevier Science Publishers; 1999, p 85 4. Hamilton M: J Neurol Neurosurg Psychiat 23:56, 1960 5. Fukunishi I, Sugawara Y, Takayama T, et al: Psychosomatics 42:163, 2001