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A prospective study of patients in chronic hemodialysis—IV
Journal of Psychosomatic Research. Vol. 18. pp. 315 to 319. Per-on
A PROSPECTIVE
PRETREATMENT
Press. 1974. Printed in Great Britain
STUDY OF PATIENTS HEMODIALYSIS-IV.
IN CHRONIC
PSYCHIATRIC AND PSYCHOLOGICAL PREDICTING OUTCOME Bo
HAGBERG
VARIABLES
and ANN MAL&~QUIST*
(Received 11 &Iarck 1974)
A STUDY of psychiatric and psychological factors predicting rehabilitation for patients in chronic hemodialysis was presented in three previous papers [l-3]. Personality characteristics significant for determining rehabilitation or non-rehabilitation (after twelve months in hemodialysis) seemed to have been present before onset of the kidney disease. Fewer social contacts and a negative reaction towards the kidney disease were predictive variables, as was the patient’s expectation of fast rehabilitation. Regarding the psychological variables, a higher intellectual level, fewer signs of organicity and a more flexible structure of defence (with mechanisms such as repression and projection and with intermittent access to anxiety experience), were found to be prognostically favourable, but only in the early phase of treatment (up to 6 months). A less flexible structure of defence, employing isolation only, predicted non-rehabilitation at six months follow-up, and was also the only variable in the psychological test with a predictive value at 12 months follow-up. Among others, Sand [4] has pointed out that the patient’s psychological characteristics must be a very important factor in adjustment to chronic hemodialysis since a brief pretreatment assessment of the patient’s characteristics does in many cases _ yield reasonably accurate predictions about potential adjustment. However, the literature to date shows a lack of reports of thorough studies regarding psychological variables relevant to treatment outcome. In our previous papers predictive psychiatric and psychological variables were presented, but dealt with separately regarding their predictability. In the present study these variables are combined, firstly to provide a wider description of the patient group, and secondly to investigate whether better predictive ability could be obtained by combining psychiatric and psychological data. MATERIAL
AND METHOD
The patients presented in this study were the same as those described in previous publications [l-3]. The material consisted of 23 patients who started on the hemodialysis program in Lund and Malmii during the period October 1968-February 1970. Twenty-two patients were followed for 6 months in hemodialysis, and seveteen patients for 12 months. All patients were interviewed before the start of hemodialysis and again after 6 and 12 months of treatment. All patients, except two were psychologically evaluated parallel to the psychiatric interviews. One of the patients refused testing, and one patient had to be disregarded due to technical deficiencies. A third patient was excluded because of a complicated situation after a transplantation. The tests were used to estimate primary intellectual level, to detect cognitive reductions of the kind similar to that observed in patients with brain damage, and to identify personality adjustment patterns in terms of defence mechanisms. All except one of the tests were described in detail in a previous paper 131. The test not described before was tachistoscopic exposure of a mother-child *From the Department
of Psychiatry I, University Hospital, S-221 85 Lund, Sweden. 315
316
Bo HACBERG and AW MAL~VQUIST
picture. The purpose of this test was to study the patient’s reactions to a specific theme, the motherchild relationship. The picture depicts a mother and a child in an affectionate scene. The picture was repeatedly presented at gradually increasing exposure times. The patient’s reports following each exposure were analysed. The reports were evaluated against the general background of projective techniques and percept genetic theory [5J with the purpose of studying the readiness with which the patient approaches and handles the presented theme. The report on the theme presented here could be interpreted as indicative of the patient’s degree of self-identification, maturity and independence [q. In the present study, the results of the psychological tests obtained before the start of dialysis were tirst correlated with background variables reported by the patients and their relatives before dialysis was begun. Secondly, the background variables and pretreatment testing variables significant for predicting rehabilitation after twelve months’ dialysis were combined to obtain, if possible, a more valid prediction. Fischer’s e.xact probability test was used as test of significance. RESULTS As was pointed out by Hagberg [3], the general intellectual level of the patient group as a whole did not deviate from the normal level, even though individual patients differed from each other regarding IQ. A definite tendency was found among the patients with lower intellectual level to be cared for by relatives to a greater degree. The relatives also reacted with more anxiety when these patients became ill. This group also tended to be more dependent compared with those patients with higher intellectual level. It was also found that patients with signs of organicity were significantly more often overprotected by their spouses compared with patients with fewer such signs (p c 0.025). Obviously, a somewhat reduced capacity of the patient, intellectual or other, results in a more overprotective attitude on the part of the relatives. The mirror-test revealed that patients with an inability to shift tended more frequently to have expectations of fast rehabilitation. Thus it seems that a more rigid person can more easily be rehabilitated, possibly because his rigidity makes him less ready to give up his old, established way of living. In the mother-child test, the patients who were able to identify the mother in the picture as a mother, and not as a neutral woman, were less dependent (p c 0.05). They also showed less anxiety when their relatives became ill (p c 0.05). and were less anxious about their own illness. Thus, the patients with an adequate interpretation of the picture (i.e., with an ability to accept the relationship in the picture without frustration) seemed to be independent persons with an ability to cope with situations of stress. In the personality test five patients showed a high frequency of isolation signs without any other alternative defence mechanisms. The other patients showed a variety of defence mechanisms, with repression highest in priority. Patients showing isolation in the test situation also reported having had very few social contacts outside the family before the start of kidney symptoms (p < 0.025). Isolation in the personality test also correlated with presence of psychiatric reactions in connection with life trauma after the onset of the kidney disease (p < 0.025), anxious reactions towards the kidney disease (p < OOOS),presence of nervous disturbances as an adult (p < 0.05), and a negative attitude towards fast rehabilitation (p < 0.005). At the psychiatric interview before the start of dialysis, these patients also showed more overt anxiety (p c 0405), more tension (p < 0.025), and more depression (p c 0.05), compared with the rest of the patients. Thus, patients showing isolation as the only defence mechanism seemed to be more vulnerable, probably because of their defence system being less flexible and ineffective, and also because the actual situation could be a precipitating factor potentiating previous isolation effects and making them manifest. The above results put the personality test in focus, as this test provided the most information about, and also the most interesting correlations with, the patients’ psychiatric histories and present psychiatric conditions. From Hagberg’s report it was also clear that the personality test was the only psychological test predicting rehabilitation after twelve months in hemodialysis (p < 0.025). Therefore only the personality test variable predicting rehabilitation after 12 months’ hemodialysis was combined with the three predictive psychiatric variables: social contacts, reactions towards the kidney disease, and expectation of rehabilitation. All four variables were recorded for the fourteen patients (followed 12 months) regarding negative or positive signs, as is shown in Table 1. Positive signs were: regular social contacts, adequate reaction towards the kidney disease, positive expectation of fast rehabilitation, and other defence mechanisms than isolation only. Negative signs were: few social contacts, negative reaction towards the kidney disease, no expectation of fast rehabilitation, and isolation as the only defence mechanism. All of the patients with four positive signs were rehabilitated, while none of the patients with four
A prospective study of patients in chronic hemodialysis-IV TABLE I.---COMBINATIONS
OF
PSYCHIATRIC AFIER
12
AND MONTHS
Variables predicting rehabilitation/non-rehabilitation 4-k Social contacts Reaction towards the disease (adequate) Expectation of fast rehabilitation Defence mechanism (other than isolation only) 3+ lSocial contacts (few) Reaction towards the disease (adequate) Expectation of fast rehabilitation Defence mechanism (other than isolation only) 2+ 2Social contacts (few) Reaction towards disease (negative) Expectation of fast rehabilitation Defence mechanism (other than isolation only) 3+ lSocial contacts Reaction towards disease (adequate) Expectation of fast rehabilitation (negative) Defence mechanism (other than isolation only) 4Social contacts (few) Reaction towards disease (negative) Expectation of fast rehabilitation (negative) Defence mechanism (isolation only)
PSYCHOLOGICAL
VARIABLES
317 PREDICITNG
OUTCOME
IN HEMODIALYSIS
Positive/ negative
No. of patients rehabilitated
No. of patients non-rehabilitated
+ + + +
4
0
1
0
1
(1)
0
2
0
5
+ : + i + + + -
negative signs were rehabilitated. Of the three patients with three positive signs and one negative sign, one belonged to the rehabilitated group, and two to the non-rehabilitated group. They differed in type of negative sign. The rehabilitated patient had a positive expectation of fast rehabilitation, while the other two patients had a negative expectation in this respect. The presence of a negative attitude towards fast rehabilitation seems to be of such importance that this factor alone predicts nonrehabilitation, even if other signs are positive. In the intermediate group, consisting of two patients, one was rehabilitated and the other not. Both had two positive and two negative signs, and both expected fast rehabilitation. In spite of this one of them was not rehabilitated. This patient was the only one with such a positive expectation who could not fulfill it. However, this patient is unique in another aspect. Signs of organicity, which for the patient group as a whole were reversed during treatment, re-appeared in this patient at the 12 month follow-up, and progressive dementia was suspected. This fact could presumably affect the patients’ own expectation of adjustment in a negative way, and also his adjustment per se. Negative expectation, however, predicted non-rehabilitation in all cases, and so did signs of isolation in the personality tests. The latter also correlated in a!! cases with few social contacts and a negative reaction toward the disease. DISCUSSION
The intercorrelation of psychiatric and psychological data gave further valuable information about the prediction, in addition to the information already obtained and presented in previous papers [l-3]. Surprisingly, an inability to shift was found to be a positive prognostic factor. The rigid patient apparently has a good support in his unwillingness to give up his established way of living. Even such a psychologically loaded treatment as chronic hemodialysis does not make him change his expectations of himself as a human and social individual. Other authors have not considered this rigidity variable in particular, but it is possible that it is included in other variables, such as “emotional stoicism and self-control” mentioned by Shaldon [7j, “ego
318
Bo HAGBERGand ANN MALMQWST
strength” mentioned by Meldrum [S] and “high self-esteem” mentioned by Sand [4]. The emotional acceptance of the affectionate relationship in the mother-child picture correlated with less dependency and better acceptance of stress situations. This was interpreted as an expression of being more stable, of having more “basic trust”, which confirm impressions by, among others, Sand, who in her 1966 study emphasized the importance of the hemodialysis patient’s ability to tolerate stress. So far personality characteristics emerging in this study as positive for rehabilitation have been discussed. These are additional to earlier described positive predictive variables, namely regular social contacts, adequate reaction towards the kidney disease and positive expectation of fast rehabilitation. This gives a picture of a person with basic trust, with persistency of life pattern, and ability for positive identification. Regarding the non-rehabilitated patients, a homogeneous and psychologically understandable picture was obtained, based on personality test results and psychiatric variables. All except two of the non rehabilitated patients showed isolation as the only accessible defence mechanism. Our study confirms earlier impressions that this type of defence correlates with the presence of overt psychiatric symptoms in stress situations, as well as with restrictions of interpersonal relations. As pointed out by Hagberg, extroversion in the form of regular social contacts contributes to rehabilitation. The present finding of social contact as a positive sign is in agreement with this statement. Considering all positive predictive variables together (social contact, positive attitude toward fast rehabilitation and toward the kidney disease, and positive ego defence structure), a perfect discrimination was established with regard to the criterion. Even if quite as good a prediction could be obtained by two of the four variables separately (expectation of fast rehabilitation and isolation in the personality test), the prediction was considered to be more valid when based on all four variables. Thus congruent signs, positive or negative, gave accurate prediction in all cases, while the single variable of expectation of fast rehabilitation determined the outcome of the prediction when incongruent signs were present. SUMMARY
Twenty-three patients with chronic renal failure, described in a previous paper, who were psychiatrically and psychologically evaluated before beginning hemodialysis, were included in the study. Psychiatric and psychological pretreatment variables were intercorrelated to give a wider description of the patient group. Psychiatric and psychological data were also combined to better predict ability regarding rehabilitation. Positive and negative personality characteristics are described. The rehabilitated patient seemed to be more stable, with an ability for positive identification and with a persistency of life pattern. Further prognostically favourable variables were regular social contacts, adequate reaction towards kidney disease, expectation of fast rehabilitation and other defence mechanisms than isolation only in the personality test. The presence or absence of all four variables gave a more valid prediction. REFERENCES 1. MALMQUIST A. A prospective
study of patients in chronic hemodialysis-I. teristics of the patient group. J. Psychosom. Res. 17, 333 (1973). 2. MALMQUI~TA. A prospective study of patients in chronic hemodialysis-4. regarding rehabilitation. /. Psychosotn. Res. 17, 339 (1973).
Method and characPredicting factors
A prospective study of patients in chronic hemodialysis-IV
319
3. HAGEERGB. A prospective study of patients in chronic hemodialysis-III. Predictive value of intelligence, cognitive deficit and ego defence structures in rehabilitation. J. Psyc/rosom. Res. in press (1974). 4. SAhp P., LIMNG~TONG. and WRIGHTR. G. Psychological assessment of candidates for a hemodialysis program. Ann. Inr. Med. 64, 602 (1966). 5. KRAGH U. and SMITH G. J. W. Percept-genefic Analysis. Gleerups, Lund (1970). 6. WEI~~KOPFE. A. and DUNLEVYG. P. JR. Bodily similarity between subject and central figure in the TAT as an influence on projection. J. Abn. Sot. Psycho!. 47, 441 (1952). 7. SHALWN S. Independence in maintenance haemodialysis. Lancet 1, 520 (1968). 8. MELDRUMM. W.. WOLFRAMS. G. and RUFIINM. E. The impact of chronic hemodialysis upon the socio-economics of a veteran patient group. J. Chran. Dis. 21, 37 (1968).
A PROSPECTIVE
PRETREATMENT
Press. 1974. Printed in Great Britain
STUDY OF PATIENTS HEMODIALYSIS-IV.
IN CHRONIC
PSYCHIATRIC AND PSYCHOLOGICAL PREDICTING OUTCOME Bo
HAGBERG
VARIABLES
and ANN MAL&~QUIST*
(Received 11 &Iarck 1974)
A STUDY of psychiatric and psychological factors predicting rehabilitation for patients in chronic hemodialysis was presented in three previous papers [l-3]. Personality characteristics significant for determining rehabilitation or non-rehabilitation (after twelve months in hemodialysis) seemed to have been present before onset of the kidney disease. Fewer social contacts and a negative reaction towards the kidney disease were predictive variables, as was the patient’s expectation of fast rehabilitation. Regarding the psychological variables, a higher intellectual level, fewer signs of organicity and a more flexible structure of defence (with mechanisms such as repression and projection and with intermittent access to anxiety experience), were found to be prognostically favourable, but only in the early phase of treatment (up to 6 months). A less flexible structure of defence, employing isolation only, predicted non-rehabilitation at six months follow-up, and was also the only variable in the psychological test with a predictive value at 12 months follow-up. Among others, Sand [4] has pointed out that the patient’s psychological characteristics must be a very important factor in adjustment to chronic hemodialysis since a brief pretreatment assessment of the patient’s characteristics does in many cases _ yield reasonably accurate predictions about potential adjustment. However, the literature to date shows a lack of reports of thorough studies regarding psychological variables relevant to treatment outcome. In our previous papers predictive psychiatric and psychological variables were presented, but dealt with separately regarding their predictability. In the present study these variables are combined, firstly to provide a wider description of the patient group, and secondly to investigate whether better predictive ability could be obtained by combining psychiatric and psychological data. MATERIAL
AND METHOD
The patients presented in this study were the same as those described in previous publications [l-3]. The material consisted of 23 patients who started on the hemodialysis program in Lund and Malmii during the period October 1968-February 1970. Twenty-two patients were followed for 6 months in hemodialysis, and seveteen patients for 12 months. All patients were interviewed before the start of hemodialysis and again after 6 and 12 months of treatment. All patients, except two were psychologically evaluated parallel to the psychiatric interviews. One of the patients refused testing, and one patient had to be disregarded due to technical deficiencies. A third patient was excluded because of a complicated situation after a transplantation. The tests were used to estimate primary intellectual level, to detect cognitive reductions of the kind similar to that observed in patients with brain damage, and to identify personality adjustment patterns in terms of defence mechanisms. All except one of the tests were described in detail in a previous paper 131. The test not described before was tachistoscopic exposure of a mother-child *From the Department
of Psychiatry I, University Hospital, S-221 85 Lund, Sweden. 315
316
Bo HACBERG and AW MAL~VQUIST
picture. The purpose of this test was to study the patient’s reactions to a specific theme, the motherchild relationship. The picture depicts a mother and a child in an affectionate scene. The picture was repeatedly presented at gradually increasing exposure times. The patient’s reports following each exposure were analysed. The reports were evaluated against the general background of projective techniques and percept genetic theory [5J with the purpose of studying the readiness with which the patient approaches and handles the presented theme. The report on the theme presented here could be interpreted as indicative of the patient’s degree of self-identification, maturity and independence [q. In the present study, the results of the psychological tests obtained before the start of dialysis were tirst correlated with background variables reported by the patients and their relatives before dialysis was begun. Secondly, the background variables and pretreatment testing variables significant for predicting rehabilitation after twelve months’ dialysis were combined to obtain, if possible, a more valid prediction. Fischer’s e.xact probability test was used as test of significance. RESULTS As was pointed out by Hagberg [3], the general intellectual level of the patient group as a whole did not deviate from the normal level, even though individual patients differed from each other regarding IQ. A definite tendency was found among the patients with lower intellectual level to be cared for by relatives to a greater degree. The relatives also reacted with more anxiety when these patients became ill. This group also tended to be more dependent compared with those patients with higher intellectual level. It was also found that patients with signs of organicity were significantly more often overprotected by their spouses compared with patients with fewer such signs (p c 0.025). Obviously, a somewhat reduced capacity of the patient, intellectual or other, results in a more overprotective attitude on the part of the relatives. The mirror-test revealed that patients with an inability to shift tended more frequently to have expectations of fast rehabilitation. Thus it seems that a more rigid person can more easily be rehabilitated, possibly because his rigidity makes him less ready to give up his old, established way of living. In the mother-child test, the patients who were able to identify the mother in the picture as a mother, and not as a neutral woman, were less dependent (p c 0.05). They also showed less anxiety when their relatives became ill (p c 0.05). and were less anxious about their own illness. Thus, the patients with an adequate interpretation of the picture (i.e., with an ability to accept the relationship in the picture without frustration) seemed to be independent persons with an ability to cope with situations of stress. In the personality test five patients showed a high frequency of isolation signs without any other alternative defence mechanisms. The other patients showed a variety of defence mechanisms, with repression highest in priority. Patients showing isolation in the test situation also reported having had very few social contacts outside the family before the start of kidney symptoms (p < 0.025). Isolation in the personality test also correlated with presence of psychiatric reactions in connection with life trauma after the onset of the kidney disease (p < 0.025), anxious reactions towards the kidney disease (p < OOOS),presence of nervous disturbances as an adult (p < 0.05), and a negative attitude towards fast rehabilitation (p < 0.005). At the psychiatric interview before the start of dialysis, these patients also showed more overt anxiety (p c 0405), more tension (p < 0.025), and more depression (p c 0.05), compared with the rest of the patients. Thus, patients showing isolation as the only defence mechanism seemed to be more vulnerable, probably because of their defence system being less flexible and ineffective, and also because the actual situation could be a precipitating factor potentiating previous isolation effects and making them manifest. The above results put the personality test in focus, as this test provided the most information about, and also the most interesting correlations with, the patients’ psychiatric histories and present psychiatric conditions. From Hagberg’s report it was also clear that the personality test was the only psychological test predicting rehabilitation after twelve months in hemodialysis (p < 0.025). Therefore only the personality test variable predicting rehabilitation after 12 months’ hemodialysis was combined with the three predictive psychiatric variables: social contacts, reactions towards the kidney disease, and expectation of rehabilitation. All four variables were recorded for the fourteen patients (followed 12 months) regarding negative or positive signs, as is shown in Table 1. Positive signs were: regular social contacts, adequate reaction towards the kidney disease, positive expectation of fast rehabilitation, and other defence mechanisms than isolation only. Negative signs were: few social contacts, negative reaction towards the kidney disease, no expectation of fast rehabilitation, and isolation as the only defence mechanism. All of the patients with four positive signs were rehabilitated, while none of the patients with four
A prospective study of patients in chronic hemodialysis-IV TABLE I.---COMBINATIONS
OF
PSYCHIATRIC AFIER
12
AND MONTHS
Variables predicting rehabilitation/non-rehabilitation 4-k Social contacts Reaction towards the disease (adequate) Expectation of fast rehabilitation Defence mechanism (other than isolation only) 3+ lSocial contacts (few) Reaction towards the disease (adequate) Expectation of fast rehabilitation Defence mechanism (other than isolation only) 2+ 2Social contacts (few) Reaction towards disease (negative) Expectation of fast rehabilitation Defence mechanism (other than isolation only) 3+ lSocial contacts Reaction towards disease (adequate) Expectation of fast rehabilitation (negative) Defence mechanism (other than isolation only) 4Social contacts (few) Reaction towards disease (negative) Expectation of fast rehabilitation (negative) Defence mechanism (isolation only)
PSYCHOLOGICAL
VARIABLES
317 PREDICITNG
OUTCOME
IN HEMODIALYSIS
Positive/ negative
No. of patients rehabilitated
No. of patients non-rehabilitated
+ + + +
4
0
1
0
1
(1)
0
2
0
5
+ : + i + + + -
negative signs were rehabilitated. Of the three patients with three positive signs and one negative sign, one belonged to the rehabilitated group, and two to the non-rehabilitated group. They differed in type of negative sign. The rehabilitated patient had a positive expectation of fast rehabilitation, while the other two patients had a negative expectation in this respect. The presence of a negative attitude towards fast rehabilitation seems to be of such importance that this factor alone predicts nonrehabilitation, even if other signs are positive. In the intermediate group, consisting of two patients, one was rehabilitated and the other not. Both had two positive and two negative signs, and both expected fast rehabilitation. In spite of this one of them was not rehabilitated. This patient was the only one with such a positive expectation who could not fulfill it. However, this patient is unique in another aspect. Signs of organicity, which for the patient group as a whole were reversed during treatment, re-appeared in this patient at the 12 month follow-up, and progressive dementia was suspected. This fact could presumably affect the patients’ own expectation of adjustment in a negative way, and also his adjustment per se. Negative expectation, however, predicted non-rehabilitation in all cases, and so did signs of isolation in the personality tests. The latter also correlated in a!! cases with few social contacts and a negative reaction toward the disease. DISCUSSION
The intercorrelation of psychiatric and psychological data gave further valuable information about the prediction, in addition to the information already obtained and presented in previous papers [l-3]. Surprisingly, an inability to shift was found to be a positive prognostic factor. The rigid patient apparently has a good support in his unwillingness to give up his established way of living. Even such a psychologically loaded treatment as chronic hemodialysis does not make him change his expectations of himself as a human and social individual. Other authors have not considered this rigidity variable in particular, but it is possible that it is included in other variables, such as “emotional stoicism and self-control” mentioned by Shaldon [7j, “ego
318
Bo HAGBERGand ANN MALMQWST
strength” mentioned by Meldrum [S] and “high self-esteem” mentioned by Sand [4]. The emotional acceptance of the affectionate relationship in the mother-child picture correlated with less dependency and better acceptance of stress situations. This was interpreted as an expression of being more stable, of having more “basic trust”, which confirm impressions by, among others, Sand, who in her 1966 study emphasized the importance of the hemodialysis patient’s ability to tolerate stress. So far personality characteristics emerging in this study as positive for rehabilitation have been discussed. These are additional to earlier described positive predictive variables, namely regular social contacts, adequate reaction towards the kidney disease and positive expectation of fast rehabilitation. This gives a picture of a person with basic trust, with persistency of life pattern, and ability for positive identification. Regarding the non-rehabilitated patients, a homogeneous and psychologically understandable picture was obtained, based on personality test results and psychiatric variables. All except two of the non rehabilitated patients showed isolation as the only accessible defence mechanism. Our study confirms earlier impressions that this type of defence correlates with the presence of overt psychiatric symptoms in stress situations, as well as with restrictions of interpersonal relations. As pointed out by Hagberg, extroversion in the form of regular social contacts contributes to rehabilitation. The present finding of social contact as a positive sign is in agreement with this statement. Considering all positive predictive variables together (social contact, positive attitude toward fast rehabilitation and toward the kidney disease, and positive ego defence structure), a perfect discrimination was established with regard to the criterion. Even if quite as good a prediction could be obtained by two of the four variables separately (expectation of fast rehabilitation and isolation in the personality test), the prediction was considered to be more valid when based on all four variables. Thus congruent signs, positive or negative, gave accurate prediction in all cases, while the single variable of expectation of fast rehabilitation determined the outcome of the prediction when incongruent signs were present. SUMMARY
Twenty-three patients with chronic renal failure, described in a previous paper, who were psychiatrically and psychologically evaluated before beginning hemodialysis, were included in the study. Psychiatric and psychological pretreatment variables were intercorrelated to give a wider description of the patient group. Psychiatric and psychological data were also combined to better predict ability regarding rehabilitation. Positive and negative personality characteristics are described. The rehabilitated patient seemed to be more stable, with an ability for positive identification and with a persistency of life pattern. Further prognostically favourable variables were regular social contacts, adequate reaction towards kidney disease, expectation of fast rehabilitation and other defence mechanisms than isolation only in the personality test. The presence or absence of all four variables gave a more valid prediction. REFERENCES 1. MALMQUIST A. A prospective
study of patients in chronic hemodialysis-I. teristics of the patient group. J. Psychosom. Res. 17, 333 (1973). 2. MALMQUI~TA. A prospective study of patients in chronic hemodialysis-4. regarding rehabilitation. /. Psychosotn. Res. 17, 339 (1973).
Method and characPredicting factors
A prospective study of patients in chronic hemodialysis-IV
319
3. HAGEERGB. A prospective study of patients in chronic hemodialysis-III. Predictive value of intelligence, cognitive deficit and ego defence structures in rehabilitation. J. Psyc/rosom. Res. in press (1974). 4. SAhp P., LIMNG~TONG. and WRIGHTR. G. Psychological assessment of candidates for a hemodialysis program. Ann. Inr. Med. 64, 602 (1966). 5. KRAGH U. and SMITH G. J. W. Percept-genefic Analysis. Gleerups, Lund (1970). 6. WEI~~KOPFE. A. and DUNLEVYG. P. JR. Bodily similarity between subject and central figure in the TAT as an influence on projection. J. Abn. Sot. Psycho!. 47, 441 (1952). 7. SHALWN S. Independence in maintenance haemodialysis. Lancet 1, 520 (1968). 8. MELDRUMM. W.. WOLFRAMS. G. and RUFIINM. E. The impact of chronic hemodialysis upon the socio-economics of a veteran patient group. J. Chran. Dis. 21, 37 (1968).