- Email: [email protected]
Obsessive-Compulsive Psychological Symptoms of Patients on the Liver Transplant Waiting List
Obsessive-Compulsive Psychological Symptoms of Patients on the Liver Transplant Waiting List A. López-Navas, A. Ríos, A. Riquelme, L. Martínez-Alarcón, J.A. Pons, P. Ramírez, and P. Parrilla ABSTRACT Introduction. Patients on the liver transplant waiting list have increased emotional and clinical symptoms. The presence of psychopathologic symptoms associated with obsessioncompulsion as a reflection of alterations due to anxiety disorders is common in these patients. Objective. To evaluate obsessive-compulsive psychopathological symptoms in patients on the liver transplant waiting list. Materials and methods. The study included 50 patients on the liver transplant waiting list. The instrument was the SA-45 questionnaire (Derogatis, 75), whose Spanish version was adapted by González Rivera and De las Cuevas (1988). This dimension was evaluated using five statements. Results. Among of the patients on the liver transplant waiting list, 46% had no relevant obsessive-compulsive symptoms. Of these, 28% had no symptoms and 18% had some symptoms, but the overall evaluation in these patients was no greater than the cutoff point. The remaining 54% had relevant obsessive-compulsive clinical symptoms, most commonly (1) “Having difficulty making decisions” (P ⬍ 3.45 · 10⫺9); (2) “Having difficulty concentrating” (P ⬍ 1.70 · 10⫺8); (3) “One’s mind goes blank” (P ⬍ 3.04 · 10⫺4); (4) “Having to repeatedly check everything being done” (P ⬍ 1.37 · 10⫺1); and (5) “Having to do things slowly to make sure they are done properly” (P ⬍ 5.02 · 10⫺1). Conclusions. Many patients on the liver transplant waiting list have obsessive-compulsive psychopathologic symptoms. Their detection and application of adequate psychological treatment are important to minimize the effects of emotional changes onward from the pretransplant phase. MPORTANT PERTURBATIONS in anxiety disorders include obsessive-compulsive disorders.1 These disorders are characterized by the presence of a thought, image, impulse, or recurring and/or persistent action generally associated with a feeling of subjective compulsion, accompanied by the desire to resist it.2 The incidence of this psychopathology is 2% among the psychiatric population and nearly 1% in the nonpsychiatric population.3 Another feature of this disorder is its sensitivity in stressful situations or events. For instance, a person who has not had any previous problems of this kind may develop obsessivecompulsive symptoms in a situation of considerable anguish, such as the development and evolution of a disease.3 Faced with this situation, and taking into account that psychiatric comorbidity is a cause of deterioration in any
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kind of pathology, it is interesting to evaluate, diagnose, and treat psychological alterations of patients on the liver transplant waiting list.4 – 6 In this case, the detection of relevant obsessive-compulsive symptoms in patients who are on the transplant waiting list is important to optimize From the Hospital Universitario Virgen de la Arrixaca (A.L.-N., A.R., L.M.-A., J.A.P., P.R., P.P.), Consejería de Sanidad, Murcia; Coordinación Autonómica de Trasplantes, Consejería de Sanidad, Servicio Murciano de Salud, Murcia; and Departamento de Personalidad, Evaluación y Tratamiento Psicológico (A.R.), Facultad de Psicología, Universidad de Murcia, Murcia, Spain. Address reprint requests to Dr Antonio Ríos Zambudio, Avda de la Libertad n° 208, Casillas, 30007 Murcia, Spain. E-mail: [email protected]
© 2010 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter doi:10.1016/j.transproceed.2010.05.060
Transplantation Proceedings, 42, 3153–3155 (2010)
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psychotherapeutic interventions in these patients. The objective of this study was to evaluate obsessive-compulsive psychopathologic symptoms among patients on the liver transplant waiting list in a tertiary-level hospital with a liver transplant program. MATERIALS AND METHODS Study Population Fifty patients were assessed in a transplant hospital (with a liver transplant program) in the southeast of Spain. All subjects were included on the liver transplant waiting list from February to November 2009.
Evaluation Instrument Obsessive-compulsive psychopathologic symptoms were evaluated using the SA-45 questionnaire (abbreviated as SCL-90) (Derogatis, 75),4 using a Spanish version adapted by González Rivera and De las Cuevas (1988).4 This is a self-reporting instrument, although in our case, given the clinical features of the patients, a professional psychologist applied the questionnaire. This dimension was evaluated using five statements: “Having to do things very slowly to make sure they are done properly”; “Having to repeatedly check what one is doing”; “Having difficulty in taking decisions”; “One’s mind goes blank”; “Having difficulty concentrating.” There were five response options on a Likert-type scale (0 ⫽ nothing, 1 ⫽ a little, 2 ⫽ moderate, 3 ⫽ quite a lot, 4 ⫽ a lot). The presence of symptoms covered the patient’s experience over the 7 days before the questionnaire.
Sample Description Among the 50 waiting list patients that we evaluated, 80% were men and 20% women. The overall mean age was 55 years (range ⫽ 30 – 68). With respect to marital status, 70% were married, 14% single, 14% separated, and 2% widowed; 82% had children. With regard to the level of education, 44% had completed secondary education, 34% had no formal education, 14% completed postcompulsory secondary education, and 8% had a university education.
Statistical Analysis The data were analyzed using the SPSS 15.0. statistical package. The bivariate analysis used the x2 test complemented by an analysis of normalized remainders. When P ⬍ .05, the relationship was considered to be significant.
RESULTS
Among the liver transplant waiting list patients 46% did not show relevant obsessive-compulsive symptoms, 28% did not
have any symptoms, and 18% had some symptoms but the overall evaluation of these patients failed to pass the cutoff point (11 points) to suggest a significant psychopathologic disorder. In this group, the most common statements were: “Having to do things slowly to make sure they were done properly” (30%), followed by “Having to repeatedly check everything one does” (17%) and “Having difficulty taking decisions” and “One’s mind goes blank” (8%; Table 1). The remaining 54% of patients had relevant clinical symptoms of an obsessive-compulsive type. The presence of psychopathologic symptoms in this group was distributed as follows: “Having to check everything over and over again” among 96% of respondents with relevant clinical symptoms, “Having to do things very slowly to make sure that they are done properly” in 93%, “Having difficulty concentrating” in 85%, “Having difficulty taking decisions” in 74%, and “One’s mind goes blank” in 67%. In the analysis of symptoms that formed this dimension, those patients who had relevant obsessive-compulsive symptoms also reported “Having difficulty making decisions” to a greater degree compared with those who did not have any clinical symptoms (74% vs 8%; P ⬍ 3.45 · 10⫺9). The same applied to the other four statements—“Having difficulty concentrating” (85% vs 0%; P ⬍ 1.70 · 10⫺8), “One’s mind goes blank” (67% vs 8%; P ⬍ 3.04 · 10⫺4), “Having to repeatedly check everything one is doing” (96% vs 17%; P ⬍ 1.37 · 10⫺1), and “Having to do things very slowly to make sure that one is doing them properly” (93% vs 30%; P ⬍ 5.02 · 10⫺1; Table 1). DISCUSSION
Obsessive-compulsive symptoms existed among 50% patients on the liver transplant waiting list. It is notable that the obsessive ideas and compulsive behaviors of these patients were the consequence of high levels of anxiety in stressful situations and not as a consequence of a personality disorder. These patients with chronic and terminal liver disease can only survive by joining the liver transplant waiting list.7–9 The evolution of liver disease together with worsening symptoms and uncertainty in waiting and other prognostic expectations are some of the factors affecting the increased alterations, especially those of an anxious nature.5 Difficulties focalizing care can be seen in three of the statements that comprise the obsessive-compulsive dimension: “Having to repeatedly check what one is doing,” “Having difficulty concentrating,” and “One’s mind goes
Table 1. Obsessive-Compulsive Psychopathologic Symptoms in Patients on the Liver Transplant Waiting List
“Having difficulty making decisions” “Having difficulty concentrating” “One’s mind goes blank” “Having to repeatedly check what one is doing” “Having to do things very slowly to make sure they are done properly”
NO Obsessive-Compulsive Symptoms (46%)
Obsessive-Compulsive Symptoms (54%)
P
8% 0% 8% 17% 30%
74% 85% 67% 96% 93%
⬍3.45 · 10⫺9 ⬍1.70 · 10⫺8 ⬍3.04 · 10⫺4 ⬍1.37 · 10⫺1 ⬍5.02 · 10⫺1
OBSESSIVE-COMPULSIVE SYMPTOMS
blank.” Among those subjects with symptoms, 96% needed to check what they were doing more than once to make sure that they had completed the task properly, 85% reported having great difficulty concentrating on anything that they were doing, and 67% had a natural tendency for episodes when their “mind goes blank.” These difficulties arise as a consequence of constant, persistent mental occupation with obsessive thoughts, generally related to the current state of one’s disease or its evolution and which in addition, to relieve anxiety, require some kind of ritual behavior to generate a reduction in the adverse emotional state.3,10 Concerning the two remaining statements of this dimension— “Having difficulty taking decisions” and “Having to do things very slowly to be sure that they are done properly”— those patients who had relevant obsessive-compulsive symptoms had high scores as well: 74% reported having difficulties in taking decisions and 93% needed to do things more slowly than normal. Insecurity, the feeling of dependency on others as the disease advances, and the continual decline in self-esteem are some of the factors causing an increase in these statements. Faced with this situation, and after ruling out the possibility of an obsessive-compulsive personality disorder, we must consider the need to deal adequately with these psychological alterations, since they adversely impact the patient’s quality of life and have implications for pretransplant and posttransplant medical treatment.9 To conclude, many patients on the liver transplant waiting list show obsessive-compulsive psychopathologic symptoms. The need for detection and application of adequate psychological treatment are of considerable relevance to
3155
minimize the effects of changes in the emotional condition of these patients from the pretransplant phase onward. REFERENCES 1. Carrobles JA: El trastorno obsesivo-compulsivo. In Carrobles JA (ed): Análisis y modificación de la conducta II, Vol 1. Madrid: UNED; 1985 2. Foa EB, Steketee GS: Obsessive-compulsive conceptual signs and treatment interventions. In Goldstein A, Foa EB (eds): Handbook of Behavioral Interventions, New York: Wiley; 1980 3. Raich RM: Evaluación y tratamiento de un caso de trastorno obsesivo-compulsivo. In Maciá D, Méndez F (eds): Aplicaciones clínicas de la evaluación y modificación de conducta. Madrid: Pirámide; 1993 4. López-Navas A, Rios A, Riquelme A, et al: The importance of the introduction of a psychological care unit in a liver transplant unit. Transplant Proc 42:302, 2010 5. Pérez San Gregorio MA, Martín A, Galán A: Problemas psicológicos asociados al trasplante de órganos. Int J Clin Health Psychol 5:99, 2005 6. Dobbels F, Vanhaecke J, Dupont L, et al: Pretransplant predictors of posttransplant adherence and clinical outcome: an evidence base for pretransplant psychosocial screening. Transplantation 87:1497, 2009 7. Conesa C, Ríos A, Ramírez P, et al: Psycho-social profile in favour of organ donation. Transplant Proc 35:1276, 2003 8. Martínez-Alarcón L, Ríos A, Conesa C: Attitude toward living related donation of patients on the waiting list for deceased donor solid organ transplant. Transplant Proc 37:3614, 2005 9. Ríos A, Ramírez P, Rodríguez M, et al: Attitude of ancillary personnel faced with living kidney donation in a hospital with a living donor kidney transplant program. Transplantation 83:336, 2007 10. Pérez-San-Gregorio MA, Martín-Rodríguez A, PérezBernal J: Influence of the psychological state of relatives on the quality of life of patients at 1 year after transplantation. Transplant Proc 40:3109, 2008
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kind of pathology, it is interesting to evaluate, diagnose, and treat psychological alterations of patients on the liver transplant waiting list.4 – 6 In this case, the detection of relevant obsessive-compulsive symptoms in patients who are on the transplant waiting list is important to optimize From the Hospital Universitario Virgen de la Arrixaca (A.L.-N., A.R., L.M.-A., J.A.P., P.R., P.P.), Consejería de Sanidad, Murcia; Coordinación Autonómica de Trasplantes, Consejería de Sanidad, Servicio Murciano de Salud, Murcia; and Departamento de Personalidad, Evaluación y Tratamiento Psicológico (A.R.), Facultad de Psicología, Universidad de Murcia, Murcia, Spain. Address reprint requests to Dr Antonio Ríos Zambudio, Avda de la Libertad n° 208, Casillas, 30007 Murcia, Spain. E-mail: [email protected]
© 2010 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/–see front matter doi:10.1016/j.transproceed.2010.05.060
Transplantation Proceedings, 42, 3153–3155 (2010)
3153
3154
LÓPEZ-NAVAS, RÍOS, RIQUELME ET AL
psychotherapeutic interventions in these patients. The objective of this study was to evaluate obsessive-compulsive psychopathologic symptoms among patients on the liver transplant waiting list in a tertiary-level hospital with a liver transplant program. MATERIALS AND METHODS Study Population Fifty patients were assessed in a transplant hospital (with a liver transplant program) in the southeast of Spain. All subjects were included on the liver transplant waiting list from February to November 2009.
Evaluation Instrument Obsessive-compulsive psychopathologic symptoms were evaluated using the SA-45 questionnaire (abbreviated as SCL-90) (Derogatis, 75),4 using a Spanish version adapted by González Rivera and De las Cuevas (1988).4 This is a self-reporting instrument, although in our case, given the clinical features of the patients, a professional psychologist applied the questionnaire. This dimension was evaluated using five statements: “Having to do things very slowly to make sure they are done properly”; “Having to repeatedly check what one is doing”; “Having difficulty in taking decisions”; “One’s mind goes blank”; “Having difficulty concentrating.” There were five response options on a Likert-type scale (0 ⫽ nothing, 1 ⫽ a little, 2 ⫽ moderate, 3 ⫽ quite a lot, 4 ⫽ a lot). The presence of symptoms covered the patient’s experience over the 7 days before the questionnaire.
Sample Description Among the 50 waiting list patients that we evaluated, 80% were men and 20% women. The overall mean age was 55 years (range ⫽ 30 – 68). With respect to marital status, 70% were married, 14% single, 14% separated, and 2% widowed; 82% had children. With regard to the level of education, 44% had completed secondary education, 34% had no formal education, 14% completed postcompulsory secondary education, and 8% had a university education.
Statistical Analysis The data were analyzed using the SPSS 15.0. statistical package. The bivariate analysis used the x2 test complemented by an analysis of normalized remainders. When P ⬍ .05, the relationship was considered to be significant.
RESULTS
Among the liver transplant waiting list patients 46% did not show relevant obsessive-compulsive symptoms, 28% did not
have any symptoms, and 18% had some symptoms but the overall evaluation of these patients failed to pass the cutoff point (11 points) to suggest a significant psychopathologic disorder. In this group, the most common statements were: “Having to do things slowly to make sure they were done properly” (30%), followed by “Having to repeatedly check everything one does” (17%) and “Having difficulty taking decisions” and “One’s mind goes blank” (8%; Table 1). The remaining 54% of patients had relevant clinical symptoms of an obsessive-compulsive type. The presence of psychopathologic symptoms in this group was distributed as follows: “Having to check everything over and over again” among 96% of respondents with relevant clinical symptoms, “Having to do things very slowly to make sure that they are done properly” in 93%, “Having difficulty concentrating” in 85%, “Having difficulty taking decisions” in 74%, and “One’s mind goes blank” in 67%. In the analysis of symptoms that formed this dimension, those patients who had relevant obsessive-compulsive symptoms also reported “Having difficulty making decisions” to a greater degree compared with those who did not have any clinical symptoms (74% vs 8%; P ⬍ 3.45 · 10⫺9). The same applied to the other four statements—“Having difficulty concentrating” (85% vs 0%; P ⬍ 1.70 · 10⫺8), “One’s mind goes blank” (67% vs 8%; P ⬍ 3.04 · 10⫺4), “Having to repeatedly check everything one is doing” (96% vs 17%; P ⬍ 1.37 · 10⫺1), and “Having to do things very slowly to make sure that one is doing them properly” (93% vs 30%; P ⬍ 5.02 · 10⫺1; Table 1). DISCUSSION
Obsessive-compulsive symptoms existed among 50% patients on the liver transplant waiting list. It is notable that the obsessive ideas and compulsive behaviors of these patients were the consequence of high levels of anxiety in stressful situations and not as a consequence of a personality disorder. These patients with chronic and terminal liver disease can only survive by joining the liver transplant waiting list.7–9 The evolution of liver disease together with worsening symptoms and uncertainty in waiting and other prognostic expectations are some of the factors affecting the increased alterations, especially those of an anxious nature.5 Difficulties focalizing care can be seen in three of the statements that comprise the obsessive-compulsive dimension: “Having to repeatedly check what one is doing,” “Having difficulty concentrating,” and “One’s mind goes
Table 1. Obsessive-Compulsive Psychopathologic Symptoms in Patients on the Liver Transplant Waiting List
“Having difficulty making decisions” “Having difficulty concentrating” “One’s mind goes blank” “Having to repeatedly check what one is doing” “Having to do things very slowly to make sure they are done properly”
NO Obsessive-Compulsive Symptoms (46%)
Obsessive-Compulsive Symptoms (54%)
P
8% 0% 8% 17% 30%
74% 85% 67% 96% 93%
⬍3.45 · 10⫺9 ⬍1.70 · 10⫺8 ⬍3.04 · 10⫺4 ⬍1.37 · 10⫺1 ⬍5.02 · 10⫺1
OBSESSIVE-COMPULSIVE SYMPTOMS
blank.” Among those subjects with symptoms, 96% needed to check what they were doing more than once to make sure that they had completed the task properly, 85% reported having great difficulty concentrating on anything that they were doing, and 67% had a natural tendency for episodes when their “mind goes blank.” These difficulties arise as a consequence of constant, persistent mental occupation with obsessive thoughts, generally related to the current state of one’s disease or its evolution and which in addition, to relieve anxiety, require some kind of ritual behavior to generate a reduction in the adverse emotional state.3,10 Concerning the two remaining statements of this dimension— “Having difficulty taking decisions” and “Having to do things very slowly to be sure that they are done properly”— those patients who had relevant obsessive-compulsive symptoms had high scores as well: 74% reported having difficulties in taking decisions and 93% needed to do things more slowly than normal. Insecurity, the feeling of dependency on others as the disease advances, and the continual decline in self-esteem are some of the factors causing an increase in these statements. Faced with this situation, and after ruling out the possibility of an obsessive-compulsive personality disorder, we must consider the need to deal adequately with these psychological alterations, since they adversely impact the patient’s quality of life and have implications for pretransplant and posttransplant medical treatment.9 To conclude, many patients on the liver transplant waiting list show obsessive-compulsive psychopathologic symptoms. The need for detection and application of adequate psychological treatment are of considerable relevance to
3155
minimize the effects of changes in the emotional condition of these patients from the pretransplant phase onward. REFERENCES 1. Carrobles JA: El trastorno obsesivo-compulsivo. In Carrobles JA (ed): Análisis y modificación de la conducta II, Vol 1. Madrid: UNED; 1985 2. Foa EB, Steketee GS: Obsessive-compulsive conceptual signs and treatment interventions. In Goldstein A, Foa EB (eds): Handbook of Behavioral Interventions, New York: Wiley; 1980 3. Raich RM: Evaluación y tratamiento de un caso de trastorno obsesivo-compulsivo. In Maciá D, Méndez F (eds): Aplicaciones clínicas de la evaluación y modificación de conducta. Madrid: Pirámide; 1993 4. López-Navas A, Rios A, Riquelme A, et al: The importance of the introduction of a psychological care unit in a liver transplant unit. Transplant Proc 42:302, 2010 5. Pérez San Gregorio MA, Martín A, Galán A: Problemas psicológicos asociados al trasplante de órganos. Int J Clin Health Psychol 5:99, 2005 6. Dobbels F, Vanhaecke J, Dupont L, et al: Pretransplant predictors of posttransplant adherence and clinical outcome: an evidence base for pretransplant psychosocial screening. Transplantation 87:1497, 2009 7. Conesa C, Ríos A, Ramírez P, et al: Psycho-social profile in favour of organ donation. Transplant Proc 35:1276, 2003 8. Martínez-Alarcón L, Ríos A, Conesa C: Attitude toward living related donation of patients on the waiting list for deceased donor solid organ transplant. Transplant Proc 37:3614, 2005 9. Ríos A, Ramírez P, Rodríguez M, et al: Attitude of ancillary personnel faced with living kidney donation in a hospital with a living donor kidney transplant program. Transplantation 83:336, 2007 10. Pérez-San-Gregorio MA, Martín-Rodríguez A, PérezBernal J: Influence of the psychological state of relatives on the quality of life of patients at 1 year after transplantation. Transplant Proc 40:3109, 2008