DENIAL IN THE PATIENTS TREATED WITH BONE MARROW TRANSPLANTATION Short running head: Denial in the patient treated with BMT
Clinic for Psychological Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
Rudolf Gregurek, M.D.
Psychiatrist, Clinic for Psychological Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
Irena Ladika, M.D.
Clinic for Psychological Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
Eduard Klain, M.D., Ph.D.
Professor of Psychiatry, Clinic for Psychological Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
The study is a part of the projects supported by the Ministry of Science, Technology and Informatics: "Quality of life of chronic patients and patients treated by transplantation", number 3-01-442, conductor of the project professor Eduard Klain, M.D., D.Sc.
Anxiety is the accompanying phenomenon of all stressful situations. Bone marrow transplantation with uncertainty of its result and painfulness of therapeutic procedures (cytostatic therapy, irradiation, insertion of catheter etc.) contributes to the development of anxiety. The present research evaluates denial as the dominant defence mechanism in patients treated with alogenous bone marrow transplantation. The results are analyzed as to the sex of the patients and the outcome of treatment of a selected group of patients who suffered from acute leucose and underwent alogenous bone marrow transplantation. According to the findings, denial was their predominant defence mechanism. Also, a statistically significant difference in using denial was found between the patients who survived the transplantation procedure and those who did not - in the second group denial was significantly more explicit in the first few days of the treatment. These results might serve as a motivation for similar researches in the future in order to achieve a more successful outcome of the treatment of these patients.
Introduction The modern era of clinical bone marrow transplantation (BMT) began in 1968, when the first BMT in a human being was done (1). In the Institute for Haematology of the Internal Clinic Rebro in Zagreb, the first bone marrow transplantation was done in 1983 (2). Today BMT is a very efficient method of treating benign and malign haematological diseases. BMT procedure in isolation of a sterile unit (tent) is difficult for the patients because of its painfulness (cytostatic therapy, irradiation and its accompanying disturbances, insertion of catheter etc.), uncertainty of the treatment, complexity and duration of therapeutic procedure.
Every somatic illness, besides objective organic disturbances, causes also a change in psychic state of the patient. This is especially evident in serious, life endangering illnesses, the knowledge of which comes as a shock to the patient, requiring all his adaptation psychological mechanisms to be mobilized in order to overcome the knowledge of endagerness, to accept the struggle for life in an entirely changed form, accompanied by many restrictions and deprivations. The present-day experiences show that mentally healthy and emotionaly firm persons cope better with that knowledge. Psychically unstable persons with intrapsychic or interpersonal emotional problems, with reduced tolerance of frustrations, may easily, when confronted with the illness, develop an anxious reaction with psychotic disorganization of personality. Therefore psychological preparation of the patient is of extreme importance for BMT. Psychological preparation is based on meetings with psychiatrist-psychotherapist since the admission of the patient in the ward, follow-up of his/her behaviour, defence mechanisms, adaptation capacity, tolerance of frustrations, and, sometimes, the necessary interpretations of medical procedures and interventions, along with supportive psychotherapeutic interventions.
Disturbances of mental state during BMT treatment can appear in an acute or chronic form. Arrival to the sterile unit and intensity of medical interventions, especially in the first days of the treatment, contribute a lot to the development of acute anxiety. Sterile unit itself may seem frightening, and manipulations with the patient like insertion of a cava-catheter, cytostatic therapy, irradiation and transplantation are both painful and unpleasant. They all represent conditions in which the patient's psychic equilibrium and his environmental reality are impaired and his physical integrity endangered.
The main characteristic of psychic reactions to the transplantation procedure is anxiety, which may manifest in various degrees and which influences considerably the quality of the patient's life. During his stay in sterile unit such anxious reaction always demands psychiatric help and intervention (both psychotherapeutic and pharmacotherapeutic), primarily because of a possibility that the patient, unable to endure isolation, leaves the "tent". In our everyday conversations with the patients we could observe the increase of anxiety, so one of our psychotherapeutic tasks was to keep it at the level the patients could tolerate. We also observed the absence of manifest depression, and the predominant defence mechanism in the "tent" was denial. Similar observations were reported by Freeman et all (3), Hotson and Pedley (4), Mai et all. (5) in their studies on heart transplantation, Freyberger (6) and Maletic (7) saw the same in the patients undergone kidney transplantation, and Beard and Sampson (8) in patients on haemodialysis.
Freud (9) defines denial as a defence mechanism characterized by the subject's refusing to admit the reality of traumatic perception. Rycroft (10) defines denial as a defence mechanism in which the subject denies a painful event or some impulse or aspect of the self. Hackett and Cassem (11) define denial as a "conscious or unconscious nonadmittance of a part or the complete meaning of the event as a possibility of mitigating fear, anxiety or other upsetting effects". In the present study we have not dealt with psychoanalytic aspects of denial.
In the course of our work in transplantation team we observed the patients use this defence mechanism in order to protect themselves from too much anxiety. They used denial as a defence against an unpleasant or fringtening part of reality. We differ constructive denial - denial adapted to reality - and destructive denial, which is contradictory to the reality principle. The first group of patients is characterized by recognizing the nature of their illness and acceptance of therapeutic measures. Like all other patients, they too suffer from anxiety and depressive reactions to the sad reality, but they have sufficient insight not to leave the therapy. Denial, however, can be a very dangerous defence mechanism because it can change the very experience and ability to evaluate the reality properly. We could see such situations during our work with the patients in the "tent", when they completely denied reality and, refusing even a slightest thought about their illness, endangered in fact the course and success of the medical treatment.
We assumed that psychotherapeutic interventions during life in sterile unit would prevent excessive increase of anxiety which might result in the so-called acting out reactions (leaving the tent) and make neuroleptic therapy necessary.
The aim of the present research was to verify denial in the patients suffering from leukemia who were treated with transplantation of alogenous bone marrow during their stay in sterile unit. This parameter was related to the sex and the outcome of therapeutic process, i.e. with a successful or lethal issue of therapeutic process.
Subjects and methods Patients: The subjects were 35 patients treated with transplantation of bone marrow from HLA identical sibling in the Institute for Haematology of the Internal Clinic Rebro. Table 1 shows the main characteristics of the patients.
BMT method: First the patients were put into a sterile unit. Prior to transplantation the patients were irradiated and cyklophosphamide or combination of cyclophosphamide and busulfan was administered. The way the patients were cared for during the BMT procedure was presented already in detail. Psychotherapist talked with them every day and minutes of these meetings were kept.
Questionnaires: All the patients treated with BMT filled Beck's inventory for measuring depression (12) in the first and sixth week of their stay in the sterile unit. Two items were selected from it (question no 2 - I am not very discouraged as to my future, and the question no 20 - I am not worried over my health more than usual) which represented best their denial of reality, and answering these two questions the patients could get from 0 to 6 points. Lower numbers represented a higher degree of denial, while higher numbers pointed at the absence of that defence mechanism. After 4 to 5 weeks, i.e. before leaving the sterile unit, the patients filled the same questionnaires once more, so we could follow the changes in their anxiety during their stay in sterile unit.
Statistical analysis: Statistical package for the social sciences (13) was used as a statistical method.
The Table 2 presents the means of depression and denial at the beginning of the treatment and just before leaving the sterile unit in correlation with the patient's sex. It should be emphasized that there is no statistically significant difference between the first and the last measuring of the intensity of depression and denial in male and female patients. There is also no statistically significant difference between male and female patients as to the degree of depression and denial in the first and the last week of their stay in the tent.
The Table 3 shows correlation of depression and denial in relation to the success of the treatment or end of therapy. It can be seen from the results of the degree of depression that there is no statistically significant difference between the first and the second measuring, nor between the group of those who have survived and the group of those who died. There is a statistically significant difference in denial (p=0.020), i.e. the mechanism of denial was statistically significantly less manifest in the first measuring in the group of patients who did not survive. In the patients who did survive denial was more manifest in the first week. At the time just before leaving the sterile unit the situation was quite the opposite: the patients who did not survive manifested denial in greater degree, but the difference was not statistically significant (p=0.052).
Discussion Transplantation medicine is a unique clinical situation made possible by the modern biotechnological medicine. It offers us the opportunity to observe the specific models of adaptation and also to test the traditional concepts of symbolization and experience of one's own body.
Anxiety is the basic pattern of response to a stressful situation, and the transplantation procedure is certainly such a situation (5,6,8,14,15).
Being put into the tent, life in such an isolated room, and all the other manipulations, together with painfullness of the treatment and uncertainty about its outcome, are the circumstances which contribute to the development of excessive anxious reactions that may endanger the patient's life because he may leave the sterile unit (any infection is a threat to an immunologically weakened organism).
The absence of manifest depression in the patients treated with autologous BMT made us try to objectivize the degree of their depression (Table 2). Beck's inventory enabled us to confirm the observations about denial as a predominant defence mechanism in the patients undergoing transplantation procedures. Although denial is analyzed on the basis of two statements only, these statements reflected adequately our observations from everyday meetings with the patients. Similar observations are reported by other authors (5,6,7,8,16,17,18).
Table 2 shows that there is no statistically significant difference in depression between male and female patients at the end of their stay in sterile unit.
Interesting findings of our investigation are presented in the Table 3, where two groups of patients are compared as to the success of therapeutic process. There is a statistically significant correlation of denial in the first week of stay in the tent with mortality of the patients (p=0.034), as confirmed by clinical observations, which also pointed at the use of destructive denial. Young et all. (18) report on similar findings in the patients undergoing heart transplantation.
Psychotherapeutic work with these patients made us possible to distribute them into two groups: those who used destructive denial during their stay in the tent and those who manifested quick interchanges of insight into reality and relapses into denial as a way to make therapeutic procedures easier for them (constructive denial). In the first group were the patients who from the very beginning refused to speak of their illness and accompanying phenomena of transplantation process, who were undisciplined and accused the staff. Such a patient was D.L., aged 24, who would not talk about her illness, but talked always of her family, episodes from the time before her illness. All the time she spent in the tent she complained of sterilized food, wanted her mother to bring her food from home, which provoked endless conflicts with the staff who did not allow that. She could not accept persistent explanations that she ought not to do this and immediately on leaving the tent she started to take her mother's food. As a consequence, an exceptionally intense GvHD developed and the patient died.
Another example is the patient S.R., a nurse, who was constantly on move while preparing to enter the tent, helped her colleagues, and in the contact with psychiatrist presented the problems of nurses working at such a ward, always avoiding to talk about her illness. She did not change her behaviour during her stay in the tent; she kept experiencing herself as a nurse, not as a patient. She did not accept the psychiatrist's interventions, refusing to see the reality of her illness.
The third example is the patient Z.S. During the preparations for transplantation he showed hardly any interest in therapeutic process. He communicated reluctantly with the staff and the psychiatrist's questions about how he felt he answered: "I must endure that, it must be done, there is nothing to talk about." He was happy only when his family visited him. During the transplantation process he tried to present himself as a brave person with almost no health difficulties, minimalizing his disturbances at any cost. In the fourth week of his stay in the tent he developed GvHD and died.
The other group of patients were those with quick interchange between reality and denial (use of constructive denial). The patient B.M. asked for explanations about therapeutic procedures, but soon he began to avoid long conversations about his illness, changing the subject to his condition before the illness, his job, or showing interest in our work. He stuck to such kind of communication through the whole treatment, as if wanting to learn something about his treatment, but painfullness of the procedures forced him to return to the past, to the time when he was not ill.
M.S., aged 22, in the beginning was interested in the duration of the treatment, the possible accompanying phenomena. He showed the same interest on entering the tent, but at the same time he tried to make jokes, made fun of the nurses, tried to "seduce" them, impress them by his tolerance of pain. Conversations with psychiatrist served him to get the "information about his illness, results of examinations". We supported him, thus enabling him to keep the "impression" he wanted to make on the nurses.
The patient I.S. surrounded herself by photographs of her family, especially cildren, talked about her family, only occasionally she was interested in reality, i.e. her therapy. During her stay in the tent she moved between refusal of reality through stories about her children and cautious inquiries about the results of the transplantation procedure.
Conclusion On the basis of the results and these short case reports one can realize the patients' need to use denial as the only possible solution in such a traumatic situation. Of great importnce is support offered to the patient in confronting the reality, which is necessary for real assessment of his health state and engagement in overcoming the difficulties he is faced with. The role of psychiatrist is to assess the patient's capacity for tolerance of frustrations in order not to go beyond the threshold of his adaptation abilities. This can be achieved in preparing the patient for transplantation, but also in everyday contacts with the patient and transplantation team, especially the nurses who are in continuous contact with these seriously ill patients. A great attention should be paid to the recognition of destructive denial and the need of resolving it.
The results of this study, as well as similarities with other studies in the field of transplantation medicine, are a stimulus for further investigations in this field, not neglecting the indicators showing that psychological factors have a great influence on the success of transplantation treatment.
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Table 1. Characteristics of the patients treated with alogenous bone marrow transplantation
Number of patients
Table 2. Depression and denial correlated with gender at the beginning and at the end of BMT
Table 3. Depression and denial correlated with the outcome of transplantation procedure