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families. At the same time, their physical health, dialysis.3,12 Another one significant stressor is
their functional status, their personal fatigue, which can negatively affect a person’s
relationships and their social and economic status ability to work and to participate in various daily
are greatly affected.1,4 activities. Physical or mental fatigue can be
caused by sleep disorders or fatigue after dialysis.3
STRESSORS OF PATIENTS UNDERGOING
HAEMODIALYSIS INDIVIDUAL PSYCHOLOGICAL FACTORS OF
Many authors have dealt with the stressors of PATIENTS UNDERGOING HAEMODIALYSIS
individuals with chronic renal failure undergoing Psychopathology
regular dialysis, since they increase both the
psychological and socio-economic problems of Psychopathology of patients undergoing
these patients. The most common stressors are haemodialysis plays an important role in the final
financial difficulties, changes in social and marital outcome of renal disease and in occurrence of
relationships,2 regular hospital admission, inability psychiatric symptoms. Social or family support of
of holiday vacation, restriction of leisure time, the patient and medical staff support are very
relationships with nursing and medical staff, fear important factors, as they affect patient’s
of disability or death, increased dependence on compliance to the disease. In a patient with such a
artificial kidney machine, uncertainness about the chronic health problem, a powerful 'Ego' tries to
future and physical fatigue.3-9 mobilize adaptable strategies of the disease, while
Furthermore, according to Gerogianni,3 a weak ‘Ego’ is leading him to the development of
limitation of liquids and foods is the most psychiatric disorders, non-compliance with the
frequent stressor for these patients. That is treatment and usually disruption of interpersonal
because the daily consumption of fluids should and family relations.13
not exceed of 500 ml per day due to the risk of
causing pulmonary edema. An equally distressing Personality
factor is the requiring effort to follow the dietary
Psychosocial patient’s compliance with a regular
guidelines, as the excessive intake of potassium
haemodialysis program depends on the
and phosphorus is responsible for causing heart
personality of the patient in conjunction with the
failure and possible itching or renal
support received from health professionals, family
osteodystrophy respectively.3
and social environment. 13,14
A recent research study conducted in Greece
by Kaitelidou et al.,10 showed that unemployment According to the research study of
is a significant stressor for haemodialysis patients. Koutsopoulou et al.,14 about the effect of chronic
According to that study, 60.2% of patients dialysis on the personality of patients with CRF,
receiving dialysis were not able to keep their patients who are forced to join in a program of
profession and 36.7% had to retire after the periodic dialysis, exhibit personality disorders,
beginning of dialysis. Loss of employment is which are different, regarding gender and age.
responsible for the appearance of intense anxiety Specifically, these patients, before the enrollment
and problems of sexual function while in a program of CRF, are facing a health problem as
employment positively affects the psychological most people with a chronic problem. After the
status and libido of spouses.3,11 beginning of dialysis, they exhibit considerable
Also, Ormandy argues that stressors affecting psychological personality disorders, such as
sexual appetite of patients are body image issues alexithymia, neuroticism, introversion and
(weight loss, muscle wasting, change of skin color, psychotism.14
visible signs of venous puncture) after starting
During the period of adjustment to the dialysis According to the theory of self-determination,
procedure, patient is going through three periods: autonomy is one of the basic human psychological
a) The period of honeymoon, beginning 1-3 weeks needs contributing to daily well-being and
from the first dialysis psychological well-being.25 When the fulfillment of
autonomy need is hampered by various factors,
patients experience poor self-esteem and bad social disorders (isolation, negligence) and
psychological condition.26,27 economic impact (e.g. inability to keep the job). 31
Anemia is the most common complication of CKD. In the field of periodic dialysis, wellbeing and
According to existing data from the U.S. (National patient’s health depend on the active
Health and Nutrition Examination Survey), the participation of patient in the treatment program
incidence of anemia in patients of 3rd Stage of CKD and the compliance with medical instructions,
is 5.2%, in patients of 4th stage is 44.1%, and in requirements regimen and recommendations.
end -stage renal disease patients is universal.
Furthermore, in certain patient groups, such as Patient’s compliance in the treatment process
African Americans and patients with diabetes, the is very important as it affects the prognosis of a
incidence of anemia is greater in all stages of chronic illness such as End Stage Renal Disease
kidney disease.28 Anemia appears clinically as (ESRD) and thus the quality of life of those
fatigue and / or depression, due to reduced patients.32 Compliance, involves adherence to a
secretion of erythropoietin by the kidneys and treatment regimen (dialysis schedule, duration of
adversely affects the quality of life of these treatment, special diet, fluid limitation, right
patients.13,29 Key components of quality of life of medication), changes in behavior, habits and
patients, such as motor activity, sleep, morbidity, lifestyle and sometimes adjustment of the
social activity, emotional relationships, anxiety, personality aspects to the dialysis treatment.33,34,35
depression and mental satisfaction are being
A percentage of haemodialysis patients do not
influenced favorably by correcting anemia.30
comply with medical instructions, medication and
The administration of erythropoietin, folic acid, dosage, monitoring of the planned treatment,
vitamin B12, vitamin complexes and iron is completing the required treatment time,
important in the treatment of anemia and iron restriction of fluids and dietary restriction. 5
deficiency while transfusions are recommended Reduced compliance is often a result of a
for severe anemia.28 depressive phenomenon and associated with
increased mortality and poor medical results.5,36
Pain
Also, a research study of Tijerina36 on
The appearance of chronic pain in dialysis patients psychosocial factors affecting the compliance of
is usually in rate 37% to 50%, while 82% of them Mexican - American women during the dialysis
show a moderate to severe intensity pain. The procedure, classifies poverty, long-term periodic
etiology of pain is multifactorial and may be either haemodialysis, immigrant status, loss of identity
due to the process of dialysis (puncture, muscle and family dysfunction among the factors
cramps, headaches) or due to the existence of affecting patients’ compliance in the dialysis
accompanying systemic diseases and painful treatment. Regarding poverty, patients who are of
syndromes. Pain is the most common symptom - low income are compatible in the use of limited
discomfort of patients which causes significantly resources, buying low-cost drugs, using low-cost
impaired quality of life. This is because the health services and not following specific dietary
incidence of chronic pain is associated with the restrictions.
onset of affective disorders (anxiety, depression),
of life. At this point, it is worth mentioning the 5. Cukor D, Scott D, Cohen Rolf A, Peterson,
close cooperation of the members of the Kimmel P. Psychosocial Aspects of Chronic
multidisciplinary treatment team (nutritionists, Disease: ESRD as a Paradigmatic Illness. J Am
psychologists, machine technicians). Also, Soc Nephrol 2007; 18: 3042–305.
patients’ involvement in support networks or 6. Horsburgh ME, Rice VH, Matuk L. Sense of
rehabilitation activities and participation in a coherence and life satisfaction: Patient and
program of physical activity or in educational spousal adaptation to home dialysis. American
programs can help these people to create new Nephrology Nurses' Association Journal 1998;
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recognition and appreciation and to prevent social 7. Triantaphillopoulou E, Iphou A, Arvaniti P,
isolation. In the meanwhile, individualized Michalopoulos D, Nousis T, Tserkezis G,
psychotherapeutic interventions for patients who Velissari E, Iphos C. Psychological nursing
report depressive symptoms and anxiety support for elderly patients undergoing
disorders and the development of psychiatric chronic regular haemodialysis. European
services in primary and secondary health care in Dialysis and Transplant Nurses Association/
patients undergoing regular haemodialysis would European Renal Care Association Journal
help those patients. 1998; 1: 29-31.
Moreover, the promotion of health programs 8. Dingwall RR. Living with renal failure: the
towards patients suffering from CRF should psychological issues. European Dialysis and
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programs would raise awareness and promote the the differences and sharing the common
biopsychosocial approach to the disease and the problems. Patient Education and Counseling
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10.Kaitelidou D, Liaropoulos L, Siskou O, Mamas T,
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