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Transplants and Psychiatry

Key Words: Letter

TO THE EDITOR: Research work conducted on transplant patients brings us various results. In view of these, what synthetic model can we propose now?

The fundamental question concerning transplants is "how will an individual react psychologically to something living and foreign being added to the person's body?"

As far as we know, no one has ever put forward any theories concerning additions to the body. However, the technique is an old one. Consider the prostheses that we wear nowadays without even noticing they that are in fact prostheses, that is, spectacles. Nevertheless, these have a particular feature by which they differ radically from transplants: eyeglasses are lifeless and impersonal.

Being affected by failing eyesight is in the first instance a "narcissistic wound." It is an attack on our self-esteem, that is to say on the affected portrait we have of ourselves through the image of our bodies. This reaction involves an adaptive depressive symptomatology¹ that is nonspecific. Indeed, any loss of a precious object is experienced as a bereavement and as a loss of a part of oneself. The distinctive feature in this case is that we are dealing with a part of the body. If, at the outset, the subject denies what has happened and revolts, after the bereavement and the lamentation he/she becomes resigned. The person may then "cosset" his/her spectacles and even look for them when the person is already wearing them. The same applies to a transplant patient, the only difference being that the spectacles did not belong to anyone and are inert objects.

Now let us imagine the same aforementioned process, but now applied to teeth, and with this difference we are now offered second-hand dentures. We will experience some degree of uneasiness even if we know that the germs are dead. We have not really explained anything with this metaphor. We have simply sought to find a similar situation that could occur in everyday life. The hypothesis that we put forward here to explain this feeling of disgust, that is, faced with this kind of situation, we are confronted by an impression of "disturbing strangeness" in Freud's sense of the term.² A reaction of anxiety on the part of any person who is confronted with aspects of the person's earlier childhood beliefs, disturbing and animistic phantasmagoric elements that have been suppressed and eliminated from one's mind and that are then reactivated by the situation.

We believe that this reaction is characteristic of the mechanisms of adaptation and that its expression is variable. One of the variables involved in transplantation is whether the donor is either a living donor (LD) or dead donor (DD). One study³ has found that the greater incidence of complications in the liver transplant patients (DD), compared with the kidney transplant patients (LD), is related to the fact that the liver transplant patients were more anxious about the origins of the organ. As regards living donors, there are other difficulties, especially if the donor is a relation. These difficulties have been studied in kidney and bone marrow transplant patients, mainly in children and adolescents. After transplantation, the youngster finds him-/herself indebted to the family⁴ for his/her life, and he/she will have to come to terms with this if he/she is to grow up and become independent. In this respect, there will be advantages in the case in which the donor is dead, because although there is still a feeling of debt, it is to the medical team.⁵

There are other variables when children are involved. At this age, the image of the body and therapeutic freedom depend on the parents, which means that "giving a child an organ transplant is to give the parents one too."⁶ Moreover, when these children become adolescents, they talk about their organ transplant as if they had to accept it all over again when the image they have of their bodies undergoes the changes that adolescence brings. It is also because of these changes that it is more difficult for adolescents to accept transplants.

Just as we would not buy spectacles designed for the opposite gender, so certain recipients believe that because the organ is "of the opposite gender" they have been "transplanted" with characteristics of that gender. This is true of any personality trait, real or imagined, and the frequency with which it occurs depends on the organ transplanted.⁷ Thus, as the heart represents the center of the emotions,⁸ of love and of our desires, there are likely to be more complications than in the case of the kidneys, which have only an impersonal cleansing function.

We propose a model in which a phase of narcissistic injury is followed by a feeling of disturbing strangeness prior to the incorporation of the new part into one's body. This feeling foreshadows the reconstruction of an identity, that is to say a unity of the different parts of the body understood as a familiar whole, and therefore "Heimlich" rather than "un-Heimlich," and on which the emotions and a new quality of life will be built. This model remains to be tested.

REFERENCES

1. Phipps L: Psychiatric aspects of heart transplantation. Can J Psychiatry 1991; 36:563–568[Medline]
2. Freud S: The Uncanny. James Strachey. London, UK, Standard Edition, 1955, p. T 17
3. House R, Dubovsky S, Penn I: Psychiatric aspects of hepatic transplantation. Transplant 1983; 36:146–150[Medline]
4. Consoli SM, Baudin ML: Vivre avec l'organe d'un autre: fiction, fantasmes et réalités ... Psychologie Médicale 1994; 26:102–110
5. Heyink J, Tymstra T, Slooff MJH: Liver transplantation—psychosocial problems following the operation. Transplantation 1990; 35:361–367
6. Stuber ML: Psychiatric aspects of organ transplantation in children and adolescents. Psychosomatics 1993; 34:379–387[Abstract/Free Full Text]
7. Owen S: Psychiatric aspects of organ transplantation. Am J Psychiatry 1989; 146:972–982[Abstract/Free Full Text]
8. Mai FM: Psychiatric aspects of heart transplantation. Br J Psychiatry 1993; 163:285–292[Abstract/Free Full Text]

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