Psychosomatics 39:501-511, December 1998
© 1998 The Academy of Psychosomatic Medine
Personality Disorder as a Contraindication for Liver Transplantation in Alcoholic Cirrhosis
William R. Yates, M.D.,
Douglas R. LaBrecque, M.D., and
Debra Pfab, B.A.
Received September 17, 1997; revised January 30, 1998; accepted February 11, 1998. From the Department of Psychiatry, University of Oklahoma College of Medicine, Tulsa Campus; and the Department of Internal Medicine, University of Iowa College of Medicine, Iowa City. Address reprint requests to Dr. Yates, Department of Psychiatry, University of Oklahoma College of Medicine, Tulsa Campus, 2808 South Sheridan Road, Tulsa, OK 74129–1077.
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ABSTRACT
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Severe personality disorder has been proposed as a contraindication for liver transplantation. Seventy-three subjects with alcoholic-related liver disease were evaluated for personality disorder and followed for 6 months. The subjects with severe personality disorder had higher rates of divorce, higher rates of comorbid drug abuse or dependence, lower Weschler Adult Inventory Scale IQ estimates, and higher scores on indicators of emotional impairment. Personality disorder was not associated with a higher rate of return to alcohol use during the follow-up period. Three subjects with personality disorder underwent liver transplantation without behavioral or substance abuse complications. This study does not support routine exclusion of subjects based solely on a diagnosis of a severe personality disorder.
Key Words: personality disorder • transplants • alcoholism
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INTRODUCTION
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Psychiatric evaluation before organ transplantation is common. A survey of transplant coordinators for heart, liver, and kidney transplantation programs documented the involvement of psychiatrists and other mental health professionals in the transplant process.1 In the majority of programs, a mental health professional evaluates all potential transplant candidates for psychosocial suitability for transplantation. Psychiatrists are involved in the transplant assessment program in 60% of all liver transplant programs.
Although mental health evaluations are nearly universal, the psychosocial criteria for transplantation are not standardized. Some psychiatric disorders, such as active schizophrenia and dementia, are considered an absolute contraindication for transplantation in the majority of transplantation programs. Other psychiatric illnesses and behaviors, such as mood disorders, suicidal ideation, suicide attempts, and personality disorder, are more likely to be considered relative contraindications. In these situations, individualized decisions about transplant candidacy are made based on specific factors relevant to the clinical situation.
The stringency of screening criteria for organ transplantation appears related to the specific organ involved. Heart transplantation programs appear to have higher psychiatric standards than liver transplantation programs. Liver transplantation programs appear to have higher standards than kidney transplantation programs. These differences may to be related to the relative availability of those specific organs for transplantation.1
Severe personality disorder has been proposed as a potential absolute or relative contraindication for transplantation.2 In the survey of transplant programs by Levenson and Olbrisch,3 14.1% of heart transplantation programs viewed personality disorder as an absolute contraindication to transplantation. The rates of absolute contraindication ratings for personality disorder in the liver and kidney programs were 8.7% and 5.2%, respectively. The majority of the programs considered personality disorder a relative contraindication to transplantation. Personality disorder was considered an irrelevant criteria in 23% of heart transplant programs, 26% of liver transplantation programs, and 38.7% of kidney transplant programs.
In their survey of liver transplant programs, Snyder et al.1 assessed the effect of various comorbid psychiatric disorders on transplant eligibility for patients with alcohol dependence. One out of 14 programs (7%) reported they would reject a candidate for comorbid borderline personality disorder. Four out of 14 programs (29%) would reject a candidate for comorbid antisocial personality disorder.
The reasons for proposing severe personality disorder as an absolute or relative contraindication to transplantation do not appear to be based on empirical or outcome studies. Clearly, such studies are needed to assess the validity of the presence of a personality disorder as a criterion for transplantation ineligibility.
To examine the validity of personality disorder as an individual and specific screening criterion, we examined the personality characteristics of a series of patients with medically serious liver disease related to alcohol use. We hypothesized that personality disorder would be prevalent in this clinical population. Additionally, we hypothesized that support for the validity of the personality disorder criterion would be supported by 1) evidence that personality disorder status added specific information about suitability for transplantation beyond other psychosocial and alcoholism variables and 2) evidence that personality disorder status adversely affected treatment outcome regarding alcohol and drug abuse posttransplant.
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METHODS
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Subjects
Study subjects were recruited from two sources: 1) the Liver Clinic and 2) the Liver Transplant Service from the University of Iowa Hospitals and Clinics. Subjects were identified from a group of all patients seeking inpatient and outpatient assessment and treatment for alcohol-related liver disorders. The University of Iowa Hospitals and Clinics has an active liver transplantation service, with 30 to 50 transplants completed yearly.
To be medically eligible for study participation, subjects were required to have a diagnosis of alcoholic cirrhosis or alcoholic hepatitis. A liver biopsy confirmation was required for either diagnosis. For the subjects without a biopsy, a clinical diagnosis made by a faculty gastroenterologist was accepted.
The subjects in the study were part of a longitudinal study of predictors of alcoholism relapse in alcoholic liver disease. Additional eligibility requirements for this study included 1) a stated goal of abstinence from alcohol, 2) absence of acute or chronic cognitive impairment, 3) agreement to be followed by the research team for a period of 1 year, and 4) agreement to allow a collateral source (if one was available) to provide baseline information and to be available during the follow-up period.
The subjects signed consent forms approved by the University of Iowa's Institutional Review Board. Recruitment involved both inpatients and outpatient populations at the University of Iowa Hospitals and Clinics. Potential subjects were identified by a review of patient diagnoses on medical and surgical floors and by referral from gastroenterologists and transplant surgeons familiar with this study. The participants were reimbursed for their interview time and the time required for completing self-reports.
Collateral Sources
Each subject was asked to identify a collateral source. The subjects were told this collateral source should know about the subject's drinking history and be available in the year after the initial interview to provide information about the subject's progress and drinking status. Collateral sources also signed informed consent.
Interviews
The subjects were interviewed by a faculty psychiatrist (WRY) for important alcoholism history variables. This interview gathered information about DSM-IV4 criteria for alcohol abuse and dependence by using the Structured Clinical Interview for DSM-III-R (SCID)5 as well as information about important historical variables, such as age at onset of drinking, age at onset of heavy drinking (getting intoxicated at least once a week), usual quantities of alcohol consumed daily, and prior inpatient and/or outpatient treatment. This interview was done in person when feasible or alternately by phone.
Collateral sources were interviewed separately by the research assistant (DP) at the index evaluation. Collateral sources were contacted during the follow-up period to corroborate drinking status of the subjects.
Personality Diagnostic Questionnaire-Revised
The role of personality disorder in outcome was assessed by using the Personality Diagnostic Questionnaire-Revised (PDQ-R).6 The PDQ-R is a 162-item self-report instrument for screening personality disorders. It includes 11 PD scale questions corresponding to the criteria from DSM-III-R for individual personality disorder criteria. There are two validity scales and an impairment distress scale designed to detect random responders and reduce false-positive diagnoses. The PDQ-R has received considerable attention in reports of its use with many different clinical populations.7,8 Sensitivities for individual personality disorder have been reported to range from 0.61–0.93, and specificities have been reported to range from 0.43–0.85.9,10
Classification of Severe Personality Disorder
Severe personality disorder classification was based on meeting one of two criteria: 1) presence of DSM-III-R antisocial personality disorder criteria from the SCID or 2) scoring greater than 50 on the total score for the PDQ;n-R.
Psychometric Testing
Neuropsychological screening was done by using two measures: 1) the Shipley Institute of Living Scale (SILS)11 and 2) The Trails B measure of visuomotor performance and cognitive set shifting.12 The Shipley Institute of Living Scale is a brief timed test that can provide an estimate of Weschler Adult Intelligence Scale (WAIS) verbal and performance IQ. Forty vocabulary items and 20 items measuring abstract thinking are completed. From standardized scales, a WAIS IQ estimate can be made.12 The test has also been used to assess mental deterioration. In this form, the abstract IQ score is subtracted from the verbal IQ score to yield an index of cognitive impairment. The Trail-Making Test has been widely used as an easily administered test of visual–conceptual and visuomotor tracking.13 Like other tests with a large attentional component, the Trail-Making Test is highly sensitive to effects of brain injury and impairment. In the Trails A Test, the patient is asked to draw lines connecting consecutively numbered circles placed randomly on a sheet of paper. This task simulates the well-known dot-to-dot drawing skill. In the Trails B test, the subject is asked to connect another series of dots—some of the Trails B dots contain a number, and some contain a letter. Subjects are asked to connect alternate numbers and letters, for example, A,1, B,2, C,3.
Psychosocial Assessment of Candidates for Transplantation
A second, commonly used assessment instrument for organ transplant screening is the Psychosocial Assessment of Candidates for Transplantation (PACT) scale.14 The PACT scale is considered appropriate for transplant candidates facing heart, liver, or kidney transplantation. Items are scored on a 1-to-5 Likert-type scale, with descriptors around anchor points. Higher scores indicate more favorable ratings. The PACT scale identifies four domains. First, social support is assessed on two factors: family or support system stability and family or social support availability. Second, psychological health is assessed on two factors: psychopathology and risk for psychopathology. Third, life-style factors are assessed on three items: healthy life-style, drug and alcohol use, and compliance with medications and medical advice. The final domain assesses the patient's relevant knowledge about his/her condition and receptiveness to patient education. To obtain a summary score for the PACT scale, we summed all eight subscale scores. This process would result in a continuous measure from 8 to 40, with 40 indicating the highest rating on all 8 subscales.
Alcoholism Prognosis Scale for Transplantation
The Alcoholism Prognosis Scale for Transplantation (APST)15 assesses three domains believed to influence the prognosis in alcoholism. The first domain assesses the recognition by the patient and family of the subject's diagnosis of alcoholism. Acknowledgment that alcoholism is a problem by both the patient and family is considered the first step in establishing and maintaining abstinence. A second domain is social stability. Social stability is assessed by using the four measures of social function identified by Strauss and Bacon.16 These four measures are commonly known as the Strauss–Bacon index. The final domain in the Alcoholism Prognosis Scale for Transplantation identifies factors developed from the research of Vaillant,17 which focused on personal factors believed to influence abstinence. By using prospective data carried out beyond 2 years, Vaillant identified "secure abstinence" (3 years or more) as being associated with the presence of at least two of four factors: a substitute dependency, a source of hope or self-esteem, acceptance by another human being, and the presence of a negative behavioral reinforcer. All subjects were rated with this instrument. The scale has weights for individual criteria and when summed ranges from 0 to 20.
High-Risk Alcoholism Relapse Scale (HRAR Scale)
The HRAR scale is a three-item scale empirically developed to estimate the risk of alcoholism relapse following an index evaluation. This scale was developed from a study of relapse following inpatient alcoholism treatment in a cohort of male U.S. veterans.18–20 This scale was replicated and demonstrated to have predictive validity in a second cohort of similar subjects.
The scale includes an item for duration of heavy drinking, daily usual drink number, and number of prior alcoholism inpatient treatment experiences. Each item in previous cohorts has had independent contributions to relapse risk. Each item can be score 0, 1, or 2, for a total score of from 0 to 6. Subjects scoring 0–2 are considered low risk for relapse, 3–4 considered medium risk for relapse, and 5–6 considered high risk for relapse.
Outcome Assessment
The subjects were followed during the year after index evaluation through multiple methods, including daily diaries, direct interviews, collateral interviews, and reviews of medical records. The subjects completed daily diaries that recorded number of drinks and contact with medical and substance abuse treatment services. Additionally, every 3 months, the subjects were interviewed by phone to determine their reports of the use of alcohol and drugs. Collaterals were also contacted to confirm subject reports. Clinical contacts with the University of Iowa Hospitals and Clinics were reviewed for drinking and drug use information. Urine drug screens collected for clinical purposes were reviewed for evidence of illicit substance use. No routine biochemical tests of alcohol use were collected. However, when urine tests for alcohol were collected for clinical purposes, these results were available to assist in assigning drinking status.
We elected to define relapse in three ways: as any return to drinking, return to heavy drinking (greater than 5 drinks per day on any occasion), or return to problem drinking.
Statistical Analysis
The subjects with and without personality disorder were compared with each other on a variety of continuous and categorical measures. For continuous measures, nonpaired Students' t-tests were used. For categorical measures, chi-square analyses and odds ratios (ORs) were calculated. Ninety-five percent confidence intervals (CI) were calculated on the ORs.21 ORs were considered statistically significant when the lower 95% CI exceeded 1.0.
About 25 tests of statistical significance were calculated in this analysis. A Bonferroni correction for multiple tests would indicate a P-value of <0.002 as statistically significant. P-values between 0.002 and 0.05 should be interpreted cautiously.
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RESULTS
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Seventy-three subjects met eligibility criteria and consented to enroll in the study. By protocol, all had evidence of alcohol-related liver disease. Twenty-nine subjects (39.7%) were listed for liver transplantation. Those not listed did not meet medical or psychological criteria for listing or were not considered severely ill enough to be listed. During the follow-up period, 15 subjects (21%) received a liver transplant.
Twenty subjects (27%) in this series met the criteria for severe personality disorder. Fifteen subjects met DSM-IV criteria for antisocial personality disorder, 13 subjects scored greater than 50 on the PDQ, and 8 subjects met both antisocial personality disorder and scored greater than 50 on PDQ-R. Table 1 summarizes the sociodemographic status for the personality disorder group, compared with those without personality disorder. As expected, women comprise a minority of subjects with alcoholic liver disease because men predominate in diagnoses for alcohol dependence. The mean age for this sample is 46 years. This figure reflects the long period of exposure to alcohol required for the development of cirrhotic changes. Although many of the study's subjects began drinking at an early age, the cumulative effects of alcohol exposure to produce cirrhosis often take 20 years or more to develop.
There were no differences in the racial composition, educational level, or occupational status between the two subject groups. Eighty-nine percent of the subjects were Caucasian—this figure reflects the racial demographics of the state of Iowa. Only a minority of subjects were employed at the time of the study, which reflects the serious effect that hepatic illness has on work status. During the follow-up period, 15 subjects had gone on to receive a liver transplant. Three subjects in the personality disorder group received a transplant. The research database on personality disorder status was collected separate from any transplantation psychiatric evaluation information. Research information was not available to the Liver Transplant Committee before making a decision about transplant eligibility.
One significant demographic difference between the personality disorder group and no personality disorder group was marital status. Fifty-five percent of the personality disorder group were divorced or separated at the time of the evaluation. This figure was higher than the group without personality disorder (OR=3.40, 95% CI=1.17, 9.95). From a similar perspective, 49% of the group without severe personality disorder had a spouse for social support, compared with only 20% of the personality disorder group (OR=3.85, 95% CI=1.14, 13.06).
Table 2 outlines some of the clinical correlates of personality disorder in the series. Although the ages of the two groups did not differ, the personality disorder subjects had a significantly earlier onset of first episode of intoxication, first alcohol problems, and first alcoholism treatment contact.
Psychometric performance measures demonstrated no statistically significant difference in performance on the Trails B test. However, of note, the personality disorder group did take on average 25 more seconds than the no personality disorder group to complete the Trails B. The WAIS IQ estimates, as derived from the Shipley Institute of Living Scale, did differ between the groups. The personality disorder group did score about eight points lower than the group without personality disorder. However, the personality disorder group mean was still in the normal IQ range.
Health service utilization measures demonstrated a split between use of medical services and use of substance abuse services. There was no difference between the groups in rates of hospitalization and number of medically hospitalized days within the last year. The personality disorder group had fewer (but not statistically significant) medical hospitalizations. However, the reverse was true for historical use of substance abuse services. The personality disorder group reported over 5 previous hospitalizations for substance dependence, compared with slightly more than 1 hospitalization for the group without personality disorder. Similarly, the number of days hospitalized for substance abuse treatment was over 5 times higher for the personality disorder group (130 days vs. 24 days).
The level of symptoms and impairment between the two groups can be compared by the Short Form (SF)-36 scores obtained at the baseline period. Lower SF-36 scores indicate more impairment or more severe symptoms. Table 2 outlines the scores from the eight subscales of the SF-36. The very low scores on limitations attributable to physical problems underscores the seriousness of the medical problems in this group. Both groups endorsed a severe impairment in physical function because of their medical conditions. The subjects with personality disorder endorsed more symptoms and impairment related to pain and to problems with emotional well-being. Additionally, the personality disorder group tended to have more problems with general health and energy.
Table 3 compares the two groups on a series of measures commonly used to assess eligibility for transplantation. There was no difference between the groups on the PACT score or the reported duration of sobriety in months. The subjects with severe personality disorder demonstrated a trend toward lower scores on the APST scale. The HRAR scale demonstrated the most significant difference between the groups, with the severe personality disorder group having a higher severity rating.
The eligibility measures comparison between the subject groups can be also made in a categorical fashion. We defined transplant eligibility as meeting all of the following cutoff scores: 1) PACT score >20, 2) APST score >10, 3) duration of sobriety of 6 or more months, and 4) HRAR score of 4 or less.
By using a combination of these four ratings, 23 (43%) of the group without personality disorder would meet transplant eligibility, compared with only 3 (15%) of the severe personality disorder group (OR=4.3, 95% CI=1.1, 16.6).
Table 4 summarizes the outcome data for the two groups. Nineteen subjects relapsed to alcohol use (12 with problem drinking, 3 with heavy drinking, and 4 with any drinking). Return to drinking was strongly associated with not being on the waiting list for transplantation. Eighteen of those relapsing were not on the transplant list, whereas only one patient on the transplant waiting list relapsed to any drinking ( 2=9.5, P=0.002). Return to any alcohol use occurred in about one-fourth of the personality disorder groups and one-fourth of the no personality disorder group. More subjects with personality disorder demonstrated drug use during follow-up, although this difference was not statistically significant (OR=2.7, 95% CI=0.7, 10.2). This higher rate of drug use is not surprising given that the personality disorder group had a higher rate of DSM-IV drug abuse or dependence at index evaluation (50% vs. 15%, OR=5.6, 95% CI=1.8, 17.9). There was a trend for any alcohol or drug use during follow-up to be higher in the personality disorder group (OR=1.9, 95% CI=0.7, 5.5).
We evaluated the three subjects identified with serious personality disorder who were transplanted. One subject died about 6 months following transplant because of a systemic infection. At follow-up, two subjects were at 6 months posttransplant and doing well. None of the three subjects demonstrated return to alcohol or drug use or any behavioral complications that influenced their medical outcome.
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DISCUSSION
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Severe personality disorder appears common among patients with serious alcohol-related liver problems. Eighteen percent of this series of patients with alcoholic cirrhosis scored greater than 50 on items related to personality disorder. This figure is in contrast to only 8% of a community sample scoring greater than 50 through use of a previous but similarly constructed PDQ scale (OR=2.6, 95% CI=1.2, 5.5). In view of the estimated frequency of serious personality psychopathology, clinical study of the effects of personality on presentation and outcome are warranted.
Personality disorder is correlated with a variety of clinical variables in this series. Many of these variables are important to the transplant selection process. Personality disorder appears related to high rates of divorce and absence of a supportive spouse at the time of evaluation. Prior studies have confirmed the link between personality disorders and divorce. The process of transplantation requires a significant commitment by a supportive family member or friend. This commitment includes being available to assist in transportation to medical outpatient visits and to facilitate the transition to home after transplantation. Personality disorder, and the disturbed interpersonal relationships associated with the disorder, may decrease the likelihood of having/identifying a reliable source of social support.
In our series, personality disorder correlated with lower WAIS IQ scores, as derived from the Shipley Institute of Living Scale. The reason for this correlation is unclear. Impairment in cognitive function may be caused by several factors. Baseline cognitive differences may exist between those with and without personality disorder. Alternately, the cognitive differences may be attributable to differences in the timing and severity of substance use. Since personality disorder appears to be associated with early onset of substance use, nonalcohol drug use, and heavy quantities of alcohol consumed, cognitive differences may reflect this relationship. Another explanation would be possible differences in psychometric performance caused by cognitive impairment related to liver disease. However, there were no other indicators that personality disorder correlated with severity of liver disease.
To further examine possible causes for the difference in WAIS IQ estimates, the vocabulary and abstraction measures on the SILS were reviewed. Vocabulary skills are felt to be relatively well preserved in contrast to abstraction skills, which can decline with brain injury or other causes of acquired cognitive impairment. The vocabulary score minus the abstraction score has been proposed as an index of an acquired brain deficit. For the severe personality disorder subjects, mean vocabulary scores were lower than the control group (26.4 vs. 30.6, t=-2.92, df=69, P=0.005). The difference between vocabulary score and the abstraction score did not differ between the personality disorder group and the control subjects (8.5 vs 9.3, t=-0.38, df=69, P=0.705), although both groups demonstrated some evidence of acquired cognitive impairment. This analysis suggests that the difference in cognitive performance stems from a preexisting difference rather than an acquired difference in level of cognitive impairment.
Personality disorder correlated with more impairment and symptoms, as measured by the baseline SF-36 scores. As expected, personality disorder status correlated with impaired emotional well-being. It would be expected that a psychiatric disorder would be likely to result in emotional distress and reduced scores on the psychological factors of the SF-36. Somewhat unexpected is the higher endorsement of problems with pain and energy level among the group with severe personality disorder. Higher pain reports in the personality disorder group appear in the context of equal levels of physical function and physical role limitations among the group. Pain management issues may be more difficult for patients with comorbid cirrhosis and personality disorder.
Personality disorder appears to influence several measures commonly used to assess transplant candidacy, including social support, chronicity and severity of alcohol dependence, and treatment for substance dependence. Despite these correlates, this study did not confirm a link between personality disorder and increased risk for adverse substance abuse outcome.
The study limitations must be kept in mind when interpreting these results. Our series of subjects came from a tertiary-care center, where they were being treated for alcohol-related liver problems. Tertiary-care populations are open to bias because of diagnostic issues that affect referral. Our results cannot be generalized to all people with alcohol-related liver disease in the community. However, since the majority of liver transplant procedures occur in tertiary-care centers, our study may reflect common experiences at such centers.
A significant number of eligible subjects did not participate in this study. During the course of the study, about 150 patients were identified as meeting eligibility criteria and approached about study participation. Only about 50% of all eligible subjects agreed to participate. Common reasons for not participating included feeling too medically ill to complete the study, reluctance to become involved in research, and not enough time to schedule interviews and complete instruments. Because of the 50% refusal rate, our results cannot be generalized to all groups of patients with alcoholic liver disease in our tertiary-care center. Rates of severe personality may be higher (or lower) than our estimate because of this nonparticipation factor.
Personality disorder was defined according to a limited interview and self-report data. A complete direct interview for all DSM-III-R personality disorders was not done because of time constraints and the general level of medical illness in the study sample. Additional studies that use comprehensive, structured personality disorder interviews need to be done.
The number of subjects identified in this study is subject to effects of small sample bias. Small samples are open to Type II errors, in which a true difference exists between populations but is not found becaue of the limited sample size. Additional correlates of severe personality disorder may be identified in studies using larger sample sizes. Also, studies of larger samples of subjects over a longer period of time may identify differences in medical and substance abuse outcomes for those with severe personality disorder.
Despite these limitations, our study appears to have implications for the liver transplant selection process in alcohol-related liver disease.
Caution should be used in excluding individuals based upon only a diagnosis of severe personality disorder. A better approach appears to document how personality disorder might have influenced other important prognostic variables, such as availability of necessary social support, acceptability and compliance with appropriate substance dependence treatment recommendations, and use of drugs other than alcohol. Without evidence of influence in these areas, this study found no specific effect of the presence of severe personality disorder on substance abuse outcome.
The intensity of personality disorder symptoms may diminish over time. There is some evidence that personality disorder symptoms peak during the second, third, and fourth decades.7 Most serious crimes committed by people with antisocial personality disorder occur early in life. Cirrhosis related to alcohol use generally takes a long period to develop. The period of maximum personality psychopathology may have passed for the majority of patients with personality disorder and alcohol-related liver disease by the time cirrhosis develops. This factor may make assessment of personality disorder less important in cirrhotic populations than in medical populations seen earlier in life. Some individual patients with cirrhosis may decompensate earlier during periods of more severe symptoms associated with personality disorder.
It is common for patients with liver disease to wait for 6 months or more after being put on the list for transplantation. During this time, the compliance with recommended medical treatment can be assessed as an indicator of potential compliance problems posttransplant. Significant compliance problems during this time would be an appropriate reason for taking someone off the transplantation list. During this waiting period, it is also possible to assess how interpersonal conflicts might develop and whether such conflicts can be resolved.
Personality disorders are associated with higher rates of other Axis I disorders. The effect of comorbid Axis I disorders on compliance and outcome needs to be considered when assessing transplant eligibility.
Although psychiatric factors appear important in transplantation outcome, clearer standards for diagnosis and eligibility are needed. Multicenter studies on the reliability and validity of psychiatric criteria in this setting are necessary. Such studies would provide for a better understanding of how psychiatric disorders interact with behaviors that might influence medical outcomes. The use of specific psychiatric disorders as exclusionary criteria for transplantation fails to acknowledge the variability in clinical presentations of these psychiatric disorders. Many patients with psychiatric disorders may appropriately benefit from transplantation. Absolute contraindications for transplantation based on psychiatric diagnoses need particular scrutiny. We would propose that even in cases of severe personality disorder, some individuals may still be appropriate transplant candidates. Selecting such individuals requires a comprehensive evaluation and management strategy, one that can be provided by a psychiatry liaison service to transplant programs.
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ACKNOWLEDGMENTS
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This work was supported by a grant from the National Institute of Alcohol Abuse and Alcoholism (Grant No. RO1–AA10289–03) from the National Institutes of Health.
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REFERENCES
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ABSTRACT
INTRODUCTION
