Psychosomatics 44:172-173, April 2003
© 2003 The Academy of Psychosomatic Medicine
Pain in Liver Donors
Isao Fukunishi, M.D.,
Yasuhiko Sugawara, M.D.,
Masatoshi Makuuchi, M.D., and
Owen S. Surman, M.D., Tokyo, Japan
TO THE EDITOR: Previous studies have reported that recipients who undergo liver transplants frequently exhibit various psychiatric symptoms, including postoperative delirium.1,2 In liver transplants from living subjects, several studies have recently proposed that recipients tend to report reactive psychiatric symptoms, including depression and psychogenic pain, despite otherwise favorable surgical courses for both donor and recipient. This manifestation of symptoms has been called paradoxical psychiatric syndrome.3,4 Psychopathologically, recipients' guilt feelings toward their living donors are closely related to the manifestation of paradoxical psychiatric syndrome.5
Only one living donor with paradoxical psychiatric syndrome after a living-related kidney transplant has been reported.6 However, we found three donors who exhibited paradoxical psychiatric syndrome, including pain disorders, after a living-related liver transplant.
Case Report
Ms. A, the first donor, was a 35-year-old unmarried woman with no psychiatric history. She was to be a donor for her father, who suffered from cirrhosis of the liver. His family consisted of his wife and two children, a son and a daughter. At first, Ms. A's father did not want to undergo a living-related liver transplant because his daughter was a single woman, and he worried about the postoperative scar that the transplant would leave her with. However, he finally agreed to receive a living-related liver transplant in order stay alive. Fortunately, his postoperative clinical course was favorable, and there were no severe complications or acute tissue rejections.
However, 5 days after the living-related liver transplant was performed, Ms. A suddenly complained of strong right abdominal pain, although there were no medical abnormalities. She appeared to be in extreme pain. The transplant surgeon prescribed haloperidol, 5 mg, intravenously. Ms. A could not walk because of the severe pain and greatly depended on the transplant staff to go about her daily life. In psychiatric interviews, she appeared to be in a regressive state and could not verbalize her inner emotions. She suffered from insomnia and loss of appetite and took fluvoxamine, 25 mg, and brotizolam, 0.25 mg, at bedtime to induce sleep. After 1 week, her pain gradually decreased. At the same time, she started to complain about the postoperative scar. Before the living-related liver transplant, she had not seemed concerned about the scar or other possible negative results. We believe that she suppressed her various anxieties and fears, including cosmetic anxiety, before the transplant. Yet these suppressed anxieties and fears were manifested in a form of psychogenic pain because she could not verbalize these anxieties or else her father would worry too much. However, after the living-related liver transplant, she gradually began to complain of various anxieties and fears, including cosmetic anxieties. Her abdominal pain disappeared completely 1 month after the transplant.
Ms. B and Ms. C, the second and third patients, were 24-year-old and 27-year-old unmarried women without any psychiatric history. They donated parts of their livers to their parents. Like the first donor, the second and third donors also exhibited psychogenic pain. Psychopathologically, their pains were closely related to the existence of postoperative scars after living-related liver transplants.
Discussion
The three living donors with pain disorders all 1) were donors for adult-to-adult living-related liver transplants, 2) were children of the recipients, 3) were unmarried women, 4) had strong cosmetic anxieties about the matured abdominal scars required for skin closure, and 5) had no any psychiatric history before the living-related liver transplants. Before the transplants, the donors felt a sense of duty to donate partial livers in order to save their parents. After the living-related liver transplants, they were shocked to see the scar required for skin closure. Although they had strong cosmetic anxiety concerning the postoperative scar, this anxiety was masked by their stronger sense of duty toward their parents. However, after knowing the recipients' favorable postoperative outcomes, these unmarried women manifested their cosmetic anxieties in the form of psychogenic pain. This was because they could not verbalize their negative feelings and they could not justify themselves as donors for their parents.
This letter suggests that pain disorders are manifested not only in recipients but also in donors—in particular, unmarried female donors—who undergo the child-to-parent type of adult-to-adult living-related liver transplant. Therefore, the transplant staff should pay close attention to the mental health of unmarried female donors involved in child-to-adult living-related liver transplants.
REFERENCES
- Levenson JL, Olbrisch ME: Psychosocial evaluation of organ transplant candidates: a comparative survey of process, criteria, and outcomes in heart, liver, and kidney transplantation. Psychosomatics 1993; 34:314-323[Abstract/Free Full Text]
- Surman OS: Psychiatric considerations of organ transplantation, in Transplantation. Edited by Genns LC, Cosimi AB, Morris PJ. Malden, Mass, Blackwell Science, 1999, pp 709-724
- Fukunishi I, Sugawara Y, Takayama T, Makuuchi M, Kawarasaki H, Surman OS: Psychiatric disorders before and after living-related transplantation. Psychosomatics 2001; 42:337-343[Abstract/Free Full Text]
- Fukunishi I, Sugawara Y, Takayama T, Makuuchi M, Kawarazaki H, Surman OS, Kita Y: "Paradoxical psychiatric syndrome" of the recipient after child-to-parent living-related liver transplantation (letter). Psychosomatics 2001; 42:163[Free Full Text]
- Fukunishi I, Sugawara Y, Takayama T, Makuuchi M, Kawarazaki H, Kita Y, Aikawa A, Hasegawa A: Psychiatric problems in living-related transplantation, II: the association between paradoxical psychiatric syndrome and guilt feelings in adult recipients after living donor liver transplantation. Transplant Proc 2002; 34:2632-2633[CrossRef][Medline]
- Fukunishi I, Ohara T, Kobayashi M, Aikawa A, Hasegawa A, Suzuki J: "Paradoxical depression" in a female donor after kidney transplantation. Psychosomatics 1998; 39:396-397[Free Full Text]
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