Shemesh E, Lurie S, Stuber M L, Emre S, Patel Y, Vohra P, Aromando M, Shneider B L
Department of Psychiatry, Division of Child and Adolescent Psychiatry, Mount Sinai Medical Center, New York, New York 10029, USA.
Pediatrics. 2000 Feb;105(2):E29. doi: 10.1542/peds.105.2.e29.
Symptoms of posttraumatic stress disorder (PTSD) were described in survivors of life-threatening diseases, the trauma being the experiences associated with the disease or its treatment. Their prevalence in liver transplant recipients is unknown. Based on clinical observations, we hypothesize that a significant proportion of pediatric liver transplant recipients suffers from PTSD symptoms. We further hypothesize that nonadherence (noncompliance) to medical management may, in some cases, be associated with these symptoms. Traumatized patients, according to this hypothesis, will avoid taking their medications, because these serve as painful reminders of the disease.
To determine the prevalence of PTSD symptoms in a sample of pediatric liver transplant recipients. To determine whether symptoms of PTSD are associated with nonadherence in these patients. To describe the clinical presentation of PTSD and the management of severe nonadherence in patients who suffer from this disorder.
Nineteen pediatric liver transplant recipients and their caretakers were interviewed, using the UCLA Post Traumatic Stress Disorder Reaction Index (PTSRI). Data were obtained on a few demographic parameters and perception of disease threat. Adherence was evaluated by 2 methods: 1) a clinician panel (taking into account the clinical sequelae of severe nonadherence); and 2) computation of the standard deviations (SDs) of consecutive determinations of blood levels of Tacrolimus (a higher SD means higher variability between individual measures and is therefore an indicator of nonadherence). As an illustration of the general phenomenon, we describe 3 cases of liver transplant recipients who were nonadherent and who suffered from PTSD.
Six of 19 patients had positive scores on all 3 components of the PTSRI (PTSD patients). Three of these, and none of the others, were considered significantly nonadherent by the panel. Therefore, nonadherence was significantly associated with the existence of symptoms from all 3 domains of PTSD (Fisher's exact test) in our sample. In particular, a high avoidance score on the PTSRI was highly correlated with panel-determined nonadherence. Further, SD of medication levels were significantly higher in PTSD patients, compared with the rest of our sample. No significant differences were found in perception of disease threat or demographic variables between PTSD patients and the rest of our sample. The 3 cases that we describe became adherent to their medications when symptoms of PTSD subsided during the course of therapy.
Clinically significant nonadherence, determined by 2 different methods, was associated with the full spectrum of PTSD symptoms in this sample. It was especially associated with a high avoidance score, which suggests that avoidance of reminders of the disease (eg, medications) may be a mechanism of nonadherence. Screening for and management of these symptoms, therefore, may improve adherence. This novel concept may be applicable to other patient populations. However, more data are needed before any definite conclusions can be drawn.
创伤后应激障碍（PTSD）的症状在危及生命疾病的幸存者中已有描述，创伤是与疾病或其治疗相关的经历。其在肝移植受者中的患病率尚不清楚。基于临床观察，我们推测相当一部分小儿肝移植受者患有PTSD症状。我们进一步推测，在某些情况下，不依从（不遵守）医疗管理可能与这些症状有关。根据这一假设，受过创伤的患者会避免服药，因为这些药物会痛苦地提醒他们疾病的存在。
确定小儿肝移植受者样本中PTSD症状的患病率。确定PTSD症状是否与这些患者的不依从有关。描述PTSD的临床表现以及患有这种疾病的患者严重不依从的管理方法。
使用加州大学洛杉矶分校创伤后应激障碍反应指数（PTSRI）对19名小儿肝移植受者及其照料者进行访谈。获取了一些人口统计学参数和对疾病威胁的认知数据。通过两种方法评估依从性：1）临床医生小组（考虑严重不依从的临床后果）；2）计算他克莫司血药浓度连续测定值的标准差（SD）（SD越高意味着个体测量值之间的变异性越大，因此是不依从的一个指标）。作为这一普遍现象的例证，我们描述了3例不依从且患有PTSD的肝移植受者病例。
19名患者中有6名在PTSRI的所有3个分量表上得分呈阳性（PTSD患者）。其中3名被小组认为严重不依从，其他患者均未被认为严重不依从。因此，在我们的样本中，不依从与PTSD所有3个领域的症状存在显著关联（Fisher精确检验）。特别是，PTSRI上的高回避得分与小组确定的不依从高度相关。此外，与我们样本中的其他患者相比，PTSD患者的药物水平标准差显著更高。PTSD患者与我们样本中的其他患者在疾病威胁认知或人口统计学变量方面未发现显著差异。我们描述的3例患者在治疗过程中PTSD症状消退后开始坚持服药。
通过两种不同方法确定的具有临床意义的不依从与该样本中PTSD症状的全谱相关。它尤其与高回避得分相关，这表明回避疾病提醒（如药物）可能是不依从的一种机制。因此，对这些症状进行筛查和管理可能会提高依从性。这一新颖概念可能适用于其他患者群体。然而，在得出任何明确结论之前还需要更多数据。
