Management of Psychiatric Aspects of Renal Disorders

Management of Psychiatric Aspects of Renal Disorders – An Integrated Approach With Homoeopathy

Abstract: Renal disorders are common clinically affecting around 14% of general population especially in adults. Hypertension and diabetes are the common causes leading to renal disorders. The treatment expenses and severity of illness often makes it a stressor for the patient leading to psychiatric co morbidity in most cases. The following article gives an insight regarding management of psychiatric aspects of renal disorders with the help of psychotherapy and homoeopathy.

Keywords: Homoeopathic management, renal disorders, psychotherapy, constitutional medicine, integrated approach

Introduction

It is not mandatory to develop psychiatric problem as a consequence of a serious physical illness. But persons with maladaptive or partially adaptive coping skills can develop psychiatric problems associated with serious physical illness such as acute or chronic renal failure. (1)There are high levels of association of many of these chronic conditions with psychiatric disorders. Comorbid medical and psychiatric conditions increase use of medical resources and costs, as well as amplify functional impairment.(1)

As important as a comprehensive knowledge of psychiatric diagnosis and psychosocial formulation is to a consulting psychiatrist, it is also vital to understand the pathophysiology and clinical characteristics of the medical condition that frequently coexist with psychiatric disorders. It is also important to know the behavioural and psychiatric side effects of medications and substances. Lacking this data permits only a partial and inadequate approach to diagnosis and treatment.(1)

The common renal conditions associated with psychiatric disorder are acute renal failure, chronic renal failure, end stage renal disease, haemodialysis and kidney transplant.

Acute renal failure : Acute renal failure is an abrupt decrease in renal function sufficient to result in azotaemia – retention of nitrogenous waste in the body.(2) Acute renal failure can result from a decrease of renal blood flow(prerenal azotaemia),intrinsic renal disease(renal azotaemia) or obstruction of urine flow(postrenal azotaemia). Prerenal azotaemia can be caused by renal arterial occlusion or decrease in effective blood volume. Intrinsic renal azotaemia is caused by acute tubular necrosis due toan acute ischaemic or nephrotoxic insult. Postrenal azotaemia is due to obstruction of the urine collecting system; this may occur when there is bladder outlwt obstruction or ureteral obstruction.(1)

Medical complications of acute renal failure include hyperkalaemia, hyperuricaemia, arrhythmias, anaemia, coagulopathies, vomiting, nausea and urinary tract infections. Metabolic pertubations can lead to delirium. Neuropsychiatric manifestations include somnolence, asterixis (flapping tremor), neuromuscular irritability and seizures. Mental status abnormalities in acute renal failure begin to occur for most adults when the serum creatinine level acutely rises to about 4.0mg/dl. In oliguric renal failure, serum blood urea nitrogen levels can be expected to rise by about 10 to 20 mg/dl per day.(1)

Chronic renal failure and end stage renal disease: Chronic renal failure is a progressive and irreversible loss of renal function.(3) Diabetes, hypertension, and glomerulinephritis are the most common aetiologies of renal insufficiency leading to end stage renal disease. Serum creatinine is a sensitive indicator of early, subclinical, chronic renal failure.(1)

Neuropsychiatric manifestations of chronic renal failure include irritability, insomnia, lethargy, anorexia, seizures, and restless leg syndrome.(3) In contrast to acute renal failure- where neuropsychiatric signs and symptoms may appear with a creatinine level as low as 4mg/dl- in chronic renal failure, patients my have a normal mental status examination with a serum creatinine level as high as 9 to 10mg/dl.(1)

Dementia and depression along with suicidal thoughts are common with end-stage renal failure. Disruption in sexual function, which may be physiological (example, vascular complications of diabetes, fatigue following dialysis treatments), or psychological, or both, account for at least a portion of the dysphoria experienced by patients with end stage renal disease.(1)

Haemodialysis : The average patient on haemodialysis requires 3.5h of dialysis three times per week to achieve adequate creatinine clearance.(3) It is not a benign procedure, and has a number of potential neuropsychiatric complications. Patients on haemodialysis are at high risk for developing volume overload, pulmonary oedema, hyperkalaemia, hyperphosphataemia and metabolic bone disease if compliance with restricted diet and fluid intake us not optimal. Patient adherence to these diet and fluid-intake proticols is used as one of the criteria for making decisions about appropriateness for transplantation. Psychiatric reasons for non-adherence should be addressed and are usually reversible, with the exception of personality disorders. These include mood disorders, phobias, panic disorder, substance-related disorders, adjustment disorder and cognitive disorders.

Psychological treatment adopted for the medically ill: (1)

1. Motivational interviewing helps the patient in improving adhwrence to treatment regimes.
2. Anger management (modified cognitive behavioural therapy) helps in managing the irritability or aggressive behaviour.
3. Interpersonal therapy was initially developed for thetreatment of depression, but it has obvious applications in the field of physical illness. In the terminology of interpersonal therapy, illness represents a role transition, and the focus in therapy is therefore on negotiating that transition with key others in the patients life.(4)
4. Family therapy and couples therapy are rarely considered (or available) for adults with physical illness and yet many of the external resources needed for coping are in the family.

Along with this the neuropsychiatric manifestations of acute renal failure should be treated by correcting the underlying cause.

Homoeopathic approach in managing the psychiatric disorder associated with renal disorders.

            The foremost merit of homoeopathy is that while curing one disease it does not create another as found mostly in allopathic treatment. Also, even a new or unknown disease can be correctly and successfully treated when the symptoms of the disease are unknown.

Master Hahnemann has given instruction about mental disease and its treatment in his 6^th edition of  Organon  of Medicine in aphorism 210 to 230.²⁹ He considers mental diseases as one sided diseases affecting the whole psycho-somatic entity where the derangement of mind and disposition is increased while the corporeal symptoms decline. Like all other one-sided diseases, they are psoric in origin.(5)

Mental diseases constitute a class of disease sharply separated from all others, since in all other so-called corporeal diseases the condition of the disposition and mind is always altered; and in all cases of disease we are called on to cure the state of the patient’s disposition, is to be particularly noted, along with the totality of the symptoms.(6)

According to Farokh J. Master, in order to cure mental disease the prescription being aimed towards inner most mental and emotional state rather than outward physical expression. The prescription should be given the form of single remedy in a single dose, in higher potency, and then wait for the response to the prescription has clearly ceased before repeating or represcribing.(6)

According to homoeopathic classification of mental disease this comes under mental disease arusing from corporeal origin(aphorism 216 – corporeal disease transformed into insanity, into a kind of melancholia or into mania by a rapid increase of the physical symptoms that were previously present, whereupon the corporeal symptoms lose all their danger.)

These are some of the medicines found useful in cases of renal disorders associated with psychiatric disease which are discussed below, but they should be prescribed based on symptom similarity only.

1. Arsenicum album : Great anguish and restlessness. Fears, of desth of being left alone. Great fear with cold sweat. Suicidal. Despaor drives him from place to place. Sensitive to disorder and confusion. Albuminous urine. Epithelial cells; cylindrical clots of fibrin and globules of pus and blood. Bright’s disease. Diabetes.
2. Hyoscyamus niger : Very suspicious. Talkative, obscene, lascivious mania, uncovers body; jealous, foolish. Great hilarity; inclined to laugh at everything. Delirium, with attempt to run away. Low, muttering speech; constant carphologia, deep stupor. Symptoms of uraemia and acute nervous exhaustion.
3. Sulphur : Very forgetful. Difficult thinking. Delusions; thinks rags beautiful things-that he is immensely wealthy. Busy all the time. Childish peevishness in grown people. Irritable. Affections vitiated; very selfish, no regard for others. Religious melancholy. Averse to business; loafs-too lazy to arouse himself. Imagining giving wrong things to people, causing their death. Sulphur subjects are nearly always irritable, depressed, thin and weak, even with good appetite. Mucus and pus in urine, parts sore over which it passes. Frequent micturition. Must hurry, sudden call to urinate. Great quantities of colourless urine.
4. Aurum metallicum : Feeling of self-condemnation and utter worthlessness. Profound despondency, with increased blood pressure, with thorough disgust of life, and thoughts of suicide. Talks of committing suicide. Great fear of death. Peevish and vehement at least contradiction. Anthropophobia. Mental derangements. Constant rapid questioning without waiting for reply. Cannot do things fast enough. Oversensitiveness; to noise, excitement, confusion. Turbid urine like buttermilk with thick sediment. Painful retention.
5. Staphysagria : Impetuous, violent outbursts of passion, hypochondriacal, sad. Very sensitive as to what others say about her. Dwells on sexual matters; prefers solitude. Peevish. Child cries for many things, and refuses them when offered. Ill effects of anger and insults. Sexual sins and excesses. Very sensitive. Cystitis in lying- in patients. Pressure upon bladder feels as if it did not empty. Sensation as if a drop of urine were rolling continuously along the channel. Burning in urethra during micturition and when not urinating. Urging and pain after urination.
6. Pulsatilla nigricans : Sad, crying readily; weeps when talking; changeable, contradictory. Timid, irresolute. Fears in evening to be alone, dark, ghost. Likes sympathy. Children like fuss and caresses. Easily discouraged. Morbid dread of the opposite sex. Religious melancholy. Given to extremes of pleasure and pain. Highly emotional. Increased desire to urinate worse when lying down. Burning in orifice of urethra during and after micturition. Involuntary micturition at night, while coughing or passing flatus. After urinating spasmodic pain in bladder.
7. Lycopodium clavatum : Melancholy; afraid to be alone. Little things annoy, Extremely sensitive. Averse to undertaking new things. Head strong and haughty when sick. Loss of self-confidence. Hurried when eating. Constant fear of breaking down under stress. Apprehensive. Weak memory, confused thoughts; spells or writes wrong words and syllables. Failing brain-power. Cannot bear to see anything new. Cannot read what he writes. Sadness in morning on awaking. Pain in back before urinating , ceases after flow, slow in coming must strain. Retention. Polyuria during the night. Heavy red sediment.

Discussion and conclusion : Once human bodies have become stressed to the point that they have produced symptoms of illness which, in itself, can be an additional stress(8) leading to development of psychiatric disorders. Renal disorder comes in such category that puts the patients under stressful situation due to the depth of disease as well as the huge financial burden imposed by the treatment especially in cases of haemodialysis and transplant if required. Sufferes find that every area of lives is affected such as sleep, appetite, energy and mood.(8) The most common psychiatric manifestations along with renal disorders are depression, aggresiveness and suicidal ideation. Psychotherapy along with homoeopathic medicines when prescribed on the principle of similarity yields the best result. Some of the medicines found to be useful in treating psychiatric disorders associated with renal disorders are Arsenicum album, Hyoscyamus niger, Sulphur, Aurum metallicum, Staphysagria, Pulsatilla nigricans and Lycopodium clavatum. Remedy should be selected after erecting totality of symptoms and based on the principles of homoeopathy referring Organon of Medicine, materia medica and repertory.

References

1. Gelder M. G. et al. New oxford textbook of psychiatry. 2^nd edition, Vol 1. New york: Oxford university Press; 2009. p.1065,1081,1087,1069.
2. Cohen, L.M.(2000). Rebak disease.In American psychiatric publishing textbook of consultation-liason psychoatry (2^nd edn) (eds. M. Wise and J.R. Rundell),pp.573-8. American Psychiatric publishing, Washington,DC.
3. Kimmel, P.L., Thamer, M., Richard, C.M., et al. (1998). Psychiatric illnessin patients witb end-stage renal disease. The American Journal of Medicine,105,214-21.
4. Klerman, G.L. and Weissman, M.M. (1993). New applications of interpersonal psychotherapy. American Psychiatric Press, Washington, DC.
5. Das A. K. A treatise on organon of medicine. 2^nd edition. Part 1, 2, 3. Kolkata: Books and allied (p) ltd. 2007.
6. Master F. J. The Bedside: organon of medicine. 1^st edition. New delhi: B. Jain publishers (p) ltd; 1996. p.92-94.
7. Boericke W. Boericke’s new manual of homoeopathic materia medica with repertory. Third revised & augmented edition based on ninth edition. New delhi: B. Jain publishers (p) ltd. 2015.
8. Castro M. Homoeopathic guide to stress. First edition. New delhi: B. Jain publishers (p) ltd. 2008. p201,202.

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Dr Diana R