A Consultant Psychotherapist in hospital for diseases of the

Document Sample
A Consultant Psychotherapist in hospital for diseases of the Powered By Docstoc
					Living with a Stoma-A Psychological

             Dr Julian Stern
   Consultant Psychiatrist in Psychotherapy
     St. Mark‟s Hospital, Harrow, UK
    Living with a Stoma - Structure of

•   Introduction
•   2 Cases-Mr T and Gemma
•   Who does well psychologically ?
•   Internal and external support
•   Principles of management, and support for
    Colorectal and Stoma Nurses
    Living with a Stoma - Introduction

•   What does it mean to have a stoma ?
•   Life-saving surgery or mistake?
•   Lifelong illness or recent ?
•   Medical and nursing support
•   Emotional support
•   Stage in life-cycle
• Achievement of continence crucial developmental
  step-praised, rewarded
• “Incontinence”-a word with very negative
  connotations. Which adult is incontinent ? Only
  the Elderly, Demented or Psychiatrically ill
• Faeces is kept private in our 21st Century society.
  The stoma threatens this privacy
• Faeces is also mostly kept separate from sex-FI
  and a stoma threaten this too
                Case 1: Mr T.

• Man , mid- 60‟s, referred by surgical team
• Failed graciloplasty as the “muscle became too
  tight” and increased perianal pain
• Now - permanent colostomy
• Enormous trouble accepting it, changes bag at all
  times. “It smells”
            Referral (continued)

• Refuses to go out, has become a recluse
• Moved to a separate bedroom, no sexual contact
  with wife
• Spends his days in the greenhouse and when he
  goes into the bathroom, locks the door at all times
• “Refuses to see you or Stoma Nurse Specialist”
            Re-referred a year later

•   Sees a new surgeon and re-referred to me
•   “He now lives as a total recluse”
•   Is the diagnosis „stoma phobia‟ ?
•   On antidepressants for 18 months, and for the first
    time, seems quite enthused about psychiatric help
Psychotherapy assessment

            • Arrived on time
            • Been depressed for the
              past 18 months
            • On sertraline (SSRI)
              which “doesn‟t really
         Assessment (continued)

• Anal pain since 1980
• 4 operations at another hospital for abscesses and
  eventually fistula formation
• 1990: referred to St Mark‟s with fistula and
• Temporary colostomy, then Graciloplasty
• Finally, permanent colostomy 18 months ago
• Eventually permanent colostomy 18 months ago
         Assessment (continued)

• Anal discharge stinks, leaks -disgusting.
• Plugs it with swabs and a plug
• Stoma is ugly and disgusting-“If I had a knife I
  would cut it off”
• “If people deny that it smells, they are lying”
• “There must be something wrong with your nose”
            Restrictions to life

• Cannot swim with grandchildren, nor play with
  them lest they jump on his bag
• In past- enjoyed caravanning, dancing, clubs
• Now does not leave the house. Showers 4 times
  daily, new locks on the bathroom door
• No sex with wife
               Personal History

• 4th of 5 children
• Father strict but “a terrific man”-would
  occasionally belt patient. Died at 83
• Mother “lovely woman”-died at 53
• “No physical abuse” at home
      Personal History (Continued)

• School till 15, then worked in sausage factory
  where he met his wife to be-”a diamond”
• Ended up as a carpenter, then running his own
• Since 1990 (age 45) on State benefits
     Personal History (Continued)

• Has been married (after a 4 month courtship) for
  40 years
• 5 children, 7 grandchildren-sees them all weekly
• “No psychiatric history”
• Temazepam 20mg nocte and Sertraline
Personal History (Continued)
              • Age 13-anally raped in
                isolated park near his
              • Cried about it at the
                time, washed himself
                thoroughly when home
              • Never told parents -
                would have got belting
        Mental State Examination

• A tall sad man, clearly embarrassed, humiliated
  and depressed

• If not for religion “I would have killed myself”
• Voices inside his head –”Mary is a tart”
• Cries daily. Poor sleep, no enjoyment, no appetite
          Mental State (Continued)

• Obsessional features regarding cleanliness-body,
  home. “I always leave home with polished shoes, a
  crease in my trousers and an ironed shirt”

• Doctor : “I think you have an inner sense of disgust
  and contamination”
• Mr T: “I just get on with life, and cope as I can”
         Additional information

• Seen in 1984 on a number of occasions by
  psychiatrists at the previous hospital
• Anxiety, depression and insomnia
• “Bed wetting till 14”
• “Inadequate personality”
• “Try him on anti-depressants”
          Additional information

• May 1984, at follow up-headaches, violent feelings
  towards his wife. Dx - ? Frontal tumour
• August 1984-CT scan normal. “He needs to stop
  lazing around all day”
• May 1985-Discontinues medication. Wants to
  remain on benefits. “I will see again in 6 months,
  but he should look for work because there is no
  real mental illness”
           In psychiatric history

• No mention of bowel/ anal problems

• No history of abuse
In surgical history

          • No mention of abuse

          • Occasional mentions
            of his personality
Psychiatric follow up
           •DSH (deliberate self
           •Relationship with me
           •Relationship with wife
           •Further revelations
Mr T‟s attitude towards his stoma

 •What does it represent ?
 •What does his faeces mean to him ?
 •Can he allow himself to get better ?
 •Even if technically perfect, he will always
 have trouble with it !
               Case 2: Gemma

• 24 year old woman from Scotland

• Congenital malformation-surgery as a neonate

• Constant incontinence and excoriation as a child
  and teenager

• Eventually agrees to pouch formation in her 20‟s
  but with preservation of continence

• Surgery goes wrong-anastamotic breakdown,
  sepsis, ITU.

• Hysterctomy at 24
•   Now on HPN, high output stoma, suing surgeon
•   Describes her life as “Imprisonment”
•   Daily routine
•   Filled with sadness and much resentment

• (Problems in dealing with someone currently
  involved in litigation)
• 2 Dreams-of being trapped

• High rate of line infections-Why ?

• Problematic stoma care-never can get the “Right
• Wish to punish the surgeon, even if it meant
  killing herself

• (Do patients always want to get better-and what
  does it evoke in you if they don‟t?)
Her attitude towards her stoma

•What does it represent ?

•Can she allow herself to get better ?
The Psychological Assessment of the
       patient with a stoma

•Confidential Setting and Respect for the ostomate
•Manic denial
•Behaviours which worsen the situation ?
          Stoma‟s -Who does well ?
             1. Nature of illness

• Nature of illness-life threatening ?

• Acute v chronic-did they have any preparation?

• Act of God v Act of Man
         Stoma‟s -Who does well ?
             2. Surgical issues

• Ileostomy v colostomy

• Technical issues

• Spout, siting, adherence of bags
         Stoma‟s -Who does well ?
            3. Personality issues

• Relationship to body, body fluids

• Very conservative and prude ; “at peace” with
  body fluids-how comfortable with sexuality ?

• Current relationship/marriage?
          Stoma‟s -Who does well ?
           4. Psychological issues

• If generally well, will cope

• If previous abuse or trauma-how does the stoma
  “fit in”?-further punishment; further confirmation
  of worthlessness.
         Stoma‟s -Who does well ?
      5. Internal and external support

• Is there someone they can turn to ?

• Internal support-does the patient have an internal
  sense of being cared for (mother, father)
• What support is there from family/friends?
• What support is there from the nurse/ team?
          Stoma‟s -Who does well ?
       6. Internal and external support

• If the patient is well internally supported, he/she
  can often make good use of external support

• Where little internal support , he/she is less able
  to use external support-either very suspicious, or
  so needy it drives carers away-leaving patient
  feeling again alone, abandoned, not looked after
        Principles of management
• Collaboration with physicians, surgeons,
  members of multidisciplinary team, G.P,
  psychiatry or psychology

• Find out as much as possible about patient and
     Principles of management (2)
• If needed, what options for psychological support
  are available ?

• Are you able to refer?

• And what is acceptable to the patient ?
     Principles of management (3)
• Specific psychotherapies-psychoanalytic, family,
  group, cognitive-behavioural therapy;
• Drug therapy-antidepressants, anxiolytics
• Voluntary organisations

Frequently it is You (Stoma care nurse specialists)
     Principles of management (4)-
     questions for you in Budapest

Despair, anger, marital difficulties, body image
  issues, sexual problems, suicidal patients
Leaves you feeling –
Desperate        Depressed
Upset                  Disgusted
Hopeless         Tearful
Angry                  Wanting to resign
     Principles of management (5)-
     questions for you in Budapest

“Despair, anger, marital difficulties, body image
  issues, sexual problems, suicidal patients”
The same feelings psychotherapists have to deal
  with. Yet as psychotherapists we have:
Supervision to learn ways of dealing with feelings
Often our own psychotherapy treatment
What Do You Have?
     Principles of management (6)-
     questions for you in Budapest

Who are you expected to see, over what timescale?
What skills are you encouraged to develop ?
What support (supervision) do you get to help your
 psychological understanding of patients ?
What are the risks to your mental health of getting
 very involved ? (or of trying to block it all out ?)
     Principles of management (7)-
     questions for you in Budapest

At St Mark‟s Hospital:-
Regular sessions with nurses to look at their own
   feelings in dealing with these patients
External courses for visiting nurses

Should there be regular psychological supervision
   as a weekly/monthly part of your job plans ?
• Stern JM (2003) Review Article: psychiatry,
  psychotherapy and gastroenterology-bringing it all
  together. Alimentary Pharm Therapeutics. 17;175-184

• White C (1997) Living with a Stoma. Sheldon Press

Shared By: