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A Consultant Psychotherapist in hospital for diseases of the

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




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

•   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
                  Continence
• 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
              help”
         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
  incontinence
• Temporary colostomy, then Graciloplasty
• Finally, permanent colostomy 18 months ago
Graciloplasty
                   Colostomy
• 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
  business
• 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
                home
              • 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
           harm)
           •Religion
           •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
                      Gemma

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

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

• Hysterctomy at 24
                     Gemma
•   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)
                    Gemma
• 2 Dreams-of being trapped

• High rate of line infections-Why ?

• Problematic stoma care-never can get the “Right
  size”
                    Gemma
• 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
•Shame
•Guilt
•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
  background
     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;
  hypnotherapy
• 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 ?
                   References
• 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

				
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