The Effects of Post-Traumatic Stress on Pediatric Organ Transplant Patients

What is post-traumatic stress?

Post-traumatic Stress (PTS) is a psychiatric disorder resulting from the experience of a stressful or traumatic event. PTS is either the diagnostic entity known as post-traumatic stress disorder (PTSD) or PTSD-related symptomology known as PTSS [1]. PTS symptoms are clustered into three categories: reexperiencing, avoidance, and hyperarousal [2]. Reexperiencing can entail flashbacks of traumatic events, while avoidance of reminders of the stressor characterizes the avoidance dimension of symptomology. Finally, prominent anxiety and hypervigilance underly the hyperarousal dimension.

Symptoms of PTS can greatly vary, but can include:

• Uncontrollable thoughts and memories related to the event
• Bad dreams about the event
• Physical bodily reactions (e.g., sweating, beating heart, dizziness)
• Changes in mood
• Difficulty paying attention
• Feelings of fear, guilt, anger, and shame
• Sleep disturbances

Organ transplantation can be considered a traumatic event for a child. PTS resulting from an organ transplantation could arise from many factors, including surgical procedures, repeated laboratory and imaging investigations, life-threatening incidents in care, and dependence on technology for organ function and survival [1].

How common is post-traumatic stress in pediatric organ transplant patients?

A 2021 study conducted at BC Children’s Hospital by Hind et al. investigated the effects of PTS on the life quality of 61 pediatric organ transplant recipients. The sample included 12 heart transplant recipients, 30 kidney transplant recipients, and 19 liver transplant recipients [1].

They found that a total of 52 patients (85.2%) reported at least one trauma symptom, and eight (13.1%) of these patients indicated symptoms that put them at significant risk of PTSD. They also observed that kidney recipients had higher overall trauma scores than other organ transplant patients, perhaps due to the extensive post-transplant care involved after kidney transplantation. Non-white patients reported significantly higher trauma scores, while females reported higher trauma scores than their male counterparts, though this result was not statistically significant. Spending more days in the hospital and being prescribed more medication were also associated with higher trauma scores [2].

How does post-traumatic stress affect the daily life of organ transplant patients?

Hind et al. also found that quality-of-life questionnaire scores were negatively correlated with trauma scores. This means that physical, emotional, social, academic, and psychosocial functioning decreased as trauma increased, leading to poorer quality of life. The results of this study indicate that PTS is a prevalent issue amongst pediatric organ transplant recipients and it can have detrimental effects on the daily functioning of patients post-transplant.

How does post-traumatic stress affect treatment?

Studies have shown that PTS in pediatric organ transplant recipients can impact treatment outcomes by causing post-transplant treatment nonadherence [1,3,4].

Why is treatment nonadherence significant to treatment outcomes?

Consider the example of a 19-year-old female, whose first transplant was lost due to nonadherence [3]. The patient was granted a second organ transplant after stating that she would adhere to post-operative treatment. However, two days following her second surgery, she stopped taking her medications. When questioned, the patient revealed that she had been suffering for more than one year from recurrent intrusive thoughts about her liver disease, and recurrent dreams about her wait for the first transplant. She reported wanting to avoid any reminder of her illness, including even the sight of a nurse or medication. Healthcare practitioners applied Cognitive Behavioural Therapy in the form of gradual exposure to a hospital environment to this patient. Family intervention was also undertaken to increase her social support network. Following this treatment, the patient resumed taking her medications and continued doing so for more than a year after her second transplant.

This case study shows the profound impact PTS can have on medical care, and how addressing trauma symptoms can improve patient outcomes. Therefore, its findings reinforce that providing access to mental health resources is an imperative for this population considering their effects on the psychological and physical wellbeing of patients.

It is important to recognize that transplantation can be a traumatic experience from which patients and their families may develop PTS symptoms. Therefore, providing resources and support services for PTS before, during and after transplantation can help patient health outcomes as well as their overall quality of life. Treatment for PTS may vary, but collaboration between healthcare practitioners and psychologists, social workers, councilors, and other support personnel helping with psychosocial coping can enhance patient experience and facilitate the transplantation journey for patients and families alike.

References:

1. Hind T, Lui S, Moon E, Broad K, Lang S, Schreiber RA, et al. Post-traumatic stress as a determinant of quality of life in pediatric solid-organ transplant recipients. Pediatr Transplant. 2021;25(4):e14005, https://doi.org/10.1111/petr.14005

2. Nash RP, Loiselle MM, Stahl JL, Conklin JL, Rose TL, Hutto A, et al. Post-Traumatic Stress Disorder and Post-Traumatic Growth following Kidney Transplantation. Kidney360. 2022 Sep 29;3(9):1590, https://doi.org/10.34067/KID.0008152021

3. Shemesh E, Lurie S, Stuber ML, Emre S, Patel Y, Vohra P, et al. A pilot study of posttraumatic stress and nonadherence in pediatric liver transplant recipients. Pediatrics. 2000 Feb;105(2):E29, https://doi.org/10.1542/peds.105.2.e29

4. Martin LR, Feig C, Maksoudian CR, Wysong K, Faasse K. A perspective on nonadherence to drug therapy: psychological barriers and strategies to overcome nonadherence. Patient Prefer Adherence. 2018 Aug 22;12:1527–35, https://doi.org/10.2147/PPA.S155971

Anna Riminchan was born in Bulgaria, where she spent her early childhood before immigrating to Canada with her family. Anna is currently working towards a Bachelor of Science Degree, majoring in Behavioural Neuroscience and minoring in Visual Arts at the University of British Columbia. In the meantime, she is contributing to advancing research in neuroscience, after which, she plans to pursue a degree in medicine. In her spare time, you can find Anna working on her latest art piece!

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Drugs for Therapeutic Forgetting? – Forget about it.

Over that past decade, there has been a great deal of interest in the prospect that we might be able to edit unpleasant memories (a phenomenon dubbed therapeutic forgetting) by capitalizing upon the phenomenon of reconsolidation.  The basic idea is this: although memories are stable for years, when we recall a memory it becomes labile.  Once the memory is transformed into this more flexible state, it can be modified by subsequent experience.  The memory is not lost, but becomes reconsolidated (most probably during the subsequent night’s sleep); in this way, new experiences are integrated with old ones, providing a mechanism by which experiences throughout the lifetime can be in amalgamated in meaningful fashion.

Spearheaded by studies from Joseph Le Doux’s laboratory, several groups have reasoned that if one were to induce individuals to recall problematic memories and then interfere with reconsolidation using pharmacological means, we might be able to specifically amend our memories of past events.  From a therapeutic perspective, this would be most useful in treating patients with post-traumatic stress disorder (PTSD) in which the memories of certain emotionally charged events become so troublesome that they have outsized effects on the quality of life.  The problem has been with the potential side effects of the pharmacological approach – protein synthesis inhibitors, partial NMDA receptor agonists, viral vectors with toxins as the payload, & beta-adrenergic receptor blockers have all been shown to be effective in laboratory experiments, but, with the notable exception of beta-blockers, none are really suitable for use in the clinical setting.

But a good idea does not lay fallow for long, and a collaboration between Elizabeth Phelps and Joe LeDoux’s groups has again advanced the field in impressive fashion.