**9.2 Psychosocial intervention in patients with advanced liver disease**

The role of the psychological assessment and monitoring during the pre-and post-transplant phases, has been recognized. Identifying and reducing psychological risk factors may play a role in the long-term success of transplantation (Crone, 2006).

Previous studies suggest that psychological intervention during the process of hepatitis C disease and transplantation is important and necessary (Quelhas &Lopes, 2009). Emotional support during the illness, before and after transplantation, both individually or in groups, can improve the emotional well being, HRQOL, survival, facilitate the adaptation and adherence of transplant candidates and transplant patients (Knott et al. 2006; Quelhas &

As we mentioned above, non-adherence before transplantation is predictive of nonadherence after transplantation. It is known that anti hepatitis C virus viral treatment is associated with neuropsychiatric side effects (Quelhas,& Lopes, 2009). Therefore, in these situations, psychopharmacological treatment is required to be initiated as soon as possible, especially in patients with a history of psychiatric disorder, to assure adherence to medication (Gangeri, 2007; Quelhas & Lopes, 2009). Many factors may affect the process of adaptation to the disease (Kendall; 1995; Uchino, 1996; Telles-Correia, 2008). Patients can have different coping strategies, the most common being, stoic acceptance, denial,

Coping strategies may change over time, depending on specific stressors and the development that follows the disease. Studies show that fighting spirit and denial are ways of coping better than the rest, in the sense that facilitate adjustment to illness (Carver, 2005; Russell, 2008).

Emotions are stressful for the patient and also for the family and can lead to physical and emotional exhaustion (Nickel, 2002). Family members usually have emotional troubles, sometimes overlapping those presented by the patient. The most common are: fear, anxiety, sleep disturbances, difficulty concentrating, loss of appetite, and fatigue (Sanders, 2008). When the patient gets all the attention, a feeling of isolation among other family members may appear (Pérez San Gregorio, 2008; Stilley, 2010). Moreover, other perceptions have been observed, such as guilt, when the patient is left alone, or fear of not doing enough or not

It is also important to mention two phenomena that may affect the whole family, and they are: the conspiracy of silence and family claudication (Miyazaki, 2010). The conspiracy of silence attempts to prevent that the parties involved become aware of the diagnosis and prognosis of the disease. The results are the emergence of mistrust, isolation, limited emotional expression and isolation which can create family-physician-patient misleading relationships (Bolkhir, 2007). To avoid the conspiracy of silence we must always take into account the real needs and desires of the patient information that can change with the time

Family claudication: expresses the absence of the family's ability to respond adequately to the demands and needs of the patient due to a state of exhaustion and an overwhelming feeling that results in difficulties in maintaining a positive communication between the

The role of the psychological assessment and monitoring during the pre-and post-transplant phases, has been recognized. Identifying and reducing psychological risk factors may play a

Previous studies suggest that psychological intervention during the process of hepatitis C disease and transplantation is important and necessary (Quelhas &Lopes, 2009). Emotional support during the illness, before and after transplantation, both individually or in groups, can improve the emotional well being, HRQOL, survival, facilitate the adaptation and adherence of transplant candidates and transplant patients (Knott et al. 2006; Quelhas &

patient, family members, and the healthcare team (Szeifert, 2010; Kramer, 2011).

**9.2 Psychosocial intervention in patients with advanced liver disease** 

role in the long-term success of transplantation (Crone, 2006).

hopelessness, anxious concern and fighting spirit.

doing something correctly, etc..,

(Carr, 2001).

**9.1 Psychosocial aspects in family and advanced liver disease** 

Lopes, 2009; Steel, 2007). The goals of psychological intervention are to improve the QOL in patients with liver disease, facilitating their adaptation to the disease, accepting adaptive coping strategies and ultimately improving the patient's sense of self-control (Goetzmann et al, found in a sample of 69 patients, that almost half (47%) expressed the need for emotional support during the assessment for the procedure of liver transplantation (Goetzmann, 2007).

Van den Plas et al., showed that for transplant patients psychological support in the pre-and post-transplant periods besides the rehabilitation provided by the medical and nursing team and family, were one of the essential aspects of the transplant program (Van den Plas, 2003).

In mood disorders and anxiety disorder, psychopharmacological therapy in conjunction with psychotherapy may ameliorate the disturbance to the point at which patients can reach an emotional, and affective balance. Their equilibrium, allows them to manage the eventual distress related to the transplant (Crone, 2006). Such patients, however, need constant support before, during and after transplantation; during the pre-transplantation phase, specifically for sensitivity to stress, (Table 6) and in the post-transplant phase, most significantly because of immunosuppressant therapy that might precipitate mood swings, irritability, mania and anxiety. Psychotherapy and/or psychotherapy in conjunction with pharmacological treatment might be indicated during all the phases of the transplant process as they are individuals who tend to manifest traits such as depression, anxiety and phobia (Marcellin, 2007). Anxiety reduction techniques, autogenic training, systematic relaxation techniques, guided imagery, and pain management are recommended (Pasquini, 2006; Pelgur, 2009).



A mail survey was done to assess the importance of professionals assigned to psychosocial factors in evaluations for liver transplant candidacy and liver transplant surgeons from the highest volume liver transplant centers in the United States. Psychosocial evaluators assigned greater importance to availability of transportation, adaptation to stress and coping skills and were less likely than transplant surgeons to recommend that a patient with a history of poor social support be listed for liver transplant. The results of the study showed that factors identified by psychosocial evaluators are important and transplant outcomes should be studied (Santos Junior, 2007).
