Journal of Psychosomorrc Research, Vol. Zh, No. I, pp.I I-22, ,982. 0022.3999/82/01001 I-12 %03.

00/O
Printed in Great Britam. ‘?I 1982 Pergamon Press Ltd.

PSYCHOSOCIAL ADJUSTMENT TO ILLNESS SCALE (PAIS):

A STUDY OF CHRONIC HEMODIALYSIS PATIENTS

A. KAPLAN DE-NOUR*
(Recieved 19 February 1981; accepted in revisedform 9 June 1981)

Abstract-One hundred and two patients on chronic hemodialysis were studied by the self-report version
of the Psychosocial Adjustment to Illness Scale (PAIS). High agreement was found between patients’
total scores (global adjustment) and physicians’ assessment of the patients’ adjustment. High agreement
was also found between patients’ reports on specific aspects of adjustment, e.g. vocational rehabilitation,
psychological distress and social environment, and the physicians’ assessments of the same aspects of
adjustment. It is suggested that the PAIS is adequate for measuring some aspects of adjustment/
maladjustment and therefore large scale studies can be undertaken, aiming at filling gaps in knowledge,
clarifying contradictory information, comparing adjustment in different modalities of treatment, as
well as measuring the effectiveness of different psychotherapeutic interventions.

A GREAT number of psychiatric studies of chronic hemodialysis patients have been

carried out, and some hundreds of papers have been published about the adjustment
of dialysis patients. Yet, the picture that emerges is far from clear. There is only
limited information available about some aspects of adjustment, e.g. social activities
or compliance with the medical regimen [+I]. The information regarding several
aspects of adjustment is often contradictory, e.g. different rates of vocational
rehabilitation of hospital dialysis patients have been quoted, ranging from 28 to
51% of the patients working full-time [l, 51. Regarding depression some studies
reported over half of the patients as moderately or severely depressed [6, 71 while
other studies reported only 13% of their patients as being depressed [8]. Thus, after
about 15 years of intensive research, a clear picture of patients’ adjustment to
chronic hemodialysis is still missing.
The aim of the present study has been to find out whether it is possible to measure
patients’ adjustment. In order to carry out such an investigation we looked for a
questionnaire that would fulfil the following requirements:
(a) A questionnaire that measures a number of aspects of adjustment and not
overall adjustment, as done in some studies [9, lo], nor only one aspect of adjust-
ment [ll].
(b) A questionnaire that could be used in large patient populations, enabling a
study of the possible influence background or variety of treatment may have on
patients’ adjustment.
(c) A questionnaire that would enable correlation of assessments of patients’
clinical state and adjustment.
It was believed that if an instrument was found that fulfils these basic require-
ments, a second stage could be entered, i.e. to test whether the questionnaire fulfils
the fourth requirement: to measure change with psychotherapeutic interventions,
etc.
The aim of the present study is to present preliminary results of the usefulness
of such a questionnaire, i.e. the Psychosocial Adjustment to Illness Scale (PAIS)
[12] in measuring the adjustment of a group of dialysis patients.

*Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel.

11
12 A. KAPLAN DF-NOLJR

SUBJECTS AND METHODS

The subjects were 102 Jewish patients on chronic hemodialysis in 6 units. The
dialysis itself, e.g. type of machines, number of treatments per week and number
of hours per treatment, was the same in all the units. Not all the patients on treat-
ment in those units participated in the present study. “New” patients, i.e. patients
who had been on dialysis for less than 3 months, were excluded from the study.
Also those who could not read and write the language and those who did not want
to participate were excluded. Thus, the sample, which included only half of the
patients treated in these units, was actually composed of the more educated and
more cooperative patients who already have had some experience in chronic dialysis.
Fifty-nine of the patients were male and 43 were female. The majority of the women
(75%) were in their 40s and 50s and less than 20070 under the age of 40, with 3OYo
under the age of 40 and 25% over the age of 60. The difference in the age composition
was statistically significant (x j = 10.849, p < 0.05). Most of the group were married
(80 patients), 14 were single and 8 widowed or divorced. There were no significant
differences in the marital condition of the male and female patients.
The mean number of years on dialysis was 3.8 (s.D. 3.38). Sixteen percent of the
patients were on dialysis for less than 1 yr, 40% for l-3 yr, and 23% of the patients
were on dialysis 7 yr or more.
The patients were requested to participate in a study on psychosocial problems
of dialysis and were asked to fill the questionnaires anonymously. Only minimal
background information was asked for, including age, marital condition, years
on dialysis, whether they had been transplanted or whether they plan for trans-
plantation.
The Psychosocial Adjustment to Illness Scale (PAIS) [12] was used in order to
gather information about patients’ opinions on their own adjustment. The PAIS
is composed of seven sections: Section I-“Health Care Orientation”-is concerned
with “the current health care posture and whether it is conducive to positive ad-
justment to the illness and its treatment”. The second section-“Vocational En-
vironment”-assesses “disruption in job performance, satisfaction and adjustment
which is attributable to the present illness”. The third section-“Domestic Environ-
merit”-assesses “illness induced difficulties which arise primarily in the home or
usual family environment”. Section IV-“Sexual Relationships”-evaluates “any
shifts in quality of sexual behavior or relationship attributable to the present illness
or its aftermath”. Section V deals with the “Extended Family Relationships”, and
Section VI-“Social Environment”-“assesses the degree to which the illness has
impaired the patients’ social and leisure activities”. The last section-“Psychological
Distress”-“covers the degree to which pertinent psychological difficulties have
risen associated with the occurrence of the disease”.
Forty-four of the original items of the PAIS questionnaire were used, excluding
the one concerning financial difficulties. The Self Report version was used in which
each item is composed of four statements used as a 4-point scale and scored from
O-no disturbance, to 3-marked disturbance. The total score of the PAIS (44
items) ranges from 0 to 132. Thus, the lower scores indicate better adjustment and
higher scores indicate worse adjustment.
All the patients were also administered the Multiple Affect Adjective Checklist
(MAACL) [13], but only 78 of the 102 participants filled it in in a “storable” way.
 Chronic hemodialysis patients 13

The physician-in-charge of each unit rated his patients on physical condition,

psychological condition and diet adherance, each on a 4-point scale from very good
scored as 1, to very bad scored as 4. Vocational rehabilitation was rated by the
physicians on a 3-point scale from 1 working full-time, to 2 working about half-
time, and to 3 not working. Thus, an overall adjustment score could be calculated,
ranging from 4-patients who did very well in all four aspects, to 15-indicating
patients who did very badly in physical and psychological condition and in diet
adherance, and who were not working.

RESULTS

PAZS scores
A very wide distribution of total PAIS scores was found, indicating that the
patient population is not homogenous, i.e. some patients reported very good ad-
justment on the PAIS while others reported very poor adjustment. The mean for
the whole group was just under 50 (s.D. 22.88) and the various sections contributed
somewhat differently to the total score (Table 1). Most distress was reported on
vocational environment, with social environment and sexual relations coming next.

TABLE 1.-MEAN PAIS SCORESBY SECTIONS

Section No. of items Mean score

I. Health care orientation 8 8.8

II. Vocational environment 6 9.0
III. Domestic environment I 1.7
IV. Sexual relations 6 7.5
V. Extended family relationship 4 2.2
VI. Social environment 6 1.9
VII. Psychological distress I 6.4
Total 44 49.5

Table 2 summarizes the 20 items which were highest scored, indicating that those
are the major problem areas for the tested patients. It should be noted that among
the 10 highest-scored items 3 were from the health care orientation section, 3 from

TABLE 2.-MEAN SCORESON SEPARATEITEMS(RANGE O-3)

Mean Mean
Section Item score S.D. Section Item score S.D.

II Vocational impairment 2.05 1.08 I General health care

I Pt. expectancies disorder 1.95 0.90 orientation 1.58 1.20
I Health care present IV Sexual dysfunction 1.49 1.18
disorder 1.94 1.20 IV Sexual interest 1.48 1.19
III Physical disability 1.77 0.97 IV Sexual satisfaction 1.47 1.18
II Personal performance III Time lost on job 1.47 1.43
evaluation 1.75 0.94 VI Family leisure activities 1.39 1.09
VI Social leisure activities 1.67 1.15 III Family adaptability 1.37 1.27
II Vocational goals 1.66 1.22 VI Social leisure interest 1.36 1.21
III Domestic impairment 1.64 1.20 VII Worry 1.35 1.02
IV Frequency of sexual VI Individual leisure activity 1.34 1.11
activity 1.58 1.20 II Vocational investment 1.30 1.14
14 A. KAPLAN DE-NOUR

vocational environment, 2 from domestic environment, 1 from social environment

and 1 from sexual relations. On the other hand, on all items dealing more with
relationship-whether with the extended family, with cohabitants or with colleagues
at work-the patients scored low (mean of under 0.75), indicating that these relation-
ships have not been greatly affected.
It should be stressed that the patients reported a surprisingly high rate of problems,
some of which should be elaborated: over 70% of the patients reported moderate
to severe vocational impairment and nearly 50% moderate to severe domestic
impairment also. About 10% of the patients refused to answer the section on sexual
relationship. The others, however, reported severe problems, e.g. nearly 30%
reported no sexual interest at all and another 20% reported greatly decreased interest.
Nearly 60% of the group reported that sexual activity decreased greatly or stopped
totally. The patients also reported many problems in their social life: the questionnaire
taps separately the interest and participation in three areas-individual, family
and social leisure activities. It was found that interest is more maintained than
participation and that both in interest and in participation the individual area is
most maintained and the social area most reduced. Thus, for example, nearly 60%
reported that interest in individual leisure activities remained as before the disease,
but only 30% reported no change in such activities. Or, a third reported that interest
in social activities did not change and only just over 20% reported that participation
in social activities did not change. One should add that 70% of the group reported
that they are moderately or greatly worried about their medical condition and that
they do not expect to overcome it. Thus the picture that emerges is of a group of
patients who report many problems in the vocational and domestic environment,
in their sexual relations and in social activities.
Interrelations between the scores on the sections of the PAIS were looked into
(excluding the section of extended family relations on which the patients scored
very low) (Table 3). All the coefficient correlations are of statistical significance,

TABLE 3.-CORRELATIONS BETWEEN PAIS SECTIONS

Section I II III IV VI

I Health care orientation

II 0.330 Vocational environment
III 0.387 0.53 I Domestic environment
IV 0.251 0.406 0.534 Sexual relationship
VI 0.301 0.519 0.563 0.507 Social environment
VII 0.485 0.558 0.597 0.499 0.398 Psychological distress

beyond the 0.01 level, raising the question whether other factors might be of over-
whelming influence. Therefore, the relationship of the total PAIS scores and the
scores of depression, anxiety and hostility on the MAACL was studied (Table 4).
The mean score on the PAIS of the 78 patients who answered the MAACL was
50.1, indicating that the group did not differ from the total patient population
(who had a mean of 49.5). Positive significant correlations were indeed found
between the total PAIS scores and anxiety, depression and even hostility, although
the means of all three affects are within the normal range.
 Chronic hemodialysis patients 15

TABLE 4.-CORRELATION BETWEEN PAIS AND MAACL

SCORES

PAIS Anxiety Depression Hostility

x 50.1 x 1.22 x 11.64 x 7.31

S.D. 20.95 S.D. 3.07 S.D. 5.87 S.D. 3.85
r= 0.270* 0.370t 0.226:

*Significant at 0.05 level.

i-significant at 0.01 level.

PAIS scores and physicians’ assessments

The next question was whether there is indeed an agrement between patients’
reported adjustment on the PAIS and the physicians’ assessment of the patients’
adjustment.
Physicians’ assessments were received only on 93 of the 102 patients. These
assessments were divided into three categories-good, fair and bad adjustment
(Table 5). The three groups were found to differ significantly on their PAIS mean
scores. Furthermore, a significant positive correlation of 0.463 was found between
physicians’ assessment and PAIS scores.

TABLE 5.-PHYSICIANS' EVALUATIONS AND PATIENTS' PAlS

SCORES

Physicians’ evaluations
Physicians’ No. of
scores Adjustment patients PAIS score S.D.

4-7 Good 32 37.8 21.71

8-9 Fair 38 49.1 20.38
10+ Bad 23 64.4 22.19

t-test Good/fair = 2.231 l

Fair/bad = 3.626’
Good/bad = 4.419t

*Significant at 0.05 level.

TSignificant at 0.01 level.

The physicians’ assessments of vocational rehabilitation were compared to patients’

scores on vocational environment (excluding retired patients) (Table 6). Although
the difference in mean scores of full-time and half-time work failed to reach statistical
significance, all other differences were highly significant, indicating a strong relation-
ship between physicians’ assessments of patients’ vocational rehabilitation and
patients’ reports on vocational environment.
In a similar way physicians’ assessments of psychological condition was compared
first to the patients’ reports on the section of psychological distress and then to a
combined score of that same section and social environment (Table 7). Again, most
differences were found to be significant, indicating the high agreement between
physicians’ assessments of patients’ psychological condtion and patients’ reports
on the relevant sections of the PAIS.
16 A. KAPLAN DE-NOUR

TABLE6. -VOCATIONAL REHABILITATION

Physicians’ No. of Patients’ scores on

assessment patients “Vocational environment”
x S.D.

Full-time work 30 5.77 4.38

Half-time work 20 7.60 4.10
None 35 Il.74 4.71

t-test Full-time/half time 1.506

Half-time/none 3.413*
Full-time/none 5.297*

*Significant at 0.01 level.

TABLE‘I.-Ps~cHoLocrc~~ CONDITION

Patients’ scores on
Physicians’ No. of Patients’ scores on “Psychological distress”
assessment patients “Psychological distress” and “Social environment”
x S.D. x S.D.

Very good 21 4.26 4.40 9.93 7.17

Good 43 6.47 3.72 13.88 7.84
Fair < bad 25 8.88 5.40 19.56 6.92

I-test Very good/good 2.169* 2.064*

Good/fair < bad 1.915 3.107+
Very good/fair < bad 3.367-t 4.72st

*Significant at 0.05 level.

j-significant at 0.01 level.

Good and poor adjusters

We tried to find out from the available data what makes a patient a good or a
poor adjuster. In order to obtain information on that, the best adjusted patients,
i.e. the 23 patients who scored less than 30 on the PAIS (mean 24.5) were compared
to the most maladjusted patients, i.e. 20 patients who scored 70 and above on the
PAIS (82.7). As could be expected, the physicians’ assessments also differed signifi-
cantly, i.e. 6.8 in the good adjuster and 9.6 in the bad adjuster groups (t = 4.834,
p < 0.01).
As could be expected from the way the two groups were selected, they differed
significantly not only on the total score of the PAIS but also on each of the sub-
sections. However, the two groups seemed also to differ in the distribution of
complaints. In the poor adjusters (high scores) each section, except for extended
family relationships, contributed about 15% of the total score. Thus, in that group
of patients the severity of complaints was high and covered all aspects of adjustment.
On the other hand, in the good adjusters (low scores) the section of health care
orientation contributed more than a quarter of the total score and vocational
environment another 20%. The sections on adjustment of the PAIS were ranked
separately for the two groups by severity, and the Spearman rank correlation was
non-significant (0.450), indicating again that the poor and good adjusters differ not
only in amount of complaints but also in what they complain about.
 Chronic hemodialysis patients 17

There was no significant difference in mean years on dialysis (4.7 yr in the good
and 3.3 yr in the bad adjustment group). The poor adjusters were found to have
significantly higher scores of anxiety, 9.6 vs. 6.1 (t = 2.842, p < 0.01) and of
depression, 14.9 vs. 9.6 (t = 2.395, p = 0.05) on the MAACL.
In the poor adjustment group the number of female patients was significantly
higher than in the good adjustment group as well as the number of older (50 years
and more) patients. Therefore, the influence of sex and age on adjustment was
looked into.

Adjustment by sex
Poor adjustment, as defined in the previous section, was found to be significantly
more frequent in female patients. In order to obtain more information the PAIS
of the whole patient population was analyzed by sex (Table 8). Female patients
were found indeed to have significantly higher scores on the total PAIS. They also
had higher scores on each of the 7 sections; on 2 sections-vocational environment
and sexual relationship-the differences were nearly of statistical significance, and
on another 2 sections-domestic environment and psychological distress-the
differences were of statistical significance.

TABLET.-INFLUENCEOFSEXON PAIS SCORES

Female Male

Total score X 51.4 43.5 t = 2.99

S.D. 24.9 19.6 p < 0.01
Domestic environment x 9.4 6.0 t=3.360
(Section III) S.D. 5.7 3.9 p <0.01
Psychological distress x 8.6 5.2 t=3.664
(Section VII) S.D. 5.1 3.9 p <O.Ol
Vocational environment x 10.0 8.0 t= 1.944
(Section II) S.D. 4.9 4.9
Sexual relationships x 8.6 6.7 t= 1.693
(Section IV) S.D. 5.2 5.3

In an effort to try to understand the poorer adjustment of the female patients

the scores on the MAACL of male and female patients were compared. On all three
scales the women had indeed higher scores than the men, but it reached statistical
significance only on anxiety (female mean 8.42, male mean 6.80, t = 2.08, p < 0.05).

Age and adjustment

The relationship of adjustment and age is not clear. In the women the age group
of 50-59 (13 subjects) had significantly higher total PAIS scores than any other
age group (74.5). All other age groups, in the women, had nearly the same scores.
The differences in PAIS scores in the age groups of men failed to reach statistical
significance. The age group 40-49 had the lowest score (38.9) and the oldest age
group (60 +) had the highest score (49.1). In all age groups the women had a higher
18 A. KAPLANDE-NOUR

score than the men, but it reached statistical significance only in the SO-59 age
group (F = 74.5; M = 41.7; t = 4.323, p < 0.01).
Anxiety, depression and hostility as derived from the MAACL also did not show
clear-cut relations with age. Still the impression is that age group 4049 (25 patients)
is indeed doing better than other age groups and especially than the 50-59 years
old (22 patients): anxiety level was the same, but depression was significantly lower
(9.9 vs. 14.9, t = 2.398, p <0.05) as was hostility (6.3 vs. 8.6, t = 2.170, p < 0.05).
In each age group the women had higher scores on anxiety, depression and hostility,
but the differences did not reach statistical significance, probably because of the
small size of the groups and the high standard deviations.

Transplantation and adjustment

It is often claimed that transplantation-whether previous unsuccessful trans-
plantation or plans for future transplantation-disturbs adjustment. The opportunity
was taken to check on that observation.
Sixteen of the patients had undergone a transplantation and were later returned
to dialysis. They were found to have an exactly the same mean total score of the
PAIS (49.6) as the rest of the group. Thus, it seems that previous unsuccessful
transplantation does not disturb adjustment as measured by the PAIS.
Not all the patients answered the question whether they plan transplantation.
Furthermore, the patients of one unit were excluded from analysis about future
plans for transplantation as they all stated the same opinion (no transplantation),
which was suspected as being a strong unit effect. The sample analyzed about future
transplantation, therefore, consisted of 31 patients who stated that they plan trans-
plantation and 38 patients who stated that they do not want transplantation.
As could be expected the patients who wanted transplantation were significantly
younger than those who refused. No difference in sex distribution was found, nor
in mean years on dialysis. The patients who stated that they plan transplantation
had lower scores on the PAIS, indicating better adjustment on all the sections. On
the health care orientation section (8.1 compared with 9.9, t = 2.531, p < 0.05), as
well as on the total score (144.0 compared with 54.6, t = 2.055, p < 0.05), the
patients who wanted transplantation had significantly lower scores.
No differences were found between patients who wanted and did not want
transplantation on anxiety, depression and hostility scales of the MAACL.

Dialysis unit and adjustment

The last analysis that was done aimed at clarifying whether the unit influences
adjustment as reflected by the PAIS scores. Three of the units had each just over
20 patients: Unit B had 21 patients, 11 of them female; Unit C also had 21 patients,
9 of them female; and Unit E had 22 patients, I1 female and 11 male. The scores
of the patients of each of these units were compared to the scores of all the other
patients: the patients in Unit B did not differ significantly from the other 82 patients
on any of the sections, nor on the total score of the PAIS. The significant differences
of the patients of units C and E from the rest of the group are summarized in Table 9:
the patients of Unit E reported significantly more problems in vocational environ-
ment and in sexual relationships. On the other hand, the patients in Unit C reported
 Chronic hemodialysis patients 19

TABLET.--INFLLJENCEOFUNITONPAISSCORES

All other
Unit C pts.

Total score X 37.90 52.11 t=2.671

S.D. 20.95 22.57 p <O.Ol
I Health care orientation x 6.71 9.19 t=2.942
S.D. 3.44 3.44 p<O.Ol
II Vocational environment X 5.22 9.79 t=3.880
S.D. 4.51 4.74 p < 0.01
VI Social environment x 5.62 8.44 t=2.358
S.D. 4.80 5.18 p < 0.05
VII Psychological distress x 4.52 6.93 t=2.500
S.D. 3.71 4.71 p < 0.05
All other
Unit E pts.
II Vocational environment X 11.50 8.05 t=3.467
S.D. 3.58 5.10 p<O.Ol
IV Sexual relationship X 9.70 6.90 t = 2.397
S.D. 4.40 5.33 p < 0.05

significantly fewer problems in four areas-Health care orientation, Psychological

distress and Vocational and Social environment-and had also a significantly lower
total score. Thus it seems that a specific unit might indeed influence the adjustment
of its patients.

DISCUSSION

The main aim of the present study has been to gather preliminary data about
whether it is indeed possible to receive meaningful information about patients’
adjustment to chronic disease by self-reports. The information was therefore
presented mostly by means. However, it should be stressed that the patients reported
a much higher rate and severity of problems than could have been expected from
the literature, and therefore it seems that they do not use suppression. At the same
time it does seem that the patients use denial: they do not deny the severity of the
problems but do seem to deny the impact of these problems on themselves and on
others, e.g. the severity reported on psychological distress was comparatively lower.
Supporting evidence for the reported low psychological distress was found on the
MAACL: anxiety, depression and hostility were found to be within the normal
range. Further evidence of denial was found in the patients’ reports on their relation-
ship with others, e.g. no interpersonal conflicts at work in 60% of the patients,
in the same number very good relations with the principle cohabitant and in 80%
very good relations with other cohabitants and with the extended family, etc. Thus
it seems that the patients do deny that their severe decrease in vocational, domestic,
sexual and social functioning may also have a great impact on their relations with
the people around them.
One could say, therefore, that the questionnaire used seems adequate in gathering
information about adjustment or maladjustment on the functioning level, but
much less so for gathering information about psychological distress and relation-
ships.
20 A. KAPLAN DENOUR

One should mention again that the studied group is not a random sample: language,
literacy and willingness to cooperate in the study determined the inclusion of
patients. One should therefore be careful in drawing conclusions that the results
reflect the condition of all dialysis patients.
The distribution of the total scores on the PAIS suggests that the scale is adequate
for distinguishing between levels of adjustment. Furthermore, a strong relationship
was found between assessment of patients’ condition by their physicians and the
PAIS scores. On the whole the physician did not often rate his patients as bad in
any area. Therefore, whenever analysis was done by groups the “fair” and “bad”
were combined. Not all the sections of the PAIS could be compared to the physicians’
assessments, still whenever such comparisons could be made the relationship was
significant: a significant correlation was found between the physicians’ combined
score (combined of their assessment of physical and psychological condition,
compliance and vocational rehabilitation) and the total PAIS scores. Furthermore,
significant correlations were found between physicians’ assessments of vocational
rehabilitation and patients’ scores on the section of Vocational environment, as
well as between physicians’ assessments of Psychological condition and patients’
reports on Psychological distress and Psychological distress together with Social
environment.
These findings may be of extreme importance, suggesting that the PAIS is indeed
an adequate scale for obtaining measured information about patients’ global
adjustment as well as their adjustment in specific areas. Thus the PAIS was actually
found to fulfil all three basic requirements: it was comparatively easy to administer
to a fairly large population, it covers several aspects on adjustment, and good
correlations were found between patients’ reports and the physicians’ assessments.
Contrary to the original report on the PAIS, significant positive correlation
coefficients were found between the different sections of the PAIS. The weakest,
though still significant, correlations were found between the section on Health care
orientation and the other 5 sections. The other correlations were higher, often over
0.5 (for a sample of just over 100 patients). Thus it seems that a patient who reported
doing well in one area, e.g. Vocational environment, was inclined to report doing
well also in domestic life, in sexual relationship, in social activities, etc., and vice
versa. One cou!d suggest that this phenomenon is caused by denial and/or sup-
pression or lack of those mechanisms, i.e. some patients complain a lot about
everything and others just do not. Actually, however, such interrelations between
various aspects of adjustment should not be surprising. In previous limited clinical
studies strong relationship was found between vocational and social rehabilitation
[14] as well as between sexual functioning, psychological condition and vocational
rehabilitation [ 151.
In the present study most of the patients also did the MAACL. On can doubt
whether it was a good choice for measuring mood. On the whole the patients did
not like doing this test. Furthermore, the mean scores on anxiety, depression and
hostility were all within the normal range. Yet, significant-though weak-correlations
were found between psychological distress, i.e. anxiety, depression and hostility,
as measured by the MAACL, and the total PAIS scores. This finding seems to
suggest that the patient’s psychological condition influences his report on the PAIS,
i.e. the depressed and anxious patient would report more problems in all areas.
 Chronic hemodialysis patients 21

The previously discussed strong relations between physicians’ assessment and PAIS
scores prove that patients who report more problems indeed do less well. One can
therefore make the tentative suggestion that the more depressed and anxious patients
not only report more problems but are also less well adjusted in other areas.
The data is insufficient to claim that the patients’ psychological condition is
the source of all evils and that once improved, adjustment in the other areas would
automatically improve. However, it would be extremely interesting to institute
treatments aimed at changing only psychological condition and then follow up to
discover whether indeed other aspects improve also.
The comparison of the “bad” and “good” patients by PAIS scores tend to
support the suggestion that psychological condition may be the source of the overall
maladjustment. In the “bad” group the anxiety and depression scores on the MAACL
were in the psychopathological range. Furthermore, in that group the patients
complained a lot about all aspects measured by the PAIS, while in the “good”
group the complaints were more differential.
The finding that the “bad” group included significantly more women was sur-
prising and therefore some of the data was analyzed by sex. The female patients
were indeed found to report poorer adjustment in all areas and significantly so in
domestic environment and psychological condition. The available information
does not explain this finding. It is felt that this finding of female patients doing less
well than male patients should be further studied, especially as the clinical impression
has often been the opposite.
The data does not prove the common clinical statement that plans for transplantation
disturbs adjustment to dialysis. If anything, the opposite was found, confirming
earlier findings that more active capers are inclinded to plan for transplantation
[161.
One last finding concerning the differences between units should be mentioned.
There were no differences in the method of dialysis, yet in one unit especially the
adjustment of the patients, as measured by the PAIS, was found to be far better
than in other units. A number of studies have suggested that patients’ adjustment
is influenced not only by their personalities and their families, but also by their
units [17-191. The present finding that the patients in one unit are doing so much
better than in other units strongly support the suggestion that units may influence
the adjustment of their patients. This finding, however, may also explain some of
the extreme contradictions published about patients’ adjustment to chronic hemo-
dialysis: most reports are based on the population of one unit and the differences
between such samples may be extreme, whether due to patients’ background,
personality, families or to staff attitudes.
One should stress that the aim of the present preliminary report has not been to
go into details about the adjustment of 100 patients to chronic hemodialysis.
Therefore, many findings about this group’s adjustment were not included. Our
aim has been to try out a fairly new scale that measures psychosocial adjustment
to illness. As far as we could find out no results gathered by PAIS in chronic hemo-
dialysis or any other chronic medical condition have been published. The results
seem to indicate that the scale is indeed adequate for gathering meaningful in-
formation that correlates to physicians’ assessments and that differentiates between
“good” and “bad” patients. The study should be regarded as preliminary because
22 A. KAPLAN DE-NOUR

of the selectiveness of the population, the small size of the sample, and the fact
that the physicians’ assessments were left up to their own judgment, e.g. one can
presume that each physician had his own definition of the meaning of “very good”
physical or psychological condition. Yet, the results are very encouraging and
further study of a large population is indicated. The preliminary results suggest
that the PAIS is an adequate method for measuring adjustment and if so, further
studies that measure change with psychotherapeutic interventions or differences
in adjustment in various modalities of treatment, can be indeed undertaken.

Acknowledgemen&-The author gratefully acknowledges the permission to use the PAIS granted by
Leonard R. Derogatis, Ph.D., Director, Division of Medical Psychology, The Johns Hopkins University
School of Medicine, Baltimore, Maryland. The author also acknowledges with gratitude the cooperation
and willingness of the units to complete the questionnaires.

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