The Open Nutraceuticals Journal, 2011, 4, 61-64 61

Open Access

The Influence of Psychological Intervention on Cognitive Appraisal and

Level of Anxiety in Dialysis Patients: A Pilot Study

K. Bargiel-Matusiewicz1,*, A. Trzcieniecka-Green2 and A. Koz
owska3

1
Faculty of Psychology, University of Warsaw, Poland
2
Department of Psychology, Medical University of Silesia, Poland
3
Faculty of Psychology, University of Warsaw, Poland

Abstract: Objective: The great progress with the application of a dialysis allows patients with the end-stage renal disease
to live in a satisfactory somatic state for many years. This pilot study examined if the psychological intervention improves
psychic state of the patients with renal disease undergoing hemodyalisis.
Methods: The study was a randomized controlled trial using a convenience sample of 62 fully informed and consenting
patients with the end-stage renal disease who were assigned to experimental (psychological intervention) or control (usual
care) groups. Participants in the experimental group listened to a CD with a psychological intervention twice a day during
3 weeks. The instruments were the Cognitive Appraisal Inventory and the STAI-Anxiety Inventory.
Results: After the application of a psychological intervention, the experimental group had a lower level of anxiety t(30) =
2.99; p < .005, a weaker intensity of cognitive appraisal of the treatment situation as a threat t(30)=3.48; p < .05, a weaker
intensity of cognitive appraisal of the situation as a harm/loss t(30)=2.75; p < .05 and a stronger intensity of cognitive
appraisal of the situation as a challenge t(30) = 3.49; p < .05. The applied psychological intervention makes it possible to
decrease the level of anxiety and to change cognitive appraisal of treatment situation.
Conclusions: The applied psychological intervention influences the patients' psychological state in a positive way. Such
changes may indirectly contribute to improving social contacts as well as to increasing satisfaction with the undertaken
activities.
Keywords: Psychological intervention, anxiety, cognitive appraisal, dialysis patients.

INTRODUCTION already existing metabolic disturbances. Lack of motivation

and weakening may lead to neglecting doctor’s guidelines.
This article aims at presenting a psychological interven-
G. Brownbridge and D. Fielding [5] have shown a very im-
tion applied in a group of dialysis patients to evaluate and
portant dependence of the most important indicators of a
change their cognitive appraisal of the situation and to de-
somatic condition in dialysis patients (the level of potassium,
crease the level of their anxiety. Both aspects have a great
blood pressure, the level of urea, putting on weight between
importance from the perspective of a health prognosis in this
dialyses, etc., among others) on psychosocial factors, in par-
group of patients.
ticular on the level of depressiveness and anxiety. Depres-
The patients who suffer from the end-stage renal disease sive symptoms may predict the future risk of developing
comprise a very specific group. Their life as they know it severe bodily pain in dialysis patients [6].
undergoes a radical change. The necessity to observe a diet
and to control the amounts of the intake of fluids emerges. In A fall in one’s mood may even lead to abandoning the
the case of dialysis patients, the necessity to visit the dialysis treatment. The E. McDade-Montez’s [7] research showed
station about three times a week for a few hours at a time that, within the period of up to 4 years since the occurrence
becomes burdensome, too [1-3]. The psychological problems of the symptoms of depression, 18% of patients gave up on
which accompany dialysis treatments have many aspects the dialyses.
worth noting. The fact that the dialysis patients have fallen ill is not the
The first aspect is a lowered mood and a resignation only source of their anxiety. Such factors as advanced tech-
attitude. The symptoms which usually occur in depression nical medical procedures and lack of knowledge of how in-
take on a particular importance in dialysis patients [4]. Loss dividual life and health saving equipment and machines op-
of appetite in these patients may lead to deepening the erate are another source of anxiety in these patients [8].
Hence, possibilities of psychological support are worth con-
sidering in the case of dialysis patients.
*Address correspondence to this author at the Faculty of Psychology, University
of Warsaw, 5/7 Stawki St, 00-183 Warsaw, Poland; Tel: +48 22 5549769; The conducted empirical research on the quality of life in
Fax: +48 22 554 97 03; E-mail: kmatusiewicz@psych.uw.edu.pl somatically ill patients shows that the earliest possible psy-

1876-3960/11 2011 Bentham Open

62 The Open Nutraceuticals Journal, 2011, Volume 4 Bargiel-Matusiewicz et al.

chological intervention is very helpful [9]. Cardiological and METHODS

oncological patients undergo psychological interventions
The study was approved by an institutional Ethics
most often [10]. So far, dialysis patients have received
Committee.
such help on rare occasions [11]. This research analyses the
influence of a psychological intervention on the cognitive Description of the Intervention:
appraisal of the situation and the level of anxiety.
Between 2007-2008, a psychological intervention was
MATERIAL verified, in which the patients listened to a CD with a re-
corded psychological intervention twice a day for a period of
As mentioned earlier, the patients’ expectations regarding
three weeks. The duration of the recording was twenty min-
their future lives, including possibilities and limitations, have
utes.
a marked importance for their functioning. The process of
appraising individual situations is an indispensable element The presented intervention is based on the principles of the
of a daily life. Those aspects of a situation are taken into Ericksonian therapy [14] and includes the following thera-
consideration which are crucial from the standpoint of a peutic metaphors:
broadly understood feeling of well-being. Thus, it is not only - The birds that experience freedom and, in a bad weather,
the objective properties of a situation that decide about the they look for a temporary shelter.
intensity of the stress one experiences but also the way the
person perceives the situation, i.e. subjective factors [12]. Many dialyzed persons lead a daily life in the way that is
Categorizing an event is possible thanks to the existence of very close to a regular life style in the community they
patterns shaped as a result of the experience, among others. function normally. They work (more often part time),
Appraising a situation as stressful may be done in three cate- they have spouses and children. The research shows,
gories: harm/loss (when some values are lost); threat (when a however, that their feeling of limited freedom connected
loss of values is anticipated) and a challenge (if the subject with the necessity of spending about 5 hours three times
assumes a possibility of meeting the expectations of the a week at a dialysis station has an adverse impact on their
surroundings). level of satisfaction with their lives.

The STAI-Anxiety Inventory was used to measure The feeling of limitation as regards controlling their own
anxiety and the Cognitive Appraisal Inventory was used for time often makes them resign from many activities
which, with appropriate motivation and attitude, they
the cognitive appraisal. The tools are discussed in the next
could do. The metaphor of the birds which during rain
part of the article.
and a storm must seek shelter in a safe place to enjoy
The inventory for measuring anxiety as a state and as freedom in good weather again is an analogy to the dialy-
a trait (State-Trait Anxiety Inventory-STAI) was developed sis therapy. The aim of the metaphor is to make the dia-
by Spielberger et al. [13]. This method is self-descriptive lyzed persons become aware of the value of freedom and
and consists of two separate, 20-item scales, the first one the latitude they have in between dialyses. By way of re-
(X-1) is intended for measuring anxiety as a state and ferring to natural phenomena, the analogy of the rain and
the other (X-2) for measuring anxiety as a feature. In this the birds hiding from it may also make the situation of
research, we used the scale of measuring anxiety as a state going through the dialysis therapy more neutral in its re-
(X-1). ception.
The Cognitive Appraisal Inventory consists of 33 - A Found Treasure
statements to which answers are given on a four-grade scale. This metaphor is to make the patients aware of everyday
The questionnaire consists of three subscales: threat, values, little pleasures, hence to increase the intensity of
harm/loss, and a challenge [1, 12]. Both of the applied tools experiencing positive emotions.
have satisfactory psychometric characteristics.
- People Taking a Walk in the Park
THE SUBJECTS
This image and the suggestion of recalling warm-hearted
72 persons participated in the first phase and 62 persons and nice people aims at increasing the awareness of
participated in the second phase of the study. The following sources of social support one already has.
is the characteristic of the studied group.
The subjects were divided into two groups of the same
The men comprised 54.2% of the subjects and women number of participants: a control group (with no psychologi-
comprised 45.8%. The average age was 50.17 years with a cal intervention applied) and an experimental group (sub-
standard deviation of 11.76 years. The youngest participant jected to a psychological intervention). The study had a pro-
in the study was 22 years old and the oldest was 75. The spective character and was carried out in a natural environ-
highest number of subjects were high school graduates ment. The dialyzed patients were randomly assigned to the
(40.28%), and the second largest group had vocational edu- control or experimental group and filled a set of question-
cation (27.78%). The persons with tertiary education com- naires during researchers’ first visit. During the 3 weeks be-
prised 18.06% of the studied group, while the remaining tween the researchers’ visits, they listened to the recordings
persons had primary education (8.33%) or a bachelor’s de- with the psychological intervention.
gree (5.56%). The subjects most often declared (72.22%)
that they live in a steady relationship. Only 11.11% persons RESULTS AND STATISTICS
were single. Less than 3% were in separation, and over 5.5% As mentioned earlier, the study included the differences
were divorced. Over 8.3% of the participants were widowed. between anxiety and cognitive appraisal. The results of the
The Influence of Psychological Intervention on Cognitive Appraisal The Open Nutraceuticals Journal, 2011, Volume 4 63

measurement before and after the psychological intervention coping with the illness. For such a patient, the illness be-
were compared. Because the distribution of the analyzed comes an obstacle, something that must be overcome by way
variables was concordant with the normal distribution, para- of available resources. Everything that can lead to success
metric tests were applied. and decrease anxiety becomes important. Increasing the in-
Table 1 presents the difference at the anxiety level before tensity of perception in dialysis therapy in the category of a
challenge can foster constructive coping with stress, increase
and after the application of a psychological intervention.
patients’ motivation to follow physician’s guidelines,
Statistics t was 2.99 at the significance level p < .005. There-
thereby have an advantageous influence on the prognosis of
fore, it can be stated that the anxiety level dropped signifi-
their health.
cantly.
Table 1 depicts also the difference in the intensification This is especially important in the group of dialysis pa-
tients as, so far, the research shows that they fail to follow
of cognitive appraisal as a challenge before and after applica-
their recommended diet periodically, therefore it is important
tion of the psychological intervention. Statistics t was 3.49 at
to increase the patients’ motivation for treatment [2]. The
the level of significance p < .05. Therefore, it can be stated
most extreme lack of adjustment to the situation is refusal of
that the intensity of the perception of a challenging situation
treatment, i.e. stopping the dialysis therapy altogether, which
increased significantly.
can even lead to death [4, 7]. It is also worth to mention that
The table shows the difference in the intensification of part of the psychological abnormalities may also be due to
cognitive appraisal as threat before and after a psychological coenzyme Q10 deficiency which is common among patients
intervention. Statistics t was 3.48 at the level of significance with renal failure [15].
p < .05. We can say, then, that the intensification of the per-
The studies conducted by L. Timmer’s team [3] also con-
ception of a situation as danger decreased significantly.
firm the importance of cognitive evaluation of the illness.
Table 1 shows also the difference in intensification of The researchers showed that the perception of the illness
cognitive appraisal as harm/loss before and after the applica- in the dialyzed patients explains between 17 and 51% of
tion of the psychological intervention. Statistics t was 2.75 at variance of the experienced quality of life.
the significance level p < .05. Therefore, we can say that the
Under the dominating view on co-variation of cognition
intensification of the perception as harm/loss decreased sig-
nificantly. No significant statistical differences between the and emotions one can predict that the influence on the cogni-
tive sphere may result in benefits in the emotional sphere and
first and the second measurement of the analyzed variables
vice versa. From the Lazarus’ paradigm [12] follows an as-
were noted in the control group.
sumption of the cognitive appraisal influence upon emotions;
DISCUSSION however, contemporary studies indicate co-variation of emo-
tions and cognition. Parrot and Sabini [16] confirm that, in-
Based on the presented study, we can say that the applied deed, the mechanism of cognitive appraisal is not purely
psychological intervention had a positive influence on the cognitive. It is saturated with evaluative elements to a
perception of the patients’ health situation. The patients smaller or higher degree.
evaluated their situation more often as a challenge and less
often as a threat and harm/loss. Nowadays, many authors stress the importance of a
patient’s emotional state. Experiencing positive emotions
The intervention also had a positive impact on the pa- is of a great importance in better coping with stress [7] and
tients’ emotional state through lowering the level of their to broaden the scope of attention, cognition and action as
anxiety. The positive impact of psychological influence on well as to increase physical, intellectual and social resources
the dialysis patients was also noted by researchers from Tai- [17].
wan [11].
S. Folkman and J. Moskowitz [18] also note the impor-
The changes in the scope of the cognitive appraisal seem tant role of positive emotions in adaptive coping, especially
to have a great importance in the process of dealing with the in the conditions of long-lasting stress. It is interesting,
difficulties. The perception of a situation as a challenge can therefore, to look for factors which allow a positive reap-
have a very positive impact on the patient’s behavior and praisal and experiencing positive emotions. Such a search

Table 1. Comparison of the Variables Before and after the Psychological Intervention

Time 1 Time 2

Variable Average Before Intervention SD Average After Intervention SD N df Statistics

anxiety 3.42 0.64 3.11 0.61 31 30 2.99 (**)

challenge 31.32 3.04 33.24 3.06 31 30 3.49 (*)

threat 23.64 2.61 21.81 2.58 31 30 3.48 (*)

harm/loss 13.58 1.77 12.71 1.84 31 30 2.75 (*)

* p< 0.05.
** p<0.005.
64 The Open Nutraceuticals Journal, 2011, Volume 4 Bargiel-Matusiewicz et al.

can manifest itself in the application of a psychological [5] Brownbridge G, Fielding DM. Psychosocial adjustment and adher-
intervention. L. Timmers [3] expresses the view that the ence to dialysis treatment regimes. Pediatr Nephrol 1994; 8: 744-9.
[6] Yamamoto Y, Hayashino Y, Akiba T, et al. Depressive symptoms
interventions which are focused on coping with the illness predict the subsequent risk of bodily pain in dialysis patients: Japan
and its consequences can improve the quality of life in dialysis outcomes and practice patterns study. Pain Med 2009; 10:
dialysis patients. 883-9.
[7] McDade-Montez EA, Christensen AJ, Cvengros JA. The role of
The interventions the authors describe in this article can depression symptoms in dialysis withdrawal. Health Psychol 2006;
constitute one of many forms of affecting the frame of mind 25: 198-204.
in dialysis patients as they contribute to its improvement. [8] Welch JL, Austin JK. Stressors, coping and depression in hemo-
dialysis patients. J Adv Nurs 2001; 33: 200–7.
ACKNOWLEDGEMENTS [9] Cosette S, Frasure-Smith N, Lesperance F. Clinical implications of
a reduction in psychological distress on cardiac prognosis in pa-
This project was realized at The Faculty of Psychology, tients participating in a psychosocial intervention program. Psycho-
som Med 2001; 63: 257-66.
University of Warsaw in cooperation with The Department [10] Linden W, Stossel C, Maurice J. Psychosocial interventions for
of Psychology, Medical University of Silesia and was patients with coronary artery disease: a meta- analysis. Arch Intern
supported by The Polish Ministry of Science and Higher Med 1996; 156: 745-52.
Education. [11] Tsay SL, Lee YC, Lee YC. Effects of an adaptation training pro-
gramme for patients with end-stage renal disease. J Adv Nurs 2005;
CONFLICTS OF INTEREST 50: 39-46.
[12] Lazarus RS. From psychological stress to the emotions: A history
The authors declared no conflicts of interest in relation to of changing outlooks. Annu Rev Psychol 1993; 44: 1-21.
this article. [13] Spielberger CD. Manual for the State -Trait Anxiety Inventory.
Palo Alto, California, Consulting Psychologists Press 1983.
REFERENCES [14] Erickson BA. Ericksonian therapy demystified: A straightforward
approach. In: Zeig JK, Ed. Ericksonian methods: The essence of
[1] Bargiel-Matusiewicz K. Psychological influence on the psychical the story. pp. 147-162. Brunner/Mazel: Philadelphia 1994.
state of hemodialysis patients. J Physiol Pharmacol 2005; 57: 33-8. [15] Singh RB, Khanna HK, Niaz MA. Randomized, double blind,
[2] Barnett T, Li Yoong T, Pinikahana J, Si-Yen T. Fluid compliance placebo controlled trial of coenzyme Q10 in chronic renal failure;
among patients having hemodialysis: Can an educational pro- discovery of a new role. J Nutr Environ Med 2001; 11: 43-51.
gramme make a difference? J Adv Nurs 2008; 61: 300-6. [16] Parrot WG, Sabini J. On the emotional qualities of certain types of
[3] Timmers L, Thong M, Dekker FW, et al. Illness perception in cognition: A reply to arguments for the independence of cognition
dialysis patients and their association with quality of life. Psychology and affect. Cognit Ther Res 1989; 13: 49-65.
Health 2008; 23: 679-90. [17] Fredrickson BL. What good are positive emotions? Rev Gen Psy-
[4] Everest KD, Brantley J, Sletten C, Jones GN, McKnight GT. The chol 1998; 2: 300-19.
relation of stress and depression to interdialytic weight gain in [18] Folkman S, Moskowitz JT. Coping: Pitfalls and promise. Annu Rev
hemodialysis patients. Behav Med 1995; 21: 25-30. Psychol 2004; 55: 745-74.

Received: September 25, 2010 Revised: October 22, 2010 Accepted: October 26, 2010

© Bargiel-Matusiewicz et al.; Licensee Bentham Open.

This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.