With the advent of anesthesia, radiology, antibiotics, and improved technical skills, the scope of surgical intervention in disease processes has been changing rapidly. Historically, surgery was a last-resort procedure; now, however, it is not only performed for acute critical illness (e.g., appendicitis or trauma) but also planned as an elective or preventive procedure (e.g., cholecystectomy for removal of gallstones or tubal ligation for prevention of further pregnancy). It may also be used for diagnostic purposes (e.g., identification of an abdominal or mammillary mass) and reparative ones (e.g., plastic surgery or organ transplants).
The prospective surgical patient leaves his home, where he has been functioning according to his own social and cultural norms in a definite manner of interaction with family members, to enter hospital. This is an institution representing other social norms, with guidelines for interpersonal relationships that are very different from those to which the patient is accustomed. He is expected to assume a definite new role in the context of the total institutional structure.
The experience of stress that results from a situation is based on the way a person perceives and interprets the situation. Each patient who enters a hospital has developed particular ways of coping with stressful situations, based on his personal endowment and his developmental and family history in the context of a specific ethnic and cultural setting. He also has his own ways of dealing with situations in which he is autonomous in his decisions and actions or in which he is dependent on the judgments, decisions, and actions of other people.
The patient's factual knowledge of organs and their relationships is in most cases incomplete, lacking, or distorted. Even more important is his body image, which evolves in the course of his development by means of kinesthetic, tactile, visual, and other sensory perceptions and which associates specific conscious or unconscious feelings to various body parts. This predisposes the patient to unique feelings in regard to the body part affected by the surgical procedure.
When the patient enters a modern hospital, although informed consent has to be given before any operation can be undertaken, he rarely has the breadth of knowledge to understand the process and its implications. Anticipation of the loss of consciousness, being helpless while being manipulated by others, and submitting to a procedure with a questionable outcome create apprehension. He may not have had previous experience with surgery, and foreknowledge of the postoperative course is available neither to him nor to his physicians. So the patient who is about to undergo surgery is understandably filled with anxiety and frightening fantasies. The expression of his anxiety can take many forms; sometimes his feelings are obvious, and sometimes they are not. Hospital staff and physicians are often unaware that they frequently make demands on the patient that prevent him from expressing his true feelings, since he is fully aware that he might otherwise not receive the same care and attention.
Depending on the effectiveness of a person's adaptive capacity during a stressful situation, the patient anticipating surgery will show normal or abnormal emotional responses. It is typical of human psychologic functioning that many times, under stress, the adult form of logical, reality-oriented thinking is temporarily lost and the person may regress to a developmentally earlier form of magical thinking in his attempt to ward off an anticipated poor outcome.
A 59-year-old patient of Irish extraction, educated as a Catholic, had undergone surgery of the bowel following occlusion. As she developed adhesions, a second operation had to be scheduled a few months later. On admission she was a cheerful, cooperative patient who enjoyed talking with her doctor and did not complain about the preparations for surgery.
In the late evening of the day before the operation, the patient suddenly became very upset, started weeping, and said that if she did not get a scapular to wear around her neck, she knew she would die during the operation. The intern promised to look for one and walked through several nursing stations until one was finally located. The patient expressed her gratefulness, denied any fears, and went to sleep. She did not express any apprehension the next morning when she was prepared by the same intern for the operating room, but she made sure that she had the scapular around her neck and insisted to the nurses that it should not be removed. She returned from the recovery room in good spirits.
Some patients ward off anxiety by asking technical questions, defending themselves partly by acquiring information for its own sake and partly by gaining intellectual control over an otherwise uncontrollable situation.
A 17-year-old boy was scheduled for splenectomy as part of treatment for a malignant lymphadenopathy. He was bright and sarcastic, and his general relationship to the staff had a teasing and joking quality. He asked the residents to show him an anatomic atlas, which was done with the consent of the attending physician. He then asked his father to bring him a medical dictionary and spent days before the operation reading it and then discussing the material with the residents, who became quite defensive and uneasy about all his questions. He kept up this questioning all the way to the operating room.
Some patients, under the pressure of their anxiety, give excessively detailed answers to any questions posed by staff or physician. There may be two unconscious reasons for this. Either their anxiety is so great that they have difficulty sorting out essential details from unessential ones, displaying a reduction in their conscious control of verbal communication, or they are attempting to hold the questioner's attention because of their need for support.
A very common phenomenon in the patient anticipating surgery is regression to the typical behavior of a two-year-old child, demanding and suspicious.
A recently married 28-year-old man was hospitalized after a large kidney stone necessitating surgery had been diagnosed. He was tearful and anxious before the operation, demanding the constant attention of his young wife and of the staff, toward whom he was demanding and critical. This led the resident to request a psychiatric evaluation, which was highly resented by the patient.
Surgery went without difficulty, but he developed a severe postoperative infection, with extensive drainage from the wound and prolonged hospitalization. During this period he continued his preoperative behavior, accusing the doctors of not having done their job, becoming angry with his wife, demanding increased visits from his mother, and pressuring his parents to speak to the doctors.
After discharge he was seen in the outpatient clinic and was friendly, talked with other patients about his operation in quite technical terms, and expressed his gratefulness to the physicians who had treated him.
Many patients go into anesthesia with severe trepidation. Fantasies of feeling pain or dying and fears of not being in control or of behaving badly are expressed by patients. Occasionally a patient gets so anxious that the operation has to be postponed. In such cases a psychiatrist is usually called for consultation.
A 43-year-old Puerto Rican woman had been scheduled for an elective gallbladder operation. She was in a depressed mood, and as the day of the operation approached she started to express great fear of anesthesia to the nursing staff. As her anxiety increased, a psychiatric consultation was requested. During the interview she explained that she was living in a common-law relationship with a man, a situation against which her mother had repeatedly warned her when she was a young girl. Then, spontaneously, she mentioned that when her mother was the same age - 43 - she had died of a stroke during the same month as that in which the daughter's operation was scheduled.
This woman had feelings of guilt about breaking sodai taboos, and the fact that her mother had died at the age she had now reached was creating magical associations that could lead to punishment while she was not under conscious control of herself during anesthesia and might result in death. Since the surgery was elective, it was postponed and the patient was seen daily for one week by the psychiatrist. She then voluntarily opted for the operation. Anesthesia and operative and postoperative procedures were uneventful. The patient was discharged 10 days after surgery with a suggestion that she attend the psychiatric clinic if she wanted to do so. She made no further contact.
In each of these cases, the patient expressed anxiety in a personal way, and thus it took many forms. We have found that anxiety may also be expressed in such forms as increased irritability, aggressive behavior, frequent demands for help or markedly independent behavior (including even the rejection of help). Some patients may withdraw into a depression, complain about their inability to sleep, or request pain medications for somatic complaints.
Usually such reactions are reversible without resort to psychiatric intervention (although this depends, of course, on the person's adaptive capacity). However, emotional supports - including supportive psychotherapy - will speed recovery and prevent complications for most surgical patients.
The physiologic changes produced by the disease, anesthesia, surgical trauma, and changes in electrolytes, pH, and nutritional state may significantly affect brain metabolism. When this happens, the patient's mental status is often remarkably altered; delirium occurs much more frequently than is apparent. The patient is often reluctant to describe the delusions and hallucinations of delirium and may dismiss them as vivid fantasies and "daydreams" during his recovery.
Delirium is characterized as a confused, disordered state of mind that exists when cerebral metabolism is disturbed, often in the presence of endogenous or exogenous toxins. The cause for this disturbance can be local or systemic, and it can be reversible (acute) or irreversible (chronic). The patient may be impaired in his sense of location and disoriented as to time and time sequences. Intellectual functions are diminished, judgment and memory are faulty, and the patient usually shows lability and shallowness of affect. Occasionally he becomes highly agitated and has to be restrained. Delirium often causes fluctuation in the patient's state of awareness; he is unable to focus attention when left alone but regains some clarity when addressed directly. In severe delirium the patient may be totally disoriented and unable to recognize close family members or even respond to his own name. Auditory and visual hallucinations, delusions, and illusions are frequent.
There is a high incidence of delirium in severely ill patients. Freedman and Kaplan1 estimate that 10 to 15 per cent of patients hospitalized in acute medical and surgical services manifest some degree of delirium. A higher incidence seems to occur in elderly patients. The typical emotional pattern that delirium takes is characterized by the patient's personality patterns and conscious or unconscious conflicts.
A highly intelligent and cooperative patient developed an acute brain syndrome after a prolonged period of uremic syndrome, a kidney transplant, and rejection of the transplant. He developed the delusion that the doctors and nursing staff were trying to poison him, and therefore he refused medication. Before this time he had never manifested psychotic thinking, but he had always been quite aitical and suspicious of other people. What had previously been a normal personality trend of suspiciousness became a paranoid delusion when toxic metabolites, immunosuppressive drugs, and acid-base imbalance produced a change in brain metabolism with a resultant loosening of logical thought.
The more agitated patient is, of course, more easily recognized by the medical staff than the withdrawn, confused patient. Each patient should be checked after surgery for confusional states, a procedure that can be easily done by a brief evaluation of the patient's thought processes. Such an evaluation can be made by any physician or nurse, and when disturbance in thinking or judgment is suspected, medication or supportive psychotherapy may be provided to prevent more overt psychotic behavior. Too frequently the psychiatrist is called only after an overt psychotic reaction has developed.
A patient began to scream illogical accusations at anyone passing the door to his room several days after surgery. A psychiatrist was called in for consultation. The patient was found to have an acute brain syndrome caused by a severe electrolyte imbalance; within 48 hours after treatment was begun, his behavior and thinking returned to normal. At that time he remembered being somewhat confused in his thinking after awakening in the recovery room. For three days he struggled to maintain a grasp on reality, but finally he was unable to think rationally at all and was besieged by wild visual hallucinations. Had he been tested each day or asked to describe his thoughts and concerns, his psychotic episode could very probably have been prevented.
EMOTIONAL REACTIONS IN SPECIFIC SURGICAL CIRCUMSTANCES
Sensory deprivation or sensory monotony. Experimental research and clinical experience have shown that normal awareness and reality testing require a constant stream of varying external stimuli. In situations of sensory deprivation or sensory monotony, the lack of such stimuli causes an emergence of unconscious psychologic material that may take the form of fantasies, preoccupation with physical functions, perceptual distortions, hallucinations, or psychotic behavior. These symptoms have been encountered in polio patients treated in iron lungs, in open-heart surgery patients monitored in intensive-care units, and in patients after cataract surgery when both eyes were bandaged.
In a confused postsurgical patient, various pleasant sensory stimuli should be provided and, if possible, human isolation and monotony avoided. For the severely ill patient, when treatment of the disease or trauma necessitates isolation or the use of supportive machines, the need for consistent, concerned human contact is especially great.
Removal of limbs. The amputation of extremities is always a traumatic experience, and the patient should be prepared for the loss. A very important consideration is the patient's image of his body. Also, how will the removal of part of his body affect his physical skills? How will the patient adjust to such a change? How will the loss affect his capacity to care for himself, to move around, and to perform his work? These issues have to be taken into consideration when the patient's reaction to such surgical intervention is assessed and, if possible, should be explored preoperatively with the patient.
A phenomenon frequently associated with the amputation of body members is phantom limb. It seems that a person's body image persists for some time as an integral whole after the loss of a body part. As time passes, the perceived phantom limb seems to shrink, until finally the body image adjusts itself to present reality. Different types of pain, paresthesia, and burning have been described by patients.
Simmel2 has described a difference between patients suffering from loss of body parts due to leprosy and those who had surgical amputations. The patients undergoing surgery experienced phantom limb phenomena, while none were reported by nonsurgical patients. Fisher and Cleveland,3 in reviewing research and theories on the issue of body image, have stated that a person resists accepting the reality of radical amputation and tends to view his body as remaining intact. Gradually he integrates his current body scheme, but this may produce changes in sensitivity in the altered body area.
Operations on the genitourinary tract. Any operation affecting the external or internal genital organs elicits strong emotional reactions in the patients. Although some stoic persons deny this, projective psychologic tests reveal powerful unconscious emotional reactions of fear, anxiety, and depression and fantasies of gross body distortion and mutilation. In female patients, intactness of the reproductive organs is essential for childbearing and maintaining the feminine role. Even in postmenopausal women, hysterectomy is experienced as traumatic to the self-image. In most cases pre- and postoperative supportive therapy is indicated to help in the emotional sequelae of this operation.
In the male patient, reactions to urologie operations or procedures are severe. These operations are often unconsciously interpreted as a threat of castration; the patient is afraid that he may become impotent and responds with anxiety or anger. Psychologic intervention is indicated to deal with the conflicting issues and allow the patient to gain some control over his fears by exploring and clarifying his self-doubts. For example, in the reparative plastic surgery of constricted urethra, more than one procedure is required. For a period of months, two flaps of the genital organ are created to allow for the growth of internal lining for the repaired...