Psychological care fear of surgery

Two types of fear commonly encountered in the surgical patient are fear of bodily injury and fear of death, typically fear of not awakening from anesthesia (narcosis anxiety). Other common sources of apprehension are fear of pain, fear of cancer being discovered at operation, fear of intraoperative wakefulness, and fears of non-specific factors common to the hospital experience such as separation from job and family. Studies of patients undergoing orthopaedic and gynaecological surgery have demonstrated that high levels of anxiety precede hospital admission and persist for several days following operative intervention.

ORIGIN OF PREOPERATIVE ANXIETY

Past trauma

The surgical experience recalls early life stress. For some, parental separation at a time of childhood surgery, or unpleasant exposure to a mask for anaesthesia induction may trigger abnormal fear of surgery in adulthood. Those with a traumatic past are especially vulnerable.

Identification

Emotional adaptation to surgery may differ, according to expectations derived from the surgical experience of relatives. Patients encountering a similar disease process may observe, share, and compare outcomes in a way that modifies the impact of events: visits from recipients of organ transplants improve the hopes and coping skills of patients awaiting a suitable organ.

Expectation

Surgery is often a source of hope and improved identity, as in the case of cosmetic procedures and transplantation. In other instances, however, surgery may represent a substantial loss. The burden of mastectomy or colostomy has inspired the formation of successful self-help groups. Although there is an implicit gain for the patient whose life is maintained by removal of cancer or whose proximal limb is saved by amputation of a gangrenous distal part, the subjective or symbolic meaning of operative intervention is also of significance to recovery. Emotional outcome is particularly influenced by the patient's knowledge and orientation to perioperative events, particularly the realistic appraisal of what can be expected. Two factors that increase perioperative anxiety are unpredictability and underestimation of pain and risk.

Preoperative psychological evaluation

Patients with psychopathological states require identification and specialized medical management.

Personality disorder

The different types of personality disorder have in common a basic problem with trust and a pattern of failed or strained relationships. Problems with medical compliance may occur as well as strain in the doctor–patient relationship. The patient may discharge him or herself. Costly litigation, or even personal injury to the caregiver or a colleague, may follow from the perceived injustice of a malcontent. Some patients who are unlikely to benefit from surgery may seek an operation or a series of operations in a neurotic attempt to gain attention.

In addition to identifying personality pathology, it is important to recognize normal variations in coping style, particularly individual tendencies toward anxiety and in locus of control. Some attribute the outcome of events to external factors beyond control, while others perceive events to be under greater personal influence. Some patients may adopt an avoidance or denial approach to the threat of surgery, while others may exaggerate risks. More stress is encountered among the young, among those with an ‘excess of recent life events’ and among those with medical conditions that are relatively demanding. Good outcomes are more likely for those with an active and energetic orientation.