The relationship of preoperative distress to endocrine and subjective responses to surgery: support for Janis' theory

Search Activity Concept: Relationship between Behavior, Health and Brain Functions

Search activity concept provides a new classification of the behavior which distinguishes search activity (activity in the uncertain situation with the constant feedback between behavior and its outcome), stereotyped behavior with a definite probability forecast, panic (activity without feedback between activity and its outcome) and renunciation of search. Only search activity which includes fight, flight, orienting behavior and creativity raises the body’s resistance to stress, to natural and experimentally induced pathology whereas renunciation of search which display itself in freezing, helplessness and depression forms a nonspecific predisposition to somatic disturbances (e.g. psychosomatic diseases). Dreams in REM sleep are regarded as a specific form of search activity aimed at compensating for the lack of search in waking. REM sleep deprivation on a small as well as on rotating platform raises the requirement in REM sleep by frustrating search activity. It is suggested that in wakefulness characterized by the prominent search activity the inhibitory alpha-2- adrenoreceptors became less sensitive to stimulation and consequently in this state the activity of the brain monoamine neurons is less limited by the level of brain monoamines. During renunciation of search brain monoamine synthesis is not stimulated by monoamine exhaustion. In REM sleep the critical level of brain monoamines for search activity to start is lower than in wakefulness and alpha-2-adrenoreceptors are less sensitive than in the state of renunciation of search although more sensitive than during search behavior in waking. REM sleep indirectly contributes to memory consolidation by carrying out its main function — restoration of search activity. A functionally sufficient REM sleep contains search activity in dreams (subject is active in his/her own dream scenario) while in functionally insufficient REM sleep dreams are characterized by subject’s passive position and feeling of helplessness. REM sleep insufficiency is an obligate condition for mental and somatic disorders to appear. The difference between normal (adaptive) and pathological (maladaptive) emotional tension is determined by the presence or absence of search activity in the structure of emotional tension. Repression of the unacceptable motive causing neurotic anxiety is a human variant of renunciation of search. Hypochondriac symptoms are in negative relationships with psychosomatic disorders and they, as well as positive symptoms in schizophrenia and anorectic behavior in anorexia nervosa, represent a pathological misdirected search activity.

Psychological factors in immunomodulation induced by cancer surgery: a review

The immune system's efficacy in detecting and destroying cancer cells varies considerably throughout the stages of cancer development and its role may be critical particularly during the surgical period. Although surgery causes tumor cells to shed into the blood, immune cells have the capacity to destroy these tumor cells. However, surgery also suppresses cytotoxic capacity. It is particularly during this surgical period that psychological factors can have a significant dampening or strengthening impact on surgery-related immunomodulation response, thus exerting an effect on survival. This review describes the immune changes during the peri-surgical period and the influences psychological factors have on immune function, including the immune effects caused by psychological interventions in cancer patients. We recommend that future studies exploring the role of psychological factors on immune function and survival focus more on their influence during the peri-surgical period.

The impact of preoperative education on postoperative pain. Part 1

This article, the first of two parts, explores the general concept of preoperative education through a literature review. The relatively complex relationships between the ways people perceive a threatening situation, their levels of anxiety, coping styles and postoperative pain is explored. In dealing with these complex relationships, teaching strategies and forms of presentation of preoperative education are also discussed. The second part will examine the impact of preoperative education on postoperative anxiety, pain and recovery. This will be achieved by analysing the evidence available to provide a rigorous appraisal of the literature.

Physiological and psychological influences on postoperative fatigue

Fatigue is common after major surgery and delays recovery. We studied the role of physiological and psychological factors in determining fatigue and physical well being after surgery in 102 patients undergoing primary hip arthroplasty. Self-administered questionnaires were used to measure the intensity of feelings of fatigue, vigor, depression, and subjective physical well being on the day before surgery, on the third and seventh postoperative days, and 1 and 6 mo after surgery. The physiological response to surgery was determined by sequential measurements of circulating norepinephrine, epinephrine, cortisol, interleukin-6, and C-reactive protein during the 7 days after surgery. The peak value of each variable was used for statistical analysis. Physical well being decreased significantly at 3 and 7 days but increased significantly at 1 and 6 mo. Fatigue decreased significantly at 1 and 6 mo. Multiple regression analysis showed that the main predictor of worse physical well being at 3 days was the size of the C-reactive protein response. Subsequently, the main predictor was the level of preoperative well being. The severity of fatigue and vigor after surgery were predicted mostly by the preoperative levels of the respective variable. We conclude that fatigue after hip arthroplasty was not predicted by physiological variables but was largely predicted by preoperative levels of fatigue.

IMPLICATIONS

Fatigue is common after major surgery and delays recovery. It is usually attributed to the physiological response to surgery. We studied patients undergoing hip arthroplasty and found that the severity of postoperative fatigue was not predicted by physiological changes. Instead, it was predicted by the preoperative level of fatigue.

Day surgery preoperative anxiety reduction and coping strategies

Hospitalization, even in patients who are not faced with the prospect of surgery, is known to cause anxiety. One may, therefore, expect some degree of anxiety in patients attending for day surgery. Anxiety provokes a physiological stress response, which impedes the healing process. Thus, the reduction of preoperative anxiety is widely accepted as part of nursing care. This article investigates the coping strategies that patients adopt and the suitability of current anxiety-reduction interventions. It argues that individual coping styles do not remain static but adapt according to need and proposes that, as a result of lack of awareness, the therapeutic potential of the nurse-patient relationship in anxiety-reduction is being overshadowed by uncertainty-reduction approaches which place a disproportionate emphasis on the provision of information.

Recovery from hip and knee arthroplasty: Patients' perspective on pain, function, quality of life, and well-being up to 6 months postoperatively

OBJECTIVE

To provide a more detailed description from patients' perspectives than is yet available of recovery from hip and knee arthroplasty and to use this information to test 2 assumptions about recovery from these procedures: that recovery from knee arthroplasty, as assessed by patients, routinely reaches the level achieved by hip arthroplasty; and that fatigue is prolonged after major orthopedic surgery.

DESIGN

A cohort study.

SETTING

University teaching hospitals.

PARTICIPANTS

Consecutive patients undergoing hip (n = 107) or knee (n = 53) arthroplasty.

INTERVENTIONS

Unilateral hip or knee arthroplasty.

MAIN OUTCOME MEASURES

Standardized self-rated measurements of pain, function, quality of life, and well-being from preoperatively to 6 months follow-up.

RESULTS

Pain and function improved significantly less after knee arthroplasty than after hip arthroplasty, but the 2 procedures led to similar improvements in life evaluation, mood, and subjective health. Fatigue was only transiently increased.

CONCLUSION

The findings were inconsistent with both assumptions. Nevertheless, despite poorer recovery in pain and function, patients receiving knee arthroplasty felt that life had improved as much as did patients with hip arthroplasty. Detailed information about how major joint arthroplasty in routine practice affects patients' lives can be used to advise patients and clinicians and can invalidate influential, but inaccurate, assumptions.

The patient from receiver of information to informed decision-maker

In this article the change of paradigm currently taking place within the field of patient education is indicated. In this change of paradigm the patient is increasingly being seen as responsible for his own health and as someone who makes independent choices in this respect. This has consequences for the role the patient is given in decisions on individuals care. The consequences of current developments within the Dutch society and in medical techniques as these relate to the need for patient education are enlightened. Some of the main topics for patient education are mentioned and the effects of patient education as established through meta-analyses are summarised. A planning model for a systematic development of patient education interventions is recommended. Relevant topics for research on patient education in the Netherlands are indicated.

Fatigue after major joint arthroplasty: relationship to preoperative fatigue and postoperative emotional state

Fatigue has been widely assumed to increase after major surgery, and possible physical explanations have been intensively investigated. Nevertheless, existing data are almost exclusively from abdominal surgery and are based on the use of a single visual analogue scale. Moreover, no physical basis has been found. The present study used a more homogeneous surgical model than has been employed hitherto in order to find whether fatigue was related to emotional state. We measured fatigue before and 1 and 7 weeks after major joint arthroplasty in 63 patients, using a questionnaire that separates mental and physical fatigue. Physical function and subjective emotional and somatic state were measured at the same times; optimism was measured preoperatively. Neither mental nor physical fatigue increased after this form of surgery. Mental and physical fatigue each correlated with low positive mood throughout. The best predictor of physical fatigue postoperatively and at follow-up was preoperative physical fatigue. Preoperative mental fatigue and negative mood were independent predictors of mental fatigue postoperatively and at follow-up. Preoperative fatigue also predicted worse subjective emotional and physical state after surgery. These results suggest that fatigue should be regarded as an aspect of emotional distress perioperatively and that complaints of fatigue postoperatively may reflect the tendency to complain of fatigue or negative mood preoperatively rather than being attributable to surgical trauma.

Preoperative rehearsal of active coping imagery influences subjective and hormonal responses to abdominal surgery

Existing evidence suggests that preoperative psychological preparation that is designed to reduce anxiety may sensitize cortisol and adrenaline responses to surgery. In a controlled trial of abdominal surgery patients, we therefore tested the effects of a preoperative preparation that used guided imagery, not to reduce anxiety, but to increase patients' feelings of being able to cope with surgical stress; 26 imagery patients were compared with 25 controls who received, instead, background information about the hospital. State-anxiety was similar in each group, but imagery patients experienced less postoperative pain than did the controls, were less distressed by it, felt that they coped with it better, and requested less analgesia. Hormone levels measured in peripheral venous blood did not differ on the afternoon of admission, before preparation. Cortisol levels were, however, lower in imagery patients than in controls immediately before and after surgery. Noradrenaline levels were greater on these occasions in imagery patients than controls. The results are interpreted in relation to two theories. One states that preoperative "worry" reduces surgical stress. The other concerns the influence of active and passive coping on endocrine responses to stress.

The reduction of anxiety in surgical patients: an important nursing task or the medicalization of preparatory worry?

The reduction of pre-operative anxiety in surgical patients is a routine part of nursing care, but much of the evidence which supports the view that high anxiety is related to worse recovery is based on ambiguous or unreliable indices of recovery. Instead, it has been argued that moderate levels of preoperative anxiety can help patients to prepare for surgery and reduce its stressfulness. On this basis, attempts to reduce anxiety would amount to the "medicalization" of a normal and useful state. Until recently little evidence supported this view, but research which has used hormonal changes to index surgical stress has provided evidence consistent with it. Alternative strategies for psychological preparation can be designed, which are not based on an attempt to reduce anxiety. However, attempts at psychological preparation of surgical patients pre-operatively should be regarded as experimental until more evidence is available about their effects on recovery.

Anxiety levels following anaesthesia for day-case surgery. A comparison of state anxiety levels following induction of anaesthesia with propofol or thiopentone

The effect of different induction agents on postoperative state anxiety levels was investigated. Propofol produces statistically significant lower levels when compared with thiopentone. This finding suggests that propofol should remain the drug of choice for short duration anaesthesia.

Critique: Research strategies for decoding the neurochemical basis of resistance to stress

Because stress is implicated in serious psychiatric and physical illnesses, it is important to investigate the central neurochemical mechanisms which determine resistance to stress. Two features of much existing animal work limit its relevance to man. First, it has disregarded differences between individuals, focussing instead on group means. Secondly, it has concentrated on noxious forms of stress. Preliminary studies suggest that inferences from this work may not apply to individual differences, or to non-noxious stress. Therefore, a strategy is proposed for addressing the neurochemical basis of individual differences in resistance to non-noxious stress.

Sympathoadrenal effects on extinction of rewarded running in the rat

Two groups of rats underwent adrenal demedullation or sham surgery before being trained to run in a straight runaway for food reward at a short intertrial interval (90 s). Half of each group of animals were then injected IP with the sympathetic neurotoxin, 6-hydroxydopamine HBr (6-OHDA; 30 mg/kg); the remainder received saline vehicle. After 3 more days of acquisition training, running was extinguished over 12 trials in all rats. Running times were similar in all groups at the start of extinction. In saline-injected animals, extinction proceeded more slowly in the demedullated than in the sham-operated group, but this effect was largely abolished by 6-OHDA. Consistent with previous results, there was evidence that 6-OHDA facilitated extinction, irrespective of adrenal demedullation, but this effect was most apparent in the time taken to emerge from the start-box. The rats were killed two days after the end of the experiment; cardiac noradrenaline levels were depleted by 83% of control values in 6-OHDA-treated animals. The results suggest that the adrenal medulla and sympathetic neurones have opposing and interacting effects on the response to nonreward.