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'''Preoperational anxiety''' is a universal reaction experienced by patients who are admitted to the hospital for surgery. Just the initial idea of having surgical procedures can bring about very high levels of anxiety in patients <ref name="#5"> Pritchard, Michael John "Identifying and assessing anxiety in pre-operative patients." ''Nursing Standard'' 23.51 (2009): 35-40. Academic Search Premier. EBSCO. Web. 29 September 2009. </ref>. Preoperational anxiety can be described as an unpleasant state of tension or uneasiness that results from a patient's doubts or fears (from a vast array) before an operation<ref name="#5"></ref>.
'''Preoperational anxiety''', or '''preoperative anxiety''', is a common reaction experienced by patients who are admitted to a hospital for [[surgery]].<ref name="#5">{{cite journal | author = Pritchard Michael John | year = 2009 | title = Identifying and assessing anxiety in pre-operative patients | journal = Nursing Standard | volume = 23 | issue = 51| pages = 35–40 | doi = 10.7748/ns2009.08.23.51.35.c7222 | pmid = 19753776 }}</ref> It can be described as an unpleasant state of tension or uneasiness that results from a patient's doubts or fears before an operation.<ref name="#5" />


== Measuring Preoperational Anxiety ==
==Measuring preoperative anxiety==
The [[State-Trait Anxiety Inventory]] (STAI) is a widespread method of measuring preoperative anxiety for research purposes. It consists of two 20-item scales on which patients are asked to rate particular symptoms.<ref name="stai">{{cite journal | author = Brown Roger L., Tluczek Audrey, Henriques Jeffrey B. | year = 2009 | title = Support for the Reliability and Validity of a Six-Item State Anxiety Scale Derived From the State-Trait Anxiety Inventory | journal = Journal of Nursing Measurement }}</ref>


The STAI is based on the theory that there are two distinct aspects of anxiety. The State scale is designed to measure the circumstantial or temporary arousal of anxiety, and the Trait scale is designed to measure longstanding personality characteristics related to anxiety. The items on each scale are based on a two-factor model: "anxiety present" or "anxiety absent".<ref name="stai" />
The State Trait Anxiety Inventory (STAI) is a widespread method of measuring pre-operative anxiety for research. The STAI consists of two 20-item self-report scales that attempt to accurately measure the worry and apprehension based on both present circumstances and personality traits<ref name="stai">Brown, Roger L., Audrey Tluczek, Jeffrey B. Henriques. “Support for the Reliability and Validity of a Six-Item State Anxiety Scale Derived From the State-Trait Anxiety Inventory”. ''Journal of Nursing Measurement'' (2009) Bnet. Web. 9 December 2009. </ref>. Patients are asked to rate the frequency of particular symptoms<ref name="stai"></ref>.<br />
<br />
The STAI was based on the theory that there are two different aspects of anxiety. This caused two different sections of the STAI to develop: the State scale (designed to measure the circumstantial or temporary arousal of anxiety), and the Trait scale (designed to measure the long-standing personality characteristics related to anxiety). The items on each scale are based on a two-factor model: anxiety present, anxiety absent <ref name="stai">Insert footnote text here</ref>.<br />
<br />
In the 2009 Journal of Nursing Measurement, Tluczek, Henriques, and Brown mention that one of the problems with the STAI is that the fast-paced hospital environment makes it is difficult to get each patient through all 20 items, especially when there are other assessments that need to be done.<ref name="stai">Insert footnote text here</ref>.<br />
<br />
Recently, other people have tried to create shortened versions of the 20-item STAI. For example, Tluczek et al. (2009) have found that the Marteau and Bekker’s six-item version of the State Anxiety scale has “favorable internal consistency reliability and validity when correlated with the parent 20-item State scale”<ref name="stai">Insert footnote text here</ref>. Research on new and improved methods is sure to be continuing. Other alternatives for quick and accurate measurements may be found in the future<ref name="stai">Insert footnote text here</ref>.<br />


In a 2009 paper in ''The'' ''Journal of Nursing Measurement'', researchers argued that fast-paced hospital environments make it difficult to get each patient through all 20 items, especially when other assessments must also be done.<ref name="stai" /> Shorter versions of the STAI have been developed. For example, Marteau and Bekker's six-item version of the State scale was found in 2009 to have "favorable internal consistency reliability and validity when correlated with the parent 20-item State scale".<ref name="stai" />
== Causes ==


=== General Fears ===
==Causes of anxiety==
A variety of fears can cause preoperative anxiety. They include fear of:
Through the research done by several individuals, it is concluded that many different there are many different fears that can cause preoperational anxiety. These fears include:<br />
1. “the unknown”<ref name="#5">Insert footnote text here</ref> <br />
* "The unknown"<ref name="#5" />
* Surgical failure
2. surgical failure <br />
3. [[anesthesia]]<ref name="#8">Bajaj, A. et al. “Pre-operative Anxiety” ''Anaethesia''. 51 (1996):344-346. EBSCO. Web. September 2009.</ref> <br />
* [[Anesthesia]]<ref name="#8">Bajaj, A. et al. "Pre-operative Anxiety" ''Anaethesia''. 51 (1996):344-346. EBSCO. Web. September 2009.</ref>
4. loss of personal identity <br />
* Loss of personal identity
5. recuperation around strangers <ref name="#2">Insert footnote text here</ref><br />
* Recuperation around strangers<ref name="#2" />
6. pain<ref name="#5">Insert footnote text here</ref><br />
* Pain<ref name="#5" />
7. loss of control<br />
* Loss of control
8. death <ref name="#7">Dirik, G., A.N. Karanci “Predictors of Pre- and Postoperational Anxiety in Emergency Surgery Patients” ''Journal of psychosomatic Research '' 55.4 (2003): 363-369. ScienceDirect. Web. 29 September, 2009. </ref> <br />
* Death<ref name="#7">{{cite journal | author = Dirik G., Karanci A.N. | year = 2003 | title = Predictors of Pre- and Postoperational Anxiety in Emergency Surgery Patients | journal = Journal of Psychosomatic Research | volume = 55 | issue = 4| pages = 363–369 | doi = 10.1016/S0022-3999(02)00631-1 | pmid = 14507548 }}</ref>
9. unsuccessful recovery <ref name="#5"></ref><br />
* Unsuccessful recovery<ref name="#5" />
10. strange environment <ref name="#7">Insert footnote text here</ref><br />
* Strange environment<ref name="#7" />
Other factors in the intensity of preoperative anxiety are:
* Previous hospital experiences<ref name="#5" />
*Sociodemographic characteristics (such as age, marital status, and education)<ref name="#7" />
* Psychological characteristics (such as coping strategies and perceived social support)<ref name="#7" />
* Gender (females tend to have higher levels of preoperative anxiety than males).<ref name="#7" />


Irving Janis separates the factor trends that are commonly seen affecting anxiety into three different levels:<ref name="book">Janis, Irving L. ''Psychological Stress: Psychoanalytic and Behavioral Studies of Surgical Patients''. Hoboken, NJ, US: John Wiley & Sons Inc, 1958. Web. Dec. 2009.</ref>
=== General factors ===
* '''Low anxiety''': This is seen among people with personality predispositions that incline a person to deny signs of impending dangers and ignore harsh warnings of medical personnel. This group also includes severe obsessives, withdrawn [[schizoid]]al characters, and patients with other avoidance disorders. Some of the patients that experience low levels of anxiety are emotional and responsive to their environment, but if unpleasant information is given, there is an immediate shift to a moderate degree of apprehension.<ref name="book" />
There are many different factors that play into the level of anxiety a patient might experience:<br />
* '''Moderate anxiety''': This is seen among people who are highly responsive to external stimulation. Usually, people in this group are greatly influenced by the information that is given to them. Information seems to have a positive influence on these people: potential dangers, how dangers are overcome, and protective factors help the patients grasp reality and overcome worry.<ref name="book" />
1. Previous hospital experiences <ref name="#5">Insert footnote text here</ref><br />
* '''High anxiety''': This is seen among patients with predispositions to have [[neurosis|neurotic]] symptoms, and among those who have an extremely hard time with the threat of body damage. This includes those with repressed inner struggles that are brought out through the external threat.<ref name ="book" />
2. Sociodemographic characteristics (such as age, marital status and education) <ref name= "#7">Insert footnote text here</ref><br />
3. Psychological characteristics (such as coping strategies and perceived social support) <ref name= "#7">Insert footnote text here</ref><br />
4. Gender (females tend to have higher levels of preoperational anxiety than males) <ref name="#7">Insert footnote text here</ref>.<br />
<br />'''Pre- and post-operation STAI State scores for males and females<ref name="#7">Insert footnote text here</ref>'''<br />
This is an average obtained through research done by Dirik and Karancei<ref name="#7">Insert footnote text here</ref>. They were obtained using the 20-items of the STAI-State scale administered before and after surgery<ref name="#7">Insert footnote text here</ref>.<br />
{| class="wikitable"
|-
!
! Preoperation
! Postoperation
|-
| Female
| 51.98
| 42.92
|-
| Male
| 47.05
| 43.06
|}


==Effects of preoperative anxiety==
Irving Janis separates the factor trends that are commonly seen affecting anxiety into three different levels<ref name="book">Janis, Irving L. ''Psychological Stress: Psychoanalytic and Behavioral Studies of Surgical Patients''. Hoboken, NJ, US: John Wiley & Sons Inc, 1958. Web. Dec. 2009.</ref>:<br />
=== Physiological effects ===
• '''Low anxiety''': This is seen among people with personality predispositions that incline a person to deny signs of impending dangers and ignore harsh warnings of medical personnel. This group also includes severe obsessionals, withdrawn [[schizoid|schizoidal]] characters and patients with other avoidance disorders. Some of the patients that experinece low levels of anxiety are emotional and responsive to their environment, but, if unpleasant information is given, there is an immediate shift to a moderate degree of apprehension <ref name="book"> </ref>.<br />
Anxiety can cause physiological responses such as [[tachycardia]], [[hypertension]], elevated temperature, [[Perspiration|sweating]], [[nausea]], and a heightened sense of touch, smell, or hearing.<ref name="#5" /><ref name="#8" />
• '''Moderate anxiety''': This is seen among people who are highly responsive to external stimulation. Usually, people in this group are greatly influenced by the information that is given to them. Information seems to have a positive influence on these people: potential dangers, how dangers are overcome, and protective factors help the patients grasp reality and overcome worry<ref name="book">Insert footnote text here</ref>.<br />
• '''High anxiety''': This is seen among patients with predispositions to suffer from [[neurotic]] symptoms. It is also seen among patients who have an extremely hard time with the threat of body damage<ref name="book">Insert footnote text here</ref>. This those includes those with repressed inner struggles that are brought out through the external threat<ref name ="book">Insert footnote text here</ref>.<br />


A patient may also experience peripheral [[vasoconstriction]], which makes it difficult for the hospital staff to obtain blood.<ref name="#5" />
== Different reactions to preoperative anxiety ==


=== Physiology ===
===Psychological effects===
Anxiety may cause behavioral and cognitive changes that result in increased tension, apprehension, nervousness, and aggression.<ref name="#5" />


Some patients may become so apprehensive that they cannot understand or follow simple instructions. Some may be so aggressive and demanding that they require constant attention of the nursing staff.<ref name="#5" />
When anxiety alters the patient’s vital signs, it results in physiological responses such as [[tachycardia]], [[hypertension]], elevated temperature, sweating, nausea and a heightened sense of touch, smell or hearing <ref name="#5">Insert footnote text here</ref><ref name="#8">Insert footnote text here</ref>. <br />
A patient may also experience peripheral [[vasoconstriction]], which makes it difficult for the hospital staff to obtain blood from the individual <ref name="#5">Insert footnote text here</ref>.<br />


=== Psychology ===
===Behavioral strategies and trends===
In research conducted by Irving Janis, common reactions and strategies were separated into three different levels of preoperative anxiety:
Anxiety may cause behavioral and cognitive changes which can result in increased tension, apprehension, nervousness and aggression<ref name="#5">Insert footnote text here</ref>.<br />
Some patients may become so nervous and apprehensive that they cannot understand or follow simple instructions. Some may be so aggressive and demanding that they require constant attention of the nursing staff <ref name="#5">Insert footnote text here</ref>.<br />


'''Low anxiety'''
=== Behavioral Strategies and Trends ===
In research conducted by Irving Janis, common reactions and strategies were separated into three different levels of preoperational anxiety:<br />
1. '''Low Anxiety'''<br />
Patients in this category tend to adopt a joking attitude or to say things like “there’s nothing to it!” Because most pain is not preconceived by the patient, the patients tends to be blame their pain on the hospital staff<ref name="book">Insert footnote text here</ref>. In this case, the patient feels as if they have been mistreated. This is because the patient doesn't have the usual mindset that pain is an unavoidable result of an operation<ref name="book">Insert footnote text here</ref>.<br />
<br />
Other trends include displaying a calm and relaxed attitude during preoperative care. They don't usually experience any sleeping disturbances<ref name="book">Insert footnote text here</ref>. They also tend to make little effort to seek more information about medical procedures. This may be due to the fact that they are unaware of the potential threats, or it may just be because they have succeeded in shutting themselves out and eliminating all thought of doubt and fear <ref name="book">Insert footnote text here</ref>.<br />
<br />
The main concern that low anxiety patients tend to express is finances, and they usually deny apprehension about operational dangers <ref name="book">Insert footnote text here</ref>.<br />


Patients in this category tend to adopt a joking attitude or to say things like "there's nothing to it!" Because most pain is not preconceived by the patient, the patients tends to blame their pain on the hospital staff.<ref name="book" /> In this case, the patient feels as if they have been mistreated. This is because the patient doesn't have the usual mindset that pain is an unavoidable result of an operation.<ref name="book" />
2. '''Moderate Anxiety'''<br />
Patients in this category may only experience minor emotional tension. The occasional worry or fear that is experienced by a patient with moderate anxiety can usually be suppressed<ref name="book">Insert footnote text here</ref>. <br />
<br />
Some may suffer from [[insomnia]], but they also usually respond well to mild sedatives. Their outward manner may seem relatively calm and well controlled, except for small moments where it is apparent to others that the patient is suffering from an inner conflict. They can usually perform daily tasks, only becoming restless from time to time <ref name="book">Insert footnote text here</ref>.<br />
<br />
These patients are usually very motivated to develop reliable information from medical authority in order to reach a point of comfortable relief <ref name="book">Insert footnote text here</ref>.<br />


Other trends include displaying a calm and relaxed attitude during preoperative care. They don't usually experience any sleeping disturbances.<ref name="book" /> They also tend to make little effort to seek more information about medical procedures. This may be due to the fact that they are unaware of the potential threats, or it may just be because they have succeeded in shutting themselves out and eliminating all thought of doubt and fear.<ref name="book" />
3. '''High Anxiety'''<br />
Patients in this category will usually try to reassure themselves by seeking information, but these attempts, in the long-run, are unsuccessful at helping the patient reach a comfortable point because the fear is so dominant <ref name="book">Insert footnote text here</ref>. <br />
<br />
It is common for patients in this level of anxiety to engage in mentally distracting activities in an attempt to get their mind off of anticipated danger. They have a hard time idealizing their situation or maintaining any sort of conception that things could turn out well in the end. This because they tend to dwell on improbable dangers<ref name="book">Insert footnote text here</ref>.<br />


The main concern that low anxiety patients tend to express is finances, and they usually deny apprehension about operational dangers.<ref name="book" />
== Effects ==
=== Preparation for Surgery ===
On the positive side, if a patient experiences moderate amounts of anxiety, the anxiety can aid in the preparation for surgery<ref name="#5">Insert footnote text here</ref>. On the negative side, the anxiety can cause harm if the patient experiences an excessive or diminutive amount. One reason for this is that small amounts of anxiety will not adequately prepare the patient for pain <ref name="#5">Insert footnote text here</ref>. Also, higher levels of anxiety can over-sensitize the patient to unpleasant stimuli, which would heighten their senses of touch, smell or hearing. This results in intense pain, dizziness, and nausea. It can also increase the patient’s feelings of uneasiness in the unfamiliar surroundings<ref name="#2">Carr, Eloise, et al. "Patterns and frequency of anxiety in women undergoing gynaecological surgery." ''Journal of Clinical Nursing'' 15.3 (2006): 341-352. Health Source: Nursing/Academic Edition. EBSCO. Web. 8 September 2009.</ref>.<br />


'''Moderate anxiety'''
=== Post-Operation ===
Anxiety has also been proven to cause higher [[analgesic]] and [[anaesthetic]] requirement, postoperative pain, and prolonged hospital stay<ref name="#3">Agarwal, A., et al. "Acupressure for prevention of pre-operative anxiety: a prospective, randomised, placebo controlled study." ''Anaesthesia'' 60.10 (2005): 978-981. Biomedical Reference Collection: Basic. EBSCO. Web. 9 September 2009. </ref>. <br />
<br />
Irving L. Janis describes the effect of preoperative aniety on postoperative reactions to by separating it into the three levels:<ref name="book">Insert footnote text here</ref><br />
1. '''Low Anxiety''':. The defenses of denial and other reassurances that were created to ward off the worry and aprehension preoperatively are not effective long-term. When all the pain and stress is experienced post-operatively, the emotional tension is unrelieved because there aren’t any real reassurances available from the pre-operational stage<ref name="book">Insert footnote text here</ref>.<br />


Patients in this category may only experience minor emotional tension. The occasional worry or fear that is experienced by a patient with moderate anxiety can usually be suppressed.<ref name="book" />
2. '''Moderate Anxiety''': Reality-oriented reassurances that were used to prepare a patient with moderate anxiety for an operation are stored in the patient’s memory, so they are available to aid in post-operational stress <ref name="book">Insert footnote text here</ref>.<br />


Some may develop [[insomnia]], but they also usually respond well to mild sedatives. Their outward manner may seem relatively calm and well controlled, except for small moments where it is apparent to others that the patient is suffering from an inner conflict. They can usually perform daily tasks, only becoming restless from time to time.<ref name="book" />
3. '''High Anxiety''': Because the reassurances given by hospital personnel were not effective pre-operatively, there aren’t any real reassurances available to aid with the stress stimuli that are subsequently encountered <ref name="book">Insert footnote text here</ref>.<br />


These patients are usually very motivated to develop reliable information from medical authority in order to reach a point of comfortable relief.<ref name="book" />
== Alleviating or prevention techniques for High Levels of Anxiety ==
1. preoperative patient teaching or tours<ref name="#1">Lepczyk, Marybeth, Edith Hunt Raleigh, and Constance Rowley "Timing of preoperative patient teaching." ''Journal of Advanced Nursing'' 15.3 (1990): 300-306. Health Source: Nursing/Academic Edition. EBSCO. Web. 8 September 2009. </ref>.<br />
2. accurate and thorough information about the operation<ref name="#2"> </ref>.<br />
3. relaxation therapy <ref name="#2">Insert footnote text here</ref>.<br />
4. cognitive behavioural therapy <ref name="#2">Insert footnote text here</ref>.<br />
5. [[acupressure]]<ref name="#3"></ref>.<br />
6. auricular [[acupuncture]]<ref name="#3">Insert footnote text here</ref>.<br />
7. permitting family members to be present before the operation<ref name="#5">Insert footnote text here</ref>.<br />
8. anti-anxiety medication <ref name="#5">Insert footnote text here</ref>.<br />
9. nurse-patient relationships <ref name="#2">Insert footnote text here</ref>.<br />
10. A visit from the anaesthestist preoperatively<ref name="#8">Insert footnote text here</ref>


'''High anxiety'''
==References==

{{reflist}}
Patients in this category will usually try to reassure themselves by seeking information, but these attempts, in the long-run, are unsuccessful at helping the patient reach a comfortable point because the fear is so dominant.<ref name="book" />

It is common for patients in this level of anxiety to engage in mentally distracting activities in an attempt to get their mind off of anticipated danger. They have a hard time idealizing their situation or maintaining any sort of conception that things could turn out well in the end. This because they tend to dwell on improbable dangers.<ref name="book" />

==Effects==
=== Preparation for surgery ===
On the positive side, if a patient experiences moderate amounts of anxiety, the anxiety can aid in the preparation for surgery.<ref name="#5" /> On the negative side, the anxiety can cause harm if the patient experiences an excessive or diminutive amount. One reason for this is that small amounts of anxiety will not adequately prepare the patient for pain.<ref name="#5" /> Also, higher levels of anxiety can over-sensitize the patient to unpleasant stimuli, which would heighten their senses of touch, smell or hearing. This results in intense pain, dizziness, and nausea. It can also increase the patient's feelings of uneasiness in the unfamiliar surroundings.<ref name="#2">{{cite journal | author = Carr Eloise | display-authors = etal | year = 2006 | title = Patterns and frequency of anxiety in women undergoing gynaecological surgery | url = http://eprints.bournemouth.ac.uk/11478/1/jcn12851_patterns_Anx_Proof.pdf| journal = Journal of Clinical Nursing | volume = 15 | issue = 3| pages = 341–352 | doi = 10.1111/j.1365-2702.2006.01285.x | pmid = 16466484 }}</ref>

===Post-operation===
Anxiety has also been proven to cause higher [[analgesic]] and [[anaesthetic]] requirement, postoperative pain, and prolonged hospital stay.<ref name="#3">{{cite journal | author = Agarwal A | display-authors = etal | year = 2005 | title = Acupressure for prevention of pre-operative anxiety: a prospective, randomised, placebo controlled study | journal = Anaesthesia | volume = 60 | issue = 10| pages = 978–981 | doi = 10.1111/j.1365-2044.2005.04332.x | pmid = 16179042 | s2cid = 21158736 | doi-access = free }}</ref>

Irving L. Janis separates the effects of preoperative anxiety on postoperative reactions into three levels:<ref name="book" />
* '''Low anxiety''': The defenses of denial and other reassurances that were created to ward off the worry and apprehension preoperatively are not effective long-term. When all the pain and stress is experienced post-operatively, the emotional tension is unrelieved because there aren't any real reassurances available from the pre-operational stage.<ref name="book" />
* '''Moderate anxiety''': Reality-oriented reassurances that were used to prepare a patient with moderate anxiety for an operation are stored in the patient's memory, so they are available to aid in post-operational stress.<ref name="book" />
* '''High anxiety''': Because the reassurances given by hospital personnel were not effective pre-operatively, there aren't any real reassurances available to aid with the stress stimuli that are subsequently encountered.<ref name="book" />

==Treatment==
Treatment of preoperative anxiety may include:
* Preoperative patient teaching or tours<ref name="#1">{{cite journal | author = Lepczyk Marybeth, Hunt Raleigh Edith, Rowley Constance | year = 1990 | title = Timing of preoperative patient teaching | journal = Journal of Advanced Nursing | volume = 15 | issue = 3| pages = 300–306 | doi = 10.1111/j.1365-2648.1990.tb01817.x | pmid = 2332553 | hdl = 2027.42/73141 | hdl-access = free }}</ref>
* Accurate and thorough information about the operation<ref name="#2" />
* Relaxation therapy<ref name="#2" />
* Cognitive behavioural therapy<ref name="#2" />
* Permitting family members to be present before the operation<ref name="#5" />
* Anti-anxiety medication<ref name="#5" /> such as [[benzodiazepine]]s or [[melatonin]]. An advantage of melatonin is that it has no known serious side effects, such as a hangover effect post-surgery.<ref>{{cite journal|last1=Madsen BK, Zetner D, Møller AM, Rosenberg J|date=December 8, 2020|title=Melatonin for preoperative and postoperative anxiety in adults|journal=Cochrane Database of Systematic Reviews|volume=2020 |issue=12 |pages=CD009861 |doi=10.1002/14651858.CD009861.pub3 |pmc=8092422|pmid=33319916}}</ref>
* Nurse-patient relationships<ref name="#2" />
* A preoperative visit from the anaesthesiologist<ref name="#8" />
* [[Pregabalin]], [[gabapentin]]<ref>{{Cite journal |date=2022-10-17 |title=Review finds little evidence to support gabapentinoid use in bipolar disorder or insomnia |url=https://evidence.nihr.ac.uk/alert/review-finds-little-evidence-support-gabapentinoid-use-bipolar-disorder-or-insomnia/ |journal=NIHR Evidence |type=Plain English summary |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/nihrevidence_54173 |s2cid=252983016}}</ref><ref name=":1">{{cite journal |display-authors=6 |vauthors=Hong JS, Atkinson LZ, Al-Juffali N, Awad A, Geddes JR, Tunbridge EM, Harrison PJ, Cipriani A |date=March 2022 |title=Gabapentin and pregabalin in bipolar disorder, anxiety states, and insomnia: Systematic review, meta-analysis, and rationale |journal=Molecular Psychiatry |volume=27 |issue=3 |pages=1339–1349 |doi=10.1038/s41380-021-01386-6 |pmc=9095464 |pmid=34819636}}</ref>

== References ==
{{Reflist}}

[[Category:Physiology]]

Revision as of 10:40, 28 October 2022

Preoperational anxiety, or preoperative anxiety, is a common reaction experienced by patients who are admitted to a hospital for surgery.[1] It can be described as an unpleasant state of tension or uneasiness that results from a patient's doubts or fears before an operation.[1]

Measuring preoperative anxiety

The State-Trait Anxiety Inventory (STAI) is a widespread method of measuring preoperative anxiety for research purposes. It consists of two 20-item scales on which patients are asked to rate particular symptoms.[2]

The STAI is based on the theory that there are two distinct aspects of anxiety. The State scale is designed to measure the circumstantial or temporary arousal of anxiety, and the Trait scale is designed to measure longstanding personality characteristics related to anxiety. The items on each scale are based on a two-factor model: "anxiety present" or "anxiety absent".[2]

In a 2009 paper in The Journal of Nursing Measurement, researchers argued that fast-paced hospital environments make it difficult to get each patient through all 20 items, especially when other assessments must also be done.[2] Shorter versions of the STAI have been developed. For example, Marteau and Bekker's six-item version of the State scale was found in 2009 to have "favorable internal consistency reliability and validity when correlated with the parent 20-item State scale".[2]

Causes of anxiety

A variety of fears can cause preoperative anxiety. They include fear of:

  • "The unknown"[1]
  • Surgical failure
  • Anesthesia[3]
  • Loss of personal identity
  • Recuperation around strangers[4]
  • Pain[1]
  • Loss of control
  • Death[5]
  • Unsuccessful recovery[1]
  • Strange environment[5]

Other factors in the intensity of preoperative anxiety are:

  • Previous hospital experiences[1]
  • Sociodemographic characteristics (such as age, marital status, and education)[5]
  • Psychological characteristics (such as coping strategies and perceived social support)[5]
  • Gender (females tend to have higher levels of preoperative anxiety than males).[5]

Irving Janis separates the factor trends that are commonly seen affecting anxiety into three different levels:[6]

  • Low anxiety: This is seen among people with personality predispositions that incline a person to deny signs of impending dangers and ignore harsh warnings of medical personnel. This group also includes severe obsessives, withdrawn schizoidal characters, and patients with other avoidance disorders. Some of the patients that experience low levels of anxiety are emotional and responsive to their environment, but if unpleasant information is given, there is an immediate shift to a moderate degree of apprehension.[6]
  • Moderate anxiety: This is seen among people who are highly responsive to external stimulation. Usually, people in this group are greatly influenced by the information that is given to them. Information seems to have a positive influence on these people: potential dangers, how dangers are overcome, and protective factors help the patients grasp reality and overcome worry.[6]
  • High anxiety: This is seen among patients with predispositions to have neurotic symptoms, and among those who have an extremely hard time with the threat of body damage. This includes those with repressed inner struggles that are brought out through the external threat.[6]

Effects of preoperative anxiety

Physiological effects

Anxiety can cause physiological responses such as tachycardia, hypertension, elevated temperature, sweating, nausea, and a heightened sense of touch, smell, or hearing.[1][3]

A patient may also experience peripheral vasoconstriction, which makes it difficult for the hospital staff to obtain blood.[1]

Psychological effects

Anxiety may cause behavioral and cognitive changes that result in increased tension, apprehension, nervousness, and aggression.[1]

Some patients may become so apprehensive that they cannot understand or follow simple instructions. Some may be so aggressive and demanding that they require constant attention of the nursing staff.[1]

In research conducted by Irving Janis, common reactions and strategies were separated into three different levels of preoperative anxiety:

Low anxiety

Patients in this category tend to adopt a joking attitude or to say things like "there's nothing to it!" Because most pain is not preconceived by the patient, the patients tends to blame their pain on the hospital staff.[6] In this case, the patient feels as if they have been mistreated. This is because the patient doesn't have the usual mindset that pain is an unavoidable result of an operation.[6]

Other trends include displaying a calm and relaxed attitude during preoperative care. They don't usually experience any sleeping disturbances.[6] They also tend to make little effort to seek more information about medical procedures. This may be due to the fact that they are unaware of the potential threats, or it may just be because they have succeeded in shutting themselves out and eliminating all thought of doubt and fear.[6]

The main concern that low anxiety patients tend to express is finances, and they usually deny apprehension about operational dangers.[6]

Moderate anxiety

Patients in this category may only experience minor emotional tension. The occasional worry or fear that is experienced by a patient with moderate anxiety can usually be suppressed.[6]

Some may develop insomnia, but they also usually respond well to mild sedatives. Their outward manner may seem relatively calm and well controlled, except for small moments where it is apparent to others that the patient is suffering from an inner conflict. They can usually perform daily tasks, only becoming restless from time to time.[6]

These patients are usually very motivated to develop reliable information from medical authority in order to reach a point of comfortable relief.[6]

High anxiety

Patients in this category will usually try to reassure themselves by seeking information, but these attempts, in the long-run, are unsuccessful at helping the patient reach a comfortable point because the fear is so dominant.[6]

It is common for patients in this level of anxiety to engage in mentally distracting activities in an attempt to get their mind off of anticipated danger. They have a hard time idealizing their situation or maintaining any sort of conception that things could turn out well in the end. This because they tend to dwell on improbable dangers.[6]

Effects

Preparation for surgery

On the positive side, if a patient experiences moderate amounts of anxiety, the anxiety can aid in the preparation for surgery.[1] On the negative side, the anxiety can cause harm if the patient experiences an excessive or diminutive amount. One reason for this is that small amounts of anxiety will not adequately prepare the patient for pain.[1] Also, higher levels of anxiety can over-sensitize the patient to unpleasant stimuli, which would heighten their senses of touch, smell or hearing. This results in intense pain, dizziness, and nausea. It can also increase the patient's feelings of uneasiness in the unfamiliar surroundings.[4]

Post-operation

Anxiety has also been proven to cause higher analgesic and anaesthetic requirement, postoperative pain, and prolonged hospital stay.[7]

Irving L. Janis separates the effects of preoperative anxiety on postoperative reactions into three levels:[6]

  • Low anxiety: The defenses of denial and other reassurances that were created to ward off the worry and apprehension preoperatively are not effective long-term. When all the pain and stress is experienced post-operatively, the emotional tension is unrelieved because there aren't any real reassurances available from the pre-operational stage.[6]
  • Moderate anxiety: Reality-oriented reassurances that were used to prepare a patient with moderate anxiety for an operation are stored in the patient's memory, so they are available to aid in post-operational stress.[6]
  • High anxiety: Because the reassurances given by hospital personnel were not effective pre-operatively, there aren't any real reassurances available to aid with the stress stimuli that are subsequently encountered.[6]

Treatment

Treatment of preoperative anxiety may include:

  • Preoperative patient teaching or tours[8]
  • Accurate and thorough information about the operation[4]
  • Relaxation therapy[4]
  • Cognitive behavioural therapy[4]
  • Permitting family members to be present before the operation[1]
  • Anti-anxiety medication[1] such as benzodiazepines or melatonin. An advantage of melatonin is that it has no known serious side effects, such as a hangover effect post-surgery.[9]
  • Nurse-patient relationships[4]
  • A preoperative visit from the anaesthesiologist[3]
  • Pregabalin, gabapentin[10][11]

References

  1. ^ a b c d e f g h i j k l m n Pritchard Michael John (2009). "Identifying and assessing anxiety in pre-operative patients". Nursing Standard. 23 (51): 35–40. doi:10.7748/ns2009.08.23.51.35.c7222. PMID 19753776.
  2. ^ a b c d Brown Roger L., Tluczek Audrey, Henriques Jeffrey B. (2009). "Support for the Reliability and Validity of a Six-Item State Anxiety Scale Derived From the State-Trait Anxiety Inventory". Journal of Nursing Measurement.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  3. ^ a b c Bajaj, A. et al. "Pre-operative Anxiety" Anaethesia. 51 (1996):344-346. EBSCO. Web. September 2009.
  4. ^ a b c d e f Carr Eloise; et al. (2006). "Patterns and frequency of anxiety in women undergoing gynaecological surgery" (PDF). Journal of Clinical Nursing. 15 (3): 341–352. doi:10.1111/j.1365-2702.2006.01285.x. PMID 16466484.
  5. ^ a b c d e Dirik G., Karanci A.N. (2003). "Predictors of Pre- and Postoperational Anxiety in Emergency Surgery Patients". Journal of Psychosomatic Research. 55 (4): 363–369. doi:10.1016/S0022-3999(02)00631-1. PMID 14507548.
  6. ^ a b c d e f g h i j k l m n o p q r Janis, Irving L. Psychological Stress: Psychoanalytic and Behavioral Studies of Surgical Patients. Hoboken, NJ, US: John Wiley & Sons Inc, 1958. Web. Dec. 2009.
  7. ^ Agarwal A; et al. (2005). "Acupressure for prevention of pre-operative anxiety: a prospective, randomised, placebo controlled study". Anaesthesia. 60 (10): 978–981. doi:10.1111/j.1365-2044.2005.04332.x. PMID 16179042. S2CID 21158736.
  8. ^ Lepczyk Marybeth, Hunt Raleigh Edith, Rowley Constance (1990). "Timing of preoperative patient teaching". Journal of Advanced Nursing. 15 (3): 300–306. doi:10.1111/j.1365-2648.1990.tb01817.x. hdl:2027.42/73141. PMID 2332553.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ Madsen BK, Zetner D, Møller AM, Rosenberg J (December 8, 2020). "Melatonin for preoperative and postoperative anxiety in adults". Cochrane Database of Systematic Reviews. 2020 (12): CD009861. doi:10.1002/14651858.CD009861.pub3. PMC 8092422. PMID 33319916.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ "Review finds little evidence to support gabapentinoid use in bipolar disorder or insomnia". NIHR Evidence (Plain English summary). National Institute for Health and Care Research. 2022-10-17. doi:10.3310/nihrevidence_54173. S2CID 252983016.
  11. ^ Hong JS, Atkinson LZ, Al-Juffali N, Awad A, Geddes JR, Tunbridge EM, et al. (March 2022). "Gabapentin and pregabalin in bipolar disorder, anxiety states, and insomnia: Systematic review, meta-analysis, and rationale". Molecular Psychiatry. 27 (3): 1339–1349. doi:10.1038/s41380-021-01386-6. PMC 9095464. PMID 34819636.
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