Anxiety and surgical recovery: Reinterpreting the literature

https://doi.org/10.1016/S0022-3999(01)00258-6Get rights and content

Abstract

Objective: To critically evaluate the interpretation of the findings reported in the peer-reviewed literature concerning the association of state and trait anxiety with surgical recovery and response to surgery. Methods: The Social Science Citation Index (SSCI), Science Citation Index (SCI), Medline and Psychological Abstracts (PsycInfo) databases were searched for studies published since 1981. Reference lists from previous reviews were also searched for additional references. Studies that were not in the public domain were not searched for. Results: Twenty-seven studies were identified by the search strategy, met the inclusion criteria and contributed to the review. Conclusions: Associations between preoperative measures of anxiety and postoperative mood and pain have been consistently reported. Associations with regard to other recovery variables are less consistent. The existing evidence does not rule out an interpretation of the results as reflecting consistent self-reporting bias rather than causal association.

Introduction

An extensive literature exists that attempts to show relationships between psychological factors, usually measured preoperatively, and surgical recovery. The main psychological factors of interest are affective, with a great deal of emphasis on anxiety, as this is a particularly salient feature of the perioperative period [15]. The ability to predict surgical recovery would be of both clinical and theoretical value.

Surgery represents a major trauma that provokes a relatively stereotyped physiological response [32]. A period of postoperative recovery follows, ranging from a few days to several weeks depending, primarily, on the severity of the preexisting pathology and the surgical procedure performed. There is also variability across patients who have undergone a comparable surgical procedure. What accounts for this difference across patients is unclear, and it is this difference that led to the suggestion (e.g., Ref. [15]) that psychological factors such as current (or state) anxiety and depression might play some part in determining the duration and quality of the recovery period.

Janis [15] proposed that a curvilinear relationship exists between preoperative “distress” (not necessarily analogous to state anxiety) and postoperative recovery. That is, moderate levels of “distress” are proposed to result in optimal postoperative recovery, while excessively low or excessively high levels of “distress” both result in impaired or suboptimal recovery, although the mechanisms underlying these relationships may differ. This moderate level of “distress” related to optimal postoperative recovery was termed, by Janis, “the work of worry,” which was hypothesised to prepare the surgical patient for the distress and suffering associated with postoperative recovery. An inability to prepare oneself appropriately, reflected in low preoperative “distress,” was suggested to result in greater distress postoperatively, for example, because of the shock of such unexpected pain, while excessive preoperative “distress” was also supposed to result in greater postoperative suffering, perhaps because of sensitization to noxious stimuli. More recently, experimental work in psychoneuroimmunology has suggested that stress delays wound healing and, in addition, that pain has adverse effects on endocrine and immune function [18]. Taken together, this suggests the possibility of both biologically and behaviorally mediated associations between preoperative state anxiety and postoperative state. An obvious question that results from this thesis is whether “distress” as envisaged by Janis necessarily reflects the same thing as “stress” as investigated by Kiecolt–Glaser et al. [18] and “anxiety” as used by others. This is tacitly assumed in the literature that has followed, but the basis for this assumption is not clear.

There are a number of physiological, cognitive and behavioral correlates of anxiety that could conceivably be introduced as measures of anxiety [27] if one accepts a strong association with subjective anxiety as an indication of validity. These may be more closely related to the mechanisms that underlie and drive anxiety, but may also be removed from the subjective experience that is relevant to the individual. Nevertheless, such an approach would strengthen the claim that the association between perioperative anxiety and recovery is causal and potentially amenable to intervention.

If elevated state anxiety, for example, is reliably shown to predict slower wound healing [18], then it might be hypothesized that this is due to the endocrinological and autonomic changes associated with elevated state anxiety, and their subsequent impact on the wound healing process. The prediction of surgical recovery provides a testing ground for hypotheses regarding the relationships that obtain between psychological and behavioral indices and physical health. Prediction allows for the subsequent testing of hypotheses regarding causation.

Effective and reliable prediction of surgical recovery might also provide the potential to facilitate recovery in “high-risk” surgical patients if interventions to modify the predictor variables thought to be causal were developed. Indeed, early evidence that this might be possible (e.g., Ref. [13]) has motivated much of the research that has followed. This would be of clinical benefit given that slower recovery, inactivity and so on is strongly associated with subsequent morbidity, impairment of muscle function and elevated risk of complication (e.g., deep vein thrombosis) [32]. It is important to make a distinction between clinical and statistical significance: While theoretical models require tests of statistical significance, this is only of importance in a clinical context in conjunction with evidence for the efficacy of a clinically significant effect. Elevated state anxiety might predict some aspect of surgical recovery to a statistically significant degree, but if this effect is weak (i.e., the effect size is small) then the effort and cost associated with intervention might not be justified by the beneficial impact of such an intervention. In such an instance the relationship would not be regarded as clinically significant. This would also be the case if the risk factor was not amenable to intervention.

The majority of studies that investigate the role of affect in surgical recovery use self-report measures of generic state anxiety as an index of preoperative distress. They then attempt to relate this to a constellation of postoperative factors that may be regarded as making up the global concept of postoperative distress and suffering, including state anxiety, pain, analgesia consumption, time to discharge and so on. Consequently, for any review to be able to make consistent comparisons across studies, it is important to state a particular measure of anxiety that will be used in the selection of studies. This could potentially include one of the physiological correlates of anxiety, such as salivary cortisol, or one of the several questionnaire measures of anxiety. Behavioral measures, such as information seeking or coping behavior, might also be regarded as important.

In the case of this review, only those studies that report associations between self-reported state and trait anxiety as measured by the State–Trait Anxiety Inventory (STAI) [36] and postoperative outcome are included. A large proportion of studies have used this measure of current and dispositional anxiety as both a predictor and outcome measure, and the inclusion of only those studies that use this measure will simplify the comparison of results across studies. As already mentioned, state anxiety as measured by questionnaires may reflect something quite different to the “worry” envisaged by Janis [30], and this should be borne in mind when interpreting the results of studies.

The aim of this paper, therefore, is to critically evaluate the interpretation of the findings reported in the peer-reviewed literature concerning the association of state and trait anxiety as measured by the STAI with surgical recovery and response to surgery, and to try to evaluate the validity and parsimony of these interpretations.

Section snippets

Methods

The review was based upon the Social Science Citation Index (SSCI), Science Citation Index (SCI), Medline and Psychological Abstracts (PsycInfo) databases. These were searched for studies published since 1981, the start date of the SCI and SSCI, that had the words “anxiety” and “surgical” or “surgery” or “patient” in the title, abstract or keywords. In addition, the reference lists from previous reviews (e.g., [18], [32]) were searched for additional references. Studies that were not in the

Results

The studies included form the basis of the review presented below, grouped by the type of outcome measure used.

Conclusions

This review has shown that preoperative state anxiety has been reported to be associated with postoperative mood and pain in a number of studies with some consistency, and to other recovery variables in a smaller number of studies with less consistency, with a number of studies reporting no significant associations.

All studies included in this review report linear relationships, with very few actually having included a test for curvilinear relationships, with a few exceptions (e.g., [16], [42]

References (43)

  • P Salmon et al.

    Good patients cope with their pain: postoperative analgesia and nurses' perceptions of their patients' pain

    Pain

    (1996)
  • P Salmon et al.

    A theory of postoperative fatigue: an interaction of biological, psychological, and social processes

    Pharmacol, Biochem Behav

    (1997)
  • LE Scott et al.

    Preoperative predictors of postoperative pain

    Pain

    (1983)
  • CJ Simpson et al.

    The relationship between pre-operative anxiety and post-operative delirium

    J Psychosom Res

    (1987)
  • P Taenzer et al.

    Influence of psychological factors on postoperative pain, mood and analgesic requirements

    Pain

    (1986)
  • N Timberlake et al.

    Incidence and patterns of depression following coronary artery bypass graft surgery

    J Psychosom Res

    (1997)
  • V Bachiocco et al.

    Request of analgesics in post-surgical pain. Relationships to psychological factors and pain-related variables

    Pain Clin

    (1996)
  • S Boeke et al.

    Pre-operative anxiety variables as possible predictors of post-operative stay in hospital

    Br J Clin Psychol

    (1992)
  • T Christensen et al.

    Fatigue and anxiety in surgical patients

    Acta Psychiatr Scand

    (1986)
  • J Cohen

    A power primer

    Psychol Bull

    (1992)
  • KI De Groot et al.

    Assessing short- and long-term recovery from lumbar surgery with pre-operative biographical, medical and psychological variables

    Br J Health Psychol

    (1997)
  • Cited by (193)

    • The Effect of Preoperative Nursing Visit on Anxiety and Pain Level of Patients After Surgery

      2023, Journal of Perianesthesia Nursing
      Citation Excerpt :

      In a similar study conducted with patients undergoing heart surgery, preoperative anxiety significantly increased the postoperative pain level.32 In a systematic review with surgical patients, a positive relationship was found between preoperative and postoperative pain and anxiety.33 However, in studies conducted with patients having cardiac surgery, the education given to reduce anxiety before surgery did not affect the level of postoperative pain.21,34

    • Factors associated with greater patient satisfaction in outpatient neurosurgical clinics: Recommendation for surgery, older age, cranial chief complaint, and public health insurance

      2022, Clinical Neurology and Neurosurgery
      Citation Excerpt :

      This is inconsistent with prior literature that has demonstrated that patients with either mental distress or depression before or after surgery tend to report decreased satisfaction in the clinic. [13] It is well-established that patients with psychiatric disorders tend to have increased perioperative perceptions of pain and postoperative readmission rates, complications, and emergency department visits; these outcomes are independent risk factors of poor satisfaction. [6,20] These factors lead to decreased willingness to work with physical therapy, lower work satisfaction, and longer duration of sick leave from employment. [2,6,14]

    • Preparation for Medical Interventions

      2022, Comprehensive Clinical Psychology, Second Edition
    View all citing articles on Scopus
    View full text