Abstract
Background
Surgery may possibly be undermined by psychologic, psychiatric and psychosomatic problems, as long as these problems interfere with a patient’s capacity to cope with surgery adaptively. Recent studies have shown that interpersonal trauma, e.g. abuse or neglect, and its correlates are involved in the adaptation to surgery. This observation is heuristically coherent, given the respective traumatization is an interpersonal event occurring in a relationship. Notably, surgery inevitably leads to the violation of physical boundaries within a doctor-patient relationship. Based on the principles of psycho-traumatologic thinking, such a constellation is deemed qualified to activate posttraumatic symptoms in the traumatized.
Method
The present topical review summarizes the respective findings which point to a subgroup of patients undergoing surgery, in whom difficulty bearing tension and confiding in others may cause adaptive problems relevant to surgery. Although this theorizing is empirically substantiated primarily with respect to total knee arthroplasty (TKA), a pubmed-research reveals psychopathologic distress to occur prior to surgery beyond TKA. Likewise, posttraumatic distress occurs in large numbers in the context of several operations, including cardiac, cancer and hernia surgery.
Conclusion
Aspects of psychological trauma may be linked to the outcomes of general surgery, as well, e.g. biliary, hernia or appendix surgery. The mechanisms possibly involved in this process are outlined in terms of a hierarchical organization of specific anxiety and negative affect as well as in terms of psychodynamics which imply the unconscious action of psychologic defenses at their core.
Implications
Not least, we encourage the screening for trauma and its correlates including defenses prior to general surgery in order to identify surgical candidates at risk of, e.g. chronic postoperative pain, before the operation.
Background
The prospect of surgery: an imposition for most, if not all patients
Surgical procedures represent a remarkable stressor and a far-reaching challenge for the individual’s coping resources [1]. Reasons for this are evident not only as far as nocebo reactions regarding the risks inherent to surgery, to which patients consent prior to surgery, are concerned, but also with respect to the primary disease meant to be treated by the operation. The latter statement may be especially valid with regards to aggressive disease such as cancer, and also with regard to chronic disease such as osteaoarthritis, but the capacity of pending surgery to elicitate a fearful and negative affective anticipation, is nevertheless regarded as the rule, not the exception [1], [2]. This dictum is especially applicable, if the operation coincides with an accentuated emotional strain conferred by the illness and/or the pending operation [2]. Yet, recent findings and theorizing propose a different pathway to postoperative maladaptation which results from individual psychic and psychosomatic predispositions such as a preponderance of negative affect or the vulnerability for the activation of trauma-related mnemonic, mental or psychic contents [3]. As far as such experience is concerned, psycho-traumatology has coined the paradigm that trauma, such as abuse or neglect, is capable of inducing specific syndromic sequelae, which may at any time be activated by such experience which resembles the prior traumatizing event [4]. In this context, a trauma is understood as an adverse experience straining the individual’s adaptive resources to the effect of their breakdown due to excessive demand [5]. Given their developmental impact [6], [7], especially childhood traumas may be linked to insufficient coping in adulthood as a consequence of posttraumatic symptomatology. Moreover, it is worthwhile in this realm to consider the association between childhood trauma and psychosomatic as well as psychiatric disease [8], including personality disorders [9], since these conditions might harbor a heightened risk of maladaptation in general, and specifically with regards to surgery [10]. In order to shortly review the clinical appearance of such dispositions, the following paragraph shall summarize some essentials of the psycho-traumatologic nosology.
Entities of a posttraumatic character
Posttraumatic stress disorder (PTSD) is, by name, the most obvious posttraumatic condition. It unites the symptoms of re-experiencing the trauma (or aspects thereof), avoidance of trauma-related stimuli and arousal (i.e. psychophysical tension) under the umbrella of definition termed PTSD [11]. Apart from PTSD, dissociation or dissociative symptomatology is regarded as a response to prior trauma [4], whereby dissociation is defined as the disintegration of the usually integrated functions of consciousness, perception, memory and identity [11]. Dissociative disorders such as dissociative amnesia or depersonalization/derealisation disorder [11] aside, dissociation often occurs as an accessory symptom in the frame of other psychiatric disorders such as anxiety disorders [12], depression [13], somatization [14], and severe mental illness [15], [16]. Dissociation is, albeit not beyond controversy [17], believed to be caused by trauma and to serve the splitting-off of feared mental, physical, emotional and interpersonal experience from the stream of consciousness [4]. Thus, the concept of dissociation posits a protective function of dissociation, in analogy with the understanding of psychoanalytic defense mechanisms [18]. Defenses, in general, are viewed as mental action enabling us to cope with frustration, to deal with conflict and to tolerate unbearable affects or emotions of the kind, which is encountered during interpersonal traumatization. Dissociative symptoms are associated with chronic pain [19], however, the interpretation of this association is two-fold: dissociation is either viewed as inhibiting, or amplifying the perception of pain [20], [14]. In parallel with the assumption that different patterns of interaction are involved in the interplay between pain and dissociation some researchers view dissociation as heterogenous [21], or bipartite in nature. Notably, the bipartite concept of dissociation is in sharp contrast to the traditional concept of a dissociative continuum, which Holmes et al. [22] have replaced by suggesting the two distinguishable classes of dissociation referred to as detachment- and compartmentalization-dissociation [22]. The former indicates a sense of separation from self, others and the environment (derealisation/depersonalization), whereas the latter points to a temporary loss of deliberate control resulting in the mal-integration of distinct systems, such as sensible or motor functions, and, importantly, memory (including autobiographic). Such mal-integration may present clinically as dissociative amnesia, fragmented identity or conversion disorder [23]. Those alleged classes of dissociative symptomatology, detachment- and compartmentalization-dissociation, are different enough to potentially diverge also as regards each of their effects on coping with illness. Such has been demonstrated with respect to schizophrenia, which is a psychiatric disease negatively associated with pain [24]. Precisely, detachment- and compartmentalization-dissociation have been found associated with the bipartite symptoms of schizophrenia, i.e. positive schizophrenic symptoms were associated with detachment- dissociation, and negative schizophrenic symptomatology with compartmentalization- dissociation [25]. Likewise, detachment-dissociation, but not compartmentalization-dissociation, was linked to pain-catastrophizing and chronic pain after total knee arthroplasty (TKA) for osteoarthritis of the knee by another study [3]. To continue with posttraumatic symptomatology, the concept of complex PTSD combines PTSD, dissociation and alterations of personal values or relational tolerance and posits that this syndrome be reflective of a complex trauma. The latter is understood as the combined and/or repetitive and/or continuous influence of abuse and neglect, predominantly in childhood [26]. The coincidence, or rather the clinical overlap, between cPTSD and borderline personality is reported to be as high as 80% [27], casting doubt on the specificity of cPTSD. Meanwhile, one explanation for this clinical confluence of the two constructs could be the high rates of traumatization, and esp. childhood traumatization [28] reported regarding borderline personality, suggesting BPD to be no less posttraumatic than cPTSD. Borderline personality is characterized by recurrent relational problems and rapid, as well as frequent mood changes [11]. Furthermore, it is associated with an increased health care utilization which [29], at least partly, results from the also comparatively higher prevalence of pain disorders in borderline personality [30]. After all, an early interpersonal trauma impedes the individual development and maturing of the psyche possibly leading to the inherence of psychic, emotional and interpersonal problems which make up the profile of BPD [31]. Through the lifespan [32], however, BPD tends to comprise an increasing propensity for chronic pain which may possibly manifest as postoperative pain on the occasion of any major surgery.
Method
We searched Medline (1966–2020), as of May, 2020. Our search strategy included the following terms mapped to the appropriate MeSH subject headings: (“childhood trauma” OR “PTSD” OR “dissociation” OR “amnesia” OR “derealisation” OR “depersonalisation”) AND (“surgery” OR “postoperative maladaptation” OR “perioperative maladaptation” OR “depression and anxiety” OR “posttraumatic distress” OR “perioperative negative affectivity”). The following terms were also included: (“CBAG” OR “hernia” OR “general surgery” OR “appendectomy” OR “cholecystectomy” OR “cancer surgery” OR “arthroplasty (of the knee)”).
Pain and posttraumatic conditions
The clinical wisdom that self-harm is pathognomonic for BPD, yet not painful for its perpetrators, is a very strong indication of an altered central processing of pain within the frame of BPD [33]. Accordingly, Sansone and Sansone [10] have introduced the pain paradox of BPD by which they posit that the immunization against acute pain comes at the cost of a heightened vulnerability for chronic pain. The pain paradox has recently been corroborated with respect to TKA, where borderline features predicted lower levels of acute (after <3 months), but, paradoxically, also higher levels of chronic pain (after 12 months) [34], [35]. Interestingly, a similar typological pattern of a specific interaction with pain has also been formulated with respect to PTSD, in which Defrin et al. [36] view dissociation as an “analgetic” agent of the psyche. Although Defrin et al. [36] did not investigate the course of the pain perception, their results show dissociation to cause a higher pain threshold, and, contrarily, anxiety sensitivity to lower it. All in all, those findings indicate a complex, possibly bi-phasic and apparently typological association between posttraumatic conditions and pain. Such a pattern may result from complex trauma interfering with the individual psychic maturation, likely affecting the psycho-physiologic interface, as well. This notion on maturity is based on the assumption that the maturation of the personality and its underlying psychic structures manifests as the competence to handle tension more adaptively, whereas less maturity is said to give rise to the propulsion of the surplus of excitement into the body, a process referred to as acting-in [37]. Regarding dissociation, its relationship with pain does not appear to be clear-cut and consistent, either. Rather, as already mentioned above [20], [21], it may be structured by different classes of dissociative symptoms possibly exerting unequal effects on the perception of pain [22].
The psyche and the arts of surgery: a hypothesis derived from TKA
Surgery involves the violation of physical and personal boundaries within an interpersonal relationship between the patient and the doctor. This constellation may be processed as a potential trigger of posttraumatic symptomatology by the traumatized, according to the psychotraumatologic theory (e.g. 4), and therefore promote further emotional suffering [38]. To make matters worse, orthopedic surgery seems to be compromised by psychopathology, especially negative affectivity, as can be derived from findings on arthroplasty, in particular of the knee [39]. Osteoarthritis (OA) of the knee likely poses specific challenges for the individual’s coping resources, given that knee OA causes functional problems as a result of malposition due to fear of pain and re-injury [40], as well as dependence on help with personal care and routine needs [41] and a faster decline in gait speed resulting in poor participation, compared to OA of the hip [42]. Hence, the psychological strain on the respective patients may be more pronounced than in other indications, although not necessarily outstraining those more acute ones which exert an implicit threat to life. In addition, psychologic peculiarities appear to be inherent to the primary disorder treated by TKA, i.e. OA itself. OA is indeed associated with negative affect [43], borderline personality [34], [44] and childhood trauma [45]. Moreover, David et al. [46] reported the comorbidity of OA with PTSD as high as 50%, compared to ca. 17% in CBAG [47]. It comes as no surprise, therefore, that borderline features and posttraumatic symptomatology proved predictive of the postoperative algofunction [3], [34] after arthroplasty for OA of the knee. Apart from such determinants of personality functioning, mainly anxiety, especially content-related anxiety, and depression have been linked to the outcomes of TKA [48], [49], which fails to satisfy the patients in no less than 25% of the operations done, albeit in the absence of an identifiable medical cause for such a complicated postoperative course [50]. Yet, accidentally or not, this rate of postoperative complications in the form of pain and malfunction of the knee, equals that of childhood abuse in the general population [51]. Given the apparent involvement of the individual psychic “apparatus” and its possible individual characteristic of predominantly producing negative affectivity, the question arises as to how personality features and psychopathologic symptoms may co-determine the success or failure of the adaptation to surgery. This is why a recent study has made the suggestion to apply the hierarchical model of negative affect and content-related anxiety to the realm of postoperative maladaptation [3]. The hierarchical model of negative affect and content-related anxiety [52], [53] posits negative affect and pain-related anxieties to be nested, and the latter to increase due to their being triggered by the former. Indeed, a postoperative increase in psychopathology signifies less satisfaction with the operation, as far as TKA is concerned [54]. The hierarchical model has been extended to include detachment-dissociation (e.g. derealisation) as a variant of negative affect, which one study found to be nested not only with emotional lability, but also with pain-related anxiety [3]. Precisely, absorptive detachment (a self-absorbed state of blurry perception) emerged as an inductor of pain-catastrophizing in that study, thus demonstrating a hierarchical relation-ship between (higher-order) dissociation and content-related anxieties. At this point, a functional link between trauma, posttraumatic symptoms and pain appears to be concrete and plausible. Another instance which makes psychodynamic theorizing tangible in a surgical setting, is presented by a study, which showed borderline personality organization to entail a paradox pain perception with regards to TKA [3]. In exact terms, identity confusion predicted the postoperative levels of pain after 8 weeks by a negative exponent B, suggesting less pain, whereas the opposite occurred after one year, when primitive defenses positively predicted more intense pain at that point in time. Identity confusion might therefore de-focus and numb not only psychic contents such as emotions, but have this very effect also on the perception of physical pain. Although this process likely serves the neutralization of inner tensity, defenses in the narrower sense, such as projection or splitting, appear to only come into play at a later stage when they apparently reverse the numbing of the pain. This finding points to a higher-order function of defenses in analogy with dissociative defenses functioning as a trigger of negative affect, pain-related anxiety and, ultimately, a maximizing pain focus. In a nutshell, personality factors, which correspond to the experience of interpersonal trauma that has led to, e.g. a personality disorder or dissociative symptoms [4], [28], determine the individual’s prevailing affectivity, which in turn controls pain-related anxieties and thus adds to the experience of pain on an emotional base. Such a cascade of psychologic dispositions and their effects could not only explain the covariation of its elements, negative affect (including dissociation) and pain-related anxieties, but also their association with prior trauma and personality pathology. Along these lines, understanding this association is a prerequisite for the establishment of specific therapeutic endeavors which could then serve the secondary prevention after surgery.
The hypothesized dispositional maladaptation and general surgery
This assumption of psychosomatic, psychosocial and otherwise psychic complications in general surgery is encouraged by findings which show, on the one hand, postoperative maladaptation, and, on the other, its nestedness with psychopathology (e.g. negative affect, [47]). That aside, the gap between the report of psychopathologic symptoms, the actual experience of pain and the pain focus, respectively, must be bridged by suitable psychologic models of pain in order to understand the character and direction of the interaction between the painful result and the psychic factors enhancing it. A psychosomatic approach aims at the integration of both sides of this coin, and the hierarchical model of negative affect and pain-related anxieties [52] offers a context to which personality and posttraumatic disorders can be connected sensibly.
With respect to (chronic) postoperative pain [55], which is defined as pain occuring or increasing after the operation, the literature reveals 30–50% of patients undergoing cholecystectomy to complain about such pain [55]. Regarding hernia surgery, the respective figures are 10–43% [56], and not only do they correspond to preoperative pain levels, but also to measures of negative affect and pain-related anxiety [55], [56]. On this note, Simanski et al. [57], investigating a mixed sample of surgical patients found chronic postsurgical pain in 14.8% of whom 28% were representative of general surgery. Moreover, this study also elucidated an association between postsurgical pain and current unemployment which disproportionally affects people diagnosed with personality disorders [58]. Along these lines, Hoofwijk [59], investigating the outcomes of outpatient surgery, found chronic postsurgical pain to be common, with fear, lack of optimism and low quality of life being risk factors for poor overall recovery. Likewise, Powell [60] reported low optimism and low perceived control to contribute to the risk of postoperative maladaptation. Hence, two out of three prerequisites for a psychologic pathway to maladaptation seem to be met in the field of general surgery, and several studies have suggested the involvement of higher-order factors representing supra-ordinate functions of the personality as a possibility. This theorizing is based on the assumption that such higher-order factors exert control over the prevailing affectivity and, thus, ultimately, the pain-focus. The hierarchical model of pain-related anxiety and negative affect provides a sound theory to be tested in this realm, as well. However, posttraumatic distress and correlates of trauma have not yet been specifically investigated as a potential pre- or postoperative factor to complicate general surgery, with the exception of one study [61], which found PTSD in 32% of a sample with incisional hernia.
Surgery can be (re-) traumatizing
Likewise, there are several indications of a traumatizing potential which surgery apparently sometimes unfolds in its aftermath. Some indications, such as coronary artery bypass grafting (CABG) seem to confer a special risk of postoperative PTSD with anxiety, pain and respiratory distress being the respective predictors [62], [63]. The prevalence of PTSD in surgical patients is the topic of only a paucity of studies, which indicate the rates of postoperative PTSD to vary from 8–20% in cardiac surgery, from 8–34% in gynecologic cancer surgery and from 8–51% in traumatic surgery [63]. However, little is known about the impact of PTSD and other correlates of trauma on surgical outcomes. Very interestingly, the perioperative administration of benzodiazepines is another modulator of the risk of surgery-related PTSD [64]. Since benzodiazepines are anxiolytics, their perioperative prescription offers a clinical hint on the relevance of negative affect in this phase of the treatment. Moreover, depression is another frequent reaction to CABG [65]. As with other stressors [66], [67], the extent to which an individual is vulnerable for the labilization through this stressor, may depend on the prior experience of a traumatic event. Accordingly, pre-operative posttraumatic distress is associated with postoperative posttraumatic distress in patients with spine surgery [68] as a consequence of the mediation through peri-operative dissociation. In addition, as far as posttraumatic distress related to intense medical treatments is concerned, its risk factors are held similar to risk factors for PTSD in general, including prior trauma and posttraumatic distress [69]. Thus, there may be a common predisposition for emotional distress in the face of not only surgical, but also of non-surgical circumstances. However, fear in the perioperative setting may be specifically driven by disease factors, affected organs and specific disease characteristics, where the heart is linked to fear in terms of a neurotic misalignment, and the acuteness, as well as the threatening potential of a disorder, represent further challenges for the process of coping with the perioperative experience.
Research on the psychosomatic implications of surgery is not abundant and focused on specific indications, such as TKA, CABG and gynecologic cancer. With respect to TKA, postoperative posttraumatic distress has, in addition, been shown to be linked to lower levels of postoperative pain three months postoperative [70]. One may interpret this finding as a reflection of the paradox findings on the relationship between postoperative pain and BPD, which is apparently characterized by initial numbing of acute pain and subsequent amplification of chronic pain.
Surgical interventions appear to be at risk of being counteracted by psychic processes within the patient, which may apparently thwart the surgeon’s efforts effectively [1]. Those psychic processes pertain to biographic burdens such as childhood, as well as adult trauma, PTSD and other posttraumatic symptomatology. While a depressed mood and feelings of anxiety are likely normal reactions to the imminence of surgery [1], there may be a subgroup of patients undergoing surgery who generate such negative affectivity systematically and based on their psychic structure, presenting as, e.g. personality disorder. Among the personality disorders, borderline personality is the most reasonable candidate to examine, because it is often associated with prior trauma and, as a result of interpersonal trauma, also with complicated attachment [71]. The proneness to chronic pain typical of borderline personality is believed to emerge from the corresponding mechanisms of self-regulation, esp. as regards the handling of tension [32], which is said to include pain and pain-behavior [72]. On the contrary, the more acute the sensation of pain, the more it is apparently inhibited by the dissociative nature of identity confusion [73]. With respect to the activation of this cascade, the belief is that the imminence of a factual though not malicious interpersonal encounter, nevertheless heading for the violation of the bodily integrity on the part of the emotionally instable patient, may re-activate trauma-related symptoms of cognitive, emotional, as well as interpersonal kinds [34]. Given the association of various surgical procedures with postoperative posttraumatic distress or even PTSD [62] the preoperative existence of specific associations between posttraumatic symptomatology and pain-catastrophizing [34] points to the possibility that the vulnerability for posttraumatic distress is providing an occasion for this distress to manifest itself, as the operation impends. Further research suggests this diathesis to function on the grounds of a synergism between dissociative, negative affective and pain-related emotional responses [3], [34]. Moreover, as prior research has shown [1], [48], [52], the latter results in maximized attention drawn to the sensation of pain.
Furthermore, by virtue of psychological defenses, the postoperative phase may be experienced under the influence of a bias which fosters the belief that it is one’s exclusive fate to attract man-made complications not only in social, but also in medical contexts [74]. Luckily for the distressed surgical patient, a longer hospitalization is the correlate of peri-operative kinesiophobia [75] which likely is a correlate of further psychothologic distress [76] including posttraumatic. The hospital implicitly offers a caring and attentive function to the patient, thus meeting her or his unconscious needs which may be especially yearning under the impression of the perioperative phase. At last [75], those patients may end up satisfied with their operation, although their way to satisfying recovery has turned out to be longer and more burdensome than other patients’ as a result of their own inner burdensome psychological dispositions. Social disadvantages are predictors of surgical outcomes, as well, and are, at the same time, linked to personality functioning, too [77], [78]. As a result, (psycho-)social hardship may not only be linked to postoperative pain levels [78], but also lead to unconscious interpersonal approaches serving the mobilization of care and devotion. The present review underscores the significance of the patient’s psychosomatic, psychosocial as well as psychodynamic facets for the peri- and postoperative course and her or his proneness to complication, respectively. As a consequence, the present topical review encourages research aiming at the profound understanding of psychological mechanisms and reasons of surgery-related adaptive misfortune. Since dissociative symptoms may, moreover, be involved in suggestibility [17] which possibly increases an individual’s propensity for nocebo-reactions [79], nocebo reactions themselves might be part of the posttraumatic spectrum of psychophysical distress, too. The trauma- and the hierarchical models which posit re-activation of trauma-related pathology by cues reminiscent of the initial trauma and the hierarchical organization of negative affective, posttraumatic, as well as pain-related psychopathology, together lend an expedient explanation to the clinical association between personality characteristics [43], psychopathology, and physical outcomes. For the sake of clinical convenience, its elements are easily screened for, e.g. using the childhood trauma screener [80] or short versions of measures of posttraumatic and pain-related psychopathology. Moreover, as Cremeans-Smith et al. [81] suggest, basic clinical information may help identify patients at risk for negative surgical outcomes, such as female gender, a record of depression and the preoperative heart rate all of which those authors regard as surgery-related posttraumatic risk factors. Apart from diagnosing potential adaptive risks, it is an emerging necessity to develop adequate therapeutic strategies, which are feasible also in a perioperative medical setting. Comparable to contemporary proceedings in oncology, a regular psychiatric screening for trauma and its correlates, as well as low-threshold psychosocial support on indication or demand, could be a reasonable complement to the surgical routine, since they would implement measures of secondary prevention already peri-operatively.
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Research funding: No funding took place with respect to this submission.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Competing interests: All authors report no conflict of interest.
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Informed consent: Not applicable in the absence of empirical data.
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Ethical approval: Not applicable in the absence of empirical data.
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