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

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

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

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

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

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

The depressed patient may be irritable, agitated, or quietly withdrawn. Postoperative mobilization is a challenge and impaired nutrition undermines the process of surgical repair. Treatment of depression requires supportive psychotherapy, psychopharmacological intervention, and social support. When depression is secondary to surgically correctable physical impairment, successful operative intervention is most often followed by improvement in mood and well being. For example, hysterectomy is often preceded by psychiatric morbidity, which decreases after the operation.

Anxiety may result from misconceptions about surgery, from anniversary reaction to past trauma, or from the impact of new learning or increased physical impairment on established coping skills. Those who deny their disease are especially likely to react anxiously to detailed preoperative information. Isolated phobias, such as needle phobias, claustrophobia, or pathological dread of anaesthesia are occasionally encountered, as are generalized anxiety states and multiple phobias with panic attacks.

Treatment of anxiety begins with preoperative teaching and formation of a therapeutic alliance. Some patients may derive considerable support from contact with others who have successfully completed a similar operative procedure. Such peer group support has been useful in a variety of surgical settings. Those who are unresponsive to these measures or who have chronic anxiety disorders often benefit from psychotherapy and treatment with anxiolytic agents.

Impaired cognition in patients requiring surgery is most frequently of metabolic origin and is associated with increased risk of postoperative delirium. Functionally psychotic, demented or retarded patients must be recognized, however. The Mini-Mental State test is an excellent screening tool for delirium and dementia but has a high rate of false-positive results among those with less than 9 years of education and among people aged 60 or more.

Alcoholic patients are often exquisitely sensitive to rejection and given to pathological denial. Preoperative recognition of the potential for delirium tremens and of the higher risk of postoperative delirium is important in patients with a history of alcoholism. Postoperative delirium may occur in the form of delirium tremens, as a manifestation of alcohol withdrawal, or, delirium may occur de novo in an otherwise recovered alcoholic with established sobriety.

Along with a statement of risks and benefits, the consent process is a declaration of clinical goals. A factual, caring presentation marks the beginning of a collaborative bond for patient and surgeon.

Patients must be informed of discomfort associated with the procedure and about availability of pain relief. The need for intravenous therapy, indwelling catheter, drains, and endotracheal tube should be discussed, as well as the customary length of the operation and the anticipated time for recuperation in hospital and following discharge. The surgeon must provide information about necessary postoperative care including medication, diet, activity restriction, and medical visits. The patient should know of complications, including psychological difficulties, commonly associated with the procedure, and the risk of dying. Information should be addressed in a candid but constructive fashion. A visit to areas of the hospital dedicated to postoperative care can be beneficial, as is the opportunity for contact with other patients who have had similar surgery.

The informed consent process allows the surgeon an opportunity to observe the patient's mental status. Preoccupation with excessive detail may be evidence of anxiety or paranoia. Failed comprehension may signal encephalopathy, internal distraction, or deficient intellect. Dress and deportment are a statement of self worth as well as personal management and socioeconomic status. A despondent, tearful, or lethargic manner signals depression. Attempts by the patient at good-natured evasion of a proper alcohol and drug history may be a clue to pathological denial. An ingratiating attitude coupled with criticism of former physicians is typical of paranoid individuals. Adjustment problems or evidence of greater psychopathology should be followed by formal psychiatric consultation and by social service intervention when there is a need for additional perioperative support.

The pace of medical science has made some former experimental procedures routine. New experiments with the artificial heart and transplantation of multiple organs have aroused the interest of ethicists and health policy planners. The economics of current health care has put a spotlight on quality of life aspects for all such interventions.

The selection process for emerging surgical technology is based on capacity to benefit from the procedure, degree of present need, and time of initial presentation. The need to establish a priority list among patients is a source of stress for physicians; this intensifies as patients die while waiting for treatment. Since patients with a specific medical handicap or psychosocial impairment may have differing levels of limitation, suitability for costly new procedures, such as heart transplantation, is best determined on an individual basis to avoid discrimination. Factors such as older age and prior alcoholism may not be valid reasons for excluding people who otherwise appear to have a good chance of recovery and long life.

Emphasis should be on individual concerns. Patients need to know that pain is normal and that early postoperative mobilization is healthy. The surgeon should review past difficulty with specific analgesic drugs, anaesthetic agents, or other medications essential to the operation. Patients should be encouraged to request pain medication as needed and they should be reassured about fears of addiction.

Disfigurement is a frequent source of worry but may be couched in understatement such as ‘Will I be able to wear a bikini?’ Other common worries concern sexual function, future childbearing capacity, return to active life-styles, and loss of privacy. Some may wish to maintain access to aspects of their work. Dietary considerations, visiting arrangements, health care directives, and financial issues should be discussed. A preoperative visit with a medical social worker, or dietitian may be helpful. Patients with histories of lengthy medical problems, such as those with juvenile onset diabetes, often have firm opinions about their medical needs. When they do, preoperative discussion with the nursing staff is beneficial since it helps to accommodate to specific needs. It is equally important to shape expectations and to encourage patients to modify their life-styles. Timely referral to a smoking cessation programme or substance abuse clinic may make a profound difference to postoperative outcome.

A preoperative visit by the anaesthetist has benefits compared to sedation alone. In a study of patients undergoing abdominal surgery, those who were taught about the normality of postoperative pain and encouraged to request analgesics when needed had greater postoperative comfort and used far fewer narcotics than those receiving no information about pain control. Subsequent studies have employed preoperative interventions such as support, teaching, hypnosis, and relaxation training, and have looked at varying measures of postoperative outcome. Although methodological problems exist, such as lack of ‘blind’ controls, these studies document a major reduction of time in hospital. For example, in one study the hospital stay of elderly patients undergoing repair of a fractured femur was 12 days shorter in those who received additional care by a psychiatrist compared with a similar group treated a year earlier without psychiatric support.

Patients undergoing surgical procedures benefit from information that fosters healthy expectations and from behavioural or cognitive techniques that provide effective coping strategies and an enhanced sense of control. The challenge is to refine these interventions in a manner that allows for differences in individual coping style, variation in operative requirements, and nature of the relationship between the patient and members of the surgical team.

Some researchers have attempted to modify the risk of postoperative delirium. Supportive preoperative visits by a psychiatrist were shown in two studies to reduce the incidence of delirium following cardiac surgery. In a third study, preoperative psychiatric support combined with autohypnosis training failed to produce a statistically significant reduction in postcardiotomy delirium relative to controls with routine care. However, the number of patients who became delirious was insufficient to provide a conclusive result. In a more recent study 64 cardiac surgery patients informed by a nurse investigator of the possibility for unusual postoperative experiences were better able to cope with changes in cognition or perception.

Preoperative participation of a psychiatrist may be especially helpful in high risk procedures and when there is a critical demand for patient self-monitoring and compliance. Whenever the surgeon suspects significant psychopathology, or when there is a prior history of postoperative psychiatric difficulty or past medical non-compliance, a psychiatrist should be consulted.

When a personality problem is identified, collaboration among primary physician, psychiatrist, and surgeon is necessary. Consistency is essential. The marginally adaptive patient should be enlisted in a specific care plan with a minimum of ambiguity. Good communication among caregivers helps with the demanding dependency of such patients and the emotions they may arouse. Paranoid and obsessive individuals manage best when one member of the team is designated as doctor in charge. The designated physician is ideally one who can relate to the patient and who can expend the time for repeated questions and detailed review of the care plan. At times one can advantageously enlist an interested family member who is a reassuring influence.

If the patient is depressed, psychiatric help should be requested. It is often advisable to postpone the operation and to treat the depressive disorder. However, if a surgically correctable condition is strongly contributory to the mood disorder, there is little benefit in delay. In other instances the surgery may be urgent or the mood disorder intractable. Appropriate antidepressant medication should be given through the first preoperative day, and resumed postoperatively as soon as the patient can safely take sips by mouth. There are isolated reports of adverse interaction between tricyclics and anaesthetic agents, but the morbidity of recurrent depression carries a greater risk. Because combined use of halothane and tricyclic antidepressants may increase catecholamine levels, sympathomimetic agents should be used with caution in such situations.

Since antidepressants are metabolized in the liver, careful dosing and measurement of serum levels of the drug are required in patients with abnormal liver function. Imipramine is available for parenteral administration. Fluoxetine should be used with attention to its long half-life and with knowledge that it may increase levels of some other drugs. In all instances the anaesthetist and surgeon should be informed of medication requirements. Although there has been some controversy about preoperative use of monoamine oxidase inhibitors, they can be administered safely. Numerous patients have successfully undergone surgery and reported their prior monoamine oxidase inhibitor treatment after the operation.

Monoamine oxidase inhibitors interfere with the breakdown of central nervous system depressants. Potentially fatal adverse reactions are known to occur with meperidine, atropine, or other anticholinergic agents and with barbiturates. However morphine, oxycodone, and codeine can be used postoperatively for analgesia. Because monoamine oxidase inhibitors increase the level of catecholamines in peripheral nerve endings and potentiate the effect of sympathomimetic agents, hypertensive crisis may result from the use of pressors and the diet must be low in tyramine (which is especially high in aged cheese). Hypertensive crisis may also occur when monoamine oxidase inhibitors are combined with other classes of antidepressants such as tricyclics, serotonin uptake inhibitors (e.g. fluoxetine), or bupropion.

Anxiety may be acute in onset and related to fear of surgery, or it may represent a chronic emotional disorder or personality trait. Some patients may not acknowledge distress, or may do so with difficulty because of social custom or personality style. It is best to ask the patient about special concerns. Some patients dread specific types of intervention, such as endotracheal tube placement. Since the average patient knows little about anatomy, much can be learned by eliciting misconceptions. It is helpful to know how patients have coped with prior surgery and with other stressful events. In a recent study of 1420 patients undergoing surgery at University of Iowa Hospital and Clinics, the best predictor of postoperative psychological distress was found to be preoperative psychological distress.

Anxiety may be increased by an over-zealous account of the planned procedure. However, an excessively paternal approach is insufficient to allow for the education and discussion necessary for the patient to make a judgement about the procedure and postoperative outcome.

Minor tranquillizers in the benzodiazepine class are a useful adjunct to psychological support. Shorter acting agents (for example alprazolam, lorazepam, oxazepam) are preferable for use in elderly and debilitated patients. Oxazepam and diphenhydramine are most easily metabolized in the liver and are the anxiolytic and sedative hypnotic agents of choice in patients with impaired hepatic function. The prescribing physician should be aware of the half-life and the potency of psychotropic agents and of the patient's past psychopharmacological history. Patients with debilitating anxiety should be referred for psychiatric assessment.

Panic disorder, with or without agoraphobia, responds effectively to alprazolam, imipramine, or monoamine oxidase inhibitors. Ideally, monoamine oxidase inhibitors are best avoided or gradually discontinued 2 weeks prior to the operation. However, they can be continued when there is insufficient time for withdrawal, when anxiety symptoms are severe, or if alternative agents have proved ineffectual. Although imipramine has a slower onset of response than does alprazolam, it can be effectively instituted when surgery is elective, and it is available for parenteral administration. Sudden cessation following chronic administration of anxiolytics is often associated with rebound anxiety as well as by withdrawal symptoms. When oral medication cannot be administered a parenterally administered benzodiazepine can be used to provide sedation. Intravenous lorazepam and oral alprazolam are equipotential for the treatment of generalized anxiety. Lorazepam is also available for sublingual administration.

For patients with simple phobias a combination of behaviour therapy and anxiolytic agents can be helpful.

Hackett and Weisman give the example of a farmer whose certainty of postoperative fatality presaged his cardiovascular death 3 days after subtotal gastrectomy. These patients are noteworthy for the absence of anxiety or depression. When such a conviction is evident surgery is best avoided, if possible.

Psychotic patients often accommodate satisfactorily to the structure of a busy surgical service. Actively suicidal individuals require continuous close supervision by special duty nurses. Antipsychotic agents should be administered in full dose throughout the pre- and postoperative period. Aliphatic substituted phenothiazines (e.g. chlorpromazine,) are more likely to be associated with hypotension than the high potency neuroleptics (e.g. haloperidol). Patients should be managed in a simple direct manner aided, where possible, by supportive family members. The patient should be sheltered from stressful interpersonal relations. Competency should be established or appropriate guardianship arranged in consultation with hospital legal advisers.

Organic central nervous system disorders should be addressed with an appropriate search for underlying metabolic, infectious, and neurological causes. An unexpected rise in serum ammonia is sometimes evident in patients in whom other liver function tests are relatively mildly impaired. Treatment depends on the cause. Standard techniques should be employed, with reference to clock, calendar, availability of special personal effects, and gentle review of the daily routine. Excessive sedation should be avoided. Supportive nursing techniques and family visits often reduce agitation; low doses of haloperidol are also helpful. Caution is necessary when drugs are administered to patients with hepatic dysfunction. Diphenhydramine is a gentle treatment for insomnia. Benzodiazepines may cause confusion in the elderly, but some do benefit from low doses of short-acting agents.

Supportive care should be coupled with a search for specific aetiology. Anaesthetic agents or intolerance to specific analgesic agents or their metabolites (normeperidine delirium is an example) should be suspect as well as idiosyncratic reaction or toxicity to other medication. Depression of central nervous system function may be evidence of postoperative cardiopulmonary or infectious complication or of endocrinopathy. Postoperative delirium requires energetic treatment when agitation, mood lability, hallucinations, and delusions pose a threat to medical management. When delirium occurs in the intensive care unit, pharmacological intervention may include intravenous morphine, haloperidol, or lorazepam. A psychiatric consultant should visit daily, when possible, until the patient's sensorium is clear. Return of normal consciousness may be associated with feelings of shame or guilt among patients who retain memory for delusional material or perceptual aberrations. It is therefore wise to ‘debrief’ patients as cognition returns to baseline and to explain events in a supportive fashion. Patients are comforted to know that delirium does not represent a weakness of character or spirit but is rather a product of understandable biological events and environmental stress.

Although delirium was once a frequent complication of cardiovascular surgery, its incidence following coronary artery bypass grafting and cardiotomy has declined with improvement in surgical technology. The risk of delirium is increased with increasing age and lessened tolerance to decreased perfusion pressure, severity of physical illness, history of myocardial infarction, preoperative organic brain syndrome, duration of extracorporeal circulation, sustained mean arterial pressure under 50 mmHg during bypass, and postoperative hypotension requiring pressure pressors or an intra-aortic balloon pump. In a study of 23 patients undergoing aortic valve replacement, a previously unreported association was found between low preoperative cholesterol level, which was attributed to a probable catabolic state, and to postoperative psychopathology.

Steroid-induced psychosis following organ transplantation has become less frequent. Cyclosporin encephalopathy has been most frequent among liver transplant recipients and is characteristically associated with other signs of toxicity such as tremor, impaired renal function, and elevated blood pressure.

Delirium may occur secondary to alcohol withdrawal in current drinkers or in the recovered alcoholic in the absence of recent alcohol abuse. Another cause of delirium is acute sensory deprivation. Complex partial seizures should also be considered in the differential diagnosis.

The one reported drink per night may be from a bottomless glass. Preoperative detoxification is best whenever possible; however, prevention of withdrawal is a primary goal. Supplemental nutritional support should be instituted and full doses of chlordiazepoxide should be administered every 4 to 6 h in patients suspected of alcoholic withdrawal. Intravenous alcohol is an alternative. Patients with addictive disorders may provoke an angry response from otherwise caring physicians. Participation of a psychiatric consultant is desirable.

Recovered alcoholics may feel vulnerable and are often apprehensive about a stress-related relapse. Patients who are attending Alcoholics Anonymous may be especially vigilant about perioperative medications and the potential euphoriant effects of narcotic analgesics. When psychotropic agents are advisable, pain should be taken to point out the medical indication. Some hospitals sponsor weekly Alcoholics Anonymous meetings. Supportive visits from ‘safe’ companions may reduce perioperative stress.

Treatment is similar to that of the alcoholic patient. Barbiturate requirements for patients addicted to depressants are established with a test dose of phenobarbital. Narcotic addicts who require surgery should not undergo drug withdrawal until after the operation. Pain relieving medication should be given in addition to that required for daily maintenance. After surgery, drug withdrawal can be approached in a standard method.

Inadequate analgesia is the most likely cause of persistent postoperative pain. Tolerance may occur among those receiving frequent daily analgesics over a period of weeks, but addiction is rare. Depression, anxiety, and tolerance to opioids increase postoperative analgesic needs and should be considered whenever pain persists in the absence of postoperative complications. Antidepressants of traditional narcotic adjuvants can be highly beneficial. Psychiatric consultants who are familiar with relaxation techniques and hypnosis can often provide symptom relief.

Blacher reported six patients in whom postoperative symptoms of irritability, preoccupation with death, and nightmares were associated with expressed doubts about their sanity. All had experienced wakefulness at some point during their operation, unknown to the anaesthesiologist, and all benefited once a link was established between that event and their postoperative anxiety. One study reported a 1 per cent incidence of awareness among 490 patients undergoing various operative procedures who were interviewed by the same anaesthesiologist in each of the first three postoperative days. Studies of awareness, memory, and hearing among patients who were apparently unconscious under anaesthesia have led to surgeons being cautioned to avoid making disparaging or frightening remarks.

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