Anxiety-depressive disorders in women under
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Anxiety-depressive disorders in women under
●●JOURNAL OF HEALTH, NURSING RESCUE 2013 (3) (8-12) ● ● JOURNAL JOURNAL OF PUBLIC OFPUBLIC PUBLIC HEALTH, HEALTH, NURSING NURSING ANDAND MEDICAL ANDMEDICAL MEDICAL RESCUE RESCUE ● No.3/2013 ● No.3/2013 ●● 8 Anxiety-depressive disorders in women undergoing surgery for gynaecological diseases (Zaburzenia lękowo-depresyjne u kobiet leczonych operacyjnie z powodu chorób narządu rodnego) M Lewicka 1, A,B,F M Sulima 1,C,D,E Author Affiliations: Abstract – Health problems of women treated for gynaecological diseases as well as the need for hospitalization in the department of gynaecology are a heavy mental burden for a patient. Anxiety and depression are psychological factors that determine the reaction of a patient’s system to gynaecological surgical trauma. How well the patient can deal with negative emotional changes during the perioperative period depends on the patient's personal resources as well as the support provided by medical staff and relatives. Higher intensity of anxiety-depressive reactions before and after the surgery may surpass a woman’s capacity to adapt, thereby introducing complications to the treatment and convalescence. Medical personnel should pay special attention to patients who experience negative emotions in the perioperative period. Key words - anxiety, depression, surgery, gynaecology. Streszczenie – Problemy zdrowotne kobiet leczonych z powodu chorób narządu rodnego, oraz konieczność hospitalizacji w oddziale ginekologii stanowią dla pacjentki duże obciążenie psychiczne. Lęk i depresja są czynnikami psychologicznymi kształtującymi reakcję ustroju kobiety chorej ginekologicznie na uraz chirurgiczny. Możliwość radzenia sobie z negatywnymi zmianami emocjonalnymi w okresie okołooperacyjnym zależy od zasobów osobistych pacjentki oraz wsparcia udzielanego przez personel medyczny i osoby bliskie. Duże nasilenie reakcji lękowo–depresyjnych w okresie przed i pooperacyjnym, przekraczające możliwości adaptacyjne kobiety, może przyczynić się do komplikacji w przebiegu leczenia i rekonwalescencji. Personel medyczny powinien zwrócić szczególną uwagę na pacjentki, u których występują negatywne emocje w okresie okołooperacyjnym. Słowa kluczowe - lęk, depresja, leczenie operacyjne, ginekologia. 1.Department of Midwifery, Gynaecology and Gynaecological Nursing; Faculty of Nursing and Health Sciences, Medical University of Lublin Authors’ contributions to the article: A. The idea and the planning of the study B. Gathering and listing data C. The data analysis and interpretation D. Writing the article E. Critical review of the article F. Final approval of the article Correspondence to: Dr Magdalena Lewicka Department of Midwifery, Gynaecology and Gynaecological Nursing; Faculty of Nursing and Health Sciences, Medical University of Lublin, Chodźki 6 Str., PL-20-093 Lublin, Poland, e-mail: [email protected] I. INTRODUCTION ealth problems of women treated for gynaecological diseases as well as the need for hospitalization in the department of gynaecology are a heavy mental burden for a patient. The impending surgery is usually perceived as a threat, which may be reflected in emotional changes such as increased anxiety or intensification of depressive symptoms [1,2]. The purpose of the paper is to discuss mixed anxiety-depressive disorders of women undergoing surgeries for gynaecological diseases. H ●●JOURNAL (3) ● JOURNALOF OFPUBLIC PUBLICHEALTH, HEALTH,NURSING NURSINGAND ANDMEDICAL MEDICALRESCUE RESCUE2013 ● No.3/2013 II. THE ESSENCE OF ANXIETY AND DEPRESSION IN THE CONTEXT OF ILLNESS Anxiety has been present in human life since its very beginning. It is a psychophysiological state characterized by feeling insecure and helpless and accompanied by specific somatic symptoms [3,4]. Most authors are in agreement that anxiety should be considered a negative emotion and a peculiar mental reaction to internal or external stimuli [5-7]. Anxiety is present at the subsequent stages of an illness, usually reflecting its seriousness and expected consequences. Anxiety may lead to a “denial of the illness consisting in the fact that the patient will not acknowledge his condition or its implications, although he or she has access to information and mental capacity to use it” [8 ]. The anxiety of patients can be divided into two subtypes: anxiety about outcomes, i.e. about the effects of the illness and the treatment and procedural anxiety, stemming from fearing the clinical methods of the treatment. It is the author’s opinion that patients’ anxiety is a result of changes in their way of thinking and processing information. It is materialised mainly in the increase of patients’ sensitivity to threatening stimuli, the inclination towards interpreting vague information as threatening and the tendency to bring back memories that reflect their present state of mind. Araszkiewicz et al. [9] claimed the presence of patient’s anxiety should be considered in four interrelated dimensions: 1. situational anxiety related to anticipating potentially mutilating outcomes of the illness and treatment as well as the approach to them, 2. illness-related, 3. treatment-related, 4. related to the history of anxiety disorders, which often intensify during an illness. The symptoms of anxiety could be subdivided into [10,11]: a) cognitive – including insecurity, fright, absentmindedness and racing thoughts, b) behavioural – manifested by hyperactivity, repeated movements, verbal diarrhoea, fearfulness, facial expression reflecting insecurity or anxiety, c) physiological – including tachycardia, heart pounding, chest tightness, dry mouth, dizziness, hyperventilation, trepidation. Dubrovsky [5] points to the fact that quite a lot of patients have anxiety symptoms which cannot be classified into any diagnostic category of anxiety disorders according to the ● 9 DSM–IV, and still they are the reason of patients’ incapacity or bad mood. Those non-specific forms of anxiety often reflect the patient’s problems. Their examples include the following: situational anxiety – its intensity and nature are dependent on the meaning ascribed by the patient to his or her current situation in life as well as on his or her previous level of adaptation, death anxiety – especially in cases of illnesses which are likely to have unfavourable consequences, mutilation anxiety, anxiety about the loss of one’s fitness or attractiveness – it can be observed in cases of illnesses that pose a threat to appearance or fitness, anxiety about the loss of one’s self-esteem – it occurs in patients who are especially prone to experience illness as a sign of their imperfection, weakness or failure, stranger anxiety (separation anxiety) – it can trigger the bad mood of the hospitalized if there are changes in the medical staff, anxiety about losing control – experienced by people who have a dire need of feeling their life and environment are under their control, anxiety about being dependent – it is related to the anxiety about losing control and is manifested by independence consisting in disobeying doctor’s orders or neglecting the signs of the deterioration of the illness, anxiety about close contact with others – during hospitalization, it is manifested by increasing the emotional distance and attempts of isolation from the relationships with the medical staff or other patients. An authority on the present anxiety theory is Charles Spielberger, who introduced a discrimination between state anxiety and train anxiety. While the former is considered as a changeable emotional state of an individual, the latter is a personality feature (trait). Spilberger’s theory of anxiety involves certain elements of the sense of coherence, especially as far as cognitive assessment of threatening situations is concerned. According to this theory, anxiety emerges when a person is incapable of grasping and processing the pieces of information in the world around him or her – especially those lacking coherence, obviousness and logic [3]. An important issue is making a distinction between anxiety and depression despite the fact that those two states often coexist or even overlap. Until not long ago, it was believed that anxiety is an undeveloped (not full-blown) depression and that depression is a continuation of anxiety disorders. This view has been less and less popular in the recent years [5]. Depression is a broad concept which includes both mood changes and a complex clinical syndrome. Depression as a ●●JOURNAL (3) ● JOURNALOF OFPUBLIC PUBLICHEALTH, HEALTH,NURSING NURSINGAND ANDMEDICAL MEDICALRESCUE RESCUE2013 ● No.3/2013 change of mood is characterised by sadness, impaired ability to experience joy, lower activity and reactivity, guilt, hopelessness and the sense of one’ worthlessness. Depression, if approached as a complex clinical process, is a multidimensional disorder, in which the following factors dominate: mood changes, irregularities of verbal expression, impairment of cognitive abilities, motivation disorders and neurovegetative symptoms [7,10]. Depression may stem from internal factors (endogenous depression) – the word “internal” is used here in its casual sense and includes both known used by clinicians when there are no visible factors causing the depression. Moreover, depression can be the result of certain occurrences (reactive depression) that took place in the person’s life. In this case, the term “depression” has a clinical meaning and implies that the affective reaction is inappropriate in terms of the occurrences themselves, which draws a line between depression and despair [7]. Beck [12] claimed that any interactions between genetic, biological, developmental, environmental, cognitive and personality factors may cause depression. The course of depression and the intensity of some of its features and symptoms can be diverse. Some people may experience a sudden emergence of depressive disorders within a couple of days (even 24 hours), with the condition rapidly intensifying and then withdrawing. However, more often than not symptoms intensify gradually over a dozen or so days or even weeks [7]. The attitudes and beliefs of the ill people at that time lead them to emphasise: a) their low self-esteem – feeling worthless, unsuccessful and incapacitated and that some important sources of support (health, respect) are lost, b) a low esteem of their past – feeling they haven’t accomplished anything, they have neglected no do something, with guilty conscience, c) a low esteem of their future – full of pessimism, with no faith in improvement, feeling of losing health and being helpless [13]. Beck lists the belief in one’s own incompetence, a feeling of having lost something and overestimating certain phenomena as factors of exposure to the emergence and sustenance of depression. He states that beliefs that are characteristic of depression can be divided into beliefs in one’s own hopelessness and in not being loved. According to Beck, some types of past experiences shape dysfunctional assumptions are activated by critical occurrences confirming them later on in life. At the same time, the symptoms of depression (behavioural, motivational, affective, cognitive and somatic ones) solidify automatic negative thoughts. Beck also claims that automatic negative thoughts may pertain to three spheres of experiences, which he ● 10 called a cognitive triad. It is composed of negative thoughts about: the self, the world around and the future [12]. In psychological theories of depression, a reference to the sense of coherence and its three constituents may be found in spite of the fact that the language of the idea of salutogenesis is not used there [14]. In the cognitive reading [15], depressive mood is a consequence of disorders of interpreting and ordering the data received. It is related mainly to magnifying failures and diminishing successes as well as to belief in the insignificance of one’s influence on different occurrences. In Beck’s opinion, depressive people tend to feel pessimistic about the future and themselves, which can especially be observed in stressful conditions, especially if the situation is associated to failure, loss or hopelessness. In Lewinsohn’s behavioural approach [14], depression and a decrease in activity stemming from it are related to, among others, a deficit of social skills of receiving positive reinforcements, an impaired ability of self-rewarding, inappropriate reactions to the elements of the sequence: situation → behaviour → consequences as well as expecting solely negative outcomes of one’s reactions. In Seligman’s theory of learned helplessness [16], depression is the product of pessimistic expectations towards the effects of one’s own actions, which in turn brings about the motivational deficit in difficult, challenging situations. The interpersonal approach of Klerman and Weissman [17] associates depression with negative experiences of reacting to changes in the environment (especially during conflicts with others) which are a result of social skills deficit. Anxiety and depression of women in the perioperative period A gynaecological surgery can be a strain for a woman’s health. Negative emotions experienced by women in perioperative period are manifested in the form of physical, mental and behavioural disorders, especially as symptoms typical of anxiety and depression [18,19]. Analysing the categories of gynaecological surgeries, it is certainly worth to mention the data provided by Jawor et al. [20], who, quoting some other authors, stated that around 70% of women who underwent hysterectomy suffer from depressive disorders. The authors point to the fact that the manifestation of anxiety-depressive disorders during the post-operative period is related to the presence of those disorders before the surgery. Reroń and Huras [21] concluded on the basis of their analysis that surgical treatment of uterine fibroids is directly related to the increase in the frequency of depressive disorders and that complete hysterectomy and BSO is related to the highest percentage of depressive disorders in the preoperative period as well as 6 months after the surgery. ●●JOURNAL (3) ● JOURNALOF OFPUBLIC PUBLICHEALTH, HEALTH,NURSING NURSINGAND ANDMEDICAL MEDICALRESCUE RESCUE2013 ● No.3/2013 Carr et al. [22] observed that a gynaecological surgery is related to an increased anxiety in women, which negatively affect the treatment as a result. Authors suggested that it is imperative that patients with increased anxiety be identified before the surgery and an effort be made to reduce the anxiety level. Vachova et al. [23] claim that in order to optimally provide for the pre- and postoperative period of the patients undergoing gynaecological surgeries, the task of reducing anxiety-related and stressful factors must be performed. According to the authors, special attention must be paid to the individual relationship of the patient and her doctor and hospital psychologist during hospitalization. The study by Sjoling et al. [24] indicates that the level of preoperative anxiety is related to informing (or failing to inform) the patient about all the relevant details before the surgery. Cheung et al. [25] compared the levels of anxiety in women who underwent hysterectomy using laparotomy. The study group was offered extensive information in the pre- and postoperative periods, while the control group had to find out what they needed to know on their own. The results indicated that the women of the study group had a lower level of anxiety before the operation, felt the pain to a lower degree and their satisfaction level was higher than in the control group. Hawighorst et al. [26] and Ghulam et al. [19] claimed that offering reliable information on the benefits, risks and methods connected to their surgeries to patients in their preoperative periods not only contributes to the lower anxiety level but also improves the patient-doctor relationship. Kain et al. [27] observed that the psychological variable of the anxiety experienced may be a factor that predicts the level of pain after the operation on women who underwent abdominal hysterectomy. According to the authors, preoperative anxiety affects the extent of pain experienced by the patients not only during their stay in hospital but also after they are discharged. Also Cosentino et al. [28] showed that the level of preoperative anxiety correlates with the level of pain after the surgery. What is more, the anxiety level is related to a patient’s uncertainty about the necessity of gynaecological surgery. Some authors claim that the development of anxiety and depressive symptoms after surgeries is dependent on a patient’s belief in her own responsibility for her condition and blaming herself [18,29-31]. Bearing in mind the aforementioned correlations, medical staff should pay special attention to patients who experience negative emotions in the perioperative period and perform tasks aimed at reducing stress factors. ● 11 III. CONCLUSIONS Anxiety and depression are psychological factors that determine the reaction of a patient’s system to gynaecological surgical trauma. How well the patient can deal with negative emotional changes during the perioperative period depends on the patient's personal resources as well as the support provided by medical staff and relatives. 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