Anxiety-depressive disorders in women under

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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
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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
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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
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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
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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.
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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.
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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. Higher intensity of anxietydepressive reactions before and after the surgery may surpass a
woman’s capacity to adapt, thereby introducing complications
to the treatment and convalescence.
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