Holistic medicine is based on the principle of psychosomatic unity of man viewed as interconnections of mental, somatic and vegetative processes. The essential role is played by emotions, anxiety in particular, which affects the functioning of a patient from the onset of disease symptoms, through diagnostics and hospitalization until the recovery. Since the relations of anxiety with pain, complications, length of hospitalization and psychological costs have been well documented, possible impact on the severity of anxiety and higher accuracy of simple methods of its assessment are of interest.

Anxiety accompanies man throughout his/her life and is defined as “a negative emotion connected with anticipation of external or internal danger”. According to another definition, anxiety is “the response of an organism to unknown threats” [1]. Recently, the notions of fear and anxiety has been used interchangeably [2]. However, fear is defined as “dread of real danger” whereas anxiety is associated with the threat perceived subjectively, without a defined risk factor. Therefore, the cause of fear is found in the external world while the cause of anxiety inside the individual, in his/her personality. We are usually aware of the former whereas the latter is often unperceived. Anxiety is the fear of anticipated threats, a negative emotion, usually unpleasant for an individual, induced by the factor (situation or object) subjectively considered as threatening. Some factors determining intensity and duration of anxiety in the perioperative period were identified, which included female sex, tobacco smoking, neoplastic diseases, mental disorders, depression, pessimism, pain and diseases impairing normal functioning [3]. Some studies evidence that perioperative anxiety is associated not only with the outcome of therapy but also with pain, death or even anaesthesia.

For the majority of individuals, the disease and disease-associated experiences are a serious burden as the accomplishment of goals set earlier is impeded, essential values are endangered; moreover, physical complaints develop, which are accompanied by strong and usually negative emotions [4]. Patients are forced to mobilize all mental and physical powers in order to recover as quickly as possible.

The symptoms of anxiety are divided into physiological, mental and behavioural. The physiological ones include accelerated heart rate and respiratory rate, increased arterial pressure and muscle tone, abdominal pain, urgency. The mental symptoms are tiredness, feeling of threat, reduced self-esteem, withdrawal from interpersonal relations, cognitive disorders. The behavioural symptoms involve motor anxiety, pointless activities, frequent position changes, twitches. Sometimes, dysarthria and insomnia are observed. It is believed that slight anxiety is beneficial as it mobilizes and strengthens the protective forces whereas panic anxiety impairs functioning and exerts highly disorganizing effects [1, 5, 6]. A relevant variable is time – the longer the anxiety persists, the bigger the risk of its negative consequences: anxiety neurosis, obsessions or phobias. In the normal mechanism, anxiety occurs during threats and disappears after their subsidence. Persistent anxiety is more dangerous for man than the stimulus, from which anxiety is to protect us.

 The presence and intensity of anxiety may be confirmed using special questionnaires. However, they are not commonly applied in hospital settings, as they are troublesome for patients and personnel and generate additional costs; the utility of the data collected is limited as there are no psychological, educational, prophylactic or supportive programs of the process of therapy. The costs of such tests are considered disproportionate to potential benefits; therefore, they are used almost exclusively in research. Thus, simple methods of anxiety evaluation, such as the visual analogue scale, seem to be satisfactory providing a compromise between time-consumption (hence – cost and inconvenience) and accuracy.

The aim of the study was to compare methods of assessment of perioperative anxiety and to determine relations between the intensity of anxiety and sex, age, type of surgery, as well as health status of patients.

METHODS

The study was carried out in patients awaiting abdominal or otolaryngological surgery. The exclusion criteria involved surgical procedures within the last 20 years, block anaesthesia planned, medical or psychological education, chronic use of sedatives or hypnotics, diagnosis or suspicion of neoplastic diseases. Anxiety was quantitatively assessed using the State-Trait Anxiety Inventory (STAI) and Visual Analogue Scale (VAS). Qualitative evaluation was based on a single categorized question.

STAI consists of two „self-report questionnaires”: X-1 assessing the level of state anxiety and X-2 measuring trait anxiety. Respondents are to choose one out of 20 short statements best reflecting their feelings. The score ranges from 20 to 80 points; the higher the score, the more severe the anxiety [7].

VAS is the method of anxiety assessment adapted from the methodology of pain evaluation. The measurement tool is the 10-cm measure, with the left-hand end denoting absence of anxiety while the right-hand one – the most severe imaginable anxiety. Respondents are to mark the point corresponding to the anxiety level currently experienced.

A single categorized question is the method in which respondents declare the presence of anxiety or otherwise ( The question:” Are you anxious about anything at the moment”. The answer:” Yes” or “No”). Since anxiety experienced on the day preceding surgery is a natural, understandable and socially accepted reaction, it was assumed that the reliability of answers would be verified with STAI and VAS. All “I am anxious” answers should be reflected in appropriate values of both scales, which are to quantify them. The “I am not anxious” answers should correspond to “0” on the VAS and about 20 score for state anxiety in STAI.

The tests were commenced on the day preceding surgery with qualifying interviews once written consent was obtained. To eliminate potential effects of the sequence of questionnaire completion on the level of anxiety, half of respondents first filled X-1 and X-2 STAI questionnaires and then marked the severity of anxiety on the VAS measure. The remaining patients started tests with the anxiety measure and then filled the questionnaires. After completion, all patients answered the question about experiencing anxiety at the time of testing.

The findings were statistically analysed. Normal distribution was verified using the one-sample Kolmogorov-Smirnov test. Intergroup differences were verified with the Student’s t test for independent samples. The distribution of variables was checked using the ?2. Correlations were tested using r-Pearson statistics. P< 0.05 was considered significant.

RESULTS

The study involved 38 patients, 18 women and 20 men aged 18-60 years fulfilling ASA I-II criteria (Table 1).

The sequence of questionnaire completion had no effect on anxiety measurements. There were no differences in assessments of state anxiety, trait anxiety and severity of anxiety during VAS tests between respondents starting with X-1 and X-2 STAI and those starting with VAS.

On the day preceding surgery, the majority of patients declared anxiety. Out of 38 respondents, 25 (66%) answered affirmatively to a single categorized question about anxiety experienced at the time of testing.

Based on STAI scores, the levels of state anxiety and trait anxiety were found to be 44.6±10.5 and 42.9±7.9, respectively whereas the intensity of anxiety measured according to VAS – 3.7±2.6.

A significant positive correlation was demonstrated between: a) the level of state anxiety according to STAI and severity of anxiety measured with VAS (r=0.7; p<0.001), b) the level of state anxiety and trait anxiety (r=0.5; p=0.001) and c) the level of trait anxiety assessed with STAI and severity of anxiety measured with VAS (r= 0.43; p=0.004).

In the group of 25 patients declaring anxiety, levels of state and trait anxiety were 48.6±9.3 and 43.9±8.6, respectively; the severity of anxiety according to VAS was found to be – 4.9±2.2.

In the group of 13 patients declaring no anxiety, the level of state anxiety was 36.9±8.2, of trait anxiety – 41.0±6.3, and the mean severity of anxiety according to VAS – 1.5±1.7.

In respondents maintaining they experienced anxiety, state anxiety and severity of anxiety according to VAS were significantly higher compared to the remaining patients (p<0.001, p<0.001, respectively); on the other hand, levels of trait anxiety were not statistically different (Fig.1).

In female patients, levels of state anxiety and trait anxiety were 45.6±10.9 and 43.8±8.1, respectively, and the severity of anxiety – 4.4±2.6. In male patients, levels of state anxiety and trait anxiety were 43.8±10.4 and 42.1±7.9, respectively whereas the severity of anxiety was 3.1±2.5. The differences between the male and female group were not significant.

In females, significant positive correlations were observed between the level of state anxiety and severity of anxiety (r=0.6; p=0.004) as well as between the level of state anxiety and trait anxiety (r=0.6; p=0.003). Similar results were observed in the group of male patients. Strong positive correlations were demonstrated between the level of state anxiety vs severity of anxiety (r=0.8; p<0.0001) and between the level of trait anxiety vs severity of anxiety (r=0.46; p=0.02).

Compared to men, more women claimed they experienced anxiety. Amongst 18 women involved in the study, 15 answered affirmatively to the question about anxiety at the time of testing; amongst 20 male patients – only 10 (p=0.03).

In the group of younger patients (<40 years of age), the STAI levels of state anxiety and trait anxiety were found to be 43.2±11.4 and 42.1±7.4; the severity of anxiety according to VAS was 3.6±2.6. In the group of older patients (>40 years of age), levels of state anxiety and trait anxiety were 46.2±9.4 and 43.8±8.5 respectively; the severity of anxiety – 3.9±2.7. Differences between the younger and older group were not significant.

In the younger group, significant positive correlations were demonstrated between the level of state anxiety and severity of anxiety according to VAS (r=0.77; p<0.001), the level of state and trait anxiety (r=0.65; p=0.001) as well as the level of trait anxiety and severity of anxiety (r=0.6; p=0.002).

In the older group, similar correlations were observed between the level of state anxiety and severity of anxiety (r=0.6; p=0.002). The incidence of answers concerning the anxiety experienced was similar in both groups of patients: 13 – amongst 20 younger and 6 amongst 18 older patients.

In the group awaiting abdominal surgeries, the level of state anxiety was 42.6±10.7, of trait anxiety – 44.0±7.7, whereas the severity of anxiety – 3.9±2.6. In patients scheduled for otolaryngological procedures these values were 45.6±10.4, 42.3±8.2, and 3.7±2.7, respectively. The differences between the patients awaiting abdominal or otolaryngological surgeries were not significant.

No differences were observed in anxiety levels between patients with different ASA scores. 

DISCUSSION

To date, no standards or guidelines for management of patients experiencing perioperative anxiety have been designed. Intuitive measures of reassurance, usually verbal, do not bring desirable effects and may be even interpreted negatively. Therefore, the methods accounting for the causes of anxiety are searched for which would enable to reduce it. Moreover, effective and simple in clinical use tools measuring anxiety are required. This seems relevant since there is a clear divergence between the levels of anxiety as assessed by anaesthesiologists and questionnaire findings [8].

At present, the golden standard to assess anxiety is the State and Trait Anxiety Inventory. However, in the clinical setting, its usefulness is limited due to complex procedures of collecting and processing data. Moreover, slight changes in the severity of anxiety are difficult to assess with STAI. The clinical studies describe also some other methods to estimate anxiety, including VAS. This method is of interest due to its simple form, easy completion, quick assessment and possible bedside use. The studies concerning the use of VAS for assessment of severity of anxiety showed significant correlations between this scale and scores of state anxiety using STAI [9, 10].

Three factors of anxiety of patients awaiting surgeries were distinguished: fear of unknown, fear of complaints and fear of loosing life. The VAS scores were most strongly correlated with the STAI scores concerning “fear of unknown” [9]. Hence, it is supposed that information about the disease, methods of treatment, successive stages of diagnostic-therapeutic processes and anticipated duration of hospitalization provided for patients are likely to reduce the level of anxiety. However, the form and amount of information should be adjusted to the needs of a given individual to avoid paradoxical increases in the level of anxiety [11]. Furthermore, studies on effectiveness of various forms of providing information in particular groups of patients in the Polish population are required.

Our findings confirmed that the severity of anxiety according to VAS corresponded to the level of state anxiety measured with STAI. This is indirectly confirmed by the correlation of results concerning state anxiety and trait anxiety as well as severity of anxiety. It is well known that the high level of trait anxiety is associated with high level of state anxiety only in situations perceived by an individual as highly threatening; such a correlation is not observed during normal everyday activities. Moreover, it seems that the significant correlation observed between trait anxiety and state anxiety as well as between trait anxiety and severity of anxiety in the younger group is likely to evidence subjectively higher situation-related threats compared to the older group, despite lack of differences in the parameters studied.

Our results confirmed the usefulness of the Visual Analogue Scale for assessment of the severity of anxiety on the day preceding the surgery. VAS is easy to use and does not pose interpretative problems, yet it has some limitations, which should be considered. “The impact of central tendency” on results is stressed. In situations where some doubts concerning proper answers occur, the tendency to avoid extreme assessments is observed (e.g. definitely yes – definitely no; not at all – very) in favour of more central answers (e.g. rather yes – rather no; slightly – moderately) [10]. Moreover, the optimal moment of assessment and choice of an examiner should be considered. It should be also remembered that VAS measuring the severity of anxiety provides more information than the categorized question about the anxiety experienced.

In the present study, declarations of patients concerning anxiety were found to be reliable. If a patient answered “Yes” to a simple question about experiencing anxiety, we should believe him/her and suitably orient further management. Two/thirds of patients admitted they experienced anxiety before surgery, which is understandable, not surprising and not connected with disapproval. From the research point of view, however, it is interesting that some patients declared the absence of anxiety choosing the VAS score 3 yet in the questionnaire assessment had the results even similar to the average level of state anxiety. The reasons are likely to be associated with the need of social approval, distance to the research procedure, lack of involvement or other individual factors.

Surgery-related anxiety was more often reported by women, which is confirmed by our results indicating clearly that female sex is an independent factor favouring preoperative anxiety in adults [3, 6]. Moreover, higher levels of anxiety were demonstrated in females, younger individuals and those never anaesthetized or with earlier negative experiences related to anaesthesia [9]. Some authors wonder whether the sex itself predisposes to a given level of anxiety or rather the established social role. According to this hypothesis, males characteristically disclose courage whereas women are more eager to admit experiencing the anxiety.

Numerous surgical procedures are associated with a particularly high level of anxiety, which was demonstrated in thoracic, otolaryngological, cardiac and abdominal surgeries [9, 12]. The mean level of state anxiety in the general adult population is 35 points, and the change by over 10 points is considered clinically significant [13]. In our study, the mean level of state anxiety in patients awaiting otolaryngological procedures was higher. Compared to the general population, those patients would be considered as having high levels of anxiety; however, no significant differences in the value of this parameter were observed between patients before otolaryngological and general surgeries. It seems that lack of differences may depend on wider characteristics of the population examined, size of the sample and interval between testing and surgery.

One of the independent risk factors of pre- and postoperative anxiety is the general status assessed as ASA III [3]. Our study involved only ASA I and II patients and, as expected, no differences in the level of anxiety were observed.

The identification of factors affecting perioperative emotions of patients may help the staff to provide the optimal care and support. Based on such factors, physicians will be able to recognize the real disease-related problems of patients which affect the quality and outcome of treatment as well as recovery. Once patients with high levels of anxiety are placed top on surgical waiting lists, their anxiety should be reduced by shortening the stressogenic waiting for surgery.
To our knowledge, there are no literature reports concerning the effects of the sequence of questionnaire completion on the level of perioperative anxiety. The exclusion of such effects was important as the categorized question disclosed the aim of the study, which could have led to false results. Our findings demonstrate lack of such effects.

To sum up, reliable estimation of the severity of anxiety is essential for preoperative assessment of patients. Such an assessment can be easily provided using the Visual Analogue Scale. This method is an alternative to the State and Trait Anxiety Inventory. Moreover, individual characteristics of patients, including sex, age, general status according to ASA and type of surgery may serve as the basis for anticipation of increased levels of anxiety in some patients. In this respect, our results are similar to or exactly the same as literature data. To increase their reliability, bigger sample sizes should be studied.

CONCLUSIONS

1. The visual Analogue Scale is a reliable clinical method for quick quantitative assessment of preoperative anxiety.

2. The sequence of the measurement tools used does not affect the reliability of results.

3. The patients` declarations about experiencing anxiety are reliable and sufficient qualitative assessments.

4. Women more commonly declare the presence of preoperative anxiety compared to men.

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Address:

*Wojciech Romanik
II Klinika Anestezjologii i Terapii, Warszawski UM
ul. Banacha 1a, 02-097 Warszawa
tel.: 0-2220 02, fax: 0-2221 01
e-mail: roomanik@gmail.com
 
Received: 18.02.2009
Accepted: 20.04.2009