The Psychiatrist in the Surgical Intensive Care Unit I.
Postoperative
Delirium
Theodore Nadelson, MD
\s=b\ Delirium
has been defined
as a
condition of cerebral insuffi-
ciency consisting of impairment of cognitive processes, with a characteristic slowing of the electroencephalographic pattern. Present also is a global "clouding" of consciousness, resulting from a potentially reversible impairment of ability to maintain attention. In these states there is usually a simultaneous diminution of the ability to think, perceive, and remember. Although drowsiness may be a part of this state, patients can be awake and yet delirious, with diminished consciousness of their surroundings. Postoperative delirium is seen more often in patients over 50 years of age, in those who are "vigilant" or overalert, and in those undergoing more complex surgery. Adverse influences in the postoperative period are certain drugs and the psychological stresses engendered by the ICU environment. Appropriate management obtains from attention to the impact of the strange environment on the patient. (Arch Surg 111:113-117, 1976) delirious while in a hospi¬ tal. A or silently hallucinating pa¬ tient is often by the medical or surgical staff. The florid, agitated, and delirious patient is more visible, and the symptoms may interfere with care or may trouble those around him. Such a patient often first directs the at¬ tention of the staff to the presence and general impor¬ tance of psychological issues that affect everyone in the Surgical Intensive Care Unit (SICU).
become Many patients quietly deluded unnoticed
Clinical Description
The subject of postoperative delirium continues to hold the attention of many writers in this arena where medipublication May 20, 1975. Psychiatry Service, Beth Israel Hospital, and the Department of Psychiatry, Harvard Medical School, Boston. Reprint requests to Beth Israel Hospital, 330 Brookline Ave, Boston, MA 02215 (Dr Nadelson).
Accepted
From the
for
cal, surgical, and psychological interests converge. In un¬ derstanding the multiconvergence of forces leading to de¬ lirium, we approach etiologic factors, diagnostic problems,
prophylactic principles that have a wider range of ap¬ plication in several problems of psychological disequi¬ librium. In addition, patients with this syndrome also tend to have a less successful surgical result. and
In the 16th century, Paré mentioned a state of postoper¬ ative psychological disequilibrium that Dupuytren, in the 19th century, termed "delirium nervosum."1 Many terms have subsequently been used to characterize this extreme state; it is often unclear whether authors are referring to the rarer schizophrenic reactions, which may be precipi¬ tated postoperatively, or to the more commonly found pe¬ riods of excitement with confusion and disorientation best called "delirium." The difficulty in defining a clinical entity depends in part on the general problems inherent in psychonosology, particularly those involved in cate¬ gorizing a portion of a spectrum of observed aberrations. The terms postoperative "dementia," "delirium," and "psychosis" are still often used interchangeably. Dementia, in the older terminology, referred generally to insanity or madness; it is still used to describe loss of the intellectual functions, resulting from gross changes in the physical functioning of the brain. Delirium has been defined as a condition of cerebral insufficiency, character¬ ized by the basic properties of impairment of cognitive processes along with a slowing of the electroencephalo¬ graphic pattern.- Present also is a global "clouding" of consciousness, resulting from a potentially reversible im¬ pairment of ability to maintain attention and cognitive processes.3 In these states there is usually a simultaneous diminution of the ability to think, perceive, and remem¬ ber. Although drowsiness may be a part of this state, pa¬ tients can be awake and yet delirious, with diminished consciousness of their surroundings.
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Disorientation with regard to time, place, and person has been regarded as the primary distinguishing feature of delirium,2 but patients may be fully oriented, particu¬ larly in the earlier stages.3 Slight disorientation, however, often goes unrecognized because the eliciting questions are not asked or because the patients cannot communicate for other reasons. Patients have difficulty in coherent
thinking, accompanied by anxiety, depression, or apathy, and sleep may be disturbed. Patients can pass rapidly from this stage into full-blown turbulent delirium. They may be transiently aware of their delirious state and even comment on how strangely they are acting. There is usually a paranoid coloring to the patient's thinking. With time the patient's thoughts may become more disorga¬ nized. There are usually wide fluctuations of the level of consciousness during any 24-hour period, so that it is often impossible to ascertain whether there is a positive or negative trend.3 Delirium differs from psychosis in that there is no con¬ stant "structure" to the ideas, such as is found in psychotic states. The steady regressiveness of psychotic thinking is not usually seen, and there is no "fixed ideas."4 A patient with delirium is usually more restless than one who is psy¬ chotic; there is generally less psychological "organiza¬ tion." The quality of the delirious state is haphazard; it is a tangle and confusion of shifting thoughts and feelings, and agitated activity may occur unpredictably. Psychotic states tend to last longer and to remit, when they do, slowly. This is especially true in those cases where there are preoperative psychotic tendencies. Delirium with agitation manifests itself usually before the third to seventh postoperative day and lasts from 24 to 48 hours.5 A longer duration of 14.7 days (average) has been reported in 57% of 139 patients who survived heart surgery.7 Disorientation has been reported lasting as long as a month.8 There is usually a lucid interval of two or three days after surgery before delirium ensues. Some au¬ 6
thors make a distinction between delirium that occurs af¬ ter the lucid interval and another condition, with a differ¬ ent cause, early organic brain syndrome, present from the outset postoperatively.9 The organic brain syndrome is perhaps less influenced by factors within the SICU envi¬ ronment and does not spontaneously remit, although such patients usually become worse in the unit. Cause of
Postoperative Delirium Syndrome
The cause of the postoperative delirium syndrome has been viewed variously as biochemically10 or psychologi¬ cally1112 derived. The syndrome emerges from interaction of a number of specifiable factors. The first set of factors includes the variables present prior to surgery. The second set of factors includes procedures and manipulations in¬ trinsic to the operative procedure. The third set of factors includes both drugs used postoperatively and those vari¬ ables that reside within the SICU milieu itself.
Preoperative The
Factors Associated With Delirium
preoperative factors include those that are usually expected to decrease the ability to withstand stress. In-
creasing age of over 50 years notably increases the risk.3 Senile patients may show a deterioration of postoperative psychological functioning without a lucid interval.9 Viewpoints regarding the influence of gross preopera¬ tive psychological aberrations (psychosis or family history of psychosis) vary, and it is difficult to assess this factor. However, personality styles or modes of coping, with less than usual flexibility under stress, are seen to correlate with delirium postoperatively.13 Patients with depression, functional psychosomatic disease, sleep disturbance, or history of habitual drug use have generally less than aver¬ age coping ability. Preoperative modes of psychological "coping" or "flexi¬ bility" are also important in overall surgical success. In this regard, denial often has been regarded as a maladaptive psychological defense mechanism, correlating with general postoperative psychological complications and in¬ creased morbidity and mortality. It is suggested that the physician approach avoidance actively before surgery.141" Others contest this position.51718 For the psychotherapist, a "breakthrough" in the patient's denial is usually fol¬ lowed by anxiety, which may herald a positive change and emotional reintegration. In our experience most patients who are physically ill deny the extent of their illness or the intensity of their feeling about it in varying degrees. Some degree of denial is normal and functions as a posi¬ tive psychological defensive posture. It has been found by others that a coping style termed "avoidance" (of knowl¬ edge or awareness of the medical condition) leads to more rapid postoperative recovery than does "vigilance" (overalertness to the threatening aspects of upcoming sur¬ gery).19 Most physicians, we have found, have more diffi¬ culty in establishing an alliance with patients who are vigilant, questioning, and suspicious than with those who deny, but are accepting of the physicians good intentions and skill. Denial of a steadfast, unwavering sort, however, often presents a problem for the staff in that it makes it difficult to establish a mutual or cooperative relationship with the patient. General interest in preoperative psychological charac¬ teristics has been in the direction of prediction of postop¬ erative psychiatric complications such as delirium.917 but also in extended psychological effects. The surgeon's par¬ ticular interest in this subject may be more specifically fo¬ cused on whether or not knowledge of preoperative per¬ sonality characteristics should be among the factors to be considered in surgical risk and prognosis. Difference in scores on a battery of psychological and intellectual tests were found to have predictive value in distinguishing sur¬ vivors and nonsurvivors in cardiac surgery.20 It is sug¬ gested that it may be possible, with such information, to ameliorate the degree of risk for some patients.
Operative Factors Associated With Delirium Type of Procedure.—An incidence of 1,250 "mental dis¬ orders" (without specification of the clinical findings) was
reported in all surgical patients in 1910.2' An overall inci¬ psychiatric problems was reported, loosely en¬ compassing delirium or psychosis, which ranges from 0 to dence of
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60%. In
a
random sampling of 200 general surgical pa¬
tients, delirium was found in 78%.22 Some procedures char¬ acteristically eventuate in affectual disturbance; hysterec¬ tomy particularly is indicted.23 Eye operations show a
higher incidence
of postoperative psychiatric states than other nonthoracic surgery.16'24-25 It is difficult to assess in¬ dependence of variables; for example, the age of the pa¬ tient may be highly correlated with the type of procedure, as in cataract surgery. Cardiotomy generally has exceeded other surgical pro¬ cedures in the incidence of postoperative psychiatric com¬ plications, including the major ones of delirium, but also the incidence of the rarer psychosis. The predominance of articles written exclusively on psychiatric aspects of treat¬ ment of the surgical heart patients attests to that. Before 1963, incidence of such complications ranged from 5% to 17%.6 After 1963, an increase has been reported, ranging from 38% to 61%2"-27 and occasionally higher for all behav¬ ioral disorders including delirium. Delirium is reported in one article at 57% of 139 surviving patients.28 More recent studies point to decreasing incidence of postcardiotomy
delirium.9-29
Complexity of Procedure.—It was first suggested that there was a causal relationship between mitral valve pro¬ cedures per se and the postoperative psychiatric complica¬ tions that followed.6 As numbers of intracardiac proce¬ dures increased, it became clear that the abnormality could be causally linked, at least in part, to physiological stresses induced by the operation. As procedures on the heart developed from closed-heart, "finger fracture" valvulotomy to more complicated oper¬ ations involving cardiopulmonary bypass and hypother¬ mia (with attendant longer hours of operation and anes¬ thesia time), the incidence of psychological complications increased. The increasing complexity of newer procedures and technical improvement brought into play the follow¬ ing factors: (1) greater manipulation of life processes, ie, longer anesthesia and bypass time, with greater numbers of drugs in larger amounts and hypothermia, and (2) oper¬ ations on older, sicker patients. In patients subjected to anesthesia time longer than eight hours and bypass time exceeding four hours, there is a 75% incidence of postoperative delirium.28 It is not clear what the underlying physiological factors are; it has been suggested that at least one of the conditions present in long operations is decreased brain perfusion or hypoxia or both. Anoxia resulting from decreased circulating volume has been correlated with postoperative delirium.30 Pa¬ tients who receive transfusion of more than 2 units of blood had a higher incidence of such psychiatric symp¬ toms. However, patients receiving no blood had a higher incidence of symptoms than those receiving up to 10 units. A similar situation is found in the use of hypothermia; hy¬ pothermia of a few degrees below 37 C correlated with a low incidence of psychiatric complications than did an ab¬ sence of hypothermia, and with a much lower incidence than chilling of the patient below 27 C.28 Embolization from use of silicones in the bypass apparatus or from antifoam agents also have been suggested as a cause of de-
creased brain circulation.6 Disturbance of blood gases, hy¬ poxia, hypocapnia, and hypercapnia, are known to cause confusion or psychotic behavior.10 Agents such as suc¬ cinylcholine chloride have been implicated in abnormal psychological states.31 Although one could assume as well
that decreased cardiac output would also be associated with abnormal psychological states, it has been found paradoxically that hallucinations occur with a rapid rise in cardiac output and never when the output is falling.7 High cardiac output is not always associated with hallucina¬ tions, however. One of the more interesting and compelling physiolog¬ ical explanations is in research on catecholamine activ¬ ity. Catecholamine levels are measured at their highest after open-heart surgery and during the time of the usual occurrence of psychiatric symptoms of delirium.6-32 Hy¬ poxia may be a stimulus to increased epinephrine secre¬ tion, and adrenochromes may be produced from epineph¬ rine through abnormal metabolic pathways in some patients on a purely hereditary basis, or released by direct oxygénation of blood in the bypass apparatus. The ob¬ served phenomenon of children's "immunity" to postoper¬ ative psychosis may be due to differences in need or in ability to metabolize amines.26-28 The effect of phenothiazines on postoperative delirium stands in partial support of the "amine theory" as well, since phenothiazines are known to block amine synthesis. There is still some diffi¬ culty in disentangling cause from effect; it c¿.n be specu¬ lated as to whether increase in circulating amines pro¬ ceeds from a psychological state or vice versa. In the past five years, however, a decreased incidence of postcardiotomy delirium has been found.9-29 The operative factors seen as responsible for the change are decreased operative-anesthesia-pump time. As ease with cardiotomy techniques increases more complicated cases are per¬ formed faster. Other factors responsible are better preop¬ erative psychological preparation and greater attention to psychological issues in the SICU postoperatively, which often occurs when the staff becomes more expert in tech¬ nical matters.
Postoperative Factors Associated With Delirium Drugs.—Most of the drugs used after surgery are poten¬ tial factors in the induction of depression, anxiety, delir¬ ium, or psychosis in a predisposed patient. Many of the side-effects of such drugs are well-known and documented, perhaps especially so is that of barbiturate use. The para¬ doxical effect of barbiturates is, however, sometimes for¬ gotten, and in the face of accelerating restlessness a phy¬ sician may order increased doses of barbiturate to "calm" the patient. Anticholinergic drugs (atropine, scopolamine, and re¬ lated compounds), antitussives, anti-Parkinson agents, drugs to control cardiac output and rhythm, the tricyclic antidepressants, and antihistamines may not be recog¬ nized as potential causes of untoward psychological ef¬ fects. Some of these drugs may be used after surgery to provide relief of symptoms; all are said to be capable of promoting major psychological disturbance.10 Cortico-
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steroids have definite dose-related psychological effects. Patients taking steroids (or withdrawing from them) show degrees of aberration ranging through mild eu¬ phoria to delirium and hallucinations. The SICU Environment.-The environment of the SICU itself has long been indicted as a factor in delirium. The first impression of the SICU relates to the intensity of il¬ lumination, visibility of patients, and movements of the staff. Sleeping and dreaming, which impose order on the day and perhaps integrate emotional experience,33 are often disturbed. Patients frequently experience a dis¬ torted sense of expansion and contraction of time. Such a perception arises from fatigue, lack of sleep, or pain with its "minutes-into-hours" phenomenon, and anxiety and depression. There may be no calendar or clock for refer¬ ence, or the patient may not be able to see it. Perception, dulled by pain, weakness, or beginning toxic delirium is further dulled by the limitation imposed by the environ¬ ment. It was found in a medical intensive care unit that half of the patients had lost their time sense.34 Personal change frequently, and the patient often cannot establish a
trusting relationship.
Death is a constant presence and threat. It occurs often in the SICU, and patients are bound to be aware of it, often despite the efforts of the staff to screen them from it. It figures in their fantasies despite denial either of its presence or of the intensity of its emotional impact. Treatment
Phenothiazines are effective against postoperative de¬ lirium.11·28 There is often a reluctance to use these potent agents because of potential hypotensive side-effects. In one study, however, the major hypotensive effect of phenothiazines is postoperative delirium was found to be minimal.8 Phenothiazines may be used safely in treatment of postoperative delirium if the initial dose of chlorpromazine does not exceed 25 mg given intramuscularly and if there is careful monitoring. If this dose is tolerated, addi¬ tional doses may be used from five to six hours thereafter until abnormal behavior remits. The hypotensive effect does not seem to be dose-related. Trifiuoperazine hydrochloride is less sedating, may have a lesser hypotensive ef¬ fect, and is suggested as a possible alternative treatment in doses of 2 mg, four times daily. Haloperidol, a butyrophenone derivative, 2 mg given two to four times a day, is an effective medication against psychosis, with a wide dose range of therapeutic efficacy and a minimal risk of hypotensive side-effect. Barbiturates should not be used since they often increase agitation.6 Supportive psychological treatment in the SICU is often effective and less dangerous than drug treatment. More¬ over, most symptoms remit without intervention after a relatively short period of time. There is often an insis¬ tence on the part of medical personnel to control the pa¬ tient either by medication or physical restraint. Such mu¬ tual agitation usually has "feedback" characteristics. If there is calm in the face of the patient's delirium, and ac¬ ceptance of such behavior without necessity for immedi¬ ate control, staff members can quietly and firmly control
such
behavior, often without use of medication (and its side-effects), and usually without physical restraints. Calm on the part of the staff can be promoted by open discussion
of the stresses induced by the aberrant behavior. The atti¬ tude of the nursing personnel toward such psychological issues has been important in our experience. The patient should not be placed in restraints unless absolutely neces¬ sary, and then only when a staff member can be close to him. Group discussions with the unit psychiatrist allows for ventilation, sharing, and understanding of staff feel¬
ings.
The question certainly can be raised in some cases as to whether factors within the environment are responsible for symptoms or their remission. With many patients a persuasive cause-effect relationship has been demon¬
strated. For example, a request for a psychiatric consultation was made for a 56-year-old man with a postmyocardial in¬ farcì and described as "agitated, delirious, and combat¬ ive." When first seen he was in bed in a single, windowless room, in physical restraints, struggling, and inappropriate in his responses. His room was next to the medication station where two nurses were talking. His door was ajar, and the room was half illuminated. The psychiatric consultant spoke to the patient by name, removed the restraints, turned the room lights on to full illumination. The psychiatrist continued to talk with the patient loudly and clearly. The patient's re¬ sponses became increasingly appropriate. Personnel were advised to be as definite with the patient as possible, to leave the room door either fully open or fully closed, and not to talk outside of his door. A calendar and clock were provided. The patient exhibited no further delirium. CONCLUSIONS
Delirium, from
psychological perspective, is an overbehavioral/psychological ma¬ neuvers, with particular use of those defenses lowest on the adaptive hierarchy (denial, isolation, projection, and delusion). It then is both a last ditch defense and also a de¬ terioration of defenses. (It is analogous on the behavioral level to the biological phenomenon of anaphylaxis.) The usual feeling of being in touch with reality and with one's own feelings depends both on intactness of internal regu¬ latory mechanisms and external constancies embedded in the "average expectable environment." Internal controls emerge from (1) neurologically based perceptual mecha¬ nisms (innate and learned), (2) cognitive mechanisms, and (3) affectual controls derived from parental and societal training and reinforcement. These internal controls are known as ego functions. The average expectable environ¬ ment is one of more or less usual stimulus input. There is
magnification
a
of the usual
continuous interaction between an individual's ego func¬ tions and the environment. Certain actions of the person are reinforced by the environment (and particularly by the people within it), other actions are tolerated, and still others are unacceptable. The physical environment "rein¬ forces" or "condemns" acts (playing with fire often leads to pain), as does society. The individual affects his envi-
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ronment too,
by changing it to his needs and accepting or
rejecting aspects of it. The adult patient in the SICU is in a state of more than usual dependence on his environment. He is forced both by illness and the passivity necessitated by treatment to abdicate the usual decision-making processes. This posi¬ tion of enforced passivity usually leads to relinquishing many of the adult psychological functions. With a norma¬ tive internal state the person can recognize an environ¬ ment as "strange." An aberrant event can be "put in place" as unique. With the regressive pull enforced by his extreme passivity and with physiological shifts altering perception and cognition, the patient often cannot distin¬ guish an event as strange; he feels strange in the face of stimuli that are not immediately understandable. The en¬ vironment also engenders fatigue and reduces sleeping and dreaming. (There is sometimes a dramatic termi¬ nation of delirium after a long, restful sleep, somewhat
like recovery from delirium tremens.28) It is also a strange, constricted milieu without the usual props to reality; cy¬ cles of the day are disturbed and the interaction with other people is unusual. In states of fatigue and with anxi¬ ety related to death and dying, induced both by a height¬ ened state of internal vigilance and the strangeness of the environment, unexpected events will trip a massive psy¬ chological response in the direction of retreat from real¬ ity. Physiological shifts have altered the internal regu¬ latory mechanism so that it can no longer perform the usual function of distinguishing external fact from inter-
nal
fantasy. The external environment in the SICU does
more usual expectable clues for reality and madness testing, may result. This model can be of practical help in dealing with all patients in the SICU. A good assumption is that all pa¬ tients have a potential for psychological problems (includ¬ ing delirium) as the internal and external factors for keeping reality in focus undergo change; such changes are a certainty for intensive care patients. Most of the pa¬ tients in the SICU will have delusional states in varying degrees while on the unit. Personnel should attempt to keep the external environment unambiguous, and remain patient and human in the face of the patient's unavoid¬ able shifts in internal controls. Calendars (with large type and pull-off pages) and clocks in clear view (perhaps with digital readings) are helpful. Most important is the staff's awareness of the terror the patient feels when disoriented. Such awareness may soften staff annoyance when the patient asks sequential redundant questions. Repetition is always necessary to establish and maintain contact. The sense of a benign environment is essential for the patient. Such attitudes and actions on the part of the staff operate to reduce and to limit delirious states. On occasion, when necessary, the internal state may be directly changed by use of psychoactive medication.
not contain the
Nonproprietary Name
and Trademarks of
Chlorpromazine—Chlor-PZ, Cromedazine, Promachel,
Drug Thorazine.
References 1. Muncie W:
703, 1934.
Postoperative
states of excitement. Arch Neurol 32:681\x=req-\
2. Engel GL, Romano J: Delirium: A syndrome of cerebral insufficiency. J Chronic Dis 9:260-277, 1959. 3. Lipowski ZJ: Delirium: Clouding of consciousness and confusion. J Nerv Ment Dis 145:227-255, 1967. 4. Hackett TP, Weisman AD: Psychiatric management of operative syndromes: II. Psychodynamic factors in formulation and management. Psychosom Med 22:256-372, 1960. 5. Abram HS: Adaptation to open heart surgery: A psychiatric study of response to threat of death. Am J Psychiatry 122:659-667, 1965. 6. Hazan SJ: Psychiatric complications following cardiac surgery: I. A review article. J Thorac Cardiovasc Surg 51:307-318, 1966. 7. Blachly PH, Kloster FE: Relation of cardiac output to postcardiotomy delirium. J Thorac Cardiovasc Surg 52:422-427, 1966. 8. Blachly PH, Starr A: Treatment of delirium with phenothiazine drugs following open heart surgery. Dis Nerv Syst 27:107-110, 1966. 9. Heller SS, Frank KA, Malm JR, et al: Psychiatric complications of open heart surgery. N Engl J Med 283:1015-1019, 1970. 10. Altschule MD: Postoperative psychosis: A biochemical disorder. Med Counterpoint, 1969, pp 23-27. 11. McKegney FP: The intensive care syndrome: The definition, treatment and prevention of a new "disease of medical progress." Conn Med 30:633-636, 1966. 12. Nahum LH: Madness in the recovery room from open heart surgery or "They kept waking me up." Conn Med 29:771, 1965. 13. Morse RM, Litin EH: Postoperative delirium: A study of etiologic factors. Am J Psychiatry 126:388-395, 1969. 14. Deutsch H: Some psychoanalytic observations in surgery. Psychosom Med 4:105-115, 1942. 15. Dlin BM, Fischer HK, Huddell B: Psychological adaption to pacemaker and open heart surgery. Arch Gen Psychiatry 19:599-610, 1968. 16. Linn L, Kahn RL, Coles R, et al: Patterns of behavior disturbances following cataract extraction. Am J Psychiatry 110:281-289, 1953. 17. Gilberstadt H, Sako Y: Intellectual and personality changes following open heart surgery. Arch Gen Psychiatry 16:210-214, 1967. 18. Kennedy JA, Bakst H: The influence of emotions on the outcome of cardiac surgery: A predictive study. NY Acad Med 42:811-845, 1966.
19. Cohen F, Lazarus RS: Active coping processes, coping dispositions and recovery from surgery. Psychosom Med 35:375-389, 1973. 20. Kilpatrick DG, Miller WC, Allain AN, et al: The use of psychological test data to predict open-heart surgery outcome: A prospective study. Psychosom Med 37:62-73, 1975. 21. Da Costa JC: The diagnosis of postoperative insanity. Surg Gynecol Obstet 11:577-584, 1910. 22. Titchener JL, Zwerling I, Gottschalk L, et al: Psychosis in surgical patients. Surg Gynecol Obstet 102:59-65, 1956. 23. Lazaras HR, Hagens JH: Prevention of psychosis following open heart surgery. Am J Psychiatry 124:1190-1195, 1968. 24. Knox SJ: Severe psychiatric disorders in postoperative period: Five year survey of Belfast Hospitals. J Ment Sci 107:1078, 1961. 25. Weisman AD, Hackett TP: Psychosis after eye surgery: Establishment of a specific doctor-patient relationship and treatment of "black patch" delirium. N Engl J Med 258:1284-1289, 1958. 26. Egerton N, Kay JH: Psychological disturbances associated with open heart surgery. Br J Psychiatry 110:433-439, 1964. 27. Kornfield DS, Zimberg S, Malm JR: Psychiatric complications of open heart surgery. N Engl J Med 273:287-292, 1965. 28. Blachly PH, Starr A: Postcardiotomy delirium. Am J Psychiatry 121:371-375, 1965. 29. Layne HR, Yudofsky SC: Postoperative psychosis in cardiotomy patients: The role of organic and psychiatric factors. N Engl J Med 284:518\x=req-\ 520, 1971. 30. Fox JM, Rizzo NO, Clifford S: Psychological observations of patients undergoing mitral surgery. Psychosom Med 16:186-208, 1954. 31. Meyer E, Mendelson M: Psychiatric consultation with patients on medical and surgical wards: Patterns and processes. Psychiatry 24:197, 1961. 32. Sensenback W, Madison L, Eisenberg S: Cerebral hemodynamic and metabolic studies in patients with congestive heart failure: I. Observations in lucid subjects. Circulation 2:697-708, 1960. 33. Greenberg R, Pearlman C, Fingar R, et al: The effects of dream deprivation: Implications for a theory of the psychological function of dreaming. Br J Psychol 43:1, 1970. 34. Hackett TP, Cassom NH, Wishne HA: The coronary care unit: An appraisal of its psychological hazards. N Engl J Med 279:365-370, 1968.
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Postoperative
Delirium
Theodore Nadelson, MD
\s=b\ Delirium
has been defined
as a
condition of cerebral insuffi-
ciency consisting of impairment of cognitive processes, with a characteristic slowing of the electroencephalographic pattern. Present also is a global "clouding" of consciousness, resulting from a potentially reversible impairment of ability to maintain attention. In these states there is usually a simultaneous diminution of the ability to think, perceive, and remember. Although drowsiness may be a part of this state, patients can be awake and yet delirious, with diminished consciousness of their surroundings. Postoperative delirium is seen more often in patients over 50 years of age, in those who are "vigilant" or overalert, and in those undergoing more complex surgery. Adverse influences in the postoperative period are certain drugs and the psychological stresses engendered by the ICU environment. Appropriate management obtains from attention to the impact of the strange environment on the patient. (Arch Surg 111:113-117, 1976) delirious while in a hospi¬ tal. A or silently hallucinating pa¬ tient is often by the medical or surgical staff. The florid, agitated, and delirious patient is more visible, and the symptoms may interfere with care or may trouble those around him. Such a patient often first directs the at¬ tention of the staff to the presence and general impor¬ tance of psychological issues that affect everyone in the Surgical Intensive Care Unit (SICU).
become Many patients quietly deluded unnoticed
Clinical Description
The subject of postoperative delirium continues to hold the attention of many writers in this arena where medipublication May 20, 1975. Psychiatry Service, Beth Israel Hospital, and the Department of Psychiatry, Harvard Medical School, Boston. Reprint requests to Beth Israel Hospital, 330 Brookline Ave, Boston, MA 02215 (Dr Nadelson).
Accepted
From the
for
cal, surgical, and psychological interests converge. In un¬ derstanding the multiconvergence of forces leading to de¬ lirium, we approach etiologic factors, diagnostic problems,
prophylactic principles that have a wider range of ap¬ plication in several problems of psychological disequi¬ librium. In addition, patients with this syndrome also tend to have a less successful surgical result. and
In the 16th century, Paré mentioned a state of postoper¬ ative psychological disequilibrium that Dupuytren, in the 19th century, termed "delirium nervosum."1 Many terms have subsequently been used to characterize this extreme state; it is often unclear whether authors are referring to the rarer schizophrenic reactions, which may be precipi¬ tated postoperatively, or to the more commonly found pe¬ riods of excitement with confusion and disorientation best called "delirium." The difficulty in defining a clinical entity depends in part on the general problems inherent in psychonosology, particularly those involved in cate¬ gorizing a portion of a spectrum of observed aberrations. The terms postoperative "dementia," "delirium," and "psychosis" are still often used interchangeably. Dementia, in the older terminology, referred generally to insanity or madness; it is still used to describe loss of the intellectual functions, resulting from gross changes in the physical functioning of the brain. Delirium has been defined as a condition of cerebral insufficiency, character¬ ized by the basic properties of impairment of cognitive processes along with a slowing of the electroencephalo¬ graphic pattern.- Present also is a global "clouding" of consciousness, resulting from a potentially reversible im¬ pairment of ability to maintain attention and cognitive processes.3 In these states there is usually a simultaneous diminution of the ability to think, perceive, and remem¬ ber. Although drowsiness may be a part of this state, pa¬ tients can be awake and yet delirious, with diminished consciousness of their surroundings.
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Disorientation with regard to time, place, and person has been regarded as the primary distinguishing feature of delirium,2 but patients may be fully oriented, particu¬ larly in the earlier stages.3 Slight disorientation, however, often goes unrecognized because the eliciting questions are not asked or because the patients cannot communicate for other reasons. Patients have difficulty in coherent
thinking, accompanied by anxiety, depression, or apathy, and sleep may be disturbed. Patients can pass rapidly from this stage into full-blown turbulent delirium. They may be transiently aware of their delirious state and even comment on how strangely they are acting. There is usually a paranoid coloring to the patient's thinking. With time the patient's thoughts may become more disorga¬ nized. There are usually wide fluctuations of the level of consciousness during any 24-hour period, so that it is often impossible to ascertain whether there is a positive or negative trend.3 Delirium differs from psychosis in that there is no con¬ stant "structure" to the ideas, such as is found in psychotic states. The steady regressiveness of psychotic thinking is not usually seen, and there is no "fixed ideas."4 A patient with delirium is usually more restless than one who is psy¬ chotic; there is generally less psychological "organiza¬ tion." The quality of the delirious state is haphazard; it is a tangle and confusion of shifting thoughts and feelings, and agitated activity may occur unpredictably. Psychotic states tend to last longer and to remit, when they do, slowly. This is especially true in those cases where there are preoperative psychotic tendencies. Delirium with agitation manifests itself usually before the third to seventh postoperative day and lasts from 24 to 48 hours.5 A longer duration of 14.7 days (average) has been reported in 57% of 139 patients who survived heart surgery.7 Disorientation has been reported lasting as long as a month.8 There is usually a lucid interval of two or three days after surgery before delirium ensues. Some au¬ 6
thors make a distinction between delirium that occurs af¬ ter the lucid interval and another condition, with a differ¬ ent cause, early organic brain syndrome, present from the outset postoperatively.9 The organic brain syndrome is perhaps less influenced by factors within the SICU envi¬ ronment and does not spontaneously remit, although such patients usually become worse in the unit. Cause of
Postoperative Delirium Syndrome
The cause of the postoperative delirium syndrome has been viewed variously as biochemically10 or psychologi¬ cally1112 derived. The syndrome emerges from interaction of a number of specifiable factors. The first set of factors includes the variables present prior to surgery. The second set of factors includes procedures and manipulations in¬ trinsic to the operative procedure. The third set of factors includes both drugs used postoperatively and those vari¬ ables that reside within the SICU milieu itself.
Preoperative The
Factors Associated With Delirium
preoperative factors include those that are usually expected to decrease the ability to withstand stress. In-
creasing age of over 50 years notably increases the risk.3 Senile patients may show a deterioration of postoperative psychological functioning without a lucid interval.9 Viewpoints regarding the influence of gross preopera¬ tive psychological aberrations (psychosis or family history of psychosis) vary, and it is difficult to assess this factor. However, personality styles or modes of coping, with less than usual flexibility under stress, are seen to correlate with delirium postoperatively.13 Patients with depression, functional psychosomatic disease, sleep disturbance, or history of habitual drug use have generally less than aver¬ age coping ability. Preoperative modes of psychological "coping" or "flexi¬ bility" are also important in overall surgical success. In this regard, denial often has been regarded as a maladaptive psychological defense mechanism, correlating with general postoperative psychological complications and in¬ creased morbidity and mortality. It is suggested that the physician approach avoidance actively before surgery.141" Others contest this position.51718 For the psychotherapist, a "breakthrough" in the patient's denial is usually fol¬ lowed by anxiety, which may herald a positive change and emotional reintegration. In our experience most patients who are physically ill deny the extent of their illness or the intensity of their feeling about it in varying degrees. Some degree of denial is normal and functions as a posi¬ tive psychological defensive posture. It has been found by others that a coping style termed "avoidance" (of knowl¬ edge or awareness of the medical condition) leads to more rapid postoperative recovery than does "vigilance" (overalertness to the threatening aspects of upcoming sur¬ gery).19 Most physicians, we have found, have more diffi¬ culty in establishing an alliance with patients who are vigilant, questioning, and suspicious than with those who deny, but are accepting of the physicians good intentions and skill. Denial of a steadfast, unwavering sort, however, often presents a problem for the staff in that it makes it difficult to establish a mutual or cooperative relationship with the patient. General interest in preoperative psychological charac¬ teristics has been in the direction of prediction of postop¬ erative psychiatric complications such as delirium.917 but also in extended psychological effects. The surgeon's par¬ ticular interest in this subject may be more specifically fo¬ cused on whether or not knowledge of preoperative per¬ sonality characteristics should be among the factors to be considered in surgical risk and prognosis. Difference in scores on a battery of psychological and intellectual tests were found to have predictive value in distinguishing sur¬ vivors and nonsurvivors in cardiac surgery.20 It is sug¬ gested that it may be possible, with such information, to ameliorate the degree of risk for some patients.
Operative Factors Associated With Delirium Type of Procedure.—An incidence of 1,250 "mental dis¬ orders" (without specification of the clinical findings) was
reported in all surgical patients in 1910.2' An overall inci¬ psychiatric problems was reported, loosely en¬ compassing delirium or psychosis, which ranges from 0 to dence of
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60%. In
a
random sampling of 200 general surgical pa¬
tients, delirium was found in 78%.22 Some procedures char¬ acteristically eventuate in affectual disturbance; hysterec¬ tomy particularly is indicted.23 Eye operations show a
higher incidence
of postoperative psychiatric states than other nonthoracic surgery.16'24-25 It is difficult to assess in¬ dependence of variables; for example, the age of the pa¬ tient may be highly correlated with the type of procedure, as in cataract surgery. Cardiotomy generally has exceeded other surgical pro¬ cedures in the incidence of postoperative psychiatric com¬ plications, including the major ones of delirium, but also the incidence of the rarer psychosis. The predominance of articles written exclusively on psychiatric aspects of treat¬ ment of the surgical heart patients attests to that. Before 1963, incidence of such complications ranged from 5% to 17%.6 After 1963, an increase has been reported, ranging from 38% to 61%2"-27 and occasionally higher for all behav¬ ioral disorders including delirium. Delirium is reported in one article at 57% of 139 surviving patients.28 More recent studies point to decreasing incidence of postcardiotomy
delirium.9-29
Complexity of Procedure.—It was first suggested that there was a causal relationship between mitral valve pro¬ cedures per se and the postoperative psychiatric complica¬ tions that followed.6 As numbers of intracardiac proce¬ dures increased, it became clear that the abnormality could be causally linked, at least in part, to physiological stresses induced by the operation. As procedures on the heart developed from closed-heart, "finger fracture" valvulotomy to more complicated oper¬ ations involving cardiopulmonary bypass and hypother¬ mia (with attendant longer hours of operation and anes¬ thesia time), the incidence of psychological complications increased. The increasing complexity of newer procedures and technical improvement brought into play the follow¬ ing factors: (1) greater manipulation of life processes, ie, longer anesthesia and bypass time, with greater numbers of drugs in larger amounts and hypothermia, and (2) oper¬ ations on older, sicker patients. In patients subjected to anesthesia time longer than eight hours and bypass time exceeding four hours, there is a 75% incidence of postoperative delirium.28 It is not clear what the underlying physiological factors are; it has been suggested that at least one of the conditions present in long operations is decreased brain perfusion or hypoxia or both. Anoxia resulting from decreased circulating volume has been correlated with postoperative delirium.30 Pa¬ tients who receive transfusion of more than 2 units of blood had a higher incidence of such psychiatric symp¬ toms. However, patients receiving no blood had a higher incidence of symptoms than those receiving up to 10 units. A similar situation is found in the use of hypothermia; hy¬ pothermia of a few degrees below 37 C correlated with a low incidence of psychiatric complications than did an ab¬ sence of hypothermia, and with a much lower incidence than chilling of the patient below 27 C.28 Embolization from use of silicones in the bypass apparatus or from antifoam agents also have been suggested as a cause of de-
creased brain circulation.6 Disturbance of blood gases, hy¬ poxia, hypocapnia, and hypercapnia, are known to cause confusion or psychotic behavior.10 Agents such as suc¬ cinylcholine chloride have been implicated in abnormal psychological states.31 Although one could assume as well
that decreased cardiac output would also be associated with abnormal psychological states, it has been found paradoxically that hallucinations occur with a rapid rise in cardiac output and never when the output is falling.7 High cardiac output is not always associated with hallucina¬ tions, however. One of the more interesting and compelling physiolog¬ ical explanations is in research on catecholamine activ¬ ity. Catecholamine levels are measured at their highest after open-heart surgery and during the time of the usual occurrence of psychiatric symptoms of delirium.6-32 Hy¬ poxia may be a stimulus to increased epinephrine secre¬ tion, and adrenochromes may be produced from epineph¬ rine through abnormal metabolic pathways in some patients on a purely hereditary basis, or released by direct oxygénation of blood in the bypass apparatus. The ob¬ served phenomenon of children's "immunity" to postoper¬ ative psychosis may be due to differences in need or in ability to metabolize amines.26-28 The effect of phenothiazines on postoperative delirium stands in partial support of the "amine theory" as well, since phenothiazines are known to block amine synthesis. There is still some diffi¬ culty in disentangling cause from effect; it c¿.n be specu¬ lated as to whether increase in circulating amines pro¬ ceeds from a psychological state or vice versa. In the past five years, however, a decreased incidence of postcardiotomy delirium has been found.9-29 The operative factors seen as responsible for the change are decreased operative-anesthesia-pump time. As ease with cardiotomy techniques increases more complicated cases are per¬ formed faster. Other factors responsible are better preop¬ erative psychological preparation and greater attention to psychological issues in the SICU postoperatively, which often occurs when the staff becomes more expert in tech¬ nical matters.
Postoperative Factors Associated With Delirium Drugs.—Most of the drugs used after surgery are poten¬ tial factors in the induction of depression, anxiety, delir¬ ium, or psychosis in a predisposed patient. Many of the side-effects of such drugs are well-known and documented, perhaps especially so is that of barbiturate use. The para¬ doxical effect of barbiturates is, however, sometimes for¬ gotten, and in the face of accelerating restlessness a phy¬ sician may order increased doses of barbiturate to "calm" the patient. Anticholinergic drugs (atropine, scopolamine, and re¬ lated compounds), antitussives, anti-Parkinson agents, drugs to control cardiac output and rhythm, the tricyclic antidepressants, and antihistamines may not be recog¬ nized as potential causes of untoward psychological ef¬ fects. Some of these drugs may be used after surgery to provide relief of symptoms; all are said to be capable of promoting major psychological disturbance.10 Cortico-
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steroids have definite dose-related psychological effects. Patients taking steroids (or withdrawing from them) show degrees of aberration ranging through mild eu¬ phoria to delirium and hallucinations. The SICU Environment.-The environment of the SICU itself has long been indicted as a factor in delirium. The first impression of the SICU relates to the intensity of il¬ lumination, visibility of patients, and movements of the staff. Sleeping and dreaming, which impose order on the day and perhaps integrate emotional experience,33 are often disturbed. Patients frequently experience a dis¬ torted sense of expansion and contraction of time. Such a perception arises from fatigue, lack of sleep, or pain with its "minutes-into-hours" phenomenon, and anxiety and depression. There may be no calendar or clock for refer¬ ence, or the patient may not be able to see it. Perception, dulled by pain, weakness, or beginning toxic delirium is further dulled by the limitation imposed by the environ¬ ment. It was found in a medical intensive care unit that half of the patients had lost their time sense.34 Personal change frequently, and the patient often cannot establish a
trusting relationship.
Death is a constant presence and threat. It occurs often in the SICU, and patients are bound to be aware of it, often despite the efforts of the staff to screen them from it. It figures in their fantasies despite denial either of its presence or of the intensity of its emotional impact. Treatment
Phenothiazines are effective against postoperative de¬ lirium.11·28 There is often a reluctance to use these potent agents because of potential hypotensive side-effects. In one study, however, the major hypotensive effect of phenothiazines is postoperative delirium was found to be minimal.8 Phenothiazines may be used safely in treatment of postoperative delirium if the initial dose of chlorpromazine does not exceed 25 mg given intramuscularly and if there is careful monitoring. If this dose is tolerated, addi¬ tional doses may be used from five to six hours thereafter until abnormal behavior remits. The hypotensive effect does not seem to be dose-related. Trifiuoperazine hydrochloride is less sedating, may have a lesser hypotensive ef¬ fect, and is suggested as a possible alternative treatment in doses of 2 mg, four times daily. Haloperidol, a butyrophenone derivative, 2 mg given two to four times a day, is an effective medication against psychosis, with a wide dose range of therapeutic efficacy and a minimal risk of hypotensive side-effect. Barbiturates should not be used since they often increase agitation.6 Supportive psychological treatment in the SICU is often effective and less dangerous than drug treatment. More¬ over, most symptoms remit without intervention after a relatively short period of time. There is often an insis¬ tence on the part of medical personnel to control the pa¬ tient either by medication or physical restraint. Such mu¬ tual agitation usually has "feedback" characteristics. If there is calm in the face of the patient's delirium, and ac¬ ceptance of such behavior without necessity for immedi¬ ate control, staff members can quietly and firmly control
such
behavior, often without use of medication (and its side-effects), and usually without physical restraints. Calm on the part of the staff can be promoted by open discussion
of the stresses induced by the aberrant behavior. The atti¬ tude of the nursing personnel toward such psychological issues has been important in our experience. The patient should not be placed in restraints unless absolutely neces¬ sary, and then only when a staff member can be close to him. Group discussions with the unit psychiatrist allows for ventilation, sharing, and understanding of staff feel¬
ings.
The question certainly can be raised in some cases as to whether factors within the environment are responsible for symptoms or their remission. With many patients a persuasive cause-effect relationship has been demon¬
strated. For example, a request for a psychiatric consultation was made for a 56-year-old man with a postmyocardial in¬ farcì and described as "agitated, delirious, and combat¬ ive." When first seen he was in bed in a single, windowless room, in physical restraints, struggling, and inappropriate in his responses. His room was next to the medication station where two nurses were talking. His door was ajar, and the room was half illuminated. The psychiatric consultant spoke to the patient by name, removed the restraints, turned the room lights on to full illumination. The psychiatrist continued to talk with the patient loudly and clearly. The patient's re¬ sponses became increasingly appropriate. Personnel were advised to be as definite with the patient as possible, to leave the room door either fully open or fully closed, and not to talk outside of his door. A calendar and clock were provided. The patient exhibited no further delirium. CONCLUSIONS
Delirium, from
psychological perspective, is an overbehavioral/psychological ma¬ neuvers, with particular use of those defenses lowest on the adaptive hierarchy (denial, isolation, projection, and delusion). It then is both a last ditch defense and also a de¬ terioration of defenses. (It is analogous on the behavioral level to the biological phenomenon of anaphylaxis.) The usual feeling of being in touch with reality and with one's own feelings depends both on intactness of internal regu¬ latory mechanisms and external constancies embedded in the "average expectable environment." Internal controls emerge from (1) neurologically based perceptual mecha¬ nisms (innate and learned), (2) cognitive mechanisms, and (3) affectual controls derived from parental and societal training and reinforcement. These internal controls are known as ego functions. The average expectable environ¬ ment is one of more or less usual stimulus input. There is
magnification
a
of the usual
continuous interaction between an individual's ego func¬ tions and the environment. Certain actions of the person are reinforced by the environment (and particularly by the people within it), other actions are tolerated, and still others are unacceptable. The physical environment "rein¬ forces" or "condemns" acts (playing with fire often leads to pain), as does society. The individual affects his envi-
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ronment too,
by changing it to his needs and accepting or
rejecting aspects of it. The adult patient in the SICU is in a state of more than usual dependence on his environment. He is forced both by illness and the passivity necessitated by treatment to abdicate the usual decision-making processes. This posi¬ tion of enforced passivity usually leads to relinquishing many of the adult psychological functions. With a norma¬ tive internal state the person can recognize an environ¬ ment as "strange." An aberrant event can be "put in place" as unique. With the regressive pull enforced by his extreme passivity and with physiological shifts altering perception and cognition, the patient often cannot distin¬ guish an event as strange; he feels strange in the face of stimuli that are not immediately understandable. The en¬ vironment also engenders fatigue and reduces sleeping and dreaming. (There is sometimes a dramatic termi¬ nation of delirium after a long, restful sleep, somewhat
like recovery from delirium tremens.28) It is also a strange, constricted milieu without the usual props to reality; cy¬ cles of the day are disturbed and the interaction with other people is unusual. In states of fatigue and with anxi¬ ety related to death and dying, induced both by a height¬ ened state of internal vigilance and the strangeness of the environment, unexpected events will trip a massive psy¬ chological response in the direction of retreat from real¬ ity. Physiological shifts have altered the internal regu¬ latory mechanism so that it can no longer perform the usual function of distinguishing external fact from inter-
nal
fantasy. The external environment in the SICU does
more usual expectable clues for reality and madness testing, may result. This model can be of practical help in dealing with all patients in the SICU. A good assumption is that all pa¬ tients have a potential for psychological problems (includ¬ ing delirium) as the internal and external factors for keeping reality in focus undergo change; such changes are a certainty for intensive care patients. Most of the pa¬ tients in the SICU will have delusional states in varying degrees while on the unit. Personnel should attempt to keep the external environment unambiguous, and remain patient and human in the face of the patient's unavoid¬ able shifts in internal controls. Calendars (with large type and pull-off pages) and clocks in clear view (perhaps with digital readings) are helpful. Most important is the staff's awareness of the terror the patient feels when disoriented. Such awareness may soften staff annoyance when the patient asks sequential redundant questions. Repetition is always necessary to establish and maintain contact. The sense of a benign environment is essential for the patient. Such attitudes and actions on the part of the staff operate to reduce and to limit delirious states. On occasion, when necessary, the internal state may be directly changed by use of psychoactive medication.
not contain the
Nonproprietary Name
and Trademarks of
Chlorpromazine—Chlor-PZ, Cromedazine, Promachel,
Drug Thorazine.
References 1. Muncie W:
703, 1934.
Postoperative
states of excitement. Arch Neurol 32:681\x=req-\
2. Engel GL, Romano J: Delirium: A syndrome of cerebral insufficiency. J Chronic Dis 9:260-277, 1959. 3. Lipowski ZJ: Delirium: Clouding of consciousness and confusion. J Nerv Ment Dis 145:227-255, 1967. 4. Hackett TP, Weisman AD: Psychiatric management of operative syndromes: II. Psychodynamic factors in formulation and management. Psychosom Med 22:256-372, 1960. 5. Abram HS: Adaptation to open heart surgery: A psychiatric study of response to threat of death. Am J Psychiatry 122:659-667, 1965. 6. Hazan SJ: Psychiatric complications following cardiac surgery: I. A review article. J Thorac Cardiovasc Surg 51:307-318, 1966. 7. Blachly PH, Kloster FE: Relation of cardiac output to postcardiotomy delirium. J Thorac Cardiovasc Surg 52:422-427, 1966. 8. Blachly PH, Starr A: Treatment of delirium with phenothiazine drugs following open heart surgery. Dis Nerv Syst 27:107-110, 1966. 9. Heller SS, Frank KA, Malm JR, et al: Psychiatric complications of open heart surgery. N Engl J Med 283:1015-1019, 1970. 10. Altschule MD: Postoperative psychosis: A biochemical disorder. Med Counterpoint, 1969, pp 23-27. 11. McKegney FP: The intensive care syndrome: The definition, treatment and prevention of a new "disease of medical progress." Conn Med 30:633-636, 1966. 12. Nahum LH: Madness in the recovery room from open heart surgery or "They kept waking me up." Conn Med 29:771, 1965. 13. Morse RM, Litin EH: Postoperative delirium: A study of etiologic factors. Am J Psychiatry 126:388-395, 1969. 14. Deutsch H: Some psychoanalytic observations in surgery. Psychosom Med 4:105-115, 1942. 15. Dlin BM, Fischer HK, Huddell B: Psychological adaption to pacemaker and open heart surgery. Arch Gen Psychiatry 19:599-610, 1968. 16. Linn L, Kahn RL, Coles R, et al: Patterns of behavior disturbances following cataract extraction. Am J Psychiatry 110:281-289, 1953. 17. Gilberstadt H, Sako Y: Intellectual and personality changes following open heart surgery. Arch Gen Psychiatry 16:210-214, 1967. 18. Kennedy JA, Bakst H: The influence of emotions on the outcome of cardiac surgery: A predictive study. NY Acad Med 42:811-845, 1966.
19. Cohen F, Lazarus RS: Active coping processes, coping dispositions and recovery from surgery. Psychosom Med 35:375-389, 1973. 20. Kilpatrick DG, Miller WC, Allain AN, et al: The use of psychological test data to predict open-heart surgery outcome: A prospective study. Psychosom Med 37:62-73, 1975. 21. Da Costa JC: The diagnosis of postoperative insanity. Surg Gynecol Obstet 11:577-584, 1910. 22. Titchener JL, Zwerling I, Gottschalk L, et al: Psychosis in surgical patients. Surg Gynecol Obstet 102:59-65, 1956. 23. Lazaras HR, Hagens JH: Prevention of psychosis following open heart surgery. Am J Psychiatry 124:1190-1195, 1968. 24. Knox SJ: Severe psychiatric disorders in postoperative period: Five year survey of Belfast Hospitals. J Ment Sci 107:1078, 1961. 25. Weisman AD, Hackett TP: Psychosis after eye surgery: Establishment of a specific doctor-patient relationship and treatment of "black patch" delirium. N Engl J Med 258:1284-1289, 1958. 26. Egerton N, Kay JH: Psychological disturbances associated with open heart surgery. Br J Psychiatry 110:433-439, 1964. 27. Kornfield DS, Zimberg S, Malm JR: Psychiatric complications of open heart surgery. N Engl J Med 273:287-292, 1965. 28. Blachly PH, Starr A: Postcardiotomy delirium. Am J Psychiatry 121:371-375, 1965. 29. Layne HR, Yudofsky SC: Postoperative psychosis in cardiotomy patients: The role of organic and psychiatric factors. N Engl J Med 284:518\x=req-\ 520, 1971. 30. Fox JM, Rizzo NO, Clifford S: Psychological observations of patients undergoing mitral surgery. Psychosom Med 16:186-208, 1954. 31. Meyer E, Mendelson M: Psychiatric consultation with patients on medical and surgical wards: Patterns and processes. Psychiatry 24:197, 1961. 32. Sensenback W, Madison L, Eisenberg S: Cerebral hemodynamic and metabolic studies in patients with congestive heart failure: I. Observations in lucid subjects. Circulation 2:697-708, 1960. 33. Greenberg R, Pearlman C, Fingar R, et al: The effects of dream deprivation: Implications for a theory of the psychological function of dreaming. Br J Psychol 43:1, 1970. 34. Hackett TP, Cassom NH, Wishne HA: The coronary care unit: An appraisal of its psychological hazards. N Engl J Med 279:365-370, 1968.
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