The most common psychological factor that complicates the surgical assessment is a low pain threshold and a tendency to somatize, i.e. to experience and communicate emotional distress in physical terms. When emotional factors amplify somatic symptoms, it is more difficult to distinguish organic from functional disorders on the basis of the clinical history. At the extreme end of the continuum of somatization is the dramatic presentation of physical symptoms, which may mimic a surgical condition, in the absence of organic disease. This syndrome may fulfil criteria for a somatoform disorder, such as a somatization disorder, conversion disorder, or somatoform pain disorder.⁽¹⁾ In such cases, careful attention to the objective indications for surgery is required. Individuals with a body dysmorphic disorder, a syndrome of perceived or imagined ugliness, may present with repeated requests for cosmetic surgery.⁽²⁾ However, cosmetic surgery is unlikely to relieve the body dissatisfaction of such patients, whose condition has much in common with obsessive–compulsive disorder. Dissatisfaction with the results of surgery is common in patients with body dysmorphic disorder, and litigiousness and threats towards the treating surgeon may occur in a small proportion of cases. In general, the failure of clinicians to consider the contribution of somatization to the clinical presentation may lead to unnecessary or inappropriate surgery. When this occurs, post-surgical complications may interfere with the subsequent evaluation of persistent physical symptoms. Somatoform disorders are discussed further in Chapter 5.2.2.

Although physicians commonly consider that emotional factors may amplify physical symptoms, the possibility that disease has been intentionally simulated or fabricated is usually not entertained. Factitious disorder refers to a syndrome in which such behaviour is enacted for no apparent reason, other than to assume the patient role. This is in contrast with malingering, in which there may be reports of physical symptoms motivated by the desire for some specific secondary gain, which may be financial or compensationrelated. While relatively rare, factitious disorder poses particular challenges, in both detection and treatment, to psychiatric and surgical teams. Individuals with this disorder may produce or simulate disease in various ways, such as by self-inflicting wounds that require surgical intervention or by surreptitiously contaminating themselves to produce infection. Patients with this condition may also communicate plausible symptoms of a surgical condition. Such patients are at risk to receive unnecessary surgery and should be regarded as suffering from a serious and potentially life-threatening condition. The majority of such patients are unwilling to accept psychological or psychiatric assistance, but an ongoing, supportive relationship with a medical caregiver may diminish this symptom pattern. Factitious disorder is discussed further in Chapter 5.2.9.

Providing information and obtaining informed consent are routine and essential aspects of preoperative care provided by the surgical team. Informed consent to a surgical procedure requires disclosure of pertinent information by the treating physician, and understanding of the information, decisional capacity, and voluntary choice on the part of the patient.⁽³⁾ The decisional capacity of patients depends on their ability not only to understand information relevant to the decision, but also to apply it to their own situation and to express a consistent voluntary choice.⁽⁴⁾ Information required by patients to make an informed surgical decision includes the rationale, risks, and benefits of the surgery, the potential alternative treatments, and the risk of not proceeding with surgery. In most jurisdictions, the emergency treatment of incapable persons is permitted, when substitute consent is not available, unless the clinician has reason to believe that the person would refuse such treatment if he or she were capable.⁽³⁾ When it is not an emergency, substitute consent must be obtained on behalf of individuals who are incapable of providing informed consent. The legal requirements for substitute consent vary in different jurisdictions.

The capacity to provide informed consent may be impaired by cognitive dysfunction, by psychiatric illness, or by contextual factors, such as the clarity and relevance of the information disclosed or the manner of disclosure. If screening by the treating surgeon indicates that the patient may be incapable, a psychiatric consultation may be requested to evaluate the patient’s decisional capacity.⁽⁵⁾ Patients with cognitive impairment or a major psychiatric disorder, such as schizophrenia, are not necessarily incapable of making treatment decisions, unless these conditions affect their understanding and appreciation of information relevant to the decision. Numerous tools have been developed to assess decisional capacity but there is no current gold standard.⁽⁶⁾

Obtaining informed consent for surgery is not only a legal and ethical requirement, but also a crucial dimension of the surgeon– patient relationship. In some cases, treatment refusal reflects a breakdown in the relationship between the surgeon and the patient more than it does an informed decision of the patient to reject a
recommendation for surgery. When this occurs, attention to the physician–patient relationship, and the provision of additional information, may help to relieve the impasse so that an informed decision can be made. In other cases, treatment of a major psychiatric illness, such as a psychotic episode in a patient with schizophrenia, is necessary to restore the patient’s capacity to provide consent.

Surgical patients face numerous stressors, including the fear of pain, disfigurement, and the loss of control, as well as the possibility of major medical complications and death. The response to these stressors may be affected by the nature of the illness and the surgical procedure, its personal meaning, the prior history of trauma, the support which is anticipated and perceived from medical caregivers and significant others, and the prior experience of the individual with medical or surgical procedures. The age and life stage of the individual, the risk associated with the procedure, and the prognosis of the underlying or associated medical conditions may also affect the psychological response in the perioperative period. Apprehension and mistrust are more common in those who have previously suffered from the adverse effects of missed or delayed diagnosis or treatment. Attitudinal factors, including positive expectations and the desire to participate actively in the recovery process, may also affect clinical outcomes. The desire to maintain a sense of control may be adaptive during the preparation and rehabilitation phases but may be associated with greater distress immediately following surgery, when there is an inescapable and predominant requirement to depend on others.⁽⁷⁾ Those with more attachment anxiety, i.e. concern about the availability of support from others, may benefit from predictability and reliability in relation to caregivers, whereas those who tend to be more self-sufficient may benefit most from strategies which promote self-reliance and self-care.^{(8, 9)}

There has been particular interest in psychosocial issues in the setting of transplantation surgery. This occurred, in part, because of the desire of transplant programmes to select optimal candidates for organ transplants, which were experimental and/or in scarce supply. However, the psychiatric and psychosocial selection criteria for transplant surgery have become less stringent, as the transplantation of particular organs has become more routine.⁽¹⁰⁾ At present, psychosocial evaluation of transplant candidates by a multidisciplinary team allows for the identification, treatment, and monitoring of factors that may affect compliance, morbidity, and psychosocial outcomes. Organ transplants from living donors, such as for bone marrow, kidney, and liver transplantation, are unlike most other surgical interventions in that they necessitate surgery for individuals without pre-existing disease. Psychosocial evaluation of such donors includes consideration of the process of decisionmaking and informed consent, the adaptive capacities of the individual, the degree of social support, and the relationship of the donor to the recipient.⁽¹¹⁾ Although there has been concern about the psychological consequences of such surgery, the available evidence suggests that organ donation is usually well tolerated and experienced in positive terms by the donor, particularly when the surgical and medical outcomes are favourable.⁽¹²⁾

There is now increasing evidence that the systematic preoperative education of patients and their family caregivers in a therapeutic context may enhance adjustment to surgical procedures.⁽¹³⁾ Postoperative education may also improve subsequent rehabilitation following surgical procedures. Such approaches are consistent with modern Western trends towards consumerism and patient empowerment, in which greater emphasis is placed on assisting patients to assume more responsibility for their medical course and treatment outcome. This approach has also been necessitated by the trend towards earlier hospital discharge of surgical patients into the community where much more self-care is required.

Preoperative anxiety is common and may be particularly problematic in patients awaiting procedures such as transplantation, which usually occur in the course of a life-threatening condition, and are associated with long and unpredictable waiting periods for surgery. Anxiety has been reported to be more common in younger patients, in females, and in those who are unmarried or who have less perceived social support.⁽¹⁴⁾ Research suggests that preoperative anxiety may complicate postoperative recovery through behavioural and physiological mechanisms.⁽¹⁵⁾ Symptoms of anxiety can usually be managed with education and reassurance, but when they are persistent and problematic, interventions such as progressive relaxation and guided imagery may be helpful both to reduce symptoms of anxiety and to enhance feelings of self-control.⁽¹⁶⁾ Some patients benefit from a benzodiazepine to reduce preoperative anxiety, but those with antecedent anxiety disorders may require more intensive intervention, as outlined in Chapter 4.6.1. Prior to elective procedures, patients with specific blood or needle phobias may benefit from systematic desensitization. Those with comorbid panic disorder may require a higher dose of anxiolytic medication in the preoperative period. The surgical team should be aware of such treatment so that the medication can be restarted promptly after surgery, to avoid symptoms of withdrawal and anxiety. If oral medications cannot be reinstituted for a prolonged period of time after surgery, intramuscular lorazepam or intravenous lorazepam or diazepam may be used.