Professional Documents
Culture Documents
of Orthopaedics
Abstract
Although psychiatric problems are seen less frequently than
previously, the orthopaedic surgeon must remain aware of their
possible effect. A high index of suspicion for the presence of
psychiatric disorders is important in treating the orthopaedic
patient with multiple trauma, chronic disease, factitious disorder,
or suspected malingering or who fails to improve with recognized
treatment. Recognition of a psychiatric problem should be part of
preoperative planning in orthopaedic practice, and a formal
psychiatric referral for diagnosis and treatment should be made for
the patient with significant psychiatric involvement. When
associated psychiatric disease is diagnosed and controlled before
orthopaedic treatment commences, the patient is more likely to
comply with the treatment regimen, which may lead to better
results.
Patient Well-being
Vital balance, which is the life process in mental health and illness, is
dependent on the interaction of the
psychological and physiologic adaptation to illness, surgery, and recovery.5 The surgeon, anesthetist, consultant psychiatrist, and nursing
42
staff are jointly responsible for maintaining or improving the vital balance of the patient who is undergoing successive phases of surgical
care. Staff members should be aware
of the frequent temporary events of
emotional disturbance that may occur following surgery.3 The health
care staff, including the surgeon,
should cultivate a relationship with
the patient.5
The same sympathetic capacity
helps the surgeon decide when to defer treatment, when to reassure the
patient, and when to share with the
patient his or her own perceptions
and observations of the patients
feelings and behavior. All of this assistance depends on a constructive
surgeon-patient relationship6 and a
supportive emotional environment
provided by the coordinated efforts
of the staff.
Psychiatric Assessment
A full psychiatric history is not
needed. However, it is necessary to
identify patients in whom there is a
high index of suspicion of psychiatric illness. The decision for psychological testing is based on a previous
history of psychiatric disorder and a
positive family history, as well as on
the presence of severe mutilating
injury, limb amputation or genital
injury, or a chronic or incurable condition (eg, amyotrophic lateral sclerosis, malignancy, advanced rheumatoid arthritis).
The mental status of the patient
usually can be discerned by careful
observation during the patient interview. A few additional minutes
spent with the patient, addressing
general health-related complaints
and assessing the attitude related to
the disease or injury, can help in
making this evaluation. The orthopaedic surgeon should observe
whether a mood change is an appropriate response to the physical condition of the patient. Diminishing
effectiveness of analgesic medication is suggestive of a reduced pain
with physical illness include somatoform disorders, factitious disorder, malingering, compensation neurosis, and chronic fatigue syndrome.
Somatoform Disorders
Table 1
Psychiatric Disorders in
Orthopaedic Patients
Psychiatric disorder presenting
with physical illness
Somatoform disorders
Somatization disorder
Conversion disorder
Pain disorder
Hypochondriasis
Dysmorphic disorder
Factitious disorder
Malingering
Compensation neurosis
Chronic fatigue syndrome
Psychiatric consequence of
orthopaedic disease or injury
Orthopaedic disease
Psychiatric side effects of
medications
Posttraumatic stress disorder
Psychological factors as a cause of
physical illness
Psychiatric factors affecting
medical condition
Psychiatric disorder
Psychological symptoms
Personality trait
Maladaptive health behaviors
Stress-related physiologic
response
The patient with factitious disorder intentionally simulates or produces symptoms of illness for the
purpose of achieving the sick role
but presents with no obvious, recognizable pathology or reasons for
persistent underlying illness.6-8 Selfinjury may be present. Direct efforts
to confront a patient with factitious
disorder may be counterproductive.
43
Malingering
Psychological Symptoms
When stress producers are causally related to the onset or exacerbation of a condition, the patient is
said to be experiencing a stressrelated physiologic response.6 An example is the patient with disk prolapse whose back pain and radicular
symptoms are well controlled but
who becomes symptomatic following exposure to a stressor. At times,
however, this response can serve the
patient well. For example, I have observed rapid fracture healing in political prisoners and patients who are
under security arrest.
Discussion
Orthopaedic disease, injury, and
multisystem trauma may tax the
psyche of a patient in many ways in
both acute and chronic conditions.
Awareness of the interplay between
the orthopaedic condition and any
comorbid psychiatric problem is
central to treatment. An attempt
should be made with every patient
to assess the contribution of psychological factors to the clinical presentation. A formal psychiatric referral
Volume 16, Number 1, January 2008
Summary
Psychological and social factors
should be taken into consideration
when diagnosing and developing a
treatment plan for the patient with
orthopaedic disease or injury. Depression may appear in the postoperative period without warning; it usually forecasts poor recovery from
surgery, recurrence of original symptoms, and onset of new physical or
psychological symptoms. Although
the surgeon may prescribe medication for the patient with a minor
psychiatric disorder, comprehensive
treatment should be left to a psychiatrist.
A high index of suspicion for the
presence of psychiatric disorders is
mandatory in treating the ortho45
Acknowledgment
The author acknowledges the kind
help and support of Dr. Alexander
Benjamin, Consultant Orthopaedic
Surgeon, Retired. His constructive
remarks were very useful and encouraging.
References
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