Technological advances in medicine and dentistry have led to an increase in stressful medical procedures (diagnostic and treatment), presenting problems for health care providers. Agitated patients require more analgesia or sedation, and are more likely to encounter complications. Evidence also indicates that those who tolerate procedures poorly recover more slowly. Finally, those who experience greater distress during a medical or dental procedure may be less likely to return for additional diagnosis or treatment.
Invasive and Noninvasive Procedures
Stressful procedures are those that tax a patient’s ability to adapt physically and emotionally. Many procedures invade the person’s physical boundaries, often while the person is conscious or only minimally sedated. Invasive procedures include all types of surgery, many dental procedures, diagnostic procedures such as cardiac catheterization and colonoscopy, specimen collection, particularly the drawing of blood, and repetitive procedures such as burn debridement and cancer chemotherapy.
Procedures do not need to be invasive to be considered stressful. Noninvasive diagnostic procedures such as magnetic resonance imaging and computed tomography (CT) scan often require the patient to remain perfectly still for several minutes inside a narrow tunnel. Other procedures involve relatively minor bodily invasions, but may involve great psychological threat, such as genetic testing for breast cancer vulnerability.
There is great variability among people in how a procedure may affect them. For some, the experience of surgery is less challenging than lying inside a CT scanner for 45 min. According to Hans Selye, the Austrian physiologist and father of the concept of human stress, the stressfulness of a situation lies not in the situation itself, but in how the person reacts to it.
Emotional and Cognitive Responses to Stressful Medical Procedures
The emotional response to a stressful procedure is characterized by feelings of fear, anxiety, and panic. The accompanying physiological response to these emotions can include increased heart rate, sweating, increased blood pressure, and increased muscle tension. Selye referred to this initial response as the alarm reaction.
The cognitive reactions, the thoughts that accompany this experience, may include catastrophizing cognitions (“This is terrible!”), predictions of harm, and a perception of loss of control. The psychologist Richard Lazarus called this cognitive process the primary appraisal of the situation. Efforts to prepare patients to tolerate stressful medical and dental procedures have primarily been aimed at altering these initial emotional and cognitive responses.
Efforts at Intervention
The first study to systematically prepare patients for a stressful medical procedure was conducted by the physician Lawrence Egbert and his colleagues at the Massachusetts General Hospital in 1964. A group of patients scheduled for major surgery was given specific information about what they would experience before, during, and after the operation, and about how to best manage pain after the surgery. This group required less pain medication in the hospital and were ready for discharge sooner than a comparable group of patients that was not given the information and instructions. This study set the stage for more systematic studies of preparing patients for surgery. Since then, interventions have been tested in primarily two areas: the provision of information, intended to alter patients’ stress-related cognitions, and variants of distraction and relaxation training, intended to alter the emotional and physical responses to stressful medical and dental procedures.
Provision of Information
There are two types of information that may be given in preparing people for medical or dental procedures: procedural and sensory. Procedural information consists of a description of the procedures involved in the event: what actions will be taken, the timing of actions, and the likely outcomes. Sensory information consists of the sensations a person is likely to experience during and after the procedure.
Both types of information should help a patient develop accurate expectations and feel a sense of increased control in the situation. Some have argued, however, that sensory information should be more effective than procedural information because the foreknowledge of how something will feel can actually help alter the sensation. Procedural information only provides a view of what will occur. In the case of extensive or very invasive procedures, this type of information might actually be undesirable for some people.
To answer the question as to which type of information is more effective, psychologists Jerry Suls and Choi K. Wan reviewed studies in which procedural and sensory information was compared. Although sensory information yielded better outcomes than procedural information in some categories, the biggest effects were seen with a combination of procedural and sensory information. The recommendation for patients facing stressful procedures, then, would be that both sensory and procedural information should be provided.
Distraction interventions seek to draw the patient’s attention away from the details of the stressful procedure. In this way the person is less apt to fully process the experiences as they occur, and the emotional impact should be less. Distraction procedures may involve having the patient listen to music, watch a video, or perform a cognitive task such as mental arithmetic. Intentional shifting of attention away from a stressful experience can increase pain tolerance and decrease physiological arousal and emotional distress.
Literature reviews by Mullen and Suls in 1982 and by McCaul and Malott in 1984 added to our knowledge about the utility of distraction. Distraction results in less distress in the short term, but attentional strategies that seek to change perception of the stressor may have better effects in the long-term. Additionally, the more attention the distraction strategy requires, the more effective it becomes. Distraction strategies are effective at low intensities of pain or distress, but are ineffective at higher intensities. At higher intensities of distress, people may no longer be able to distract themselves, and may be forced to employ a more attention-oriented coping strategy (e.g., trying to control the sensory aspects of the experience through relaxation). Distraction remains an attractive option for intervention in relatively low-stress procedures.
Relaxation has frequently been used to alter the emotional and physiological impact of stressful procedures. Relaxation accomplishes several goals at once. First, it directly dampens the physiological reactivity seen in stressful situations. It lowers heart rate and blood pressure, and helps to diminish muscle tension. Second, because systematic relaxation requires concentration, it acts as a distraction from the stressful experience. Finally, the availability of relaxation offers the person a way to have some control in the situation.
Relaxation training may consist in having the person alternately contract and release muscle groups, as in progressive muscle relaxation, or may simply involve asking the patient to breathe deeply and to concentrate on keeping the body relaxed. The training may consist of practice before the medical procedure, or of following taped relaxation instructions while undergoing the procedure. Relaxation training has demonstrated effectiveness in reducing patient distress in a number of settings, including abdominal surgery, oral surgery, and gastrointestinal endoscopy.
Other methods have also been used to help prepare patients, particularly children, for stressful medical procedures. In systematic desensitization, the patient is exposed to anxiety-provoking stimuli (e.g., the dental drill, a syringe) while relaxed and calm, before the actual medical or dental procedure begins. The intent is to minimize the physical and emotional reactions of the patient when he or she encounters those stimuli during the actual procedure.
Modeling involves the patient watching another person, usually on film, go through the same stressful procedure that he or she will go through. The models provide sensory and procedural information, and set a standard of behavior to follow. Models tend to work best in those with no experience with the stressful procedure.
Combined techniques or programs have also been used to prepare patients. Stress inoculation, for example, occurs in three stages: client preparation (information), skills training, and application training. Stress inoculation has been conducted for patients undergoing orthopedic surgery, dental treatment, and open heart surgery. Most programs to prepare patients for stressful procedures have multiple components, combining information with coping skills training (e.g., relaxation, distraction).
Other techniques have been employed to help patients prepare for stressful procedures, including hypnosis, meditation, and imagery. Hypnosis has been used extensively in medicine and dentistry for acute pain control. The effectiveness reported for hypnosis, however, as for meditation and imagery interventions, may simply be the result of relaxation.
Interactions with Coping Style
It is generally assumed that any intervention that provides the patient with an increased sense of control will be helpful to that person. However, an intervention that is not congruent with a person’s coping style may be ineffective, or even harmful.
Coping style refers to a person’s preferred way of dealing with a stressful encounter. Several coping styles have been identified in the literature. Among these is the tendency to either avoid, ignore, or deny the details of a situation. Those who do this have been termed blunters by psychologist Suzanne Miller, and those who attend to those details are called monitors. Related coping-style types include repressors, who are similar to blunters, and sensitizers, who resemble monitors.
Providing detailed information to blunters has been found to actually increase patient distress in some cases. On the other hand, relaxation and distraction strategies tend to be most effective with those people who prefer to avoid or ignore the details of stressful situations.
As medicine continues to advance and access to care widens, exposure to stressful medical procedures will increase. The demand for high-quality care will increasingly require that patients facing stressful medical and dental procedures be prepared. Intervention programs that combine multiple modalities, including preparatory information, distraction, and relaxation, will probably prove to be the most useful. Delivery of these interventions, however, will have to be adjusted according to the coping preferences of the patient.
- Egbert, L. D., Batit, G. E., Welch, C. E., & Bartlett, M. K. (1964). Reduction of postoperative pain by encouragement and instruction of patients: A study of doctor-patient rapport. New England Journal of Medicine, 270, 825-827.
- Lazarus, R. S. (1966). Psychological stress and the coping process. New York: McGraw-Hill.
- Litt, M. D., Nye, C., & Shafer, D. (1995). Preparing for oral surgery: Evaluating elements of coping. Journal of Behavioral Medicine, 18, 435-459.
- Logan, H., Baron, R. S., Keeley, K., Law, A., & Stein, S. (1991). Desired and felt control as mediators of stress in a dental setting. Health Psychology, 10, 352-359.
- Miller, S. M. (1988). The interacting effects of coping styles and situational variables in gynecologic settings: Implications for research and treatment. Journal of Psychosomatic Obstetrics and Gynecology, 9, 23-34.
- McCaul, K. D., & Malott, J. M. (1984). Distraction and coping with pain. Psychological Bulletin, 95, 516-533.
- Mullen, B., &c Suls, J. (1982). The effectiveness of attention and rejection as coping styles: A meta-analysis of temporal differences. Journal of Psychosomatic Research, 26, 43-49.
- Selye, H. (1956). The stress of life. New York: McGraw-Hill.
- Suls, J., & Wan, C. K. (1989). Effects of sensory and procedural information on coping with stressful medical procedures and pain. A meta-analysis. Journal of Consulting and Clinical Psychology, 57, 372-379.
- Turk, D. C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: A cognitive—behavioral perspective. New York: Guilford.
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