Psychological Observations of Patients Undergoing Mitral Surgery

Summary Thirty-two patients with mitral stenosis who had mitral surgery were interviewed by psychiatrists preoperatively and also postoperatively. An understanding of long-term adaptation to progressive limitation of activities provided the necessary background for the recognition of emergency defenses as they developed in the hospital situation both before and after operation. The interviewing technique focused on emotionally meaningful material concerning the adjustment to limitation of activities and on the feelings and phantasies about the operation. Complete tape recordings were made of all the interviews. This information was then condensed to the essential preoperative and postoperative observations and charted with a brief interpretation of the psychological defenses illustrated by each case. The most important medical and surgical events during hospitalization were also reviewed. The patients were grouped according to the clinical classification of Harken and Dexter as follows: Group I, o; Group II, 5; Group III, 18; Group IV, 9 (in 4 of these, mitral insufficiency rather than mitral stenosis was predominant). There were 23 females and 9 males. The median age was 37 years. The medical histories were summarized and charted. The effect on the patient of learning that he had heart disease depended on the stage of his emotional development, his life circumstances, and his personality. The awareness of dyspnea was found to be a realistic response to the increasing disturbance of the cardiovascular function but was also influenced by experiences to which the patient was psychologically vulnerable. The attitude of the patients toward limitation of activity was influenced by the meaning of the illness to them. Long-term psychological defenses included narcissism, submission to a higher power, and activity. Emergency defenses included immobilization, hysterical amnesia or depersonalization, belligerence, excitement, and desperate denial. In some instances the stress was so severe that the patients seemed virtually defenseless and were close to panic. In others the psychological defenses were inadequate and unsuccessful to such an extent that the patients bordered on psychosis. All of these complained of pain to such an exaggerated extent that it seemed to represent a masochistic clinging to suffering. The transference to the surgeon is described and psychotherapy is discussed.