Psychosomatic Medicine 22:356-372 (1960)
© 1960 American Psychosomatic Society

Psychiatric Management of Operative Syndromes

II. Psychodynamic Factors in Formulation and Management

¹ Department of Psychiatry, Massachusetts General Hospital
² Department of Neurology and Psychiatry, Harvard Medical School

Surgical patients may develop a variety of psychological disorders during the preoperative, postoperative, and convalescent periods. These psychiatric complications of surgery are called operative syndromes. While one syndrome may differ empirically from another, they have a common psychodynamic structure.

It is possible to manage these patients effectively by means of the therapeutic consultation. This consists of a four-fold method of intervention which is deliberately calibrated with the surgical exigencies: (1) rapid evaluation of the presenting problem in its clinical context; (2) psychodynamic formulation of the patient's pressing conflicts and his ways of meeting them; (3) a specific, rational program of management based on the formulation; and (4) active implementation and direct participation by the psychiatrist in carrying out the program during the hospitalization.

The dynamic evaluation uses content derived from the intrapersonal, interpersonal, and impersonal dimensions of the patient's experience as a human being who is confronted with a critical event. It recognizes the elements of ego regulator functions, predominant emotional patterns object relationships, and conflicts which are impinged upon by the impact of the im personal operation, and formulates each operative syndrome on this basis.

The therapeutic interventions which arise from the encounter of doctor and patient are limited only by the doctor's psychodynamic understanding and operationa ingenuity. In any event, while the interventions are essentially noninterpretive whatever is done has psychodynamic justification. The technique presupposes in sight by the doctor, but insists upon mean of dealing with the patient other than b verbal interpretation.

The basic concept is that patients with operative syndromes suffer from disorder of motivation in their anticipations of hope and dread, and from disturbances of ego capacity resulting from the imminent or actual operation. Some of the various factors which contribute to the development of operative syndromes are discussed, as well as a few therapeutic factors which help to restore an efficient ego capacity. Intuitive psychiatrists, it is presumed, are able to encounter a patient, without deliberate forethought, and constructively fortify the important ego deficit. The aim of this study has been to indicate how some of the crude products of intuition may be refined by careful dynamic formulation and rational implementation.

Note:
Part I appeared in the July-August issue.

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