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Psychiatric Aspects

of Orthopaedics

Thamer A. Hamdan, FRCS,


FACS, FICS

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.

Dr. Hamdan is Professor, Department of


Orthopaedic Surgery, and Dean, Basrah
Medical College, Basrah, Iraq.
Neither Dr. Hamdan nor a member of his
immediate family has received anything
of value from or owns stock in a
commercial company or institution
related directly or indirectly to the
subject of this article.
Reprint requests: Dr. Hamdan,
Department of Orthopaedic Surgery,
Basrah Medical College, SICOT
National Delegate, PO Box 763, Basrah,
Iraq.
J Am Acad Orthop Surg 2008;16:
41-46
Copyright 2008 by the American
Academy of Orthopaedic Surgeons.

Volume 16, Number 1, January 2008

sychological factors may contribute to patient symptoms, if


not outright cause them. As an example, abuse and neglect in childhood play a part in the psychological
response to a stressful condition.
Victims of childhood physical or
sexual abuse and neglect are at
increased risk of developing posttraumatic stress disorder (PTSD).1
Schofferman et al2 reported an unsuccessful surgical outcome in 85%
of patients (n = 86) who had experienced three or more of five childhood psychological traumas (physical abuse, drug abuse, sexual abuse,
alcoholism, abandonment).
Generally, the likelihood of successful treatment may be increased
when the role of psychological and
psychiatric factors is considered by
the treating physician. Collaboration
between the orthopaedic surgeon
and psychiatrist therefore can add
understanding to the way in which
many musculoskeletal disorders are

managed. Hormonal and biochemical responses to both bodily injury


and emotional disturbance are mediated by the hypothalamus and the
pituitary-adrenal axis, with similar
consequences.3 Grief and depression
may activate the adrenal cortex as
much as a fractured femur does.3 Direct bodily injury from trauma stimulates the adrenal gland, as does anxiety. Also, psychiatric disorders and
orthopaedic problems may simulate
each other, and psychiatric disease
may contribute to poor orthopaedic
outcomes. In addition, psychiatric
disorders may interfere with making
a precise diagnosis, contribute to patient noncompliance, and lead to difficult rehabilitation.3 Although the
published literature includes few
studies of the psychiatric aspects of
orthopaedic practice, a greater index
of suspicion for psychiatric problems
in orthopaedic practice may assist
both the patient and the orthopaedic
surgeon.
41

Psychiatric Aspects of Orthopaedics

Early Detection and


Psychological
Predisposition to Injury
Early diagnosis and prophylactic measures are important in the effective
treatment of the patient with an established psychological condition. As
noted, psychiatric disorders may contribute to an increased degree of pain
and suffering, magnify the disability,
interfere with physiotherapy and
other rehabilitation efforts, and lead
to noncompliance.4 Psychiatric illness may even mask clinical features.
Physical, psychological, and social
stress may compromise the adaptive
equilibrium, resulting in the appearance of illness or in a disease state.
Some patients are more vulnerable
than others to psychological upset
and loss of adaptive capacity as the
result of any of a number of factors
(eg, genetic predisposition, substance
abuse, relationship difficulties, broken home, loss of a job, loss of a parent). As mentioned, an accident may
result in psychological trauma. In addition, socioeconomic factors may
play a role in the appearance of a disease state (eg, loss of income).
For the patient in a nonemergent
situation, the psychiatrist may suggest delaying surgical treatment for
as long as several weeks. However,
in an emergency, urgent identification of the mental status is necessary; this is best done by a liaison
psychiatrist. Team-managed care is
essential. For example, the interaction between the drugs required for
anesthesia and those given to the patient by the psychiatrist must be reviewed for potential interaction or
additive effect.

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

threshold, which may be indicative


of depression. The patient with depressive disorder may exhibit signs
of hopelessness and guilt, and symptoms such as loss of general interest
and early-morning waking.7 Other
factors to look for in the psychiatric
assessment include previous psychiatric disorder, lifelong difficulty in
managing family and social problems, and illness that requires
lengthy and unpleasant treatment or
that is life-threatening.
The patient should be asked about
the health and well-being of other
family members and how they are reacting to the patients illness. Brief interviews with relatives and friends
may clarify an aspect of the patients
personality and how the family is
coping with the situation. Notable
mood change may indicate the need
for a full investigation of the family
structure by a psychiatrist.
Although the patient assessment
is subjective, by performing it routinely, the clinician will become familiar with the range of emotional
states seen in patients with orthopaedic problems. Distinguishing the
emotional responses to physical illness and treatment from those of
anxiety and clinical depressive disorders can be difficult. Thus, clinical
experience helps.
The presence of somatic symptoms of psychiatric significance,
such as recent change in sleep pattern, appetite, and libido, may indicate psychological distress. The surgeon should evaluate the effect of the
presenting symptom on the patients
life in addition to the degree of handicap and restriction. Physical signs of
distress include an overall look of
sadness, a glassy-eyed look, sagging
of the corners of the mouth, drooping shoulders, and no or few smiles.7
Measurement scales, such as the
Carroll Depression Scale8 and the
Zung Self-Rating Depression Scale,9
are useful in diagnosing depression.8-10 The Minnesota Multiphasic Personality Inventory (MMPI),
which assesses personality strengths

Journal of the American Academy of Orthopaedic Surgeons

Thamer A. Hamdan, FRCS, FACS, FICS

and weaknesses, may aid in detecting


psychiatric disorders. However, results of the MMPI alone are not diagnostic of depression.
It may be difficult to recognize the
orthopaedic patient who is suffering
from psychosis. Psychotic depressive
reactions are encountered most frequently, whereas the excited or agitated forms of psychosis, accompanied by a cognitive disorder, are most
easily recognized. The quiet patient
who presents with withdrawn depression, paranoid reactions, and incipient delirious reaction often goes unnoticed. Delirium is particularly
common after major surgery and in
the elderly.7
Many patients feel anxious during
the preoperative period. In general,
the patient who is most anxious before surgery is also the most distressed afterward. A clear explanation of the operation and the recovery
period may help reduce this anxiety.
A handout explaining the postoperative period is often helpful.

Psychiatric Disease and


Orthopaedics
Establishing the cause of a psychiatric disorder in an orthopaedic patient
may be challenging. The risk factors
for the development of psychiatric
disorders may be related to the nature of the physical illness, the
meaning of that illness to the patient, the nature and personality of
the patient, and the nature and pattern of treatment. The surgeon must
determine which of the following
four scenarios is applicable: (1) psychiatric disorder presenting with
physical illness, (2) psychiatric consequence of orthopaedic disease or
injury, (3) psychological factors as a
cause of physical illness, or (4) psychiatric factors affecting the medical
condition6 (Table 1).
Psychiatric Disorder
Presenting With Physical
Illness
Psychiatric disorders presenting
Volume 16, Number 1, January 2008

with physical illness include somatoform disorders, factitious disorder, malingering, compensation neurosis, and chronic fatigue syndrome.
Somatoform Disorders

Somatoform disorders can be


classified as somatization disorder,
conversion disorder, pain disorder,
hypochondriasis, and dysmorphic
disorder. Somatization disorder is
polysymptomatic, generally beginning before age 30 years and lasting
for many years. The patient experiences multiple unexplained somatic
physical symptoms, and the subjective experience of a physical condition is out of proportion to the objective findings. Often there are
multiple symptoms involving neurologic or pseudoneurologic disturbance. Patients with this disorder
place their symptoms and treatment
at the center of their lives and are
not aware of having a psychological,
emotional, or personality disorder.
These patients may threaten or attempt suicide.11
Conversion disorder is a monosymptomatic somatoform disorder
that specifically affects the voluntary
motor system and sensory function.
The patient may experience blindness, deafness, paralysis, or an inability to walk or stand. The symptoms
typically are physical manifestations
of an underlying emotional conflict.
Pain disorder causes significant
impairment or distress in important
areas of functioning.6-8 The patient
with pain disorder exhibits no organic pathology or pathophysiology sufficient to account for the degree or
location of the pain. Analgesics may
afford temporary pain relief.
The patient with hypochondriasis
is preoccupied with the fear or belief
of having a serious disease6,8,12 and
frequently misinterprets normal
bodily function as pathologic. The
belief of having an illness with no
symptoms leads many patients to go
from doctor to doctor, hoping to find
a physician who will discover the
cause of the problem.

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 essential feature of dysmorphic disorder (eg, dysmorphophobia)


is a preoccupation with an imagined
defect in ones physical appearance.
The patient presents with complaints that are grossly disproportionate to the objective findings of a
slight physical defect. Depression is
a common finding.
Factitious Disorder

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

Psychiatric Aspects of Orthopaedics

Malingering

With malingering, the patient intentionally produces symptoms and


is motivated by a recognizable goal
(eg, financial gain, drugs). Such patients typically have a severe personality disorder and exhibit disturbance in many aspects of life.
Malingering is notably resistant to
treatment. As with factitious disorder, direct efforts to confront a patient with malingering disorder may
be counterproductive.
Compensation Neurosis

The patient with compensation


neurosis typically presents following
industrial or traffic accidents with
the potential to result in compensation to the victim.6-8 The patient develops posttraumatic symptoms that
are completely resistant to treatment. A fair proportion (26%) can remain severely and permanently
handicapped even after a claim has
been settled.13 Direct efforts to confront a patient with compensation
neurosis may be counterproductive.
Chronic Fatigue Syndrome

The patient with chronic fatigue


syndrome presents with undue fatigue associated with multiple recurrent medically unexplained symptoms over a long period.14,15 There is
a strong association between chronic fatigue syndrome and major depressive disorder. Some patients are
better described as having an anxiety
disorder. Landay et al14 believe that
there is a stronger link between
chronic fatigue syndrome and immunologic abnormalities than between infective agents and immunologic abnormalities. Several studies
have suggested abnormalities in
lymphocyte function in the patient
with chronic fatigue syndrome.16,17
Psychiatric Consequence
of Orthopaedic Disease or
Injury
Orthopaedic Disease

Chronic crippling and disabling


disease may lead to a change in self44

image. The patient who has had an


extremity amputated, for example,
may experience severe anxiety,
acute depressive psychosis, or conversion disorder. Numerous studies
have demonstrated that chronic pain
may cause a grossly abnormal personality profile.18,19 The degree and
extent of psychological change may
be related to many underlying latent
or manifested factors. The same condition may elicit different responses
in different patients. When such
conditions are observed, prophylactic measures (eg, examination by a
psychiatrist, use of drugs) should be
taken to guard against the expected
development of psychological disorders.
Psychiatric Side Effects of
Medication

Simple analgesics (eg, salicylate,


nonsteroidal anti-inflammatory drugs
[NSAIDs]), antibiotics, corticosteroids, and other drugs prescribed to orthopaedic patients may have unwanted side effects. Salicylates may
cause delirium with psychotic symptoms (although usually only at high
blood levels). NSAIDs may produce
vertigo, dizziness, sedation, and delirium; depression also has been reported.20 NSAIDs may cause a range
of disorders, from mild delirium
(characterized chiefly by sleep disturbance) to depressive disorders, paranoia, and hypomania.21

induced trauma. Females are more


likely than males to develop PTSD.
A history of major depression is a
significant factor for development of
PTSD.24 Ursano et al25 confirmed
that persons with peritraumatic dissociation appear to be at greater risk
for chronic PTSD.26 PTSD may be
prevented with psychiatric referral;
early cognitive behavior therapy and
prolonged psychotherapy are crucial
to proper treatment.
Psychological Factors as a
Cause of Physical Illness
Drug and alcohol abuse is a frequent cause of motor vehicle accidents, which can result in physical
injury to the patient, passengers, and
pedestrians. Drugs used for psychiatric disorders may induce deliberate
self-harm; an attempted suicide may
lead to harmful physical injury. Electroconvulsive therapy may induce
physical injury (eg, fracture, dislocation) requiring urgent treatment.27,28
Psychiatric Factors
Affecting Medical Condition
Psychiatric Disorder

A medically ill patient may have


a coexisting psychiatric disorder that
adversely affects the course or treatment of his or her medical condition.
For example, a patient with schizophrenia who has a fracture or dislocation may continue to use the injured limb.

Posttraumatic Stress Disorder

Psychological Symptoms

PTSD may be acute (occurring


within 6 months of trauma) or delayed (>6 months). This condition is
characterized by nightmares, repetitive dreams, intrusive memory,
depression, insomnia, guilty rumination, phobic response, and, sometimes, poor concentration and memory impairment.22 Previous exposure
to trauma increases risk of PTSD.23
The disorder may remain pronounced 9 months after the precipitating event or events. The rate of
PTSD is high in victims of serious
motor vehicle accidents and warfare-

Psychological or psychiatric symptoms can significantly affect the


treatment of musculoskeletal conditions.6 These symptoms may exacerbate the medical symptoms through
increased anxiety and interference
with postoperative recovery, as well
as by disturbing the medical staff
with excessive demands for care and
attention.
Personality Trait

Personality trait and character


style refer to the characteristic way
(eg, coping style) in which a person

Journal of the American Academy of Orthopaedic Surgeons

Thamer A. Hamdan, FRCS, FACS, FICS

interprets or responds to a stressful


situation.6 An example of a coping
style is pathologic denial by a patient who assures himself or herself,
without consulting a physician, that
a thigh mass is not significant. A further example is maladaptive regression in the hospitalized patient who
alienates the nursing staff with constant and excessive demands for attention and care.
Maladaptive Health Behaviors

Maladaptive health behaviors are


high-risk behaviors that adversely
affect patient health and the course
of illness.6 A common example is
the patient with diabetes with a foot
injury who continues to smoke and
consume a high-carbohydrate diet
and consistently ignores medical advice to engage in healthful behavior.
Stress-related Physiologic
Response

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

for diagnosis and treatment should


be made for the patient with significant psychiatric involvement.
The clinician must remain aware
that psychiatric disorders do not
necessarily invalidate the reality of
the presenting physical symptoms.
In most patients, the orthopaedic pathology has both a physical and a
psychological component. Behavioral immunologists have demonstrated increased B- and T-cell immune
response after stressful life events.29
Such events are one cause of major
depression.29 Organic illness may result from psychological disorders.
Conversely, psychological disorders
may intensify, prolong, or prevent
adequate control of organic disease.
Usually, establishing a diagnosis
in the patient with a clear-cut abnormal mood or personality is not a
challenge. However, diagnosis may
be difficult in the marginally adjusted (ie, borderline) patient. This patient may give no hint of psychiatric
involvement in the initial interview
but may exhibit problems after the
development of complications or following unexpected results.
Psychological parameters must be
taken into account when determining nonsurgical treatment in the patient with chronic low back pain.30
To some extent, the outcome of
treatment in the patient with chronic back pain is always related to psychological factors.
The patient with a somatization
disorder who goes from doctor to
doctor is at higher risk of a poor outcome than the patient who remains
with one doctor. Somatization is relevant in the treatment outcome of
the patient with low back pain.31
The patient with chronic pain may
suffer from depression, anxiety, and
other psychiatric conditions that are
either not recognized or insufficiently treated.
Psychological factors may represent generalized risk factors for musculoskeletal injury. Thus, consideration of the mind-body connection is
useful in evaluating the patient who

has been in an accident. A relationship has been demonstrated between


preinjury emotional trauma and
chronic back pain following accidents.32 Physical workload and psychosocial job factors both independently predict spinal injury in
vehicle operators.33 Job dissatisfaction, low supervisor support, high
psychosocial demand, and the frequency of specific job problems contribute to the increased incidence of
accidents during work that can result in physical injury. Anniversary
reactions, which are correlated to
the occurrence of traumatic events,
occur in numbers greater than those
expected by chance. These reactions
may be part of PTSD.34
Medications available for managing specific psychiatric conditions
include olanzapine, clozapine, and
risperidone for the treatment of
schizophrenia, and citalopram for
the treatment of depression.
Preoperatively, control of associated psychiatric disorder is mandatory, regardless how minor the procedure may be. The anesthetist should
be notified about the details of the
drugs used by the patient so that he
or she can avoid unwanted drug interactions.

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

Psychiatric Aspects of Orthopaedics

paedic 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.
Through careful patient interviewing, the surgeon can avoid unnecessary treatment, which may
create emotional stress. 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.

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.

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Journal of the American Academy of Orthopaedic Surgeons