Psychogenic Aspects of Nursing

Abstract

Closed Eyes – Closed Emotions

We call her a “drama queen” – a gynecological client, who after two hours in PACU refuses to arouse. Unwilling to open her eyes, she appears as a “ragdoll”; client is oblivious to the world around her. Her recalcitrance to our authority is interpreted as passive-aggression or manipulation. Her “cat’s got your tongue” histrionics effectively halts the required fast paced turnover essential to the PACU. Is this behavior a reaction to anesthesia, a bid for more sleep time, a poor coping capacity, or is “closed eyes” phenomenon a clinical syndrome?

This author interprets the behavior of these clients as demonstrating a syndrome. A Syndrome Greek sundrom , concurrence of symptoms, from sundromos, running together”.1 By syndrome, we mean “a group of signs and symptoms that occur together and characterize a particular abnormality”.2

Concurrence of Symptoms

In “closed eyes” the concurrent symptoms running together are exaggerated body limpness, muteness, and the refusal to open the eyes postoperatively. Client appears helpless, recalcitrant to verbal commands. Anxieties and fears are expressed bodily rather than verbally resulting in the conversion of psychological conflict into extravagant physical symptoms. Demands by an authority figure results in deeper emotional regression.

Culture Bound Syndrome

“Closed eyes” is a culture-bound syndrome3 occurring in the Hispanic population where fertility largely defines womanhood. Culture -bound syndromes are expressed in diverse ways and tend to be local. Expressive experiences to high stress are inextricably linked to culture and articulated through culturally specific idioms. These culture-specific syndromes do not always have a correlation with existing allopathic nosologies. As our population becomes more ethnically diverse it is important that we recognize culturally-specific idioms so as to have culturally-relevant treatments.

Culture-specific Idioms of Anxiety 4

• Ataque de Nervios
o Caribbean, Latin America, Latin Mediterranean
 Uncontrollable shouting
 Crying
 Trembling
 Heat in Chest rising to head
 Verbal and Physical aggression
• Bilis and Colera (Hot and Cold)
o Latin America
 Physical and mental illness resulting from extreme emotion especially anger.
• Mal de Ojo (Evil Eye)
o Spain, Latin America, and Muslim Worlds
 Misfortune
 Social Disruption
• Nervios (Stress)
o Latin America
 Headache, irritability, stomach disturbances, sleep disturbances, nervousness, easy tearfulness, inability to concentrate, tingling sensations, and dizziness
• Rootwork (hexing, witchcraft, voodoo)
o Southern United States and Caribbean
 Illness

It’s interesting that among the many expressions (idioms) of response to anxiety, the construct of “closed eyes” as a salient feature of emotional distress is not listed.

Closed Eyes is a post gynecological phenomenon where surgery affects fertility. These include laparoscopic tubal sterilizations, hysterectomies, or surgery for polycystic ovaries. My limited investigations reveal the client often has a history of depression and anxiety. Communication with colleagues reveal a significant number of these clients to have a history of verbal and physical abuse. Variants of Closed Eyes in our Southwestern Culture are thrusting the head from side to side, somatic complaints including pseudo seizures, numbness and chest pain.

Closed Eyes Scenario

Typically Post Anesthesia Care Units are structured for swift efficient turnovers due to limited bays. Imagine a scenario in which a young post surgical LTS client admits to outpatient PACU after an uneventful laparoscopic tubal sterilization. After two hours the client is no more arousable than when first admitted. It soon becomes apparent that this client is not a slow wake-up but rather a no wake-up. Therefore, the RN is forced to face and adjust to the unnerving truth of an unwanted psychogenic facet of nursing care, “closed eyes”.

The well-oiled machinations of patient flow are effectively reduced to a time-slowed stream of unfolding and frustrating intrigues. The RN is forced to contend with the client’s excessive emotions for which the nurse may not be prepared. Operating within a contracted and now compromised time frame, the nurse must contend with an emotionally handicapped client, a nervous family, an abrupt surgeon, and possibly a medical-surgical staff nurse who herself is on a compressed time schedule.

The PACU nurse must deal with a family who is wondering why a simple procedure is taking so long. Additionally, the PACU is now short one nurse who would otherwise be using her critical care skills. If it’s approaching 4:00 p.m., the client must be transferred to another unit as PACU wraps up for the day. Finally, the probability for contentious counterposing exists between nurse-client, nurse-nurse, or nurse-family.

Emotions

My observation is that PACU gynecological clients have deeper emotional needs than the general population of gall bladders and appendectomies. They are often sobbing, overcome by ambiguous feelings and verbalizing, “Why am I tearful?”

We may call this an aberration and yet we are all emotional beings with emotional responses to stress; we are consistently setting up elaborate emotive defense schemes and safety nets. Our desire is to avoid unpleasant situations. The reality, however, is that occasionally we must all confront a difficult situation.

“Closed eyes” clients avoids confrontation. Rather than avoiding avoidance (confronting), “closed eyes” choose to retreat to a safe place. Note, however, I did not say a Disney place but rather a place which serves as a refuge. Unfortunately, this safe place must be violated in order for the client to be discharged.

What gains does a “closed eyes” desire? Is she in avoidance? Is she demanding attention? Is she feeling rejection, worthlessness, eliciting sympathy, or affirming significance? Are dissociative or hysterical components present? Are there idiosyncratic anesthesia considerations? These questions must be answered before a good strategy can be developed to facilitate a timely discharge.

Etiology

Closed Eyes does not meet the criteria of a dissociative disorder 5 as the patient is intentionally unwilling to open her eyes but not unable to open her eyes. An unintentional closing of eyes would justify a classification into a “dissociative (conversion) disorder”. 6 Conversion disorders are not produced intentionally.

Although not a dissociative disorder there is a dissociative “aspect” to Closed Eyes, the blocking out of awareness. The client blocks out reality to banish painful thoughts. Closed Eyes somatically express their angst through passive withdrawal.

Histrionic Aspects

“Histrionic personality disorder has a prevalence of approximately 2-3% of the general population. It begins in early adulthood and has been diagnosed more frequently in women than in men. Histrionic personalities are typically self-centered and attention seeking. They operate on emotion, rather than fact or logic, and their conversation is full of generalizations and dramatic appeals.” 7

Author’s View

Although anecdotal, I do have my own thoughts on what causes a person to tilt toward Closed Eyes. The client avoids or marginalizes her own emotions retreating into a mental safety zone. This safety zone is enhanced by warm blankets and dim lights, The client is overcome by feelings for a short duration, therefore, incapable of responding to the demands of the outside world. The outside world, after all, reaffirms her barrenness and sterility in a familial and religious culture which venerates mothers. My own curiosity has caused me to wonder if their minds are in a place of solitude and peace, a place of altered perception, or a place of shame and fear? It’s likely that there are many layers to “closed eyes” i.e. cultural, physical and psychological.

History of Hystera

Of interest is the fact that until the eighteenth century hysteria was associated with emotions and the uterus. Hystera = uterus, hence hysterectomy, Greek Origin. 8 Hippocrates linked a woman’s strange emotional behavior to a displaced uterus. Attributing the cause of hysterical behavior to a dysfunctional uterus persisted two thousand years. Hysteria was a woman’s disease. If a woman demonstrated emotional problems she was obviously possessed by the devil.

Not until Robert Whytt 9 in the late 1800’s demonstrated that psychosomatic illness takes on many forms did the uterine connection disappear. To suggest a connection of “closed eyes” to uterine manipulation one would have to accept that the hypothalamus-hypophysis-ovaries axis or other hormonal and/or neurological processing plays a role. A woman’s gynecologic makeup is indeed endocrinologic and the relationship of manipulation of the uterus during surgery to post surgical hysteria may be underestimated.

A few years ago I helped my wife insert a pessary. She was fine emotionally until I hit a part of the anatomy that caused a huge flood of jarred emotion that was directly related to something physical. It resolved immediately. It appears that minute physical touches or manipulations can cause fluctuations in a very delicately balanced hormonal –neurological system.

Protean

Physical manifestations are colored by culture and take on many manifestations. In Saudi Arabia the post surgical gynecological client might present with aphonia instead of “closed eyes”. Research by Tariq Ali Al-Habeeb demonstrated that hysteria is a normal acceptable way of expressing themselves in Saudi Arabia. Ali Al-Habeeb reports that 21% 10 of hysterical subjects in a study of in-house hospital patients presented with aphonia. Statistically 7.5% are gynecological. The author believes silence (muteness) to be a variant of hysterical shouting. Similarly there exists a relationship between aphonia and the “unwillingness” to open eyes. Are these different manifestations of the same clinical entity?

Alexithymia

Alexithymia, 11 a difficulty in communicating emotions, may play a role in closed eyes. 11 Typical deficiencies may include problems identifying, describing, and working with one's own feelings, often marked by a lack of understanding of the feelings of others; difficulty distinguishing between feelings and the bodily sensations of emotional arousal.

Choice

The following is a letter to the Royal Marsden of the United Kingdom dated 2004 addressed to Tony at the Chi Clinic.12

“September 2004, I was diagnosed with cervical cancer. On referral to the Royal Marsden my options were discussed at length . . . it was decided that a Laparoscopically Assisted Vaginal Hysterectomy and a Laparoscopic Lymphadenectomy was the most appropriate treatment.

“What I tried to explain, and what they could not understand, was that it wasn’t not being a

ble to have children that upset me. It was the fact that it was no longer my choice. Up until the 23rd October 2004, I could have woken up one morning thinking ‘I really want a baby’, and I would have been able to try for one. As of 24th October, that choice was no longer mine”. 12

Expectations

Closed Eyes clients are frustrating because they violate our expectations. After all, what PACU client could be more simple than an LTS procedure? The patient wakes up quickly and with brisk energetic speech and good movement (and no bleeding) is ready for discharge. The expectation of an in-out recovery that will entail managing an airway for a short duration ends up a three hour nightmare. Pain travelling through afferent pain fibers can be eased within ten minutes but pain travelling through a troubled mind is not so easily assuaged.

If an outpatient appears to be a “no wake up” rather than a “slow wake up” consider the possibility of “closed eyes”. Does the client’s nonverbal body language scream “leave me alone”? Does she respond to your commands? Is your client in a different reality?

If the client is perceived to exhibit “closed eyes” syndrome there are two options available. The first is an attempt to breach the client’s passivity with authoritative commands. This choice has the potential of pushing the client further into withdrawal.

The second option is to adopt the mnemonic F-A-S-T developed by the author as a strategy in addressing “closed eyes”.


Figure 1: Strategy for engaging clients who require space and time.

Time Pressures

“Closed eyes” clients as well as those with pseudo-disorders require time. PACU nurses must remain focused and flexible, able to prioritize when confronted with these psychosomatic projections or they will risk burn out. Be careful the client does not detect your urgency in dealing with time issues. Although withdrawn into her own reality, she still interprets what’s going on around her.

Studies by Michael DeDonno, Case Western University, suggests that most frustration from time pressures are artificial.

“It’s not the time pressure but the “perception” of time pressure that affects us. If you feel you don’t have enough time to do something, it’s going to affect you . . . But instead of more time, maybe what they need is a change of perception”.13

Nurses confronted with a client presenting with psychosomatic projections such as “closed eyes” must shift from a strict biomedical modality to a holistic biopsychosocial model. The PACU adopts only the communicative aspects of this model. The psychosocial paradigm shifts from disease centered to client centered.

A biopsychosocial model will prevent being locked into a numbers game. This game teaches that therapeutic interventions produce outcomes within predictable time blocks. It’s “treat ‘em and street ‘em”.

The PACU is largely about numbers. Our monitors reflect numbers that give us insight into the hemodynamic and ventilation status of a client. These numbers are real and objective. We rely on these numbers sufficiently to perform interventional critical care. We trust these numbers as we discharge our client. Numbers define the essentials of a biomedical model.

Biomedical Model vs Biopsychosocial Model

Johannes Bitzer defines the biomedical model as the following:

“Symptoms are caused by objectively measurable (biological) factors, which constitute disease entities independent of individuals. These diseases are defined in the biomedical code and structured into subunits like etiology, pathophysiology, diagnostic procedures, and therapeutic interventions. This code is international, is continuously adapted and the “truth” of the code is evaluated by using scientific evidence, which is the basis of standardized practice.14

Biopsychosocial Model

Symptoms as the manifestation of individual suffering are the result of an interaction of biological, psychological, and social factors specific to the patient. . . Diagnostic procedures have therefore to add to the detection of measurable biological abnormalities an understanding of the patient’s life situation and patterns of thoughts, feelings, and behavior to the illness state. Therapeutic plans take into account the characteristics of the motivation, the objectives, the decisions, and the behavior of the patient”. 15

Nurses involved in recovery of post surgical clients are not interested (during recovery) of a clients “life situations”. They are interested in one’s airway, bleeding, ventilation status, wound status, electrolytes, monitoring pressors and relieving pain. There is more satisfaction in putting the numbers on track of someone whose physical defenses have crashed than dealing with someone whose emotional defenses have been breached.

Do nurses ignore the cultural, social, and psychological factors of healing? Absolutely not. Nurses are trained and keen to the cultural and religious facets of disease recognizing that cultural factors are at the core of how we respond to disease. We know that “affect” communicates pain, i.e. grimacing, and that behavior elicits signs of impending crisis, i.e. restlessness and anxiety caused by bleeding. We perceive when a client fears surgery or discharge. We take seriously the client’s feelings of impending doom. We detect and intervene when we suspect emotional abuse. We understand that most disease is caused by stress and we appreciate the need for ego support systems and family care. As PACU nurses we get great satisfaction in knowing our discharged client will have improved function, improved sexuality, freedom from pain and anxiety, a sense of being socially active where social inhibition ruled, or economic freedom from a hernia or muscle repair.

The PACU nurse does not, as protocol, embrace a direct holistic approach to recovery for the same reasons physicians don’t practice holistic medicine in their offices. There is simply not enough time. Physicians must maintain a high client flow to be economically solvent.. Clients can be difficult, time consuming, and complicated even within the boundaries of a biomedical model.

Research

“Closed eyes” bring into our “ focus” the need for divergence as well as convergence.
Focus is defined as “a point at which rays of light or other radiation converge or from
which they appear to diverge 16 . . . “

Allopathic medicine focuses on pathogenicity and assumes epidemiological convergence of “universals”. Reality demonstrates there is more pathoplasticity than pathogenicity in the expression of anxiety. This plasticity is provided by the introduction of culturally divergent aspects, i.e. aspects of voodoo, witchcraft, fear of sterility, or social stigma. Future research must consider the ethnographic idioms of anxiety as well as epidemiological.

Closed eyes offers the research psychologist a challenge. What medical history contributes to “closed eyes”? Certainly depression, anxiety and abuse alone does not guarantee closed eyes. What factor predisposes a reasonable, logical client into a passive immature client who refuses to respond to medical and nursing authority?

Research investigations should explore the role of culture, sensory processing, hysterical or dissociative aspects, physical manipulation of the uterus as related to emotions, or perhaps premorbid predispositions such as Avoidant Personality Disorders. Are there pervasive psychological indicators that warn of coming “closed eyes”? The answers will help nurses develop interventional protocols.

Predicting Convalescence

It has been my experience that Closed Eyes do not do well in hospital convalescence. They become morbidly self conscious, prefer isolation, are more likely to manifest pseudo conversion-type disorders and at greater risk of surrender to impulses. They generally do not respond to anti-anxiety medications. They are inhibited socially and regress when those of authority challenge them “Social anxiety is a devastating and persistent condition that is characterized by a fear of social interaction.” [Luterek, 2006}.17

Summary

Non Judgmental

For women who have difficulty conceptualizing their illness we must be patient and non-judgmental. Closed Eyes clients have apparently failed to resolve issues surrounding sterility. Was it her choice for sterilization or was it her husband’s? Does she believe others are limiting her choices or is the conflict within herself? Is there contradiction between that which is matriarchal and freedom of choosing a career.

Although the somatic manifestations may differ, the psychological components are the same and ultimately involve beliefs. All behavior results from what we believe. Beliefs are profoundly influenced by our culture. These beliefs can result in “closed eyes” for the Hispanic but for others a lack of eye contact, tearfulness, trembling, being garrulous, or continued requests for pain medication. I have on several occasions had clients coming out of anesthesia demand that I tell them a joke. They were noticeably agitated until I recited a joke. Was this anesthesia related or were psychological components present?

Appropriate Response

As PACU nurses we focus on the physiological sensory aspects of recovery and do quite well across space-time. However, there will be times when we encounter the affective-cultural expressions of disease (dis-ease) . The cultural-social genre is a time sensitive frustration for the PACU nurse. We must not react to these inappropriate emotions by escalating our own inappropriate emotions. Closed Eyes can bring into “focus” a need for compassion and understanding when these attributes seem most unattainable. A soft voice and empathy may trump the psychological principles of Psych 101.

Normal is What?

Closed Eyes may simply have a greater capacity for experiencing their own bodies than those considered more mature in responses to illness. Obviously, their accelerated feelings need appropriate brakes. And when their emotional brakes fail them, we as PACU nurses must intervene with a strategy that recognizes we are all individual when it comes to response to illness. Our culture has defined what emotional competence looks like. However, we need to put all emotional responses through a cultural and social filter and think pathoplasticity – not pathogenicity.

“That hormone cycle that you have been taught to ignore/dismiss/cover/hide, actually is your foundation of being; the definition of who you are, your connection to yourself, to other women, to your partners, children, to your life!
“Women’s hormone cycles are not just a cyclical pain; they are our integral link to all the other cycles in life. They are so much more than hormones ‘raging’ through our body. Your hormone cycle earns you the right to be a healer, a spiritualist, and wise woman, respected by all”. 17

REFERENCES
1. The American Heritage® Dictionary of the English Language, Fourth Edition. Houghton Mifflin Company, 2004.
2. Syndrome. (n.d.). Merriam-Webster's Medical Dictionary.
3. Simons, Ronald C.; and Hughes, Charles C. (eds.) (1985) The Culture-Bound Syndromes: folk illnesses of psychiatric and anthropological interest. Dordrecht, The Netherlands: D. Reidel Publishing Company.
4. List of Culture-Specific Idioms derived from DSM IV (pp. 845-849) and “Kaplan and Sadock’s Synopsis of Psychiatry pp. l90-192, 493-495; Simon and Hughes l985: pp. 475-506
5-6. DSM-IV, Dissociative Disorders, Depersonalization Code 300.15
7. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, APA l994 Histrionic Personality Disorder, Code 301.50
8-9. National Library of Medicine, Emotions and Disease Psychosomatic Medicine: “The Puzzling Leap”,

10 .Al-Habeeb, Tariq Ali, "Hysteria: A Clinical and Sociodemographic Profile of 40 Patients Admitted to a Teaching Hospital, 1985-1995", Ann Saudi Med 1997; pp.35-38.
11. "alexithymia." Dictionary.com Unabridged. Random House, Inc. 05 Dec. 2009. .
12. Letter written to Hardiman, Tony of the Chi Clinic
13. Perception of Time Pressure Impairs Performance Science Daily (Feb.16,2009) – “Ask Anyone Working On a Project” Accessed November 25, 2009
14. Psychological Challenges to Obstetrics and Gynecology: The Clinical Management, Jayne Cockburn, Michael Pawson, “Teaching Psychosomatic Obstetrics and Gynecology” by Johannes Bitzer, Essentials of Psychosomatic OB/GYN Cp 2007, pp. 3-14
15. Obstetrics and Gynecology, The Clinical Management, J. Bitzer, Essentials of Psychosomatic OB/GYN, Cp 2007, ISBN 9781846288074, pp.3-1
16. Answers.Com Q&A Site , (fō'kəs) n., pl., -cus•es, or -ci (-sī', -kī'). Accessed December 5, 2009
17. Rojas, Stephanie and Bartlett, Jocelyn, The Relationship Between Social Anxiety and Emotional Expressivity: Univ. of Nevada, Las Vegas, Dept. of Psychology
18. Botha-Williams, Leslie, Female Mystique: The three Phases of Eve.