Hypnotherapeutic Ego Strengthening with Male South African Coronary Artery Bypass Patients

American Journal of Clinical Hypnosis,  Oct 2004  by de Klerk, Jacoba E,  Plessis, Wynand F du,  Steyn, Hendrik S,  Botha, Mike

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Morbidity (i.e., elevated anxiety and depression) is a common feature of coronary artery bypass surgery (CABS) patients, pre- and postoperatively. Since hypnotherapy can possibly reduce morbidity in CABS patients, the aim of this study was to determine the feasibility of hypnotherapeutic ego strengthening (HES) to facilitate patient coping with concomitant anxiety and depression. Fifty patients were randomly assigned to a non-intervention control group (n = 25) and an experimental group (n = 25) and exposed to a pre- and postoperative HES intervention. Anxiety and depression were assessed with the Beck Depression Inventory and Profile of Mood States, administered preoperatively, at discharge, and at 6-week follow-up. Findings confirmed large practical reductions of anxiety and depression in the experimental group and were maintained at follow-up, while a trend towards increased depression levels occurred in the control group. Although not generalizable, results suggest broadened applications of hypnotherapy with patients in cardiac centers.

Keywords: Anxiety, coronary artery bypass surgery, depression, ego strengthening, hypnosis, hypnotherapy

South Africa has one of the highest mortality rates due to coronary heart disease (CHD) in the world (South African Heart Foundation [SAHF], 1995; Van der Poel & Greeff, 2003). According to the SAHF (1995), four million White South Africans suffer from CHD and statistics indicate that one in three males and one in four females will develop CHD before age 60. However, even the customary low incidence of heart disease among Blacks is gradually rising as they adopt western life styles concomitant with westernization and urbanization (seedat, Mayet, Latiff, & Joubert, 1992, 1993).

Coronary artery bypass surgery (CABS) revolutionized the treatment of CHD and emerged as the treatment of choice in patients with left main-stem and triple-vessel disease, particularly when left ventricular function is already impaired (Mack, Magee, & Dewey, 2001; Underwood, Firman, & Jehu, 1993). Since CABS is a life-threatening event, patients approach surgery with tremendous distress. Apprehension, fear, anxiety, depression, anger, and emotional lability are common responses and are often the most problematic part of the procedure to endure (Martin & Thompson, 2000; Moore & Dolansky, 2001; Sunnen, 2000), causing such psychological strain on the adaptive capacity of the ego (Gahlaut, Srivastava, & Rastogi, 1993) that it is referred to as ego infarction (Hackett & Rosenbaum, 1980). Ironically hearts may recover more rapidly after CABS than patients' mental states (Cohan, Pimm, & Jude, 1998).

Elevated pre- and postoperative anxiety and depression levels are common (Duits, Boeke, Duivenvoorden, Passchier, & Erdman, 1996). Vingerhoets (1998) reported a 33% increase in anxiety prior to surgery, escalating to 66% after surgery. Prevalence levels of preoperative depression ranges from 27% to 47%, but postoperative depression from 19% to 61% (Andrew, Baker, Kneebone, & Knight, 2000; Burg, Benedetto, Rosenberg, & Soufer, 2003; McKhann, Borowicz, Goldsborough, Enger, & Seines, 1997). Although these reactions reflect a normal way of coping with CABS, untreated depression and anxiety can deplete patients' physical and emotional reserves (Shuster, Stern, & Tesar, 1992), thus disrupting natural recuperative processes (Timmermans & Pelc, 1995). Hence, patients may pay enormous physical, psychological, and economic costs (Burg et al., 2003). Stress and depression are also associated with heightened postoperative morbidity and mortality in cardiac patients (Ashton, Whitworth, Seldomridge, Shapiro, & Weinberg, 1997; Connerney, Shapiro, McLaughlin, Bagiella, & Sloan, 2001 ; Trzcieniecka-Green & Steptoe, 1994).

Often poorly equipped psychologically to deal with the discomfort of surgery, patients experience increased psychosomatic symptoms due to psychological distress, which they attribute to bodily illness. They typically deny feelings of anxiety and depression and tend to report physical symptoms rather than affective or emotional complaints (Duits, Duivenvoorden, Boeke, Mochtar, Passchier, & Erdman, 2002). Medical professionals sometimes disregard emotional complaints, assuming they are consistent with and appropriate to cardiac surgery. Anxiety and depression in CABS patients can be so ambiguous that they are often undiagnosed and untreated (Wool, 1990). The psychological state of patients profoundly impacts on their quality of life and other aspects of postoperative behavior (Cohan et al., 1998). Lamarche, Taddeo, and Pépier (1998) propose that the way patients cope with CABS related Stressors is determined by their psychological state, pre- and postoperatively. Diagnosing and treating clinically significant levels of anxiety and depression is therefore crucial in planning effective treatment (Duits, Boeke, Taams, Passchier, & Erdman, 1997; Martin & Thompson, 2000; Trzcieniecka-Green & Steptoe, 1996).

Early psychological interventions can be therapeutic to patients across several quality of life domains (Martin & Thompson, 2000). Furthermore, Prevost and Deshotels (1993) report that proper psychological management can significantly reduce patient morbidity, possibly even constituting the single most important contributory factor to positive outcomes of CABS. Thus, recent research confirms that CABS patients experience unique Stressors which require attention and immediate pre- and postoperative psychological intervention (Martin & Thompson, 2000; Sullivan, LaCroix, Russo, & Walker, 2001). The need for psychotherapeutic interventions is also supported by research findings indicating that surgery can be made more tolerable if patients are involved in a multidisciplinary environment (Dantas, Motzer, & Ciol, 2002).