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Body image and surgical alterations
W
hat effect does surgical disturbance have upon body image and the ego’s homeostatic mechanisms? To the uninitiated, the word, “surgery,” portrays a stretcher ride through unknown corridors, the administration of anesthesia, and a ritual known only to a select few. Surgery is a planned anatomic alteration designed to arrest, alleviate, or eradicate a pathologic process occurring either within or on the surface of the body. Occasionally surgery is elected by the patient (mammoplasty, rhinoplasty) , but more commonly it is prescribed. Titchener reminds us that an operation revives fears of severe injury and retaliation I that were planted in childhood and infancy.’ In other words it is a “I-must-have-donesomething-wrong-and-now-(God)(my child) (my wife) (my parent) (my friend)-is getting-even” punishment feeling. When one becomes aware of an illness an “increasing portion of the available mental energy flows . . . toward concern with the body and the mental image of i t 2 This produces “intense shame and fear of loss of love and respect”3 and leads to many questions, Will my husband love me if I have only one breast? Will I be covered while I’m in the OR? Will other people know that I have a colostomy? Will it smell? Titchener also notes that “stability Whifeside Wells, and psychological equilibrium depends in RN, MSN part upon intactness of the body and consistency of its functions.”* Any change in this intactness requires an adjustment to maintain psychological equilibrium. Noyes and Kolb describe how the body precept evolves. This developmental process is complex, and any alteration involves a good deal of mental adjustment. The various sensory impressions conveyed by . . . kinesthetic, visual, and tactile apparatus to the cortex lead to an expanding and growing perception of body awareness, presumably organized and integrated in the parietotemporal cortex of the brain. In addition to this physiological substratum . . . each indi-
Body image I
and surgical a Iterations
Robin
812
AORN Journal, April 1975, Vol 21, N o 5
vidual attaches . . . attitudes with emotional overtones that derive from his early experience in the family and as a result of the parental evaluations of his physiq~e.~ The relationship between body image and self-image is most effectively portrayed by Somerset Maugham. Philip Carey, the protagonist in Of Human Bondage is an example of the development of body image. With his club foot and short stature, he tromps through life trying to compensate for the body image which he designates as inferior.
Robin Whiteside Wells, R N , MSN, is an instructor in the graduate division of the School of Nursing,
University of Pennsylvania, Philadelphia. She is a graduate of the Cooper Hospital School of Nursing, Camden, N J , and received her BSN and MSN degrees from the University of Pennsylvania. Because i t alters the body itself, surgery leads to altered body-ego experiences. Altered body-ego experiences, according to Woodbury, are “sensations of a change in the organization (size, configuration, and spatial orientation) and sense of unity of the body ego with effects
. . upon object and self-representstion and the relationship between the tW0.”6 To derive a body image score, Schwab and Harmeling conducted a study in which they asked 124 medical inpatients to express their attitudes toward 50 bodily parts and functions. Their findings included: 1. Relative dissatisfaction with the body. 2. Most respondents focused their dissatisfaction on the affected body part. 3. Twenty percent indicated gross dissatisfaction with many bodily parts and functions. 4. There were sexual differences. Females were (1) more dissatisfied with their bodies than males, (2) negative attitudes were more closely tied to conditions of illness and their psychological well-being, (3) negative body image was associated with high anxiety, increased anxiety, and distortions of the severity of the illness and prognosis. Males had negative attitudes scores (1) independent of this illness orientation and (2) correlated with advancing age and high socioeconomic status.’ Another aspect of body image is “human territoriality.” This includes not only the space surrounding the body, but the penetrability of this space in reference to other persons. . . . Humans seem to have feelings about the space that immediately surrounds them that are almost as individual and particular as their feelings about the body itself.8 Surgery, in all facets, radically invades the body-buffer zone. The patient is literally invaded by a horde of strangers armed with strange instruments. His body is viewed as a ,
AORN Journal, April 1975, Vol 21, N o 5
813
drawing board and the battle plan of attack is drawn on his skin. Once the fartress is penetrated, the internal area is altered. Following alteration, the patient is constantly reminded of it by the pain, the dressing, the stitches, and the horde attending him. He is not the same person he was no matter how minor the procedure or how slight the alteration. He is left with a feeling of loss, and he mourns, either consciously or unconsciously, for what he once was. He grieves for the “dead” part-be it his mole, tonsil, or leg. The normal process of grieving as outlined by Engel is (1)shock and disbelief, (2) developing awareness, (3) restituPation and (4) resolving the tients must be given support at each stage throughout this normal proce3s. Radical surgery for carcinoma has attendant problems of disfigurement and ablation of organs. There is a sense of insecurity from the new body image as well as the possibility that the cancer is still there and growing. The organs ablated are also important to consider, especially if they concern sexuality. Dlin et a1 describe adjustments that must be made with an ileostomy or colostomy; Gribbons and Aliapoulios discuss carcinoma of the breast; Christopherson reviews the disabled male; and Carnevali talks about preoperative anxiety.l0 The problems cannot be ignored if one wishes to effectively assist the patient through a disconcerting experience. Another area of adjustment to a new body image is reliance upon mechanical objects such as pacemakers, heart valves, vascular prosthetic grafts, hip and bone pins, total joints, and silastic implants. The list
814
lengthens as medical science advances. Receiving another person’s heart, kidney, or cornea adds the dimension of indebtedness and a sense of responsibility for another person’s organs. No longer is the original body capable of functioning on its own. Now it must rely on an artificial part or a transplant and there is always the possibility that these may fail to perform properly. It is little wonder that surgery is an anxiety-producing experience in terms of body image. The stress associated with alteration speaks for the benefit of preoperative visits. The OR nurse is present during the invasion and reassures the patient that he or she will be the guardian of his modesty, his body, and his ego. She gives the patient an idea of what to expect; the stretcher ride, IVs, personnel, anesthesia, awakening in recovery room, and the reality of phantom phenomena. She also answers the patient’s questions. When a patient sees “his nurse” in the operating room, he often reaches out to touch her hand, a sign that the nurse is trusted and allowed within the body-buffer zone. Preoperative teaching makes the transition easier for the patient in the postoperative period. Knowing what to expect eases the anxiety of the unknown. However, preoperative teaching must consider ego alterations that occur. Knowing that an operation revives fears of Severe injury and concerns of punishment, the OR nurse must reassure the patient that physicians and nurses are healers and helpers, not punishers, and the body, like everything else in this world, has times of breakdown and must be repaired.
AORN Journal, April 1975, Vol 21, N o 5
Because the patient expends a large portion of mental energy toward bodily concern, his attention span and retention abilities are impaired. Therefore, the nurse must remember to keep explanations short and simple. If the area involved causes feelings of intense shame and fear of loss of love and respect, the patient may appear disinterested or refuse to listen. At times the presence of a close family member or friend helps to reinforce the nurse's comments. At other times, however, privacy is needed to elicit fearful questions. Because the grieving process may begin before the operation, one must try to discern what stage the person is in and give support. A visit by a person who has already undergone the procedure can be beneficial because he has been "through it" and provides proof that one can function in a socially acceptable manner after a disfiguring or disabling or frightening procedure. A resource to aid medical personnel in developing a teaching approach is Shoenberg's Loss and Grief." Each chapter discusses a particular type of loss and the implications drawn are excellent. Surgical patients undergo a tremendous amount of stress and change. Because the OR nurse is present when the change occurs, he o r she is in a pivotal position to help make the transition as easy as possible. Summary. Surgical alterations of the body produce anxieties associated not only with the procedure itself, but also with the results as they relate to the body image. Feelings of loss and dissatisfaction accompany any body disfigurement. Preoperative teaching and visits by similarly affected individuals can aid in reducing these anxieties.
Notes I. Charles K Hofling, Textbook of Psychiafry for Medical Practice (Philadelphia: J B Lippincott Co, 1968) 244. 2. lbid. 3. Ibid. 4. lbid. 5. Arthur P Noyes, Lawrence C Kolb, Modern Clinical Psychiatry (Philadelphia: W B Saunders Co, 1966) 408. 6. Michael A
"Altered body-ego of the American Psychoanalytic Associution, 14 (January 1966) 273. 7. John J Schwab, James D Harmeling, "Body image and medical illness,'' Psychosomatic Medicine. 30 (January-February 1968) 59-60. 8. M a r d i J Horowifz, "Body image," Archives of General Psychiotry. 14 (May 1966) 460. 9. George L Engel, "Grief and grieving," American Journal o f Nursing, 64 (September 1964) 95-98. 10. Barney M Dlin, e t al, "Psychosexual response t o ileostomy and colostomy," AORN Journal, 10 (November 1969) 77-84; Carol A Gribbons, M A Aliapoulios, "Early carcinoma of the breast," American Journal of Nursing, 69 (September 1969) 1945-1950; Victor A Christopherson, "Role modifications of the disabled male," Americon Journal of Nursing (February 1968) 290-293: Doris L Carnevali. "Preoperative anxiety," American Journal of Nursing (July 1966) 1536-1538. I I . Bernard Schoenberg, et al, Loss and Grief: Psychological Management i n Medical Practice (New York: Columbia University Press, 1971). experiences,"
Woodbury,
Journal
Buzzell, HlMA president Harold 0 Buzzell, administrator of the Health Services Administration of the US Department of Health, Education, and Welfare (HEW), has been selected as the first president of the Health Industry Manufacturers Association (HIMA). The association was recently formed through the merger of the Medical-Surgical Manufacturers Association and the Health Industries Association to provide a unified voice and leadership for firms engaged in research, manufacturing, and marketing of medical devices, products, and related services.
AORN Journal, ApriE 1975, Vol 21, No 5
815
hat effect does surgical disturbance have upon body image and the ego’s homeostatic mechanisms? To the uninitiated, the word, “surgery,” portrays a stretcher ride through unknown corridors, the administration of anesthesia, and a ritual known only to a select few. Surgery is a planned anatomic alteration designed to arrest, alleviate, or eradicate a pathologic process occurring either within or on the surface of the body. Occasionally surgery is elected by the patient (mammoplasty, rhinoplasty) , but more commonly it is prescribed. Titchener reminds us that an operation revives fears of severe injury and retaliation I that were planted in childhood and infancy.’ In other words it is a “I-must-have-donesomething-wrong-and-now-(God)(my child) (my wife) (my parent) (my friend)-is getting-even” punishment feeling. When one becomes aware of an illness an “increasing portion of the available mental energy flows . . . toward concern with the body and the mental image of i t 2 This produces “intense shame and fear of loss of love and respect”3 and leads to many questions, Will my husband love me if I have only one breast? Will I be covered while I’m in the OR? Will other people know that I have a colostomy? Will it smell? Titchener also notes that “stability Whifeside Wells, and psychological equilibrium depends in RN, MSN part upon intactness of the body and consistency of its functions.”* Any change in this intactness requires an adjustment to maintain psychological equilibrium. Noyes and Kolb describe how the body precept evolves. This developmental process is complex, and any alteration involves a good deal of mental adjustment. The various sensory impressions conveyed by . . . kinesthetic, visual, and tactile apparatus to the cortex lead to an expanding and growing perception of body awareness, presumably organized and integrated in the parietotemporal cortex of the brain. In addition to this physiological substratum . . . each indi-
Body image I
and surgical a Iterations
Robin
812
AORN Journal, April 1975, Vol 21, N o 5
vidual attaches . . . attitudes with emotional overtones that derive from his early experience in the family and as a result of the parental evaluations of his physiq~e.~ The relationship between body image and self-image is most effectively portrayed by Somerset Maugham. Philip Carey, the protagonist in Of Human Bondage is an example of the development of body image. With his club foot and short stature, he tromps through life trying to compensate for the body image which he designates as inferior.
Robin Whiteside Wells, R N , MSN, is an instructor in the graduate division of the School of Nursing,
University of Pennsylvania, Philadelphia. She is a graduate of the Cooper Hospital School of Nursing, Camden, N J , and received her BSN and MSN degrees from the University of Pennsylvania. Because i t alters the body itself, surgery leads to altered body-ego experiences. Altered body-ego experiences, according to Woodbury, are “sensations of a change in the organization (size, configuration, and spatial orientation) and sense of unity of the body ego with effects
. . upon object and self-representstion and the relationship between the tW0.”6 To derive a body image score, Schwab and Harmeling conducted a study in which they asked 124 medical inpatients to express their attitudes toward 50 bodily parts and functions. Their findings included: 1. Relative dissatisfaction with the body. 2. Most respondents focused their dissatisfaction on the affected body part. 3. Twenty percent indicated gross dissatisfaction with many bodily parts and functions. 4. There were sexual differences. Females were (1) more dissatisfied with their bodies than males, (2) negative attitudes were more closely tied to conditions of illness and their psychological well-being, (3) negative body image was associated with high anxiety, increased anxiety, and distortions of the severity of the illness and prognosis. Males had negative attitudes scores (1) independent of this illness orientation and (2) correlated with advancing age and high socioeconomic status.’ Another aspect of body image is “human territoriality.” This includes not only the space surrounding the body, but the penetrability of this space in reference to other persons. . . . Humans seem to have feelings about the space that immediately surrounds them that are almost as individual and particular as their feelings about the body itself.8 Surgery, in all facets, radically invades the body-buffer zone. The patient is literally invaded by a horde of strangers armed with strange instruments. His body is viewed as a ,
AORN Journal, April 1975, Vol 21, N o 5
813
drawing board and the battle plan of attack is drawn on his skin. Once the fartress is penetrated, the internal area is altered. Following alteration, the patient is constantly reminded of it by the pain, the dressing, the stitches, and the horde attending him. He is not the same person he was no matter how minor the procedure or how slight the alteration. He is left with a feeling of loss, and he mourns, either consciously or unconsciously, for what he once was. He grieves for the “dead” part-be it his mole, tonsil, or leg. The normal process of grieving as outlined by Engel is (1)shock and disbelief, (2) developing awareness, (3) restituPation and (4) resolving the tients must be given support at each stage throughout this normal proce3s. Radical surgery for carcinoma has attendant problems of disfigurement and ablation of organs. There is a sense of insecurity from the new body image as well as the possibility that the cancer is still there and growing. The organs ablated are also important to consider, especially if they concern sexuality. Dlin et a1 describe adjustments that must be made with an ileostomy or colostomy; Gribbons and Aliapoulios discuss carcinoma of the breast; Christopherson reviews the disabled male; and Carnevali talks about preoperative anxiety.l0 The problems cannot be ignored if one wishes to effectively assist the patient through a disconcerting experience. Another area of adjustment to a new body image is reliance upon mechanical objects such as pacemakers, heart valves, vascular prosthetic grafts, hip and bone pins, total joints, and silastic implants. The list
814
lengthens as medical science advances. Receiving another person’s heart, kidney, or cornea adds the dimension of indebtedness and a sense of responsibility for another person’s organs. No longer is the original body capable of functioning on its own. Now it must rely on an artificial part or a transplant and there is always the possibility that these may fail to perform properly. It is little wonder that surgery is an anxiety-producing experience in terms of body image. The stress associated with alteration speaks for the benefit of preoperative visits. The OR nurse is present during the invasion and reassures the patient that he or she will be the guardian of his modesty, his body, and his ego. She gives the patient an idea of what to expect; the stretcher ride, IVs, personnel, anesthesia, awakening in recovery room, and the reality of phantom phenomena. She also answers the patient’s questions. When a patient sees “his nurse” in the operating room, he often reaches out to touch her hand, a sign that the nurse is trusted and allowed within the body-buffer zone. Preoperative teaching makes the transition easier for the patient in the postoperative period. Knowing what to expect eases the anxiety of the unknown. However, preoperative teaching must consider ego alterations that occur. Knowing that an operation revives fears of Severe injury and concerns of punishment, the OR nurse must reassure the patient that physicians and nurses are healers and helpers, not punishers, and the body, like everything else in this world, has times of breakdown and must be repaired.
AORN Journal, April 1975, Vol 21, N o 5
Because the patient expends a large portion of mental energy toward bodily concern, his attention span and retention abilities are impaired. Therefore, the nurse must remember to keep explanations short and simple. If the area involved causes feelings of intense shame and fear of loss of love and respect, the patient may appear disinterested or refuse to listen. At times the presence of a close family member or friend helps to reinforce the nurse's comments. At other times, however, privacy is needed to elicit fearful questions. Because the grieving process may begin before the operation, one must try to discern what stage the person is in and give support. A visit by a person who has already undergone the procedure can be beneficial because he has been "through it" and provides proof that one can function in a socially acceptable manner after a disfiguring or disabling or frightening procedure. A resource to aid medical personnel in developing a teaching approach is Shoenberg's Loss and Grief." Each chapter discusses a particular type of loss and the implications drawn are excellent. Surgical patients undergo a tremendous amount of stress and change. Because the OR nurse is present when the change occurs, he o r she is in a pivotal position to help make the transition as easy as possible. Summary. Surgical alterations of the body produce anxieties associated not only with the procedure itself, but also with the results as they relate to the body image. Feelings of loss and dissatisfaction accompany any body disfigurement. Preoperative teaching and visits by similarly affected individuals can aid in reducing these anxieties.
Notes I. Charles K Hofling, Textbook of Psychiafry for Medical Practice (Philadelphia: J B Lippincott Co, 1968) 244. 2. lbid. 3. Ibid. 4. lbid. 5. Arthur P Noyes, Lawrence C Kolb, Modern Clinical Psychiatry (Philadelphia: W B Saunders Co, 1966) 408. 6. Michael A
"Altered body-ego of the American Psychoanalytic Associution, 14 (January 1966) 273. 7. John J Schwab, James D Harmeling, "Body image and medical illness,'' Psychosomatic Medicine. 30 (January-February 1968) 59-60. 8. M a r d i J Horowifz, "Body image," Archives of General Psychiotry. 14 (May 1966) 460. 9. George L Engel, "Grief and grieving," American Journal o f Nursing, 64 (September 1964) 95-98. 10. Barney M Dlin, e t al, "Psychosexual response t o ileostomy and colostomy," AORN Journal, 10 (November 1969) 77-84; Carol A Gribbons, M A Aliapoulios, "Early carcinoma of the breast," American Journal of Nursing, 69 (September 1969) 1945-1950; Victor A Christopherson, "Role modifications of the disabled male," Americon Journal of Nursing (February 1968) 290-293: Doris L Carnevali. "Preoperative anxiety," American Journal of Nursing (July 1966) 1536-1538. I I . Bernard Schoenberg, et al, Loss and Grief: Psychological Management i n Medical Practice (New York: Columbia University Press, 1971). experiences,"
Woodbury,
Journal
Buzzell, HlMA president Harold 0 Buzzell, administrator of the Health Services Administration of the US Department of Health, Education, and Welfare (HEW), has been selected as the first president of the Health Industry Manufacturers Association (HIMA). The association was recently formed through the merger of the Medical-Surgical Manufacturers Association and the Health Industries Association to provide a unified voice and leadership for firms engaged in research, manufacturing, and marketing of medical devices, products, and related services.
AORN Journal, ApriE 1975, Vol 21, No 5
815