Depressive reactions following hysterectomy

Depressive reactions following hysterectomy

GEORGE F. MELODY, M.D. San Francisco, California

A R E v 1 E w of the postoperative course of 267 American women who underwent hysterectomy indicates that such previously feared complications 1 as hemorrhage, infection, peritonitis, and intestinal obstruction2' 3 have been displaced in frequency by a psychiatric sequela, namely depression, which occurred in 11, or 4 per cent, of the present series. This statistical fact is perhaps understood best in terms of the improvements in pre- and postoperative care, anesthesiology, and surgical technique that have developed in the last 20 years, along with the profession's heightened awareness of psychiatric illness. A severe depressive reaction. \vas the only psychiatric complication noted in the current series during the first 3 months following operation, there having been no instances of schizophrenia, paranoia, toxic psychosis, and so on. The term "posthysterectomy depression" is advisedly not used in this communication, inasmuch as there is nothing unique about the clinical features of depressive reactions after hysterectomy any more than there is anything characteristic about the clinical manifestations of "postpartum psychoses" 4 except that they occur after childbirth. Moreover, in keeping with current psychiatric practice, such diagnostic labels as "depressive phase of manic-depressive psychosis," "involutional melancholia," "cyclothymic depression," and "psychoneurotic reactive depression" have been avoided; m-

stead, designations such as "depressive reaction," "depressive episode," "syndrome of depression," and "depressive illness" will be used in describing the psychiatric complication herein discussed. The thesis herein offered is that woman (like man) is a biologic, social, and cultural creature, and as such is dependent for health* on the acceptance, approval, support, and encouragement of significant individual members of the social group to which she belongs. In other words, her selfevaluation5 is determined, in the last analysis, on how she perceives and symbolizes the attitude, behavior, expectations, etc., of the group of v;hich she is a member. Intimate human relations and interactions are so essential to health that one's sanity and potential for self-fulfillment are jeopardized for the most part by the perceived threat of disapproval, rejection, devaluation, or loss of security. The principles of human ecology~ are nowhere more convincingly demonstrated than in the clinical observation of how social interactions determine the postoperative course of the woman after hysterectomy. In other words, the depressive reactions that followed hysterectomy were precipitated in each instance by a traumatic social event that the patient perceived as a a real, threatened, or sytnbolic act of disapproval or rejection. Hysterectomy, to the woman who became depressed postoperatively, carne to mean ejection from the "According

From the Department of Obstetrics and Gynecology, University of California School of Medicine, San Francisco, California.

ganization,

to

the definition of the World Health Or-

"Health is a state of complete physical and

social well-being and not merely the absence of disease or infirmity." (Italics added.)

410

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Depressive reactions after hysterectomy

social milieu in which she had previously functioned; that is to say social discontinuity* follovved hysterectomy and the depressive illness was the particular adaptive pattern that evolved in response to the discontinuity of the patient's preoperative social life. Clinical material

A severe depressive illness occurred in 11 or 4 per cent of 267 hysterectomized women (personal series) during the first 3 months after operation. The diagnosis of depression was confirmed in each instance by one or more psychiatrists. While the average age of the woman who developed a depressive episode was 41 years, the age distribution ranged from 35 to 52 years, and the fact of depression was diagnosed on the average between the fourth and sixth weeks following operation. All hysterectomies were total abdominal, and the indications for operation are summarized in Table I. Of the 5 women in whom ovarian function was terminated at the time of operation, estrogenic replacement therapy was provided for all except Patient A, whose operation was done for endometrial carcinoma. There was one nonpsychiatric complication in the 11 patients, namely, intestinal obstruction (Patient C), which was relieved by secondary laparotomy.

Table I. Indications for hysterectomy Patient

D E

F

32

G

44 44 46

c

H I

J

K

*Social discontinuities7,

8

tThe method used for conducting such interviews incor-

Carcinoma of endometrium Pelvic inflammatory disease Placenta accreta Uterine myomas Carcinoma in situ of cervix Rupture of uterus at fourth cesarean sectiOn Uterine myomas Adenomyosis Pelvic inflammatory disease and myomas Carcinoma in situ of cervix Carcinoma in situ of cervix and endometriosis

illness after hysterectomy Patient

Event

A

Deserted by husband 2 months after operation Rejected by husband who accused patient of infidelity and adultery Husband arrested, convicted, and imprisoned in state penal institution for grand larceny that occurred 5 days after hysterectomy Impotence of husband who claimed that patient was "just a shell of a woman after hysterectomy" Abandoned by paramour who "disappeared" while patient was still hospitalized Impotence of husband who feared penile injury from coitus with a "desexed woman" Terrorized and physically assaulted by chronically impotent paranoid husband ( 30 years her senior) who accused patient of promiscuity and adultery "after that operation" Deserted by husband (after 18 years of marriage) who departed 2 months after operation to marry another woman, vvhich he did even before interlocutory decree of divorce was granted; he claimed that first wife was a "neuter" after hysterectomy Discharged by emp.loyer 2 months after hysterectomy because of disabling alcoholic polyneuropathy Deserted by husband who feared "contracting cancer through intercourse" Disinherited by wealthy parents shortly after operation which they believed was the penalty for promiscuity and "venereal" disease

B

C

D E

G

H

I

are many and varied, and in-

porated the ideas and techniques credited to the American psychologist, Car1 Rogers.9

35 45

Indications

Table II. Social events preceding depressive

F

clude the impact of such crucial events as desertion, divorce, legal separation, widowhood, termination of engagement to marry, severance from employment, retirement, disinheritance~ and so on.

I Age 52 35 40 38 41

A B

Preoperative personality profile

Anamnesis of the 11 women who developed a depressive illness after hysterectomy indicated that all had had one or more depressive episodes during the 5 years prior to operation, and the symptoms that brought them to doctors included "nervous breakdown," "blue spells," unexplained "chronic fatigue," "melancholia," and an "alcoholic problem." In the course of nondirective interviewingt about the illnesses just mentioned,

411

J K

412 Melody

February 1, 1962 Am.

J. Obst. & Gynec.

it was learned that the depressive bout was usually precipitated by a disappointing life situation, actual or threatened loss of selfesteem, or a predicament of (real or imaginary) helplessness vis-a-vis "overwhelming odds." Alcoholism to a degree that had caused physical illness and social and/or economic malfunctioning had been a major problem in 7 of the 11 women prior to hysterectomy. In fact, at the time of operation 3 of the 7 intemperate women had alcoholic polyneuropathy and a fourth (Patient A) already had early cirrhosis of the liver from which she died 22 months after hysterectomy.* Among the 4 abstainers in the series of 11 patients, 2 gave a history of chronic recurrent duodenal ulcer, whereas the other 2 had an essentially negative medical history, aside from episodes of depression mentioned above. In summary, the patients who displayed the syndrome of depression after hysterectomy were women who had demonstrated over the years prior to operation the proclivity for reacting to threat with the particular adaptive pattern of depression, episodes of vvhich occurred mainly in a conflict setting that involved loss of status, security, or acceptance (actual, threatened, or symbolic) . Depression of mood, thought, and behavior had evolved as their habitual adaptive pattern for responding to conflict situations in which they felt rejected, devalued, and angry but-at the same time-hopeless and helpless. The parameter of alcoholism, in the present series at least, appeared to be simply a secondary deiivative, that is to say, symptomatic of the basically depressed personality.

While the decisive events are summarized in Table II, the common denominator among them appeared clearly to be an act that the patient perceived as a rejection, devaluation, or disaffection on the part of a significant person in her social milieu. That is to say, from the point of view of the patient the experience of hysterectomy meant not only the loss of a valued social-contact organ,* but simultaneously a social discontinuity of her preoperative way of life. This implied correlatively, it would seem, the loss of one or more such essential social rolest as womanhood, sexual partner, motherhood, valued employee (Patient I), beloved daughter (Patient K), and so on. Inasmuch as woman is a tribal creature, she interacts and reacts according to her particular "blueprint for social living" (which is how the anthropologist Benjamin D. PauPR defines culture), and contrariwise, one may infer that how a husband or other significant figu.re semantically reacts to a hysterectomized woman is determined--along with other dynamic factors to be sure---by his "blueprint for social living." The human creature is unique in his capacity and proclivity for reacting to symbols as though they were significant events. If the sociologist were called upon to theorize about the dynamic factors that may determine depressive reactions after hysterectomy he might focus on the theorem that the false definition or evaluation of a human situation leads to behavior that has the capacity of making the originally false evaluation come true. In other words, if a significant person in the social group of the hysterectomized woman falsely defines the hysterectomized woman as "desexed,"

Social determinants of depression folldwing hysterectomy The episodes of depressive illness herein discussed seemed clearly precipitated by an antecedent traumatic social experience.

·*Besides the genitals, other social-contact organs ate the female breasts, the mouth, the skin surface of the body. The social roles available to an individual, as well as one'!> body image, self-concept, or selfwevaluation, are to a large degree determined by the ~ocial-contact organs and their symbolic meaning to the individual.

*Necropsy examination of Patient A showed no evidence of recurrent tumor; the primary cause of death was attributed to cirrhosis of the liver.

tThe psychologist T. R. Sarbin10 defines role as what the person does in contrast to self or what the person is. The question of the impact of hysterectomy on the selfimage and social roles has recently received the attention of the psychiatrists Drellich and Bieberll and Hollender .12

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Depressive reactions after hysterectomy

413

"neuter," "shell of a woman," "promiscuous," and so on, the rejected or devalued woman may eventually behave in such a way that the originally false evaluation comes true; and, among other aspects of the clinical response, the syndrome of depression may evolve. As W. I. Thomas, 14 the dean of

perience of hysterectomy be perceived as a social as well as a biologic discontinuity. Social and cultural as well as biologic factors determine health or disease during the months after operation. A traumatogenic social event that was perceived by the hysterectomized woman as a threat to her self-

.A...merican

sociologists, stated: ''If men define

esteem, self-evaluation, self-image, and pre-

situations as real, they are real in their consequences." Of 267 American women who underwent hysterectomy, the most common postoperative complication observed was a psychiatric illness, namely depression, and this occurred during the first 3 months after operation in 11 patients ( 4 per cent of the series) . A history of a previous depression is of predictive significance in anticipating the postoperative woman who is prone to reacting with depressive symptoms should the ex-

operative social role ( s), was seemingly a precipitating factor for the depressive illness that followed hysterectomy. Inasmuch as woman is a tribal creature, the acceptance, approval, and support of significant members of the social group of which she herself is a member are critical factors in the prevention of adverse reactions to hysterectomy, especially in women who preoperatively have shown the proclivity for reacting to threat with the syndrome of depression as their particular adaptive pattern.

REFERENCES

1. Melody, G. F.: West. J. Surg. 62: 235, 1954. 2. Melody, G. F.: Obst. & Gynec. 11: 139, 1958.

3. Melody, G. F.: J. Internat. Coil. Surgeons 35: 283, 1961. . 4. Boesky; D.; Cross; T. N.; and Morley, G. W.: AM. J. 0BST. & GYNEC. 80: 1209, 1960. 5. Mead, G. H.: Mind, Self and Society, Chicago, 1934, University of Chicago Press, p. 138. 6. Bews, J. W.: Human Ecology, London, 1935, Oxford University Press. 7. Benedict, R.: Psychiatry 1: 161, 1938. 8. Patterson, R. M., Craig, J. B., Simon, D., Lefton, M., and Pasamanick, B.: Obst. & Gynec. 15: 209, 1960.

9. Rogers, C. R.: Counseling and Psychotherapy, Boston, 1942, Houghton Miffiin. 10. Sarbin, T. R.: In G. Lindzey, editor: Handbook of Social Psychology, Reading, Mass., 1952, Addison-Wesley, p. 244. 11. Drellich, M. G., and Bieber, I.: J. Nerv. & }v{ent. Dis. 126: 322, 195ft 12. Hollender, M. H.: AM. J. 0BST. & GYNEC. 79: 498, 1960. 13. Paul, B. D.: Am. J. Pub. Health 48: 1502, 1958. 14. Merton, R. K.: Social Theory and Social Structure, Glencoe, III., 1957, The Free Press, chap. XI, pp. 421-436. 490 Post Street San Francisco, California