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Psychiatric Reaction to Threatened Blindness; A Personal Account
" " ReactI"on to Threatened Blindness; Psych IatrIc A Personal Account SANFORD
I.
R. WOLF, M.D.
Introduction
• A wide variety of disordered behavior has been reported among patients undergoing a crisis in vision, usually in those cases that have exhibited organic eye disease and are in the postoperative period subsequent to corrective surgery. It is beyond the scope of this paper to describe in depth the various types of disordered behavior observed in such patients or the etiologies hypothesized to explain why particular forms of behavior occurred. Both have been well summarized by Jackson I in a review spanning the earliest case reports of Posey", and Kipp and Finley' through the more recent reports of Linn and his associates " ", Ziskind and associates,,·g and Jackson's own series of patients. Certain salient facts are evident from these reports: 1) Though a variety of behaviors have been reported, most descriptions of post-eye surgery behavior emphasize a tendency toward early irritability, restlessness, and occasionally suspiciousness. These beginning symptoms progress on through degrees of irrational speech and movement to various degrees of disorientation and often psychotic symptoms such as incoherence, visual and/or auditory hallucinations: such emotional symptoms are usually combined with physical actions of non-compliance with physicians' orders, or frankly self-destructive behavior such as tearin~ off of eye patches. 2) Writers have tended to blur the issues bv including in their reports patients of markedly different ages (raising the question of organic brain deficits in the elderly) and differin~ types of surgery; contrary to this trend Dr. Wolf is Assistant Professor of Psychiatry and Director, Psychiatric Liaison Service, School of Medicine. University of California, San Diego, La Jolla. California 92037. 316
Ziskind and associates reported that 30% of their post-cataract patients exhibited "mental" symptoms following surgery for intra-ocular disease, principally cataracts, while 100% of their patients exhibited "mental" symp~oms following surgery for retinal detachment'. 3) Reports of disordered behavior following types of eye surgery are also difficult to compare because the surgical p~ocedur~s themselves as well as the accompanymg medical management have changed frequently (length of hospitalization, degree and length of patching of eyes, etc.). . 4) Explanations of behavioral reactions following eye surgery have tended to change over the years in accordance with curr~nt theoretical models of the etiology of behaVior. Thus the earliest reports placed emphasis on homesickness and a change from familiar surroundings in the post-surgical period. Later, more emphasis was placed on the use of eye patches and concomitant lack of visual orientation, or the psychological stress of surgery. A significant model accounting for disordered behavior under such conditions emerged from the sensory deprivation experiments initiated by Hebb and associates in the 1950's.0·'1 As Solomon 12 has said of the interest in sensory deprivation experiments, "It was intriguing to think that simply doing nothing and being cut off from the outside world could bring about a transient psychotic state". Those seeking to explain the striking; behavior following eye surgery could readily identify with the findings from such experiments. Ziskind and associates 7 •8 utilized the results of research on altered states of consciousness, especially dream research, to emphasize the significance of periods of reduced awareness in accounting for both the symptoms reported in sensory deprivation work and the reactions of patients to eye surgery; this view has been of~en contested. Volume XII
THREATENED BLINDNESS-WOLF
I found a unique opportunity for data gathering and introspection into the behavior of patients following eye surgery, when I, myself, underwent surgery for unilateral retinal detachment at about the time that my psychiatric residency was completed; prior to the surgery I had already been gravitating toward a career in psychosomatic medicine. Though my own case was not as serious as most, in that hospitalization was not unduly long and the support of family and colleagues was near, I found the experience traumatic, at times to the point of terror. The many reports I read following this experience seemed, in the light of it, unduly simplistic and neglective of important factors. It is understandable that many patients do not report their feelings to their physicians during an experience such as that following eye surgery. It was nearly five years before the author could recall (or review notes on) the details of his experience without anxiety preventing the task.
II.
Personal Case Report
Retinal holes were discovered in one eye during a routine ophthalmologic examination (which included "indirect" vision of the retina). I had requested the examination as a prophylactic measure because an episode of retinal detachment had occurred in one parent. Following the detection of this lesion, regular visits were scheduled to keep careful watch on it; about six months after the start of these visits, a detachment was noted. At this time I requested that the surgery be performed by a consulting surgeon with an outstanding clinical reputation in retinal work. Surgery was rapidly scheduled. Prior to surgery, perhaps because of the asymptomatic nature of the lesion, no patching of the eye, bed rest or wearing of pin-hole glasses were ordered. Conversation prior to surgery, as well as conscious thought (and all but the vaguest feeling of unrest) were centered on other neutral topics; in retrospect, it seems clear that this was due to my own use of denial, reinforced by those about me. In fact, we euphemistically referred to the impending surgery as a "procedure" rather than an "operation". Following routine pre-op medication, the surgery was performed under general inhalation (intubation) anaesthesia after pentothal induction. Upon awakening, I slowly became aware of my condition and recalled that before the operation I had attempted to prepare myself for this certainty of awakening with both eyes bandaged. As I attempted to orient and calm myself, I spoke September-October 1971
with those about me: my wife, a person whom I perceived to be a nurse, and others whom I presumed wcre acquaintances. The first instance of irrationality came when I answered a question vo:ced by an appropriate sounding person across the room; I had thought the voice familiar but could not readily identify it. At that time, I felt my wife's hand on my arm, and heard her say, gently, but firmly, '"There is no one there." Startled, I nodded and began to speak of other things, alternately dozing, but the same experience repeated itself a number of times. I realized that, whatever the cause, I was actually hallucinating. This type of hallucinatory experience gradually faded during the first post-operative day. It was replaced by a continuously accelerating condition best described as a mixture of boredom, utter dependency, preoccupation with blindness, and a tendency to center attention and affect on each and every ache and pain for fear of what it might portend, and on each movement, especially of my head, for fear that somehow healing of my eye depended on supersensitive attention to such detail. From the second post-operative day onward, I noticed a series of vivid, changing, uncontrollable visual images which were continuously before me. At first they tended more toward changing geometric patterns with vivid colors; later the visual images took on the form of symbolic scenic entities. In the early postoperative period r noticed a tendency to drift in and out of somnolescence. More frequently, however, these bizarre dream-like visions occurred while I was quite awake, and at times, I would describe them to colleagues or dictate their description for periods as long as one hour. The changing symbolic forms could best be described as at once human and magical, frequently shifting, and having strong sexual or aggressive overtones. In describing the experience, I remarked several times that it seemed that I was in front of a very widescreened movie which I could neither control. nor look away from. There seemed to be some gross correlation between the types of symbolic scenes, and the general mood that I was in - boredom, depression, anger. Mixed in with the symbolic scenes just described were periods of quite realistic visions of seeming-ly real places and people, often of a panoramic landscape nature. Some of these scenes were familiar, like remembrances of walking- through the High Sierras; in most of them I felt as thoug-h the scenes and people should be familiar, but I could not place them. Perhaps the most painful part of the experience was the dependency on some one else for each need. Blindness as a symbolic equivalent of castration seems entirely at>propriate now in recalline: a feeling- of impotence at mv inabilitv to care for myself in any way. Episodes of anxiety became more frequent from the second dav on-
317
PSYCHOSOMATICS ward and when these occurred together with feelings of helplessness, dependency, and depression, there was a tendency to associate toward thoughts of death. Though I was depressed at times during the post-operative period, I would not now consider these thoughts (nor did I consider them at the time) to be suicidal. Rather, they seemed to be a curious, thoughtful, and detached reflection on the nature of death. Though my attending surgeon was kindly and inspiring of confidence, he had a tendency toward terseness and avoided giving out even rudimentary information (such as when my eyes would be unbandaged and examined, etc.) which led to anger often bordering upon rage. Though I wished to be informed on my medical condition, It is difficult to know what knowledge would have been enough at that time. At the end of the first week, the combination of boredom, dependency, anxiety and rage (which I dared not express to so powerful a person) led to a series of acute anxiety attacks. My remembrance of the constant visual aberrations becoming, or at least seeming to become, more frightening and more ominous during these anxiety attacks is vivid. The attacks passed in waves. I was given diazepam orally, 5 mg. every four hours, as needed, up to three times a day. This greatly alleviated the anxiety. Both the visual images and the anxiety I was experiencing seemed to lessen when my eyes were finally unbandaged for examination on the seventh day; this was in spite of the fact that I saw little if anything during this unbandaging, and my eyes were immediately rebandaged. Gradually, the eondition eased to the extent that the last three days of hospitalization were considerably less anxiety-ridden than the first seven. Both the altered visual perceptions and the waves of anxiety had largely cleared by the time of discharge. At that time. my eyes were unbandaged and I was fitted with pin-hole glasses, and wore them for one month after leaving the hospital.
III.
Discussion
In reading published reports of disordered or highly anxious behavior following eye surgery, I readily identified with certain of the actions or words attributed to the patients described. I found, however, that there was a significant incongruence between my own experience and these reports. I could not help but feel that both the etiologies hypothesized as causes, as well as the descriptions of the patient experiences were presented in an oversimplified and too neatly packaged manner. To the extent that I could relate my own ex318
perience to the manner of handling, philosophy of approach, and explanation of the events offered in descriptive reports, that of Weisman and Hackett l :! would be closest. The following points are pertinent. 1) In the period immediately preceding surgery, facing possible catastrophe, my experience came closest to the description of partial depersonalization, difficulty in concentration, and distance described by Wertham H • 2) I do not believe that there can be any meaningful grouping of the post-operative experiences of patients following cataract surgery and those following retinal detachment surgery. The age differences of the two groups are well known; many symptoms of the cataract group may be due to organic effects of the aging process 1 • 15• Cataracts form slowly and gradually dim the vision, allowing time for psychological adjustment, while retinal surgery is nearly always sudden with little or no time to prepare for threatened blindness. 3) Patients report (or are observed having) disordered behavior only when such symptoms become too marked to ignore. There is then a tendency to consider the constellation of symptoms in the post-operative course as a unity. In my experience, the immediate post-operative experience, the types of bizarre visual forms more often associated with somnolescence, and the less bizarre, photographic-recall images that tended to occur while I was entirely awake seemed totally separate entities. 4) While bizarre symbolic images occurred more often while I was in a semi-stuporous or hypnoid state (from my own recall and the observation of others), it does not appear that either the experiences of sensory deprivation or post-eye surgery disordered behavior are due to patients entering reduced states of awareness as Ziskind and associates have hypothesized. Many of the most vivid visual images, including those that provoked the highest anxiety, were recorded while I was fully awake and speaking to others. Many were described, while ongoing, in the midst of other conversation. S) Not only have conflicting results been obtained from different sensory deprivation Volume XII
THREATENED BLINDNESS-WOLF
laboratories, but there is a discrepancy in the behavior reported during many visual sensory deprivation experiments, and that reported in post-surgical eye patients. This does not belie the effect of visual sensory deprivation as the primary etiology of the post-eye surgery patients' symptoms. In these various circumstances, it is the inner percept that differs. In sensory deprivation experiments, whatever the stress, there is the certain knowledge that one's vision will return. The ego assault of threatened blindness, the uncertainty, dependency, physical trauma and the frequently present rage associated with the surgical procedure superimposed on the experience of sensory deprivation account for the difference between the reports of patients and those of sensory deprivation laboratories. As ego assaults, uncertainty, and dependency are highly personal events, it seems natural to expect a degree of difference in the behavioral response of different people to surgery. 6) The thoughts of death hovering over portions of the post-operative experience can easily be written off as depression, or perhaps a form of castration anxiety; blindness has long been considered as symbolic castration and the patient recovering from retinal surgery is near the nadir of potency as a functioning person. This would, I believe, be gross over-simplification. In the developmental studies of children, thoughts or fears of death in childhood, also, are usually considered to be a form taken by castration anxiety that is currently present. However, Wahp6 reminds us of the frequent occurrence in children of thoughts of death prior to the expected onset of castration anxiety, and the total denial by Freud, in developing this developmental theory, of thoughts of death in children of this age. One might consider the possibility that in certain cases the concept of castration anxiety might have evolved to mask the fear of death rather than the reverse. 7) The experience of threatened blindness afforded me an unusual insight into the feelings and defenses of patients and their physicians. When I awakened from general anaesthesia, with both eyes bandaged, I gained my deepest insight into the nature and threat of September-October 1971
hallucinations. Though I thought I fully understood that the most terrifying part of any experience of altered perception or cognition was not the alteration itself, but the fear of "going crazy," it is impossible to describe the terror at realizing that I was unable to screen "real" from "unreal" voices and the disturbing finding that those voices that sounded unreal were, in the context of my thinking, just as appropriate in tone and manner as those voices that were "real". To this day, I wonder what would have been my fate if I had not prepared myself for the experience of awakening sightless; in the same context, I wonder how I would have fared if I, as a physician, had not had the comforting knowledge that this was most likely a toxic reaction due to the stress of the surgery and anaesthesia, and would pass. The experience of seeing my own dependency upon my surgeon afforded me a perspective of the enormous emotional demands placed upon surgeons who attend sizable numbers of such patients. It is clear that unless the surgeon in point possesses a personality that is not only empathetic and "giving," but also able to set limits on the dependency demands of this patients, a situation could easily arise that would lead to the surgeon's withdrawal from his patient as a defensive, or even self-preservative maneuver. 8) Concerning the management of patients in similar circumstances, it is essential that the attending surgeon take sufficient time to explain the procedure, its consequences, and the probability of its success as straightforwardly as possible. During my convalescence, I compared my own preparation for surgery with those of a sizable number of fellow patients who had undergone the same operation perfomed by several different surgeons; their comments made it clear that an over-optimistic attitude engendered as much rage and anxiety as a manner that was too terse and uninformative. The manner that has best been described by Weisman and Hackett of utilizing familiar objects, radios, familiar foods, and conversation on familiar topics proved very helpful in my case. It is essential that as many familiar, simple and interesting auditory, olfactory and 319
PSYCHOSOMATICS
possibly tactile cues as possible be furnished for constant reorientation during the period of sightlessness. It might well be helpful to acquaint patients prior to surgery with the probability and the nature of altered perceptions likely to ensue. Though this might be construed as suggestive, it seems that the terror and fear of total loss of control which occurs in most patients under such circumstances is worth the risk. Because many of the serious cognitive alterations begin as an ever-increasing anxiety, it seems advisable to prescribe "minor" tranquilizers on a routine basis at the first sign of anxiety in post-eye surgery patients as a means of possibly preventing the more serious behavioral disorders. Certainly the effects of such tranquilizers prescribed on this basis should be studied. This would be most appropriate in younger patients (detached retina groups) where the danger of clouding the sensorium is less. It appears that newer methods of ophthamologic surgery, especially those concerned with the repair of detached retina, may minimize the period of sensory deprivation and, indeed, the entire operative course. Until such time, however, a certain amount of impatience, dependency and fear seems unavoidable; perhaps such management might minimize it. Reprint Address: Sanford R. Wolf, M.D. 278
North Annex, University Hospital of San Diego County, San Diego, California 92103.
3.
4.
5.
6.
7.
8.
9. 10.
11.
12.
13.
14.
REFERENCES
1. Jackson, C.W.: Clinical sensory deprivation: a review of hospitalized eye-surgery patients, in ZUbek, J. P., ed., Sensory Deprivation: Fifteen Years of Research, New York: Appleton-Century-Crofts, 1969. 2. Posey, W. C.: Mental disturbances after oper-
320
15.
16.
ations upon the eye, Ophth. Rev., 19: 23'5-237, 1900. Kipp, C. J.: The mental derangement which is occasionally developed in patients in eye hospitals, Arch. O]Jhth., 32: 375-387, 1903. Linn, L.: Psychiatric reactions complicating cataract surgery, Int. Ophth. Olinics, 5: 143154, 1965. Linn, L., Kahn, R. L., Coles, R., Cohen, J., Marshall, D., and Weinstein, E.: Patterns of Behavior disturbance following cataract extraction, Amer. J. Psychiat., 110: 281-289, 1953. Filante, W., Goldberg, J., Jones, H., and Ziskind, E.: Sensory deprivation on an eye service, Calif. Med., 93: 355-356, 1960. Ziskind, E.: An explanation of mental symptoms found in acute sensory deprivation: researches 1958-196'5, Amer. J. Psychiat., 121: 939-946, 1965. Ziskind, E., Graham, R. W., Kuninobu, L., and Ainsworth, R.: The hypnoid syndrome in sensory deprivation, in Wortis, J., ed., Recent Advances in Biological Psychiatry, New York: Plenum Press, 1963. Hebb, D. 0.: The mammal and his environment, Amer. J. Psychiat., 111: 826-831, 1955. Hebb, D. 0.: The problem of consciousness and introspection, Delafresnaye, J. F., ed., Brain Mechanisms and Consciousness, Springfield, Ill.: Charles C. Thomas, 1954. Hebb, D. 0.: Sensory deprivation: facts in search of a theory, J. Nerv. Ment. Dis., 132: 40-43, 1961. Solomon, P.: Sensory deprivation, in Freedman, A. M., and Kaplan, H. I., eds., Comprehensivp- Textbook Of Psychiatry, Baltimore: Williams and Wilkens Company, 1967. Weisman, A. D., and Hackett, T. P.: Psychoses after eye surgery, New Eng. J. Med., 258: 1284-1289, 1958. Wertham, F.: A psychosomatic study of myself, in Pinner, M., and Miller, B. F., eds., When Doctors are Patients, New York: Norton, 1952. Stonecypher, D. D.: The cause and prevention of postoperative psychoses in the elderly, Amer. J. Ophth., 55: 605-610, 1963. Wahl, C. W.: The fear of death, BuU. Menninger Clin., 22: 214-223, 1958.
Volume XII
I.
R. WOLF, M.D.
Introduction
• A wide variety of disordered behavior has been reported among patients undergoing a crisis in vision, usually in those cases that have exhibited organic eye disease and are in the postoperative period subsequent to corrective surgery. It is beyond the scope of this paper to describe in depth the various types of disordered behavior observed in such patients or the etiologies hypothesized to explain why particular forms of behavior occurred. Both have been well summarized by Jackson I in a review spanning the earliest case reports of Posey", and Kipp and Finley' through the more recent reports of Linn and his associates " ", Ziskind and associates,,·g and Jackson's own series of patients. Certain salient facts are evident from these reports: 1) Though a variety of behaviors have been reported, most descriptions of post-eye surgery behavior emphasize a tendency toward early irritability, restlessness, and occasionally suspiciousness. These beginning symptoms progress on through degrees of irrational speech and movement to various degrees of disorientation and often psychotic symptoms such as incoherence, visual and/or auditory hallucinations: such emotional symptoms are usually combined with physical actions of non-compliance with physicians' orders, or frankly self-destructive behavior such as tearin~ off of eye patches. 2) Writers have tended to blur the issues bv including in their reports patients of markedly different ages (raising the question of organic brain deficits in the elderly) and differin~ types of surgery; contrary to this trend Dr. Wolf is Assistant Professor of Psychiatry and Director, Psychiatric Liaison Service, School of Medicine. University of California, San Diego, La Jolla. California 92037. 316
Ziskind and associates reported that 30% of their post-cataract patients exhibited "mental" symptoms following surgery for intra-ocular disease, principally cataracts, while 100% of their patients exhibited "mental" symp~oms following surgery for retinal detachment'. 3) Reports of disordered behavior following types of eye surgery are also difficult to compare because the surgical p~ocedur~s themselves as well as the accompanymg medical management have changed frequently (length of hospitalization, degree and length of patching of eyes, etc.). . 4) Explanations of behavioral reactions following eye surgery have tended to change over the years in accordance with curr~nt theoretical models of the etiology of behaVior. Thus the earliest reports placed emphasis on homesickness and a change from familiar surroundings in the post-surgical period. Later, more emphasis was placed on the use of eye patches and concomitant lack of visual orientation, or the psychological stress of surgery. A significant model accounting for disordered behavior under such conditions emerged from the sensory deprivation experiments initiated by Hebb and associates in the 1950's.0·'1 As Solomon 12 has said of the interest in sensory deprivation experiments, "It was intriguing to think that simply doing nothing and being cut off from the outside world could bring about a transient psychotic state". Those seeking to explain the striking; behavior following eye surgery could readily identify with the findings from such experiments. Ziskind and associates 7 •8 utilized the results of research on altered states of consciousness, especially dream research, to emphasize the significance of periods of reduced awareness in accounting for both the symptoms reported in sensory deprivation work and the reactions of patients to eye surgery; this view has been of~en contested. Volume XII
THREATENED BLINDNESS-WOLF
I found a unique opportunity for data gathering and introspection into the behavior of patients following eye surgery, when I, myself, underwent surgery for unilateral retinal detachment at about the time that my psychiatric residency was completed; prior to the surgery I had already been gravitating toward a career in psychosomatic medicine. Though my own case was not as serious as most, in that hospitalization was not unduly long and the support of family and colleagues was near, I found the experience traumatic, at times to the point of terror. The many reports I read following this experience seemed, in the light of it, unduly simplistic and neglective of important factors. It is understandable that many patients do not report their feelings to their physicians during an experience such as that following eye surgery. It was nearly five years before the author could recall (or review notes on) the details of his experience without anxiety preventing the task.
II.
Personal Case Report
Retinal holes were discovered in one eye during a routine ophthalmologic examination (which included "indirect" vision of the retina). I had requested the examination as a prophylactic measure because an episode of retinal detachment had occurred in one parent. Following the detection of this lesion, regular visits were scheduled to keep careful watch on it; about six months after the start of these visits, a detachment was noted. At this time I requested that the surgery be performed by a consulting surgeon with an outstanding clinical reputation in retinal work. Surgery was rapidly scheduled. Prior to surgery, perhaps because of the asymptomatic nature of the lesion, no patching of the eye, bed rest or wearing of pin-hole glasses were ordered. Conversation prior to surgery, as well as conscious thought (and all but the vaguest feeling of unrest) were centered on other neutral topics; in retrospect, it seems clear that this was due to my own use of denial, reinforced by those about me. In fact, we euphemistically referred to the impending surgery as a "procedure" rather than an "operation". Following routine pre-op medication, the surgery was performed under general inhalation (intubation) anaesthesia after pentothal induction. Upon awakening, I slowly became aware of my condition and recalled that before the operation I had attempted to prepare myself for this certainty of awakening with both eyes bandaged. As I attempted to orient and calm myself, I spoke September-October 1971
with those about me: my wife, a person whom I perceived to be a nurse, and others whom I presumed wcre acquaintances. The first instance of irrationality came when I answered a question vo:ced by an appropriate sounding person across the room; I had thought the voice familiar but could not readily identify it. At that time, I felt my wife's hand on my arm, and heard her say, gently, but firmly, '"There is no one there." Startled, I nodded and began to speak of other things, alternately dozing, but the same experience repeated itself a number of times. I realized that, whatever the cause, I was actually hallucinating. This type of hallucinatory experience gradually faded during the first post-operative day. It was replaced by a continuously accelerating condition best described as a mixture of boredom, utter dependency, preoccupation with blindness, and a tendency to center attention and affect on each and every ache and pain for fear of what it might portend, and on each movement, especially of my head, for fear that somehow healing of my eye depended on supersensitive attention to such detail. From the second post-operative day onward, I noticed a series of vivid, changing, uncontrollable visual images which were continuously before me. At first they tended more toward changing geometric patterns with vivid colors; later the visual images took on the form of symbolic scenic entities. In the early postoperative period r noticed a tendency to drift in and out of somnolescence. More frequently, however, these bizarre dream-like visions occurred while I was quite awake, and at times, I would describe them to colleagues or dictate their description for periods as long as one hour. The changing symbolic forms could best be described as at once human and magical, frequently shifting, and having strong sexual or aggressive overtones. In describing the experience, I remarked several times that it seemed that I was in front of a very widescreened movie which I could neither control. nor look away from. There seemed to be some gross correlation between the types of symbolic scenes, and the general mood that I was in - boredom, depression, anger. Mixed in with the symbolic scenes just described were periods of quite realistic visions of seeming-ly real places and people, often of a panoramic landscape nature. Some of these scenes were familiar, like remembrances of walking- through the High Sierras; in most of them I felt as thoug-h the scenes and people should be familiar, but I could not place them. Perhaps the most painful part of the experience was the dependency on some one else for each need. Blindness as a symbolic equivalent of castration seems entirely at>propriate now in recalline: a feeling- of impotence at mv inabilitv to care for myself in any way. Episodes of anxiety became more frequent from the second dav on-
317
PSYCHOSOMATICS ward and when these occurred together with feelings of helplessness, dependency, and depression, there was a tendency to associate toward thoughts of death. Though I was depressed at times during the post-operative period, I would not now consider these thoughts (nor did I consider them at the time) to be suicidal. Rather, they seemed to be a curious, thoughtful, and detached reflection on the nature of death. Though my attending surgeon was kindly and inspiring of confidence, he had a tendency toward terseness and avoided giving out even rudimentary information (such as when my eyes would be unbandaged and examined, etc.) which led to anger often bordering upon rage. Though I wished to be informed on my medical condition, It is difficult to know what knowledge would have been enough at that time. At the end of the first week, the combination of boredom, dependency, anxiety and rage (which I dared not express to so powerful a person) led to a series of acute anxiety attacks. My remembrance of the constant visual aberrations becoming, or at least seeming to become, more frightening and more ominous during these anxiety attacks is vivid. The attacks passed in waves. I was given diazepam orally, 5 mg. every four hours, as needed, up to three times a day. This greatly alleviated the anxiety. Both the visual images and the anxiety I was experiencing seemed to lessen when my eyes were finally unbandaged for examination on the seventh day; this was in spite of the fact that I saw little if anything during this unbandaging, and my eyes were immediately rebandaged. Gradually, the eondition eased to the extent that the last three days of hospitalization were considerably less anxiety-ridden than the first seven. Both the altered visual perceptions and the waves of anxiety had largely cleared by the time of discharge. At that time. my eyes were unbandaged and I was fitted with pin-hole glasses, and wore them for one month after leaving the hospital.
III.
Discussion
In reading published reports of disordered or highly anxious behavior following eye surgery, I readily identified with certain of the actions or words attributed to the patients described. I found, however, that there was a significant incongruence between my own experience and these reports. I could not help but feel that both the etiologies hypothesized as causes, as well as the descriptions of the patient experiences were presented in an oversimplified and too neatly packaged manner. To the extent that I could relate my own ex318
perience to the manner of handling, philosophy of approach, and explanation of the events offered in descriptive reports, that of Weisman and Hackett l :! would be closest. The following points are pertinent. 1) In the period immediately preceding surgery, facing possible catastrophe, my experience came closest to the description of partial depersonalization, difficulty in concentration, and distance described by Wertham H • 2) I do not believe that there can be any meaningful grouping of the post-operative experiences of patients following cataract surgery and those following retinal detachment surgery. The age differences of the two groups are well known; many symptoms of the cataract group may be due to organic effects of the aging process 1 • 15• Cataracts form slowly and gradually dim the vision, allowing time for psychological adjustment, while retinal surgery is nearly always sudden with little or no time to prepare for threatened blindness. 3) Patients report (or are observed having) disordered behavior only when such symptoms become too marked to ignore. There is then a tendency to consider the constellation of symptoms in the post-operative course as a unity. In my experience, the immediate post-operative experience, the types of bizarre visual forms more often associated with somnolescence, and the less bizarre, photographic-recall images that tended to occur while I was entirely awake seemed totally separate entities. 4) While bizarre symbolic images occurred more often while I was in a semi-stuporous or hypnoid state (from my own recall and the observation of others), it does not appear that either the experiences of sensory deprivation or post-eye surgery disordered behavior are due to patients entering reduced states of awareness as Ziskind and associates have hypothesized. Many of the most vivid visual images, including those that provoked the highest anxiety, were recorded while I was fully awake and speaking to others. Many were described, while ongoing, in the midst of other conversation. S) Not only have conflicting results been obtained from different sensory deprivation Volume XII
THREATENED BLINDNESS-WOLF
laboratories, but there is a discrepancy in the behavior reported during many visual sensory deprivation experiments, and that reported in post-surgical eye patients. This does not belie the effect of visual sensory deprivation as the primary etiology of the post-eye surgery patients' symptoms. In these various circumstances, it is the inner percept that differs. In sensory deprivation experiments, whatever the stress, there is the certain knowledge that one's vision will return. The ego assault of threatened blindness, the uncertainty, dependency, physical trauma and the frequently present rage associated with the surgical procedure superimposed on the experience of sensory deprivation account for the difference between the reports of patients and those of sensory deprivation laboratories. As ego assaults, uncertainty, and dependency are highly personal events, it seems natural to expect a degree of difference in the behavioral response of different people to surgery. 6) The thoughts of death hovering over portions of the post-operative experience can easily be written off as depression, or perhaps a form of castration anxiety; blindness has long been considered as symbolic castration and the patient recovering from retinal surgery is near the nadir of potency as a functioning person. This would, I believe, be gross over-simplification. In the developmental studies of children, thoughts or fears of death in childhood, also, are usually considered to be a form taken by castration anxiety that is currently present. However, Wahp6 reminds us of the frequent occurrence in children of thoughts of death prior to the expected onset of castration anxiety, and the total denial by Freud, in developing this developmental theory, of thoughts of death in children of this age. One might consider the possibility that in certain cases the concept of castration anxiety might have evolved to mask the fear of death rather than the reverse. 7) The experience of threatened blindness afforded me an unusual insight into the feelings and defenses of patients and their physicians. When I awakened from general anaesthesia, with both eyes bandaged, I gained my deepest insight into the nature and threat of September-October 1971
hallucinations. Though I thought I fully understood that the most terrifying part of any experience of altered perception or cognition was not the alteration itself, but the fear of "going crazy," it is impossible to describe the terror at realizing that I was unable to screen "real" from "unreal" voices and the disturbing finding that those voices that sounded unreal were, in the context of my thinking, just as appropriate in tone and manner as those voices that were "real". To this day, I wonder what would have been my fate if I had not prepared myself for the experience of awakening sightless; in the same context, I wonder how I would have fared if I, as a physician, had not had the comforting knowledge that this was most likely a toxic reaction due to the stress of the surgery and anaesthesia, and would pass. The experience of seeing my own dependency upon my surgeon afforded me a perspective of the enormous emotional demands placed upon surgeons who attend sizable numbers of such patients. It is clear that unless the surgeon in point possesses a personality that is not only empathetic and "giving," but also able to set limits on the dependency demands of this patients, a situation could easily arise that would lead to the surgeon's withdrawal from his patient as a defensive, or even self-preservative maneuver. 8) Concerning the management of patients in similar circumstances, it is essential that the attending surgeon take sufficient time to explain the procedure, its consequences, and the probability of its success as straightforwardly as possible. During my convalescence, I compared my own preparation for surgery with those of a sizable number of fellow patients who had undergone the same operation perfomed by several different surgeons; their comments made it clear that an over-optimistic attitude engendered as much rage and anxiety as a manner that was too terse and uninformative. The manner that has best been described by Weisman and Hackett of utilizing familiar objects, radios, familiar foods, and conversation on familiar topics proved very helpful in my case. It is essential that as many familiar, simple and interesting auditory, olfactory and 319
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possibly tactile cues as possible be furnished for constant reorientation during the period of sightlessness. It might well be helpful to acquaint patients prior to surgery with the probability and the nature of altered perceptions likely to ensue. Though this might be construed as suggestive, it seems that the terror and fear of total loss of control which occurs in most patients under such circumstances is worth the risk. Because many of the serious cognitive alterations begin as an ever-increasing anxiety, it seems advisable to prescribe "minor" tranquilizers on a routine basis at the first sign of anxiety in post-eye surgery patients as a means of possibly preventing the more serious behavioral disorders. Certainly the effects of such tranquilizers prescribed on this basis should be studied. This would be most appropriate in younger patients (detached retina groups) where the danger of clouding the sensorium is less. It appears that newer methods of ophthamologic surgery, especially those concerned with the repair of detached retina, may minimize the period of sensory deprivation and, indeed, the entire operative course. Until such time, however, a certain amount of impatience, dependency and fear seems unavoidable; perhaps such management might minimize it. Reprint Address: Sanford R. Wolf, M.D. 278
North Annex, University Hospital of San Diego County, San Diego, California 92103.
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REFERENCES
1. Jackson, C.W.: Clinical sensory deprivation: a review of hospitalized eye-surgery patients, in ZUbek, J. P., ed., Sensory Deprivation: Fifteen Years of Research, New York: Appleton-Century-Crofts, 1969. 2. Posey, W. C.: Mental disturbances after oper-
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ations upon the eye, Ophth. Rev., 19: 23'5-237, 1900. Kipp, C. J.: The mental derangement which is occasionally developed in patients in eye hospitals, Arch. O]Jhth., 32: 375-387, 1903. Linn, L.: Psychiatric reactions complicating cataract surgery, Int. Ophth. Olinics, 5: 143154, 1965. Linn, L., Kahn, R. L., Coles, R., Cohen, J., Marshall, D., and Weinstein, E.: Patterns of Behavior disturbance following cataract extraction, Amer. J. Psychiat., 110: 281-289, 1953. Filante, W., Goldberg, J., Jones, H., and Ziskind, E.: Sensory deprivation on an eye service, Calif. Med., 93: 355-356, 1960. Ziskind, E.: An explanation of mental symptoms found in acute sensory deprivation: researches 1958-196'5, Amer. J. Psychiat., 121: 939-946, 1965. Ziskind, E., Graham, R. W., Kuninobu, L., and Ainsworth, R.: The hypnoid syndrome in sensory deprivation, in Wortis, J., ed., Recent Advances in Biological Psychiatry, New York: Plenum Press, 1963. Hebb, D. 0.: The mammal and his environment, Amer. J. Psychiat., 111: 826-831, 1955. Hebb, D. 0.: The problem of consciousness and introspection, Delafresnaye, J. F., ed., Brain Mechanisms and Consciousness, Springfield, Ill.: Charles C. Thomas, 1954. Hebb, D. 0.: Sensory deprivation: facts in search of a theory, J. Nerv. Ment. Dis., 132: 40-43, 1961. Solomon, P.: Sensory deprivation, in Freedman, A. M., and Kaplan, H. I., eds., Comprehensivp- Textbook Of Psychiatry, Baltimore: Williams and Wilkens Company, 1967. Weisman, A. D., and Hackett, T. P.: Psychoses after eye surgery, New Eng. J. Med., 258: 1284-1289, 1958. Wertham, F.: A psychosomatic study of myself, in Pinner, M., and Miller, B. F., eds., When Doctors are Patients, New York: Norton, 1952. Stonecypher, D. D.: The cause and prevention of postoperative psychoses in the elderly, Amer. J. Ophth., 55: 605-610, 1963. Wahl, C. W.: The fear of death, BuU. Menninger Clin., 22: 214-223, 1958.
Volume XII