A SOCIAL PSYCHOLOGICAL STU DY OF PATIENTS UNDERGOING OPEN HEART SURGERY Soumen Acharya IJMRA PUBLICATIONS All Right reserved. No Part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage or retrieval system, without prior permission in writing from the publishers. No responsibility for loss caused to any individual or organization action on or refraining from action as a result or the material in this publication can be accepted by IJMRA publications or the author/editor. IJMRA PUBLICATIONS Published by IJMRA Publications International Standard Book Number (ISBN): 978-93-87176-14-0 IJMRA Publications 129 New Grain Market, Jagadhri-135003, India Disclaimer: The Contents of the paper are written by the authors. The originality, authenticity of the papers, the interpretation and views expressed therein are the sole responsibility of the authors. Although every care has been taken to avoid errors and omission, this compendium is being published on the condition and understanding that the information given in the book is merely for reference and must not be taken as having authority of or binding in any manner on the author (s), editor(s) of publisher. The publisher believes that the content of this book does not existing copyright/intellectual property of others in any manner whatsoever. However, in case any source has not been duly attributed, the publisher may be notified in writing for necessary action. A SOCIAL PSYCHOLOGICAL STUDY OF PATIENTS UNDERGOING OPEN HEART SURGERY THESIS SUBMITTED FOR THE AWARD OF THE DEGREE OF DOCTOR OF PHILOSOPHY IN PSYCHOLOGY By SOUMEN ACHARYA Under The Supervision of M.G. HUSAIN Ph.D. Professor & Head, Department of Psychology, Faculty of Social Science Jamia Millia Islamia, New Delhi 1994 i ACKNOWLEDGEMENT It is my priviledge here to express my enduring gratitude to my guide. Dr. M. G. Husain Professor and Head of Department of Psychology, Jamia Milia Islamia, New Delhi. He has been the fountainhead giving constant encouragement and guidance though all the phases of this study. I am indebted to him for his meticulous care in planning working and critically evaluating the data and manuscript. It is my priviledge here to express my enduring gratitude to Prof. P. Venugopal, Prof. and Head Department of CTVS, All India Institute of Medical Science, New Delhi, under whom I had the pleasure of working for over three years during the data collection phase of the work. I thank my mother, and father for their teachings of values which they inculcated in me from childhood. Above all I bow before my guru Rama Krishna Pramhansa and Ma Sharda who is my constant source of spiritual strength and inspiration. The laudable assistance rendered by Dr. K. R. sundaram of A.I.I.M.S., New Delhi and Rajbir Singh of the department of Bio-Statistics, New Delhi. in this statistical analysis is gratefully acknowledged, as also his spontaneous support. I am indebted to all the faculty staff and all my colleagues of the A.I.I.M.S., CTVS department for their encouragement and assistance. It is my pleasure to thank my colleagues and the staff at the Psychology department of Jamia Millia Islamia during this study. ii CONTENTS CHAPTER I INTRODUCTION 1 CHAPTER II REVIEW OF LITERATURE 56 CHAPTER III METHODOLOGY 56 CHAPTER IV RESULTS AND INTERPRETATION 78 CHAPTER V DISCUSSION 87 CHAPTER VI SUMMARY AND CONCLUSION 89 BIBLIOGRAPHY 78 APPENDIX iii CHAPTER 1 INTRODUCTION “The heart is the chief mansion of the soul, the organ of the vital faculty, the beginning of life, the fountain of vital spirits and so, consequently, the nourisher of the vital heat, the first to live and the last to die”. Ambroise Pare (1510-1590) Ambroise Pare‟ (1510-1590) the famous 16th Century French Surgeon was not alone in the above and similar views about the heart. But in course of time the heart came to be recognised and studied as a muscular pump responsible for receiving the impure blood from the body and for its redistribution after oxygenation in the lungs. The heart has lost its halo but not is importance. It was no longer the chief mansion of the soul, only a mundane thing but a vital member of the corporeal anatomy. The surgeon laid siege to it. But unlike the other organ in the body it defied the attack and eluded conquest. The heart still remains the last position in the body which the surgeons has not yet fully conquered. All the same a good deal has been gained. It walls, and its interior have been invaded again and again not for devastation or covnage, but for repair and renovation. This process of subligation goes on continuously and the define and the resistance are crumbling. In fact it has recently been estimated that over 90% or cardiac lesion are amenable to surgical correction and the Ist of surgical irremediable cardiac lesion is fast shrinking. Now in the modern time the heart and lung transplantation is taking place in the country where the Government has passed law. Heart is one of the most vital organs of the body. By its pumping action it supplies oxygen to various parts of the body. Normally the heart lies on the left side of the chest and behind the breast bone. Development of the heart is completed in the mother‟s womb as early as 8 weeks. The heart comprises of 4 chambers. The upper part of the heart is called the atria and receives blood from the body and the lungs. The lower chambers are called ventricles and function to pump blood away from the heart. The right ventricle pumps impure blood, which is oxygen 1 poor and is brought from the body to the lungs. In the lungs the blood is saturated with oxygen. This blood flows to the left atrium from where it is pumped by the left ventricle to various parts of the body. The heart contains 4 valves, 2 separating the atria from the ventricles and the other 2 separating the ventricles from the arteries which arise from it. These valves prevent back flow of blood and only alow forward flow to occur. Heart disease can be congenital (present since birth), or acquired anytime during childhood. These patients who needs an operation to correct the heart disease, sometimes a special that (cardiac catheterisation) is advised for complete diagnosis. In this test a special fine tube (catheter) is passed inside the heart. Though it is like a minor operation, the procedure is quite safe. The catheter is put in through the vessel of the groin after local anesthesia. Congenital Heart Disease (CHD) Heart defects present from birth are called congenital heart disease. In majority of the cases the exact cause of congenital heart defect is not known, congenital heart disease may occasionally be inherited. As a rule, if one child in the family is affected with congenital heart disease, the risk of a second child having a similar heart disease is about 2-3 times that of the normal children. There is a higher likelihood for the baby to have congenital heart disease if the parental age is above 35 years or if the marriage has taken place between blood relations. Manifestations of congenital heart disease may be present at birth or occur much later in life. Some of the common forms of congenital heart disease are: 1. Obstruction of various valves producing obstruction to forward flow. If obstruction is very severe the heart cannot pump the required amount of blood forward across the obstruction and fails. 2. Abnormal communication between chambers usually called as holes or defects. Because of higher pressures on the left side such communications produce blood flow from left-to-right (shunting of blood). If the hole is between the upper two receiving chambers of the heart (the atria), it is called "a trial septal defect. The hole between the two lower pumping chambers (the ventricles is called "ventricular septal defect." A communication between the pulmonary artery and the aorta is called "patent ductus arteriosus". The extra blood shunted to the right side produces load on the right side of the heart. This extra blood also goes through the lungs. So in patients the lungs get a large amount of blood and are prone to infections. 2 3. Combinations of communication and obstruction. In one of the common heart disease, a large communication between the two ventricles and an obstruction in the valve between the right ventricles and lungs is present. The results in a "blue baby" and defect is called "Tetralogy of Fallot". Congenital heart defects are structured malformations present since birth due to abnormalities in embryonic development. The etiology of congenital heart disease remain unknown in most patients. However genetic factor (8 percent- 5 percent chromosomal and 3 percent single mutant gene disorders) Environment factor (2 percent tevatogons, Viruses drugs) In remaining 90 percent patients genetic, environmental interaction or mutifactional inheritance Congenital heart disease due to genetic factors Chromosomal disorders Cardiac defect Trisomy 21 (Downs Syndrome) Ventricular septal defect Trisomy D (Pantan Syndrome ) Ventricular septal defect Turner's Syndrome (Xo) Coation of aorta Trisome X (Edward's Syndrome) Ventricular septal defect Single gene disorders Ardiac defect Ellis Van Crevald (R) Single atrium Carpenter (R) Ventricular Septal Defect Holt - Oram (D) Atrial Septal Defect Noonal (2D) Atrial Septal Defect Congenital heart disease due to Environmental factors Environmental Cardiac defect Teratogen Rubella Virus Patent ductus arterious Thalidomide Atrial septal defect Tridione Ventricular Septal defect Maternal Systemic Lupus Congenital Complete erythematosus Heart block Rheumatic Heart Disease (RHD) The second most common form of heart disease is an acquired form called rheumatic heart disease. This problem is usually encountered amongst children from the poor socioeconomic status, poor sanitation and over-crowding. Rheumatic heart disease follows a bacterial throat infection by a apecific organism called streptococcus. After a gap of 3-4 weeks following the throat infection, the child develops fever, joint pains with or without swelling and involvement of the heart. The most common 3 age of occurrence of streptococcal throat infections in between 5-15 years although it can occur in younger children also. Abnormal movements (chorea) of body can also occur. The heart is usually involved by inflammation of all the three layers - the covering called pericardium, the heart muscle and the valves. The first attack may be very severe and produce heart failure. If not properly treated, repeated attacks of rheumatic fever may occur leading to permanent damage to the heart. The patient may present after several years with symptoms due to damage of the valves. Such damage is most common in the valves of the left side of the heart and can take two forms: (a) due to obstruction (atenosis) of the valve, or (b) due to leakage (regurgitation of the valve. They can be corrected by open heart surgery like Mitral Valve Replacement, Aortic Valve Replacement and Double Valve Replacement. In patient to whom valve replacement is performed anticoagulation is routinely prescribed. These drugs need to be taken lifelong such drugs make the blood thin and prevent blood from clotting easily and specially so over the valves. The side effects of such a treatment, if not regularly monitored by the doctor, is an abnormal bleeding tendency which sometimes can be life threatening. The rheumatic heart disease is common, patients with acute rheumatic fever are seen in frequently. The reason for this is not clear but could be due to non recognition of the disease. In case the low incidence of acute rheumatic fever is because patients do not seek medical help till they become sympathetic from heart disease. Both sex are nearly equally affected. Mitral valve disease and are relatively move common in the female patients where as aortic valve involvent is more common in male patients. Ischemic Heart Disease (IHD) Ischemia refers to a lack of oxygen due to inadequate perfusion. IHD is a condition of diverse etiologies all having in common a disturbance of cardiac function due to an imbalance between oxygen supply and demand substantially collection of abnormal fat cells and debar i.e. artherosclerotic plagues develop different segment on epicardial coronary artery area, and reduces in cross sectional area. When the narrowing of epicardial coronary artery is takes place the reduction in coronary blood flow and cause myocardial Ischemia. All of these transient event can upset the critical balance between oxygen supply and demand and this cause MI. When the block is caused CABG operation is done. In this case a section of a vein is used connection between the aorta and the coronary artery distal to the obstruction lesion or the mammary artery is used. 4 Myocardial Ischemia due to occlusive artherosclerotic Coronary artery disease in the third commonent condition requiring the surgical treatment. Surgery is not established as an effective method of treatment. Surgery is not established as an effective method of treatment of occlusive Coronary artery disease. The risk associated with there operation has become less and the operative mortality has rapidly decreased to and acceptable level of less than 5% the risk patients. Myocardial revasculirazation improves quality of life. There is in clear evidence it indicates that its prolong the life span with the patients with left main coronary, three vessel and two vessel disease. When individuals develop cardiac disease, their concepts of themselves and their relationship to the environment change and as a result it is quite likely that certain personality modification will occur if the cardiac disorder is relieved. It would seem, then, that a further understanding of the emotional problems of the patients with heart disease could be obtained if a group of patients who experienced physical improvement from mitral value replacement procedure was studied. In addition such a study could provide additional information regarding the better ways of prepare these prople psychologically for the operation and to rehabilitate them optimally after operation Patients undergoing open heart surgery provide an unusual opportunity for the study of acute and chronic stress. The various psychological responses of these patients to hospitalization and operation illustrate the effects of prolonged adaptation to an increasingly disabling disease which is followed by the hope of surgical rescue but also with risk of sudden death on the table. All these patients had, of course, been victims of rheumatic fever and each had learned during the months or years before coming for operation that his heart had become diseased. Usually such a patient has also been warned at different times by shortness of breath, palpitation. Or an episode of haemoptysis that is physical capacity was limited. This danger not only effected vital decisions concerning marriage, pregnancy and choice of vocation but also influenced the intimate details of daily living including the manner of walking, talking and breathing. Number of patients with have been incapactitated for many years by this chronic disease and for the new developments in the surgical techniques offer at least partial release from invalidism. Paradoxically enough, the accomplishment of such an operation is not always followed by healthy psychological adaptation. For these patients, illness has been invested with neurotic gains and by their symptoms they have been provided, often for many years, 5