Post-Traumatic Stress Disorder Related to Surgery: Prevalence and Risk Factors

  • Kate G. Deatrich
  • Bret A. BoyerEmail author
Reference work entry


The experience of undergoing surgery is a trauma significant enough to result in PTSD for some patients. This chapter reviews the research on factors related to the development of PTSD: patient characteristics (demographic factors, psychiatric history, cognitive appraisal, and coping), disease factors (severity, predictability and controllability of symptoms, curative potential for surgery), and surgical factors (length of stay, recall of traumatic memories), as well as PTSD effects on self-care activities after surgery, recovery, and health outcomes. Interventions that may be effective for reducing the risk of PTSD (intensive case management, giving patients adequate information, providing appropriate control, behavioral techniques to manage acute distress) are discussed.


Surgery Post-traumatic stress Cognitive appraisal Coping 

List of Abbreviations


Coronary artery bypass graft


Coronary artery disease


Cognitive behavioral therapy


Functional independence


Implantable cardioverter defibrillator


Intensive care unit


Myocardial infarction


Post-traumatic growth


Post-traumatic stress


Post-traumatic stress disorder


Spinal cord injury


Socioeconomic status


Selective serotonin reuptake inhibitor


Treatment as usual


  1. Allan JL, Johnston DW, Johnston M, Mant D. Depression and perceived behavioral control are independent predictors of future activity and fitness after coronary syndrome events. J Psychosom Med. 2007;63:501–8.CrossRefGoogle Scholar
  2. Anastasiou I, Yiannopoulou K, Mihalakis A, et al. Symptoms of acute posttraumatic stress disorder in prostate cancer patients following radical prostatectomy. Am J Mens Health. 2011;5:84–9.CrossRefPubMedGoogle Scholar
  3. Anisman H, Merali Z. Understanding stress: characteristics and caveats. Alcohol Res Health. 1999;23:241–9.PubMedGoogle Scholar
  4. Beyea S. Addressing the trauma of anesthesia awareness. AORN J. 2005;81:603–6.CrossRefPubMedGoogle Scholar
  5. Boso M, Politi P, Barale F, Emanuele E. Neurophysiology and neurobiology of the musical experience. Funct Neurol. 2006;21:187–91.PubMedGoogle Scholar
  6. Boyer BA, Knolls ML, Kafkalas CM, Tollen LG. What is the trauma? Patients’, mothers’ and fathers’ fear and helplessness related to posttraumatic aspects of pediatric SCI. Top Spinal Cord Inj Rehabil. 2000a;6:134–47.CrossRefGoogle Scholar
  7. Boyer BA, Knolls ML, Kafkalas CM, Tollen LG. Prevalence of posttraumatic stress disorder in patients with pediatric spinal cord injury: relationship to functional independence. Top Spinal Cord Inj Rehabil. 2000b;6:125–33.CrossRefGoogle Scholar
  8. Boyer BA, Bubel D, Jacobs S, et al. Posttraumatic stress in women with breast cancer and their daughters. Am J Fam Ther. 2002;30:232–338.CrossRefGoogle Scholar
  9. Boyer BA, Nowcid CA, Ware C. Functional independence in pediatric-onset spinal cord injury: two levels of mediation. Rehabil Psychol. 2012;57:328–36.CrossRefPubMedGoogle Scholar
  10. Boyer BA, Matour SJ, Crittenden KB, Larson KA, Cox JM, Link DD. Appraisals of fear, helplessness, and perceived life-threat during emergent cardiac surgery: relationship to pre-surgical depression, trauma history, and posttraumatic stress. J Clin Psychol Med Settings. 2013;20:173–85.CrossRefPubMedGoogle Scholar
  11. Buchanan TW, Lovallo WR. Enhanced memory for emotional material following stress-level cortisol treatment in humans. Psychoneuroendocrinology. 2001;26:307–17.CrossRefPubMedGoogle Scholar
  12. Cahill L, Prins B, Weber M, McGaugh J. β-adrenergic activation and memory for emotional events. Nature. 1994;371:702–4.CrossRefPubMedGoogle Scholar
  13. Caldwell P, Arthur H, Natarajan M, Anand S. Fears and beliefs of patients undergoing cardiac catheterization. Soc Sci Med. 2007;65:1038–48.CrossRefPubMedGoogle Scholar
  14. Cavalcanti-Ribeiro P, Andrade-Nascimento M, Morais-De-Jesus M, et al. Post-traumatic stress disorder as a comorbidity: impact on disease outcomes. Expert Rev Neurother. 2012;12:1023–37.CrossRefPubMedGoogle Scholar
  15. Chan M, Ho S, Tedeschi R, Leung C. The valence of attentional bias and cancer-related rumination in posttraumatic stress and posttraumatic growth among women with breast cancer. Psychooncology. 2011;20:544–52.CrossRefPubMedGoogle Scholar
  16. Ciccone D, Kline A. A longitudinal study of pain and pain catastrophizing in a cohort of National Guard troops at risk for PTSD. Pain. 2012;153:2055–60.CrossRefPubMedGoogle Scholar
  17. Cremeans-Smith J, Krupko T, Greene K, Delahanty D. Predicting symptoms of post-traumatic stress among patients undergoing orthopedic surgery on the basis of routinely collected cardiovascular data. J Health Psychol. 2012;18:55–64.CrossRefPubMedGoogle Scholar
  18. Dao TK, Chu D, Springer J, et al. Clinical depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder as risk factors for in-hospital mortality after coronary artery bypass grafting surgery. J Thorac Cardiovasc Surg. 2010;140:606–10.CrossRefPubMedGoogle Scholar
  19. Davydow D, Gifford J, Desai S, Needham D, Bienvenu O. Posttraumatic stress disorder in general intensive care unit survivors: a systematic review. Gen Hosp Psychiatry. 2008;30:421–34.CrossRefPubMedPubMedCentralGoogle Scholar
  20. Davydow D, Katon W, Zatzick D. Psychiatric morbidity and functional impairments in survivors of burns, traumatic injuries, and ICU stays for other critical illnesses: a review of the literature. Int Rev Psychiatry. 2009;21:531–8.CrossRefPubMedPubMedCentralGoogle Scholar
  21. De Geest S, Dobbels F, Fluri C, Paris W, Troosters T. Adherence to the therapeutic regimen in heart, lung, and heart-lung transplant recipients. J Cardiovasc Nurs. 2005;20:S88–98.CrossRefPubMedGoogle Scholar
  22. Dew M, Kormos R, Roth L, Murali S, DiMartini A, Griffith BP. Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation. J Heart Lung Transplant. 1999;18:549–62.CrossRefPubMedGoogle Scholar
  23. Doerfler L, Paraskos J. Anxiety, posttraumatic stress disorder, and depression in patients with coronary heart disease. J Cardiopulm Rehabil. 2004;24:414–21.CrossRefPubMedGoogle Scholar
  24. Doerfler L, Pbert L, Decosimo D. Symptoms of posttraumatic stress disorder following myocardial infarction and coronary artery bypass surgery. Gen Hosp Psychiatry. 1994;16:193–9.CrossRefPubMedGoogle Scholar
  25. Ehlers A, Mayou RA, Bryant B. Cognitive predictors of posttraumatic stress disorder in children: results of a prospective longitudinal study. Behav Res Ther. 2003;41:1.CrossRefPubMedGoogle Scholar
  26. Eshelman A, Mason S, Nemeh H, Williams C. LVAD destination therapy: applying what we know about psychiatric evaluation and management from cardiac failure and transplant. Heart Fail Rev. 2009;14:21–8.CrossRefPubMedGoogle Scholar
  27. Fabian I, Abudy A, Kinori M, et al. Diagnosis of posttraumatic stress disorder after surgery for primary rhegmatogenous retinal detachment. Retin J Ret Vis Dis. 2013;33:111–9.Google Scholar
  28. Fusar-Poli P, Martinelli V, Klersy C, et al. Depression and quality of life in patients living 10 to 18 years beyond heart transplantation. J Heart Lung Transplant. 2005;24:2269–78.CrossRefPubMedGoogle Scholar
  29. Guimaro M, Lacerda S, Aguilar M, Karam C, Kernkraut A, Ferraz-Neto BH. Post-traumatic stress disorders, mood disorders, and quality of life in transplant recipients with acute liver failure. Transplant Proc. 2011;43:187–8.CrossRefPubMedGoogle Scholar
  30. Hudetz J, Gandhi S, Iqbal Z, et al. History of post-traumatic stress disorder is associated with impaired neuropsychometric performance after coronary artery surgery. J Cardiothorac Vasc Anesth. 2010;24:964–8.CrossRefPubMedGoogle Scholar
  31. Hyland P, Shevlin M, Adamson G, Boduszek D. The role of trauma-specific irrational beliefs and sociodemographic risk factors in posttraumatic stress responses. J Ration Emot Cogn Behav Ther. 2013;31:152–66.CrossRefGoogle Scholar
  32. Kapa S, Rotondi-Trevisan D, Mariano Z, et al. Psychopathology in patients with ICDs over time: results of a prospective study. Pacing Clin Electrophysiol. 2009;33:198–208.CrossRefPubMedGoogle Scholar
  33. Karanci A, Dirik G. Predictors of pre- and postoperative anxiety in emergency surgery patients. J Psychosom Res. 2003;55:363–9.CrossRefPubMedGoogle Scholar
  34. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatry. 1994;51:8–19.CrossRefPubMedGoogle Scholar
  35. King K. A review of the effects of guided imagery on cancer patients with pain. Complement Health Pract Rev. 2010;15:98–107.Google Scholar
  36. Koivula M, Hautamaki-Lamminen K, Åstedt-Kurki P. Predictors of fear and anxiety nine years after coronary artery bypass grafting. J Adv Nurs. 2010;66:595–606.CrossRefPubMedGoogle Scholar
  37. Krantz DS, McCeney MK. Effects of psychological and social factors on organic disease: a critical assessment of research on coronary heart disease. Annu Rev Psychol. 2002;53:341–69.CrossRefPubMedGoogle Scholar
  38. Lawndy S, Withagen M, Kluivers K, Vierhout M. Between hope and fear: patient’s expectations prior to pelvic organ prolapse surgery. Int Urogynecol J. 2011;22:1159–63.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Liberzon I, Abelson J, Amdur R, et al. Increased psychiatric morbidity after abdominal aortic surgery: risk factors for stress-related disorders. Yearb Vasc Surg. 2006;43:137–8.Google Scholar
  40. Martin A, Halket E, Asmundson G, Flora D, Katz J. Posttraumatic stress symptoms and the diathesis-stress model of chronic pain and disability in patients undergoing major surgery. Clin J Pain. 2010;26:518–27.CrossRefPubMedGoogle Scholar
  41. Mashour G, Avidan M. Pharmacologic approaches to the prevention of intraoperative awareness. Expert Rev Neurother. 2011;11:611–3.CrossRefPubMedGoogle Scholar
  42. Mehnert A, Koch U. Prevalence of acute and post-traumatic stress disorder and comorbid mental disorders in breast cancer patients during primary cancer care: a prospective study. Psychooncology. 2007;16:181–8.CrossRefPubMedGoogle Scholar
  43. Miller SM. Controllability and human stress: method, evidence and theory. Behav Res Ther. 1979;17:287–306.CrossRefPubMedGoogle Scholar
  44. Moerman N, Bonke B, Oosting J. Awareness and recall during general anesthesia. Anesthesiology. 1993;79:454–64.CrossRefPubMedGoogle Scholar
  45. Morris MC, Rao U. Psychobiology of PTSD in the acute aftermath of trauma: integrating research on coping, HPA function and sympathetic nervous system activity. Asian J Psychiatry. 2013;6:3–21.CrossRefGoogle Scholar
  46. Nagata S, Funakosi S, Amae S, et al. Posttraumatic stress disorder in mothers of children who have undergone surgery for congenital disease at a pediatric surgery department. J Pediatr Surg. 2008;43:1480–6.CrossRefPubMedGoogle Scholar
  47. O’Connor M, Christensen S, Jensen A, Moller S, Zachariae R. How traumatic is breast cancer? Post-traumatic stress symptoms (PTSS) and risk factors for severe PTSS at 3 and 15 months after surgery in a nationwide cohort of Danish women treated for primary breast cancer. Br J Cancer. 2011;104:419–26.CrossRefPubMedPubMedCentralGoogle Scholar
  48. Olatunji B, Armstrong T, Fan Q, Zhao M. Risk and resiliency in posttraumatic stress disorder: distinct roles of anxiety and disgust sensitivity. Psychol Trauma Theory Res Pract Policy. 2014;6:50–5.CrossRefGoogle Scholar
  49. Osterman J, Hopper J, Heran W, Keane T, van der Kolk B. Awareness under anesthesia and the development of posttraumatic stress disorder. Gen Hosp Psychiatry. 2001;23:198–204.CrossRefPubMedGoogle Scholar
  50. Oxlad M, Wade TD. Longitudinal risk factors for adverse psychological functioning six months after coronary artery bypass graft surgery. J Health Psychol. 2008;13:79–92.CrossRefPubMedGoogle Scholar
  51. Panagopoulou E, Maes S, Tyrodimos E, Benos A. Symptoms of traumatic stress after coronary artery bypass grafting. Int J Behav Med. 2008;15:227–31.CrossRefPubMedGoogle Scholar
  52. Pereira M, Figueiredo A, Fincham F. Anxiety, depression, traumatic stress and quality of life in colorectal cancer after different treatments: a study with Portuguese patients and their partners. Eur J Oncol Nurs. 2012;16:227–32.CrossRefGoogle Scholar
  53. Petrie M, Zatzick D. Collaborative care interventions in general trauma patients. Oral Maxillofac Surg Clin North Am. 2010;22:261–7.CrossRefPubMedPubMedCentralGoogle Scholar
  54. Posluszny D, Edwards R, Dew M, Baum A. Perceived threat and PTSD symptoms in women undergoing surgery for gynecologic cancer or benign conditions. Psychooncology. 2011;20:783–7.CrossRefPubMedGoogle Scholar
  55. Post-traumatic stress disorders; study: one-fifth of spine surgery patients develop PTSD symptoms. NewsRx Health Sci. 2012:166.
  56. Powell R, Johnston M, Smith W, et al. Rehabilitation following surgery: clinical and psychological predictors of activity limitations. Rehabil Psychol. 2013;58:350–60.CrossRefPubMedGoogle Scholar
  57. Prendergast K, Cullen-Drill M. Anesthesia awareness-induced posttraumatic stress disorder. J Psychosoc Nurs Ment Health Serv. 2012;50:39–44.CrossRefPubMedGoogle Scholar
  58. Ramchand R, Marshall G, Schell T, Jaycox L. Post-traumatic stress and physical functioning: a longitudinal study of injured survivors of community violence. J Consult Clin Psychol. 2005;76:668–76.CrossRefGoogle Scholar
  59. Richter J, Waydhas C, Pajonk F. Incidence of post traumatic stress disorder after prolonged surgical intensive care unit treatment. Psychosomatics. 2006;47:223–30.CrossRefPubMedGoogle Scholar
  60. Rothenhausler H. The effects of cardiac surgical procedures on health-related quality of life, cognitive performance, and emotional status outcomes: a prospective 6-month follow-up study. Psychiatr Danub. 2010;22:135–6.PubMedGoogle Scholar
  61. Rothenhausler H, Grieser B, Nollert G, Reichart B, Schelling G, Kapfhammer HP. Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary bypass: a prospective 12-month follow-up study. Gen Hosp Psychiatry. 2005;27:18–28.CrossRefPubMedGoogle Scholar
  62. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation. 1999;99:2192–217.CrossRefPubMedGoogle Scholar
  63. Salmon P, Hill J, Krespi R, Clark L, Fisher J, Holcombe C. The role of child abuse and age in vulnerability to emotional problems after surgery for breast cancer. Eur J Cancer. 2006;42:2517–23.CrossRefPubMedGoogle Scholar
  64. Schelling G, Richter M, Roozendaal B, et al. Exposure to high stress in the intensive care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery. Crit Care Med. 2003;31:1971–80.CrossRefPubMedGoogle Scholar
  65. Schreiber S, Soskolne V, Kozohovitch H, Deviri E. Holocaust survivors coping with open heart surgery decades later: posttraumatic symptoms and quality of life. Gen Hosp Psychiatry. 2004;26:443–52.CrossRefPubMedGoogle Scholar
  66. Sime A. Relationship of preoperative fear, type of coping, and information received about surgery to recovery from surgery. J Pers Soc Psychol. 1976;34:716–24.CrossRefPubMedGoogle Scholar
  67. Skrzypulec V, Tobor E, Drosdzol A, Nowosielski K. Biopsychosocial functioning of women after mastectomy. J Clin Nurs. 2008;18:613–9.CrossRefPubMedGoogle Scholar
  68. Spindler H, Pedersen SS. Posttraumatic stress disorder in the wake of heart disease: prevalence, risk factors, and future research directions. Psychosom Med. 2005;67:715–23.CrossRefPubMedGoogle Scholar
  69. Stoll C, Schelling G, Goetz AE, et al. Health-related quality of life and post-traumatic stress disorder in patients after cardiac surgery and intensive care treatment. J Thorac Cardiovasc Surg. 2000;120:505–12.CrossRefPubMedGoogle Scholar
  70. Stukas AS, Dew M, Switzer G, DiMartini A, Kormos R, Griffith BP. PTSD in heart transplant recipients and their primary family caregivers. Psychosomatics. 1999;40:212–21.CrossRefPubMedGoogle Scholar
  71. Tarsitani L, DeSantis V, Mistretta M, et al. Treatment with β-blockers and incidence of post-traumatic stress disorder after cardiac surgery: a prospective observational study. J Cardiothorac Vasc Anesth. 2012;26:265–9.CrossRefPubMedGoogle Scholar
  72. Taylor C, Richardson A, Cowley S. Surviving cancer treatment: an investigation of the experience of fear about, and monitoring for, recurrence in patients following treatment for colorectal cancer. Eur J Oncol Nurs. 2011;15:243–9.CrossRefPubMedGoogle Scholar
  73. Toren P, Horesh N. Psychiatric morbidity in adolescents operated in childhood for congenital cyanotic heart disease. J Pediatr Child Health. 2007;43:662–6.CrossRefGoogle Scholar
  74. Van Stegeren A, Everaerd W, Gooren L. The effect of beta-adrenergic blockade after encoding on memory of an emotional event. Psychopharmacology (Berl). 2002;163:202–12.CrossRefGoogle Scholar
  75. Voshaar R, Banerjee S, Horan M, et al. Fear of falling more important than pain and depression for functional recovery after surgery for hip fracture in older people. Psychol Med. 2006;36:1635–45.CrossRefGoogle Scholar
  76. Wade T, Nehmy T, Koczwara B. Predicting worries about health after breast cancer surgery. Psychooncology. 2005;14:503–9.CrossRefPubMedGoogle Scholar
  77. Weissman MM, Bland RC, Canino GJ, et al. Cross-national epidemiology of major depression and bipolar disorder. J Am Med Assoc. 1996;276:293–9.CrossRefGoogle Scholar
  78. Yu SH, Chen SH, Chang KJ. Rumination predicting depression and PTSD symptoms in postoperative breast cancer patients. Chin J Psychol. 2008;50:289–302.Google Scholar
  79. Zatzick D, Kang S, Kim S, et al. Patients with recognized psychiatric disorders in trauma surgery: incidence, inpatient length of stay, and cost. J Trauma. 2000;49:487–95.CrossRefPubMedGoogle Scholar
  80. Zatzick D, Russo J, Katon W. Somatic, posttraumatic stress, and depressive symptoms among injured patients treated in trauma surgery. Psychosomatics. 2003;44:479–84.CrossRefPubMedGoogle Scholar
  81. Zatzick D, Jurkovich G, Rivara F, et al. A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Ann Surg. 2013;257:390–9.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Institute for Graduate Clinical PsychologyWidener UniversityChesterUSA

Personalised recommendations