Psychological preparation for an endoscopic examination

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Psychological preparation for an endoscopic examination

Jean E. Johnson, Ph.D. John F. Morrissey, M.D. Howard Leventhal, Ph.D. Madison, Wisconsin

An intricate and controlled investigation shows that pre-endoscopic instruction can lessen the requirement for ataraxic medication and can reduce the patient's reaction to the procedure. Endoscopists have recognized for many years that the patient's psychological reactions to an endoscopic procedure have a major influence on the patient's tolerance for the examination. The effects of various drugs on patients' tolerance to the procedure have been the focus of previous studies. These studies have relied on the endoscopists's subjective evaluation to assess patients' tolerance. The present study focuses on the effects of a specific kind of information on patients' tolerance as measured with quantitatvie indicators.

message included information about what to expect to feel during the administration of intravenous medicine, such as a needle stick and drowsiness. The size of the tube was described by relating it to familiar objects, i.e., a thimble and a pencil. The patients were told that the physician would put a finger into their mouths to guide the tube, about the changes in lighting of the room, and because air would be pumped into their stomachs they would feel a sensation of fullness very much like after eating a large meal.

The kinds of information that patients can be given about the examination are as diverse as the drugs he can be given. There is no reason to assume that different kinds of information will have a common or beneficial effect on patients' ability to tolerate the endoscopic examination any more than that all drugs will have the same effect. We must have a theory about how information works and then test its effect in clinical experiments. The present study is based on psychological theories which state that distress and fear during a threatening procedure, e.g., the endoscopic examination, are produced when the patient's sensory experience-what he sees, feels, tastes, smells, and hears-is discrepant with or irrelevant to his prior expectations.' METHODS To test this hypothesis we formed 3 groups of

The description of procedure message described the steps of the examination. The photographs were void of people. The message included descriptions of the clinic where endoscopic examinations were performed. The diameter and length of the tubes were given in millimeters and centimeters, and a metric ruler appeared in the photographs of the tubes. The composition of the tube and how it was possible to view the upper gastrointestinal tract and take photographs through a flexible tube were explained. The message included statements about throat swabbing, intravenous medication, the use of a bite piece, picture taking, the patient's position, lighting in the room, and air being pumped into the stomach. Explanations of the purpose of these activities were given. The message included statements about the skill and experience of the medical team.

patients. One group heard a message which described the sensations most patients experience. A second group heard a preparatory message which gave an objective description of the procedure. Recommendations in the nursing literature gu ided the selection of the information for th is message. These 2 conditions were compared to each other and to a third "control" group who heard no experimental message. All of the patients received an explanation of the examination from a fellow in gastroenterology as recommended in the medical literature. 2 Thus, the study was designed to demonstrate the effects of information based on psychological theory as compared to current recommended nursing and medical

The sample consisted of 99 in- and out-patients who were not disoriented, had not had more than 2 previous gastrointestinal endoscopy examinations, and were no more than 60 years old. Patients who had had previous experience with the exam ination were incl uded because premed ications frequently cause amnesia for the experience. All patients were premedicated with 50 mg to 75 mg of meperidine (Demerol) and 0.6 mg of atropine. In-patients received 25 mg to 50 mg of promethazine (Phenergan) in addition to the other drugs. Local anesthesia of the pharynx was accomplished with 0.5% tetracaine, using a Jackson forceps. Diazepam (Valium) was given intravenously at a rate

practices. Dr. Morrissey recorded both messages and introduced himself on both tapes by name and as the doctor in charge of

of 2 mg per minute until patients were somnolent and showed a delay in response to simple questions or commands.

the endoscopy clinic. Both messages informed patients that the examination required 15 to 30 minutes, and that most patients did not find the examination difficult. Each tape was 7V2 minutes long and was accompanied by 11 photographs. Thedeseription of sensations message described sensations that patients experience in the various steps of the examination. The sensory experiences were related to similar past experiences, and patients and staff appeared in the photographs. The sensations produced by each step ofthe exam ination were described as exemplified by the following. The

Behavioral indicators of distress and fear were recorded during the examination by the rhird"'trained experimenter, who wore a gown identical to that worn by the clinic staff. The indicators of distress and fear were (a) dose in mg of diazepam required for sedation, (b) heart rate changes during the examination, (c) hand and arm movements indicating tension during tube passage, (d) gagging during the insertion of the tube, and (e) restlessness during the first 15 minutes of the procedure. The measure of diazepam included the amount administered before the tube was passed and any

From the Departments of Medicine and Psychology, University of Wisconsin, Madison, Wisconsin. Reprint requests: Jean E. Johnson, Ph.D., Wayne State University, Center for Health Research, 5557 Cass Avenue, Detroit, Michigan 48202. GASTROINTESTINAL ENDOSCOPY

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