Emotional aspects of self-attitude of adolescents with Pectus excavatum (PE) before and after surgery (pilot study)

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Abstract


The present study deals with preliminary assessment of adolescents’ with Pectus excavatus (PE) personal emotional characters of selt-attitude prior to and after surgical treatment. PE is a congenital defect manifesting in retraction of sternum and cartilaginous portions of the ribs into the rib-cage. It constitutes about 90% of the entire number of cases of congenital pathology of the chest, its rate as high as 1-8 per 1000 neonates. The only method of treatment for this pathology is surgical operation for conservative measures can’t stop progressive deformation of the chest. The peak of this pathology coincides with adolescent period which is particularly sensitive for forming of personality. The goal of the present study is the assessment of emotional and personality features of adolescents with PE that are manifesting in peculiarities of cognitive, affective and behavioral reactivity. 26 adolescent patients aged 13 to 17 years with PE hospitalized at surgical clinic of St. Petersburg State Pediatric Medical University for subsequent primary operative elimination of this defect or recurring operation – ablation of the implant (1-4 years after the primary surgery) took part in the present study. High level of anxiety and depression associated with negative perception of their bodies prior to surgery was revealed. Urgent need for psychological assistance of these adolescents is evident as well as extension of further studies associated with peculiarities of emotional self-perception and its correlation with children-parents relationship character.


The hollowed chest (HC), or pectus excavatum (PE) comprises 90% of the total number of congenital abnormalities of the chest and occurs in 1–8 individuals per 1000 newborns. HC is a developmental defect that manifests as a depression in the sternum and the cartilaginous rib divisions of the chest. To date, the etiopathogenesis of this disease remains unknown [5]. This pathology can only be surgically treated because it is impossible to conservatively halt the progression of this deformity. Major development of this disease occurs in adolescence, which is a period sensitive to the formation of personality. During this period, along with the growth spurt, a previously minimal cosmetic defect can become gross and disfiguring within a few months [2], and this can greatly affect subsequent quality of life. Hence, current indications for surgical treatmentinclude not only functional changes in the cardiovascular and respiratory systems but also gross cosmetic defects that significantly affect the quality of life of the patient [1, 13, 14, 16, 17].

According to other researchers, adolescents with a chest deformity occasionally develop a negative body image, which leads to reduction in self-esteem, increase in anxiety, and disturbances in social interaction [3, 4, 9, 15].

This study aimed to investigate the emotional and personal characteristics of adolescents with HC, including the characteristics of cognitive, affective, and behavioral responses.

International studies focused on the psychological state of adolescents with this disease [10–12] mostly utilized questionnaires that assessed particular signs through scores and provided an extensive knowledge base on this issue. In this study, we qualitatively evaluated the indicators that reflect the degree of psychological well-being in adolescents with HC as well as their self-esteem and anxiety levels.

The relevance of studying the psychological components of this problem is that modern medical technologies are primarily directed at eliminating anatomical and physiological defects, and it undoubtedly plays a major role in the treatment of adolescents with HC. Moreover, it is important to consider various aspects of the emotional state of these patients during the surgical preparation and recovery periods.

MATERIALS AND METHODS

In this study, adolescents with HC were enrolled; they stayed in the surgical department No. 2 of the Fe deral State Budgetary Educational Institution of Higher Education, Saint Petersburg State Pediatric Medical University of the Russian Ministry of Health, for surgical treatment. A total of 26 adolescents aged 13–17 years were examined. Group I included 14 adolescents aged 13–17 years (10 boys and 4 girls) who were admitted for primary surgery to eliminate the chest deformity; group II included 12 adolescents aged 14–17 years (10 boys and 2 girls) who had been re-admitted (at 1–4 years after the initial surgery) for removing the implant.

The objectives of this study were the identification of the emotional and personal characteristics of self-attitude of the adolescents with HC before and after surgical treatment. The methods used were clinical interview-questioning, analysis of data from medical records, and application of the Stolin self-attitude questionnaire [8], E.E. Malkova method of multivariable estimation of children’s anxiety [6], Depriscope by P. Heimas and A.I. Podolsky [7], and the original projective method-color image of the body (CIB) deve loped by A.O. Teplyakova under the guidance of Prof. E.E. Malkova [9], in which special attention was paid to the analysis of the color relationship to the thoracic part of the silhouette.

RESULTS OF THE STUDY

According to the clinical interview conducted, 78.6% of the adolescents in group I denied that a physical defect had an effect on their emotional state and relationships with their peers and did not associate their failures with the presence of the disease. However, 64.2% of the subjects noted that HC seriously limited their physical activity (due to the deterioration in their physical condition, they were forced to restrict or stop their participation in various sports). Most adolescents (85.7%) complained of frequent exhaustion and rapid fatigue. In 71.4% of subjects, the recovery of physical activity was the only reason for which they consented for the reconstructive surgery. Not more than a third (28.6%) of the respondents reported dissatisfaction with the condition of their body, complaining that due to the deformity, they felt constrained around their peers while changing clothes on the beach and in the pool. All the adolescents expecting surgery unequivocally answered “No” to the question “Would you like your chest to remain in the state that it is now?”

Adolescents in the group II were generally more confident and willingly described their feelings. Absence of pain and a marked improvement in physical condition after surgery was noted in 83.3% of respondents, which according to the adolescents, significantly improved the quality of their lives. Psychological assessment revealed that 41.7% of the respondents noted a subjective decrease in their anxiety level (“Somehow, I immediately stopped worrying; it left me”), and 58.3% had an active desire to communicate with their peers. In addition, 16.7% of children retrospectively admitted that before the surgery, there were moments when they did not want to live, which is an extremely alarming fact. Nevertheless, at the time of implant removal, all of them noted a significant improvement in their psychoemotional state (“Now life has changed verymuch for the better”); 58.3% of adolescents retrospectively admitted that many of their previous problems were due to the presence of HC and that this was something that they had not previously realized. Furthermore, 75% of adolescents believed that the psychological support of their parents played an important role before the surgical treatment and especially in the postoperative recovery period.

Meanwhile, after the reconstructive surgery, 41.7% of adolescents experienced some difficulties in integrating into ordinary life. According to them, “It was scary to run at first” and “I was afraid that I would lose consciousness while swimming.” However, 16.7% of the children expressed regret that doctors do not allow full-fledged participation in sports.

To identify the attitude of adolescents toward their body, the projective method CIB was applied. The results did not reveal significant differences between the colors chosen by the groups or the level of detail and harmony, but they did subjectively reflect higher level of acceptance of one’s body as a whole (Figure 1) and the chest in particular (Figure 2) in the adolescents of group II compared with the adolescents of group I.

 

Fig. 1. Level of acceptance of one’s body in the adolescents

 

Fig. 2. Level of acceptance of the whole chest in the adolescents

 

An analysis of the self-attitude assessment data revealed differences between the two groups of adolescents in terms of self-confidence and expectation of a positive attitude from others (Figure 3). Furthermore, the level of these indicators among adolescents in group I was not only lower than the indices of adolescents in group II but also lower than the normative values. Regarding other scales of the questionnaire, the resultsfor the adolescents of both groups did not significantly differ.

 

Fig. 3. Special aspects of self-attitude in the studied adolescents

 

The results of multivariable estimation of anxiety levels revealed a predominantly higher level of this index in the adolescents of group I (Table 1). The most significant levels of anxiety (including values above the normative values) were observed in the “anxiety in relations with peers”, “anxiety associated with the assessment of others”, “anxiety in situations of self-expression”, and “increased autonomic responsiveness”scales, which may indicate a higher level of anxiety and emotional tension in group I adolescents before surgical treatment than in group II adolescents.

 

Table 1. Multivariable estimation of anxiety in the studied adolescents

Anxiety parameter

Group I

Group II

М

m

M

m

General anxiety

3.43

0.18

1.5

0.16

Anxiety in relations with peers

4.07

0.17

2.42

0.16

Anxiety associated with the assessment of others

4.29

0.17

2.58

0.16

Anxiety in relations with teachers

2.27

0.16

1.92

0.16

Anxiety in relations with parents

4.51

0.18

2.50

0.16

Anxiety associated with success in training

3.14

0.15

2.25

0.19

Anxiety in situations of self-expression

4.14

0.18

2.58

0.16

Anxiety arising in the situation of testing knowledge

2.50

0.18

2.17

0.17

Reduced mental activity due to anxiety

3.93

0.17

2.92

0.16

Increased autonomic responsiveness caused by anxiety

2.64

0.18

1.00

0.18

 

Table 2 shows the manifestations of depressive tendencies. In adolescents of group I, these tendencies were manifested as sleep disorders (78.6%), fatigue (85.7%) accompanied with a lack of energy (85.7%), and difficulty in concentrating (92.9%). The most significant was the indicator of the degree of intervention of depressive manifestations in the sphere of teenage experiences (DINTRUS). According to the recommendation of the authors of the questionnaire “Depriscope”, if the value of this indicator reaches or exceeds 21 points, it can be assumed that the adolescent has a risk of depression [7]. In this group of adolescents, the DINTRUS indicator had an average of 19.8 ± 3.0 points.

 

Table 2. Manifestation of depressive tendencies in the studied adolescents

Statement

Group I

Group II

I felt fear

57.1%

33.3%

I was irritated

64.3%

58.3%

I did not believe in the future

21.4%

0

I was worried for nothing

42.9%

33.3%

I felt lonely

28.6%

0

I found it difficult to fall asleep

78.6%

44.3%

When I woke up, I felt tired

85.7%

41.7%

Usually, I felt tired and exhausted

57.1%

0

I was afraid to go to school

35.7%

0

I easily got tired

64.3%

0

I lost my appetite

42.9%

0

I was disappointed in love

28.6%

0

I could not forgive myself for my mistakes

50%

0

I tried to avoid communication with other people

50%

0

I did not want to live

14.3%

0

It was difficult for me to concentrate on one thing

92.9%

25%

I did everything slower than usual

64.3%

41.7%

I felt a lack of energy

85.7%

41.7%

I could sleep day and night

50%

25%

I really did not like myself

42.9%

0

I was touchy

50%

0

 

In addition, the adolescents of group II experienced a general surge of energy, an absence of loneliness, a fear of going to school, along with the fear of communication, touchiness, and disbelief in the future. In general, these adolescents exhibited significantly fewer signs of depression, and their DINTRUS score averaged 5.6 ± 2.0 points.

DISCUSSION

The results of the study revealed that the psychological state of the majority of adolescents in group I differed from that of group II adolescents (after surgical treatment).

Importantly, the results of experimental psychological research methods confirmed the findings obtained through clinical interviews and observation by doctors and medical psychologists. However, some of the facts revealed in the interview, as a result of research using the projective method CIB and the self-attitude questionnaire, were unexpected.

For example, in a conversation, the adolescents of group I tried to deny the negative effect of a physical defect on their psychological state, but the data of experimental psychological research testified to the contrary.

The use of the CIB method enabled the analysis and comparison of the degree of acceptance of the one’s body and the thoracic part of the skeleton in the adolescents of both groups. Using the data obtained at a relatively equal level of harmony and detail in the adolescents of group I, the subjectively experienced dissatisfaction with the body was revealed. The adolescents of group II, who had undergone the first stage of surgical treatment, expressed great satisfaction with their bodies, and they liked themselves, which was reflected both in the results of the experimental study and in the clinical interview.

Notably, the survey results of some adolescents from both groups were not included in the study because their psychological state was largely unrelated to HC. For example, in one of the adolescents from group I, HC suddenly appeared at the age of 14 years, and he participated in the study at 3 months after establishing the diagnosis. Thus, the external defect did not have a significant influence on his psychological state. Another adolescent (from group II) experienced internal anxiety, mostly because of the stay in the institution, which was reflected in the results of his survey as well as in the experimental study of the levels of anxiety and depression.

During the study, we did not detect a significant correlation between the severity of chest deformity and the dissatisfaction with one’s own appearance. Even a small deformity caused dissatisfaction with one’s own appearance. In addition, regardless of the severity of the external defect, the adolescents of group I experienced a negative effect on their psychoemotional state to a different degree, which was established both during the interview and through the results of the experimental study.

This study identified the need for psychological support for adolescents at all stages of treatment as well as the need for further research, possibly involving data on intrafamily and parental relationships to search for psychological resources for overcoming the anxiety and depression that occurs at various stages of treatment.

Thus, based on the data obtained from the pilot study, the following preliminary conclusions can be drawn.

  1. In adolescents with HC who are under the influence of an external defect, a negative perception of one’s own body image is formed, which leads to a decrease in self-esteem, an increase in anxiety, and actualization of depressive manifestations in the structure of the psychoemotional state.
  2. After surgical treatment in adolescents with HC, we noted qualitative changes in the formation of body image, a decrease in the level of anxiety, and the disappearance of depressive signs.

Adolescents with HC need psychological support at all stages of inpatient treatment.

Elena E. Malkova

Herzen State Pedagogical University of Russia

Author for correspondence.
Email: Helen_malkova@mail.ru

Russian Federation, St. Petersburg

Dr Sci, Professor, Department of Clinical Psychology and Psychological Assistance

Igor A. Komolkin

St. Petersburg State Pediatric Medical University

Email: Igor_komolkin@mail.ru

Russian Federation, St. Petersburg

MD, PhD, Assistant Professor, Department of Surgical Diseases of Childhood

Maria A. Pakhomova

St. Petersburg State Pediatric Medical University

Email: mariya.pahomova@mail.ru

Russian Federation, St. Petersburg

Senior Researcher, Research Сenter

Maya V. Vitenberg

Herzen State Pedagogical University of Russia

Email: vitenberg3@yandex.ru

Russian Federation, St. Petersburg

Department of Clinical Psychology and Psychological Assistance

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Supplementary files

Supplementary Files Action
1. Fig. 1. Level of acceptance of one’s body in the adolescents View (4KB) Indexing metadata
2. Fig. 2. Level of acceptance of the whole chest in the adolescents View (4KB) Indexing metadata
3. Fig. 3. Special aspects of self-attitude in the studied adolescents View (34KB) Indexing metadata

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Copyright (c) 2017 Malkova E.E., Komolkin I.A., Pakhomova M.A., Vitenberg M.V.

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