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Review Article

Preoperative anxiety‑an important but neglected issue:

A narrative review
Teena Bansal, Akanksha Joon
Department of Anaesthesiology and Critical Care, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India

Abstract Anxiety is an emotional state characterized by apprehension and fear resulting from the anticipation of
a threatening event. The incidence of preoperative anxiety ranges from 11% to 80% in adult patients and
also varies among different surgical groups. Preoperative anxiety may lead to various problems and a wide
range of physiological and psychological responses. A variety of objective and subjective methods are
available for measuring preoperative anxiety. Every patient scheduled for surgery should be assessed for
the presence of anxiety in their routine preoperative anesthesia assessment, and counseling should be
done by anesthesiologist in patients with a high level of anxiety. Surgery information reduces anxiety in
the preoperative period.

Key Words: Management, measurement, preoperative anxiety, prevention

Address for correspondence:

Dr. Teena Bansal, 2/8 FM, Medical Campus, PGIMS, Rohtak ‑ 124 001, Haryana, India. E‑mail: aggarwalteenu@rediffmail.com
Received: 29.04.2016, Accepted: 29.07.2016

INTRODUCTION neuroendocrine response which might be deleterious

Anxiety is an emotional state characterized by
apprehension and fear resulting from the anticipation
of a threatening event. The incidence of preoperative
anxiety ranges from 11% to 80% in adult patients and
also varies among different surgical groups.[1]
Preoperative anxiety may lead to various problems
such as difficult venous access due to peripheral
vasoconstriction, autonomic fluctuations, delayed jaw
relaxation and coughing during induction of anesthesia,
and increased anesthetic requirement. In addition, it
also has been correlated with increased pain, nausea,
and vomiting in the postoperative period; prolonged
recovery; and increased the risk of infection.[2‑4] High
preoperative anxiety levels are related to an altered
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in the postoperative period.[5,6]
A wide range of responses may be caused by
anxiety. Physiological responses include tachycardia;
hypertension; elevated temperature; sweating; nausea;
and a heightened sense of touch, smell, or hearing.[7]
Psychological responses include changes in behavior
such as increased tension, apprehension, nervousness,
and aggression.[8]
Anxiety is a subjective emotion. Various factors
influencing anxiety in a patient planned for surgery
include age, gender, the extent and type of surgery,
previous hospital experiences, susceptibility to
and ability to cope with stressful experiences, and
preoperative information.[9]
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DOI:
10.4103/0973-0311.195955 How to cite this article: Bansal T, Joon A. Preoperative anxiety-an important
but neglected issue: A narrative review. Indian Anaesth Forum 2016;17:37-42.

© 2016 The Indian Anaesthetists’ Forum | Published by Wolters Kluwer - Medknow 37

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Bansal and Joon: Preoperative anxiety: A narrative review
We searched PubMed and Scopus databases with
preoperative anxiety, prevention, and management
as keywords for literature search.
MEASUREMENT OF PREOPERATIVE ANXIETY
• Objective methods
• Subjective methods.
The measurement of preoperative anxiety in modern
elective surgery is becoming very difficult, mainly due
to the imposed time restrictions. A variety of objective
and subjective methods are available for measuring
preoperative anxiety. Objective methods include indirect
measurement of sympatheticoadrenal activity using
heart rate and blood pressure or skin conductance.[10,11]
Plasma cortisol, urinary catecholamine excretion, and
plasma catecholamines have been used as more direct
measures of sympatheticoadrenal activity.[12‑14]
Nisbet et al. measured and displayed changes in electrical
skin potential and suggested that these changes
provide a continuous record of one sign known to vary
with anxiety and sedation.[11] In a study by Martinez
et al., in thirty patients scheduled for elective surgery
emotional responses before anesthesia and surgery
and the sedative effect of drugs used for preoperative
medications were estimated by the measurement
of urine catecholamines. Values of 20 ng/min of
adrenaline in the urine were considered indicative of
significant emotional tension.[13] Fell et al. assessed
the value of measurement of plasma catecholamine
concentration as an objective index of anxiety. A study
was performed on 48 surgical patients who were asked
to rate their perceived anxiety on the linear analog scale
immediately before premedication and immediately
before induction of anesthesia. There were no significant
changes in perceived anxiety or plasma noradrenaline
concentration following premedication. However,
compared with values before premedication, there
was a mean percentage increase in plasma adrenaline
concentration of 40% before induction of anesthesia.
The authors suggested that the measurement of plasma
catecholamine concentration may be a useful method
for the objective assessment of anxiety in the period
before the operation and for assessing the efficacy of
different preoperative medications.[14]
Subjective methods include hospital anxiety and
depression (HAD), state‑trait anxiety inventory (STAI),
visual analog scale for anxiety (VAS‑A), the Amsterdam
preoperative anxiety and information scale (APAIS),
38
multiple affect adjective check list (MAACL), and linear
analog anxiety scale (LAAS).[15‑19]
HOSPITAL ANXIETY AND DEPRESSION SCALE
[TABLE 1]
HAD was originally developed by Zigmond and Snaith
and is commonly used by clinicians to determine
the levels of anxiety and depression that a patient is
experiencing.[15] It is a fourteen item scale. Seven of the
items relate to anxiety and seven relate to depression.
This is a useful tool for the detection of anxiety and
depression in people with physical health problems.
The items of questionnaire that relate to anxiety are as
follows:
• I feel tense or wound up
• I get a sort of frightened feeling as if something bad
is about to happen
• Worrying thoughts go through my mind
• I can sit at ease and feel relaxed
• I get a sort of frightened feeling like butterflies in
the stomach
• I feel restless and have to be on the move
• I get a sudden feeling of panic.
The items of questionnaire that relate to depression
are as follows:
• I still enjoy the things I used to enjoy
• I can laugh and see the funny side of things
• I feel cheerful
• I feel as if I am slowed down
• I have lost interest in my appearance
• I look forward with enjoyment to things
• I can enjoy a good book or radio or TV program.
Each item on the questionnaire is scored from 0 to 3 with
three indicating higher symptom frequencies. Score for
each subscale (anxiety and depression) can range from
0 to 21 [Table 1]:
However, the limitation of this scale is that it measures
the psychological stress expressed as anxiety by the
patients during the week before surgery.
STATE‑TRAIT ANXIETY INVENTORY
[TABLES 2 AND 3]
STAI is suitable for individuals who are 15‑year‑old and
older [Tables 2 and 3]. The STAI Form Y is the definitive
instrument for measuring anxiety in adults. It clearly
differentiates between the temporary condition of “state
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Bansal and Joon: Preoperative anxiety: A narrative review

Table 1: Hospital anxiety and depression scale[15] ideal for evaluating individuals with lower educational
Score Category backgrounds. Adapted in more than forty languages,
0-7 Normal the STAI is the leading measure of personal anxiety
8-10 Mild globally. The STAI has forty questions with a range
11-14 Moderate
15-21 Severe of four possible responses to each. The state anxiety
scale (STAI Form Y‑1) consists of twenty statements that
evaluate how the respondent feels “right now” at this
Table 2: State trait anxiety inventory Form Y-1
moment. The trait anxiety scale (STAI Form Y‑2) consists
Self‑evaluation questionnaire STAI Form Y‑1
1 2 3 4
of twenty statements that evaluate how the respondent
1. I feel calm □ □ □ □ feels “generally.” In responding to the S‑anxiety scale,
2. I feel secure □ □ □ □ the patients choose the number that best describes the
3. I am tense □ □ □ □ intensity of their feelings: (1) not at all, (2) somewhat,
4. I feel strained □ □ □ □
5. I feel at ease □ □ □ □ (3) moderately, and (4) very much so. In responding to
6. I feel upset □ □ □ □ the T‑anxiety scale, patients rate the frequency of their
7. I am presently worrying over possible misfortunes □ □ □ □ feelings on the following four‑point scale: (1) almost
8. I feel satisfied □ □ □ □
9. I feel frightened □ □ □ □ never, (2) sometimes, (3) often, and (4) almost always.
10. I feel comfortable □ □ □ □
11. I feel self‑confident □ □ □ □ Each STAI item is given a weighted score of 1–4. A rating
12. I feel nervous □ □ □ □
13. I am jittery □ □ □ □ of four indicates the presence of high levels of anxiety for
14. I feel indecisive □ □ □ □ the ten S‑anxiety items (#3, 4, 6, 7, 9, 12, 13, 14, 17, and
15. I am relaxed □ □ □ □ 18) and eleven T‑anxiety items (#22, 24, 25, 28, 29, 31, 32,
16. I feel content □ □ □ □
17. I am worried □ □ □ □ 35, 37, 38, and 40). A high rating indicates the absence
18. I feel confused □ □ □ □ of anxiety for the remaining ten S‑anxiety items and
19. I feel steady □ □ □ □ nine T‑anxiety items. The scoring weights for the anxiety
20. I feel pleasant □ □ □ □
1: Not at all, 2: Somewhat, 3: Moderately so, 4: Very much so
present items are the same as the chosen numbers on
the test form. The scoring weights for the anxiety‑absent
items are reversed. Scores for both the S‑Anxiety and the
Table 3: State trait anxiety inventory Form Y-2
Self‑evaluation questionnaire STAI Form Y‑2
T‑anxiety scales can vary from a minimum of twenty to a
1 2 3 4 maximum of eighty. The sum of the scores on all items
21. I feel pleasant □ □ □ □ constitutes the individual’s score.[16]
22. I feel nervous and restless □ □ □ □
23. I feel satisfied with myself □ □ □ □ VISUAL ANALOG SCALE‑A
24. I wish I could be as happy as others seem to be □ □ □ □
25. I feel like a failure □ □ □ □
26. I feel rested □ □ □ □
VAS‑A is a useful and easily applicable method for
27. I am “calm, cool, and collected” □ □ □ □ evaluation of preoperative anxiety and allows detection
28. I feel that difficulties are piling up so that I □ □ □ □ of high anxiety levels in various surgical groups. The VAS
cannot overcome them
29. I worry too much over something that really □ □ □ □ comprises a 100 mm line, at the left hand of which is a
doesn’t matter statement indicating zero anxiety (“not anxiety at all”)
30. I am happy □ □ □ □ and at the right hand the statement “most anxious I can
31. I have disturbing thoughts □ □ □ □
32. I lack self‑confidence □ □ □ □ imagine.” Patients are asked to mark the line to indicate
33. I feel secure □ □ □ □ the degree of their anxiety.[17]
34. I make decisions easily □ □ □ □
35. I feel inadequate □ □ □ □ AMSTERDAM PREOPERATIVE ANXIETY AND
36. I am content □ □ □ □
INFORMATION SCALE [TABLE 4]
37. Some unimportant thought runs through my □ □ □ □
mind and bothers me
38. I take disappointments so keenly that I can’t □ □ □ □ Moerman et al. developed the APAIS, which is a six‑item
put them out of my mind questionnaire. The aim of this questionnaire was two‑fold:
39. I am a steady person □ □ □ □
40. I get in a state of tension or turmoil as I think □ □ □ □ To identify those patients who are anxious and to identify
over my recent concerns and interests the level of information required by each individual.[18]
1: Almost never, 2: Sometimes, 3: Often, 4: Almost always
The APAIS is a simple tool designed to be used in the
anxiety” and the more general and long‑standing quality clinical area. Each question has a five‑point Likert scale
of “trait anxiety.” The inventory’s simplicity makes it ranging from 1 (not at all) to 5 (extremely) [Table 4].
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Bansal and Joon: Preoperative anxiety: A narrative review

Scoring is straightforward, and patients mark their Table 4: Amsterdam preoperative anxiety and information
feelings with regard to each question. The tool allows scale[18]
the health‑care professional to identify what the patient Questions The Amsterdam preoperative
anxiety and information scale
is feeling at that time. 1 2 3 4 5
1. I am worried about the anesthetic □ □ □ □ □
The scores from questions 1, 2, 4, and 5 are added 2. The anesthetic is on my mind □ □ □ □ □
together to show the patient’s level of anxiety, continually
3. I would like to know as much as □ □ □ □ □
while the scores for questions 3 and 6 are added possible about the anesthetic
together to identify the patient’s need for information. 4. I am worried about the procedure □ □ □ □ □
A patient with a score of 11 or more on the anxiety 5. The procedure is on my mind □ □ □ □ □
continually
scale experiences anxiety. On the information scale, 6. I would like to know as much as □ □ □ □ □
patients scoring 2–4 are classified as having little or possible about the procedure
no information requirements, patients scoring 5–7 are 1: Not at all, 2: Somewhat, 3: Moderate, 4: Moderately high, 5: Extremely
classified as having an average information requirement
and the patients scoring 8–10 are considered as having Table 5: Multiple affect adjective check list[19]
high information requirements. Patients with a score of This scale consists of 21 adjectives presented in random order
5 or above should be given information on the topics Upset □(+)
Thoughtful □(‑)
about which they wish to be informed and in accordance Happy □(‑)
with their score. A score below 5 should be a signal to Terrified □(+)
provide the patient with no more information than Contented □(‑)
Nervous □(+)
is legally required. The main limitation of this scale is Tense □(+)
that the tools do not distinguish well between fear of Cheerful □(‑)
anesthesia and fear of surgery. Frightened □(+)
Calm □(‑)
Shaky □(+)
MULTIPLE AFFECT ADJECTIVE CHECK LIST Fearful □(+)
[TABLE 5] Steady □(‑)
Desperate □(+)
The sign in parentheses indicates either an “anxiety Afraid □(+)
Loving □(‑)
present” (+) or “anxiety absent” (‑) adjective. Patients Panicky □(+)
are asked to tick all those words which describe their Pleasant □(‑)
Worrying □(+)
feeling at the moment. One mark is scored for each of Secure □(‑)
11 “anxiety present” adjectives selected and also for Joyful □(‑)
each of 10 “anxiety absent” adjectives not selected. +: Anxiety present, ‑: Anxiety absent
The possible range of scores is therefore 0‑21, with
higher scores indicating greater levels of anxiety STUDIES ON PREOPERATIVE ANXIETY
[Table 5].
Various studies have been done to measure the
LINEAR ANALOG ANXIETY SCALE preoperative anxiety using different scales. Millar
et al. compared the three measurements of anxiety to
Patients are asked to indicate on a 100 mm horizontal determine their equivalence in assessing anxiety before
scale, between the limits “calm” and “terrified,” how surgery. Forty‑four patients awaiting breast cancer
tense they feel at that moment. surgery completed the state scale of the STAI, the HAD
scale, and a 100 mm VAS. The authors concluded that
The objective methods are considered to be reasonably the scales were equivalent in their assessment of anxiety
good indicators of preoperative anxiety though before surgery, but the reference to normative data
they may be fallacious in patients suffering from was important in establishing such equivalence and in
systemic diseases such as hypertension, cardiac rhythm determining the patient’s state.[17]
disturbances, or some endocrine disorders. Moreover,
they require monitoring team and financial expenditure. Hicks et al. assessed preoperative anxiety using HAD
Subjective method is a sensitive and accurate method of scale, MAACL, and LAAS in 100 consecutive day care
measurement of anxiety, but observer bias is inevitable patients undergoing the termination of pregnancy. The
in such a method of assessment. HAD scale was readily accepted and easily understood

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Bansal and Joon: Preoperative anxiety: A narrative review
by the patients. There was a high degree of correlation
between the HAD scale and both the MAACL (correlation
coefficient 0.74) and LAAS (correlation coefficient
0.67). There was only a moderate degree of correlation
between the HAD scale and the anesthetist’s assessment
of anxiety (correlation coefficient 0.46) and concluded
that HAD scale is a useful method of subjective
measurement of preoperative anxiety.[19]
Facco et al. validated VAS‑A in preanesthetic evaluation.[20]
Kindler et al. studied anxiety in 734 patients by means of
VAS and the State Anxiety Score of the Spielberger STAI.
The mean STAI anxiety score was 39 ± 1 (n = 486) and
the mean VAS for fear of anesthesia was 29 ± 1 (n = 539).
Patients feared surgery significantly more than
anesthesia (P < 0.001). The VAS measuring fear of
anesthesia correlated well with the STAI score (r = 0.55,
P < 0.01). Young patients, female patients, and patients
with no previous anesthetic experience or a previous
negative anesthetic experience had higher anxiety
scores. Patients worried most about the waiting period
preceding surgery and were least concerned about
possible awareness intraoperatively.[21]
Hernandez–Palazon et al. carried out a prospective
longitudinal study on 300 cardiac surgery patients. The
patients were assessed regarding their preoperative
anxiety level using VAS‑A, APAIS, and a set of specific
anxiety‑related questions. Ninety‑four percent of the
patients presented preoperative anxiety with 37%
developing high anxiety (VAS‑A ≥7). The preoperative
length of stay >2 days was the only significant risk factor
for preoperative anxiety. A positive correlation was
found between anxiety level (APAISa) and requirement
of knowledge (APAISk). APAISa and APAISk scores were
greater for surgery than for anesthesia. In addition,
the results showed that the most common anxieties
resulted from the operation, waiting for surgery,
not knowing what is happening, postoperative pain,
awareness during anesthesia, and not awakening from
anesthesia.[22]
Maheshwari et al. evaluated preoperative anxiety in
patients selecting either general or regional anesthesia
for elective cesarean section. The overall rate of anxiety
was observed in 72.7% (112/154) patients. The rate
of anxiety was significantly high in patients of general
anesthesia group as compared to regional anesthesia
group (97.2% [69/7] vs. 51.8% [43/83]; P < 0.01).
A statistically significant association with preoperative
anxiety (VAS ≥50) was observed with factors such
as age <25 years, working women, nulliparous and
The Indian Anaesthetists’ Forum | December 2016 | Vol 17 | Issue 2
primiparous, no previous anesthesia experience,
having previous anesthesia experience under general
anesthesia, and those having their source of information
from nonanesthetists. The authors concluded that
anxiety was one of the reasons for refusing regional
anesthesia and suggested that every patient coming
for the elective cesarean section should be assessed
for the presence of anxiety in their routine preoperative
anesthesia assessment. This measure may help to reduce
the anxiety and assist in making a rational decision
regarding their choice of anesthesia technique.[23]
PREVENTION AND TREATMENT OF
PREOPERATIVE ANXIETY
Patients preparing to undergo surgery should not suffer
needless anxiety. Various steps have been taken to
reduce preoperative anxiety like the use of premedicant
drugs, preoperative visit by anesthetist, counseling, and
videos. Sedative premedication is routinely administered
to reduce preoperative anxiety. However, sedatives have
their own side effects which can be minimized by the
use of nonpharmacological interventions.
Information about surgery reduces anxiety in the
preoperative period.[24,25] Preanesthetic consultation
clinic could be the right place to transmit the necessary
information and clarify the patients’ enquiries. A study
conducted by Stephen et al. demonstrated that
consultation at the preanesthetic checkup clinic has
a statistically significant positive effect on alleviating
patients’ anxiety.[26] Preoperative visit by the anesthetist
also plays a major role to relieve anxiety.[27]
Jlala et al. have reported the beneficial outcomes
after presenting a video containing information
concerning anesthesia to patients before their
surgery. [28] Synder–Ramos et al. compared three
methods of conducting the preanesthetic visit. The
patients were randomized to a routine preanesthetic
interview, a brochure plus an interview, or a self‑made
documentary video plus an interview. These authors
suggested that the use of a documentary video to
supplement a patient interview during the preanesthetic
visit may be a more effective technique than a brochure
or a personal interview alone for conveying information
to patients undergoing surgery.[29]
A systematic review was conducted to investigate
the effectiveness of various preoperative educational
interventions in reducing preoperative anxiety. Twelve
randomized trials involving a total of 1752 participants
41
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Bansal and Joon: Preoperative anxiety: A narrative review
were included in the review. Four studies used
audiovisual, two trials used visual, two trials used
multimedia supported education, one trial used a
website, two trials involved verbal education delivered
by a psychologist or a nurse facilitator couplets
with leaflets, and one trial used information leaflets
only. Eight trials demonstrated that preoperative
education intervention reduced preoperative anxiety
significantly.[30] Acupressure has also been found to be
effective in decreasing preoperative anxiety.[31]
Every patient requiring surgery should be assessed for
the presence of anxiety in their routine preoperative
anesthesia assessment and the patient found to have
a high level of anxiety should be scheduled for an
additional counseling session from the anesthetist.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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