Journal of Psychosomatic Research 51 (2001) 589 – 596

Anxiety and surgical recovery

Reinterpreting the literature
Marcus R. Munafò*, Jim Stevenson
University of Southampton, Southampton, UK
Received 12 October 2000; accepted 30 May 2001

Abstract

Objective: To critically evaluate the interpretation of the
findings reported in the peer-reviewed literature concerning the
association of state and trait anxiety with surgical recovery and
response to surgery. Methods: The Social Science Citation Index
(SSCI), Science Citation Index (SCI), Medline and Psychological
Abstracts (PsycInfo) databases were searched for studies published
since 1981. Reference lists from previous reviews were also
searched for additional references. Studies that were not in the
public domain were not searched for. Results: Twenty-seven
studies were identified by the search strategy, met the inclusion
criteria and contributed to the review. Conclusions: Associations
between preoperative measures of anxiety and postoperative mood
and pain have been consistently reported. Associations with regard
to other recovery variables are less consistent. The existing
evidence does not rule out an interpretation of the results as
reflecting consistent self-reporting bias rather than causal associ-
ation. D 2001 Elsevier Science Inc. All rights reserved.

Keywords: Anxiety; State – Trait Anxiety Inventory; Surgery; Surgical patients; Surgical recovery; Prediction; Self-report

Introduction factors such as current (or state) anxiety and depression

An extensive literature exists that attempts to show
relationships between psychological factors, usually meas-
ured preoperatively, and surgical recovery. The main psy-
chological factors of interest are affective, with a great deal
of emphasis on anxiety, as this is a particularly salient
feature of the perioperative period [15]. The ability to
predict surgical recovery would be of both clinical and
theoretical value.
Surgery represents a major trauma that provokes a
relatively stereotyped physiological response [32]. A period
of postoperative recovery follows, ranging from a few days
to several weeks depending, primarily, on the severity of the
preexisting pathology and the surgical procedure performed.
There is also variability across patients who have undergone
a comparable surgical procedure. What accounts for this
difference across patients is unclear, and it is this difference
that led to the suggestion (e.g., Ref. [15]) that psychological
* Corresponding author. ICRF GPRG, Institute of Health Sciences,
University of Oxford, Oxford OX3 7LF, UK. Tel.: +44-1865-226756; fax:
+44-1865-227137.
E-mail address: marcus.munafo@dphpc.ox.ac.uk (M.R. Munafò).
might play some part in determining the duration and
quality of the recovery period.
Janis [15] proposed that a curvilinear relationship exists
between preoperative ‘‘distress’’ (not necessarily analogous
to state anxiety) and postoperative recovery. That is, mod-
erate levels of ‘‘distress’’ are proposed to result in optimal
postoperative recovery, while excessively low or exces-
sively high levels of ‘‘distress’’ both result in impaired or
suboptimal recovery, although the mechanisms underlying
these relationships may differ. This moderate level of
‘‘distress’’ related to optimal postoperative recovery was
termed, by Janis, ‘‘the work of worry,’’ which was hypo-
thesised to prepare the surgical patient for the distress and
suffering associated with postoperative recovery. An in-
ability to prepare oneself appropriately, reflected in low
preoperative ‘‘distress,’’ was suggested to result in greater
distress postoperatively, for example, because of the shock
of such unexpected pain, while excessive preoperative
‘‘distress’’ was also supposed to result in greater postoper-
ative suffering, perhaps because of sensitization to noxious
stimuli. More recently, experimental work in psychoneu-
roimmunology has suggested that stress delays wound
healing and, in addition, that pain has adverse effects on

0022-3999/01/$ – see front matter D 2001 Elsevier Science Inc. All rights reserved.
PII: S 0 0 2 2 - 3 9 9 9 ( 0 1 ) 0 0 2 5 8 - 6
590 M.R. Munafò, J. Stevenson / Journal of Psychosomatic Research 51 (2001) 589–596
endocrine and immune function [18]. Taken together, this
suggests the possibility of both biologically and behavior-
ally mediated associations between preoperative state anxi-
ety and postoperative state. An obvious question that results
from this thesis is whether ‘‘distress’’ as envisaged by Janis
necessarily reflects the same thing as ‘‘stress’’ as inves-
tigated by Kiecolt – Glaser et al. [18] and ‘‘anxiety’’ as used
by others. This is tacitly assumed in the literature that has
followed, but the basis for this assumption is not clear.
There are a number of physiological, cognitive and
behavioral correlates of anxiety that could conceivably be
introduced as measures of anxiety [27] if one accepts a
strong association with subjective anxiety as an indication
of validity. These may be more closely related to the
mechanisms that underlie and drive anxiety, but may also
be removed from the subjective experience that is relevant
to the individual. Nevertheless, such an approach would
strengthen the claim that the association between perioper-
ative anxiety and recovery is causal and potentially amen-
able to intervention.
If elevated state anxiety, for example, is reliably shown to
predict slower wound healing [18], then it might be hypo-
thesized that this is due to the endocrinological and auto-
nomic changes associated with elevated state anxiety, and
their subsequent impact on the wound healing process. The
prediction of surgical recovery provides a testing ground for
hypotheses regarding the relationships that obtain between
psychological and behavioral indices and physical health.
Prediction allows for the subsequent testing of hypotheses
regarding causation.
Effective and reliable prediction of surgical recovery
might also provide the potential to facilitate recovery in
‘‘high-risk’’ surgical patients if interventions to modify the
predictor variables thought to be causal were developed.
Indeed, early evidence that this might be possible (e.g., Ref.
[13]) has motivated much of the research that has followed.
This would be of clinical benefit given that slower recovery,
inactivity and so on is strongly associated with subsequent
morbidity, impairment of muscle function and elevated risk
of complication (e.g., deep vein thrombosis) [32]. It is
important to make a distinction between clinical and
statistical significance: While theoretical models require
tests of statistical significance, this is only of importance
in a clinical context in conjunction with evidence for the
efficacy of a clinically significant effect. Elevated state
anxiety might predict some aspect of surgical recovery to
a statistically significant degree, but if this effect is weak
(i.e., the effect size is small) then the effort and cost
associated with intervention might not be justified by the
beneficial impact of such an intervention. In such an
instance the relationship would not be regarded as clinically
significant. This would also be the case if the risk factor
was not amenable to intervention.
The majority of studies that investigate the role of affect
in surgical recovery use self-report measures of generic state
anxiety as an index of preoperative distress. They then
attempt to relate this to a constellation of postoperative
factors that may be regarded as making up the global
concept of postoperative distress and suffering, including
state anxiety, pain, analgesia consumption, time to discharge
and so on. Consequently, for any review to be able to make
consistent comparisons across studies, it is important to state
a particular measure of anxiety that will be used in the
selection of studies. This could potentially include one of
the physiological correlates of anxiety, such as salivary
cortisol, or one of the several questionnaire measures of
anxiety. Behavioral measures, such as information seeking
or coping behavior, might also be regarded as important.
In the case of this review, only those studies that report
associations between self-reported state and trait anxiety as
measured by the State – Trait Anxiety Inventory (STAI) [36]
and postoperative outcome are included. A large proportion
of studies have used this measure of current and disposi-
tional anxiety as both a predictor and outcome measure, and
the inclusion of only those studies that use this measure will
simplify the comparison of results across studies. As already
mentioned, state anxiety as measured by questionnaires may
reflect something quite different to the ‘‘worry’’ envisaged
by Janis [30], and this should be borne in mind when
interpreting the results of studies.
The aim of this paper, therefore, is to critically evaluate
the interpretation of the findings reported in the peer-
reviewed literature concerning the association of state and
trait anxiety as measured by the STAI with surgical recovery
and response to surgery, and to try to evaluate the validity
and parsimony of these interpretations.
Methods
The review was based upon the Social Science Citation
Index (SSCI), Science Citation Index (SCI), Medline and
Psychological Abstracts (PsycInfo) databases. These were
searched for studies published since 1981, the start date of
the SCI and SSCI, that had the words ‘‘anxiety’’ and
‘‘surgical’’ or ‘‘surgery’’ or ‘‘patient’’ in the title, abstract
or keywords. In addition, the reference lists from previous
reviews (e.g., Refs. [18,32]) were searched for additional
references. Studies that were not in the public domain were
not searched for.
Studies generated by the search strategy were checked
for relevance. Observational studies that used the STAI as
an index of current (i.e., state) anxiety and/or dispositional
(i.e., trait) anxiety prior to surgery were included. Only
studies that recruited adults (aged 16 years or older) admit-
ted for inpatient elective surgical procedures were included.
Intervention studies were not included to concentrate on the
naturally occurring linkages between perioperative anxiety
and recovery. For each study selected for inclusion, the
following data were extracted:
(i) author(s) and year
 M.R. Munafò, J. Stevenson / Journal of Psychosomatic Research 51 (2001) 589–596 591

Table 1
Measures of mood
Preoperative Postoperative
Study N Sex Age Type of surgery measures measures Effect
Boeke et al. [2] 111 (93%) M/F 19 – 86 Gallbladder STAI S STAI S r =.30***
Christensen et al. [5] 15 M/F 42 – 64 Abdominal STAI S STAI S Decrease*
De Groot et al. [7] 126 (93%) M/F 20 – 77 Lumbar STAI S STAI S b =.31*
De Groot et al. [9] 126 (93%) M/F 20 – 77 Lumbar STAI S STAI S b =.38***
Duits et al. [11] 217 (71%) M/F 28 – 78 Coronary Bypass STAI S STAI S Decrease***
Duits et al. [12] 217 (71%) M/F 28 – 78 Coronary Bypass STAI S STAI S r =.25***
Jamison et al. [14] 50 (96%) F 18 – 50 Laparoscopic STAI S Psychological reaction r =.39**
STAI T r =.35*
Johnston and Carpenter [16] 73 F 23 – 79 Gynaecological (major) STAI S STAI S F = 9.69**
Kain et al. [17] 53 F 26 – 56 Gynaecological (major) STAI S STAI S r =.47** (1-tailed)
STAI T r =.39** (1-tailed)
Kugler et al. [19] 20 (69%) M/F 19 – 63 Heart Transplant STAI S STAI S r =.11 ns
Manyande and Salmon [23] 40 (75%) M/F 17 – 67 Abdominal STAI S STAI S r =.62**
Martinez-Urrutia [25] 59 M < 65 Not stated STAI S STAI S Decreasea
STAI T + ve assoc.***
Salmon et al. [33] 17 M/F 41 (mean) Middle ear STAI S STAI S Decrease**
Taenzer et al. [38] 40 M/F 20 – 65 Gallbladder STAI S STAI S r =.65***
STAI T r =.53***
Timberlake et al. [39] 121 M/F 35 – 75 Coronary artery bypass STAI S Depression t = 2.33*
STAI T t = 2.16*
Wallace [42] 120 (92%) F Not stated Gynaecological (minor) STAI S STAI S F = 5.5*
Wallace [43] 118 F Not stated Laparoscopic STAI T STAI S r =.22**
a
P not stated.
* P < .05.
** P < .01.
*** P < .001.

Table 2
Measures of pain
Preoperative Postoperative
Study N Sex Age Type of surgery measures measures Effect
Bachiocco et al. [1] 114 (95%) M/F 17 – 78 Thoracic STAI S Analgesia request + ve assoc.**
STAI T + ve assoc.**
Boeke et al. [2] 111 (93%) M/F 19 – 86 Gallbladder STAI S Pain Likert r =.20*
De Groot et al. [8] 126 (93%) M/F 20 – 77 Lumbar STAI S Pain Visual r =.21*
Analogue Scale
Jamison et al. [14] 50 (96%) F 18 – 45 Laparoscopic STAI S Pain Likert r =.46****
STAI T r =.38**
Johnston and Carpenter [16] 73 F 23 – 79 Gynaecological (major) STAI S Pain Visual F = 0.12a
Analogue Scale
Kain et al. [17] 53 F 26 – 56 Gynaecological (major) STAI S Pain Visual r =.29**
STAI T Analogue Scale r =.09a

Manyande and Salmon [23] 40 (75%) M/F 17 – 67 Abdominal (minor) STAI S Pain Visual r =.43**
Analogue Scale
Martinez-Urrutia [25] 59 M Not stated Not stated STAI S Pain questionnaireb r =.27*
STAI T F = 12.31***
Nelson et al. [28] 96 M/F 37 – 84 Coronary artery bypass STAI S Pain questionnaireb r =.41***
STAI T r =.01a
Scott et al. [34] 48 M/F 21 – 73 Gallbladder STAI S Pain questionnairec r =.26*
STAI T r =.37 *
Taenzer et al. [38] 40 M/F 20 – 65 Gallbladder STAI T Pain questionnairec r =.33*
Wallace [41] 118 F Not stated Laparoscopic gynaecological STAI S Pain Expectancy r =.18*
a
P nonsignificant.
b
Melzack and Torgesen Pain Questionnaire.
c
McGill Pain Questionnaire.
* P < .05.
** P < .01.
*** P < .001.
**** P < .0001.
592 M.R. Munafò, J. Stevenson / Journal of Psychosomatic Research 51 (2001) 589–596

Table 3
Measures of physical recovery and behaviour
Study N Sex Age Type of surgery Preoperative measures Postoperative measures Effect
Boeke et al. [2] 111 (93%) M/F 19 – 86 Gallbladder STAI S Length of stay b = .29**
Boeke et al. [3] 58 (95%) M/F 19 – 78 Gallbladder STAI S Length of stay r = .05a
STAI T r = .10a
Boeke et al. [4] 81 M/F Not stated Gallbladder STAI S Length of stay r =.05a
Christensen et al. [5] 15 M/F 42 – 64 Abdominal STAI S change Fatigue Likert change r =.65**
STAI T change r =.38a
De Groot et al. [7] 126 (93%) M/F 20 – 77 Lumbar STAI S Symptom Checklist 90 b =.27**
De Groot et al. [8] 126 (93%) M/F 20 – 77 Lumbar STAI S Physician rated outcome r =.24**
De Groot et al. [9] 126 (93%) M/F 20 – 77 Lumbar STAI S Symptom Checklist 90 b =.28**
Jamison et al. [14] 50 (96%) F 18 – 45 Laparoscopic STAI S Physical state r =.46****
STAI T r =.38**
Johnston and Carpenter [16] 73 F 23 – 79 Gynaecological (major) STAI S Wolfer – Davis scale F = 0.76a
Manyande and Salmon [23] 40 (75%) M/F 17 – 67 Abdominal (minor) STAI S Wolfer – Davis scale r = .05a
STAI T r = .07a
Salmon et al. [33] 17 M/F Not stated Middle ear STAI S Wolfer – Davis scale r = .86**
Simpson and Kellett [35] 45 (94%) M/F > 60 Orthopaedic STAI S Delirium change r = .27a
STAI T r = .15a
a
Stengrevics et al. [37] 94 (82%) M/F Not stated Cardiac STAI S Length of stay
a
STAI T
a
P nonsignificant.
** P < .01.
**** P < .0001.

(ii) number of participants and recruitment rate
(iii) age range of participants
(iv) type of surgery
(v) preoperative measures
(vi) postoperative measures
(vii) effect/relationship
This information was recorded in tabular form, grouped
by the type of postoperative measure under consideration.
This included outcome measures of:
(i) mood
(ii) pain
(iii) physical recovery/behavior (other than pain)
(iv) physiological correlates
Twenty-seven studies conducted in the United States, the
United Kingdom, The Netherlands and Denmark between
1975 and 2000 were identified by the search strategy, met the
inclusion criteria and contributed to the review. Seventeen
studies contributed to the review of measures of mood (see
Table 1). Twelve studies contributed to the review of meas-
ures of pain (see Table 2). Thirteen studies contributed to the
review of measures of physical recovery and behavior (see
Table 3), and two studies contributed to the review of
measures of physiological correlates (see Table 4).
Six studies did not specify the age range of participants
[4,25,33,37,41,42]. Most studies included participants
undergoing abdominal, orthopaedic, gynaecological or cor-
onary bypass surgical procedures, with the exceptions of
Bachiocco et al. [1] (thoracic), Kugler et al. [19] (heart
transplant) and Salmon et al. [33] (middle ear). One study
[25] did not specify the surgical procedure or procedures
undergone by the participants. Six studies necessarily
included female participants only because the surgical group
was undergoing gynaecological procedures [14,16,17,
42,43] and one study included male participants only [25].
No studies reported the basis for sample size selection or
provided a power analysis, and recruitment rates (i.e., the
proportion of those approached who agreed to take part in
the study) were also not recorded in several studies
[4,5,16,17,25,28,33,34,38,39,41,43].

Table 4
Measures of physiological correlates of recovery
Study N Sex Age Type of surgery Preoperative measures Postoperative measures Effect
Salmon et al. [33] 17 M/F Not stated Middle ear STAI S Cortisol r =.02a
STAI S Noradrenaline r =.05a
Salmon et al. [29] 27 M/F 18 – 77 Abdominal (major) STAI T Cortisol r = .55*
STAI T Adrenaline r = .67*
STAI T Noradrenaline r =.53*
a
P nonsignificant.
* P < .05.
 M.R. Munafò, J. Stevenson / Journal of Psychosomatic Research 51 (2001) 589–596
Results
The studies included form the basis of the review pre-
sented below, grouped by the type of outcome measure used.
Mood
Seventeen studies reported on the relationship between
preoperative levels of anxiety and postoperative mood.
All studies used the state subscale of the STAI as an
index of postoperative mood, with the exception of two
studies [14,39] that used self-report measures of ‘‘psycho-
logical reaction’’ and depression, respectively. Six studies
reported on the relationship between trait anxiety, meas-
ured preoperatively, and postoperative mood [14,17,25,38,
39,43].
Three primary associations emerge from a review of
these studies. Eleven studies report that self-reported
preoperative state anxiety is positively correlated with
postoperative state anxiety or an equivalent (‘‘psycho-
logical reaction’’ in the case of Jamison et al. [14] and
depression in the case of Timberlake et al. [39]. Reported
correlation coefficients range from .25 to .65, with two
studies reporting beta coefficients, two studies reporting F
statistics and one study reporting t statistics. Five studies
report a second association that self-reported preoperative
trait anxiety is positively correlated with postoperative
state anxiety or an equivalent. In this case the range of
reported correlation coefficients is from .22 to .53, with
one study reporting t statistics. Finally, four studies report
a significant decrease in self-reported state anxiety over
the perioperative period. One study reported a nonsigni-
ficant relationship between preoperative and postoperative
state anxiety.
The majority of studies report correlation coefficients,
from which it is possible to calculate an effect size index. In
the case of the association between preoperative state
anxiety and postoperative mood the effect size indices range
from .25 to .65, which indicates a moderate to large effect
size [6]. Three studies report F statistics, of which one
reports sufficient data to calculate an effect size index (.30),
which also indicates a moderate effect size [6]. One study
reports t statistics, from which an effect size of .46 can be
calculated, which indicates a moderate effect size [6]. A
further four studies that report statistically significant results
do not report statistics that allow the calculation of an effect
size index.
In the case of the association between trait anxiety and
postoperative mood the effect size indices for the reported
correlation coefficients range from .22 to .53, which
indicates a moderate to large effect size [6]. One study
reports t statistics, from which an effect size of .39 can be
calculated, which indicates a moderate effect size [6]. One
study that reports a statistically significant association
does not report statistics that allow the calculation of an
effect size index.
593
Pain
Twelve studies reported on the relationship between
preoperative levels of anxiety and postoperative pain.
The majority of studies used either a Likert scale or a
visual analogue scale to assess postoperative pain. Four
studies [25,28,34,38] used a pain questionnaire, in the first
case the Melzack and Torgesen Pain Questionnaire and in
the other three cases the McGill Pain Questionnaire. One
study [41] used a self-report measure of pain expectancy
(assessed prior to surgery), and one study [1] used a
measure of number of analgesia requests. Seven studies
reported on the relationship between trait anxiety, meas-
ured preoperatively, and postoperative pain [1,14,17,25,28,
34,38].
Two primary associations emerge from a review of these
studies. The first is that self-reported preoperative state
anxiety is positively correlated with self-reported postoper-
ative pain. Nine studies report correlation coefficients
ranging from .18 to .46. One study [16] reports non-
significant results for this association, although this could
simply be a function of small sample size. One study also
reports a significant positive association between preoper-
ative state anxiety and postoperative analgesia request [1]
without stating the test statistic. The second is that self-
reported preoperative trait anxiety is also positively corre-
lated with self-reported postoperative pain. In this case four
studies report correlation coefficients of between .33 and
.38 and one study reports an F statistic of 12.31. One study
[1] also reports a significant, positive association without
stating the test statistic. Two studies [17,28] report non-
significant correlations.
In all cases the only measure of pain was taken post-
operatively. For some surgical procedures this is necessary
given the absence of preoperative pain. However, it should
be noted that there is, therefore, no control for baseline
levels of expression of pain behaviors.
The majority of studies report correlation coefficients,
from which it is possible to calculate an effect size index.
In the case of the association between preoperative state
anxiety and postoperative pain the effect size indices
range from .18 to .41, which indicates a moderate effect
size [6] in those studies reporting statistically significant
results. One study that reports a significant association
between preoperative state anxiety and postoperative pain
does not report statistics that allow the calculation of an
effect size index.
In the case of the association between trait anxiety
and postoperative pain the effect size indices for the two
studies for which it is possible to calculate an effect size
index are .37 and .38, which indicates a moderate effect
size [6] in those studies reporting statistically significant
results. Two studies that report a significant association
between trait anxiety and postoperative pain do not
report statistics that allow the calculation of an effect
size index.
594 M.R. Munafò, J. Stevenson / Journal of Psychosomatic Research 51 (2001) 589–596
Physical state and behavior
Thirteen studies reported on the relationship between
preoperative levels of anxiety and postoperative physical
recovery and behavior. Four studies [2– 4,37] used length
of inpatient stay as an index of physical recovery. Five
studies [7,9,16,23,33] used questionnaire measures of post-
operative physical state. Other measures used included
self-reported fatigue [5], physician-rated physical state
[8], self-reported physical state [14] and change in delirium
as measured by the Mini-Mental State Examination [35].
Six studies reported on the relationship between trait
anxiety, measured preoperatively, and postoperative phys-
ical recovery [3,5,14,23,35,37].
A review of these studies produces the least clear picture
of the associations between anxiety and postoperative out-
come. Six studies report only nonsignificant results, while
another reports some nonsignificant results. Among those
that report significant results, the only outcome measure
consistently reported to be associated with self-reported
state anxiety is the Symptom Checklist 90, with beta
coefficients of .27 and .28 being reported by two studies.
A closer inspection of these two papers [7,9], however,
suggests that these results might be drawn from a single data
set. One study reports a significant beta coefficient for the
association between state anxiety and length of stay. One
study reports a significant, positive correlation between state
anxiety and physician rated outcome. One study reports
significant, positive correlations between state and trait
anxiety and self-reported physical state, and one study
reports a significant, negative correlation between state
anxiety and self-reported physical state as measured by
the Wolfer –Davis Scale. Of the four studies reporting data
on length of inpatient stay, three report nonsignificant
associations with preoperative state anxiety.
Given the inconsistent pattern of results that emerges
from an analysis of the studies presented here, it would be
premature to estimate the size of effect of any reported
relationships. Much of this inconsistency stems from the use
of a variety of postoperative measures of physical state
across studies.
Physiological correlates
Two studies reported on the relationship between
preoperative levels of anxiety and physiological correlates.
Both studies reported on the associations between anxiety
and levels of cortisol and noradrenaline [29,33]. One
study [29] also reported on the associations between
anxiety and adrenaline. One study assessed state anxiety
preoperatively [33], while the other [29] assessed trait
anxiety preoperatively.
The lack of studies makes broad generalizations dif-
ficult, but in the case of self-reported preoperative state
anxiety there were no significant associations with physio-
logical measures (cortisol and noradrenaline). In the case
of self-reported preoperative trait anxiety, however, cor-
relation coefficients ranging in magnitude from .53 to .67
were reported for cortisol, adrenaline and noradrenaline
(negative in the case of the first two and positive in the
case of the last).
The correlation coefficients reported for the association
between trait anxiety and postoperative physiological meas-
ures result in effect size indices ranging from .73 to .82,
which indicates a large effect size [6].
Conclusions
This review has shown that preoperative state anxiety has
been reported to be associated with postoperative mood and
pain in a number of studies with some consistency, and to
other recovery variables in a smaller number of studies with
less consistency, with a number of studies reporting no
significant associations.
All studies included in this review report linear relation-
ships, with very few actually having included a test for
curvilinear relationships, with a few exceptions (e.g., Refs.
[16,42]). In the cases where a test for a curvilinear relation-
ship was included there was no evidence to support such an
association. This failure to support Janis’s original hypo-
thesis does not mean that the hypothesis is false. In
particular, the difficulties associated with self-report indices
of state anxiety (see below) and the fact that excessively low
state anxiety may be both rare and difficult to assess
accurately may prevent an adequate test being made.
One shortcoming of research of the kind reviewed above
that is apparent is the lack of comparability across studies.
Even when studies to be included are restricted to those
employing a single preoperative questionnaire (in this case
the STAI) there is substantial variation in the type of
surgical procedure investigated, the sex and age range of
participants included, the postoperative measure of recovery
or postoperative state employed, and the statistical analysis
performed. There is also the perennial problem of unreport-
ed nonsignificant findings, which suggests that any rela-
tionship may be even weaker still.
A more significant problem, however, is the extent to
which the potential confound of behavioral consistency is
not controlled for in the studies reviewed. For example,
without a baseline index of pain behavior and pain expres-
sion, any differences in postoperative pain report are
difficult to interpret. Conversely, the fact that preoperative
and postoperative state anxiety are frequently reported to be
positively correlated may reflect nothing more than behav-
ioral consistency. In this case the behaviors are anxiety-
related behaviors, which may include responses to items on
a questionnaire measure. It is important to bear in mind that
most of the preoperative and postoperative measures
reported in fact measure a particular behavior or group of
behaviors, and that behaviors tend to show consistency
over time.
 M.R. Munafò, J. Stevenson / Journal of Psychosomatic Research 51 (2001) 589–596
It would seem that there is no reason at present to
interpret the data reported in the studies reviewed here as
representing anything more than behavioral consistency.
This may be largely (although not necessarily exclusively)
self-reporting consistency, since most measures of post-
operative outcome rely on self-report. In a given context
specific behaviors, such as self-report, will be systematic-
ally interpreted in a given way, so that even ostensibly
objective measures of postoperative state, such as time to
discharge, will be influenced by the self-reported state of
the patient. This is, in fact, an interesting finding in itself,
but the mechanisms that underlie the association between
preoperative anxiety and postoperative recovery might
therefore be quite different to those suggested in many
of the studies that have been reviewed. It is revealing that
intervention studies have at best resulted in modest bene-
fits for those given an intervention designed to reduce
anxiety and subsequently improve recovery (e.g., Refs.
[20,22,26,40]).
The only postoperative recovery measures where an
explanation in terms of self-reporting consistency would
be difficult are physiological correlates of emotional state
and other physiological measures, such as wound healing.
Unfortunately, the number of studies that employ such
measures is very limited, and the data that are reported
suggest that trait anxiety is a more reliable predictor of such
outcome measures than state anxiety. If this is the case it is
unlikely that an intervention designed to ameliorate state
anxiety will be successful. Some studies have investigated
the relationship between preoperative state anxiety and
intraoperative measures, such as analgesia requirement
(e.g., Ref. [24]), but it is not clear how this relates to
postoperative state, although such variables are certainly
of interest as mediators of recovery.
Given that behavioral consistency and reporting bias is a
potential confound, efforts to measure and control this would
be of value. Unfortunately, the measures that might be used
to assess baseline expression of particular behaviors are the
same as those currently used as preoperative predictors of
outcome. Measures of change, as opposed to absolute values
of, say, state anxiety might go some way to controlling for
this potential confound. However, this will be limited by that
impossibility of measuring baseline levels of, say, pain
behaviors in the case of the majority of surgical populations.
Another alternative would be to rely on assessments of
preoperative and postoperative variables by others (e.g.,
nursing staff ). Unfortunately, this is equally liable to con-
founding. For example, Salmon and Manyande [31] report
evidence that nursing staff systematically underestimate how
well patients feel they are coping with their pain. Moreover,
the perception by nursing staff that a patient was coping
poorly was associated with negative evaluation in other
areas. Including both self-report measures and assessments
made by others may go some way to countering this problem
of confounding, but this increase in the number of variables
measured will require an increase in sample sizes, and it is
595
debatable whether this will address the problem of behav-
ioral consistency, since such assessment will inevitably
depend on certain aspects of the behavior of the patient.
The associations reported between state and trait anxiety
and postoperative mood and pain suggest that anxiety is a
potentially important predictor of recovery. However, the
evidence as it stands is largely consistent with an interpreta-
tion in terms of consistency in self-reporting. One advance
would be to include measures of state and trait anxiety that
are not dependent on self-report. This circumvents the
possible confound of reporting bias and consistency, but it
does introduce novel difficulties, such as whether the index
of anxiety chosen (such as cortisol) reflects subjective
anxiety as felt by the patient.
In addition, given the potential for confounding one
might hope for a greater degree of consistency in the
measures used, the population studied and so on. In practice,
however, this is likely to be difficult to achieve. It would also
be desirable to test for nonlinear as well as linear associa-
tions. The evidence that does exist suggests that linear
models fit the data better than nonlinear models, but it would
be desirable to have more data to support this position.
Finally, it should be borne in mind that anxiety is not
something that exists in isolation but rather operates in a
given context and serves to modify an individual’s behavior
and physiology in an adaptive way. There are, therefore, a
number of related psychological characteristics, such as
coping behaviors, which may be relevant in understanding
any associations between anxiety and recovery. Some studies
do report data on these characteristics (e.g., Refs. [10,21]),
but often in the context of an intervention design where a
particular coping style is manipulated as part of an interven-
tion designed to improve recovery. A clearer understanding
of the associations that obtain in surgical patients between
anxiety, coping and recovery would guide the development
of subsequent intervention studies, which have so far been
comparatively unsuccessful in improving recovery.
The role of anxiety in surgical recovery remains unclear
but potentially both theoretically revealing and clinically
important. For further advances to be made in our under-
standing to be made, however, what will be required will be
an appreciation of the limitations of the research that has
gone before and an attempt to address these. There are two
questions that result from this review: One is what is
required to improve the quality of research, while another
is whether there are any psychological characteristics other
than anxiety that deserve greater attention.
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