Adjustment to Disability - Amputation

8/6/2019 Adjustment to Disability - Amputation

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ADJUSTMENT TO

DISABILITY:Amputations

Erika Zipf-Williams, Ph.D.


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Coping Skills

Coping skills are the behavioral

tools which we use to offset orovercome adversity,disadvantage, or disabilitywithout correcting or eliminatingthe underlying condition.
http://en.wikipedia.org/wiki/Adversityhttp://en.wikipedia.org/wiki/Disadvantagehttp://en.wikipedia.org/wiki/Disabilityhttp://en.wikipedia.org/wiki/Disabilityhttp://en.wikipedia.org/wiki/Disadvantagehttp://en.wikipedia.org/wiki/Adversity


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Predictors of Adjustment

How well one has coped withpast adversity in their life is thebest predictor of how one willcope with any new problem.


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Psychosocial Predictors ofAdjustment

Perception of disability severity

(how much can I do for myself) Self-esteem (premorbid level

plays a big role)

Social skills

Social support (new and oldfriends and family)


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Factors Affecting Adjustmentafter Amputation Body image, perceived social stigma, perceived

vulnerability, social support and optimism accountfor psychological adjusment post amputation more

than residual limb pain and activity restrictions. Psychological factors and coping strategies that are

associated with poor outcome post amputation arecatastrophizing, avoidance and helplessness.

Females tend to rate the importance of the aestheticcomponents of the prosthesis more highly, while

males rate the importance of the functional aspectsmore highly. Post rehabilitation, however, malesshifted and found their prosthesis less aestheticallypleasing.


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Adjustment issues and Typeof Amputation

Upper extremity amputations are

considerably less frequent than lowerextremity amputations.

Less available peer group for UE amputeesthan LE amputees, leading to a sense ofisolation.

UE amputees cannot hide their prosthesis aseasily, thus affecting body image differently.

Greater likelihood of UE amputation beingtraumatic than LE.


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Family

Experience a loss of the way

their life was before the injury. Take on new roles caregiver,

bread-winner.

Experience different views ofwhat happened (relief, guilt,anger)


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Adjustment Models

Stage theories

Recurrent/Ongoing cycle

models


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Stage Models

Three Common Stages:

Initial period of shock and/or denialSignificant Distress

Acceptance of ones situation


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Stage Models Despite the number of stage

models that exist, adjustment is

not a linear process.

One can slip back and forthbetween stages, remaining

longer in one stage than another. Hopefully, one will progress to a

final stage where he/she accepts

his/her disability.


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Stage Model Theorists Falek and Britton (Shock and Denial,

Anxiety, Anger and/or Guilt, Depression,

Acceptance) Kerr (Shock, Expectancy of Recovery,

Mourning, Defense (Healthy or Neurotic),Adjustment)

Kubler-Ross (Denial, Anger, Bargaining,Depression, Acceptance) Krueger (Shock, Denial, Depressive

Reaction, Reaction Against Independence,Adjustment)


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Shock The period immediately following the

injury.

Experienced as a state of numbness,both physical and emotional

An inability to integrate the severity

of the injury. This phase is generally experienced in

the very acute phases of theinjury/amputation.


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Denial Denial is used by all and it allows one to slowly

introduce the seriousness of what one is havingto cope with.

Denial is used because the current stressor isbeyond the capacity of the individual toemotionally tolerate.

Denial is only maladaptive/dysfunctional when itinterferes with treatment/rehabilitation efforts(e.g., dont want to learn to use crutches).

Examples of denial include believing it will all getbetter or forgetting to inspect the stump (Once Ihave the prosthesis, ).


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Depression As denial diminishes, grief and depression emerge. Depression often presents as withdrawal and

hostility. Hostility, anger and blame are often

directed at family and staff. This should not be takenpersonally, but this is the point where the patientneeds help with directing the anger and hostilitymore appropriately.

Understanding the patients pre-injury self esteemand coping mechanisms will allow the clinician to

assist the patient in incorporating the injury into thepatients sense of self and in more appropriatelydirecting anger and frustration.


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Anger/Hostility/Dependency

These symptoms tend to bepronounced in adolescence, whereautonomy and independence is notfully resolved. They can become upsetat any limits placed on their

independence, as well as have a needto fall back on being dependent.

The more passive person, may preferthe sick role.


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Patient Distress & StaffReactions This time of stress is when

responses or reactions are pulledfor from staff.

Annoyance feelings can lead staff

to feel like terminating therapy. Mothering feelings can lead staff

to provide more assistance thanis appropriate for the patient.


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Patient Distress & StaffReactions

As a psychologist, educating staff

as to why the behavior is presentis necessary.

There will likely become a need

for the team to place limits, withclear expectations andconsistency is very important at

this point in treatment.


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Adjustment/Acceptance Acceptance does not mean one is happy

about his/her disability.

Acceptance means one can realistically planand effectively cope with his/her disability.

The early phase of acceptance is workingwith the here-and-now. There is no need totake away hope. (e.g., for now we need tolearn to use a wheelchair outside, but thisdoes not mean you will have to rely on thisforever).


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Adaption Once grief and mourning of the loss

are complete and one relinquishes

false hopes, one can develop a newrole with new potentials based inrealistic limitations.

Individuals with disabilities need to

learn to give credit to themselves forwhat they can do in the face of theirlimitations. Stop comparing to theirpre-disability self.


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Recurrent/Cycle Model(Kendal & Buys) Adjustment is viewed as a gradual process of

learning to tolerate an almost intolerable

circumstance. Seen as a continuous life transition rather then a

time-limited process. Involves the development of new cognitive schemas

(Beck), which is how one views oneself relative toothers and the environment

Through the development new cognitive schemas thedisabled person is thought to work through severalthemes: The search for meaning in the disability The need for a sense of mastery and control over the

environment, the disability and the future.

The effort to create a new self and a post-disabilityidentity.


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Recurrent/Cycle Model(Kendal & Buys) Adjustment is a unique process by

which one experiences continual

peaks and troughs as one seeks toredefine oneself in the face of his orher disability.

The implications this model clinically

is that treatment should beconsidered more long-term and asavailable as needed and notnecessarily as completed in a certaintime.


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Comorbid PsychiatricDisorders Adjustment Disorder

Major Depressive Disorder

Post Traumatic Stress Disorder

Axis II/Personality Disorders


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Adjustment Disorder An adjustment disorder is a

debilitating reaction, usually lastingless than six months, to a stressful

event or situation. Adjustment Disorders Subtypes: Depressed Mood Anxiety

Mixed Anxiety/Depressed Mood Disturbance of Conduct Mixed Disturbance of Emotions and

Conduct

Unspecified


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Major DepressiveDisorder A. At least five of the following and must include

depressed mood and loss of interest or pleasure.

(1) depressed mood most of the day, nearly everyday(2) markedly diminished interest or pleasure in allactivities most of the day, nearly every day(3) significant weight loss or weight gain(4) insomnia or hypersomnia nearly every day

(5) psychomotor agitation or retardation nearlyevery day(6) fatigue or loss of energy nearly every day(7) feelings of worthlessness or excessive guilt(8) diminished ability to think or concentrate(9) recurrent thoughts of death


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Major Depressive Disorder(Cont.)

The symptoms are not due to the direct

physiological effects of a substance (e.g., adrug of abuse, a medication) or a generalmedical condition (e.g., hypothyroidism).

The symptoms symptoms persist for longer

than 2 months or are characterized bymarked functional impairment, morbidpreoccupation with worthlessness, suicidalideation, psychotic symptoms, orpsychomotor retardation.


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Acute Stress/PostTraumatic Stress Disorder A. The person has experienced, witnessed, or was

confronted with an event that involved actual orthreatened death or serious injury. The person

experienced intense fear, helplessness, or horror.

B. The traumatic event is reexperienced(1) recollections(2) dream/nightmares.

(3) feeling as though the traumatic event wererecurring-flashbacks (dissociative)(4) intense psychological distress at exposure tocues

C. Persistent avoidance of stimuli associated with the

trauma and numbing of general responsiveness
http://behavenet.com/capsules/path/numbing.htmhttp://behavenet.com/capsules/path/numbing.htmhttp://behavenet.com/capsules/path/numbing.htm


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Resources/InterventionsFor Amputees

1:1 psychotherapy with psychologist

or counselor trained in rehabilitationand adjustment issues.

Pain management

Peer/Support Groups

Psychoeducational classes

Family support

Vocational Training


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ReferencesCavanagh, S.R., Shin, L.M., Karamouz, N., Rauch, S.L. (2006).

Psychiatric and Emotional Sequelae of Surgical Amputation.Psychosomatics, 47, 459-464.

Kendall, E. & Buys, N. (1998). An Integrated Model ofPsychosocial Adjustment Following Acquired Disability.

Journal of Rehabilitation, 64 (3), 16-20Krueger, D.W. (1981-1982). Emotional Rehabilitation of the

Physical Rehabilitation Patient. TheInternational Journalof Psychiatry in Medicine, 11 (2), 183-191.

Morris, R.M. (2008). Therapeutic Influences on the Upper-

Limb Amputee. The Academy Today, A4-A7.Murray, C.D., & Fox, J. Body Image and ProsthesisSatisfaction in the Lower Limb Amputee.

Peters, E.J., Childs, M.R., Wunderlich, R.P., Harkless, L.B.,Armstrong, D.G., & Lavery, L.A. (2001). Functional Statusof persons with Diabetes-Relates Lower-ExtremityAmputations. Diabetes Care, 24 (10), 1799-1804

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