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original article
Prevalence of Post Traumatic Stress Disorder after Amputation: A Preliminary
Study from Kashmir
Mushtaq A Margoob; Akash Yousuf Khan; Naseemul Gani; Abdul Majid; Imtiyaz Mansur; Mohammed Farooq Bhat; Huda Mushtaq
Hinan Jeelani; Dharmender Nehra.
The socio-political world scenario of today on one hand and the increasing frequency of
natural disasters on the other is increasing exposing people of all ages, groups and regions
1
to variety of traumatic events . This not only results in multiple physical injuries but also
2,3
substantial psychological burden which may persist in some persons for years after the
4
exposure . Clinicians must therefore not only become familiar with the characteristics of
5
the spectrum of psychological injuries inflicted by bullets, blasts and explosions but also
the psychological impact of natural calamities and industrial/transportation mishaps. Such
understanding could greatly improve the nature and extent of interventional strategies
6
surrounding the management thereafter .
Traumatic amputations as a catastrophic injury are often a major cause of
disability. The irrevocable loss of one's body part resulting in loss of practical and
expressive functions, which were formerly carried out by means of the part body lost, the
individual's body image may get so distorted that the victim may no longer perceive himself
7
as a complete human being . Traumatic loss of a limb has been equated with loss of a
8,9, 10
spouse, symbolic castration, and even death .
It is not unusual to observe alterations in attitude, mood and behavior during the
11
task of adaptation to the loss of body parts . Research on the prevalence of specific
psychiatric morbidity after amputation has largely focused on depression symptoms, and
12 13
results of those studies depicted prevalence rates varying from 7.4% to 28% . Post
traumatic stress disorder (PTSD) is a psychiatric disorder that can emerge after an
individual is exposed to an event involving threatened or actual serious injury, to self or
14
others which causes a response of fear, helplessness, or horror. A recent study using a
structured clinical interview reported that 18.5% of individuals experiencing digital
15
amputation met criteria for PTSD in 6 months after trauma
Jammu and Kashmir has been witnessing a continuous mass trauma situation for
16
past 19 years with thousands of people dead, maimed and mutilated . The fury unleashed
by natural disasters (snowstorm and earthquakes to recount a few) during the same time
17,18
cannot be undermined as a prominent cause for injury, trauma and amputations. The
purpose of the present study was to perform the initial assessment of the prevalence of Post
Traumatic Stress Disorder (PTSD), in individuals who experienced amputations both
accidental and therapeutic, in a surgical setting.
Method:
Amputees attending orthopedic services of a tertiary care hospital were approached to
explain them the objectives of the study and consent for their participation was sought.
Excluding individuals who declined to participate, 16 cases with amputation (8
men, 8 women), who gave informed consent were taken up for the study..
In majority (62.5%) of the sample (N=10) amputation was the result of trauma
which included 4 cases of road traffic accident, 2 blast trauma, 2 firearm and 2 earthquake
survivors. This trauma group comprised of 5 below knee amputations, 3 above knee
amputations and 2 had amputation of an arm. 6 patients (37.5%) had undergone amputation
as a therapeutic intervention which included 3 for osteosarcoma, 1 for gangrene (peripheral
vascular disease) and 2 for neglected Congenital Talepes Equino Varus (CTEV).
19
All the participants were interviewed using DSM IV based Structured Interview and
20
Clinical Administered PTSD Scale (CAPS)
Results:
8 (80%) of the 10 individuals who had lost their limb in traumatic accidents met criteria for
PTSD and the remaining two had an elevated score on CAPS but did not meet the threshold
criteria for PTSD. PTSD cluster symptoms were related to the traumatic events which lead
to the loss of body part. In contrast, among the group who had under gone therapeutic
surgical amputation (N=6), only one individual (16.7%) met criteria for current PTSD.
Keywords: amputation, post traumatic stress disorder, trauma.
Authors’ Affiliations:
Mushtaq A Marqoob,
Akash Yousuf Khan,
Abdul Majid, Imtiyaz Mansur;
Department of Psychiatry.
Nassemul Gani, Mohammed Farooq
Bhat;
Department of Othopaedics
Government Medical College,
Srinagar.
Huda Mushtaq, Dharmender Nehra
Department of Clinical Psychology
Institute of Human Behaviour and
Allied Sciences, New Delhi
Hinan Jeelani
SKIMS, Medical College, Srinagar.
Accepetd for Publication June-2007
Correspondence
Dr. Mushtaq A Margooq
Associate Professor, Department of
Psychiatry, Government Medical
College, Srinagar.
mushtaqmargoob@yahoo.comEmail:
JK- Practitioner Vol.15, No ( 1- 4) January-December 2008
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Abstract
Jammu and Kashmir State has been under stress for the last 19 years with thousand of people dead, maimed and mutilated. The present
study was conceived to perform the initial assessment of the prevalence of post traumatic stress disorder (PTSD) in individuals who
experienced amputation both accidental and therapeutic in a surgical setting. A total of 16 cases with amputations formed the study
group. All participant were interviewed using DSM IV 19 based structured interview and clinical administered PTSD scale (CAPS).
10 individuals (80%) who had lost the limb in traumatic accidents met criteria for PTSD. In contrast only one individual computation
(N=6) met criteria for current PTSD. The study is limited by the small sample size.
JK-Practitioner 2008; 15 (1-4): 5-7
6
original article .
Discussion develop in majority of those cases who had undergone therapeutic
The results of this small study reveal that traumatic amputations met criteria for PTSD. These findings are supported by study
6
following accidental injuries or violence leads to an alarmingly
conducted by Cavanagh et.al . The reason for this could be that
higher (80%) rates of PTSD. These results are consistent with
these patients met the experience with acceptance and optimism
12, 15, 21
findings of studies conducted by researchers in the west . The for future; as most of the patients had undergone planned
reason for such high prevalence of PTSD in these cases could be amputations necessitated by complications of chronic illness and
related to amputation itself, the accident leading to injury or the were prepared for the procedures and its consequences weeks to
combination of the two factors. In addition it could be that for months ahead. Still the development of PTSD in surgical
those losing limb to such events, the pain, the disability, and the amputations could e due to learning of the need for amputation,
psychological adjustment required, exacerbates existing post the anxiety of preparing for the surgery, or awakening after the
traumatic stress by way of constant physical reminders of trauma surgery to confront the actual loss of the body part, they would not
and added complexities of daily living. Another reason could be have consciously experienced the event that would generally be
that amputation heightens the perceived threat to life embodied considered most traumatic (i.e amputation).
22,23
The findings of our study therefore are consistent with
by the accident and thus contribute to PTSD symptoms . In
the models of PTSD suggesting that the more uncontrollable and
addition multiple exposures to traumatic events is known to be a
24,25,26
unpredictable the traumatic event, the more likely it is to lead to
grave risk factor to develop PTSD .
15
PTSD .
In view of chronic conflict situation prevailing here in
Small sample size was a limiting factor in our study. So
Kashmir, majority (58.69%) of people (males = 59.51%, females
this sparse data in our study suggests that extensive study of
= 57.39%), , as revealed by one of the first such studies from an
psychiatric morbidity in this population is warranted and
Asian region by Margoob and his associates, have experienced a
clinicians traumatic amputation. Further research should aim at
lifetime prevalence of traumatic events with firing and explosions
27
evaluating a larger group of participants (both therapeutic and
being the commonest traumatic events encountered (81.37%) .
accidental/violence related amputations), with a detailed,
Another reason for high prevalence of PTSD among
preferably longitudinal, assessment of a wide variety of socio
our study group could also be due to very poor or nonexistent
demographic and other pertinent factors like functional
systematic post amputation rehabilitation programmes which
limitations involved, time since injury, nature and extent of social
hampers coping and recovery after such tragedies.
28
support network and previous experience with loses
.
The results of our study regarding emotional reactions
to the experience of amputation also revealed that PTSD did not
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JK- Practitioner Vol.15, No ( 1- 4) January-December 2008
S.No. Type of Amputation No. of Part amputation Reason for amputation
Patients (N)
1. Therapeutic surgical 06 L forearm 1 Osteosarcoma 3
Amputation Below knee 3 Gangrene 1
Above knee 2 Neglected CTEV2
2. Traumatic 10 R arm 2 RTA 4
Amputation Below knee 5 Blast trauma 2
Above knee 2 Firearm 2
Earthquake 2
Table-1: Total number of Patients (N) =16
Male = 08; Female = 08
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