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Psychiatric and Emotional Sequelae of Surgical Amputation

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The prevalence of posttraumatic stress symptoms after the experience of amputation is not well established. The current study gathered data on the prevalence of posttraumatic stress disorder (PTSD) and other psychiatric disorders after amputation. Participants were recruited from a large Northeastern rehabilitation hospital and were assessed with structured clinical interviews. The data suggest that planned surgical amputations resulting from chronic illness do not frequently lead to PTSD symptoms. In contrast, data suggest that amputation resulting from accidental injury may lead to a higher prevalence of PTSD, in part because of the emotional stress surrounding the accident.
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Psychosomatics 47:6, November-December 2006 http://psy.psychiatryonline.org 459
Psychiatric and Emotional Sequelae of Surgical Amputation
S
ARAH
R. C
AVANAGH
, M.S., L
ISA
M. S
HIN
,P
H
.D.
N
ASSER
K
ARAMOUZ
, M.D., S
COTT
L. R
AUCH
, M.D.
The prevalence of posttraumatic stress symptoms after the experience of amputation is not well
established. The current study gathered data on the prevalence of posttraumatic stress disorder
(PTSD) and other psychiatric disorders after amputation. Participants were recruited from a
large Northeastern rehabilitation hospital and were assessed with structured clinical interviews.
The data suggest that planned surgical amputations resulting from chronic illness do not fre-
quently lead to PTSD symptoms. In contrast, data suggest that amputation resulting from acci-
dental injury may lead to a higher prevalence of PTSD, in part because of the emotional stress
surrounding the accident. (Psychosomatics 2006; 47:459–464)
Received October 13, 2005; revised January 31, 2006; accepted February
9, 2006. From the Department of Psychology, Tufts University, Medford,
MA. Address correspondence and reprint requests to Scott L. Rauch,
M.D., Dept. of Psychiatry, Massachusetts General Hospital, Bldg. 149,
13th Street, Room 2618, Charlestown, MA 02129. e-mail: rauch@
psych.mgh.harvard.edu
Copyright 2006 The Academy of Psychosomatic Medicine
The irrevocable loss of a part of one’s body readily
meets lay definitions of trauma. However, there is little
systematic research examining whether the experience of
amputation provokes a posttraumatic stress response. 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 oth-
ers that causes a response of fear, helplessness, or horror.
1
Understanding the psychiatric and emotional sequelae of
amputation could greatly improve the nature and extent of
psychological intervention surrounding the amputation and
thereafter. Moreover, if there is a significant rate of PTSD
after planned, surgical amputations, this population could
present a unique opportunity to investigate the pathogen-
esis of PTSD. The primary aim of this study was to collect
initial data on the prevalence of PTSD and other psychi-
atric disorders after surgical, therapeutic amputation, as-
certained in the context of a rehabilitation hospital.
Previous research on the psychological consequences
of amputation has focused primarily on the relationships
among demographic variables, various coping mecha-
nisms, and outcome measures.
2,3
A review of the literature
performed by Rybarczyk and colleagues
4
indicated that re-
sidual limb pain, activity restriction, and medical and dis-
ability-related factors (other than phantom pain) predict
less variance in psychological adjustment than do body im-
age, perceived social stigma, perceived vulnerability, social
support, and optimism. Psychological factors and coping
strategies that have been found to be associated with poor
outcome after amputation include catastrophizing,
5,6
per-
ceived vulnerability,
7
avoidance,
2
and helplessness.
8
Research on the prevalence of specific psychiatric
morbidity after amputation has largely focused on depres-
sive symptoms, and the results of these studies report prev-
alence rates varying from 7.4%
9
to 28%.
10
This variance
in prevalence rates is likely due to methodological differ-
ences in assessment of clinical depression. Those studies
relying on self-report measures, such as the Center for Ep-
idemiological Studies Depression Scale (CES–D), report
much higher rates of clinical depression
7,10,11
than those
using structured clinical interviews.
9
A major difficulty with assessing the prevalence of
major depressive disorder (MDD) or levels of depressive
symptoms in individuals with amputations is that the am-
putation very often adversely affects the individual’sability
to engage in his or her previous activities and otherwise
Sequelae of Surgical Amputation
460 http://psy.psychiatryonline.org Psychosomatics 47:6, November-December 2006
restricts the full range of previous living. Many of the in-
ventories of depression symptoms, and certainly the DSM-
IV criteria for MDD, rely on evidence of activity restriction
that would be considered indicative of psychopathology in
an individual free from medical illness, but that may be
misleading if attributed to psychopathology in someone
who has recently experienced a major physically limiting
event such as an amputation. Alternatively, individuals ex-
periencing depression after amputation may be well ad-
justed to the loss of a limb emotionally but may struggle
with depression symptoms surrounding the more practical
loss of mobility and activities. Indeed, in one sample, a
regression analysis revealed that younger age, less satis-
faction with social contacts, and perceived restriction of
activities explained 40% of the variance in depression
symptoms.
11
Although several researchers have investigated the
prevalence of MDD in individuals with amputations, very
few researchers have examined the prevalence of PTSD
after an amputation procedure. A retrospective epidemio-
logical study of Vietnam veterans found that the relative
risk of PTSD was 1.64 times greater for individuals with
amputations versus those without amputations.
12
A study
utilizing the SCID–III–R indicated that 19% of 27 individ-
uals recently having undergone digit replantation after am-
putation met criteria for PTSD.
13
A retrospective file re-
view of symptoms of PTSD, depression, and pain
complaints stemming from work-related limb amputations
found that participants with upper-limb amputations ex-
perienced more symptoms of PTSD than those with lower-
limb amputations.
14
A study of individuals many years af-
ter their amputations found that the time elapsed since the
amputation significantly predicted levels of anxiety, with
longer elapsed time related to lower anxiety level.
2
In one
of the only studies using a structured clinical interview,
18.5% of individuals experiencing digital amputation met
criteria for PTSD in the 6 months after the trauma.
9
All of
these previous studies explored the prevalence of PTSD in
subject samples either entirely
9,12–14
or largely
2
made up of
individuals with amputations resulting from accidental
traumatic injuries.
Given the current literature, it is difficult to reach
strong conclusions about the rate of PTSD after amputation
because previous samples were extremely heterogeneous
in terms of the time since amputation, the etiology of the
amputation, and other demographic variables, such as age,
health status, and social support. Of critical importance,
most of the previous samples consisted of individuals with
amputations arising from accidental injuries. As such, it is
unclear whether the PTSD was due to the emotional trauma
surrounding the accident that was the cause of the ampu-
tation or to the experience of losing a part of one’s body.
The purpose of the present study was to perform an
initial assessment of the prevalence of PTSD and other
psychiatric disorders, by use of the Structured Clinical In-
terview for the DSM–IV (SCID)
15
in individuals who ex-
perienced surgical amputations in a therapeutic setting, in
order to ascertain whether amputation in the absence of a
co-occurring emotionally traumatic accident is an experi-
ence that frequently leads to PTSD. This study is one of
the first to examine the prevalence of PTSD by use of a
full, structured clinical interview based on DSM–IV cri-
teria in a sample of individuals undergoing therapeutic am-
putation. As such, we did not pose an a priori hypothesis
about the rate of PTSD in this sample. A secondary aim of
the study was to obtain semi-structured descriptions of the
emotional aspects of the amputation experience.
METHOD
Participants
Twenty-six participants with amputations (19 men, 7
women) were recruited from a large rehabilitation hospital
in the northeastern United States. With the permission of
their treating physician, a psychiatrist affiliated with the
study approached patients about their participation and ob-
tained written informed consent. We attempted to recruit
the majority of new admissions to the hospital. However,
some individuals were not approached for participation,
most often because of acute medical crisis, very brief ad-
missions, and rehabilitative care that dominated their hos-
pital stay. A large number of individuals approached (over
50%) declined participation, most often because of not
feeling physically well enough for a long interview and/or
having limited free time.
The average age of the participants was 63.6 years,
with a range of 29 to 86. The mean time since amputation
was approximately 6 weeks (standard deviation [SD]:
55.46 days), with a range of 6 days to almost 5 years. The
median time since amputation was 6.7 weeks. Twenty-one
of the participants were self-identified as white, and five
were self-identified as black/African American. Eighteen
of the participants had had a leg amputated, four had lost
both legs, two had lost an arm, and two had lost toes. The
majority of the sample (N23) underwent their amputa-
tions through therapeutic intervention: 1 for cancer, 18 for
diabetes, and 4 for vascular or other health complications.
Cavanagh et al.
Psychosomatics 47:6, November-December 2006 http://psy.psychiatryonline.org 461
FIGURE 1. Observed Frequencies of Total CAPS Scores
Frequency, N
0–10 11–20 21–30 31–40 41–50
Reason for amputation:
Accidental
Surgical
Total CAPS Score
20
15
10
5
0
Surgical: N23; accidental: N3. CAPS: Clinician-Administered
PTSD Scale.
Three individuals had lost limbs as a result of motorcycle
accidents. All participants were currently undergoing re-
habilitation treatment in an inpatient setting.
Structured Clinical Evaluation
All participants were interviewed with the full SCID
and the Clinician-Administered PTSD Scale (CAPS).
16
The CAPS is a structured interview based on DSM–IV
criteria to assess PTSD. Each symptom is scored for Fre-
quency (from 0: Never to 4: Daily or almost every day),
and for Intensity (from 0: None/NA to 4: Extreme). The
CAPS thus yields both a dichotomous diagnosis of PTSD
and a continuous score that reflects the severity of PTSD
symptoms. A symptom is considered “present” if it is
coded with a frequency of at least 1 and a severity of at
least 2, and then the DSM–IV criteria for each cluster of
symptoms are followed (this scoring rubric has been re-
ported to have a kappa reliability score between 0.68 and
0.81).
17
Data were also collected in a semi-structured fash-
ion regarding time since amputation, emotional reactions
at different stages of the amputation experience, whether
behavioral/mental health care had been sought out at any
stage in the amputation experience, and information about
current health complications and medications.
RESULTS
Psychiatric Sequelae
Considering those participants undergoing surgical
amputation secondary to vascular, diabetic, or other health
complications (N23), only one individual met criteria for
current PTSD. This individual had suffered from PTSD in
the past after exposure to combat, and his current PTSD
symptoms were a mixture of amputation-related symptoms
and a reemergence of combat-related symptoms.
In contrast, two of the three individuals who had lost
their limbs in traumatic accidents met criteria for PTSD,
and the third had an elevated score on the CAPS (score:
46) but did not meet threshold criteria for the avoidance
cluster (Criteria C) of PTSD (see Figure 1). Of note, for
these individuals, the content of their PTSD symptoms in-
cluded elements related to the motorcycle accidents them-
selves, in addition to material directly related to the loss of
their limbs.
Three out of the 23 participants undergoing therapeu-
tic amputation met criteria for current MDD. Two of the
five participants meeting criteria for current MDD had a
history of past major depressive episodes. One participant
met criteria for current generalized anxiety disorder
(GAD), which was preexisting at the time of amputation.
One of the three individuals with accidental amputations
met criteria for both current MDD and panic disorder.
These current symptoms appeared to be related to the ac-
cident and amputation experiences, but this individual had
struggled with episodes of anxiety and depression since
adolescence.
Emotional Sequelae
Participants reported a wide variety of emotions upon
hearing that they would need to have a part of their body
surgically removed. Although many participants reported
experiencing feelings of shock, disappointment, and/or
sadness (14/23), many also reported feeling acceptance,
trust in their treating physician, and even relief that the
news had not been worse or that a series of treatments
aimed at keeping the body part would be ceased (10/23).
Several of the participants reported that they accepted the
amputation as something they needed to have done to ben-
efit their health and longevity (8/23). Interestingly, none of
these patients saw the amputation as the beginning of a
long struggle with the complications of their disease. Three
of the participants sought behavioral/mental health care
upon learning of the need for amputation, and four did so
after the amputation (including two of the three who sought
such care pre-operatively).
Sequelae of Surgical Amputation
462 http://psy.psychiatryonline.org Psychosomatics 47:6, November-December 2006
Participants undergoing surgical amputation rated
their feeling of being emotionally prepared at a mean level
of 5.6 (SD: 4.1) on a scale of 1 to 10, with 1 being not at
all prepared and 10 being completely prepared. Retrospec-
tively, participants reported very low overall anxiety levels
a week before, a day before, and even the hour before
surgery, with each of these means below 2.5 on a scale of
1 (no anxiety) to 10 (extreme anxiety). The most common
emotional reaction upon awakening after the surgery was
a feeling of acceptance and even relief (10/23). Other emo-
tions reported were shock (3/23), sadness (2/23), and in
one case, revulsion. Some participants (3/23) mentioned
feeling happy to be alive.
In contrast, the three participants losing their limbs to
an accidental injury all reported feeling shock, sadness, and
disbelief at the realization that they had lost a limb (3/3),
although one also noted that he was grateful to have sur-
vived the accident. Only one of these individuals sought
professional assistance in dealing with the emotional af-
termath of the accident and amputation.
Overall, the participants having undergone surgical
amputation did not view the amputation experience as a
horrifying one. Indeed, several of the participants spoke
about it as a positive event that had realigned their priorities
in life and even made life easier, in the cases where the
limb or toes had been causing pain and discomfort before
amputation. The three individuals with amputations result-
ing from accidental injuries, however, were clearly dev-
astated by their loss of a limb. In addition to the amputation
being coupled with motorcycle accidents that were highly
emotionally traumatic in their own right, these individuals
also had no preparation for their amputation and were
much younger and premorbidly more mobile than the par-
ticipants with surgical/therapeutic amputations. Therefore,
these individuals experienced a double trauma, and the am-
putation was conceptualized as more likely to deleteriously
affect their daily routines and living.
DISCUSSION
The results of both the structured clinical interview based
on DSM–IV criteria and our semi-structured interview re-
garding emotional reactions to the experience of amputa-
tion suggest that surgical/therapeutic amputation secondary
to diabetic, vascular, or other health complications doesnot
typically lead to the development of PTSD. Only 1 of 23
participants (4.3%) having undergone such an amputation
met criteria for current PTSD, and, in that case, it was
unclear whether the PTSD was attributable to the ampu-
tation itself, past combat trauma, or a combination of the
two. Although some participants felt shocked and/or dis-
mayed at news of the amputation, many met the experience
with acceptance and optimism for the future.
The very low rate of PTSD in this study stands in
contrast to the findings of previous studies.
9,12–14
However,
the participants in those previous studies had largely ex-
perienced accidental amputations, whereas our sample was
primarily older individuals undergoing planned surgical/
therapeutic amputations necessitated by complications of
chronic illness. As such, the majority of the individuals in
our sample were prepared weeks or months ahead of time
for the surgery and its consequences. They also were all in
a rehabilitation setting, where the focus is on successfully
managing the transition back into everyday life. The ex-
tremely low rate of PTSD in these individuals is consistent
with models of PTSD suggesting that the more uncon-
trolled and unpredictable the traumatic event, the more
likely it is to lead to the development of the disorder
18
and
research finding that level of perceived control is inversely
related to the development of PTSD symptoms.
19,20
Importantly, the individuals undergoing surgical am-
putation also were unconscious and medicated for the ac-
tual amputation experience. Research on individuals un-
dergoing traumatic injury indicates that those participants
with a memory of the event are significantly more likely
to develop PTSD than those without such a memory
21
and
that psychological reactions such as dissociation and neg-
ative emotional reaction at the time of the trauma are im-
plicated in the development of PTSD.
22,23
Lacking con-
sciousness during the event precludes the formation of a
memory or the experience of these implicated peritrau-
matic reactions. Although individuals undergoing surgical
amputation could develop PTSD after events surrounding
the amputation, such as learning of the need for amputa-
tion, the anxiety of preparing for the surgery, or awakening
after the surgery to confront the loss of the body part, they
would not have actually consciously experienced the event
that would generally be considered most emotionally trau-
matic (i.e., the amputation).
On the other hand, amputations caused by accidental
injury appear to be more commonly associated with the
development of PTSD, although neither quantitative esti-
mates nor firm conclusions about the sequelae of accidental
amputations can be made from the very few participants in
the current study. These cases of PTSD after accidental
injuries could be related to the amputation itself, the acci-
dent leading to the injury, or a combination of the two
factors. It could be that for those losing limbs to physical
Cavanagh et al.
Psychosomatics 47:6, November-December 2006 http://psy.psychiatryonline.org 463
trauma, the pain, disability, and psychological adjustment
required exacerbates existing posttraumatic stress by way
of a constant physical reminder of the trauma and added
complexities of daily living. Another possibility is that the
amputation heightens the perceived threat to life embodied
by the accident and thus contributes to the PTSD symp-
toms.
24,25
This study is limited by several factors. First and fore-
most, the sample size is small. Also, a high proportion of
individuals approached (over 50%) declined participation
in the study. It could be that the very low rate of PTSD
symptoms was due to sampling bias, in that only the most
well patients agreed to participate in the study. Moreover,
28% of our sample was interviewed before the mandatory
duration of 4 weeks of symptoms required for the PTSD
diagnosis. Thus, it could be that some of these individuals
would have gone on to develop PTSD if they had been
interviewed at a later date, although none of the partici-
pants met criteria for acute stress disorder, which is thought
to be a common precursor to PTSD. Furthermore, our data
on emotional responses to amputation were gathered ret-
rospectively and thus were subject to recall bias and error.
Finally, the extent to which our findings from a sample of
individuals in inpatient rehabilitative care are generalizable
to all individuals undergoing amputation is not clear. One
population study found that only 16% of individuals un-
dergoing amputation in Massachusetts were admitted for
such care.
26
Individuals who are not referred to inpatient
care could include those who are more healthy and func-
tional and/or those who are too ill to engage in extensive
physical rehabilitation.
Nevertheless, given our focus on planned, therapeutic,
surgical amputations, we were able to assess whether am-
putation in the absence of a co-occurring emotionally trau-
matic accident is a sufficient trauma to lead to the devel-
opment of PTSD, whereas previous studies had
confounded the posttraumatic effects of the amputation
with those of the event resulting in the amputation. Also,
this appears to be one of the few studies using a full, face-
to-face structured clinical interview based on DSM–IV cri-
teria.
Our study suggests that the rate of PTSD after thera-
peutic amputation in the context of a rehabilitation hospital
is relatively low. If this finding is replicated, it would in-
dicate that if PTSD symptoms emerge in patients under-
going surgical amputation, the treating clinician would be
wise to probe for the presence of previous traumas unre-
lated to the surgery. This is consistent with previous re-
search indicating that the experience of multiple traumas
may be associated with greater posttraumatic symptom-
atology than single traumas.
27,28
Our sparse data on indi-
viduals with accidental amputations, however, suggest that
extensive further study of psychiatric morbidity in this
population is warranted. Clinicians should be cognizant of
the possibility of PTSD in individuals having recently ex-
perienced an accidental amputation. Future research should
evaluate a larger number of participants who have under-
gone both surgical/therapeutic and accidental amputations,
represent a wide variety of ages and backgrounds, and over
a longer period, longitudinally, to delineate the variance in
adaptation to the amputation.
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... Amputation typically stirs up unpleasant emotional experiences (Cavanagh et al., 2006;Wain et al., 2004). The findings of this present study has revealed that, these unpleasant emotional experiences are common to both amputees (Liu et al., 2010;Queiroz et al., 2016) and their caregivers (Ae-Ngibise et al., 2015;Volker, 2015). ...
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Amputation is necessitated following an accident or a medical condition often to save a patient’s life. Despite the existence of the procedure and the rising number of amputees in the Ghanaian context, the emotional experiences of both amputees and their caregivers following amputation have been largely ignored. This qualitative exploratory study explored the emotional experiences of amputees and their caregivers following amputation. Using a semi-structured interview guide, ten (10) amputees and ten (10) caregivers were interviewed. Findings revealed that caregivers and amputees experienced a built-up of negative emotions following amputation. There were slight disparities in the negative emotions experienced by amputees and their caregivers. However, for both amputees and their caregiver, the experience of gratitude and news breaking method influenced their emotional experiences. Implications of the findings are discussed.
... Amputation typically stirs up unpleasant emotional experiences (Cavanagh et al., 2006;Wain et al., 2004). The findings of this present study has revealed that, these unpleasant emotional experiences are common to both amputees (Liu et al., 2010;Queiroz et al., 2016) and their caregivers (Ae-Ngibise et al., 2015;Volker, 2015). ...
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Full-text available
Amputation is necessitated following an accident or a medical condition often to save a patient’s life. Despite the existence of the procedure and the rising number of amputees in the Ghanaian context, the emotional experiences of both amputees and their caregivers following amputation have been largely ignored. This qualitative exploratory study explored the emotional experiences of amputees and their caregivers following amputation. Using a semi-structured interview guide, ten (10) amputees and ten (10) caregivers were interviewed. Findings revealed that caregivers and amputees experienced a built up of negative emotions following amputation. There were slight disparities in the negative emotions experienced by amputees and their caregivers. However, for both amputees and their caregiver, the experience of gratitude and news breaking method influenced their emotional experiences. Implications of the findings are discussed.
... [3][4][5] Patients may also grieve, feel depressed, and anxious 3,6,4,7 or have posttraumatic stress disorder symptoms. 8,9 They may be apprehensive about their future plans and inconclusive regarding life challenges. Grief is one of the most common reactions to amputation, 10,1,7 but often gets neglected in intensive surgical units. 1 Many times, grief reactions are not resolved, turning into complicated grief or prolonged grief, leading to conditions like depression, anxiety, or even suicide. ...
Article
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Amputation is the surgical removal of all or part of a body part. It demands an adjustment in almost every sphere of a person’s life in addition to physical disability. An amputee faces problems in almost every psychosocial sphere.1, 2 Along with physical pain in the stump, patients may experience phantom sensations.3–5 Patients may also grieve, feel depressed, and anxious3, 6, 4, 7 or have posttraumatic stress disorder symptoms.8, 9 They may be apprehensive about their future plans and inconclusive regarding life challenges. Grief is one of the most common reactions to amputation,10, 1, 7 but often gets neglected in intensive surgical units.1 Many times, grief reactions are not resolved, turning into complicated grief or prolonged grief, leading to conditions like depression, anxiety, or even suicide. This article is about an attempt to help a patient initiate the grieving process for healthy outcomes.
... According to a study done by Vázquez et al. (2018), depression prevalence among amputees in Mexico was reported to be as high as 92.5% which is comparable to what has been found in this study though the sample size was smaller compared to this study by 40. Amputees may present depressive symptoms (Cavanagh et al.,2006;Phelps et al., 2008). Moreover, it has been shown that the presence of depressive symptoms may be linked to an array of debilitating outcomes like increased pain intensity, restriction of activity, self-consciousness, body image associated anxiety, and a significantly reduced quality of life (Asano et al., 2008;Hanley et al., 2004). ...
... Thus, a poor score among traumatic amputees may be due to the result of a poor adaptation to self-image after trauma. In contrast, post-traumatic stress disorder (PTSD) is relatively rare (<5%) among amputees whose surgery follows a chronic illness [18]. ...
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Introduction Amputation of a limb is a loss of physical integrity that has disastrous consequences for a person's mental, physical, and social well-being. Aim We aim to analyze the quality of life (QoL) after major amputations and long-term outcomes. Method and materials A prospective, observational study has been conducted in a health care institute in western Rajasthan from January 2019 to July 2020. This study included 64 patients who had major upper or lower limb amputations. We analyzed the sociodemographic factors of the patients, the type of procedure, postoperative hospital stay, complications, and follow-up status with both the SF-12 and the World Health Organization Quality of Life (WHOQOL)-BREF questionnaires. Mean, median, range, standard deviation, percentages, univariable, and multivariable logistic regression were analyzed with SPSS version 23.0 software (IBM Corp., Armonk, NY). Results The mean age of the study patients was 53.6 years (SD 2.6) and they were mostly male (71.9%). Atherosclerotic peripheral vascular disease (PVD) was the most common indication (37.5%) of amputation, and below-the-knee amputation (46.88%) was the most commonly performed procedure. There was a significant increment in both PCS (p-value= 0.001), MCS scores (p-value=0.0001) of SF-12 and physical (p-value=0.0001) and psychological domains (p-value=0.001) of the WHOQOL-BREF questionnaire in the postoperative period. A total of 83.9% of patients have used prostheses, and 15.6% had mortality. Conclusions Major amputations can significantly affect the quality of life of patients, and all efforts should be made to avoid factors that adversely affect their quality of life.
... An example item is "I'm concerned about getting sick with COVID-19". Psychological distress is quantified by the five-item scale which was developed by Cavanagh et al. [69], also used in previous literature [14]. Psychological well-being is measured by the five-item scale of the World Health Organization. ...
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Introduction : Phantom limb syndrome is a debilitating complication after extremity amputation that poses significant challenges to recovery. This study aims to examine the relationship between phantom limb syndrome and mental and physical comorbidities, including a comparison between phantom limb pain and phantom limb syndrome without pain in below knee amputees. Methods : This is a retrospective cohort study of patients who underwent below knee amputation of the lower extremity in the PearlDiver database, as identified using CPT codes. Analysis was carried out to evaluate the absence or presence of phantom limb syndrome. Matched bivariate analysis accounting for age, sex, Charlson Comorbidity Index score, and region was used to assess whether the presence of pain in phantom limb syndrome patients was associated with increased comorbidity. Results : In total, 44,028 patients with below knee amputation were examined: 95% (42,493 patients) did not develop phantom limb syndrome while 4.8% (1,535 patients) of patients did develop phantom limb syndrome. Phantom limb syndrome was significantly associated with increased odds of coexistent major depressive disorder (OR = 1.86, p <0.0001), generalized anxiety disorder (OR = 2.14, p = 0.04), posttraumatic stress disorder (OR = 1.7, p <0.0001), suicidal ideation (OR = 1.62, p <0.0001), obesity (OR = 1.28, p = 0.0007), osteoarthritis (OR = 1.53, p <0.0001), osteoporosis (OR = 1.64, p <0.0001), and low back pain (OR = 2.31, p <0.0001). Analysis of patient cohorts of phantom limb syndrome with pain and those without pain did not reveal a statistically significant relationship between the presence of pain and any dependent variable. Conclusions : This investigation of over 44,000 patients with below knee amputation revealed that patients with phantom limb syndrome exhibit significantly higher rate of psychiatric comorbidities compared to those without documented phantom limb pain. Suicidal ideation, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder were especially common, and consequently a multi-disciplinary approach to management is essential.
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Amputation affects the patient physically, psychologically, socially, economically, and spiritually. The highest number of prevalent traumatic amputations was in East Asia and South Asia followed by Western Europe, North Africa, and the Middle East, high-income North America and Eastern Europe. Similarly in Nigeria, amputation has devastating effects on individuals, and on the economy. A number of researchers have invested time and energy in reducing the challenges but it appear that the number of depression and other effects are increasing daily. Therefore, the research aimed at assessing the psychological well-being, social support and coping strategies of patients with amputation. The study adopted a quantitative descriptive cross-sectional designed to investigate the psychological well-being of amputees. Total enumeration was adopted for the research. A validated questionnaire was used with a Cronbach’s alpha internal consistency ranging from 0.81 to 0.81. Data were collected and analyzed using IBM SPSS version 23 to generate summaries of descriptive statistics and inferential statistics. Results showed that the age ranged of the participants were from 25-34 years. The characterization of the degree of Psychological well-being of patients shows that majority of the respondents are of high level of disappointment, discouragement, dissatisfaction and despondent about their present conditions and life. Similarly, the first regression result indicate that there is a significant relationship between the psychological well-being and coping strategies which affects the duration of the amputees attending the clinics with [R2 = .721, R2 adj = .558, F(27, 46) = 4.411, p < .001], therefore this hypothesis was accepted. Also, the second hypothesis indicated that there is a significantly relationship among the psychological well-being, social support and coping strategies of amputees attending clinic with [R2 = .909, R2 adj = .805, F(39, 34) = 8.748, p < .001]. Therefore, this hypothesis was accepted. The study concluded that complexity of psychological well-being, social and coping strategies in the lives of human being and their inter relationships were well exposed and their relationships were evaluated. Future research should be conducted on a larger sample, using a mixed-method approach to uncover a large diversity of coping efforts used, by individuals who had a lower limb amputation.
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The use of structured interviews that yield continuous measures of symptom severity has become increasingly widespread in the assessment of posttraumatic stress disorder (PTSD). To date, however, few scoring rules have been developed for converting continuous severity scores into dichotomous PTSD diagnoses. In this article, we describe and evaluate 9 such rules for the Clinician-Administered PTSD Scale (CAPS). Overall, these rules demonstrated good to excellent reliability and good correspondence with a PTSD diagnosis based on the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III—R ; American Psychiatric Association, 1987). However, the rules yielded widely varying prevalence estimates in 2 samples of male Vietnam veterans. Also, the use of DSM-III—R versus DSM-IV criteria had negligible impact on PTSD diagnostic status. The selection of CAPS scoring rules for different assessment tasks is discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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A review of 2,647 studies of posttraumatic stress disorder (PTSD) yielded 476 potential candidates for a meta-analysis of predictors of PTSD or of its symptoms. From these, 68 studies met criteria for inclusion in a meta-analysis of 7 predictors: (a) prior trauma, (b) prior psychological adjustment, (c) family history of psychopathology, (d) perceived life threat during the trauma, (e) posttrauma social support, (f) peritraumatic emotional responses, and (g) peritraumatic dissociation. All yielded significant effect sizes, with family history, prior trauma, and prior adjustment the smallest (weighted r = .17) and peritraumatic dissociation the largest (weighted r = .35). The results suggest that peritraumatic psychological processes, not prior characteristics, are the strongest predictors of PTSD.
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Objective: To examine the role of feelings of vulnerability in postamputation adjustment problems such as depression and diminished quality of life. Participants: Eighty-four patients with a lower extremity amputation. Setting: Five affiliated prosthetic clinics in Chicago. Main Measures: The Center for Epidemiologic Studies Depression Scale (CES-D), a 3-item quality-of-life measure, and a 2-item vulnerability measure. Participants' prosthetists completed a single-item rating of perceived adjustment. Results: Vulnerability accounted for significant portions of the variance in CES-D scores, quality-of-life ratings, and prosthetists' adjustment ratings. Conclusion: Feelings of vulnerability significantly affect adjustment in persons with amputations, and this impact is not limited to a single domain. Clinicians should assess feelings of vulnerability, the degree to which such feelings are realistic, and any past experiences with victimization. These issues need to be addressed with both individual counseling and community interventions aimed at reducing victimization of individuals with disabilities. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Examined whether body image (BI) and perceived social stigma (PSS) are important predictors of psychosocial adjustment (PA) to leg amputation, in 112 clients (aged 21–83 yrs) from 5 prosthetic clinics. Two scales were developed to measure BI disturbances and PSS resulting from amputation. The Center for Epidemiological Studies Depression Scale, a quality of life scale, and prosthesist ratings, were used to measure PA. BI was an independent predictor of all 3 adjustment measures after controlling for effects of age at the time and site of amputation, time since amputation, self-rated health, and perceived social support. PSS made a significant contribution to depression, but was not an independent predictor for the other 2 measures of adjustment. The overall rate of depression was 28%, indicating that this is both a short-, and a long-term adjustment problem following amputation. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The case-control method, a retrospective design useful in studying the etiology of rare diseases, was utilized to examine the relative risk of posttraumatic stress disorder (PTSD) among individuals with six types of traumatic physical impairments. Odds ratios and associated confidence intervals were calculated for each impairment in a group of 45,320 veterans receiving medical services. Four of the six impairments were found to be risk factors for PTSD. Implications for rehabilitation counseling and research are discussed.
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This study has two aims: (1) to examine the associations between battlefield functioning and perceived self efficacy (PSE) and attributional style; (2) to examine the unique and cumulative contributions of bat-tlefield functioning, PSE, and attributional style to long term PTSD. The subjects were three groups of Israeli veterans of the 1973 Yom Kippur, who differed in their battlefield functioning: 112 combat stress reaction (CSR) casualties, 98 veterans who received medals for bravery, and 189 controls. The subjects filled out a series of questionnaires that assessed PTSD, PCE, attributional style and PTSD, two decades after the war. CSR casualties exhibited the lowest level of PSE, decorated veterans the highest. The three groups also differed in locus of control, with different attribution for failure. Discriminant analysis of PTSD and non-PTSD veterans showed that sociodemographic background, battlefield performance, PSE and attributional style classified 81% of all veterans correctly. The implications of these findings are dis-cussed. #
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Examines a conceptual model that hypothesized that the restriction of normal activities would play a pivotal role in the association between antecedent variables and symptoms of depression. A study of 160 amputees (aged 32–90 yrs) assessed impact of amputation on Ss' lives and emotions. Consistent with the model, greater activity restriction and less satisfaction with social contacts were closely related to more symptoms of depression, and the effects of prosthesis use and household income adequacy on depressed affect were mediated by activity restriction. Amputees who used a prosthesis less and those whose incomes were not adequate to meet their needs reported more restriction of routine activities as a result of their amputation, predicting greater depressive symptomatology. Perceptions of primary and secondary control are discussed as potential mechanisms underlying the association between activity restriction and emotional distress. (PsycINFO Database Record (c) 2012 APA, all rights reserved)