Introduction
Traumatic amputation refers to a non-surgical severance of a limb or part of a limb from the trunk of the body. By and large, an amputation can be categorised as either being incomplete, or complete. In complete amputation, the severed ligament is totally detached from the muscle, tissue, or tendons (Medical Disability Advisor 2004). Conversely, partial traumatic amputation involves leaving a single or several connections with the severed part.
Surgical amputation encompasses a planned process to remove a whole or section of limb due to vascular insufficiency, injury, burns, or malignant tumour. On the contrary, traumatic amputation is the accidental severing of a limb resulting from accident involving a car, motor cycles, heavy machinery, workplace equipment, or explosion (Medical Disability Advisor 2004).
This paper is an explanatory essay which explores the psychosocial perspective of a traumatic amputation. The various psychosocial factors associated with this concept will be extensively explained. These factors systematically include; body image, body image evaluation, ill health and amputation, the phantom phenomenon, pain, stress and immunological alteration, depression and disability, health improvement and social adjustment, and the stages of loss.
Body Image
Body image refers to the mental vision a person develops of physical self. Based on Kolb (Kolb, 1959, p. 749-69, in Breakey, 1997, par. 7), any changes in a person’s body image may trigger a string of emotional, psychosocial, and cognitive responses (Kolb, 1974, p. 810-37). Particularly, Kolb supposes that loss of a limb via amputation may result in perpetual imbalance in body experience (Kolb, 1974, p. 810-37).
The perceived incongruity between the initial between the initial physical state and the transformed physical state due to say mutilating injury induces emotional stress that may present in the form of psychotic disorders such as anxiety. This disorder normally becomes chronic and provided the incongruity persists (Henker, 1979, 812- 20).
Various researches have opened up a better perception of ill-being especially unpleasant emotions, depression and anxiety. Study has been performed on the basis of subjective well-being (Diener, 1984, p. 542-75; Diener & Emmons 1984 p. 405-15). This study led to the establishment of two general aspect of subjective well-being which comprise two components, namely; an affective component which is made up of pleasant and unpleasant affect (Diener, 1984, p. 105-7); while the other is the cognitive component (Andrew, 1976, in Breakey, 1997, par. 9) that signifies life satisfaction.
In a study conducted by Cash and colleagues (1986, p. 30-7), several elements were identified as constituting psychosocial well-being. The participants with pessimistic attitudes portrayed undesirable level of psychosocial adaptation.
Similarly, in this circumstance, the patient’s psychosocial adjustment to her situation will depend on her self esteem, sense of social acceptance, loneliness, depression, and life satisfaction. The nurse providing the care to the patient should work towards captivating her to develop positive perception about the body image.
According to Bolton, Lobben, and Stern (2010), the body image concept entails perception, beliefs, and behaviours associated with a person’s appearance. Contextually, the female patient will be dominated by the prospect of having to endure the challenges of disability. Obviously she is contemplating the reactions of her peers in the corporate world.
When a patient’s body image or world view negatively affects the provision of medical care services, primary care practitioners including the nurses ought to focus their concerns on those views and adjust health care plans considerably (Bolton, Lobben). The patient’s expression of discomfort during rounds should be reacted to by empathy and encouragement, to help her accept the fact and psychologically come to terms with the amputation.
Nevertheless, body image is distinct from “quality of life” or “self-esteem” since the latter two entails not only a person’s religious beliefs, culture, values, career and relationship besides, but also appearance. Body image often determines a person’s self esteem and quality of life, although, alteration in body image do not always translate to alteration in quality of life and self esteem, and the converse is true (Bolton, Pruzinsky & Cash 2003, p. 626-627).
Normally, body image is developed prior to age 6, such that when children attain this age, they are conscious of their own look and the societal bias against persons with certain body shapes (Smolak & Levine 2001, p. 41- ).
Besides biological growth process, outside elements such as trauma, life experiences, relationship, cultural principles, and influence of the media, determines an individual’s body image (Bolton, Lobben, Stern, 2010). In this context the patient’s body image will be affected by the anticipated behaviours of her peers after amputation.
Body image evaluation
Basically, inquiring about a person’s views about the world, such as optimistic, pessimistic, unappealing, insecure, confident, or attractive; serves to initiate conversation between the practitioner and the patient concerning body image. Various quantifiable measures have been developed to facilitate the evaluation of body image in adults, adolescent and children. Every age bracket uses distinct measure consistent with its unique developmental challenges (Bolton, Lobben, Stern, 2010).
Analysis of the person’s attitude must be distinguished with discontent with appearance. Noteworthy, dissatisfaction with various body parts reflects the person’s values, such as the degree of dissatisfaction or satisfaction which exist. In a medical setting, a patient’s concern, cognition, and characteristics are usually oversimplified, although sometimes a comprehensive examination of the body image is necessary (Bolton, Lobben, Stern, 2010).
Moreover, certain concerns and processes including fashion, sexual activity, and peer pressure apply more strongly in adolescent and adults than in children. When social relation or observances with care are far below the optimal level, evaluation of the patient’s body image may promote doctor-patients communication as well as patient’s characteristics. Body image assessment demands that the expression satisfaction be subdivided into satisfaction, such as with particular body parts, with weight and shape; or be subdivided based on severity such as of the body image disorder (Bolton, Lobben & Stern, 2010).
A patient’s reaction to illness can be determined by factors such as the way she or he appears, act, and believe. Alteration of physical impression, body dignity, and function are basically essential to the experience of sickness and to the health care. Nevertheless, the prevalence of body image dissatisfaction has increased since the early 1970s (Bolton, Lobben & Stern, 2010).
Ill health and amputation
It is medically accepted that amputation due to ill health is the definitive consequence of inadequate blood supply to the concerned limb. Although diabetes stands out as the major cause of vascular insufficiency leading to limb amputation, injury of the limb resulting from fatal car accident may result in amputation of the involved limb (Medical Disability Advisor 2004). The vascular distortion associated with fatal limb injury is similar to those of diabetic limb, which ranks the leading cause for limb amputation. Such distortion presents in the form of neuropathic ulcers, gangrene, microcirculatory disorders, and Charcot arthropathy. The wounds on the limb cannot heal, while charcoal arthropathy denotes the breakdown of the skeletal framework of the limb.
The phantom phenomenon
Once medical assessment has established that the injury has reached the point which necessitates amputation of the respective limb, it is logical to speculate that the patient concerned will be faced with very critical and intricate issues to address. The pain associated with the injury has been relieved, and the psychological repercussions of the injury have developed into the psychological repercussion of both the body image and injury (Breaker 1997).
As Melzack and Wall (1998) have noted, phantom limb pain ranks the leading most severe and captivating medical pain syndrome. They assert that, although the event of phantom limb is seldom represented as painful, the feeling of the absent limb being intact even after amputation is very common.
Most of the amputees present with phantom limb feeling shortly following surgery. Phantom feeling has been described as tingling sensation wherein the real size of the limb is perceived. After sometime the size of the phantom limb begins to recede back into the trunk and eventual it appears to be attached exactly to the stub.
Pain, stress and immunological modification
Significant to the accident casualty are the implications of stress and pain on the immune system. Various researches have established that the effect of stress on the immune system is profound. Individual pattern of cognitive behavioural and affective responses have profound effect on the patient’s response to physiological implications and stress (Kemeny & Laudenslager, 1999).
Pain and stress are reciprocated in the sense that pain can induce stress which in turn produces immunological effects. Chronic stress, on the other hand, can predispose the patient to chronic pain (Williamson 1995). In this context the care provider(s) is encouraged to discuss stress alleviation processes and provide materials for stress treatment to the patient. In addition, provider should discuss with the patient the prospective consequences of stress in relation to pain and phantom pain and the converse.
Depression and disability
Depression is “a state of low mental vitality” or simply “dejection.” Depression can manifest through the following characteristics:
- Depressed frame of mind almost the entire day nearly on a daily basis.
- Noticeably diminished interest or delight in all or majority of routine activities.
- Remarkable weight loss or gain.
- Insomnia or hyper-insomnia more or less on daily basis.
- Psychomotor retardation or agitation almost on daily basis.
- Fatigue almost on daily basis.
- Sense of worthlessness or extreme or incorrect of guilt.
- Recurrent ideas of death, suicidal inclination, or a suicide attempt.
Individuals who have already been diagnosed with depression have a higher likelihood of presenting with depression in the various lifecycle stages of life (Gallagher & MacLachlan1999). In addition, this mental disturbance may present prior to, in the course of or immediately following a major life occurrence. Inception of disability is an outstanding example of a major life occurrence that triggers the mental disorder. It widely accepted that physical impediment may be caused by trauma or from serious disease.
When the care provider for the mention patient is knowledgeable, he or she will be in a position to understand the state of the patient and take the necessary steps to try and alleviate the problem.
According to Ormel et al (1997), the characteristics of the physical condition does not influence the psychological disturbance; instead it is determined the ruthlessness of the disability, coupled with the psychological resources and the personality characteristics of the victim. Depression is the most common psychological distress that arises following a disability event (Landreville & Gercais 1997).
Studies by Langer (1994), found that Studies found that amputees expressed a remarkable indecisiveness, ideas of death, as well as thoughts of self destruction. Additional study by Rybarczk, Szmanski, and Nicholas (2000), discuss on the importance of the amputees to accept their loss of limb and the subsequent functional limitations.
Furthermore, restriction of function is associated with the public self-awareness and psychological disturbance (Williamson 1995). Research performed by Williamson in 1995, established that the amputees who expressed limited levels of performance were unwilling to interact with the public due to their sense of self, coupled with the feeling of vulnerability and the inability to defend themselves. Awareness of social stigma has been shown to play an important role in effecting depression (Rybarczyk, Nyenhuis, Nicholas, & Cash 1995).
Perception alteration following amputation has been found to be a prospective cause of emotional despair (Kübler-Ross 1969). Research by Rybarczyk (1995) unearths the psychophysiological effects of amputation by showing that phantom sensation can be induced by stimulating domains adjacent to amputation domains and by triggering certain facial domains. Substantial evidence from study conducted by Melzak and Wall (1988), indicate phantom limb pain involvement in some depressive disturbances, particularly when it is induced by unrelated body processes. Some of the most notable implications of an amputation include sense of loss, disfigurement, loss of self-confidence, changes in self-esteem, guilt, loss of stability, awareness of mortality, and phantom limb sensation (McGarry 1993).
Health improvement and social adjustment
Social psychological concerns are associated with matters pertaining to amputee rehabilitation since adjustment, adaptation, and response to such matters are determined by the social conduct, judgment, and perception of the perceiver. The incident of disability from the victim’s perspective may depend on his or her personality characteristics (Dunn 1996).
Personality characteristics generally play a great role in the amputee’s adaptability to various circumstances. Adaptability strategy has been proven to facilitate adjustment to prosthetic use (Gallagher & MacLachlan 1999). For the class of those whose personality are inclined away from the self-healing class, focus should be placed by the care provider to initiative that support positive techniques of addressing stress and the overall adjustment to adverse circumstances. A consistent positive lifestyle including; i) rich diet, ii) sufficient sleep, and iii) regular exercise.
For the category of amputees who are faced with the problem of circumventing the injurious psychological consequences of a disabling event often find themselves in the pivotal position necessitating lifestyle modification. Various researches have proven that exercise, particularly the intensity of exercise is an indicator of self-efficacy which in turn reflects positive lifestyle characteristics (Ryff 1998).
It has been noted that acute bouts of exercise induce self-efficacy improvement, and subsequent sense of well-being; and decreased psychological trauma and perception of fatigue (Longino & Mittelmark 1998). The importance of understanding the efficacy alteration was emphasized by Longino and Mittelmark in their study of participants in an exercise program. It was established that self-determination played a significant role in behaviour adjustment characterization, so that motivational concern is very critical in the process of adjustment. Noteworthy, appropriate instruction and education immediately after the onset of disability will likely enhance self-efficacy and subsequent success of the rehabilitation initiative via problem-centred adjustment.
Ryff et al (1998) argues that the manifestation of resilience is attributed to the ultimate consequence of mind-body integration independent of the various socio-demographic factors. Mind-body integration signifies the positive mental initiatives such as resisting depression, anxiety and physical illness under adverse circumstances. In addition, it involves positive physical interventions such as rich diet, extensive exercise, adequate sleep, and aerobic capacities. Optimistic self-evaluation regardless of objective decline is significant in sustaining the perception of well-being (Borchelt, Gilberg, Horgas, & Geiselmann, 1999).
Social networks and friendships have been established to be a critical factor of a person support structure (Cavenaugh 1998). Lack of support prior to amputation is consistent with the consequential phantom limb pain following amputation (Gallagher & MacLachlan 1998). Further, studies by Gallager and MacLachlan reinforced the significance of support to adjustment process. Communication and interaction with fellow amputees is a major significant experience for a fresh amputee. On the other hand, the awareness of little support has been proven to correspond with depressive disorder and decline in quality of life in victims of physical impairment. Landreville and Gervais (1997) have observed that social resources along with socio-demographic dimensions assume the role of enjoining the social settings that impact on the health status of a victim. This implicates the role of friends, siblings, and relevant others in improving physical health through reduction of the predisposition to stress and anxiety due to discrimination. In fact it has been shown by (Antonucci and Akiyama 1997), that elevated social association reduces mortality rates amongst the amputees.
According to Antonucci and Akiyama (1997), the most important support afforded to amputees that would help improve their perception of self and their surrounding world are; i) confiding, ii) discussion of the problems and health issues., iii) provision of care, iv) respect towards the amputee, and v) reassurance.
Inclusive amputee programs provide an indispensable service to new patients, and triggers a perception of purpose, which is a major component for satisfying their expectations. Engagement helps individuals to overcome feelings of disenfranchise by restructuring their lives and sustaining a sense of place and identity. Patients who do not participate in the network are likely to present reduced communicative effort and increased distress (Andrews & Withey 1976).
The stages of loss (Kubler-Ross 1969)
The process of grieving cannot be predetermined since it a personal experience. To begin with I will look at denial. Based on Elisabeth Kubler in denial phase an individual refuse to come to terms with what actually happened, the loss. Also the person can resort to make believes to some level by restaging things they used to do with the loved one. In this context, however in this context the person may try to reminisce on the things that he or she used to do with the limb.
Denial refers to a conscious or subconscious rejection of reality, facts, and information relevant to the respective event. Kubler supports that this is a defense mechanism which is typically a natural response. Certain individuals can become confined in this phase when confronting a traumatic transformation which could be overlooked.
Second stage of grief is the anger emotion which can express in various ways. Persons undergoing emotional disturbances can direct their anger to their selves, and/or other persons, particularly those they closely relate with (Cash et al 1986).. Appreciating this fact helps someone to understand the anger of someone who is emotionally upset when it is directed towards them.
The third stage of grief is bargaining. This can be clearly be depicted by expressions like “can we still be friends?” when a break up is imminent. However, bargaining seldom offers a long-lasting resolution particularly in case pertaining to issues of life and death.
The fourth stage of grief involves depression. Depression can literally be described as preparatory grieving. In other words depression can be termed as the dress rehearsal. However this phase of grief may take different meaning depending on the person who is affected. It is a stage which denotes emotional response to acceptance of the loss. This emotional attachment may express as sadness coupled with regrets, fear, uncertainty and many emotions depending on the person concerned. The last stage of grief concerns the acceptance of the loss (Body Image, Eating Disorders, and Obesity in Youth para. 4). This phase also differs depending on the person’s circumstances. However, generally it implies that the person undergoing some emotional detachment and impartiality. This phase is often a characteristic of persons facing imminent death who may succumb to this phase relatively earlier than the persons they leave behind.
Conclusion
The grieving process usually takes time and it ought not to be quickened. The duration of the grieving process is varied and depends on the individual and the circumstances. Nevertheless it takes majority of persons between a year and two to fully recover from a loss.
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