INTRODUCTION:
Amputation is defined as the removal of extremities of body part by trauma or by
Surgical procedure. Amputees may feel empty, and mutilated. Amputation due to
Trauma is a catastrophic injury and causes major disability in most of the cases
(Wald 2004)1. Loss of limb is associated with low self-esteem, body image
Disturbance, social isolation and also a sense of stigmatization (William et al.
2004). In many conditions amputation is unavoidable. Irrespective of the aetiology,
Amputation is considered as a mutilating surgery and it definitely affects the lives
Of the patients (De Godoy et al. 2002). Limb amputation is a more commonly
Occurring event in the present society.
The loss of a limb distorts the individual’s body image leading to the thought of
Not being a complete human being. The loss of the functions performed with that
Limb renders him helpless for sometime. The amputee not only loses physical
Functioning, he also loses hope and future aspirations, his plans and ambitions get
Shattered. Thus, he loses not only a limb but also a part of his world and future.
Most of them remain anxious and worried about their interpersonal relationship in
The social, vocational, familial and marital milieu. Individuals having an overt
Mental breakdown will need active psychiatric intervention whereas careful
Psychiatric interview is necessary for the ones whose mental symptoms are not so
Obvious.
Limb loss is a major event that can severely impact the psychological health of the
Individual concerned. Studies show that 20-60% of the amputees attending follow
Up clinics are assessed to be clinically depressed. Individuals with traumatic
Amputation irrespective of the age are likely to suffer from body image problems,
But these findings are more common in younger individuals. The psychological
Reactions to amputation are clearly diverse ranging from severe disability at one
Extreme; and a determination to effectively resume a full and active life at other
End. In adults the age at which an individual receives the amputation is an
Important factor. Studies by Bradway JK et al (1984)2, Kohl SJ Et al (1984)3,
Livneh H (1999)4, on the psycho-social adaptation to amputation has led to a
Plethora of clinical and empirical findings. Kingdon D et al 1982 equated
Amputation with loss of one’s perception of wholeness, while (Parkes CM 1976)5
With loss of spouse and (Block WE et al (1963)6 with symbolic castration & even
Death. The individual’s response to a traumatic event is influenced by personality
Traits, pre-morbid psychological state, gender, peri-traumatic dissociation,
Prolonged disability of traumatic events, lack of social support and inadequate
Coping strategies. Previous studies on amputation mainly focused on demographic
Profile, coping skills and outcome; with there being a scarcity of literature on
Prevalence of various specific psychiatric disorders in the post-amputation period.
Most patients with a limb loss irrespective of whether due to traumatic injury or
Surgical procedures go through a series of complex psychological reactions
Reported by Cansever et al (2003)8. Most people try to cope with it, those who
Don’t succeed develop psychiatric symptoms Frank et al (1984)7. Shukla et
Al9 noted that psychological intervention in some form is needed in about 50% of
All amputees, and Shukla et al9 reported depression to be the most common
Psychological reaction following amputation.
The three major problems faced by many amputees are anxiety, depression and
Physical disability (Green 2007)
Horgan & maclachlan (2004)10 found that anxiety is associated with depression,
Low self esteem, poorer quality of life and higher level of general anxiety. Both
Anxiety and depression are associated with higher disability as age increases.
Body image is the combination of psychosocial adjustment and attitude of the
Individual that are related to the function and appearance of one’s own body which
Can be influenced by the individual and his environmental factors (Horgan &
Maclachlan 2004)10. Each person has an idealized body image, which he uses for
Measuring perceptions and concepts of his or her own body (Fishman, 1959)11.
From another perspective, Flannery & Faria (1999) body image is viewed as a
Dynamic, changing phenomenon occurring in a person and it is formed by the
Constantly changing perceptions about his body. According to Newell (1991)13,
Attractive people after amputation will receive less reinforcement from others
Leading to low self-esteem and reduced positive self-image. Jacobsen et al (1997)
Supports this stating i.e. Amputation leads to disfigurement which in turn leads to a
Negative body image and greater loss of social acceptance. The relationship
Between disability experience and stigma are interwoven and inter-dependent. The
Reason for the amputee’s subjective perception of being unfit for the society
Probably is that body image provides a sense of ‘’self’ ’and also affects the
Persons thinking (Wald 2004)1. According to Kolb (1975)14, changes in body
Image may cause series of psychological reactions.
The psychiatric aspect of amputation has received scant interest in our country, in
Spite of accidental injuries being common (Shukla et al., 1982)9. The commonest
Psychiatric disorder seen in amputees is major depression. Randall et al. (1945)15
Have reported an incidence of 61 % in non-battle casualties, while Shukla et al.
(1982)9 found depressive neurosis (40%) and psychiatric depression (22%) to be
The leading psychiatric disorders in amputees; only 35% of the total sample in the
Later study had nil psychiatric disorders. The paucity of literature in this field has
Prompted us to study about amputation and its co morbid psychiatric conditions so
That proper care & management for the patients can be planned. The present study
Was undertaken with the aim of studying the psychiatric problems especially
Anxiety, depression and Body Dysmorphic Disorder which may be associated with
Disability or changed life circumstances in the immediate post-amputation period.
A comparison was made with Stroke patients, as these patients often experience
Physical and social handicaps similar to amputees.
Depression is the most common mood disorder to follow stroke (Starkstein &
Robinson, 1989), with major depression affecting around one quarter to one third
Of patients (Hackett16)..
Depression hampers functional recovery in a post stroke individual. In Diagnostic
And statistical manual (DSM) IV Post Stroke Depression classified under “mood
Disorder due to general medical condition (i.e. Stroke)” with the specific depressive
Features, major depressive-like episodes, manic features or mixed features. Studies
Describe that cerebral ischemia is associated with two types of depressive disorder.
Incidence of major and minor depression is 25% and 30% respectively. Prevalence
May vary over time with an apparent peak 3months after the stroke and
Subsequently decline in prevalence at 1 year. Robinson and colleagues studies
Showed a spontaneous remission in the natural course of major depression
Occurring post stroke in the first to second year following stroke. However in few
Cases depression may become chronic and persist for a longer period.
While some propose that post stroke depression is due to stroke affecting the
Neural circuits concerned with mood regulation (thereby supporting a primary
Biological mechanism), others in the scientific community claim it to be due to the
Ensuing psycho-social stressors occurring as a result of stroke. Though an
Integrated bio- psycho- social model is warranted, most studies clearly suggest
Biological mechanism to have an upper hand in the later post stroke period than in
The immediate phase.
In the same way Anxiety is also common in post stroke individuals with the
Incidence rate being 20%, and it is most common in first three to four months after
The stroke.
Studies and literatures on post stroke anxiety are very few still remain in its
Infancy. Studies have concentrated on socio-demographic variables, cognitive
Functions and laterality as examined for post stroke depression. Many studies show
That there is correlation between anxiety and right hemisphere lesions and also that
Co-morbid post stroke anxiety and depression are associated with left hemisphere
Lesions [Astrom, (1996)17]. Many studies have shown the relationship between post
Stroke anxiety, age and gender. Women and younger individuals are more
Vulnerable to develop post stroke anxiety (Morrison, walter et al 200069), while
Another study reports no such relationship (Schultz et al).1
