Original article
Coping, affective distress, and psychosocial adjustment among people with traumatic upper limb amputations

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Abstract

Objective

This study investigated the prevalence of symptoms of depression and anxiety in a sample of predominantly elderly males with acquired upper limb amputations (n=138) and examined the contribution of coping strategies to the prediction of psychosocial adjustment.

Method

One hundred and thirty-eight men with injury-related upper limb amputations completed self-report questionnaires assessing coping strategies, symptoms of anxiety and depression, and psychosocial adaptation to prosthesis use.

Results

Prevalence of significant depressive symptoms was 28.3% [Hospital Anxiety and Depression Scale, Depression subscale (HADS-D) score ≥8]. Prevalence of significant anxiety symptoms was 35.5% [HADS Anxiety subscale (HADS-A) score ≥8]. Coping styles emerged as important predictors of psychosocial adaptation. In particular, avoidance was strongly associated with psychological distress and poor adjustment.

Conclusions

These findings suggest the potential benefits of interventions to reduce reliance on avoidant coping and stimulate more problem-focused approaches to coping with difficulties and challenges in order to facilitate adaptation and prevent problems in psychosocial functioning postamputation.

Introduction

Amputation of an upper limb engenders a multitude of physical and psychosocial challenges including alterations in body image and lifestyle, changes in self-concept, impairments in physical functioning, prosthesis use, and pain [1], [2], [3]. The complexity and diversity of functions performed by the hands and their salience in communication and self-presentation [4] represent significant and distinct challenges for rehabilitation and prosthetic restoration. In recent years, significant technological advances in design and fabrication of upper limb prosthetic devices have greatly improved the potential functional and cosmetic outcomes for individuals with upper limb amputations [5]. There remains, however, a dearth of research explicitly addressing psychosocial adaptation to upper limb amputation and associated mediating factors [6], despite the importance of such variables in clinical rehabilitation, sustained prosthesis use, and long-term adjustment and quality of life.

It is not surprising that negotiating the evolving stressors associated with amputation may challenge the individual's ability to maintain emotional well-being and, in some instances, may promote maladaptive reactions leading to poor psychosocial adjustment. The extent to which this occurs may be partly dependent on the coping strategies or styles individuals adopt to manage experiences associated with their illness or injury [7], [8], [9], [10]. Investigation of the role of coping strategies in adjustment to lower limb amputation, consistent with the wider coping literature, suggests that active/task-oriented strategies such as problem solving and perceiving control over the disability are conducive to positive psychosocial adjustment (e.g., Refs. [7], [11], [12]). In contrast, emotion-focused and passive strategies such as cognitive disengagement, avoidance, and catastrophizing have been associated with poor psychosocial outcomes [7], [12], [13]. For example, Livneh et al. [7] found that greater active problem solving was negatively associated with depression and internalised anger and positively associated with adjustment and acceptance of disability. In contrast, emotion-focused coping and cognitive disengagement were positively associated with depression, externalised hostility, and lack of acceptance of disability.

Despite a large and growing literature on psychosocial adaptation to lower limb amputation (see Ref. [14] for a review) there is little evidence regarding the prevalence of clinically significant affective distress amongst individuals with upper limb amputations. Indeed, to date, associations between coping strategies and psychosocial adjustment to upper limb amputation, as a unique condition, have not been investigated. This may be explained in terms of the lower incidence of major upper limb amputation. However, findings based on analyses of cases of lower limb amputation are clearly of limited generalizability to cases of upper limb amputation. There are obvious differences in terms of functional implications, visibility/concealability of the amputation and/or prosthesis, and in the characteristic circumstances surrounding upper and lower limb amputations. Amputations of the upper limbs typically result from traumatic injury and are characteristically sustained by relatively young adults who are otherwise in good health [15]. In contrast, the majority of lower limb amputations are performed secondary to peripheral vascular disease (PVD) [16], [17], [18]. The incidence of this condition increases with age; hence, those typically undergoing PVD-related amputation are older than 60 years [19] and commonly experience concurrent medical conditions [17]. Moreover, survival following major lower limb amputation for PVD is poor [20].

The purpose of the study is to determine the prevalence of clinically significant affective distress (symptoms of depression and anxiety) in a sample of individuals with upper limb amputations and to examine the contribution of coping strategies to the prediction of psychosocial adjustment of individuals with acquired upper limb amputations. In the current research, psychosocial adjustment is conceptualized as the absence of clinically elevated symptoms of anxiety and depression and evidence of positive adjustment to amputation and prosthesis use.

Section snippets

Study design and participants

Eligible members of the British Limbless Ex-Service Men's Association (BLESMA), a British national charity dedicated to promotion of the welfare of those who have lost a limb or limbs, one or both eyes, or the use of a limb in any branch of Her Majesty's Forces or Auxiliary Forces were invited to participate in a research project concerning psychosocial adjustment to physical injury. Data were gathered by using self-report postal questionnaires. An article outlining the aims of the study was

Measures

Coping strategies were assessed by using the Coping Strategy Indicator (CSI) [23]. This 33-item self-report questionnaire measures the use of three coping strategies, namely, Problem Solving, Seeking Social Support, and Avoidance, in response to a specific stressor. Responses are indicated by means of a 3-point scale: a lot[3], a little[2], or not at all[1]. The three subscales each contain 11 items, and subscale scores are calculated by summing responses to appropriate items (range, 0–33);

Descriptive characteristics

The means and standard deviations for all variables are presented in Table 2. HADS depression scores ranged from 0 to 20. The mean score was 5.42 (S.D.=4.18). Five individuals (3.6%) had scores in the range representing severe symptoms, while 7.2% of respondents (n=10) had scores in the range indicative of moderate symptoms and 17.4% (n=24) met the criterion for mild symptoms of depression. Thus, in total, 28.3% met the criterion indicative of possible clinical depression. The average score on

Discussion

This study provides [1] prevalence data on symptoms of depression and anxiety in a sample of individuals with acquired upper limb amputations, and [2] the first reported investigation of the contribution of coping strategies to the prediction of psychosocial adjustment to upper limb amputation. The prevalence of depressive symptomatolgy (28.3%) for the current sample was almost three times greater than rates reported in a nonclinical sample broadly representative of UK adults [33]. This finding

Acknowledgments

This research was funded by the Irish Research Council for the Humanities and Social Sciences and the BLESMA. A debt of gratitude is owed to the individual members of BLESMA who took great time and care in responding to the survey, to Jerome Church and Stephen Coltman at BELSMA HQ for their assistance; to Professor Malcolm MacLachlan, School of Psychology, Trinity College Dublin, for his guidance; and to three anonymous reviewers for their constructive comments.

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