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Psychiatric and Emotional Sequelae of Surgical Amputation

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{at}psych.mgh.harvard.edu

ABSTRACT

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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.

INTRODUCTION

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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. Posttraumatic 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 others 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 pathogenesis of PTSD. The primary aim of this study was to collect initial data on the prevalence of PTSD and other psychiatric disorders after surgical, therapeutic amputation, ascertained 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 mechanisms, and outcome measures.^2,3 A review of the literature performed by Rybarczyk and colleagues⁴ indicated that residual limb pain, activity restriction, and medical and disability-related factors (other than phantom pain) predict less variance in psychological adjustment than do body image, 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 perceived vulnerability,⁷ avoidance,² and helplessness.⁸

Research on the prevalence of specific psychiatric morbidity after amputation has largely focused on depressive symptoms, and the results of these studies report prevalence rates varying from 7.4%⁹ to 28%.¹⁰ This variance in prevalence rates is likely due to methodological differences in assessment of clinical depression. Those studies relying on self-report measures, such as the Center for Epidemiological 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 amputation very often adversely affects the individual’s ability to engage in his or her previous activities and otherwise restricts the full range of previous living. Many of the inventories 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 experiencing depression after amputation may be well adjusted 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 satisfaction 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 epidemiological 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 individuals recently having undergone digit replantation after amputation met criteria for PTSD.¹³ A retrospective file review of symptoms of PTSD, depression, and pain complaints stemming from work-related limb amputations found that participants with upper-limb amputations experienced more symptoms of PTSD than those with lower-limb amputations.¹⁴ A study of individuals many years after 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 largely² 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 amputation 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 Interview for the DSM–IV (SCID)¹⁵ in individuals who experienced surgical amputations in a therapeutic setting, in order to ascertain whether amputation in the absence of a co-occurring emotionally traumatic accident is an experience 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 criteria in a sample of individuals undergoing therapeutic amputation. 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

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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 obtained 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 admissions, and rehabilitative care that dominated their hospital 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 (N=23) underwent their amputations through therapeutic intervention: 1 for cancer, 18 for diabetes, and 4 for vascular or other health complications. Three individuals had lost limbs as a result of motorcycle accidents. All participants were currently undergoing rehabilitation 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 Frequency (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 reported to have a kappa reliability score between 0.68 and 0.81).¹⁷ Data were also collected in a semi-structured fashion 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

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Psychiatric Sequelae
Considering those participants undergoing surgical amputation secondary to vascular, diabetic, or other health complications (N=23), 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 included elements related to the motorcycle accidents themselves, in addition to material directly related to the loss of their limbs.

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FIGURE 1.  Observed Frequencies of Total CAPS Scores Surgical: N=23; accidental: N=3. CAPS: Clinician-Administered PTSD Scale.

Three out of the 23 participants undergoing therapeutic 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 accident 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 benefit 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).

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. Retrospectively, 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 emotions 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 survived the accident. Only one of these individuals sought professional assistance in dealing with the emotional aftermath 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 resulting from accidental injuries, however, were clearly devastated 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 participants with surgical/therapeutic amputations. Therefore, these individuals experienced a double trauma, and the amputation was conceptualized as more likely to deleteriously affect their daily routines and living.

DISCUSSION

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The results of both the structured clinical interview based on DSM–IV criteria and our semi-structured interview regarding emotional reactions to the experience of amputation suggest that surgical/therapeutic amputation secondary to diabetic, vascular, or other health complications does not 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 amputation itself, past combat trauma, or a combination of the two. Although some participants felt shocked and/or dismayed 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 experienced 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 extremely low rate of PTSD in these individuals is consistent with models of PTSD suggesting that the more uncontrolled and unpredictable the traumatic event, the more likely it is to lead to the development of the disorder¹⁸ and research finding that level of perceived control is inversely related to the development of PTSD symptoms.^19,20

Importantly, the individuals undergoing surgical amputation also were unconscious and medicated for the actual amputation experience. Research on individuals undergoing traumatic injury indicates that those participants with a memory of the event are significantly more likely to develop PTSD than those without such a memory²¹ and that psychological reactions such as dissociation and negative emotional reaction at the time of the trauma are implicated in the development of PTSD.^22,23 Lacking consciousness during the event precludes the formation of a memory or the experience of these implicated peritraumatic reactions. Although individuals undergoing surgical amputation could develop PTSD after events surrounding the amputation, such as learning of the need for amputation, 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 traumatic (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 estimates 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 accident leading to the injury, or a combination of the two factors. It could be that for those losing limbs to physical 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 symptoms.^24,25

This study is limited by several factors. First and foremost, 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 participants 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 retrospectively 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 undergoing 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 functional 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 amputation in the absence of a co-occurring emotionally traumatic accident is a sufficient trauma to lead to the development 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 criteria.

Our study suggests that the rate of PTSD after therapeutic amputation in the context of a rehabilitation hospital is relatively low. If this finding is replicated, it would indicate that if PTSD symptoms emerge in patients undergoing surgical amputation, the treating clinician would be wise to probe for the presence of previous traumas unrelated to the surgery. This is consistent with previous research indicating that the experience of multiple traumas may be associated with greater posttraumatic symptomatology than single traumas.^27,28 Our sparse data on individuals 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 experienced an accidental amputation. Future research should evaluate a larger number of participants who have undergone 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.

REFERENCES

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Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Cavanagh, S. R. Articles by Rauch, S. L. Search for Related Content PubMed Citation Articles by Cavanagh, S. R. Articles by Rauch, S. L. Depression Syndromes Secondary to General Medical Disorders

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