PSIHOSOCIJALNII BIOMEDICINSKIASPEKTIADAPTACUENA AMPUTACIJUEKSTREMITETA

Aleksandar JovanovicMirko Pejovic

Institut za psihijatriju, Klinicki Centar Srbije,Beograd

Kratak sadria]: Nasa studija bavi se psihosocijalnimi biomedicinskim aspektima adaptacije pacijenata naamputaciju ekstremiteta. Najnovija saznanja iz oveoblasti propustena su kroz prizmu iskustva koje suautori stekli kao psihijatri-konsultanti u Zavodu zaortopedsku protetiku (ZOP) u Beogradu i tokom ra­da na projektu »Psihosocijalna podrska invalidima ra­ta u ZOP »ko]i je realizovan zahvaljujuci finansijskojpodrsci japanske humanitarne organizacije »Associa­tion to Aid Refugees, Japan (AAR,[apan)«.

Kljucne reii: amputacija, psihosocijalna rehabilitacija.

Liinost

Amputacija znaci trostruki gubitak: gubi­tak funkcije, gubitak senzacije i gubitak te­lesne sheme - adaptacija na njih zavisi, ka­ko od licnih, socijalnih i porodicnih poten­cijala, tako i od strucnosti i nesebicnog tru­da svih profesionalaca i laika koji se brinu 0

ljudima onesposobljenim zbog amputacije.

Adaptacija na amputaciju je odredena ni­zom psihosocijalnih i biomedicinskih fak­tora, cije poznavanje je neophodno za ade­kvatan dizajn relevantnih terapijskih stra­tegija u okviru celovitog koncepta rehabi­litacije pacijenata sa amputacijom.

Psihosocijalni faktori adaptacijena amputaciju

Uzrast

Psiholoski problemi povezani za amputa­cije generalno se povecavaju sa uzrastom.Deca sa kongenitalnim nedostatkom udovase adekvatno adaptiraju uceci da kompen­zatorno koriste ostale potencijale. Deca ve­oma vesto koriste protezu i ostale udove,

ali su izuzetno osetljiva na stay prihvatanjaiii odbijanja svojih vrsnjaka. U periodu ado­lescencije amputacija je skopcana sa tesko­cama sazrevanja seksualnog identiteta.Mladi odrasli reaguju na gubitak u zavis­nosti od stepena onesposobljenosti i una­kazenja, a olaksavajuci faktori su formiranidentitet, intelektualna zrelost, kao i fizickakondicija i socijalna kompetentnost. Kodstarijih osoba, problem predstavljaju na­ruseno opste zdravlje, socijalna i porodicnaizolacija (smrt bracnog druga iii napustanjeod strane potornstva) i sklonost ka de­presivnim porernecajima koja i u opstoj po­pulaciji raste sa uzrastom i samocom.

l'M

Osobe koje su narcisticki investirale u svoj 8fizicki izgled, na gubitak ekstremiteta re- g

~aguju gubitkom samopostovanja, dok zavi- C'lC'lsne licnosti prihvatiti ulogu bolesnika kao~dobrodoslu mogucnost da izbegnu licnu ~

odgovomost i socijalnu kompeticiju. Za oso- ozbe sklonije depresivnom reagovanju, am- w

putacija je dodatna kockica u mozaiku licneneadekvatnosti. Za paranoidne osobe, trau- 83

rna je jos jedna karika u paranoidnom siste­mu, sa mogucom eskalacijom psihopato­logije i okrivljavanjem drugih za licne prob­Ierne. Socijalno anksiozne, hiperskrupulo­zne osobe ce u uslovima socijale ekspozicijeimati znacajno vece probleme nego ekstro­vertne i samopouzdane osobe. Nekada one­sposobljenost moze da donese znacajnu se­kundarnu i tercijarnu dobit, tj. psiholoskudobit usled razresenja nekih intrapsihickihkonflikata, kao i materijalnu korist, kojeolaksavaju psihosocijalnu adaptaciju.

Zanimanje i primanja

Svakako da ce osobe cija profesija zavisi odmotornih vestina biti emocionalno vulne­rabilnije na amputaciju, s obzirom na ne­gativne egzistencijalne posledice onespo­sobljenosti. Postoji mogucnost, kao kodmnogih ispitanika u ovoj studiji, da je ma­terijalna naknada za boravak u bolnici vecanego primanja koja pacijenti imaju nakonotpusta (penzija iIi plata posle prekvaIifi­kacije, na teritorijama ratom opustoseneprethodne ]ugoslavije), sto smanjuje moti­vaciju da se zavrsi hospitalna rehabilitacija.Takode, nije retko da pacijent, napr. izbegIi­ca povreden u ratu, nakon hospitalizacijenema gde da stanuje niti ima stalan posao.Takav pacijent ce izbegavati otpust sa kli­nike uz brojne zamerke na racun proteze ilose saradnje tokom rehabilitacije.

Psihosocijalna podrska

Za emocionalno zdravlje svake osobe ne­ophodan je sistern podrske tokom citavog

-<t- zivota. Generalno usamljene osobe vise~ pate zbog amputacije nego one koje imaju§' dobru potpornu mrezu znacajnih osoba izo~ svojoj okoIini. Podrska bracnog druga,

deteta iIi prijatelja je od sustinskog zna­:E caja za samopstovanje onesposobljene~ osobe. Pri tome su mlade osobe posebno~ osetljive na prihvatanje u siroj socijalnoj

(ekstraporodicnoj) sredini.

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Veoma je vazno da podrska bude fleksibil­na i usmerena na sve faktore od znacaja zaredukciju nesposobnosti i hendikepa. Tozahteva dobro i stalno pracenje procesapacijentove rehabiIitacije i redukcije nes­posobnosti, a u cilju da mu se pruzi mo­gucnost za preuzimanje kompetencija cimpostane za to sposoban.

Biomedicinski faktori adaptacijena amputaciju

Opite zdravstveno stanje

Osobe sa dobrim opstim zdravstvenim sta­njem su u prednosti u odnosu na osobekoje imaju poIimorfne telesne poremecaje.Mlada i zdrava osoba ce se lakse vratiti sva­kodnevnom zivotu od stare i bolesne osobe(npr. sa generalizovanim vaskularnim obo­ljenjem i diabetesom) koja ima brojnefunkcionalne Iimitacije, ne sarno zbog am­putacije nego i zbog ostalih somatskih po­remecaja.

Razlozi za amputaciju

S obzirom na razloge za amputaciju, uobi­cajena je podela na ratne i mirndopskeamputacije.

Amputacije u ratnim okolnostima su eks­tremno stresogene zbog nagle promenepracene zivotnom ugrozenoscu i osecajernbespomocnosti. Ratni amputirac nema mo­gucnosti za adekvatnu pripremu ni vreme­na za adaptaciju. Takode, kumulacija psi­hotrauma u ratnoj zoni predstavlja dodat­ni izvor kompIikacija u vidu psihijatrijskihpoststresnih sindroma koji u znacajnojmeri kompIikuju dalju rehabilitaciju. Sdruge strane, ratne amputacije kod ranje­nih vojnika ornogucavaju trajnu evakuaci­ju iz ratne zone, penzionisnje iIi prekvali­fikaciju sa materijalnim i moralnim gratifi­kacijama koji olaksavaju dalju socijalnu re­integraciju. Najproblernaticnije su ratne

amputacije civila koji, zbog teske ekonom­ske i politicke krize svojstvene ratnom vi­horu, cesto ne mogu da ostvare svoje ele­mentarne potrebe i prava u pogledu odste­te, nege, smestaja, prekvalifikacije iii pen­zionisanja, a dodatno su suoceni sa potre­born reparacije gubitka imovine, bliznjihili domovine, sto je tipicna sudbina izbe­glica i proteranih amputiraca u jugoslo­venskom gradanskom ratu.

Mirnodopske traumatske i urgentne hirur­ske amputacije se generalno smatraju stre­sogenijim od jatrogenih amputacija. Na­irne, jatrogene amputacije koje pruzajudovoljno vremena za preoperativnu psiho­losku pripremu, daju pacijentu i njegovojporodici sansu za razvijanje realistickihocekivanja i mogucnosti, Posebno se mozeocekivati dobra saradnja sa strucnim ti­mom u slucajevima kada amputacija znacii zaustavljanje (npr. maligne) bolesti. Sud­ska parnica za nadoknadu neimovinskestete povezana sa amputacijom u znacaj­noj meri moze da komplikuje proces reha­bilitacije. Slican slucaj je i sa pacijentimakojima izlazak iz bolnice znaci suocavanjesa nedostatkom srnestaja i gubitkom finan­sijske naknade vezane za hospitalizaciju.

Amputacije kod starijih osoba obicno sle­de nakon hronicne bolesti sa dugotrajnimtegobama (diabetes, vaskularna boest).Ponekad se amputacija dozivaljava kaokraj patnje, a ponekad kao neuspeh kon­zervativnog tretmana. Strahovit hendikepi tragedija za staru osobu predstavljaju za­nemarivanje i losa nega od strane poro­dice, sto uzrokuje pogorsanje bolesti takoda je indikovana amputacija.

Priprema za amputaciju

Adekvatna preoperativna priprema, kad zanju postoji rnogucnost, podrazumeva: jas­no objasnjenje razloga za amputacijn; pri­kazivanje amputacije kao intervencije ne­ophodne da bi se sacuvao i poboljsao(hirurska korekcija patrljka) zivot: jasne

informacije 0 hirurskoj proceduri; pozi­tivno anticipiranje daljeg toka rehabilitaci­je i egzistencijalnih dihotomija koje se od­nosi na informacije 0 protetisanju, odnosi­rna sa porodicom i prijateljima, mogucno­stima korekcije onesposobljenosti, zna­cenju hendikepa, radnoj sposobnosti, sek­sualnim problemima, pravima i mogucno­stima u okviru zajednice. Neophodno je dasvaki clan strucnog tima, pored pruzanjanege, bude spreman i na davanje informa­cija i psiholoske podrske. Medutim, glavniautoritet i oslonac u odnosu sa pacijentomu preoperativnom i postoperativnom peri­odu je hirurg operator (Bradway, J. K. etal. 1984).

Hirurihi tretman

Lose uradena amputaeija je predznak 10­seg ishoda proteticke rehabiIitacije. Madahirurski dobro izvedena amputaeija ne ga­rantuje potpun uspeh rehabiIitacije, onasvakako pruza vise sanse za uspesan ishodproteticke rehabilitaeije. Osobe cija je pro­teticka rehabilitaeija skopcana sa bolom,potrebom revizije patrljka ili infekcijom,bice pod vecim stresom, sklonije beznadui depresiji, sa znacajno kompromitovanommotivacijom za saradnju sa strucnim ti­mom. Razumljiva je praksa u vecini bolni­ca da najiskusniji hirurg bude direktnoukljucen u obavljanja svake amputacije isupervizije ciravog procesa rehabilitacije.

Nivo amputacije

Nema jasnog konsenzusa 0 tome kakva jeveza izmedu intenziteta psihopatoloskih 'T

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reakeija i nivoa amputacije, ali se smatra ada je najveci izazov za adaptacione poten- g

!j,cijale obostrana nadlakatna amputaeija, N

Nnasuport potkolenoj amputaeiji sa relativ-

~no dobrom restitueijom i telesne sheme i ;;2funkcije. Moguce su neocekivano teske re- o

Zakcije na relativno mali fizicki gubitak UJ

(npr. prst na nozi iii ruei) iii blaze reakcijena visestruki gubitak ekstremitata. Prog- 85

noza adaptacije se svakako moze dovesti uvezu sa socijalnim, psiholoskim, biolos­kim i znacenjem gubitka za osobu i sprem­noscu za preusmeravanje na druge zdravelicne potencijale.

Protetiiha rehabilitacija

Sto pre osoba dobije protezu bice kracepod stresom u najvulnerabilnijem perioduproteticke rehabilitacije, a to je period odhirurske intervencije do dobijanja proteze.Kljucni elementi motivacije za rehabilita­ciju formiraju se bas u ovom periodu iobuhvataju integraciju proteze u telesnushemu i usmeravanje paznje na ono sto semoze i mora uraditi u buducnosti, umestolamentiranja nad nepopravljivim gubitci­rna u proslosti i preokupacije bolom i one­sposobljenosti. Neophodan preduslov po­zitivne motivacije za proteticku rehabili­taciju i upotrebu proteze je udobnost ifunkcionalnost proteze, a veoma povoljnoutice i podrska od strane drugog uspesnorehabilitovanog amputirca. Dosadasnjeiskustvo pokazuje da amputirci sa podla­katnom arnputacijom lakse prihvataju pro­tezu od amputiraca s nadlakatnom ampu­tacijom. Mladi amputirci sa amputacijomna nedominantnoj strani i general no arnpu­tirci, u slobodno vreme imaju izrazenijutendenciju da ne upotrebljavaju protezu.

Timski pristup

S obzirom na sirok spektar aspekata ada­ptacije na amputaciju i potrebu za razli­citim vrstama intevencija, timski pristupje standardni imperativ proteticke rehabil-

~

rh itacije. Osnovni zadatak timskog pristupag je sto brze osposobljavanje amputirca zao~ samostalan i kvalitetan zivot, pri cernu je

neophodno dosledno sprovodenje princi­5@- pa informisanog pristanka pacijenta to­~ kom citavog procesa rehabilitacije. Dobrar5 longitudinalna evaluacija i siri opseg stru-

cnih intervencija, koje moze da ponudi

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strucni tim, povecava rnogucnost da ce svepotrebe pacijenta biti zadovoljene i sma­njuje mogucnost previda.

Tim profesionalaca koji sprovodi rehabi­litaciju pacijenta sa arnputacijom treba daobuhvata: hirurga, hirurske sestre, fizija­tra, proteticara, fizioterapeuta, radnog ter­apeuta, socijalnog radnika, psihologa i psi­hijatra. Korisno je da tim, pored profe­sionalaca, obuhvata i clanove rodbine, us­pesno tretirne amputirce, duhovnu podr­sku svestenika i druge znacajne osobe izuze okoline pacijenta. U poslednje vremesu se izuzetno korisnim pokazali grupnioblici psihoterapije, networking grupe igrupe samopomoci, cime se obezbedujedragocena pomoc visoko motivisanih i ce­sto veoma iskusnih laika.

Profesionalna rehabilitacija

Obnavljanje radnih sposobnosti i vracanjena zadovcljavajuci posao je integralni deooporavka pacijenta. Povratak na posao zna­Ci rnogucnost za slobodan izbor zivotnogstila, samopostovanje i uspostavljanje ade­kvatne uloge u porodicnoj i siroj socijalnojsredini. Korisno je imati na umu Kohl-ovusugestiju da je bitno voditi racuna 0 tomesta pacijent (a ne sarno strucni tim) smatrauspesnorn rehabilitacijom - za nekoga us­pesna rehabilitacija znaci ultimativno po­vratak na posao, a za nekoga mogucnost zasto kvalitetniji zivot u penziji.

Faze rehabilitacije

Faze adaptacije na amputaciju mozernokoncipirati sa psihijatrijskog i biomedicin­skog aspekta. Smatrarno da svaka arnpu­tacija ekstremiteta, a posebno traumatska,zbog ratnih povreda, predstavlja katastro­ficnu psihotraumu maksimalnog intenzi­teta, zbog prisutne vitalne ugrozenosti, fi­zickog bola i trajne onesposobljenosti. Onadovodi do porernecaja telene sheme i ko-

renitih privremenih iii trajnih promena ulicnoj, profesionalnoj i drustvenoj sferifunkcionisanja. Za uspesnu rehabiIitacijuje neophodno maksimalno angazovanjesvih mehanizama prilagodavanja u okvirusvake pojedine faze, a to u krajnjoj linijiznaci da pacijent moze ostvariti optimumzivctnog funkcionisanja, tj. minimum one­sposobljenosti i hendikepa za dato telesnoostecenje i socijalno okruzenje.

Proces adaptacije na amputacijuiz perspektive konsultativne-liezonpsihijatrije

Sa psihijatrijskog aspekta, razlikujemo triglobalne faze individualnog odgovora naamputaciju: akutnu, subakutnu i kasnu.Ovakva kategorizacija je izuzetno korisnau domenu konsultativne-liezon psihijatri­je jer vremenske odrednice ovako koncipi­ranih faza korenspondiraju sa psihijatrij­skim porernecajima koji se mogu ocekivatiu relevantnim vremenskim okvirima.

AkutnaJaza

Akutnu fazu karakterisu stanje soka, poja­cana afektivnost i hiper iii hipokinetskoreagovanje, sto se taksoloski rnoze svrsta­ti u akutne stresne reakcije s raznovrsnomsimptomatologijom. Gotovo svi amputirciopisuju period od prve 3 do 4 nedelje na­kon amputacije kao kritican period kon­fuzije i dezorganizacije, a vecina saopstavaprisustvo suicidalnih tendencija, pa i po­kusaja suicida (17%). Taj period se karak­terise i povremenim psihomotornim ne­mirom, nesanicom i prisustvom »flash­back--ova. Moze doci do neprepoznavanjalikova clanova porodice. Moze nastati eks­plozija plahovitosti zbog beznacajne (a ne­kad i bez ikakve) provokacije. Moze nastu­piti intelektualna konfuzija i nerazumeva­nje sasvim proste komunikacije. Radikalnepromene stanja tela, koje prate odjednomnastala velika onesposobljenja, kao sto je

amputacija, same po sebi dovode do dras­ticnih promena na sensorskom inputu ko­je uzrokuju dezorganizaciju ponasanja,Slucaj kada je veliki deo tela naglo lisensenzacija pretstavlja prototip Hobb-ovogkoncepta, jer nervni sistem osobe naglodobija sasvim razlicitu konfiguraciju ki­netickih, taktilnih i proprioceptvnih impu­tao Osim promena izazvanih ostecenjimaneurofizioloskih senzora, i sam dolazak ubolnicki krevet, kao i promena sredine,odgovarajuce promene u mobilnosti, uop­ste, stres prihvatanja cinjenice ozbiljnogostecenja, koje je vece nego sto osoba rno­

ze da kontrolise, nuzno dovodi do drama­ticnih promena u smislu razlicitog stepenadezorganizacije ponasanja.

Subakutna [aza

Posle akutne faze sledi subakutna faza saelementima posttraumatskog stresnog po­rernecaja i ostalih posttraumatskih stres­nih sindroma. Prilagodavanje je olaksanosusretom sa velikim brojem sapatnika ubolnicama i rehabiIitacionim centrima. Sviispitanici isticu znacaj podrske i pomociporodice. Medutirn, psihoterapijska podr­ska i podrska osoblja i ostalih pacijenatatakode predstavlja znacajan faktor za us­pesno prevladavanje stresa i ishod stresnereakcije. Porodica i prijatelji su cesto da­leko, a pacijenti provode vecinu vremenaokruzeni ostalim pacijentima, zaokupljenirazrnisljanima 0 buducoj egzistenciji, po­slu, prekvalifikaciji. Cesto su pod pritiskominformacija 0 socijalno ekonomskoj krizi

l'sa kojom je suocena zajednica u kojoj su M

ostale njihove porodice i u koju i sami tre- gba da se vrate. ~

N

Ispitanici su predstavljali izuzetno homoge- N

nu grupu uspostavljenu prema spoljasnjern ~svetu, kao vid susprotstavljanja frustrira- ozjucoj realnosti. Ovako formirana homoge- U-l

nost, zasnovana na mehanizmima grupneidentifikacije, podstice izolaciju, sto za po- 87

sledicu moze imati otezano prilagodavanjeu spoljasnjoj neprotektivnoj sredini.

Tokom razgovora cesto se ispoljava narcis­ticko-agresivan stay kroz potrebu da seimpresionira opisima borbi i masakra, uztrazenje priznanja za podnetu zrtvu, kao iinsistiranje na pokazivanju ostatka ampu­tiranog uda. Mrznja i zelja za osvetom bilaje prisutna kod ispitanika koji su izgubi­li clanove svoje porodice, drugove i svojaimanja u ratu,

Kasnafaza

Treca faza, je tzv. kasna faza koju karakte­risu dva tipa reagovanja, kompenzovani idekompenzovani. Kompenzovani tip se od­likuje dobrom psihosocijalnom adaptaci­jom sa uspostavljanjem personalne i soci­jalne homeostaze uz maksimalno angazo­vanje licnih i socijalnih res ursa. Dekom­penzovani tip se odlikuje psihosocijalnommaladaptacijom i obuhvata: autisticnost,hipersenzitivnost, depresivnost, konver­zivne tendencije ili agresivnost. U ovomperiodu se vee moze govoriti 0 trajnim po­remecajima licnosti pod dejstvom katas­troficnog zivotnog iskustva (ratna ampu­tacija). Poseban problem, nakon dugotraj­ne rehabilitacije u hospitalnim uslovima,predstavlja suocavanje sa spoljasnjorn re­alnoscu koju Cine: rasturene porodice, spa­ljena porodicna ognjista, nernastina, soci­jalne barijere i stigma.

Proces adaptacije na amputacijuiz perspektive biomedicinskog tretmana

Proces adaptacije na amputaciju, sa aspek-"1 ta biomedicinskog tretmana, moze da ser<)

0' koncipira kroz cetiri faze medicinske reha-g bilitacije amputacije, a podrazumeva: pre­2!.N operativnu fazu, neposrednu postoperativ-N

::g nu fazu, fazu hospitalne proteticke rehabi-~ litacije i fazu vanbolnicke rehabilitacije.ozU.l

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Preoperativna faza

Za pacijente sa traumatskom amputacijompreoperativna faza je izuzetno kratka ipredstavlja period do hirurskog zbrinja­vanja vee postojece traumatske amputaci­je. Medu amputircima koji imaju dovoljnovremena da mogu da budu preoperativnopsiholoski pripremljeni, vecina ce ampu­taciju doziveti kao sastavni deo lecenja iolaksanje patnji, tako da nova faza prilago­davanja rnoze da pocne. Strepnja koja pos­toji kod svakoga se, pre svega, odnosi naprakticne aspekte kao sto su gubitak funk­cije, gubitak prihoda, bol, teskoce u adap­tiranju na protezu i materijalni troskovi le­cenja. Druga vrsta strepnji se odnosi naneke vise simbolicke aspekte, kao sto supromene u telesnom izgledu, seksualnaosujecenost, slika u ocima drugih i s1. De­presivna reakcija, koja se razvija neposred­no nakon saopstenja pacijentu da ce muekstremitet biti amputiran, rnoze progre­dirati dugo nakon operacije sa teskim po­remecajern licnog identiteta.

Kljucna strategija u preoperativnoj pripre­mi je razvijanje realistickih ocekivanja i kodpacijenta i kod clanova njegove porodice uvezi kratkorocnih i dugorocnih zahteva kojise pred njih postavljaju u postoperativnomperiodu i tokom rehabilitacije. Amputacijapri tome mora biti definisana kao neopho­dna da se popravi zivot (ili prezivi), a nekao prornasaj, stigma i gubitak. Neophod­no je da pristanak pacijenta na amputacijubude pracen detaljnim i razumljivim infor­macijama 0 hirurskim i rehabilitacionimaspektima amputacije, sa otvorenim odgo­vorima na sva pitanja, rna koliko ona iz­gledala trivijalna, sto u znacajnoj meri ot­klanja anksioznost, ljutnju i ocajanje.

Neposredni postoperativni period

Neposredni postoperativni period moze bi­ti razlicite duzine i akutna psiholoska reak­cija, koja se moze ocekivati u ovom perio-

du, sadrzi tokom nekoliko sati pocetnukonfuziju i emocionalnu tupost, pracenuosecanjern obamrlosti i parestezijama.Prvih nedelju do dye dana sadrze patnjuzbog fizickog bola, ali i sazrevanje svesti 0

definitivnom gubitku ekstremiteta i strep­nje za dalji tok oporavka zbog mogucihkomplikacija. Izuzetno je vazno davanjeadekvatnih informacija i emocionalne po­drske od strane strucnog tima. Prisustvoclanova porodice je od vitalnog znacaja, nesarno za decu nego i za odrasle, zbog na­glasene regresije i simbiotskih tendencija uobjektivno vitalno ugrozavajucoj situaciji,koja u isto vreme najavljuje verovatno naj­znacajniju egzistencijanu prekretnicu u zi­votu pacijenta.

Hospitalna proteticka rehabilitacija

Hospitalna proteticka rehabilitacija se, saaspekta protetisanja, moze podeliti na trifaze: faza bez adekvatne proteze, faza saadekvatnom protezom, faza kada je paci­jent obucen da koristi protezu. Sa aspektapsiholoske krize izazvane amputacijom,proces psiholoske reintegracije se odvijakroz tri faze: fazu »tuposti« u odnosu naspoljasnje stimuluse, depresivnu fazu bi­lansiranja gubitka sa beznadeznoscu i de­zorganizacijom i fazu reintegracije. Ne tre­ba gubiti iz vida da depresivna faza moze daima hronican tok i nastavi se nakon otpus­tanja iz bolnice, sto zahteva dug, a ponekadi hospitalni psihijatrijski tretman.

Hospitalna proteticka rehabilitacija je kri­ticna faza rehabilitacije, kako za pacijenta,tako i za clanove njegove porodice. Strucnitim mora da bude izuzetno senzibilan ifleksibilan jer je potrebno voditi racuna nesarno 0 strucnorn protetisanju vee i 0 nizufaktora znacajnih za rehabilitaciju, kao stosu: motivacija pacijenta, njegova dusevnapatnja zbog bola i unakazenja, njegova eg­zistencijalna strepnja zbog buducnosti,

njegova porodicna, socijalna i profesional­na reintegracija.

U ovoj fazi se mogu ocekivati brojne psi­hopatoloske reakcije, kao sto su depresiv­ne reakcije, problemi kontrole agresivnihimpulsa sa psihomotornom agitacijom,afektivna labilnost sa brzim smenjivanjemeuforije i depresivnih pomaka, koji mogubiti praceni i suicidalnim razmisljanjirnapa i pokusajima suicida.

Kljucni fakotri za uspesnu rehabilitaciju uovoj fazi su: brzo i strucno protetisanje,integracija u zajednicu koju sacinjavajupacijenti i osoblje bolnice, prihvatanje odstrane porodice i prijatelja, podrska od stra­ne drugih uspesno protetisanih ampu­tiraca, kognitivna restrukturacija sa ciljemda se razviju pozitivne anticipacije i plani­ranje buducnosti umesto bilansiranja ono­ga sto je izgubljeno.

Posthospitalna rehabilitacija

Tokom ove faze pacijent je prinuden da na­pusti zastitnicki bolnicki milje i da se upotpunosti suoci sa realnoscu i svim po­sledicama gubitka. Ovo suocavanje, kojeneki nazivaju i »drugim uvidom« (secondrealization), cesto rezultira depresijorn,raznim oblicima regresivnog ponasanja,odbijanjem da se napusti uloga bolesnika iprenaglasenim zahtevima za negom kojisu neopravdani u odnosu na onesposo­bljenost.

Podrska znacajnih osoba iz pacijentoveokoline, a to su pre svega clanovi porodi-ce, a zatim prijatelji, od neprocenjive je l'

r()

vrednosti u svakoj, a posebno ovoj fazi 0'

rehabilitacije, za pacijentovo sarnoposto- g~

vanje i pozitivnu motivaciju. Kljucni zada- ~

ci u ovom periodu su porodicna homeo- ~

staza, radno osposobljavanje, medicinsko ~

pracenje i prosvecivanje, socijalno prihva- ~

tanje i seksualno prilagodavanje. UJ

89

PSYCHOSOCIAL ANBIOMEDICAL ASPECTSOF ADAPTATION TOLIMB AMPUTATION

Aleksandar JovanovicMirko Pejovi:

Institute of psychiatry, Clinical Centre Serbia,Belgrade

Summary: Our study deals with psychosocial andbiomedical aspects of adaptation to limb amputation.Contemporary knowledge in this domain has beenanalyzed through the prism of the authors« experiencein consultatnt-liaison psychiatry at the Institute ofOrthopedic Prosthetics (Zap), Belgrade and on theproject »Psychosocial Support to Disabled War Vic­tims in ZOP« funded by the »Association to Aid Re­fugees (AAR, japan)«.

Key words: amputation, psychosocial, rehabilitation.

An amputation represents a triple loss:the loss of function, the loss of sensationand the loss of body image - adaptation tothem depends on the personal, social andfamily resources and on the professionalexperience and unselfish efforts of all theprofessionals and laymen taking care ofthe persons disabled by amputations (1).

The adaptation to amputation is determi­ned by many psychosocial and biomedicalfactors, the knowledge of which is neces­sary for adequate designing of relevanttherapeutical strategies within the overallconcept of rehabilitation of patients withamputations (2, 3, 4, 5).

§ Psychosocial factors of ataptation~ to amputationNN

52d AgeCIz Psychological problems connected withUJ

amputations generally increase with Chil-

90

dren with congenital limb deficiency canbe adequately adapted by learning to usethe other potentials through compensa­tion. Children use prosthesis and otherlimbs with great skill, but they are verysensitive to the acceptance or repulsionfrom their piers. In the period of adoles­cence amputation is closely connectedwith the complications regarding thematurity of thier sexual identity. Youngadults react to the loss in proportion withthe level of disability and deformation,and extenuating circumstances influencethe already formed identity, intellectualmaturity as well as physical condition andsocial competence. In the older persons,the problem is in a generally bad heakthcondition, social and family isolation(death of a spouse or abandoning by thechildren) and tendency towards depres­sive disorders which increases even in thegeneral population with the increase inage and loneliness (6, 7, 8).

Personality

The persons who have narcissisticaly in­vested in their physical appearance reactwith the loss of self-respect to the loss of alimb, while dependent persons welcomethe role. of a patient, as a possibility toavoid the personal responsibility and socialcompetence. For the persons who are aptto depressive reactions, amputation is justanother brick in the mosaic of personalinadequacy. For paranoid persons, traumais just another link in the paranoid system,with possible escalation of psychopatholo­gy and blaming the others for the personalproblems. Socially anxious, hiperscrupu­lous persons shall, in the conditions ofsocial explosion, have significantly biggerproblems than extrovert and self-confidentpersons. Sometimes, disability can bringabout significant secondary and tertiarygain, i.e. psychological gain due to solvingsome intrapsychological conflicts, as wellas material benefit, which enables psy­chosocial adaptation (9, 10, 11, 12).

Occupation and income

It is certain that the persons whose pro­fession depends on their motoric abilitiesshall be emotionally more vulnerable tothe amputation, considering the negativeexistential consequences of disability.There is a possibility, as in many of thepatients examined through this study, thatthe financial compensation for the timespent in hospital is much higher than theamount the patient receives after beingdischarged from the hospital (pension orpay after additional occupational trainingon the territories of the war affected Yugo­slavia), which decreases the motivation tofinish the hospital rehabilitation. It alsohappens often that a patient, a refugeewounded in war, after hospitalisation has

no accommodation or job. Such a patientwill avoid being discharged form the hos­pital with many complaints about theprosthesis and bad cooperation during therehabilitation (13).

Psychosocial support

The system of support during life-time isnecessary for the emotional health of anyperson. Generally lonely persons suffermore due to amputation than the personswho enjoy good support network of theimportant persons from their surround­ings. The support of a spouse, a child or afriend is of essential importance for theself-respect of the disabled person. Youn­ger persons are especially sensitive to theacceptance in the wider social (extrafami­ly) surroundings.

It is very important for the support to beflexible and turned toward all the factorsimportant for reduction of the disabilityand handicap. That demands constant mo­nitoring of the process of patient's reha­bilitation and reduction of disability withan aim to provide him with possibilities toovertake the competencies as soon as hebecomes ready for them (14).

Biomedical factors of adaptationto amputation

General health condition

Persons with good general health have an 'Tadvantage over the persons with polimorph ~

physical disorders. A young and a healthy gperson shall return to the everyday life 2'much more ease1y than an old and sick one N

~(with generalised vascular problems and ~

diabetes, e.g.) who has numerous function- ozallimitations, not only due to amputation, UJ

but also because of other somatic disor-ders. 91

NN

Reasons for amputation

Considering the reasons for amputation,the usual division considers the war-rela­ted and non-war-related amputations.

Amputations in war circumstances are ex­tremely stressogene due to the abruptchange followed by life danger and thefeeling of helplessness (15, 16). War am­putee has no time for adequate prepara­tion nor adaptation. Also, the accumula­tion of psychotraumas in the war zonerepresents additional source of problemsin the shape of psychiatric poststress syn­dromes which significantly complicatefurther rehabilitation. On the other hand,war amputations in wounded soldiersenable permanent evacuation from thewar zone, retirement or additional job tra­ining with material and moral gratificationwhich enable further social integration.The most complicated are war amputati­ons in civilians who, due to economic andpolitical crisis attributed to a war time,usually can not provide for the basic needsand rights, regarding war reparations, care,accommodation, additional job training orretirement, and they are additionally facedwith the need for reparation of their lossof property, family and homeland, whichis a typical fate of the refugees and exilledamputees in the Yugoslav civil war.

Non-war related traumatic and urgent sur­gical amputations are generally consideredto be more stressogene than iatrogene am­putations. Namely, iatrogene amputations

-e-rJ., which provide for enough time for pre-ope-g rational psychological preparation give the§. patient and his family a chance to develop

realistic expectations and alternatives.~ Especiallygood cooperation can be expect­d ed with the expert team in the cases whenCJ~ amputation means stopping the develop-

ment of (usually malignant) disease. Law-

92

suit for reparation of non-property damageconnected with amputation can significant­ly complicate the process of rehabilitation.It is a similar case with the patients forwhom leaving the hospital means facingthe lack of accommodation and losing thefinancial compensation connected withhospitalisation.

Amputations in older persons usually co­me after a chronic disease with long-termproblems (diabetes, vascular disease). So­metimes amputation is experienced as anend of the suffering, and sometimes as afailure of a conservative treatment. A terri­ble handicap and a tragedy for an older per­son is rejection and bad treatment from theside of his family, which causes deteriora­tion of disease, which, on the other hand,leads to amputation (17).

Preparation for amputation

Adequate pre-operation preparation, whenit is possible, means: clearly stating the rea­sons for amputation; describing the ampu­tation as an intervention necessary to pre­serve and improve life (surgical correctionof the stub); giving clear information aboutthe surgical procedure; positive anticipa­tion of the further rehabilitation and exis­tential dichotomies regarding informationabout prosthesis, relationships with the fa­mily and friends, possibilities of correctionof disability, the meaning of handicap, wor­king ability, sexual problems, rights andpossibilities within the community. It isnecessary that every member of the expertteam, apart from providing care, is ready to

give information regarding psychologicalsupport. But, the main authority and sup­port for the patient in the pre-operationaland the post-operational period is the oper­ating surgeon (18).

Surgical treatment

Bad amputation predicts bad results ofprosthetic rehabilitation. Although welldone amputation does not necessarilymean complete success of rehabilitation, itsurely provides more chance for successfulprosthetic rehabilitation. The personswhose prosthetic rehabilitation is connect­ed with pain, the necessity of stub revisionor infection, will be under greater stress,more hopeless and depressive, with signif­icantly compromised motivation for coop­eration with the expert team. Therefore, itis understandable that in most of the hos­pitals the most experienced surgeon isdirectly involved in performing everyamputation and supervision of the overallprocess of rehabilitation.

The level of amputation

There is no clear consensus about connec­tion between the intensity of psychopa­thological reactions and the level of ampu­tation, but the double above the elbowamputation is considered to be the great­est challenge for adaptation resources, asopposed to the below the knee amputa­tion with relatively good restitution of bo­dy imagined function (19, 20). Unexpec­tedly complicated reactions to a relativelysmall physical loss (e.g. the loss of a toe)or mild reactions to a multiple loss of li­mbs are also possible (21). The prognosisof adaptation can be connected with thesocial, psychological, biological and themeaning of the loss to the person and hisreadiness for turning to other healthy per­sonal resources (22, 23).

Prosthetic rehabilitation

The sooner the person gets the prosthesisthe shorter the stress period in the most

vulnerable period of prosthetic rehabilita­tion. Bookmark not defined., which is theperiod from the surgery until the date ofreceiving the prosthesis. The key elementsof the motivation for rehabilitation areformed in this period and include theintegration of the prosthesis into the bodyimageand turning the patient's attentionto what can and must be done in the fu­ture, instead of lamenting under the irre­coverable losses in the past and preoccu­pation with pain and disability.

The necessary precondition for positivemotivation for prosthetic rehabilitationand the use of prosthesis is the comfort ofthe prosthesis and its functioning. Goodinfluence is also the support by anothersuccessfully rehabilitated amputee-s. Upto now experience shows that amputeeswith below the elbow amputation moreeasily accept the prosthesis than theamputees with above the elbow amputa­tion. Younger amputees with amputationon the non-dominant side and generallyamputees in their free time have moreemphasised tendency not to use the pros­thesis (25).

Team approach

Considering the wide aspect of adaptationto amputation and the need for differenttypes of interventions, the team approachis the standard imperative of prostheticrehabilitation. Bookmark not defined. The ,-main task of the team approach is to r<"l

8enabe an amputee to live independently as gfast as possible, which requires employing ~

N

the principle of informed agreement of the N

patient during the whole of the rehabilita- ~tion process. Good longitudinal evalua- C)

ztion and a wider range of expert interven- t.LJ

tions, which can be offered by the expertteam, increase the possibility that all the 93

needs of a patient shall be met and de­crease the possibility or omission.

The team of professionals who performthe rehabilitation of an amputee patientshould include: surgeon, surgery nurses,physiatrist, prosthetician, physiotherapist,working therapist, social worker, psychol­ogist and a psychiatrist. It is very usefulthat the team, apart from the profession­als, include the members of the family,successfully treated amputees, spiritualsupport by the priest and other importantpersons from the patient's immediate sur­roundings. Lately, different types of grouptherapy can be very useful, including net­working groups and self-help groups,which provide valuable help of highlymotivated and often experienced laymen(26, 27, 28, 29).

Professional rehabilitation

Renovation of working abilities and retur­ning to the satisfying job is an integrativepart of the patient's recovery. Returning tothe old job represents a possibility for afree choice of the life style, self-respectand establishment of the appropriate rolein the family and the wider social environ­ment.

It is useful to have in mind Kohl's sugges­tion30 that it is important to pay attentionto what the patient (and not only the ex­pert team) considers to be a successful re­habilitation - for someone, successfulrehabili tation can mean returning to the

! old job, while for the other it represents aa possibility for a quality life in retirement.oo[j.

~ Stages in rehabilitation

g Stages in adaptation to amputation can be~ considered from the psychiatric and from

the biomedical aspects. It is believed that

94

every limb amputation, the traumatic oneespecially, due to war injuries, representsa catastrophic psychotrauma of maximumintensity, due to present vital danger, phy­sical pain and permanent disability. It

brings about the disorder in the body ima­ge and very deep temporary or permanentchanges in the personal, professional andsocial sphere of functioning. For success­ful rehabilitation it is necessary to engageall the mechanisms of adaptation withinevery separate stage, which in the endmeans that a patient can realise the opti­mum of life functioning, i.e. minimum ofdisability and handicap for the given phy­sical impairment and social environment.

The process of adaptation to theamputation from the perspectiveof consultant-liaison psychiatry

From the psychiatric aspect we can distin­guish three global stages of as individualresponse to amputation: acute, subacuteand late (31). Such categorisation is veryuseful in the domain of consultant-liaisonpsychiatry because the time determinatorsin this case correspond to psychiatric dis­orders which can be expected in the rele­vant time frame.

Acute stage

The acute stageis characterised by thestate of shock, increased affectivity andhyper- or hipokinetic reacting, which can,from the aspect of taxology, be defined asacute stress reaction with varied sympto­matology. Almost all the amputees de­scribe the period of the first 3 to 4 weeksafter the amputation as a critical period ofconfusion and disorganisation, and mostof them claim the presence of suicidal ten­dencies, even actual attempts (17%). Thisperiod is also interesting for temporary

psychomotor restlessness, sleeplessnessand the presence of flashbacks'<. It mightbe hard for the patient to recognise mem­bers of his family. There is also the possi­bility of explosion of temper due to aninsignificant (sometimes without any atall) provocation. There can be intellectualconfusion and misunderstanding of a verybasic communication. Radical changes inthe body, followed by sudden disabilities,such as amputation, bring about drasticchanges in the sensory input which caus­es disorganisation in behaviours>. The ca­se when a great part of the body is sud­denly void of sensations represent the pro­totype of the Hobb's concept, because thenervous system all of a sudden starts get­ting a completely different configurationof kinetic, tactile and proprioceptive in­puts. Besides the changes caused by theimpairments of neurophysiological sen­sors, the sole act of coming to the hospitalbed, as well as the change of environment,changes in mobility, overall stress causedby accepting the fact of a serious impair­ment, which is bigger than the person cancontrol, necessarily bring about dramaticchanges in the sense of different level ofdisorganisation in behaviour.

Subacute stage

After the acute stage comes the subacuteone with elements of posttraumatic stressdisorder and other posttraumatic stresssyndromes. Adaptation is facilitated thro­ugh meetings with a large number of fel­low-sufferers in hospitals and rehabilita­tion centres. All our clients emphasise therole of support and help by the family. Onthe other hand, psychotherapy as well asthe support of stuff and other patients 34,35 also represents a significant factor forsuccessful overcoming of stress and theresult of a stress reaction. The family and

friends are often far away, ana patientsspend most of their time surrounded byother patients, deeply involved in thoug­hts of future life and work. Very often theyare under the pressure of informationregarding social and economic crisis facedby the community to which their familiesbelong and into which they are supposedto return.

The clients represent a very homogenousgroup as opposed to the outside world, asa kind of opponent to the frustrating rea­lity. Such homogeneity, based on the me­chanisms of group identification, enha­nces isolation, which as a consequencecan have difficult adaptation in the out­side unproductive environment.

During the conversation a narcissistic­aggressive attitude is very often expres­sed, through the need to impress a liste­ner by descriptions of battles and massa­cres, asking for recognition of endured sa­crifice, as well as insisting on showing theremains of the amputated limb. The ha­tred and wish for revenge are always pres­ent in clients who have lost their familymembers, friends and property in the war.

Late stage

The third stageis the so called late stage,marked by two types of reactions, thecompensated and decompensated one.The compensated type is characterised bygood psychosocial adaptation which in- ,.dudes establishing of personal and social r<">

8homeostasis with maximum engagement gof personal and social resources. Decem- t:!-

N

pensated type is characterised by psy- N

chosocial maladaptation and includes: S§autism, hypersensitivity, depression, con- ~versive tendencies or aggression. In this r5period it is already possible to discusspermanent personality disorders under 95

the influence of catastrophic life experi­ence (war amputation). The special prob­lem, after long-lasting hospital rehabilita­tion, represents the moment of facing upto the outside reality represented by: dis­located families, burned homes, poverty,social barriers and stigma.

The process of adaptationto the amputation from the perspectiveof biomedical treatment

The process of adaptation to the amputa­tion, from the aspect of biomedical treat­ment, can be defined through 4 stages ofmedical rehabilitation of amputations andincludes: pre-surgery stage, immediatepost-surgery stage, the stage of hospitalprosthetic rehabilitation and the stage ofout-patient rehabilitation (36, 37).

Pre-surgery stage

For the patients with traumaticamputa­tions the pre-surgery stage is extremelyshort and represents the period up to thesurgical treatment of the present traumaticamputation. Among the amputees whohave enough time to be pre-surgery psy­chologically treated, most of them willexperience amputation as a part of treat­ment and a relief from suffering, so thatthe new stage of adaptation can begin. Thefright which exists in everyone, refers pri­marily to the practical aspects, such as theloss of function, loss of income, pain, ob­stacles in adaptation to prosthesis and thetreatment costs. The other type of fears

0' fig re ers to some other symbolic aspects, such2!- as the changes in physical appearance, sex-NN ual obstacles, the image in the eyes of the~ others, etc. Depressive reaction, which de­~ velops immediately after telling the patient~ about the limb amputation, can last for a

96

long time after surgery with heavy disorderof personal identity (38).

The key strategy in pre-surgery prepara­tion is developing realistic expectations ofpatient and the members of his familyregarding the short and the long-termrequests which are placed before them inthe post-surgery period and during therehabilitation. The amputation must bedefined as a necessity to improve life (orsurvive), and not as a failure, stigma and aloss. It is necessary that the patient's ag­reement to amputation is followed by adetailed and clear information about thesurgical and rehabilitational aspects ofamputation, with frank answers to all thequestions, no matter how trivial theymight seem, which significantly decreasesanxiety, rage and desperation.

Immediate post-surgery period

The Immediate post-surgery period can beof different length and acute psychologicalreaction, which can be expected in thisperiod, includes, during the first few ho­urs, confusion and emotional bleaknessfollowed by sense of numbness and pa~restesis. The first week or two contain suf­fering due to the physical pain, but alsogrowing consciousness about the definiteloss of the limb and the fear about furtherrecovery. It is extremely important to pro­vide the adequate information and emo­tional support by the expert team (39).The presence of the family members isalso important, not only for the childrenbut also for the adults, because of theemphasised regression and symbiotic ten­dencies in the actually life-threatening sit­uation, which at the same time announcesprobably the most important existentialturning point in the life of a patient.

Saa~

Hospital prosthetic rehabilitation

Hospital prosthetic rehabilitation can bedivided into three stages from the aspectof prosthetics: the stage without properprosthesis, the stage with the proper pros­thesis and the stage when the patient istrained to use the prosthesis. From theaspect of psychological crisis caused byamputation, the process of psychologicalreintegration develop through the threestages: the »numbness« stage compared tothe outside stimulus, depressive stage ofsumming up the losses with hopelessnessand disorganisation and the stage of rein­tegration40. We should not forget the factthat the depressive stage can becomechronic and continue after leaving hospi­tal, which requires long and sometimeseven hospital psychiatric treatment.

Hospital prosthetic rehabilitationis thecritical stage of rehabilitation, for the pa­tient as well as for the members of his fa­mily. The expert team must be extremelysensitive and flexible because it is neces­sary to pay attention not only to the pro­fessional prosthetics but also to a wholeline of factors important for the rehabilita­tion, such as: motivation of the patient,his psychological sufferings caused bypain and deformation, his existential fearfor the future, his family, social and pro­fessional reintegration.

At this stage we can expect many psycho­pathological reactions, such as depressivereactions, problems of aggressive impulsecontrol with psychomotoric agitation, af­fective lability with quick exchanging of

euphoria and depression, which can beaccompanied by suicidal thoughts andeven suicide itself.

The key factors for successful rehabilita­tion in this stage are: fast and profession­al prosthetics, integration into the com­munity of patients and the hospital staff,acceptance by family and friends, supportby the other successfully prosthetised am­putees, cognitive reconstruction with anaim to develop positive anticipation andplanning of future instead of summing upof what has been lost (41).

Posthospital rehabilitation

During this stage, a patient is forced toabandon the hospital milieu and com­pletely face the reality and all the conse­quences of the loss. This facing, whichsome call »second realisation«, often res­ults in depression, different types of re­gressive behaviour, rejecting to abandonthe role of a patient and overemphasisedrequests for care which are not justified incomparison to the disability.

The support by the important persons fromthe patient's surroundings, and those are,first of all, his family members and friends,is of a valuable importance in any and espe­cially in this stage of rehabilitation, for thepatient's self-respect and positive motiva­tion. The key tasks in this period are thefamily homeostasis, work training, medicalmonitoring and education, social accept- !ance and sexual adaptation.

97

NN

98

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