Emotional disturbances in trauma patients during the rehabilitation phase

ELSEVIER

Emotional Disturbances in Trauma Patients During the Rehabilitation Phase Studies of Posttraumatic

Stress Disorder and Alexithymia

Isao Fukunishi, M.D., Keiichi Sasaki, M.D., Yasunori Chishima, M.D., Masanori Anze, M.D., and Masaki Saijo, M.D. Abstract: Recent studies have shown a partial similarity between posttraumatic stress disorder (PTSD) and alexitkymia. In this study, the authors examined the relationship between PTSD and alexitkymia in two samples of 26 patients with burn injury and 27 patients with digit amputation during rekabilitation. The prevalence rates of DSM-111-R PTSD and alexitkymia assessed by the Toronto Alexitkymia Scale (TAS) were significantly higher for injury patients than for healthy volunteers. The rate of PTSD symptoms of avoidance and emotional numbing was significantly and positively correlated with the TAS scores in injury patients. The PTSD symptoms of avoidance and emotional numbing had a significant relationship with function after digit replantation. Alexitkymia also had a similar relationship with physical conditions. These results suggest that 2) in some cases, alexitkymia may be evident when PTSD emotional symptoms appear in injury patients, and 2) emotionnl disturbances (i.e., PTSD symptoms of avoidance and emotional numbing and alexitkymia) may be influenced by the Iez~cl of functional recovery after digit replantation.

Introduction in recent years remarkable progress has been made in plastic surgery medical techniques. These advancements and developments contribute greatly to the lives of patients. For example, the odds of survival for severe burn victims have improved considerably. Patients with severed limbs can now anticipate at least a partial return of functioning after reattachment. Recent attention has been inTokyo Institute of Psychiatry, Tokyo, Japan 0.1; Critical Care and EmeraencT Center, Yokohama Citv Urafune Hosuital. Yokohama, Ja&n (K.S., M.A.1; and Department of Plasiic Surgery, Yokohama City Hospital University, Yokohama, Japan KC., M.S.1 Address reprint requests to: Isao Fukunishi, Tokyo Institute of Psychiatry, 2-I-8 Kamikitazawa, Setagaya-ku, Tokyo 156, Japan.

General Hospital Psychiatry 18, 121-127, 1996 0 1996 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010

creasingly focused on how it is possible to improve the quality of life for these patients 11-31. For patients with severe burn injuries, for instance, physicians try to minimize loss of physical function and facial scarring in order to facilitate the smooth return of these patients to society [1,2]. In addition to restoring function after reattaching severed digits, plastic surgeons attempt to return external appearance as closely as possible to the original state 131. The extent of functional recovery and restoration of external appearances is a factor directly linked not only to quality of life, but also to the psychological well being of the patient. Moreover, these factors are closely connected to the degree of satisfaction among plastic surgery patients. Functional and asthetic recovery exerts an enormous effect on the psychological state and behavior of the patient. Psychiatric morbidity is often seen in cases of burn injury or severed limbs incurred through attempted suicide or accident [4,51. During the acute stage, shortly after trauma, patients experience a psychological shock brought on by the accident and may feel anxious about the future. In the rehabilitation phase, although patients with injury gradually seem to stabilize psychologically, emotional disturbances (e.g., flashbacks, recurrent dreams, and restricted range of affect1 often occur as a psychological response to the event 16-91. In 1972, Andreasen and Norris 161 reported on transient traumatic neurosis in many burn patients. Burn victims are likely to exhibit psychological problems including poor body image, regression, and depression [7-91. The American Psychiatric Association described psychiatric symptoms related to trauma as posttraumatic stress disorder WED) 11Cl. Recently,

121 [SSN 0163-H.743/Y6/$15.00 SSD! rllhn-n’:1”!95)0(1121-2

I. Fukunishi et al. the number of studies on burn injury patients with PTSD has been increasing 17-91. Several researchers have examined PTSD and related psychological factors in patients with hand injury 111-131. Several PTSD symptoms of emotional disturbances (e.g., restricted range of affect) are similar to alexithymia [14-181. In 1992, Perry et al. 181pointed out a partial similarity between PTSD and alexithymia [19,20]. The term alexithymiu refers to a cognitive-affective disturbance characterized by the difficulty in identifying and describing feelings and in elaborating fantasies; it was derived from clinical observations that were made initially on patients with classical psychosomatic diseases [16,211. However, many studies have shown that patients with diagnoses of PTSD, eating disorders, and substance use disorders also show high rates of alexithymia 122-241. This study was designed to examine the relationship between alexithymia and PTSD in two samples of patients with burn injury and those with digit amputation.

Methods Subjects included two groups: 26 patients (17 males and 9 females) with burn injury and 27 (20 males and 7 females) with digit amputation. All subjects were undergoing postinjury rehabilitation at Yokohama City Urafune Hospital in Japan. This population was chosen because these two injuries are representative of plastic surgery cases and the number of cases was relatively high compared with other injuries. All of the subjects were Japanese. The mean age was 42.8 (SD = 18.8) and 44.4 years old (SD = 14.9) in the burn injury and the digit amputation groups, respectively. The mean number of years of education was 14.2 (SD = 2.0) in the burn injury group and 14.4 (SD = 2.3) in the digit amputation group. The mean postinjury duration was 21.0 months (SD = 12.1) in the burn injury group and 21.9 months (SD = 13.6) in the digit amputation group. The patient sample was drawn from 33 patients with burn injury and 41 patients with digit amputation. Patients meeting any of the following criteria were excluded from the present study: 1) less than 3 months of clinical observations by two plastic surgeons; 2) inadequate psychiatric interviews by a psychiatrist or inadequate psychological testing due to aging or psychotic state (schizophrenia with hallucination and/or delusion, organic mental disorder, alcohol and/or drug abuse disorder).

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As a control group, 24 healthy persons (17 males and 7 females) participated voluntarily in this study. The control group was recruited from 37 healthy persons who were undergoing routine physicals and volunteered to participate in the study. They were admitted to the primary medical health service at Takinomiya General Hospital. The controls’ mean age was 43.1 years (SD = 15.7), and their mean number of years of education was 14.5 (SD = 2.4). The control group was matched for demographic characteristics with the two subject groups.

Physical Assessments Two plastic surgeons evaluated subjects’ physical indicators. In the burn injury group, two objective physical indicators were used: percentage of total body surface burned and percentage of facial disfigurement. Mean percentage of the two indicators was 27.1% (SD = 26.7) and 72.0% (SD = 35.11, respectively. As for patients with digit amputation, reattachment of the amputated digits was possible in all patients. According to Nakamura and Tamai’s evaluation [25], function after digit replantation was assessed as a physical indicator. The evaluation consisted of five categories: (I) motion [range of motion and activities of daily living (ADL)], (II) sensation, (III) subjective symptoms such as pain, (IV) cosmesis such as atrophy and scar, and (V) patient satisfaction. The full score was 100 points (range O-100). The higher the score, the higher the patient’s QOL. The number of digit amputations ranged from 1 to 4 digits with a mean of 2.1 (one digit, 7 cases; two digits, 9 cases; three digits, 8 cases; four digits, 3 cases). All patients received digit amputation in either hand and no patient had digit amputations in both hands. ADL’s assessment was also used for burn injury patients.

Psychiatric Assessments One psychiatrist and/or one psychologist conducted the Structured Clinical Interviews for the DSM-III-R (SCID) [261 to assess the presence or absence of a current psychiatric disorder according to the DSM-III-R diagnostic criteria 1271. After completion of the SCID, the Japanese version of the 26-item Toronto Alexithymia Scale (TAS) 115,161 was administered to both subject and control groups to assess alexithymia by patients’ selfreport. The English version of the 26-item TAS was

Emotional Disturbances in ?-auma Patients translated into Japanese [30,311. Like the English version, the Japanese version of the TAS also had high construct validity and adequate reliability [30,31 I. The TAS scores can range from 26 (no alexithymia) to 130 (highly alexithymia). According to reports by Zeitlin et al. 128,291, TAS scores were treated as continuous variables. This is consistent with the view that alexithymia is a graded rather than an “all-or-none” phenomenon [141. Taylor et al., however, have established the cutoff score of 74 or higher which indicates alexithymia [16]. The Japanese version of the cutoff score on alexithymia was also found to be 74 or higher 1301. We used the cutoff score in secondary analysis to assess the prevalence rates of alexithymia. For consistency in data collection, we read questionnaires and marked responses using standardized instruments. Statistical

Analysis

The results were analyzed statistically using analysis of variance (ANOVA), post-hoc t test (adjusted with Bonferroni) after the ANOVA, Chi-square test, and Pearson product-moment correlation. Systat software (version 5.2.) 1321 for the Macintosh was used. All differences were considered significant at p < 0.05.

Results To determine whether the three groups (two subject groups and one control group) were successfully matched with respect to demographic composition, a factorial ANOVA statistic for continuous demographics (i.e., age), and Chi-square test for categorical demographics (i.e., gender) was calculated. Variances were nonsignificant, indicating that the three groups were adequately matched for demographic composition. Similarly, to determine whether the two subject groups were matched with respect to age of injury onset and postinjury duration, a factorial ANOVA statistic was calculated. Variances were nonsignificant, indicating that the two subject groups were matched for age of injury onset and postinjury duration. Table 1 presents the frequencies of PTSD symptoms in the three groups, based on the three DSMIII-R PTSD criteria: reexperiencing symptoms (DSM-III-R criterion B>, symptoms of avoidance and emotional numbing (criterion C), and symptoms of increased arousal (criterion D). In the bum injury group, 9 of 26 (35%) patients fulfilled the

DSM-III-R diagnostic criteria for PTSD. In the digit amputation group, 5 of 27 (19%) fulfilled the DSMIII-R diagnostic criteria for PTSD. Although not shown in Table, 2 of 26 (8%) patients with burn injury and 2 of 27 (7%) patients with digit amputation fulfilled the DSM-III-R diagnostic criteria for major depression. Except for PTSD and major depression, other patients did not fulfiI1 the DSM-III-R diagnostic criteria for other psychiatric disorders, In the control group, healthy volunteers did not fulfill the DSM-III-R diagnostic criteria for any psychiatric disorders. As shown in Table 1, the number of cases judged as PTSD was significantly higher for the burn injury group than for the control group (x’: = 10.1, p = 0.001). Also, the number of cases judged as PTSD was significantly higher for the digit amputation group than for the control group (x2, = 5.1, p = 0.02). The number of PTSD symptoms by the DSM-III-II criterion B, C, and D was significantly higher for the burn injury group than for the control group !criterion B, x2, = 8.9, p = 0.003; criterion C, x2, -= 10.1, p = 0.001; criterion D, x2, = 6.2, p = 0.01. Also, the prevalence of PTSD symptoms by the DSM-III-R criterion B, C, and D for the digit amputation group was significantly higher than for the control group (criterion B, x2* = 19.0, p = 0.00001; criterion C, x*1 = 5.1, p = 0.02, criterion D, x2, = 15.4, r: = 0.00009). Table 2 shows the mean TAS scores in the subject and control groups. ANOVA analysis revealed that there were statistically significant differences among the three groups for the TAS scores (F - 14.8, df = 2,75, p = 0.0001). Post-hoc t tests after the ANOVA revealed that the TAS scores were significantly higher for the bum injury group than for the control group (t,, = 2.32, p = 0.02) and higher for the digit amputation group than for the control group (t,, = 5.92, f7 = 0.0000003). For secondary analysis, we examined the prevalence rates of alexithymia using the cutoff score of the TAS. The rate of alexithymia was 30.8% (8 of 26 patients with burn injury), 48.1% (13 of 27 patients with digit amputation), and 4.3 % (I of 24 healthy volunteers) in the three groups. The number of cases with alexithymia was significantly higher for the bum injury group than for the control group (x2* = 6.0, df = 1, p = 0.01) and for the digit amputation group than for the control group (x”, = 12.3, df = 1, p = 0.0004). In the burn injury group, there were significant positive correlations between the number of PTSD symptoms by criterion C and the TAS scores (TAS

123

I. Fukunishi et al. Table 1. PTSD symptoms

in subject and control

groups Subject groups Digit amputation

Healthy persons

(N = 27)

(N = 24)

N (%)

N (%)

N t%)

9 (35)“”

5 (19)”

0 (0)

20 (74)**

2 (8) 1 (4) 2 (8) 1 (4)

Burn injury (N = 26) PTSD symptoms Met DSM-III-R PTSD diagnosis (1) Reexperiencingsymptoms (DSM-III-R criterion B) Intrusive memories Recurrent dreams Flashbacks Intense distressat similar event Any (met criterion B) (2) Symptoms of avoidance and emotional numbing (DSM-III-R criterion C) Avoidance of thoughts related to event Avoidance of activities related to event Inability to recall aspectsof event Diminished interest in usual activities Feelingsof estrangementfrom others Restricted range of affect Senseof foreshortened future At least three symptoms (met criterion C) (3) Symptoms of increasedarousal (DSM-III-R criterion D) Difficulty sleeping Increasedirritability Difficulty concentrating Hypervigilance Increasedstartle response Physiological reactions to event At least two symptoms (met criterion D) Results Significant

are expressed difference

as number between

13 4 7 5 15

(5OY” (15) (27) (19) (58)**

9 (35)** 7 (27)* 6 (23)** 6 (23)** 7 (27)* 7 (27)* 9 (35P 9 (35P

9 4 9 8 7 6 13

(35Y (15) (35P (31)** (27)* (23) (5OP

0 (0) 22 (81)“” 1 (4) 21 (78)**

7 6 7 5 6 5 7 5

(26)* (22) (26)** u9j* (22) (19) (26)* (19Y

11 (41P

2 7 22 7 20 18

(7) (26) (81)** (26)+ (74)** (67)**

4 (17)

1 (4) 1 (4) 0 (0) 0 (0) 1 (4) 1 (4) 1 (4) 0 (0)

2 (8) 2 (8) 2 (8) 1 (4) 1 14) 1 (4) 3 03)

(%). subject

and control

scores, rz4 = 0.442, p = 0.03). As for the number of PTSD symptoms by criterion B and criterion D, no significant differences were noted. Also, in the digit amputation group, the number of PTSD symptoms by criterion C was positively correlated with TAS scores (rz5 = 0.430, p = 0.04). As for the number of PTSD symptoms by criterion B and criterion D, no significant differences were found. There was significant correlation between TAS score and percentage of facial disfigurement in the burn injury group (rz4 = 0.471, p = 0.02). However, no significant correlation on any pairing of physical assessment including ADL and emotional disturbances (DSM-III-R PTSD symptoms and alexi-

124

Control group

groups.

(Chi-square

test) *p < 0.05, **p < 0.01.

thymia) was found. In the digit amputation group, significant differences between physical assessments of function after digit replantation and PTSD symptoms (avoidance of thoughts related to event) and those between physical assessment and TAS score were found by simple correlational analysis Y25= 0.451, p = 0.03; 7-25= 0.398, p = 0.04. Among five categories of physical assessments,ADL score was most strongly correlated with a PTSD symptom and TAS score (rz5 = 0.633, p = 0.001; rq5 = 0.609, p = 0.002). In the digit amputation group, the results of this study were not influenced by number of amputated digits or the presence or absence of replantation. In

Emotional Disturbances Table 2. Assessments of alexithymia

Bum injury (N = 26)

TAS total score

67.3 t 8.8

TAS = Toronto Results Significant

were

Alexithymia expressed

difference

Patients

in subject and control groups

Subject groups Assessments of alexithymia

in ‘Itaurna

Control group

Digit amputation

Healthy persons

(N = 27)

(N = 24)

74.6 zt 7.8

Statistical analysis ANOVA

62.0 + 7.2

F

df

14.8

2, 74

P o.oool*~

i’ost-pot

f-test

._l..-_.--_l__

Brtrn :> Control** Digit 1 Control** Digit > Burn**

Scale. as mean

among

three

f SD. groups.

(ANOVA

and post-hoc

the two subject groups, the results of this study were not influenced by demographic data such as gender difference and years of education in both groups.

Discussion Many papers have demonstrated that plastic surgery patients with burn injury or digit amputation are prone to PTSD [6-9,11-131. The results of this study indicated that the prevalence rate of MSD is significantly higher for patients with burn injury than for healthy controls. Also, the rate of I’TSD was significantly higher for patients with digit amputation than for healthy controls. The prevalence rate of alexithymia assessed by cutoff score of the TAS was approximately 30.8% in patients with burn injury and approximately 48.1% in patients with digit amputation. The rate of alexithymia was significantly higher for injury patients than for healthy volunteers, indicating that injury patients are prone to alexithymia characteristics. Several studies have demonstrated that an emotional processing disturbance (e.g., restricted range of affect) seen in injury patients with PTSD is similar to alexithymia characteristics 118,191. One study reported on the importance of the construct of alexithymia among Vietnam veterans with PTSD 1181. The result, however, was obtained from the MMPI alexithymia scale which lacks reliability and validity 133-351. Alexithymia, assessed by the TAS with adequate reliability and validity [15,16,36-381, is the most valid measure. Zeitlin et al. [281 reported that 15 (60%) of 25 male Vietnam veterans with PTSD showed alexithymia as assessed by the 26-item TAS. This suggested the concurrence of alexithymia among Vietnam veterans with PTSD. Zeitlin et al.

t-test)

*p < 0.05, ‘“p < 0.01

1291 also reported that rape victims were more alexithymic than nontraumatized comparison subjects. Also, victims with a history of more than one episode of rape were more alexithymic than were subjects with a single episode. The two studies of Zeitlin et al. indicate that at least in some cases, alexithymia may develop as a means of avoiding painful affect. In this study, of the three IXM-III-R PTSD criteria, the severity of PTSD symptoms of avoidance and emotional numbing was significantly and positively correlated with the TAS scores. Results indicate that the PTSD symptoms of avoidance and emotional numbing are closely related to the construct of alexithymia. Although further examination that includes a longitudinal follow-up study is needed, the findings of this study suggest that alexithymia may be evident when an emotional processing disturbance of the PTSD svmptoms appears in injury patients. Since Hyer et al. have demonstrated that alexithymic characteristics among Vietnam veterans with PTSD are not significantly correlated with the subjective experience to stressors IlSl, we did not estimate patients’ subjective experiences to stressor. However, we examined the influence of patients’ physical indicators on psychiatric condition. The PTSD symptoms of avoidance and emotional numbing had a significant relationshjp with function after digit replantation, in particular for level of ADL. Alexithymia also had a similar relationship with physical conditions. The results of this study suggest that emotional disturbances (i.e., PTSD symptoms of avoidance and emotional numbing and alexithymia) may be influenced by level of functional recovery after digit replant&ion. In the burn injury group, although percentage of facial disfigurement was significantly and positively cor-

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et al.

related with the TAS scores, no significant relationship between the PTSD symptoms and physical assessments was found. There may be several reasons for this result, which differs from the result seen in patients with digit amputation. In this study, the homogeneity of the burn injury group was lower compared with the digit amputation group. As for the digit amputation group, reattachment of the amputated digits was possible in all patients. All patients received digit amputation in either hand and no patients had digit amputations in both hands. Thus, the homogeneity of digit amputation sample was relatively high. The severity of the burn injury group, however, ranged from slight to severe. This point is also seen in the large SD of two physical indicators in the burn injury sample. Moreover, compared with that in the digit amputation group, the assessment of ADL in the burn injury group greatly depended on the severity of injury itself. Although these limitations may influence the results of this study, two findings may be useful for liaison psychiatrists with trauma patients in plastic surgery: 1) alexithymia may be evident when an emotional processing disturbance of PTSD symptoms appear and 2) the emotional disturbances may be related to the level of functional recovery after injury. The results of this study must be viewed as preliminary because of the small number of injury victims examined.

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