183 International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 Original Article Study on Post-Traumatic Stress Disorder (PTSD) Among Traumatic Amputated Patients Using DSM-5 Revised Criteria Refat Zahan1, Md. Abdur Rahman2, Md. Shamsul Huda Mamun3, Farhana Ferdaus4, Akhiruzzaman5, Rasheda Yasmin6, Sunjida Shahriah7, Mazharul Islam8 Abstract: Background: Limb amputation is a common surgical procedure done for therapeutic reasons to prevent further deterioration and save lives. Objective: To assess the level of post-traumatic stress disorder (PTSD) among trauma related amputated patients. Methods: This cross-sectional study was conducted between January and December of 2016 on 296 amputated patients who were admitted in the National Institute of Traumatology and Orthopedic Rehabilitation (NITOR), Dhaka, and BDM Hospital and Diagnostic Center, Dhaka, Bangladesh. A semi-structured, questionnaire was developed both English and Bangla (local language) using the variables of the study and validated. Using that tool, face to face interview was taken. The checklists were used to collect their socio-demographic characteristics, information regarding amputation and stress severity and diagnosis of PTSD, collectively termed as DSM-5. Results: Among 296 respondents, 213(72%) were male and 83(28%) were female. The mean age of the respondents was 32.013±5.35 years. PTSD was found in221 (75%), while the rest 75 (25%) had acute traumatic stressdisorder. Among PTSD patients, 10(50%) with digit amputated, 41(68.33%) of upper limb amputated, 155(77.11%) of lower limb amputated, and 15(100%) of both or multiple limbs amputated respondents. 61% had extreme level of stress. PTSD had significant association with sex, age, habitat, occupationposition and part of limb loss (P<0.05). Conclusion: In our country, PTSD is very common in amputated patients and has significant association with sex, age, habitat, occupation as well as part of limb loss. Multidisciplinary team of health professionals should emphasize on the need of amputees, both physically and psychologically and provide an effective rehabilitation plan. Keywords: Post-traumatic stress disorder (PTSD), amputated patient, CAPS-5, PCL-5, LEC-5. Correspondence to: Dr. Refat Zahan, Assistant Professor and Head, Department of Community Medicine, Ad-dinAkij Medical College, Khulna, Bangladesh. Email:dr.refat1986@gmail.com 1. Assistant Professor and Head, Department of Community Medicine, Ad-dinAkij Medical College, Khulna, Bangladesh. 2. Assistant Professor, Department of Pharmacology &Therapeutics, Ad-dinAkij Medical College, Khulna, Bangladesh. 3. Assistant Professor, Department of Forensic Medicine, Ad-dinAkij Medical College, Khulna, Bangladesh. 4. Assistant Professor and Head, Department of Community Medicine, Khulna City Medical College, Khulna, Bangladesh. 5. Assistant Professor, Department of Community Medicine,Diabetic Association Medical College,Faridpur, Bangladesh. 6. Assistant Professor, Department of Community Medicine, Nightingale Medical College, Ashulia, Dhaka, Bangladesh. 7. Professor and Director, Phoenix Wellness Centre, Dhaka, Bangladesh. 8. Professor and Head,Department of Community Medicine, Mugda Medical College, Dhaka, Bangladesh. International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 Page : 183-187 DOI: http://dx.doi.org/10.31344/ijhhs.v6i2.443 Introduction Limb amputation is a common surgical procedure performed by orthopedic, general, vascular and trauma surgeons to prevent further deterioration and save lives. However, loss of a limb due to trauma has a devastating emotional impact on a patient, escalating to mental trauma that may be more harmful than that the loss of the limb1. We know that in case of organic, tumoral, or infections, amputation is planned; in contrast, in traumatic amputations are unplanned. Thus, there is a certain sequential order regarding risk for developing mental disorders, starting from the immediate reaction to the acute stress disorder leading to and ending with the post-traumatic stress disorder (PTSD). It is mostly related to ones perceived image, which further aggravates the disability2. It has profound economic, social and psychological effects3. International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 184 Post-traumatic stress disorder (PTSD) is an anxiety disorder that can occur following the experience or witnessing of a traumatic event4-6. A traumatic event is a life-threatening event such as military combat, natural disasters, terrorist incidents, serious accidents or physical or sexual assault in adult or childhood5. PTSD develops in response to traumatic event. About 60% of men and 50% of women experience a traumatic event in their lifetime7. Most people who are exposed to a traumatic event will have some of the symptoms of PTSD in the days and weeks after the event. For some people these symptoms are more severe and long lasting. There are biological, psychological and social factors that affect the development of PTSD8,9. Due to the differences in indication and pattern of amputation between different countries and even different cities in a country. This study was performed to identify the traumatic events causes amputation, diagnose post-traumatic stress disorder (PTSD), by using DSM-5 published by the American Psychiatric Association (APA) in 2013,10 and to determine association between socio demographic factors with the development and severity of amputation (part of limb loss). Methods This cross-sectional study was conducted between January and December of 2016 on 296 amputated patients who were admitted in the inpatient departments of National Institute of Traumatology and Orthopedic Rehabilitation (NITOR), Dhaka, and BDM Hospital and Diagnostic Center, Dhaka, Bangladesh. Patients were selected based on the following inclusion and exclusion criteria: Inclusion criteria: 1) Amputated respondent with traumatic history; 2) Hospital admitted respondent. 3) Respondent will be included irrespective of sex. 4) Respondent’s willingness to participate in this study. 5) Day after amputation not more than 6months. 6) Children more than 7 years. Exclusion criteria: 1) Mentally unsound people; 2) Non-traumatic amputated patients; 3) Severely ill patient who will be unable to take part in the interview; 4) Child under 7 years. Convenience sampling technique was followed. After fulfilling the eligibility criteria,a total of 296 amputated respondents were taken in the study.Informed written consent was taken from the respondent before interview. Privacy of the respondents was ensured, and interview was not disclosed to any unauthorized person. Complete assurance was given that all information provided by the respondent will be kept confidential. A semi-structured questionnairewas developed both English and in Bangla (local language) using the variables and specific objectives of the study from the patients by face-to-face interview. It contained questions related to their socio-demographic characteristics, information regarding amputation and PTSD checklist (as follows): 1. A checklist was used to collect the Trauma related information ofamputated patients by LEC-5 (life event checklist -5).11 A single indextrauma was identified in an individual; 2. Then, Criteria A was used for applicability of PCL-5 and CAPS-5;12 3. After met the Criteria A, PCL-5 was used to provisional diagnosis andassess PTSD severity; 4. After provisional diagnosis, CAPS-5 (Past Week, Past Month and Worst Month Versions where applicable) was used for clinical diagnosis. However, before data collection, pre-testing of the questionnaire and checklist were used in the in-patient unit of PRIME Orthopedic Hospital, Dhaka, Bangladesh. According to the finding of pre-testing necessary modifications were in the questionnaire and checklist. Data were analyzed by Statistical Package for Social Science (SPSS) version 24.0. For descriptive statistics, means, standard deviation and ranges for categorical data were calculated as required. Data were presented in frequency table. For inferential statistics, chi-square(ꭓ2) test was done to analyze association of PTSD with different parameters. Results The mean age of the respondents was 32.013±5.35 years.Among 296 respondents, 128 (43.3%) were from the age group 20-29 years while about 52 (17.5%) of them were from the age group 185 International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 Table 1. Socio-demographic characteristics of the participants (N=296) Variables Frequency Percentage Age group 7-19 50 16.85 20-29 128 43.3 31-49 52 17.5 50-59 48 16.2 60 and above 18 6.1 Mean age 32.013±5.35 Sex Male 213 72 Female 83 28 Habitat Rural 172 58.1 Sub-urban 46 15.5 Urban 78 26.4 Education Illiterate 75 25.3 Self-educated 6 2 Primary 97 32 Junior Secondary 38 12.8 Secondary 47 15.9 Higher Secondary 21 7.1 Graduate 12 4.1 Occupation Unemployed 11 3.7 Student 50 16.9 Housewife 46 15.5 Transport Driver andHelper 37 12.5 Day Labourer 51 17.23 Industrial Worker 51 17.23 Business 34 11.5 Civil Service 16 5.4 Marital status Married 152 51.34 Unmarried 144 48.65 Income level <10000 BD Taka (Lower income group) 87 29.39 <25000 BD Taka (Lower middle income group) 170 57.43 <50000 BD Taka (Uppermiddle income group) 28 9.46 >50000 BD Taka (High income group) 11 3.71 30-49 years, 50(16.85%) were child and adolescents and 48 (16.2%) from 60 years and above. 213 (72%) were male and 83 (28%) were female. Most of the respondent 172 (58.1%) came from Rural area, 78 (26.4%) from urban area and rest were from sub-urban area 46 (15.5%). Most of the respondent 97 (32%) completed primary education. The remaining 25.3% were illiterate, 15.9% were completed secondary education, while 12.8%, 7.1%, 4.1%, and 2% were completed junior secondary education, higher secondary, graduate studies, and self-educated respectively. By occupation, industrial worker 11 (3.7%), 51 (17.23%), whereas 50 (16.9%), 46 (15.5%), 37 (12.5%), 51 (17.23%), 51 (17.23%), 34 (11.5%) and 16 (5.4%) were unemployed, students, housewives, transport driver and helper, day labourer, industrial worker, businessman, drivers, in civil service respectively. 152 (51.35%) were married and 144 (48.65%) were unmarried. Majority of the respondent 170 (57.43%) were from lower middle socio- economic status) had monthly family income of taka 11000-25000 (Lower socio-economic status), 87 (29.4%), 28 (9.5%) had monthly family income up to 10000 taka, and 26000 -50000 (Upper middle socio-economic status) taka while lowest no of the respondent 11 (3.71%) had monthly family income 51000-100000 (Upper socio-economic status) taka(Table 1). Age, sex, habitat and occupation are associated to events of PTSD among the respondents(Table 2).Most of the events231 (78%) happened due to road traffic accidents, while 56 (19%) at working place, 6 (2%) at home working and 3 (1%) by explosion through bombs/firearms.Among the respondents diagnosed with PTSD, 10 (50%) had only digits amputated, while 41 (68.33%) had upper limb amputated, 155 (77.11%) lower limb, and 15 (100%) had both/multiple limbs amputated. The difference was statistically significant (P<0.05)(Table 3). International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 186 Table 2. Association of prevalence of PTSD with age, sex, living and occupation Variables Distribution of PTSD Chi- square (ꭓ2) P value Yes No Age group 7-19 40 10 13.7916 0.007991 20-29 106 22 31-49 32 20 50-59 30 18 60 and above 13 5 Sex Male 148 65 10.7683 0.001033 Female 73 10 Habitant Rural 155 17 55.5071 0.00001Sub-urban 20 26 Urban 46 32 Occupation Unemployed 11 0 52.769 0.00001 Student 40 10 Housewife 40 6 Transport Driver andHelper 17 20 Day Labourer 45 6 Industrial Worker 46 5 Business 16 18 Civil Service 6 10 Table 3. Association between PTSD and part of limb loss Amputation Distribution of PTSD Chi- square (ꭓ2) P value Yes No Digit 10 10 13.43 0.003793 Upper limb 41 19 Lower limb 155 46 Both limbs 15 0 Discussion In the present study, the mean age of the respondents was 32.013±5.35 years; 72% of the respondents were male and 28% female. In a study done by Dar et al.13in Kashmir region of India, there was a higher rate of morbidity in females than in males following trauma (45.87% vs. 40.68% respectively). In another study done by Mansoor et al.14, males out-numbered females by approximately 4:1 ratio (79% vs. 21%). Higher prevalence of PTSD in females was also reported in the study done by Bryant & Harvey15. Male predominance could be derived from the reason that ours is a patriarchal type of society, where men are the bread earners of the family and the women usually prefer to stay at home. Another reason could be that men report for rehabilitation and also seek help for their psychological problems more readily than women. In the present study, the young age group suffered most trauma and subsequent morbidities. Dar et al.13 reported that maximum number of cases with trauma and subsequent morbidities belonged to 20-40 years age group (P <0.001). Mansoor et al.14reported that majority (45%) of the amputees were males in the age group of 15-30 years, followedby 30% in the age group of 31-45 years and 25% in the age group of 46-60 years. Similar evidence was produced by the study done by Pooja & Sangeeta.16 The amputees in that report were at young age. This may be due to the fact that most amputations were due to trauma, which occurred more frequently in younger people who led more active lives. However, victim suffering from PTSD at a young age may not benefit from powerful confronting strategies and need more times to be able to develop effective coping strategies and implement them.17 We Observedthat majority (81%) of the cases were from rural areas with low literacy rates. Similar results were found in the study done by Mansoor et al.14 Most likely explanation for this observation is that the majority (74.9%) of the population in the sub-continent region are from rural background and the literacy rate is low that of urban areas. Limitations of the study Although optimum care had been tried by the researcher in every step of this study, still some limitations exist.The study population was not taken from the population of all the amputated cases of the community, rather the sample was representative of only those amputated cases who got admitted in in-patient unit of specialized hospitals. No follow up of amputated respondent was possible as because they came from different areas of the country. There were no similar studies conducted before in the country, making our task arduous in finding out relevant information. Our study period was short and sample size was small, due to the budget constraint. 187 International Journal of Human and Health Sciences Vol. 06 No. 02 April’22 Conclusion Our data suggest that PTSD is very common in amputated patients in our country and symptom severity has significant association with sex, age, socio-economic status as well as part of limb loss and time passed after amputation. Multidisciplinary team of health professionals should emphasize on the need of amputees, both physically and psychologically and provide an effective rehabilitation plan. Conflict of interest: None declared. Ethical approval issue: Ethical clearance was taken from the Institutional Ethical Committee of National Institute of Preventive and Social Medicine (NIPSOM), Dhaka, Bangladesh. Funding statement: No funding. Authors’contribution: Conception and design of the study: RZ, MI; Data collection and compilation: RZ, MAR, MSHM, FF, AZ, RY, SS; Data analysis: RZ, SS; Manuscript writing, revision and finalizing: RZ, MAR, MSHM, FF, AZ, RY, SS, MI. References: 1. Monson CM, Resick PA, Rizvi SL. Posttraumatic stress disorder. In: Barlow DH. ed. Clinical handbook of psychological disorders. New York: Guilford Press; 2014: p.80-113. 2. Mckechnie PS, John A. Anxiety and depression following traumatic limb amputation: a systematic review. Injury. 2014;45(12):1859-66. 3. Clasper J, Ramasamy A. Traumatic amputations. Br J Pain. 2013;7(2):67-73. 4. Cavanagh SR, Shin LM, Karamouz N, Rauch SL. Psychiatric and emotional sequelae of surgical amputation. Psychosomatics. 2006;47(6):459-64. 5. Giummarra MJ, Fitzgibbon BM, Tsao JW, Gibson SJ, Rich AN, Georgiou-Karistianis N, et al. Symptoms of PTSD associated with painful and nonpainful vicarious reactivity following amputation. J Trauma Stress. 2015;28(4):330-8. 6. 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