P sych iatric Aspects o f Spinal C ord Injury A. J. LASICH physiotherapy, November 1986, vol 42 no 4 -H 3 ! SUM M ARY | The nature of behavioural and emotional reac- 1 tions displayed by persons with spinal cord injury are described and the value of psychiatric involvement in the routine management is dis- | cussed. The importance of emotional care of spinal cord injured patients is emphasized with ! reference to certain general principles. The psychiatrist should be accessible to both staff and patients for ventilation of feelings. S p in al co rd in ju ry (S C I) rep resen ts one o f th e m ost d e v a sta tin g disab ilities k n o w n to m an . T he severity o f th e lesion resu lts in th e to ta l d is ru p tio n o f th e v ic tim ’s life a n d m ay subject him to p e rm a n e n t suffering and in s titu tio n a liz a tio n . By fa r th e m a jo rity o f S C I p a tie n ts are m ale and usu ally y o u n g e r th a n 40 years o f age. T y p ically th e p a tie n t is a fit h e a lth y y o u n g m a n w ho has been accu sto m ed to physical activity. A p p ro x im a te ly h a lf o f th e S C I cases are p arap leg ics and the o th e r h a lf q u a d ri­ plegics. M o st injuries a re cau sed by m o to r vehicle accidents, w hile falls, g u n sh o t an d sta b w o u n d s a c c o u n t fo r a larg e p r o p o r tio n o f th e re m a in d e r. T h e m o rta lity ra te a m o n g s t th ese cases has fallen in recen t years w ith im proved n u rsin g tech n iq u es. R O L E O F T H E P S Y C H IA T R IS T It is felt by som e p ra c titio n e rs th a t th e p sy c h ia trist sh o u ld be involved in an in itial p sy c h ia tric ev a lu a tio n so o n afte r a d m issio n , i.e. d u rin g th e acu te stag e o f th e illness. T h e aim o f th is early c o n ta c t is to assess a) the co p in g strateg ies used by th e p a tie n ts in d ealin g w ith p ast stresses a n d b) th e need if an y , fo r fu r th e r psy­ c h ia tric in te rv e n tio n . T his in itial in terv iew helps to A. J. Lasich, M.B. B.Ch., D .P .M ., FF. Psych. Senior Sp e cia list/S en io r Lecturer, Dept of Psychiatry, Faculty of Medicine, University of N atal, D urban 4001 OPSO M M IN G Die aard van die gedrags- en emosionele reak- i sies wat vertoon word deur persone met rug- murgbesering word beskryf, en die waarde van psigiatriese inwikkeling in die roetine han- | tering word bespreek. Die belangrikheid van | die em osionele sorg van rugm urgbeseerde | pasiente word beklemtoon met verwysing tot | sek e re algem ene b eg in sels. Die psigiater behoort beskikbaar te wees vir die ventilasie van g em oedere deur b eide p erson ee l en pasiente. e sta b lish th e p sy ch iatrist as a m em b er o f the te a m and n o t reg ard ed as a stra n g e r sho u ld th e p a tie n t require assista n c e at a la te r stage o f th e illness. I m p o rta n t aspects o f th e p a tie n t’s h is to ry w hich need to be investi­ gated are his w ork history, social relatio n sh ip s, in fo rm a ­ tio n co ncerning pastim es, interests an d habits an d lastly, w h eth er he has know ledge o f som eo n e else w ith SC I. ' A p a rt fro m th e occasions w hen a p sy c h ia trist m ay be ask ed to a tte n d to a p a tie n t w ith sy m p to m s o f a p sy c h ia tric d is o rd e r, he sh o u ld w hen possible also be a v a ila b le to c o n d u c t g ro u p s fo r staff. It is im p o rta n t to re m e m b e r t h a t th e in d iv id u a ls (in c lu d in g e n ro lle d n u rsin g assista n ts) w ho have th e m ost c o n ta c t w ith the p a tie n t have th e g reatest im p a c t on his ad ju stm en t. S T A F F G R O U P S 1. F a c to rs th a t m ak e g ro u p w ork necessary are: a) C o n s ta n t e x p o su re to severely d isab led people is a n e m o tio n a lly d ep letin g ex p erien ce an d can challenge th e sta ff m e m b e r’s sense o f psychological well being. b) T he h ierarch ical stru c tu re o f the h o sp ital o rg a n iz a ­ tio n ru n s o n q u a si-m ilita ry lines in w hich resen tm e n ts flow do w n the c o m m a n d chain. c) P ro lo n g e d p a tie n t c o n ta c t w hich often results in positive an d negative feelings as ex perienced in any lo n g te rm relatio n sh ip . 2. F u n c tio n o f S ta ff G ro u p s a) G ro u p w ork allows fo r sharing and m u tu al support. b) V enting o f resen tm e n ts o r am b iv a le n t feelings w hich help to reduce pressure th a t can influence p atien t- s ta ff in teractio n s. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 114 Fisioterapie, November 1986, deel 42 no 4 c) B enefit o f p e e r feed b ack an d p sy c h ia tric in p u t b o th o f w hich can give perspective to the d is to rtio n s th a t arise so easily in this w o rk .2 P R O BL E M S TH A T M A Y BE E N C O U N T E R E D A N D R E Q U IR E A TTE N T IO N 1. M a n y o f th e p sy ch o lo g ical re a c tio n s w hich are ex p ected to o c c u r in th e p a tie n t w ith S C I are regarded as n o rm al: a) In the a c u te p h ase p a tie n ts m ay d evelop p h a n to m sen satio n s; th ey m ay feel as th o u g h th e ir extrem ities are lying in im possible p o sitio n s. T h e tr a u m a tic effort o f sp in al c o rd injuries o ften causes e x trem e fe a r e.g. o f dying, bein g a lo n e o r surgery. Feelings such as f r u s tr a ­ tio n , an x iety , a n g e r a n d d is a p p o in tm e n t tend to be felt m ore intensely by the S C I p a tie n t, as are issues of id en tity , m ean in g , v o catio n an d sexuality. F re q u e n t re a s s u ra n c e , a sk in g a b o u t fe a rs, c o m m u n ic a tio n by to u c h a n d in stillin g con fid en ce will help to alleviate the p a tie n t’s distress. b) In th e la te r stages one m ay e n c o u n te r p a tie n ts w ho are d e m a n d in g , a u to c ra tic and m an ip u lativ e. W hile th e b e h a v io u r m ay be m a la d a p tiv e , th e need it seeks to fulfil m ay be a d a p tiv e , i.e. to o b ta in a sense o f m astery o r c o n tro l over th e en v iro n m en t. A p a tie n t w ho is m a n ip u la tiv e an d v erbally abusive can p ro v e p a rtic u la rly d ifficult to m anage. E ffo rts to u n d e rs ta n d th e ad a p tiv e a n d h ealth y need being m et by these p a tie n t b e h a v io u rs will p e rm it the sta ff to a d d re s s the need ra th e r th a n be d is tra c te d by th e a ctin g o u t b eh av io u r. M an ip u la tiv e p a tie n ts can d is ru p t the e n tire s ta ff by p lacin g one n u rse a g ain st a n o th e r . A n g ry , u p se t s ta ff d o n o t p ro v id e g o o d care an d fin d in g o th e r av en u es o f c o n tr o l, e.g. n e g o tia tin g w ith th e p a tie n t tim es o f O ccu p atio n al T h erap y , P h y sio ­ th erap y , etc. will be helpful. 2. Specific p sy ch iatric d iso rd ers T h e p a tie n t m ay p re s e n t w ith a fu n c tio n a l p sy ch o tic d is o rd e r such as S c h iz o p h re n ia , B rief R eactiv e P sy ­ c hosis o r P a ra n o id D iso rd e r o r an o rg a n ic b ra in sy n ­ d ro m e, e.g. d e liriu m , hallu cin o sis. It is possible fo r a p e rs o n a lity d is o rd e r to becom e m an ifest u n d e r th e c o n ­ d itio n s o f severe d isab lin g illness. Less b e h av io u rally d isruptive illnesses such as D epression (M a jo r o r M inor) A nxiety S ta te s/D iso rd e rs m ay also occur. It is im p o rta n t to re m e m b e r th a t m a n y o f th e p sy c h o tro p ic d ru g s used to t r e a t p s y c h o tic c o n d itio n s a n d d e p re s siv e s ta te s possess a n tic h o lin e rg ic a n d hypotensive effects and th a t these effects are en h a n c e d as a re su lt o f th e sp in a l c o rd injury p articu larly in the quadriplegic patient. A nxiolytic a g e n ts a re u se fu l b e c a u se o f th e ir m u sc le r e la x in g p ro p e rtie s an d can be u sed to m a n a g e a n x ie ty w ith little risk .2 S om e p a tie n ts re q u ire p sy c h o th e ra p y w hich is neces­ sary to d eal w ith p sy c h o lo g ic a l sy m p to m s o f a su b je c ­ tively d istre ssin g n a tu re (acu te o r ch ro n ic) and w hich re q u ire m o re specific tech n iq u es o f m an ag e m en t. G E N E R A L PSY C H O L O G IC A L P R IN C IP L E S OF C A R E T h e tra g e d y in h o sp itals is th a t the en v iro n m e n t assum es an im p erso n al q u ality . 1. T h e p e rso n w ith S C I has dig n ity , value an d im p o r­ ta n c e . O ne sh o u ld reco g n ize th a t n o th in g a b o u t the e ssen tial v alu e an d w o rth w h ilen ess o f the p e rso n has ch an g ed as a re su lt o f th e injury. 2. A d e ta ile d e x p la n a tio n o f w h a t is b ein g d o n e and w hy as well as the c o n s ta n t presence an d reassu ran ce o f th e tr e a tm e n t te a m is re q u ire d to secure th e e m o tio n a l s u p p o r t o f S C I p a tie n ts. R eassu ra n c e an d s u p p o r t o f this n a tu re sho u ld also ex ten d to the p a tie n t’s im m ediate fam ily. It is necessary to o , th a t th e fam ily develop som e in sig h t in to th e a n a to m y an d p h y sio lo g y o f sp in al co rd injury. 3. S ta f f s h o u ld m ak e it p o ssib le fo r th e p a tie n t w ith S C I to experience an d enjoy fa v o u rite activities. 4. S ta f f sh o u ld avoid ta lk in g “a b o u t ”, “ o v e r”, or “f o r ” th e p a tie n t as th o u g h he w ere n o t th e re o r u n a b le / to ex p ress him self. T his advice s h o u ld ex te n d to the'! fa m ily as well. T h e use o f lab els sh o u ld be a v o id ed and the s ta ff sh o u ld c o m m u n ic a te respect by an n o u n c in g th e ir presence before en te rin g th e w a rd .3 C O N C L U SIO N S p in a l c o rd injury is one o f th e causes o f severe d isa b ility u su ally o c c u rrin g in th e very early years o f a d u lth o o d . T h e p erso n a b ru p tly becom es seriously d is­ abled a n d h a n d ic a p p e d w ith the e x te n t o f p a ra ly tic in v o lv em en t d e p e n d e n t on th e level o f th e lesion. T he m ed ical p ro b le m s a re m u ltifaceted a n d fre q u e n tly d iffi­ c u lt to solve. A p a rt fro m the m ed ical co m p lic a tio n s w hich re su lt, severe b e h a v io u ra l an d a d ju s tm e n t p r o b ­ lem s occur. T h e p a tie n t as a re s u lt o f in ju ry is re d u c e d to e c o ­ no m ic d e p en d en cy an d v a ry in g degrees o f physical dep en d en cy . T h e a ttitu d e o f the sta ff w hich is critical to th e p a ti e n t’s re h a b ilita tio n m u st be su p p o rtiv e w ith o u t u n re a listic goal setting. P e rs o n a l re a c tio n s su ch as h o s­ tility to th e d ifficu lt p a tie n t m u st be a v o id ed a n d a r u a tm o s p h e re o f calm , firm c o m m itm e n t m u st be m a i n " tain ed . T h e a p p ro a c h to th e c are o f su c h p a tie n ts h as to be co m p reh en siv e b earin g in m in d th a t the needs o f the p a tie n t an d the fam ily re q u ire m u ch m o re th a n tr e a t­ m e n t o f m edical p roblem s. References 1. F ra se r A. T he Psychiatrist in the Spinal Unit. A u st N Z J o f Psychiatry 1981; 16: 246-250. 2. S tew art T hom as D. S pinal C ord Injury: A Role for the Psychiatrist. A m J P sychiatry 1977; 134: 538-541. 3. B rackett TU , C ondon N, K indelnan KM , Bassett L. The E m otional C are of a Person with a Spinal Cord Injury. Brief R eport. J A M A 1984; 252: 793-795. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )