Chapter 26: Psychosocial Disorders

Psychosocial factors pertain to the psychological development of an individual in relation to his or her social environment.¹ Psychosocial factors are numerous, as a person's psyche is affected by countless events in the internal and external environments. This chapter focuses on the psychosocial factors that may influence the direction of physical therapy intervention. Some examples of psychosocial factors include premorbid status or mental illnesses, personality styles, coping strategies, defense mechanisms, and emotional reactions to disability. Others include spirituality, values, environment, adjustment, cognitive abilities, motivation, family, social supports, life roles, and educational level. All of these factors can affect patients and treatment outcomes.

This chapter (1) identifies and describes how psychosocial factors can influence rehabilitation; (2) demonstrates how to address such factors during physical therapy intervention; and (3) provides indications for referral to psychosocial rehabilitation specialists. Psychosocial factors profoundly affect a patient's ability to recover. Patients who are emotionally upset will have difficulty concentrating on physical therapy goals until emotional issues are addressed. If a patient is motivated to participate in rehabilitation, but his or her family members do not support the patient's rehabilitation goals, the patient will be unlikely to progress on returning home. Mental health status has been shown to be one of the most important predictors of physical health.² Wickramasekera et al³ found that more than 50% of all visits to primary care doctors involved somatic complaints resulting from psychosocial problems. Patients with physical disabilities may fail to respond to treatment if a prominent psychosocial issue is affecting them as well.

Treatment outcomes will be influenced by patients' perceptions of their role in the rehabilitation process. Patients who believe that they possess control regarding their treatment and feel respected by staff tend to experience better health outcomes.^4,5 Empowerment, education, inclusion in goal setting, and a high level of engagement are important factors that positively influence recovery.

The mind and the body are highly connected.⁶ Because of their reciprocal influence, psychosocial and physical issues should be addressed simultaneously to best facilitate recovery. A slow recovery may cause or prolong depression, which may in turn further delay the rehabilitation period. Watts⁷ believes that mental health interventions should be provided to all rehabilitation patients, because health outcomes tend to be poor and prolonged when psychosocial problems remain unaddressed.

Physical therapists regularly encounter patients who have psychiatric illnesses. Psychiatric conditions occur with some frequency in the general population (Table 26.1), but occur at an even higher rate in rehabilitation settings.⁸ For instance, panic disorder occurs in 10% to 30% of patients treated in cardiovascular, respiratory, and neurological rehabilitation units, and in 60% of those treated in cardiology clinics (compared to 1% to 2% in the general population).⁹ Conversion disorder has been reported to occur at a rate of up to 14% in general medical or surgical inpatient units (compared to 0.5% in the general population).¹⁰ Friedland and McColl¹¹ found the prevalence of depression and substance abuse to be significantly higher among people with disabilities than in the general population, as did Turner and Beiser,¹² who documented the rate to be three times higher regardless of gender and age. Seventeen percent of senior adults with disabilities also had a diagnosis of major depression, and 14% had mild depression that interfered with daily activities.¹³ Twenty-seven percent of patients with stroke were found to be depressed—a finding that correlated with poorer rehabilitation outcomes.¹⁴ Patients with traumatic brain injury (TBI), spinal cord injury (SCI), and Parkinson's disease also reported higher levels of depression compared to the general public.^15,16

If a patient does not have a preexisting psychosocial illness, he or she is more likely to develop one after the onset of physical illness. Anxiety disorders can result from endocrine (e.g., hyperthyroidism and hypothyroidism, pheochromocytoma, hypoglycemia, and hyperadrenocorticism), cardiovascular (e.g., congestive heart failure, pulmonary embolism, and arrhythmia), respiratory (e.g., chronic obstructive pulmonary disease, pneumonia, and hyperventilation), metabolic (e.g., vitamin B₁₂ deficiency and porphyria), and neurological conditions (e.g., vestibular dysfunctions, encephalitis, and neoplasm).⁹ The onset of depression has also been linked to the presence of an existing physical disability.^11,12 There is evidence for the converse as well; the longer one possesses some form of mental health concern, the greater the risk for developing a physical illness. Depression is a risk factor for heart disease and post-stroke mortality.^17,18 Heinemann et al¹⁹ found that alcohol-related automobile accidents are responsible for a significant number of SCIs, and Zegans²⁰ reported that psychological problems could be exacerbated by physical illness or injuries. Anxiety can also increase the risk of cardiovascular disease and hypertension.²¹

Although the co-occurrence of physical disabilities and mental illness is high, the rate of treatment for mental illness among people with disabilities is low. In 1997, only 23% of adults with depression, 38% with anxiety disorders, and 47% with serious mental illness received treatment.¹³

A thorough examination of the patient's psychological and social functioning can contribute significantly to a better understanding of needs, fears, anxieties, and capabilities, as well as furnish essential information about the patient's emotional adjustment to disability, assets and liabilities, personality structure, and cognitive functioning. These can then be used to better understand the patient's emotional barriers and behavioral difficulties that can impede recovery. Although not inclusive, Box 26.1 highlights the major areas of consideration in a mental health examination.

Whether physical therapists should address psychosocial issues during treatment or refer psychologically impaired patients to other professionals depends on several variables: (1) the severity of the patient's psychosocial issue; (2) the level of comfort with which the physical therapist can address psychosocial problems; and (3) the patient's ability to progress in rehabilitation if existing psychosocial issues are not addressed. Professionals to whom referrals may be made for additional psychosocial intervention include but are not limited to psychiatrists, psychologists, psychiatric nurses, occupational therapists, social workers, creative arts therapists, vocational counselors, rehabilitation counselors, substance abuse professionals, and pastoral counselors.

The combination of intense psychological stress, uncertain prognosis, prolonged treatment, and interference with daily activities can greatly affect the rehabilitation of patients with disabilities and chronic illnesses. Disability is loss of or diminished ability to perform specific social roles normally expected of the patient. Psychosocial adaptation to disability and chronic illness is an ongoing, dynamic, evolving process through which a patient strives to attain an optimal state of function within his or her environment.²² Successful psychosocial adaptation may be characterized by (1) a sense of personal mastery; (2) participation in social, recreational, or vocational pursuits; (3) successful negotiation of the environment; and (4) a realistic awareness of one's current strengths, deficits, and functional capacities.²³ Adjustment is the final phase in adaptation and includes striving to achieve life goals, feeling self-confident and having positive self-esteem, possessing a positive attitude toward one's disability, forming emotional connections to others, and establishing a community member role.²⁴

The processes of adaptation and adjustment are influenced by whether or not a chronic illness or disability is congenital or adventitious, of sudden onset or gradually progressive, and stable or unstable. Patients born with a physical disability and those who acquire them as a result of accident or disease later in life have substantial psychological differences.²⁵ Children born with a physical disability have only experienced life with their impairment; the development of their self-identity commonly mirrors that of children without disabilities.

In contrast, patients with adventitious disabilities often experience acute loss and grief. Patients with gradually progressive diseases or disabilities of sudden onset often experience anxiety and shock when first becoming aware of their condition. Such anxiety and shock is often followed by anger and depression, as patients realize the magnitude and consequences of their diagnosis.²² Disabilities of sudden onset (e.g., injuries or accidents) are usually experienced as crises that will change the lives of patients and their families for all time.

Grief, Mourning, and Sorrow

Grief is a psychological state of distress resulting from a significant loss. In reaction to a disability, grief may emerge from lost function, broken relationships, the loss of one's familiar self-identity, and disrupted roles. Grief is characterized by preoccupation with loss and feelings of worthlessness or helplessness. Specific symptoms include feelings of tightness of the throat, muscular weakness, emptiness in the abdomen, anxiety that is described as painful, shortness of breath and choking, and periodic waves of physical distress lasting up to an hour. Other symptoms may include forgetfulness, poor concentration, dissociation, insomnia, loss of appetite, compulsive behavior, an inability to manage time in a productive manner, disorganized cognitive functioning, social withdrawal, guilt, decreased ability to make decisions, excessive speech, and hostility.²⁶ Severe, prolonged cases of grief can compromise the immune system.²⁷ The grief–mourning period is unpredictable, lasting anywhere from 6 months to 2 or more years. According to Donatelle and Davis, the grieving process consists of 10 stages: (1) frozen feelings; (2) emotional release; (3) loneliness; (4) physical symptoms; (5) guilt; (6) panic; (7) hostility; (8) selective memory; (9) struggle for a new life pattern; and (10) a sense that life is okay.²⁶ It is important to note that such stages do not always occur in a progressive linear fashion, and some stages may occur simultaneously.

Grief is a natural experience necessary to regain or adapt to one's losses and construct a new self-concept. New coping skills are learned as patients adjust to unfamiliar challenges. There may be a difference between people grieving over loss from a disability and those grieving over other types of losses.²⁷ When grief occurs as a result of disability, it may become prolonged, as the patient must continuously strive to accept the disability and his or her altered self. Burke et al²⁸ described the grief of people with disabilities as "chronic sorrow," or a grief regarding the loss of normality. Lindgren et al²⁹ defined chronic sorrow as (1) progressive sadness that often increases after the initial loss; (2) prolonged periods of sorrow with no predictable end; and (3) recurrent or cyclic in nature as the sadness is continuously triggered by internal or external events that reawaken loss. Patients with chronic sorrow can eventually experience adaptation to their losses if they are highly motivated to rebuild their lives and find meaning in their experience. Conversely, patients with pathological grief often experience prolonged feelings of guilt, anger, and sadness that inhibit function and adaptation.

It is important to recognize that grief can be an all-encompassing experience that can take time and energy away from rehabilitation, thereby affecting the process of rehabilitation and its outcomes. Physical therapists must understand grieving, mourning, and sorrow so that a patient's lack of progress or motivation is not misinterpreted as malingering.

Phase Models of Psychosocial Adaptation

The literature regarding psychosocial adaptation to chronic disability and illness falls into two opposing theories of adaptation—one in which adaptation occurs as a set of nonsequential and independent patterns of behavior, and the other in which adaptation occurs progressively through a series of phases.

Phase models suggest that a patient's reaction to chronic disability or illness follows a stable sequence of phases, or stages, that are hierarchically and temporally ordered. This progression is gradual, linear, and involves the psychological assimilation of changes to one's body image and self-concept. The most frequently identified phases in the adaptation to chronic disability and disease are shock, anxiety, denial, depression, internalized anger, externalized hostility, acknowledgment, and final adjustment.²²

Shock

Shock usually occurs as the initial reaction to a psychological trauma or severe and sudden physical injury. It results from an overwhelming experience and may include the inability to move or speak, psychic numbness, decreased cognitive skills, disorganization, and depersonalization.

During a traumatic event, an individual will respond primarily at the physiological level; emotional reactions are commonly delayed until the event is over and the individual is medically stable. Likewise, the medical emergency team will first implement immediate lifesaving attempts before addressing accompanying psychological issues.

During a perceived or real catastrophic event, an organism would most likely respond with what Selye termed the general adaptation syndrome (GAS).³⁰ Selye described GAS as an organism's defensive adaptation attempt, which expresses itself through physiological and emotional responses aimed at dealing with such emergencies. During GAS, there is a physiochemical chain reaction, whereby a peptide called corticotropin-releasing factor (CRF) is secreted to stimulate the release of adrenocorticotropic hormone (ACTH). ACTH sets into motion an increase of specific physiological activity designed to maximize the body's defense capacity while minimizing the utilization of nonessential physiological activities. Although an increase in CRF serves the person's self-defensive strategies, its inhibitory effect on other body functions—such as the production of insulin and calcium—is undesirable in the long run.

Studies have shown that injection of a CRF antagonist reduces anxiety in stressful situations.³¹ When the inhibitory effects of CRF are prolonged, however, the additional undesirable effects of hypertension, digestive problems, and interference with the immune system result. Selye³⁰ documented the devastating effect that a prolonged GAS response has on human mental and physical functioning.³⁰ Theorell et al³² documented the occurrence of resultant illnesses long after the stress-producing event had ended.

Anxiety

Once the magnitude of the traumatic event is comprehended, anxiety in the form of a panic-stricken reaction commonly occurs and is marked by compulsive activity, confusion, elevated pulse rate, difficulty breathing, and cognitive flooding (e.g., when emotions such as anxiety preclude logical thought). Situations that activate the sympathetic nervous system through repeated alarm or chronic stress may alter synaptic transmission and lead to depression and malfunction of normal body systems.

It should be noted that the physiological and psychological reactions to stress are not limited to catastrophic conditions. An extensive body of research shows stress reactions to be present in individuals under conditions that may not be traumatic but nevertheless persistent and disruptive. Everyday life frustrations, internal and external conflicts, and changes in life conditions are major causes of the stress reaction that, over time, have a deleterious effect on a person's function and health. Physical therapists should be cognizant that even though a patient's emergency situation is over, a stress reaction may continue to be present.

Denial

Denial is often used as a defense mechanism to alleviate the anxiety and pain associated with a disability or illness. Denial occurs as a specific phase early in the adaptation process and protects the person from having to confront the overwhelming implications of illness or injury all at once. Instead, denial allows a gradual assimilation of one's altered reality. Breznitz³³ identified seven types of denial:

1. Denial of threatening information (using selective inattention and partial awareness)

2. Denial of vulnerability (exerting control and maximizing personal strengths)

3. Denial of urgency (using methods to see the situation as less pressing than it is)

4. Denial of affect (reduction of emotional impact)

5. Denial of affect relevance (diverting attention to other issues and believing that an emotion is coming from an unrelated cause)

6. Denial of personal relevance (attributing difficulties to a benign cause and blaming others when involvement was one's own)

7. Denial of all information (creating a barrier between external reality and one's psyche resulting in total disbelief of having an illness or disability)

Patients in the stage of denial may selectively attend to the environment, choose facts that support their beliefs about themselves and their condition, and ignore facts that remind them of their new challenges. They may have unrealistic and wishful goals for recovery and may be seen as indifferent and aloof.

Depression

The phase of depression occurs as denial lessens, allowing a greater awareness of one's losses. Depression is a reactive response of bereavement for impending death, suffering, or the loss of body function. Neurochemical and biological changes resulting from disability or disease, premorbid personality and family history, and reactions to stress have all been identified as risk factors for depression.^34,35

Internalized Anger

Anger occurs in reaction to anxiety, misperception, threats of abandonment, feelings of helplessness, or fear of losing control. Characteristics of anger include hostility, resentment, or hatred. Anger is a response to loss and if not expressed is termed internalized anger. Internalized anger is associated with self-blame and is a manifestation of self-directed bitterness and resentment. Signs of internalized anger include manipulation, sabotage, and passive-aggressive behavior. Sometimes anger emerges when a patient attributes his or her own behaviors to the onset of disability or disease. In such cases, internalized anger can result in depression, suicidal tendencies, or psychosomatic complaints—particularly in people who have a chronic condition.³⁶

There are many reasons why patients may not express anger: fear of losing loved ones or social isolation, cultural restraints, lack of awareness, fear of losing control, or belief that expressing anger is inappropriate or dangerous. Repressed anger not only affects a patient's psychological well-being, but may also slow rehabilitation. It is important for physical therapists to encourage expression of angry feelings by providing a safe environment for patients to verbalize their anger in appropriate ways. Therapists might state that anger is a normal emotion—especially under the patient's circumstances— offer reasons why it is important to express anger, and provide anger management techniques (e.g., effective coping strategies). It is equally important for therapists to understand that although a patient's anger may be directed at the therapist, such anger more often reflects the patient's own projected feelings regarding his or her disability.

Externalized Hostility

Externalized hostility is anger directed toward other people or objects in the environment and is an attempt to retaliate against activity limitations. Challenges encountered during rehabilitation may trigger externalized hostility. As time from the onset of the disability passes, externalized hostility tends to become more apparent.³⁷ Signs include passive-aggressive behaviors that obstruct rehabilitation, aggressive acts, hypercriticism, demanding or antagonistic behaviors, falsely blaming others, and abusive accusations. Patients who express anger aggressively through physical or verbal abuse, sarcasm, or controlling behaviors need the help of the entire team to redirect their anger into productive therapeutic activities that further their rehabilitation goals.

Acknowledgment

Acknowledgment is the first sign that the patient has accepted or recognized the permanency of the condition and its future implications. The patient begins to integrate activity limitations into his or her self-concept. During this phase, the patient accepts himself or herself as a person with a disability, develops a new self-concept, reassesses values, and searches for new goals and meaning.

Adjustment

Adjustment is the final phase in adaptation and involves the development of new ways of interacting successfully with others and one's environment. The person is now adjusted to the outside world after having fully assimilated his or her activity limitations from disability into a new, cohesive self. In this phase, the person regains self-worth, understands that new potentials are possible, pursues vocational and social goals, and overcomes obstacles that arise in the attainment of goals.

There is evidence that the phase model of adjustment to chronic disability or illness is nonlinear, multidimensional, and progressive. Phase models tend to have 10 common assumptions:²²

1. People may skip one or more phases or may regress to an earlier phase, but adaptation is not usually reversible.

2. The pace and structure of adaptation can be influenced by external events or interventions (e.g., environmental changes or counseling) yet are mainly determined by internal processes.

3. Not everyone achieves adjustment; some fixate at earlier phases.

4. Adaptation is an unfolding, dynamic process that gradually shifts from initial experiences of distress to assimilation of loss and reconciliation.

5. The adaptation process is initiated by significant and permanent changes in the body's functional capacities and appearance, which are usually followed by alteration of self-concept and body image.

6. The amount of time spent in each phase varies and may be determined by a combination of the following factors: social support, financial and human resources, past exposure to crises, age at onset, severity, nature of the disability or illness, and premorbid personality.

7. Psychological maturity and growth occur as the patient progresses through the phases.

8. Psychological re-equilibrium occurs through gradual adaptation and integration of the perceived misfortune.

9. Human variability and uniqueness have a strong influence on the temporal ordering of phases—the sequence of phases is not universal.

10. Occasionally, phases may overlap, be nondiscrete, or fluctuate, causing patients to experience more than one reaction at a time.

Chronic Illness and Disability: Differences in Adaptation

There are marked differences in the way that people adapt psychosocially to a disability associated with a traumatic event—such as TBI—versus a chronic illness— such as multiple sclerosis (MS). The onset of disability in a traumatic event is sudden, and medical stability may be achieved shortly after. The onset of a chronic illness is usually insidious and gradual; its course is often uncertain and marked by states of remission and deterioration.³⁸ In chronic illness each onset of symptoms can be experienced as a new illness.

Shock may not be experienced by people with gradually deteriorating medical conditions (e.g., Parkinson's disease, rheumatoid arthritis, or diabetes mellitus), but is usually experienced following a trauma (e.g., TBI, myocardial infarction, amputation, or SCI). The phases of anxiety and depression relate more to the past, such as grieving over the loss of premorbid functioning. Shock may be present but not as strong in people with life-threatening or end-stage diseases (e.g., AIDS, cancer, or amyotrophic lateral sclerosis). In a chronic illness, anxiety and depression relate more to the future (e.g., fear of death, feelings of hopelessness, and fear of the unknown).³⁹ The acknowledgment and adjustment phases may be more difficult to achieve in chronic, life-threatening conditions that require the internalization of and acceptance that the condition may worsen and result in death.

Post-traumatic Rehabilitation

The post-traumatic period may include phases of anxiety, depression, denial, internalized anger, and externalized hostility mentioned earlier, and is usually the time during which much, if not most, of the rehabilitative intervention takes place. It is also the period during which the psychological effects of the traumatic experience are more strongly felt by the patient. It seems as if the psychological defenses and reactions that became secondary during the initial traumatic period (shock phase) begin emerging as the physical injury is dealt with. These repressed reactions seem to interact with a growing awareness of the effects of the disability creating fears, anxieties, and behaviors that the rehabilitation team must address.

Regardless of which phase the patient is in, physical therapists need to be aware of each patient's psychological needs. During the initial phases of adaptation, patients may experience an awareness of their injuries that facilitates panic and fear of total dependence. Patients may also experience anxiety as a result of anticipating painful medical treatment. Some patients react to these feelings by desperately seeking control over their rehabilitation. Others experience shock regarding their losses and become overly dependent. Patients may idealize the past and have unrealistic expectations about the duration of their recovery.

During these early stages, physical therapists should praise small gains and work with caregivers so they can offer hope and support to the patient. Therapists should be supportive but careful not to make unrealistic predictions about the expected degree of recovery, because this may lead to disappointment, resentment, and depression.⁴⁰ One of the first approaches physical therapists can use to help patients regain self-control is diaphragmatic breathing, which may decrease pain and anxiety through the relaxation response.⁴¹

During the middle stages, physical therapists may need to educate patients about medical precautions, contraindicated movements or activities, how the patient's body has adapted to disability, and how to reformulate expectations. Psychosocial instruction should be integrated with information about activities of daily living (ADL), mobility, strengthening, and endurance. The transition from the patient role to an independent adult member of society is a difficult adjustment and can result in anxiety, depression, and poor social integration.^22,42 Physical therapists should help patients prepare psychologically for discharge and reintegration into society. Some of the issues that patients may fear include negative reactions to their disability, feelings of inadequacy, having to identify new social supports, receiving help in the home environment, and adjusting to a new body image.

Body image includes judgment about one's appearance, an awareness of boundaries and personal space, judgment about one's bodily responses, perception of one's body parts and their movement, and an awareness of physical pleasure and pain. Body image is intimately related to self-concept and self-esteem. It affects a person's functional abilities, cognition, perceptions, attitudes, and emotions, as well as the reactions of others to oneself. Because body image changes throughout life, it is thought to be both dynamic and developmentally based. Difficulties brought on by a disability—such as activity limitations and pain and disfigurement—alter body image and threaten its stability. Patients must then reconstruct their body image and self-perception to adapt to this physical change.²²

Biordi⁴³ has identified the following patterns in patients who experienced shifts in body image after disability: (1) denying the existence of one's body; (2) fantasizing about a lost or damaged body part being magically replaced or healthy; (3) concentrating solely on noninjured body parts in order to deny impairment of the affected area; and (4) experiencing a period of defensiveness followed by gradual acceptance and assimilation of their altered body.⁴³ The physical therapist's comfort level with the patient's physical disability and the therapist's attention to the affected body part may help the patient feel less ashamed about body changes.

The more a patient has evolved socially and psychologically, the better he or she will be at using adaptive methods to deal with crises. Hence, a patient with a healthy premorbid personality but a severe physical disability may do better in rehabilitation than one with a less severe disability and a pathological premorbid personality.⁴⁴ When aware of their patients' personality styles, physical therapists will be more adept at strategizing interventions, developing a plan of care (POC), and motivating and guiding patients through rehabilitation.

Personality Types

Although each personality is unique, personalities have been categorized into different types, such as type A, perfectionistic, authoritative, and passive-aggressive. These personality types are nonpathological and develop in response to one's environment when young.

Individuals with type A personalities have a compulsive need to be achievers in all aspects of life. They are extremely independent and productive. These qualities also serve as defenses against low self-esteem and interpersonal conflicts. These people usually derive satisfaction from being strong individuals who can help others. If they can no longer participate in this role, they may become depressed because of a perceived inability to confirm their worth through altruistic activities. Physical therapists can use these qualities in patients with type A personalities to motivate their interest in rehabilitation. Because they are often self-starters and take initiative for their own learning, they can usually be depended on to independently practice home exercise programs (HEPs).

Individuals with perfectionistic personalities uphold high standards in order to maintain self-esteem. These individuals judge themselves by inflexible and possibly unachievable criteria and may not be able to tolerate slow progress during rehabilitation. Physical therapists may aid these patients by helping them derive pleasure from simple things, such as a meal, a sunset, a new shirt, or interesting information. Helping them discover value in these things offers them sources of self-esteem other than meeting impossibly high standards.

Individuals with authoritative personalities need to be in control and need things to be done in a particular way because of rigid perceptions regarding values, rules, and the manner in which others should behave. They are often concerned with status, tend to be judgmental, and have difficulty empathizing with others. During rehabilitation, these patients may try to dictate their treatment and engage in a power struggle with their physical therapists. Patients with authoritative personalities have difficulty adapting to disability, which often requires acceptance and compromise. They may require alternative strategies to solve what may have been perceived as an unsolvable problem. Physical therapists should engage patients in problem solving to generate strategies to meet their goals.

Individuals with passive-aggressive personalities express hostility by using passive techniques such as procrastination, resistance, stubbornness, and intentional inefficiency. These personalities react to authority negatively and have difficulty working with others. Physical therapists may work more efficiently with passive-aggressive patients by placing the responsibility for progress onto them. Patients can be instructed to make decisions about their treatment whenever possible and then summarize their progress after each session. This deemphasizes the physical therapist's role as an authority figure, and therefore the need for a passive-aggressive response.

Personality Disorders

When an individual's personality style deviates from cultural norms over a long period of time, is inflexible or pervasive, causes distress to oneself and others, and leads to activity limitations, that personality style is considered to be dysfunctional.⁹ Personality disorders have been thoroughly classified. They include paranoid, antisocial (also referred to as sociopath or psychopath), borderline, histrionic, narcissistic, avoidant, dependent, obsessive-compulsive, schizoid, and schizotypal personalities. Freidman and Booth-Kewley⁴⁵ state that disability exacerbates preexisting pathology, meaning that the stress of dealing with a physical illness can make personality disorders even more pronounced.

Patients with paranoid personality disorder interpret the motives of others as malevolent when they may not be. This results from a pattern of suspiciousness and distrust. These patients believe that others are trying to exploit, deceive, or harm them. Because of such mistrust, they may discharge themselves from treatment. Physical therapists should look for behaviors that indicate paranoid thoughts such as hostile reactions, guardedness, argumentation, and stubbornness, and encourage patients to express their thoughts at that moment. If the patient seems paranoid, the physical therapist should help him or her to better understand the reality of a specific situation. For instance, if the patient complains about being forced to participate in an elaborate intervention so that, in his or her view, the therapist can make more money, the therapist should review the pros and cons of various treatments and discuss the clinical reasoning involved. Literature can be very convincing since it does not come directly from the therapist.

Patients with antisocial personality frequently engage in deceit and manipulation. In rehabilitation, they may use an alias, lie to the staff, or malinger. They are irresponsible and often fail to comply with self-care procedures such as hygiene and home maintenance. They seek out and take advantage of weaker staff members, often using wit and charm. When they do not receive what they want, they commonly become irritable and violent, especially when staff members attempt to impose restrictions. They frequently cause disruption to others in rehabilitation. These patients require a cohesive team approach with immediate and strong intercommunication to minimize disruptive behaviors and refocus on rehabilitation goals.

Patients with borderline personality disorder have instability in emotions, relationships, and self-image; are impulsive; use primitive defense mechanisms such as splitting (Box 26.2) and devaluation; and tend to engage in self-destructive behaviors such as abusing drugs or self-mutilation. On the surface, they may appear critical of others but these are signs of deep vulnerability and should be treated as such. Therapists should respond with understanding and empathy instead of anger, and should emphasize strengths and strategies for ongoing work. Self-mutilating behaviors, such as repetitive cutting with razor blades, pinpricking, or cigarette burning, should be immediately reported to a doctor and referral made to a psychiatrist.

Patients with histrionic personality disorder seek attention via excessive emotionality. Since these patients respond well to audiences, therapists should provide situations in which patients can gain positive attention from doing well in rehabilitation. Physical therapists should set boundaries to help patients achieve a balance between their need to express themselves and their need to focus on therapeutic interventions. A calm and logical approach to rehabilitation helps settle intense emotions. Patients who have difficulty verbalizing their feelings can be referred to a creative arts therapist to facilitate expression through nonverbal means—such as music, dance or art.

Patients with narcissistic personality disorder are condescending and have a need for admiration and feelings of superiority. If an illness causes a reduction in this image, they will require help from their physical therapists to identify strengths and feel acceptable.

Patients with schizoid personality disorder have a flat affect, or limited range of emotional expression, and are detached from social interactions. The therapist should attend to the patient's rehabilitation without trying to engage him or her in a great deal of social interaction. If the disorder has been long-standing, the patient will likely feel uncomfortable socializing.

Patients with schizotypal personality disorder have eccentric behavior, perceptual or cognitive distortions, and marked distress in social relationships. The social intimacy and physical restriction of a rehabilitation environment may cause anxiety. Slow, unforced integration into the therapeutic setting may be required. Asking patients whether their views of reality are accurate may help them remain focused on achieving rehabilitation goals.

Patients with avoidant personality disorder suffer from social inhibition, feelings of inadequacy, and hypersensitivity to criticism. Physical therapists should reassure these patients that they are doing well and emphasize their strengths.

Patients with dependent personality disorder exhibit clinging behavior, need others to care for them, and are submissive. They may fail to function independently in their life roles even after physical functioning has returned, continuing the pattern of dependency. They fear abandonment and require constant reassurances that staff members understand their condition and care about them. Some respond to clear explanations and feedback about their progress and treatment plans. The therapist should reinforce independent behavior through attention and positive feedback while extinguishing dependent behavior by ignoring or redirecting it.

Patients with obsessive-compulsive personality disorder have a long-standing preoccupation with control and order and are often perfectionists. Their self-esteem may suffer if they perceive a loss of control, and they may react by becoming more obstinate, demanding, and inflexible. Those who publicly express their anger may become ashamed. These patients require greater predictability in treatment than usual, dislike change, and do well when given an established routine to follow. The therapist should provide rehabilitative activities that promote a sense of control and predictability, and consider allowing patients to set treatment goals, and then monitor their daily progress.

Coping Styles

Coping styles are ways that people deal with stress and include behavioral, emotional, and cognitive efforts to cope with internal and external challenges that strain ordinary resources.⁴⁶ Theories of coping suggest that it is not what happens to people that is important, but rather how they react.⁴⁷ Various coping strategies have been identified in the literature and summarized by Livneh and Antonak.²² They include planning, problem solving, wishful thinking, avoiding, minimizing, seeking social support, searching for meaning, emoting feelings, blaming, accepting, negotiating, disengaging, and turning to religion. These and others can be categorized into three different types of coping: (1) seeking versus avoiding control and information; (2) expressing versus repressing emotional reactions; and (3) seeking versus withdrawing from social interactions and networks.

Coping strategies have been found to be of great importance in rehabilitation. Patients with higher-level coping skills can more easily identify and report symptoms, make treatment decisions, comply with intervention, and accept support. Patients with good problem solving skills and positive attitudes have been found to make more positive adjustments to their disabilities than patients with low self-esteem and poor self-concept.⁴⁸ Coping styles often determine whether or not patients seek medical help and follow advice.⁴⁶

Social influences, psychological characteristics, and health beliefs have been shown to modify the impact of disability and disease on an individual. Social activism, positive self-acceptance, and information seeking have predicted better ability to cope with a disability.⁴⁹ Krause and Rohe⁵⁰ studied the relationship between adjustment and personality following SCI and found that positive values, emotions, actions, and warmth correlated with superior outcomes. Adaptive coping styles that result in positive outcomes for people with disabilities utilize positive, direct, and active problem solving, social support seeking, and information seeking. Maladaptive coping styles that lead to unfavorable adaptation outcomes include self-blame; non-direct, passive, and escape/avoidance modes of coping; and substance abuse.

Locus of control is a belief about one's ability to control life conditions and events.⁵¹ Patients with an external locus of control believe that other people or outside factors determine outcomes. Patients with an internal locus of control take responsibility for change because they believe they can affect their own circumstances. The latter leads to goal-directed activity and active coping.

The ability to intentionally change the relative importance of events that occur in one's life requires constant practice.⁵² It has been shown that patients with external loci of control experience stress and anxiety in rehabilitation, whereas patients with internal loci of control have quicker recoveries, better motivation, more hope, and more energy.

Coping styles can be examined through interviews, observations, self-report surveys, checklists, and information from the family. Treatment considerations based on these findings should include emphasis on previous ways of successfully coping and expanding the range of coping strategies, such as maintaining a journal to increase self-expression. Taking care of a pet or using animal assistance can lend help, comfort, and companionship, as well as increase motivation. Group treatment can also be used to increase social networks.^53,54

Many people with disabilities who have risk factors for emotional problems, such as lower education, less income, and social isolation, still do well in life because of a certain resilience defined as successful adaptation to stressful situations or events.⁵⁵ Researchers of resilience identify protective factors that safeguard people from adverse consequences. Protective factors can arise from the individual, family, and society and are concerned with how these strengths and supports provide security, safety, and positive opportunities.

Turning points are important experiences and realizations that enable people to find new direction, purpose, or meaning in life. King et al⁵⁶ reported four protective factors: determination, perseverance, spiritual beliefs, and social support. Seven protective processes were also identified: transcending, self-understanding, accommodating, receiving a diagnosis that helps explain a patient's experiences, believing in oneself, using anger as motivation, and setting goals. These protective factors and processes help people with disabilities during turning points in their lives. Analysis of turning points revealed three major ways that patients maintained meaning in their lives: through doing, belonging, and understanding themselves in relationship to the world. Doing involves participating in activities that are fulfilling and facilitate competency. Belonging involves perceived acceptance by others or membership in a valued group. Understanding oneself in relationship to the larger world provides a sense of identity and sometimes purpose.

Defense mechanisms are coping styles that people use to defend against internal and external stressors. They happen automatically and unconsciously. Some individuals use many different defense mechanisms throughout their lives, but most tend to utilize only one or two. The goal is not to change or modify these defense mechanisms, but to identify them in order to understand the patient's psychological processes that underlie certain behaviors and resistance. Understanding these behaviors can help physical therapists to motivate or redirect patients during difficult times in their rehabilitation. The defense mechanisms described in Box 26.2 are common reactions to disability and can be further explored in the Diagnostic and Statistical Manual of Mental Disorders.⁹

Anxiety

Anxiety is the apprehensive anticipation of future danger or misfortune accompanied by feelings of tension and agitation. The anticipated danger may be real or imagined, but is experienced both psychologically and physiologically.⁵⁷ The experience of anxiety varies in different patients. When someone is nervous (indicating a moderate level of anxiety), he or she may experience an upset stomach or headache. When someone is experiencing a panic attack (indicating a high level of anxiety), he or she may feel impending doom and terror. A symptom of anxiety in one patient may be heart palpitations, while in another it may be shortness of breath. What is anxiety producing to one patient may cause little to no anxiety in another. Given these variables, the following definitions may facilitate physical therapists' understanding of their patients' conditions.

A panic attack is a sudden onset of intense, overwhelming fear that may include feelings of imminent danger or impending doom. These attacks are marked by symptoms of palpitations, chest pain, smothering or choking sensations, shortness of breath, and fear of losing control, dying, or going crazy. Panic attacks may be unexpected (occurring without an internal or external trigger) or situational. It is unclear what kind of physiological change in the brain may trigger such a severe response. A phobia is an anxiety disorder characterized by intense anxiety resulting from thoughts of, or exposure to, a specific feared situation or object (such as heights, spiders, or elevators) leading to avoidance of that object or situation. Generalized anxiety disorder is defined as excessive worry and anxiety without an apparent source persisting for at least 6 months.⁹

Causes of Anxiety

Twenty to 30 million Americans suffer from anxiety.²⁶ Some signs and symptoms of anxiety are listed in Table 26.2, and behaviors that may result from anxiety are provided in Table 26.3. Much of the literature on stress and coping has identified major life events as stressors. Life events refer to major changes in lifestyle, status, role, or situation. This view is consistent with the notion that stress, though individually mediated, is to some degree environmentally based and/or exacerbated by environmental and social conditions. Various life event measures have been developed and are used in examining potential environmental stress. One of the more well-known and used instruments is the Holmes-Rahe Social Readjustment Rating Scale (Appendix 26.A), which quantifies the effects of life changes on stress and health.⁵⁸ Such measures of life events assume a relatively global impact, and take into account only those items listed. Although there is justified validity in such an approach, there exist potentially more sensitive and valid measures, one of which is the Hassles Scale.

The Hassles Scale (Appendix 26.B), developed by Kanner et al,⁵⁹ requires subjects to identify the irritating and frustrating demands of everyday transactions with the environment. This approach takes into account the individual's perception of events believed to pose a threat. It is consistent with the theoretical assumption that chronic struggle may tax coping abilities and lead to greater difficulty in the management of daily life events. Considering the enormous changes in a person's function when disability occurs, patients are more likely to expect an increase in daily hassles and stressors. Dealing with life becomes more taxing when disabling circumstances block one's coping style, causing a gap between the person and his or her fit within the world. Repeat occurrences of stress and the continual need to adjust to new situations can result in repetition of the fight-or-flight response, which can, over time, result in high blood pressure leading to heart attack or stroke.²¹

Anxiety and Rehabilitation

Different levels of anxiety have different effects on patients. If anxiety is completely absent, patients may not be motivated to achieve treatment goals. Mild anxiety can be motivating if directed toward rehabilitation. Severe anxiety can escalate quickly and impair all aspects of the patient's life, including rehabilitation outcomes, by intensifying the perception of pain, inhibiting immunosuppression, and prolonging recovery time.^60,61 Patients who had difficulty managing anxiety before physical illness will probably have more difficulty managing stress brought on by disability.

When a patient is anxious, thought and energy often become focused on the anxiety instead of physical therapy, resulting in decreased concentration. Decreased learning may be observed when a patient is unable to concentrate on the therapist's instructions. The patient may be unable to perform motor tasks that require multiple-step directions. Poor concentration can also result in safety risks as the patient's attention may be alternating between the anxiety and the demands of rehabilitation. To appear functional, the patient may try to perform a task having heard only part of the therapist's instructions. Such a patient may fail to understand directions given by the therapist and may not realize that he or she missed important information. Steps may be skipped and a patient may jump ahead too quickly, resulting in injuries to the patient or others.

If patients become fearful because of anxiety, they may avoid certain behaviors in an attempt to decrease their fear. Fearful, anxious patients are reluctant to try new things. They may refuse treatment, remain in their rooms, request a bedpan when they are capable of using the commode, or be reluctant to progress to the next step in therapy. Such patients will commonly make statements such as, "I can't. I don't feel well. I'm too tired. Leave me alone. Not now, I'll do it later. I'm afraid. You can't help me. You don't look strong enough. I'm going to fall."

Patients who express anxiety through overactivity may attempt to progress too quickly through rehabilitation. They often want to achieve everything at once and appear impatient. They tend to rush through a treatment activity without mastering each step. Such patients frequently talk of discharge before it is an option. They may make rash decisions regarding major life changes, such as purchasing new cars or planning vacations when neither would be in their best interest. Such behaviors may provide immediate relief from anxiety for both patients and their families yet cause more distress in the long run.

When anxiety causes misperception, patients may perceive their level of dysfunction and improvement differently than do their therapists. They often leave therapy sessions with an unrealistic opinion concerning any progress or gains made. Such patients may believe they performed at a higher level than they actually did.

Watching a patient experience a panic attack for the first time can be frightening. It may not be immediately evident to either the patient or physical therapist if the patient has never experienced one before. Patients experiencing a panic attack usually report fear of immediate death. They may start to hyperventilate, then suffer shortness of breath. Sometimes they believe they are having a heart attack as a result of chest pain, heart palpitations, and increased heart rate. Terror and panic ensue, and the therapist may call a code or, if in an outpatient setting, initiate emergency transport of the patient to the hospital.

How to Address Anxiety

Physical therapists need to help patients control anxiety so they can proceed with treatment. Some patients may find it beneficial to discuss their fears and concerns with their physical therapists. In such cases the therapist should initiate a dialogue with the patient, asking, "How are you feeling?" "What is your greatest concern?" "What is the worst thing you believe may happen?" and so forth. Physical therapists can work with patients to help defuse anxiety by using cognitive restructuring— or the reshaping of the patient's thoughts and beliefs regarding the feared event. For example, a therapist might help the patient to engage in reality testing by assisting the patient to understand that the occurrence of the feared event is unlikely.

Patients with real and imminent crises may benefit from assistance with problem solving, should their worst-case scenario occur. Such problem solving can help patients to believe that they can survive and live meaningful lives despite the occurrence of feared events. After patients have expressed their feelings, therapists can help them segue into treatment and redirect their emotion into physical activity.

It should be noted that patients who are verbose and cannot stop talking about their fears should not be encouraged to dwell on them during physical therapy sessions. Encouraging patients to verbalize their anxieties is also contraindicated with patients whose psychosomatic complaints are fueled by conversation regarding their anxieties. For patients who are very anxious, it may help to conduct treatment in a setting that is familiar, calm, and comfortable. An unfamiliar setting, too much stimulation in the environment, too many people, or too much noise can increase anxiety levels. It may be helpful to reorient patients to the therapy room and to treatment expectations—each session—to allow them to feel a greater sense of control.

Physical therapists should choose a purposeful activity with the patient's anxiety in mind. Some anxious patients have been known to respond to activities that consist of one repetitive motor action, as rhythmic motion helps to calm them.⁶² Gross motor movements help decrease the physical symptoms of anxiety such as muscle aches, agitation, and restlessness. Therapists should begin by involving patients in a therapeutic activity that is easily performed and then increase the complexity of the task once the patient has gained confidence.

Anxious patients who may interrupt the physical therapist while he or she is with other patients may be reassured that they will be seen on a certain date and time. Physical therapists should ignore, without anger, all subsequent intrusions. Setting limits in this fashion helps patients improve their frustration tolerance. Very anxious people often welcome clear boundaries set by therapists because they have difficulty setting limits for themselves.

Stress management techniques are useful before and after a session. Techniques such as meditation, imagery, relaxation, stretching, stress management diaries, identifying stressors, biofeedback, nutrition, prioritizing, problem solving, decision making, anger management, Reiki (a Japanese technique for decreasing stress that involves the transfer of healing energy from the practitioner to the patient), music therapy, therapeutic massage, and prayer have been shown to improve both physical and emotional wellbeing.^63,64,65 Some of these techniques work more effectively for some patients than others. Choosing one depends on the patient's preference, amount of time available, and materials required.

Relaxation Response

Whichever stress management technique is selected, the overall goal is to teach patients how to experience the relaxation response and replicate it independently during stressful situations.⁶⁶ After studying the relaxation response for 20 years, Dr. Herbert Benson identified two essential components that elicit the response: (1) repetition of a sound, word, phrase, prayer, or muscular activity; and (2) disregarding distracting thoughts and returning to the repetition. Benson²¹ suggests that patients use the following techniques:

1. Choose a phrase, word, or prayer that is part of your belief system.

2. Sit comfortably and quietly.

3. Close your eyes.

4. Relax your muscles beginning with your feet and working your way up your body.

5. Breathe naturally and slowly. Say your phrase, word, or prayer silently as you exhale.

6. Rid yourself of all distracting thoughts by letting them flow in and out of your mind like waves on the ocean, always returning to your phrase, word, or prayer.

7. Continue for up to 20 minutes.

8. Sit quietly for a minute, allowing your thoughts to return before opening your eyes. Sit for another minute before standing.

9. Practice this technique daily on an empty stomach if possible.

The relaxation response has proven to be effective in treating headaches, hypertension, anxiety, cardiac rhythm irregularities, mild and moderate depression, and premenstrual syndrome. The relaxation response works by decreasing heart rate, rate of breathing, metabolism rate, oxygen consumption, and carbon dioxide elimination, and returning the body to a healthier balance.^21,66,67 When within-subject comparisons were made between blood pressure before and after meditation using the nine aforementioned steps above for several weeks, the average systolic blood pressure for the 36 subjects dropped from 146 to 137 mm Hg, and diastolic pressure dropped from 93.5 to 88.9 mm Hg; both are statistically significant changes.²¹ The relaxation response seems to decrease blood pressure through counteracting the activity of the sympathetic nervous system—the same mechanism underlying the action of antihypertensive drugs. Lower blood pressure leads to lower risk for atherosclerosis and related diseases.

Guided Imagery

Another intervention is guided imagery, frequently used as a standard of care to improve rehabilitation through relaxation. Guided imagery is said to work by decreasing the levels of cortisol that can inhibit the immune system and slow tissue repair.⁶⁸ As in eliciting the relaxation response, the patient should be guided to a state in which the mind is silent and calm. Through use of an audiotape, videotape, or therapy guide, the patient is asked to imagine a special place (e.g., the ocean, a forest, a sunset) and focus on vivid details using the five senses. By focusing on this location for increasing lengths of time, patients learn to gain relief from constant worry by releasing concerns for a period of time and returning to a place of relaxation and peace. Guided imagery enhances the mind–body–spirit connection through the induction of an altered state in which the mind communicates more effectively with the body.⁶⁰

The use of guided imagery has achieved improved outcomes of care through significant reductions in pain, blood pressure, stress, side effects of treatments, headaches, uncertainty, depression, insomnia, blood glucose levels, and histamine response to allergies. Significant enhancement of the immune system and wound and bone healing has also been noted.⁶⁹ Because music may trigger emotional responses by influencing the limbic system when used with imagery, music used with guided imagery has been shown to decrease pain through increasing endorphin release.^70,71 Guided imagery with music has also been found to reduce the need for large doses of medication and reduce recovery time.⁶⁰

Desensitization

Phobias severe enough to interfere with daily functioning have been reported by one out of every eight American adults.²⁶ Patients suffering from phobias that interfere with treatment may require desensitization techniques, also called situational exposure exercises. For example, wheelchair users with a fear of elevators who always used stairs before injury now require help in coping with their fears. In a comfortable, calm treatment environment far from an elevator, the physical therapist can have the patient begin to talk about benign aspects of elevators (e.g., what they look like, where they are located, and how many floors are in the building). While the patient is answering these questions, the physical therapist should determine the patient's level of anxiety. What specific issue regarding the elevator is the patient discussing when his or her anxiety increases? If the patient has not as yet become too anxious, the therapist may ask more anxiety-producing questions, such as, "How high is the elevator's ceiling?" "Is there an emergency phone?" "Are you more fearful of taking an elevator by yourself or with a crowd of people and why?" "Have you ever taken an elevator before and if so, what happened?" The therapist should continue to examine the patient's level of anxiety during questioning, stopping just before the patient's anxiety reaches a point at which the patient cannot easily be calmed.

This process, called desensitization, allows the patient to discuss his or her fear in a safe environment where he or she does not feel overwhelmingly anxious. The physical therapist slowly increases the level of anxiety by asking more difficult questions, but only to a tolerable degree. The patient is then asked to visually imagine that he or she is in an elevator, while practicing relaxation techniques. The patient continues to practice this visualization, over time, until he or she can do so without experiencing fear. When the patient can visualize himself or herself in an elevator without experiencing fear, therapy progresses to the real-life experience of riding in an elevator with the therapist. Relaxation techniques continue to be used during such real-life practice. The activity of riding in an elevator with the therapist using relaxation techniques continues until the patient can do so without fear. The final step would be for the patient to practice riding in an elevator alone while using self-induced relaxation techniques. Desensitization therapy has a high rate of effectiveness in the treatment of phobias.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (or cognitive restructuring) can help decrease anxiety by changing maladaptive thought patterns and modifying unhealthy behaviors.⁷² Before unhealthy behaviors can be modified, they must first be identified and classified. Because many patients are not conscious of their anxiety, an initial step when using cognitive-behavioral therapy is to help patients recognize anxiety. Determine what the patient's first signs of stress tend to be. Many will reply that they react severely to stress, stating "I throw up," or "I cannot breathe." In these cases, therapists should ask about the existence of less severe signs, such as nail biting or leg shaking.

Next, patients should count how many times a day they experience stress, recording these in a journal. Physical therapists should help patients look for patterns in their anxiety. Are patients more anxious in the morning or evening, when they attend therapy, or when family members visit? The more patients can identify patterns of anxiety, the more they can anticipate it and prepare for anxiety before it occurs. Therapists should encourage patients to use stress management techniques as soon as they experience the first sign of stress so that their anxiety does not escalate. Keeping a stress management journal can give patients insight into how their thoughts affect their behavior. Research has shown that cognitive-behavioral therapy can be as effective as medication.^{73,74,75,76,77} Box 26.3 Evidence Summary presents a summary of research data examining the effects of cognitive therapy versus use of antidepressants for depression.

Treatment for Panic Attacks

If the therapist knows that a patient has a history of panic attacks, the following techniques can be helpful. Have the patient describe the first signs of discomfort during the attack. Immediately help him or her to breathe long, deep, and slow breaths. This may require the use of a brown paper bag held by the patient over the mouth while breathing into it to slow the inhalation rate. It is beneficial to acknowledge that a panic attack is occurring and that the patient will be all right if he or she continues to focus on breathing slowly and deeply. The panic attack can become severe within minutes and pass just as quickly. The patient most likely will be seated or lying down throughout the panic attack, as it may render him or her incapable of doing anything else.

Patients are usually embarrassed after an attack and may avoid all situations in which they believe one may occur. They may sit on the end of the aisle while watching a movie, may avoid crowds, or, in extreme cases, stop leaving their homes entirely (referred to as agoraphobia). Therapists can help patients who experience panic attacks to achieve a more productive life by teaching them techniques to control the attacks before they become severe. Families and patients should be educated to understand that panic attacks involve a real physiological reaction, tend to last only several minutes, and often recur without further intervention. Patients with severe, continuous panic attacks should be referred to a psychiatrist for possible medication management.

When to Make a Referral for Anxiety

Multiple referrals may be necessary. Patients who have panic attacks should be referred to a psychiatrist for a medication consultation. Generalized anxiety can be treated with medication; hence, a referral to a psychiatrist would be appropriate if the anxiety lasts more than a week and interferes with the patient's performance in rehabilitation. Those who continue to experience anxiety from phobias despite desensitization therapy and medication should be referred to a psychologist for a more in-depth exploration of their fears. A referral to a psychologist is indicated if the anxiety seems to be a deeply rooted characteristic of the patient's personality. A social work referral can be helpful if the patient's anxiety results from a lack of necessary resources or involves family members.

In many cases, medication does not fully alleviate patients' anxiety. However, it may decrease it sufficiently enough for patients to begin expressing their fears and implementing strategies to decrease stress. Sometimes a patient may not be forthcoming about his or her anxiety and a formal diagnosis may not be present in the chart. If this is the case, the physical therapist may become aware of an anxiety disorder through the type of medication prescribed. By becoming familiar with the names of different antianxiety medications, physical therapists can identify patients suffering from anxiety. The names, effects, and adverse side effects of commonly prescribed antianxiety medications are presented in Table 26.4.

People who were disabled as a result of a traumatic event (e.g., a violent crime, abuse, an accident, a natural disaster, or war) or individuals who have witnessed such are at risk for post-traumatic stress disorder (PTSD) or acute stress disorder (ASD). Both are specific forms or subsets of anxiety disorders. The Diagnostic and Statistical Manual of Mental Disorders differentiates between both disorders in terms of the duration of the disorder and its symptoms.⁹ ASD involves symptoms that must range in duration between 2 days to a maximum of 4 weeks. If symptoms of ASD persist longer than 4 weeks, the diagnosis of ASD is discontinued and changed to PTSD. Post-traumatic stress disorder is differentiated as acute PTSD if symptoms last more than 4 weeks but less than 3 months and as chronic PTSD if symptoms last 3 months or longer. Both ASD and PTSD, however, must result from exposure to a traumatic event, and PTSD can be qualified with the term "with delayed onset" if symptoms first occur at least half a year after the traumatic event. Research notes that PTSD is an expected outcome for a certain percentage of patients experiencing even mild traumas.^78,79

Among the symptoms exhibited are one or more of the following: reexperiencing the traumatic event; numbing of responsiveness to, or reduced involvement with, the external world; and/or a variety of autonomic, dysphoric, or cognitive symptoms. The reexperiencing of the event is described as recurrent, painful, and consisting of intrusive recollections, dreams and nightmares, and, on rare occasions, dissociative states during which the individual may act as if reliving the actual traumatic event. This may last only several minutes or occur for hours or even days. The numbing of responsiveness, also called psychic numbing or emotional anesthesia, is expressed by complaints of feeling detached or estranged from others, a loss of ability or interest in previously enjoyable activities, or the lack of any emotions or feelings. Cognitive symptoms may include impairment of memory, concentration, and task completion ability. Patients may experience excessive autonomic arousal resulting in hyperalertness, anticipatory anxiety, an exaggerated startle response, constant scanning of the environment, the perception of people and objects that are not real (i.e., hallucinations), or difficulty falling and remaining asleep.⁸⁰ Following this state of hypervigilance, the patient may experience a denial reaction marked by a diminution of responsiveness to the environment. Survival guilt may be present in those cases in which others were harmed or killed during a catastrophic event.

Additional associated features that should alert the physical therapist to the presence of PTSD are increased irritability, hostile behavior, constant tension, chronic free-floating anxiety, muscle tension, sexual and social difficulties, and somatic stress symptoms. Box 26.4 summarizes some of the prominent behavioral features of PTSD.

Not everyone who experiences trauma develops PTSD. The triple vulnerability model postulates that three vulnerabilities need to be present to develop an anxiety disorder: (1) a biological vulnerability; (2) a generalized psychological vulnerability (existing from past experiences of lost control over unpredictable events); and (3) a specific psychological vulnerability that links anxiety to specific situations.⁸¹ Keane and Barlow⁸² have proposed an explanation for how PTSD develops based on the triple vulnerability model. They suggest that during a traumatic event, a person experiences alarm and other intense emotions. The person is more likely to develop PTSD if the event and resultant emotions are perceived to be unpredictable and beyond the person's control. If the event is perceived to be predictable and within the person's control, it is less likely that PTSD will occur.

Chronic pain frequently occurs concurrently with PTSD, and the occurrence of both disorders tends to negatively affect the treatment outcome for each.⁸³ Similar processes, such as avoidance, fear, anxiety, oversensitivity, and catastrophizing (i.e., interpreting an experience as overly threatening), may act to maintain both conditions. Given the high co-morbidity of PTSD and chronic pain, physical therapists should examine patients with PTSD for the existence of chronic pain. The Yale Multidimensional Pain Inventory or the McGill Pain Questionnaire can be administered.^84,85 PTSD may be examined using the Clinician Administered PTSD Scale Revised or the Posttraumatic Stress Disorder Checklist.^86,87 Examination should also include the patient's beliefs, self-efficacy, level of anxiety, sensitivity, coping style, expectations, and degree of behavioral and cognitive avoidance in order to understand the mechanisms that may maintain these conditions. See Chapter 25, Chronic Pain, for a more detailed discussion of instruments designed to measure pain.

The main desired outcome of treatment for PTSD should be engagement in healthy, satisfying, necessary activities. The physical therapist can help patients to build positive self-efficacy through cognitive restructuring, development of healthy coping skills, and learning to use the relaxation response—all in a predictable, safe environment. Techniques used to help decrease catastrophizing and avoidance include situational exposure exercises (mentioned earlier) and interoceptive exposure exercises (such as running in place or spinning in a chair).⁸⁸ Interoceptive exposure exercises help patients cope with uncomfortable physiological sensations that may prevent participation in activities. Finally, the therapist should provide the patient education regarding how PTSD and pain can facilitate each other and result in avoidance. As participation in healthy activities increases, co-occurring disorders—such as depression, anxiety, panic, and substance abuse—may decrease, and a higher quality of life may ensue for the patient with PTSD.

Depression

Depression refers to feelings of despair and hopelessness, negative shifts in perception, and decreased interest in activities that once provided pleasure. A person may have a depressed personality (referred to as dysthymia) and therefore experience sadness throughout his or her entire life. As in most cases of depression, a person may have one or more episodes of depression, before and after which a normal mood exists. A certain degree of depression is normal in response to life's events, but when depression lasts 2 or more weeks and affects occupational and social functioning, it is considered to be major depression. Depression may occur as a biochemical imbalance in the brain, which may be triggered by stress, or in response to internal conflicts or life events. For example, the rate of depression in people with SCI is five times higher than that of the general population.⁸⁹

Women with disabilities are more prone to depression (30%)⁹⁰ than women without disabilities (10% to 25%),⁹ men with disabilities (26%),⁹⁰ and the general population (10%).⁹ Other researchers support the finding that women with disabilities tend to experience depression more commonly than their male counterparts. In their analysis of 443 women with disabilities, Hughes et al⁹¹ found depression to be a frequently occurring secondary condition (51% of the sample scored in the mildly depressed range or higher on the Beck Depression Inventory–II [BDI-II]). Fifty-nine percent of women with SCI were found to be clinically depressed, compared to a rate of 4.5% to 9.3% of women in the United States at any given time.⁹² This high rate of depression among disabled women may be due to the combination of being a woman and having a disability, since both are risk factors for depression. Women are more than twice as likely to have a depressive episode than men due to economic, social, psychological, and biological factors.⁹³ Female socialization experiences and gender-based roles may also increase their vulnerability to depression. Depression in women has been linked to experiences of abuse and poverty, lack of social support, reduced mobility, chronic pain, lower educational levels, and lower levels of perceived control.⁹⁴

If untreated, depression can spiral into greater severity and may result in suicide; 15% of people who are depressed commit suicide each year.¹⁸ Depression may begin with loss, such as the onset of a physical disability, divorce, death, or the departure of a close friend. As a result of such losses, patients may become appropriately sad and mournful. If patients reach out to friends and express their feelings, they can alleviate feelings of loneliness and isolation that commonly occur in response to loss. However, if patients do not take steps to express their feelings, the downward spiral of depression may continue. Over time, patients may lose interest in activities and remain at home. They may lack the energy or motivation to attend to their responsibilities, and feelings of guilt may ensue. A decrease in role participation usually leads to diminished self-esteem and feelings of worthlessness. Eventually, people stop caring about their hygiene. They may avoid social contact and become increasingly lonely. At this point, staying in bed becomes a welcome alternative to dealing with the outside world and the painful feelings it may incur.

Depression and Rehabilitation

Given the signs and symptoms of depression (Table 26.5) and its associated behaviors (Table 26.6), depression may negatively affect the outcome of treatment. Depressed patients may have difficulty getting out of bed and may not be motivated to attend therapy. If they do attend treatment, they may display psychomotor retardation and lack energy and interest; they may also verbalize self-deprecating remarks, feel criticized, and believe that they are progressing inadequately. It may be difficult for physical therapists to leave depressed patients unattended while working with others because the depressed patient may not engage in the prescribed exercises. Patients may feel guilty that they are in the hospital instead of taking care of their children, working to earn money for their family, or engaging in other life roles.

Depression usually affects performance negatively. Depressed patients may not want to make gains in rehabilitation because of decreased motivation and lack of pleasure in life. They may believe that they are unable to progress in rehabilitation as a result of low self-esteem or feelings of hopelessness. Such patients may also have difficulty asserting themselves because of feelings of worthlessness and an inability to express anger. When people feel worthless or have low self-esteem, they may feel unworthy of having or voicing an opinion. Depression may result from anger turned inward. Instead of expressing anger in the moment, depressed patients may turn their anger against themselves or repress it. People who experience this type of depression may not have been allowed to express hostility in the past.

Depressed patients often become immobilized because they have difficulty making decisions. They may weigh the pros and cons of each choice and become overwhelmed. They may be unable to concentrate on one thought long enough to make decisions. Sometimes depressed patients experience the opposite; when they attempt to execute a decision they may have no thoughts at all (referred to as thought blocking). Consequently, they may need 1 to 2 minutes to think about and answer questions.

Treating Patients with Depression

Depressed patients require assistance with motivation. Physical therapists can facilitate motivation by providing encouragement, emphasizing strengths, offering positive feedback, addressing values, and mobilizing guilt into goal acquisition. Empowering patients by providing activities that offer opportunities for self-control and success have been shown to decrease depression.^95,96

Depressed patients experience a narrowing of perception. They have difficulty seeing alternate solutions to problems or simple tasks and often feel there is no solution to obstacles. They may perceive their condition as terminal when there is no justification for such a belief. Because of these distortions, it is important to offer reality checks—such as pointing out their strengths when they feel worthless. Cognitive therapy can be used to correct ongoing pessimism by challenging negative thought patterns.

If given choices about their treatment, depressed patients may become ambivalent and unable to decide on a course of action. As a result, they may do nothing. Physical therapists should choose treatment that provides the patient with opportunities for progressive success experiences, avoiding feelings of failure. When reluctant patients perceive that they can succeed in therapy instead of giving up, their chances of continuing treatment increase. Progress made in physical rehabilitation can alleviate depression, as patients report feeling better after having succeeded in an activity they believed they could not accomplish.

Perhaps the most valuable information that a physical therapist can offer depressed patients is that depression will not last forever. Patients will eventually become better through the combination of therapy and possible medication management. Depression can cause an activity or life role that once seemed effortless—such as being a partner in a relationship—to become arduous. It is important for the patient to understand that this does not mean that the relationship caused the depression; more likely, the role of partner has become more difficult to carry out because of depression.

Families often experience a depressed family member as lazy, obstinate, or uncaring, and may not recognize that he or she is suffering from an illness. Depression can be just as disabling as a physical illness. Families need to be educated that depression, like physical disability, causes decreased functioning and requires treatment. Recovery from depression does not have a specific time-line. Each patient's situation is unique, as is the recovery period. Most patients cannot "snap out of it" as many family members desire.

When to Make a Referral for Depression

If depression is suspected, the physical therapist should determine if the patient is currently being treated for depression or has received treatment in the past. If the patient has never been treated for depression and is experiencing suicidal ideation (see section on Suicide below) or symptoms of depression that markedly impair life roles, the therapist should refer the patient to a psychiatrist for possible medication management. Medication can enable patients to attend therapy, more readily discuss problems, and express repressed feelings. However, some patients are reluctant to inform their physical therapist of their depression out of stoicism or shame. (There is often a negative stigma attached to being depressed because, to the uninformed, it may imply weakness or feeling sorry for one's self.) A diagnosis of depression may not be in the chart and the symptoms may be misinterpreted as fatigue. In these cases, knowledge of the names of medications used to treat depression may help therapists identify patients with depression. The names, effects, and adverse side effects of frequently prescribed antidepressant medications are presented in Table 26.7.

Patients with less severe symptoms who are not suicidal can be referred to a psychologist for verbal therapy. If a patient's depression seems to be caused by family turmoil, a referral to a social worker for family intervention can be made. Patients who have difficulty verbalizing their feelings can be referred to a creative arts therapist to facilitate expression through nonverbal means such as music, dance or art. A referral to an occupational therapist can be made to help patients regain function in daily life roles that have been disrupted by depression.

Suicide

Each year more than 35,000 cases of suicide are reported in the United States, and 65,000 additional cases may go unreported due to complications regarding the cause of death.²⁶ More people lose their lives to suicide than to any other cause, with the exception of cancer and cardiovascular disease. Suicide is often a result of poor social support, low self-esteem, ineffective coping skills, and the inability to see a solution to difficult situations. Risk factors include serious illness, previous suicide attempts, family history of suicide, alcohol and substance abuse/dependence, loss of a loved one through rejection or death, prolonged depression, and financial difficulties.

Recognizing the warning signs of possible suicide risk is important for its prevention. The most frequent signs of suicide risk include the following:

• Direct comments about suicide, such as, "I just want to die"

• Indirect comments about suicide, such as, "My mother will not have to worry about me anymore"

• A plan to commit suicide

• Writing a suicide note

• Preoccupation with death

• A sudden flight into happiness or relief after a long depression

• Excessive risk taking (e.g., driving while inebriated) and a careless attitude

• Final preparations (e.g., composing a will, giving away personal possessions, repairing broken relationships, or writing revealing letters)

• Self-hatred

• Changes in personal appearance, eating habits, sexual drive, sleep patterns, menstrual cycle, behavior (e.g., inability to concentrate or disinterest in activities), or personality (e.g., withdrawal, anxiousness, sadness, irritability, apathy, indecisiveness, or fatigue)

• A recent loss accompanied by an inability to stop grieving

The most important thing for a physical therapist to do when suspecting that a patient is suicidal is to prevent him or her from carrying out the act. This usually involves obtaining help from a mental health professional, preferably a physician with the knowledge and ability to admit the person to a hospital if needed. It is important not to leave the patient alone while waiting for help. During this period, the following should take place:

• Ask patients if they are thinking of hurting or killing themselves.

• Listen to patients without expressing shock, without discrediting what they say, and without devaluing their feelings; take all suicide threats seriously even if you do not believe them at the time.

• Respond to patients with empathy and understanding; tell them how much you care about them and that you will be available to help them.

• Help patients think of alternatives; offer choices based on your knowledge about the patient's life, rather than generic answers that are easy to offer when under pressure.

• Alert family members, friends, and significant others to the patient's suicide risk; all of these individuals may help prevent the patient from trying to commit suicide; suicidal ideation does not go away in a day; additional help is required from all possible sources over time.

Substance abuse occurs when an individual demonstrates a dysfunctional pattern of drug and/or alcohol use characterized by recurrent and significant adverse consequences. Substances may include, but are not limited to, alcohol, amphetamines, caffeine, marijuana, cocaine, hallucinogens, inhalants, opioids, or sedatives.⁹

Substance Abuse and Rehabilitation

If clients come to the clinic under the influence of drugs or alcohol, they may be inappropriate, argumentative, irritable, disinhibited, stubborn, illogical, or angry and will have difficulty following treatment plans. They may also disturb other clients, some of who may be in their own substance abuse recovery. For these reasons, intoxicated clients should be escorted out of the treatment area and referred back to their substance abuse programs, with a call to their substance abuse program provider describing the incident that occurred. If they are not currently engaged in a substance abuse program, a referral should be made. Although many drugs have unique and specific consequences, Table 26.8 presents an overview of common physiological, psychological, and behavioral manifestations associated with substance abuse.

If patients are not under the influence during treatment, but are using drugs or alcohol at home, they may miss treatment sessions or may come to rehabilitation tired, hungry, or late. They may have poor concentration and irritable moods resulting from hangovers. They may experience recurring injuries from falls. Often, patients will not comply with treatment and fail to complete their home exercises or forget to take their prescribed medications. When prescribed medications are ingested along with illegal substances, adverse drug reactions can occur. Patients may lack insight about the extent of their abuse and the trouble that it produces in their lives. They may mask feelings such as anger, guilt, anxiety, or depression through the numbing effect of the substance, but try to present themselves as though they are fine.

Patients in denial commonly do not perceive their need for physical rehabilitation, often neglect to follow precautions, and frequently attempt to obtain discharge before completing rehabilitation goals. Their low frustration tolerance causes them to quit treatment easily. Whether they are actively using substances or not, patients who have abused substances may have cognitive deficits that inhibit their ability to follow or remember instructions. They may experience family discord and lose family support, thus finding themselves homeless. Patients with a history of chronic alcohol abuse tend to have poor balance resulting from changes in the cerebellum and peripheral nerves.⁹⁷ To maintain balance, they develop a stereotypic, wide-based gait. Such factors should be considered during gait examination and training. Despite their gruff demeanor, patients who abuse substances can be overly sensitive, easily hurt, suffer from low self-esteem, and easily stressed once they are no longer abusing substances. These patients tend to have poor boundaries. They can be intrusive, flirtatious, or deal seeking in order to obtain what they want, such as alcohol, cigarettes, or extra medication.

Treating Patients Who Abuse Substances

Physical therapists can help patients in recovery by providing opportunities that allow them to gain control over their lives again. Such assistance may include opportunities to practice setting boundaries, regulating emotions, and tolerating frustration. Physical therapists can emphasize healthy activities that provide pleasure and decrease cravings. Stress management, time management, ADL, and social skills are usually necessary skills to promote recovery.

Education on Substance Abuse

Physical therapists, patients, and patients' family members should be aware that substance abuse is an illness. Like physical or mental illness, it causes a decrease in function, requires skilled intervention for recovery, results in decreased role performance, and can affect anyone. Patients with a diagnosis of substance abuse usually cannot stop using drugs and alcohol on their own. They need help, and recovery is a lifelong process that includes developing skills to manage cravings, dealing with stress in healthy ways, expressing feelings, participating in 12-step programs, and engaging in drug-free activities.

When to Make a Referral for Substance Abuse

If the patient is going through withdrawal, the physical therapist should immediately refer the patient to a physician. Signs of withdrawal can include sweating, impaired sleep, seizures, impaired motor coordination, faulty judgment, anxiety, shaking, slurred speech, fluctuating levels of consciousness, and visual and tactile hallucinations. After stabilizing the patient, the physician may transfer him or her to a detoxification unit. If the patient is not experiencing withdrawal and is not already in a substance abuse treatment program, physical therapists can make a referral to an appropriate treatment center. Such treatment centers include 28-day inpatient rehabilitation programs, long-term (1 to 1.5 years) inpatient therapeutic communities, 12-step programs for community-dwelling outpatients, and dual diagnosis programs for patients who have also been diagnosed with mental illness.

Patients who have been abusing substances for long periods of time should be referred to a nutritionist for proper dietary regulation. Physical therapy patients who have been abusing substances can be referred to occupational therapists to address regulating emotions, setting and maintaining appropriate boundaries, tolerating frustration, managing time, obtaining social skills, and regaining necessary ADL. Occupational therapists also can help patients learn that healthy activities can be pleasurable, through task groups in which patients choose, engage in, and discuss healthy activities. A social work referral can be made if the patient requires community integration, family intervention, or social supports.

Physical therapists may not expect patients to demonstrate sexual, aggressive, or violent behaviors, yet most have witnessed such behaviors at least once. Therapists should learn how to predict violence, identify signs of escalation, manage aggressive patients, and verbally respond to threats. Violence is not always predictable, but the more therapists understand its signs, the better equipped they will be to handle a dangerous situation.

An initial step involves recognizing the early signs of agitation. Agitation usually does not diminish by itself. Instead, it may build to a verbal altercation or physical act. Some signs of agitation may include clenching fists, pacing back and forth, making angry facial expressions, grunting, groaning, swearing, tapping a foot, spitting, refusing to engage in therapy, throwing objects, and banging weights or other therapeutic equipment.

After observing signs of agitation, physical therapists should identify the source of the agitation in order to better control it. While many situations can cause agitation, it is important to remember that events that agitate one person may have no effect on another; levels of frustration vary from person to person. People with Alzheimer's disease may become agitated because they cannot recall the names of familiar objects or remember familiar motor plans. They may believe that family members are lying to them, deceiving them, or attempting to place them in a nursing home. People can become agitated as a result of physical pain, memory failure, hunger, fatigue, and dependency on others. Temporal lobe injury, psychosis, and the side effects of certain medications can cause agitation. People with personality disorders who have difficulty managing anger and who have experienced an upsetting event can easily become agitated.

Addressing the underlying circumstance causing the agitation may help to defuse it. If the source of agitation is unknown, the physical therapist should acknowledge to the patient, in a non-accusatory manner, that he or she seems upset. Many people are unaware of their agitation and calm down once it is brought to their attention. The therapist can then encourage the patient to verbally express why he or she feels upset. Therapists can also attempt to redirect patient anger into more productive channels and help alter their perspective regarding the disturbing issue.

Violence also can happen without warning. Many therapists working on inpatient TBI units have been bitten, kicked, punched, or scratched. Patients may feel that they are being forced to participate in therapy they do not need, or that they are being treated like children. They may believe that staff members have assumed control over their lives. To avoid humiliating the patient, therapists can use a client-centered therapy approach in which patients are offered respect and included in goal setting and treatment planning.

If efforts to defuse the patient's agitation do not work and he or she becomes violent, the physical therapist should remove all other patients from the area, then leave and call for help. After an act of violence, members of the rehabilitation team should examine what occurred to learn from the incident, prevent a future recurrence, and provide support and education to those involved. In reviewing the incident, the physical therapist should address the following questions:

• What was the patient's potential for aggression?

• What were the signs of escalating anger?

• Did the patient have a history of violence? If yes, under what circumstances did it occur?

• How did therapists and patients respond to the aggressor before, during, and after the act?

• What could have been done differently during the incident?

In addition to managing an agitated or violent patient, physical therapists need to recognize when a patient is undergoing abuse. It is estimated that 10% of women with disabilities experience sexual, physical, or disability-related violence.⁹⁸ Abuse has been related to decreased social support, increased social isolation, and elevated levels of depression and stress.⁹⁷ Women with disabilities may be even more susceptible to abuse, due to their dual minority status as people with disabilities and as women. As compared to women without disabilities, women having disabilities experienced longer periods of abuse and abuse from a greater number of perpetrators.⁹⁹ Nosek et al¹⁰⁰ have identified several factors that predict with 80% accuracy whether or not a woman has experienced abuse within the past year. These include decreased mobility, social isolation, depression, and a lack of education. Examination for abuse should be considered for women with disabilities.¹⁰⁰ Nosek et al developed a four-item screening tool, the Abuse Assessment Screen— Disability (AAS-D), that examines sexual, physical, and disability-related abuse in the past year.

Hypersexuality is a state of heightened sexual arousal that may be accompanied by verbal or physical aggression. These behaviors can be caused by mania, childhood sexual abuse, or brain damage. Patients may desire attention, or want to provoke or exert power over others, to impress others, or to show off. Verbal signs of hypersexuality can include whistling; verbalizing sexual desires; or asking for physical closeness, phone numbers, or dates. Physical behaviors include staring, pinching, brushing up against another's body, touching, kissing, exposing genitalia, masturbating, and blocking another's exit from a room.

There are several ways to proceed when a patient exhibits hypersexual behavior. If the therapist feels threatened, he or she should leave the area and obtain assistance. If the patient's hypersexual behavior is a newly observed behavior, the therapist can describe the behavior to the patient and firmly state that it is inappropriate and will not be tolerated. If the therapist believes that the patient is exhibiting symptoms of mania or hypomania, referral should be immediately made to a psychiatrist. Holding a multidisciplinary team conference may help the patient understand that hypersexual behaviors are not tolerated in the clinic.

According to Jacobs and Jacobs¹⁰¹ and Donatelle and Davis,²⁶ wellness is a dynamic process in which people attempt to fully develop their emotional, social, environmental, physical, spiritual, and intellectual health. Donatelle and Davis describe a well individual as someone who can forgive himself or herself and others, learn from mistakes, appreciate all things both grand and small, develop a realistic sense of self and the environment, achieve a balance in life roles and daily activities, respect others and maintain healthy relationships, feel a sense of life satisfaction, understand one's needs and express emotions appropriately, and function in his or her community. Achieving this definition of wellness may require substantial effort for someone with a disability who may experience multiple barriers to wellness.

Barriers to Wellness for People with Disabilities

Healthy People 2020 identified gaps and disparities in the health and wellness of Americans with disabilities.⁹⁰ It reported that people with disabilities exhibited more symptoms of psychological distress and tended to not engage in as many physical activities as people without disabilities. Objectives to overcome these barriers included to "Increase the proportion of people with disabilities who participate in social, spiritual, recreational, community and civic activities to the degree that they wish" (DH-13) and "Reduce the proportion of people with disabilities who report serious psychological distress" (DH-18).

More specifically, research has found that women with disabilities experience higher levels of stress than do males with disabilities, possibly owing to higher incidences of poverty, violence, abuse, chronic health problems, and social isolation.⁹³ Economic disadvantage may be due to stress-inducing factors such as earning a lower income, having less access to disability benefits from public programs, having less education than their male counterparts with disabilities, and having a higher likelihood of being unemployed or unmarried.¹⁰² People with SCI report a higher level of perceived stress than the general population, and women with SCI tend to have a higher level of perceived stress than men with SCI.¹⁰³

Social Support

Social support is critical in maintaining or achieving psychosocial wellness. Social support is defined as the availability of other persons in the environment who can offer emotional support, financial or material help, a listening ear, guidance, or encouragement. Social support has been associated with increased self-esteem, coping, and adjustment for individuals with disabilities. Evidence suggests that social support plays a strong preventative and palliative role in a wide range of physical and medical conditions. Rintala et al¹⁰⁴ found that the amount of social support was directly related to a sense of life satisfaction and well-being in patients with SCI. Hardy et al¹⁰⁵ and Kaplan¹⁰⁶ found that high social support was predictive of a return to vocational functioning after rehabilitation.

Researchers have suggested that failure to recover from depression stemming from disability may correlate to a lack of adequate social support. Social isolation is a frequently encountered condition associated with disability. Physical restrictions such as pain and mobility limitations may discourage connections with others. The combination of diminished social opportunities, negative societal perceptions, and multiple environmental barriers may result in isolation and a lack of emotional intimacy.

Social support can be used to enhance treatment and promote patient adherence. The physical therapist plays an important role in guiding patient education, including access to resources and instruction in use of adaptive equipment and environmental devices designed to improve a patient's access to social networks and socialization. Appendix 26.C provides Web-based resources for patients, families, and caregivers. It provides resources for improving community accessibility (independent living centers), depression, substance abuse, anxiety, and PTSD.

Psychosocial wellness requires that patients experience success in both rehabilitation activities and long-term relationships and roles. Rehabilitation activities focus on improving functional outcomes, involvement in meaningful events that foster socialization (e.g., playing wheelchair basketball with other patients), and community reintegration. Long-term relationships and roles include being a spouse, parent, worker, and friend. Psychologists, social workers, and occupational therapists can facilitate readjustment to these long-term roles. Both rehabilitation activities and long-term relationships and roles should provide a sense of contentment, happiness, and well-being. Physical therapists can promote and provide opportunities for patients to choose and engage in meaningful activities that promote psychosocial wellness.

Patients who spend a great deal of time dwelling on the past and worrying about the future are unable to be fully cognizant of the present moment. The ability to become absorbed in the present moment can decrease anxiety concerning the past or future—the patient's emotional energy is focused on his or her immediate activities. Each instance in which a patient can focus on the present offers him or her the power to change, to break through old habits, to view circumstances differently, and to recognize available choices. Physical therapists can help patients remain focused on the present moment by selecting activities that are both meaningful to and congruent with the patient's goals for rehabilitation.

Having a daily balance of work, leisure, and social activities is important to sustain psychosocial wellness. Any psychological or physical impairment can disrupt this balance. In a study of the relationship between depression and leisure participation in people with SCI, Loy et al¹⁰⁷ found that patients without depression had wider repertoires and higher levels of leisure activity than patients with depression. Therapists can help patients engage in leisure activities through the use of activity interest surveys and schedules. Activity interest surveys are used to gather information about the types of leisure pursuits patients previously engaged in, which leisure pursuits they currently hold interest in, and which leisure activities they would like to pursue in the future.

A negative outlook inhibits psychosocial wellness. Physical therapists can help patients with negative perspectives to positively alter their expectations through goal setting, identifying optimistic options, using cognitive-behavioral techniques that challenge the validity of negative perceptions, or referring the patient to a psychologist for longer-term intervention.

Bill, a 19-year-old who was training to be an Olympic gymnast, sustained an SCI in a motorcycle accident. Bill had developed a strong social support system and participated in a variety of extracurricular activities. He was engaged and planning to be married, participated on his college's gymnastic team, and worked as an athletic counselor in the summer camp he had attended since age 7. The SCI he sustained caused a loss of function from his chest down.

All of Bill's energy is now focused on getting through each day. He does not view himself as able to work or attend school. The accident has changed his expectations for the future, his outlook on life, his environmental challenges, and his social support system. His depression was compounded by his broken marriage engagement, and Bill no longer meets his friends for social events; in fact, he rarely leaves his home other than to attend rehabilitation. Just when he was becoming independent of his parents, Bill has now become dependent on them again. He observes his younger sisters and brothers progressing in their lives and feels stagnant, angry, depressed, and ashamed. His self-esteem, which was once high, is now severely diminished and he has lost his familiar identity.

As part of his rehabilitation, the therapist should provide a safe way for Bill to express his anger; referral to a psychologist is also warranted. The therapist can help him to better understand his physical limitations and capabilities. Based on Bill's strengths and limitations, the therapist should help him to redefine interests that could emerge into new roles and a new identity. For instance, it might be helpful if Bill could identify a meaningful activity that could take the place of his athletic training (such as coaching a children's gymnastic team). Information about college and distance learning could also be beneficial. The therapist also can assist Bill and his family in the understanding of SCI and reasonable expectations for the future.

Table 26.9 offers a list of behaviors that suggest inappropriate and pathological response patterns to disability. This list is not meant to be fully inclusive, but rather indicates areas requiring further consideration. It is important to understand that even mild expressions of pathological response patterns can become chronic and worsen in severity over time. Table 26.10 identifies patient behaviors that warrant a mental health consultation.

Box 26.5¹⁰⁸ gives examples of general goals and outcomes for patients with psychosocial issues, and Box 26.6 provides instruments typically used to measure these outcomes organized by the International Classification of Functioning, Disability, and Health (ICF) Categories.¹⁰⁹ However, human reactions, response patterns, and the adaptation process are variable and individualistic. Each patient must be approached uniquely and treatment goals should incorporate the patient's individual personality characteristics, responses, and needs. An important component of rehabilitation is the patient–practitioner relationship. Physical therapists can establish a therapeutic atmosphere of communication, understanding, and cooperation with patients, which can serve as the foundation necessary to produce positive rehabilitation outcomes. Therapists can sometimes forget the powerful influence they have in setting the tone of this interaction. The very structure and atmosphere of service delivery and the personality and type of communication provided by the practitioner exert a strong influence on patient participation and response to rehabilitation efforts.

Optimizing Patient Involvement

Patients should be involved as fully as possible in their own treatment. This includes involvement in goal setting and treatment planning, as well as in the ongoing evaluation of progress. Patient cooperation is also dependent on the therapist's clear explanation of the patient's situation, anticipated goals and expected outcomes, and interventions. Relating to the patient as a partner in therapy can engender cooperation and trust in the therapeutic relationship. When patients feel a heightened sense of control and ability (i.e., locus of control), feelings of despair and helplessness can be mitigated.

Therapists should also maintain a receptive ear to patient concerns and encourage communication. Listening carefully to patients in a nonjudgmental manner will allow them to reveal concerns and issues they may otherwise feel uncomfortable discussing. Clear and articulate communication, however, can be disrupted by emotion, uncertainty, or power discrepancies that exist when patients become passive recipients of service. Although it may sometimes appear easier to do for patients than to witness their struggle— particularly when patients assume a passive role in rehabilitation—promoting self-reliance andindependence fosters patients' engagement and responsibility in their recovery. Allowing patients to maintain a passive role fosters helplessness, encourages dependency, and slows progress in the long term.

Use of Jargon and Labels

Patient–therapist communication should be characterized by simple and easy to understand language that matches the cognitive level of the patient. The use of scientific jargon and labels should be avoided when speaking with patients, because it impedes patient understanding and emotionally distances patients from therapists. Similarly, when patients hear therapists referring to fellow patients by their diagnosis, they receive the message that patients are nothing more than disabilities. Such practice should be avoided and, instead, therapists should use language that reflects respect for the patient's dignity and unique life circumstances.

Rehabilitation Team Members' Self-Awareness

Finally, and perhaps most important, therapists need to be aware of their own feelings, motivations, and responses. Such self-awareness is critical for therapists to understand their own reactions to patients. It is normal for people to respond to others based on conscious or unconscious memories. Sometimes patients can remind therapists of significant others, such as siblings, parents, spouses, or employers. However, when therapists react to patients based on unconscious associations to others, they can misperceive patient needs and respond inappropriately. For example, unconscious reactions to patients can cause therapists to become overprotective or, at the other extreme, become frustrated with patients without recognizing that their own reactions have more to do with other relationships than with the patient at hand.

Generally, when therapists feel a heightened sense of emotion in response to a particular patient it may often serve as a cue that such emotions stem from unconscious associations to others. When this occurs, it is important for therapists to step back and evaluate their own feelings in order to discern the connection between their reactions to the patient and how the patient may be triggering unconscious emotions.

The converse is also true; patients will respond to therapists based on their own unconscious associations with significant others who have similar personality characteristics to those of the therapist. Therapists must be aware of this normal phenomenon and refrain from responding emotionally to the patient's unconscious associations. Rather, the therapist should continue to build a respectful relationship with the patient that, in time, will demonstrate to the patient that his or her first impressions were misperceptions.

It is important for physical therapists to identify and understand the individual psychosocial factors that enhance or inhibit the rehabilitation of their patients, and intervene accordingly. Successful intervention depends on the following:

• Understanding the psychosocial aspects of each patient, including personality styles and coping skills

• Recognizing and interpreting the common defense mechanisms that patients use in rehabilitation

• Distinguishing the stages of psychosocial adaptation to disability and helping patients' progress in their own adjustment

• Understanding how to identify anxiety, depression, and substance abuse; determining how to address these problems; and recognizing when referral to other team members is warranted

• Integrating a patient/client-centered approach that emphasizes respect, empathy, and compassion

• Empowering patients and families through psychosocial education, and wellness and prevention strategies

• Working together with patients to develop anticipated goals and expected outcomes congruent with their needs, values, and level of functioning

• Collaborating with patients and team members to establish and implement appropriate interventions

• Developing a team approach and providing referrals as necessary

Questions for Review

1. Identify five psychosocial factors and state how each factor may influence rehabilitation.

2. Give examples of interventions for each psychosocial factor identified in question 1.

3. Differentiate among the different mental health professionals who can treat patients with psychosocial issues by describing their roles.

4. What should therapists do to calm an agitated patient?

5. Describe an approach for managing a violent patient and how to analyze an act of violence after it has occurred.

6. What are the manifestations of hypersexuality and how should it be addressed?

7. Identify and describe the phases of psychosocial adaptation to disability.

8. Discuss three coping strategies that have been found to be effective in the psychosocial adaptation to chronic disability and illness.

9. Describe five common defense mechanisms that patients use in response to disability.

10. What are the signs and symptoms of post-traumatic stress disorder?

11. Differentiate between typical reactions to grieving and pathological reactions.

12. Explain several ways to optimize patient involvement in the rehabilitation process and promote self-reliance.

13. Why is patient/client-centered intervention important? What strategies can be used to achieve this type of interaction?

14. Describe the general adaptation syndrome.

The patient is a 68-year-old female, admitted to an inpatient unit 2 days after sustaining a right femoral neck fracture from falling down her basement stairs. Hip replacement surgery (arthroplasty) was performed on the same day as the fall. The referring documentation indicates "weight-bearing as tolerated." The patient complains that she "can't do anything" for herself owing to the fall.

Before her fall, she was in fair health but was experiencing declining eyesight, poor short-term memory, and osteoporosis. Her hip fracture has placed her at high risk for further deconditioning and loss of function. The patient's husband had suffered a prolonged illness; the patient cared for him during the last 5 years until he passed away. She has a son whom she rarely sees, because he is married with children and living in another part of the country. A close friend lives several miles from her and the rest of her friends have died. The patient is embarrassed to be seen in public in a wheelchair.

Given the deaths of her husband and friends, and given her recent accident, the patient is now very anxious about her own mortality for the first time in her life. She is preoccupied with her husband's death since he was so much a part of her life. She feels that she has no future and nothing to look forward to. She no longer knows who she is and longs to "be reunited with" her husband.

1. Identify the psychosocial factors apparent in this case study.

2. What relevant questions about the patient remain unanswered (i.e., what relevant information is missing)?

3. How might the patient's emotional condition affect rehabilitation?

4. Develop a problem list for the patient.

5. Identify the patient's assets.

6. Identify the general goals of physical therapy intervention on which specific anticipated goals and expected outcomes will be based.

7. Identify the general categories of procedural interventions appropriate for this patient.

8. Identify referrals to other professionals or resources.

Directions: Hassles are irritants that can range from minor annoyances to fairly major pressures, problems, or difficulties. They can occur few or many times.

Listed on the following pages are a number of ways in which a person can feel hassled. First, circle the hassles that have happened to you in the past month. Then look at the numbers on the right of the items you circled. Indicate by circling a 1, 2, or 3 how severe each of the circled hassles has been for you in the past month. If a hassle did not occur in the last month, do not circle it.

Improving Community Accessibility

Independent Living Centers: www.senioroutlook.com

Searches over 40,000 apartment communities for people with disabilities. Includes virtual tours, searches by distance, photographs, and floor plans. Contains information on insurance, storage, home mortgages, moving, types of housing facilities, and a glossary of housing terms. Updated weekly.

Links to Centers for Independent Living: www.abledata.com

Includes information on and links to periodicals and research on disability, assistive technology, and lists of health care professionals.

The Design Link: www.designlinc.com/centers3.htm

Provides product information and design tips for families, consumers, and therapists designing for people with disabilities.

Depression Resources

WebMD Depression Guide: www.webmd.com/depression/guide/depression_support_resources

All About Depression: www.allaboutdepression.com Internet Mental Health: www.mentalhealth.com/p71.html

Substance Abuse Resources

National Institutes of Health, National Institute on Drug Abuse, Science of Drug Abuse Addiction: www.nida.nih.gov/nidahome.html

The Substance Abuse and Mental Health Services Administration: www.samhsa.gov

National Substance Abuse Index—Directory of Substance Abuse Resources: www.nationalsubstanceabuseindex.org

Anxiety Resources

HealthCentralAnxietyConnection.com: www.healthcentral.com/anxiety/websites.html

MedlinePlus—Anxiety: www.nlm.nih.gov/medlineplus/anxiety.html

Post-Traumatic Stress Disorder (PTSD) Resources

2010 Best Posttraumatic Stress Disorder Resources for Trauma Survivors: http://thirdofalifetime.wordpress.com/2010-best-ptsd-resources-for-trauma-survivors-pt-1

Department of Defense—Resources for Military Vets with Posttraumatic Stress Disorder: United States Department of Veterans Affairs Veterans and Military—Web Resource Links: www.ptsd.va.gov/public/web-resources/web-military-resources.asp

National Center for Posttraumatic Stress Disorder: www.ptsd.va.gov/