Hand and upper extremity injuries are often accompanied by a variety of psychological reactions related to the function of the extremity and to the perceived social acceptance of the individual, particularly if the patient has sustained a mutilating type of injury. The hands and the face are the most socially visible portions of any person’s body. Because the hand is often used as a medium of nonverbal communication, disfigurement to the hand often results in loss of positive self-image and perceptions of impaired social competence. The patient’s frequent concerns of cosmesis are often related to whether the injured hand is abnormal enough in appearance to be conspicuous and disturbing to others. In addition, the patient’s perception of disfigurement is often more important than the actual degree of disfigurement present. Barely perceptible injuries often result in profound changes in self-image. Even for patients who have no mutilating injury to the upper extremity, psychological factors can still exert a profound influence over the course of recovery when chronic pain and/or chronically debilitating conditions such as cumulative trauma disorders (CTDs) are present. However, upper extremity disorders can also be caused by psychological factors, as evidenced by patients with conversion and factitious disorders. This chapter examines the psychological effects accompanying acute traumatic injury to the hand, psychological changes resulting from chronic upper extremity pain and dysfunction, and psychological factors precipitating psychogenic hand conditions.
Acute Traumatic Injuries
According to statistics compiled by the U.S. Department of Health and Human Services, the hand is one of the most commonly injured parts of the body. Hand injuries accounted for nearly 22% of all industrial injuries during 1990. The National Health Interview Survey from 1997 to 1999 reported annually that 36.7% of all work-related injuries were upper extremity injuries. The annual cost in the United States to treat upper extremity disorders including hand injuries was over $18 billion. These costs do not even take into consideration the indirect costs to family, employers, or the community in the form of time off work, lost earnings, costs of getting to doctors and therapists, and the added strain of dependency on others. Kelsey et al. reported that in 1997 patients spent $1.7 billion to attend to their treatment, while $5.1 billion was spent on lost wages, costs to employers and industry, and other miscellaneous indirect costs. This amounted to a 58% overall cost of care in the indirect category in the United States in 1995. In addition, Kelsey et al. reported that $11.7 billion was expended in 1995 for the direct treatment of upper limb disorders. These staggering costs are due in part to unrecognized and untreated psychological ramifications resultant of these serious injuries or from the impact of other psychogenic disorders. A fair number of articles have been published dealing with psychological adjustment to traumatic hand injury and upper extremity injuries. These studies document that injuries often result in a wide range of psychological changes.
Addressing the psychological aspects of upper extremity injuries often includes the expertise of various concerned, qualified health care professionals present to assist with this process. The appropriate health-care providers include a hand surgeon, counselor, and hand therapist. It may be necessary to recruit additional members to the rehabilitation team, including a representative of the patient’s employer and a rehabilitation specialist from the workers’ compensation company (if the injury occurred in the work setting) to address all of the psychological aspects surrounding the injury. By addressing all components of effective rehabilitation in a multidisciplinary manner, the patient is able to recover in an efficacious and timely manner.
Psychological Adjustment Following Mutilating Injury
A wide variety of psychological reactions accompany mutilating upper extremity injuries. The most prevalent and frightening are episodes of intrusive thoughts, including flashbacks and nightmares of the traumatic injury. Research has demonstrated that patients may begin experiencing flashbacks of the injury as early as 30 minutes postinjury. Flashbacks have been shown to be among the most persistent and disruptive symptoms accompanying mutilating injuries. Flashback types have also been demonstrated to have prognostic value. Replay flashbacks are the most easily treated flashbacks and consist of the patient replaying the entire injury. Appraisal flashbacks are much more difficult to treat. In these the patient reexperiences the moment in which the injury occurred without any other images accompanying them. Projected flashbacks occur when the patient has an image of an even worse injury occurring than actually happened and can be more difficult to treat. An example would be when a patient loses a finger in a roller accident but has a flashback of the entire arm being torn off by the rollers. Flashbacks can also combine in various ways such as replay/projected or appraisal/projected flashbacks.
A variety of interventions have been developed to assist in reducing these symptoms. Imaginal exposure, in which the patient imagines the injury again, has been successful with reducing flashbacks and nightmares in children, adolescents, and adults. It is most effective when the predominant emotion accompanying the intrusive images is fear. For individuals experiencing anger, guilt, or other emotions, cognitive reprocessing procedures seem to be more effective. This may consist of imagery rescripting, in which patients revisualize the injury and then visualize themselves in the present having survived the injury. In addition, cognitive reprocessing can be an effective treatment and includes the verbal processing of emotions and traumatic thoughts (without the use of imaginal exposure). The nature of the flashbacks may also influence the type of treatment that is most effective. Nonvisual flashbacks may include auditory, tactile/kinesthetic or olfactory components. Nonvisual flashbacks, in which patients may describe feeling or hearing the bones breaking, seem to respond better to in vivo exposure rather than any imaginal interventions.
For patients sustaining amputations, preoccupation with phantom limb pain can trigger frustration and irritation. Initially, phantom limb pain may assist patients’ denial of the full extent of the injury, allowing for a graduated psychological acceptance. Later, however, it may compromise the integration of the amputation into the new body image by presenting incongruent tactile and visual sensations to the patient.
A variety of other difficulties also accompany mutilating upper extremity injuries. Concentration and attention problems are often present. The patient is often easily distracted and has poor short-term recall. Appearance-related concerns occur and may be characterized by pronounced aversion of gaze, in which the patient will not look at the injured extremity, or by the constant covering of the injured part in public. Many patients also experience an initial fear of death, and a few have more persistent fears of dying that can extend well into the future, leading to hypervigilance regarding possible additional injury. Preoccupation with cosmesis and phantom limb pain tend to increase from the time of the initial injury for the first 2 months and then decrease, whereas concentration problems, fear of death, and denial of amputation generally subside by the 2-month follow-up.
Many psychological symptoms can be addressed within the first 3 to 5 days following injury. Interventions such as imaginal exposure and cognitive processing techniques accompanied by psychoeducation regarding the nature of traumatic symptomatology can facilitate recovery. With imaginal exposure, patients go through the entire trauma using recollected images and memories that allow them to emotionally process the accident. This normalization of symptoms and structured reexposure to thoughts and memories of the trauma will often desensitize patients and lead to complete recovery within a very short time after injury. The benefits of early intervention have been well demonstrated by Weis, who compared early- versus delayed-treatment groups following hand trauma. When early intervention is not provided for acute psychological symptoms, post-traumatic stress disorder (PTSD) often results.
Case Study—Acute Stress Disorder
John was a 22-year-old Caucasian male who sustained a work-related hand injury. The left hand index, middle, ring, and little fingers were crushed between a dump truck and a skid-loader, resulting in amputations of all four digits at the proximal interphalangeal joint level. Less than 1 week postinjury he was seen by the hand therapist, who noted the patient’s unwillingness to view his hand. He acknowledged multiple flashbacks, reported an unwillingness to leave his home, and expressed an inability to complete home dressing changes and exercises. He declined an initial referral to a psychologist. On subsequent visits he continued to be symptomatic for flashbacks and was tearful. He was unable to follow through with his home exercise program. Concerns were discussed with his surgeon, and an appointment was made to see the psychologist. Treatment was initiated 2 weeks postinjury.
John was diagnosed as having an acute stress disorder due to his flashbacks, avoidance, physiologic arousal, and fears of reinjury. The psychologist developed an in vivo desensitization program for him as well as helping him to process his feelings regarding the accident in session. He also discussed how others reacted to his injury and the loss of his fingers. After five sessions he had made considerable progress and was willing to attempt a return to work. He began back for 4 hours per day and increased this to full time over the next few weeks. He continued in hand therapy as well as his psychotherapy, in which his progress was reinforced. By 10 weeks postinjury he reported no psychological residuals and was discharged from care. He was able to work with no dressings on his hand and was able to view his hand with no problems.
Post-traumatic Stress Disorder
PTSD is a combination of symptoms occurring after a specific traumatic event. A variety of criteria must be present to make the diagnosis of PTSD, including (1) intrusive thoughts, (2) avoidance of stimuli associated with the injury, (3) physiologic arousal, and (4) symptoms persisting for at least 30 days after the injury. The hallmark of PTSD is the persistent reexperiencing of the traumatic event. This often results in patients avoiding stimuli associated with the trauma and in a generalized numbing of responsiveness in the environment. Persistent symptoms of increased arousal are also present and contribute to concentration and short-term memory deficits previously described. People with PTSD generally have flashbacks or nightmares, exaggerated startle responses to any reminders of the original traumatic event, significant disturbance of sleep, avoidance of close interpersonal relationships, high levels of anxiety and depression, and hypervigilance for any future events in which they may sustain an injury. Additional symptoms accompanying PTSD include depression, anxiety, fear of death, impulsive behavior, substance abuse, body preoccupation, cosmetic concerns, and reduced self-esteem.
Virtually all of the effective treatment modalities for PTSD rely on some component of exposure. A variety of strategies for environmental exposure (in vivo) have been researched, including returning patients to their worksite shortly after their injury, either on a graded basis or accompanied by their counselor. Each technique has proven to be beneficial in assisting various patient population groups to effectively return to work. Imaginal exposure techniques have also been successfully used with this patient population, as documented by Weis, in which patients were asked to go back and imagine the entire accident again as a means of emotionally reintegrating their experience. Additional strategies for imaginal exposure include imagery rescripting, which has proven quite effective in those injuries in which another person actually triggered the resultant traumatic injury. Imagery rescripting uses imaginal exposure to relive the traumatic accident and facilitates mastery by allowing patients to imagine themselves as they currently are entering the imagery to confront the person responsible for causing their injuries. This technique facilitates the patient’s transition from “victim” to “survivor” of the accident. The hallmark of successful exposure techniques is the emotional reintegration that occurs as the patient desensitizes to exposure to previously feared reminders of the trauma.
Recently, research on the role of language and cultural considerations has been explored with non-English-speaking and English as second language populations. The current findings indicate that interpreters can be used to effectively conduct treatment with non-English-speaking patients using the same techniques for exposure and reprocessing discussed previously. While the indications are that it may take longer to accomplish symptom resolution using an interpreter, the long-term benefits are equal to those patients treated without need for an interpreter. Additional research has examined the role of intervention with multilingual patients for whom English is not the initially acquired language. The findings indicate that it is important to assess in which language the patient has linguistically represented the trauma, as this is the language in which the treatment must occur for maximum benefit.
Case Study—Post-traumatic Stress Disorder
Osmar was a 30-year-old Hispanic male who sustained a work-related injury resulting in the amputation of his left arm at the mid-forearm level. This injury occurred when his co-workers neglected to follow the standard safety procedures for the job that they were doing, leaving him still working on the piece when the operator closed the machine. He developed full-spectrum PTSD with flashbacks, nightmares, avoidance of his worksite, co-workers, friends, and family, hypervigilance to potential future injury, irritability, an easy startle reaction to reminders of the accident, and a loss of any sense of the future. Initial psychological treatment used imagery rescripting and reprocessing therapy to aid him in processing his anger over what had happened to him. As he felt more in control, a lunch meeting off of the worksite was arranged for him and the owner of the company. He was able to express his concerns as well as hear the regrets of the owner over what had occurred. The owner also reminded Osmar of his past contributions to the company and expressed a desire to have him return to work. Several potential jobs were discussed. Following this, his psychologist accompanied him to the worksite for further desensitization. After this, a graded work return was developed in which Osmar began back at the company working in a different building from the one in which he had been injured. Once he had reached 8 hours per day, a graded program for introducing him back into the building in which he had been injured was initiated. This also proceeded uneventfully, and he has returned to all normal work activities with the exception of working on the machine on which he was injured. He reports no flashbacks, nightmares, or any other psychological symptomatology.
Therapist Involvement
The hand therapist is often the only person who sees the patient on a frequent, one-on-one basis, and therefore plays an important role in helping the patient return to preinjury physical and emotional functioning. At various stages in the continuum of treatment certain psychological issues must be addressed. Close contact with the treating physician should be maintained if concerns regarding the patient’s emotional adjustment are present. The accompanying screening tool in Box 101-1 should be used as a guide throughout this process.
Injury
How did the injury happen?
What are the patient’s occupation and job tasks?
If a work-related injury, how long has the patient worked at the employer at which he or she was injured?
If a work injury, to what does the patient attribute the cause for his or her injury (remember that this may change from immediately after the injury to months later)?
Intrusive Thoughts
Does the patient have flashbacks or nightmares?
Have the patient describe the flashbacks—including content and occurrence.
Does the patient have difficulty sleeping?
Support System
Does the patient live alone or with family or friends?
How is the patient’s family handling the injury?
Is the patient able to talk to family and friends about the injury and feelings?
Have relationships between patient and family and friends changed since the injury?
Pain
Does the patient have significant pain (more than expected)?
Has the pain been decreasing or increasing?
How does the patient handle pain (what does he or she do to decrease it)?
Are there issues with concentration and/or memory problems?
Does the patient remember directions?
Assess short-term memory: For example, Can the patient read a newspaper article or watch a show and remember the content? Does the patient forget appointments? Does the patient go into a room and forget his purpose for being there?
Avoidance
Is the patient engaging in preinjury activities?
If work-related, has the patient been back to work to visit?
If work-related, has the patient had contact with the employer or co-workers?
Is the patient seeing friends?
Is the patient staying home more?
Is the patient drinking, using drugs, or gaining weight?
Cosmetic
Does the patient avoid looking at the hand?
Does the patient keep the hand hidden when entering or leaving the clinic?
Does the patient keep the hand hidden in public?
Does the patient use the injured hand?
Does the patient report that people stare at the injured hand?
Can the patient comfortably touch the injured hand? Are family members and friends allowed to touch the hand?
Red Flags
Note inconsistencies in progress or the patient’s explanations.
Be alert for unexplained delayed wound healing or the development of new wounds.
Be aware of inconsistent follow-through, such as missing therapy appointments or being repeatedly confused as to when appointments are scheduled.
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