Psychology of Medicine and Surgery - Essay Example

NAME : XXXXXXXXXX TUTOR : XXXXXXXXXX TITLE : XXXXXXXXXXX COURSE : XXXXXXXXXX INSTITUTION : XXXXXXXXXX @2009 Introduction Diabetes is a chronic disease which results when body is not producing enough insulin or is not able to use the insulin properly resulting to too much sugar in the blood. Insulin is a hormone which assists in conversion of glucose to energy. Every single cell in the body requires energy to function properly; the main source of this energy is glucose. There are two types of diabetes, type 1 and type 2 diabetes. Type 1 diabetes is insulin dependent and occurs when the pancreases can no longer produce the insulin required. It represents 10-15% of all cases of diabetes and is more common among children in developed countries. Type 2 diabetes results when the pancreas is not able to produce adequate insulin and the insulin is not working properly. It represents 85-90% of all cases of diabetes and is more common among the older people. The risk factors associated with type 2 diabetes include the family background, physical activity, unhealthy eating habits and obesity (Australian Institute of Health and Welfare 2008). Diabetes is a common disease in Australia with 3 million people at risk of developing diabetes. It has result in serious cardiovascular, renal and eye complications as well as deteriorating quality of life. 3.8% of the adult population is suffering form diabetes. Phantom limb amputation presents itself as one of the most disabling complications of diabetes. Virtually, a half of all the non-traumatic amputations are associated with diabetes complications, where as, it is estimated that one- third of diabetics patients are at high risk for phantom amputation. In the year 2006-07, there were 865 hospitalizations for diabetics patients with lower limb amputations, which is 11.6% of Australian population. The male population is at a high risk (18%) of developing lower limb complication than women (6.1%) (ABS 2006a). Age and diabetes are significantly associated with peripheral nerves dysfunction (PND). The decrease in PND is more prevalent in older people with most disabilities rate being observed in people above 65 years old. Peripheral nerve disease and blood vessel damage may lead to leg ulcers and severe foot problems which may lead to limb amputation. In 2004, 33% of diabetic of patients were found to be suffering from foot complications. The major risks associated with limb amputation in diabetic patients include foot problems such as ulcers and infection, the loss in sensation of the sensory neuropathy, motor neuropathy deformity and gait abnormalities, ischemia from the macro-vascular disease, partial joint mobility from the increased glycolation of collage, poor glycaemia control and high risk of infection contribute to foot problems and limb amputation (Colman PG, Beischer 2000). Ulcers of neuropathy, gangrene, and micro-circulatory disturbances lead to uncontrollable oedema resulting to vascular disruptions. These disruptions damage the blood tissues making then unable to regenerate due to the compromised blood supply. These obviously result in amputation of the affected limb. Ulcers result in open wounds that which cannot be cured. Gangrene is necrotic tissue that propagates if it is not unattended to. Charcot arthropathy is a condition which occurs when the skeletal structure of the foot is destroyed. Edema owing to micro-vascular disease limit blood flow, can ultimately lead to limb amputation. The absent of pulsation in the foot accompanied by ischemia and eventual tissue damage, make it impossible to be cured (Ariyo et al 2003). The other risk associated with limb amputation is coronary thrombosis. This is the most primary grounds for death in diabetics. People who suffer from renal disease are at high risks of developing diabetes and are likely to be amputated after the kidney transplant. Lifestyle risk factors associated with amputations in diabetics are alcohol and cigarette abuse, overweight, insulin sensitivity, blood glucose control, and lipoprotein patterns. Haemostatic function is the major contributing factor in diabetic disorders. The high level of sugar in the blood and proteins makes the situation worse. The increase in glucose intolerance level is linked to the human aging process. This alteration in glucose metabolism has been observed to be due to the decreased insulin sensitivity level and the improper low pancreatic B cell function. As a result, the rates and incidences of diabetes increase significantly with age. It has been observed that as the insulin resistance levels increases so do the Immune-reactive insulin (IRI) and pro-insulin (PI) levels. High levels of IRI/PI levels result in the subsequent development of type 2 diabetes, five or even 20 years later. There is a high rate of type 2 diabetes and post challenge hyperglycemia among the older people than in children or adolescence because glucose tolerance gradually decline with age. There are a number of factors which are associated with aging which are likely to lead to the changes in glucose tolerance in this group of people. These factors include physical inactivity, increased adiposity, medications, insulin secretory deficiencies and coexisting sickness related to the aging process. However, the mechanism of age-related glucose intolerance is not clearly explained in most of the existing literature review (Payne 2000). According to the Australian Institute of Health and Welfare survey report which was carried out from 1988 to 1994, the rate of type 2 diabetes in Australia is high among the older people and especially those who fall between 60-74 years. This population also experiences high incidences of glucose intolerance and a high level of glucose in the blood which is even not in the diabetic range of 126mg/dI. A previous study done by AIHW from 1970 to 1980 also indicates similar results showing a persistent high rate of glucose intolerance in the older generation for over two decades. A cardiovascular health study for adults showed that the high rate for diabetes continues in people above 75 years old. Isolated post-challenge hyperglycemia is especially common in people above 60 years old. Population research studies have shown that the post-challenge glucose levels increases with age by 6-9 mg/dI per decade, whereas, fasting glucose levels increases with age by 1-2mg/dI per decade (Peterson 2004). The insulin became resistance in old age due to the high level of glucose intolerance. However, the flowing insulin levels are like those of children or adolescents. The hyperglycemia challenge in adulthood leads to low insulin levels, signifying β-cell dysfunction. The incidences of insulin secretory deficiencies observed in older people have played a significant role in their glucose metabolism alterations and have contributed to the high rates of glucose intolerance in old age. Moreover, B-cell sensitivity for hormones secretion decline with age. β-cell dysfunction companied with insulin resistance in old age exposes older people to develop post-challenge hyperglycemia and type 2 diabetes. It is therefore important to understand the metabolic changes associated with age so that we can be able to come up with preventive and therapeutic measures for population which is at high risk for glucose intolerance (Colman PG, Beischer 2000). Though various studies have examined the impacts of aging on pancreatic β-cell role in human beings, there is a great deal of inconsistency in the outcomes of the studies. The inconsistency in these outcomes can be due to numerous factors, which involve the use of different insulin secretion measures, the small magnitude of the age impact and the perplexing factors linked to aging such as physical inactivity, overweight and corresponding insulin resistance. The sensitivity of the tests to detect early abnormalities of β-cell function is one of the limitations in studying the time course development of glucose intolerance in any population. Sometimes, the early insulin secretory deficiencies in the development of insulin tolerance from normal to abnormal may be slight. Hence, the measures for β-cell function should be extremely sensitive (Ariyo et al 2003). One of the biggest challenges for persons facing limb amputation is that there are other illness associated with diabetes which can affect the function and lifespan of such individuals. For example, Heart attack and cardiac diseases may claim the lives of thousands of limb amputees. Moreover, it has been established that one-third of phantom amputees may die six months after being amputated due to vascular disease. It also more probable that 30% of these amputees will have the other leg amputated after 2-3 years. Phantom amputees experience other medical problems which affect their functional status. It has been estimated that 10% of older amputees suffer from stroke during the process of amputation (AIHW 2008). Phantom Limb sensation and pain Phantom limb sensation can be defined as the feeling of the presence of the amputated limb. Phantom limb sensations are not painful by definition. Phantom limb pain occurs to patients who are not able to access prosthesis 6 months after amputation. A variety of theories have been used to try and explain phantom limb pain in diabetic amputees. They include peripheral, psychological and central theories. Early researchers believed that phantom pain resulted form the cut end nerves that formerly innervated the extremity. Other peripheral sources, for example bone fragment, stitch absence and neuroma, are believed to lead to phantom limb pain. Exposing the amputated limb to extreme cold is also believed to lead to phantom limb pain. However, peripheral theories do not adequately explain phantom pain in diabetic amputated patients because complete sensory blockage has failed to provide relief to most victims. Only 20% of the patients suffering from phantom limb pain have been found to have neuromas. Moreover, it has been found that phantom limb pain occurs even before neuroma formation (Payne 2000). As a result of the failure of the peripheral theories, central theorists have come up with their theories to try and explain this phenomenon. Central theorists use the gate-control theory to explain phantom limb pain. According to them, amputation causes significant destruction of the sensory axons and hence numerous neurons are set free through inhibitory control. This may result in self-sustaining movement of the spinal cord neurons and if this movement exceeds a certain critical level, it may lead to phantom limb pain. It is also likely that patients who experience pre-surgery and post-surgery pain are likely to develop phantom limb pain after the surgery. In fact, in most instances, phantom pain is an expression of the pre-amputation pain. It has even been established that prevention of pre-amputation pain by the use of epidural route reduces the rates of phantom pain. Contemporary research scientists have tried to use Psychological theories to try and explain phantom pain diabetic amputated patients. Though there has been no consistent personality defect associated with phantom limb pain, psychological problems linked to limb loss or feelings of dependence can occur to any limb amputee. Both phantom limb sensation and pain are defense mechanisms employed by limb amputees to fight against reality in an effort to maintain physical and psychological integrity by failing to accept limb loss. It has been observed that diabetic amputee patients suffering from phantom limb pain are more rigid, independent and compulsive than those who do not experience phantom limb pain. Diabetic amputees displaying such a personality are likely to repress their emotional distress and maintain their self-esteem by not accepting the reality. However, the high rates of phantom limb pain in patients with this personality type can probably be due to patient selection bias, because they are likely to be more open, talkative and truthful in reporting pain and failures in treatment than their cohorts. It is also possible that amputees diabetic patients who are more dependent and delicate refused to be included in the study sample and therefore their views and opinions were not taken into consideration leading to such distorted results. Despite the fact that 58% of amputees become more dependent after amputation, dependency is not directly related to amputation itself but to the corresponding medical difficulties associated with amputation. There is no research study which has found any significant correlation between the acceptance of limb loss and occurrence of phantom limb symptoms. Psychological theorists also believe that phantom limb pain occurs as a result of psychopathic understanding of phantom limb sensation as being painful (Peterson 2004). Psychological implications for Limp amputation Limb amputation affects the lives of the victims involved profoundly. Most individuals are unable to continue working or have an active social life and hence they rely on others for their upkeep. Amputation leads to various problems in key aspects of life, psychological, social, emotional and cognitive aspects of life. Studies examining the quality of life of diabetic limb amputees have revealed declined levels of physical, emotional and social function. Depression is one of the common problems experienced by amputees. Most of them live in fear of repeated infection and life-long disability. Amputated individuals need to wear special shoes and hence, it is easier to identify such persons in the public which makes them feel embarrassed. The psychological implications associated with limb amputation are complex as they are mostly related to the new body image. Phantom limb pain presents itself as the most dreadful and fascinating of all medical pain syndromes. Though the experience of phantom limb amputation is not painful, the sensation of the missing the limb is extremely rampant. Phantom limb sensation is observed among victims 6 months after the amputation, where as, 50 % of the victims experiences severe or chronic phantom pain (Salmon 2000). High-levels of emotional distress in amputated diabetic patients are associated with poor dietary habits and poor adherence to recommended self-care behaviors. This tends to impact negatively on limb amputation treatment and the ability to care for one’s amputation. The social stigma associated with disability has contributed significantly to the high levels of depression among amputees. Low self esteem, lack of confidence, guilt, and loss of balance, loss of sense and awareness of death are some of the psychological implications of limb amputation. It is important therefore to come up with appropriate coping strategies which encourage positive social change. It has been observed that diabetic patients suffering from limb amputation experience diminishing energy and get tired faster than other diabetics individuals, especially in the evening. As a result, they are not able to participate in social and family activities and hence spend less time with their family which affects their family and interpersonal communications. These have a negative impact on their families and marriage. The lack of physical activity in adults suffering from limb amputation is linked to public self-consciousness and depression. It has been observed that amputees are reluctant to go out in the public because they are embarrassed of their new body image and they also feel more vulnerable and not able to defend themselves in case of any eventuality (Morrison et al 2008). Diabetes is associated with high risks for cognitive impairments. People suffering from diabetes experience cognitive deficient especially hypoglycemic coma. There are also high cases of mental disorders reported among limb amputee’s diabetic patients. They are likely to suffer from dementia, depression, stroke and hypertension. The kidney failure and blood circulation problems are the risk factors associated with cognitive decline in patients suffering from diabetes. However, it has not been clearly established whether the decline in cognitive capacity is due to diabetes complications or due to treatment of diabetes (Morrison et al 2008). Recommendations There is a significant association between a reduction in anxiety and pain relief in amputees. Research studies have recommended counseling for victims of phantom limb pain. Nurses and other health care workers should encourage amputees to come into contact with a rehabilitation center immediately after they have been discharged from the hospital. This is result to decline in anxiety and depression levels. This will also help amputees to accept their new body image. It is also highly recommendable to use antidepressants and anticonvulsants for patient suffering from depression and anxiety. Appropriate psychological preparation of patients prior to amputation may help prevent some of the post-surgery phantom limb pains. Some patients may experience phantom limb pain due to their fantasies as regards the disposal of the removed limb part. Patients should be made aware of the possibility of experiencing phantom limn sensation and pain before amputation. Patients should also be well prepared to face and deal with these conditions and this make it easier for them to report incidences of phantom pain to their caregivers during the post-surgery period. It is also important to provide psychological support to patients during the grieving period. It is also recommendable to fit the stamp immediately with a prosthesis as this is will reduce the psychological distress related to amputation as this will lead to decrease in dependence and feelings of loss. Patients who have been fitted with an immediate temporary prosthesis experiences less phantom pain in the post-surgery period than those without (Colman and Beischer 2000). However, controversies have existed as to whether pre-surgery preparation reduces the incidences of phantom limb pain in the post-surgery period. In one study, patients who had experienced pre-amputation pain experienced more frequent phantom limb pains in the first 6 months after amputations. In another study, there was no any significant correlation between pre-surgery preparation and phantom limb pain during the post-amputation period. Most of the complications associated with diabetes are preventable if the disease is detected in its early stages in life. It is therefore imperative to come up with appropriate diabetes management strategies that can help prevent amputations. Therefore, it is highly recommended that diabetic patients should be screened at least ones in a year. It also important to do regular foot checks for patient suffering from diabetes, according to clinical guidelines, in order are to monitor the health of the feet and reduce the likelihood of complications. Most of diabetic persons suffering from limb amputations do not have the necessary skills and knowledge for self foot care. It is therefore imperative to create awareness among such individuals for the need of regular self-inspection, the risk of having insensate feet, foot hygiene and the actions to be taken in the event of foot ulcers. Many research studies have identified high incidence rates of psychiatric disorders among victims of limb amputation. It is therefore imperative to come up with to carry out psychiatric evaluation, follow up, and rehabilitation for all individuals with lower limb amputation. Occupational rehabilitation and psychiatric therapy approaches should be used to reduces the impact of disability and improve the functional status and quality of life of these individuals. All health professionals should adapt such approaches in their amputees’ care process. One of the successful ways to make amputees resume their work duties is by use of extensive rehabilitation programs which take into consideration all interdisciplinary team. The combination use of vocational therapy, physical therapy, psychological therapy and occupational therapy generally promote a sense-esteem and self-reliance (Salmon 2000). References ABS. National Health Survey summary of Results, 2004005. Canberra, ABS, 2006a. Ariyo AA, Thach C, Tracy R. Cardiovascular Health Study Investigators. Lp(a) lipoprotein, vascular disease, and mortality in the elderly. N Eng J Med 2003;349: 2108-15. Australian Institute of Health and Welfare. Diabetes: Australian facts 2008. Canberra: AIHW, 2008. Colman PG, Beischer AD. Lower-limb amputation and diabetes: the key is prevention. MJA 2000; 173:341-2. Morrison, V, Bennett, P, Butow, P, Mullan, B, & White, K. Introduction to health psychology in Australia, Pearson, Frenchs Forest, 2008. Payne C.D. Diabetes-related lower-limb amputations in Australia. Med J Aust, 173 (7): 352-4, 2000. Peterson, C. Looking forward through the lifespan, 4th edn, Pearson, Frenchs Forest, NSW, Australia, 2004. Salmon P. Psychology of medicine and surgery: a guide for psychologists, counselors, nurses and doctors, Wiley, Chichester, 2000. Read More