Chapter# 29
Psychosocial disorders
Psychological factors (such as; mental illness, personality style, coping strategies, defense mechanism, emotional reactions,
spirituality, values, adjustment & motivation etc.) & social factors ( such as; drug abuse, physical or sexual abuse or social
support etc.) may affect the outcomes of the rehabilitations. Other factors which will influence the rehabilitation outcomes
includes; patient’s perception (positive or negative), patient’s empowerment, educational level & the patient high level of
engagement in the clinical decision makings.
The mind & body are highly connected. Because of their reciprocal influence psychosocial & physical issues should be address at
the same time for the effective recovery. PT frequently encounters patients who have psychiatric problems, the prevalence of
these psychiatric problems varies, which are;
Major psychiatric or personality problems Life time world prevalence
Alzheimer’s (85+ years old) 16-25
Alcohol abuse or dependence 15
Major depression 10
Marijuana abuse or dependence 5
Schizotypal personality disorder 3
Dependent personality disorder 3
Obsessive –compulsive disorder 2.5
Histrionic personality disorder 2.3
Borderline personality disorder 2
Panic disorder 1-2
Schizophrenia 1
If a patient doesn’t have a pre-existing psychological disorders, he/she is more likely to develop one after the onset of the
physical illness. Anxiety disorder can result from;
a) Endocrinal abnormalities such as; hyperthyroidism, hypothyroidism, Pheochromocytoma, hypoglycemia & hype-
adrenocortism.
b) Cardiovascular abnormalities: such as; CHF, pulmonary embolism & arrhythmia.
c) Respiratory abnormalities: such as; COPD, pneumonia & hyperventilation.
d) Metabolic disorders; such as Porphyria & Vit-B deficiency.
e) Neurological conditions: such as vestibular dysfunctions, neoplasm & encephalitis etc.
The role of the PT is a) to identify psychosocial factors which can influence rehabilitation outcomes 2) address these identified
factors during the physical therapy session 3) or provide referral to the psychosocial rehabilitation experts such as;
psychologists, psychiatrist nurses, occupational therapist, social workers, creative art therapists, vocational counselors,
rehabilitation counselor, substance abuse experts & pastoral professionals.
Elements of the mental health examination
Client It includes;
demographics a) Gender, age, culture, ethnicity, economic status, primary & secondary languages.
b) Living environment (past, present & projected future) & environmental support.
c) Family Hx of psychiatric illness & interventions.
d) Current complains;
e) Psychiatric medications current & past.
f) Role of the patient (past, present & projected future)
g) Occupation (past, present & projected future)
h) Social support (past, present & projected future)
i) Leisure interest (past, present & projected future)
j) Goals (past, present & projected future)
k) Values (past, present & projected future)
l) Hx of the psychiatric hospitalizations, substance abuse detoxifications & rehabilitation language.
Examination It includes the following;
, a) Examination of the cognitive status; orientation, memory (STM & LTM & working memory),
executive functioning, judgment, calculations, attentions, processing, metacognitions, use of
the cognitive strategies, volition, self-awareness, mental status, degree of organ-city, cognitive
disability & its relationship to the patient’s rehabilitative capacity.
b) Emotional status; Primary impairments; anxiety, depression, mania, hypomania, grief,
mourning, shock, angers, social ideations, emotional numbness, overwhelm, paranoia, agitated,
low self-esteem, regression, delusion, poor reality sense, blunted & inappropriate affect,
hypervigilance or hypo- vigilance & anhedonia ( refer to the patient inability to experience
pleasure).
c) Defense mechanism; Primary impairments : the use of the predominantly primitive defense
mechanism such as; splitting, acting out, denial, devaluation, dissociation, idealization, isolation
of affects & projections as opposed to more mature defense such as; sublimation, humor,
rationalization, omnipotence, altruism, autistic fantasy. Defense mechanism are tough enough
to impair ego functioning.
d) Personality type; Primary impairments: personality disorders such as; paranoid, antisocial,
dependent, borderline, histrionic, narcissistic, avoidant, obsessive –compulsive, schizoid,
schizotypal.
e) Copping styles; Primary impairments : external locus of control, self-blame, substance abuse &
non-direct or passive or avoidance mode of coping etc.
f) Determination of the social tendencies, decompensation & other risks; Primary impairments :
Hx of suicidal attempts n self- or family members, current suicidal ideation, suicide note, plan
for suicide, emotional or behavioral regression, substance abuse, feelings of hopelessness,
birthdays or death anniversaries of loved one & holiday anniversaries of the traumatic event.
g) Symbolic meaning of the disability & loss & the compensatory reserve that can be elicited.
Primary impairments: poor compensatory reserves or use of the compensatory strategies. The
meaning of the disability is both rigid and fixed & negative.
h) Levels of pain, stress, tolerance & secondary gain. Primary impairments : low frustration
tolerance coupled with high level of pain or stress. The secondary gain of the impairment is high
enough to cause a fixation at a lower than expected level of functioning, which results in
malingering or interfere in the process of the patient’s rehabilitation.
i) Sexual practice; Primary impairments : sexual dysfunction, impotence secondary to psychiatric
medications, unprotected sex, impulsive sexual behaviors, sexual abuse, perversions, hyper
sexuality or sexual addictions.
j) Current functional capacity; Primary impairments: problems with the basic activities of daily
living or instrumental activities of daily livings, inability to perform in current roles &
occupations, decreased community mobility & inability to live independently.
Psychosocial adaptation
Psychological adaptations is dynamic, ongoing & evolving process through which the chronically disable patient strives to attain
an optimal state of functions with the contextual environment & which are characterized by a) a sense of personal mastery b)
participation in the social, recreational & vocational activities c) successful negotiations of the environment d) realistic
awareness of one’s current strength, deficits & functional capacities. Adjustment is the final stage in the adaptation & which is
characterized by a) the patient’s strive to achieve life goals b) improved level of self-confidence c) positive self-esteem.
The process of the adaptation & adjustment is influenced by whither the disability is congenital or acquired, of sudden onset or
gradual, progressive or stable etc. It is because the psychosocial profiles of these patients are different from each other which
eventually makes the adaptation & adjustments different.
The phase model of adjustment to chronic disability or illness is non-linear, multidimensional & progressive. Phase models
tends to have 10-common assumptions which are;
1) People my skip one or more phases or may regress to an earlier phase but adaptation is not usually reversible.
2) The pace structure of the adaptation can be influenced by the external events or interventions such as; environmental
changes or counseling etc. but are mainly determined by the internal process.
3) Not every patient with the chronic illness or disability achieve adjustments, some fixate at earlier phases.
, 4) Adaptation is dynamic & progressive in nature that that gradually shifts from the initial experience of distress to the
assimilation of loss & reconciliation.
5) The adaptation process is initiated by significant & permanent changes in the body functional capacities &
appearance, which are usually followed by alteration of self-concept & body image.
6) The amount of time spent in each phase varies & may be determined by the combinations of the following factors; a)
social support b) financial or human resources c) past exposure to crisis d) age at onset e) severity f) nature of the
disability or illness h) premorbid personality.
7) Psychological maturity & growths occurs as the patient progress through these phases.
8) Psychological re-equilibrium occurs through gradual adaptations & integration of the perceived misfortune.
9) Humane variability & uniqueness have strong influence on the temporal ordering of the phases- thus, the sequence of
phases are not universal.
10) Occasionally phases may overlap, be non-discrete or fluctuate causing patients to experience more than one reactions
at a time.
Grief, mourning Grief: It is psychological state of distress resulting from a significant loss such as; loss of functions,
& sorrow broken relationships or the loss of role or identity etc. signs of the grief includes; tightness of the
throat, muscular weakness, emptiness in the abdomen, painful anxiety, periodic waves of physical
distress, forgetfulness, poor concentration, insomnia, loss of appetite & choking etc. According to
Donatele & co the grieving process consist of 10-stages, which are;
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
10) A sense that life is OK.
Mourning: It is the intense form of grief. Grief-mourning period is unpredictable lasting anywhere from
6 months to2 years or more.
Sorrow: Lindgren & co defined chronic sorrow as “progressive sadness that often increase after the
initial loss 2) prolong period of sorrows with unpredictable end 3) recurrent or cyclic in nature as the
sorrow is continually triggered by the intrinsic & extrinsic events that re-waken loss.
PT must understand grief, mourning & sorrow as it will affect the outcomes of the rehabilitation.
Phase models of Adaptation can occurs in two ways a) adaptation occurs as set of non-sequential & independent
psychosocial pattern of behaviors b) adaptations occurs through a series of progressive phases.
adaptations Phases models suggests that the patient’s reaction to chronic illness or disability follows a stable
sequence of phases that are progressively (gradual & linear) & temporally in order. These phases are;
1) socks 2) anxiety 3) denial 4) depression 5) internalized anger 6) externalized anger or hostility 7)
acknowledgement 8) final adjustment.
Shock; Shocks occurs as initial reactions to psychological trauma or physical trauma. It results from the
overwhelming experience & characterized by the inability to move or speak, psychic numbness.
Decreased cognitive skills, disorganization & depersonalization. During the shocks the individuals will
response primary at the physiological level, then emotional & cognitive level.
Anxiety; Shocks is followed by the anxiety which are the panic-stricken reactions characterized by
compulsive activity, elevated pulse rate, dyspnea &cognitive flooding etc. Stress reactions may not
necessarily may be trigger by the catastrophic conditions but it may be trigger by other conditions such
as; daily life frustration, internal & external conflicts & change in the life conditions.
Denial; Denial is often used as defense mechanism to alleviate painful anxiety associated with chronic
illness or disability. Denial allows a gradual assimilation of one’s altered reality & protect the person to
confront the overwhelming implications of chronic illness or disability.
Breznitz identified 7-types of denial;
a) Denial of threatening information, by using selective inattention or partial awareness.
b) Denial of vulnerability (exerting control & maximizing personal strength).
c) Denial of urgency (using methods to see the situation as less pressing than it is).
d) Denial of affect ( reduction of emotional impacts)
e) Denial of effect relevance (diverting attentions to other issues & believing that emotions is
Psychosocial disorders
Psychological factors (such as; mental illness, personality style, coping strategies, defense mechanism, emotional reactions,
spirituality, values, adjustment & motivation etc.) & social factors ( such as; drug abuse, physical or sexual abuse or social
support etc.) may affect the outcomes of the rehabilitations. Other factors which will influence the rehabilitation outcomes
includes; patient’s perception (positive or negative), patient’s empowerment, educational level & the patient high level of
engagement in the clinical decision makings.
The mind & body are highly connected. Because of their reciprocal influence psychosocial & physical issues should be address at
the same time for the effective recovery. PT frequently encounters patients who have psychiatric problems, the prevalence of
these psychiatric problems varies, which are;
Major psychiatric or personality problems Life time world prevalence
Alzheimer’s (85+ years old) 16-25
Alcohol abuse or dependence 15
Major depression 10
Marijuana abuse or dependence 5
Schizotypal personality disorder 3
Dependent personality disorder 3
Obsessive –compulsive disorder 2.5
Histrionic personality disorder 2.3
Borderline personality disorder 2
Panic disorder 1-2
Schizophrenia 1
If a patient doesn’t have a pre-existing psychological disorders, he/she is more likely to develop one after the onset of the
physical illness. Anxiety disorder can result from;
a) Endocrinal abnormalities such as; hyperthyroidism, hypothyroidism, Pheochromocytoma, hypoglycemia & hype-
adrenocortism.
b) Cardiovascular abnormalities: such as; CHF, pulmonary embolism & arrhythmia.
c) Respiratory abnormalities: such as; COPD, pneumonia & hyperventilation.
d) Metabolic disorders; such as Porphyria & Vit-B deficiency.
e) Neurological conditions: such as vestibular dysfunctions, neoplasm & encephalitis etc.
The role of the PT is a) to identify psychosocial factors which can influence rehabilitation outcomes 2) address these identified
factors during the physical therapy session 3) or provide referral to the psychosocial rehabilitation experts such as;
psychologists, psychiatrist nurses, occupational therapist, social workers, creative art therapists, vocational counselors,
rehabilitation counselor, substance abuse experts & pastoral professionals.
Elements of the mental health examination
Client It includes;
demographics a) Gender, age, culture, ethnicity, economic status, primary & secondary languages.
b) Living environment (past, present & projected future) & environmental support.
c) Family Hx of psychiatric illness & interventions.
d) Current complains;
e) Psychiatric medications current & past.
f) Role of the patient (past, present & projected future)
g) Occupation (past, present & projected future)
h) Social support (past, present & projected future)
i) Leisure interest (past, present & projected future)
j) Goals (past, present & projected future)
k) Values (past, present & projected future)
l) Hx of the psychiatric hospitalizations, substance abuse detoxifications & rehabilitation language.
Examination It includes the following;
, a) Examination of the cognitive status; orientation, memory (STM & LTM & working memory),
executive functioning, judgment, calculations, attentions, processing, metacognitions, use of
the cognitive strategies, volition, self-awareness, mental status, degree of organ-city, cognitive
disability & its relationship to the patient’s rehabilitative capacity.
b) Emotional status; Primary impairments; anxiety, depression, mania, hypomania, grief,
mourning, shock, angers, social ideations, emotional numbness, overwhelm, paranoia, agitated,
low self-esteem, regression, delusion, poor reality sense, blunted & inappropriate affect,
hypervigilance or hypo- vigilance & anhedonia ( refer to the patient inability to experience
pleasure).
c) Defense mechanism; Primary impairments : the use of the predominantly primitive defense
mechanism such as; splitting, acting out, denial, devaluation, dissociation, idealization, isolation
of affects & projections as opposed to more mature defense such as; sublimation, humor,
rationalization, omnipotence, altruism, autistic fantasy. Defense mechanism are tough enough
to impair ego functioning.
d) Personality type; Primary impairments: personality disorders such as; paranoid, antisocial,
dependent, borderline, histrionic, narcissistic, avoidant, obsessive –compulsive, schizoid,
schizotypal.
e) Copping styles; Primary impairments : external locus of control, self-blame, substance abuse &
non-direct or passive or avoidance mode of coping etc.
f) Determination of the social tendencies, decompensation & other risks; Primary impairments :
Hx of suicidal attempts n self- or family members, current suicidal ideation, suicide note, plan
for suicide, emotional or behavioral regression, substance abuse, feelings of hopelessness,
birthdays or death anniversaries of loved one & holiday anniversaries of the traumatic event.
g) Symbolic meaning of the disability & loss & the compensatory reserve that can be elicited.
Primary impairments: poor compensatory reserves or use of the compensatory strategies. The
meaning of the disability is both rigid and fixed & negative.
h) Levels of pain, stress, tolerance & secondary gain. Primary impairments : low frustration
tolerance coupled with high level of pain or stress. The secondary gain of the impairment is high
enough to cause a fixation at a lower than expected level of functioning, which results in
malingering or interfere in the process of the patient’s rehabilitation.
i) Sexual practice; Primary impairments : sexual dysfunction, impotence secondary to psychiatric
medications, unprotected sex, impulsive sexual behaviors, sexual abuse, perversions, hyper
sexuality or sexual addictions.
j) Current functional capacity; Primary impairments: problems with the basic activities of daily
living or instrumental activities of daily livings, inability to perform in current roles &
occupations, decreased community mobility & inability to live independently.
Psychosocial adaptation
Psychological adaptations is dynamic, ongoing & evolving process through which the chronically disable patient strives to attain
an optimal state of functions with the contextual environment & which are characterized by a) a sense of personal mastery b)
participation in the social, recreational & vocational activities c) successful negotiations of the environment d) realistic
awareness of one’s current strength, deficits & functional capacities. Adjustment is the final stage in the adaptation & which is
characterized by a) the patient’s strive to achieve life goals b) improved level of self-confidence c) positive self-esteem.
The process of the adaptation & adjustment is influenced by whither the disability is congenital or acquired, of sudden onset or
gradual, progressive or stable etc. It is because the psychosocial profiles of these patients are different from each other which
eventually makes the adaptation & adjustments different.
The phase model of adjustment to chronic disability or illness is non-linear, multidimensional & progressive. Phase models
tends to have 10-common assumptions which are;
1) People my skip one or more phases or may regress to an earlier phase but adaptation is not usually reversible.
2) The pace structure of the adaptation can be influenced by the external events or interventions such as; environmental
changes or counseling etc. but are mainly determined by the internal process.
3) Not every patient with the chronic illness or disability achieve adjustments, some fixate at earlier phases.
, 4) Adaptation is dynamic & progressive in nature that that gradually shifts from the initial experience of distress to the
assimilation of loss & reconciliation.
5) The adaptation process is initiated by significant & permanent changes in the body functional capacities &
appearance, which are usually followed by alteration of self-concept & body image.
6) The amount of time spent in each phase varies & may be determined by the combinations of the following factors; a)
social support b) financial or human resources c) past exposure to crisis d) age at onset e) severity f) nature of the
disability or illness h) premorbid personality.
7) Psychological maturity & growths occurs as the patient progress through these phases.
8) Psychological re-equilibrium occurs through gradual adaptations & integration of the perceived misfortune.
9) Humane variability & uniqueness have strong influence on the temporal ordering of the phases- thus, the sequence of
phases are not universal.
10) Occasionally phases may overlap, be non-discrete or fluctuate causing patients to experience more than one reactions
at a time.
Grief, mourning Grief: It is psychological state of distress resulting from a significant loss such as; loss of functions,
& sorrow broken relationships or the loss of role or identity etc. signs of the grief includes; tightness of the
throat, muscular weakness, emptiness in the abdomen, painful anxiety, periodic waves of physical
distress, forgetfulness, poor concentration, insomnia, loss of appetite & choking etc. According to
Donatele & co the grieving process consist of 10-stages, which are;
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
10) A sense that life is OK.
Mourning: It is the intense form of grief. Grief-mourning period is unpredictable lasting anywhere from
6 months to2 years or more.
Sorrow: Lindgren & co defined chronic sorrow as “progressive sadness that often increase after the
initial loss 2) prolong period of sorrows with unpredictable end 3) recurrent or cyclic in nature as the
sorrow is continually triggered by the intrinsic & extrinsic events that re-waken loss.
PT must understand grief, mourning & sorrow as it will affect the outcomes of the rehabilitation.
Phase models of Adaptation can occurs in two ways a) adaptation occurs as set of non-sequential & independent
psychosocial pattern of behaviors b) adaptations occurs through a series of progressive phases.
adaptations Phases models suggests that the patient’s reaction to chronic illness or disability follows a stable
sequence of phases that are progressively (gradual & linear) & temporally in order. These phases are;
1) socks 2) anxiety 3) denial 4) depression 5) internalized anger 6) externalized anger or hostility 7)
acknowledgement 8) final adjustment.
Shock; Shocks occurs as initial reactions to psychological trauma or physical trauma. It results from the
overwhelming experience & characterized by the inability to move or speak, psychic numbness.
Decreased cognitive skills, disorganization & depersonalization. During the shocks the individuals will
response primary at the physiological level, then emotional & cognitive level.
Anxiety; Shocks is followed by the anxiety which are the panic-stricken reactions characterized by
compulsive activity, elevated pulse rate, dyspnea &cognitive flooding etc. Stress reactions may not
necessarily may be trigger by the catastrophic conditions but it may be trigger by other conditions such
as; daily life frustration, internal & external conflicts & change in the life conditions.
Denial; Denial is often used as defense mechanism to alleviate painful anxiety associated with chronic
illness or disability. Denial allows a gradual assimilation of one’s altered reality & protect the person to
confront the overwhelming implications of chronic illness or disability.
Breznitz identified 7-types of denial;
a) Denial of threatening information, by using selective inattention or partial awareness.
b) Denial of vulnerability (exerting control & maximizing personal strength).
c) Denial of urgency (using methods to see the situation as less pressing than it is).
d) Denial of affect ( reduction of emotional impacts)
e) Denial of effect relevance (diverting attentions to other issues & believing that emotions is
