Is There a Link Between Body Image and Perceptionof Social Acceptability, and the Adjustment toAmputation?

Bruce Rybarczyk, David L. Nyenhuis, John J. Nicholas, Susan M. Cash, andJames Kaiser, Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois

(The following is an adaptation of an extremely interesting article by theauthors listed above, which appeared in the journal, RehabilitationPsychology, Vol. 40, No. 2, 1995, pps. 95-109.)

  Previous research has shown that psychological adjustment toamputation is a common problem. Most research has been done with legamputees (presumably because of their abundance relative to armamputees, however one might argue that arm amputees' problems may besimilar, if not more pronounced. Ed.) These problems include anxiety,social isolation, decreased sexual activity, and depression. Considering thatthe National Center for Health Statistics estimates one in 200 persons inthe United States is a lower extremity amputee (and the literatureindicates that there is one arm amputee for every nine or ten legamputees, Ed.), these adjustment difficulties represent a significant publichealth problem.

  Earlier studies revealed other interesting things. For example, womenare more likely to be depressed than men after an amputation. Also, olderadults were more depressed than younger adults during the first 18months after amputation, but the reverse was found to be true after agreater passage of time. Also, greater life satisfaction seemed to followamputation where there was a higher level of heath and social support,peripheral vascular disease was NOT involved, and the amputees weremen. Conversely, lower levels of health and social support have beenscientifically linked to depression., Finally, studies have showed thatperceived health, functional status, optimistic attitude, and satisfactionwith social support were the strongest predictors of whether or not adultswith amputations could be expected to suffer from depression.

  Considering earlier research, the authors conjectured that body imageconcerns (i.e., Do you avoid being out in public because of how you thinkyour amputation makes you look?) would have a direct connection withpsychological adjustment.   The researchers also hypothesized that social stigma (i.e., the amputees'idea that others have a negative stereotypical attitude about them becauseof their disability) would be an important predictor of adjustment. Theyrealized, and the research literature supports, that all disabled peopleencounter a wide range of biased attitudes among non-disabled people (i.e.,I feel you are turned-off by the way I look or the way I have to do things.).

Research Method

  To test these hypotheses, the authors assembled 112 people with legamputations and subjected them at a variety of psychological tests.Research subjects were all clients of prosthetists and were chosenrandomly.

The sample consisted of:

  The psychological tests administered over a period of 10 months werestandardized tests or adaptations of standardized tests (to make them moreapplicable to amputees) and were designed to measure 1) amputation-related body image, 2) perceived social stigma, 3) perceived social support,4) self-rated health, 5) depression, and 5) quality of life. In addition, theirprosthetists were asked to rate their adjustment in relation to their"average" clients.


Depression - In this study, the presence of depression was used as anindicator of maladjustment. The study found that 28% of the researchsubjects scored in the "clinical depression" range. This compares with areported 10% in the random community and is consistent with earlierstudies with amputees and with those having a variety of physicaldisabilities (35%) and chronic pain (24%). The other amputee studiesincluded people who were an average of 4 years post-amputation, whilethe average in this study was 17 years. This indicates that depression isboth a short term and long term adjustment problem followingamputation.

Body Image - The study showed a significant connection between bodyimage concerns and depression. These factors have been linked in studiesof the general population, and they have been studied using individualswith other stigmatizing physical conditions, but only one other study(using colostomy patients) confirmed the connection between body imageand depression.

Perceived Social Stigma - Along with body image, perceived socialstigma was found to be an effective predictor of depression. The importantquestion that remains unresolved is whether the individuals areexperiencing "real" stigma or are only projecting their own lack of self-acceptance to others. Although it's well known that the general public canexhibit both negative attitudes and behavior toward people with obviousdisabilities, the subjects of this study, being prosthesis users, were notgenerally detectable in social situations as being "different." This mightlead one to suspect that lack of social acceptability was more perceived thanreal.

Social Support - The role that low social support had in predictingdepression was consistent with other studies involving both amputees andthose with other physical disabilities, and was seen to be independent ofboth body image and perceived social stigma. as a predictor.


  This study tends to confirm scientifically what seems common-sensical;that a positive body image, a sense that their disability doesn't matter toothers, and the availability of an amputee support or other social supportgroup all combine to help people with amputations adjust successfully.

  If the participants in this study are truly representative of the generalpopulation of people with amputations, there is evidence that amputeesupport groups are failing to fulfill their outreach function. Only 12 of theparticipants were involved in a support group while 42 reported aninterest in becoming involved. 50% of those presenting clinical depressionwere not involved in a support group but expressed an interest in joiningone.

  Finally, this study suggests that mental health professionals pay too littleattention to persons with amputations. Perhaps this is because theyassume most amputees will eventually seek the services of prosthetists to"become rehabilitated." However, they fail to realize that the servicesdispensed by prosthetists are primarily mechanical--focusing principallyon making their clients two-armed and two-legged, and generally ignoringtheir mental health and psychological recovery needs.

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