ADJUSTMENT AND COPING RESPONSES
There is a wide spectrum of emotional responses to illness/injury, with one’s coping and adjustment playing a signihcant role in the response. Some individuals will demonstrate signs of the normal grieving process following the onset of an injury or illness that impacts their functioning. Within the rehabilitation setting, it is also common to observe the presence of frustration, anxiety, and emotional liability related to the physiological impact of neurological conditions as well as one’s response to the impact of these conditions (e.g., frustration due to aphasia). It is important for the rehabilitation clinician to monitor the grieving process and any other emotional or behavioral responses to help guard against any worsening of symptoms of depression or anxiety. Providing active interventions to address depressive and anxiety symptoms early on in the process can help to avoid prolongation of this process and guard against a worsening of these symptoms.
According to the DSM-5,13 responses to a signihcant loss (which can include medical illness or disability) may include symptoms that resemble a depressive episode (e.g., feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss). While these symptoms may be considered appropriate or understandable due to the loss, the presence of a major depressive episode or adjustment disorder should also be considered. Differential diagnosis can be challenging, but should take into account clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss. In differentiating between grief and a major depressive episode, an additional point to consider is the predominant affect and thoughts that the individual experiences; grief and loss are characterized by feelings of emptiness and loss while a major depressive episode is characterized by persistent depressed mood and the inability to anticipate happiness or pleasure. Additional information about differential diagnosis is available in the DSM-5.13
Along the spectrum of responses to illness/injury, some individuals will experience symptoms of an adjustment disorder, which can include any combination of depressed mood, anxiety, or behavioral changes in response to a stressor. To meet DSM-5 criteria13 for an adjustment disorder, the symptoms must have a clinically signihcant impact on functioning (as dehned by either marked distress that is out of proportion to the severity of the stressor or signihcant impairment in social, occupational, or other important areas of functioning).
When depressive symptoms persist, worsen, and/or signihcantly impact functioning, a major depressive episode must also be considered and treated promptly. The diagnostic criteria for a major depressive disorder and differential diagnosis are discussed in detail within the DSM-5.13 To summarize, a certain number of symptoms (hve or more) must be present during the same 2-week period, and the symptoms must not be attributable to other conditions or causes (as detailed in the DSM-5). The symptoms outlined in the DSM-5 include depressed mood, loss of interest or pleasure, signihcant changes in appetite or weight loss/gain, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, problems with concentration, and/or recurrent thoughts of death or suicidal ideation. In addition, to meet criteria, the symptoms must cause clinically signihcant distress or impairment in social, occupational, or other areas of functioning.
Anxiety is also a common response to illness/injury and can have a signihcant impact on one’s functioning. A person can experience anxiety related to the diagnosis or prognosis itself as well as its implications for changing various aspects of their lives. Within the rehabilitation setting, it is also commonly observed that individuals can experience anxiety associated with pain, fear of falling, meeting the requirements of therapies, and discharge planning. These symptoms are common experiences when an individual copes with illness/injury and may not be at a level to warrant diagnosis (i.e., they could be judged as being appropriate or understandable based on the loss, as described above). However, when the symptoms of anxiety cause clinically signihcant distress or impairment in functioning, the presence of an adjustment disorder or other anxiety disorder should be considered. In addition, some individuals within the rehabilitation setting experience symptoms of acute stress disorder or posttraumatic stress disorder (PTSD), with a variety of traumatic events that could trigger this response (e.g., a traumatic accident causing injury, the trauma of being in the ICU, etc.). Symptoms that might indicate such a response include intrusive memories, dreams, or flashbacks about the event, intense psychological distress or physiological reactions upon exposure to cues that resemble the traumatic event, avoidance of stimuli associated with the traumatic event, negative alterations in cognitions and mood associated with the event, and alterations in arousal and reactivity.13
In addition to new-onset psychiatric diagnoses that can occur in association with injury/illness in individuals with no prior psychiatric history, some individuals already have a premorbid psychological disorder that can be exacerbated by the additional stressor of injury/illness. Pre-existing psychological disorders also need to be considered in relation to the potential impact on adjustment and health-related behaviors. Another consideration is that the individual may have been experiencing a subsyndromal or undiagnosed psychological disorder that became evident within the context of their adjustment to the stressors related to their medical condition.
One’s ability to adjust to and cope with illness/injury has been widely studied. Studies indicate that perseverative negative cognitive processes (e.g., worry, suppression, and avoidance of undesirable thoughts), have been linked to persistence of depression.14 Further, depression has been found to be significantly related to functional recovery.15 Positive psychological variables present during the rehabilitation stay may help to predict positive functional outcomes after discharge within rehabilitation populations. For example, Kortte et al.16 found that hope accounted for a statistically significant amount of the variance in the prediction of functional role participation at 3 months postdischarge, underscoring the importance of incorporating interventions that enhance hope and build on the individual’s psychological strengths. Although empirical investigation into the concept of hope following illness and disability is still limited, there are studies that have similarly demonstrated that hope is an important mediating factor in the coping process contributing to optimal recovery.17
The role of coping and emotional functioning has also been examined in specific patient populations commonly treated within the rehabilitation field. Van Leeuwen et al.18 conducted a systematic literature review within the spinal cord injury (SCI) population in regards to the associations between psychological factors and quality of life ratings. In their review, they found that locus of control, sense of coherence, self-worth, hope, purpose in life, and positive affect were consistently associated with greater quality of life; negative affect was consistently associated with lower quality of life.18 Peter et al.19 similarly conducted a systematic literature review of psychological resources in the SCI population, with self-efficacy and self-esteem consistently associated with positive adjustment indicators, including better mental health.
Other studies have also investigated coping and adjustment as it relates to outcomes, with findings indicating that appraisals and coping are significantly related to functional outcome, psychological adjustment, and quality of life.20,21 The presence of hope and positive affect were associated with greater life satisfaction during the initial acute rehabilitation period as well as at 3 months after discharge for individuals with SCI.22 Social support was found to be associated with life satisfaction after SCI for at least up to 1 year after inpatient rehabilitation.23 Increases in life satisfaction were also found in persons with SCI for at least up to 5 years after discharge from inpatient rehabilitation when associated with factors such as high functional status, low pain, good social skills, and high self-efficacy.24 In contrast, individuals with SCI who utilized emotion-focused coping styles reported greater ratings of depression during acute rehabilitation, and physical setbacks were more likely to contribute to negative mood.25 Similarly, the use of disengagement coping skills helped to predict levels of depression and PTSD in individuals with SCI.26
Within the stroke population, Skidmore et al.27 found that cognitive impairment (e.g., executive dysfunction) and depressive symptoms correlated significantly with participation during stroke rehabilitation. Similarly, Ostir et al.28 found that positive emotion ratings at discharge from inpatient rehabilitation were significantly associated with higher overall functional status and cognitive status at 3 months postdischarge. Depression, which is common following stroke, has been associated with increased morbidity and mortality.29 The presence of preinjury factors in predicting life satisfaction following traumatic brain injury (TBI) has also been examined. For example, Davis et al.30 demonstrated that preinjury functioning (e.g., education and employment) and preinjury condition (e.g., psychiatric and substance use problems, learning problems, prior TBI) each contributed significantly to variance in life satisfaction following TBI.