NeuroRehabilitation An InterdllCiplllllry Journal

ELSEVIER

NeuroRehabilitation 11 (1998) 155-174

Spinal cord injury and anxiety: a comprehensive review

w. David Crews Jr. a,*, Laura G. Hensleyb, Aaron M. Goeringc, Jeffrey T. Bartha, Judith T. Rusek a

a Division

of Neuropsychology, Box 203, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA b Our Lady of the Lake College, Baton Rouge, LA, USA CLynchburg College, Lynchburg, VA, USA Accepted 21 August 1998

Abstract

Although there have been past literature reviews which have addressed the psychological adjustment, consequences, and impact/reaction to spinal cord injury, as well as reviews of depression after spinal cord injury, there appears to be an absence of reviews which have focused primarily on the relationship between spinal cord injury and anxiety. The purpose of this paper is to present a comprehensive review of the relatively recent (the past 23-31 years depending on the database utilized) scientific literature as it pertains to anxiety reactions in spinal cord injured individuals. Specifically, this paper provides reviews of the prevalence/presence of anxiety reactions, as well as the correlates of anxiety, in the spinal cord injured population. Furthermore, this paper reviews the relatively few articles which have addressed the treatment of such symptomatology in spinal cord injured individuals. Methodological concerns and limitations of the existing literature and directions for future research are also provided. © 1998 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Spinal cord injury; Depression; Anxiety

1. Introduction

Anxiety has been proposed as a frequently occurring psychological reaction in many models of adjustment to spinal cord injury (see Frank et al.

* Corresponding author. Tel.: 2436546.

+ 1 804 9242701; fax: + 1 904

[1] for a review). Clinically, anxiety reactions are often noted in spinal cord injury (SCI) patients, especially while they are hospitalized in acute care settings. Although there have been past literature reviews of the psychological adjustment [2,3], consequences [4] and impact/reaction [5] to spinal cord injury, as well as reviews of depression and SCI [2,6], there appears to be a relative absence of reviews which have focused primarily on the

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156

WD. Crews Jr. et al. / NeuroRehabilitation 11 (J998) 155-174

relationship between spinal cord injury and anxiety. The purpose of this paper is to provide a comprehensive review of the relatively recent (past 23-31 years depending on the database utilized) scientific literature as it pertains to anxiety reactions in spinal cord injured individuals. Specifically, this paper will review the prevalence/presence of anxiety reactions, as well as the correlates of anxiety in the SCI population. Furthermore, this paper will review the relatively few articles which have addressed the treatment of such symptomatology in spinal cord injured individuals. Methodological concerns and limitations of the existing literature and directions for future research will also be provided. 2. Method A comprehensive literature review was conducted based on searches of the following databases using the key words, 'Anxiety and Spinal Cord Injury, Psychology and Spinal Cord Injury, Anxiety and Spinal Cord Injury and Treatment, and Anxiety and Spinal Cord Injury and MMPI': Medline (1966 to July, 1997; 'Entire Database'); PsycLIT (1974 to June, 1997); HealthSTAR (1975-1994); HealthSTAR (1995 to June, 1997); Nursing and Allied Health (1982 to April, 1997), and Current Contents (week 01, 1996 to week 26, 1997). All articles obtained via these searches were also carefully reviewed for additional, related articles that addressed the relationship between spinal cord injury and anxiety. 3. Review of the prevalence / presence of anxiety studies The following section provides a review of those studies that have addressed the prevalence and/or presence of anxiety among spinal cord injured individuals. A chronologically presented overview of these studies is provided in Table 1. Although many of these investigations also examined other areas of psychological functioning (e.g. depression), this review focuses primarily on their findings as they pertain to spinal cord injury and anxiety. Headings similar to those cited in the table will be utilized throughout this section.

3.1. Studies

A total of 19 studies were found which addressed the prevalence and/or the presence of anxiety in spinal cord injured individuals. 3.2. Subjects

The majority of studies (n = 15) utilized significantly more spinal cord injured males than females, while one study [7] examined only females. Alternatively, in three studies, the male/female breakdown was not provided [8-10]. Non-spinal cord injured/'able-bodied' control subjects, patients' family members, or psychological inventories' normative samples were utilized in five studies [8,9,11-13], while another study surveyed rehabilitation staff in addition to SCI patients [14]. Three studies [10,15,16] compared different groups of SCI patients (e.g. depressed vs. non-depressed; complete vs. incomplete injuries), and two other investigations examined both SCI patients and those with closed head injuries [12,17]. Additionally, one study [15] compared SCI patients to those from a Comprehensive Pain Clinic (i.e. non-SCI patients). 3.3. Level of injury

Two studies examined predominantly more individuals with quadriplegia [9,18], three predominantly more patients with paraplegia [14,19,20], and four articles employed relatively equal numbers of persons with quadriplegia and paraplegia [8,11,21,22]. In five studies the levels of injury for at least part of the samples were unspecified [7,10,12,13,16] while four other studies [17,23--25] utilized 'mixed' (e.g. cervical, thoracic, lumbar, paresis, 'normals', or Frankel D incompletes) patient samples. One additional study [15] provided only the number of patients with incomplete injuries. 3.4. Time since injury

Two of the prevalence/presence articles [10,20] appeared to examine SCI patients in the 'acute' phase of injury (less than 1 month post-injury),

Table 1 Prevalence/presence of anxiety Study

Subjects

Level of injury

Time since injury

Anxiety criteria/measures

Findings

Cook [19]

M = 91; F= 27 (All SCI patients)

Quadriplegic = 37% Paraplegic = 63%

84% impaired < 1 year

Mini-Mult STAI (State and Trait) (Self Report)

13% of sample met MMPI criteria for an anxiety reaction; scores suggested moderate anxiety reactions in most of these patients Mean scores for the STAI State and Trait Anxiety Scales fell near the average range

Bracken et al. [23]

M = 158; F= 32 (All SCI patients)

Motor function: Quadriplegics: 29% Paraplegics: 25.4% Paresis: 18.3% Normal: 27.2%

Mean = 46.0 days (S.D. = 32.2)

5 point' Likert' type scale Adjective Checklists (Self Report) Ratings by an interviewer using the above scales

Majority of patients reportedly displayed evidence of anxiety, anger, depression, and denial of injury at discharge Patient and interviewer ratings of anxiety highly correlated No specific prevalence rate provided

Nestoros et al. [22]

M=31;F=4 (All SCI patients)

Quadriplegics = 19 Paraplegics = 16

Quadriplegic Mean = 17.7 months Paraplegic Mean = 15.6 months

Zung Self Rating Scales for Anxiety and Depression (Self Report)

Majority of patients scored within the normal range 3 (15.79%) Quadriplegic and 3 (18.75%) paraplegic patients had mild to moderate anxiety; 1 (5.26%) quadriplegic had marked to severe anxiety Overall, 20.0% of these SCI patients exhibited e.levated anxiety

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Ernst [21]

SCI patients: M=37; F=9 30 Rehab. staff members

C4 - 7 = 32% Cs-Ls = 67%

M =8; F= 1 (All SCI patients)

Quadriplegics = 5 Paraplegics = 4

41% injured < 6 months 9% injured 6 months to 1 year 50% injured 1-5 years

35-Item Psychosocial Questionnaire for Spinal Cord Injured Persons (PQ for SCIP) developed by authors (included an anxiety subscale) (Self Report)

SCI patients reported more anxiety than anticipated by caregivers No specific prevalence of anxiety rates provided

All injured at least 1 year (Mean = 3.0 years)

Bodenhamer PQ for SCIP (Self Report)

Staff significantly overestimated patients' levels of anxiety Suggested that this study may have scored the questionnaire differently than in Bodenhamer et aJ.'s [14] study No specific prevalence of anxiety rates provided

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Table 1 (Continued) Study

Subjects

Level of injury

Time since injury

Anxiety criteria/measures

Findings

Cohen et al. [15]

SCI patients n =49 Comprehensive Pain Clinic (CPC) patients n=98 (each group was 95% male)

Incomplete injuries = 30 (remainder complete?)

Unspecified (minimum 6 months history of chronic pain)

MMPI

Psychasthenia (Pt) scale of the MMPI elevated for CPC group and missed clinical significance for the SCI-Complete (SCI-C) group by one point (i.e. T = 69). No significant differences between these two groups on any MMPI scale Overall, the SCI-I group exhibited substantially less elevated MMPI profiles (and Pt scores) as compared to the CPC and SCI-C groups No specific prevalence of anxiety rates provided

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Buckelew et al. [18]

Huang et al. [24]

Tate et al. [13]

M =47; F= 10 (All SCI patients)

M=62; F=2 (All SCI patients)

SCI patients n=79 M=73.4%; F= 26.6% BSI normative sample n =974 M =50.7%; F=49.3%

Quadriplegics = 35 Paraplegics = 22

Cervical = 37 Thoracic = 20 Lumbar = 7

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Mean = 1.86 years (S.D. = 3.7 years) Median = 0.30 years

SCL-90-R (Self Report)

All injured < 1 year Acute ( < 3 months post-injury) n = 45 Rehab. (3-6 months post-injury) n = 13 Chronic (6 months to < 1 year postinjury) n = 6

Mini-Mult

Mean = 7 months (1-12 months)

Brief Symptom Inventory (BSJ) SCL-90-R (Self Report)

Mean SCL-90-R T-scores for both the Anxiety (x = 56.05, S.D. = 13.37) and Phobic Anxiety (x = 53.18, S.D. = 14.06) scales not clinically elevated No specific prevalence of anxiety rates provided For the Psychasthenia (Pt) scale, 30.8% of the Acute group, 46.2% of the Rehab. Group, and 16.7% of the Chronic group exhibited elevated (T> 70) scores, although no significant differences were found between groups

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SCI patients exhibited significantly higher BSI anxiety and phobiC anxiety scores as compared to the normative sample Clinically, mean scores on both measures were generally within the normal range of distress No specific prevalence rate provided

Table 1 (Continued) Fedoroff et al. [10]

Judd and Brown [20]

Subjects who met DSM-III criteria for Major Depression: SCI: n = 12 MI: n = 25 CVA: n =44 M =?; F=? Non-depressed subjects: SCI: n = 48 MI: n = 104 CVA: n = 171 M =?; F=?

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M = 186; F =41 (All SCI patients)

Quadriplegics= 91 Para-

'Acute' SCI patients (time since injury not provided)

Glass [9]

1 (8.33%) SCI patient met criteria for Major Depression and a Generalized Anxiety Disorder as compared to 3 MI and 16 CVA patients Among non-depressed patients, 2 of 48 (4.17%) SCI patients met criteria for GAD while 10 of 104 MI and 8 of 171 CV A patients did Authors noted several potential confounding factors: SCI patients were significantly younger, more likely to have been treated with benzidiazepines, and have a positive history of alcoholism

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Within 1 week of admission? plegics = 136

Alfano et al. [17]

Modified Present State Exam 17 Specific PSE syndrome clusters (CATEGO scores) (e.g. generalized anxiety, simple depression, etc.) (A semi-structured interview) DSM-III criteria for generalized anxiety disorder (GAD) modified to be more stringent

Semi-structured interviews, epidemiological, personal and clinical data Psychiatric diagnoses based on DSM-III criteria

SCI patients: M = 14; F=3 CHI patients: M =25; F=7

Cervical = 6 All patients at Thoracic = 8 least 1 year Lumbar = 3 post-injury

STAI (State and Trait) (Self Report)

SCI patients: n = 6 M =?; F=? Family members N=6 M =?; F=?

All tetraplegic

Snaith Irritability, Depression, and Anxiety (IDA) Scale (Self Report)

Unknown; however, all patients had returned home from the hospital

Adjustment disorder with anxious/depressed mood diagnosed in 4 (4.40%) quadriplegic and 3 (2.21 %) paraplegic patients Overall, 3.08% of this sample was diagnosed with this disorder GAD diagnosed in one (0.74%) paraplegic Diagnoses reflected onsets of illness after SCI hospitalization SCI patients typically displayed STAI Sand T scores that were within the range of normal variability No significant differences between groups No specific prevalence of anxiety rates provided

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1 S.D. above the norm (42) on the STAI(Trait) representing anxious responses up to 1 year later Both of these subgroups became less anxious across time (over 1 year)

Abbreviations. M, males; F, females; SCL-90, symptom checklist-90; SCI, spinal cord injury; MMPI, Minnesota Multiphasic Personality Inventory; STAI, Spielberger State-Trait Anxiety Inventory; S, State, T, Trait.

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W.D. Crews fr. et af. / NeuroRehabilitation 11 (1998) 155-174

although the mean lengths of time since injury were not provided. Three investigations studied patients who were, on average, 1 month to 1 year post-injury [13,19,23], while five studies examined patients who were, on average, more than 1 year post-injury [12,17,18,21,22]. Four longitudinal investigations were also found in the literature [8,11,16,25]. Furthermore, in three studies, the time since injury was unspecified [7,9,15], and in two other studies, the time since injury was mixed [14,24]. 3.5. Anxiety criteria / measures

The large majority of studies (n = 17) employed primarily (or only) self-report questionnaires/inventories of anxiety. In contrast, two studies [10,20] utilized semi-structured interviews (clinical data, etc.) and DSM-III criteria. 3.6. Findings

A review of the prevalence/presence of anxiety studies· revealed only two studies where the time since injury appeared to be less than 1 month, or was described as 'acute'. Judd and Brown [20], found that four of 91 (4.40%) patients with quadriplegia and three of 136 (2.21%) patients with paraplegia were suffering from a diagnosable Adjustment Disorder with anxious/depressed mood, for an overall prevalence rate of 3.08% (7/227 patients) for this diagnosis. One of the 136 individuals with paraplegia was also diagnosed with a Generalized Anxiety Disorder. Similarly, Fedoroff et al. [10] found that two out of 48 (4.17%) of their sample of non-depressed SCI patients met criteria for a Generalized Anxiety Disorder (GAD) while one of 12 (8.33%) of their SCI patients with Major Depression met GAD criteria. There were only two studies where the time since injury ranged from more than 1 month to less than 1 year, and where a prevalence rate of anxiety reactions could be ascertained. Cook [19] found that 13% of his sample of 118 SCI patients met MMPI criteria for primarily 'moderate' anxiety reactions. In contrast, Huang et al. [24] found that 30.8% of SCI patients injured less than 3

months, 46.2% of those injured 3-6 months, and 16.7% of those patients injured 6 months to less than 1 year exhibited elevated T scores (T> 70) on the Psychasthenia (Pt) scale of the Mini-Mult. For the two cross-sectional studies where the time since injury was greater than 1 year, and where rates of anxiety reactions could be obtained, overall prevalence rates narrowly ranged approx. 20%. Specifically, Hammell [12] found that three out of 15 (20.0%) patients in his SCI sample fell within the clinical range of anxiety on the Leeds Anxiety Scale. Similarly, Nestoros et al. [22] found that three out of 19 (15.79%) individuals with quadriplegia and three out of 16 (18.75%) persons with paraplegia reported mild to moderate anxiety on the Zung Anxiety Scale, while one individual with quadriplegia had marked to severe anxiety. Overall, however, 20% (7/35) of this sample of SCI patients were calculated to be suffering from some level of anxiety. For studies where the time since injury was unclear or unspecified, and where a prevalence rate could be determined, prevalence of anxiety reactions in SCI patients ranged from 30.7% in a sample of females [7] to 33.33% in a small sample of individuals with tetraplegia [9]. Furthermore, Harrison et al. [7] noted that 25.6% and 43.6% of their sample of female SCI patients fell within the 'doubtful' and 'non-cases' categories of anxiety reactions, respectively, as assessed via the Hospital Anxiety and Depression Scale. A review of the longitudinal studies revealed that elevated anxiety and phobic anxiety (as assessed via the Brief Symptoms Inventory) were found in 19.8 and 25.3% of a sample of SCI patients, respectively at 2-6 years (x = 4.6 years) post-injury, while a year later, 25.7% of these patients exhibited both such reactions [25]. In two studies, prevalence rates for anxiety reactions ranged from 25% (averaged over 1 year) of a sample of SCI patients [11] to 15 out of 41 (36.5%) SCI patients who served as control subjects in a cognitive-behavioral treatment study [16]. Furthermore, Craig et al. [8] reported that 'up to 30% at least' of his sample of SCI patients were significantly anxious or depressed long term. In several studies a prevalence rate could not be determined. Bracken et al. [23] noted, how-

W.D. Crews Jr. et al. / NeuroRehabilitation 11 (1998) 155-174

ever, that the majority of his sample of SCI patients displayed evidence of anxiety, anger, depression, and denial of injury at the time of discharge. Cohen et al. [15] also found that his group of patients with complete spinal cord injuries missed having clinically significant (T> 70) MMPI Psychasthenia (Pt) scale scores by one point. It should be noted, however, that this study's SCI-incomplete group exhibited notably less elevated scores on this scale. Two additional studies reported that while their samples of SCI patients were more anxious than control subjects, or normative samples, their overall means were generally within normal limits [11,13]. Furthermore, other investigations have found that the majority of their SCI patients scored within the 'normal' range on self-report measures of anxiety [22] or that their SCI samples' mean scores were generally within normal limits and not clinically elevated [17-19,25]. These findings suggest that like depression, anxiety is not a universal or inevitable reaction to spinal cord injury [6]. Additionally, two studies compared SCI patients' anxiety levels to ratings by their caregivers. Bodenhamer et al. [14] found that their sample of SCI patients reported more anxiety than anticipated by caregivers, while another study [21] found that staff significantly overrated SCI patients' levels of anxiety. Although both of these studies utilized the same self-report measure (i.e. Psychosocial Questionnaire for Spinal Cord Injured Persons), Ernst noted that the contrasting findings may have been due, in part, to his use of an alternative scoring system. In sum, a total of 19 studies were found that examined the prevalence/presence of anxiety in SCI individuals. Overall, the prevalence rate of anxiety reactions in these studies (in which a prevalence rate could be determined) ranged from a low of three of 136 (2.21%) 'acutely' injun~d patients with paraplegia who met criteria for an Adjustment Disorder with anxious/depressed mood [20], to a high of 46.2% of a sample of SCI patients who had been injured between 3 and 6 months and who exhibited elevated T-scores (T > 70) on the Psychasthenia (Pt) scale of the MiniMult [24]. The varying prevalence rates observed

163

across these studies likely reflect the heterogeneity of patient characteristics and methods/procedures that were utilized in these investigations. An overview of the methodological concerns/ limitations that may have also impacted these studies is provided later in this paper. 4. Review of the correlates of anxiety studies

The following section provides a review of those studies that have addressed the correlates of anxiety among spinal cord injured individuals. A chronologically presented overview of these studies is provided in Table 2. Similar to the prevalence/presence of anxiety studies described earlier, many of these 'correlate' studies also examined other areas of psychological functioning. This section, however, focuses primarily on their findings as they pertain to spinal cord injury and anxiety. Headings similar to those cited in the table will be utilized throughout this review. 4.1. Studies

A total of 21 studies were found that addressed the correlates of anxiety in spinal cord injured individuals. 4.2. Subjects

The majority of studies (n = 18) utilized significantly more males than females, while one study [7] examined only females. In two studies, the male/female breakdown was not provided [8,9].

Non-spinal cord injured/'able-bodied' control subjects, or patients' family members, were employed in four studies [8,9,11,12] while three studies [15,16,26] compared different groups of SCI patients (e.g. anti-spasmatic medication vs. no medication, complete vs. incomplete injuries). Two other investigations examined both SCI patients and those with closed head injuries [17,12], while one study [15] compared SCI patients to those from a Comprehensive Pain Clinic (i.e. non-spinal cord injured patients).

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Table 2 Correlates of anxiety

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Study

Subjects

Level of paralysis/ injury

Time since injury

Anxiety criteria/ measures

Findings

Cook [19]

M=91; F=27 (All SCI patients)

Quadriplegics: 37% Paraplegics: 63%

84% impaired < 1 year

Mini-Mult STAI(S&T) (Self Report)

Anxiety reactions not related to age, sex, severity of impairment, time since injury, point in rehabilitation process, or cause of injury Proportionally more quadriplegics than paraplegics classified with anxiety reactions, although more paraplegics classified as deniers of emotional problems

Richards et al. [27]

M = 53; F= 22 (All SCI patients)

Quadriplegics: 38% Paraplegics: 62%

> 1 year

MMPI (Self Report)

Greater pain severity associated with higher anxiety levels

M = 158; F= 32 (All SCI patients)

Motor function: Quadriplegics: 29% Paraplegics: 25.4% Paresis: 18.3% Normal: 27.2%

Bracken et al. [23]

Nestoros et al. [22]

M=31;F=4 (All SCI patients)

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Quadriplegics: 19 Paraplegics: 16

Five Point Likerttype scale Adjective Checklist (ACL) (Self Report) Rating by an interviewer using the above scales

Patients scoring higher on anxiety measures were significantly more uncertain about their futures and less well adapted to life Anxiety reactions positively related to severity of motor disability and to a lesser degree with loss of sensory function Anxiety positively intercorrelated with anger and depression)

Quadriplegics: x = 17.7 months Paraplegics: X = 15.6 months

Zung Self-Rating Scales for Anxiety and Depression (Self Report)

No significant differences between quadriplegics and paraplegics on the self-rating anxiety scale index

SCL-90 (Self Report)

Patients reporting high life stress were significantly more anxious as compared to those experiencing low life stress Passage of time since injury did not moderate psychological wellbeing

Multiple Affect Adjective Checklist (MAACL) (Self Report)

No significant differences between quadriplegics and paraplegics' anxiety scores on the MAACL

Mean = 46.0 days (S.D. = 32.2)

Frank and M=44; F=9 Elliott [30] (All SCI patients)

Quadriplegics: 32 Paraplegics: ?

x = 43.5 months

MacDonald et al. [29]

Quadriplegics: 24 Paraplegics: 29

All had received inpatient rehabilitation 1-28 years prior to study (x = 7.3 years)

M = 41; F= 12 (All SCI patients)

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(S.D. = 66.46) Injured < 12 months, n = 27 Injured> 12 months, n = 26

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Table 2 (Continued) Cohen et al. [15]

SCI patients n=49

Incomplete injuries =30 (remainder complete ?)

Unspecified (minimum 6 month history of chronic pain)

MMPI

Overall, the SCI-Incomplete group exhibited substantially less Elevated MMPI profiles (and Psychasthenia scores) as compared to the CPC and SCI-complete groups

M=44; F= 9 (All SCI patients)

Quadriplegics: 32 Paraplegics: ?

x = 43.58 months (S.D. = 66.46)

SCL-90 (Self Report)

Patients reporting high life stress were significantly more anxious as compared to those experiencing low life stress No effects found for age on the SCL-90 scales

M=62;F=2 (All SCI patients)

Cervical: 37 Thoracic: 20 Lumbar: 7

Compreh. Pain Clinic (CPC) patients n=98 M=95% Frank et al. [31]

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Buckelewet al. [33]

M =90;F= 16 (All SCI patients)

Quadriplegics: 63 Paraplegics: 39 Cauda Equina: 3 Central Cord: 1

All injured < 1 year Acute ( < 3 months post-injury) n = 45 Rehab. (3-6 months post-injury) n = 13 Chronic (6 months to < 1 year post-injury) n=6 Sample 1 x = 3.6 years Sample 2 x = 1.7 years

Mini-Mult

No significant differences found between the Acute, Rehab., or Chronic groups on any of the Mini-Mult scales (including the Psychasthenia (Pt) scale) No relationships found between any Mini-Mult variables and motor, erectile, or bladder functioning, or completeness of spinal cord injuries

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Abbreviations. M, males; F, females; SCI, spinal cord injury; STAI, Spielberger State-Trait Anxiety Inventory; S, state; T, Trait; SCL-90, symptom checklist-90; MMPI, Minnesota Multiphasic Personality Inventory.

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W.D. Crews Jr. et al. / NeuroRehabilitation 11 (1998) 155-174

4.3. Level of injury

One study examined predominantly more individuals with quadriplegia [9], three predominantly more patients with paraplegia [19,27,28], and four articles studied relatively equal numbers of persons with quadriplegia and paraplegia [8,11,22,29]. In six studies, the levels of injury, for at least part of the samples, were unspecified [7,12,16,30-32] while six other studies [17,23,24,26,33,34] utilized 'mixed' (e.g. cervical, thoracic, lumbar, paresis, 'normals', cauda equina, or central cord injuries) patient samples. One additional study [15] provided only the number of SCI patients with incomplete injuries. 4.4. Time since injury

There appears to be an absence of 'correlates of anxiety' studies which have examined SCI patients in the 'acute' phase of injury (less than 1 month post-injury). Three investigations studied patients who were, on average, 1 month to 1 year post-injury [19,23,26], while 10 studies examined individuals who were, on average, more than 1 year post-injury [12,17,22,27-31,33,34]' Three longitudinal studies were also found in the literature [8,11,16]. Additionally, in four studies [7,9,15,32], the time since injury was unspecified while in one study [24], the time since injury for the sample was mixed. 4.5. Anxiety criteria / measures

All of the studies pertaining to the correlates of anxiety in SCI patients employed primarily (or only) self-report questionnaires/inventories of anxiety. None of these studies utilized clinical interviews or DSM criteria. 4.6. Findings

Higher levels of anxiety in spinal cord injured individuals have been associated with a diversity of variables which may be loosely classified in the following categories: injury-related characteristics, hospitalization/rehabilitation variables, psychological variables/constructs, and sexuality.

169

An array of injury-related characteristics have been found to be related to higher levels of anxiety in SCI patients. Cook [19], in his study of 118 SCI patients, reported that proportionately more individuals with quadriplegia were classified with anxiety reactions as compared to those with paraplegia, although more persons with paraplegia were classified as deniers of emotional problems. Cohen et al. [15] also found more elevated MMPI Psychasthenia scores among individuals with complete vs. incomplete spinal cord injuries while Richards et al. [27] reported that higher anxiety levels were associated with greater pain severity in their sample of SCI individuals. Similarly, Bracken et al. [23], in their study of 190 SCI patients, found that anxiety reactions were positively correlated to the severity of individuals' motor disabilities, and to a lesser degree, with the loss of their sensory functions. Furthermore, Glickman and Kamm [34] found that several injury-related toileting/bowel dysfunctions were associated with greater anxiety and emotional distress. Specifically, longer periods required for completion of toileting procedures, greater frequency of fecal incontinence, and greater disability in bowel functioning were associated with higher anxiety scores as assessed via the Hospital Anxiety and Depression Scale. Hospitalization/rehabilitation variables have also been related to heightened levels of anxiety in SCI individuals. Buckelew et al. [33], in their study of 106 SCI patients, found that those individuals who entered rehabilitation programs more quickly post-injury acknowledged greater anxiety and phobic anxiety. Glass [9], in his small study of six SCI patients, indicated that there was some evidence that those individuals who had been home the shortest periods of time experienced elevated anxiety. Patients who initially reported heightened levels of anxiety have also been found to become less anxious over time (i.e. over 1 year; [16]). Furthermore, patients who had at least one unplanned hospitalization within the first annual follow-up period obtained significantly higher anxiety scores as compared to those who did not [32]. A number of psychological variables/constructs have been associated with higher levels of

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anxiety in SCI individuals. Specifically, four studies [7,23,11,28] have found positive correlations between anxiety and depression, while two studies have reported positive relationships between levels of anxiety and anger [23,28]. Higher levels of anxiety have also been related to greater worry (as assessed via the Pain Experience Scale; [28]) and high life stress [30,31]. Furthermore, Bracken et al. [23], in their study of 190 SCI patients, found that individuals scoring higher on anxiety measures were significantly less certain about their futures and less well adapted to life. Summers et al. [28] also found that as anxiety levels increased, patients' levels of vigor (as assessed by the Profile of Mood States) decreased. Aspects of SCI individuals' sexuality have also been related to higher anxiety levels. Harrison et al. [7] found that higher anxiety levels were associated with negative feelings about sexual activity and greater frequency of current sexual dysfunction. Alternatively, SCI patients' levels of anxiety have not been found to be associated with a diversity of variables which may be loosely classified in the following categories: patient demographic variables, injury-related characteristics, rehabilitation/treatment variables, and psychosocial variables/constructs. Several SCI patient demographic variables have not been found to be associated with their anxiety levels. Three studies [11,19,31] failed to find a relationship between anxiety reactions and patients' ages. Likewise, Cook [19] found no association between the sex of SCI individuals and anxiety, while Hancock et al. [11] failed to find a significant correlation between anxiety and patients' levels of education. In contrast to investigations which have found associations between SCI patients' levels of anxiety and injury-related variables, a number of other studies have failed to find such relationships. Three studies [11,22,29] reviewed found no significant differences between individuals with quadriplegia or paraplegia and their respective scores on various self-report measures of anxiety. Hancock et al. [11] also found no correlation between SCI individuals' anxiety scores on the State-Trait Anxiety Inventory (STAI) and their

types of spinal cord lesions (complete vs. incomplete). Similarly, Huang et al. [24] reported no significant relationships between personality variables as measured by the Mini-Mult (including the Psychasthenia scale) and completeness of patients' spinal cord injuries. In two studies [7,19], anxiety was not found to be related to patients' severity of impairment/ disability. Five studies also failed to find an association between SCI patients' anxiety levels and the elapsed time since their injuries/across time [7,11,19,24,30], while Cook [19] reported that anxiety reactions were not related to the cause of individuals' injuries. Summers et al. [28] found that SCI patients' anxiety levels were not correlated with the severity of their pain, while Glickman and Kamm [34] noted no significant differences between patients with or without post-injury bowel disorders as regards their reported levels of anxiety. Additionally, Huang et al. [24] found no relationships between any Mini-Mult variables (including the Psychasthenia scale) and changes in SCI patients' motor, erectile, or bladder functioning. Rehabilitation/treatment variables have not been found to be related to heightened anxiety in SCI individuals in two studies. Specifically, Cook [19] reported that anxiety reactions were not related to SCI patients' points in their rehabilitation processes, while Jamous et al. [26] failed to find significant differences between the anxiety scores of patients taking Baclofen and a no-drug group. No significant correlations were noted between the dosages of Baclofen which were administered to patients and any of the study'S anxiety measures. Other studies have failed to find significant correlations between SCI patients' levels of anxiety and certain psychosocial variables. Alfano et al. [17] found no significant correlation between patients' State-Trait Anxiety Inventory scores and their psychosocial adjustment in response to illness (as assessed via the Psychosocial Adjustment to Illness Scale). Furthermore, Hammell [12] failed to find a significant correlation between SCI individuals' levels of anxiety and their levels of social support. In sum, higher levels of anxiety in SCI individuals have been associated with a diversity of vari-

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abies across studies which may be loosely classified in the following categories: injury-related characteris tics, hospitalization/rehabilitation variables, psychological variables/constructs, and sexuality. In contrast, other investigations have failed to find notable correlations/associations between SCI patients' levels of anxiety and variables which may be loosely classified in the following categories: patient demographic variables, injury-related characteristics, rehabilitation/treatment variables, and psychosocial variables/constructs. It should be noted that for certain variables (e.g. injury-related variables), the anxiety-related findings across studies were mixed (i.e. notable associations with anxiety in some studies vs. no relationship in others). Similar to the prevalence/presence of anxiety studies, the results of the 'correlates of anxiety' investigations, especially the contrasting results of some of these studies (e.g. studies assessing injury-related variables), likely reflect, at least in part, the heterogeneity of patient characteristics and methods/ procedures that were utilized in these investigations. An overview of the methodological concerns/limitations that may have also impacted these studies is provided later in this paper. 5. Treatment of anxiety in SCI individuals A search of the databases described earlier revealed only one controlled, empirical study which has specifically addressed the psychological treatment of anxiety in SCI individuals. Craig et al. [16] longitudinally (over 1 year) examined the efficacy of cognitive behavior therapy on anxiety, depressed mood, and self-esteem levels in 28 SCI patients undergoing rehabilitation as compared to 41 SCI patients who received only traditional rehabilitation services. While no significant differences were found between the two groups' anxiety levels, there was a trend for those who were anxious initially in the treatment group to improve more than individuals in the control group. Although there has been a relative absence of controlled trials which have examined the treatment of anxiety in SCI individuals, there have been several published articles which have dis-

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cussed various aspects of the clinical psychological/behavioral treatment of anxiety in SCI patients. The following is an overview of the various interventions which have been proposed in these articles to treat SCI patients suffering from heightened anxiety. In their paper focusing on powerlessness in patients with cervical spinal cord injuries, Mahon-Darby et al. [35] recommended a diversity of interventions to redirect and treat acute panic and anxiety. These include: • • • • •

Altering the patient's environment (e.g. ask visitors to leave) to decrease stimulation. Staying with the patient. Continuing to talk quietly to the patient. Participating in slow deep breathing with the patient (if ventilated, the patient may need breathing slowed via manual bagging). Using consistent, repetitive phrases (e.g. you are okay, calm your breathing) to help restore the patient's control.

The authors note that during initial panic attacks, lab studies and pulmonary assessments are required to rule out underlying physiological causes. Mahon-Darby et al. [35] have also proposed several other interventions that can potentially prove helpful in the management of anxiety in SCI patients: •

• • • •

Identify patterns of events (stressors) that appear to promote or proceed anxiety/panic with patients when they are calm; assist them to identify the underlying causes and early symptoms of panic. Assess your own feelings of anxiety and not be drawn into an anxious state as panic and anxiety are easily transmittable. Acknowledge and label anxiety as normal reactions to trauma. Reassure patients of the temporary nature of their out-of-control/anxious feelings. Use touch as a calming force if patients can tolerate it during a panic/anxious state (the authors note that awareness of patients' sensory levels are critical for effective touching).

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Similarly, Curcoll [36] reported on his experiences with SCI patients regarding the contribution of relaxation techniques in the treatment of anxiety. He argues that these techniques can prove beneficial when they are applied flexibly, and adapted to the physical and emotional statuses of patients as they progress through the rehabilitative process. Specifically, Curcoll [36] divides the rehabilitation process into three stages. In the 'acute stage', verbal relaxation is utilized where patients are encouraged to form a 'corporal inventory' of both 'sensitive and non-sensitive' body regions. Focusing attention on breathing and visual imagery are also employed during this stage. In the 'intermediate stage', progressive relaxation procedures are used in conjunction with electromyograph feedback from the frontalis muscle during individual sessions. In group settings, progressive relaxation techniques are also paired with induction exercises and sharing of sensations and experiences with others. In the final 'predischarge stage', relaxation techniques are utilized to combat anxiety secondary to social situations, provide emotional support, and prepare patients for discharge. Curcoll [36] also adds that if patients are readmitted to the hospital, relaxation techniques similar to those employed during the 'intermediate' phase may prove useful. It should be noted, however, that Wilson [37] recommends caution when utilizing relaxation techniques involving 'tense and release' exercises with patients with central nervous system damage as tensing of muscles may trigger increased spasticity. In her book concerning the management of spinal cord injuries, Zejdlik [38] proposed a number of 'general' interventions for use with SCI patients presenting with 'underlying neurotic behavior'. These include: • • • • • •

Establish trust and confidence. Provide reassurance. Teach relaxation techniques. Explain and repeat interventions clearly as anxious patients may not hear nor retain information well. Encourage and expect participation in rehabilitation. Allow expression of feelings and concerns

•

without excessive focus on phobias or compulsive behaviors. Teach coping skills that enhance interpersonal relationships.

Additionally, Weller and Miller [39], in their article describing the emotional reactions of SCI patients, their families, and staff during the acute-care period have provided suggestions to lessen the possibility of anxiety reactions and fear. First, the authors note the importance of regular, but limited visits by family members, especially those who exhibit excessive 'hovering and fleeing', since numerous 'frantic relatives' can contribute to increased anxiety in SCI patients. Secondly, since transfers to different settings, and the resulting fact of leaving staff members that patients (and their families) have come to trust, may intensify negative feelings such as fear (and possibly anxiety), patients may benefit from extra attention and support during these periods. Allowing patients (and their families) to tour and visit the new units/facilities and/or talk to staff prior to being transferred may also prove beneficial. 6. Methodological concerns /limitations of the literature

From this review of the literature concerning spinal cord injury and anxiety, there appears to be a number of methodological concerns of the existing studies that limit their contributions to the understanding of this area, their comparability across studies, and/or the generalizability of their findings. These concerns/limitations include: • • • •

Small sample sizes of a number of these studies. The large majority of studies have utilized predominantly more SCI males vs. females. Lack of non-SCI control groups/matched control subjects in many studies. Heterogeneity of samples and methodologies across studies (e.g. different studies have employed SCI patients with differing levels of injury, times since injury, measures, procedures, etc.).

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•

• •

•

• • •

•

Failure of some studies to precisely define /identify the characteristics of their samples (e.g. level of injury, time since injury, etc.). Relative lack of studies which have examined anxiety reactions during the acute phase (less than 1 month post-injury) of SCI. Relative lack of comprehensive, longitudinal studies which have examined the prevalence, correlates, course, treatment, and resolution of anxiety from the acute phase of injury through several years follow-up. The fact that the large majority of studies have utilized a diversity of self-report measures and definitions of anxiety vs. actual clinical interviews and DSM criteria to ascertain the presence of diagnosable disorders as opposed to just symptoms/presence of anxiety. As with depression [6], there is a relative lack of testable, theoretical approaches concerning anxiety following SCI. A lack of studies that have attempted to replicate the findings from previous studies. The studies addressing the prevalence of anxiety in SCI individuals typically appear to reflect only point-prevalence vs. lifetime-prevalence or incidence of new cases of anxiety reactions. It should be noted, however, that the types of prevalence rates reported in these studies have typically not been provided. Relative lack of empirical, controlled trials that have focused on the treatment of anxiety in SCI patients.

7. Directions for future research Based on this review, and in light of the limitations of past research, there remain a number of directions for future research. First, large scale, longitudinal studies are required which compare various groups of SCI patients (e.g. with paraplegia/quadriplegia) to non-SCI/matched control groups as regards the prevalence, correlates, course, treatment, and resolution of anxiety from the acute phase of injury through several years follow-up. Additional studies are needed which employ clinical data (e.g. interviews, observations,

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etc.) and DSM-IV criteria (vs. only self-report inventories) to evaluate the prevalence of diagnosable anxiety disorders, as opposed to only the presence of anxiety symptoms. More studies are also required that investigate anxiety reactions in SCI women, as the majority of past studies have examined significantly more men than women. Finally, controlled, empirical trials are needed which concentrate on the psychologicaljbehavioral treatment of anxiety in SCI individuals. References [1] Frank RG, Van Valin PH, Elliott TR. Adjustment to spinal cord injury: a review of empirical and nonempirical studies. J Rehabil 1987;53:43-48. [2] Frank RG, Elliott TR, Corcoran J, Wonderlich S. Depression after spinal cord injury: is it necessary? Clin Psychol Rev 1987;7:611-630. [3] Woodbury B. Psychological adjustment to spinal cord injury: A literature review, 1950-1977. Rehabil Psychol 1978;25: 119-134.

[4] Craig AR, Hancock KM, Dickson H, Martin J, Chang E. Psychological consequences of spinal injury: a review of the literature. Aust N Z J Psychiatry 1990;24:418-425. [5] Cook DW. Psychological aspects of spinal cord injury. Rehabil Couns Bull 1976:535-543. [6] Elliott TR, Frank RG. Depression following spinal cord injury. Arch Phys Med Rehabil 1996;77:816-823. [7] Harrison J, Glass CA, Owens RG, Soni BM. Factors associated with sexual functioning in women following spinal cord injury. Paraplegia 1995;33:687-692. [8] Craig AR, Hancock KM, Dickson HG. A longitudinal investigation into anxiety and depression in the first 2 years following a spinal cord injury. Paraplegia 1994;32:675-679.

[9] Glass CA. The impact of home based ventilator dependence on family life. Paraplegia 1993;31 :93-101. [10] Fedoroff JP, Lipsey JR, Starkstein SE, Forrester A, Price TR, Robinson RG. Phenomenological comparisons of major depression following stroke, myocardial infarction or spinal cord lesions. J Affect Disord 1991;22:83-89.

[11] Hancock KM, Craig AR, Dickson HG, Chang E, Martin J. Anxiety and depression over the first year of spinal cord injury: a longitudinal study. Paraplegia 1993; 31:349-357.

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