Adjustment Following Spinal Cord Injury 423symptoms of diagnosable depressive syndromes. These in-
struments yield useful information, but care should be taken
in extrapolating from this work. It is probable that these
instruments assess an underlying distress that may not distin-
guish depressive behavior from related problems with
anxiety. Studies using these instruments have shown that de-
pressive behavior is associated with increased expenditures,
longer rehabilitation stays, and decreased self-reported qual-
ity of life (Elliott & Frank, 1996).
Depression is often associated with suicidal ideation,
impaired quality of life, and requests for terminating life.
Research has shown that persons with severe SCIs„
ventilator- and nonventilator-dependent individuals with
tetraplegia„report a high self-esteem and quality of life that
extends up to decades postinjury (Crewe & Krause, 1990;
Hall et al., 1999). An individual•s request for termination of
life support often occurs in a medical setting and tends to be
met with paternalistic assumptions that health care profes-
sionals are best prepared to determine the patient•s well-
being. This concept is in opposition to the principle of auton-
omy that endorses informed consent and self-governance and
is guaranteed by the Bill of Rights. However, competency
must be established to exercise informed consent. Psychol-
ogists are often called on to evaluate a person•s ability to
(a) understand relevant information, (b) communicate avail-
able choices, (c) understand the implications of such choices,
and (d) demonstrate logical decision-making processes.
Persons with high-level tetraplegia, who are ventilator-
dependent, are more likely to request termination of life sup-
port than any other level of SCI. Individuals with high-level
tetraplegia are at risk of cognitive de“cits due to anoxia
and may require neuropsychological testing to determine
whether the impairment signi“cantly af fects their level of
competency.
Anxiety
Problems with anxiety and related disorders have been ob-
served among persons with SCI. In some situations, individu-
als will develop speci“c anxieties about social and personal
problems that might cause considerable discomfort or embar-
rassment (e.g., bowel accidents in public places or during
moments of intimacy; Dunn, 1977). In extreme cases, these
anxieties may exacerbate and result in social isolation or spe-
ci“c phobias. In other cases, anxiety about general appearance
and acceptance can compromise social interactions. Persons
with recent-onset SCI may have signi“cantly higher levels of
anxiety than comparison groups, and these differences may be
evident two years later (Craig, Hancock, & Dickson, 1994;
Hancock, Craig, Dickson, Chang, & Martin, 1993).
When people incur SCI in acts of violence or in accidents
that have traumatizing qualities, posttraumatic stress disorder
(PTSD) may be observed. Radnitz and colleagues have
shown that a signi“cant minority of military service veterans
with SCI met criteria for current PTSD (11% to 15%); 28% to
34% met criteria for lifetime incidence. In their research,
3.2% met criteria for a general anxiety disorder (Radnitz
et al., 1995, 1996). Subsequent research suggests that persons
with high-level tetraplegia report less intense PTSD symp-
toms than persons with paraplegia (Radnitz et al., 1998).ADJUSTMENT FOLLOWING SPINAL
CORD INJURYAdjustment following SCI is a dynamic and ”uid process in
which characteristics of the person and the injury, their social
and interpersonal world, the environment in general, and the
historical and temporal context interact to in”uence physical
and psychological health (see Figure 18.3). Rehabilitation
psychology has long embraced the Lewinian “eld-theory per-
spective to understand behavior within the Bf(P, E) equa-
tion (D. Dunn, 2000). However, aspects of this equation may
receive different emphasis from individuals, depending on
their perspective. Many physicians place greater emphasis on
the nature and concomitants of the SCI, as is evident in the
extant literature. Psychologists and other rehabilitation pro-
fessionals tend to place greater weight on the person (Wright
& Fletcher, 1982). Consumers and their advocates are much
more sensitive to the demands and issues centered in the en-
vironment in which any behavior is framed (Olkin, 1999).Figure 18.3 Model for understanding adjustment following spinal cord
injury.