480
CHAPTER 29
paralysis of the respiratory muscles resulting in profound lowering of the vital capacity
of the lungs, and this mental retardation may deteriorate into confusion and unconscious
ness, if the respiratory distress is not relieved quickly by appropriate measures. Para
plegics with associated injuries to the skull resulting in cerebral concussion may be
unconscious for days and weeks, followed by a state of confusion.
(b)
Stage of realization
The stage of psychological shock is followed by an early stage of shallow awareness of
the disability and, in due course, by increasing realization of its extent. Some paraplegics
exhibit anxieties already in this early stage of realization of their paraplegia, at first
mainly concerned with the paralysis of their legs, and questions such as 'Will I walk
again ?' are by no means uncommon. Other patients avoid questions about the finality
of their spinal cord lesion as if they are afraid to have full knowledge of the reality. In
agreement with Nagler (1954) we found that they take refuge in an 'ostrich policy' as an
escape reaction. They appear superficially reconciled and show co-operation with the
medical, nursing and physiotherapy staff. In this frame of mind, the patient often reverts
psychologically into childhood, by leaning on the doctor, nurse and physiotherapist as
he did as a child on his mother, and he is quite content with the various passive measures
of treatment. The full realization of his bodily plight begins really when more active
co-operation is demanded of him and he becomes fully aware of his profound physical
limitations and the implications for his future. It is mainly in this phase that a number of
anxieties will become manifest, some of which are identical with those of other severely
injured persons, such as fear of chronic crippledom, with all its restrictions in social
activities and economic consequences, resulting in loss of earning capacity and thus
becoming a burden to the family and everybody else. There are, however, in addition,
anxieties of specific nature associated with paraplegia, in connection with the loss of con
trol of bladder, bowel and sexual functions. To some patients, these are at first over
whelming barriers and may set up negativistic and provocative attitudes and breaches
of discipline towards medical and nursing staff, while in others they may result in
frustration, self-pity and self-centredness, associated with a sense of resentment against
their fate and society. No doubt, most authors agree that the loss of control of sexual
function constitutes a severe psychological shock in most paraplegics, regardless of
whether married or single, the more so as the libido remains (see page 446). Although
this stage of regression and denial can be overcome in the great majority of spinal para
plegics by empathy on the one hand and firm handling on the other on the part of the
medical and paramedical staff, there are certain individuals who will develop more
serious abnormal emotional reactions. It must be remembered, that one admits to a spinal
unit individuals with a variety of constitutional psychological make-ups, including psycho
pathic individuals, who, as one would expect, may exhibit excessive emotional reactions.
Trifling reasons such as having to wait their turn to be attended to for changing their
urine bottles or being refused permission to get up may be exaggerated, leading to
outbursts of excessive irritability and displays of temper, in which they may be quite
capable of doing damage to others and themselves. In the writer's monograph of 1953?
