Ayesha Complete Thesis

ORTHOPEDIC PATIENTS AND PSYCHOLOGICAL DISTRESS,
A ROLE OF SOCIAL SUPPORT
BY
AYESHA RAUF
REGISTRATION # 17049211003
BS
Department of Psychology
UNIVERSITY OF GUJRAT
Session 2017-2021
i
ORTHOPEDIC PATIENTS AND PSYCHOLOGICAL DISTRESS,
A ROLE OF SOCIAL SUPPORT
A Thesis Submitted in Partial Fulfillment of the Requirements for the Award

of Degree of
BACHELOR’S IN SCIENCE
In
Psychology
BY
AYESHARAUF
REGISTRATION # 17049211003
Department of Psychology
UNIVERSITY OF GUJRAT
2017-2021
ii
DEDICATION
Dedicated to my love and Hope, my late grandfather, Ammi and Abu, friends, and my teachers.
To Precious Memories of Late Abdul Aziz
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ACKNOWLEDGEMENTS
All praise to Allah who is the most beneficent and merciful who has given me the strength and courage to
complete my research project.
I express my deepest gratitude to my supervisor Dr.ZAQIA BANO, Assistant Professor, (Department of
Psychology, and University of Gujrat) for her valuable guidance. constant support and encouragement.
constructive criticism and enthusiasm which have always been a source of inspiration for me. It is my
honor that I completed this hard task under her supervision.
My sincere thanks to all participants and staff of all the hospitals who facilitated in my data collection.
Many people directly or indirectly helped me in process of this work supported me in finishing the heavy
task in the end. Thanks to all my friends Hira Siddique, Laiba Sai, Kainat Ashfaq, Ayesha Sajid, and
Memona Javed, and others who have supported and encouraged me in completing this task. May Allah
bless them forever.
I am extremely grateful to my sweet parents, Abdul Rauf and Rubina Rauf. Special thanks to my late
grandfather Abdul Aziz who is my real source of inspiration. His kind affection and cooperation helped
me to cope with all odds with a good heart. He taught me the true meaning of life and directed me
towards the right path of success. I am also grateful to my brothers. Muhammad Tausif and Abu Bakar
who always encouraged me throughout my qualification. Without my family I would not been able to
achieve anything in life.
Ayesha Rauf
DECLARATION
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I, Ayesha Rauf D/O Abdul Rauf, roll # 17271511-003, student of BS, department of Psychology, Faculty
of Social Sciences, University of Gujrat, Pakistan, hereby solemnly declare that this thesis titled
“Orthopedic patients and Psychological distress, a role of social support.” is based on my genuine work. I
also declare that the entire thesis is free of deliberate plagiarism. Furthermore, I shall not use this thesis
for obtaining any other degree from this or any other institution.
I also understand that if proof of plagiarism is found in this thesis at any stage, even after award of
degree, the degree may be cancelled by the university authority.
(Ayesha Rauf)
I certify that Ayesha Rauf D/O Abdul Rauf, roll # 17271511-003, student of BS, department of
Psychology, Faculty of Social Sciences, University of Gujrat, Pakistan, worked under my supervision and
the above stated declaration is true to the best of my knowledge.
__________________________
Zaqia Bano,Ph.D
Assistant Professor,
Department of Psychology,
University of Gujrat, Punjab, Pakistan.
Email: zaqia.bano@uog.edu
Date: ___________________
v
THESIS COMPLETION CERTIFICATE
It is certified that this thesis “ Orthopedic patients and Psychological distress, a role of social
support”, submitted by Ayesha Rauf D/O Abdul Rauf, roll # 17271511-003, student of BS ,
department of Psychology, Faculty of Social Sciences, University of Gujrat, Pakistan is evaluated and
accepted for the award of degree “Bachelor of Science in Psychology” by the following members of
Thesis/Dissertation Viva Voce Examination Committee.
_________________________________
IramNaz,Ph.D. (External Examiner )
Lecturer,
University Of Gujrat, Punjab, Pakistan
Email:iram.naz@uog.edu.pk
Dated: _______________________
_________________________________
SaimaRiaz, Ph.D. (Internal Examiner)
Lecturer,
University Of Gujrat, Punjab, Pakistan
Email:saima.riaz@uog.edu.pk
Dated: _____________________
_________________________________
ZaqiaBano, Ph.D.
Assistant Professor/Research Supervisor
University of Gujrat, Punjab, Pakistan
Email:zaqia.bano@uog.edu.
Dated: ____________________
_________________________________
BushraAkram, Ph.D.
Assistant Professor/Head
University of Gujrat, Punjab, Pakistan
Email: bushra.akram@uog.edu.pk
Office Dispatch #: PSY/UOG
Dated: _____________________
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TABLES OF CONTENTS
CONTENTS PAGE
LIST OF FIGURES ………………………………………………………….. ix
LIST OF TABLES ……………………………………………………………
ix
LIST OF APPENDIXES………………………………………………………
x
ABSTRACT………………………………………………………………….. 01
CHAPTER 01: INTRODUCTION………………………………………….. 02
1.1: Rationale of Study…………………………………………………… 07
1.2 Hypothesis of study………………………………………………….. 08
CHAPTER 02: LITURATURE REVIEW…………………………………… 09
2.1: Orthopedic impairment……………………………….. 09
Categorization………………………………………… 09
Causes…………………………………………. 10
Factors affecting orthopedic impairment……………………………………… 13
Assessment …………………………………………….. 13
Prevalence……………………………………………… 14
2.2: Psychological distress………………………………………………………............. 14
A) Theories of psychological 15
distress……………………………………………....
B) Depression ………………………………………………. 17
C) Anxiety 18
D) Stress 19
E) Studies on psychological distress and orthopedic patients 22
2.3 :Social support………………………………………………… 24
A) Theoretical perspective………………………………………………. 24
B) Studies on social support and psychological distress 24
26
CHAPTER 03: RESEARCH METHODOLOGY………………………. 27
CHAPTER 04: RESUTS 31

4.1; DISCUSSION………………………… 41
CHAPTE 05: CONCLUSIN AND RECOMMENDATIONS…………
5.1: Conclusion………………………………………………………….
5.2: Recommendations…………………………………. 48
REFERENCES………………………………………………………….
APPENDICES…………………………………………………………. 50
vii
51
56
LIST OF FIGURES
CONTENTS PAG
E
Figure- 2.1 Pearlin psychological distress theory…………… 16
Figure-2.2 Stimuls based model of stress…………… 20
Figure - 2.3 Response based model of stress ……………….... 21
Figure-2.4 Transactional model of stress…………………….. 22
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Figure-2.5 Conceptual model of stress …………………………. 25
Figure-2.6 Stress buffering conceptual model……………….. 26
LIST OF TABLES
CONTENTS
Table-4.1 Summary of demographic variables for N=250 31-32
Table-4.2 Summary of correlation of family history and depression… 33
Table-4.3(a) Summary of correlation of gender with depression…. 34
Table-4.3(b) Summary of correlation of gender with anxiety…. 34
Table-4.3(c): Summary of correlation of gender with stress…. 35
Table-4.4(a) Summary of n correlation of hospitalizations with anxiety... 36
Table-4.4(b): Summary of correlation of hospitalizations with depression… 36
Table-4.4 (c): Summary of correlation of hospitalizations with stress… 37
Table-4.5(a): Summary of correlation of age with anxiety……… 37
Table-4.5(b): Summary of correlation of age with depression…. 38
Table-4.5(c): Summary of correlation of age with stress……. 38
Table-4.6(a): Summary of regression of social support and anxiety…… 39
Table-4.6(b): Summary of ANNOVA for social support and anxiety 39
Table-4.7(a): Summary of regression of social support and depression …. 40
Table-4.7(b): Summary of ANNOVA for social support and depression 40
Table-4.8(a) : Summary of regression of social support and stress… 40
Table-4.8(b) Summary of ANNOVA for social support and anxiety 41
LIST OF APPENDICES
CONTENTS PAGE
Appendix-01: List of Abbreviations………….……………………… 56
Appendix-02: Consent form…………………….. 57
Appendix-03: Demographic form …………………. 58-59
Appendix-04: Social support scale………………….. 60
Appendix-05: Psychological distress scale ………………… 61-62
Appendix-06: Turnitin report ……………………………………. 63-65
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x
Abstract
Orthopedic problems exert a holistic influence on patients’ physical health including a range of mental
health problems. Assessing psychological distress among orthopedic patients plays a pivotal role to
implement further intervention. The rationale of the research was to study the three variables of
psychological distress (i.e., anxiety, stress, and depression) in orthopedic patients and role of social
support and other related factors that are associated with psychological distress. Cross-sectional study was
conducted at different orthopedic hospitals of district Gujrat. A systematic sampling technique was used
to select a total of 250 participants. The instruments used for collection of data were demographic form,
Social support scale (SSS) (Awan, 2020), and Psychological distress scale (PSD) (Khalid, 2020). Data
has been analyzed using SPSS 24. For the analysis of the data following statistical operations were used.
The statistical operations involved were descriptive statistical, linear correlation, and linear regression
analysis. Variables with p-value <0.01 have been considered as statistically significant. Results have
indicated that being female, old aged, having family history of illness, more hospitalizations, and poor
social support were significantly associated factors with psychological distress. Clinicians should
emphasize orthopedic patients especially to females, old aged, with family history, more hospitalizations
and with poor support.
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CHAPTER I
INTRODUCTION
An orthopedic impairment is an impairment that interferes with the normal functioning of bones, muscles,
or joint (Tver & Tver, 1991). Orthopedics patients have skeletal deformities such as diseases of nerves,
skin, bones, ligaments, and tendons. The different conditions that orthopedic patients could suffer include
pulled muscles, low back pain, fractures, dislocations, torn ligaments, sciatica, bowlegs, bursitis ruptured
disks, sprains and strains tendon injuries, bunions and hammer toes, bone tumors, club foot, scoliosis
knock knees, arthritis and osteoporosis, muscular dystrophy, unequal leg length, cerebral palsy, growth
abnormalities and abnormalities of the fingers and toes. All orthopedic conditions fall in the category of
physical impairment. The characteristics of an orthopedic patient might include deformity, paralysis,
average or above average intelligence, jerky movements, high anxiety, or frustration, dependent on
others, inaccurate coordination of limbs, difficulty in walking, grasping and have shorter attention span.
The symptoms of orthopedic problems vary depending on the body part and on the specific condition of
the disease. Some basic symptoms of orthopedic issues include muscle spasms, fatigue with swelling or
joint pain, numbness, weakness or tumbling, unusual appearance of a joint, redness and warmth in case of
inflammation or infection, pain (which may be burning, mild, moderate, or severe, dull, achy, or
stabbing), limited range of motion and joint stiffness and swelling of the injured area (Lewis, 2020).
According to Sarah Lewis, some of these symptoms such as pain or swelling may appear for certain times
and disappear for a while and then reappear depending on the activity level of the patient or the condition
of the disease. If these symptoms get worsen with movement, it can limit the activity of the patient.
Orthopedic conditions can be caused by trauma, either acute or chronic. (Lewis, 2020). Chronic trauma
occurs when joint or tendon suffers repetitive motions whereas acute trauma is a sudden injury. The
chronic trauma gradually happens over time such as days, weeks, months or even years. The orthopedic
issues can also be caused by the degenerative issues, such as a missing arm or leg. The potential causes of
the disease include amputation, fractures, burns, birth trauma, injury, diseases like poliomyelitis or
genetic abnormality such as club foot. Orthopedic impairments can be caused by hereditary,
environmental, and congenital factors. For example, a person may be born with muscular dystrophy. An
individual can acquire the orthopedic issue through injury or surgery or disease for example loss of limb
or bone loss due to injury or surgery. Congenital defects include infections, rubella, lack of child
immunization, various diseases, hydrocephalia and microcephalia etc.
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Orthopedic patients might experience some behavioral, psychological, physiological, or emotional
changes. The behavioral changes of orthopedic patients include dislikeness towards transfer from one
place to another, behavioral problems when being moved discomfort in certain positions such as lying-in
bed, grimaces or cries while moving, lack of energy, moves stiffly from the position, avoid participating
in previously enjoyed activities. The physiological changes that they might experience include, fever,
stiffness, sweating, pain in joint, swelling of joints, limping, cerebral palsy, pain with range of motion,
difficulty in walking, down syndrome, scraping sound when joints move, swelling around bone etc. The
emotional changes include social anxiety, irritability, emotional lability, anger, mood swings, general
anxiety, feelings of overwhelm (Fong, 2020).
The existence if psychological distress has been identified for many centuries. The orthopedic patients
suffer psychological distress because of their impairment. According to Tina Arvidsdotter, Psychological
distress is a common psychological problem and a state of anxiety and depression. These symptoms co-
occur with chronic conditions and somatic complaints. Risk factors of psychological distress inadequate
resources, sociodemographic factors, and stress related factors.
This study aims to study whether orthopedic patients feel psychological distress. We know that
psychological distress consists of depression, anxiety, and stress. This study will look at the ratio of
depression, anxiety, and stress that the orthopedic patients feel because of their orthopedic issues.
Depression is a mental disorder, consists of bad mood, poor attention, disturbed sleep or hunger, less
interest in daily activities, low confidence, and self-blame. Additionally, depression may precede anxiety.
If these symptoms persist, they may lead a person towards considerable damages in completing his daily
life activities or they may have suicidal ideations (WHO, 2012).
According to DSM-5 (American Psychiatric Association, 2013), the common symptoms of a depression
are unhappy mood and loss of pleasure in almost all activities of life. Other related symptoms are weight
changes, sleep disturbances, fatigue, feelings of unimportance or incorrect blame, loss of attentiveness or
indecisiveness, and repeated thoughts of death. Some indications also show strong relationship among
self-stigma and reduced self-esteem, depression, low worth of life and anxiety in people who suffer
stigma (Crocker & Quinn, 2003; Markowitz, 1998).
Depression is common in orthopedic patients. Because of their orthopedic issues’ patients feel depressed.
Many studies have been conducted to study the depression level of orthopedic patients. Some studies also
aimed to study the factors behind depression of orthopedic patients. Most of the orthopedic patients were
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found to have symptoms of depression, Mental health is a crucial element of successful orthopedic care
(Joy & Elizabeth, 2019). A cohort study conducted by Stephen Becher et al. J Orthop Trauma in 2014
concluded that depression was quite prevalent in the orthopedic patients. Another cohort study conducted
by Santosh Kumar and Abhishek Agarwal in India in 2020 concluded that depression was common in
indoor orthopedic trauma patients.
Anxiety is a feeling of uneasiness, usually generalized and unfocused as an overreaction to a situation that
is only subjectively seen as threatning (Bouras & Holt, 2007). Anxiety can be experienced with daily
symptoms that reduce quality of life, known as chronic anxiety or, it can be experienced in short spurts
with sporadic, stressful panic attacks, known as acute anxiety (Rynn & Brawman, 2004).
According to DSM-5 (APA, 2013), Anxiety is an emotion that include feelings of tension, worried
thoughts, and physical changes such as increased blood pressure. People with anxiety may have recurring
intrusive thoughts or concerns. Such people avoid certain situations out of worry. They may also
experience physical symptoms such as sweating, dizziness, or a rapid heartbeat.
Orthopedic patients experience anxiety. Several studies have been conducted to see study the anxiety
level and the factors behind anxiety of orthopedic patients. In a study, prevalence of anxiety was found to
be high in orthopedic patients. Several factors such as being female, family history of mental illness,
having severe pain, chronic medical illness, lower extremity injury was significantly associated with
anxiety. Clinicians working at orthopedic clinics should give emphasis on patients’ psychological states
during evaluation especially to those that have comorbid medical illness, females, patients who have
severe pain or amputation (Mengesha, Srahbzu, Niguse,Tolesa, Dawit & Enguday, 2017). A cross-
sectional study conducted new orthopedic patients reported anxiety level that may warrant intervention.
Many orthopedic patients experienced anxiety (Casey, 2019). Anxiety was diagnosed in 29 out of 100
patients. Mental and behavioral disorders were common in patients with orthopedic diseases (Bilal,
2012).
Stress is a feeling of emotional strain and pressure. (Mental Health America, 2013). Stress is a kind of a
psychological pain. Stress can increase the risk of strokes, heart attacks, ulcers, and mental illnesses such
as depression and aggravation of a pre-existing condition (Sapolsky & Robert, 2004).
According to DSM-5, stress is the physiological or psychological response to internal or external
stressors. Stress involves changes affecting nearly every system of the body, influencing how people feel
and behave (American Psychological Association). Orthopedic patients experience stress. Stressed is also
common in orthopedic patients. This study will aim at the stress level of orthopedic patients.
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Another objective of the study is to study the role of social support on the psychological distress of
orthopedic patients. In psychology (APA,2013), Social support is the provision of comfort to others, to
help them cope with biological, psychological, and social stressors. Support may arise from any
interpersonal relationship in an individual’s social network, involving family members, friends,
neighbors, religious institutions, colleagues, caregivers, or support groups. This study will find out that if
orthopedic patients with limited physical ability are given social support, will it reduce the level of
psychological distress among them.
Many studies have been conducted on this factor of psychological distress among orthopedic students.
Perceived social support was found to be highly correlated with psychological distress. Family, friends,
and significant others were reported to be negatively correlated with psychological distress. Social
support is proposed to be a coping mechanism against anxiety and depression of orthopedic patients. Lack
of social support was highly associated with psychological distress of orthopedic patients (Nusrat &
Humail, 2010). Positive social support is important for maintaining good psychological health. Poor
social support has negative effects on the mental health of orthopedic patients. Social support has been
widely studied as a factor that reduces the effects of psychological distress. There are different types of
social support; emotional, materialistic, informational, and belonging. Social support helps people to cope
with stress. Research has shown that having strong social support can help reduce the psychological
distress among orthopedic patients. Orthopedic patients with a stronger social support had an inverse
correlation for psychological distress (Stephen, 2014).
In a study that was conducted in Philippines, psychological distress was 43.9% in the orthopedic patients
(Guzman, 2013). According to a research, psychological distress appears to be very common in
orthopedic patients in Pakistan. Orthopedic surgeons need to develop special methods for screening of
psychological distress either by asking pertinent questions or by using questionnaires. Patients who screen
positive can be referred to mental health professionals. Treatment of psychological distress in Pakistan’s
population should aid complete recovery and treatment studies are required to demonstrate this (Nusrat,
Humail, Imran, Raza, Robinson & Francis, 2010). In another research that was conducted at Ethopia
revealed that 35.4% had psychological disress. Being female, severe pain, poor social support were highly
associated factors of psychological distress (Mengesha, Tolesa & Enguday, 2009). A study revealed that
depression, anxiety, and psychological distress was high in 100 orthopedic patients of Peshawar as
compared to the control group. Women had more psychological distress than men. (Sabiha, Kalsoom,
Hanifa & Raheela, 2017). In another study conducted on orthopedic patients found 14% of the patients
had psychological distress (O’Donell, Creamer, Elliot & Kossmann, 2005). Psychological distress was
found among 30% male orthopedic patients. (Mason, Wardrope, Turpin & Rowlands, 2002). In a 24-
5
month follow-up study on the topic revealed that 42% orthopedic patients had psychological distress.
22% of these patients reported to receive mental health services (McCarthy, MacKenzie, Edwin &
Castillo, 2003).
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1.1 RATIONLE OF THE STUDY:
An estimated 1.71 billion people have orthopedic problems worldwide, among these the prevalence low
back pain is 56 million people. The orthopedic issues are the leading contributor of the disability
worldwide. In 160 countries low back pain is the leading contributor to physical disability. These
problems limit mobility and leads to lower level of wellbeing, limited ability to participate in the society,
reduced ability to perform tasks and poor mental health. The number of people with orthopedic problems
is increasing as the population is increasing and these problems are projected to increase in the next
decade. There is a strong connection between chronic pain, reduced mobility, and psychological distress.
According to physical therapist Joe Herdzina, the connection between the three is simple that they all start
in brain. People who because of orthopedic issue has reduced mobility are at a risk of developing
psychological distress. Active movement and exercise can provide hormone boost which may be missing
in orthopedic patients. 30-50% patients having chronic pain also experience anxiety and depression
(Joe,2021).
Around 240 million people are affected by depression worldwide. Pakistan is the ninth most depressed
country in the world (Deidre, 2016). A study conducted in 2004 found that 0.8 million people suffer from
depression in Pakistan (Gadit, 2004). About 275 million people suffer from anxiety worldwide (Fleming,
2019). Pakistan in on number sixth among the top 10 countries to have anxiety. Psychological distress can
cause people to feel isolated, aggressive, fearful, sad, inattentive. It affects the normal functioning of
individuals. People who have or are at a risk of psychological distress should be encouraged to receive
mental health care from professionals. Psychological distress common among orthopedic patients is
associated with functional outcomes. This study aimed to investigate the role, prevalence, and associating
factor i.e., social support in the orthopedic patients. Little is known about the psychological distress of
orthopedic patients. The objective of the study is to investigate the extent of psychological symptoms
patients experience because of orthopedic issues and whether these are associated with the social support
that they receive. This topic was chosen to be explored because it is an untouched topic. Orthopedic
patients are being given physical support but not emotional and psychological support. The literature on
orthopedic patients and psychological distress is limited about clarifying the relationship between degree
of orthopedic issues and psychological distress and between physical functions of orthopedic patients
with less severity and psychological distress.
It is obvious that people need support from their loved ones in difficult situations. The orthopedic
impairment is chronic and those suffering from it are at a risk of experiencing psychological distress.
Their physical activity and mobility become reduced, so they become dependent on others not only for
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mobility but also for emotional support. In this situation if others specially, their family leave them alone
they develop symptoms of psychological distress. Even if others are providing them physical or
materialistic help but not psychological support, they still are at a risk of developing psychological
distress. Most of the studies did not emphasize enough on the role of social support in psychological
distress of orthopedic patients. This study will investigate whether psychological distress is associated
with social support of orthopedic patients or not. If patients with limited mobility are provided with
sufficient social support, will it reduce the level of psychological distress which was related with their
orthopedic problems? This study will compare the level of psychological distress of orthopedic patients
that receive good social support with those that do not receive enough social support.
1.2 HYPOTHESIS OF INVESTIGATION
Considering the objectives of the present study, following hypothesis were made:
1. There would be a significant relationship between family history of orthopedic disease
and depression.
2. Female orthopedic patients would tend to have more psychological distress.
3. There would be a significant relationship between number of admissions in hospital and
psychological distress (anxiety, depression, and stress) in people with orthopedic
impairment.
4. Age is a significant predictor of psychological distress in orthopedic patients.
5. Social support would moderate the psychological distress (anxiety, depression, and
stress) in people with orthopedic impairment.
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CHAPTER II
LITERATURE REVIEW
This section will describe an overview of psychological distress among people with orthopedic
impairment and role of perceived social support in moderating the severity of psychological distress.
Followed by this, an overview of prevalence of orthopedic impairment and psychological distress related
to it will be discussed. Furthermore, this section will describe the theoretical background of depression,
anxiety, and stress. It will also describe perceive social support and its moderating role in the orthopedic
patients who are suffering from psychological distress.
2.1 Orthopedic impairment

A severe orthopedic impairment that adversely affects a child’s educational performance. The term
includes impairments caused by a congenital anomaly, impairments caused by disease (e.g., poliomyelitis,
bone tuberculosis), and impairments from other causes (e.g., cerebral palsy, amputations, and fractures or
burns that cause contractures) (Individuals with Disabilities Education Act, 2004).
Categorization of orthopedic impairment:

There are three different categories of orthopedic impairments: degenerative diseases, neuromotor
impairments and musculoskeletal disorders.
Degenerative diseases:
The orthopedic impairment in which the function or structure of affected organs or tissues
changes and deteriorate over time. For example, spinal muscular atrophy and muscular dystrophy.
Neuromotor impairment:
Neuromotor impairment is the condition of nervous system in which motor movement is affected
(Holmbeck, Greenley, Coakly, Greco & Hagstrom, 2006). For example, spina bifida, spinal cord
injuries and cerebral palsy etc.
Musculoskeletal disorders:
These are conditions that can affect your joints, bones and muscles (Kristeen, 2018). For
example, scoliosis, club foot and deformed limbs.
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Causes of orthopedic impairment:
Amputation:
Loss of limb because of trauma, surgery or disease might result in an acquired condition called
Amputation. If the infant is born without the limb or some of its part, congenital limb deficiency occurs.
Vascular diseases could lead to amputations. Upper limbs are involved mostly when the amputation is
caused by a trauma. Amputations can result from diseases such as peripheral vascular disease, diabetes
etc. Injuries specially of arms could lead to trauma. Moreover, surgeries performed to remove bone and
muscle tumors could also cause amputation. Amputation may impact the orthopedic patient’s self-care,
mobility, and self-image. During the acute treatment phase after surgery, the rehabilitation of the
orthopedic patient should begin (Brookmeyer, 2008). More extensive rehabilitation services are suggested
as the condition of the patient with amputation increases. Whether the provided rehabilitation is beneficial
or not, it depends on different variables such as degree of impairments, family support, level of
amputation and health of orthopedic patient. It is good to emphasize on patient’s capabilities in the
community (Harper, 2007). By promoting independence and enhancing self-esteem recovery of a patient
can be ensured using positive reinforcement. Then needs of patients can be meet using rehabilitation
program. Family of the patient should provide active role to make this program more beneficial. This
program is based on healing of wounds, artificial limbs, activities to enhance motor skills, pain
management, assistive devices, vocational counseling, exercise to improve muscle strength, emotional
support, nutritional counseling, family, and patient education. orthopedic surgeon, rehabilitation
specialist, physical therapist, psychologist, psychiatrist, and vocational counselor should work together to
promote rehabilitation of an orthopedic patient with amputation (Wilson, 2016).
Cerebral palsy:
The conditions that affect muscle tone, and movement are grouped together and characterized as cerebral
palsy. Before birth, if the immature brain of the infant becomes damaged, it causes cerebral palsy. The
symptoms of the disease can be characterized during infancy or early childhood years. In this disease,
there is an abnormal movement which is mostly linked with abnormal reflexes, involuntary movements,
rigidity of limbs, or unsteady walking (Pringsheim, 2013). Orthopedic patient with cerebral palsy might
have swallowing problems, and their eyes are unable to focus on the same object. Due to muscle
10
swiftness, they have limited motion at different joints. Some patients with cerebral palsy can walk by
themselves, while some need help. Some patients are intellectually disabled while others are completely
normal. So, we can say that the effect of the disease on patient’s functioning greatly varies. Some patients
may be deaf, blind or some might have epilepsy. The problems that orthopedic patients because of
cerebral palsy face are variations in muscle tone, favoring one side of body, rigidity, spasticity, tremors,
difficulty in walking, ataxia, slow movements, excessive drooling, seizures, abnormal fine motor skills,
and learning difficulties. These symptoms do not get worsen with time as the brain disorder that causes
cerebral palsy does not change (Rosenbaum, 2007). The causes of the disease could be genetic mutations,
bleeding into brain, oxygen deficiency, maternal infections, infant infections, head injuries, and fetal
stroke. The pregnant women can take some preventive measures to prevent the infant from cerebral palsy,
by getting vaccinated, take caring of oneself, seek prenatal care, avoid alcohol and drugs, by providing
good safety to the child (Kent, 2013).
Genetic Abnormality:
Orthopedic problems can be caused by genetic abnormalities such as chromosomal abnormality,

multifactorial or mendelian diseases. In chromosomal abnormality, a specific number of genes is either
absent or duplicated. In multifactorial conditions, there is a combination of environmental and genetic
factors. In mendelian disorders, a single gene is absent and follow mendelian inheritance rules. The
multifactorial conditions recur in those orthopedic patients who have family history of these conditions.,
but these do not follow mendelian inheritance rules (Cowell, 1975). When orthopedic impairment is
caused due to genetic abnormality, the orthopedic conditions are transmitted by genes from parents to
their offspring. In Osteogenesis imperfecta, the bone collagen of the patient is inadequately formed
(Berger, 2006). This results in easily breakable teeth and fragile bones of the child. in Muscular
dystrophy, the child has a genetic tendency to break down muscles and become weak. The symptoms of
the disease include, clumsy movement, leg pain, shoulder weakness, inability to jump, difficulty in
climbing stairs, and inability to close eyes. It can be diagnosed using blood tests, EMG, ECG, or muscle
biopsy. If the treatment of the child starts at early age, the child can learn to lead an active life. Physical
therapy, medications, braces, psychological and nutritional counseling, etc. Surgical interventions of
scoliosis may be considered (Cortini, 2019).
Burns:
Sometimes the burn injuries could lead to orthopedic injuries. There are different types of burns, in fourth
degree of burn, the bones, tendons or joints of the patient are damaged. Orthopedic surgeons may have to
11
perform surgeries such as in burned hands. Due to burning, there is a rigidity or deformity of joints,
caused by hardening or shortening of muscles or other tissues. These conditions are often developed after
months of original burn. Sometimes the burning results in deep full thickness, in this condition the patient
need immediate emergency assistance. There are some preventions that might help in reducing risk of
burns, such as smoking, using tap extremely hot water, alcohol or drug use, substandard housing,
unsupervised children, or illegal burning of trash or leaves. For less severe burns, the immediate treatment
might reduce the risk of burning. A cold damp cloth can be used to cool down the burn, a pain killer
might relive pain of the patient immediately, and the burned area could be covered with clean cloth (Paso,
2018).
Fractures:
When the continuity of the bone is broken, the medical condition is characterized as Bone fracture. A
bone can fracture in several different ways. A closed fracture occurs when a cracking of bones does not
damage surrounding tissues. Open fracture contrarily occurs when the breaking of bone penetrated the
skin and damages it. Open fractures are infected, so they are more severe than closed fractures. Human
bones have strong bones, but strong force can result in fracture (Katherine, 2013). The strength of bones
decreases with aging. The types of fractures include, commented fracture dislocation, hairline, greenstick,
avulsion, compression, impacted, spiral, oblique, intraarticular, torus, pathological, transverse, stress, and
longitudinal fracture (Sloan, 2010). The symptoms of fracture include pain, bleeding, swelling, discolored
skin, bruising, angulation, patient cannot put pressure on the area and cannot move it, dizziness, nausea,
and grating sensation. Mostly fractures result from falling badly or accidents. Doctor will perform X-ray,
MRI or maybe CT scan to examine the fracture. Bones usually heals naturally. However, plaster cats,
metal plates and external fixators are required mostly (Leonard, 2000).
Birth Trauma:
A trauma during childbirth, results in infant’s tissues and organ damage. It can occur as perineal tears,
cesarean wounds, pelvic floor muscles damage, pelvic organ prolapse and pelvic fractures (Petersburg,
2009). The main risk factors that can contribute birth trauma are assisted delivery using vacuum, position
of the baby, having small or unusual pelvis, having a large baby, and labor complications. Although birth
trauma is beyond one’s control, but we can take some precautions to prevent its risk, such as by
exercising regularly, avoid getting constipated, giving birth by caesarean, and daily pelvic floor exercises
to strengthen the pelvic muscles (Alexander, 2006). Sometimes the birth trauma is minor, such as minor
perineal tear which heals on its own. But sometimes, conditions become severe such as deeper tear which
12
treatment such as need of stitches. Pain killers can be used for immediate relief. Physiotherapy is also
suggested.
Factors affecting orthopedic impairment:
There are three environmental factors that affect orthopedic problems (Verma, 2015).
Pre-natal environment:
The pre-natal environmental factors include oxygen deprivation, brain damage, drug addiction of
mother, intoxication, viral infection of the mother, exposure to radioactive rays or smoking etc.
Post-natal environment:
The post-natal environmental factors include caesarian cases, accidental factors, infection with
chronic disease, oxygen deprivation, unhygienic conditions, improper use of anesthesia and
prolonged labor.
Para-natal environmental factors:
The para-natal environmental factors of the impairment include poverty and socio-economic
conditions, child abuse, lead poisoning, polio, malnutrition, spinal injury, accidental factors and
lack of vitamin D or calcium. The risk factors of orthopedic issues include aging, smoking,
overweight, participating in sports, chronic disease such as diabetes, working in a field the
requires the same physical task every day or using improper lifting techniques.
Assessment:
A licensed physician can assess a person’s orthopedic impairment by a thorough medical evaluation.
Assessment focuses on pain, instability and swelling of the affected area. An orthopedic surgeon will use
medical history exam, imaging, and physical tests for assessment. Medical history exam will cover
13
complete medical history of the patients including symptoms and severity of symptoms and the possible
underlying medical conditions. Physical tests involve physician may have patients walk, bend, move
upstairs or downstairs or sit down to test the range of motion of the patient. In imaging tests, physician
may perform Magnetic resonance imaging (MRI) or X-rays.
Prevalence:
According to the U.S. Department of Education, Orthopedic Impairments represent approximately 1.0
percent of all students having a classification in special education. Orthopedic impairment is the most
common cause of limitation around 8.6 million conditions accounting for 14.1% of all conditions that
contribute to limitations (National Academic Press, 1992).
2.2 Psychological distress:

Psychological distress is a collection of painful mental and physical symptoms that are associated with
normal variations of mood in most people. It is thought to be what is assessed by many putative self-
report measures of depression and anxiety (American Psychological Association, 2020). Psychological
distress has been assessed with different scales, such as the “Psychological Distress Scale”, K-6 or K-10
(Kesseler, Barker, Colpe, Epstein, Gfroerer & Hiripi, 2003). The “General Health Questionnaire (GHQ-
12)” (Goldberg & Blackwell, 1970) and several different psychological distress items, such as anxiety,
loneliness, sadness, and suicide plan (Siziya & Mazaba, 2015), or no close friends, anxiety, loneliness,
suicidal ideation, and attempt (Pengpid & Peltzer, 2020). Psychological distress is defined as a continuous
experience of unhappiness, nervousness, irritability, and problematic interpersonal relationships
(Chalfant, 1990).
Psychological distress is a lack of enthusiasm, problems with sleep (trouble falling asleep or staying
asleep), feeling downhearted or blue, feeling hopeless about the future, feeling emotional (Decker,
Burnette & Mui, 1997). For example, crying easily or feeling like crying and feeling bored or a passing
interest in things and thoughts of suicide (Weaver, 1995).
It is the emotional condition that one feels when it is necessary to cope with unsettling, frustrating or
harmful situations (Lerutla, 2000). Psychological distress is the unpleasant subjective state of depression
and anxiety (being tense, restless, worried, irritable, and afraid), which has both emotional and
physiological manifestation. There is an extended range of psychological distress, that ranges from mild
to extreme, and the extreme levels are considered as mental illness such as schizoaffective disorder
(Mirowsky & Ross,1989).
14
Psychological distress is the deflection from some healthy state of being. It suggests dysfunctional ways
of coping. It is somehow related to psychopathology along with those symptoms that are common in the
community. It is negative feelings of fatigue, depression, anger, anxiety, isolation, and problematic
interpersonal relationships (Burnette & Mui, 1997).
Theories of Psychological distress:
Medical theory of psychological distress:
The medical model is a prevailing or dominant view of pathology in the world (Novello, Kaplan
& Sadock, 1998). It is categorized with other physical illness. The medical model uses the model
in defining psychological distress related to the one that medical practitioners use. Psychological
distress is a form of neurological defect responsible for the disordered thinking and behavior and
requires medical treatment and care (Carson, Butcher & Mineka, 1996).
Interpersonal theory:
Interpersonal theories attribute psychological difficulties to dysfunctional patterns of interaction

(Carson, 1996). Interpersonal theories state that we are social beings and a product of our
relationships with others. Unsatisfactory relationships of past or present which causes
maladaptive behavior in relationship which we describe as psychological distress. While
identifying the different patterns of interpersonal relationships in a person’s life, we can identify
the psychological distress. This perspective emphasizes that interpersonal therapy (that focuses
on reducing problems that exists within relationships) alleviates psychological distress.
Interpersonal therapy also helps people to achieve more satisfied relationships by teaching new
interpersonal skills.
Psychodynamic Theory:
Traditional psychoanalytic theories have an intrapsychic view about psychological distress. They
emphasize that behavior either normal or abnormal is determined by unconscious and there is a
15
role of defense mechanisms. They believed that early childhood experiences determine later
personality development. The presence of a symptom in the present is the consequence of past
conflicts (Box & Clair, 1996). Psychological distress is a person’s ability to cope with the
problems of present by using defense mechanisms of childhood which are now seemed as
socially inacceptable and maladaptive.
Cognitive Theory:
This theory emphasize that negatively biased cognition is a core process in psychological distress
(Barlow & Durand 1999). The cognitive process is observed when distressed patients have a
negative view of themselves, their environment, and the future (Weinrach, 1988). Distressed
people view themselves as deficient, insufficient, worthless, and unlovable. Cognitive theorists
believe that people inappropriately and excessively interpret their experiences which leads to their
excessive effect and dysfunctional behavior. In conclusion this theory emphasizes that when we
perceive events exaggeratively beyond their realities it leads to emotional difficulties, and it has a
negative influence on our behavior and feelings in a maleficent manner.
Leonard Pearlin theory of psychological distress:
This theory states that there is a lifetime of continuous change in which a person experiences
occasional periods of stability. Pearlin gave four elements that determine the path that individual
lives will take. (Sharmina, 2014). 1) Individual characteristics like Gender, family background,
race, personality, intelligence, and education. For example, intelligence determines whole future,
race affects family. 2) The range of skills that individuals have for coping with stress and change.
For example, moving out of parents’ house, trying to find a job, applying for a job etc. 3) The
availability of social support networks. For example, no support leads to abandonment, or family
expectations or only child etc. 4) The nature and timing if stress that requires response (Bee,
1987). For, example losing a job, parenting, financial issues etc.
Figure 2.1 Pearlin psychological distress theory
16
We know that psychological distress consists of depression, anxiety, and stress.
Depression: Depression is the devastating problem that disturbs the daily routines and the relationships
of an individual with others. It is just like a common cold among psychological disorders because it can
be frequently diagnosed (Seligman, 1973).
Theoretical view of depression
Behaviorist theory:
As this theory focuses that the behavior of an individual is shaped by the environment.
Observational behavior should be emphasized. (Watson, 1913). Depression is a result of
interaction of a person with his environment. Classical conditioning believes that a
person learns depression if he associates certain stimuli with a negative emotional state.
(Pavlov, 1987). Social learning theory emphasize on role of reinforcement, observation,
and imitation in learning depression. (Bandura, 1963). Operant conditioning believes that
when a positive reinforcement is removed from an individual’s environment, it leads to
depression in person for example, losing a job. (Skinner, 1950).
Psychodynamic theory:
Depression is the inwardly directed anger (Freud, 1917). Depression can be because of
loss of self-esteem (Bibring & Fenichel, 1968). It can be because of severe super ego
demands (Freud, 1917). Depression can be caused by deprivation in the mother child
relationship during early childhood (Kleine, 1934). Freud believed that sometimes
depression is caused by biological factors but sometimes it can be caused in absence of
17
parental love. Freud modified this theory and stated that excessive super ego leads to
depression. When a person’s conscience or super-ego becomes dominant, his depressive
phase starts.
Cognitive theory:
Cognitive theory believes that instead of behavior, thinking pattern of an individual
should be focused. A systematic negative bias in person’s thinking process results in
depression. Depressed people think differently than healthy people. The onset of
depressed mood is followed by changing in thinking process. Beck’s Theory: A
cognitive theorists Aaron Beck studied depressed people and concluded that depressed
individual appraises events in a negative way. He identified three mechanisms that can
cause depression (Beck, 1952). The cognitive triad of negative automatic feeling, faulty
information, and negative self-schemas. Depressed people have cognitive triad i.e., they
have negative image of themselves, of their future and of the world. These negative
thoughts are spontaneous, so they occur automatically in depressed people. Learned
Helplessness: Depression occurs when a person learns that his attempt to escape negative
situations makes no difference (Seligman, !974). They will endure aversive stimuli even
when escape is possible.
Humanistic Theory:
The self-actualization is the need to achieve out full potential. (Maslow, 1943). If
something blocks a person’s attempt to become self-actualize, this can lead to depression.
If parents impose conditions of worth on their children, it could cause depression in
children if they fail to live up on the standards that their parents have imposed on them. If
children deny their true self and project image of someone, they want to be on
themselves, it will lead to hatred towards themselves, and they will feel depressed.
Unhappy relationships or unfulfilling jobs can lead to depression in children (McLeod,
2015).
Anxiety: Anxiety is a psychological emotional state or reaction. It consists of unpleasant feelings of

tension, nervousness, worry, apprehension, and activation of autonomic nervous system. According to
Freud anxiety can be realistic, neurotic, or moral. According to Spielberg there are two types of anxiety
i.e., state anxiety or trait anxiety. The psychological disorders of anxiety include panic disorder, different
18
types of phobias, Obsessive Compulsive Disorder, Post-Traumatic Stress Disorder, or Generalized
anxiety disorder.
Psychological theories of anxiety:
Psychodynamic theory: The anxiety is at the root of neurosis. Anxiety is supported in

the form of unacceptable ID impulses which attempt to enter consciousness. The relief of
anxiety in all neurosis is through various defense mechanisms (Freud, 1930).
Humanistic-existential theory: When there is a conflict between individual and society,

it leads to the anxiety. The discrepancy between ideal self and real self is the source of
neurosis. If we perceive ourselves differently than the reality and fail to meet life’s
challenges, it will lead to anxiety (Rogers, 1949).
Behavioral Theory: To relieve anxiety, people learn avoidance response. The major
source of anxiety is avoidance learning. Avoidance learning is a two-stage process. In
first stage, a neutral stimulus becomes anxiety arousing through respondent conditioning.
In the second stage, the negative reinforcement by avoidance response relives anxiety and
becomes habitual. People may also learn anxiety through modeling (Bernstein, 1999).
Cognitive theory: Anxiety results when people misperceive their internal and external
stimuli. People perceive events as threating when they are not, and anxiety results (Bhatt,
2019).
Neuroscience Theory: Anxiety can be caused by genetic factors. In Generalized anxiety

disorder, there is a role of abnormalities of neurotransmitters such as serotonin and
GABA. Serotonin also plays major role in social phobia and OCD. According to a study
conducted in Norway, the concordance rate is 31% for panic disorder in MZ twins, as
opposed to 0% for D twins (Torgersen, 1983).
Socio-cultural Theory: Societal pressure in people might develop phobia or GAD. The
prevalence of anxiety has been increased as the stressful challenges in the society have
occurred (Vygotsky, 1934).
19
Stress: It is a pattern of disruptive psychological reaction to events that threatens the coping
ability. Stress can be positive or negative. There might be physical, mental, emotional, or
behavioral symptoms of stress. Stress is a condition that results from a discrepancy between
resources of a person’s psychological, biological, and social system with the demands of the
situation (Scott, 2020).
Stress according to psychological theories
James-Lange theory of stress:

Emotions do not immediately succeed the perception of the stressor or the stressful
event; they become present after the body’s response to the stress (James & Lange,
1885). Unless an emotional behavior is connected to brain, it is not possible for it to
occur because the feeling of emotion begins after we experience the bodily changes
associated with it.
Cannon-bard theory:
When the bodily changes are not present, emotion can occur in response to stress. The
brain releases emotional response before and later recognize the physiological changes of
the body. Thalamus is responsible for production of emotional responses (Cannon &
Bard, 1927).
Schachter-singer theory:
To experience an emotion, both emotional arousal and cognitive activity must
appropriately identify the emotion. We are aware of the reason behind stressful events, if
the reason is not obvious, to interpret the emotion we start to look for environmental
clues (Schachter & Singer, 1962).
Models of stress
There are three models of stress:
The stimulus-based model of stress:
20
The psychological and physiological strains that cause health problems in an individual
are caused when the life events or other stressors tax the adaptation capacity of an
individual (Holmes & Rahes, 1960).
figure 2.2 Stimulus based model of stress
The response-based model of stress:
It is like fight or flight responses which occur in threating situations. The common
physiological consequences of stressful situation are emphasized by this model. Somatic
and physiological changes result because of arousal of sympathetic nervous system in
respond to a stressful event and finally results in disruption of homeostasis. This model is
represented in Hans Selye’s General Adaptation Syndrome theory. In this theory Selye
defined stress as a non-specific response and the demand made upon the body. Different
types of stimuli would result in similar physiological responses (Seyle, 1956).
Figure 2.3 Response based model of stress
21
The transactional model of stress:
People have an inborn tendency to think, evaluate and then react. Thinking can either
increase or decrease stress (Lazarus & Folkman, 1980). Lazarus proposed interaction
theory which emphasize the importance of thinking. There are two stages of appraisal.
The first stage is Primary appraisal process, in this stage a person determines whether
the event is threating or not and the Secondary appraisal process, in this stage a person
assess his coping skills such as environmental factors, social support, skills to reduce the
threat and knowledge.
Figure 2.4 Transactional model of stress
22
Studies on psychological distress and orthopedic patients
Although most people with orthopedic impairment will survive, there is a psychological distress which
they must experience because of their orthopedic problems. Present study is focused on psychological
distress (depression, anxiety, and stress) of orthopedic patients, and the role of social support. The
psychological distress in orthopedic is reported five times more in orthopedic trauma patients than general
population globally (Kuhn, Bell, Netscher, & Seligson, 1990). A lot of studies have found that the
orthopedic patients even after completing clinical recovery may have to experience long-term disability.
Such studies have also highlighted the risk factors that explain why some patients suffer life-long
disability while others experience full recovery. Psychological distress is among the key factors that play
a central role as predictor of disability. A study that was conducted in India found that 1 in 5 i.e., 22%
orthopedic patients had psychological distress (Remizov, 2008). An association between mental health
and reduced-health related quantity of life was found in a quantitative study (Hutson, 2004). Another
study found 35.4% prevalence of psychological distress among orthopedic patients. It was higher in
females. (Mengesha, Tolesa & Enguday, 2019). The orthopedic trauma greatly affects patient’s
psychological health and eventually interferes with the orthopedic patient’s recovery (Woolf & Pfleger,
2003). Only few of the orthopedic patients are encouraged to get professional psychological health even
though there are many trauma patients that suffer from serious psychological distress (Wong, Kennedy,
Marshall & Galliot, 2011). A study found that the patients experiencing orthopedic conditions greatly
report different behavioral and emotional problems (Chaitanya & Kumar, 2015).
A study conducted in USA found that the prevalence of psychological distress in orthopedic patients was
19%. (Brewer, Petipas, Van, Sklar & Ditmar, 1995). The duration of study period and the screening tool
determines the magnitude of psychological distress in patients who are undergone orthopedic trauma
(Mengesha, Tolesa & Enguday, 2019). A study found 14% of psychological distress in patients who have
survived orthopedic trauma (Creamer, Elliot, & Kossman, 2005). Another research which was conducted
in 24-months in USA found that the prevalence was 42%. Only 22% patients reported about receiving
psychological help (McCarthy, MacKenzie, Edwin & Castillo, 2003). And the other study which was also
conducted in USA found 45% psychological distress using Beck Depression Inventory (BDI) (Crichlow,
Andres, Morrison, Haley & Vrahas,2006). A large-scale study conducted in Philippines among
orthopedic inpatients found 43.9% psychological distress (Guzman, 2013). Orthopedic trauma victims
have difficulties to carry out daily activities of life which may result in increased chance of psychological
distress (Woolf & Pfleger, 2003). After experiencing the trauma, within months the patients might
develop psychological distress (Latchford, 2003). A studied conducted on male orthopedic patients have
23
found 30% psychological distress (Mason, Wardope, Turpin, & Rowlands, 2002). The prevalence rate
was higher among females in a study conducted by Mengesha & Tolesa in 2019. A study conducted in
Pakistan, also found a strong association between orthopedic impairment and psychological distress
(Husain, Humail, Rahman & Robinson, 2010). A study conducted in Korea found that the physiological
changes in pain can trigger negative symptoms of psychological distress (Lam & Chan, 2011).
Orthopedic patients have increased rates of psychological distress in extensive studies conducted in high
income countries (Mayou, Bryant & Duthie, 1993; Holbrook, Anderson & Browner, 1998; McCarthy &
Mackenzie, 2003). A US-study conducted on orthopedic patients found 45% of psychological distress
(Crichlow & Andres, 2006). Psychological distress is common in Pakistan among physical disabled
people (Husain & Creed, 2000; Mirza & Jenkins, 2004). A study conducted in rural Pakistan found a
sufficient link between orthopedic problems and psychological distress (Husain, Gater, Tomenson, &
Creed, 2007). The prevalence of psychological disorder in orthopedic patients was 23% (Mayou, Bryant
& Duthie, 1993). This prevalence was 26% in another study (Castillo & Starr, 2003). Similarly, another
study found this prevalence to be 32% which presents a relatively high association (Holbrook, Anderson,
Sieber & Browner, 1999). 43% prevalence between orthopedic conditions and psychological distress was
found in an extensive study (Ponzer, Begman, Brigsmar & Johanson, 1996). The orthopedic patients are
so distressed that 5% of the patients had suicidal ideas which may be caused b their limitations of
physical activites (Husaim, Creed, & Tomenson, 1999). The level psychological distress is high in
orthopedic population, but certainty can be established (Mirza & Jenkins, 2004). The outpatient clinics in
Pakistan need to meet the psychological needs of orthopedic patients (Nusrat & Syed, 2010).
The prevalence of psychological distress in orthopedic patients was 39.2% in orthopedic patients and was
found to be associated with poor outcomes (McQueen & Margeret, 2016). 50% of the survivors of
orthopedic trauma has psychological distress that usually lasts for more than a decade after the incident
(Heather, 2015). In a study conducted at northern Tanzania, 61% of the orthopedic patients indicated
psychological distress using cross-sectional questionnaire (Joy, Elizabeth & Neil, 2019). In Denmark, a
study found 12.2% prevalence of depressive symptoms in orthopedic patients. Another study in Tanzania
found that the baseline of psychological distress in females is 3.6 % and in males is 2.5% of orthopedic
patients (Uriyo, Abubakar & Pederson, 2013). In Uganda, 35% of orthopedic patients with femur or
fractures had psychological distress (Hara, Mugarura, Slobogean & Bouchard, 2014). The efficacy of the
orthopedic clinics should be improved to make patients experience less psychological distress (Shirima,
Massawe, Mandari & Premkaur, 2018). A study conducted to investigate psychological distress in
orthopedic clinics, to determine the connection between psychological distress and use of primary care
physicians. About 25% patients of the study, among these 17% of the female orthopedic patients were
distressed (Feldman & Yehuda, 1999).
24
2.3 Social Support
The concept of social support evolved in nineteenth century. Durkheim who was a sociologist, found a
connection between increase in suicide and reducing social ties. (Vaux & Harrison, 1985). The
importance of social relationships has been recognized since the Darwin’s evolution theory. Many studies
have been conducted to study the importance of social support in different problems of life.
Theoretical perspective of social support

There are three well viewpoints on the theories of social support.
The relationship perspective
Basic relationship procedures are emphasized in this perspective. This perspective supposes that
closeness, community relations, attachment with friends are related to better results of emotional
and physical happiness. It predicts that people have poor health if they are involved in small
conflicts (Cohen & Lakey, 2000).
The stress and coping perspective

Lazarus and Folkman in 1984 suggested a stress and coping theory. This perspective is evolved
from that theory. This theory supposes that social support works as a defensive sheet in the time
of difficult situation. This theory states that after a trauma, the neurological and biological health
of a person is severely affected, if he has a strong social support at that time, it will help him to
cope with trauma. We can give advice to others or get advice from others in stressful situations
(Lakey & Cohen, 2000).
The social cognition perspective

It is based on Beck’s cognitive model (Lakey & Drew, 1997). This model suggests that an
individual’s health is affected by observation of social support. A person develops emotional
problems and negative self-evaluations when he feels that the environment and the relations are
not supportive for him. It is focused on unrealistic thinking and not on coping skills of the person
and the traumatic events (Lakey & Cohen, 2000).
Models of Social support
Conceptual model of social support
25
To understand how social support works and how it is valuable for mental and physical health,
two different conceptual models have been proposed (Mohamad, 2017).
Figure 2.5 Conceptual model of social support
Stress buffering model

This model states that people’ physical and physiological health may be suffered if they
experience stressful evens. If they have strong social support in such situations they can cope
with stress (Rodriguez, 2018).
Figure 2.6 Stress buffering conceptual model
Direct effect model
26
Irrespective of undesirable and stressful events, social support is beneficial for mental health.
This model is observed in structural measures of social support specially in social integration.
When a person has various social network, social combination would boost the well-being.
Diverse social networking is advantageous for people because people can play active role in
communal and social relationship with the help of it (Rodriguez & Cohen, 1998).
Studies on social support
A study found significantly negative association between social support and psychological
distress (Yasin & Dzulkifli, 2010). Another study claimed that strong social support can
positively change the well-being of patients (Goz et al.., 2007). Studies have also indicated high
risk of illnesses in socially inaccessible people. Social support or lack of social support can
obstruct development and recovery from disease (Glynn, Christenfiels, Gerin, Hemingway &
Marmoot, 1999). A study conducted in Turkey to find link social support and self-esteem among
257 adolescents found positive relationship between the two. The severity of illness and recovery
can be helped by the social support (Taylor, Sherman & Kim, 2004).
CHAPTER III
METHOD
The present study aims to examine psychological distress in people with orthopedic
impairment. Further, this study will investigate the role of social support in mediatizing
the psychological distress in people with orthopedic impairment.
Participants of the study

Participants of the present study were 250 patients with orthopedic impairment. The
age range of whole sample was 18-89 years with (Mean age = 49.3280, S.D = 18.69316).
The sample was enrolled from different hospitals with orthopedic patients situated in
27
different areas of district Gujrat, through purposive sampling technique. The researcher
also followed the inclusion/exclusion criteria.
Inclusion and Exclusion criteria
Sample was taken by following all the points to maintain the transparency of the
research.
Inclusion criteria
• Both indoor and outdoor orthopedic patients were included in the sample.
• Female and male orthopedic patients both were included in the sample.
• Patients who had orthopedic problems at least for a week were included in the sample.
Exclusion criteria
 Those patients who did not complete the questionnaires.

 Participants with other serious substantial illness and other brain disorder were excluded.
 Patients who had orthopedic problems for lesser than a week were excluded.
 Indoor orthopedic trauma patients were also excluded who had survived from the accident
recently.
 Patients who had too severe orthopedic impairment to fill the questionnaire.
Tools
Three reliable and valid scales including demographic form, social support scale and a scale of
psychological distress were used to determine the psychological distress, social support in people
with orthopedic impairment.
Demographic form
It was consisted of personal as well as ancestral information. The items on the scale were name,
age, gender, education, residence, occupation, family system, income, weight, exercise, walk,
28
medicine, duration of medicine, doctor prescription, admission duration of hospital, history of
present illness, number of times of admission in hospital.
Psychological distress scale
This scale was developed by Khalid in 2020. It has 38 items. This scale is used to measure
anxiety, depression, and stress in participants. Likert response scale ranging from 1= never to 4=
often”. In this scale the item number 1 to 15 check the anxiety. Further, symptoms of depression
were having item 16 to 26. Moreover, cognitive symptoms of stress encompassed item number 27
to 38. Psychological distress scale has satisfactory psychometric properties as it’s Cronbach’s
Alpha is 0.91.
Social support scale
Scale of Social Support was developed by Awan in 2020). It is a 16-items questionnaire. This
scale is used to measure social support in participants. Likert response scale ranging from 1=
never” to 4 = always. Scale of Social Support has satisfactory psychometric properties as it’s
Cronbach’s Alpha is 0.840. (Awan,2021)
Procedure
The sample of the study was recruited from different hospitals situated in different areas of
Kharian. The selection of the sample for data collection was completed by using purposive
sampling technique. First, the researcher identified the orthopedic hospitals knowing the fact that
there are only few orthopedic hospitals in Kharian city, all the hospitals with orthopedic
department were approached. The authorities of the hospital were given the signed permission
letter from the university along with a set of questionnaires which were to be used in the study.
The hospital authorities were briefed about the purposes of the study and its implementation. The
incentive of the study was also informed to them. It was assured to the hospital authorities that
the researcher will follow all the guidelines and the rules of the hospital and will not violate the
ethics of the hospital. Then the researcher approached the orthopedic patients with the informed
consent and gave a briefing to the patients regarding the purpose and procedure of research study
29
and the right of the patients to withdraw at any time. They were completely assured that their
personal information will be held confidential, and their data is only used for the research
purpose. Data was filled through two processes. A) The researcher identified the educated
participants for the study and instructed them to fill the questionnaires in the proper way. B) The
researcher identified the uneducated participants and filled the questionnaires herself by taking
the responses from the participants vocally. After the competition of the task, the patients and the
hospital authorities were appreciated for their participation. The patients and the hospital staff
were given a brief incentive on the psychological distress. This incentive was offered just to
create awareness among them regarding the effects of psychological distress and to stay
motivated even in the time of difficulties.
Ethical consideration
The study was conducted while maintaining the rights, dignity, and welfare of the participants as
well as the competence of the study researcher. The right to withdraw and the confidentiality of
the personal information were completely ensured to the orthopedic patients who participated in
the study. They were also briefed about the purpose and the procedure of the study.
Statistical analysis
Initially the data was assembled on the Microsoft Excel sheet, and then was evaluated on the
Statistical Package for Social Sciences. Descriptive statistics (Mean, standard deviation, and
percentage) was used to interpret the study results. Moreover, the correlational method to
determine the link between the variables and to determine the role of social support on the
variables, regression analysis was used. Statistical Package for Social Sciences (SPSS-V.20) was
used to perform all the statistical computations.
Operational definitions
Orthopedic impairment
Orthopedic impairment is the physical disability of a patient to efficiently move from one place to
another and to carry out daily activities.
30
Psychological distress
Psychological distress is an emotional state of a patient that results when the patient faces
stressful situation which demands mobility, is unable to fulfil demands of daily life activities due
to his impairment.
Depression
Depression is the devastating anarchy that interferes with the daily activities and the relationship
of the patient with others. Sad mood, loss of appetite, suicidal thoughts and loss of sleep are the
symptoms of depression. Participant’s score on Beck’s Depression Inventory, the number of
depressive symptoms on beck’s inventory identify whether he is experiencing depression.
Anxiety
Anxiety is characterized by feeling of tension, uneasy, apprehensive, worried thoughts, and the
physical changes of the body because of the impairment.
Stress
Stress is a threat that involves physiological, cognitive, affective, and behavioral components of
orthopedic patients.
Social support
The perception of an orthopedic patient that he has actual received assistance from other people.
CHAPTER 1V
RESULTS
Table 4.1
Summary for descriptive statistics for the age of sample, gender, education, income, family system,
weight, exercise, medicine, doctor prescription, and history of present illness. (N=250)
31
Variables Frequency %
Age
18-30 37 14.7
31-40 21 8.4
41-50 48 19.1
51-60 59 23.5
61-70 36 14.3
71-80 23 9.2
81-90 16 6.4
91-100 9 3.6
Mean age of sample 49.33
group
Gender
Male 90 35.6
Female 159 62.8
Education
1-5 39 15.4
6-10 101 39.9
11-14 77 30.4
15-18 33 13
Income
0-15k 47 18.6
15k-30k 79 31.2
30k-50k 53 20.9
Above 50k 71 28.1
Family system
Joint 108 43.0
Separate 139 55.4
Weight
32
40-60 53 20.9
60-80 149 58.9
80-110 47 18.6
Exercise
yes 91 36.4
No 159 63.6
Medicine
Yes 208 82.9
No 40 15.9
Doctor prescription
0% 3 1.2
50% 82 32.4
100% 125 49.4
Family history of
disease
Yes 145 57.8
No 101 40.2
Hypothesis 1
The first hypothesis was that family history of orthopedic impairment is the significant predictor of
depression. To test the hypothesis Pearson correlation analysis was computed on Statistical Package for
Social Sciences (SPSS) on significance level of 0.01. The results in statistical table 2 present the
significant relationship between family history and depression.
Table 4.2
Summary of Pearson correlation in relation of family history of orthopedic problems with depression
33
Correlations
DT Family history
DT Pearson Correlation 1 .265**
Sig. (2-tailed) .000
N 250 250
Family history Pearson Correlation .265** 1
N 250 250
**. Correlation is significant at the 0.01 level (2-tailed).
Hypothesis 2
The second hypothesis was that gender is a significant predictor of psychological distress in orthopedic
patients. To test this hypothesis Pearson correlation analysis was computed on Statistical Package for
Social Sciences (SPSS)on significance level of 0.01. The results in statistical table 3 (a) presents the
significant relationship between gender and depression. The results in statistical table 3 (b) presents the
significant relationship between gender and anxiety. The results in statistical table 3 (c) presents the
significant relationship between gender and stress.
Table 4.3 (a)
Summary of Pearson correlation in relation of gender with depression
Correlations
gender DT
gender Pearson Correlation 1 .395**
34
N 250 250
DT Pearson Correlation .395** 1
N 250 250
Table 4.3 (b) Summary of Pearson correlation gender with anxiety
Correlations
gender AT
gender Pearson Correlation 1 .324**
N 250 250
AT Pearson Correlation .324** 1
N 250 250
Table 4.3 (c) Summary of Pearson correlation in relation of gender with stress
Correlations
ST gender
35
ST Pearson Correlation 1 .367**
N 250 250
gender Pearson Correlation .367** 1
N 250 250
Hypothesis 3
The third hypothesis was the number of admissions in hospital is a significant predictor of psychological
distress in orthopedic patients. To test this hypothesis Pearson correlation analysis was computed on
Statistical Package for Social sciences (SPSS) on significance level of 0.01. The results in statistical table
4 (a) presents the significant relationship between number of admissions in hospital and anxiety. The
results in statistical table 4 (b) presents the significant relationship between number of admissions in
hospital and depression. The results in statistical table 4 (c) presents the significant relationship between
number of admissions in hospital and stress.
Table 4.4 (a) Summary of Pearson correlation in relation of number of hospital admissions with
anxiety
Correlations
howmanytimeadmitinhospita
AT l
AT Pearson Correlation 1 .249**
N 250 250
36
howmanytimeadmitinhospita Pearson Correlation .249** 1
l Sig. (2-tailed) .000
N 250 250
Table 4.4 (b) Summary of Pearson correlation in relation of number of hospital

admissions with depression
Correlations
DT howmanytimeadmitinhospital
DT Pearson Correlation 1 .274**
N 250 250
howmanytimeadmitinhospital Pearson Correlation .274** 1

N 250 250
Table 4.4 (c) Summary of Pearson correlation in relation of number of hospital

admissions with stress
Correlations
howmanytimeadmitinhospita
ST l
ST Pearson Correlation 1 .224**
N 250 250
37
howmanytimeadmitinhospita Pearson Correlation .224** 1
l Sig. (2-tailed) .000
N 250 250
Hypothesis 4
The fourth hypothesis of the study is that age is a significant predictor of psychological distress among
people with orthopedic impairment. To test this hypothesis Pearson correlation analysis was computed on
Statistical Package for Social sciences (SPSS) on significance level of 0.01. The results in statistical table
5 (a) presents the significant relationship between age and anxiety. The results in statistical table 5 (b)
presents the significant relationship between age and depression. The results in statistical table 5 (c)
presents the significant relationship between age and stress.
Table 4.5 (a) Summary of Pearson correlation in relation of age with anxiety
Correlations
age AT
age Pearson Correlation 1 .247**
N 250 250
AT Pearson Correlation .247** 1
N 250 250
Table 4.5 (b) Summary of Pearson correlation in relation of age

with depression
Correlations
age DT
age Pearson Correlation 1 .321**
N 250 250
38
DT Pearson Correlation .321** 1
N 250 250
Table 4.5 (c) Summary of Pearson correlation in relation of

age with stress
Correlations
ST age
ST Pearson Correlation 1 .151*
N 250 250
age Pearson Correlation .151* 1

N 250 250
*. Correlation is significant at the 0.05 level (2-tailed).
Hypothesis 5
The fifth hypothesis of the study was that the social support would moderate the psychological distress
among people with orthopedic impairment. To test this hypothesis linear regression analysis was
computed on Statistical Package for Social Sciences (SPSS) on significance level of 0.01. The tables 6 (a)
and 6 (b) present the significant predictive relationship between social support and anxiety. The tables 7
(a) and 7 (b) present the significant predictive relationship between social support and depression. The
tables 8 (a) and 8 (b) present the significant predictive relationship between social support and stress.
Table 4.6 (a) Summary of regression analysis of social support and anxiety
39
Model Summary
Change Statistics
Adjusted R Std. Error of the R Square
Model R R Square Square Estimate Change F Change df1 df2
a
1 .549 .302 .299 7.16416 .302 107.087 1 2
a. Predictors: (Constant), TSS
Table 4.6 (b) Summary of anova of social support and anxiety
ANOVAa
Model Sum of Squares df Mean Square F Sig.

1 Regression 5496.259 1 5496.259 107.087 .000b
Residual 12728.657 249 51.325
Total 18224.916 250
a. Dependent Variable: AT
b. Predictors: (Constant), TSS
Table 4.7 (a) Summary of regression analysis of social support and depression
Model Summary
Change Statistics
a
1 .421 .177 .174 5.72896 .177 53.288 1 2
Table 4.7 (b) Summary of annova of social support and depression
ANOVAa
40
ANOVAa
Model Sum of Squares df Mean Square F Sig.

1 Regression 2884.675 1 2884.675 70.197 .000b
Residual 10191.281 249 41.094
Model Total Sum13075.956

of Squares df
250 Mean Square F Sig.
1 Regression 1748.959 1 1748.959 53.288 .000b
a. Dependent Variable: ST
Residual
b. Predictors: (Constant), TSS 8139.605 249 32.821
Total 9888.564 250
a. Dependent Variable: DT
b. Predictors: (Constant), TSS
Table 4.8 (a) Summary of regression analysis of social support and stress
Model Summary
Change Statistics
a
1 .470 .221 .217 6.41045 .221 70.197 1 2
Table 4.8 (b) Summary of annova of social support and stress
41
4.1 DISCUSSION
Orthopedic impairment is associated with the musculoskeletal system. The orthopedic issues are mostly
painful and if left untreated, they can lead to other health and psychological problems. There are different
causes of orthopedic impairment, including injuries, degenerative issues, diseases, cerebral palsy, genetic
abnormality, birth traumas etc. (Wajid, 2019). The risk factors of orthopedic problems could be aging,
chronic diseases, smoking, engaging in tasks which increase strain on body, sports, and obesity etc. There
is no specific solution or treatment of such problems, it differs depending on the type or intensity of
orthopedic condition. Physical therapy, joint injections and prescribed medicine are usually used for the
treatment of such impairment. The goals are usually to overcome physical issues, improve quality of life,
relieving symptoms and prevent future problems. But orthopedic problems not only affect physical health,
but it also affects mental health, so another important goal is to work on the psychological health of such
patients (Lewis, 2020). There are many factors that can lead to psychological distress in orthopedic
patients. These patients have reduced mobility, limited social interaction and enormous expectations for
42
healing (Herdzina, 2019). Orthopedic patients with reduced mobility have an increased risk of developing
psychological distress. Patients with orthopedic issues often present with differing degrees of anxiety,
depression, and stress.
Orthopedic patients might clinically recover earlier, but the psychological affects of the disease persist for
longer period, these include stress, anxiety, depression, and posttraumatic stress disorder (PTSD)
(Castillo, Renan, Archer & Kristin, 2016). Orthopedic patients’ overall functional outcome may be
influenced by mental health. Their mental health may be associated with poor outcome after orthopedic
trauma (Anderson, 2019). Poor mental health along with other psychological problems have a negative
effect on the overall outcome of orthopedic patients, on their life satisfaction and even on morbidity and
mortality (Christoffer, 2015). According to Per Kjaersgard Andersen, A Danish orthopedic surgeon, all
the surgeons of the world should set up a screening program to evaluate psychological health of patients.
Before surgery, surgeons should discuss the mental health with their patients. Orthopedic patients
reporting psychological distress should be referred to a general practitioner to help orthopedic patient in
managing his psychological issues. Or the best way is to refer him to the psychiatrist so that he can
accurately diagnose the psychological condition and initiate the best possible treatment. To ensure the
expectations of orthopedic patients for the planned treatment, orthopedic specialist should carefully deal
with those orthopedic patients who have psychological distress.
In Pakistan few research on the estimation of psychological distress in orthopedic patients has been
conducted. The prevalence of psychological distress in orthopedic patients was 34% in an extensive study
(Mirza & Jenkins, 2004). A research was conducted by Nusrat Husain, Syed M Humail along with other
fellows in Karachi to study psychological distress in orthopedic patients of a low-income country. This
study used a self-rating questionnaire, Oslo social support questionnaire and the brief disability
questionnaire. The results of the study found that 76.1% of females and 45.6% of males had depressive
symptoms. The factors associated with psychological distress were found to be being female, low
education, social support, and income. The study concluded that psychological distress is common and
the nature of bone pathology along with social circumstances are associated in orthopedic patients of
Pakistan (Husian, Humail, Rahman & Robinson, 2010). Pakistan has a high prevalence of psychological
distress more than the other developing countries which may be due to the social adversity in the area
(Husain, Creed & Tomenson. 2000). In Pakistan, the factors associated with anxiety and depression are
female, middle age, low education, financial difficulty, and relationship problems (Mirza, Jenkins, 2004).
43
Social support is a critical factor that is responsible for psychological well-being and life satisfaction
among physical disabled patients. In Japan, a study the social support sub scales of family, friends, and
significant others was negatively associated with psychological distress. All these subscales were
positively associated with life satisfaction of individuals. To minimize psychological distress of people,
the social support should be strengthened by expanding interpersonal network (Januka, Muzembo, Wada,
& Ikeda, 2020). Social support is considered as a coping mechanism throughout the world against
anxiety, depression, and stress. When a person is having bad day due to some issues, or a long period of
stress filled with loss and sadness, he has an immediate need to spend time with loved ones who cares
about him, who is sympathetic. A lack of social support can lead to feeling of isolation. Psychologists
discuss about significance of strong social support network. Other than psychological impacts of social
support, researchers are investigating association between social support and all the aspects of wellness.
Research has found a strong association between poor social support and psychological distress (Cherry
& Morin, 2020). In a 7-year longitudinal study conducted among middle aged people found that people
with weaker social support are more likely to die than those with stronger emotional and social support
(Grav, Hellzen, Romild & Stordal, 2012). Social support helps people cope with stress. Research has
found that in times of crisis, social support can help reduce effects of trauma induced disorders such as
orthopedic trauma and PTSD (Gros, Flanagan, Korte, Mills & Brady, 2016).
Findings of the present study investigate psychological distress, the factors affecting psychological
distress, and the role of social support in people with orthopedic problems. First hypothesis was that
“There would be a significant relationship between family history of orthopedic disease and depression”.
Statistical analysis of the present study [(R=.265); p<.01] has shown the positive relationship between
family history and depression of orthopedic patients. It reflects that those orthopedic patients who have
family history of this disease may suffer depression.
The present study tends to find the depression due to family history of orthopedic impairment. Individuals
may generalize that if other members of the family who has orthopedic impairment are not recovering so
they would also not be able to recover from the disease and this increase the chance for them to suffer
depressive symptoms. These findings are consistent with previously conducted studies for example, in a
study conducted in Ethiopia on prevalence of depression in orthopedic patients. It was investigated that
the odds of developing depression among those who had family history of orthopedic disease were 2.44
times higher as compared to those who did not have family history of orthopedic (Srahbzu, Yigizaw,
Fanta, Assefa & Tirfeneh, 2017). Three studies have found a significant association between family
history of physical disorders and depression (Res, 2002; Med, 2009; Med, 1959). A study conducted by
44
Weissman in 1984 also supports our hypothesis. The association may be due to the role of genetic
predisposition in making patients susceptible for depression when it combines with orthopedic problems.
Some studies have shown significant association between family history and depression. Although there
is not enough evidence in orthopedic population.
Second hypothesis of the study is that “There would be a significant relationship between gender and
psychological distress”. Statistical analysis of the present study has shown that there is a positive
relationship between gender and three variables i.e., anxiety [(R= .324); p<.01)], depression [(R=.395);
p<.01)], and stress [(R=.367); p<.01)]. It reflects that female orthopedic patient may suffer more
psychological distress than male orthopedic patients.
This study aims to find whether being female is a significant predictor of psychological distress. Women
are nearly twice as likely as men to be diagnosed with psychological distress (Mayo, 2019). This can be
due to the hormonal differences between the two genders. Estrogen and progesterone affect
neurotransmitter, circadian systems, and neuroendocrine which are implicated with psychological
distress. Researchers have found that socialization differences between males and females could explain
the difference between psychological distress of the two genders. Females are more sensitive to the
opinion of others and are emotionally weak than males. On the other hand, males are independent and
emotionally strong. The societal pressure on women could also be a factor behind psychological distress.
Moreover, the coping style of women is emotion-focused while men use problem-focused coping style.
Another factor could be the diagnosis differences. Women seek more help and report their symptoms
differently than men. We can also say that the cultural expectations in female orthopedic patients could
lead to more psychological distress in them (Schimelpfening, 2020). The interpersonal, relationship,
financial, biological, and cultural factors might be responsible for poor psychological health of females.
The findings of this hypothesis can be related to previous studies for example, a study conducted to find
the prevalence of psychological distress and associated factors among orthopedic patients in Ethiopia,
found that the prevalence rate was higher among females (47%) as compared to males (27.6%). Females
were 1.66 times more likely to develop psychological distress than males (Srahbzu, Yigizaw, Fanta,
Assefa & Tirfeneh, 2017). This hypothesis was also related to a study conducted in China (AOR=2.62)
(Wu, Zhang, Cheng & Wang, 2017). A research conducted in US on the similar topic also found that
orthopedic female patients are more subjected to psychological distress than males (Wood, Maclean &
Pallister, 2011). A recent study found that interpersonal, financial, and family problems are associated
with psychological distress of women (Tareen, 2000). In Jordon, a study conducted on assessment of
anxiety and depression in orthopedic patients found the results that are in line with this hypothesis of the
study (Hawamdeh, Othman & Ibrahim, 2008). In Pakistan, a study conducted on psychological distress of
45
orthopedic patients found the being female was a significant predictor of psychological distress and
76.1% of females had psychological distress (Husian, Humail, Rahman & Robinson, 2010). A research
conducted in India, found the similar results (Jain, Rishi, Sharma & Kiyawat, 2015). Similarly, a study
conducted in Hong Kong was consistent with our study (Lam & Chan, 2011). Another study in Pakistan
found that being female was a predictor of anxiety and depression in Pakistan (Mirza & Jenkins, 2004).
The third hypothesis is that “There would be a significant relationship between number of admissions
in hospital and psychological distress (anxiety, depression, and stress) in people with orthopedic
impairment”. Statistical analysis of this study has shown that there is a positive relationship between
number of admissions in hospital and three variables of psychological distress i.e., anxiety [(R= .249);
p<.01)], depression [(R=.274); p<.01)], and stress [(R=.224); p<.01)]. It reflects that if the orthopedic
patients who get admitted in the hospital are more subjected to psychological distress.
The present study aims to find whether number of admissions in hospital is a significant predictor of
psychological distress. In the results of this study, degree of psychological distress and the number of
hospital admissions was positively correlated. This can be because of the reason that hospitalization has a
huge impact on financial and work life of people. Both personal and professional life of orthopedic
patients will by highly effected if they will spend more time in the hospital. The hospital expenses can
lead to more psychological distress among them. These results are similar to those of previous studies. A
study conducted in China to investigate the factors related to depression and anxiety in patients with
orthopedic problems, concluded that persistent psychological distress is associated with number of
hospitalizations and some other factors (Wu, Zhang & Wang, 2017). In orthopedic patients, there is a
tendency towards more hospitalization and over-treatment (Tseng, Cheng & Hu, 2011).
The fourth hypothesis is that “There would be a significant relationship between age and
psychological distress”. Statistical analysis of this study has shown that there is a positive relationship
between number of admissions in hospital and three variables of psychological distress i.e., anxiety [(R= .
24)7; p<.01)], depression [(R=.321); p<.01)], and stress [(R=.151); p<.005)]. It reflects those older
orthopedic patients suffer more psychological distress.
The objective of the study was to investigate the occurrence of psychological distress due to age of
orthopedic patients. Older orthopedic patients may feel more psychological distress because they have
more physical disabilities than young patients, also because they have a lower chance to rehabilitate and
have less supportive social network. The results of the study are in line with a previous study conducted
in Pakistan, the study found that there is a significant association between psychological distress and age
(r=0.016, P<0.01) (Husian, Humail, Rahman & Robinson, 2010). Age can be the factor behind
46
psychological distress (Byles, Galliene, Blyth & Banks, 2012). In Pakistan, a study found that age is the
significant predictor of depression and anxiety (Mirza & Jenkins, 2004). A study found that in women,
mean level of psychological distress decreases beginning at 18 age and becomes the lowest in 60=70 age
group and rises after that (Alina, Alain & Charoletter, 2014). In rural Bangaladesh, psycholigcal distress
high among older women (Fakir, 2018).
The fifth hypothesis is that “Social support would moderate the psychological distress (anxiety,
depression, and stress) in people with orthopedic impairment. Statistical analysis of the study [anxiety
(R= -.549)7; p<.01)], depression [(R= -.421); p<.01)], and stress [(R= -.470); p<.01)] has shown a
negative association between social support and orthopedic impairment. It is evident that social support is
a critical part of a person’s psychological health, with social support psychological problems may occur
more intensively. When people perceive social support from others, all the negative attitudes and bad
feelings of a person diminish. Individuals feel stronger when they receive social support, so psychological
distress may affect orthopedic patients less than those with absence of social support. These results are
supported by previous studies. The odds of developing psychological distress were 3.51 times higher in
those who have less social support than those who have strong social support (Srahbzu, Yigizaw, Fanta,
Assefa & Tirfeneh, 2017). A research conducted in India, found the similar results (Jain, Rishi, Sharma &
Kiyawat, 2015). The reason behind this negative association can be because good social support will
buffer the negative consequences of orthopedic impairment (Cohen & Wills, 1985). A study conducted in
US also found similar association (Wood, Maclean & Pallister, 2011). Another research conducted in
Pakistan have found a strong negative association between social support and psychological distress of
orthopedic patients (Husian, Humail, Rahman & Robinson, 2010).
Social support plays a significant role in the lives of orthopedic patients by reducing the psychological
distress associated with the orthopedic impairment. It is also linked with the reduction in severity of the
illness as well as it is linked with recovery from diseases (Tylor, Sherman & Kim, 2004). A study found
that decreased psychological changes are associated with negative perception of social support and
increased perception of psychological distress (Curtis, Groake, Coughlam & Gel, 2004). Because when
people are distressed due to physical disabilities, they need a strong social support to tolerate such
impairments. In orthopedic impairment, patients feel helpless and do not get social support they may
develop psychological distress. A study supported the similar results by concluded that perception of
strong social support was linked with psychological functioning and physical problems (Yang, Chen,
Kuo, & Wang, 2003). Another study explored that social support positively affect social wellbeing
(Walen & Lackman, 2000).
47
A lot of studies have found that people who are living without social support are at high risk of physical
and psychological problems. Social support from significant others makes orthopedic patients realize the
importance of physical and psychological health. Social support also increases will power and the ability
to overcome the orthopedic impairment.
CHAPTER V
CONCLUSION
This study aimed to investigate psychological distress of orthopedic patients. The topic of the study was
selected because it is an untouched topic. There was a need to explore this topic as not enough research
has been done on it. Most of the previous research on the topic did not emphasize on the role of social
support in moderating psychological distress among orthopedic patients. Orthopedic impairment is the
category of conditions which affects our musculoskeletal system, including muscles, bones, tendons,
joints, nerves, and connective tissues. These conditions can result from injuries, degenerative causes,
diseases, or environmental factors. The symptoms of orthopedic problems include deformities, numbness,
pain, fatigue, swelling, redness, and stiffness. These symptoms are not persistent, they may disappear for
a while and then reappear. The orthopedic patients have reduced mobility and physical pain. These
48
symptoms depend on the body parts and on the specific conditions of the orthopedic patient. If these
symptoms get worsen with the passage of time, it might limit the activity of orthopedic patient.
Orthopedic patients may experience physical, psychological, emotional, and behavioral changes. They
have strong dislikeness while moving from one place to other, they lack energy, and avoid participating in
social interactions. These patients may suffer social anxiety, mood swings, general anxiety, stress, and
depression. They have average or above average intelligence and are dependent on others for the
fulfillment of their basic tasks. Their social life is also affected because of their limitations. They feel
anxious in social interactions. These difficulties in life make them suffer from psychological distress.
They are subjected to psychological distress because they feel that they are unable to fulfill the demands
of life due to their physical disability, they cannot complete daily tasks like normal people. Such patients
should seek professional help, not only from health care professionals but also from mental health
specialists. The mental health of such patients should be highly emphasized, along with their physical
symptoms.
In Pakistan, it is seen that orthopedic patients are mostly provided with the physical help while
psychological needs of such patients are usually ignored. The objective of the study was to focus on
psychological distress and the related factors. The present study aimed to find factors that are associated
with psychological distress of orthopedic patients. Our study found that some demographic factors such
as age, family history, gender, hospitalization, and social support were significantly associated with
psychological distress. Females are more subjected towards psychological distress than males. Older
orthopedic patients suffer more psychological distress. Those orthopedic patients who have a greater
number of hospitalizations feel more psychological distress than those who do not. Patients with family
history of illness may feel more psychological issues. And poor social support is also a determinant of
psychological distress in orthopedic patients. So, we can conclude that being female, having family
history of disease, being aged, and poor social support could be responsible for psychological distress.
Perception of social support from family, friends, peers, and significant others play an important role in
the lives of orthopedic patients, it is helpful for them to cope with orthopedic limitations. Without social
support life becomes difficult and the situations become miserable to handle. It is obvious that orthopedic
problems are difficult for people with orthopedic impairment, and it may lead to psychological distress
but with the presence of social support, it is relatively easier to manage the situation. Social support is
helpful for the recovery of people with orthopedic difficulties. Likewise, psychological distress related to
orthopedic impairment is reduced with the presence of social support. If we are related to any orthopedic
patients, we should support them by giving them advice, sharing wealth, by making dua for them and
motivating them. With social support, we can help them to overcome their limitations and live a happy
49
life just like non-orthopedic healthy people. Abu Hurairah (RAA) narrated that Prophet Muhammad (AS)
said: Whoever relieves a believer’s distress of the distressful aspects of this world, Allah will rescue
him from a difficulty of the difficulties of the Hereafter. Whoever alleviates [the situation of] one in
dire straits who cannot repay his debt, Allah will alleviate his lot in both this world and in the
Hereafter. Whoever conceals [the faults of] a Muslim, Allah will conceal [his faults] in this life and
the Hereafter. (Muslim, 2699)
This study suggests that in Pakistan, the clinicians working at orthopedic hospitals should start
emphasizing on individual’s psychological health during evaluations, and specially to females, older
patients, those who had family history of illness, and those with more hospitalizations and, also those with
poor social support. In Pakistan, there is a lack of research on psychological distress among orthopedic
patients, this study may open new track for the researchers to investigate relationship between factors
such as age, gender, hospitalization, family history, and psychological distress. This research may help
orthopedic clinics across Pakistan to focus on mental health of the patients as well.
5.1 LIMITATIONS AND SUGGESTIONS
Regardless of all the positive aspects, the study also contains certain limitations. The sample of the
present study was collected from different hospitals situated in district. Due to this reason the results of
the study cannot generalized to the entire population of Pakistan. Conducting a quantitative research like
this during a current pandemic of COVID-19, brought many challenges. One main issue was the strength
of orthopedic patients in the hospital declined due to various lockdown and restrictions. It was not
possible to conduct this research through online questionnaires as the reach out for orthopedic patients
would have been less. This affected the sample size of our study. It is recommended that the further
research should recruit the sample in large population from the different orthopedic hospitals of all the
provinces of Pakistan so that we can have more precise results to prove that orthopedic patients of
Pakistan suffer psychological distress.
50
As there are different conditions of orthopedic problems and they affect patients differently. We can not
generalize the results of the conditions of this sample to all the types of orthopedic impairment. This
study cannot prove that all the orthopedic problems would lead to psychological distress. Moreover, the
psychological distress found in our sample could possibly be triggered by the ongoing pandemic. It is
proposed that the further research to draw sample with specific orthopedic diseases such as, osteoarthritis,
ligament injuries, fractures, muscle atrophy, tendinitis, and osteomyelitis etc. Further relationship of
psychological distress with other factors such as presence of amputation, having severe pain, and chronic
medical illness are also recommended to be explored.
Further this study beheld the role of social support as a mediator in psychological distress and orthopedic
impairment. Social support is a vast area, and it affects different aspects of life either negatively or
positively. strong social support has positive affects while weaker social support negatively affects
aspects of life. It is recommended to further research should study other variables such as psychological
wellbeing and life satisfaction with social support.
Much demographic information such as marital status, chronic medical illness, lower extremity injury,
pain intensity, complication and amputation were not included in the present study. It is suggested to
consider these characteristics as well for the further research.
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Appendix 1
Abbreviations Used in the Thesis
S# item Abbreviation
1 Social support scale SS

2 Psychological distress scale PSD
3 Total of stress items ST
4 Total of anxiety items AT
5 Total of depression items DT
56
6 Total of social support scale TSS
7 United states of America USA
8. Khyber phakhtunkhaw KPK
9 American psychological association APA
10 Corona virus disease 2019 COVID-19
11 Statistical packages for social sciences SPSS
12 Diagnostic and statistical manual DSM
13 Sample Size N
14 Probablity value P
15 Radeyallāhu ′anhu RAA
15 Sallahlahu Alayhi Wa Sallam S.A.W
16 Post-traumatic stress disorder PTSD
17 United states of America USA
18 Obsessive compulsive disorder OCD
19 General health questionnaire GHQ
Appendix 2
CONSENT FORM
57
Appendix 3
DEMOGRHAPHIC FORM
-۱ _____________________:‫نام‬
۲-‫عمر‬:__________________
58
‫جنس‪ :‬مرد‪ /‬عورت‪۳-‬‬
‫__________________ ‪:‬تعلیم‪۴-‬‬
‫_________________‪:‬رہایش‪۵-‬‬
‫____________ ‪:‬پیشہ‪۶-‬‬
‫خاندانی نظام‪ :‬مشترکہ‪ /‬انفراد‪۷-‬‬
‫‪:‬خاندنى آمدنی‪۸-‬‬
‫‪15 ‬ہزار سے کم؟‬

‫‪15 ‬ہزار‪30 -‬ہزار؟‬
‫‪31 ‬ہزار‪50-‬ہزار؟‬
‫‪50 ‬ہزار سے زائد؟‬
‫_________________ ‪:‬وزن‪۹-‬‬
‫ورزش‪ :‬ہاں‪ /‬نہیں؟ ‪۱۰-‬‬
‫____________‪:‬چہل قدمی‪۱۱-‬‬
‫کیا آپ دوا لے رہے ہی‪۱۲-‬‬
‫ہاں ‪ /‬نہیں‬
‫_______________ اگر ہاں تو کتنے عرصے سے؟‬
‫‪-‬ہدایات پر کتنا عمل کرتے ہیں؟ ڈاکٹر کی‪۱۳‬‬
‫ہسپتال میں کتنے عرصے سے داخل ہیں؟‪۱۴-‬‬
‫کیا آپ کے خاندان میں کسی کو یہ بیماری تھی؟ ہاں‪ /‬نہیں‪۱۵-‬‬
‫اگر ہاں تو کتنے افراد کو؟‬
‫_________________________________________‬
‫___________________________ بیماری کا دورانیہ؟‪۱۶-‬‬
‫‪59‬‬
‫بیماری کا معلوم ہونے کے کتنے عرصے بعد اعالج شروع کیا؟‪۱۷-‬‬
‫___________________ کتنی دفعہ ہسپتال میں راخل ہوئے؟‪۱۸-‬‬
‫‪Appendix 4‬‬
‫ت‬
‫سماج ی عاون کا پ یمان ہ‬
‫)‪(Scale of Social Support‬‬

‫ن‬ ‫ن ش‬
‫ب ہت‬ ‫کسی حد ت ک‬ ‫ب ہت کم‬ ‫ب لکل ہی ں‬ ‫سواالت‬ ‫مب ر مار‬
‫زی ادہ‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬
‫‪4‬‬ ‫ت‬ ‫ن‬ ‫ش‬
‫من ک ئ‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے حوصلہ دی ا ج ا ا‬ ‫ے جم ھ‬ ‫ے یل‬ ‫م ل کام سے ٹ‬
‫ک‬
‫‪1‬‬
‫س ت‬ ‫ے۔‬ ‫ہ‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے۔‬ ‫می رے ج ذب ات تکو جم ھا ج ا ا ہ‬ ‫‪2‬‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ن ت‬ ‫ے۔ ف‬ ‫ام ی د رکھا ج ا ا ہ‬ ‫ے پر‬‫جمشھ‬ ‫‪3‬‬
‫ق‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے کوئ ی صلہ تکر ا ہ و و‬ ‫نں اگر جم ھ‬ ‫مص فل و ت می‬
‫ک‬
‫‪4‬‬
‫ے۔‬ ‫ج ہ‬ ‫ی‬ ‫ا‬ ‫کی‬ ‫ن‬
‫مدد‬ ‫ری‬
‫ی ی ش‬ ‫م‬ ‫ں‬ ‫م‬ ‫ے‬ ‫کر‬ ‫ت‬ ‫صلہ‬ ‫ی‬ ‫یح ح‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے کہ می ں پری ا ی کو زی ادہ‬ ‫ے ب ت ای ا ج ا ا ہ‬ ‫جم ھ‬ ‫‪5‬‬
‫وں۔‬ ‫ہ‬ ‫ا‬ ‫ہ‬‫ر‬ ‫دے‬ ‫ن‬ ‫ت‬ ‫ہ‬
‫ش‬ ‫کن‬ ‫اجم می ت ش‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے کی کو ش‬ ‫ے پری ا ی والے کام سے دور ر ھ‬ ‫ھ‬ ‫‪6‬‬
‫ے۔ن‬ ‫کی ج ا ی ہ‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے دوسرے کاموں‬ ‫می نرا قدھ ی ان ہ ت ٹ اے کے یل‬ ‫‪7‬‬
‫ت‬ ‫ے۔ئ‬ ‫جمکا ا عف اد ک ی ا جل ان ا کہئ‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے۔‬ ‫ش ج تہ‬‫ی‬ ‫ا‬ ‫دی‬ ‫ے‬ ‫را‬ ‫ے‬ ‫ے ی صلہے ل‬ ‫ھ‬ ‫‪8‬‬
‫جم ہ ش م ی ی ہ ن‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے۔‬ ‫ی ج نہ‬‫ا‬ ‫ا‬ ‫ا‬ ‫د‬ ‫ورہ‬ ‫م‬ ‫کا‬ ‫ے‬ ‫ت‬ ‫ر‬ ‫ت‬ ‫ھ می ث ب‬
‫ہ‬ ‫ے‬ ‫‪9‬‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے کہ می ں ہ ار ہی ں مان‬ ‫ے احساس دالی ا ج ا ا ہ‬ ‫جم ھ‬ ‫‪10‬‬
‫سکت ا۔‬
‫‪60‬‬
‫ت‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ت‬ ‫ے۔‬ ‫می را حوصلہ بڑھای ا ج ا ا ہ‬ ‫‪11‬‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے حوصلہ ملت ا‬ ‫ج ب می ں کمت ر محسوس کروں و جم ھ‬ ‫‪12‬‬
‫ن‬ ‫ے۔ت ق‬ ‫ہ‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے سے معامالت کو حل کرے کا‬ ‫جمشھ‬
‫ے ب ہشر طرتی‬ ‫‪13‬‬
‫ت‬ ‫ے۔‬ ‫م ورہ دی اخج ا ا ہ‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ت پ ہلوؤں کو الش‬ ‫ری صی ت کے ثم ب ت‬ ‫مین‬ ‫‪14‬‬
‫ے۔‬ ‫کرے می یں می ری مدد کی ج ا ی ہ‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫دوسرے لوگ برے‬ ‫ت کہ ت‬ ‫میق ں ی ہ د کھت ا ہ وں‬ ‫‪15‬‬
‫و ت می تں ک ی ا کرے ہ ی ں و می ں ب ھی ان کی‬
‫ت‬ ‫پجیروی کر ا ہ وں۔‬
‫‪4‬‬ ‫‪3‬‬ ‫‪2‬‬ ‫‪1‬‬ ‫ے کہ می ں ک ن ا اچ ھا اور‬‫ے محسوس کروای ا ہ‬ ‫م ضھ‬ ‫‪16‬‬
‫م ب وط ہ وں۔‬
‫‪Appendix 5‬‬
‫)‪(PSD SCALE‬‬
‫‪61‬‬
62
63
Appendix 6
TurnitinOriginality Report
Tested on June 2, 2021, by Turnitin Anti Plagiarism Software Provided by Higher Education
Commission, Pakistan to the Instructor of the University of Gujrat, Punjab, Pakistan.
Thesis Title: Orthopedic patients and psychological distress. A role of social support.
Author’s Name: Ayesha Rauf
Institution: University of Gujrat,Punjab,Pakistan.
PRIMARY SOURCES
SIMILARITY INTERNET PUBLICATIONS STUDENTPAPERS
INDEX SOURCES
16% 14% 5% 11%
Internet sources
2. eprints.lancs.ac.uk
3. www.humanappeal.org.uk
4. www.slideshare.net
5. theprofesional.com
6. library.iugaza.edu.ps
7. sada.drugfreenation.org
8. ijcrar.com
9. irigs.iiu.edu.pk:64447
10. citeseerx.ist.psu.edu
11. www.simplypsychology.org
12. scholarworks.umass.edu
13. www.questia.com
14. dspace.uta.edu
15. pt.scribd.com
16. files.aiscience.org
17. ir.amu.ac.in
18. www.ncbi.nlm.nih.gov
19. www.verywellmind.com
20. iris.lib.neu.edu
21. mafiadoc.com
22. tailieu.vn
23. journal.walisongo.ac.id
24. www.researchsquare.com
25. es.scribd.com
26. repository.sustech.edu
27. shodhganga.inflibnet.ac.in
28. www.benttreepress.com
29. ojs.unm.ac.id
30. researchleap.com
31. scholarworks.wm.edu
32. www.casadelbere.com
33. www.journalindj.com
64
34. en.wikipedia.org
Publications
35.Supa Pengpid, Karl Peltzer. "Prevalence and correlates of

psychological distress among a national population-based sample of adults
in Solomon Islands" , International Journal of Social Psychiatry, 2020
36. Husain, N.. "P01-235 Psychological distress among patients of an
orthopaedic out patient clinic: Study from a low income country" ,
European Psychiatry, 2009
37. "Social support as a coping strategy" , Salem Press Encyclopedia of
Health, 2013
38. Ambreen Kazi, Zafar Fatmi, Juanita Hatcher, Muhammad Masood
Kadir, Unaiza Niaz, Gail A. Wasserman. "Social environment and
depression among pregnant women in urban areas of Pakistan: Importance
of social relations" , Social Science & Medicine, 2006
39. C. A. KENNEDY. "Gender differences in HIVrelated psychological
distress in heterosexual couples" , AIDS Care, 2010
40. Stephanos Papadamou, Georgios Oikonomou. "The Monetary

Transmission Mechanism: Evidence from Eight Economies in
Transition" , International Economic Journal, 2007
41. Bick-har LAM. "Social Support, Well-being, and Teacher
Development" , Springer Science and Business Media LLC, 2019
Student papers
42.Submitted to Higher education commission of Pakistan.
43. Submitted to Liberty University
44. Submitted to Benedictine University
45. Submitted to University College London
46. Submitted to College of the Redwoods
47. Submitted to Howard University
48. Submitted to 56557
49. Submitted to City University College of Science and Technology
51. Submitted to Grand Canyon University
52. Submitted to Conroe Independent School District
53. Submitted to Florida A&M University
54. Submitted to University of Glamorgan
55. Submitted to Birkbeck College
65
56. Submitted to The University of the South Pacific
57. Submitted to Northampton College, Northamptonshire
58. Submitted to University of Ghana
59. Submitted to Maple Leaf International School

60. Submitted to CSU, Long Beach
61. Submitted to St. Patrick's College
62. Submitted to Sim University
63. Submitted to University of Hull
64. Submitted to South West College
65. Submitted to Cardiff University
66. Submitted to Macquarie University
67. Submitted to University of Southern Mississippi
66

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ORTHOPEDIC PATIENTS AND PSYCHOLOGICAL DISTRESS,

A ROLE OF SOCIAL SUPPORT

A Thesis Submitted in Partial Fulfillment of the Requirements for the Award

CHAPTER 03: RESEARCH METHODOLOGY………………………. 27

CHAPTER 04: RESUTS 31

1.2 HYPOTHESIS OF INVESTIGATION

2.1 Orthopedic impairment

Categorization of orthopedic impairment:

Orthopedic problems can be caused by genetic abnormalities such as chromosomal abnormality,

Factors affecting orthopedic impairment:

Para-natal environmental factors:

2.2 Psychological distress:

Theories of Psychological distress:

Medical theory of psychological distress:

Interpersonal theories attribute psychological difficulties to dysfunctional patterns of interaction

Leonard Pearlin theory of psychological distress:

Figure 2.1 Pearlin psychological distress theory

Theoretical view of depression

Anxiety: Anxiety is a psychological emotional state or reaction. It consists of unpleasant feelings of

Psychological theories of anxiety:

Psychodynamic theory: The anxiety is at the root of neurosis. Anxiety is supported in

Humanistic-existential theory: When there is a conflict between individual and society,

Neuroscience Theory: Anxiety can be caused by genetic factors. In Generalized anxiety

Stress according to psychological theories

James-Lange theory of stress:

The stimulus-based model of stress:

figure 2.2 Stimulus based model of stress

The response-based model of stress:

Figure 2.3 Response based model of stress

Figure 2.4 Transactional model of stress

Theoretical perspective of social support

The stress and coping perspective

The social cognition perspective

Models of Social support

Conceptual model of social support

Figure 2.5 Conceptual model of social support

Stress buffering model

Figure 2.6 Stress buffering conceptual model

Direct effect model

Studies on social support

Participants of the study

Inclusion and Exclusion criteria

 Those patients who did not complete the questionnaires.

Psychological distress scale

Social support scale

Sig. (2-tailed) .000

Family history Pearson Correlation .265** 1

Sig. (2-tailed) .000

**. Correlation is significant at the 0.01 level (2-tailed).

Table 4.3 (a)

Summary of Pearson correlation in relation of gender with depression

Sig. (2-tailed) .000

DT Pearson Correlation .395** 1

Sig. (2-tailed) .000

**. Correlation is significant at the 0.01 level (2-tailed).

Table 4.3 (b) Summary of Pearson correlation gender with anxiety

Sig. (2-tailed) .000

AT Pearson Correlation .324** 1