http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(6): 534–540 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.933898
RESEARCH PAPER
Impact of personality disorders on health-related quality of life one year after burn injury Frida Ekeblad1, Bengt Gerdin2, and Caisa O¨ster1 1
Department of Neuroscience Psychiatry, Uppsala University, Uppsala, Sweden and 2Department of Surgical Sciences, Plastic Surgery and Burns, Uppsala University Hospital, Uppsala, Sweden Abstract
Keywords
Purpose: Personality disorders (PDs) are associated with significant distress, disability, and cause great difficulties in life. PDs have been suggested to influence adaptation after major burns, but the potential relationship has not been fully elucidated. This study aimed to describe the prevalence of PDs in 107 patients with major burn injury, and to identify the impact of PDs on perceived patient outcome assessed as health-related quality of life (HRQoL) one year after burn. Methods: One burn-specific instrument (Burn Specific Health Scale-Brief (BSHS-B)) and two generic instruments (EuroQol Five Dimensions and Short Form 36 Health Survey) were used, and Psychiatric Axis I and II disorders were assessed one year post burn. Results: This study identified an above normal prevalence of PDs among individuals afflicted by burn, and participants with PD had a significantly larger lifetime burden of Axis I disorders compared to participants without PD. Participants with PDs scored significantly lower than those without PD in the BSHS-B domain Skin involvement, and the effect of having a PD was related to the subscale Treatment regimens. There was no relationship between the presence of PD and generic HRQoL. Conclusions: An implication of these observations is that special rehabilitation efforts including more tailored interventions must be offered to these patients to ensure that the obstacles they perceive to caring for themselves in this respect are eliminated.
Burn injury, health-related quality of life, outcome measure, personality disorder History Received 18 September 2013 Revised 4 June 2014 Accepted 9 June 2014 Published online 25 June 2014
ä Implications for Rehabilitation
This study identified an above normal prevalence of PDs among individuals afflicted by burn and these individuals reported poor burn-specific health-related quality of life. The identification of difficulties with compliance and endurance regarding daily skin care may cause negative consequences for optimal rehabilitation and underscore the importance of offering more tailored interventions in rehabilitation. Inflexible behavioral patterns related to the PD diagnosis imply the need for communication strategies by the rehabilitation team, which include flexibility, creativity, and diplomacy. There is a need for further research focusing on identifying the factors that facilitate the individual’s own ability to take action and have control.
Introduction Personality disorders (PDs), termed Axis II disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), constitute a group of different clinical conditions with the common feature of an enduring pattern of inner experience and behavior that markedly deviates from the expectations of the individual’s culture [1], and that are manifested in cognition, affectivity, interpersonal functioning and/or impulse control. PDs are common conditions with a reported mean prevalence rate of 11% [2]. They are associated with significant impairment in social, occupational, and other important areas of functioning ¨ ster, Department of Neuroscience Address for correspondence: Caisa O Psychiatry, Uppsala University, University Hospital, SE-751 85 Uppsala, Sweden. Tel: +46-18-6115243 (office). Fax: +46-18-510656. E-mail: [email protected]
[1] as well as in quality of life [3–7]. Individuals with PDs frequently fulfill criteria for more than one disorder. Furthermore, there is a substantial co-morbidity with respect to Axis I disorders [8]. A relationship between burns and Axis II disorders, PDs, has been sparsely described, although an overrepresentation of individuals with PDs in burn populations has been suggested, with prevalence rates of 22–23% [9,10]. A tentative explanation is that personality traits that are exaggerated in individuals with PDs, such as high neuroticism and high extroversion, have been suggested to predispose to trauma exposure [11], and individuals afflicted by burn injuries have been reported to exhibit such personality traits to a greater extent than a normative sample [12,13]. Furthermore, prior psychiatric morbidity has also been suggested as a major factor in adaptation and outcome after major burns [14–17]. Thus, psychiatric symptoms, as part of the multifaceted response to burn injuries, are frequent in the first
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year after a major burn. The reported prevalence of depression in the first year post burn varies between 17 [18] and 34% [19], and for posttraumatic stress disorder (PTSD) it varies between 20 and 45% [20]. A recent Swedish study suggests that psychiatric symptoms post burn are associated with psychiatric conditions prior to burn; a majority of the patients meeting criteria for major depression or PTSD at one-year post burn had experienced psychiatric morbidity previously in life [17]. It has also been reported that children afflicted with severe burn injury develop more PDs than expected, with almost half of the burn study population meeting criteria for at least one subsequent PD in young adulthood [21]. Adaptation viewed in terms of the subjective outcome perceived by patients, assessed as healthrelated quality of life (HRQoL), has recently become an important measure for evaluating burn care [22]. Patients who have had a longer hospitalization [23,24], a history of psychiatric disorders before the burn [18,25–29], and those with PTSD or with post-burn pain [27,30] report consequences regarding their HRQoL after burns. Recent studies have also suggested a relationship between personality traits [31–33], coping strategies, dysfunctional beliefs [34], and impaired HRQoL after major burns. The identified general burden of disease associated with PDs [35], with a poor quality of life, implies that individuals fulfilling criteria for one or more PDs may have difficulties during rehabilitation and adaptation after burns. The multifaceted response to burn injuries involves physical, psychological and social demands, and rehabilitation is often long-lasting and challenging. Dysfunctions related to PDs such as impaired social and interpersonal functioning and inflexible behavioral patterns could be detrimental to optimal rehabilitation. However, there is limited knowledge about how PDs influence outcome after burn. Thus, the aim of this study was to describe the prevalence of PDs in patients with a burn injury, and to identify the impact of PDs on the perceived outcome assessed as both generic and disease-specific HRQoL 12 months after major burn.
Methods Participants This was part of a prospective, longitudinal study at a national burn center on physical and psychological outcome after burns. The Burn Center at Uppsala University Hospital, one of the two national burn centers in Sweden, has a catchment area comprising the northern parts of Sweden with approximately four million inhabitants. Patients admitted to the Burn Center between March 2000 and March 2009 were consecutively included if they met the following inclusion criteria: (i) 18 years of age or older, (ii) Swedish speaking, (iii) without documented mental retardation or dementia, and (iv) had 5% total body surface area (TBSA) burned or a length of hospital stay (LOS) at the burn intensive care unit of 2 days or more. During this period, 357 patients were treated at the Burn Center, of whom 151 met the inclusion criteria. Twenty patients chose not to participate and 14 were not included due to administrative reasons, leaving a group of 107 participants (76%). The 34 non-participants were older than the participants at the time of the burn injury (55.1 years versus 43.4 years; p50.001) and their mean TBSA burned was smaller (14%, SD 15 versus 24%, SD 19; p ¼ 0.013), but they did not significantly differ from the participants regarding sex, full thickness injury, or LOS. Data concerning other aspects of the same sample have been published previously [25,36]. This study was performed according to the Helsinki Declaration [37] and was approved in 2000 by the Regional Ethical Review Board in Uppsala, registration no. 00-122.
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Measures Sociodemographic variables and injury characteristics were obtained from medical records. The Structured Clinical Interview for DSM-IV Axis I disorders (SCID I) was used to assess psychiatric Axis I disorders [38]. The Structured Clinical Interview for DSM-IV axis II disorders (SCID II) was used to assess PDs, and findings are reported as diagnoses [39]. Perceived patient outcome was assessed as health-related quality of life (HRQoL). The concept of HRQoL is a commonly used patient-reported outcome measure (PROM) [40]. It focuses on the impact injury or illness has on quality of life, and how it interferes with the individual’s ability to live a fulfilling life [41]. The use of both generic and disease-specific instruments is proposed in guidelines for follow-up studies after injury. Diseasespecific instruments allow for more detailed evaluations of consequences after injury or disease, while generic instruments enable comparison between injury-related disability and population health [22]. The Burn Specific Health Scale-Brief (BSHS-B) is a diseasespecific instrument developed to assess perceived health status after burns. The self-report questionnaire consists of 40 items divided into nine subscales. The 40 items are scored on a five-step scale ranging from 0 to 4. High scores indicate good perceived health status [42]. Eight of the nine subscales can be grouped into three domains of burn-specific health: Function, skin involvement, and affect and relations. The last subscale (Work) can be considered as a separate domain [43]. The Short Form 36 Health Survey (SF-36) is a self-report questionnaire used to assess perceived generic HRQoL [44] and is validated in a burn population [45]. The questionnaire consists of 36 items divided into eight subscales. The scores of the eight subscales are transformed with an algorithm, and the final scores for each subscale range from 0 to 100. High scores indicate good perceived health. The SF-36 can also be transformed into summary scales reflecting perceived physical and psychosocial health and function: the Physical Component Score (PCS) and the Mental Component Score (MCS). The EuroQol Five Dimensions (EQ-5D) is a self-report questionnaire used to assess generic HRQoL [46]. It has been translated into more than 60 languages, is used worldwide, and is validated in a burn population [36]. The EQ-5D descriptive system is composed of five questions covering five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/ depression. Each dimension of perceived health can be scored as an area where the respondent experiences ‘‘none’’, ‘‘moderate’’, or ‘‘extreme problems’’. This descriptive part of the EQ-5D can be converted into a weighted index (i.e., the EQ-5D index). The conversion index is based on population-based enquiries. The EQ-5D index ranges from 0.594, ‘‘death or a state worse than death’’, to 1, ‘‘full health’’ [47]. The EQ-5D also contains the EQ-5D VAS, a vertical 20-cm line graded from 0 (worst possible health state) to 100 (best possible health state). The respondent is asked to mark his or her own current perceived state of health. Procedures The SCID I and SCID II interviews were conducted during acute care as soon as the patient’s medical condition was stable and he or she could contribute fully. As a routine, patients were screened by the Mini Mental State Examination [48]. The SCID I interviews assessed Axis I disorders at any time in life and within 12 months before injury including the time of the burn. The SCID II interview assessed the presence of any PD. The SCID interviews were performed by trained professionals who were not part of the regular staff at the Burn Center, and thus not
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involved in treatment decisions. The psychiatric assessments lasted from 1 to 1.5 hours and were sometimes carried out in two sessions. Six SCID interviews were independently rated for interrater reliability with complete inter-rater agreement on obtained diagnoses (kappa ¼ 1). The EQ-5D questionnaire was completed during acute care and at 3, 6, and 12 months post burn. During acute care, the questionnaire was administered by a member of the research team, and at 3, 6 and 12 months, the questionnaires were distributed and collected by postal services. At 6 and 12 months, the SF-36 and BSHS-B questionnaires were included as well. Non-responders received one reminder letter with relevant questionnaires.
Table 1. Distribution of personality disorders assessed at baseline and using criteria in DSM-IV. Personality disorder
Number of persons (%)
Any PD Paranoid PD Schizoid PD Schizotyp PD Antisocial PDa Borderline PDa Histrionic PD Narcissistic PD Avoidant PD Dependent PD Obsessive-compulsive PD Passive-aggressive PD Depressive PD Personality disorder NOS More than one disorder
23 (21) 6 (6) 0 (0) 1(1) 8 (7) 4 (4) 0 (0) 1 (1) 4 (4) 2 (2) 4 (4) 3 (3) 4 (4) 3 (3) 8/23 (35%)
As some individuals were diagnosed with more than one PD, the total number of personality disorder diagnoses is not equivalent to the number of persons with a PD diagnosis in the study population. a Due to missing values, sample size was 106.
Statistical analyses The 2 test was used for categorical variables and Fisher’s exact test was used when expected observations in each cell were less than five. For metric variables, the two-sample t-test was used. When necessary, scale values were logarithmically transformed to obtain normal distribution before analysis. Multiple regressions were carried out with a stepwise backward strategy as described in the text and tables. Analyses were performed with the statistical package IBM SPSS 20.0.
Results During the first year following the burn injury, 17 of the 107 participants withdrew from the study, leaving 90 participants to be evaluated at 12 months post burn. The dropouts were younger (34.2 versus 45.2 years; p ¼ 0.007) than the 90 remaining participants, but did not differ regarding sociodemographic, burn-related or psychiatric variables. Almost two-thirds (57 %) of the participants had at least one Axis I disorder during their lifetime preceding the burn injury. Affective disorders were most prevalent (36%), while psychotic disorders were rare (2%). Twenty-three participants, 21%, met criteria for at least one PD and of these, 35% met criteria for more than one PD (Table 1). Furthermore, they had a significantly larger burden of lifetime Axis I disorders. In fact, 22 of the 23 individuals with at least one PD exhibited at least one lifetime Axis I disorder, 14 an affective disorder, 12 an anxiety disorder, and 17 individuals exhibited a substance use disorder (Table 2). The participants with PDs were significantly younger than those without PDs, but in other aspects did not differ with respect to sociodemographic or burn-related variables (Table 2). There were no differences between those who exhibited a diagnosis of one or more PDs and those who did not regarding HRQoL at 12 months as assessed by the three generic measures (Table 3). With respect to burn-specific health, participants with PDs only scored significantly lower than those without PDs in the domain Skin involvement in the BSHS-B (Table 3). Of the three subscales constituting the domain Skin involvement, those with
Table 2. Sociodemographics and burn characteristics in the PD and non-PD groups. PDs (n ¼ 23)
Women/men Working/studying Living alone Cause of injury: fire/scald/electrical/chemical Psychiatric history Lifetime Any psychiatric disorder Any affective disorder Any anxiety disorder Any psychotic disorder Any substance use disorder 12 months before injury Any psychiatric disorder Any affective disorder Any anxiety disorder Any psychotic disorder Any substance use disorder Age at injury (years) Years of educationa Total body surface area Total body surface area full thickness Length of stay a
Due to missing values, sample size was 104.
No PDs (n ¼ 84)
n
%
6/17 17 11 19/2/2/0
26/74 74 58
22 14 12 0 17
96 61 52 0 74
17 10 10 0 8 Mean (Range) 38 (19–52) 11 (9–17) 25 (4–69) 10 (0–36) 22 (2–65)
74 44 44 0 35 SD 10 2.3 17 11 18
%
p ( 2-test)
25/75 75 42
ns ns ns
39 25 18 2 14
46 30 21 2 17
50.001 0.006 0.004 ns 50.001
28 14 15 2 12 Mean (Range) 45 (19–89) 11 (6–18) 23 (1–80) 11 (0–64) 26 (1–277)
33 17 18 2 14 SD 16 2.6 19 14 39
50.001 0.006 0.010 ns 0.025 t-test p Value 0.039 ns ns ns ns
n 21/63 63 30 56/14/8/5
Impact of personality disorders after a burn injury
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PDs scored lower than those without PDs in heat sensitivity and treatment regimens, but not in body image. Considering the large comorbidity between Axis I disorders and PDs, an attempt was made to assess whether the effect of PDs on skin involvement was related to simultaneous comorbid Axis I disorders. This was done utilizing a multiple regression approach where skin involvement as a dependent variable was regressed versus Axis I disorder and PD variables together with length of stay, which is a covariate to describe the effect of the seriousness of the burn itself (Table 4). In most regressions, the Axis I disorder variable and the PD variable mutually excluded one
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another, which was related at least in part to the considerable comorbidity. However, with respect to the presence of Any anxiety disorder, where the comorbidity was only about 50%, 12 out of the 23 patients with a PD had an anxiety disorder lifetime (Table 2), and the presence of a PD had an independent effect on the Skin involvement scale score (Table 4). In a next step, we therefore replaced Skin involvement in the regressions with their original subscales. This confirmed that the effect of having a PD was related above all to the subscale Treatment regimens.
Discussion Table 3. Health-related quality of life 12 months after burn in the PD and non-PD groups.
EQ-5D EQ-5D index EQ-VAS SF-36 PCS MCS BSHS-B Function Affect and relations Skin involvement Heat sensitivity Body image Treatment regimens
PDs (n ¼ 20)
No PDs (n ¼ 70)
p (t-test)
0.61 (0.32) 72.4 (20.4)
0.71 (0.26) 70.3 (21.5)
ns ns
43.0 (12.1) 41.1 (15.0)
44.7 (12.3) 44.3 (13.5)
ns ns
3.69 3.13 1.90 1.45 2.26 2.00
(0.35) (0.87) (1.07) (1.27) (1.33) (1.33)
3.58 3.28 2.55 2.18 2.56 3.00
(0.80) (0.76) (0.94) (1.19) (1.22) (0.94)
ns ns 0.011 0.023 ns 50.001
PCS, Physical Component Score; MCS, Mental Component Score. Values are given as mean (SD).
This study identified an above normal prevalence of PD among individuals afflicted by burn. Study participants meeting criteria for a PD had a significantly larger lifetime burden of Axis I disorders compared to participants without a PD. Furthermore, participants with PDs scored significantly lower than those without in the BSHS-B domain skin involvement, and regression analyses confirmed that the effect of having a PD was related above all to the subscale treatment regimens. Importantly, there were no differences identified in the generic HRQoL, the EQ-index and EQ VAS, or in the SF-36 component scores, between those who fulfilled and those who did not fulfill criteria for a PD. The finding of a higher-than-normal prevalence of PDs in a burn population supports findings from previous studies suggesting an overrepresentation of individuals with PDs among burn victims as compared to the general population [2,9,10]. One explanation for such overrepresentation of PDs in burn populations could be that these individuals are at increased risk of trauma in general, or burn in particular. An increased risk of burn
Table 4. Multiple regressions using a stepwise strategy where factors with a p value of 50.10 are in the final model. Independent variables
Dependent variable Lifetime Axis I disorders and covariates Skin involvement
Any personality disorder Length of Stay
Skin involvement
Any affective disorder Length of Stay
Skin involvement
Anxiety disorder Any personality disorder Length of Stay
Heat sensitivity
Any Anxiety disorder Length of Stay
Treatment regimens Any personality disorder Length of Stay Body image
Any Anxiety disorder Length of Stay
Skin involvement
Any substance use disorder Length OF Stay
Axis I disorders within 12 mo. before injury and covariates
Any Axis I disorder 0.227 Any personality disorder 0.467 Length of Stay R2 ¼ 0.26 Any affective disorder 0.276 Any personality disorder 0.477 Length of Stay 2 R ¼ 0.29 Anxiety disorder 0.190 Anxiety disorder 0.178 Any personality disorder 0.441 Length of Stay R2 ¼ 0.28 0.223 Anxiety disorder 0.347 Length of Stay R2 ¼ 0.17 Any Anxiety disorder 0.350 Any personality disorder 0.421 Length of Stay R2 ¼ 0.29 0.179 Any Anxiety disorder 0.343 Length of Stay R2 ¼ 0.15 Any substance use disorder 0.229 Any personality disorder 0.456 Length of Stay R2 ¼ 0.26
0.227 0.467 R2 ¼ 0.26 0.227 0.467 R2 ¼ 0.26 0.238 0.167 0.445 R2 ¼ 0.13 0.242 0.343 R2 ¼ 0.18 0.206 0.298 0.403 R2 ¼ 0.33 0.210 0.348 R2 ¼ 0.16 0.227 0.467 R2 ¼ 0.26
Results are shown as beta-values and adjusted R2 Different Axis I disorder groups and the covariate length of stay were assessed as independent variables together with the variable Any Personality Disorder. Only significant variables remaining in the model are shown.
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exposure in persons with PDs should be further investigated, and could highlight the need for strategies to prevent trauma in these individuals as well as for providing information to healthcare staff about PDs in trauma care [49]. It must be pointed out, however, that knowledge concerning prevalence rates of PDs in general trauma populations is scarce, although it is known that extreme expression of some personality traits as such is related to risk behavior [50,51]. In one study, an increased prevalence of PDs in a traffic-related trauma population was identified [52]. Participants meeting criteria for a PD diagnosis reported lower scores than those without a PD diagnosis in only one aspect of burn-specific health, the BSHS-B domain skin involvement. This should be considered in the context of the present research group’s observations that a history of psychiatric Axis I morbidity, either lifelong or within 12 months prior to burn, is related to worse burn-specific health at 12 months post burn in both the domains skin involvement and affect and relations [25]. The present results suggest that meeting criteria for having a PD is in some respects more closely related to worse burn-specific health than having an Axis I disorder history. The results also show that having a PD and having a history of any anxiety disorder are each independent predictors of outcome regarding Skin involvement. A rational interpretation of these results is that there is a mutually reinforcing effect of Axis I and II disorders on each other with respect to being risk factors for poor perceived health after burns. Reasonably, some aspects of post-burn health are more affected by the Axis I component and others by the Axis II component. Thus our results suggest, for example, that a history of any affective disorder is more related to heat sensitivity than having an Axis II PD. The fact that having a history of any affective disorder was also related to burn-specific health in the BSHS domain affect and relations in a previous study, while having a PD did not have any impact on this variable in the present study, suggests that post-burn affect and relations is above all a function of a previous Axis I history. The domain Skin involvement assesses different aspects of skin health, and the last step in the regressions, using the original three subscales, confirmed that the effect of having a PD was related above all to the subscale Treatment regimens. The items in the subscale predominantly reflect difficulties with compliance and endurance regarding daily skin care and include items such as: ‘‘Taking care of my skin is a bother’’; ‘‘I wish that I didn’t have to do so many things to take care of my burn’’. Since functional impairment is a diagnostic criterion for PD [1], it is understandable that individuals with PDs can encounter problems when they are responsible for everyday self-care and treatment. There can be individual complications during rehabilitation, and in rehabilitation programs, after injury. A diagnosis of an Axis II disorder has previously been identified as predictive of noncompletion [53,54], poor outcome [55] and non-adherence [56] in treatment programs. Daily skin care and treatment over a long period of time after a burn can be demanding, and conceivable difficulties could result in worse actual as well as perceived skin health. This could indicate a need for management of and additional support in post-burn skin care. We could not identify a relationship between the presence of PDs and poorer generic HRQoL. This was contradictory to previous studies identifying impaired quality of life in individuals with PDs compared to control individuals without PDs [3–7,57]. Based on these studies, our hypothesis was that the presence of a PD, with subsequent functional impairment, would influence adaptation and recovery after major burn assessed as HRQoL at one year post burn. Some tentative explanations for the observed lack of such association between PDs and impaired HRQoL could be considered. One interpretation could be that at one year post burn, quite an early time point during rehabilitation after a severe
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burn, the impact of the extent of the burn trauma as such may overshadow other factors that may influence adaptation later on. Another explanation is a smaller-than-expected difference in functional level between study participants with and without PDs. No significant differences were seen in educational level, occupational status or marital status between the groups, variables that might be expected to reflect functional level. One might speculate that these study participants with PDs, identified as part of a burn population, might have a higher functional level compared to individuals with PDs identified among patients seeking psychiatric treatment. It has been shown previously that individuals with PDs do return to work after burn but that they take a longer time to do so compared to individuals without PDs [58]. Another possibility is that the non-PD group also represents a select group of individuals with poorer general health than in the general population, something that could decrease presumed differences between the study groups. Support for such an hypothesis is that the non-PD participants in this study also had a much higher prevalence of Axis I disorders compared to a general population [59,60]. Like every study, this investigation has its methodological limitations. Given the relative rarity of major burn trauma in developed countries, the study population in the present study is relatively small, although representing all patients meeting inclusion criteria in one of the two national burn centers in Sweden during a 10-year period. A larger study population may have had greater power to reveal differences in subgroups. A definite strength is the use of established semi-structured psychiatric interviews to assess both Axis I and II disorders, which allowed for a careful and accurate assessment of diagnoses and psychiatric symptoms both pre and post burn. The use of diagnostic instruments enables comparisons with international population prevalence studies. The instruments, however, do not completely control for recall bias, which is known to underestimate lifetime prevalence. A recent study comparing retrospective versus prospective methods of assessing the lifetime prevalence of psychiatric disorders suggests that the prevalence is only half what it could be in reality [61]. On the other hand, all assessments were made by experienced interviewers, trained in the use of these instruments and with known inter-observer agreement, which strengthens the validity and reliability of the diagnostic instruments. It is possible that the use of a dimensional model of PD instead of a categorical diagnostic model (with a subset of items that must be fulfilled to meet a diagnostic threshold) might have enabled further understanding of the relationship between dysfunctional personality traits and HRQoL. However, this was beyond the scope of the study. In addition, the use of validated generic and disease-specific instruments for assessing HRQoL increased the possibility of capturing different aspects of perceived HRQoL. To conclude, this study shows that individuals with PDs are overrepresented among persons afflicted by burn. Having a PD was associated with impaired burn-specific HRQoL in the skin domain, but not with generic HRQoL, at one year post burn. Specifically, having a PD was linked to the ability to focus on treating the skin well. An implication of this observation is that special rehabilitation efforts including more tailored interventions must be offered to these patients to ensure that the obstacles they perceive to caring for themselves in this respect are eliminated.
Acknowledgements The authors thank all of the former burn patients for participating in the study.
DOI: 10.3109/09638288.2014.933898
Declaration of interest There are no conflicts of interest to declare. This research was supported by the Swedish Research Council and the Swedish Council for Working Life and Social Research.
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RESEARCH PAPER
Impact of personality disorders on health-related quality of life one year after burn injury Frida Ekeblad1, Bengt Gerdin2, and Caisa O¨ster1 1
Department of Neuroscience Psychiatry, Uppsala University, Uppsala, Sweden and 2Department of Surgical Sciences, Plastic Surgery and Burns, Uppsala University Hospital, Uppsala, Sweden Abstract
Keywords
Purpose: Personality disorders (PDs) are associated with significant distress, disability, and cause great difficulties in life. PDs have been suggested to influence adaptation after major burns, but the potential relationship has not been fully elucidated. This study aimed to describe the prevalence of PDs in 107 patients with major burn injury, and to identify the impact of PDs on perceived patient outcome assessed as health-related quality of life (HRQoL) one year after burn. Methods: One burn-specific instrument (Burn Specific Health Scale-Brief (BSHS-B)) and two generic instruments (EuroQol Five Dimensions and Short Form 36 Health Survey) were used, and Psychiatric Axis I and II disorders were assessed one year post burn. Results: This study identified an above normal prevalence of PDs among individuals afflicted by burn, and participants with PD had a significantly larger lifetime burden of Axis I disorders compared to participants without PD. Participants with PDs scored significantly lower than those without PD in the BSHS-B domain Skin involvement, and the effect of having a PD was related to the subscale Treatment regimens. There was no relationship between the presence of PD and generic HRQoL. Conclusions: An implication of these observations is that special rehabilitation efforts including more tailored interventions must be offered to these patients to ensure that the obstacles they perceive to caring for themselves in this respect are eliminated.
Burn injury, health-related quality of life, outcome measure, personality disorder History Received 18 September 2013 Revised 4 June 2014 Accepted 9 June 2014 Published online 25 June 2014
ä Implications for Rehabilitation
This study identified an above normal prevalence of PDs among individuals afflicted by burn and these individuals reported poor burn-specific health-related quality of life. The identification of difficulties with compliance and endurance regarding daily skin care may cause negative consequences for optimal rehabilitation and underscore the importance of offering more tailored interventions in rehabilitation. Inflexible behavioral patterns related to the PD diagnosis imply the need for communication strategies by the rehabilitation team, which include flexibility, creativity, and diplomacy. There is a need for further research focusing on identifying the factors that facilitate the individual’s own ability to take action and have control.
Introduction Personality disorders (PDs), termed Axis II disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), constitute a group of different clinical conditions with the common feature of an enduring pattern of inner experience and behavior that markedly deviates from the expectations of the individual’s culture [1], and that are manifested in cognition, affectivity, interpersonal functioning and/or impulse control. PDs are common conditions with a reported mean prevalence rate of 11% [2]. They are associated with significant impairment in social, occupational, and other important areas of functioning ¨ ster, Department of Neuroscience Address for correspondence: Caisa O Psychiatry, Uppsala University, University Hospital, SE-751 85 Uppsala, Sweden. Tel: +46-18-6115243 (office). Fax: +46-18-510656. E-mail: [email protected]
[1] as well as in quality of life [3–7]. Individuals with PDs frequently fulfill criteria for more than one disorder. Furthermore, there is a substantial co-morbidity with respect to Axis I disorders [8]. A relationship between burns and Axis II disorders, PDs, has been sparsely described, although an overrepresentation of individuals with PDs in burn populations has been suggested, with prevalence rates of 22–23% [9,10]. A tentative explanation is that personality traits that are exaggerated in individuals with PDs, such as high neuroticism and high extroversion, have been suggested to predispose to trauma exposure [11], and individuals afflicted by burn injuries have been reported to exhibit such personality traits to a greater extent than a normative sample [12,13]. Furthermore, prior psychiatric morbidity has also been suggested as a major factor in adaptation and outcome after major burns [14–17]. Thus, psychiatric symptoms, as part of the multifaceted response to burn injuries, are frequent in the first
DOI: 10.3109/09638288.2014.933898
year after a major burn. The reported prevalence of depression in the first year post burn varies between 17 [18] and 34% [19], and for posttraumatic stress disorder (PTSD) it varies between 20 and 45% [20]. A recent Swedish study suggests that psychiatric symptoms post burn are associated with psychiatric conditions prior to burn; a majority of the patients meeting criteria for major depression or PTSD at one-year post burn had experienced psychiatric morbidity previously in life [17]. It has also been reported that children afflicted with severe burn injury develop more PDs than expected, with almost half of the burn study population meeting criteria for at least one subsequent PD in young adulthood [21]. Adaptation viewed in terms of the subjective outcome perceived by patients, assessed as healthrelated quality of life (HRQoL), has recently become an important measure for evaluating burn care [22]. Patients who have had a longer hospitalization [23,24], a history of psychiatric disorders before the burn [18,25–29], and those with PTSD or with post-burn pain [27,30] report consequences regarding their HRQoL after burns. Recent studies have also suggested a relationship between personality traits [31–33], coping strategies, dysfunctional beliefs [34], and impaired HRQoL after major burns. The identified general burden of disease associated with PDs [35], with a poor quality of life, implies that individuals fulfilling criteria for one or more PDs may have difficulties during rehabilitation and adaptation after burns. The multifaceted response to burn injuries involves physical, psychological and social demands, and rehabilitation is often long-lasting and challenging. Dysfunctions related to PDs such as impaired social and interpersonal functioning and inflexible behavioral patterns could be detrimental to optimal rehabilitation. However, there is limited knowledge about how PDs influence outcome after burn. Thus, the aim of this study was to describe the prevalence of PDs in patients with a burn injury, and to identify the impact of PDs on the perceived outcome assessed as both generic and disease-specific HRQoL 12 months after major burn.
Methods Participants This was part of a prospective, longitudinal study at a national burn center on physical and psychological outcome after burns. The Burn Center at Uppsala University Hospital, one of the two national burn centers in Sweden, has a catchment area comprising the northern parts of Sweden with approximately four million inhabitants. Patients admitted to the Burn Center between March 2000 and March 2009 were consecutively included if they met the following inclusion criteria: (i) 18 years of age or older, (ii) Swedish speaking, (iii) without documented mental retardation or dementia, and (iv) had 5% total body surface area (TBSA) burned or a length of hospital stay (LOS) at the burn intensive care unit of 2 days or more. During this period, 357 patients were treated at the Burn Center, of whom 151 met the inclusion criteria. Twenty patients chose not to participate and 14 were not included due to administrative reasons, leaving a group of 107 participants (76%). The 34 non-participants were older than the participants at the time of the burn injury (55.1 years versus 43.4 years; p50.001) and their mean TBSA burned was smaller (14%, SD 15 versus 24%, SD 19; p ¼ 0.013), but they did not significantly differ from the participants regarding sex, full thickness injury, or LOS. Data concerning other aspects of the same sample have been published previously [25,36]. This study was performed according to the Helsinki Declaration [37] and was approved in 2000 by the Regional Ethical Review Board in Uppsala, registration no. 00-122.
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Measures Sociodemographic variables and injury characteristics were obtained from medical records. The Structured Clinical Interview for DSM-IV Axis I disorders (SCID I) was used to assess psychiatric Axis I disorders [38]. The Structured Clinical Interview for DSM-IV axis II disorders (SCID II) was used to assess PDs, and findings are reported as diagnoses [39]. Perceived patient outcome was assessed as health-related quality of life (HRQoL). The concept of HRQoL is a commonly used patient-reported outcome measure (PROM) [40]. It focuses on the impact injury or illness has on quality of life, and how it interferes with the individual’s ability to live a fulfilling life [41]. The use of both generic and disease-specific instruments is proposed in guidelines for follow-up studies after injury. Diseasespecific instruments allow for more detailed evaluations of consequences after injury or disease, while generic instruments enable comparison between injury-related disability and population health [22]. The Burn Specific Health Scale-Brief (BSHS-B) is a diseasespecific instrument developed to assess perceived health status after burns. The self-report questionnaire consists of 40 items divided into nine subscales. The 40 items are scored on a five-step scale ranging from 0 to 4. High scores indicate good perceived health status [42]. Eight of the nine subscales can be grouped into three domains of burn-specific health: Function, skin involvement, and affect and relations. The last subscale (Work) can be considered as a separate domain [43]. The Short Form 36 Health Survey (SF-36) is a self-report questionnaire used to assess perceived generic HRQoL [44] and is validated in a burn population [45]. The questionnaire consists of 36 items divided into eight subscales. The scores of the eight subscales are transformed with an algorithm, and the final scores for each subscale range from 0 to 100. High scores indicate good perceived health. The SF-36 can also be transformed into summary scales reflecting perceived physical and psychosocial health and function: the Physical Component Score (PCS) and the Mental Component Score (MCS). The EuroQol Five Dimensions (EQ-5D) is a self-report questionnaire used to assess generic HRQoL [46]. It has been translated into more than 60 languages, is used worldwide, and is validated in a burn population [36]. The EQ-5D descriptive system is composed of five questions covering five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/ depression. Each dimension of perceived health can be scored as an area where the respondent experiences ‘‘none’’, ‘‘moderate’’, or ‘‘extreme problems’’. This descriptive part of the EQ-5D can be converted into a weighted index (i.e., the EQ-5D index). The conversion index is based on population-based enquiries. The EQ-5D index ranges from 0.594, ‘‘death or a state worse than death’’, to 1, ‘‘full health’’ [47]. The EQ-5D also contains the EQ-5D VAS, a vertical 20-cm line graded from 0 (worst possible health state) to 100 (best possible health state). The respondent is asked to mark his or her own current perceived state of health. Procedures The SCID I and SCID II interviews were conducted during acute care as soon as the patient’s medical condition was stable and he or she could contribute fully. As a routine, patients were screened by the Mini Mental State Examination [48]. The SCID I interviews assessed Axis I disorders at any time in life and within 12 months before injury including the time of the burn. The SCID II interview assessed the presence of any PD. The SCID interviews were performed by trained professionals who were not part of the regular staff at the Burn Center, and thus not
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involved in treatment decisions. The psychiatric assessments lasted from 1 to 1.5 hours and were sometimes carried out in two sessions. Six SCID interviews were independently rated for interrater reliability with complete inter-rater agreement on obtained diagnoses (kappa ¼ 1). The EQ-5D questionnaire was completed during acute care and at 3, 6, and 12 months post burn. During acute care, the questionnaire was administered by a member of the research team, and at 3, 6 and 12 months, the questionnaires were distributed and collected by postal services. At 6 and 12 months, the SF-36 and BSHS-B questionnaires were included as well. Non-responders received one reminder letter with relevant questionnaires.
Table 1. Distribution of personality disorders assessed at baseline and using criteria in DSM-IV. Personality disorder
Number of persons (%)
Any PD Paranoid PD Schizoid PD Schizotyp PD Antisocial PDa Borderline PDa Histrionic PD Narcissistic PD Avoidant PD Dependent PD Obsessive-compulsive PD Passive-aggressive PD Depressive PD Personality disorder NOS More than one disorder
23 (21) 6 (6) 0 (0) 1(1) 8 (7) 4 (4) 0 (0) 1 (1) 4 (4) 2 (2) 4 (4) 3 (3) 4 (4) 3 (3) 8/23 (35%)
As some individuals were diagnosed with more than one PD, the total number of personality disorder diagnoses is not equivalent to the number of persons with a PD diagnosis in the study population. a Due to missing values, sample size was 106.
Statistical analyses The 2 test was used for categorical variables and Fisher’s exact test was used when expected observations in each cell were less than five. For metric variables, the two-sample t-test was used. When necessary, scale values were logarithmically transformed to obtain normal distribution before analysis. Multiple regressions were carried out with a stepwise backward strategy as described in the text and tables. Analyses were performed with the statistical package IBM SPSS 20.0.
Results During the first year following the burn injury, 17 of the 107 participants withdrew from the study, leaving 90 participants to be evaluated at 12 months post burn. The dropouts were younger (34.2 versus 45.2 years; p ¼ 0.007) than the 90 remaining participants, but did not differ regarding sociodemographic, burn-related or psychiatric variables. Almost two-thirds (57 %) of the participants had at least one Axis I disorder during their lifetime preceding the burn injury. Affective disorders were most prevalent (36%), while psychotic disorders were rare (2%). Twenty-three participants, 21%, met criteria for at least one PD and of these, 35% met criteria for more than one PD (Table 1). Furthermore, they had a significantly larger burden of lifetime Axis I disorders. In fact, 22 of the 23 individuals with at least one PD exhibited at least one lifetime Axis I disorder, 14 an affective disorder, 12 an anxiety disorder, and 17 individuals exhibited a substance use disorder (Table 2). The participants with PDs were significantly younger than those without PDs, but in other aspects did not differ with respect to sociodemographic or burn-related variables (Table 2). There were no differences between those who exhibited a diagnosis of one or more PDs and those who did not regarding HRQoL at 12 months as assessed by the three generic measures (Table 3). With respect to burn-specific health, participants with PDs only scored significantly lower than those without PDs in the domain Skin involvement in the BSHS-B (Table 3). Of the three subscales constituting the domain Skin involvement, those with
Table 2. Sociodemographics and burn characteristics in the PD and non-PD groups. PDs (n ¼ 23)
Women/men Working/studying Living alone Cause of injury: fire/scald/electrical/chemical Psychiatric history Lifetime Any psychiatric disorder Any affective disorder Any anxiety disorder Any psychotic disorder Any substance use disorder 12 months before injury Any psychiatric disorder Any affective disorder Any anxiety disorder Any psychotic disorder Any substance use disorder Age at injury (years) Years of educationa Total body surface area Total body surface area full thickness Length of stay a
Due to missing values, sample size was 104.
No PDs (n ¼ 84)
n
%
6/17 17 11 19/2/2/0
26/74 74 58
22 14 12 0 17
96 61 52 0 74
17 10 10 0 8 Mean (Range) 38 (19–52) 11 (9–17) 25 (4–69) 10 (0–36) 22 (2–65)
74 44 44 0 35 SD 10 2.3 17 11 18
%
p ( 2-test)
25/75 75 42
ns ns ns
39 25 18 2 14
46 30 21 2 17
50.001 0.006 0.004 ns 50.001
28 14 15 2 12 Mean (Range) 45 (19–89) 11 (6–18) 23 (1–80) 11 (0–64) 26 (1–277)
33 17 18 2 14 SD 16 2.6 19 14 39
50.001 0.006 0.010 ns 0.025 t-test p Value 0.039 ns ns ns ns
n 21/63 63 30 56/14/8/5
Impact of personality disorders after a burn injury
DOI: 10.3109/09638288.2014.933898
PDs scored lower than those without PDs in heat sensitivity and treatment regimens, but not in body image. Considering the large comorbidity between Axis I disorders and PDs, an attempt was made to assess whether the effect of PDs on skin involvement was related to simultaneous comorbid Axis I disorders. This was done utilizing a multiple regression approach where skin involvement as a dependent variable was regressed versus Axis I disorder and PD variables together with length of stay, which is a covariate to describe the effect of the seriousness of the burn itself (Table 4). In most regressions, the Axis I disorder variable and the PD variable mutually excluded one
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another, which was related at least in part to the considerable comorbidity. However, with respect to the presence of Any anxiety disorder, where the comorbidity was only about 50%, 12 out of the 23 patients with a PD had an anxiety disorder lifetime (Table 2), and the presence of a PD had an independent effect on the Skin involvement scale score (Table 4). In a next step, we therefore replaced Skin involvement in the regressions with their original subscales. This confirmed that the effect of having a PD was related above all to the subscale Treatment regimens.
Discussion Table 3. Health-related quality of life 12 months after burn in the PD and non-PD groups.
EQ-5D EQ-5D index EQ-VAS SF-36 PCS MCS BSHS-B Function Affect and relations Skin involvement Heat sensitivity Body image Treatment regimens
PDs (n ¼ 20)
No PDs (n ¼ 70)
p (t-test)
0.61 (0.32) 72.4 (20.4)
0.71 (0.26) 70.3 (21.5)
ns ns
43.0 (12.1) 41.1 (15.0)
44.7 (12.3) 44.3 (13.5)
ns ns
3.69 3.13 1.90 1.45 2.26 2.00
(0.35) (0.87) (1.07) (1.27) (1.33) (1.33)
3.58 3.28 2.55 2.18 2.56 3.00
(0.80) (0.76) (0.94) (1.19) (1.22) (0.94)
ns ns 0.011 0.023 ns 50.001
PCS, Physical Component Score; MCS, Mental Component Score. Values are given as mean (SD).
This study identified an above normal prevalence of PD among individuals afflicted by burn. Study participants meeting criteria for a PD had a significantly larger lifetime burden of Axis I disorders compared to participants without a PD. Furthermore, participants with PDs scored significantly lower than those without in the BSHS-B domain skin involvement, and regression analyses confirmed that the effect of having a PD was related above all to the subscale treatment regimens. Importantly, there were no differences identified in the generic HRQoL, the EQ-index and EQ VAS, or in the SF-36 component scores, between those who fulfilled and those who did not fulfill criteria for a PD. The finding of a higher-than-normal prevalence of PDs in a burn population supports findings from previous studies suggesting an overrepresentation of individuals with PDs among burn victims as compared to the general population [2,9,10]. One explanation for such overrepresentation of PDs in burn populations could be that these individuals are at increased risk of trauma in general, or burn in particular. An increased risk of burn
Table 4. Multiple regressions using a stepwise strategy where factors with a p value of 50.10 are in the final model. Independent variables
Dependent variable Lifetime Axis I disorders and covariates Skin involvement
Any personality disorder Length of Stay
Skin involvement
Any affective disorder Length of Stay
Skin involvement
Anxiety disorder Any personality disorder Length of Stay
Heat sensitivity
Any Anxiety disorder Length of Stay
Treatment regimens Any personality disorder Length of Stay Body image
Any Anxiety disorder Length of Stay
Skin involvement
Any substance use disorder Length OF Stay
Axis I disorders within 12 mo. before injury and covariates
Any Axis I disorder 0.227 Any personality disorder 0.467 Length of Stay R2 ¼ 0.26 Any affective disorder 0.276 Any personality disorder 0.477 Length of Stay 2 R ¼ 0.29 Anxiety disorder 0.190 Anxiety disorder 0.178 Any personality disorder 0.441 Length of Stay R2 ¼ 0.28 0.223 Anxiety disorder 0.347 Length of Stay R2 ¼ 0.17 Any Anxiety disorder 0.350 Any personality disorder 0.421 Length of Stay R2 ¼ 0.29 0.179 Any Anxiety disorder 0.343 Length of Stay R2 ¼ 0.15 Any substance use disorder 0.229 Any personality disorder 0.456 Length of Stay R2 ¼ 0.26
0.227 0.467 R2 ¼ 0.26 0.227 0.467 R2 ¼ 0.26 0.238 0.167 0.445 R2 ¼ 0.13 0.242 0.343 R2 ¼ 0.18 0.206 0.298 0.403 R2 ¼ 0.33 0.210 0.348 R2 ¼ 0.16 0.227 0.467 R2 ¼ 0.26
Results are shown as beta-values and adjusted R2 Different Axis I disorder groups and the covariate length of stay were assessed as independent variables together with the variable Any Personality Disorder. Only significant variables remaining in the model are shown.
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exposure in persons with PDs should be further investigated, and could highlight the need for strategies to prevent trauma in these individuals as well as for providing information to healthcare staff about PDs in trauma care [49]. It must be pointed out, however, that knowledge concerning prevalence rates of PDs in general trauma populations is scarce, although it is known that extreme expression of some personality traits as such is related to risk behavior [50,51]. In one study, an increased prevalence of PDs in a traffic-related trauma population was identified [52]. Participants meeting criteria for a PD diagnosis reported lower scores than those without a PD diagnosis in only one aspect of burn-specific health, the BSHS-B domain skin involvement. This should be considered in the context of the present research group’s observations that a history of psychiatric Axis I morbidity, either lifelong or within 12 months prior to burn, is related to worse burn-specific health at 12 months post burn in both the domains skin involvement and affect and relations [25]. The present results suggest that meeting criteria for having a PD is in some respects more closely related to worse burn-specific health than having an Axis I disorder history. The results also show that having a PD and having a history of any anxiety disorder are each independent predictors of outcome regarding Skin involvement. A rational interpretation of these results is that there is a mutually reinforcing effect of Axis I and II disorders on each other with respect to being risk factors for poor perceived health after burns. Reasonably, some aspects of post-burn health are more affected by the Axis I component and others by the Axis II component. Thus our results suggest, for example, that a history of any affective disorder is more related to heat sensitivity than having an Axis II PD. The fact that having a history of any affective disorder was also related to burn-specific health in the BSHS domain affect and relations in a previous study, while having a PD did not have any impact on this variable in the present study, suggests that post-burn affect and relations is above all a function of a previous Axis I history. The domain Skin involvement assesses different aspects of skin health, and the last step in the regressions, using the original three subscales, confirmed that the effect of having a PD was related above all to the subscale Treatment regimens. The items in the subscale predominantly reflect difficulties with compliance and endurance regarding daily skin care and include items such as: ‘‘Taking care of my skin is a bother’’; ‘‘I wish that I didn’t have to do so many things to take care of my burn’’. Since functional impairment is a diagnostic criterion for PD [1], it is understandable that individuals with PDs can encounter problems when they are responsible for everyday self-care and treatment. There can be individual complications during rehabilitation, and in rehabilitation programs, after injury. A diagnosis of an Axis II disorder has previously been identified as predictive of noncompletion [53,54], poor outcome [55] and non-adherence [56] in treatment programs. Daily skin care and treatment over a long period of time after a burn can be demanding, and conceivable difficulties could result in worse actual as well as perceived skin health. This could indicate a need for management of and additional support in post-burn skin care. We could not identify a relationship between the presence of PDs and poorer generic HRQoL. This was contradictory to previous studies identifying impaired quality of life in individuals with PDs compared to control individuals without PDs [3–7,57]. Based on these studies, our hypothesis was that the presence of a PD, with subsequent functional impairment, would influence adaptation and recovery after major burn assessed as HRQoL at one year post burn. Some tentative explanations for the observed lack of such association between PDs and impaired HRQoL could be considered. One interpretation could be that at one year post burn, quite an early time point during rehabilitation after a severe
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burn, the impact of the extent of the burn trauma as such may overshadow other factors that may influence adaptation later on. Another explanation is a smaller-than-expected difference in functional level between study participants with and without PDs. No significant differences were seen in educational level, occupational status or marital status between the groups, variables that might be expected to reflect functional level. One might speculate that these study participants with PDs, identified as part of a burn population, might have a higher functional level compared to individuals with PDs identified among patients seeking psychiatric treatment. It has been shown previously that individuals with PDs do return to work after burn but that they take a longer time to do so compared to individuals without PDs [58]. Another possibility is that the non-PD group also represents a select group of individuals with poorer general health than in the general population, something that could decrease presumed differences between the study groups. Support for such an hypothesis is that the non-PD participants in this study also had a much higher prevalence of Axis I disorders compared to a general population [59,60]. Like every study, this investigation has its methodological limitations. Given the relative rarity of major burn trauma in developed countries, the study population in the present study is relatively small, although representing all patients meeting inclusion criteria in one of the two national burn centers in Sweden during a 10-year period. A larger study population may have had greater power to reveal differences in subgroups. A definite strength is the use of established semi-structured psychiatric interviews to assess both Axis I and II disorders, which allowed for a careful and accurate assessment of diagnoses and psychiatric symptoms both pre and post burn. The use of diagnostic instruments enables comparisons with international population prevalence studies. The instruments, however, do not completely control for recall bias, which is known to underestimate lifetime prevalence. A recent study comparing retrospective versus prospective methods of assessing the lifetime prevalence of psychiatric disorders suggests that the prevalence is only half what it could be in reality [61]. On the other hand, all assessments were made by experienced interviewers, trained in the use of these instruments and with known inter-observer agreement, which strengthens the validity and reliability of the diagnostic instruments. It is possible that the use of a dimensional model of PD instead of a categorical diagnostic model (with a subset of items that must be fulfilled to meet a diagnostic threshold) might have enabled further understanding of the relationship between dysfunctional personality traits and HRQoL. However, this was beyond the scope of the study. In addition, the use of validated generic and disease-specific instruments for assessing HRQoL increased the possibility of capturing different aspects of perceived HRQoL. To conclude, this study shows that individuals with PDs are overrepresented among persons afflicted by burn. Having a PD was associated with impaired burn-specific HRQoL in the skin domain, but not with generic HRQoL, at one year post burn. Specifically, having a PD was linked to the ability to focus on treating the skin well. An implication of this observation is that special rehabilitation efforts including more tailored interventions must be offered to these patients to ensure that the obstacles they perceive to caring for themselves in this respect are eliminated.
Acknowledgements The authors thank all of the former burn patients for participating in the study.
DOI: 10.3109/09638288.2014.933898
Declaration of interest There are no conflicts of interest to declare. This research was supported by the Swedish Research Council and the Swedish Council for Working Life and Social Research.
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