Bums (1991) 17, (6), 478-480
Printed in Great Britain
Psychological consequences of burn injury E. E. Williams and T. A. Griffiths Bangour Village Hospital, Broxbum,
West Lothian, Scotland
The major psychologiculsequebzeexperiencedby patients I year after burn injury were investigated. Data were collectedon a consecutiveseries of adult bum patients, (n= 551, including major demographic and epidemiological characteristics.Parficipunfs (n = 23) completed the Hospital Anxiefy DepressionScale (HADS), the Impact of Event Scale (1E.S)and a questionnaire covering fimcfionnl impairment, visibility of the bum, experienceof pain, etc. Over one-third of the patients (36.4 per cent) were found fo have premorbid charackrisfics which could predisposefhem to injury. Over one-fhird (34.7 per cent) were still experiencingsignificant psychological problems. Anxiefy was most common, followed by posffraumatic sfresssympfoms and depression. ihe visibilify of the bum was found to be a useful factor in the predicfion of psychological outcome (P = 0.001-0.018). No additional variables were found lo increase the signifkunce of prediction. Patients indicuted that prucficaf advice in the fom of staff-led discussions, before or immediufely affer discharge, wouti be fhe most valuable help.
Introduction Although the importance of psychological variables associated with severe bums was recognized in the 1940s (Adler, 1943), the area has only relatively recently become the focus of systematic research. The three main areas in which the psychological aspects of bums have been addressed are: epidemiology, reactions to acute admission to hospital and rehabilitation outcome. The present study focuses on the long-term adjustment of these patients. After discharge bum patients are offered a full and comprehensive follow-up service with regard to their physical health. In contrast, the psychological well-being of these patients is seldom adequately addressed (Wallace and Lees, 1988). The study explores this apparent deficiency in the bum care service by addressing the following questions; What percentage of adult bum patients experience significant psychological problems after discharge7 What type of problems are manifested? Is it possible to predict, before discharge, those patients who will be likely to experience psychological problems after discharge? Do the patients want help and, if so, what type and when do they want it?
Methods The patient sample comprised an unselected consecutive series of adult bum patients. All patients were included regardless of severity of bum, co-morbidity or demographic characteristics. All had been inpatients in the Bum Unit of Bangour General Hospital, West Lothian and were dis0 1991 Butterworth-Heinemann 0305-4179/91/060478-03
charged between September 1988 and June 1989. The study was controlled for temporal differences among patients by contacting the patient as near as possible to I year after first discharge from the unit. This yielded a total of 68 patients; deaths and unavailability of medical records reduced the number to 55. Demographic and epidemiological data were collected from these patients’ medical records to include age, sex, marital status, time in hospital, percentage total body surface area burned, cause of burn, previous medical and psychiatric history. After contacting the patients’ general medical practitioners, eight further patients were excluded for medical reasons. The remaining 47 were contacted and 23 of these agreed to take part in the study. Due to the difference between the number of eligible patients and number of participating patients, both groups were compared to assess possible differences between the groups that might bias the study. The &-squared technique was used to compare the frequencies of variables in each group. There were no significant differences in any of the patient variables measured. The participating group was therefore representative of the total sample. Postal questionnaires were completed by these patients; The Hospital Anxiety Depression Scale (Zigmond and Snaith, 1983), a self-assessment scale designed to detect mood disorders in non-psychiatric populations, and The Impact of Event Scale (Horowitz et al., 1979), designed to measure current subjective distress related to a specific event (post-traumatic stress disorder). This is a self-report scale based on items comprising the commonly reported experiences of intrusion and avoidance. In addition, information concerning mobility, functional impairment, visibility of bum, pain, etc., was gathered in a further series of questions.
Results All results were analysed using the Statistical Package for the Social Sciences (SPSSX). Pre-disposing factors are shown in Table 1. To evaluate the number of patients experiencing significant psychological problems after discharge total scores were calculated for each outcome measure. Frequencies and percentages for each score were computed to produce the ‘caseness figures‘ shown in Table Il. To assess whether any significant relationships existed between patient variables (e.g. TBSA) and outcome measures, Pearson’s Product Moment Correlation Coefficients were computed. Visibility of the injury was the only patient variable found to be significantly related to outcome. To see whether it would be possible to predict, using predischarge variables (e.g. previous medical or psychiatric history), those patients who would be likely to experience problems after discharge, a regression analysis was made
Williams and Griffiths: Psychological Table I. Predisposing
consequences of bum injury
factors in bum-injured
patients (n = 55)
Psychiatric illness Neurological illness (including epilepsy) Alcohol intoxication Physical illness (including multiple sclerosis) Senile dementia Total
HADS Depression (HADD)
Non-cases Possible cases Definite cases Total cases
20 2 1 3
87 8.7 4.3 13
HADS Anxiety (HADA)
Non-cases Possible cases Definite cases Total cases
15 5 3 8
65.2 21.7 13.0 34.7
Table III. Variables associated with prediction stepwise multiple regression analysis Dependent variable HADD’ HADA” IESI’ IESA’ I EST’
0.576 0.332 V No variables entered/removed 0.239 0.488 V 0.627 0.393 V 0.326 0.571 V
of outcome, using
% of var. explained
0.004 33 for this block’ 0.018 24 0.001 39 0.005 33
* As in Table Il. ‘No variables were found to predict HADA usefully. V, Extent of visibility of burn.
Table IV. Patient’s (n = 23)
Questions What type of help would you have found most useful? a. Practical advice b. Information c. Emotional support Would you be interested in any of the following? a. Staff-led talks b. Self-help group c. Newsletter d. Individual help When would be the best time for any of the above? a. Before discharge b. After discharge c. Six months after discharge
Percentage of respondents
62 17 17
26 22 22 9
using all variables of possible prognostic value. Stepwise multiple regression showed that one variable, visibility of bum, was the most useful in the prediction of outcome. No further variables were found to increase the significance of prediction when combined with visibility (TableZIZ). Patients were asked to indicate what type and form of help they would like and the timing of such help (Wallace and Lees, 1988). The results are presented in Table IV.
Table II. Frequency and percentage of patients having significant psychological problems postdischarge (n = 23) Outcome measures
Several common characteristics were found among the population of the Bum Unit. Over one-third of all eligible patients (37.4 per cent) had evidence of a physical, psychiatric or alcohol-related problem which could predispose the person to injury. The higher percentage of predisposed patients (50 per cent) found by MacArthur and Moore (1975) might be due to the wider inclusion criteria used. Predisposition in their study was used to denote ‘any factor which decreases the persons ability to respond appropriately’. An extensive study of 585 bum patients (Dark0 et al., 1986) identified 33.1 per cent having active symptomatic and disabling diseases or psychiatric illnesses. These findings match those of the present study. The incidence of premorbid psychiatric disorders among adult bum patients has been investigated in several studies. Incidence figures vary between 0.4 per cent (Maisels and Gosh, 1969) and 38 per cent (Andreasen et al., 1971). The present study found an incidence of 9.1 per cent using patients’ medical records only. A retrospective chart review of 115 patients also found psychiatric disorders in 9 per cent of bum patients (MacArthur and Moore, 1975). Higher incidence rates have been found using direct patient interviews (Rockwell et al., 1988). The high prebum psychiatric morbidity found in previous studies has led to the realization that the provision of psychiatric services is an important constituent of bum care (Noyes et al., 1979). More specific and preventive advice might also be beneficial in the light of such findings, e.g. people with alcohol-related problems may be usefully targetted given the high proportion of patients burned while intoxicated (almost 10 per cent). The study found that up to 34.7 per cent of patients were experiencing significant problems 1 year after discharge from the Bums Unit. The most common problem was anxiety, which affected almost one-third of patients. Similar findings have been reported elsewhere (Wallace and Lees, 1988). Post-traumatic stress disorder as measured by the Impact of Event scale, found that 17.4 per cent of patients experienced significant avoidance symptoms and 13 per cent significant intrusion symptoms 1 years after discharge. It is commonly reported that the majority of post-traumatic stress symptoms decline 6 months after the traumatic event (Silverman, 1986). The symptoms experienced by patients in the present study could therefore be described as chronic post-traumatic stress. Unfortunately, no measure of the onset of the symptoms was available. It is therefore not known whether the symptoms were delayed, i.e. started several months after the traumatic event, or whether they had been present since the bum occurred. Factors which might be related to outcome, such as severity, cause and visibility of the bum as well as patient variables such as age, sex and premorbid psychopathology were analysed to see if there was any correlation between these variables and subsequent outcome. Visibility of bum was the only variable which usefully contributed to the
480 prediction of psychological outcome. The addition of further variables did not increase the predictive power. Approximately one-third of the total variance was explained by the visibility variable for the outcome measures of depression (HADS Depression Scale) and posttraumatic stress (IES). The highest predictor was of the IES Avoidance Scale where visibility accounted for 39 per cent of the variance (P= 0.001). Research findings concerning the importance of bum visibility or disfigurement with regard to outcome have been contradictory. One study (Chang and Herzog, 1976) found that burns of the hands and face. predisposed patients to depression and that patients with physical deformities took longer to adapt and return to work compared to those with no visible deformities. Another study (White, 1982) found no correlation between the location of bums on the body and occurrence of psychiatric disorder. A study (Knudson-Cooper, 1981) of 89 young adults who suffered severe (over 10 per cent) bums in childhood resulting in visible disfigurement found that the majority of patients made a good adjustment as measured by social integration, emotional adjustment and self-esteem. The study concludes that victims of severe burns adjust well to the injury and that outcome is not related to physical variables such as severity or visibility of the bum. However, a body of literature on the social and interpersonal effects of disfigurement has found significant influences on human behaviour. It has been proposed (Goffman, 1963) that society assigns to a person with a peculiar appearance the role of someone ‘quite thoroughly bad, dangerous or weak’. Bull (1979) from his experience in preoperative assessments of patients undergoing craniofacial surgery found that facially disfigured people receive ‘avoidance and negative behavioural reactions from the public’. In a culture where physical attractiveness is highly valued, visible disfigurement will negatively affect peoples’ reactions to the disfigured person. Whether a person adjusts to these reactions or not may depend on such factors as amount of social and family support, personal reactions to the injury and coping strategies. In the present study, bums of both the hands and/or face were considered in the visibility scale. The two patients with bums to the hands only did not experience any significant psychological problems. Four of the seven facial bums only group experienced significant problems and none of the mixed group experienced problems, suggesting that facial disfigurement may be a better predictor of psychological outcome than visibility. It was also found that the same number of patients with visible and not visible bums were concerned about their appearance and the same number were concerned about their physical well-being. One possible reason for this finding is that those patients with non-visible bums who were concerned with their appearance had bums to other ‘culturally valued areas, i.e. those of sexual significance - buttocks, genitalia and anterior trunk (females). These patients also noted difficulties with sexual relationships and with depression. A surprising and incidental finding of the present study was the positive impact that the injury experience had on some patients. Three patients described feeling lucky to be alive and of now trying to make the most of their lives. A major factor in this positive attitude towards the experience appeared to be the life-threatening nature of the injury either directly or vicariously. The patients’ needs survey found that the majority of patients would have found practical advice most useful (52 per cent) compared to 17 per cent preferring information and a further 17 per cent indicating the usefulness of emotional support. The most popular form of help was
Bums (1991) Vol. 17/No. 6 staff-led talks (26 per cent). The best time for intervention was seen as before or immediately after discharge. Patients’ concerns were most commonly about their appearance/ scarring (30 per cent) and physical problems (17 per cent). It appears that small pre- or postdischarge discussion groups may be of valuein helping patients to prepare for discharge. The aim of these would be to provide practical advice and to anticipate problems, for example in dealing with disfigurement, and to rehearse possible ways of coping with these. In addition, the production of a booklet containing, for example, practical advice, information and coping strategies for a variety of possible problems particularly covering the most common difficulties, anxiety and post-traumatic stress would be useful. The attachment of a psychologist to the Bum Unit team could provide a focus for the development of such services and thereby reduce the significant proportion of patients who are still experiencing psychological problems 1 year after discharge.
Acknowledgements We would like to thank the staff and patients in the Bums Unit, Bangour General Hospital for their help and Mrs Christine McCabe for preparing the manuscript.
References Adler A. (1943) Neuropsychiatric complications in victims of Boston’s Coconut Grove disaster. JAMA 123,1098. Andreasen N. J. C., Noms A. S. and Hartford C. E. (1971) Incidence of long-term psychiatric complications in severely burned adults. Ann. Surg. 174, 785. Bull R. (1979) The psychological significance of facial disfigurement. In: Wilson G. and Cook M. (eds.), Love and Attraction. London: Academic. Chang F. C. and Herzog B. (1976) A follow-up study of physical and psychological disability. Ann. Surg. 183,34. Darko D. F., Wachtel T. L., Ward, H. W. et al. (1986) Analysis of 585 bum patients hospitalised over a 6-year period. Btrrm 12, 395. Goffinan E. (1963) Stigma. London: Penguin. Horowitz M., Wilner N. and Alvarez W. (1979) Impact of event scale: a measure of subjective stress. Psychmom. Med. 41, 209. Knudson-Cooper M. S. (1981) Adjustment to visible stigma: the case of the severely burned. Sot. Sci. Med. 15B,31. MacArthur J. D. and Moore F. D. (1975) Epidemidogy of bums; the bum-prone patient. JAIwfA 231,259. Maisels D. 0. and Ghosh J. (1968) Predisposing causes of bums in adults. Practitioner 20'1, 767. Noyes R., Frye S. J., Slymen D. J. et al. (1979) Stressful life events and bum injuries. J. Truurnu 19, 141. Rockwell E., Dimsdale J. E., Carroll W. et al. (1988) Pre-existing psychiatric disorders in bum patients. J. Burn Cure Rehubil. 9,83. Silverman J. J. (1986) Post-traumatic stress disorder. In: Peterson L. G. and O’Shanick (eds), Advances in Psychmmutic Medicine, vol. 16,p. 115. Wallace L. M. and Lees J. (1988) A psychological follow-up study of adult patients discharged from a British bum unit. Bwns 14, 39. White A. C. (1982) Psychiatric study of patients with severe bum injuries. Br. Med. 1. 284,465. Zigmond A. S. and Snaith R. P. (1983) The hospital anxiety and depression scale. Actu Psychiutr. Scund. 67,361. Paper accepted 23 July 1991. Correqmndence shozdd be uddressed to: Mrs T. A. Griffiths, Psychology Department, Bangour Village Hospital Broxbum, West Lothian EH52 6LW, Scotland, UK.