Burn injury causes severe acute pain that patients describe as excruciating, even with opioid analgesics. High levels of pain-related anxiety often increase acute pain severity. Acute pain symptoms are ubiquitous and persistent after major thermal burn injury. ^, Burn pain varies significantly across patients and fluctuates highly over time, irrespective of the injury severity.

The most recent definition of pain from the International Association for the Study of Pain (IASP) is: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” Pain intensity and duration fluctuate as a result of the interplay of peripheral nociceptor and inflammatory receptors as well as central nervous system (CNS) processing of nociceptive, inflammatory, and neuropathic pain. Acute pain results from the damaged skin, which activates peripheral nociceptors and forwards pain signals to a subset of primary afferent sensory neurons that are mainly Aδ and C fibers. From there, the excitatory nociceptive pain signaling is conveyed to the spinal dorsal horn, where it activates nociceptive projection neurons in lamina I. This activation occurs directly and indirectly via a complex neural circuit of excitatory and inhibitory interneurons through the spinothalamic tract to the CNS centers for pain processing (i.e., thalamus, somatosensory cortex). ^,

Many have wondered:

“What could possibly be the benefit of having a nervous system evolve the ability to generate such an intense level of pain, that is, what is the function of pain?”

Pain researchers have proposed an evolutionary perspective whereby organisms developed various defense systems, including acute pain, that have differentially supported survival and reproduction. For example, acute nociceptive pain is a crucial defense system that enables the detection of danger signals (e.g., pain, hopefully before harm ensues) that threaten homeostasis and survival, and, as such, this protective function alerts the organism and, if required, this triggers the “alarm” response to enable the living organism to prevent or to minimize tissue damage by initiating the fight-flight-freeze response. Given the extent and severity of acute burn pain, and despite decades of research into its neurophysiology, anatomy, and pharmacologic properties, its management remains one of the significant challenges during the acute and subacute periods of wound healing.

Many activities are associated with intensified burn pain during acute burn treatment, and patients will benefit from specific assessments to develop individualized pain and anxiety management plans. Assessment should precede and inform each pain and anxiety medication prescription. Each administration needs reevaluation to determine whether optimum pain and anxiety management have been achieved. In addition to wound care and the pain associated with open wounds, patients often also report intense pain associated with tasks prescribed by physiotherapy, such as standing, walking, and climbing stairs, performing a range of motion, and activities of daily living such as eating and toileting. Just as with wound care–related pain management, these therapeutic activities often warrant individualized and valid assessment to inform healthcare providers about the need for pain medication and the patient’s response to the analgesics. Such reassessment after medications have had time to work allows the provider to adjust the pain protocol if the pain is under- or overtreated. Information about aggravating (e.g., anger, anxiety, addiction) and alleviating factors (e.g., active distraction, problem solving, frequency-specified and time-limited breaks) enable providers to tailor pain management. Reassessments may also identify easily adjusted factors that can help ease the pain, such as changing dressings and adequately managing neuropathic pain.

Daily wound care sessions are required to prevent infection and promote healing. Unfortunately, wound cleaning can elicit intermittently repeated experiences of undercontrolled and unpredictable pain severity and trauma reminders.

These two characteristics of pain and distress are experienced and perceived as harmful-painful and fearful-threatening. Such qualities are classic triggers of the emergency threat response and are likely to trigger memories and emotions like those experienced during the burn injury event. These treatment-related, unpredictable pain events of great intensity can elicit anxious anticipation, fear, worry, and sleep disturbances and increase apprehension about subsequent sessions. ^{, , ,} Brief episodes when the pain intensifies are referred to as breakthrough pain; they are typically unpredictable and usually occur while the patient is resting and there is no apparent external cause. Chronic pain refers to pain that is still present 3 months after wounds have healed. One study of patients admitted to a large burn center found that of those who had undergone skin grafting when assessed at 6 weeks, 28% reported continued moderate to severe acute pain in the grafted areas; when reassessed at 6 months, 21% reported the same.

Self-reported pain severity for a specified period (e.g., “past 10 minutes,” “past 7 days”) is the preferred strategy of pain measurement with adults who can communicate verbally. Validated self-report instruments include the Visual Analogue Thermometer/Scale and verbal or graphic Numeric Rating Scale, which are well validated, frequently used, and easily administered. ^, Other validated scales exist and may be selected based on patient characteristics (e.g., alert and oriented, obtunded, delusional) or the intended use of the data (e.g., outcome research, repeated measures to document pain control). The Burn-Specific Pain Anxiety Scale and the McGill Pain Questionnaire–Short Form are often used in burn research and tap into diverse aspects of pain over varying lengths of time. Behavior observation measures, such as the Critical Care Pain Observation Tool, are recommended for patients unable to verbalize because they systematically guide observation of pain signals using a structured assessment with operationally defined pain criteria (e.g., facial expression). In young children, validated behavioral observation scales include the Comfort-B and the FLACC (Face, Legs, Activity, Cry, Consolability).

As with wound care–related pain management, these therapy activities often warrant individualized and valid assessment to inform healthcare providers about the need for pain medication and the patient’s response to the analgesics. After drugs have had time to work, such reassessment allows the provider to adjust the pain protocol if the pain is undertreated. Information about aggravating (e.g., anger, anxiety, addiction) and alleviating factors (e.g., active distraction, problem solving, frequency-specified and time-limited breaks) enables appropriate management. Such reassessments also may discover easily adjusted factors that can help ease the pain and add to its effective management (e.g., a tight dressing) and the nature of the pain (e.g., “pins and needles” may indicate neuropathic pain).

Many psychological, behavioral, and social factors can increase pain’s severity, volatility, or duration. The combination of preexisting psychological problems (e.g., anxiety, depression), loss of behavioral and emotional control, and personality disorder symptoms is frequently observed in patients with burns and can exacerbate pain. Patients with preexisting psychopathology often display dysfunctional coping strategies that can exacerbate pain and anxiety and negatively affect relationships with healthcare providers. The constant background pain and the diverse activities that increase nociceptive inflammatory pain have been summed up in the term “exhausting pain.”

Two additional means of coping with severe pain are commonly observed in the burn unit. Yet, both make matters worse: catastrophizing and using opiates for purposes other than reducing pain. Catastrophizing about the event or its outcome is a dysfunctional cognitive means of anticipating or responding to stressful events and has been confirmed to worsen the pain experience. Catastrophizing is defined as unfavorable, repetitive thinking and the tendency to magnify problems and may relate to the subjective perception of ongoing threat or a magnification of the threat value of pain. ^, For example, one study elicited the use of catastrophizing and other means of coping with experimental pain applied to produce spontaneously employed coping methods (i.e., participants had no prior training or instructions). The aim was to evaluate the detrimental or beneficial effects of the deployed coping methods. The findings indicated that the self-generated coping methods (i.e., catastrophizing, distraction, hoping, ignoring the pain) were associated with more incredible perceived pain, whereas catastrophizing also reduced pain tolerance.

Individuals who sustain burn injuries often have a history of substance use or misuse or a history of opiate use that requires opioid replacement therapy. For these individuals, a complete and accurate history of current and recent past drug and alcohol use history must be assessed to prevent withdrawal and pain-related counterproductive behavior. Managing burn pain responsibly involves not only creating or reinstating dependence or addiction in vulnerable individuals but also achieving adequate analgesia.

The need to balance adequate treatment without creating dependency has risen in value in recent years because of the aversive impact on society caused by the opioid epidemic. One study found it is possible to address pain management while succeeding at reducing opioid usage without compromising either. Pregroups and postgroups rated their pain severity, which was contrasted, and results indicated no significant difference in average normalized pain scores. Another study sought to reduce the use of opioids. Still, the investigators found that continued opioid therapy was necessary as the patients transitioned through sequential painful stages of wound healing and outpatient rehabilitation. They derived a successful means of reducing opioids, such that 85.7% of patients were prescribed opiates at discharge. However, by outpatient day 14, 90% of the 84.3% still seen in the clinic were no longer taking opioids.

CBT involves using cognitive and behavioral techniques to treat pain and is indicated when the target is to end catastrophizing thoughts and facilitate reinterpretation of pain signals. One example of a cognitive technique involves making the procedure more predictable (e.g., by describing the next task, its duration, and likely pain) to reduce the need for guessing and worrying about it. This can also be enhanced by encouraging patient participation in self-care and offering opportunities for increased autonomy, such as encouraging patients to remove their own dressings. Based on the empirically derived theory of Foa et al., reducing uncontrollability and unpredictability may limit the aversive nature of an event. Using experimental pain (cold pressor test) to elicit spontaneously used coping methods (i.e., no prior training or instructions) to evaluate their efficacious or detrimental effect, those coping methods that were associated with greater pain tolerance included self-instructions, ignoring the pain, reinterpreting the pain, faith and praying, while catastrophizing reduced pain tolerance.

Hypnosis is defined as “a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestions.” ^, Hypnosis is most effective when patients experience high pain levels; when in the posthypnotic state, many affective components of pain are targeted. ^, However, hypnosis depends on personal factors such as sensitivity to suggestion, coping style, culture, pain history, and memory. It requires a personalized approach. ^, In children, a randomized controlled trial indicated no significant effect on pain, but it effectively reduced preprocedural anxiety and heart rate. A similar effect on pain-related pressure was found in a blinded, randomized placebo-controlled study in adult male burn survivors.

Two crucial, adaptive, and frequently used coping strategies include distraction and interaction with healthcare providers and other patients. Distraction diverts the attention away from pain and includes interventions such as VR, music therapy, video games, and movies. VR achieves distraction by immersing patients in an interactive virtual environment. The attention drawn to the virtual environment is not available for the perception of pain, affecting the pain experience positively. A meta-analysis of randomized trials showed that VR reduced pain intensity and time spent thinking about pain. A study that compared VR with still-nature pictures did not show superior pain control. Yet, VR resulted in more positive affect, likely contributing to more pleasant memories, reduced anticipatory anxiety, and reduced aversive conditioning. Some evidence suggests that music therapy may effectively decrease pain and distress and improve relaxation. Inhaled aromatherapy can ease pain after a dressing change, and aromatherapy massage positively affects anxiety. Breathing exercise techniques have also been reported to decrease pain and anxiety associated with burn treatment effectively. However, a meta-analysis could not substantiate superior effects on pain. ^,

Other nonpharmacologic interventions that focus on environmental factors, such as where stressful and painful treatment-related tasks occur in the burn center and who is present during the activity, can facilitate comfort and reduce pain. For example, parent presence during dressing changes for pediatric patients enables adaptive coping for the child and parents. ^, Experimental research shows that attachment figures can reduce pain by releasing endorphins. For adult patients, offering the opportunity to speak by phone with a support person for 5 minutes before and after wound care may be helpful. Furthermore, establishing working relationships with nursing staff and behavioral healthcare providers may enhance the patient’s sense of control via trust and compassionate care—the latter refers to a respectful relationship, communication, and provision of competent care. Information itself can reduce anxious apprehension before and during procedures. For example, explaining the purpose of each procedure may help improve patients’ tolerance by increasing predictability or building rapport with the provider. This was illustrated by the finding that the choice of words used to explain procedures lessened anxiety and reduced the expectancy of extreme pain (e.g., stating “Some people feel a poke; others feel a prick or a tingle—you tell me what you feel” rather than “This is going to hurt now”).

Careful selection of the physical location and environment for painful procedures may also improve distress management. When painful activities are repeated in a specific location (e.g., a hospital bed), that location becomes associated with aversive thoughts, feelings, and memories. Conducting wound care and other painful procedures in areas that are physically separate from the patients’ sleeping and visiting areas may help prevent patients from associating their sleeping and resting areas with pain and distress. Keeping treatment and resting areas separate will help them feel more relaxed while sleeping, resting, and visiting. Similarly, this will provide more predictability over when to plan and prepare for the challenges of the wound care and physiotherapy areas.

“Pain can be described as a complex multidimensional experience that includes sensory-discriminative, affective-motivational, and cognitive-evaluative components.” To be classified as chronic, pain must persist at least 3 months after the acute injury has healed. There are two categories of chronic pain in the new IASP classification system that are most relevant to burn injuries. The first category, which has two alternative etiologies, is “Chronic Postsurgical Pain and Chronic Posttraumatic Pain.” These etiologies of chronic pain develop or increase in intensity after a controlled, health-related surgical procedure (postsurgical pain) or an accidental or intentional tissue injury (posttrauma pain). The second category of chronic pain, also commonly observed after burn injury, is “Chronic Neuropathic Pain.” This is defined as “chronic pain caused by a lesion or disease of the somatosensory nervous system; it may be spontaneous or evoked” and may present as an increased response to a painful stimulus (i.e., hyperalgesia) or a painful response to a normally nonpainful stimulus (i.e., allodynia).

Chronic postburn pain is not simply the continuation of acute nociceptive pain; the correlation between acute and chronic pain is minimal. ^, Chronic pain is “a maladaptive nervous system function.” Almost one-half of burn survivors report experiencing chronic pain that persists far longer than the minimum criteria of 3 months after wound closure. ^, Burn-related neuropathic pain typically persists for 2 years on average after the initial tissue damage has healed, and chronic pain affects approximately 15% to 20% at 12 months postburn. ^, Interestingly, these prevalence rates are very similar to the all-cause chronic pain prevalence rate of 20% within the worldwide human population.

The development of chronic neuropathic pain after burn injury is associated with experiencing more intense acute pain, sustaining a more extensive total body surface area (TBSA) burn, and requiring dermal autograft surgery for wound closure. ^, Burn survivors describe chronic neuropathic burn pain as stabbing, itching, burning, electric shock, pins and needles, and shooting sensations. ^{, ,} Among those who have developed chronic burn pain, many survivors report that changes in ambient temperature, dependent position of the painful area, light touch, and weight-bearing activities exacerbate it. On the other hand, chronic burn pain is reported by many to be alleviated by rest, massage, compression garment use, and elevation (e.g., of the affected limb).

In addition to physiologic and biologic contributors to chronic pain, psychological factors increase the risk for neuropathic pain, including symptoms of anxiety, depression, and posttraumatic stress, as well as poor health behavior habits such as nicotine use and substance use. ^, Notably, chronic burn pain commonly cooccurs with itch (pruritus), ^, which is another distressing condition that impairs return to those family, work, and community preinjury roles.

The pain system can malfunction under pathologic conditions, including damage to the nervous system that results from many diseases, trauma, and burns. These conditions often cause debilitating chronic neuropathic pain, with symptoms that include spontaneous pain, hyperalgesia, and allodynia, and these may persist for a prolonged period after the acute tissue damage has healed. Changes in excitatory and inhibitory interneurons in lamina II or III may induce these changes, partly contributing to the development of pain hypersensitivity.

Psychological models of chronic pain and its persistence also have a long history. For example, chronic pain becomes more persistent when patients conceptualize normal sensations as being related to pain in a manner skewed by cognitive-processing biases (i.e., attentional biases, interpretation biases, and attentional control). Cognitive biases are a pivotal means of misinterpreting or overinterpreting normal body sensations to a degree that fosters the development and maintenance of chronic pain. These biases skew attention toward such sensations, interpret the sensations more pathologically, and remain vigilant for signs of worsening pain. Investigators recently found direct evidence for this bias effect in that pain intensity was significantly correlated with interpretation biases and that, at follow-up, participants with high pain intensity demonstrated a substantially greater interpretation bias toward pain relative to those with low pain intensity. Findings also suggested that attentional biases toward pain are ubiquitous among those with chronic pain. Still, for people whose pain is rated as moderate to severe, interpretation biases may be more critical to understanding their experience. Somewhat surprisingly, a cohort of burn survivors demonstrated a predisposition to detect disfigured faces better and to have a more significant bias toward labeling those with facial disfigurement as “bad.”

The impact of chronic pain on quality of life is demonstrated in several studies. Higher pain levels are associated with poorer physical functioning, psychosocial impairment, a less than full return to community activities and work roles, and sleep disturbance. ^{, , ,} These impairments clearly illustrate the urgency in preventing or moderating through rehabilitation and other means during the acute injury phase and throughout wound healing and then monitoring in later stages of postburn recovery. In addition, several common secondary conditions may become associated with pain and posttraumatic stress disorder (PTSD), including fatigue, pruritus, and hypertrophic scars. The most relevant pain complications appear to be hypertrophic scars, contractures, and chronic neuropathic pain. ^, Even after scar maturation, the affected tissue is a source of conditioned, multidimensional, trauma-related cues (e.g., neuropathic pain, somatosensory dysfunction, aversive body image). There is a growing body of evidence connecting various postburn secondary complications that each appears to have an underlying neurologic dysfunction in common. These include those caused by impaired CNS (e.g., memory deficits, amnesia, delirium), psychopathology (e.g., depression, social anxiety, PTSD), and peripheral neurologic dysfunction (e.g., peripheral neuropathy, chronic neuropathic pain and pruritus, and chronic fatigue). ^,

Survivors of burn injuries report experiencing excruciating acute pain despite receiving opioid analgesics, which typically diminishes with wound healing. ^{, , ,} Severe burn pain also occurs intermittently in acute and daily wound care. During rehabilitation sessions, these occasions of pain are also primed for the recurrence of trauma memories and pain sensations reminiscent of the injury event. Acute inflammatory and nociceptive pain and trauma-related threat of injury or death are primary reinforcers. That is, they motivate the emergency response, a primitive, automatic, and intense defensive response to fight-flight-freeze to escape, avoid the pain and threat, and seek safety. ^, Subsequently, for example, during wound care at the burn center, if pain and trauma reminders occur, then the compound stimulus bond strengthens (e.g., injury event = wound care pain) and peripheral nociception is sensitized. ^, More frequent pairing of acute pain with trauma reminders throughout the wound healing period has been associated with initiating the transition from acute to chronic pain and from critical to chronic PTSD (for description of PTSD criteria, see Acute and Chronic PTSD , later). ^,

Chronic pain is not simply the continuation of acute nociceptive pain but “a maladaptive nervous system function.” Almost one-quarter to one-half of burn survivors report experiencing chronic pain that persists far longer than 3 months after wound closure that is required to meet criteria for chronic pain. ^{, ,} Ectopic activity in, for example, nerve-end neuroma, compressed nerves or nerve roots, dorsal root ganglia, and the thalamus may underlie the spontaneous pain. Neuropathic pain typically persists for 2 years on average after the overt tissue damage has healed, but patient reports suggest that it may continue beyond 10 years. Patients have reported they experience neuropathic pain as burning, pricking, and squeezing and that it may include evoked pain, especially to light touch and cold. ^,

Acute pain is prevalent after burn injury and can often transition to chronic pain. Using a mouse model of second-degree burn, an experiment subjected the mice to preexisting stress (10 days of repeated mild foot shock) to determine if it influences pain sensitivity after a subsequent burn injury (burn foot vs. sham burn). As hypothesized, the mice that underwent burn injury experienced thermal hypersensitivity and mechanical allodynia in the ipsilateral nonburned paw. Mice stressed before the burn or sham took much longer to recover their hind paw mechanical thresholds to baseline than nonstressed mice in both burn and nonburn groups. Thus stress exposure before burn injury affects mechanical and thermal points and may be a relevant risk factor for transitioning from acute to chronic pain.

Factors affecting the intensity of burn pain include cognition (e.g., unpredictability, catastrophizing, distraction), coping (e.g., self-efficacy, expectations), predispositions (e.g., neuroticism, depression), context (e.g., past pain experiences, relations with staff), complications (e.g., infection), treatments (rehabilitation, surgery/donor sites), and opiate analgesia (adequate coverage, tolerance). ^, A recent study illustrated that even when adequate pain management is attained, it is not often maintained at the desired state. Pain management was rated as acceptable by a relatively high percentage. However, 59% of burn survivors were still unsatisfactory, and even less satisfying was the deficient 25% of wound care providers who rated pain management as acceptable. Acute and chronic burn pain are complex sources of distress and impede the return to typical activities and roles at home, community, and work. ^,

PTSD is characterized by criterion A and four symptom clusters: intrusion and reexperiencing (unwanted intrusive memories, nightmares of the trauma), avoidance and numbing (trauma-related cues, context, people), negative mood (trauma-related depression, anhedonia, numbing) and impaired cognition (poor concentration), and hyperarousal (poor sleep, startle, hypervigilance and irritability, aggression, arousal-related self-destructive behavior). Both aspects of PTSD criterion A involve burn injury, including burn trauma (threat of harm or death) and burn injury tissue damage and pain (actual damage, threat of further harm or death). Of note, both burn trauma and burn pain can trigger the fight-flight-freeze response (i.e., direct or indirect exposure to threatened or serious injury or death), and both are intensely experienced in many burn injury incidents. Importantly, the well-validated fear learning model of PTSD holds that when a traumatic injury event involves both intense pain and life-threatening fear, both pain and traumatic threats are primary reinforcers (i.e., unconditioned stimuli, meaning they both elicit the unconditioned stress response) that condition quickly to the conditioned stimuli (CS) and the conditioned response (CR). ^{, ,} Burn injuries, when viewed in terms of this formulation, often create a compound aversive stimulus that incorporates both pain and trauma owing to their simultaneous acquisition and mutual reinforcement during the injury event.

In addition to acute and chronic pain, PTSD is a highly prevalent consequence of trauma and burn injuries. ^, There is a strong tendency for the rates of PTSD and chronic pain to covary systematically. For example, among a cohort of patients with comorbid pain and PTSD, the average PTSD symptom severity was higher relative to patients with PTSD but without chronic pain. ^, Additionally, traumatic injury survivors with PTSD reported a higher incidence of chronic pain relative to trauma survivors without PTSD. Also, chronic pain patients were nearly four times more likely to manifest PTSD than nonchronic pain patients. Similarly, in an outpatient rehabilitation cohort of patients with burns referred to “get support for distress,” 75% met criteria for PTSD; of these, 39.4% had clinically significant symptom severity and 35.6% had subclinical symptom severity. It is important to note that PTSD and chronic pain share several essential features (e.g., they cooccur during the index injury event, and both initiate the fight-flight-freeze response).

Research has consistently shown that the severity of acute PTSD symptoms predicts later pain severity ^, and that acute pain predicts subsequent PTSD severity and diagnosis. ^, In addition, symptoms of PTSD and misery have been proposed to maintain each other mutually, and research evidence provides some support for this interaction. Further, survivors of traumatic injury with PTSD, compared with survivors without PTSD, have consistently reported more significant pain hypersensitivity over time, and the hypersensitivity has been associated with increased avoidance behavior. ^, Although many studies have confirmed the reciprocal relations between pain and PTSD, not all studies examining this question confirmed the hypothesis. For example, a study was conducted to determine whether a reciprocal relationship between pain and PTSD exists in burn survivors as manifested by PTSD symptom clusters predicting pain interference, and vice versa. Results indicated that hyperarousal and emotional numbing PTSD symptom clusters were each significantly associated with pain interference, even when statistically controlling for pain intensity, thus indicating that although pain and PTSD are associated, there was no evidence of reciprocity.

A common cognitive error observed among burn survivors in response to pain and trauma is catastrophizing (i.e., expecting the worst possible outcome). However, a systematic review of cross-lagged studies showed that, although pain and PTSD symptoms were related, there was inconclusive evidence of catastrophizing as a mediator. Results from two studies conducted after the Ravn et al. review showed, first, that catastrophizing mediated the relationship between acute and chronic PTSD symptoms and later chronic pain, and second, pain catastrophizing fully mediated the relationship of acute PTSD with pain severity and with pain interference above and beyond the influence of depressive symptoms. Therefore screening for catastrophizing, acute pain, and PTSD symptoms is recommended to identify persons at risk for chronic PTSD and pain.

There are reasons, in addition to catastrophizing, which lead to PTSD symptom chronicity. A critical line of research has investigated how well participants with and without PTSD performed on an extinction task for cues that are no longer a threat, the ability to recognize safety signals. The hope was that both tasks might lead to a means of enhancing resilience. The cued fear conditioning experiment results indicated that patients with PTSD show a heightened return of fear in neural and peripheral measures, which is contrary to the expected lessening of fear return. In addition, self-reported arousal was higher in the PTSD participants in response to danger signals (CS+) and safety signals (CS-) cues. At the same time, the participants without PTSD appeared to show normal responses to the return of fear and both the danger (CS+) and the safety (CS-) signals. These findings suggest that failing to maintain extinction and accurately recognize safety signals might contribute to PTSD symptom maintenance.

Fear is an adaptive emotion, like the survival benefit of pain, that protects an organism against potential dangers. It is often studied using classical conditioning paradigms where a conditioned stimulus is paired with an aversive unconditioned stimulus to induce a threat response. Latent inhibition (LI) is a paradigm in which a neutral cue is repeatedly presented without any aversive associations. The subsequent pairing of this preexposed cue with an aversive stimulus typically leads to reduced expression of a conditioned fear/threat response to the aversive stimulus (i.e., the aversive stimulus becomes less distressing to the subject). It has been suggested that LI could be useful for enhancing resilience, especially for individuals with psychiatric disorders characterized by exaggerated fear responses and impaired emotion regulation.

Research has consistently demonstrated that acute PTSD symptoms are associated with concurrent and prospective pain severity. ^, Reciprocally, research has also shown that acute pain severity is significantly related to both concurrent and prospective PTSD. ^{, ,} Furthermore, survivors of traumatic injury with PTSD have consistently reported more significant pain hypersensitivity over time compared with survivors without PTSD. ^, Interestingly, one early study evaluated longitudinal causal relations between pain and PTSD symptom clusters; the results indicated that acute, in-hospital pain was associated with 12-month pain as mediated by 3-month hyperarousal symptoms and the association of baseline hyperarousal and reexperiencing with 12-month hyperarousal, and reexperiencing was mediated by pain at 3 months.

Recently, pain-PTSD reciprocity was observed among burn survivors between discharge assessment and the 3-month follow-up. However, the study did not find evidence of reciprocal relations of pain and PTSD between 3- and 6-month follow-ups. Pain-PTSD reciprocity was observed during the acute pain phase but not after transitioning from acute to chronic pain. A multicenter group of clinical researchers conducted a study to determine whether a similar synergistic relationship exists between PTSD symptom clusters predicting pain interference. Results indicated that the PTSD symptom clusters hyperarousal and emotional numbing were each significantly associated with pain interference, even when statistically controlling for pain intensity. These findings suggest that when either PTSD or chronic pain is the presenting problem, targeted assessment and choice of treatments are more complicated but also more necessary.

Recent advances have discerned the role of immune factors in developing and maintaining chronic pain. For instance, an extensive body of research has confirmed the central involvement of microglia in the “synaptic remodeling, connectivity, and network function that underlie chronic pain.” Furthermore, reviewers have recently summarized the empiric evidence for the mechanism of action of microglia and note that microglia “have active roles in brain regions important for the emotional and memory-related aspects of chronic pain” and that chronic pain is associated with long-term plasticity of nociceptive pathways in the CNS. ^, Decades of research have also affirmed that the role of astrocytes in the pathogenesis of chronic pain is just as important as that of microglia. To paraphrase, when astrocytes respond to injury, they shift in form and function, and this affects their releasing cytokines and gliotransmitters, which are then involved in persistent changes in central nociceptive activity, and thus astrocyte-neuron metabolic coupling functions in support of the pathologic changes in central nociceptive activity. Elucidating the roles and actions of microglia in establishing chronic pain and astrocytes for maintaining persistent chronic pain will hopefully lead to new pharmacologic approaches to prevention or treatment.

The single prolonged stress (SPS) paradigm initiates persistent mechanical allodynia, thermal hyperalgesia, and anxiety-like behavior; thus it functions as a rodent model of comorbid pain-PTSD. An experiment used this rodent model of pain-PTSD comorbidity with adult male rats exposed to the SPS paradigm. SPS increased the levels of angiotensin II in the hippocampus, prefrontal cortex (PFC), and spinal cord. Notably, intraperitoneal injection of losartan attenuated the SPS-induced mechanical allodynia, suppressed SPS-induced glial activation (both microglia and astrocytes), and suppressed the proinflammatory cytokine expression in the PFC and spinal cord, but not in the hippocampus. Furthermore, intrathecal injection of losartan also exerted an antihyperalgesic effect and suppressed SPS-induced glial activation and proinflammatory cytokine expression in the spinal cord. These results, when taken together, indicate that AT1R blockade by losartan attenuated mechanical allodynia induced by PTSD-like stress, and this may be attributed to the suppression of glial activation and proinflammatory cytokine expression in the spinal cord.

The SPS paradigm initiates persistent mechanical allodynia and thermal hyperalgesia, and it has been established that increased nociceptin/orphan (N/O)FQ levels in serum and cerebrospinal fluid accompany these exaggerated nociceptive responses, as does serum tumor necrosis factor α (TNF-α). This next experiment involved a single injection of anti-TNF-α antibody to male and female rats during the SPS procedure. The results indicated that the single anti-TNF-α injection prevented the development of allodynia, hyperalgesia, and elevated serum N/OFQ. The single injection also reduced SPS-induced anxiety-like behaviors in males but not females. However, the injection blocked the development of SPS-induced allodynia in females and blocked increased hypothalamic N/OFQ in males and females. The authors’ key point drawn from these findings was that a peripheral TNF-α surge is necessary for initiating allodynia associated with SPS and the altered central and peripheral N/OFQ that maintains nociceptive sensitivity.

The relationship between burn severity and body image change is complex. A systematic review ( n = 31) recently noted 12 studies where injury severity was associated with impaired body image. In comparison, 14 other studies found no relationship. Several recent studies also found little to no relation between injury or scarring and body image. Importantly, research has shown that the degree to which burn survivors’ self-esteem before their injury depended on their appearance at that time was directly related to experiencing an increased severity of body image dissatisfaction after the burn. Recently, the mediating-moderating role of body image and resilience was investigated among an adult cohort with burns. The findings revealed that with sufficient resilience, stigma would not elicit much adverse effect. Also, negative affect and body image dissatisfaction were associated as partially accounted for by body image.

Detailed and informative results were obtained from another recent study, which revealed the following: (1) Increased burn severity may create scars that may trigger stigmatizing and hence result in the burn survivor experiencing a further reduction in body image dissatisfaction. (2) If subjected to stigmatizing and if this makes body image dissatisfaction more severe, then this may impair self-esteem. (3) Females with burns develop worsened body image dissatisfaction if they are afraid of being criticized about their appearance. (4) Fear of negative evaluation reduces self-esteem; still, if body image dissatisfaction is poor, self-esteem is reduced further. (5) Younger-aged burn survivors developed poor body image, which was associated with reduced self-esteem. The association became stronger if they thought they were being stigmatized and evaluated critically. These findings and others regarding self-esteem among burn survivors suggest that having a variety of sources of social support and providing support to others are associated with significant positive effects on self-esteem. Another study found that among burn patients, self-esteem was significantly and inversely related to severity of burn injury, TBSA, facial burn, PTSD, major depression, suicidality factors, and other psychiatric morbidity.

Survivors of a burn who are left with changes to their appearance and function are at risk of social stigmatization. When stigmatization is expected, survivors may choose to prevent this by isolating themselves from the people or locations where they feel vulnerable to being stigmatized. Unfortunately, this avoidance may reduce the quality of their life. For example, by keeping away from those likely to stigmatize them, they also keep away from other people who may be less critical of appearance. Isolating from the group has been shown to diminish one’s status. ^, A cohort of burn survivors was interviewed to develop a definition of burn-related self-stigma. The final version was “a state in which burn survivors experience unfavorable thoughts and feelings about themselves” because of others’ distorted perceptions of them (e.g., social stigmatization). Such burn-related self-stigma is formed by internalizing negative self-appraisals and by taking as valid others’ critical stigmatizations and threats of being rejected by the social group (i.e., social exclusion). By taking in these aversive words and actions about themselves, they see themselves as different from others, and they may prefer isolation as they become reluctant to appear in certain public arenas or on certain occasions. Unfortunately, the social avoidance and isolation from people and places where stigma may be experienced reinforces the avoidance and isolation behaviors, and by maintaining the anxious release, one’s quality of life is further diminished. ^,

Survivors face the dual challenges of managing their response to disfigurement and dealing with the behavior of others. Those with more severe visible scarring are at greater risk of depression, distress, and isolation. However, a burn survivor cohort with head and neck burns relative to a survivor cohort without head and neck burns demonstrated similar outcome scores on community integration, physical health, and satisfaction with life. On the other hand, the cohort with head and neck burns did report more severe body image dissatisfaction because of face/head/neck scarring. Although stigma partially mediated depressive symptoms, self-efficacy moderated the effect of stigma on depression severity. There may be a progression in worries, as shown in one study where survivors were found to focus on survival, wound healing, and minimizing scarring during the acute phase of recovery from the burn injury. Still, during later phases of recovery, the challenge becomes reintegration with family, community, and work. Survivors may develop social appearance anxiety cause by apprehension about how others may react to their altered appearance, and this may be especially true and distressing for those with visible scars. Facial burn scars may be particularly salient when returning to the community because they are visible in most settings and because faces are among the most meaningful interpersonal cues for people in social settings. For example, it has been shown that those with attractive faces are assumed to have more positive character traits and to be more adept at choosing and using social skills.

Studies conducted with diverse populations have found quite similar results. For example, a study conducted in China found that depression severity increased significantly among those burn survivors who received less social support. Interestingly, Iranian burn survivors participated less often in community activities during the first 6 months, while their body image dissatisfaction declined during the same period. The Iranian burn survivor cohort experienced increasing social support, less body image dissatisfaction, and more social participation from 6 months postburn to 1 year; yet, even with that positive finding, it was also reported that none of the group mean scores had returned to preburn levels.

The severity of body image dissatisfaction and distress regarding appearance after a burn has been related to a larger difference between body image and appearance before and after the injury. It has been shown that survivors with burn scars that are observable in typical clothing often report having low self-esteem (i.e., low self-value) and low self-efficacy in social interactions (i.e., low social self-confidence) and report being stigmatized more often (e.g., others staring, rude comments, intrusive questions). ^, Body image dissatisfaction has been shown to reduce self-esteem. Further, severe body image dissatisfaction, perceived stigmatization, and fear of negative evaluation erode self-esteem. In addition, while experiencing stigmatization can increase depression severity, self-efficacy lessens this effect. Importantly, having less social support increased the frequency of stigmatization associated with depression severity. Burn survivors who report body image dissatisfaction (i.e., self-stigma) tend to engage in more dysfunctional coping, such as coping by self-blame or self-distraction, which tends to worsen body image dissatisfaction. Burn-related changes in body image and appearance are also made worse when one manages alternately by approach (e.g., process) and avoidance (e.g., suppress); body image dissatisfaction worsens when one has developed an approach-avoidance conflict.

Poor body image may lessen self-esteem and quality of life; however, many individuals cope effectively by deemphasizing their disfigurement and concentrating on strengths and “resilience.” ^, For example, during acute hospitalization, body image has been shown to mediate the relationship between preburn and postburn psychosocial functioning. Adaptive coping may help with adjustment because positive postburn adjustment is associated with proactive problem-solving and less use of avoidant coping strategies. In one study, the most powerful predictor of positive adjustment for males was having less functional disability; for females, using a problem-solving coping style was the best predictor of positive adjustment. ^, Importantly, while coping by concealing stigma may lessen exposure to stigmatization, which one may think is beneficial, it may also limit access to social support. On the other hand, although coping by intentionally revealing an altered appearance may promote benevolent inclusions in desired groups, it may also inadvertently expose one to stigmatization or exclusion from desired groups.

Positive postburn body image has been associated with achieving a greater sense of community reintegration. It has been suggested that for burn survivors who reintegrate in satisfying ways into their community, the process may be more straightforward for those who naturally exhibit a robust and positive body image. Such a positive body image has been described as composed of traits such as the following: inner positivity, interpreting information in a body-protective manner; stable yet malleable; perceived body acceptance by others; body appreciation, body acceptance/love, adaptive investment in appearance; and shaped by social identities. Regardless of the compilation of positive traits affiliated with positive body image, it is essential to know the evidence base and to build upon it.

PTSD, found to affect nearly 10% to 30% of pediatric burn patients within 1 year of their injury, cannot be diagnosed until at least 30 days after the initial traumatic event. Acute stress disorder may be diagnosed during the child’s acute hospitalization and should be addressed to reduce the possibility of worsening symptoms or developing PTSD. Although there are conflicting reports on the incidence of negative psychological effects of burns on children and adolescents, recent studies have shown that burn-surviving children report significant anxiety disorder symptoms, especially females and those with highly visible burns and large burns. ^, Adolescents also report a high rate (70%) of appearance concerns, correlated with increased psychosocial difficulties. Therefore it is essential to screen for and address psychosocial concerns of burn-injured youth because a significant number may suffer from anxiety disorder(s), depression, body image issues, and PTSD after discharge. Any member of the interdisciplinary burn team may complete screening. If indicated, further assessment and intervention may be terminated by a psychologist, social worker, or child life specialist in the outpatient burn clinic setting. Such issues can persist for an extended period long after the initial event. ^,

When the child, adolescent, or family expresses concerns regarding these issues, they should be referred to a pediatric psychologist, mental health counselor, or psychiatrist for further evaluation and possible treatment. Unaddressed anxiety disorders or PTSD can lead to academic problems, social difficulties, diminished self-worth, and substance abuse. Intrusive memories related to the burn event and the acute burn hospitalization may elicit intense memories of pain and helplessness from the injury event and motivate the child to escape or avoid it. Similarly, viewing the healing wound or subsequent scars may trigger vivid memories of the original wound, including the blood and fear of disfigurement. Beginning during the acute hospitalization, the child also begins to incorporate an altered body image, thoughts, feelings, and appraisals of how others are reacting or may react in the neighborhood and at school. Reintegration into the family, school setting, and community can be overwhelming. Burn survivors experiencing PTSD or anxiety disorders often try to avoid people, places, or things that remind them of the burn injury event. They may react negatively to medical professionals, loud noises, or even an unexpected touch because these trauma-borne habits can significantly slow their physical and psychological recovery. Education about bullying, pain, sleep disruption, and emotional challenges is essential because parents are often unaware of the difficulties their children may be experiencing.

A major task of the burn-injured youth is reintegration into the family, school, and community. Positive psychosocial adjustment after burns has been linked to solid family and social support, the physical presence of family members, and a youth’s willingness to take social risks. ^, Programs aimed at helping youth achieve successful adjustment include school reentry, burn and family camps, young adult retreats, and online support groups.

A successful return to school is significant for the patient’s academic and social success. Burn-injured youth requiring special accommodations and those wearing pressure garments or having an amputation or other visible disfigurement may experience more difficulty and encounter stigma and discrimination from their peers at school. Bullying by classmates is a significant problem for many burn-injured youth. ^, A school reentry program can help to alleviate this problem. Because school reintegration is essential to the child’s overall well-being, it is recommended that a return to the school environment begin while the child or teenager is still in the burn center. It is essential to ensure that the reintegration program provides positive coping strategies and is tailored to the individual youth’s needs and environment. ^, If a burn center/unit lacks a school reentry program, the Phoenix Society has free online school reentry resources available for parents and teachers.

Burn camp attendance benefits the psychosocial rehabilitation of both child and adolescent burn survivors. Burn campers report that attendance allows them to interact with other burn survivors, allows for involvement in activities that increase self-worth and confidence, supports improvement in their acceptance of scars, and helps develop friendships and improved social skills. ^, Young adult or teenage retreats are effective in helping this age group develop strong peer relationships and assist them in the often difficult transition to adulthood. Family camp can help parents and siblings better understand the challenges of burn survival and increase their ability to support the burn-injured child. World Burn Congress, conducted by the Phoenix Society, also has in-person and online support programs tailored for child and adolescent burn survivors, their siblings, and parents.

Parents are at elevated risk for psychological distress after their child’s burn injury; this has been demonstrated to hurt the pediatric patient’s recovery. Mothers of thermally injured children have been shown to experience symptoms of worry, depression, tension, anxiety, diminished energy, lack of self-confidence, and ongoing guilt. ^, An interrelatedness of impaired child quality of life, greater physician and therapy appointments, and racial minority status were associated with parental PTSD and anxiety issues. It should be noted that PTSD rates in parents of burn-injured children have been found to range from 22% to 50% at 1-month postinjury. ^, Findings support parent trauma screening in the inpatient and burn clinic settings. Family therapy may also be helpful as serious burns affect the entire family unit, and research indicates that siblings’ needs should also be considered and addressed. Initiation or resumption of counseling services should be regarded as the pediatric survivor moves through different developmental stages, as parenting skills needed to support the patient may also change. Recommendations specific to a particular child and family should be referred to and discussed with a trauma-savvy psychologist or psychotherapist.

Finally, it must always be remembered that the pediatric burn patient’s emotional recovery needs will be specific to the five psychosocial developmental stages: birth to 18 months, 19 months to 3 years, 3 to 5 years, 6 to 11 years, and 12 to 21 years. The circumstances around their injury, available support systems, and the degree of location and comorbidities of their burns are also essential to note. Attention to and intervention for psychosocial problems, when needed, is paramount to self-acceptance and a successful burn recovery journey.