Adult Burn Injury

James A. Fauerbach PhD

Robert J. Spence MD

David R. Patterson PhD

Preparation of this chapter was supported by funds from the National Institute on Disability and Rehabilitation Research in the Office of Special Education and Rehabilitative Services in the U.S. Department of Education (Grant #H133A020101).

Understanding the person who presents for reconstructive surgery after a major burn is often contingent on understanding the nature and course of their lives before, during, and after the injury. Major burn injury has been defined by the American Burn Association (1) as meeting one of the following criteria:

Deep second and third degree burns greater than 10% Total Body Surface Area (TBSA) in patients under 10 or over 50 years old,
Deep second and third degree burns greater than 20% TBSA in other age groups,
Deep second and third degree burns with serious threat of functional or cosmetic threat that involve face, hands, feet, genitalia, perineum, and major joints,
Third degree burns greater than 5% TBSA in any age group,
Deep electrical burns including lightning injury; inhalation injury with burn injury, or
Circumferential burns of an extremity or chest.

Individuals who sustain these burns experience substantial biological, psychological, and social stressors (2, 3, 4). Burns may result in traumatic stress, pain, shock, sepsis, and altered functioning of the hypothalamic-pituitary-adreno-cortical system or the immune system. These can eventuate from the burn event and injury, as well as subsequent treatment components such as medication regimens, daily aversive dressing changes, physiotherapy, and surgical debridement or wound closure.

A major burn injury can substantially impair skin integrity and sensation and may lead to hypertrophic scarring. In addition to changes in appearance and function brought about by scarring, deeper burns may result in damage to, or complete loss of, functionally or cosmetically important body parts. Furthermore, many forms of psychological disturbance have been noted beyond generic distress, including body image dissatisfaction, depression, and posttraumatic distress. The physical and psychological consequences of major burn injury can interfere significantly with social and occupational role performance, which may be either minimized or exacerbated by environmental barriers or social support. The psychological well-being of patients seen in the burn reconstruction clinic becomes an important consideration not only because of the recent disfigurement, functional losses, and trauma, but also because even total compliance with preventive measures (e.g., to treat hypertrophic scarring via pressure garments) yield a demoralizing result.

The goals of this chapter are to review the growing scientific literature on the psychological, social, and physical health functioning of adult burn survivors,
including examining the role of personality variables, the size of a burn injury, stigmatization, and body image. Particular attention is given to recent research on patient experience of posttraumatic stress disorder (PTSD). The final section of the chapter reviews specific methods by which members of the plastic surgery treatment team can help burn survivors learn to cope with the effects of their injuries and to identify those patients who are in particular need of more intensive forms of psychological intervention. In many cases, because of the scarcity of work done specifically with patients presenting for burn reconstruction, it is necessary to extrapolate from the acute injury literature.

SOCIAL, PSYCHOLOGICAL, AND PHYSCIAL ADJUSTMENT FOLLOWING MAJOR BURN INJURY: A REVIEW OF THE EMPIRICAL LITERATURE

Quality of Life and Burn Injury

Quality of life is composed of many facets including disease symptoms, functional capacity, impairment, role performance, perceived well-being, and satisfaction (5). A significant measure of the degree of recovery from major burn injury is health-related quality of life (HRQL) (6). HRQL has been defined as a multifactorial construct that involves an individual’s degree of satisfaction and level of functioning in several core domains, including physical-behavioral function, psychological wellbeing, social and work role performance, and personal perception of health (7).

A recent literature review presents a profile of the patient at risk for lower quality of life following a major burn injury (8). The profile includes pre-injury factors (e.g., premorbid psychiatric disorder, personality structure), peritraumatic factors (e.g., TBSA, pain, and coping behavior) and postburn factors (e.g., social support). Re-establishing pre-injury quality of life seems problematic for some survivors, especially for those with history of preburn psychiatric disorder (9) as well as those who develop symptoms of depression (10), body image dissatisfaction (11), or posttraumatic distress (12) following the injury. Each of these is addressed in detail below.

Pre-injury Personality Variables and Postburn Adjustment

Individuals who sustain a burn are more likely to have pre-existing psychosocial needs that are important determinants of postburn psychosocial adjustment. The process of psychological coping involves any thought or behavior that a person uses with the intention of reducing negative affect. Poorer postburn adjustment appears to be a function of a combined approach and avoidant personality coping style (10,13, 14) and exhibit personality traits such as high neuroticism and low extraversion (15, 16). Patients who use approach-avoidant coping will typically alternate between ruminative thinking about the stressor (e.g., disfiguring scar) and blocking out awareness of the stressor or denying its impact. Additionally, a patient who is high in the personality trait “neuroticism” will experience more frequent, prolonged, and intense episodes of negative affect (e.g., anxiety, depression, irritability). A patient with low trait “extraversion” will experience less energy and positive affect, as well as increased social withdrawal.

The patients’ pre-injury quality of life also has been shown to influence postburn status. For example, one study has shown that the pre-injury psychosocial adjustment of burn patients, relative to published norms, was typified by greater psychological distress, anxiety, depression, and loss of behavioral and emotional control (17). Marital status, mental health treatment, and length of intensive care stay predicted satisfaction with life at discharge and at 6-month follow-up, and satisfaction at both assessments was significantly lower than norms (4). Thus, patient coping
style, personality variables (neuroticism-extraversion), and pre-injury psychological adjustment all can affect how a person adapts to a burn injury.

Extent of Burn Injury and Psychological Outcome

Despite repeated evidence to the contrary, many anecdotal and intuitive suggestions have been made over the years that psychosocial adjustment to burn scar disfigurement is related to the size and visibility of the scars. For example, the psychosocial adjustment of adults was related to current unemployment, reduced job status, avoidance coping, and restricted recreational activity; however, the severity of the burn and time since the burn were not related to psychosocial adjustment (18).

Some studies are beginning to use burn-specific measures of quality of life, such as the Burn-Specific Health Scale (19). For example, Finnish investigators, observed reduced self-reported general health among older survivors, those with larger TBSA or larger full thickness burns (TBSA-FT), and those with longer length of hospitalization. Interestingly, larger burns and hand burns were associated with greater physical impairment, and both body image and sexual functioning were associated with TBSA-FT but not the presence of hand or facial injuries (20).

Recently, investigations with adults and children have documented a fairly optimistic outlook for long-term quality of life outcome following major burn injuries. A study of survivors of massive burns in childhood, approximately 15 years after injury, found that adjustment was generally similar to published normative data (21). However, roughly 20% of the burn survivors reported substantially impaired physical functioning and had significant role interference from these impairments. Better functional status of the family predicted less role performance limitations due to physical problems, and early reintegration with preburn activities predicted better physical functioning and fewer role limitations from physical problems. A study of adult burn survivors evaluated roughly 5 years postburn, relative to a matched unburned control group, found similar level of quality of life (22). However, 25% of burn patients report clinically significant psychological disturbances compared to 12% of controls. Importantly, burn survivors with abnormal sensations in their healed wounds, relative to burn patients with normal sensation, report more somatizing and obsessive-compulsive behaviors.

Another study of burn survivors roughly 5 years after trauma found that functional impairment, regardless of its extent, was related to severe depression (23). This is of particular concern, given the chronicity of depressive symptoms among burn survivors. For example, 43% of burn survivors reported moderate to severe symptoms of depression 2 years postburn (24). Furthermore, even mild symptoms of depression are associated with an increased likelihood of becoming disabled and a decreased chance of recovery (25). Thus, even under the best of circumstances, roughly 20% to 25% of those who survive major burn injury can be expected to evidence significant physical (21) or psychological (23) impairment even years after the injury.

We recently reported a prospective, longitudinal study examining the influence of baseline physical and psychological burden on HRQL among adults with major burns from three regional burn centers (26). Physical Burden groups were defined by TBSA <10%, 10% to 30%, or >30%. Psychological Burden groups were defined by in-hospital distress on the Brief Symptom Inventory Global Severity Index (27, 28). The SF-36 Health Survey (7) was used to assess HRQL during the preburn month, at the time of discharge from acute hospitalization, and at 6 and 12 months postburn. Greater in-hospital psychological distress (i.e., high Psychological Burden) was associated with greater impairment and role disruption in both physical and psychosocial domains at least as far as 6 and 12 months after injury, as well as a slower rate of recovery in both physical and psychosocial health and function. To the contrary, larger burn size (i.e., high Physical Burden) was only associated with
more physical impairment and role disruption and a slower rate of physical recovery at 6 and 12 months postburn.

The differential effect of high and low distress (i.e., Psychological Burden) on quality of life was clearly demonstrated. At discharge, and at one-year postburn, the high distress group, relative to the low distress group, demonstrated significantly worse health and function in both physical and psychosocial domains. Furthermore, both Psychological Burden levels, relative to published U.S. population norms, experienced dramatic and statistically significant deficits in all areas of function at discharge. Importantly, at one year postinjury, the high distress group was still functioning at significantly lower physical and psychosocial levels relative to norms. Interestingly, the low distress individuals, although not differing from normative data in mental health or physical functioning domains, remained impaired in their ability to perform work and social roles requiring physical health and emotional stability. This underscores the need to evaluate psychological function at the time of the clinic visit as well as prompting early intervention when indicated.

Findings indicate that the larger the Physical Burden of injury, the longer the recovery of physical functioning. However, Physical Burden was not differentially related to the degree of loss or recovery of psychosocial function. Furthermore, relative to norms for the population of community dwelling adults (7), each of the Physical Burden groups evidenced significant deficits at baseline in all physical and psychosocial domains of function. Interestingly, by one year postburn, only the physical composite score and the Physical Functioning subscale scores differed significantly across the three Physical Burden groups. Thus, the size of the burn does not appear to be the most important determinant of health and function. Individual differences appear to play a more central role.

This point, regarding the lack of a clear relationship between the extent of an injury and the nature of psychosocial adjustment, cannot be emphasized strongly enough. It is a theme that recurs in the scientific and clinical literature reviewed in multiple chapters throughout this volume.

Social Perception, Stigmatization, and Body Image

The study of the social perception and body image of burn survivors, while still in its infancy (29, 30) is central to understanding the lives of adult burn survivors. In fact, it is a common thread that links together each of the chapters in this section of this volume.

Social Perception and Stigmatization

Stigmatization is a social process that characterizes individuals as deviant and subjects them to a variety of dehumanizing behaviors that may be overt (i.e., staring, startled reaction, double takes, whispering, teasing, bullying) or subtle (i.e., avoiding eye contact, ignoring, walking faster when approaching, ambivalence about engaging in an interaction, pity) (30, 31, 32). Teasing and negative verbal commentary are stigmatizing acts that have been shown to negatively affect body image and self-esteem for prolonged periods (33). Bull and Rumsey (34) hypothesized that when individuals with physical distinctions experience stigmatizing behavior, they may develop poor body esteem, a sense of social isolation, and a violation of their privacy. The frequency and severity of such discrimination among burn survivors is unknown (29, 30). However, a number of studies have found that positive social support is associated with better adjustment for burn survivors (35, 36). The consistency of these findings support the urgency of putting in place programs of psychosocial assessment and interventions geared towards assisting survivors accept scars, reduce depression, cope with social stigmatization, and build a strong support system.

Body Image

We recently examined the relationship among burn scar severity and visibility, and body esteem (37). Scar visibility was significantly related to reduced satisfaction with one’s appearance, increased perception of others’ negative reactions to one’s appearance, and perceived stigmatization. Social adjustment and depression accounted for substantial variance in body esteem. In contrast, scar severity and visibility accounted for very little variance in body esteem, or social and emotional adjustment. Finally, outpatients with visible distinctions reported experiencing significant anxiety, depression, social anxiety, social avoidance, and poor quality of life. Severity of disfigurement was not strongly related to distress or adjustment (38).

The impact of in-hospital body image dissatisfaction on subsequent quality of life after severe burn injury has only recently been studied (11,39). Most prior studies lacked a measure of body image satisfaction, and many did not control for other determinants of outcome including injury location, other forms of psychological distress, and preburn quality of life. Quality of life measured 2 months after discharge of groups with, and without, body image dissatisfaction during hospitalization was studied, controlling for the effect of preburn quality of life. Among those with greater in-hospital body image dissatisfaction, significantly lower psychosocial and physical quality of life was reported at 2 month follow-up. Further analyses indicated that symptoms of depression and posttraumatic distress moderated the impact of body image dissatisfaction on physical but not psychosocial health. Finally, postburn physical adjustment was poorer among all burn survivors relative to published norms, while psychosocial adjustment was poorer only for those with body image dissatisfaction. Although body image is a clinically recognized determinant of adjustment in other populations, these findings empirically demonstrated the significant negative impact of poor body image on quality of life in a representative sample of burn survivors. Typically, and perhaps not surprisingly, the body image of patients presenting for burn reconstruction is substantially worse than that observed at earlier stages of recovery.

The impact of body image dissatisfaction on psychosocial quality of life suggests the importance of early identification of populations at risk. A number of cognitive-behavioral treatments have been developed with demonstrated efficacy in treating (40) or preventing (41, 42) body image dissatisfaction. Unfortunately, no controlled studies have been completed involving individuals with burn injuries. Nevertheless, these treatment models potentially hold great promise in the treatment of body image concerns of burn survivors.

Summary

Amid the complexity of empirical findings regarding the psychosocial adjustment of burn survivors a few critical themes emerge. One is that pre-existing personality variables (e.g., coping style) can significantly affect long-term outcome. A second theme is that there is no necessary correlation between the extent of the injury and the long-term psychological affects of the injury; individual psychological differences appear to play a more influential role. And finally, a great deal of empirical and clinical attention needs to be given to the social and body image experiences of burn survivors.

POSTTRAUMATIC DISTRESS

When evaluating any burn survivor, health care providers must be sensitive to the patients’ possible experience with Post Traumatic Stress Disorder (PTSD). PTSD is characterized by three symptom clusters: (i) re-experiencing—intrusive, distressing thoughts, dreams, or images of the traumatic event; (ii) avoidance—avoidance of trauma-related thoughts, feelings, and situations; and (iii) hyperarousal—persistent sleep disturbance, easy startle, increased tension and irritability (43). Between 25%
and 38% of burn survivors meet criteria for PTSD in the first postburn year, and almost 50% of survivors meet criteria for at least one of the symptom clusters. PTSD among burn survivors has not been found to be related to the severity of the injury (46, 47, 48). On the other hand, posttrauma distress is positively related to more intense pain among hospitalized burn patients (49, 50).

We have studied the impact of mild to moderate symptoms of in-hospital posttrauma distress following severe burn injury on quality of life at 2 month follow-up (12). After adjusting for preburn psychosocial adjustment, greater in-hospital posttraumatic distress was associated with poorer psychosocial functioning at follow-up. This effect remained after covarying preburn physical domain quality of life. However, the most robust finding was that posttraumatic distress influences psychosocial but not physical adjustment over and above the influence of personality characteristics such as neuroticism.

As Patterson et al. have noted, symptoms of distress “tend to dissipate by the time of hospital discharge” for the greatest number of burn patients (29, p. 374). Similarly to the posttraumatic distress findings just described, baseline trait negative affectivity was inversely correlated and baseline trait positive affectivity was associated with better psychological and psychosomatic functioning 12 months after discharge from an acute hospitalization for burn injury (9). The results of these two studies suggest that personality traits may be important latent variables contributing to symptom report (e.g., posttraumatic distress) and level of postburn adjustment.

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