Often, perhaps too often, behaviorally challenging patients are viewed by physicians and medical staff as having a problematic personality. Although personality and personality disorders will be the starting point for our “tour” of the psychology of pressure ulcers, other psychological factors will be discussed as well. These include substance use and addiction, impaired cognition, pain, depression, and anxiety. Any of the factors presented in this section may predispose an individual to develop a pressure sore or complicate the course of treatment when an ulcer already exists. Further, pressure sore acquisition and treatment in any given patient may involve more than one psychological system, e.g., a patient newly diagnosed with paraplegia becomes depressed and self-medicates with alcohol and opioid pain medication, such that addiction to both substances eventually occurs. Unknowingly, there also are mild cognitive deficits affecting memory and problem solving that were acquired as the result of a brain injury which occurred during the motor vehicle accident that resulted in spinal injury. Skin inspection and pressure relief procedures, both taught during rehabilitation, no longer are being practiced and a pressure ulcer ensues. One or more, perhaps even all, of the above psychological variables could have led to the development of the pressure sore.

Personality disorders are an increasingly controversial topic. The existing nosology of discrete disorders published in the Diagnostic and Statistical Manual of Mental Disorders [1] has received criticism [2], including whether personality disorders constitute “distinct clinical entities” [3] and charges that certain personality disorders are not based on sound science [4]. The etiology of disordered personality falls under nature versus nurture arguments, with research supporting both genetic and social environmental factors, as well as an interaction effect between biology and experience [5, 6]. Additionally, the term personality disorder, used synonymously with character disorder, has been abused, such that persons who challenge authority, deviate from the norm, or behave in an unconventional manner may be labeled as being personality disordered.

Personality disorders are chronic and can interfere with daily functioning. DSM-IV-TR defines personality disorder as an “enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” [1, p 685]. It is important to note that personality disorder is not the result of the use of chemical substances, whether illicit drugs or prescribed medications, nor due to a medical condition, including head trauma.

Physical injury and medical illness certainly can result in change of personality. The DSM indeed recognizes this, defining it as “personality change” as opposed to personality disorder. When medical and substance abuse etiologies are present, personality disorder may be mistakenly diagnosed. When there are comorbid personality and “organic” etiologies, the personality disorder may be missed or underestimated, especially when the disorder is not severe. Mild personality disorder may not be initially apparent and only detected over time.

Psychological research clearly has established a relationship between personality disorder and spinal injury; one spinal injury clinical sample found the personality disorder prevalence rate to be 70 % [7]. Temple and Elliott [8] found that 72–84 % of persons with recent-onset SCI admitted for hospitalization and between 55 and 90 % of postoperative pressure sore skin flap patients met the diagnostic criteria for personality disorders. However, research to confirm a link between personality and pressure sore acquisition is more limited.

Personality factors are related to the use of chemical substances. Sensation seeking was found to be associated with the use of substance in a study of adult spinal-injured rehabilitation patients [16]. Sensation seeking also is associated with risky health behaviors other than substance use. High sensation seeking may be related to an overactive mesocorticolimbic dopamine system, low levels of monoamine oxidase activity, and altered dopamine receptor and dopamine transporter expression and function [17]. Antisocial behavior correlated with substance abuse, negative emotionality, and low behavioral constraint, while being inversely associated with socioeconomic status and verbal ability [18]. Alcohol abuse has been associated with high extraversion and low conscientiousness, and cannabis abuse linked to low extraversion and high openness to experience [19]. However, no significant differences on personality-related dimensions were found, using the Minnesota Multiphasic Personality Inventory (MMPI), in a study of persons with traumatic paraplegia that compared individuals with negative and positive blood alcohol concentrations at the time of injury and which also compared them to a non-SCI control group [20].

Substance abuse has been termed the “silent saboteur” in rehabilitation [21]. Premorbid abuse of illicit substances predicted increased risk of developing pressure ulcers 30 months after SCI [22]. In a sample of SCI individuals, 11 % reported the use of illicit drugs or abuse of prescription medications [23]. History of post-injury, but not pre-injury, drug abuse was identified as a factor in post-rehabilitation complications in a sample of individuals with SCI related to firearm or car crash injuries [24].

Alcohol consumption and alcohol abuse were associated with pressure sore development among persons with SCI [25–27]. Elliot et al. [25] found that pre-injury history of heavy alcohol abuse increased by 2.5 times the probability of having a pressure sore diagnosis in the first 3 years following SCI when compared with individuals without severe alcohol abuse histories. They also found that alcohol abuse history was not related to depression following admission for SCI rehabilitation nor to acceptance of disability at time of discharge. However, they questioned whether such problems may develop following community reentry and cited other studies [28, 29] that linked psychological problems to prior substance use after returning to the community. History of cigarette smoking also is tied to pressure ulcer development [26, 30].

Substance use can be a problem during the long hospitalization required following muscle flap surgery. After discharge, the mind altering effects of substance use may result in behaviors such as sitting in the wheelchair beyond tolerance and forgetting to perform pressure relief raises and skin inspections, resulting in breakdown of the still healing wound area and/or development of new pressure sores.

All pain is psychological in that how one experiences pain is mediated by psychological processes. These include depression, anxiety, anger, coping, and personality. Another variable is history of substance use, which is associated with pain tolerance such that persons with drug histories may require higher dosages of analgesics [31, 32]. All pain complaints must be considered “real” until proven otherwise. The “med-seeking” patient whose complaints of pain are without a physiological etiology and are solely to obtain medications for recreational purposes may present indistinguishably from the patient that seeks pain medication for pleasure yet also has underlying physical pain or the patient whose requests for pain medications are solely for relief of pain. Welcome to the challenging world of the psychology of pain!

Because persons with spinal injury may experience pain below the level of injury, complaints of persons with pressure sores who are SCI may be dismissed. One study found that 35 % of persons with SCI had pain below the level of injury [33]. The experience of pain may not be at the pressure sore site; rather, there may be a sense of undifferentiated pain. Burning pain and aching pain are the most prevalent types of SCI pain, with burning pain associated with frontal parts of the torso and genitals, buttocks, and lower extremities and aching pain correlated with the neck, shoulders, and back [34].

For the majority of SCI individuals with pressure sores below the level of injury, there may be no sensation of pain, which perhaps is the key reason why pressure sores deteriorate to a level where surgery is required. Awareness of buttocks pain is negatively related to acquiring a pressure sore [26], and for that reason, it has been suggested that persons without sensation may engage in activities that promote wound development, which stands in contrast to individuals with intact sensation who restrict movement and activity as means to reduce pain and suffering [35].

Non-spinal-injured persons with pressure ulcers can find the experience of the sore to be excruciating [35], with hot or burning being the most prevalent descriptor of the pain used by individuals with intact sensation [36]. A qualitative study of elderly persons with pressure sores found that restriction of movement would make pain more bearable and that individuals knowingly would go against medical advice and minimize mobility, such as not repositioning themselves when sitting or in bed. Other findings were that analgesics provided insufficient relief, that sleep was interrupted due to pain, that physicians inadequately recognized the severity of pain, and that alternating pressure mattresses, wound cleaning, and dressing changes can provoke pain [35]. Even among severely demented patients with pressure ulcers who could no longer verbally communicate, facial expressions and vocalizations during dressing changes clearly indicated pain [37]. Suffering among end-stage dementia patients was associated with pain and pressure sore acquisition [38].

Chronic pain is a fact of life for the majority of spinal cord–injured persons. In one sample of paraplegics and tetraplegics, 81 % reported at least one pain problem and 40 % had three or more areas of pain; 62 % reported experiencing high-intensity pain. Additionally, 75 % had sensations that were unpleasant, but not painful [33]. Another estimate is that nearly two-thirds of all persons with SCI live with chronic pain, with a third of them rating their pain as severe [39], and pain has been found to have an impact on quality of life that exceeds the effects of the SCI itself [40], with spinal-injured persons with low quality of life also having reduced self-efficacy [41].

It is helpful to keep in mind that SCI pain will be either nociceptive or neuropathic. Nociceptive pain is the result of injury, causing nerve activation at a specific site, and includes visceral pain, which is the result of internal organ or ligament damage, irritation, or distention. Neuropathic pain is injury of the nerve itself, at the level of the spinal cord lesion, at the nerve root or the site of a local nerve injury, and includes sympathetic pain, in which the autonomic nervous system is activated by a noxious stimulus. Nociceptive pain has been reported in 15 % of persons with SCI, with 38 % rating it as severe. Nineteen to twenty-four percent reported neuropathic pain below the level of injury, with 27 % perceiving it as severe [42]. Pressure ulcer pain can represent both nociceptive and neuropathic processes.

Pain catastrophizing is the tendency to magnify or exaggerate the experience of pain and often other aspects of one’s life [43]. Chronic SCI pain has been associated with catastrophizing, which in turn correlated with depression, helplessness, and anger. Lower levels of catastrophizing were related to lower pain intensity, higher injury level, nontraumatic SCI etiology, and better health [44]. Catastrophizing was found to be positively related to pain intensity and to higher levels of affective distress and depressive symptoms in a separate study of SCI and other individuals experiencing wound-related pain [45].

SCI pain was associated with lower life satisfaction [23, 46], loss of sense of control [47], lower self-efficacy and power performance on lifting and wheel-turning tasks [48], and substance abuse [23]. In a sample of SCI patients, the presence of pain and pressure sore acquisition was negatively related to future time orientation, a factor also linked to depression [49] and which involves the ability focus on future events and to have hopes, plans, and goals.

Cognition involves structures and processes that are responsible for thought and perception, thus permitting the acquisition and use of knowledge. Cognition can be better understood by examining the domains that constitute the mental status examination, including level of consciousness, orientation, attention, language, learning, memory, reasoning, judgment and insight, thoughts, and perceptions. Impairment of one or more of these domains can directly or indirectly play a role in pressure sore development.

Persons with spinal injury may have undiagnosed brain injuries that can affect mental status. Brain injury secondary to physical trauma, such as motor vehicle accidents, may have been overlooked when there is a concomitant spinal injury [50–53]. Cognitive deficits may be present in 40–50 of persons with SCI due to closed head injury [54], up to 60 % when other etiologies, including substance abuse, are included [55]. Neuropsychological testing of persons with spinal injury indicated deficits in attention and concentration, memory, and problem solving when compared to non-SCI controls [55].

Neuropsychological testing was administered to a sample of spinal-injured patients; over 40 % had impairments in the areas of verbal learning, processing speed, and motor speed [56]. Ineffective social problem-solving abilities were found to be a risk factor for pressure sore acquisition in a sample of persons with recent-onset spinal cord injury [57]. Problem-solving errors are associated with brain injury as well as with other cognitive factors, such as dementia and intelligence, as well as with education, life experience, culture, and mood, anxiety, and personality disorders.

Impulsivity, associated with frontal lobe brain injuries, impedes regulation of behavior. In patients where there is premorbid history of high-risk behavior, such as the use of illicit drugs and racing cars, the addition of a brain injury may make inhibition of such behaviors even more difficult!

Substance abuse, associated with pressure sore acquisition, can change brain structures, which in turn can affect behavior. For example, structural MRI studies have found changes in volume and tissue structure in the prefrontal cortex among alcohol, methamphetamine, and polysubstance abusers that could adversely influence decision making and increase impulsivity. Functional MRI studies implicate cocaine and methamphetamine for reduced activation in the prefrontal cortex. Activation of the cingulate cortex from cocaine affected emotional processing, and activation of the nucleus accumbens was related to craving [58].

Methamphetamine and cocaine abusers were found to have reduced concentrations of N-acetylaspartate, implicated in neuronal damage, according to magnetic resonance spectroscopy. Cannabis abuse was associated with glutamate loss in the frontal lobe and increased levels in the basal ganglia. Positron emission tomography studies have found that cocaine, methylphenidate, and methamphetamine result in surges of dopamine in the striatum, which produces feelings of euphoria; however, chronic use can lead to reduced availability of dopamine transporters and possibly loss of dopamine cells, which was tied to slowed motor function and decreased memory in methamphetamine abusers. It has been hypothesized that persons with low levels of dopamine receptors, whether as a result of substance abuse or genetically, obtain less than average amounts of dopamine-mediated pleasure from everyday activities and are at higher risk for substance abuse and addiction so as to feel the euphoria that others can feel naturally [58].

Depression is a misunderstood concept. There is major depressive disorder, and other less severe forms of depression, all disorders, and all with their own diagnostic criteria. However, feeling depressed may not mean that there is a depressive disorder in the same way that sneezing may not be indicative of having a cold or influenza.

Depression was predictive of pressure ulcer acquisition among persons with spinal injury [59]. Nearly 28 % percent of spinal-injured individuals developed depression during the first 6 years following injury [60]. Psychological factors found to be predictive of depression in spinal injury include helplessness and a lowered sense of self-efficacy [61].

Among medical/surgical patients aged 65 or older receiving physical rehabilitation following hospitalization, it was found that depression and acquiring a pressure sore and each were independent factors were associated with failure to return to a premorbid functional level [62]. In a comparison of patients with breast, esophageal, and head and neck cancer, depression was significantly more likely to occur when depression was present than when it was absent. The depressed cancer patients also were significantly more likely to have fatigue, insomnia, anorexia, and pain [63], all of which can be related to or exacerbated by depression.

The cognitive component of depression is associated with sense of mortality, death ideation, and lack of hope. It has been suggested that physical disability is negatively associated with death anxiety and to a foreshortened orientation toward the future, which was confirmed in a sample of spinal-injured persons that also found that the presence of depression predicted development of pressure sores and diminished future time orientation [49].

Another study found suicide to be two to six times more prevalent among persons with spinal injury than in the general population. Persons who later committed suicide, when compared with a matched sample of spinal-injured persons who had not killed themselves, scored significantly higher on measures that included shame, hopelessness, despondency, apathy, alcohol abuse, and destructive behavior [64]. An epidemiological study of the deaths of spinal-injured individuals found that, among quadriplegics and persons aged 55 years or older, pneumonia was the leading cause of death, with unintentional injuries and suicides as the top causes of death among paraplegics and persons no older than age 55 years [65]. In another sample, suicide led as the cause of death among persons with complete paraplegia and was the second leading cause of death among individuals with incomplete paraplegia. Gunshot wound was the most prevalent means of committing suicide [66].

Elliot et al. [25] found that alcohol abuse history was not related to depression following admission for SCI rehabilitation nor to acceptance of disability at time of discharge. However, they question whether such problems may develop following community reentry and cite other studies [29, 67] that linked psychological problems to prior substance use after returning to the community. Spinal-injured persons who abstained from alcohol, but once had a history of problem drinking, were most vulnerable to depression and had lower acceptance of disability and greatest risk of medical complications [68].

In geriatric medicine, pressure sores constitute a “geriatric syndrome.” A literature review of the risk factors involved in the pressure sore geriatric syndrome examined 13 studies. Out of the 13, 6 studies identified impaired cognition or dementia as a risk factor. However, an additional 6 studies included low weight or nutritional factors as risk factors for the syndrome. Clearly, compromised nutritional status can have a devastating effect on cognition and makes it useful to keep in mind the concept of the pressure sore as a syndrome, even with non-elderly populations. Impaired cognition also was identified as a factor in four other geriatric syndromes—incontinence, falls, functional decline, and delirium, all of which can have an impact on pressure ulcer development [69]. Depression, which also has been conceptualized as constituting a geriatric syndrome [70], can exacerbate the severity of cognitive impairment.

Stress among SCI individuals was found not to be related to the acquisition of pressure ulcers; however, stress correlated with depression, life satisfaction, quality of life, and alcohol consumption [71]. However, findings from another study suggest the possibility that stress may play a role in pressure sore formation among elderly persons newly admitted to a nursing facility, all free of pressure ulcers (and without medical conditions or medications that could affect cortisol level). Serum cortisol levels, assayed twice weekly over a 5-week period, were significantly higher among residents who later developed pressure sores, with the largest differences during the second week [72].

Posttraumatic stress disorder (PTSD) is a persistent reaction to the experience of acute stress that is beyond the realm of normal life experience and is classified as an anxiety disorder. The acute stress experienced or witnessed involved “actual or threatened death or serious injury, or a threat to the physical integrity of self or others” and a response of “intense fear, helplessness, or horror” [1, p 463]. Presentation of PTSD includes re-experiencing of the traumatic event in ways such as flashbacks, dreams and nightmares, avoidance of thoughts associated with the trauma, emotional numbing, and autonomic arousal, including insomnia and hypervigilance and outbursts of anger.

Kennedy and Duff [73] reviewed the literature on PTSD among persons with spinal injuries. They reported the findings of 13 studies in which the prevalence of PTSD ranged from 10 to 40 %. Recency of the trauma was not found to be a significant predictor of PTSD diagnosis and severity, and the disorder may take years to present. The studies cited by them suggested that PTSD was more prevalent with tetraplegia than with paraplegia and, among individuals with paraplegia, associated with injuries below T3, possibly due to nerve fiber impairment modulating memory of the emotional events. Concomitant brain injury was reported to correlate with severity of PTSD. However, if memory impairment occurred, the traumatic event would have had to have happened prior to the onset of retrograde amnesia or following the remission of posttraumatic amnesia.