Preburn psychiatric history affects posttrauma morbidity

Unravelling the impact of prior depression and trauma-related cognitive processes on depression following trauma: A 2-year prospective study of burn survivors

OBJECTIVE

Individuals with severe burn injuries may develop depression, yet knowledge about psychological risk factors for depression following trauma is limited. This study investigated the prospective impact and interplay of prior depression and trauma-related cognitive processes (posttraumatic negative appraisals and trauma-related rumination) to depressive symptoms between 6 and 24 months after burn injury.

METHOD

Taiwanese adult survivors of burn (N = 118) participated in surveys immediately post-burn and at 6-, 12-, and 24-months follow-up. Participants were 7 5% men, with an average age of 41.8 years and an average of TBSA of 18.3%.

RESULTS

A total of 8.5%, 5.9%, and 4.2% met criteria for probable major depression at 6, 12, and 24 months post-burn, respectively. The prevalence increased to 23.7%, 11.0%, and 5.9% using the cutoff on the PHQ-9. Prior depression and trauma-related cognitive processes immediately post-burn explained 13.5%, 20.5%, and 18.6% of the variance in depressive symptoms at 6, 12, and 24 months post-burn, respectively. Posttraumatic negative appraisals strongly predicted depressive symptoms post-burn across follow-ups. Moreover, posttraumatic negative appraisals significantly mediated the effect of prior depression on subsequent depressive symptoms across follow-ups. Prior depression significantly moderated the effect of trauma-related rumination on depressive symptoms at 6 months post-burn.

CONCLUSIONS

Our results are the first to demonstrate the role and interplay of prior depression and trauma-related cognitive processes in post-burn depression. Findings highlight that pre-and post-trauma psychological factors jointly affect depression following trauma, broadening the applicability of cognitive theories of PTSD.

Psychological Issues

Psychological distress is common following a burn injury, and many burn survivors have pre-morbid psychiatric illnesses including mood and trauma-related disorders, and substance and alcohol use. This article is intended to be used by all interdisciplinary health care team members to improve the identification and treatment of common psychological concerns experienced by survivors and is organized to follow the general recovery timeline.

Reduced heart rate variability and expressive suppression interact to prospectively predict COVID-19 pandemic-related post-traumatic stress symptoms

The COVID-19 pandemic is a unique period of stress that, in some cases, led to post-traumatic stress symptoms (PTSSs). Emotion regulation strategies are known to modulate the emotional response to stressful events. Expressive suppression (ES) is a maladaptive strategy related to the exacerbation of the physiological stress response. Heart rate variability (HRV), an index of cardiac autonomic balance strictly related to ES, was also shown to predict PTSSs. This was the first study to investigate whether the pre-pandemic ES use and resting-state HRV predicted pandemic-related PTSSs. Before the pandemic, 83 (58 females) university students completed the Emotion Regulation Questionnaire (ERQ), self-report measures of anxiety and depressive symptoms, and a three-minute resting-state electrocardiogram recording. After 12 months, 61 (45 females) participants completed a self-report measure of pandemic-related PTSSs and repeated the self-report psychological measures. Pre-pandemic anxiety symptoms prospectively predicted greater PTSSs. Moreover, a significant interaction between HRV and ES in predicting PTSSs emerged, whereby those who had higher levels of ES and reduced HRV showed higher PTSSs. These findings suggest that an integrated assessment of HRV and ES might be useful for identifying individuals who are more vulnerable to the development of PTSSs during crises.

Emotional processing prospectively modulates the impact of anxiety on COVID-19 pandemic-related post-traumatic stress symptoms: an ERP study

BACKGROUND

Considering that the elevated distress caused by the COVID-19 pandemic, in some cases, led to post-traumatic stress symptoms (PTSS), it has been proposed as a specific traumatic event. The present longitudinal study investigated pre-pandemic motivated attention to emotional stimuli, as indexed by Late Positive Potential (LPP) amplitude, in relation with the potential differential role of anxiety and depressive symptoms in predicting PTSS severity related to the COVID-19 pandemic.

METHODS

A total of 79 university students initially completed self-report measures of depression and anxiety along with a passive viewing task of emotional (pleasant, unpleasant) and neutral pictures while electroencephaloghic activity was recorded. In December 2020, 57 participants completed a questionnaire assessing PTSS.

RESULTS

Significant interactions between anxiety and LPP emerged in predicting pandemic-related PTSS, where greater anxiety symptoms predicted PTSS only in individuals with greater LPP to unpleasant or with reduced LPP to pleasant stimuli.

LIMITATIONS

The prevalence of the female sex, the relatively young age of the participants, as well as the fact that they were all enrolled in a University course might not allow the generalization of the findings.

CONCLUSIONS

Taken together, the present longitudinal study provided novel evidence on EEG predictors of pandemic-related PTSS that might be useful for the prevention and treatment of PTSS. Indeed, assessing anxiety symptoms and pre-trauma LPP to emotional stimuli might be a useful target for identifying individuals that are more vulnerable to the development of PTSS during times of crisis.

The impact of foot shock-induced stress on pain-related behavior associated with burn injury

Acute pain is prevalent following burn injury and can often transition to chronic pain. Prolonged acute pain is an important risk factor for chronic pain and there is little preclinical research to address this problem. Using a mouse model of second-degree burn, we investigated whether pre-existing stress influences pain(sensitivity) after a burn injury. We introduced a contribution of stress in two different ways: (1) the use of foot-shock as a pre-injury stressor or (2) the use of A/J mice to represent higher pre-existing stress compared to C57Bl/6 mice. C57Bl/6 and A/J mice were exposed to repeated mild foot shock to induce stress for 10 continuous days and mice underwent either burn injury or sham burn injury of the plantar surface of the right hind paw. Assessments of mechanical and thermal sensitivities of the injured and uninjured paw were conducted during the shock protocol and at intervals up to 82-day post-burn injury. In both strains of mice that underwent burn injury, thermal hypersensitivity and mechanical allodynia appeared rapidly in the ipsilateral paw. Mice that were stressed took much longer to recover their hind paw mechanical thresholds to baseline compared to non-stressed mice in both burn and non-burn groups. Analysis of the two mouse strains revealed that the recovery of mechanical thresholds in A/J mice which display higher levels of baseline anxiety was shorter than C57Bl/6 mice. No differences were observed regarding thermal sensitivities between strains. Our results support the view that stress exposure prior to burn injury affects mechanical and thermal thresholds and may be relevant to as a risk factor for the transition from acute to chronic pain. Finally, genetic differences may play a key role in modality-specific recovery following burn injury.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Burn severity and long-term psychosocial adjustment after burn injury: The mediating role of body image dissatisfaction

BACKGROUND

Persons with severe burns often develop long-term psychosocial difficulties such as posttraumatic stress disorder (PTSD) and depression. Significant appearance changes following burn injury (e.g., scarring and disfigurement) can lead to body image dissatisfaction (BID) that causes psychological problems. Using a two-wave longitudinal design, this study examined the association between burn severity and psychosocial adjustment after burns (symptoms of PTSD and depression), particularly through the mediating role of BID.

METHOD

Participants were 111 burn survivors of the 2015 Formosa Fun Coast Water Park explosion. The mean age was 24.23 years, and 62.2% were female. The average TBSA burned was 50.3%, and the mean length of stay (LOS) in hospital was 85.44 days. Data were collected two (Time 1, T1) and three years (Time 2, T2) after the 2015 explosion. A composite burn severity score (CBSS) was additionally created based on TBSA and LOS.

RESULTS

Three main findings emerged: (1) burn severity (TBSA, LOS, and CBSS) were significantly associated with T1 BID and T2 depressive symptoms, but not with T2 PTSD symptoms; (2) T1 BID significantly mediated the relationship between burn severity (TBSA and CBSS) and T2 PTSD symptoms, after controlling for T1 PTSD symptoms; and (3) T1 BID significantly mediated the relationship between burn severity (TBSA, LOS, and CBSS) and T2 depressive symptoms, after controlling for T1 depressive symptoms.

CONCLUSIONS

The current findings highlight the importance of BID in the development and maintenance of psychosocial maladjustment long after burn injury.

Examining the Impact of Psychological Factors on Hospital Length of Stay for Burn Survivors: A Systematic Review

Recovery of burn patients may be impeded by mental health problems. By gaining a better understanding of the impact that psychological factors may have on hospital length of stay, providers may be better informed to address the complex needs of burn survivors through effective and efficient practices. This systematic review summarizes existing data on the adverse psychological factors for the length of burn patients' hospitalization, and assesses the methodological quality of the extant literature on mental health conditions of burn survivors. A literature search was conducted in four electronic databases: PubMed, PsychINFO, Science Direct, and the Cumulative Index to Nursing and Allied Health Literature. Results yielded reports published between 1980 and 2016. Methodological quality was assessed by using an 11-item methodological quality score system. Seventy-four studies were identified by search; 19 articles were eligible for analysis. Findings demonstrate paucity of evidence in the area. Reports indicate longer hospital stay among burn patients with mental health problems. Substance use was the most consistent mental-health predictor of longer hospital stay. Heterogeneity in data on mental health conditions rendered impossible estimation of effect sizes of individual psychological factors on length of hospitalization. Many studies over-relied on retrospective designs, and crude indicators of psychological factors. Findings indicate that mental health problems do have an impact on the trajectory of burn recovery by increasing the length of hospital stay for burn survivors. Inpatient mental health services for burn patients are critically needed. Prospective designs, and more sensitive psychological indicators are needed for future studies.

Neuroimaging provides relevant clinical information in patients with burn injuries

INTRODUCTION

Neurological assessment of patients with burn injuries may be complicated by a variety of factors including artificial ventilation and sedation, cerebral hypoxia and intoxication. Medically unstable intubated patients present logistical challenges for radiological imaging. The role of neuroimaging as an adjunct to clinical assessment of burn injured patients has not yet been determined.

AIM

This study aims to investigate the indications, findings and outcomes of neuroimaging studies performed for burn injured patients.

METHODS

A retrospective case series study of adult burn patients admitted over an 8 year period was completed in the National Burns Centre at St James's Hospital, Dublin. Neuroimaging studies carried out for patients admitted during the study period were reviewed by a Consultant Radiologist and Consultant Stroke Physician. Outcomes included neuroimaging findings, prevalence of white matter disease (Fazekas scale), length of stay, discharge destination, predicted and observed mortality.

RESULTS

1328 consecutive patients with burn injuries were admitted during the study period. 56 patients underwent neuroimaging studies with computerised tomography, magnetic resonance imaging or both. 46 out of 56 neuroimaged patients (82.1%) had significant radiological findings, including 14 patients (25%) with acute findings. There was a high prevalence of white matter disease (mean total Fazekas score: 3.59) and acute cerebral infarction (7 patients). Patients with radiological findings required additional in-patient rehabilitation and had increased length of stay (Median 47.0 days vs. 27.5 days, p < 0.027). Patients with resuscitation burns or associated inhalation injury were significantly more likely to undergo neuroimaging (p < 0.0001) and to have positive radiological findings. Predicted mortality was higher in patients with positive neuroimaging findings compared to patients with normal neuroimaging studies, although there was no significant difference in observed mortality between these two groups.

CONCLUSION

Neuroimaging is used appropriately in patients admitted with burns and provides valuable applicable clinical information when indicated.

Mental health liaison in a regional burns unit-Past, present and future

OBJECTIVE

To describe the epidemiology of patients assessed by a Psychiatric Liaison Team (PLT) on a Regional Burns Unit in London, UK.

METHOD

A case note review of all patients assessed by the PLT over a 4-year period was carried out. Data were extracted regarding whether the burn was sustained intentionally or non-intentionally, ICD-10 psychiatric diagnosis, alcohol use at the time of injury and mechanism of injury. The independent t-test and chi-squared test were used for data analysis.

RESULTS

The PLT assessed 81 patients in total, 45 (55.6%) of burns were non-intentional, 32 (39.5%) were deliberate, and 4 patients (4.9%) were victims of an assault. The overall ratio of males to females was approximately equal. The mean age of patients with deliberate burns was younger, as compared to non-intentional burns, this difference was statistically significant (p < 0.01). Of the patients in the sample, 95% had a psychiatric diagnosis. We identified a difference in type of psychiatric diagnosis in the non-intentional and intentional burns groups. Alcohol use was linked to 38 (48%) of all patients assessed. Flame injuries were the most common mechanism of injury. Chemical burns, were significantly associated with a diagnosis of personality disorder (p < 0.05, chi-square test).

CONCLUSION

Well-resourced psychiatric liaison teams working collaboratively with burns units are essential to meet the needs of this diverse and complex group of patients.

A population-based comparison study of the mental health of patients with intentional and unintentional burns

Background

A number of studies report high prevalence of mental health conditions among burn patients. However there is a need to understand differences in the temporal relationship between mental health conditions and intentional and unintentional burns to hasten psychological prevention and intervention. This study aims to compare the socio-demographic profile, burn characteristics and pre- and post-burn psychiatric morbidity of burn patients by intent-of-injury.

Methods

De-identified linked hospital, death and mental health (MH) case registry data of burn patients hospitalised in Western Australia between 1 January 1980 and 30 June 2012 were analysed. Crude (observed) post-burn rates of mental health admissions were generated by burn intent-of-injury. Descriptive statistics were performed to compare the characteristics of the burn patients.

Results

A total of 30,997 individuals were hospitalised for a first burn; 360 (1.2%) had self-harm burns and 206 (0.7%) assault burns. Over the study period, admission rates for assault burns increased by 4.8% per year (95% confidence interval (CI) 3.1–6.5%) and self-harm burns increased 6.9% per year (95% CI 4.8–9.1%). Self-harm and assault burns occurred mainly among those aged 15 to 44 years (median age, interquartile range (IQR): self-harm 30 years, 22–40; assault 31 years, 23–38). Those with self-harm burns had a longer index hospital stay (median (IQR): self-harm 15 days (5–35) vs 4 days (1–11) assault vs 4 days (1–10) unintentional) and higher in-hospital mortality (7.2% self-harm vs 1.9% assault burns vs 0.8% unintentional). More than half (55.0%) of self-harm burns had a prior hospitalisation (5-year lookback) for a MH condition vs 10.7% of assault burns and 2.8% of unintentional burns. Crude post-burn rates of MH admissions per 100 person-years (PY) by intent-of-burn subgroups: self-harm 209 per 100 PY, assault burns 11 per 100 PY and unintentional burns 3 per 100 PY.

Conclusions

Intentional burn patients experienced significantly higher pre- and post-burn mental health morbidity along with significant adverse outcome in comparison with unintentional burns. Early psychological assessment and intervention could help in improving the MH of these patients.

PTSD in civilian populations after hospitalization following traumatic injury: A comprehensive review

BACKGROUND

Injuries and their comorbidities affect victims far beyond their physical recovery period. Some study-measures show that more than half of patients hospitalized for a traumatic injury suffer from Acute Stress Disorder, alcohol dependence, and recurrent trauma. Overall, this literature review serves to review risk factors for PTSD, screening tools, follow-up strategies, and gaps in the literature for achieving feasible patient-centered interventions for the prevention of PTSD after a traumatic injury.

DATA SOURCES

A literature review was performed from August 1, 2017 to March 19, 2018, from 3 Databases: PubMed, CINAHL and Cochrane, with keywords: "PTSD", "Post-traumatic Stress Disorder", "Civilians", "Traumatic", "Injury", "Follow-up", "Treatment", "Referral", "surgery", "surgical", "Intervention", and "Insured", "underinsured".

CONCLUSIONS

Reported risk factors for PTSD were: prior psychiatric disorder, gunshots, and lack of social support. Most articles use the Posttraumatic Stress Disorder Checklist - Civilian version. Follow-up strategies mainly focus on multidisciplinary intervention protocols, including social workers, behavioral health specialists, and psychiatrists. Finally, gaps in the literature show the need for bilingual/bicultural patient-centered care for elderly, diverse ethnic backgrounds, and insured vs. uninsured patients.

Exploring Symptoms of Post-traumatic Stress Disorders and Perceived Social Support among Patients with Burn Injury

Introduction

Burns are a serious public health problem globally, causing an estimated 265,000 deaths per year. Although the association of burn injuries with mortality and morbidity rates has been well established, data on their psychological consequences are scarce. The present study explores the frequency of post-traumatic stress disorder (PTSD) and perceived social support among patients with burn injuries in Pakistan.

Methods

This cross-sectional study was conducted at two teaching hospitals in Lahore, Pakistan from May 2015 to July 2015. Eighty patients with burn injuries were included by convenience sampling and interviewed with a specifically designed questionnaire with items on demographics, and the Impact of Events Scale-Revised (IES-R) and Multidimensional Scale of Perceived Social Support (MSPSS) instruments.

Results

Data were analyzed for a total of 80 participants: 56 women (70.0%) and 24 men (30.0%). Mean age was 35.74 (11.15) years. A high proportion of participants perceived highest social support from friends, reported high ego resiliency levels, had more severe symptoms of avoidance and intrusion, and had high overall PTSD scores. There were no differences between groups in the proportions of respondents who reported high perceived social support from significant others or family, overall social support or symptoms of hyperarousal.

Conclusion

The findings reflect a high frequency of PTSD symptomatology and poor social support among Pakistani patients with burn injuries in our sample. These factors can exacerbate the patient’s physical injury, delaying both their physical and mental rehabilitation.

Association Between Burn Injury and Mental Illness among Burn Survivors: A Population-Based, Self-Matched, Longitudinal Cohort Study

BACKGROUND

Mental health disorders are prevalent before and after burn injury. However, the impact of burn injury on risk of subsequent mental health disorders is unknown.

STUDY DESIGN

We conducted a population-based, self-matched longitudinal cohort study using administrative data in Ontario, Canada between 2003 and 2011. All adults who survived to discharge after major burn injury were included, and all mental health-related emergency department visits were identified. Rate ratios (RRs) for mental health visits in the 3 years after burn, compared with the 3 years before, were estimated using negative binomial generalized estimating equations.

RESULTS

Among 1,530 patients with major burn injury, mental health visits were common both before (141 per 1,000 person years) and after (154 per 1,000 person years) injury. Mental health visits were most common in the 12 weeks immediately preceding injury. No significant difference in the overall visit rate was observed after burn (RR 0.97; 95% CI 0.78 to 1.20), although among patients with less than 1 pre-injury visit, mental health visits tripled (RR 3.72; 95% CI 2.70 to 5.14). Self-harm emergencies increased 2-fold (RR 1.95; 95% CI 1.15 to 3.33).

CONCLUSIONS

Mental health emergencies are prevalent among burn-injured patients. Although the overall rate of mental health visits is not increased after burn, the rate increases significantly among patients with one or fewer visits pre-injury. Self-harm risk increases significantly after burn injury, underscoring the need for screening and targeted interventions after discharge. An increased rate immediately before burn suggests an opportunity for injury prevention through mental healthcare.

Prevalence and Predictors of Posttraumatic Stress Symptomatology Among Burn Survivors: A Systematic Review and Meta-Analysis

Burns can be a traumatic and stressful experience, although each patient may respond in very different ways. The aim of this study was to explore the variability on posttraumatic stress disorder (PTSD) and acute stress disorder (ASD) prevalence and evaluate the specific weight of different variables on PTSD development among adult burn patients. A systematic review was carried out to explore the prevalence of ASD and PTSD and identify their predictors. Meta-analytical methods were used to explore the strength of association between PTSD and the latter. From an initial pool of 190 studies, 24 were used in the systematic review, and only 19 studies could be used for the meta-analysis because of different methodological limitations. The prevalence of ASD at baseline ranged from 2 to 30% and prevalence of PTSD ranged from 3 to 35% at 1 month, 2 to 40% between 3 and 6 months, 9 to 45% in the year postinjury and ranged 7 to 25% more than 2 years later. Life threat perception was the strongest predictor for PTSD occurrence, followed by acute intrusive symptoms and pain associated with burn injuries. Predictive variables identified in this research may be useful in targeting burn patients who are at risk for developing posttraumatic stress symptoms and stress-related psychological symptoms.

Health-related quality of life (EQ-5D) early after injury predicts long-term pain after burn

BACKGROUND

Chronic pain after burn can have severe physical and psychological effects on former patients years after the initial injury. Although the issue of pain after burn has gained increased attention over the past years, prospective, longitudinal studies are scarce. Our aim was to prospectively investigate consecutive burn patients for pain severity over time and to evaluate the prevalence and characteristics of post-burn pain to 2-7 years after the burn. As an additional aim, the effects of burn and individual-related factors, especially health-related Quality of Life (HRQoL), were investigated.

METHOD

Sixty-seven consecutive burn patients were assessed during acute care at 3, 6, 12 and 24 months, as well as at 2-7 years post-burn. HRQoL, symptoms of post-traumatic stress disorder (PTSD) and other psychiatric disorders were investigated. During the interviews that took place 2-7 years after the injury (mean 4.6±1.9 years), current chronic post-burn pain was assessed using the Brief Pain Inventory-Short Form (BPI-SF).

RESULTS

One-third of the patients still reported pain 2-7 years after the injury. Pain severity and interference with daily life were mainly mild to moderate though they were found to be associated with significantly lower HRQoL. Chronic pain after burn was associated with both burn- and individual-related factors. In logistic regression analysis HRQoL at 3 and 12 months and symptoms of PTSD at 12 months were independent factors in predicting chronic pain after burn.

CONCLUSION

Pain after burn becomes a chronic burden for many former burn patients and decreases HRQoL. A novel finding in this study was that HRQoL assessed early after burn was a predictor for the development of chronic pain. This finding may help to predict future pain problems and serve as an indicator for pain preventive measures.

Prevalence and prediction of prolonged pruritus after severe burns

Years after injury, pruritus is a common and severe problem for many burn patients. However, its characteristics and consequences are often only partially described. The authors therefore performed a prospective detailed examination of burn- and individual-related factors and considered those in relation to pruritus severity. Sixty-seven consecutive burn patients were assessed during acute care, and at 3 and 12 months postburn regarding preburn psychiatric disorders, health-related quality of life, post traumatic stress disorder, and personality traits. Postburn pruritus was subsequently assessed 2 to 7 years postburn using the Questionnaire for Pruritus Assessment. Fifty-one individuals, 76% of the participants, reported burn pruritus any time after the burn. Thirty-three individuals, 49% of the participants, reported ongoing pruritus the last 2 months. Information on the characteristics of pruritus was obtained from 32 of these individuals. Most perceived pruritus as bothersome or annoying and as present every day, 16 (50%) were considered to have severe pruritus, and 11 (34 %) scratched themselves to the point of bleeding. In logistic regressions, this was independently related to TBSA full-thickness burn and health-related quality of life at 3 months, and to TBSA full thickness burn and the personality trait impulsiveness, respectively. About half of the previous burn patients experienced ongoing pruritus on an average of 4.5 years after injury, and half of them had severe pruritus. Scratching oneself to the point of bleeding is linked both to a certain personality and to pruritus. It is suspected that many patients are left without access to the best available treatment.

Making meaning in a burn peer support group: qualitative analysis of attendee interviews

There is a paucity of literature on the personal experiences of burn support group members, the members' perceived benefits of group participation, and the meaning the survivors make of the support they receive. In order to provide effective psychosocial rehabilitation services and to meet the needs of burn survivors, it is important to understand the influence a support group has on its members as well as the personal experiences of those individuals who attend these groups. The purpose of this study was to explore the experiences of burn survivors in a burn survivor support group. Six self-identified burn survivors were interviewed by using a guided in-depth interview technique to explore their experiences in the support group. Key informant interviews and group observations served to triangulate the findings from the individual interviews. The experiences of the group members coalesced around four main themes: acceptance of self, perspective change, value of community, and reciprocity. The findings demonstrated the overall perceived positive impact the support group had on psychosocial recovery. For these members, the group aided the process of adjustment through the encouragement of adaptive coping strategies and the facilitation of community and relationships. Their experiences mirrored much of the literature on psychological growth from adversity. Burn survivors reported unique opportunities that allowed them to integrate their injury into their identity within an encouraging and safe environment. Using these accounts, the authors generated clinical suggestions that may encourage similar growth in other support group settings.

The prevalence of post-traumatic stress disorder in patients with burn injuries, and their quality of life

OBJECTIVE

The aim of this study was to investigate the prevalence of post-traumatic stress disorder (PTSD) in patients with burn injuries undergoing physical therapy, and to evaluate their quality of life.

METHODS

A total of 21 patients who underwent physical therapy for burn injuries between October 2012 and December 2012, in the Physical Therapy and Rehabilitation outpatient clinic of a Training and Research Hospital, were included in the study. The sociodemographic form for data collection, the Clinician- Administered PTSD Scale (CAPS) for the diagnosis of PTSD, and the Short Form 36 (SF-36) Health Survey for the assessment of the quality of life, were used.

RESULTS

Eight patients (38.1%) had PTSD. These patients had poor physical functioning, and indicated a lower rate of role functioning-physical, vitality, and role functioning-social, compared to those without PTSD. However, it did not reach statistical significance. The physical functioning related to the quality of life was statistically significantly lower in the patients with contracture.

CONCLUSIONS

PTSD seems to be an important health issue in patients with burn injuries. Clinicians who attempt to tailor treatment interventions should keep in mind that these patients require psychosocial rehabilitation, as well as physical therapy.

Measuring burn injury outcomes

Burn injury affects all facets of life. Burn care has improved over time. Improved survival after burn injury has resulted in a shift in outcome measurement from inpatient morbidity and mortality to long-term functional and health-related quality-of-life measures. Integration of professionals from different disciplines has enabled burn centers to develop collaborative methods of assessing the quality of care delivered to patients with burns based on their ability to reintegrate into their normal physical, social, psychological, and functional activities. Burn outcomes will continue to develop on the foundation that has been built and will generate evidence-based best practices in the future.

The psychiatric sequelae of burn injury

OBJECTIVE

To examine factors predicting psychiatric morbidity, taking into account the full range of psychiatric disorders before and after burn injury.

METHODS

A cohort of 107 patients consecutively admitted to a Swedish national burn center was examined for lifetime psychiatric morbidity, as well as 94 patients at 1 year postinjury. Sixty-seven individuals, some from that same cohort, were interviewed at 2 to 7years postinjury. The predictive effects of psychiatric history, personality and other risk factors for psychiatric morbidity following burn were evaluated with multiple regression analyses.

RESULTS

The prevalence of having a psychiatric disorder preburn was 57%. One year postinjury 19% had minor or major depression and 23% had subsyndromal or full posttraumatic stress disorder. At 2 to 7years, 31% fulfilled the criteria for a psychiatric disorder. The strongest contributing factors were a history of psychiatric morbidity and neuroticism.

CONCLUSIONS

Two-thirds of the patients had a lifetime psychiatric disorder, and one-third had a psychiatric diagnosis 2 to 7years postburn. Mental health problems can have a major impact on daily life and functional abilities. Thus, identification and treatment of a range of psychiatric disorders, taking into account preburn psychiatric disorders and personality, is important for optimal adjustment after burn.

Aspects of sexual life in patients after burn: the most neglected part of postburn rehabilitation in the developing world

Burn patients are rendered with physical as well as mental scars; the latter usually are more protean in their manifestations. Rehabilitation after burn can be a grueling experience and the associated stress can blemish the patient's sexuality and intimacy. There is dearth of literature regarding the quality of sexual life after burn as well as sexual rehabilitation; it is fully known that a healthy sexual life is intricately related to a person's mental well being and a sexually compromised person can never be totally happy. The objective of this study was to ascertain the degree of satisfaction in postburn patients regarding their sexual lives, parameters associated with sexual dissatisfaction, if present, and ways to address the same. Quality of sexual life was investigated by making burn patients answer the Maudsley Marital Questionnaire (the sexual scale only) 6 months after burn. A control group of nonburn patients matched with the cases was made to answer the same and values were compared for significance. Results of the Maudsley Marital Questionnaire sexual scale were obtained for both groups and compared by means of a χ test (Pearson). The results were found to be highly significant, and there was a marked difference in the values of the two groups (χ = 117.8945, two-tailed P < .0001). A readily palpable deterioration in the sexual lives of burn patients is the most significant finding of this study. Also highlighted were the sociodemographic characteristics of this sexually suffering group and various other relevant parameters.

Impact of personality disorders on health-related quality of life one year after burn injury

PURPOSE

Personality disorders (PDs) are associated with significant distress, disability, and cause great difficulties in life. PDs have been suggested to influence adaptation after major burns, but the potential relationship has not been fully elucidated. This study aimed to describe the prevalence of PDs in 107 patients with major burn injury, and to identify the impact of PDs on perceived patient outcome assessed as health-related quality of life (HRQoL) one year after burn.

METHODS

One burn-specific instrument (Burn Specific Health Scale-Brief (BSHS-B)) and two generic instruments (EuroQol Five Dimensions and Short Form 36 Health Survey) were used, and Psychiatric Axis I and II disorders were assessed one year post burn.

RESULTS

This study identified an above normal prevalence of PDs among individuals afflicted by burn, and participants with PD had a significantly larger lifetime burden of Axis I disorders compared to participants without PD. Participants with PDs scored significantly lower than those without PD in the BSHS-B domain Skin involvement, and the effect of having a PD was related to the subscale Treatment regimens. There was no relationship between the presence of PD and generic HRQoL.

CONCLUSIONS

An implication of these observations is that special rehabilitation efforts including more tailored interventions must be offered to these patients to ensure that the obstacles they perceive to caring for themselves in this respect are eliminated.

IMPLICATIONS FOR REHABILITATION

This study identified an above normal prevalence of PDs among individuals afflicted by burn and these individuals reported poor burn-specific health-related quality of life. The identification of difficulties with compliance and endurance regarding daily skin care may cause negative consequences for optimal rehabilitation and underscore the importance of offering more tailored interventions in rehabilitation. Inflexible behavioral patterns related to the PD diagnosis imply the need for communication strategies by the rehabilitation team, which include flexibility, creativity, and diplomacy. There is a need for further research focusing on identifying the factors that facilitate the individual's own ability to take action and have control.

Impact of facial burns: relationship between depressive symptoms, self-esteem and scar severity

OBJECTIVE

This study assessed the role of self-reported facial scar severity as a possible influencing factor on self-esteem and depressive symptoms in patients with facial burns.

METHOD

A prospective multicentre cohort study with a 6 months follow-up was conducted including 132 patients with facial burns. Patients completed the Patient and Observer Scar Assessment Scale, the Rosenberg Self-esteem Scale and the Hospital Anxiety and Depression Scale. Structural Equation Modeling was used to assess the relations between depressive symptoms, self-esteem and scar severity.

RESULTS

The model showed that patient-rated facial scar severity was not predictive for self-esteem and depressive symptoms six months post-burn. There was, however, a significant relationship between early depressive symptoms and both patient-rated facial scar severity and subsequent self-esteem. The variables in the model accounted for 37% of the variance in depressive symptoms six months post-burn and the model provided a moderately well-fitting representation of the data.

CONCLUSION

The study suggests that self-esteem and depressive symptoms were not affected by self-reported facial scar severity but that earlier depressive symptoms were indicative for a more severe self-reported facial scar rating. Therefore, routine psychological screening during hospitalisation is recommended in order to identify patients at risk and to optimise their treatment.

Guidelines for vocational evaluation following burns: integrated review of relevant process and factors

PURPOSE

A systematic literature review was undertaken to gather evidence to develop a guideline for vocational evaluation following burn injuries (BI). This review aimed to identify the key processes evaluators should follow and the key factors they should consider when completing such evaluations.

METHODS

Steps outlined in Cochrane Handbook of Systematic Review were followed including: development of review question; search strategies and selection criteria; quality appraisal; data extraction; analysis & synthesis; drawing conclusions. Four databases (Pubmed, Medline, CINHAL, PsycINFO) and 14 websites were searched for relevant articles and studies (quantitative, qualitative), reviews and guidelines. Two reviewers independently completed reviews, performed quality assessments and extracted data into evidence tables. Using the ICF model and directed content analysis, key processes and factors were analyzed and synthesized across the evidence.

RESULTS

A total of 138 articles were identified using the key words (e.g. burns, work). Studies, reviews and guidelines were retrieved if they focused on adults and discussed the processes relevant to vocational evaluation and/or factors associated with successful return to work (RTW) following a BI. Items were excluded if they did not address adults who had suffered a burn, the process of work or RTW, or challenges related to work after a BI. Using the above criteria 76 items were retrieved for full review. Fifty-six items remained after the quality appraisal. Results were integrated to develop the Evidence-based Framework for Vocational Evaluation Following Burn Injury.

CONCLUSIONS

This framework outlines 7 key processes relevant to vocational evaluation following burn injuries.

Deployment-related injury and posttraumatic stress disorder in US military personnel

BACKGROUND

The current military conflicts in Iraq and Afghanistan have resulted in the most US casualties since the Vietnam War. Previous research on the association between deployment-related injury and posttraumatic stress disorder (PTSD) has yielded mixed results.

OBJECTIVES

To examine the effect of battle injury (BI) relative to non-battle injury (NBI) on the manifestation of PTSD symptoms in military personnel and to assess the demographic, injury-specific, and pre-injury factors associated with PTSD following a BI.

PATIENTS AND METHODS

A total of 3403 personnel with deployment-related injury (1777 BI and 1626 NBI) were identified from the Expeditionary Medical Encounter Database. Records were electronically matched to Post-Deployment Health Assessment (PDHA) data completed 1-6 months post-injury. The PTSD screening outcome was identified using a four-item screening tool on the PDHA.

RESULTS

Compared to those with NBI, personnel with BI had more severe injuries, reported higher levels of combat exposure, and had higher rates of positive PTSD screen. After adjusting for covariates, personnel with BI were twice as likely to screen positive for PTSD compared to those with NBI (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.60-2.75). In multivariable analysis among battle-injured personnel only, moderate and serious-severe injury (OR, 1.49; 95% CI, 1.12-2.00 and OR, 1.64; 95% CI, 1.01-2.68, respectively), previous mental health diagnosis within 1 year of deployment (OR, 2.69; 95% CI, 1.50-4.81), and previous BI (OR, 1.96; 95% CI, 1.22-3.16) predicted a positive PTSD screen.

CONCLUSIONS

Military personnel with BI have increased odds of positive PTSD screen following combat deployment compared to those with NBI. Post-deployment health questionnaires may benefit from questions that specifically address whether service members experienced an injury during combat.

Psychiatric morbidity predicts perceived burn-specific health 1 year after a burn

OBJECTIVE

Individual factors such as gender, age, coping and personality traits and injury-related factors such as injury severity have been implicated as risk factors for poor perceived health after burns. As psychiatric morbidity is common in individuals who sustain burns, the aim of this study was to examine the effect of preinjury psychiatric problems on perceived health after injury.

METHOD

A total of 85 consecutive patients treated at a national burn center were prospectively assessed: the patients were interviewed during acute care with the Structured Clinical Interview for DSM-IV Axis I Disorders. One year after injury, perceived health was assessed with the Burn-Specific Health Scale-Brief (BSHS-B). Multiple regression analyses were used to evaluate the predictive effect of preinjury psychiatric history on perceived postinjury health.

RESULTS

Psychiatric morbidity, especially mood disorders, affected outcome for six of the nine BSHS-B subscales, with the covariates mainly being the length of hospital stay and total burn size.

CONCLUSION

The results show that a history of preinjury psychiatric disorders, especially during the year before the burn, affects perceived outcome regarding both physical and psychological aspects of health 1 year after injury and that it is a risk factor for worse perceived outcome.

Burn Specific Health up to 24 months after the Burn-A prospective validation of the simplified model of the Burn Specific Health Scale-Brief

BACKGROUND

Outcome after burn injury is a multidimensional concept, but few multidimensional, injury-specific outcome measures have been psychometrically evaluated. A recent cross-sectional study using the Burn Specific Health Scale-Brief (BSHS-B) found three psychometrically sound health domains: function, skin involvement, and affect and relations. The aim of this study was to reexamine the psychometric properties of the BSHS-B using a prospective study design.

METHODS

Ninety-four consecutive adult patients with burns were included and asked to fill in questionnaires, the BSHS-B, the Hospital Anxiety and Depression Scale, and the short-form 36 (SF-36), at 6 months, 12 months, and 24 months postburn.

RESULTS

The factor structure was replicated and the three domains, function, skin involvement, and affect and relations, had excellent internal consistency. Over time the scores of function and skin involvement increased, indicating health improvement, whereas the domain affect and relations did not change over time. At 6 months and 12 months postburn, all domains were associated with burn severity. The function domain was highly associated with the SF-36 subscales physical functioning and role-physical, the affect and relations domain was highly associated with the Hospital Anxiety and Depression Scale and the SF-36 subscales denoting psychological health, and the domain skin involvement was highly associated with subscales indicating role-concerns, social functioning, vitality, and mental health.

CONCLUSION

The psychometric properties of the BSHS-B domains were excellent and they had intelligible concurrent associations with other measures. Thus, the simplified model of the BSHS-B is a reliable, valid, and useful tool in describing postburn health over time.

Stress disorder and PTSD after burn injuries: a prospective study of predictors of PTSD at Sina Burn Center, Iran

BACKGROUND

A burn injury can be a traumatic experience with tremendous social, physical, and psychological consequences. The aim of this study was to investigate the existence of post-traumatic stress disorder (PTSD) and predictors of PTSD Checklist score initially and 3 months after injury in burns victims admitted to the Sina Burn Center in north-west Iran.

METHODS

This prospective study examined adult patients aged 16-65 years with unintentional burns. The PTSD Checklist was used to screen for PTSD.

RESULTS

Flame burns constituted 49.4% of all burns. Mean PTSD score was 23.8 ± 14.7 early in the hospitalization period and increased to 24.2 ± 14.3, 3 months after the burn injury. Twenty percent of victims 2 weeks into treatment had a positive PTSD screening test, and this figure increased to 31.5% after 3 months. The likelihood of developing a positive PTSD screening test increased significantly after 3 months (P < 0.01). Using multivariate regression analysis, factors independently predicting PTSD score were found to be age, gender, and percentage of total body surface area burned.

CONCLUSION

PTSD was a problem in the population studied and should be managed appropriately after hospital admission due to burn injury. Male gender, younger age, and higher total body surface area burned may predict a higher PTSD score after burn injury.