Maarten J. M. van Son

Psychopathology and psychological problems in patients with burn scars: epidemiology and management.

Burn injury is often a devastating event with long-term physical and psychosocial effects. Burn scars after deep dermal injury are cosmetically disfiguring and force the scarred person to deal with an alteration in body appearance. In addition, the traumatic nature of the burn accident and the painful treatment may induce psychopathological responses.Depression and post-traumatic stress disorder (PTSD), which are prevalent in 13–23% and 13–45% of cases, respectively, have been the most common areas of research in burn patients. Risk factors related to depression are pre-burn depression and female gender in combination with facial disfigurement. Risk factors related to PTSD are pre-burn depression, type and severity of baseline symptoms, anxiety related to pain, and visibility of burn injury. Neuropsychological problems are also described, mostly associated with electrical injuries. Social problems include difficulties in sexual life and social interactions. Quality of life initially seems to be lower in burn patients compared with the general population. Problems in the mental area are more troublesome than physical problems. Over a period of many years, quality of life was reported to be rather good. Mediating variables such as low social support, emotion and avoidant coping styles, and personality traits such as neuroticism and low extraversion, negatively affect adjustment after burn injury.Few studies of psychological treatments in burn patients are available. From general trauma literature, it is concluded that cognitive (behavioral) and pharmacological (selective serotonin reuptake inhibitors) interventions have a positive effect on depression. With respect to PTSD, exposure therapy and eye movement reprocessing and desensitization are successful. Psychological debriefing aiming to prevent chronic post-trauma reactions has not, thus far, shown a positive effect in burn patients. Treatment of problems in the social area includes cognitive-behavioral therapy, social skills training, and community interventions. Sexual health promotion and counseling may decrease problems in sexual life.In conclusion, psychopathology and psychological problems are identified in a significant minority of burn patients. Symptoms of mood and anxiety disorders (of which PTSD is one) should be the subject of screening in the post-burn phase and treated if indicated. A profile of the patient at risk, based on pre-injury factors such as pre-morbid psychiatric disorder and personality characteristics, peri-traumatic factors and post-burn factors, is presented. Finally, objective characteristics of disfigurement appear to play a minor role, although other factors, such as proneness to shame, body image problems, and lack of self-esteem, may be of significance.

Characteristics of the Edinburgh post natal depression scale in The Netherlands

The Edinburgh Post Natal Depression Scale (EPDS), a 10-item self-rating depression scale, was translated into Dutch and compared in 293 postpartum women with other self-rating scales commonly in use in The Netherlands. In addition the structure of EPDS was analyzed by various factor analyses to reveal some of its dimensional aspects. The Dutch version of EPDS was found to be a self-rating scale with good psychometric characteristics which measures what it claims to measure: the strength of depressive symptoms. With LISREL a 2-factor model could be distinguished which contained subscales reflecting depressive symptoms and cognitive anxiety.

Relations among peritraumatic dissociation and posttraumatic stress: A meta-analysis

A meta-analysis was performed on the empirical literature which addressed the relationship of peritraumatic dissociation to posttraumatic stress (PTS). Extensive literature searches were conducted to identify as many relevant studies as possible, and revealed 59 independent eligible studies. All studies were coded using a detailed code sheet that included effect measures, variables that indicated the methodological quality of the studies, and substantial variables that might theoretically affect the relationship between peritraumatic dissociation and PTS. A significant positive relation between peritraumatic dissociation and PTS was found. Differences in the methodological rigor between studies - time elapsed since peritraumatic dissociation, design, sample type, and study type - significantly and sufficiently explained the variability in effect sizes between studies. Theoretical variables did not explain such variability. Although results underline earlier findings, due to designs of the reviewed studies no conclusions could be drawn as to causal relations between peritraumatic dissociation and PTS.

Prediction of depression in the postpartum period: a longitudinal follow-up study in high-risk and low-risk women

AIM The present study investigates both the antenatal prediction of the occurrence of depression during the first year postpartum and the course of depression in populations at different degrees of risk. METHODS In a population-based prospective study, 1618 women were screened during mid-pregnancy for risk factors with regard to depression. High-risk and low-risk women were identified, and depression (Research Diagnostic Criteria, RDC) was assessed at 32 weeks gestation and at 3, 6, and 12 months postpartum. RESULTS In the high-risk group (n=97), 25% of the women were depressed during the first year postpartum compared to 6% of the low-risk women (n=87). At 3 months postpartum, significantly more high-risk (17%) than low-risk women (1%) were depressed. While prevalence rates decreased after 3 months postpartum in the high-risk group, no significant fluctuations of prevalence rates were found in the low-risk group. Two risk factors were independently predictive of depression during the postpartum period: a personal history of depression, and high depressive symptomatology during mid-pregnancy. CONCLUSIONS Women at high risk and low risk for depression during the early postpartum period can be detected during pregnancy. High-risk women were only at particular risk during the first 3 months postpartum.

Psychological consequences of pediatric burns from a child and family perspective: a review of the empirical literature.

In order to inform clinical practice, we reviewed the empirical literature on emotional, behavioral and social outcomes in children with burns and their families published between 1989 and 2011. A systematic search of the literature yielded 75 articles. Qualitative synthesis of the results showed that child anxiety, traumatic stress reactions, and behavioral problems were considerably prevalent in the first months after the burn event. Among parents, high rates of posttraumatic stress, depressive symptoms, and guilt feelings were found. Cross-sectional studies, often performed many years after the injury, suggest that some children experience long-term psychological problems, such as anxiety, depression, and difficulties with social functioning. However, there was little evidence that behavior in general, self-esteem, or body image were impaired in the total population of children with a history of burns. Long-term family outcome studies suggest that psychological problems persist in a substantial subgroup of parents. Child peritraumatic factors anxiety and pain, parental posttrauma psychological reactions, and family functioning were the most consistently reported factors associated with child outcome. More recent studies have demonstrated that burn severity may have an indirect effect on child postburn psychosocial outcome. Clinical implications, methodological strengths and limitations of the reviewed studies, and directions for future research are discussed.

Relations Among Peritraumatic Dissociation and Posttraumatic Stress: A Critical Review

ABSTRACT This paper critically reviews the empirical literature addressing the relationship of peritraumatic dissociation to posttraumatic stress. PSYCHLIT and MEDLINE literature searches were conducted to identify relevant studies. The list of articles generated was supplemented by a review of their bibliographies, which resulted in a total of 53 empirical studies. These studies were classified according to the type of potentially traumatizing event investigated and discussed. In the majority of studies, evidence was found for a positive association between peritraumatic dissociation and posttraumatic stress. However, research in this area is limited by several methodological differences and shortcomings with respect to study design, sample characteristics, measurement instruments, and control for moderating or mediating variables. In addition, research is also limited by conceptual problems and the lack of specific time parameters for the occurrence of peritraumatic dissociation. The literature is evaluated according to these methodological differences or shortcomings, and directions for future research are provided.

Arousal training for children suffering from nocturnal enuresis: a 212-year follow-up

Arousal Training is a fast, simple, and effective form of bibliotherapy for nocturnal enuresis with non-clinical children between 6 and 12 years of age. The parents act as therapists. They reward the operant behavior-pattern following the urine alarm. The success rate is 98% (N = 41), which is significantly high when compared to the control conditions (79%, N = 86). There was a response rate of 100% and no drop-out from therapy. All parents (N = 127) completed and returned the record. The results of a follow-up of this bibliotherapy (N = 113) 2 1/2 years later are presented. The success rate of Arousal Training was still significantly higher (92% continent) when compared to the urine device with specific instructions (77%) and urine alarm only (72%). Arousal Training is the treatment of choice for non-clinical enuretic children between 6 and 12 years of age.

Measuring depression in women around menopausal age. Towards a validation of the Edinburgh Depression Scale

BACKGROUND The relationship between menopause and depression is still rather unclear. Studies using different methodology - especially those lacking a clear definition of depression - are hardly comparable. Since the Edinburgh Depression Scale (EDS) is not influenced by (menopause-related) somatic symptoms, the validity of the Dutch version of this instrument was investigated in a large community sample of menopausal women. METHODS In 951 women, aged between 47 and 56 years, depressive symptomatology was measured using the EDS, together with a syndromal diagnosis of depression using Research Diagnostic Criteria. RESULTS Twenty-two percent of the subjects had scores of 12 or higher on the EDS. With this cut-off point, depression (major or minor) was detected with a sensitivity of 66%, a specificity of 89%, and a positive predictive value (PPV) of 62%. A cut-off score of 15 or higher detected half of the women with major depression (sensitivity 73%, specificity 93%, PPV 53%). LIMITATIONS Screening of depressive symptomatology at menopausal age in women of the community can only partly detect women with clinical depression. The relation between menopausal status and depression should preferentially be investigated using a longitudinal rather than a cross-sectional design. CONCLUSIONS The EDS, which is easy to implement in both community and clinical settings (e.g., General Practice), might be used as an effective screening tool for detecting women at menopausal age who are at risk for depression, followed by clinical evaluation in those with high scores.

Affect Dysregulation and Dissociation in Borderline Personality Disorder and Somatoform Disorder: Differentiating Inhibitory and Excitatory Experiencing States

Affect dysregulation and dissociation may be associated with borderline personality disorder (BPD) and somatoform disorder (SoD). In this study, both under-regulation and over-regulation of affect and positive and negative somatoform and psychoform dissociative experiences were assessed. BPD and SoD diagnoses were confirmed or ruled out in 472 psychiatric inpatients using clinical interviews and clinical multidisciplinary consensus. Affect dysregulation and dissociation were measured using self-reports. Under-regulation (but not over-regulation) of affect was moderately related to positive and negative psychoform and somatoform dissociative experiences. Although both BPD and SoD can involve dissociation, there is a wide range of intensity of both somatoform and psychoform dissociative phenomena in patients with these diagnoses. Compared with other groups, SoD patients more often reported low levels of dissociative experiences and reported fewer psychoform (with or without somatoform) dissociative experiences. Compared with the other groups, patients with both BPD and SoD reported more psychoform (with or without somatoform) dissociative experiences. Evidence was found for the existence of 3 qualitatively different forms of experiencing states. Over-regulation of affect and negative psychoform dissociation, commonly occurring in SoD, can be understood as inhibitory experiencing states. Under-regulation of affect and positive psychoform dissociation, commonly occurring in BPD, can be understood as excitatory experiencing states. The combination of inhibitory and excitatory experiencing states commonly occurred in comorbid BPD + SoD. Distinguishing inhibitory versus excitatory states of experiencing may help to clarify differences in dissociation and affect dysregulation between and within BPD and SoD patients.

AFFECT DYSREGULATION IN BORDERLINE PERSONALITY DISORDER AND SOMATOFORM DISORDER: DIFFERENTIATING UNDER- AND OVER-REGULATION

Although affect dysregulation is considered a core component of borderline personality disorder (BPD) and somatoform disorders (SoD), remarkably little research has focused on prevalence and nature of affect dysregulation in these disorders. BPD and SoD diagnoses were confirmed or ruled out in 472 psychiatric inpatients using clinical interviews. Three qualitatively different forms of affect dysregulation were identified: under-regulation, over-regulation of affect and combined under- and over-regulation of affect. BPD was associated with under-regulation of affect, and SoD was associated with over-regulation of affect. However, one in five patients with BPD also reported substantial over-regulation, and one in six patients with SoD reported clinically significant under-regulation, and the comorbid BPD and SoD group reported more frequently both over- and under-regulation than patients diagnosed with BPD or SoD alone or those with other psychiatric disorders.