Mimmie Willebrand

Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity

BACKGROUND Psychiatric history has been suggested to have an impact on long-term adjustment in burn survivors. A rigorous, prospective, longitudinal approach was used to study psychiatric history in a population-based burn sample and its impact on symptomatology of depression and posttraumatic stress disorder (PTSD) at a 12-month follow-up. METHODS Seventy-three consecutive patients admitted to the Uppsala Burn Unit were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition for psychiatric disorders, of whom 64 were also assessed after 12 months. RESULTS Forty-eight patients (66%) presented with at least one lifetime psychiatric diagnosis; major depression (41%), alcohol abuse or dependence (32%), simple phobia (16%), and panic disorder (16%) were most prevalent. At 12-months postburn, 10 patients (16%) met criteria for major depression, 6 (9%) for PTSD, and 11 (17%) for subsyndromal PTSD. Patients with lifetime anxiety disorder and with lifetime psychiatric comorbidity were more likely to be depressed at 12 months, whereas those with lifetime affective disorder, substance use disorder and psychiatric comorbidity were more likely to have symptoms of PTSD. CONCLUSIONS Two-thirds of burn survivors exhibit a history of lifetime psychiatric disorders. Those with a psychiatric history have a higher risk of postburn psychiatric problems.

Return to work and health-related quality of life after burn injury.

OBJECTIVE Although severe burn injury is associated with long-term rehabilitation and disability, research on returning to work in burn patients is limited. The aims of this study were: (i) to explore injury- and personality-related predictors of returning to work, and (ii) to compare health-related quality of life and health outcome in working versus non-working individuals. DESIGN Cross-sectional study. SUBJECTS Forty-eight former patients with pre-burn employment were evaluated on average 3.8 years after the burn. METHODS Data were collected from medical records and by a questionnaire in which the patients were asked about their main activity status described in the terms: work, studies, pension, disability pension, sick leave or unemployment. It also contained the Swedish universities Scales of Personality, SF-36, Burn Specific Health Scale-Brief, items assessing fear-avoidance, Impact of Event Scale-Revised and Hospital Anxiety and Depression Scale. RESULTS Thirty-one percent had not returned to work. In logistic regression, returning to work was associated with time since injury, the extent of full-thickness injuries, and the personality trait embitterment. Those who did not work had lower health-related quality of life, poorer burn-specific health, more fear-avoidance and more symptoms of posttraumatic stress disorder, but they did not differ from those who were working regarding general mood. CONCLUSION Returning to work was explained by both injury severity and personality characteristics. Those who did not work were characterized by low health-related quality of life and poorer trauma-related physical and psychological health.

Pruritus, Personality Traits and Coping in Long-term Follow-up of Burn-injured Patients

Pruritus is a major problem after burn injury; however, prevalence and predictors of prolonged pruritus are not known. The aims were to assess frequency of pruritus and the role of personality traits and coping in prolonged pruritus. The participants were burn patients injured 1-18 years earlier (n=248). Pruritus was assessed with an item from the Abbreviated Burn Specific Health Scale, personality was assessed with the Swedish universities Scales of Personality, and coping with the Coping with Burns Questionnaire. In all, 60% of the participants had pruritus at follow-up, however as the time after injury increased, the number of patients with persistent itch decreased. In logistic regression, 39% of the likelihood of having persistent pruritus was explained by greater extent of burn, less time after injury, and psychological features (being less assertive, and using more instrumental but less emotional support). In summary, chronic burn-related pruritus is rather common and psychological factors such as anxiety-related traits and coping are significantly associated with its presence.

Validation of a Swedish version of the Impact of Event Scale-Revised (IES-R) in patients with burns

The Impact of Event Scale (IES) and the Impact of Event Scale-Revised (IES-R) are often used as self-report instruments for symptoms of post-traumatic stress disorder (PTSD). However, there are few validations of the IES and the IES-R against structured clinical interviews. In this study the two scales, together with the three subscales of the IES-R, were assessed for their agreement with a diagnosis of PTSD in patients with burns 1 year after injury. Sixty patients with burns were evaluated 1 year after injury using the Structured Clinical Interview for the DSM-IV Axis I (SCID-I) psychiatric disorders and a Swedish version of the IES-R. The total score of the IES-R had the best discriminant ability (0.89) with a sensitivity of 1.0 and a specificity of 0.78. In conclusion, the total IES-R had good properties as a screening tool for PTSD and subsyndromal PTSD 1 year after burn injury.

A Simplified Domain Structure of the Burn-Specific Health Scale-Brief (BSHS-B) : A Tool to Improve Its Value in Routine Clinical Work

BACKGROUND Injury-specific instruments with good psychometric properties are valuable in the assessment of health status after trauma. Previous studies of burn-specific health have attempted to create broad domains such as physical and psychological health, but these domains have not been validated. In this study, burn-specific health domains were explored and validated by a factor analytic approach. METHODS Participants were 334 former burn patients injured between 1980 and 2000. Data were collected from medical charts and by a postal questionnaire, the Burn Specific Health Scale-Brief (BSHS-B). The nine subscales of the BSHS-B were subjected to second-order factor analysis. The sample was split into two subsamples that were equal with respect to burn severity. RESULTS The factor structure was well replicated in each of the subsamples and in the total sample. Three internally consistent and well separated domains were derived: affect and relations (BSHS-B subscales interpersonal relationships, affect, sexuality), function (simple abilities, hand function), and skin involvement (heat sensitivity, treatment regimens, body image). The work subscale of the BSHS-B was excluded from the analysis because of consistent double loadings. The three domains had intelligible associations with injury-specific and sociodemographic variables. CONCLUSION The underlying structure of the BSHS-B comprises three clinically meaningful health domains. The work subscale is not part of these domains and can be considered a separate outcome domain. The domain scores increase the understanding of outcome after burn injury and could prove useful in clinical use of the BSHS-B.

Exploration of coping patterns in burned adults: cluster analysis of the coping with burns questionnaire (CBQ)

The aim of this study was to investigate coping patterns, health status and personality traits in burned adults. Subjects were 161 burn patients treated at the Uppsala University Hospital between 1980 and 1995. Measures were the coping with burns questionnaire (CBQ), the burn specific health scale-brief (BSHS-B) and the Swedish universities scales of personality (SSP). The CBQ was subjected to a K-means cluster analysis and three clusters were derived: extensive, adaptive, and avoidant copers. Extensive copers used the most coping and took an intermediate role regarding health status and the personality trait of neuroticism. Adaptive copers preferred the strategies emotional support and optimism/problem solving, and had the highest health status ratings. Avoidant copers preferred the strategy avoidance and reported the lowest use of emotional support and optimism/problem solving. They had the lowest health status ratings and the highest ratings on neuroticism and aggressiveness. The clusters did not differ in severity of injury or time since injury. In conclusion, coping patterns can be discerned among burn patients, and those individuals preferring avoidance and lacking other coping options displayed more maladaptive traits and poorer health status years after the burn.

Personality characteristics and perceived health problems after burn injury.

The relationship between personality traits and the perceived outcome of burn injury 1 to 18 years (mean, 9.2 years) after severe burn injury was evaluated in 166 individuals treated at the Uppsala Burn Unit. The perceived outcome was measured with the Burn Specific Health Scale-Brief (BSHS-B) and was related to personality traits evaluated by means of the Swedish universities Scales of Personality. After controlling for age at inquiry, time since injury, burn area, and sex, a stepwise logistic regression analysis revealed an association between the Swedish universities Scales of Personality domain Neuroticism and Bad outcome in all BSHS-B domains, both psychosocial and physical, and Insufficient outcome in the domains Work, Body image, Affect, and BSHS-B total score. The neurotic traits Somatic trait anxiety, Psychic trait anxiety, Stress susceptibility, Embitterment, and Mistrust each or in different combinations explained the observed relationships. The data suggest that personality is related to health status because it is perceived a long time after severe burn injury and that its effect is not confined only to psychological but also to physical aspects of life.

Validation of the EQ-5D questionnaire in burn injured adults

BACKGROUND Health-related quality of life (HRQoL) is an important aspect of adaptation after burn. The EQ-5D is a standardized generic instrument for assessing HRQoL. Its psychometric properties in a group of burn injured individuals are, however, not known. METHODS Seventy-eight consecutive patients admitted to a burn unit were included in a prospective longitudinal study. The participants completed the EQ-5D during acute care, and at 3, 6, and 12 months after the burn. At 6 and 12 months after the burn they also completed the Short-Form 36 Health Survey (SF-36) and the Burn Specific Health Scale-Brief (BSHS-B). RESULTS High feasibility of the EQ-5D was demonstrated through a high response rate and a low proportion of missing or invalid answers. The floor and ceiling effects were small. Construct validity was demonstrated through good differentiation between health states and good discrimination of health states over time. The EQ-5D was associated with burn severity and discriminated between clinical subgroups in an expected manner. Criterion validity was demonstrated through significant correlations between the EQ-5D and subscales of the SF-36 and the BSHS-B. CONCLUSIONS The EQ-5D has good psychometric properties, it is short and easy to administer and thus useful in assessment of HRQoL after burn.

Development of the coping with burns questionnaire

Abstract The aim of this study was to develop a questionnaire for measuring coping following burn injury. Furthermore, the relationship between coping and health status was explored. Participants were 162 burn patients at the Burn Unit of Uppsala University Hospital who were seen between 1980 and 1995. Health status was measured with an abbreviated version of the Burn Specific Health Scale (BSHS-B). Coping was measured retrospectively with the Coping with Burns Questionnaire (CBQ) containing 33 items. A principal components factor analysis of the CBQ resulted in six factors, with alphas ranging between 0.56 and 0.83. These were Re-evaluation/adjustment, Avoidance, Emotional support, Optimism/problem solving, Self-control, and Instrumental action. Re-evaluation/adjustment, Avoidance, Self-control and Instrumental action were related to a higher appraisal of some of the symptoms measured by the BSHS-B, but Avoidance was related to all symptoms in the BSHS-B. Emotional support and Optimism/problem solving were related to less symptom reporting. Implications for the aftercare of burn patients are discussed as well as suggestions for subsequent studies of coping and symptoms following burn injury.

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.