Approach-avoidance coping conflict in a sample of burn patients at risk for posttraumatic stress disorder.

BACKGROUND: Following an acute burn injury, higher distress is consistently observed among individuals exhibiting a conflict between approach coping (e.g., processing) and avoidance coping (e.g., suppression) relative to those individuals who use only one of these methods. Study objectives were to determine if contradictory coping messages would lead to such approach-avoidance coping conflict and to determine if experiment-induced coping conflict is also associated with higher distress. METHODS: Participants (n=59 adults hospitalized with acute burn injuries) were assigned randomly to experimental conditions differing in the order in which training was provided in two ways of coping with posttrauma re-experiencing symptoms (i.e., process-then-suppress versus suppress-then-process). The primary dependent variable was coping behavior during the 24-hr posttraining period. Coping behavior was categorized as approach coping (processing), avoidance coping (suppressing), or approach-avoidance coping conflict (both) on the basis of median splits on subscales assessing these behaviors. Secondary analyses examined the relationship between this experiment-induced coping conflict and re-experiencing symptoms. RESULTS: Results indicated that participants in the process-then-suppress condition, relative to the suppress-then-process condition, were significantly more likely to exhibit approach-avoidance coping conflict (i.e., above median split on both processing and suppressing) during the next 24 hr. Furthermore, approach-avoidance coping conflict was associated with greater re-experiencing symptoms assessed via self-report and by blinded coding of recorded speech. CONCLUSIONS: It is concluded that the order of coping skill training can influence treatment outcome, success of coping methods, and overall levels of distress. therefore, training in stabilizing and calming methods should precede training in active processing following stressful life events.

From survival to socialization: a longitudinal study of body image in survivors of severe burn injury.

OBJECTIVE: Little is known about the course of body image dissatisfaction following disfiguring injury or illness. The objective of this study was to test a proposed framework for understanding the trajectory of body image dissatisfaction among burn survivors and to longitudinally investigate the role of body image in overall psychosocial functioning. METHODS: A sample of 79 survivors of severe burn injuries completed the Satisfaction with Appearance Scale (SWAP), the Importance of Appearance subscale of the Multidimensional Body-Self Relations Questionnaire, and the SF-36 in the hospital and at 6 and 12 months postdischarge (SWAP and SF-36). A repeated-measures analysis of covariance model was used to assess the course of body image dissatisfaction over time, and a path analysis model tested the role of body image dissatisfaction in mediating the relationship between preburn and postburn psychosocial functioning. RESULTS: Female sex (P<.05), total body surface area burned (P<.01), and importance of appearance (P<.01) predicted body image dissatisfaction. From hospitalization to 12 months postdischarge, body image dissatisfaction increased for women (P<.01) and individuals with larger burns (P<.01) compared, respectively, to men and individuals with smaller burns. In the path analysis, body image dissatisfaction was the most salient predictor of psychosocial function at 12 months (beta=.53, P<.01) and mediated the relationship between preburn and 12-month psychosocial function. CONCLUSION: Findings from this study suggest the importance of routine psychological screening for body image distress during hospitalization and after discharge.

Validation of the Perceived Stigmatization Questionnaire for Brazilian adult burn patients.

Currently, there is no questionnaire to assess perceived stigmatization among people with visible differences in Brazil. The Perceived Stigmatization Questionnaire (PSQ), developed in the United States, is a valid instrument to assess the perception of stigmatizing behaviours among burn survivors. The objective of this cross-sectional and multicentre study was to assess the factor structure, reliability and validity of the Brazilian Portuguese version of the PSQ in burn patients. A Brazilian version of the 21-item PSQ was answered by 240 adult burn patients, undergoing rehabilitation in two burns units in Brazil. We tested its construct validity by correlating PSQ scores with depression (Beck Depression Index-BDI) and self-esteem (Rosenberg Self-Esteem Scale-RSE), as well as with two domains of the Revised Burn Specific Health Scale-BSHS-R: affect and body image, and interpersonal relationships. We used Confirmatory Item Factor Analysis (CIFA) to test whether the data fit a measurement model involving a three-factor structure (absence of friendly behaviour; confusing/staring behaviour; and hostile behaviour). We conducted Exploratory Factor Analyses (EFA) of the subscale in a 50% random sample of individuals (training split), treating items as ordinal categorical using unweighted least squares estimation. To assess discriminant validity of the Brazilian version of the PSQ we correlated PSQ scores with known groups (sex, total body surface area burned, and visibility of the scars) and assessed its reliability by means of Cronbach's alpha and using test-retest. Goodness-of-fit indices for confirmatory factor analysis were satisfactory for the PSQ, but not for the hostile behaviour subscale, which was modified to improve fit by eliminating 3 items. Cronbach's alphas for the PSQ refined version (PSQ-R) ranged from 0.65 to 0.88, with test-retest reliability 0.87 for the total score. The PSQ-R scores correlated strongly with depression (0.63; p < 0.001), self-esteem (-0.57; p < 0.001), body image (-0.63; p < 0.001), and interpersonal relationships (-0.55; p < 0.001). PSQ-R total scores were significantly lower for patients with visible scars (effect size = 0.51, p = 0.029). The PSQ-R showed reliability and validity comparable to the original version. However, the cross-cultural structure of the subscale "hostile behaviour" and sensitivity to change of the PSQ should be further evaluated.

Symptoms of depression predict change in physical health after burn injury.

This study investigated the prevalence of symptoms of depression in patients hospitalized with severe burns and the association of symptoms of depression in the hospital with physical health 2 months after discharge, controlling for pre-burn physical health as measured by the SF-36 physical composite score. Survivors of acute burns were evaluated during the hospitalization (N=262) and at 1 week (N=165) and 2 months (N=100) after discharge. The prevalence of at least mild to moderate symptoms of depression (Beck Depression Inventory > or = 10) ranged from 23% to 26%. In-hospital symptoms of depression predicted change in physical health from pre-burn to 2 months post-discharge (p=.02), controlling for patient demographics, burn severity, and symptoms of PTSD. These results suggest that patients should be screened for depression, both in-hospital and during rehabilitation after discharge.

The reliability and validity of the Perceived Stigmatization Questionnaire (PSQ) and the Social Comfort Questionnaire (SCQ) among an adult burn survivor sample.

In this study, 361 adult burn survivors completed the Perceived Stigmatization Questionnaire (PSQ), the Social Comfort Questionnaire (SCQ), and other measures. Both the PSQ and SCQ had good internal consistency indices. Factor analysis of the PSQ yielded 3 factors (absence of friendly behavior, confused/staring behavior, and hostile behavior). The SCQ had 1 factor. Conjoint factor analysis with measures of related constructs (body esteem, body-esteem importance, depression, social support) suggested that PSQ and SCQ measure distinct constructs. Correlations with the related psychosocial constructs and burn characteristics suggested the PSQ and SCQ have good convergent and discriminant validity. Limitations of the study are discussed.

A survey of burn professionals regarding the mental health services available to burn survivors in the United States and United Kingdom.

UNLABELLED: This investigation surveyed burn health professionals in the UK and US to investigate the psychosocial issues facing burn survivors and the psychological services available to them through their burns service. METHODS: One hundred and sixty six burn care professionals (132 from the United States and 34 from the United Kingdom) from 76 different hospitals (60 in the US and 16 in the UK) completed an online survey. Mental health practitioners (MHPs) answered questions regarding their psychotherapy practice with burn survivors. RESULTS: Respondents reported that psychosocial issues are common among burn survivors. Burn teams in the UK were more likely than those in the US to include psychologists, but social workers were more common in the US. Participants reported that routine screening for psychosocial issues was more common in the UK than the US, and indicated it was easier for burn survivors to access mental health care after discharge in the UK. Burn services in both countries routinely referred burn survivors to support organizations such as the Phoenix Society or Changing Faces. The preferred mental health treatment modality in the UK was psychotherapy without medications. Reported psychotropic medications use was more common in the US. MHPs had two primary orientations - eclectic and cognitive behavioral therapy. Among MHPs there was a modest tendency to favor evidence-based interventions. DISCUSSION: The provision of mental health services varies between these two countries. Creating international standards for assessing and treating psychosocial complications of burns could facilitate the improvement of burn mental health services.

Coping with body image changes following a disfiguring burn injury.

The influence of emotion-focused coping on distress following disfiguring injury was examined. Two types of emotion-focused coping (i.e., venting emotions vs. mental disengagement) were assessed in 78 patients with burn injury at baseline during acute hospitalization. Body image dissatisfaction (BID) was assessed 1 week and 2 months following discharge. Use at baseline of both venting emotions and mental disengagement, compared with use of only one or neither of these coping methods, was associated at the 2-month postdischarge follow-up with significantly higher BID related to nonfacial aspects of appearance and with a greater negative social impact of disfigurement. D. M. Wegner's (1994) theoretical model of mental control and a proposed motivational analysis are used to interpret these findings.

Personality, coping, chronic stress, social support and PTSD symptoms among adult burn survivors: a path analysis.

This paper presents a longitudinal study of the relationship between personality, coping, chronic stress, social support and posttraumatic stress disorder (PTSD). A hypothesized model of the relationship between the predictor variables and PTSD symptoms was proposed. Path analyses was completed to test the model. One hundred fifty-eight adult burn survivors completed questionnaires measuring each of the variables in the hospital. Of those 124 and 94 completed the PTSD measure at 1 month and 6 months postdischarge, respectively. The hypothesized model fit the data at each time point with slight variations. The model accounted for 46 and 29% of the variance of PTSD symptoms at hospitalization and 1 month. Neuroticism was the most important personality dimension in predicting PTSD. Avoidant Coping and Social Support mediated a high percentage of the relationship between Neuroticism and PTSD. The best predictor of PTSD symptoms at 1 and 6 months was PTSD symptoms at hospitalization.

Regulating acute posttrauma distress.

The influence of emotion-approach and emotion-avoidance methods of coping on the development (cohort 1) and persistence (cohort 2) of posttraumatic stress symptoms was examined. The two coping methods and the frequency and intensity of intrusive, avoidant, and hyperarousal symptoms were assessed in separate series of 71 and 94 hospitalized acute burn-injured patients. In both samples, subjects who frequently used both mental distancing (emotion-avoidance) and venting emotions (emotion-approach), relative to subjects who used only one or neither of the two coping methods, had higher levels of posttraumatic stress disorder symptoms even when controlling for baseline symptoms. Higgins' (1997) motivational framework, incorporating the needs for controllability and predictability, and Wegner's (1994) theory of mental control are used to interpret the findings.

Visible vs hidden scars and their relation to body esteem.

This study examined the relationship among burn scarring, severity and visibility, and body esteem. Previous work addressing this question has relied on case studies and small samples. We mailed a survey to 2500 members of a national burn survivor support group. Survivors were asked to complete and return the mailed survey or complete the survey on line at our Web site. Three hundred sixty-one survivors completed all questionnaires in the survey relevant to this study, which included measures of burn characteristics, social stigmatization, social support, depression, and body esteem. The sample characteristics were as follows: 52% were women, the mean age was 44.1 years, the mean age burned was 26 years, 88% were European American, 5% were African American, 4% were multiracial, 3% were other, the average TBSA was 48%, and the mean educational level was high school graduate. We measured scar visibility by asking survivors to rate "how often are your burn scars visible to others" on a six-point scale. We also asked them to rate the presence or absence of scars on 15 body parts, total TBSA, and number of surgeries. The correlation between visible scarring and different aspects of body esteem, that is, self-satisfaction with appearance (-.19) and perception of others reaction to your appearance (-.27), was statistically significant but low. Visible scarring was unrelated to self-satisfaction with weight (.01). Visible scarring had a low but significant correlation with perceived stigmatization (.23) and was not correlated with depression (0.01). Other measures of scarring also had low correlations with social and emotional outcome variables. Because scar severity and visibility are hypothesized to be particularly relevant to body esteem, we performed a multiple regression predicting body esteem. We entered the variables in three blocks: burn characteristics, demographic characteristics, and social and emotional characteristics. Burn characteristics accounted for less than 20% of the variance. R square for the final equation equaled.62, with social adjustment and depression accounting for the largest portion of the variance. In this sample, burn scar visibility and severity did not have a strong relationship with social and emotional adjustment variables. More effort must be placed into developing psychosocial interventions that help survivors accept scars, reduce depression, and build a strong loving support system.