Chăm Sóc Và Điều Trị Bỏng Toàn Diện (Total Burn Care – Tập 5)

64  •  Management of Pain and Other Discomforts in Burned Patients
692
and electroacupuncture treatment194 to reduce pruritus in
burn scar. Silicone gel sheeting has been reported to also
be effective.195
Usually the antihistamines are given orally. Using only
one antihistamine results in complete relief for only 10% of
patients.196 Diphenhydramine PO 1.25 mg/kg every 6
hours is often the first oral medicine used because of its
sedative effect as well as helping control the itch. A few
children respond better to loratadine, which is much longer
acting. If itch is not well controlled using only one, then
another class of antihistamine can be added, such as
hydroxyzine PO 0.5/kg every 6 hours. Last, if the itch is still
not well controlled, an antiserotonergic agent, such as
cyproheptadine 0.1 mg/kg every 6 hours, can be added,
scheduled so that one of the medications is given every 2
hours. This is targeted against the 5-HT3 receptors. Care
must be taken to not use the cyproheptadine with patients
who are on serotonergic antidepressants.
Gabapentin (10–35 mg/kg per day in divided doses) is
becoming a reliable safe standard for treating severe itching
following burn injury.197 The typical individual dose is
5 mg/kg during the day and 10 mg/kg at bedtime. Com­
parative studies using gabapentin have demonstrated its
efficacy. Goutos et al. demonstrated that it was usually more
poorly understood, so blocking histamine, kinins, proteases,
prostaglandins, substance P, and serotonin (5-HT) release
and receptors have all been tried. The first line of defense
is a series of moisturizing body shampoos and lotions to
alleviate itching due to dry scaly skin. If these measures
are inadequate in providing relief, Preparation H, which
contains a local anesthetic has been advocated. In contrast
topical benzocaine is not effective in treating itching even
though it reduces pain.188 Topical steroids are not usually
used until the skin is well healed because of the infection
risk. They are effective in controlling the itching. Only a
small area of skin should be treated with steroids in order
to reduce the risk of systemic adrenal suppression. Anti­
histamine creams such as Benadryl (diphenyl hydramine)
are available. Other topical medications include colloid and
oatmeal baths.189 Newer topicals are tricyclic antidepres­
sants such as doxepin.190,191 The major side effect of this
preparation is that too much is absorbed, with resultant
oversedation. Several nonpharmacologic approaches have
been used. Massage seems to have a very beneficial effect.185
In addition Hettrick et al. reported that transcutaneous
electrical nerve stimulations (TENS) considerably reduced
the perception of itching in nine adult patients compared to
controls.192 The most recent is the use of pulse dye laser193
Table 64.8  Pharmacologic Therapies for Burn Pain and Anxiety Relief
EMERGENT PHASE
Procedural Analgesics
Background Analgesics
Anxiolytics
Morphine (IVB, IVCI)
Morphine (IVCI, PCA)
Diazepam (IV) (Valium)
Meperidine (IVB)
Meperidine (PCA)
Lorazepam (IV) (Ativan)
Fentanyl (IVB, IVCI)
Methadone (PO, NPC)
Midazolam (IV, IVCI) (Versed)
Hydromorphone (IVB, PO)
(Dilaudid)
Nalbuphine (IVB) (Nubain)
Ketamine (IV) (Ketalar)
Nitrous oxide (IH)
ACUTE PHASE
Procedural Analgesics
Background Analgesics
Anxiolytics
Morphine (IVB, IVCI, PCA)
Roxanol (oral morphine)
Morphine (IVCI, PCA)
Diazepam (PO) (Valium)
Meperidine (IVB, IM)
Meperidine (IVCI, PCA)
Lorazepam (PO) (Ativan)
Fentanyl (IVB, IM)
Methadone (PO, NPC)
Alprazolam (PO) (Xanax)
Hydromorphone (PO) (Dilaudid)
Sustained-release morphine (PO, NPC)
(MS Contin)
Nalbuphine (IVB) (Nubain)
Acetaminophen (PO, NPC)
Ketamine (IV, IM) (Ketalar)
NSAIDs (PO, NPC)
Oxycodone (PO) (Percocet)
Choline magnesium trisalicylate
REHABILITATIVE PHASE
For Severe Pain
For Mild to Moderate Pain
Anxiolytics
Hydromorphone (PO) (Dilaudid)
Oxycodone (PO) (Percocet)
Diazepam (PO) (Valium)
Nonsteroidal antiinflammatory drugs
(NSAIDs) with or without narcotics
Lorazepam (PO) (Ativan)
Usually not necessary: Acetaminophen
NSAIDs
Alprazolam (PO) (Xanax)

64  •  Management of Pain and Other Discomforts in Burned Patients
693
enough to elicit a fearful response in burned children.207 In
terms of operant (reinforcement) conditioning, patients can
be thought to gain reinforcement by avoiding or escaping
painful procedures, perhaps by screaming enough to termi­
nate treatment, or to obtain some sort of reinforcement
from the staff by showing pain behaviors. Between the
stimulus that precedes pain and the pain response that
follows, there is the cognitive processing of pain. Such cog­
nitions can be modified, as can behavior, and can influence
how much pain a patient experiences. Classical and operant
conditioning principles and modifying internal cognitions
have a bearing on how nonpharmacologic approaches are
applied to burn pain. A series of articles by Thurber and
Martin and colleagues208,209 provide an extensive discussion
of the theory and application of such principles to control­
ling pain during pediatric wound care.
Classical Conditioning
If the stimuli associated with a painful procedure have been
conditioned to evoke anxiety or pain, then a logical goal is
to reduce the impact that the stimuli have on the fear/pain
response. An obvious environmental intervention is to
make the wound care procedure setting as minimally
threatening as possible. For children this might involve
making the hydrotherapy tank a “bath tub play area” with
age-appropriate floating toys and the like. Cheerful or relax­
ing music, a warm room, and pleasing art on the walls can
also lessen the threatening nature of a typical tank room.
Providing the patient with choices in music or art gives a
greater sense of control over the procedure. Some clever
children’s hospital staffs have turned their magnetic reso­
nance imaging (MRI) scanner into a “cave in a jungle”;
obviously such a setting will be less threatening to a child
than the typical scanner. Similar principles can certainly be
applied to burn care.208,209
There are other implications from classical conditioning,
the most important of which is that the best way to prevent
a conditioned pain response is to optimize pain control in
the first place. By aggressively and proactively treating pain,
the contributions of conditioned anxiety will be minimized.
Conversely, once a patient undergoes a procedure with
inadequate analgesia, concomitant anxiety can be extremely
difficult to treat. Since it is rare that a child who requires
wound care would not find the setting anxiety-provoking,
burn units will often use an anxiolytic at the first dressing
change to prevent this anticipatory anxiety.
Any attempts to enhance a patient’s control over the situ­
ation can minimize anticipatory anxiety. Patients tell us
that the hospital environment, unlike any other environ­
ment, strips a person of control. A functioning, indepen­
dent adult prior to an injury is suddenly dependent on
others for almost all aspects of care, including when and
what they eat, what medications they will be taking, the
painful procedures they will undergo, and their daily sched­
ule. In addition, burn care can be quite complicated, and
the medical information that patients are required to
process can be overwhelming. When an adult or child feels
out of control, anxiety increases. We can enhance a patient’s
sense of control over the hospital environment by allowing
them to have input into their care as much as possible. For
effective than antihistamines.198 In the experience of the
Shriners Hospital in Galveston, a daily dose of 30 mg/kg is
often needed in three divided doses. Recently a retrospective
study was done with pregabalin with promising results. For
many of those who fail gabapentin therapy, pregabalin has
been found to be effective.199
Another new class of medications to be used in chronic
itching is naltrexone. First LaSalle et al.200 reported some
improvement in itch with naltrexone. Then Jung et al.201
reported a significant decrease in itching sensation and
scratching from 9 to 5.9 on a 10-point scale after 2 weeks
of treatment with 50 mg of naltrexone at night, when it
was given with the usual antihistamines. Side effects of
headache and nausea were noted in many of the patients.
Development of Protocols
for Comfort
Interest in pain management of burned patients has been
a high priority in the treatment of burns only in the past
10–15 years. Several institutions have developed pain and
anxiety management protocols. In 1995, the Journal of
Burn Care and Rehabilitation published a special issue devoted
to then-current practices of systematic treatment of burn
pain. In the first edition of this book in 1996, we reported
the initial use of a burn pain protocol at the Shriners Burns
Hospital in Galveston; the protocol currently used there is
reviewed and updated every few years.2 In 1997, a Boston
group headed by Tompkins published a 3-year history with
a similar protocol.202 They incorporated a distinction in
treating ventilated acute patients differently from nonven­
tilated acute patients. Most recently a national consensus
on pain management has been reached. Ulmer203 brought
these recommendations to the attention of the burn com­
munity in a 1998 article. The most recent version of the
Shriners Burns Hospital protocol is shown in Table 64.9
and includes management of the most common discom­
forts of burned patients. It is extremely important to con­
tinue to improve these protocols as more is learned about
the treatment of pain in burn injury.
Nonpharmacologic Therapies in Burned Patients
As discussed, there is a strong interaction between psycho­
logical and physiological factors contributing to the pain
experience. Anxiety in particular is prevalent in patients
with burn injuries and is known to exacerbate acute pain.
Nonpharmacologic therapies play an important role in
addressing the psychological factors that exacerbate pain as
well as having a direct impact on the pain itself.204
In American Burn Association practice guidelines for the
management of burn pain, Faucher and Furukawa in 2006
argued for the use of nonpharmacological techniques as
part of the standard of care for burn centers.205 In under­
standing how nonpharmacologic approaches can be used
with burn pain, it is important to discuss how behavioral
principles contribute to the patient’s experience.206 In terms
of classical (stimulus–response) conditioning, patients
(particularly children) often develop a conditioned anxiety
response to stimuli associated with painful burn proce­
dures. One study demonstrated that the simple event of
seeing a healthcare worker who is wearing scrubs was

64  •  Management of Pain and Other Discomforts in Burned Patients
694
choices” as often as possible to create a sense of control.
Forced choice is a technique whereby a child is given two
reasonable options and allowed to choose the one they
prefer. For example, a child might be given a choice of
whether to have wound care before lunch or after lunch, or
whether he or she prefers to take medicine with apple juice
example, adults and adolescents may be able to work with
the nurse to determine the day’s schedule, to specify tech­
niques that they have found make wound care go more
smoothly, to choose to eat in the cafeteria instead of having
meals served in their room, and to choose the music played
during wound care. Children should be offered “forced
Table 64.9  Shriners Hospitals for Children (Galveston): Comfort Protocol for Children
BACKGROUND PAIN
Inpatient
Consciousness should be noted on the vital signs flow sheet.
■ IV Morphine dose: 0.03–0.06 mg/kg/dose IV q2–4h (scheduled while
awake)
■ PO Morphine dose: 0.1–0.3 mg/kg/dose PO q4h (scheduled while
awake)
Note: Begin bowel prep program simultaneously with beginning
opioids: prune juice, docusate, etc.
■ If requires longer-acting pain medicine
■ Methadone dose: 0.1 mg/kg/dose PO q6–8h, then reduce frequency
to q12h to taper off
Outpatient:
■ Oral acetaminophen 15 mg/kg/dose PO q4h
■ Tramadol 1–2 mg/kg/dose q 4–6 h
■ If inadequate, add hydrocodone 0.2 m/kg usually in combination
with acetaminophen
■ Ibuprofen PO 10 mg/kg/dose PO q6h
■ The antiplatelet effects of ibuprofen last as long as the drug is still
in the body.
Pre-Wound Cleaning:
■ Oral transmucosal Fentanyl (Actiq) dose: 10 µg/kg/dose rounded to
nearest available dose. Oral transmucosal Fentanyl is available in
200 µg, 400 µg, and 600 µg doses
■ IV Morphine dose: 0.03–0.06 mg/kg/dose IV q 2–4 h (scheduled while
awake)
■ PO Morphine dose: 0.1–0.3 mg/kg/dose PO q4h
■ PO hydrocodone 0.2 m/kg usually in combination with
acetaminophen 10–20 mg/kg
■ Benzodiazepam added: diazepam 0.1 mg/kg or lorazepam 0.05 mg/
kg.
Pre-Rehabilitation Therapy:
■ At request of therapist, PO hydrocodone 0.2 m/kg usually in
combination with acetaminophen 10–20 mg/kg given with diazepam
0.1 mg/kg
Postoperative Pain:
Option A:
■ IV Morphine via PCA pump (if >5 years), total dose 10–20 mg/kg per
4 h.
Option B:
■ Attendant administered bolus, slow IV push morphine 0.03–0.05 mg/
kg per 2 h (hold if level of responsiveness is decreased)
Neuropathic Pain
■ Pain which is described as tingling, or burning in nature; like fire ants
or ants walking with cleats; due to nerve entrapment, nerve damage,
and venous congestion
■ Pain often does not respond to opiates
■ PO gabapentin (Neurontin) 100 mg, 300 mg, 600 mg
■ Gabapentin dose: 5–30 mg/kg/dose q8h
■ PO pregabalin (Lyrica) 50 mg, 100 mg
■ Not indicated for small children
■ Begin with 50 mg tid; then titrate up to 100 mg tid.
■ PO amitriptyline 0.5–2 mg/kg. Do not advance to 2 mg/kg without
checking blood level. Do not give with fluoxetine or sertraline; check
PR interval on EKG
Reference: Pediatric and Neonatal Dosage Handbook, 21st Edition, Lexi-Comp
ANXIETY
Inpatient
■ Before using anxiolytics address pain management
■ PO lorazepam 0.05 mg/kg/dose q4h (scheduled while awake)
Outpatient
■ If muscle relaxation is also desired, PO diazepam 0.1 mg/kg/dose
q8–12h
ACUTE STRESS DISORDER OR POST-TRAUMATIC STRESS DISORDER
SYMPTOMS
■ PO Fluoxetine usually administer in the morning
≤20 kg
2.5 mg
≤40 kg
5 mg
>40 kg and <60 kg
10 mg
>60 kg
20 mg
■ PO imipramine 1 mg/kg and increase slowly to 3 mg/kg as needed
after checking concentration (usually used in young children where
duloxetine could not be easily dosed)
■ PO sertraline 1 mg/kg. Available as a 25-mg, 50-mg, and 100-mg
tablet. Begin with 25 mg once daily; titrate dose as needed
■ Approved for children 6 years old and older
Note: watch for serotonin syndrome characterized by agitation,
confusion, rapid heart rate, dilated pupils, twitching muscles, muscle
rigidity, heavy sweating
MANAGEMENT OF AGITATION AND HALLUCINATIONS NOT
ASSOCIATED WITH ASD AND PTSD:
■ PO risperidone (Risperdal)
■ Children <5 years: Oral initial dose 0.1–0.2 mg once daily at bedtime
■ Children ≥5 years and adolescents: Oral initial dose 0.2–0.5 mg once
daily at bedtime; may titrate to the lowest effective dose every 1–2
days
■ PO quetiapine (Seroquel)
■ Children ≤10 years and adolescents ≤17 years: 25 mg twice daily on
day 1; increase to 50 mg twice daily on day 2, then increase by
100 mg daily (administered twice daily) each day until 200 mg twice
day is reached on day 5. May further increase up to 600 mg daily in
increments of ≤100 mg daily. Usual dosage range: 400–600 mg daily;
maximum: 600 mg daily
MANAGEMENT OF SLEEP NOT ACCOUNTED FOR AS ASD OR PTSD:
■ Instruct in sleep hygiene
■ Rule out pain and anxiety and itching
■ PO Benadryl 1– 2 mg/kg at bedtime
■ PO melatonin 0.01 mg/kg or 3 mg at bedtime
■ PO zolpidem (Ambien) 5 or 10 mg with side effect of sleep walking
■ PO Trazodone 1.5–2 mg/kg/dose qh

64  •  Management of Pain and Other Discomforts in Burned Patients
695
motivated to escape such events. Staff members who allow
patients to terminate procedures might be reinforcing and
potentially exacerbating such escape behaviors. When left
unchecked this process can lead to a distressed patient
becoming combative rather than tolerant of procedures.
While such avoidance behavior should (more importantly)
alert the staff that analgesia is inadequate and that the
many potential pharmacologic protocols discussed earlier
should be invoked, it can also occasionally suggest a need
for further limit setting. Rewarding a patient with rest once
a stage of wound care is completed, rather than stopping
the procedure based on pain behavior, can be a useful
means to minimize such escalating behavior. Children can
also be given a predetermined number (usually five is ade­
quate) of “timeout cards” that they can present at any time
during wound care, each worth a 1-minute timeout or rest
period. Once the cards are used up, they no longer have any
timeouts. This technique can enhance their sense of control
over the environment as well as ensuring that rest periods
do not reinforce pain behaviors. Again, however, the goal
of a burn team should be to provide enough preparation
and analgesia in a preemptive fashion that the need for such
escape behaviors does not develop in the first place.
Operant conditioning also has implications for the
manner in which patients receive pain medication. When
patients are medicated in response to pain behaviors, they
are potentially receiving social reinforcement in terms of
attention from the staff as well as the euphoric effects that
the drugs might cause. This is one reason that, as men­
tioned earlier, it is far preferable that patients are medicated
at regular time intervals rather than in response to their
pain; the latter encourages them to complain more often in
order to get the reward.226 A similar application of operant
principles is particularly important for the patient who
excessively complains about pain out of emotional depen­
dency needs, attention seeking, or in seeking the euphori­
genic properties of the pain medications. In such patients,
provided that adequate levels of pharmacologic analgesia
have indeed been established, it may be important to extin­
guish pain behavior by ignoring it and simultaneously
engaging the patient in distraction unrelated to pain. This
is a model more consistent with that used for chronic pain
but one that is occasionally useful for burn patients who
seem to overreact independent of how aggressively pain is
managed.227
Another common application of operant principles has
to do with “token economies” for children. It can be
extremely useful to reward children for successful comple­
tion of procedures by using star charts, prize boxes, or rein­
forcement schedules of this nature. Thus a child, upon
completing a procedure, may receive a star in a grid that
covers a week of burn care. Older children can use an accu­
mulation of points to purchase a desired reward. Courage
beads have also become popular in pediatric hospital set­
tings. Differently colored beads are assigned to various
painful or unpleasant procedures (e.g., wound care, physi­
cal therapy, X-ray, blood draws, etc.). Each time a child com­
pletes one of these unpleasant procedures, he or she receives
a corresponding bead and adds it to a necklace. Both boys
and girls have responded positively to these necklaces and
often wear or display them as a source of pride. It is impor­
tant that children are rewarded for completing procedures
or milk. The key is to only provide two options and to ensure
that the healthcare provider and parent are agreeable to
whichever option is chosen. Kavanaugh has described how
giving children more control during procedures can reduce
the effects of learned helplessness and enhance pain toler­
ance.210 He reported that children who were provided with
the opportunity to participate in and make decisions about
their wound care showed lower depression, anxiety, hostil­
ity, and stress scores than did controls.
Finally, psychological preparation can also play an impor­
tant role in enhancing control and minimizing anticipatory
anxiety. Patients can be provided with procedural or sensory
preparatory information.211, 212 When providing procedural-
based preparatory information, patients are explained the
mechanics of their procedure (e.g., “we will unwrap your
bandages, wash your wounds and débride necrotic skin,
apply silver sulfadiazine cream, and then rewrap your dress­
ings”). When providing sensory information, patients are
prepared about what they might feel during a procedure
(“You will likely feel a pulling sensation as we remove your
dressings and a stinging sensation when we wash your
wounds with an antiseptic”). Such information is usually
helpful to patients, but it must be emphasized that some
patients prefer to have as little information as possible, given
their particular coping styles. It is best to follow a patient’s
lead in determining how much detail to provide when
explaining upcoming procedures.206
One study found that a multimodal approach that com­
bines procedural preparatory information and distraction
was more effective at reducing pain, distress, and length of
treatment than distraction alone.212
Another approach based on classical conditioning is
relaxation training. Patients can be taught deep relaxation
and imagery prior to undergoing painful procedures. The
rationale is to counteract the anxiety stimulated by prepro­
cedural stimuli with the relaxation response. If anticipatory
anxiety is minimized with deep relaxation, the potential for
a cyclical interaction between anxiety and acute pain is
reduced. Recent topographic electroencephalographic
(EEG) mapping during relaxation and imagery has shown
changes in EEG activity that are similar to stage 1 sleep.
Imagery also appears to activate the hippocampus, which
is involved in emotion regulation.213,214 Clinicians have also
reported success with administering massage therapy on
nonburned areas immediately prior to wound care.215 Chil­
dren who received 15 minutes of massage therapy reported
lower pain scores during wound care than did a control
group. A number of studies have applied relaxation train­
ing and stress inoculation techniques, as well as some of the
behavioral techniques discussed later, to reduce burn
pain.216–224 One study even found that the simple technique
of jaw relaxation practiced 20 minutes prior to dressing
changes can significantly reduce pain and anxiety during
and after the procedure.225
Operant Conditioning
The consequences that patients receive for showing pain
can have implications for pain control. Since almost all
burn procedures are extremely aversive, it will be the
natural tendency of patients, particularly children, to be

64  •  Management of Pain and Other Discomforts in Burned Patients
696
he or she can better tolerate the difficult procedures (e.g.,
positive self-talk vs. catastrophizing). Thurber et al.209 and
Martin-Herz et al.208 have published a two-part series on a
conceptualization of psychological approaches to burn
pain, as well as specific examples for treatment. Crucial in
choosing an approach is the assessment of a person’s coping
strategies. Simply, most adult and pediatric patients have
coping styles that fall on an approach-avoidant continuum.
At one end of the continuum is the avoidant coping style in
which patients prefer to turn away or be distracted during
painful procedures. Any distraction technique described in
this chapter would be appropriate for this group of patients.
On the opposite anchor of the continuum are those with an
approach coping style who seek information and like to be
involved as much as possible in their care. In this group,
having them participate in wound care and giving them as
much information as they request will help to decrease their
anxiety. If they are told to close their eyes, turn away, and
distract themselves from the procedure at hand, their
anxiety will only increase.
Distraction is another cognitively based approach to
pain control. Processing pain requires a certain amount
of conscious attention, and distracting such patients’
attention can enable them to tolerate pain better. Movies,
music therapy, and games have all been used with some
success as distraction techniques for burn pain.221,223,229
Music has the additional benefit of inducing a relaxation
response.220,230 One study found that music therapy sig­
nificantly reduced pain and anxiety levels and muscle
tension before, during, and after dressing changes.231
Augmented Reality
Another form of distraction-gaining attention is the use
of augmented reality or virtual reality (VR) technology.
Several researchers have reported on the use of immersive
VR as a powerful analgesic.229,232–242
VR can immerse patients’ attention in a computer-
generated world and engage them in interaction with that
world. These investigators indicate that VR can significantly
reduce pain during wound care and physical therapy,232
even relative to computer game distraction and televi­
sion.233,243 Recently Morris et  al. conducted a systematic
review on the use of VR distraction for reducing both
pain and anxiety in acute burn pain.244 They found nine
studies that met their rigorous inclusion criteria. Results
showed that VR distraction is most often used for burn
wound care and physical therapy and as an adjunct to
pharmacotherapy. When compared to pharmacotherapy
alone, it appears that VR distraction is superior in reduc­
ing pain. Other interactive video-gaming technology that
tracks body movements has also been shown to enhance
participation and reduce pain and anxiety during physical
therapy.245,246
Finally, one randomized controlled trial looked at the
used of augmented reality in reducing acute procedural
pain in burn patients.247 Augmented reality overlays virtual
images onto the physical world, rather than creating a
complete immersive virtual world as in traditional virtual
reality. They randomized 42 children between the ages of
3 and 14 years into either the experimental or control
rather than for “being brave” as the latter can serve as a
subtle form of punishment to children; in other words, rein­
forcement should not be withheld if children act out and
have a bad day during wound care as long as wound care
is completed.208,209
One final application of operant principles that is bor­
rowed from the chronic pain literature is the use of a quota
system that rewards activity with rest. This is particularly
useful with patients who are overwhelmed by therapies or
who appear to have poor motivation. Patients complete
predetermined quotas of activity that are within their
capacity and then are allowed to rest. A baseline assessment
determines what is within their capacity. For example, a
patient who is trying to walk with burned legs might be
instructed to walk until tired for three therapy sessions. The
distance walked is recorded for those three sessions,
the average is taken, and 80% of that average becomes the
starting point. For example, the patient walks 50, 150, and
100 feet during three sessions. The average is 100 feet, and
80% of that is 80 feet. This (80 feet) becomes the starting
point. Patients start at 80 feet and increase that amount
by 5% (about 5 feet) each session. If they fail to meet a
quota, they return to the last successful one. However they
also quit when they reach the goal. They do not keep exer­
cising even when they are having a “good day.” This
addresses the problem of pacing and overfatigue. Ehde, Pat­
terson, and Fordyce have reported the successful use of the
quota system with a number of patients with burn injury,
both in terms of increasing therapy performance and
reducing depression.228
Cognitive Interventions
How patients think about their pain can be regarded as
a modifiable behavior and, in turn, can influence the
degree of suffering they experience. As such, an impor­
tant nonpharmacologic approach is to draw out the
thoughts patients have about their pain and teach them
to modify these thoughts accordingly. A particularly salient
example is catastrophizing about pain. Catastrophizing
thoughts include those such as “I cannot stand this pain,”
“I will never get better,” or “The pain means I will die.”
Such catastrophizing thoughts have been associated with
greater amounts of pain and less favorable health out­
comes in a variety of studies. Patients can be taught to
challenge and reinterpret such thoughts. Along the same
lines, it can be useful to teach patients to reinterpret
the meaning of their pain sensations. For example, the
appearance of skin buds and enhanced pain sensation
may indicate that a wound is healing and skin grafts
may not be necessary.206
Under the rubric of cognitive interventions patients may
be taught techniques to enhance their ability to cope with
pain. Positive self-talk and imagery designed to facilitate
coping during periods of pain are examples of this. Thurber
and colleagues have described the two-process model of
control as it relates to controlling pediatric burn pain.209 In
terms of primary control, the patient attempts to modify the
objective conditions of the painful procedure, such as nego­
tiating how and when a dressing change will take place. In
secondary control, the patient makes adjustments so that

64  •  Management of Pain and Other Discomforts in Burned Patients
697
The technology simply requires patients to open their eyes
and watch the induction presented to them; minimal cogni­
tive effort or skill is required. Delivering hypnosis in this way
addresses several concerns of standard therapist-induced
hypnosis. First, this standardized procedure allows for
greater use in that it does not require a trained therapist to
be present at each session. Second, with the visual images
in front of them, it decreases the extent of cognitive effort
required. This is important for patients who are taking
opiate medications and cannot concentrate as effectively. It
also helps those who are lower in visual imagery skills and
therefore unable to visually imagine the scenes described
by the therapist during traditional hypnosis. One clinical
case series of 13 patients used hypnotic analgesia delivered
through VR technology for patients with burn injuries. Pre-
and postprocedure pain ratings were collected from patients
undergoing painful wound care procedures over a 3-day
period. There was a decrease in reported pain and anxiety,
the need for opioid medication was cut in half, and there
were no undesirable side effects. No randomized controlled
trials have yet been published.
OTHER APPROACHES
There is some evidence that TENS can be effective with burn
pain,258 but we are aware of only one study of this nature.
Massage therapy has been reported to be useful in reducing
burn pain.259 We are unaware of any studies on the efficacy
of acupuncture on burn pain although this modality has
been useful in controlling pain from a variety of different
etiologies. The acute nature and variable distribution of
burn pain may make acupuncture a challenging modality
to apply to this problem.
For patients in the post-hospital, long-term rehabilitation
phase, nonpharmacologic approaches from physical and
occupational
therapists
become
critical.
Stretching,
strengthening, increasing activity, and hot/cold therapy
may all become instrumental in enhancing pain control
during the rehabilitative stage.
EMPIRICAL SUPPORT
Recently there have been several rigorous systematic reviews
of studies that have focused on both pediatric and adult non­
pharmacological pain management strategies. In a review
of risk factors for anticipatory distress to painful medical
procedures, Racine and colleagues found 77 articles that
addressed this issue. Their review concluded that the factors
most relevant in increasing anticipatory distress in children
undergoing painful medical procedures are child psychopa­
thology, difficult child temperament, parental distress, pre­
vious painful events, a parent’s anticipation of distress, and
anxious disposition in parents. Many of these factors are
amenable to intervention with the techniques mentioned
in this chapter. It appears that parents’ presence during
painful procedures is neither inherently good nor bad, but
is instead entirely dependent on the characteristics of the
parents and their ability to provide a calming presence. A
focus on training parents in distress-reducing behaviors is
warranted.260 Hanson, Gauld, Wathen, and MacMillan con­
ducted a systematic review of nonpharmacological inter­
ventions for acute procedural pain in pediatric patients with
condition and found that augmented reality significantly
reduced mean pain scores. This technique shows promise
as well.
Hypnosis
Hypnosis involves a blend of relaxation, imagery, and
cognitive-based approaches. This technique deserves special
attention because there are a number of reports on its use
with burn pain, and, when it is effective, its impact on burn
pain can be quite dramatic. There are more than 100 anec­
dotal reports in the literature indicating that hypnosis can
dramatically reduce pain, and at least a dozen have been
done with pain from burn injuries; however such studies
lack control groups, standard measures of pain, or informa­
tion about pain medications.248 More recently, tightly con­
trolled studies with reliable measures of pain have supported
hypnosis as an effective nonpharmacologic approach to
burn pain.249,250 Patterson and Jensen have reported 12
controlled studies on chronic pain and 17 with acute pain
indicating pain reduction; indeed, this modality is becom­
ing far more scientifically acceptable.251
Patients with burn injuries are ideal candidates for hyp­
nosis for a number of reasons. In a review of such factors,
Patterson et al. listed motivation, regression, dissociation,
and hypnotizability as factors that promote hypnotic anal­
gesia on the burn unit.252 Specifically patients who are faced
with the excruciating nature of burn pain are motivated to
engage in techniques such as hypnosis. The nature of a
burn and its resulting care can cause a patient to become
emotionally regressed (i.e., more dependent on the burn
staff) and dissociated (i.e., removed from their emotions),
and both of these factors seem to be associated with hypno­
tizability. Such factors likely account for the frequent dra­
matic effects that are seen with hypnosis during burn care.
On the other hand, hypnosis clearly will not benefit some
burn patients, and the degree to which patients are inher­
ently hypnotizable (or not hypnotizable) almost certainly
has some bearing on this issue.252
The protocol used by Patterson and colleagues243–251,253–255
is to provide hypnosis prior to wound care and have nurses
provide standard post-hypnotic suggestions during wound
care. This approach is efficient for both the hypnotist and
the nurses. Patterson et al. have recommended that hypno­
sis used in this fashion be an adjunct to, rather than replace­
ment for, pain medication.250 A randomized controlled trial
by Wiechman et al. used this protocol for burn wound pain
and found that hypnosis significantly reduced the affective
component of pain when compared to an attention-only
control group.256 Furthermore Shakibaei et al. conducted a
randomized controlled trial of hypnosis for reducing pain
and flashbacks in burn patients.257 They also showed that
the hypnotherapy group had significantly lower pain ratings
and fewer flashbacks than did the control group.
VIRTUAL REALITY HYPNOSIS
More recently, investigators have combined immersive VR
with hypnosis in order to control burn pain. This approach
has the advantage of not requiring a trained hypnotist to be
present and appears to work as well as “live hypnosis.”255,257

64  •  Management of Pain and Other Discomforts in Burned Patients
698
children. It is no wonder that Perry and Heidrick264 found
great disparity in what burn care staff would order or
administer to a young child as compared to an adult with
burns of similar size and area of distribution on the body.
More pharmacokinetic studies in both adults and children
with burn injuries must be initiated.
Similar to the lack of conclusive data about the use of the
various opioids or anxiolytic agents is the scarcity of scien­
tific data to recommend any of the nonpharmacologic tech­
niques. However significant progress has been made just
since the previous edition of this book 5 years ago. Most
burn centers recognize anxiety as contributing to patient
discomfort and are beginning to treat both anxiety and
pain. Standardized protocols such as the guidelines (see
Table 64.9)2 modified for starting doses of medication from
the Shriners Burn Hospital in Galveston are being dissemi­
nated. Nonpharmacologic techniques are more frequently
included in a center’s repertoire of tools for managing
anxiety and recognized as a definite adjunct to pharmaco­
therapy. The major problem currently with these techniques
is that they are personnel intensive and therefore are often
not offered or reimbursed in the current managed care
environment in the United States.
How, then, can we provide the “best” pain management
for a burned patient? Probably the first answer to that ques­
tion is vigilance in assessment and flexibility in treatment.
Patients show great individual variation in their responses
to the variety of agents and modalities presented. A success­
ful approach with a burned patient requires that health-
care personnel understand the pain associated with the
different depths of wounds, the phase of the healing process,
and the components of the pain response. For the burned
patient during the initial 3–7 days, the more superficial
areas give rise to moderate or severe pain, while the full-
thickness areas contribute less to the overall pain response.11
Although moderate to severe pain is usually related to pro­
cedures or physical therapy, background pain (or pain at
rest) is usually described as mild or very mild but may be
exacerbated by emotional concerns and anxiety. By the
second week post-burn, the moderately deep partial-
thickness burn with its multitude of skin buds accounts for
the majority of the moderate to severe pain. In many burn
centers, deep dermal and full-thickness burns are excised
and grafted between the third and tenth days post-burn.
Although this often eliminates the severe pain associated
with wound débridement during the second and third week,
donor sites are often as painful as the areas of more super­
ficial burns were initially. Dressing changes 3–5 days post-
grafting also may be accompanied by the removal of sutures
or staples, a procedure that is usually described by patients
as excruciatingly painful. By the third or fourth week, if the
wounds are not mostly healed, anxiety and depression may
cause a patient to perceive increased levels of pain. And,
within a single phase of recovery and within a single
patient, pain frequency and intensity will vary from day to
day. A fixed and inflexible approach to treatment is likely to
overmedicate on one day and undermedicate the next.
To avoid over- and undermedication in adults, regimens
that allow patients to control their own therapy seem most
appropriate. This is very important for adults and teenagers,
but children also can benefit from having this control. PCA
can be used safely by many children and should not be
burn injuries.261 Using a systematic review of methods of
the U.S. Preventative Services Task Force, they found 12
articles that met the study criteria and seven of the 12 arti­
cles were rated as “fair or good.” They categorized these 12
articles into child-mediated interventions, parent-mediated
interventions, and healthcare provider-mediated interven­
tions. Of the child-mediated interventions, both VR distrac­
tion and stress management showed promising effects. Of
the healthcare provider interventions, massage therapy and
optimizing patient control during wound care were effective
at relieving wound care pain when compared to a control
group. Parent-mediated interventions were not found to be
effective, and, in fact, one study showed an increase in chil­
drens’ distress when parents were present.262 Although the
study designs in these interventions were rated as poor, the
findings are consistent with those reported by clinicians, in
that parental presence during painful procedures can either
help or hurt a child depending on the parents’ affect and
ability to soothe their child. This is a difficult intervention
to study, but one that deserves more attention in this era of
family-centered care and the emphasis on increased paren­
tal involvement in a child’s care. It would be a tremendous
benefit to the field if we could determine which variables
are necessary to facilitate a positive parental presence and
which variables serve as barriers to the success of this prac­
tice. Hanson et al.261 acknowledged that it is very difficult to
conduct randomized controlled trials with adequate sample
sizes in this population, but we must strive to find empirical
support for the techniques that we choose.
De Jong et al. also conducted a systematic review of the
literature for nonpharmacological interventions for acute
burn pain in adults.263 They found that hypnosis was the
most frequently studied intervention and that the majority
of the studies on hypnosis showed a beneficial effect when
compared to a control group. They concluded that hypnosis
seems to have a strong impact on the affective component
of pain. Their review also showed beneficial effects of
distraction relaxation and found that any technique
that enhances a patient’s control over the situation is
beneficial.
The authors of these systematic reviews provided
directions for future researchers that would advance
our knowledge of the effectiveness of nonpharmacological
interventions. These suggestions included the need for large
sample sizes, documentation regarding study response rates
and randomization methods, experimental control for pre­
morbid psychosocial variables, details on instructions given
to patients, cost outcomes, and assurance of treatment
integrity/adherence.261,264
Conclusion
The state of the art in burn pain management would seem
to be based more on personal bias and tradition than on a
systematic, scientific approach. In addition, the number of
pharmacokinetic studies of pain-relieving drugs of any
kind in young children is virtually nil. Since approximately
35% of all burn injuries occur in children under 16 years
of age, with a great majority of these occurring in children
under 2 years of age, we have almost no information on
which to base the use of pain-relieving drugs in burned

64  •  Management of Pain and Other Discomforts in Burned Patients
699
that successful pain management can significantly reduce
the occurrence of psychological disorders such as post-
traumatic stress syndrome.
Burn care professionals who desire to keep their patients
as comfortable as possible can perhaps best prepare them­
selves by learning to:
■ watch and listen to their patients with vigilance;
■ use a standardized assessment tool for measuring dis­
comfort on a scheduled basis as well as during moments
when the patient is complaining, either verbally or behav­
iorally, pre- and post-administration of treatment;
■ know how discomforts are likely to change as the patient
recovers;
■ include a variety of pharmacologic and nonpharmaco­
logic methods for managing discomfort and be prepared
to change as the patient’s needs change;
■ feel comfortable with a process that never ends, but
which can bring many moments of relief for the patient
and satisfaction for the caregivers.
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disregarded as a tool on the basis of age alone. For proce­
dural pain, patient control regimens may include self-
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behavioral approaches, or a combination of these
approaches. For background pain, the best control seems to
be the use of slow-release opioids or other pain cocktails
given on a nonpain contingent basis (i.e., scheduled every
4–6 hours) with the flexibility to supplement this with p.r.n.
or “as-desired” medication. Another approach is to use PCA
with or without a continuous low-dose infusion of narcot­
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As challenging as managing comfort is for the health-
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demonstrated that pain in a burned patient adds signifi­
cantly to the physiologic demands caused by stress. Sch­
reiber and Galai-Gat266 as well as Ptacek et al.8 have shown

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2008;29:730-741.
210. Kavanaugh CK, Lasoft E, Eide Y, et al. Learned helplessness and the
pediatric burn patient: dressing change behavior and serum cortisol
and beta endorphins. Adv Pedia. 1991;38:335-363.
211. Everett JJ, Patterson DR, Chen AC. Cognitive and behavioral treat­
ments for burn pain. Pain Clin. 1990;3:133-145.
212. Miller K, Rodger S, Kipping B, Kimble R. A novel technology approach
to pain management in children with burns: a prospective random­
ized controlled trial. Burns. 2011;37(3):395-405.
213. Jacobs GD. The physiology of mind-body interactions: the stress
response and the relaxation response. J Altern Complement Med.
2001;7(1 suppl):S83-S92.
214. Jacobs GD, Friedman R. EEG spectral analysis of relaxation tech­
niques. Appl Psychophysiol Biofeedback. 2004;29:245-254.
215. Field T, Peck M, Hernandez-Reif M, et al. Post-burn itching, pain, and
psychological symptoms are reduced with massage therapy. J Burn
Care Rehabil. 2000;21:189-193.
216. Fagerhaugh SY. Pain expression and control on a burn care unit.
Nurs Outlook. 1974;22:645-650.
217. Knudson-Cooper MS. Relaxation and biofeedback training in the
treatment of severely burned children. J Burn Care Rehabil. 1981;2.
218. Kueffner M. Passage through hospitalization of severely burned, iso­
lated school-age children. Commun Nurs Res. 1976;7:181-197.
219. Wernick RL, Jaremko ME, Taylor PW. Pain management in
severely burned adults: a test of stress inoculation. J Behav Med.
1981;4:103-109.
220. Whitehead-Pleaux AM, Baryza MJ, Sheridan RL. The effects of music
therapy on pediatric patients’ pain and anxiety during donor site
dressing change. J Music Ther. 2006;43:136-153.
221. Elliott CH, Olson RA. The management of children’s distress in
response to painful medical treatment for burn injuries. Behav Res
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222. Foertsch CE, O’Hara MW, Stoddard FJ, Kealey GP. Treatment resistant
pain and distress during pediatric burn dressing changes. J Burn Care
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223. Presner JD, Yowler CJ, Smith LF, Steele AL, Fratianne RB. Music
therapy for assistance with pain and anxiety management in burn
treatment. J Burn Care Rehabil. 2001;22:83-88.
224. Park E, Oh H, Kim T. The effects of relaxation breathing on proce­
dural pain and anxiety during burn care. Burns. 2013;39(6):1101-
1106.
225. Mohammadi Fakhar F, Rafii F, Jamshidi Orak R. The effect of jaw
relaxation on pain anxiety during burn dressings: randomized clini­
cal trial. Burns. 2013;39(1):61-67.
226. Melzack R. The tragedy of needless pain. Sci Amer. 1990;262(2):27-33.
227. Fordyce WE. Behavioral Methods for Chronic Pain and Illness. St. Louis:
Mosby Year Book, Inc.; 1976.
228. Ehde DM, Patterson DR, Fordyce WE. The quota system in burn
rehabilitation. J Burn Care Rehabil. 1998;19:436-439.
229. Kelley ML, Jarvie GJ, Middlebrook JL, McNeer MF, Drabman RS.
Decreasing burned children’s pain behavior: impacting the trauma
of hydrotherapy. J Appl Behav Anal. 1984;17(2):147-158.
230. Fratianne RB, Presner JD, Huston MJ, et al. The effect of music-based
imagery and musical alternate engagement on the burn debride­
ment process. J Burn Care Rehabil. 2001;22:47-53.
231. Tan X, Yowler CJ, Super DM, Fratianne RB. The efficacy of music
therapy protocols for decreasing pain, anxiety, and muscle tension
levels during burn dressing changes: a prospective randomized cross­
over trial. J Burn Care Res. 2010;31:590-597.
232. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual reality for
adjunctive treatment of adult burn pain during physical therapy: a
controlled study. Clin J Pain. 2000;16:244-250.
233. van Twillert B, Bremer M, Faber AW. Computer-generated virtual
reality to control pain and anxiety in pediatric and adult burn patients
during wound dressing changes. J Burn Care Res. 2007;28:694-702.
234. Das DA, Grimner KA, Sparnon AL, McRae SE, Thomas BH. The effi­
cacy of playing a virtual reality game in modulating pain for chil­
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Pediatr. 2005;5:1.
235. Chan EA, Chung JW, Wong TK, Lien AS, Yang JY. Application of a
virtual reality prototype for pain relief of pediatric burn in Taiwan.
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236. Sharar S, Carrougher G, Nakamura D, et al. Factors influencing
the efficacy of virtual reality distracting analgesia during postburn
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699.e6 64  •  Management of Pain and Other Discomforts in Burned Patients
262. Foertsch CE, O’Hara MW, Stoddard FJ, Kealey GP. Parent participa­
tion during burn debridement in relation to behavioral distress. J
Burn Care Rehabil. 1996;17:372-377.
263. de Jong AEE, Middlekoop E, Faber AW, Van Loey NEE. Nonpharmaco­
logical nursing interventions for procedural pain relief in adults with
burns: a systematic literature review. Burns. 2007;33:811-827.
264. Perry S, Heidrick G. Management of pain during debridement: a
survey of US burn units. Pain. 1982;13:267-280.
265. Kavanagh CK, Lasoff E, Eide Y, et al. Learned helplessness and the
pediatric burn patient: dressing change behavior and serum cortisol
and B-endorphin. Adv Pediatr. 1991;38:335-363.
266. Schreiber S, Galai-Gat T. Uncontrolled pain following physical
injury as the core trauma in post traumatic stress disorder. Pain.
1993;54:107-110.
267. Thomas C, Brazeal B, Rosenberg L, et al. Phantom Limb Pain in
Pediatric Burn Survivors. Burns. 2003;29:139-142.

700
65 
Psychiatric Disorders
Associated With Burn Injury
J. F. AILI LOW, WALTER J. MEYER III, MIMMIE WILLEBRAND, and
CHRISTOPHER R. THOMAS
suicide attempts) or indirectly through problems in impulse
control (e.g., conduct disorders), by reducing vigilance or
affecting judgment (e.g., substance abuse disorders, depres­
sion).1,7,8 The knowledge of preexisting psychiatric prob­
lems is important for burn care mainly for two reasons: first,
to better understand and identify psychiatric symptoms
occurring during treatment and to recognize them as
ongoing or reactivated problems instead of reactions to the
injury; and second, to increase awareness of potential dif­
ficulties during rehabilitation (for a comprehensive review
refer to McKibben et al.1).
Patients with preinjury psychiatric disorders have been
observed to require longer hospitalization, they more fre­
quently experience complications during treatment and
problems with rehabilitation and postburn adjustment, and
they have a higher risk of developing other psychiatric dis­
orders (e.g., posttraumatic stress disorder; PTSD).2–4,9–13
Psychiatric morbidity is common in burn patients. Two-
thirds of all patients with burns have a lifetime history of at
least one psychiatric disorder, 50% had a psychiatric disor­
der in the year before injury, and one-third have an ongoing
psychiatric disorder at the time of injury.1 Patients with pre­
existing psychiatric morbidity have a higher risk of sustain­
ing a preventable injury, and, in individuals with psychotic
disorders, self-inflicted burns are overrepresented.1
The most frequent preexisting psychiatric disorder in
burn patients is the mood disorder major depression, which
is present in up to 42% of individuals, a proportion much
higher than in the general population.1 Smoking (i.e., sub­
stance use disorder, tobacco use disorder; Z72.0 or F17.2x),
has been shown to increase the risk of burns; smoking more
than 10 cigarettes a day increases the risk of burns by up
to sixfold.1 Similarly, other substance use disorders (e.g., the
stimulant drug methamphetamine or the use of highly
volatile and flammable substances) increase the risk of sus­
taining a burn.1,14
Personality disorders are also overrepresented in burn
patients compared to the general population, and persons
who score high on the personality traits neuroticism and
extraversion appear to have a higher risk of injury.1 In addi­
tion, persons with dementia have a higher age-standardized
incidence rate of burns than do those without dementia
(22.7 vs. 14.2 per 100,000 inhabitants), and they have a
longer length of hospital stay.15
Disorders in Children
and Adolescents
Psychiatric morbidity can increase the risk for burns in chil­
dren and adolescents, and specific psychiatric disorders
Introduction
All members of the burn treatment team should have a
basic knowledge of psychiatric problems because they com­
monly occur and often play a central role in burn recovery.
It is useful to have mental health professionals as integrated
members of the team because their expertise and skills are
often needed in the management of patients with burns to
screen and identify problems and to assist in the treatment
of the multitudes of psychiatric and psychological issues
concomitant to burns.
Preexisting psychiatric disorders and symptoms are rela­
tively common in the histories of burned patients and fre­
quently appear to have contributed significantly to the
etiology of the injury itself.1–4 The converse is also true.
In addition to premorbid disorders, a number of patients
will develop psychiatric symptoms during acute treatment
for burns, as also can be seen after other major trauma.4
Pain, itching, and stress during hospitalization can contrib­
ute to problems during acute treatment, such as sleep dis­
orders and depression, starting a vicious circle. Dissociation
and anxiety experienced during the burn have been shown
to predict later psychopathology.5,6 While it is understand­
able to expect patients with major burns to be at risk, even
minor burns can result in significant psychological distress
and psychiatric symptoms.7
At present, there is no profile that can reliably predict and
identify which patients will suffer psychiatric symptoms fol­
lowing burns. Furthermore, there is a clear risk that patients
will not actively seek help for psychological distress or psy­
chiatric symptoms, and this can have a strong effect on
outcome and rehabilitation. All members of the burn team
should be aware of this risk and be observant of signs or
symptoms.
This chapter will focus on the recognition and treatment
of common mental disturbances that can be expected to
occur in patients suffering serious burns. This includes spe­
cific attention to both pediatric as well as adult patients, and
it is important to be aware that symptoms and signs may
differ between ages. Also, preexisting psychopathology may
alter the expression of a patient’s distress and complicate
medical management of the patient.
In the following text ICD-10 codes can be found in paren­
theses after each diagnosis.
Preexisting Factors
Psychiatric morbidity greatly increases the risk of sustain­
ing an injury, either directly (e.g., self-inflicted burns or

65  •  Psychiatric Disorders Associated With Burn Injury
701
have been found to occur more frequently in pediatric burn
survivors than in the general population. Commonly pedi­
atric burn survivors may not exhibit symptoms of prior
psychiatric disorders during the acute phase of treatment
due to the impact of injuries and other treatments. When
symptoms are evident, continuation of prior treatment or
implementation of indicated treatment for a preexisting
psychiatric disorder may not only control symptoms but
also facilitate patient participation and cooperation with
acute care and long-term rehabilitation.
Repeated inhaling of psychoactive volatile hydrocarbons
from, for example, glue, fuels, or paint (“sniffing”) can be
classified as inhalant use disorder (F18.x). This disorder can
result in burns because many of the substances are flam­
mable. Inhalant use disorder is most common in adoles­
cents, whereas prevalence declines rapidly in adulthood.16
Across cultures attention-deficit/hyperactivity disorder
(ADHD, F90.x) in children has a prevalence of about 5%.16
One of the key features of ADHD is impulsivity (i.e., actions
without forethought), which can expose the individual to
high-risk situations, and children with ADHD have repeat­
edly been shown to be at greater risk for burns.17–19
Conduct disorders (F91.x) encompass repetitive and per­
sistent behavioral patterns of violations of social norms and
rules. Childhood-onset conduct disorder often is concurrent
with ADHD, and individuals displaying this subtype (in con­
trast to adolescent-onset type) often display physical aggres­
sion; thrill-seeking and recklessness are frequent personality
features.16 In this context, playing with fire and fire-setting
can be symptoms of conduct disorder16 and can result in
burns. Conduct disorders have a prevalence of around 4%,
and the childhood-onset subtype has a worse prognosis
with risk for adulthood psychiatric morbidity.
In contrast, pyromania (F63.1) is a specific conduct dis­
order in which deliberate and purposeful fire-setting occurs
not as an aggression but in a setting of tension or affective
arousal. This repeated fire-setting behavior increases the
risk for burns, both for the individuals and those around
them. Possibly the prevalence of pyromania may be under­
estimated; it has been observed that a slight majority of
individuals with pyromania restrict their fire-setting to con­
trolled situations, such as controlled fires on their own
property, and therefore can remain “undetected.”20 The
prevalence of pyromania as a comorbidity has been found
to be 3–7%.16,20 There is limited knowledge about the time
course of pyromania. It has been postulated that the disor­
der is rare in children and begins in late adolescence but
that some individuals “switch” to other impulsive, reward-
seeking behaviors.16,20
Social Considerations in
Pediatric Burns
Clearly parental and family characteristics can increase
both the risk for burns in children as well as influence their
subsequent recovery and outcome. The presence of child
abuse or neglect can directly result in pediatric burns.1,21,22
The presence of parental anxiety, depression, poor coping
skills, or lack of social support at the time of injury are
associated with poorer functional outcome in pediatric
burn survivors.23,24 Possibly high parent state anxiety in
combination with ineffective coping strategies rather than
family functioning or burn severity can be most predictive
of pediatric burn outcome.25
Parents face numerous emotional challenges not only
due to the psychological trauma of their children’s burns,
but also during subsequent treatment and recovery. Parents
report more feelings of anxiety and being stressed, depressed,
and guilty than the normal reference population even in
areas unrelated to their children.24,26 These stresses can
result in psychiatric disorders in parents up to 2 years after
the injury, with mothers at greater risk for developing
mental health problems and depressive and posttraumatic
stress symptoms.27–29 Increased risk for depression was
associated with having an only child or multiple offspring
injured and with complicated burn injuries (secondary
infection or amputation). Larger burns and the presence of
parent–child conflict, parental dissociation, or PTSD symp­
toms in the child are strongly correlated with parental
PTSD symptoms.30–32 This emphasizes the need for psycho­
logical attention to parents of burned children, as well as to
the children themselves. As child and parent ratings do not
always match, recent studies suggest that burn centers
adopt a family perspective and include assessments of both
parents and children.32
Self-Inflicted Burns and
Suicide Attempts
The proportion of self-inflicted burns differs across the world:
whereas it is between 1% and 9% in North America and
Europe with no clear gender distribution, self-inflicted burns
are a major cause of burns in females in the Middle East,
Africa, and south Asia, with a prevalence of up to 28%.33,34
Of patients with self-inflicted burns, those attempting suicide
are more likely to have larger burns and longer hospitaliza­
tions than those with the intent of self-mutilation.33 Across
cultures psychiatric morbidity is an important additional
risk factor, often in conjunction with social stress factors
such as marital problems or unemployment.1
In-Hospital Contributing
Factors and Disorders
Several problems during acute burn treatment can affect
the course of treatment and the eventual outcome after
burns. Pain, itching, and sleep disorders are caused by both
the injury and its treatment. High levels of stress and
anxiety may contribute to the development of psychiatric
morbidity (e.g., PTSD). In patients with substance-related
disorders (F10.x–F19.x), withdrawal symptoms can occur
during acute care, and patients with preinjury substance
abuse have a higher risk of developing psychiatric symp­
toms during and after acute care. There is evidence that, in
the case of comorbidity of PTSD and substance-related dis­
orders, concurrent treatment of both disorders is necessary
to achieve improvement.35
After the initial postburn period patients will undergo
a series of operative procedures or dressing changes
interspersed with physical therapy. Constant pain or the
sure knowledge of repeated painful episodes in the near

65  •  Psychiatric Disorders Associated With Burn Injury
702
In contrast to delirium and psychosis, burn encephalopa­
thy is often observed in children,54,55 characterized by leth­
argy, withdrawal, or coma. Electroencephalograms (EEGs)
in such cases typically reveal diffuse, nonspecific slow
waves. Causative factors probably are the same as those for
delirium.56
Even young children can experience severe anxiety fol­
lowing burns, with up to a third of patients reporting symp­
toms of acute stress disorder (ASD) in the immediate
aftermath of burns.57 Mediating factors for the presence of
anxiety symptoms appear to be size of burn, parental stress,
and the experience of pain. High resting heart rate, poor
body image, and parental stress symptoms have been found
to be significant risk factors in development of ASD in
children.58
Similarly to adults, pain in children appears to dramati­
cally increase the risk for developing anxiety symptoms and
subsequent anxiety disorders, and appropriate pain man­
agement can reduce or resolve anxiety symptoms.59,60
DELIRIUM
Delirium (F05) is a state of acute brain dysfunction, and, in
burn patients, it is important to consider that it can both be
due to the trauma itself as well as a symptom of substance
withdrawal. It is a transient and usually reversible syn­
drome with disturbance of consciousness and cognition
compared to previous levels of functioning. Hallucinations
and delusions can occur, and patients in delirium can
become suicidal or combative. Early symptoms can be rest­
lessness, anxiety, disorientation, or sleep disorders.
Delirium in burn patients has been found to occur
more often in individuals with a history of substance
abuse or other psychological problems and with larger
burns.61,62
Other potential causes of disorientation, hallucinations,
and agitation may be medications used in the treatment of
the acute burn patient, sepsis, and metabolic conditions.62
These hallucinations can blur the line between delirium
and ASD. Sleep deprivation has also been discussed as a
cause for delirium in ICU patients.63
Acute Stress Disorder and
Posttraumatic Stress Disorder
In the course of the progression from the Diagnostic and
Statistical Manual of Nervous and Mental Disorders, Fourth
Edition (DSM-IV) to DSM-5, ASD (F43.0) and PTSD (F43.10)
no longer are regarded as anxiety disorders; they are now
listed as a separate group called trauma- and stressor-
related disorders: an overanxious patient is afraid of what
might happen, whereas the patient with PTSD reexperi­
ences and fears what has happened. The patient with PTSD
is stuck in a heightened perception of threat and uses avoid­
ant behaviors that maintain the symptoms.
ASD is the most common psychiatric disorder seen in
survivors of major burns, in addition to PTSD, and it has a
prevalence as high as 19% after burns.48,64,65 ASD symp­
toms appear immediately following the trauma, last for at
least 3 days, and usually resolve within a month after the
trauma.16
future and feelings of anxiety and powerlessness are
predominant36–38 because every movement, even shifting
position and change of bedclothes, is painful. Therefore
treatment and the experience of hospitalization may be
as traumatic psychologically as the original burn. Patients
who experience high levels of pain not only have a higher
risk of poor adjustment and psychiatric problems after
discharge, but wound healing also can be affected due to
stress.38,39 Furthermore, high levels of stress, anxiety, and
PTSD decrease pain tolerance.37
Itching is a common problem during wound healing
and scar maturation, and it can cause considerable distress
and anxiety.40,41 Persistent itching can disrupt sleep, which
increases stress levels and also impairs everyday func­
tioning and participation in rehabilitation.42 Anxiolytic,
antidepressant, and antipsychotic agents have been used
successfully to reduce itch.41
Significant sleep problems are common during and after
treatment for acute burns.43–45 The noise and light on the
unit and interruptions for treatment will disrupt sleep.46
Pain, anxiety, and itching can disrupt sleep or affect sleep
quality. Symptoms of stress and PTSD (e.g., nightmares)
can both cause awakening and a fear of going back to
sleep.44,47 Pain severity during hospitalization has been
shown to predict insomnia after discharge, and insomnia in
turn predicts long-term pain.45 Burn patients who experi­
ence poor sleep at night will also have lower pain tolerance
during the day.47
IN-HOSPITAL DISORDERS
Disorientation, confusion, delirium, transient psychosis,
depression and anxiety, stress, and sleep disorders are com­
monly observed during acute burn treatment.3 Causes of
these symptoms are multifactorial: hypoglycemia, sepsis,
and/or a variety of other organic problems can contribute.
The altered state of consciousness may be transitory, wax
and wane over several days, or, with large burns, persist for
weeks.
A significant number of burn survivors will experience
acute or posttraumatic stress disorder symptoms, includ­
ing intrusive memories of the injury, during their acute
recovery.1,48,49
Symptoms of depression and agitation related to exces­
sive pain will subside with adequate pain management. The
experience of pain has been found to be a mediating risk
factor for PTSD in both pediatric and adult burn patients.38,50
The recurrence of pain in a scar area following laser treat­
ment or with wound cleaning can lead to recurrence of the
PTSD symptoms associated with the original pain.
After severe burns patients are at risk for the development
of substance abuse in the wake of PTSD,3,35 but the use of
opioids and other pain medication will not cause depen­
dence per se if adequately administered and tapered when
pain levels decrease.37,51
Symptoms of delirium and transient psychosis rarely
occur among children under the age of 10 years.52 True
hallucinations are uncommon in children, but, when they
do occur, the most likely cause is stress, followed by pain and
medications.53 In young burn patients sepsis and metabolic
conditions are a more frequent cause of hallucinations
than are psychiatric disorders.

65  •  Psychiatric Disorders Associated With Burn Injury
703
Another predictor of psychiatric problems is the presence
of psychiatric or personality disorders preburn.2 Cognitive
processes may play an important role because, for example,
burn-related attentional bias has been shown to be strongly
associated with PTSD 1 year post injury.82 Skull burns are
associated with cognitive as well as affective disorders post
burn,83 but there does not seem to be a relationship to facial
burns or even very large burns.
It has been observed that depressive symptoms were
linked to physical limitations at 5 years after injury.84 The
appearance and location of the burn scar may be predictive
for PTSD symptoms of avoidance and emotional numbing85
or depression, especially in women.86 In contrast, other
studies found that neither the severity nor the visibility of
burn scars influence long-term adjustment, but rather
social introversion, which predicted the development of
pathological shame.87,88 Many patients with PTSD have
comorbid depression;89 both are sequelae of trauma and
share a lot of symptoms, but they develop independently of
each other.90 In the trauma literature,91 as well as in the
burns literature,92 subgroups of patients developing PTSD
symptoms in different patterns over time can be identified
(e.g., resilient with no or low symptoms, recovery, delayed,
and chronic). The chronic group carries more of the above-
mentioned medical, social, and psychological risk factors
and should, together with those who have delayed onset of
symptoms, receive the most attention from the burn reha­
bilitation team.
General Anxiety Disorder
Many patients continue beyond acute hospitalization to
have periods during which they appear extremely anxious
and express fear. These periods often recur in association
with return to a hospital for reconstructive surgeries.
General anxiety disorder (GAD, F41.1) is characterized by
excessive worry for more days than not for at least 3 months
and difficulty in controlling the anxiety. Typical symptoms
are restlessness or the feeling of being on edge, muscle
tension, and changes in behavior due to anxiety and worry,
such as avoidance of potentially negative events, procrasti­
nation, or seeking reassurance.16
In the literature, the prevalence of anxiety disorders in
adults during the year after burn—usually GAD or agora­
phobia without panic—is less than 20%, and those with
very small burns had even less anxiety.7,93 Avoidant coping
style was significantly correlated with the level of anxiety
at 3 months.6 In a study of young adults burned as children
and with much larger burns than those examined in other
studies, all the anxiety disorders were found, and they were
twice as common as in matched controls: 12.9% of the
subjects had a specific phobia and 6.9% had generalized
anxiety.94
Not infrequently, anxiety spills over to other situations
and/or becomes focused on specific objects; thus, phobias
develop that are characterized by excessive persistent
fear in response to specific stimuli. In a burned patient,
difficulty controlling anxiety, restlessness, and behav­
ioral changes are diagnostic of anxiety disorders since
some other symptoms can be related to burn injuries
specifically.
In contrast to PTSD, dissociative symptoms can be present.
Whereas these symptoms previously (i.e., in DSM-IV) had
been given a central role for the diagnosis, it is now under­
stood that some individuals develop ASD without dissocia­
tive symptoms.16,66
In children, repetitive reenactment of the traumatic
event in play can be a symptom of intrusion and/or
dissociation.
The presence of avoidant symptoms during the acute
phase of recovery has been shown to predict chronic post­
traumatic disorder in burn patients.67,68 It is of great impor­
tance to recognize symptoms of ASD and PTSD at an early
stage because the former has been shown to be a predictor
for PTSD, and, once PTSD is established, it usually will
persist.48,69
PTSD is, in addition to depression and general anxiety
disorder (GAD), one of the most common psychiatric disor­
ders seen in survivors of major burns with prevalence rates
ranging between 7% and 45%.2,48,49,65,70,71 In DSM-5 behav­
ioral symptoms of PTSD encompass four instead of the pre­
vious three clusters: (B) intrusion, (C) avoidance, (D)
negative cognition and mood—this is the new cluster—and
(E) arousal (which in DSM-IV was the D cluster).16 Aggres­
sive, reckless, or self-destructive behaviors are now recog­
nized as aspects of arousal. The DSM-5 definition of PTSD
no longer differentiates between acute and chronic PTSD.
Instead, two new subtypes of PTSD are identified in DSM-5:
PTSD in children younger than 6 years (PTSD preschool
subtype) and PTSD with prominent dissociative symptoms
(PTSD Dissociative subtype) (for a review of the changes,
see reference 66).
About one-third of burn survivors develop PTSD within
2 years of their injury,72 and this was true for even small
burns.73 Individuals should be interviewed about sleep pat­
terns and startle response because nightmares and altered
sleep patterns are usually the symptoms first noted. In fact,
in adults, it has been shown that one of the most important
piece of information when screening for PTSD is night­
mares.74 Another potential marker for ASD and PTSD is
heart rate at admission to the burn unit, although it appears
to be mediated by gender.75 A significant number of burn
survivors will experience PTSD symptoms, including intru­
sive memories of the injury, during their acute recovery.76,77
Children may express intrusive symptoms by reenactment
of the traumatic event, and nightmares may not be directly
related to the event.16
The presence of avoidant PTSD symptoms during the
acute phase of recovery is reported to predict chronic PTSD
in burn patients.67–69,72,78
Long-Term Postburn Disorders
Pain and previous psychiatric illness are the main factors
that have been suggested as reasons for psychiatric prob­
lems beyond the time of discharge from the burn care
center.49 Pain and depression seem to be linked in such
a way that they can cause each other.79 Also, acute
pain at the time of discharge from the hospital seems to
produce long-term suicidal ideation.80,81 There is a recip­
rocal relationship between pain with depression and
anxiety.81

65  •  Psychiatric Disorders Associated With Burn Injury
704
the latter do not include the symptoms anhedonia, psycho­
motor agitation/retardation, and recurrent thoughts about
death. The time frame also differs: persistent depressive dis­
order must be present for at least 2 years in adults or at least
1 year in children and adolescents in order to be diagnosed.
Patients often report chronic anger, appetite changes, sleep
difficulties, fatigue, low self-esteem, poor concentration, dif­
ficulty making decisions, and feelings of hopelessness. The
same combination of medication and psychotherapy is rec­
ommended for patients with persistent depressive disorder
as for major depression.
Substance-Related and
Addictive Disorders
There are few studies that indicate the prevalence of sub­
stance abuse or alcohol abuse in adults. Recent studies indi­
cate that substance abuse may be one of the most prevalent
psychiatric disorders. A Finnish study found that 26% of
the surveyed patients had alcohol abuse or dependence, and
6.5% had drug abuse or dependence during a 6-month
follow-up after trauma.49 Another study reported that 25%
of former patients had an at-risk drinking pattern 2–7 years
after burn injury, and it was predicted by an avoidant coping
pattern that involved using alcohol, tobacco, or other drugs
to handle problems.100 Certainly prior abuse is a major risk
factor for abuse after burns. Maes et al.93 reported an inci­
dence of 6% for new-onset psychoactive substance use dis­
orders after trauma. In a study in young adults who were
burned as children the prevalence of the use of alcohol and
substances was 7.9% for alcohol and 35.7% for other sub­
stances; however this rate later fell to 3% for alcohol and
9.9% for other substances.94 These young adult prevalence
rates are lower than the reference population in the United
States for alcohol but were higher for substance abuse/
dependence, which may reflect the socioeconomic back­
ground of the subjects studied.
Comorbidity and Problems
Beyond Psychiatric Illness
PTSD and depression are both linked to poor long-term out­
comes in adults.39,70 PTSD and pain together predicted poor
functional and increased disability after major burns. PTSD
symptoms led to greater physical and psychosocial disabil­
ity, poorer social functioning, and less vitality.39 Pain is
linked to poor concurrent physical functioning, and depres­
sion can predict decreased physical health 2 months post
discharge.80,101
Adjustment in Children
After Burns
A significant number of the children and adolescents
who survive major thermal injury develop a variety of
significant behavioral and emotional problems at some
point in their lives, but good adjustment is achieved by
the majority of individuals.102–106 In studies in adolescent
and young adult survivors of pediatric burns, about half
Although adults may express anxiety through “panic”
symptoms such as sweating, palpitations, trembling, or
nausea, children may express anxiety by crying, tantrums,
freezing, or clinging. A differential diagnosis of these
anxiety disorders distinct from PTSD is difficult and requires
a careful interview.
Major Depressive Disorder
Although feeling depressed is a reaction most observers
would expect of burned patients, only a relatively small
number of patients with burns have been observed to have
symptoms of severe depression (F32.x and F33.x).2,49,64,95,96
In most studies preinjury depression or lower levels of well-
being were stronger predictors than burn size for subse­
quent depression. All the same, those individuals who
experience symptoms of depression during hospitalization
will continue to do so after discharge so that early recogni­
tion and treatment may improve their situation consider­
ably.95 Depression is also a rare long-term sequela of burns
in children: fewer than 50% of the children had ever suf­
fered symptoms of major depression, and, in a sample of
adolescent survivors, only 6% met criteria for a major
depressive disorder.96,97
Symptoms of a major depressive episode according to
DSM-5 are as follows: (1) depressed mood, (2) diminished
interest or pleasure in activities (“anhedonia”), (3) signifi­
cant weight or appetite changes, (4) insomnia or hypersom­
nia, (5) psychomotor agitation or retardation, (6) fatigue,
(7) feelings of worthlessness or guilt, (8) diminished ability
to think or concentrate, and (9) recurrent thoughts about
death.16 Children and adolescents may display irritable
mood instead of depressed mood and a failure to gain weight
instead of weight or appetite changes.
This is an extremely difficult diagnosis to make during the
acute burn period since many of the criteria are linked to
physical symptoms. A number of approaches have been
used to determine the incidence among adult survivors of
major burns using self-report measures such as the Beck
Depression Inventory. A review of the literature on depres­
sion in burn survivors found a prevalence of major depres­
sion at 1 year post discharge of between 4% and 7%. At
more than 1 year post discharge the prevalence ranged
between 9% and 23% (for a comprehensive review, refer to
Thombs et al.98
Even beyond the acute phase, the diagnosis is often com­
plicated by grief. The critical symptoms of major depressive
disorder are the first two listed—depressed mood and
anhedonia—whereas grief is mainly characterized by feel­
ings of emptiness and loss.16
Persistent Depressive Disorder
A smaller percentage of burned patients, around 4%,
will develop a milder but more protracted type of depres­
sion called persistent depressive disorder, or dysthymia
(F34.1).98,99 In some cases the persistent depressive disorder
may be preceded and/or interspersed by major depression.
The main differences between major depression and per­
sistent depressive disorder are that diagnostic criteria for

65  •  Psychiatric Disorders Associated With Burn Injury
705
Treatment
DELIRIUM AND AGITATION
Due to the problems associated with phenothiazines, ben­
zodiazepines have been used to a greater extent in recent
years for the combative, delirious patient.117–119 The two
most commonly used benzodiazepines are diazepam and
lorazepam. Lorazepam (0.03 mg/kg) orally or intrave­
nously can usually be given every 4–8 hours; for a very
combative patient it can be given hourly. A third benzodiaz­
epine that is frequently used is midazolam at 0.05 mg/
kg IV, typically used in conjunction with morphine for pro­
cedures such as tubbing and staple removal. Midazolam is
also used for sedation as a continuous infusion for intubated
patients. When using the benzodiazepine class of medica­
tions, a clinician must balance the desired effects of relax­
ation with oversedation. Visual and auditory hallucinations
may occur if the dose of benzodiazepine is too high. In cases
of excessive anxiety in the presence of adequate pain
control, lorazepam can be added to a patient’s treatment.
Nighttime doses usually enhance sleep. Diazepam may be
used in place of lorazepam if simultaneous muscle relax­
ation is desired.120 Diazepam has an extremely long half-life,
40 hours, and therefore should be used sparingly. To avoid
excessive sedation by benzodiazepines, a patient should not
be awakened for the next dose.
ASD AND PTSD
Therapy is the same for ASD and PTSD and usually includes
a combination of psychotherapy and pharmacotherapy. For
a comprehensive description of common aspects of psycho­
therapy for PTSD, see Schnyder et al.121 Trauma-focused
cognitive behavioral therapy (TFCBT) can relieve PTSD
symptoms and typically includes imagined and in vivo
exposure, where prolonged exposure is one of the most
effective treatment protocols today. Exposure involves in-
depth recalling and verbalizing of the event, physically
revisiting the site of the accident either in person or, as most
recently studied, by means of virtual reality. Another treat­
ment component is cognitive restructuring and skills train­
ing, sometimes by role play and cognitive tasks. Training in
anxiety management using stabilizing and relaxation tech­
niques is also important for recovery from PTSD. Another
evidence-based psychological treatment is eye-movement
desensitization and reprocessing (EMDR) where in-depth
processing of the memory is achieved by having the patient
track a bilateral stimulus with his or her eyes at the same
time as the memory is retrieved. In a Cochrane review,
TFCBT and EMDR were found more effective in the treat­
ment of PTSD in the long term than were other psycho­
therapies or waitlist conditions.122
Pharmacotherapy developed over the past two decades
with the use of selective serotonin reuptake inhibitors
(SSRIs), such as sertraline and fluoxetine, as first-line drugs.
Other useful medications are tricyclic antidepressants
(TCAs); antipsychotics, such as risperidone and quetiapine
fumarate; and α2 adrenergic agonists, such as clonidine.
SSRI antidepressants, such as fluoxetine, or a TCA like imip­
ramine should be considered for ASD.123 Both SSRIs and
TCAs are helpful in reducing nightmares and improving
of the individuals met criteria for one or more psychiat­
ric disorders,94,97 and adult survivors of childhood burns
have a significantly higher relative rate of both psychiatric
and physical illnesses.107 About one-fifth of children with
burns are reported to have more problems with conduct
and peers than does the norm population,106 and 35% of
preschool children with burns were diagnosed with at least
one psychological disorder.108 A recent study also showed
that 13.2% of infants and toddlers with burns met the
proposed alternative criteria for PTSD.109 Severity of symp­
toms and adjustment were associated with family relations
and maternal PTSD. Compared to a group of survivors of
flood trauma and a community sample, burned children
had significantly more phobic disorders, overanxious dis­
orders, enuresis, encopresis, major depression, PTSD, and
substance/ethanol abuse.96,110 Sleep disorders and psy­
chotic disorders were also slightly more common among the
burned children.
Parents usually report more problems than do the chil­
dren themselves or their teachers.102,111,112 This observation
could be explained by increased problems in these children
following severe burns that would not be easily observed by
persons who do not live with them or that parents became
overly sensitive to any indication of difficulty for their chil­
dren following burns.
Another area of long-term psychiatric outcome follow­
ing pediatric burns that has received little attention is the
development of personality disorders. In the same sample
of young adults mentioned earlier,94 personality disorders
were common and significantly associated with comorbid
Axis I diagnoses.113
Diagnosis (Screening
Instruments, SCID)
Two techniques are used to determine the prevalence of
psychiatric disorders in burn survivors. The one most com­
monly used has been the self-report questionnaire, such as
the Beck Depression Inventory, Impact of Event Scale-
Revised,114 Davidson Trauma Scale, Brief Symptom Inven­
tory, McGill Pain Questionnaire, and Quality of Life surveys
such as the Short Form 36 (SF-36) or the EQ-5D, which has
been validated with burn survivors.115
For a more complete diagnostic survey, the gold standard
is the Structured Clinical Interview for DSM-5 Disorders
(SCID-5) interview.
The American Burn Association had a consensus confer­
ence in February 2013 to establish a recommendation for
uniform psychiatric screening and diagnostic tools for the
burn survivor. Wiechman et al. published a list of recom­
mended tools a few months later.116 The group focused on
depression and PTSD symptoms.
Criteria for the screening instruments were that they
be validated, easy to use, and free. For depression in
adults, the Patient Health Questionnaire (PHQ-2 and
9), Beck Depression Inventory, Brief Symptom Inven­
tory, and SCID were recommended; for childhood depres­
sion, the Child Depression Inventory was recommended.
For PTSD symptoms in adults, the PTSD Symptom
Checklist and in children the UCLA PTSD Index were
recommended.

65  •  Psychiatric Disorders Associated With Burn Injury
706
posttraumatic stress, is often helpful. Once the symptoms
have responded to medication, treatment should con­
tinue for 9 months to a year in order to avoid relapse on
discontinuation.
Many times the depression is comorbid with PTSD. There­
fore medications that affect both are preferred. Fluoxetine
and the other SSRIs are the first-line medications for treat­
ment of patients with depressive symptoms.124,132
SLEEP DISTURBANCES
After discharge, many burn survivors have significant sleep
problems. As in the hospital setting this may be secondary to
PTSD symptoms, depression, itch, or pain. Pain in the hos­
pital before discharge will predict insomnia.45 When sleep
disturbance with nightmares is associated with posttrau­
matic anxiety, as described earlier, antidepressant medica­
tions are the drugs of choice. Imipramine and doxepin are
both sedating antidepressants that are effective treatments
for sleep problems in burn patients. Trazodone and nefazo­
done are alternative medications for insomnia and do not
appear to alter sleep architecture as much as other antide­
pressants. Mirtazapine is another antidepressant that has
been used for insomnia, although little is known about its
effects on sleep architecture. Pain and itch are other prob­
lems that can interfere with sleep and should be addressed
with appropriate analgesic or antipruritic medications.133 If
a patient continues to have significant sleep problems, sleep
can be induced with diphenhydramine. Diphenhydramine
doses of 1.5 mg/kg are often used throughout the day for
itching and may be used alone for sleep at night or as an
adjunct to other sleep medications. Usually, doses of 25 or
50 mg in the evening are adequate. Recently quetiapine
fumarate (Seroquel) PO has been found to be safe and useful
in this setting.
SPECIAL ASPECTS IN PEDIATRIC TREATMENT
As with adults, pediatric patients suffering with psychiatric
symptoms can benefit from psychotherapy, with appropri­
ate indicated treatment for their specific problems. A
number of specific therapies have been adapted for treat­
ment of anxiety, PTSD, and depression in children and ado­
lescents. In addition, specific treatments for pediatric burn
survivors have been developed, such as social skills training
addressing disfigurement.134 In school-aged children there
is preliminary support for a brief, early psychological inter­
vention in reducing later internalizing problems.135
Early opiate management of burn-related pain is
important for decreasing the risk of long-term PTSD in
children.136
Pediatric burn patients appear to have a much higher rate
of adverse reactions to haloperidol, and alternative man­
agement of agitation should be considered.137 Chlorproma­
zine and thioridazine may be used in place of haloperidol in
the dosage range of 25–100 mg per dose. Chlorpromazine
and thioridazine have strong sedative effects and interfere
with learning but are less likely than haloperidol to produce
associated dystonia, pseudo-parkinsonism, and akathisia.
If more than 2 mg of haloperidol per day is used, atten­
tion must be given to simultaneous administration of 1
sleep patterns. Treatment with an SSRI or TCA should be
continued for at least 9 months to a year following the
improvement of symptoms because of the risk of relapse.
One of the major issues with the use of TCA is that cardiac
arrhythmias, associated with a prolonged PR interval, can
be life-threatening.124 When medication is discontinued,
it should be reduced over time to avoid uncomfortable—
although not medically threatening—discontinuation
symptoms. The relatively long half-life of fluoxetine usually
protects patients from any discontinuation symptoms but
requires extended vigilance for any drug–drug interactions.
Typically the SSRIs are given in the morning rather than
the evening because they may interfere with sleep onset.
Side effects of SSRIs include gastrointestinal upset, increased
agitation, headaches, sexual symptoms, and sweating. A
rare but potentially life-threatening side effect is serotoner­
gic syndrome,125 characterized by at least three of the fol­
lowing symptoms: delirium, agitation, sweating, fever,
hyperreflexia, myoclonus, tremor, incoordination, diar­
rhea, and shivering. Severe cases can result in hyperpy­
rexia, shock, or death. The risk of serotonergic syndrome
increases when patients are on multiple medications that
potentiate central nervous system serotonin, such as an
SSRI and a monoamine oxidase inhibitor. There is a reported
case of serotonin syndrome in a pediatric burn patient who
was receiving fluoxetine and linezolid, a broad-spectrum
antibiotic with monoamine oxidase inhibition.126 Sexual
side effects are the most likely reason that a teen or an adult
would refuse to take an SSRI.
In an emergency room setting, propranolol has been tried
with some success for those with minor injuries. It has been
reported to be very helpful in the treatment of PTSD and
ASD and to prevent their occurrence following a variety of
different types of trauma. Longer-term studies with larger
injuries have not shown propranolol to be helpful for the
prevention or treatment of ASD or PTSD.127,128 Benzodiaz­
epines will control some immediate symptoms but are not
useful long term.
Concerns that midazolam administration might interfere
with this process and actually enhance PTSD could not be
substantiated.129
OTHER ANXIETY DISORDERS
Most burn patients, certainly those who qualify for the diag­
nosis of generalized or overanxious disorder, will benefit
from lorazepam therapy in addition to psychotherapy. If
anxiety is associated with other symptoms of posttraumatic
stress, such as hypervigilance or poor sleep, an SSRI123 or
the older TCAs130 should be considered. The SSRIs have the
advantage of being safer drugs for outpatient treatment
since an overdose is unlikely to cause the significant cardiac
problems that have been attributed to the TCAs.131
MAJOR DEPRESSION
Major depression, with or without grief reaction, should
be treated by a team approach. The patient should be
involved in scheduled daily activities. Psychotherapy
should begin to identify and address appropriate issues.
Medication with SSRIs or TCAs, as described for acute and

65  •  Psychiatric Disorders Associated With Burn Injury
707
Resilience, Posttraumatic Growth
Although it has become generally accepted knowledge that
trauma and injury can lead to psychological and psychiat­
ric problems, the fact that a considerable proportion of indi­
viduals do not develop problems after trauma and injury
has found much less attention, and, to date, there is only an
extremely small number of studies in burn patients.
Resilience and posttraumatic growth (PTG) are two sepa­
rate constructs. Resilience is a trait that exists before expo­
sure to trauma or adverse events that PTG.147,148 Resilient
individuals have an ability to “bounce back” and regain
balance in all aspects of life, as well as having endurance in
the face of adverse events.147–151 Resilience is the most
common response pattern seen after burns: approximately
40% of adult patients respond in this way.92 Three catego­
ries of protective factors, which also are predictive of resil­
ience, have been identified:150 individual characteristics,
relationships, and social network.
In contrast, PTG is the development of new behaviors and
attitudes that were not present before the event. It is a posi­
tive psychological development, the result of struggles in the
face of hardship or traumatic events.147,152 The Posttrau­
matic Growth Inventory152 identifies five different aspects of
PTG: new possibilities, relating to others, personal strength,
spiritual change, and appreciation of life. PTG appears to be
somewhat related to the personality traits of optimism and
extraversion. Female gender and social support are the
strongest predictors of PTG, and higher levels of education
and higher socioeconomic status also are predictive.145,147
Resilience and PTG can both occur concurrently with
distress and lower quality of life; in fact PTG may not occur
without some level of distress, but distress diminishes over
time in individuals who experience PTG. Longitudinal
studies show that PTG levels out at about 6 months after
trauma.147
INTERVENTIONS TO FOSTER PTG
While alleviating distress does not foster PTG, growth can
protect from further distress. The patient’s own experiences
and psychological development appear to play a central role
in PTG. The caregiver’s role should be to support and
improve coping, strengthen self-image, and enhance social
support; caregivers “must be comfortable in allowing the
patient to struggle with the event.”147,153 Common aspects
of PTG in burn patients appear to be the use of active and
flexible coping, social support, enhanced self-image, and the
successful search for meaning.148,154,155
Conclusion
Preinjury psychiatric morbidity can have a major effect on
outcome after a burn. Furthermore, psychiatric symptoms
occur commonly as part of the complex systemic response
to burn injuries. Psychological and pharmacologic treat­
ment is important in the successful recovery of a burned
person and may reduce the risk of long-term psychiatric
sequelae of the injury. It is important to note that
or 2 mg/d of benztropine or 2–5 mg/d of trihexyphenidyl
in divided doses. Benztropine or trihexyphenidyl are used
to avoid dystonia, pseudo-parkinsonism, and akathisia.117
Occasionally, dystonia takes the form of an oculogyric
crisis, which resembles an acute neurological catastro­
phe138 and can be a true medical emergency if respira­
tion is impaired. These reactions are usually alleviated by
50 mg IV diphenhydramine.
The treatment of anxiety and depression in children
with SSRIs and TCAs requires closer attention to dosage
and potential side effects. The usual starting dose of fluox­
etine is 5 mg for children weighing less than 40 kg, 10 mg
for children between 40 and 60 kg, and the adult dose for
any children weighing more than 60 kg. The usual starting
dose of imipramine is 25 mg/d unless the patient weighs
less than 25 kg. The beginning dose is 12.5 mg for those
under 25 kg. The dose can be increased rapidly over the
next few days to a dose of 1 mg/kg. If the symptoms are
still uncontrolled, the dose may be increased stepwise to
3 mg/kg, but only with frequent checking of the plasma
level and electrocardiographic changes with each incre­
ment of dose. A steady state is usually not reached until a
given dose is maintained for 3–5 days. The preferable time
of administration is in the evening to aid with sleep. Major
side effects of the TCAs are anticholinergic (dry mouth and
dry nasal passages, constipation, urinary hesitance, and
occasional esophageal reflux).117 Autonomic complications
such as orthostatic hypotension, palpitations, and hyper­
tension have been reported in adolescents using this medi­
cation.139 Cardiac arrhythmias associated with a prolonged
PR interval can be life-threatening.124,132 Sudden death has
been reported for teenagers and children receiving desip­
ramine and other TCAs.140 Amitriptyline or doxepin may
be used in place of imipramine. The dosages are similar;
however both these medications may cause more sedation
than imipramine.117
Following clinical reports of increased suicidal ideation
in pediatric patients treated with certain antidepressant
medications and a review of clinical trial data, the U.S. Food
and Drug Administration instructed all manufacturers to
include a “black box” warning with all antidepressant med­
ications.141 Pediatric patients and their caretakers must be
aware of these risks, and clinicians should closely monitor
children and adolescents on these medications for possibly
increased suicidal ideation and behavior.142
NONPHARMACOLOGICAL PREVENTION
OF PTSD
Currently there is no evidence-based nonpharmacological
method for prevention of PTSD. The dominating approach
is psychological first aid that is largely based on consensus
agreement and has replaced the much criticized psychologi­
cal debriefing as the standard intervention for trauma
victims.143 However there are preliminary indications that
TFCBT can be effective in preventing PTSD in groups of
trauma victims with early signs of high symptomatology.144
Other complementary and alternative treatment modalities
such as meditation, mindfulness, and acupuncture may
also be effective, but to date the evidence is not as strong as
for the aforementioned modalities.145,146

65  •  Psychiatric Disorders Associated With Burn Injury
708
becomes a responsibility of the expert in burn care and the
entire burn team to be aware of frequently occurring prob­
lems, to ask the right questions to assess a patient’s status,
and to assist a patient in receiving psychological and psy­
chiatric assistance.
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psychological adaptation is a lengthy process occurring
over months or years. During the postburn years, it is
imperative that the burn team assesses the mental and
affective states of patients while assessing their physical
recovery. In most cases, patients with sleep disorders,
depression, or withdrawal from previous activities will not
seek psychiatric attention and treatment, although these
problems can be ameliorated by treatment. It therefore

708.e1
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stress symptoms vary inversely with early opiate dosing in children

709
Psychosocial Recovery and
Reintegration of Patients With
Burn Injuries
LAURA ROSENBERG, MARTA ROSENBERG, RUTH B. RIMMER, and
JAMES A. FAUERBACH
66 
family into the treatment plan from the beginning facili­
tates successful outcomes.
PREINJURY ADJUSTMENT
Shortly after being admitted to the burn unit, a clinical
interview is done to gather information regarding variables
that may influence the patient’s recovery and treatment.
Information about the burn injury, previous stressful events,
risk factors, preburn physical and psychological health,
coping skills, family and social support, and the family’s
strengths and weaknesses are important factors to take into
account when developing treatment plans.4,5 Gathering
information about factors that contributed to the circum­
stances of the burn is emphasized in instances of suspected
maltreatment and neglect.6 Because patients will be depen­
dent to some extent on family during recovery, it is essential
to identify risk factors in the family system. Risk factors that
may predispose individuals to burn injury and that may
affect postburn recovery include physical illness, substance
abuse, psychiatric illness, behavioral problems, poverty,
inadequate social support, and heightened family disrup­
tion.5,7–9 Part of the clinical interview involves initiation of
a therapeutic alliance with those who are most likely to be
involved in assisting a patient’s recovery.
ADMISSION CRISIS
When people with burns are admitted to the intensive care
unit (ICU), they may be frightened, confused, experience
shock and disbelief, have pain and anxiety, and fear dying.
While the physiological emergency is treated medically,
the psychological crisis must also be addressed. The goals
at this time are to establish therapeutic rapport with the
patient, decrease anxiety, and assess strengths and needs of
the patient. The first two tasks are addressed immediately
by orienting the patient, focusing on immediate priorities,
and assuring the patient that the burn team is composed
of knowledgeable experts who will provide excellent care.
The patient’s heightened anxiety can be expected to inter­
fere with his or her comprehension, so it is usually nec­
essary to repeat statements of reassurance. To prevent
a patient from becoming emotionally overwhelmed, it
may be necessary initially to avoid or limit talking about
trauma-related content. Children in this early stage of
recovery may exhibit signs of cognitive and emotional
regression, and it is important to respond to them on that
level. Techniques such as deep breathing, relaxation with
Introduction
Burn survivors may deal with diverse psychosocial issues in
the recovery from a major burn injury. Common concerns
include adapting to physical limitations and permanent
changes; dealing with grief and loss; experiencing trau­
matic stress, anxiety, pain, sleep disturbance, depression,
and body image concerns; and other adjustment issues.
Approximately 30% of survivors experience long-term psy­
chosocial difficulties.1,2 Psychological healing occurs across
time commensurate with physical healing in a relatively
predictable and consistent pattern.3 Awareness of this
process permits survivors and their family members to
anticipate the development of psychosocial issues, view
concerns as normal reactions to the trauma instead of
symptoms of psychological impairment, and facilitates
coping with these issues. The goal of the recovery process
is to attain optimal psychological, emotional, and social
functioning (Figs. 66.1 and 66.2). Therefore, availability of
psychosocial support is important for the recovery of the
burn survivor and the adjustment of the family.
This chapter provides an overview of psychosocial issues
that burn survivors and their families may experience
during the phases of the recovery. There is also a review of
important psychosocial constructs that can affect recovery
such as assisting with grief and loss; cultural sensitivity;
psychological distress; acute and posttrauma distress; resil­
ience and recovery; body image concerns, stigmatization
and social integration; social belongingness; long-term
quality of life; and interventions beyond acute care. The
medical management of pain and anxiety are presented in
chapter 4 in this book.
Integrating Psychological
Treatment With Physical
Treatment
Comprehensive burn treatment requires a coordinated
interdisciplinary team approach for physical and psychoso­
cial recovery to occur concurrently. Mental health profes­
sionals on a burn team provide direct patient care and work
indirectly through consultation with other caregivers to
address survivors’ psychosocial concerns and to assist
family members with their adjustment. Integrating the

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
710
opportunities for them to experience the reality of their
roles in helping the patient. The manner in which an indi­
vidual and a family will ultimately adjust to the long-term
sequelae of a burn is often determined in the early stages of
recovery.
CRITICAL CARE PHASE
This phase involves intensive medical and surgical care
until the majority of open wounds are covered, and it is
an important phase psychologically. Organic factors result­
ing from the injury and treatment can contribute to psy­
chological symptoms of disorientation, confusion, sleep
disturbance, transient psychosis, and delirium. Helpful
interventions include frequent orientation to person, place,
time; placing comforting objects in patient’s view to see and
touch; and making the environment as soothing as possible.
Visits from family and friends can provide familiarity, reas­
surance, and comfort the patient. A schedule that approxi­
mates a regular wake–sleep cycle helps patients begin to feel
normal.
Reassurance from staff about normal aspects of recovery,
the treatment plan, and how staff plans to help improve
function can decrease anxiety and provide a sense of hope.
When a patient is alert the psychotherapist can facilitate
grief work to help the patient adjust to the effects of the
burn. Patients with altered mental states may be able to hear
although not respond, and discretion should be used regard­
ing what is said near them. Psychological interventions are
aimed at diminishing anxiety and increasing comfort
instead of correcting the person’s perception of reality.10
Pain and anxiety management are crucial in this stage
of recovery. Providing good pain control enhances psycho­
logical recovery. Routine and scheduled assessments of
background and procedural pain11–13 and anxiety11,13 vali­
dates a patient’s concerns but also set an expectancy of
relief. The use of standardized scales provides the message
that experiencing a range of pain is normal. When staff
assess comfort routinely, patients are less likely to feel
anxious about their pain management. Clinicians, research­
ers, and burn survivors have noted that patient recall of
satisfaction with acute pain management in the hospital
has indicated the need to improve this salient aspect of burn
care. Perhaps this may be accomplished by combining a
standard pain medication regimen with individualized
adjustments based on behavioral observation and patient-
reported pain.14 Similarly, survivors have voiced dissatisfac­
tion with various aspects of care and aftercare, including
pain management and the means by which they observed
and coped with their injuries.15 These are ongoing areas of
focus and psychosocial intervention.
Psychological interventions for pain and anxiety should
be used in conjunction with pharmacological manage­
ment. Anticipatory anxiety may influence a person’s per­
ception of pain. Cognitive and behavioral interventions that
enhance a patient’s mastery or control can decrease pain
and anxiety. Patients often tolerate procedures better when
the reasons for each procedure are explained. They may feel
more comfortable participating in their own care and gain
some mastery over pain when they are allowed to remove
their own dressings or participate in wound debridement.
The presence of a supportive person during procedures can
focused imagery, and hypnotherapy may decrease patients’
anxiety.
Family members are often traumatized and may experi­
ence difficulty eating, sleeping, or concentrating, and feel a
loss of control and a generalized sense of incompetence and
helplessness. Providing psychosocial support and education
about recovery may facilitate the coping of the family. They
may need frequent repetition of information and direction
in providing comfort to the patient. The psychotherapeutic
goals to be accomplished with the family include establish­
ing a therapeutic relationship and diminishing anxiety. This
can be facilitated by assisting with orientation to the hospi­
tal, providing information about normal reactions to
trauma, and validating that their distress is normal and
temporary, which helps communicate empathy and under­
standing. Learning about the injury and its treatment helps
restore the family’s sense of competence and provides
Fig. 66.1  Quinceañera cutting cake with parents. (From Herndon DN,
ed. Total burn care. London: WB Saunders; 2007.)
Fig. 66.2  A relaxing day before attending college.

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
711
may experience difficulty adapting to physical limitations
and changes in their physical appearance. They may feel
apprehensive about the future, continue to grieve losses,
experience a loss of control and autonomy due to being
dependent on others, and feel ambivalent about resuming
self-care. The team can help motivate the survivor to par­
ticipate in his or her treatment and assume responsibility
for recovery. Individuals who desire optimal recovery need
to comply with the medical team’s instructions, many of
which require significant physical discomfort. Pain contin­
ues to be a concern as patients become increasingly active
in rehabilitative exercises. Pain and anxiety management
are important to regain optimal physical functioning, and
the interventions mentioned previously can facilitate pain
and anxiety management.
Emotional lability and cognitive and behavioral regres­
sion may occur with younger children. Children often have
difficulty expressing verbally their thoughts and feelings
and may exhibit behavioral outbursts. Parents may be
relieved to find that such behaviors are normal, and they
often require guidance with implementation of treatment
plans that target and positively reinforce desirable behav­
iors. Emotional reactions such as frustration, anger, and
feelings of hopelessness can be difficult for family members
to cope with. Hopelessness can occur when patients feel a
lack of control and eventually give up trying, which can
lead to depression. Research found that depressive symp­
toms may decrease during the initial hospitalization,32 and
depression during hospitalization is associated with physi­
cal functioning the first year post burn.33 Psychotherapeu­
tic work may involve helping the patient experience control,
combat feelings of hopelessness and helplessness, facilitate
healthy expression of emotions, achieve success, and feel
rewarded while progressing through difficult procedures.
Early in this phase, as the patient begins to ask about the
future, the psychotherapist can describe the predictable
pattern of emotional vicissitudes indicating that they are
normal and can be endured and managed. Staff can dem­
onstrate positive regard and acceptance of the patient while
also helping the patient exercise control over destructive
behaviors. Responses to questions should be honest but
hopeful regarding the expectations of treatment and recov­
ery. Interventions aimed at facilitating grief work, coping
with body image concerns, management of anxiety and
depression, and social skills training to facilitate social
interactions are helpful.
Much psychotherapeutic work during this phase is
accomplished with patient and family together. Families
must learn to assist the patient’s adjustment to the new
situation, and the family system must accommodate as
well. Research suggests it is important to strengthen the
family unit, facilitate family closeness, and support attempts
to organize their lives to incorporate additional duties
involved in providing continued care for the patient.34,35
Families will have to adapt to changes in their relationships
and in the home environment that are necessary for the
patient’s recovery and rehabilitation after discharge.
REINTEGRATION PHASE
Preparing for a patient’s discharge to outpatient status and
eventually home begins upon admission to the burn unit.
be effective in decreasing pain. Instructing a family member
on how to comfort his or her loved one is important during
these procedures.
Other effective interventions in decreasing pain and dis­
tress associated with burn treatment include deep breath­
ing, progressive relaxation, visual imagery, biofeedback,
hypnosis, virtual reality, mindfulness exercises, and relaxed
jaw.16 Hypnosis induces a relaxed and focused state of
awareness that can be extremely helpful in facilitating
comfort for patients. Hypnotic inductions and suggestions
must be modified to facilitate a patient’s use of imagery.
Some individuals will respond well to suggestions of imagin­
ing a “favorite place.” Older children may respond well to
storytelling, with suggestions for comfort and mastery
interwoven into the story.17 Survivors may benefit from
interventions that redirect their attention away from the
painful procedure. Studies found immersive virtual reality,
in which individuals’ attention was immersed in a computer-
generated world, was effective in reducing pain during
wound care18–20 and in the tub room.21 This intervention
may also be helpful during physical therapy.22,23 Mott and
colleagues reported augmented reality, where a character
viewed on a screen, was effective in decreasing pain ratings
of children with burns during prolonged wound care.24
Music therapy is an excellent adjunct to analgesia during
burn care with children.25–27 Fratianne and colleagues men­
tioned that music therapy significantly decreased the per­
ception of pain in children during wound care;28 whereas a
sensory-focused intervention was more effective with adult
burn survivors.29 Child life interventions such as medical
play that gives children control by having them role play and
manipulate medical equipment, preoperative preparation
about procedures or surgeries, and procedural support can
facilitate coping in children and adolescents and decrease
anxiety during burn care. The child’s age and development
need to be considered when selecting the intervention.30
Although over time family members may become more
at ease with hospital routines, they will continue to have
difficulty coping, feel anxious, and need updates about their
patient’s present and future status,31 and they may develop
new concerns as they are given new roles and responsibili­
ties. Being away from support systems can be difficult. It is
helpful to provide information about what to expect in the
immediate future, to facilitate patient interaction, and
provide honest information while allowing family members
to protect themselves from overwhelming despair. Staff can
find ways to allow family members to nurture their loved
one and can assist them in becoming comfortable in caring
for their patient’s needs. Taking the time to treat the family
is a very important part of treating the patient. This facili­
tates the family’s resumption of feelings of competence and
control, promotes hope, and encourages them to join with
the burn team in the healing and rehabilitation of the
patient. Psychotherapeutic work with the family should
also identify and plan for management of family issues that
may impede a patient’s recovery and rehabilitation.
IN-HOSPITAL RECUPERATION PHASE
This phase involves burn survivors becoming physically
and emotionally stronger as they face new challenges.
Patients begin to comprehend the extent of their injury and

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
712
assisting persons with facial disfigurement, and recom­
mends a brief social skills training program called
3-2-1-GO!46,47 Each of these programs provides strategies to
prepare patients and their loved ones to answer questions
related to the burn and to deal with staring and stigmatiza­
tion. The patient may benefit from rehearsal using these
skills on brief outings outside the hospital. If difficulties are
encountered, the patient can consult with the burn team
for direction and support to develop an alternate plan.
Support groups for inpatients, outpatients, and their fami­
lies can be extremely helpful in the process of anticipating
difficulties at discharge and rehearsing solutions while also
providing emotional support.
Reintegration of the patient into the family is also an area
where the burn team can provide assistance. Patients are
usually pleased to go home, but upon arrival, may find that
their role in the family has changed significantly. The
spouse–partner or parent–child relationship may now be
one of survivor–caregiver, and the patient may feel helpless
or burdensome. Staff can offer advice to families on ways to
make the transition home go more smoothly. Tips such as
spending time listening to the patient and trying to better
understand his or her burn and hospital experience, limit­
ing visitors so the patient can rest, working through feelings
of guilt or blame, asking for help from friends and family,
and utilizing relaxation techniques for pain management
can aid both the patient and family in an easier return
home.48
The burn team may also prepare the community to
which a patient will return. Instructing those unfamiliar
with burns in what to say or do to ease a survivor’s reentry
may assist with reintegration.49–51 Variables that may affect
burn survivors’ ability to return to work once they are dis­
charged from the hospital include size and severity of
burn,52,53 duration of hospitalization,53,54 location of
burn,52,53 physical impairment,53–56 pain,55,56 prior employ­
ment history,52,53,56 lack of vocational training,57 work envi­
ronment impediments,54 and psychosocial difficulties.53–57
Variables found to assist with return to work were psycho­
social support, positive thinking, and vocational train­
ing.56,57 Quinn and colleagues found that 66% of burn
survivors returned to work within the first 2 years post
burn.53 In a study of young adults who sustained burns
during childhood, Meyer and colleagues found 65% of the
sample were employed either full- or part-time.58 Individu­
als who do worked reported improved quality of life.59,60
Factors that affect adults returning to work can also
influence school reentry for children. Staley and colleagues
reported that children with small burns returned to school
within the first week or month post burn, and most per­
formed well academically.61 However pediatric burn survi­
vors often require assistance to return to school so they can
learn, develop, and form peer relationships. Many burn
centers in the United States have developed school reentry
programs. These programs are designed to educate staff
and students about aspects of burns, provide generic infor­
mation about treatment and recovery, emphasize the child’s
abilities and needs, clarify ways in which the child may
require assistance, address the importance of normalizing
school activities, and providing peer support and accep­
tance. Working with the family and the school, a burn pro­
fessional develops a plan to integrate the child back into
A major objective is to facilitate a person’s reintegration to
life at home with the family and back to his or her commu­
nity. Community reintegration is the process of becoming
involved in the community, school, work, and leisure activi­
ties.36 Returning home signifies social interactions with the
immediate family as well as the extended family, friends, and
strangers. Individuals must prepare for those encounters.
They often feel anxious, fear social rejection, worry about
being accepted, and are concerned about receiving social
support.37 Returning to a cohesive and supportive family
environment35,38 and loyal friends39 can make this transi­
tion much smoother.
Psychotherapeutic activities involve education and prep­
aration of patient and family about difficulties that may be
encountered at discharge. Coping skills that can help should
be discussed and practiced. Survivors and families often
deny that they will have problems; however, psychothera­
pists can help prepare patients by offering suggestions to
address problems that others have experienced. Issues such
as recurrence of posttraumatic stress symptoms, anxiety
and pain management, sleep disturbance, irritability, or fear
of resuming sexual activities should be discussed prior to
discharge.
There are now a spectrum of programs available to the
survivor and some for the family. These professional pro­
grams help individuals and families through all the phases
of recovery from major burn injuries. The Model System
Knowledge Translation Center has a large number of print
and downloadable forms containing useful information on
a wide-range of burn-specific topics available in English and
Spanish.
The Phoenix Society for Burn Survivors Inc. is “a non-
profit organization dedicated to empowering anyone
affected by a burn injury.”40 This organization has several
videos providing information and instruction on new skills,
such as social skills, training survivors how to conduct sup­
portive therapy, image enhancement, and school reentry.40
Cognitive-behavioral therapists have developed several
techniques for treating negative body image and social
anxiety related to a physical difference. Likely the most
important is teaching a specific set of social skills.41–43 Social
skills programs are available to facilitate positive reintegra­
tion into society, improve social comfort, and increase con­
fidence in social interactions. Social skills include having a
short precise answer to explain “what happened,” guiding
the topic of conversation, using confident body language
and eye contact, and assertively confronting confused and
rude behavior. After mastering these skills through in-
therapy practice, the survivor is encouraged to practice the
skills by engaging in social activities. This practice helps
break the social avoidance–depression cycle that may main­
tain the burn survivor’s negative body image.
The program Be Your Best, by Barbara Kammerer Quayle
and The Phoenix Society for Burn Survivors Inc., was devel­
oped to help burn survivors with community reintegra­
tion.44 The UBelong Social Skills program includes skills to
increase social comfort and confidence. Acquiring such
skills can make encountering new people and situations
and handling stares and unwelcome comments easier. They
can help survivors and their loved ones navigate such
encounters with added confidence.44,45 Additionally Chang­
ing Faces, by James Partridge, a program dedicated to

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
713
alcohol abuse, psychological distress, and psychological
function both before the burn and at discharge.69 These
data can inform providers and adult patients about factors
that could be modified to effect more desirable outcomes.
Assisting With Grief
Following Trauma
Traumatic events are frightening experiences that create
uncertainty, anxiety, and a sense of threat for victims and
their families.70,71 An individual who experiences a burn
injury may face multiple changes and losses, including sepa­
ration from one’s support network and home environment,
uncertainty regarding the length of hospitalization and
process, changes with physical appearance, and in certain
circumstances, death of loved ones. On the burn unit, these
issues often become the focus of psychosocial intervention.
Successful grief therapy requires that mental health pro­
fessionals have an understanding of the traumatic event
and knowledge of the individual’s past experiences with
loss and coping styles and cultural and religious beliefs.70
Mental health professionals can assist re-establishing a
sense of equilibrium following trauma by facilitating the
grieving process.
The terms “bereavement,” “grief,” and “complicated
grief” merit clarification. Bereavement refers to coping with
the death of a loved one, whereas grief is a broader term
referring to coping with loss in general.72 Grief reactions are
individually unique and age dependent.71,73 Complicated grief
occurs in adults when the grieving process is compromised
by trauma. Prigerson and Jacobs described complicated
bereavement as difficulty comprehending and accepting
the death of a loved one, persistent and intense longing for
the deceased, intrusive thoughts about the deceased, and
avoidance of painful memories.74 Children can also experi­
ence childhood traumatic grief when there is traumatic loss
or bereavement.71,75,76 This construct evolved from the lit­
erature in child development and trauma and occurs when
trauma symptoms interfere with the child’s ability to grieve
normally. The child may engage in avoidance behaviors that
interfere with the normal grieving process.71,75,76 Trau­
matic grief can co-occur with psychiatric disorders such as
depression and posttraumatic stress disorder (PTSD).71,75,77
The prevalence of burn survivors and family members who
experience traumatic grief is unknown. Clinical experience
suggests that many burn survivors progress through the
grieving process without complications and are resilient
when faced with loss. Brown and Goodman found that chil­
dren who retained a positive memory and ongoing presence
of their loved one were able to grieve normally.71
On the burn unit, mental health professionals may need
to inform the burn survivor about multiple losses and life
changes, which may include changes in appearance, loss of
body parts, the death of others such as family and friends,
loss of a pet, or loss of a home. In some circumstances it
requires informing, supporting, and preparing the family
for bereavement of the burn trauma victim. This is a deli­
cate process that requires appropriate timing and psychoso­
cial planning. Important factors to consider when planning
the disclosure process with patients and families include the
patient’s medical stability and ability to participate in
school. Usually, part of the process includes the burn profes­
sional visiting the child’s classroom, explaining the nature
of burns and rehabilitation, engendering compassion and
support for the survivor, and answering questions. Burn
professionals running school reentry programs have
received a good deal of positive feedback from schools and
families, but the long-term efficacy of school reentry pro­
grams has not been empirically demonstrated.51,62 A few
studies found interventions such as on-site school visits62
and educational videos/DVDs62,63 are beneficial. The
Journey Back, by The Phoenix Society for Burn Survivors,
is a comprehensive program providing generic materials
designed to help pediatric burn survivors, families, and
school communities with the re-entry process.64 Another
program, developed by Shriners Hospitals for Children–
Cincinnati, is the Remember Me Program, which keeps the
pediatric burn patient in touch with his or her classmates
during the lengthy burn-related hospitalization. A teddy
bear is placed in the child’s seat while he is absent, and com­
munication with and from classmates is encouraged.65
REHABILITATION PHASE, POSTDISCHARGE
When survivors transition to the outpatient setting and
home, they continue to have physical and psychosocial
needs. Rehabilitation may require several months to years,
wounds may be vulnerable to breakdown, and individuals
may need to use special splints and pressure garments’ and
continue to exercise. Grief work often continues as survi­
vors cope with losses and delayed grief reactions can occur.
Symptoms of posttraumatic stress may recur upon leaving
the protective hospital environment. Body image concerns
may become more acute as survivors confront stigmatizing
reactions from others. Family’s social and emotional
resources may become taxed as the family transitions into
becoming the patient’s primary caregivers.
The ratings of significant others on a standardized behav­
ioral scale suggested that young adult survivors of child­
hood burns who were an average of 14 years post burn
were doing well. However on standardized psychiatric inter­
views, a high percentage of survivors reported experiencing
psychiatric disorders specifically related to social situa­
tions,66 and personality disorders67 warranting diagnoses.
Similar results were found in a study of adolescents who
were an average 10 years post burn.68 In these studies sur­
vivors44,48 were rated by a physical therapist to have no
physical limitations that prevented caring for themselves
and participating in ordinary activities, their anxieties were
severe enough to limit their achievement to full capacity.68
Even if most burn survivors eventually function satisfacto­
rily by external criteria, clinically, they may be suffering
significant distress that is not easily observable. A psycho­
social goal is to understand the sources of survivors’ dis­
tress and to develop interventions that enable survivors to
become full participants in society. It would be extremely
valuable to patients leaving the hospital, as well as to their
social network, employers, and care providers, if there were
a set of predictors that could reliably estimate when and to
what degree functional improvement could be expected
over time. Fauerbach and colleagues evaluated functional
impairment of survivors from discharge and across 2 years
and found psychological impairment was predicted by prior

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
714
improve outcome. Staff can acknowledge their lack of
familiarity and ask the patient/family whether there is any­
thing the team can do to help meet their cultural, spiritual,
and religious needs. The question conveys respect for cul­
tural differences and a desire to help through the accultura­
tion process.
Knowledge and sensitivity of cultural practices is also
important when focusing on safety and prevention educa­
tion with patients and families. Epidemiological research
has focused on identification of sociodemographic risk
factors and cultural practices that have contributed to burn
injuries in developed and developing countries and found
differences among these countries.87–91 The highest inci­
dence of severe burns occurs in low- and middle-income
countries,92 with children being at highest risk.87 In devel­
oping countries, factors such as poverty, crowding, food
preparation practices, unstable cooking methods, and
inconsistent supervision practices place young children at
high risk for scald burns.88,93,94 Identification of modifiable
risk factors and cultural practices can facilitate education
about prevention for burn survivors and their families. A
recent study of children 5 and younger from Mexico who
received medical care in a U.S. hospital found the primary
causes of burns were flame and scald injuries. Flame burns
were caused by explosions of flammable substances and
house fires, and scalds were attributed to falling in large
containers of hot liquids placed on the ground and spills.91
Postburn Psychological Distress
and Long-Term Outcome
There are many disturbing aspects of a major burn injury
including memories and emotions from the burn injury
event and its circumstances, the initial sight of the wound,
and pain both at rest and during unavoidable wound care
and rehabilitation. Further challenges accrue as healing
progresses, such as changes in appearance and function as
skin contracts and scars progress through the maturation
phases. There are additional disturbances from expected or
actual reactions of family, friends, associates, and strangers
as these members of the social sphere view the wounds, the
scars throughout maturation phases, rehabilitation splints
and garments, and the like. Each of these stressors, when
exceeding individual and group resilience factors, imposes
a burden on the person (distress within mind–body self) and
between the person and his or her social network (recipro­
cal distress between/within the patient and those affected
individuals within the embedded social network).
Among the most common manifestations of psychoso­
cial distress for burn survivors following an injury are sleep
disturbance,95,96 depression,97,98 body image dissatisfac­
tion,99 and acute and posttraumatic distress.96,100 Not unex­
pectedly, the average level of psychological distress among
those with major burns was significantly higher than that
of a normative sample.34
ACUTE AND POSTTRAUMA DISTRESS
Acute stress disorder (ASD) and Post-traumatic stress dis­
order (PTSD) following exposure to trauma may occur.
According to the Diagnostic and Statistical Manual of Mental
conversations; the readiness of the patient and family to
hear the news; identification of what they know about the
trauma and the factors related to the traumatic event; their
wishes regarding disclosure; and knowledge of their cul­
tural, religious and spiritual needs.78 Bronson and Price
discussed important principles to keep in mind when
working with grieving children after burn trauma. They
suggest a process that includes supportive and compassion­
ate truth-telling, acceptance, respectfulness of individual
differences and feelings, and giving the individual an oppor­
tunity to say good-bye.79 If death occurs on the burn unit,
staff can psychologically support the family by obtaining
desired spiritual assistance, assisting them with paperwork
for the burial process, allowing them quiet private time with
the deceased, and providing distraught family with memory
items if they wish to have them.
Cultural Sensitivity
Burn survivors come from diverse cultures, and burn care
teams must be sensitive to how cultural issues can affect
survivors and families in all the phases of the recovery
process. “Culture” refers to the socially transmitted expecta­
tions, beliefs, traditions, and behavioral patterns of a given
community at a point in time.80 Factors influencing culture
include country of origin, geographical location within the
country, ethnicity, and socioeconomic background. Staff
must also be aware of their own biases, values, and assump­
tions that stem from their cultures.81,82
Acculturation is the process by which individuals from one
culture embrace patterns, customs, beliefs, values, and the
language of the dominant culture.83,84 Patients and their
families on first arriving at a burn care facility must rapidly
adapt to the culture of the hospital environment. Even if
the hospital is within their own community, they experi­
ence some level of culture shock and acculturation. This
process is even more complicated for those who are trans­
ported for care to communities far removed from their
homes and perhaps in another country. For some patients,
this traumatic situation is the first time they have traveled
to another country and the first time they have had to deal
with differences in language, currency, living accommoda­
tions, and foods. Individuals’ concepts of time and space,
appropriate hospitality, importance of greetings, how non­
verbal gestures are interpreted, and ways of expressing
gratitude may differ greatly among cultures. Ideas of what
caused the burn injury and what is necessary for healing to
occur also are determined by cultural values.85,86
Coping with such a multitude of unfamiliar experiences
in a traumatic situation is an extraordinary challenge that
can inhibit a patient’s or family’s ability to participate in the
recovery process. The burn team must be aware of cultural
differences and make culturally appropriate accommoda­
tions to a patient’s treatment plan. Cultural traditions can
be incorporated into treatment plans to enhance participa­
tion toward recovery. For example, if a Latino family believes
that the burn incident was a result of an “evil eye,” they
may request a cleansing ritual.83 It is impossible for provid­
ers to know the beliefs and expectations of every culture;
however, cultural sensitivity and a willingness to learn are
necessary for good patient–provider communication and

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
715
reliable and clinically significant change in distress that
moved them from one trajectory to another.103 Of the
5–10% of participants who changed from one trajectory to
another, about half reported less distress (improved) and
half reported increased distress (worsened). The stability in
distress trajectories among survivors of major burns is
largely unique relative to other trauma-exposed samples.
These other populations tend to show recovery trajectories
of early recovery (~6 months), mid-term recovery (~12
months), and a chronic trajectory, and some studies found
a delayed-onset trajectory with early low symptom severity
followed by increasing symptoms beginning about 6 months
out.119 Thus, some research to date has identified varied
forms of psychological distress, their prevalence, the stabil­
ity of distress level over long-term follow-up, and the endur­
ing impact of early psychological distress on longitudinal
psychological and social adjustment. These replicated find­
ings highlight the need for identifying early survivors with
high levels of distress to attempt to circumvent the suffer­
ing, impairment, and disability that may ensue.
The goal of rehabilitation is to enable full social-
environmental integration, including access to social
opportunities and physical space (absence of physical bar­
riers). The National Institute of Disability and Independent
Living Rehabilitation Research (NIDLRR) formerly the
National Institute of Disability Rehabilitation Research
(NIDRR) presents a paradigm for conceptualizing and con­
ducting rehabilitation research that places environmental
factors on an equal footing with person factors.120 Burn-
related research has begun to progress beyond identifying
forms of distress and quantifying their prevalence, largely
on the basis of targeted federal funding by the NIDLRR
through its multicenter Burn Model System database and
both multicenter and site-specific projects.121 There are at
least three key questions to address as research focus shifts
to developing new psychological, behavioral, and social
treatments: What are the mechanisms by which early dis­
tress levels are maintained across long-term follow-up? Is
the best approach to prevent distress by (a) reducing risk
factors, (b) enhancing resilience factors, or (c) reducing risk
and enhancing resilience? Also, can high levels of distress,
once developed, be effectively reduced and maintained at
low levels? Finally, can the factors that initiate and maintain
low distress levels be influenced by medical, psychological,
or social factors in a way that can provide relief to those
experiencing distress?
Theory-Guided Research as the
Next Step in Enhancing
Psychological and Social
Adjustment
Unfortunately there has not been enough burn-specific
research in which a priori aims were explicitly stated
addressing the questions just listed. It is proposed that, in
order to promote such research, a common theory and lan­
guage should be adopted in the field. Specifically, learning-
based theories grounded in biology and neuroscience122 are
the best formulated theories, and treatments developed
with these theories have acquired the strongest evidence
Disorders (DSM-5), individuals with trauma disorders expe­
rience intrusion symptoms, negative mood, dissociative
symptoms, avoidance behaviors, and increased arousal.101
The prevalence rate of ASD among adult burn survivors
has varied between 10% and 23%,100,102,103 whereas the
rate among pediatric survivors has been between 8% and
31%.11,104,105 It is estimated that 15–45% of adult burn
survivors meet the criteria for PTSD in the first year post
burn,103 and almost 50% meet the criteria for at least one
of the PTSD symptoms clusters.99,106 The current and life­
time incidences of PTSD in pediatric burn survivors are 7%
and 30% respectively;107 and in young adults who sustained
childhood burns, they were 9% and 21% respectively.66
Posttrauma distress has been found to be associated with
greater lengths of acute hospitalization,106 enhanced sense
of distress, and impaired adjustment to injury.108 In the
population of patients surviving severe burns, certain
aspects of pretrauma adjustment (history of mood disor­
der) and coping style109 can influence the risk of developing
PTSD following trauma exposure.5 Individual factors (avoid­
ance of reminders) and aspects of the injury (injury sever­
ity, facial injury) have been associated with poorer
outcome.110 Those with high levels of trait neuroticism
appear to be at greater risk of PTSD symptomatology fol­
lowing burn injury, whereas high levels of extraversion
appear protective against PTSD.52,111
It might be assumed that PTSD is related to greater initial
injury; however, PTSD among burn survivors has not been
found to be related to severity of injury.112 On the other
hand, high levels of acute posttrauma stress symptomatol­
ogy have been shown to be positively related to perception
of more intense pain among hospitalized burn patients.113,114
High emotional distress and ASD symptoms during hospi­
talization are risk factors for PTSD in adults 2 years post
burn.103,115 However, in a long-term follow-up study of chil­
dren who experienced ASD symptoms during their initial
hospitalization and a non-ASD matched comparison group,
there was no significant difference in the prevalence of life­
time PTSD between the groups. Eight percent of the chil­
dren in the ASD group and 5% in the non-ASD group met
diagnostic criteria for PTSD. Children were an average of 5
years post burn.116
Chronicity of Postburn
Psychological Distress: From
In-Hospital Through Long-Term
Follow-Up
Prospective longitudinal research has shown that the level
of distress one reports experiencing during acute hospital­
ization tends to persist across at least 2 years of follow-up.
Analyses of 2-year longitudinal data quite consistently
identified 3–4 groups of survivors whose level of distress
(posttrauma distress, body image dissatisfaction/social dis­
comfort, generalized distress) formed trajectories character­
ized as chronically severe, moderately severe hovering
around cutoff for clinical disorder, a subclinical group, and
a group essentially without symptoms.103,117,118 The stabil­
ity of these trajectories is illustrated in that, across the
2-year follow-up, only 5–10% of participants reported a

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
716
more prepared for the future. The ability to plan for the
future will reduce the likelihood of recurrence and provide
one the means for helping others to acquire this knowledge
without having to go through a similar episode.
Social learning occurs by watching another person
behave in novel ways as they respond to social situations of
importance to the observer. When observing a person
whom we hold in high esteem as that person achieves a
desired outcome (reduced distress), the observer is more
likely to acquire and practice that behavior. Social learning
can help one to learn new methods of healthy coping.
Seeing someone skillfully use social skills to defuse a nega­
tive comment can be helpful. Such learning enhances one’s
comfort and confidence in intentionally overcoming the
distress associated with trauma memories and social
stigmatization.
RESILIENCE AND RECOVERY
Resilience is the capability to adjust well when dealing with
difficult situations. While some individuals adapt well,
others experience difficulty.119 When exposed to a traumatic
event or significant stressors, coping is affected by the indi­
vidual’s characteristics and social structures. Social support
in the form of emotional, material, and cognitive support is
important in the adjustment process. These facets of social
support can be facilitated and maintained by different
systems, including family, community, state, national, and
international systems.119
BODY IMAGE, STIGMATIZATION, AND
SOCIAL INTEGRATION
Body image is one’s self-evaluation of one’s physical appear­
ance.124 Negative body image or body dissatisfaction is the
belief that one is unattractive. Body image is highly corre­
lated with self-esteem, particularly among adolescents and
young adults. Negative body image is a component of or is
highly associated with a number of psychiatric disorders
including depression, social anxiety, eating disorders, and
drug abuse.124 Due to the fact that burn survivors may be
permanently scarred by their injuries, it is commonly
hypothesized that burn survivors are at high risk of devel­
oping a negative body image.125–128 Body image is a conse­
quence of the interaction between a person and his or her
social environment.124,129 In order to understand the chal­
lenge of adapting one’s body image to having burn scars, it
is necessary to be familiar with the appearance norms of
the burn survivor’s culture. These sociocultural norms
establish criteria for the importance of appearance, how
one should appear, and the room for deviation allowed from
the norms.124,127,129,130
SOCIAL BELONGINGNESS AS CORE
SURVIVAL NEED
Belongingness is understood as one of the core needs
driving human social behavior. Individuals are particularly
sensitive to being excluded, especially when this is on the
basis of one’s appearance and function that cannot be
readily changed.131 The pivotal sociometer theory posits that
self-esteem is a marker for the degree of belonging one is
base in other trauma-related fields.123 Thus it is suggested
that burn researchers utilize theories and associated design/
methods to more effectively guide treatment development
in burns and to conceptualize the related research aims.
Our general approach to assessment is a behavioral
approach based on learning principles (e.g. conditioning,
cognitive restructuring, and social learning theories) where
adjustment is the target of intervention. Assessment and
treatment are integrally related, and both occur simultane­
ously throughout the recovery and rehabilitation process.
In this section, posttrauma distress is examined, but similar
explication will be necessary for each problem area being
addressed, such as body image dissatisfaction, social stig­
matization, and social rejection.
Formulating Psychological
Distress Following Burn Injury:
Using Posttrauma Distress as
an Illustration
Classical conditioning can be used to describe the process
involved in the development of trauma symptoms. The
traumatic event can be conceptualized as the uncondi­
tioned stimulus (UCS) that causes an unconditioned
response (UCR) such as fight–flight, freeze, and distress.
Reexperiencing the trauma is the conditioned stimulus (CS)
and elicits a conditioned response (CR) such as flight–fight,
freeze, and distress. Failure to extinguish the CR when a CS
is presented may lead to maladaptive behavior. In addition,
there are preinjury variables that may contribute to a per­
son’s difficulty coping, including early life experiences, pre­
vious traumas, learned behaviors, genetic predisposition,
and personality characteristics.
Maintenance occurs when approaching cues, reminders,
and triggers (CS) cause increased distress (feelings of
horror/helplessness) (CR) and, if perceived intolerable, can
lead to escape, avoidance, and withdrawal behaviors. The
avoidance response is reinforced by lessening the distress
and more likely to continue as the habit strengthens with
each exposure and avoidance pairing. Three key motives
have been observed in adult burn survivors, and these have
been conceptualized as: Approach (move toward threat;
Fight), Avoidance (move away from threat; Flight), and
Approach-Avoidance conflict or ambivalence (alternately
moving toward then away from threat; Freeze). The behav­
iors associated with these motives are the classic survival
responses.115 For example, re-experiencing symptoms of
ASD/PTSD can be understood as CS that elicit basic survival
motivations and behaviors (CR) that were elicited by the
life-threatening event itself (UCS).
We propose use of cognitive-behavioral interventions
designed to lessen the trauma-related distress target symp­
toms of re-experiencing (memories, flashbacks, night­
mares), avoidance behaviors (flight from cues/contexts),
and hyperarousal (anticipation or expectation of further
threat/harm). It is proposed that an important component
of the cognitive and emotional processing of traumatic
events is to provide or renew the sense that memories, even
horrific ones, can no longer harm us directly, are the means
by which we can learn from the past, and can help us to be

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
717
in comparison to all other aspects of their person or
behavior.
The most troubling challenge for many people re-entering
society following major burns is their own appraisal of
scars and related changes in appearance and function and
their expectations of what others will think and do. Social
stigmatization is a process in which people are socially
rejected (put out) and ostracized (kept out) based on a nega­
tive stereotype.139 People with visible differences have long
been stigmatized in the mass media. In many movies and
video games, the villain is a person with a physical differ­
ence, often burn scars. Stigmatizing interpersonal behav­
iors experienced by burn survivors include an absence of
friendliness and courtesy, staring, pointing, startled and
disgusted reactions, ignoring, avoidance, confused behav­
ior, teasing, bullying, and discrimination.126,127,138,140 There
is evidence that people with visible differences are more
likely than people without visible differences to experience
stigmatizing interpersonal behavior. For example, when
interacting with an actor who had makeup applied that
looked like a real disfigurement, participants were less likely
to offer assistance or sit or stand close, and they limited their
interactions. Job interviewers rated actors without such dis­
figurements as more fit for the position than those with a
mock visible difference.141–143
This emphasis on an attractive appearance is an onerous
barrier to inclusion and social participation for those with
a visible difference. In addition, acquired disfigurement can
be difficult to incorporate into preinjury body image.144
Body image, a facet of self-esteem, is formed at the nexus at
which individual differences intersect with social group
norms.145
Consequently,
injury-related
disfigurement
creates distress over both an altered body image and social
exclusion based on appearance. Burn injuries cause an
immediate change in appearance, and to complicate
matters, uncertainty about final appearance outcome per­
sists as healing is followed by months or years of scar matu­
ration during which appearance typically becomes worse
before improving.146 This change in appearance thus repre­
sents an amalgam of threats to safety, body image/self-
esteem, and social belonging.
What are the psychosocial consequences for burn survi­
vors living in a highly beauty-conscious society? Few studies
have investigated the frequency of body image dissatisfac­
tion and perceived stigmatization and their correlates
among burn survivors.
Studies that have compared the body image of burn sur­
vivors to a nonburn comparison group have found no nor­
mative differences.147,148 In one study comparing a group of
long-term pediatric burn survivors to an age-matched
nonburn comparison group on a body image measure,
there was no difference between the males in the two
groups. Among the females, on average, the burn group
had higher body image scores than the comparison group.148
This surprising finding needs to be interpreted with caution
given that it has not been replicated. Much more remains
to be done in order to discern whether, with whom, and at
what point in recovery burn survivors are most affected by
altered appearance. Furthermore, there remains much to
do in order to firmly establish what person, injury, and
social factors may protect against body image dissatisfac­
tion or promote recovery from it.
experiencing.131 As belonging improves (inclusion in an
activity), self-esteem increases. When belonging declines
(excluded from an activity), self-esteem diminishes. A recent
meta-analysis confirmed expectations that, following social
exclusion, negative mood increases and both positive mood
and self-esteem decline.132 Exclusion-related social pain
stimulates neural structures that also affect mood and self-
esteem and thus motivate adaptive coping to these threats
to social belonging.132
An elegant series of experiments found that the group of
participants who were made to feel excluded, relative to
those who were not made to feel excluded afterward attended
more to positive memories and interpreted ambiguous
stimuli more positively.133 Of note, this automatic emotion
regulation process was observed among individuals with
high self-esteem and low depression but not among those
with low self-esteem or high depression.133 In addition, a
study was conducted among participants whose self-esteem
was strongly based on appearance and who were subjected
to social exclusion. Those with high self-esteem sought to
reconnect to those who had excluded them, whereas those
with low self-esteem avoided social contact.134 Taken
together, these findings suggests that high self-esteem along
with low depression is a good marker for resilience, whereas
low self-esteem in the presence of high depression is a good
marker for vulnerability. These means of estimating vulner­
ability (low self-esteem, high depression) and resilience
(high self-esteem, low depression) may serve as a means of
discerning in the acute phase those burn survivors at high
versus low risk for having difficulty reintegrating into social
roles and public settings.
Perceived discrimination, similar in nature and impact to
social exclusion, has also been linked to poor health out­
comes.135 A systematic review found strong evidence that
discrimination increases the stress response and concluded
that it is associated with increased engagement in health
risk behavior and decreased participation in protective
health behaviors.136 Discrimination is a form of exclusion
that is omnipresent culturally and globally, is distressing,
and negatively impacts health and adjustment.135
APPEARANCE, SOCIAL STIGMATIZATION, AND
SOCIAL EXCLUSION
Appearance norms are communicated to the individual
through both mass media and interpersonal behavior. Via
mass media (magazines, television, and the Internet),
people are exposed to hundreds of images daily of “beautiful
people” technologically enhanced through processes such
as airbrushing, soft-focus camera shots, and manipulated
digital images. The message, implicit or explicit, of cosmetic
product advertisements is that you are an inadequate
person unless you are very attractive, and that a particular
product will enhance your appearance. There is also inter­
personal pressure to conform to appearance norms. One
review of the literature on appearance concluded that
people tend to both make positive assumptions about “good-
looking” people and treat them more favorably than less
attractive people.137 On the other hand people who deviate
from the beauty standard are more likely to experience stig­
matization and discrimination behavior.138 For example,
children are most frequently teased about their appearance

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
718
correlates of body image among burn survivors has been
social and emotional variables such as social support, per­
ceived social stigmatization, importance of appearance, and
depression (r’s ranging from 0.30 to 0.60).99,148,151,152,154
In regards to stigmatization a few studies have focused on
pediatric burn survivors. Among pediatric burn survivors,
there is some evidence that appearance-related stigmatiza­
tion is a common concern. In a survey of 250 pediatric
burn survivors, 60% of participants reported being bullied
within the last 6 months. Twenty-five percent of the sample
indicated that bullying was a “big problem.”155 However, to
date, there is not enough evidence to conclude that burn
survivors experience stigmatizing interpersonal behavior
more frequently than the general population. First,
appearance-related teasing appears to be very common in
the general population. In a survey of adolescents in Britain,
52% of the sample had experienced distress related to
appearance-related teasing, and 10% reported at least one
incidence of avoiding going to school fearing appearance-
related teasing.128 No studies have been completed directly
comparing the experience of burn survivors with stigmatiz­
ing behaviors to a comparison group. Two studies compar­
ing the frequency with which children with craniofacial
differences experienced teasing and other victimization
behavior to a comparison group found no differences
between groups.156,157
To date there is no empirical evidence that burn survivors
as a group experience higher levels of negative body image
or more stigmatizing behavior than nonburn comparison
groups. However relatively few studies have been com­
pleted, and these findings need to be replicated before they
are accepted as fact. Over the past decade, a number of new
standardized measures and structured interviews have
been validated to measure body image, perceived stigmati­
zation, and social comfort among people with visible differ­
ences.153,158–160 Hopefully these instruments will facilitate
future body image research among burn survivors. Clinical
experience suggests that approximately 20–30% of burn
survivors struggle with body image and social integration
issues. For these burn survivors, the emotional pain that
results from body image dissatisfaction and social discom­
fort can be very intense.
DISTRESS OF FAMILIES OF BURN SURVIVORS
Long-term impact on families of burn survivors has not
been well studied, but clinical experience and scant empiri­
cal data indicate the sequelae to be significant. Family
members may continue to experience symptoms of post­
traumatic stress after a patient has returned home.31
Parents of survivors of massive injuries appear extraordi­
narily stressed even several years after their children’s
recoveries.4,161 A series of studies found that parents of pedi­
atric burn patients reported significant depressive symp­
toms at 2 years post injury, and they attributed their distress
to their children.4,162 Although parental distress appears to
improve with time for most, parents of the most troubled
burned children continued across time to be troubled them­
selves.162 Parents also express concern for their other chil­
dren, whom some felt had been slighted of attention and
time while the child with a burn injury required a lot of the
family’s attention. Even free medical and surgical care did
FACTORS AFFECTING BODY IMAGE
DISSATISFACTION AND SOCIAL DISCOMFORT
Physical appearance is an almost universal criterion for
group membership.149 The greater the degree to which one
fits in with the group culture, including normative appear­
ance, the greater likelihood one has of being included. This
is problematic in that burn scars often change appearance
in a manner that unnecessarily disrupts inclusion and may
lower the belonging and self-esteem of some burn survi­
vors. Recent studies among burn survivors investigated the
theory that social exclusion of individuals with differences
in appearance is motivated by the fear of disease or injury149
or emotions.150 It seems plausible to consider that there may
be two stages of observer’s reactions to altered appearance.
The first is likely genetically determined and is the fear of
external signs on the body that might connote disease. This
reaction is automatic and largely beyond conscious choice.
The second reaction is more likely to involve a higher order
of cognition that is acquired through social norms, parental
training, and peer conformity. This higher level of cognitive
processing and emotion regulation involves conscious
appraisal of appearance alterations and takes into consid­
eration social norms for appropriate behavior.
In regards to risk factors for negative body image, severity
of burn scarring has proved to have a modest relationship
with body image among both adult and child burn survi­
vors. Across studies, the correlation between burn severity
and body image has ranged from 0.00 to 0.40.99,148,151,152
One study suggested that the relationship between per­
ceived scar severity and body image is moderated by impor­
tance of appearance.153 For those burn survivors who
placed little value on physical appearance, self-rated scar
severity had no relationship with body image. For those
burn survivors who highly valued physical appearance,
scar severity was highly predictive of body image dissatis­
faction. All studies investigating the relationship between
scar severity and body image have been limited by the lack
of a reliable, standardized measure of scar severity. Many
studies to date have used proxy variables to measure scar
severity, such as total body surface area (TBSA), TBSA-full
thickness (TBSA-FT), and location or number of burn-
related surgeries.
Within the literature there has been a theoretical debate
regarding the relationship between burn scar location and
body image. The “visible hypothesis” posits that socially
visible scars, such as scars on the face, will be highly related
to body image dissatisfaction because burn survivors with
visible scars will experience more frequent stigmatizing
reactions from others. The “hidden scar” hypothesis posits
that because the person has fewer opportunities to learn
how to deal with the reactions of others, he or she will live
in fear of the scar being revealed and thus have a negative
body image. There is little empirical evidence for either
hypothesis. In the studies that have tested these formula­
tions, the correlation between facial scarring and body
image ranged from 0.00 to 0.20.151 Gender has also been
investigated as a possible risk factor. In comparison to men,
women burn survivors tend to have lower body image sat­
isfaction; however the gender difference in burn survivors
has not been as great or as consistent across studies as it is
in the general population. Across studies the strongest

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
719
of significant problems with adjustment during subsequent
phases of recovery.108,176 These and other quality-of-life
outcome studies clearly establish the enduring impact of
early distress on early, mid-term, and long-term psychoso­
cial adjustment. In conclusion, the quality-of-life research
points to the importance of early detection and treatment
of psychosocial problems among burn survivors.
INTERVENTIONS FOR BURN SURVIVORS
BEYOND ACUTE CARE
Moving beyond general social support, psychologists and
psychiatrists specializing in burn recovery have been
working to develop theoretically based, empirically testable
interventions that can be tailored to the individual needs of
both pediatric and adult patients. As stated earlier, the psy­
chosocial sequelae of a burn are quite varied. In order to
create effective individual treatment plans there need to be
effective treatment protocols for treating specific common
problems. Within recent years detailed psychotherapy
treatment programs have been described to treat PTSD177
and ASD178 and to teach social skills training for coping
with disfigurement.42,43 However much more research is
needed to empirically demonstrate the efficacy of these
interventions among burn survivors and other groups with
physical differences.179
Cognitive therapy for the treatment of body image and
social integration concerns of people with visible differ­
ences is an example of a tailored psychotherapy.42,43,180,181
Although much has been learned about the risk and protec­
tive factors for body image issues and social adjustment,
there are few empirically validated treatments.154 The
therapy is based on a detailed conceptualization of how a
survivor’s social environment, thoughts, behaviors, and
emotions interact to maintain the survivor’s distress. Given
the sociocultural premium placed on appearance, it is
understandable that some burn survivors adapt personal
values that prioritize physical appearance. Consequently
these individuals may ruminate about the discrepancy
between their appearance and the ideal (their lost appear­
ance). Self-conscious about appearance, these individuals
may act in ways that confirm their belief that their appear­
ance is socially unacceptable. For example, they may mini­
mize or avoid social interactions with others. This social
avoidance may be interpreted by others as curt or rejecting
behavior by the burn survivor. Thus brief awkward social
encounters turn into self-confirming experiences that vali­
date survivors’ beliefs that their burn scars make them
socially inadequate persons.
Many burn survivors lack access to mental health care
in general and access to mental health providers with
expertise in treating burn survivors in particular. Most
burn survivors who suffer psychological symptoms of dis­
tress following discharge from a burn center and who desire
treatment must rely on mental health professionals in the
community. However, it may be difficult for them to find
helpful resources. In a study of young adults who sustained
burns during childhood, none were receiving professional
help for their difficulties as adults.66 Burn survivors do not
always qualify for financial assistance because their “dis­
abilities” are declared insufficient to require such aid. Even
when they can afford such treatment, they may be unable
not eliminate the burden of direct and indirect costs of burn
injury, and many families experience financial difficulties
attendant to the injury and treatment of their child.4
LONG-TERM OUTCOME: QUALITY OF LIFE
After survival is assured, quality of life is arguably the
most important outcome to individuals who are seriously
ill or injured. Health-related quality of life has been defined
as a multifactorial construct that involves an individual’s
degree of satisfaction and level of health and functioning in
several core domains including: physical-behavioral (ability
to perform self-care behaviors) and psychological well-
being (subjective sense of contentment and the absence
of emotional distress), social and role functioning (ability
to fulfill family, work, and community responsibilities),
and personal perception of health (satisfaction with one’s
health status).163 Research has found that participation
in a comprehensive wellness and exercise program helps
improve physical and psychosocial well-being for burn
survivors.164–168
Quality of life has been investigated using general health
questionnaires or measures that focus on specific behaviors.
Recent research has begun to focus on the overall quality
of life.169–171 As with self-report behavioral scales, most
long-term (>2 years) burn survivors appear to have eventu­
ally developed satisfactory adjustment and are within
normal range on domain subscales of the SF-36, a widely
used measure that assesses general health quality of
life.163,169,171 Using a measure that examined specific behav­
iors, young adults who sustained burns as children rated
their overall quality of life lower than the normative
group.170
Many burn survivors question if they can have meaning­
ful relationships and have questions about intimacy and
sexual activity. Meyer and colleagues examined the sexual
attitudes and behaviors of adult burn survivors and found
that, overall, they felt positive about their sexual experi­
ences; however gender differences were evident, with the
women reporting an easier time finding partners.172 Bianchi
found that there was no relationship between burn severity
and sexual esteem for male survivors.173
The past couple of decades of our burn-related research
has consistently shown that early psychological distress
(i.e., in-hospital) can have an enduring impact on physical,
psychological, and social health and function.34,100,174 For
example, psychological distress while in the hospital was
found to be associated with significantly greater impair­
ment of physical and psychological function and slower
rates of recovery over the course of the first year following
a major burn injury, even when preburn physical and psy­
chological health and function were statistically con­
trolled.174 In a second longitudinal study following burn
survivors over the first year of recovery, psychological dis­
tress was highly correlated with poor quality of life through­
out the study.175 In addition, body image dissatisfaction
upon leaving the hospital is associated with prolonged
periods of poorer mental health-related quality of life
among adult patients following disfiguring burns, and this
was independent of general distress, injury severity, and
preinjury psychosocial adjustment.99 Furthermore, post­
trauma distress during the late inpatient phase is predictive

66  •  Psychosocial Recovery and Reintegration of Patients With Burn Injuries
720
creating “a culture of inclusion for people with disfigure­
ment.”47 In addition to providing counseling and support­
ing research, it organizes sustained political campaigns
in support of the civil and human rights of people with
visible differences. For example the group has organized
the ongoing “face equality” campaign with the goal of
challenging “media, advertisers, and the film industry to
adopt more factual and unbiased portrayals of people with
disfigurements, actively avoiding language and imagery
that creates prejudice.” In addition, the campaign has
asked politicians and policy-makers to “ensure that facial
prejudice and discrimination are effectively outlawed by
improving anti-discrimination law and promoting best
practice.”47
Summary
Most burn survivors do eventually adapt well and resume
lives of productive activity with satisfactory self-esteem
and social interactions. Empirical data indicate that the
first year or so postburn is fraught with discomfort and
distress, but much of the difficulty is transient. The process
of psychological adaptation often continues for several
years. Symptoms of disturbance that linger among burn
survivors are likely to be such that only intimate friends
and family members will observe them, so it is valuable
for persons with expertise in burn care adaptation to peri­
odically assess survivors and provide an opportunity for
intervention.
That most burn survivors do amazingly well should never
be interpreted as indicative of ease in adaptation. We must
never diminish the pain and suffering they endure from
physical and psychological wounds. As psychotherapists to
a large number of burn survivors, we know very well the
struggles survivors can experience. They have moments of
true despair and hopelessness, moments of rage, and
moments of joy. Fortunate psychotherapists can know
them through all extremes: looking for glimmers of hope,
validating anger, celebrating victories, and gaining deep
respect for resilience of human beings.
Acknowldgments
We would like to acknowledge Patricia E. Blakeney, PhD,
and John W. Lawrence, PhD, who contributed to the previ­
ous psychosocial chapter(s) for this book.
Complete references available online at

to find a mental health professional to work with them who
is knowledgeable about burn care.
Given the limited access to effective psychotherapy,
perhaps more effective strategies for improving psychoso­
cial outcomes for burn survivors are those interventions
that create more accepting and tolerant social environ­
ments. Programs or organizations with the mission of
engendering social acceptance for burn survivors and other
people with physical differences include school reentry pro­
grams, burn camps, the Phoenix Society for Burn Survivors
in the United States,40 and Changing Faces based in the
United Kingdom.46,47 Burn camps provide an opportunity
for pediatric burn survivors to interact and socialize with
other burn survivors and participate in recreational activi­
ties in a supportive environment. These camps may increase
self-esteem and also help to build confidence and diminish
anxiety.182,183 Some camps were designed to provide mental
health and rehabilitation services to children once they
have left the hospital, whereas other camps are for recre­
ational purposes only.184 A recent study revealed that
increased years of attendance at burn camp was positively
correlated with lower rates of somatic, separation, and total
anxiety symptoms.185 Adolescents in another study credited
the burn camp experience with helping them with identity
formation and reflection, improved social interactions, and
increased initiative and cooperation with others. Results
suggested that burn camp participation not only helped
burn-injured youth deal with their burns, but also assisted
them in the development of social and basic life skills.186
Increased posttraumatic growth has also been a docu­
mented outcome of long-term tenure at burn camp, as well
as attendance at young adult retreats that serve burn-
injured youth ages 16–21.187 These programs provide assis­
tance with the transition to adulthood and provide burn
survivor support beyond the burn camp setting.
The Phoenix Society for Burn Survivors in conjunction
with multiple burn centers coordinates the Soar Program,
which provides peer support for hospitalized patients and
their families. “In addition, they host the annual World
Burn Congress, a conference that brings together burn sur­
vivors, their families, firefighters, and burn care profession­
als to address the aftercare and reintegration issues of burn
survivors.”40 The Phoenix Society for Burn Survivors and
the American Burn Association also have a joint Aftercare
and Reintegration Committee. This group is devoted to
improving psychological health and social reintegration fol­
lowing burns.
As mentioned previously, Changing Faces is another
charity based in the United Kingdom and is dedicated to

720.e1
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