Section of Psychiatry, Department of Experimental Biomedicine and Clinical Neurosciences, Palermo University, Palermo, Italy

Transcription

1 QUALITY OF LIFE, BODY IMAGE, AND PSYCHIATRIC COMPLICATIONS IN PATIENTS WITH A BURN TRAUMA: PRELIMINARY STUDY OF THE ITALIAN VERSION OF THE BURN SPECIFIC HEALTH SCALE-BRIEF Sideli L., 1 Prestifilippo A., 1 * Di Benedetto B., 1 Farrauto R., 1 Grassìa R., 1 Mulè A., 1 Rumeo M.V., 1 Di Pasquale A., 2 Conte F., 2 La Barbera D. 1 1 Section of Psychiatry, Department of Experimental Biomedicine and Clinical Neurosciences, Palermo University, Palermo, Italy 2 Plastic Surgery and Burns Therapy Operative Unit, Civic and Benfratelli Hospital, Palermo SUMMARY. Burn patients may suffer both physical and psychopathological consequences and their quality of life and the presence of psychopathological symptoms should be evaluated. The Burn Specific Health Scale - Brief (BHSH-B) is a tried and tested instrument for assessing burn patients quality of life. The aim of this study is to propose the Italian translation of BSHS-B and presents the preliminary results of an exploratory study. The Italian version of the BSHS-B was administered to a sample group of 50 burn victims. Reliability was verified by Cronbach s alpha, and construct validity was evaluated through correlation with the Short Form 36 Health Survey Questionnaire (SF-36) and the Self-report Symptom Inventory - Revised (SCL-90). The entire scale and two out of three domains showed Cronbach s alpha values higher than 0.8. Significant correlations were identified between BSHS-B subscales and the SF-36 subscales Physical Pain and Social Activities. Several psychopathological SCL-90 subscales correlated with BSHS-B subscales Heat Sensitivity and Body Image. It was concluded that our translation of BSHS-B was reliable and showed good construct validity. The drawbacks of this study are the limited size of the sample and the wide variety of types of burn injuries. Keywords: quality of life assessment, psychological health, body image Introduction Burns are a traumatic experience with an important emotional impact. In burn patients, somatic injury (pain, functional loss) is almost always associated with a set of psychic symptoms, partly related to the traumatic experience itself 1 and partly produced by the functional and aesthetic damage, which provokes a gross change in patients self-image and social role. Burn patients have to face hard and painful therapeutic and physical rehabilitative treatment, plus which they have to work through a difficult process of mental elaboration in order to redefine their overall self-identity. 2 There is a high incidence of delirium, cognitive disorders, anxiety, panic attacks, and depressive symptoms a few weeks after the trauma. 3 At one time it was hypothesized that these symptoms ceased spontaneously after the first year, 4 but this has not been confirmed by more recent studies. It was observed that over 40% of such patients required psychiatric treatment two years after the trauma 5 and several patients (13-45%) exhibited a post-traumatic stress disorder. 1 The extent and the severity of the burned surface are not necessarily related to the level of mental suffering, which is influenced by the perception of alterations of physical image. 6 Patients with moderate burns and good social support and without pre-morbid physical or mental disorders may present anxiety and/or depressive symptoms, as well as sexual and sleep disturbances, even several years after the trauma. 7 Face and hand burns are often disabling, causing concern about self-image. 8 Other predictive factors of an unfavourable outcome are, for example, low social and emotional support and an avoidant coping style, associated with personality traits such as neuroticism and poor extroversion, 1 whereas a lower level of pain and stress perception, associated with better social reintegration after the trauma, can be favourable prognostic factors. 9 * Corresponding author: Dr Alessia Prestifilippo, Unità Operativa Chirurgia Plastica e Terapia delle Ustioni, Ospedale Civico, Via C. Lazzaro, Palermo, Italy. Tel.: ; fax: ; AlessiaPrestifilippo@libero.it 1

2 Of all the specific instruments available for measuring burn patients quality of life (QOL), the Burn Specific Health Scale (BSHS) is one of the most widely used. The BSHS was originally created in the USA during the 1980s, combining three existing scales, namely the Sickness Impact Profile 10 (a 136-item instrument for the measurement of health conditions in the general population), the Index of Activity of Daily Living 11 (a 6-item scale for measuring physical functioning), and the General Well-Being Schedule 12 (a scale of 12 to 68 items for the assessment of psychological health). These tests were used to extract a list of items, and 160 items were added by the authors - these were termed burn specific items and were developed by a group of burn patients and a team of researchers at the Baltimore Burn Center. In its first form the BSHS consisted of 369 items, which were subsequently reduced to The BSHS was subsequently altered by several authors in order to reduce the total number of items and to increase the specificity of the investigation of the most relevant domains, obtaining a 40-item reduced version (BSHS-Brief). 14 The aim of this study is to propose the Italian translation of the BSHS-B and to present the preliminary results of an Italian validation project. In particular, we set out to verify the reliability of the scale (internal consistency) and its validity (construct validity). BSHS-B s internal consistency was verified through Cronbach s alpha, while construct validity was evaluated through correlation with the Short Form 36 Health Survey Questionnaire (SF-36) 15 and the Self-report Symptom Inventory Revised (SCL-90). 16 The Body Uneasiness Test (BUT) 17 and Coping Orientation to Problems Experienced (COPE) 18 were also administered in order to evaluate the relationship between QOL, body image, and coping styles used to face stressful life events. Methods Procedure The Burn Specific Health Scale - Brief (BSHS-B) is a questionnaire made up of 40 items encompassing nine domains: simple abilities, heat sensitivity, hand function, treatment regimens, work, body image, affect, interpersonal relationships, and sexuality. The Italian version of the instrument was elaborated by consensus using three independent translations, two of which were made using the English version and the third a Swedish version. Sample The Italian version of BSHS-B and the other instruments were administered to 59 burn patients admitted to the Plastic Surgery and Burns Therapy ward (ARNAS, Civic and Benfratelli Hospital, Palermo) over a 3-yr period ( ). The instruments were administered by trainee psychologists and resident psychiatrists. All the instruments were administered to the sample in the first month after admission. The percentage of total body surface (TBSA) burned and the severity of the burns (according to the clinical evaluation) were recorded for each patient. Data on education, employment, accident circumstances, and history of psychiatric symptoms requiring clinical care were also collected. Nine subjects with a positive psychiatric history were excluded from the original sample of 59 subjects and the final sample was therefore composed of 50 persons. Instruments Short Form 36 Health Survey Questionnaire (SF- 36) 15 : questionnaire used to evaluate the global health condition and its course through investigation of eight basic parameters: physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, mental health. Self-report Symptom Inventory - Revised (SCL- 90) 16 : a symptoms checklist assessing the presence and severity of 90 psychopathological and somatic symptoms grouped in nine clusters: obsessiveness-compulsiveness, interpersonal sensitivity, depression, anxiety, rage-hostility, somatization, phobic anxiety, paranoid ideation, and psychoticism. Body Uneasiness Test (BUT) 17 : questionnaire exploring the severity of body image dissatisfaction, evaluating the following areas: weight phobia, body image concerns, avoidance, compulsive self monitoring, and depersonalization. Coping Orientation to Problems Experienced (COPE) 18 : questionnaire investigating 15 different coping strategies: active coping, planning, suppression of competitive activities, restraint coping, instrumental social support, emotional social support, focusing on and venting of emotions, positive reinterpretation, acceptance, turning to religion, humour, mental disengagement, behavioural disengagement, denial, and use of substances. Statistics For each variable, the mean, median, mode, and standard deviation were calculated. The comparisons between groups were made using non-parametric Mann-Whitney and Kruskal- Wallis tests. Correlations were calculated using Spearman Rho. The statistic program used was SPSS version 16. Results Fifty burn patients completed the assessment. The sample mostly consisted of males, aged about 40, employed, and with a medium-low education level. TBSA ranged from 9 to 73%, while burns severity was distributed equally among moderate, moderate-severe, and severe (Table I). 2

3 Table I - Burn patients - demographic and clinical profile Number 50 Gender Male 72% Female 28% Mean age at evaluation (yr) (SD, 15.67) (range, 18-70) Education (yr) 8 64% > 9 36% Employment status Unemployed 22% Student 10% Employed 56% Retired 12% Percentage TBSA burned 31.82% (SD, 17.59) (range, 9-73) Burn severity Moderate 38% Moderate/severe 30% Severe 32% Place of injury Work 24% House 60% Street 6% Other 10% The mean BSHS-B scores were higher on the Heat Sensitivity and Work subscales, while the lowest scores regarded Interpersonal Relationships and Sexuality. Comparisons between groups made using Mann-Whitney and Kruskal-Wallis tests showed that the higher the severity of the burn, the higher were the scores on the Simple Ability subscale (chi-square = 6.924, p = 0.031) and that patients whose work involved contact with other people scored lower in the Work subscale (Mann-Whitney U = , p = 0.051). TBSA correlated positively with Interpersonal Relationships subscale scores with a mild trend of significance (Spearman s Rho = 0.258, p = 0.074). From a psychopathological point of view, patients recorded higher mean scores on the Depression (m = 0.97, SD = 2.67), Obsessiveness/Compulsiveness (m = 0.94, SD = 2.41), Somatization (m = 0.90, SD = 2.41), Anxiety (m = 0.83, SD = 1.96), and Phobic Anxiety (m = 0.81, SD = 1.99) subscales. Cronbach s alpha value was calculated for the whole scale, the nine subscales, and the three main domains. Cronbach s alpha values higher than 0.8 were found for the entire BSHS-B scale and for the Affect and relationships and Skin involvement domains. A moderate level of internal consistency ( ) was observed for all the subscales, except for Interpersonal Relationships (Table II). The construct validity of the translation was investigated through correlation with SF-36 and SCL-90; significant correlations were shown with both instruments, as Table II - Cronbach s alpha values: Scale, subscales, and main domains (according to Willbrand-Kildal, 2008) No. patients No. items Cronbach alpha Scale Affect and relationships Affect Interpersonal relationships Sexuality Function Simple abilities Hand function Work Skin involvement Heat sensitivity Treatment regimens Body image indicated in Table III. Several significant correlations were observed between the SF-36 and BSHS-B subscales related to the Affect and relationships domain. Unlike the BSHS-B, higher SF-36 scores indicated a better quality of life, so that significant correlations between the two scales were negative. Several correlations were found between BSHS-B subscales and SCL-90 Obsessiveness/Compulsiveness, Depression, Interpersonal Sensitivity, and Phobic Anxiety subscales. Most of these correlations concerned Heat Sensitivity and Body Image BSHS-B subscales. We also investigated the body image dissatisfaction and coping strategies adopted by patients to face the stressful event, and correlations were made between BSHS-B and the BUT and COPE subscales (Table IV). Higher mean scores were observed in Weight Phobia (m = 0.58, SD = 0.69), Body Image (m = 0.48, SD = 0.62), and Compulsive Self-Monitoring (m = 0.48, SD = 0.42) subscales of BUT. Significant correlations were found between the Heat Sensitivity, Hand Function, Work, Body Image, and Affect BSHS-B subscales and all the BUT subscales except for Depersonalization. Higher scores on the Body Image subscale (BUT) were associated with higher scores on the Heat Sensitivity and Hand Function BHSH-B subscales. No relationship was found between these subscales and TBSA and burn severity. Body Image and Compulsive Self-Monitoring BUT subscales correlated with the following SCL- 90 subscales (first p value referred to Body Image, second p value referred to Compulsive Self-Monitoring): Anxiety (p = 0.001, p = 0.014), Hostility (p = 0.000, p = 0.030), and Psychoticism (p = 0.007, p = 0.000). In additon Body Image correlated with Somatization (p = 0.003). In our sample, the coping strategies with the highest mean scores were Active Coping (m = 12.06, SD = 6.63), Positive Reinterpretation (m = 12.22, SD = 2.85), and Ac- 3

4 Table III - Correlation between BSHS-B, SF-36, and SCL-90 subscales BSHS-B No SF-36 SCL-90 Simple abilities 50 Physical activities * Bodily pain * Heat sensitivity 50 Somatization 0.337* Obsessiveness-Compulsiveness 0.355* Interpersonal sensitivity 0.321* Anxiety 0.315* Hostility 0.359* Psychoticism 0.334* Hand function 50 Hostility 0.342* Phobic anxiety 0.463** Treatment regimens 50 Obsessiveness-Compulsiveness 0.311* Depression 0.438** Phobic anxiety 0.321* Paranoid ideation 0.424** Work 50 Body image 50 Somatization 0.326* Obsessiveness-Compulsiveness 0.473** Interpersonal sensitivity 0.417** Depression 0.580** Anxiety 0.419** Hostility 0.383** Phobic anxiety 0.403** Paranoid ideation 0.324* Psychoticism 0.431** Affect 50 Physical role * Obsessiveness-Compulsiveness 0.323* Vitality * Depression 0.414** Mental health ** Phobic anxiety 0.279* Paranoid ideation 0.311* Interpersonal relationships 50 Bodily Pain * Obsessiveness-Compulsiveness 0.349* Social Activities ** Interpersonal sensitivity 0.301* Sexuality 50 Social Activities * Spearman s Rho test, *<0.05 **<0.01 (two-tailed test) ceptance (m = 12.88, SD = 3.39), while Humour (m =6.72, SD = 2.57) and Denial (m = 6.76, SD = 2.46) had lower average scores. A higher number of positive correlations were found between BSHS-B and Behavioural Disengagement; high scores on the latter were associated with high scores on the BSHS-B subscales Heat Sensitivity, Interpersonal Relationships, and Sexuality. It was also observed that high scores on the Treatment Regimens subscales were associated with active coping strategies that were both problemfocused and oriented towards seeking social support. Focus and Venting Emotions and Emotional Social Support were the most common strategies among severe patients, who were the most involved in their treatment (chi-square = 7.835, p = 0.020; chi-square = 5.170, p = 0.075). In contrast, high Heat Sensitivity and Body Image scores were associated with frequent use of strategies oriented to Avoidance and Mental Disengagement. Discussion The Italian version of BSHS-B exhibited a good rate of internal consistency with Cronbach s alpha values higher than 0.8 for the whole scale and for two out of three domains. Cronbach s alpha values ranging from , which are considered acceptable for psychometric scales, were found for 8 out of the 9 subscales (the one exception was Interpersonal Relationships). If we consider the mean scores obtained from the four items of the subscale (n 17 [m = 0.30, SD = 0.84], 18 [m = 0.24, SD = 0.74], 19 [m = 0.14, SD = 0.52], 20 [m = 0.16, SD = 0.65]), it is clear that 19 and 20 had lower scores than the others; in particular none patient scored more than 2 on item 19. It is possible that this variability was related to the form of expression used in items 19 and 20 (I don t like the way my family acts around me and My family would be better off without me), which were not directly addressed to the burn or to the ac- 4

5 Table IV - Correlations between BSHS-B, BUT and COPE subscales BSHS-B N BUT COPE Simple abilities 50 Planning 0.281* Heat sensitivity 50 Weight phobia 0.336* Denial 0.303* Body image concerns 0.295* Behavioural disengagement 0.389** Alcohol/drug use 0.293* Hand function 50 Body image concerns 0.357* Compulsive self-monitoring 0.378* Treatment regimens 50 Planning 0.279* Suppression of competing activities 0.279* Focusing on & venting of emotions 0.315* Emotional social support 0.526** Humour 0.315* Work 50 Weight phobia 0.329* Compulsive self-monitoring 0.312* Body image 50 Weight phobia 0.425** Positive reinterpretation * Mental disengagement 0.291* Affect 50 Avoidance 0.284* Denial * Interpersonal relationships 50 Behavioural disengagement 0.336* Sexuality 50 Behavioural disengagement 0.332* Spearman s Rho test, *<0.05 **<0.01 (two-tailed test) cident and therefore could have been interpreted as generalized devaluation or hostility towards the family. This particular aspect thus requires further investigation. The Italian version of the BSHS-B showed positive correlations with both SF-36 and SCL-90. Although Spearman s Rho values were not high ( ), these correlations indicated that the scale had good construct validity. Several correlations were found between the following subscales: Simple Abilities on the BSHS-B and the SF-36 subscales related to the Physical Health domain; and Affect and Interpersonal Relationships subscales on the BHSH-B and the SF-36 subscales related to the Mental Health domain. Moreover, most of the BHSH-B subscales were positively correlated with SCL-90 subscales related to anxiety and depression areas. Assuming that all the patients had a negative psychiatric history, this latter correlation confirmed literature findings that burn trauma can be associated with depressive and anxiety symptoms even during the first month after admission. 1-3 It was shown that a greater number of psychopathological symptoms, including psychotic symptoms, were found in people with high heat sensitivity and body image alterations. Our study underlined the fact that body image alterations correlated with a low quality of life in burn patients. High heat sensitivity, decreased hand function, and worries about the impact of the burn on working performances of the BHSH-B were associated with body image concerns and compulsive skin monitoring. It has been suggested 7 that body image concerns are relatively independent of burn extent and are much more closely related to the localization of the burn, as shown in our sample; further investigation could clarify this point. It is interesting to note that a higher body image alteration also correlated with higher scores on the SCL-90 Anxiety, Hostility and Psychoticism subscales; this suggests that attacks on somatic self-representation constituted a vulnerability factor for the development of several symptoms. 2,3,8 The main coping strategies used by patients are problem-focused (Active) and emotion-focused (Positive Reinterpretation and Acceptance). These strategies are mainly used by severely burned patients and patients needing difficult and protracted treatment. The QOL aspect of burn patients can be managed through help from other people, as indicated by the high level of social support seeking. In contrast, increased heat sensitivity, body image alteration, and interpersonal difficulties appear to lead to avoidance and detachment strategies (Denial, Behavioural and Mental Disengagement) which, as other researchers demonstrated, are associated with a poorer prognosis. 20,21 The impact of the body image concerns and coping strategies adopted in the long-term outcome should be further investigated. Conclusions The aim of this work was to investigate the quality of life of burn patients by means of a specific instrument, the Burn Specific Health Scale - Brief, through a hitherto untested Italian translation used for an exploratory study carried out on patients with severe to moderate burns. Our translation of the BSHS-B proved to possess a good rate of reliability and good construct validity. Further studies should investigate the relationship between quality of life, as measured by BHSH-B, and objective burn parameters such as extent, severity, and localization. 5

6 Quality of life should be explored also in the medium- and long-term, together with risk and protective factors. Our findings suggest the need of psychiatric and psychological evaluation and an integrated approach for burn patients. BSHS-B is currently used in several European countries and it was found to be a good screening instrument, aimed at identifying and potentially preventing the development of psychopathological sequelae which have high social and psychopathological costs. In the light of these findings, it would be worth developing the Italian standardization of the BSHS-B in order to promote its use in the assessment and treatment of burn patients. RÉSUMÉ. La brûlure est un événement qui peut déterminer non seulement des dommages physiques mais aussi des conséquences psychopathologiques considérables. Pour cette raison il est important d évaluer la qualité de la vie et la présence de symptoms psychopathologiques. La Burn Specific Health Scale (BSHS-B) (Echelle Médicale Spécifique des Brûlures) est un instrument amplement validé pour l évaluation de la qualité de la vie des patients brûlés. Les Auteurs de cette étude se sont proposés d évaluer la traduction italienne de la BSHS-B et de présenter les résultats préliminaires d une recherche d exploration. Ils ont administré à un groupe de 50 patients brûlés la traduction italienne de la BSHS-B et ils en ont vérifié la fiabilité moyennant l alpha de Cronbach, en outre on a vérifié la validité par la corrélation avec le Short Form 36 Health Survey Questionnaire (SF-36) et le Self-report Symptom Inventory - Revised (SCL-90). Ils ont trouvé que la valeur de l alpha de Cronbach était supérieure à 0,8 dans toute l échelle et dans deux des trois domaines. Des corrélations significatives ont été observées avec les sous-échelles SF-36 Douleur physique et Activités sociales. Pour ce qui concerne les échelles psychopathologiques SCL-90, plusieurs étaient corrélées aux souséchelles BHSS-B Sensibilité à la chaleur et Image corporelle. Les Auteurs concluent que la traduction de la BSHS-B a montré une bonne fiabilité et une validité de construction appropriée. Toutefois, l étude présent des limites dues au modeste nombre des patients considérés et à l hétérogénéité des types de brûlures. Mots-clés: évaluation de la qualité de vie; santé psychologique, image corporelle BIBLIOGRAPHY 1. Van Loey NE, Van Son MJ: Psychopathology and psychological problems in patients with burn scars: Epidemiology and management. American J Clinical Dermatology, 4: , Cavaleri V, Epifanio MS, Benigno A et al.: The attack on psychosomatic integrity: A study of the psychological sequelae of the burn trauma. Ann Burns Fire Disasters, 22: 83-7, Patterson DR, Everett JJ, Bombardier CH et al.: Psychological effects of severe burn injuries. Psychological Bulletin, 113: , Blades B, Mellis N, Munster AM: A burn specific health scale. J Trauma, 22: 872-5, Wallace LM, Lees J: A psychological follow-up study of adult patients discharged from a British burn unit. Burns, 14: 39-45, Thomson A, Kent G: Adjusting to disfigurement: Processes involved in dealing with being visibly different. Clinical Psychology Review, 21: , Blumenfield M, Reddish PM: Identification of psychological impairment in patients with mild-moderate thermal injury: Small burn, big problem. General Hospital Psychiatry, 9: 142-6, Solnit AJ, Priel B: Scared and scarred - psychological aspects in the treatment of soldiers with burns. Israel Ann Psychiatry and Related Disciplines, 13: , Cromes GF, Holavanahalli R, Kowalske K et al.: Predictors of quality of life as measured by the burn specific health scale in persons with major burn injury. J Burn Care Rehabil, 23: , Gilson BS, Gilson JS, Bergner M et al.: The sickness impact profile: Development of an outcome measure of health care. American J Public Health, 65: , Katz S, Ford AB et al.: Studies of illness in the aged. The Index of ADL: A standardized measure of biological and psychosocial function. J American Medical Association, 185: 914-9, Dupuy HJ: Self-representations of general psychological wellbeing of American adults. Paper presented at meeting of American Public Health Association, Los Angeles, Blades B, Mellis N, Munster A: A Burn Specific Health Scale. J Trauma, 22: 872-5, Kildal M, Andersson G, Fugl-Meyer AR et al.: Development of a Brief Version of the Burn Specific Health Scale (BSHS B). J Trauma, 51: , Ware JE, Sherbourne CD: The MOS 36-item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Medical Care, 30: , Derogatis LR, Lipman RS, Covi L: SCL-90: An outpatient psychiatric rating scale - preliminary report. Psychopharmacology Bulletin, 9: 13-28, Cuzzolaro M, Vetrone G, Marano G et al.: The Body Uneasiness Test (BUT): Development and validation of a new body image assessment scale. Eating and Weight Disorder, 11: 1-13, Carver CS, Scheier MF, Weintraub JK: Assessing coping strategies: A theoretically based approach. J Personality and Social Psychology, 56: , Willebrand M, Kildal M: A simplified domain structure of the burn-specific health scale-brief (BSHS-B): a tool to improve its value in routine clinical work. J Trauma, 64: , Willebrand M, Kildal M, Ekselius L et al.: Development of the Coping with Burns Questionnaire Personality and Individual Difference, 30: , Kildal M, Willebrand M, Andersson G et al.: Coping strategies, injury characteristics and long-term outcome after burn injury. International J Care Injured, 36: 511-8, This paper was received on 15 June