Anxiety in recovery from severe burn injury: Anexperimental comparison

N. J. HULBERT-WILLIAMS1, S. L. HULBERT-WILLIAMS2,

D. MCILROY3, & B. BUNTING4

1Department of Primary Care and Public Health, North Wales Clinical School, Cardiff University,

Wrexham, UK, 2School of Psychology, University of Wales, Bangor, UK, 3School of Psychology,

Liverpool John Moores University, Liverpool, UK, and 4School of Psychology, University of Ulster,

Ulster, Londonderry, Northern Ireland

AbstractAdjustment to burn injury is a slow process that often results in high distress and anxiety. This studyaimed to investigate the impact on anxiety of viewing various types of photographic stimuli (includingburn injuries), comparing a burn-injured and control sample. An experimental design was usedcomparing those recovering from a burn injury with age- and gender-matched controls. Thirtyparticipants from a burns support group and their matched controls were asked to complete a traitanxiety measure (STAI Y-2). Participants then completed the state anxiety measure (STAI Y-1) afterviewing different types of photographic stimuli (burn injuries, uninjured body parts, neutral) undercontrolled experimental conditions. Results demonstrated significant differences in anxiety levelsbetween groups with respect to trait anxiety and state anxiety after each experimental condition. Age ofinjury was also found to be a significant influence over trait anxiety. A significant effect of experimentalcondition was found, as was a significant interaction between group and condition. Those with burninjuries were more anxious than controls—a difference that was further exaggerated when participantsviewed photographs of burned or uninjured body parts in an experimental setting.

Keywords: Anxiety, burns, disfigurement, social norms

Introduction

Of the 250,000 people in the United Kingdom who suffer a burn injury each year, 13,000

are considered serious enough to require hospitalization (Hettiaratchy & Dziewulski, 2004).

Despite care improvements and significantly improved survival, quality of life and long-term

adjustment to disfigurement following treatment are still variable (Munster, 1999). Once the

short-term goal of survival has been attained, initial relief passes and the individual faces the

challenge of longer-term adjustment and rehabilitation; not only is self-acceptance a major

hurdle, but dealing with the reactions of others can also be challenging. Sufferers of major

burns, compared with minor burns, show higher levels of distress (Andreason & Morris,

1977), suggesting some difference in transition and adjustment.

Suffering a burn puts one at increased risk of various psychological disturbances including

post-traumatic stress disorder (PTSD), depression and anxiety (Wiechman & Patterson,

Correspondence: N. J. Hulbert-Williams, Department of Primary Care and Public Health, North Wales Clinical School, Cardiff

University, Wrexham, UK. Tel: 01978 727859. Fax: 01978 727431. E-mail: hulbertnj@cf.ac.uk

Psychology, Health & Medicine,

March 2008; 13(2): 162 – 167

ISSN 1354-8506 print/ISSN 1465-3966 online ª 2008 Taylor & Francis

DOI: 10.1080/13548500701352701

2004). Increased levels of anxiety, often in the clinical range, are particularly commonly

reported (Williams & Griffiths, 1991). Such increases in anxiety often remain up to one year

after injury (Williams & Griffith, 1991; Clarke and Cooper, 2001), and are reported as

occurring in as many as 26.6% of cases two years after injury (Wallace & Lees, 1988).

Anxiety is an affective state accompanied by emotional and behavioural concomitants

(Gibson, 2005). Two distinct forms of anxiety are generally identified: state anxiety and

trait anxiety. State anxiety is a constantly changing condition often experienced in

response to current stressful or dangerous situations, thus changing in intensity and

duration (Ray, 1984). Trait anxiety is a disposition that remains more stable over time

(Munafo & Stevenson, 2001) and is often thought of in terms of an individual’s proneness

to higher levels of state anxiety (Rachman, 1998; Spielberger, Gorsuch, Vagg, & Jacobs,

1983). High state anxiety is reported to be associated with slower illness recovery and

wound healing in post-surgery patients (Kiecolt-Glaser, Page, Marucha, MacCallum &

Glaser, 1998).

There are numerous plausible mechanisms by which burns sufferers might come to

experience heightened anxiety. First, there may be anxiety relating directly to the event in

which the burn was acquired. It is reported that anxiety can often centre around memories of

and flashbacks to the occurrence of the injury; PTSD has been reported to occur in

approximately 30% of burn injury cases (Wiechman & Patterson, 2004). Second, physical

pain may mediate the effect on anxiety: Burn sufferers report pain and physical discomfort

throughout long-term rehabilitation (Badger, 2001; Choiniere Melzack, Rondeau, Girard &

Paquin, 1989; Perry Heidrick & Ramos, 1981). Chronic pain has elsewhere been reported as

a cause of anxiety (Greenberg & Burns, 2003). Third, anxiety may arise as a result of

psychosocial processes: burns sufferers may negatively compare their physical appearance to

that of others, grieve over the loss of their previous appearance, or have concerns over the

reactions and opinions of others (Partridge & Robinson, 1995).

The current study was designed to provide evidence for the causal role of psychosocial

processes in the increased anxiety experienced by burns sufferers. If these processes

contribute significantly to the explanation of anxiety, we might expect stimuli that cue

thoughts about physical appearance to be anxiety provoking. We might further expect a

stronger provocation of anxiety in response to stimulit that cue thoughts relating to both

physical appearance and burn injuries.

Method

Participants

Sixty participants were recruited for this study. The experimental group (n¼ 30) were all

recruited from a burns rehabilitation support group and had all been treated for a variety of

serious burns injuries in the St Helen’s and Knowsley Hospitals NHS Trust. These

consisted of 18 males and 12 females of varying age chosen by target sampling, who were

matched on age category and gender to a control group (n¼ 30) who had not received any

burn injuries. Age was recorded in categorical form (in increments of 5 years) ranging from

16 to 60þ years, rather than exact age. At least one participant was recruited for each age

category, except for the 41 – 45 year-olds where no member of the support group matched

this age range. Of the burn sufferers, 19 participants had received injury within 3 years of the

study; 11 had received injury more than 3 years ago. Similar age distributions were achieved

for both the older and recent injury groups. The recent injury group consisted of 12 males

and 7 females; the older injury group consisted of 6 males and 5 females.

Anxiety following from severe burn injury 163

Materials

Experimental stimuli. Three packs of pictures were used, each containing six photographs.

Pack A contained photographs of burn disfigured individuals (burns varied between face,

arms, hand and back); Pack B contained photographs of non-injured body parts; and Pack C

contained neutral photographs (house, sofa, shopping trolley, garden path, breakfast table

and chair). Presentation of stimuli packs was varied systematically in order to counter-

balance potential order effects.

Outcome measures. Both facets of anxiety were measured using Spielberger et al’s (1983)

State-Trait Anxiety Inventory (STAI Form Y). This self-report measure consists of 40

items; 20 state items (e.g., ‘‘how you feel now’’) and 20 trait items (e.g., ‘‘how you feel

generally’’) assessed using Likert responses from 1 (¼almost never) to 4 (¼almost always).

Design and procedure

This was an experimental study comparing anxiety levels in response to pictorial stimuli

between a burn-injured patient group and non-burn-injured control participants.

NHS Ethical approval was sought; permission was given from the Burn Unit manager; and

written consent was obtained from each participant prior to recruitment. Experimental

group participants were recruited during a meeting of the Burns and Rehabilitation support

group. Age- and gender-matched controls were drawn from the general population. Verbal

and written consent was obtained prior to participation.

Firstly, participants completed a short questionnaire thus providing demographic and

injury-related information. Form STAI Y-2 was then completed by all participants in order

to assess trait anxiety. As state anxiety is highly dependent on trait anxiety levels, this

provided a baseline anxiety measurement. Each participant was then shown the three stimuli

packs and immediately completed the STAI Y-1 measure after each, in order to assess

changes in state anxiety. Each picture was shown for five seconds and unlimited time was

provided for completion of the STAI Y measures. All data was then coded for anonymity.

Results

Descriptive statistics for both state and trait anxiety measures are presented in Table I.

Graphical analysis of residuals showed that the data approximated a normal distribution.

Two-way analysis of variance (ANOVA) was used to analyse both state and trait measures of

anxiety.

Table I. Summary table of descriptive statistics demonstrating differences in the experimental and control groups in

trait anxiety and state anxiety responses to pictorial stimuli.

Condition

Experimental group Control group

M SD M SD

Trait anxiety 49.83 14.93 34.17 5.53

Burn stimuli 65.57 6.12 58.50 8.36

Non-burn stimuli 54.37 13.54 25.97 4.18

Neutral stimuli 38.77 13.90 26.47 3.44

164 N. J. Hulbert-Williams et al.

Trait anxiety levels were higher amongst the patient sample (M¼ 49.83, SD¼ 14.93) than

control participants (M¼ 34.17, SD¼ 5.53). One-way ANOVA found this difference to be

significant (F(1,29)¼ 35.87, p5 .001). Analysis of trait anxiety differences based on time

since injury revealed significantly higher trait anxiety for those who had sustained injury

within 3 years of this study, compared with those who had had longer to adjust (19 and 11

patients respectively, F(1,28)¼ 16.49, p5 .001).

Differences in state anxiety levels resulting from viewing photographic stimuli

were explored using a 263 ANOVA. A significant effect of having a burn injury was

found, with burn-injured participants reliably scoring higher on state anxiety than controls

(F(1,29)¼ 76.94, p5 .001). There was a significant effect of condition (F(2,58)¼ 360.41,

p5 .001). The group by condition interaction was also found to be significant

(F(2,58)¼ 65.83, p5 .001). The interaction effect can be seen in Figure 1; mean state

anxiety differences between burn-injured participants and controls are more pronounced

following exposure to non-burn stimuli than in the other two conditions.

Post-hoc pairwise comparisons using the Bonferroni adjustment revealed

significant differences on state anxiety between the burn-injured and control

participants on each of the experimental conditions at the a¼ .001 level. Cohen’s d effects

sizes were also calculated (burn stimuli, d¼ 0.98; non-burn stimuli, d¼ 2.88; neutral

stimuli, d¼ 1.24).

Those participants who had sustained their burn injury during the prior three years,

compared with those who had had longer to adjust reported higher state anxiety levels for

Figure 1. A graphical representation of mean state anxiety across groups and conditions. Note: Error bars represent

one standard error of measurement.

Anxiety following from severe burn injury 165

each experimental condition (burn stimuli, F(1,28)¼ 13.99, p¼ .001; non-burn stimuli,

F(1,28)¼ 35.71, p5 .001; neutral stimuli F(1,28)¼ 10.03, p¼ .004).

Discussion

This study compared the impact of photographic stimuli on self-reported state anxiety levels

in burn-injured and control participants. As expected, anxiety was higher for those with a

burn injury, an effect even more profound in those injured less than 3 years ago. Reported

anxiety for all participants significantly differed based on the type of photographic stimuli

presented, with burn-related pictures raising anxiety levels the most.

Those with a burn injury reported trait anxiety levels that were both significantly higher

than control participants and outside of the normal range of trait anxiety (as measured on

the STAI-Y). State anxiety was increased by exposure to photographs of non-burned and

burn-injured body parts in those who had received a burn injury, especially those whose

injury had occurred within three years, compared with those who had older injuries. There

are three interesting observations here. First, that viewing burn injury photographs increases

anxiety supports the notion that these may act like mirrors to the patient, reminding them of

their own disfigurement, and inducing an anxiety reaction. Second, that some level of

anxiety adjustment (decrease) occurs over time following injury. Third, that burn-injured

participants responded with anxiety to the non-burn stimuli, could imply that these

individuals respond with anxiety to stimuli that we might expected to be benign, but which

might, in fact, temporarily draw the attention of burn victim to aspects of their self-image

with which they are unhappy. The latter phenomenon may explain the interaction effect

found by analysis of variance.

The size of effect between experimental groups under the burn-stimuli condition is similar

to the effect sizes under the neutral condition (Cohen’s d of 0.98 and 1.24, respectively).

Therefore, patient anxiety levels in response to burn injury photographs could be considered

a function of the participant group rather than the experimental manipulation. A much

larger effect size was found between the groups in the neutral condition (d¼ 2.88). It would

seem that viewing photographs of non-injured body parts is considerably more anxiety

inducing for burn-injured participants, even beyond the effect seen across all conditions.

There is considerable evidence that regular exposure to slightly anxiety-provoking stimuli

can eventually reduce the power of the stimulus to so provoke (e.g., Fava et al., 2001). The

possible use of photographic stimuli to facilitate the normalization of physical disfigurement

should therefore be explored. The impact of other media types such as film or television, in

both causation of increased anxiety, and as a tool for normalization of disfigurement, may

also be worthy of future study.

Whilst there are no reasons to suppose that the patient group is unrepresentative of burn-

injured patients in general, this sample was drawn from a support group for burns patients.

As such support is repeatedly found helpful in aiding adjustment (Chedekel & Tolias, 2001;

Clarke, 1999), the sample may have been biased toward low-anxiety individuals.

Contrastingly, the sample may have been unrepresentative as those with higher anxiety

levels may be more motivated to seek help from a support group. The need for a population-

based study of burn patients is clear.

The principal conclusion from this study is that burn patients require more than medical

assistance in overcoming the trauma of suffering a burn. Whilst further research is

warranted, psychological therapists have a clear role in developing therapeutic technologies

to alleviate the generalized anxiety, the stimulus-related anxiety, and other psychological

problems encountered by burns patients.

166 N. J. Hulbert-Williams et al.

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