Prediction of Psychological Health After an Accidental Burn Mimmie Willebrand, PhD, Gerhard Andersson, PhD, and Lisa Ekselius, MD, PhD Background: Burn victims often dis- play psychological symptoms that can im- pede recovery, but knowledge about risk factors for psychopathology is limited. This study aimed to predict psychological health 3 months after burn injury from coping and trauma-related factors as- sessed early in hospitalization. Methods: For this study, 34 burn pa- tients were interviewed during hospitaliza- tion about their accident and coping. Ques- tionnaires were administered during hospitalization and 3 months after the burn including the Impact of Event Scale—Re- vised for posttraumatic stress symptoms (in- trusion, avoidance, arousal) and the Hospi- tal Anxiety and Depression Scale for mood. Results: Anxiety, depressive, and avoidant symptoms at 3 months were highly predicted by baseline levels of these symptoms and avoidant coping. The life threat at the burn event predicted intru- sive and arousal symptoms, and coping by self-control predicted less intrusive symp- toms. Burn severity was not predictive of psychological health. Conclusions: Coping style, life threat during the accident, and early symptoms are strong predictors of psychopathology after a burn. Key Words: Anxiety, Avoidance, Coping, Depression, Interview, Life threat, Trauma. J Trauma. 2004;57:367–374. B urn care has improved greatly during the past 25 years, and the focus in burn research has shifted from mor- tality to morbidity. 1 Burn injuries can cause severe long-term impairment, both physical and psychological. The extent to which psychological factors such as coping style predict the psychological outcome for burn patients is not well understood. 2 Such knowledge would be most valuable for screening purposes and for the design of more individu- alized psychological support and treatment. Psychiatric problems frequently seen in burn patients are depression and posttraumatic stress disorder (PTSD). A re- cent follow-up evaluation of depression using self-report in- struments showed that 28% of the patients were moderately depressed and 26% were severely depressed 1 month after the burn injury. 3 Posttraumatic stress disorder is characterized by a fear reaction during the trauma and subsequent intrusions, avoidance, and hyperarousal. 4 The rate of PTSD among burn victims varies between 9% and 35% at 2 to 4 months after the burn. 5 Predictors of psychopathology vary among different studies. There is no clear role for “objective factors” such as total body surface area burned, length of stay in the burn unit, location of burn, or gender, 2,6 –10 or for the predictive value of psychological symptoms during early hospitalization. 7,9,11 Some subjective experiences during the accident have been related to subsequent psychopathology. For instance, findings have shown that subjective life threat is a strong predictor of long-term psychosocial problems, in both burn victims 12 and other trauma victims. 13 Also, dissociative experiences have been related to poorer psychological outcome at discharge. 14 Dissociation entails a degree of disconnection from reality, for instance, feeling that one is in a dream, or that one is detached from one’s body during the burn accident. Both life threat and dissociation are key features of acute stress disor- der, a risk factor for later PTSD. 15 Another psychological factor is coping. Theoretically, previous traumatic experiences and the coping styles used in the past are seen as important in the development and main- tenance of PTSD generally. 16 Examples of such coping strat- egies are avoidance of reminders of the trauma and attempts to suppress or block thoughts about the event by engagement in other activities. Coping is also a factor in depression. It implies a ruminative coping style, 17 including a preoccupa- tion with negative feelings and negative appraisals of oneself and one’s experiences. Coping among burn victims has been studied in a few instances. In a prospective study using a general coping instrument, both supposedly positive and negative forms of burn-related coping predicted more symptoms of depression and PTSD 3 months after the burn. 9 Thus, it seems that different coping strategies do not affect short-term psycho- logical health in diverse ways. Conversely, use of the Coping With Burns Questionnaire 18 showed that burn-related coping strategies are related in different ways to health status and personality traits. 19 However, this coping measurement was retrospective, and the study focused on long-term outcomes. In the current study, coping was assessed with a similar approach, but the evaluation was early during hospitalization (within 2 weeks). Submitted for publication January 17, 2003. Accepted for publication May 1, 2003. Copyright © 2004 by Lippincott Williams & Wilkins, Inc. From the Departments of Neuroscience Psychiatry (M.W.), Psychology (G.A.), and Neuroscience Psychiatry (L.E.), Uppsala University Hospital, Uppsala, Sweden. Supported by the Swedish Medical Research Council (grant 14020), the Söderström-Königska Foundation, the Thuring Foundation, the Höök Foun- dation, the Nasvell Foundation, and the Vårdal Foundation. Address for reprints: Mimmie Willebrand, PhD, Department of Neu- roscience Psychiatry, Uppsala University Hospital, SE-751 85 Uppsala, Sweden; email: mimmie.willebrand@plastik.uu.se. DOI: 10.1097/01.TA.0000078697.69530.0E The Journal of TRAUMA  Injury, Infection, and Critical Care Volume 57 • Number 2 367