The Psychology of Pain and Disfigurement in Burn Patients
A summary of Dr. Mehaidat's doctoral research on the psychological effects of pain and disfigurement in burn patients — from the theory of pain and body image to a comparative study of burn patients and a control group in Jordan.
Introduction
This study emphasizes the close relationship between body and mind, through research into the psychological changes that result from burn injury.
It is worth noting that organized psychological care for burn patients began in America in 1946, when a fire broke out in an American forest, injuring hundreds of people. Psychiatric departments received many of these cases because of the severe psychological complications that followed.
Burn injuries are not an ordinary phenomenon; they are a rich subject for study and research. A person with a burn faces many problems:
- 1Beginning with the physical pain of the injury itself, in addition to the psychological conflicts and painful experiences it produces.
- 2Pain resulting from treatment procedures.
- 3The problem of disfigurement once medical treatment is complete. Disfigurement is a change in the injured person's personal appearance, and it too produces various psychological changes.
A burn injury is a serious event, because of its physical and economic complications that threaten the injured person's psychological and social adjustment. The trauma, for the injured person, is a passage into the unknown, in which their psychological structure is threatened. The result is a psychological life different from what it was before, and a social life full of problems — as if they had moved from a calm, secure life into an unfamiliar outer world, the consequences of which show throughout the stages of their life.
The Phenomenon of Pain
Pain is a complex human phenomenon with several dimensions — neurological, physiological, psychological, and social. The subject of pain was long the concern of physiologists and anatomists, and its treatment was the responsibility of neurosurgeons. In the past few years, however, these tendencies have changed: explanations of pain have begun to draw on psychological concepts, which means that psychological research and treatment methods have entered the field of pain.
Psychologists have thus turned their interests and research to this new field, and pain has come to be regarded as a clinical psychological phenomenon in addition to its medical foundations.
The psychological factor adds to the ambiguity of pain, since each individual has their own experience, shaped by their psychological life. This has made it difficult to arrive at a comprehensive, definitive definition of pain as a unit or a thing. Pain is a phenomenon that can be observed through the person's own suffering, or studied experimentally — but how can we assess it consistently every time?
Pain is therefore a psychological phenomenon that has received special attention from researchers and students of the psychological sciences, because of the reciprocal relationship it creates between mind and body. There are severe physical pains whose causes lie in psychological influences and disturbances, just as there are various psychological and behavioral troubles whose causes lie in physical pain and disorders. Psychological troubles may not be limited to the pain produced by the illness itself; they may also stem from the failure of drugs and operations to treat it. Here the individual's behavior is affected by pain, in addition to what might be called psychological pain.
Pain is a common element in all illnesses, especially chronic and serious ones such as burn injuries, various physical accidents, chronic back pain and headaches, joint pain, and so on. In a statistic published in 1976 by an American foundation for the care of joint diseases, the patient numbers were:
American foundation for the care of joint diseases, 1976
Whatever its causes, pain interacts with the individual's psychological life, and their psychological structure is affected in light of their upbringing and experiences, their past conflicts and future ambitions.
Pain then becomes a turning point in the individual's life, or a trauma that stirs repressed unconscious experiences, becoming a new pressure and burden the individual must face. It weakens motivation, increases frustration, lowers ambition, increases pessimism, and generates anxiety, depression, and more.
The Concept of Pain
The expression of pain begins from the very first moment of birth. Pain also represents an early warning for most people, or a line of defense for the human body.
Interest in pain goes back to the ancient Egyptians, who had special remedies for headaches and other pains. Aristotle regarded pain as a psychological state resulting from a physical stimulus affecting the body, while religious scholars consider pain a matter from God, to test an individual's faith or as punishment for their sins.
Pain is generally an inner sensation particular to the individual that cannot be observed; what we observe are its outward symptoms, such as verbal complaints or other signs expressing painful sensations.
Merskey defines pain as an experience associated with bodily injury that is expressed in a psychological manner, such as feelings of distress, misery, sadness, and discomfort.
The operational definition of pain for this research is the sensation and perception of a painful heat-related sensory stimulus resulting from burn injury, together with the psychological and mental effects and changes this involves in the injured person's life.
Types of Pain
- Simple painPain caused by passing everyday accidents.
- Acute painPain caused by severe physical injuries.
- Cyclical chronic painAcute but intermittent pain, such as migraine.
- Chronic painPain that is hard to relieve but is not dangerous.
- Progressive chronic painPain accompanied by other negative complications.
- Experimental painPain that can be induced by a painful heat stimulus or otherwise.
- Psychogenic painPain whose organic causes are hard to determine.
- Phantom pain (literally "false pain")Pain that occurs after amputation or resection.
Theoretical Attempts to Explain Pain
- 1Specificity theoryHolds that every organ has special receptors that perceive the nature of pain.
- 2Pattern theoryHolds that pain receptors work according to a special system by which they distinguish patterns of nerve impulses as these travel to the central nervous system.
- 3Gate control theoryConsidered among the most recent theories to attempt to explain pain. It holds that nerve mechanisms in the spinal cord act as gates that open and close to pain stimuli: if they are open, pain increases; if they are closed, pain decreases.
- 4Pain in the light of psychoanalysisIn psychoanalysis, pain appears in the form of traumatic neurosis, or psychological and physical pain. Psychoanalysis holds that psychological processes are regulated automatically according to the pleasure principle: every psychological process is a state of painful tension that finds a path toward reducing that tension, and the pleasure principle almost completely dominates life. The experience of pain has a dynamic role, leading to a drop in the psychic energy emitted from innate drives, and it may affect the formation of the superego.
- 5Pain in the light of behaviorist viewsBehaviorists regard pain as behavior that can be analyzed into its basic factors, since pain has behavioral manifestations that can be observed. In studying pain behavior, a series of factors that affect behavior must be considered, especially conditioning factors.
Pain Perception
- Mental and psychological factors relating to sensory discrimination, motivation, attention, imagination, memory, expectations, and the nature of personal need.
- Cultural and social factors.
- Religious beliefs are among the strongest factors affecting the sensation of pain.
Measuring Pain
Attempts at quantitative measurement of pain have not reached a scientific level. This is due to the absence of a fixed definition of the term "pain," and to the absence of pain stimuli that can be measured and controlled.
There are methods for measuring pain, such as:
The Phenomenon of Disfigurement
Physical disfigurement means that a change has occurred in an individual's shape in a particular body area — a change that may be hard to improve or restore to its original form, especially burn disfigurement. This disfigurement is accompanied by various psychological changes relating to self-concept, body image, and more.
An individual's outward appearance affects how others see them, which in turn affects their behavior and beliefs. Since most of the stimuli around us are visual, and we come to know the outside world in all its detail through sight, disfigurement constitutes a visual stimulus for others.
Disfigurement is visible, especially when it is on the face or hands. It evokes different attitudes in others, which in turn affect the injured person's social and personal functioning across their family, school, and work life.
Burn injuries are widespread in most societies, owing to the development of modern life and the extensive use of various forms of energy in different areas of life. Globally, one statistic from American institutes in 1979 states that:
American institutes, 1979
As for statistics at the level of the Arab world, it proved impossible to obtain any. Local statistics in Jordan were imprecise; figures were obtained only for injured people who stayed in hospital for more than three months. The number of injured was about:
Problems Resulting from Burns
- Physical problemsRelating to the nature of the injury and the pain and disfigurement it caused.
- Social problemsRelating at first to the nature of treatment and medical isolation, and to problems of disfigurement, where family disputes and feelings of rejection arise, or divorce, or reluctance to marry; and problems relating to social attitudes toward the injured person.
- Economic problemsRelating to treatment costs and the material losses resulting from the injury, and then to problems connected with work circumstances.
The Concept of Disfigurement
In this research, the concept of disfigurement relates to disfigurement specific to burn patients. The study examines the psychological responses and psychological structure in response to this sudden event in the injured person's life — an event that struck the human body, the body that is the axis of the injured person's life. What psychological changes result from physical changes? And how does the injured person respond to them in light of their new body image?
Disfigurement is a permanent psychological and physical disability for the injured person. It becomes a source of frustration and a field for the accumulation of painful experiences, leaving various psychological effects and affecting the injured person's thinking, so that they live in conflict among many issues and problems.
Operational Definition of Disfigurement
Disfigurement is a change in an individual's physical appearance due to exposure to a particular heat source, taking forms and colors foreign to the usual bodily makeup — such as protrusions and skin eruptions, or the formation of hardened skin layers in varied colors: black, white, or orange.
Key Terms Related to Disfigurement
- Burn injuryInjury to the skin or the tissues beneath it from exposure to an intense heat source, such as direct flame, hot liquids, electricity, or chemicals.
- Skin graftingSurgical operations aimed at covering injured areas of skin with healthy skin layers taken from the injured person's own body.
- Cosmetic surgerySurgical operations performed several times, at intervals after the grafting operations, in order to improve the outward appearance of the injured area.
- Body imageThe sum of subjective experiences of our feelings and attitudes toward our bodies, and the organization of these experiences. Undoubtedly, the change a burn injury produces will change the injured person's perception of body image and self-concept, as well as produce emotional disturbances that vary in degree from one individual to another.
Degrees of Disfigurement
- Slight disfigurementDoes not attract the attention of others.
- Moderate disfigurementCan be noticed.
- Marked disfigurementEvokes emotional responses in others, such as sympathy or disgust.
- Severe disfigurementShocks others and generates various positive and negative feelings in them.
Degrees of Burns
- First-degree burnsSuperficial burns affecting the outer layer of the skin.
- Second-degree burnsDeeper, affecting the middle layer of the skin.
- Third-degree burnsDeeper than second-degree burns.
- Fourth-degree burnsThe burn occurs in the internal tissues and muscles and may reach the bone.
Causes of Burn Injuries
- Exposure to direct flameSuch as the explosion of a kerosene stove, gas, and so on.
- Exposure to hot liquidsSuch as hot water, tea, or any other liquids.
- Exposure to caustic chemicals.
- Exposure to electric current.
Burn Injury, Pain, and Psychological Trauma
Burn injuries have many complications for the body's systems, such as the respiratory, digestive, and renal systems, among others.
As for the experience of pain, the injured person is exposed to the pain resulting directly from the burn, and then to the treatment procedures: painful daily baths and surgical grafting operations. The pain is twofold — pain from the area from which a layer of healthy skin was taken, and from the area covered with the new skin layer. Then follow very painful therapeutic exercises, until the wounds heal and the movement of the joints and muscles returns to normal.
A burn injury and the disfigurement that results from it is a sudden and serious event that may cause psychological trauma, varying in severity from one individual to another. Freud wrote in several works about the trauma that may arise from serious accidents and disasters. He states that trauma results from stimuli from the external world, which disrupt the working of psychic energy, temporarily suspend the pleasure principle, and may lead to some psychological disorders and problems.
Psychoanalysis has shown that fevers and painful illnesses, while they last, have a great effect on the distribution of libido. Trauma, through the mechanical violence it causes, releases on the one hand a quantity of sexual excitation that has the impact of a shock because of the lack of readiness to meet dread. The accompanying bodily injury, on the other hand, restricts this excess of excitation through the increase in narcissistic charge that the injured organ requires.
A person afflicted with a serious illness centers their interest on their body and devotes themselves to thinking about the self and fearing for it, and to all forms of self-centeredness. The injured person suffers a conflict grounded in the difference between self-love and love of others. Freud held that libido is gathered entirely in the self, and that self-love is the origin of all other kinds of love. If this libido is directed outward, it is called object love, but this external love can retreat to the self again, as happens in cases of illness or following a serious accident.
Previous Studies
Hamza holds that any circumstances that set a person apart from their environment — such as marked differences in their physical makeup or appearance — have a clear effect on the development of their personality and on its deviation from the norm.
On the injured person's idea of themselves, Hamza states that each of us forms a mental image of our physical state, whether stout or thin, tall or short. This image is of great importance in forming personality, since it forms the person's idea of themselves, and their behavior is affected accordingly.
The injured person's problem is not the injury alone and the thoughts about themselves that it will produce; there is a long personal history that cannot be ignored. Ruth states that an injury occurring to a person late in life is a sudden event requiring new ways of adjustment, unlike cases where the injury occurs early.
Studies on Psychological Factors That Cause Pain
- In a study by Torring & Draber of fifteen migraine patients, their emotional state was found not to be sufficiently mature.
- Fromm and Reichmann treated eight migraine cases by psychoanalysis, and the analysis revealed that all of them had unconsciously repressed hatred.
- In a survey study by Abu al-Nil on psychosomatic disorders among a number of patients in two Egyptian industrial companies, these patients were found to be absent more often and to leave work without official permission, which points to emotional immaturity.
From the above it is clear that some headache pain stems from psychological causes such as anxiety, guilt, loss of protection and lack of a sense of security, repressed hatred, or general maladjustment.
Studies on the Psychological Effects of Pain
- Charles conducted a study classifying the psychological responses resulting from pain, using the Multiphasic Personality Inventory. The results showed elevated patient scores on the hypochondriasis, depression, and hysteria scales.
- In Wood Forde's study, the organic illness group was found to have scored high on fears and obsessions, while the psychogenic pain group and the neurotics scored high on neuroticism and depression.
Studies on Burn Patients
- Dahinterova reported on the use of hypnosis in eight burn cases to help relieve the pain sensation resulting from the burn injury, and states that it succeeded in only three cases.
- In Fagerhangh's study on identifying ways of expressing pain, it was found that the sensation of pain is affected by psychological support, that providing patients with psychological ways of coping with pain reduces their use of analgesic medication, and that patients need anti-anxiety treatment more than analgesics.
- In studies on the causes of burn injury, Crikelair et al. found that the adults most prone to burn injury are alcohol and drug abusers, or those with psychological or mental disorders.
- Macleod observed that 22% of (723) burn cases had predisposing factors for accidents.
- Jessell et al. conducted a study on the relationship between a person's life stresses prior to the injury and burn accidents. Patients reported that in the first year preceding the injury, they experienced psychological, social, and economic stress.
- Noyes observed several psychological responses in his study of (11) burn cases, finding that they had symptoms of regression, diminished interests, self-centeredness, hypochondriasis, and an inability to tolerate feelings of frustration, and that they depended on others.
- Pavlovsky found that women with burns showed more depressive symptoms than men.
- In a study by Cooper et al., burn patients were found to be greatly affected by the way others respond to them.
- Other studies have shown that body image is affected by several factors, such as the nature of the accident and the nature of the injury — whether visible or not — as well as the injured person's chronological age: children and adolescents showed more disturbance in body image than adults. Gender is another factor, as women showed lower self-esteem than men.
From the studies presented, we note that pain causes disturbance in perceptual, emotional, and behavioral processes, and that this disturbance depends on the nature of the pain, its duration, and the individual's particular personal circumstances. The studies on burn injuries also showed the various changes the injury produces in an individual's psychological life.
Study Hypotheses
The study attempts to verify the following hypotheses:
- 1There are statistically significant differences in mental abilities between the experimental sample (burn-injured males and females) and the control group of males and females.
- 2There are statistically significant differences in mental health between the experimental sample (burn-injured males and females) and the control group of males and females.
- 3There are statistically significant differences in personality characteristics between the experimental sample (burn-injured males and females) and the control group of males and females.
Study Procedures
The study was conducted in the Jordanian environment. The experimental samples were selected from the Farah Rehabilitation Center in Amman, and the samples were made up as follows:
The samples were selected under specific conditions, such as:
- The injured person had not been exposed to previous serious accidents.
- The injured person had not consulted a psychological clinic.
- The injury was not the result of a suicide attempt.
The samples were selected in light of the variables of age, gender, and marital status, and within the variable of socioeconomic level. No statistically significant differences appeared between the groups.
For the experimental group, individuals were selected according to the percentage of injury, the degree of injury, and the causes of injury.
Study Instruments
- Primary Mental Abilities testIncludes verbal ability and spatial perception ability. The test has high reliability and validity.
- Mental health scaleIncludes several scales such as fear and inadequacy, fear for health, nervousness and anxiety, depression, hypochondriasis, and others. The test has high reliability and validity coefficients.
- Group projective personality testMeasures several aspects such as happiness, weakness of will, neurotic nurturance, withdrawal, help-seeking, and belonging. The test has high reliability and validity coefficients.
- InterviewAims to learn the extent of the injured person's acceptance of their injury, the family's acceptance of them, the injured person's perception of their injury, and their outlook on the future.
- Thematic Apperception TestThis test helps reveal an individual's psychological motives, types of conflict, and repressed tendencies. Several cards were selected — (18BM), (17BM), (16), (15), (12M), (12F), (8GF), (8BM), (3BM), (2), (1) — and the content of the participants' responses was analyzed using Bellak's method and according to the theoretical framework of the study.
Study Steps
- 1The experimental research sample was identified from the center mentioned above.
- 2The sample of normal males and females was selected according to the variables in the experimental group.
- 3A form on socioeconomic level was administered.
- 4The study instruments were applied.
- 5The tests were scored and the necessary statistical analyses were carried out, such as calculating means and standard deviations and the significance of differences.
- 6An in-depth psychological study was carried out using the psychological interview and the Thematic Apperception Test on eight cases from the experimental sample.
- 7The study instruments were applied to the research groups between February 1988 and November 1988.
Results of the Psychometric Study
Results for the Hypothesis on Mental Abilities
- Comparing males in the control group with burn-injured males inside the hospital, the spatial perception test was the only subtest that distinguished between the two groups, at the 0.05 significance level, in favor of the control group.
- Comparing males in the control group with burn-injured males outside the hospital, the spatial perception test distinguished between the two groups at the 0.05 level, in favor of the control group.
- Within the experimental group of males, the spatial perception test distinguished at the 0.05 level, in favor of the experimental group outside the hospital.
- Comparing females in the control group with burn-injured females inside the hospital, the spatial perception test distinguished between the two groups at the 0.01 level, and the difference was in favor of the control group.
- Comparing females in the control group with injured females outside the hospital, there were statistically significant differences between the two groups in the spatial perception test and the total score at the 0.01 level.
- Comparing injured males and females inside the hospital, no statistically significant differences appeared between the two groups on the mental abilities test.
- Comparing injured males and females outside the hospital, statistically significant differences appeared between the two groups in verbal ability, spatial perception, numerical ability, and the total score, at the 0.001, 0.01, and 0.05 levels respectively. All the differences were in favor of the males.
Results for the Hypothesis on Mental Health
- Comparing males in the control group with burn-injured males inside the hospital, statistically significant differences appeared at the 0.05 level on the depression, nervousness and anxiety, and fear for health scales. The differences were in favor of the control group, in terms of its lower mean scores compared with the scores of the experimental group.
- Comparing males in the control group with burn-injured males outside the hospital, statistically significant differences appeared at the 0.05 level on the adequacy and fear for health scales, and at the 0.01 level on the depression scale and the respiratory and circulatory symptoms scales. All the differences were in favor of the control group.
- Within the experimental group of males, no statistically significant differences appeared.
- Comparing females in the control group with injured females inside the hospital, statistically significant differences appeared at the 0.05 level on the psychosomatic scale, in favor of the control group.
- Comparing females in the control group with injured females outside the hospital, a statistically significant difference at the 0.05 level was found on the scales of depression, nervousness and anxiety, fear for health, gastrointestinal symptoms, psychosomatic disorders, fear and inadequacy, and sensitivity and suspicion. All the differences were in favor of the control group.
- Within the experimental group of females, statistically significant differences were found at the 0.05 level on the scales of panic, fear for health, and psychopathy, and at the 0.01 level on the scales of fear and inadequacy, depression, nervousness, psychosomatic disorders, and the total score. The differences were in favor of the injured females inside the hospital.
- Comparing injured males and females inside the hospital, statistically significant differences appeared at the 0.05 level on the psychosomatic scale and at the 0.01 level on nervousness and anxiety and on psychopathy. The differences were in favor of the females.
- Comparing injured males and females outside the hospital, statistically significant differences appeared at the 0.05 level on the depression and panic scales and on sensitivity and suspicion. The differences were in favor of the males.
Results for the Hypothesis on Personality Characteristics
- Comparing males in the control group with injured males inside the hospital, no statistically significant differences appeared.
- Comparing males in the control group with injured males outside the hospital, no statistically significant differences appeared.
- Within the experimental group of males, statistically significant differences appeared at the 0.05 level on the belonging scale, in favor of the injured inside the hospital.
- Comparing females in the control group with injured females inside the hospital, statistically significant differences appeared at the 0.05 level in the total score, in favor of the control group.
- Comparing females in the control group with injured females outside the hospital, statistically significant differences appeared at the 0.05 level on the tension-reduction coefficient and on help-seeking, and at the 0.01 level in the total score. The differences were in favor of the control group.
- Within the experimental group of females, statistically significant differences appeared at the 0.05 level on the help-seeking scale, in favor of the injured females inside the hospital.
- Comparing injured males and females inside the hospital, statistically significant differences appeared at the 0.01 level on the tension-reduction coefficient and the total score, and at the 0.05 level on the belonging scale. The differences were in favor of the males.
- Comparing injured males and females outside the hospital, statistically significant differences appeared at the 0.01 level on the tension-reduction coefficient, and at the 0.05 level on help-seeking and the total score. The differences were in favor of the males.
This is a summary of a doctoral dissertation submitted to Ain Shams University in Cairo in 1990. The research was awarded the grade of Excellent with Honors. Those who wish to read the full study may consult the Graduate Studies Library at Ain Shams University, as well as the library of the University of Jordan.