Investigating the phenomenology of imagery following traumatic burn injuries

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Investigating the phenomenology of imagery following traumatic burn injuries Elaine Sara Cockerham a,*, Soljana C¸ili b,1, Lusia Stopa b a b

Salisbury Foundation NHS Trust, Odstock Road, Salisbury SP2 8BJ, United Kingdom University of Southampton, Highfield, Southampton SO17 1BJ, United Kingdom

article info

abstract

Article history:

Intrusive images related to adverse experiences are an important feature of a number of

Accepted 18 February 2016

psychological disorders and a hallmark symptom of posttraumatic stress disorder (PTSD). Depression, anxiety, and PTSD are all common reactions following a burn injury. However,

Keywords:

the nature of burn-related trauma memories and associated intrusions and their contribu-

Imagery

tion to psychological disorders is not well understood. The aim of the study was to take a

Intrusions

broad look at the nature of imagery experienced by people who have sustained a burn injury.

Trauma

Nineteen participants completed self-report questionnaires assessing depression, anxiety,

Anxiety

and PTSD symptoms and were administered a semi-structured interview which explored

Depression

the characteristics (vividness, sensory modalities, intrusions, emotion intensity) of imagery

Burn injuries

formed in relation to their burn injuries. Ongoing intrusive imagery was reported by over half the participants and there were significant correlations between frequency of intrusive images and posttraumatic symptoms, and between intensity of emotions associated with intrusive images and depression and posttraumatic symptoms. A thematic analysis of the memory narratives revealed four main themes: threat to self, view of the world, view of others, and positive psychological change. These results are discussed in relation to existing trauma theory and burn injury literature. Implications for clinical practice and recommendations for further research are proposed. # 2016 Elsevier Ltd and ISBI. All rights reserved.

1.

Introduction

Burn injuries may be followed by a painful rehabilitation, functional limitations, disfigurement and body image issues, work and financial problems, lifestyle changes, sexual problems, mixed or negative reactions from others, and loss of interpersonal relationships [1–9]. Despite these challenges, many burn survivors experience posttraumatic growth (PTG) [10] following their injury, reporting personal growth and

transformation (e.g., becoming more resourceful, resilient, and religious/spiritual), taking up new interests, defining themselves in a more meaningful way, and developing new outlooks [2,4,9,11,12]. A significant proportion of burn survivors, however, experience psychological disorders. Palmu et al. [13] found that 55.4% of their sample had experienced an Axis I disorder in the 6 months following their injury. Assessing survivors 1–4 years (average 2.2 years) post-injury, Ter Smitten et al. [14] found that, in the year prior to data collection, 27.8% had at least one Axis I disorder that had developed after the injury.

* Corresponding author. Tel.: +44 1983 201145; fax: +44 23 8059 2588. E-mail addresses: [email protected] (E.S. Cockerham), [email protected] (S. C¸ili), [email protected] (L. Stopa). 1

London College of Fashion, University of the Arts London, 20 John Prince’s Street, London W1G 0BJ, United Kingdom. http://dx.doi.org/10.1016/j.burns.2016.02.018 0305-4179/# 2016 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: Cockerham ES, et al. Investigating the phenomenology of imagery following traumatic burn injuries. Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.02.018

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The most prevalent disorders among burn survivors are anxiety and mood disorders, particularly posttraumatic stress disorder (PTSD) and depression (e.g. [8,13,14]). A review of the literature by Van Loey and Van Son [8] reports a prevalence of 13–23% for depression and 13–45% for PTSD 1 year following the injury. More recent studies report a 1–4-year post-burn prevalence of 10–16% for depression or depression symptoms (e.g. [14–16]) and 7–29% for PTSD or posttraumatic symptoms (e.g. [14,15,17]). The discrepancies in prevalence estimates among the different studies are partly due to the fact that many studies in the area suffer from methodological issues such as small sample sizes and high attrition rates. In addition, the different methods used to assess psychopathology (questionnaires and structured diagnostic interviews) tend to yield different prevalence estimates [13]. Nevertheless, findings are consistent in indicating that some burn survivors are at risk of developing at least one Axis I psychological disorder and that they are more likely to do so than the general population [8,13,14]. To date, research has identified a series of factors that may put burn survivors at risk of psychopathology. The evidence on the role of injury characteristics such as total body surface area (TBSA) affected is inconsistent, with some studies (e.g. [13,18]) finding that this role is significant and others (e.g. [14,19]) failing to do so. The evidence on other risk factors, on the other hand, is relatively more consistent. For example, risk factors for the development of depression and PTSD include psychiatric history, burn visibility, patients’ perceptions (e.g., perceived threat to life), peri-traumatic anxiety and dissociation, maladaptive coping styles (e.g., avoidant coping), perceived lack of social support, and blaming others for the injury (e.g. [5,8,19–21]). Peri-traumatic anxiety and dissociation, in particular, may play an important role in the onset of psychological disorders because of their influence on the processing of the burn trauma and development of intrusive mental images. Mental images are cognitive representations which contain sensory qualities despite arising in the absence of external sensory input [22]. A growing body of research (see [23,24]) suggests that intrusive (involuntary) mental images are an important feature of several psychological disorders, including depression [25], PTSD [26,27], agoraphobia [28], and social phobia [29]. These images tend to be recurrent, vivid, and associated with negative emotions such as fear, helplessness, anger, guilt, anxiety, and shame (see [24]). They often relate to memories of adverse experiences and to negative core beliefs about the self, other people, and the world that may have been formed as a result of those experiences (e.g. [28,30]). Images are frequently triggered by stimuli that activate trauma memories (see [24]). In PTSD, recurrent, involuntary, and intrusive recollections of the traumatic experience that include sensory, emotional, or physiological behavioural components are one of the key diagnostic criteria [31]. PTSD intrusions often consist of brief sensory fragments of the trauma that can lead to reliving the trauma as if it is happening currently [27,32]. On some occasions, they are related to the worst moments of the trauma, during which individuals experienced cognitions revolving around two main themes: threat to one’s physical integrity (e.g., injury, death) and threat to one’s sense of self

(e.g., blame, abandonment) [26]. At other times, intrusive images in PTSD are related to the moment when events in the trauma suddenly got worse. In these cases, intrusions become warning signals that indicate impending danger if encountered again [32]. In depression, intrusive images are often related to past experiences such as one’s own or significant others’ illness or injury, threatened or actual assault, and interpersonal problems [25]. Partly because of their link with negative beliefs and their emotional impact, intrusive mental images may contribute both to the development and to the maintenance of psychological disorders [24]. For many patients with social phobia, for example, the symptoms appeared or became more intense after the adverse event associated with the intrusions [33]. Intrusions are also frequently accompanied by negative emotional and/or behavioural responses that help maintain symptoms. For example, in PTSD intrusive images may contribute to a sense of impending threat and to the use of maladaptive coping strategies such as avoidance [34]. In depression, images may trigger associated negative beliefs and negatively impact on patients’ mood [25]. In each of these cases, the experience of the intrusions may prevent patients from disconfirming and updating the negative meanings they have attached to the adverse experience (e.g., ‘‘I am a failure’’) and from modifying their behaviour (e.g., avoidance). Despite the occurrence of psychological disorders among burn survivors and the fact that burn injuries may result from life-threatening traumatic experiences, to date little is known about how the memories of these experiences and associated mental images contribute to disorder onset and maintenance. Quantitative studies (e.g. [18,35]) have found that burn patients report recurrent intrusive memories of, and flashbacks related to, their burn injury during hospitalisation. Qualitative studies (e.g. [7,9]) suggest that some burn survivors can have vivid memories of the scene of the accident and subsequent hospitalisation, associated flashbacks, and associated negative emotions several years after their accident. The development of these vivid memories and intrusions may be partly related to dissociation, which is a frequent response during a burn accident and has been found to develop as a result of peri-traumatic anxiety and to be related to symptomatology (e.g., anxiety, depressive symptoms) upon discharge from hospital [36]. Peri-traumatic anxiety and dissociation have also predicted posttraumatic symptoms in burn survivors 1 year following the injury [37], whereas intrusive symptoms at the time of discharge from hospital have been found to predict such symptoms 4 months later [38]. These findings are in line with the cognitive model of PTSD [34], which postulates that peri-traumatic factors such as strong emotions and dissociation may prevent adequate processing of the traumatic experience, leading to a failure to integrate the trauma memory into the individual’s more general autobiographical memory store and resulting in the development of trauma-related intrusions. Whereas peritraumatic factors contribute to intrusion development, factors such as burn scars may contribute to their persistence by acting as trauma reminders [3,39,40]. While the involvement of trauma-related intrusions in psychopathology in general is becoming increasingly clearer,

Please cite this article in press as: Cockerham ES, et al. Investigating the phenomenology of imagery following traumatic burn injuries. Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.02.018

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their nature and influence on burn survivors is yet to be understood in detail. Most studies to date (e.g. [18,35]) have assessed intrusions primarily through checklists or questionnaires such as the Impact of Event Scale [41] and Impact of Event Scale-Revised [42]. In addition, the only study that to our knowledge has explored patients’ memories of the burn accident and its aftermath in detail [7] is a qualitative study that focused primarily on the memories of pain and did not assess objectively the characteristics of these memories or patients’ psychological well-being at the time of data collection. Given the role that memories of the accident and associated intrusions may play in the maintenance of psychological disorders, an objective and deeper understanding may help us identify the mechanisms responsible for the continued psychological distress in burn survivors and enhance the psychological support they receive. The present study aimed to investigate and explore burn survivors’ memories of the accident leading to their injury, any associated intrusive images, and potential relationships between these images and participants’ psychological distress (specifically, symptoms of PTSD, depression, and anxiety) at the time of data collection. We used a mixed-methods design, relying on a semi-structured interview to assess the characteristics of the accident memory and associated intrusions and on standardised questionnaires to assess participants’ psychological distress. We analysed the data with both qualitative and quantitative methods. We hypothesized that vividness of the burn-injury memory, frequency of intrusive images, intensity of emotions associated with intrusive images, and intensity of emotions experienced at the time of injury would all correlate positively with psychological distress.

2.

Method

2.1.

Participants

Burn survivors who had received treatment for burn injuries at a UK National Health Service burns unit that deals with injuries covering less than 40% TBSA were invited to take part in the study. Patients who were still attending the burn outpatient clinic were approached by staff members, whereas individuals who were no longer attending this clinic were contacted by post by the burn care team who had access to the unit’s database. In each case, burn survivors were provided with an information sheet describing the study, a reply slip in which they could indicate their interest in the study and provide their contact details, and a pre-paid return envelope addressed to the research team at the University of Southampton. Individuals who expressed an interest in the study were then contacted by the researchers via phone or email, depending on the contact details they had provided. If they agreed to participate, arrangements were made for them to attend a data collection session. Exclusion criteria included age <18 years, self-inflicted injury, and a TBSA greater than 40%. Ethical approval for the study was granted by the ethics committee of the School of Psychology at the University of Southampton and by the UK National Research Ethics Service. Of the 238 burn survivors approached, 26 responded to invitations to partake in the study. Five did not follow up on

3

attending data collection. The remaining 21 participants attended a data collection session and provided written informed consent in the period June–September 2011. However, one dataset was incomplete and one participant was excluded as they had deliberately caused their injuries. The final sample comprised 19 participants (8 females and 11 males), whose ages ranged from 32 to 84 years (M = 55.47 years, SD = 14.93). The time elapsed since the injury had occurred ranged between 5 and 36 months (M = 20.22 months, SD = 7.20) and none of the participants was attending the outpatient clinic at the time of data collection. Seven participants obtained their injuries as the result of a flash burn (e.g., gas explosion), five through a flame burn (e.g., house fire), four through a scald (e.g., hot liquid), two from a contact burn (e.g., radiator), and one through an electrical burn (rail line).

2.2.

Measures

We used the following questionnaires to measure PTSD symptoms, depression, and anxiety. The Impact of Event Scale-Revised (IES-R) [42] is a 22-item selfreport standardised questionnaire that measures posttraumatic symptoms after exposure to a traumatic stressor. The measure comprises three subscales which tap into intrusive reexperiencing, avoidance, and hyperarousal. In the present study, participants rated the impact of the event that caused their burn injuries in the week prior to data collection on a scale from 0 (not at all) to 4 (extremely). Total and individual subscale scores were calculated by taking the mean of the respective items, therefore the maximum mean score on each subscale and the maximum total mean IES-R score was 4. Reliability and good internal consistency for all subscales have been reported [43]. In the present study, the internal consistency of the scale and all subscales was excellent (IES-R total: a = .95; Intrusions: a = .93; Avoidance: a = .86; Hyperarousal: a = .91). The Posttraumatic Diagnostic Scale (PDS) [44] is a 49-item scale we used to determine whether participants met PTSD criteria. Participants first reported whether they had experienced a number of traumatic events (e.g., serious accident, fire, or explosion). After indicating the event that bothered them the most, they then rated on a scale from 0 (never) to 3 (5 times per week or more/almost always) how often they were bothered by PTSD symptoms related to this event in the past month and indicated whether these symptoms had interfered with various areas of their life. The PDS has good internal consistency, test–retest reliability, and validity [44]. The Beck Depression Inventory-II (BDI-II) [45] is a 21-item selfreport standardised questionnaire that assesses the severity of depression symptoms. Participants rated on a scale of 0–3 the extent to which they had experienced symptoms such as sadness and irritability over the last 14 days. The ratings for the individual items were summed. The total score ranged from 0 to 63 and was categorised as minimal (0–9), mild (10–18), moderate (19–29), or severe (30–63). The BDI-II has good psychometric properties and is regularly used in clinical practice to assess depressive symptoms. In the present study, excellent internal consistency was found (Cronbach’s a = .97). The Beck Anxiety Inventory (BAI) [46] is a 21-item self-report standardised questionnaire used to assess the severity of anxiety symptoms such as nervousness and difficulty in

Please cite this article in press as: Cockerham ES, et al. Investigating the phenomenology of imagery following traumatic burn injuries. Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.02.018

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breathing. Participants indicated on a scale from 0 (not at all) to 3 (severely) the extent to which they had been bothered by these symptoms in the past month. Individual scores were summed to obtain a total score which could range from 0 to 63. Anxiety was classified as minimal (0–9), mild (10–18), moderate (19–29), or severe (30–63). The BAI is psychometrically sound. Internal consistency ranges from .92 to .94 and test– retest (1-week interval) reliability is .75 [46]. In this study, good internal consistency was found (Cronbach’s a = .97).

2.3.

Interview

A semi-structured interview adapted from Hackmann et al. [33] assessed the nature of imagery formed in relation to participants’ burn injuries. Participants were first provided with a description of mental images as pictures, smells, sounds, and sensations that are experienced in one’s mind but are not physically present. They were then asked to think back to the time the accident occurred and to describe it in as much detail as possible. They described, for example, where the accident happened, who else was present, what sensory perceptions (e.g., pictures, sounds, smells) and physical sensations they experienced at the time, what emotions they experienced and what thoughts were going through their mind, and what the worst moment of the experience was. Participants rated the vividness of the memory and associated images on a scale from 0 (not at all vivid) to 10 (extremely vivid). They also rated the intensity of the emotions they experienced as the accident was taking place on a scale from 0 (not at all intense) to 10 (extremely intense). Participants indicated whether they had experienced any accident-related intrusive images since this accident occurred, when and how often they experienced them, and how intense the emotions experienced when the images came to mind were. Finally, participants were asked about how they viewed the self, world, and others in relation to the images formed from their burn injury experience. Interviews lasted between 32 and 69 min (M = 51.84) and were audio-recorded.

2.4.

Procedure

At the beginning of the data collection session, participants provided written informed consent. They then completed the BDI-II, BAI, IES-R, and PDS. Finally, participants were administered the semi-structured interview that explored their memory of the burn injury and associated intrusive images. At the end of the session, participants were debriefed about the purpose of the study and informed about resources they could use to obtain psychological support if necessary.

2.5.

We analysed participants’ narratives using thematic analysis [47]. We focused on the memory for the burn trauma and imagery in relation to the meaning drawn from individual experiences, including the occurrence of ongoing intrusive imagery. Interviews were transcribed and then read several times to enhance familiarization with the data. Initial codes were then identified and organised and combined into meaningful groups or discarded. These initial themes were then reviewed and defined, and labelled. Interpretations were made in relation to existing trauma theories.

Data analysis

The quantitative data (memory and image characteristics, emotion intensity, questionnaire results) were analysed using SPSS 21.0. Descriptive statistics for each variable were obtained. Pearson’s correlations were also obtained for the relationship between the characteristics of the memory (vividness, intensity of peri-traumatic emotions) and intrusive images (frequency, intensity of emotion elicited) and psychological distress (BDI-II, BAI, IES-R scores). The level of statistical significance was set at .05.

3.

Results

3.1.

Memory characteristics

Examples of memories reported by participants included dropping a kettle with hot water or a mug with a hot drink, being trapped inside a house/room that caught fire, and having a leg trapped under the hot exhaust pipe of a motorbike. These memories were associated with very vivid images. The mean image vividness rating was 8.36 (SD = 2.24). Twelve participants (63%) reported their memory as having visual components (e.g., seeing flames, a bright ball of light, smoke, skin peeling off). Five (26.3%) reported auditory components (e.g., others screaming, whooshing of flames, a bang). Eight (42.1%) reported olfactory components (e.g., burning flesh, gas) and all participants (100%) reported somatosensory components (e.g., pain, skin stretching, heat). Eight participants (42.1%) recalled memories containing four different sensory modalities. The mean number of sensory modalities recalled was 2.89 (SD = 1.15), ranging from 1 to 4.

3.2.

Peri-traumatic emotions and thoughts

Participants reported experiencing a range of emotions at the time of injury. All 19 participants (100%) reported experiencing shock. The second most commonly reported emotion was fear, recalled by 13 participants (68.4%). Eleven participants reported disbelief (57.9%), five participants reported a sense of helplessness (26.3%), and two participants reported a sense of horror (10.5%). A composite measure for the intensity of the peri-traumatic emotions was obtained by adding the intensity ratings participants provided for each emotion and dividing the total by the number of emotions they reported. The mean intensity of these emotions was 8.16 (SD = 1.87), ranging from 2.63 to 10. Seven participants (36.8%) reported making the appraisal that they could die at the time of their injury. Other thoughts experienced at this time included ‘‘This can’t be happening to me,’’ ‘‘I have to put this fire out,’’ and ‘‘How can one be so daft?’’ Participants also reported worrying about the consequences of the burn injuries, such as the reactions of their family on learning about the accident and being permanently disfigured.

3.3.

Intrusive re-experiencing

Eleven (57.9%) participants reported continuing intrusive imagery related to their burn accident during the semistructured interview. The mean frequency of intrusions per

Please cite this article in press as: Cockerham ES, et al. Investigating the phenomenology of imagery following traumatic burn injuries. Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.02.018

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Table 1 – Means, ranges, and standard deviations for scores on self-report measures.

BDI-II BAI IES-avoidance IES-intrusions IES-hyperarousal IES-total score

N

Minimum

Maximum

Mean

19 19 19 19 19 19

0.00 0.00 0.00 0.00 0.00 0.00

54.00 48.00 2.75 3.71 2.86 8.82

9.16 7.42 0.82 1.03 0.62 2.47

12.86 10.76 0.89 1.08 0.94 2.77

Psychological well-being

The means, ranges, and standard deviations for the self-report measures of psychological distress are shown in Table 1. Overall, participants reported low depression and anxiety scores, as well as hyperarousal and avoidance symptoms. Thirteen participants (68.4%) reported minimal depression, four participants (21.1%) reported mild depression, one participant (5.3%) reported moderate depression, and one participant (5.3%) reported severe depression. Fifteen participants (78.9%) reported minimal anxiety, three participants (15.8%) reported mild anxiety, and one participant (5.3%) reported severe anxiety. Three participants (15.8%) met criteria for PTSD according to the PDS.

3.5.

emotions triggered by the intrusions, the more severe the participants’ depression and posttraumatic symptoms.

SD

month was 9.63 (SD = 17.73), ranging from 0 to 60. Triggers for the intrusions included seeing the burn scars, hearing the whooshing sound from the barbecue, and feeling heat coming from cookers or radiators. Common emotions experienced when the intrusions came to mind were panic, sadness, helplessness, disappointment, and anxiety. The mean intensity of emotions associated with intrusive images was 4.04 (SD = 3.82), ranging from 0 to 10. Participants’ average intrusive symptoms, as reported in the IES-R, are presented in Table 1.

3.4.

5

Correlational analyses

There were no significant correlations between participants’ mean ratings of intensity of emotion at the time of injury and scores of psychological distress as measured on the BDI-II, BAI, and IES-R. However, there were significant correlations between the frequency of current intrusions and posttraumatic symptoms as measured by the IES-R avoidance subscale, r = .68, p = .001, and the IES-R total score, r = .47, p = .04. Participants who reported experiencing the burnrelated intrusions more frequently also reported greater avoidance and overall posttraumatic symptoms on the IES-R. The correlations between participants’ ratings of the vividness of their burn memory and associated images and scores of psychological distress as measured on the BDI-II, BAI, and IES-R were not significant. However, there were significant correlations between the intensity of the emotions experienced during the activation of intrusive imagery and scores of depression as measured by the BDI-II, r = .53, p = .02, and posttraumatic symptoms as measured on the IES-R avoidance subscale, r = .67, p = .002; the IES-R intrusions subscale, r = .72, p < .001; the IES-R hyperarousal subscale, r = .61, p = .006; and the IES-R total score, r = .70, p = .001. The more intense the

3.6.

Qualitative data

All participants could recall their burn injury clearly. The overriding theme described by all participants that emerged from the narratives of their burn accident involved a sudden and unexpected threat to their physical integrity associated with an experience of pain. It was just a normal day. . .. then all of a sudden a flash and pain. . . I knew I was in trouble. (Participant 1) It was a birthday party, people having fun. . . then quick as a flash my skirt went up in flames. . . the pain was really really intense. . . and I was desperate, rolling around the floor. (Participant 7) My phone rang. I answered it. Next thing, I don’t know what happened. A bang. . . a flash and that was it. It was just so fast. I was on the floor. I didn’t know if I was dead, and then oh yeah the pain. (Participant 10) The strength of the images associated with the memory of the burn accident appears relevant to the meaning drawn from this accident. Four major themes emerged from the thematic analysis: threat to self, view of the world, view of others, and positive psychological changes. Several subthemes also emerged. These themes and subthemes are presented below. Theme 1: Threat to self. Within the main threat to self theme, three sub-themes emerged. Participants described blaming themselves for their injuries (self-blame), being more vulnerable (vulnerable self), and an altered sense of physical self (altered physical self). Self-blame. Ten participants (52.6%) blamed themselves for their injury. They tended to describe themselves as stupid when they felt they were to blame. Often, however, self-blame was associated with the ability to protect the self from future harm. Of course I know I shouldn’t put petrol on a bonfire. I was so stupid, but I won’t be doing that again. (Participant 13) I was drunk. We were all messing about. It happened because I was cocky and stupid. . . put your head in an oven and you’re asking for trouble. I think more now. (Participant 7) Of course it caught fire. What a stupid thing to do. . . I still enjoy cooking. . . I really do know better than that. (Participant 8) Vulnerable self. Eight participants (42.1%) described a sense of being vulnerable. The shocking and sudden nature of how an ordinary day/event can become traumatic, the realisation of how serious the event could have been and of how significant the burn injury was, made participants more aware of their physical vulnerability.

Please cite this article in press as: Cockerham ES, et al. Investigating the phenomenology of imagery following traumatic burn injuries. Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.02.018

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I absolutely could have died. I’m totally more aware now. . . I look out. (Participant 2) I thought, that’s it, I’m dead. There are so many dangers that you don’t think about until something like this happens. I have no control. (Participant 13) The human body is fragile. It doesn’t matter how fit or strong or whatever, you know, flesh is flesh and bones are bones. And bones can break and flesh can be cut, burnt, whatever, you know. . . I’m just aware. I never used to be careful. (Participant 7) Altered physical self. Some participants reported that their physical self had been permanently changed by scarring as a result of their injuries. Furthermore, scarring that remained from injuries was frequently reported as a trigger for reexperiencing intrusive imagery for a number of participants. My hair won’t grow back. My hair was so important to my identity. (Participant 4) When I look at the scars I remember the whole event and feel scared but also sad because I don’t recognize that part of me anymore. (Participant 15)

Unchanged world view. Participants who held themselves responsible for their injuries tended to report a more stable, unchanged view of the world. I’m the master of my destiny. (Participant 8) It hasn’t changed anything for me. It’s something I have control of. . . So unlikely to happen again. (Participant 5) I haven’t looked back at all. I go to bed quite easily and things like that. Life has just sort of carried on. (Participant 9) Theme 3: View of others. Only one theme emerged in relation to view of others. All participants described other people as helpful, providing assistance, reassuring and looking after them. When it happened, three of the six of us there had 30 years of experience. I felt safe with them. (Participant 1) I was in shock, but five other people were there, quickly putting wet towels over me and the paramedics were there in minutes. They took care of me. (Participant 6)

When I look at my scars, I remember the pain and I feel sorrow and regret. (Participant 7)

By the time I got to the front door, all the neighbours were there and then next thing the fire brigade and ambulance. I was a mess but they sorted me out. (Participant 10)

Eleven participants (58%) reported ongoing intrusive imagery that was associated with a current sense of threat to the physical self.

A potential reason for this positive view of others is the fact that for most participants help arrived quickly and this was associated with a sense of relief.

Sometimes I get the image and I panic. I’m scared. It’s danger and a real killer. (Participant 1)

Everyone was screaming and throwing water and stuff on me to make sure it [the fire] was out. They asked if I was OK. I smiled in relief because I thought I was OK. (Participant 7)

When the memory pops into my mind I feel helpless all over again. (Participant 13) Certain programmes bring it back to me and I feel flipping helpless and sad. (Participant 10) Theme 2: View of the world. Within the view of the world theme, two sub-themes emerged. Participants either described a changed view of the world (threatened world view) or an unchanged view of the world (unchanged world view) because they felt they could protect themselves from harm in the future. Threatened world view. Seven participants (36.8%) reported that as a result of their experience they had a changed view of the world, believing the world is more dangerous and unpredictable, leaving them feeling out of control. Now I know how dangerous this place can really be. I try to watch out for potential hazards but you just never know what might happen. (Participant 16) I can make sure I don’t do something stupid but that thing shouldn’t have happened. There was nothing I could have done to prevent it. (Participant 10)

My husband was with me. He got me laid down with cold towels and the paramedics arrived within minutes. From then on I was taken care of. (Participant 6) Theme 4: Positive psychological changes. Within the main theme of positive psychological changes, two sub-themes emerged. Six participants (31.6%) described re-evaluating life and developing an appreciation of life (renewed life appreciation) or a sense of personal growth (emotional strength). Renewed life appreciation. Some participants reflected on their experience and, having survived, felt that they were lucky and more grateful and appreciative of life. I do feel very lucky. I definitely do. Another five seconds and I would have been finished, definitely. (Participant 2) I’ve been reflecting on it generally. . . where I am. . . what I’ve achieved. . . and what I want. I had plenty of time to reflect but that was good for me. (Participant 11) Emotional strength. Participants commented on their increased sense of strength and psychological resilience.

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It’s the biggest event in my life. If someone was to write a story of my life it would merit a chapter. . . I feel more optimistic and that I can cope. (Participant 15) It’s made me stronger. I’m proud of how I coped. It’s given me a belief that I’m a strong person. (Participant 7)

4.

Discussion

The aim of the study was to take a detailed look at the phenomenology of imagery in burn injury and to investigate how this may relate to psychological distress. The results are discussed in relation to existing trauma theories and burn injury research. All participants were able to recall the accident leading to their burn injury clearly despite the fact that, on average, this accident had occurred approximately 2 years before the study took place. Our results are in line with Tengvall et al.’s [7] finding that burn survivors can describe their accident in detail and expand this finding by indicating how vivid the memoryrelated images were in participants’ minds and the fact that they included elements of different sensory modalities (e.g., pictures, sounds, smells, and physical sensations). The burn memory was associated with a number of distressing emotions (e.g., fear, disbelief, helplessness, horror) and cognitions that revolved around perceived threat to physical integrity (e.g., injury or death). This threat appeared to be powerfully driven by memories of pain, which represented the worst part of the memory for most participants, thus confirming the importance of pain in the memories of burn survivors [7]. Although intense emotions were attached to these ‘‘worst moments’’, we failed to find a correlation between reported emotional intensity at the time of the injury and symptoms of current psychological distress. This is contrary to literature indicating that peri-traumatic emotions such as anxiety may be related to posttraumatic symptoms (e.g. [34,37]). One potential explanation for this discrepancy is that, although participants reported intense negative emotions and negative appraisals of their injury, they did not report many instances of dissociation in their accounts of the accident. Peri-traumatic dissociation can be a risk factor for the development of posttraumatic distress [36,37]. Our participants may have been unlikely to experience dissociation because they had mild to moderate burns or because they felt helped and supported by others since help was available quickly to almost all of them. The fact that the burn trauma memories were very vivid and associated with perceived threat to the self may partly explain our finding that over half of the participants (58%) reported ongoing memory-related intrusive imagery. Our findings are in line with previous research [7,9] suggesting that burn survivors experience intrusions for a long time following their injury and that scars may act as triggers for these intrusions (e.g. [3,40]). The experience of intrusions may have contributed to participants’ continued distress. Although overall we found a low intensity of depression, anxiety, and posttraumatic symptoms assessed by the IES-R, some participants did report moderate to severe depression symptoms (10.6%) or severe

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anxiety (5.3%), and 15.8% met diagnostic criteria for PTSD. The prevalence of depression and PTSD in our sample is low, but in line with existing literature (e.g. [8,14–17,21]). Although our sample size was small and therefore it was not possible to compare the symptoms of patients who experienced intrusions to those of patients who did not, our findings suggest that intrusive images may have contributed to patients’ current distress. There were significant correlations between the frequency of intrusions and posttraumatic symptoms, specifically the IES-R avoidance subscale score and total score. Patients who experienced the intrusive images more frequently reported greater overall posttraumatic symptoms, especially avoidance. Given evidence that avoidance in general is a maladaptive coping strategy in burn survivors and may contribute to psychological disturbance such as PTSD [8], in our sample intrusions could have prevented the spontaneous remission of the posttraumatic symptoms. According to trauma theory [34], avoidance behaviours may maintain PTSD by preventing a change in the negative appraisals of the trauma and the processing of the trauma memory. Intrusions may have therefore triggered avoidance behaviours which prevented participants from elaborating their trauma memory and modifying their appraisals of the event as life threatening or of themselves as vulnerable. This, in turn, could have maintained their posttraumatic symptoms. Intrusive images may have also contributed to participants’ psychological distress by having a negative impact on their affect. Interestingly, the vividness of the memory-related images was not associated with symptoms of psychological distress, but the intensity of emotions associated with intrusions was positively correlated with distress measured by the BDI-II and across all subscales and the total score of the IES-R. This finding is in line with existing imagery literature (see [24]) which indicates that intrusive images are associated with negative emotional responses. An explanation for the correlation between the intensity of these responses and depressive and posttraumatic symptoms in our sample is that the experience of strong negative affect may motivate participants to engage in behaviours (e.g., avoidance) that may restore their mood temporarily but that, in the long run, are maladaptive. Existing literature, in fact, suggests that intrusive images may trigger maladaptive behaviours that contribute to disorder maintenance [24]. Intrusive imagery is likely to influence posttraumatic appraisals, and this in turn might shape the images that are ¸ ili and Stopa [24] argue that one reason for which recalled. C intrusive images may help maintain disorders is their association with negative representations or appraisals of the self. All of our participants reported a sense of threat to self. Firstly they described self-blame whereby they held themselves responsible for their injuries and thus viewed the self as stupid for having done something to cause their injury. Secondly, some participants saw themselves as physically vulnerable due to the image of threat to the physical self, knowing that their injuries were potentially life threatening. Finally, many participants saw themselves negatively; for some, this self-perception was shaped by alterations in physical appearance due to scarring. It is possible that the activation of intrusions in our sample was accompanied by the

Please cite this article in press as: Cockerham ES, et al. Investigating the phenomenology of imagery following traumatic burn injuries. Burns (2016), http://dx.doi.org/10.1016/j.burns.2016.02.018

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activation of these negative beliefs and that this could have contributed to the experience of negative emotional and (potentially) behavioural responses. Many participants reported changes in their view of the world, as well as in their views of self. This was consistently reported in terms of the world being more threatening, dangerous, and unpredictable. These new perceptions of threat intensified participants’ sense of fear and anxiety. However, not everyone felt this way and some participants denied any changes to their world view. This was often associated with a sense of responsibility for their injuries that may, paradoxically, have produced more of a sense of control over future outcomes (e.g., using protective equipment, or not adding accelerant to a bonfire). This finding is consistent with other studies where attribution of personal responsibility rather than blaming others appears to protect against the development of PTSD [20]. It may explain in part the low rates of depressive and posttraumatic symptoms in our sample. It may also be related to the fact that all the participants viewed others as helpful and most reported a quick sense of relief when help arrived from friends, colleagues, family, or paramedics. This relief was often associated with a reduction in pain (due to medication given). Since for most participants the worst moments of the burn injury were associated with significant pain, the actions of other people who brought speedy relief and a sense of being cared for and protected may have ameliorated the sense of threat carried implicitly by a painful and potentially life-threatening injury. The assistance of others could have blocked the pathway to pain images becoming recurrent warning signs of threatening imminent danger as Ehlers et al. [32] suggest. There were other positive changes reported as an outcome of participants’ burn injuries. Consistent with previous studies on burn survivors [2,4,9,11,12], a number of our participants reported renewed life appreciation as a result of having survived the event, or greater psychological resilience due to their ability to cope with a serious injury, hospitalisation, and rehabilitation. This indicates that, despite the negative consequences of their injury, these participants had experienced posttraumatic growth. Our findings need to be seen in the light of several limitations. First, they may not be generalizable to a wider population of burn survivors. Our sample was small and potentially biased. Patients experiencing significant psychological distress and intrusions may have been attracted to the study or, alternatively, declined our invitation to participate. In addition, our participants had burn injuries for 40% TBSA or less. Although the evidence on the relationship between TBSA and psychological disturbance is inconclusive (e.g. [8]), for participants with more serious injuries depression and PTSD symptoms may be more severe and the nature of the burn memory and intrusions may be different. Second, our use of questionnaires rather than structured diagnostic interviews may have affected our estimates of psychological distress in our sample. As Palmu et al. [13] point out, questionnaires and interviews may yield different prevalence estimates. Third, we did not find a correlation between the frequency with which participants reported experiencing the intrusions and the IESR intrusions subscale. This may be due to participants giving very approximate estimates of this frequency and suggests

that our finding regarding the relationship between intrusion frequency and avoidance and overall IES-R score needs to be interpreted with caution. Finally, our main quantitative analyses were correlational and therefore it is difficult to make causal claims regarding the exact mechanisms through which intrusions may be contributing to psychological distress in burn survivors. Despite these limitations, to the best of our knowledge this is the first study to look specifically at trauma memory and imagery in people sustaining burn injuries and has clear implications for clinical practice. Our findings suggest that burn survivors need to be routinely screened for depression and posttraumatic symptoms and highlight the need for integrating psychological support into the care of these patients. In particular, they suggest that some patients with burn injuries may benefit from interventions that target their trauma-related intrusive images. Imagery rescripting [48,49], a cognitive–behavioural therapeutic technique which aims to modify individuals’ negative appraisals of adverse memories, may be particularly useful for these patients. In fact, this technique has been found to successfully reduce the frequency of trauma-related intrusions and alleviate symptoms in several disorders, including depression [50] and PTSD [51]. Since scarring can serve as a trigger for intrusive imagery, our findings also suggest that scar management should remain an important area of treatment after burn injury. To conclude, our findings indicate that some burn survivors may experience intrusive images related to their burn trauma and that these images may contribute to their continued psychological distress. Future studies could build on our findings and compare imagery in individuals sustaining burn injuries with and without PTSD and depression. Linked to such investigation, it would be worth pursuing positive changes (PTG and psychological resilience) further as this might serve as a protective factor against the development of PTSD or facilitate recovery. Finally, future research would benefit from investigating the effectiveness of interventions such as imagery rescripting in addressing the intrusive images and symptoms of patients following a burn injury.

Conflict of interest None.

Acknowledgements The authors are grateful to the University of Southampton for sponsorship and support of this research project.

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