DELHI PSYCHIATRY JOURNAL Vol. 15 No.

2 OCTOBER 2012

Original Article
Quality of life in Burn Injury Patients
1
Prerna Malik, 2Rajinder Garg, 3Kuldip C. Sharma, 4Purushotam Jangid, 5Anil Gulia
1,4,5
Department of Psychiatry, PGIMS, Rohtak, Haryana
2
Department of Psychiatry, Gian Sagar Medical College & Hospital, Banur.
3
Department of Psychiatry, Government Medical College, Patiala.

Abstract
Objectives: The study was planned to assess quality of life and factors affecting it in patients
with burn injury. Methods: This is hospital based cross sectional study which involves 70 burn
patients hospitalized to the department of surgery and plastic surgery of Rajindra Hospital,
Government. Medical College, Patiala between May 07 and Aug 08. Details of burns were
taken on semi-structured proforma. All patients underwent detailed psychiatric assessment
using International Classification of Disease-10 (ICD-10) and divided into two groups. Group
A contains burn patients with psychiatric morbidity and remaining burn patients without
psychiatric morbidity were included in Group B. Further, both groups were subjected to Quality
Of Life Scale (QOL) to assess quality of life. Results: Quality of life was poor in burn injured
patients and was affected by severity of burn injury. Psychiatric morbidity was found to be
significant factor affecting quality of life in burn injury patients. Conclusion: The quality
of life following burns must be assessed at every stage of their treatment for better adjustment.
Keywords: Quality of life, Burns, Psychiatric morbidity.

Introduction and 25 % were not able to continue with their peer

group in school. The average time of disability was
Burn scars after dermal injury are cosmetically
6 months.2 The previous literature shows that only
disfiguring and forced the scarred person to deal
30 % of any given sample of adult burn survivors
with an alteration in body image or appearance. Also
consistently demonstrate moderate to severe
the traumatic nature of the burn accident and the
psychological and/or social difficulties. 3 Also in
painful treatment induce psychopathological
each sample, 2050 % of the subjects experience
responses. Problems in mental area are more
mild to moderate difficulties with adjustment.4
disabling than physical problems. Social problems
A cr itical factor in the successful or
include difficulties in sexual life and social
unsuccessful life adjustment of the badly burned
interactions. Mediating variables such as low social
patient is his familys reaction to his chronic
support, avoiding coping styles and personality
problem, their ability to support and help him to
traits such as neuroticism and low extroversion
pursue the long course of treatment and also to help
negatively affect adjustment after burn injury.
him to adjust in the social world. So, it is vital to
Quality of life is initially lower in burn patients
deal effectively in the sustained manner to assess
compared to general population but it improves over
the type of emotional disturbances which exist in
a period of many years.1
these families at very higher rate.5 Another study
Long term squeals of burn injury indicated that
shows that many burn victims are socio-
many burn survivors achieve a quality of life that
economically disadvantaged and have poor support
was satisfying to them. A retrospective study to
systems, which further contribute to poor functional
determine the duration of disability in burn patients
outcomes. 6
found that 79 % of the patients were able to return
Other study assessed the emotional distress as
to work or school, 45 % required a change in work
308 Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society
OCTOBER 2012
well as psychosocial resources in 55 patients with
burn injury. They demonstrated the importance of
routine screening of psychological symptoms as
early identification of at risk patients, allow
appropriate psychotherapeutic interventions and
can thus help to improve the quality of life and
general well being of burn patients on a long term
basis.7
The rationale behind the current study was to
evaluate the quality of life that the patients with
burns sustain as an after math of the psychological
trauma they undergo following disfigurement and
disability out of burns and the assessment of factors
affecting quality of life in burn patients. The study
was undertaken at a tertiary centre of northern India
as there was paucity of literature on quality of life
in burn patients.
Material and Methods
After obtaining due permission from
departmental ethics committee of the Department
of Psychiatry, 70 hospitalized consecutive and
consenting patients with burn injury at the
Department of surgery and plastic surgery of
Rajindra Hospital, Govt. Medical College, Patiala
between may 07 to Aug 08 were studied. 10 patients
were excluded from the study either due to chronic
medical illness, epilepsy, mental retardation or
previous psychiatric disorder. 60 patients were
found to fulfil the inclusion criterion of the study.
Based on a detailed clinical interview, psychiatric
diagnosis was established by using ICD -10 criteria.
30 patients found to have significant psychiatric
morbidity were included in group A. The remaining
patients who did not have any significant psychiatric
morbidity were grouped in group B. Quality of life
was further assessed in both groups by Quality Of
Life Scale.
Instruments
1. Semi structured Performa to record socio-
demographic details of the patients,
presenting complaints, history of illness,
circumstances of burn injury, time since
burn injury, local examination of burn
injury and percentage of burn injury.
2. Clinical interview for diagnosis of
psychiatric disorders made as per ICD-10
criteria.8
Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society
DELHI PSYCHIATRY JOURNAL Vol. 15 No.2
3. Quality of Life Scale9 (QOLS): The QOLS
is a valid instrument for measuring quality
of life across patient groups and cultures
and is conceptually distinct from health
status or other causal indicators of quality
of life. Use in chronic illness populations,
including a small group of cancer patients
with ostomies has been validated. The
QOLS measures domains that diverse
patient groups with chronic illness define
as quality of life and has low to moderate
correlations with physical health status and
disease measures. It measures 3 conceptual
domains of quality of life-
(a) Relationships and material well-being
(b) Personal, social and community commit-
ment
(c) Health and functioning
Item Scaling : A 7-point delighted-terrible
scale has been used to measure satisfaction with
each item for a broad range of affective responses
to QOL items. The seven responses were
delighted (7), pleased (6), mostly satisfied
(5), mixed (4), mostly dissatisfied (3),
unhappy (2), terrible(1). The QOLS is scored
by adding up the score on each item to yield a total
score for the instrument. Scores can range from 16
to 112. The QOLS scores are summed so that a
higher score indicates higher quality of life. Average
total score for healthy populations is about 90.
Statistical methods
The data collected was subjected to statistical
analysis. Descriptive statistics (frequencies, means,
standard deviations, and percentages) were used to
characterize the sample and inferences using t tests
for two groups and Chi-square for proportion were
applied to test the statistical significance of the
various factors that affected quality of life. Chi
square was applied for frequencies less than 5 by
applying Yates correction. Further, QOLS scores
were statistically analyzed for the two groups using
t-test. Statistical significance was set at P < 0.05
(significant) and P < 0.01 (highly significant).
Results
The table-1 shows sociodemographic attributes
of burn injury patients. Majority of the patients in
both groups were females and most of these were
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DELHI PSYCHIATRY JOURNAL Vol. 15 No.2 OCTOBER 2012

housewives. Almost equal percentage of subjects
came from urban as well as rural background.
Further, the groups did not differ significantly (p >
0.05) for marital status and education status. The
details can be seen from Table-1.
Table-5 shows the psychiatric diagnosis of
group A patients according to ICD-10 criteria.
Depression (33.33%) was most common diagnosis
followed by post traumatic stress disorder (PTSD)
(26.67%). Remaining patients had adjustment

Table - 1 : Socio-Demoghraphic attributes of Patients

Socio-demographic attributes Group A Group B Statistics
No. %age No. %age
Sex Male 6 20% 8 26.67% 2= 0.09
p = 0.7642
Female 24 80% 22 73.33% (p > 0.05)
NS*
Marital Status Married 22 73.33% 24 80% 2 = 0.09
Single/ p = 0.7642
divorced/ 8 26.66% 6 20% (p > 0.05)
Widowed NS*
Education Illiterate 6 20% 4 13.33% 2 = 1.23
Under Matric 14 46.67% 12 46.67% p = 0.7458
10-12th class 7 23.33% 10 33.33% (p > 0.05)
Graduate 3 10% 4 6.67%
NS*
Domicile Urban 12 40% 10 33.33% 2 = 0.07
Rural 18 60% 20 66.67% p = 0.7913
(p > 0.05)
NS*
Occupation Unemployed 3 10% 5 16.67% 2 = 1.3
Semi skilled 4 13.33% 6 20% p = 0.7291
Skilled 4 13.33% 3 10% (p > 0.05)
Housewives 19 63.34% 16 53.33% NS*
*Not Significant
It can be seen from table-2 that majority of majority (76.67%) of the patients with psychiatric
patients in both groups were in age group of 20-39 morbidity in group A had higher percentage and
years and their mean age did not differ significantly higher degree of burn injury as compared to group
(p > 0.05). This suggests that the burn injuries are B patients and this difference is statistically
more common in reproductive age group. significant (p < 0.05). 33.33% patients in group
The table-3 shows that both group did not differ A had second degree burns and 40% patients had
significantly (p>0.05) regarding causes of burn third degree burns. In group A, majority of the
injury. However, it can be seen that majority of the patients (66.67%) have burn injury involving the
patients of burn injury in group A (63.33%) and face with other parts of the body while in group
group B (86.67%) had accidental burn injury. Most B, 60% of patients have burn injury of other parts
of the patients in group A (60%) and group B of the body without involvement of face. Duration
(53.33%) had burns that were thermal in nature. In of burn injury was significantly shorter in patients
both group, the cause of burn injury was mostly with psychiatric morbidity as compared to other
related to stove accidents (group A [40%] and group group having no psychiatric morbidity, where
B [33.33%]). duration of burn was more than one year. The details
Through table-4, it can be observed that can be seen from Table-4.
310 Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society
OCTOBER 2012 DELHI PSYCHIATRY JOURNAL Vol. 15 No.2

Table - 2. Age of Patients

Age group (in yrs) Group (n = 30) Group B (n = 30)
No. % age No. % age
< 10 0 0% 0 0%
10 19 2 6.67% 3 10%
20 29 15 50% 7 23.33%
30 39 10 33.33% 17 56.67%
40 49 1 3.33% 2 6.67%
>50 2 6.67% 1 3.33%
Range (yrs) 17 55 17 53
Mean SD 27.87 9.192 30.36 7.973
Df 58
t and p value t = 0.4742 , P > 0.05
Significance NS*
*Not Significant
Table - 3. Various Causes of Burn Injury
Causes Group A (n = 30) Group B (n = 30) Statistics
No. % age No. % age
Medicolegal Cause Accidental 19 63.33% 26 86.67% 2 = 3.20
Non Accidental 11 36.67% 4 13.33% p > 0.05
NS*
Nature Thermal Burn 18 60% 16 53.33% 2 = 2.60
Electric Burn 5 16.67% 10 33.33% p > 0.05
Chemical Burn 7 23.33% 4 13.33% Df = 2
NS*
Cause Stove Accidents 12 40% 10 33.33% 2 = 3.47
Electricity 5 16.67% 8 26.67% p > 0.05
Hot Liquid Spill 6 20% 9 30% Df = 4
Acid Spill 4 13.33% 1 3.33% NS*
Fire with Open 3 10% 2 6.67%
Flames
*Not Significant
Table - 4. Variables of Burn Injury
Variables Group A (n = 30) Group B (n = 30) Statistics
No. %age No. %age
Percentage < 20 7 23.33% 25 83.33% c2 = 19.35
> 20 23 76.67% 5 16.67% p < 0.05
S#
Degree 1st Degree 2 6.67% 5 16.67% c2 = 16.50
2nd Degree 10 33.33% 22 73.33% p < 0.05
3rd Degree 12 40% 2 6.67% Df = 3
4th Degree 6 20% 1 3.33% S#
Site Face with other 20 66.67% 12 40% c2 = 4.29
parts of body p <0.05
Other parts of body S#
without face 10 33.33% 18 60%
Duration < 1 year 23 76.67% 6 20% c2 = 17.09
> 1 year 7 23.33% 24 80% p < 0.05
S#
# Significant
Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society 311
DELHI PSYCHIATRY JOURNAL Vol. 15 No.2 OCTOBER 2012

Table - 5. Psychiatric Diagnosis according to was lower than group B. In group A, the items with
ICD-10 Criteria the lowest rate of satisfaction were Socializing,
Participating in active recreation, Participating in
ICD-10 Diagnosis Group A
No. %
public affairs. The difference between the two
groups was found to be highly significant (p < 0.01).
Depression 10 33.33%
Post traumatic stress disorder 8 26.67% Disscussion
Adjustment Disorder 4 13.33% The present study was carried out with the
Substance use disorder 4 13.33% aim of assessing the quality of life among patients
Acute stress reaction 2 6.67% of burn injury. Effects of burn variables on quality
Phobic anxiety disorder 1 3.33%
of life were also assessed. We examined whether
Somatoform disorder 1 3.33%
presence of psychiatric morbidity affected the
disorder, substance use disorders, phobic anxiety quality of life in these patients.
disorder and somatoform disorder. It was observed in our study that gender,
Table-6 shows quality of life scale scores in different age groups, marital status, education,
both groups. In the Group with psychiatric occupation, residence and cause of burn injury
morbidity (group A) quality of life was found to in group A and group B did not differ significantly
have a mean value of 56.86 ranging from 35-73 on quality of life and on psychiatric morbidity in
while in Group B, mean value was found to be 69.17 two groups. But burn itself declines the quality
ranging from 40-89. It can be seen from table that of life of the person by limiting his/her functions.
most of the items of quality of life scale in group A A study evaluated post-burn employment in 48

Table - 6. Quality of Life Scale (QOLS) Scores

Items Group A Group B
(Mean SD) (Mean SD)
1. Material comforts home, food, conveniences, financial security 4.051.35 3.2 1.6
2. Health - being physically fit and vigorous 4.66 1.2 3.14 1.7
3. Relationships with parents, siblings & other relatives- communicating, 4.76 1.1 4.3 1.2
visiting, helping
4. Having and rearing children 3.64 1.3 3.9 0.9
5. Close relationships with spouse or significant other 4.79 1.6 5.16 1.4
6. Close friends 5.39 1.5 6.21 1.1
7. Helping and encouraging others, volunteering, giving advice 4.23 1.4 5.64 1.8
8. Participating in organizations and public affairs 3.63 1.2 5.83 1.1
9. Learning- attending school, improving understanding, getting 4.75 1.2 4.59 1.6
additional knowledge
10. Understanding yourself - knowing your assets and limitations - 3.99 1.2 4.41 1.1
knowing what life is about
11. Work - job or in home 3.66 1.2 4.95 1.7
12. Expressing yourself creatively 4.85 1.4 5.29 1.5
13. Socializing - meeting other people, doing things, parties, etc 2.76 1.3 4.68 1.4
14. Reading, listening to music, or observing entertainment 4.53 1.6 4.80 1.9
15. Participating in active recreation 2.94 1.4 4.55 1.2
16. Independence, doing for yourself 3.50 1.4 4.40 1.4
Mean SD of total scores 56.86 9.4 69.17 12.6
(Range) (35-73) (40-89)
Df 58
t value 7.32
p value p<0.05
Significance S#
# Significant
312 Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society
OCTOBER 2012
patients on average 3.8 years after the burn. 31%
patients had not returned to work. Those who did
not work had low health related quality of life
and poor er tr auma r elated physical and
psychological health. 10
Another study assessed 26 burn patients and
suggested that the electrical burn patients had the
limited ability to return to work and overall poor
quality of life. Emotional distress is the dominant
feature influencing long term outcome in these
patients.11
In current study, it was observed that patients
in group A had more percentage of burn injury, of
severe degree mostly involving face and other
regions. It was also seen that group A patients had
poor quality of life as compared to group B. In a
follow up study of 70 burn adults after 3-13 years
of burn, it was observed that patients with severe
injuries had more psychosocial problems (44%)
than patients with minor injuries (16%). A
combination of variables describing the length of
the hospital stay, presence of scars, premorbid
psychopathology and deviant behaviour during the
hospital stay were found to be the better predictors
of the negative psychosocial outcome.12
Another study examined functional and
psychological outcome of 38 severely burn patients
after 2 years of burn and observed that the mobility
and self care were significantly altered when the
burn injury was more than 20%.13 In a recent study
of patients hospitalized for burn injury, 66% of
patients returned to work within six months of their
injury and 81% had returned by one year. Patients
who sustained larger burns took longer time to
return to work. About half of the patients required
some change in job status.14
There are two important factors related to
psychological and social adjustment. The enduring
quality of family support received by the patient
and the willingness on the part of the patient to take
social risks appear to play critical roles in the
adaptation process. The factors associated with poor
prognosis for psychosocial adjustment includes
social shyness of the individual, an acceptance
within the family of dependence, lack of family
cohesion and high conflict within the family. So,
the burn care of the whole person including early
and continued attention to the psychosocial aspects
of the patients life can facilitate positive
Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society
DELHI PSYCHIATRY JOURNAL Vol. 15 No.2
psychological adaptation to the challenges of
traumatic injury, painful treatment and permanent
disfigurement. 15
In our study, it was found that quality of life
was poor in burn patients and the most common
areas affected by burn injury were participation in
active recreation and social events. These findings
were consistent with previous follow up study
which suggest that patients perceiving more social
support (friends more than family) had more
positive body images (p < 0.01), greater self-esteem
(p < 0.01) and less depression (p < 0.01).16 The
variance in psychosocial adjustment in adults was
related to unemployment, loss of occupational
status, avoidance coping and little involvement in
recreational activities. While in children, it depends
on their mother adjustment and method of coping.17
Another survey on psychological needs of burn
patients by comparing 68 burn injured patients with
44 patients having other types of traumatic injuries
suggested that burn injured individuals lack
psychological support and made suggestions for
support services that may have been beneficial.
These findings supported the need for a
comprehensive follow-up service that would make
specialist physical and psychological support more
accessible to burn injured patients post-hospita-
lization. 18 However, another study demonstrated
that burn patients enjoyed a quality of life
comparable to that of the control subjects although
they perceive some deterioration in their general
health.19
Although quality of life was poor in burn
patients but it was observed in our study that it
worsens if psychiatric morbidity supervened. The
assessment and early treatment of both depressive
and anxiety symptoms may help to improve a broad
range of long term pain related outcomes following
burn injury. A two years follow up study assessed
the prospective effects of anxiety and depression
on pain and functional outcome following burn
injury and they observed that both anxiety and
depression were strong prospective predictors of
greater pain, more fatigue and physical
dysfunction. 20 Another study found that sleep
disturbances were significantly negatively
correlated with all aspects of quality of life.21
Another study assessed the health related
quality of life, PTSD and associations between these
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DELHI PSYCHIATRY JOURNAL Vol. 15 No.2
in 43 burn survivors of 7-16 years age and found
that severity of PTSD was significantly associated
with physical, cognitive and emotional dimensions
of health related quality of life. Most dimensions
of health related quality of life were within normal
limits except social functioning which was
impaired. Children with PTSD report an impaired
overall health related quality of life and limited
physical and emotional functioning.22
Assessing quality of life in burn patients has
many implications as it might affect the treatment
compliance and causes overall poor quality of
life. This study emphasizes that there must be
more awareness and sensitization among health
care providers regarding need of assessing quality
of life in post-burn patients which may help in
their rehabilitation.
Limitations
Though the present study was conducted using
sound methodology and strict inclusion criteria,
there are certain limitations. The study was cross
sectional. The sample size was lesser than some of
the previous similar studies. The sampling done was
non-randomized because of which the finding of
the study can only be representative of the study
population and cannot be extrapolated to the
community at large. Longitudinal studies involving
larger samples selected by systematic sampling
methods would be needed further for better
assessment in these patients.
Conclusion
Quality of life in burn injured patients was
affected by severity of burn injury. Psychiatric
morbidity was found to be significant factor
affecting quality of life in burn injury patients. So,
this study also enlighten that psychiatric care must
be included at every stage of their treatment for the
better adjustment and quality of life in burn injury
patients. The eventual outcome for burn patient is
related to injury severity, individual physical
characteristics of patients, motivation of patient,
quality of treatment and after care support. Burn
patients often require years of supervised
rehabilitation, reconstruction and psychosocial
support. The quality of burn care is no longer
measured only by survival but also by long term
function and appearance.
314 Delhi Psychiatry Journal 2012; 15:(2) Delhi Psychiatric Society
OCTOBER 2012
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