Psychological and Emotional Impact of a Burn Injury

Printable Version

By Megan Bronson PMHCNS, BC

Differentiating Grief From A Trauma Response:

Physical traumas such as burn injury and the painful and intrusive medical procedures required to treat them can be profoundly traumatizing. The emotional response to any trauma is intense fear, horror, and helplessness to affect the outcome. There is, inherent in a traumatic incident, a threat to basic security and safety. The effects of burn trauma can profoundly affect an individual’s ability to cope with life stresses, as well as constrict one’s ability to relate to others for months, years, or a lifetime. Traumatic events trigger the fight or flight survival response and it can be helpful to view symptoms of trauma from this perspective. Victims of trauma often avoid or resist talking about the traumatic event. Symptoms of trauma may not emerge and become evident for weeks, months, or even years after the traumatic event occurs. 

Burn injury is often, if not always accompanied by losses. Losses vary depending on the individual situation and extent of the burn injury. Grief is a natural, innate, healing process which occurs in response to loss. This process is time limited and has as its function emotional healing and a return to life activities. Grief does not damage self worth, self esteem, or self image. The predominant feelings of grief are sadness, anxiety, longing for that which has been lost, and oftentimes anger about the loss. Anger tends to be unfocused. Most find it helpful to talk about their loss. 

Burn trauma profoundly affects all parts of the burn injured individual’s and family’s life. The losses and trauma inherent in a burn injury require ongoing assessment, attention and intervention as needed. Psychological healing and recovery need to be supported throughout all phases of recovery including reintegration.

Emotional, Social, And Spiritual Recovery:

The most fundamental psychological insult of trauma is helplessness in the face of an event which is psychologically and physically overwhelming. In burn trauma this is complicated by the repetitive nature of procedural trauma and the reactivation of the trauma response. Psychological recovery from burn trauma requires that a sense of safety and power in one’s life be restored. The following phases outline a path to psychological recovery and the reclaiming of personal power after burn trauma. This model is further elaborated upon in Trauma and Recovery by Judith Herman M.D.

Phase I:` Recovery of a sense of safety in the world
Phase II:`Remembering, Telling one’s story, and Mourning
Phase III: `Reconnecting with life

Recognizing trauma symptoms throughout the acute, rehabilitative and reintegration phases of burn treatment is imperative in order to facilitate early and ongoing intervention. Below is a list of common trauma symptoms.

Post-Traumatic Stress Symptoms in Adults

A traumatic event is defined by the DSMIV, (Diagnostic and Statistical Manual for Psychiatry 4th Edition), as an event in which the person witnessed or was confronted with an event that involved actual or threatened death or serious injury to self or others, and that the event was responded to with intense fear, helplessness, or horror.

Symptoms often seen in adults post trauma:

• easily startled
• difficulty falling asleep or staying asleep
• irritable, short tempered, restless
• loss of interest in what one previously enjoyed
• social withdrawal and isolation
• avoidance of friends and interaction with others
• intrusive recall of the traumatic event, (can’t stop thinking about what happened)
• or avoidance of thinking about or feeling about the trauma
• avoidance of the place or circumstances where the trauma occurred
• avoidance of people who might be associated with the trauma
• avoidance of the place where painful treatment of the traumatic injuries occurred, such as a burn center or clinic, (this may lead to non-compliance with treatment)
• flashbacks of the traumatic event, (seeing, hearing, smelling or tactile sensations)
• abuse of alcohol or drugs
• thinking about death, sense of pessimism about the future
• mistrustful, fearful, anxious, hypervigilance
• difficulty concentrating and problem solving
• feeling detached and distant from others
• nightmares, (may or may not be directly related to traumatic event in content)
• numbing of feelings
• feeling dazed or not real
• unable to recall important aspects of the trauma

Some of these symptoms may be present following a traumatic event and will usually diminish over time. It is important to seek help from a professional counselor who has advanced training and expertise in treating trauma if symptoms persist beyond the early days or weeks after the occurrence of the trauma.

Recognizing the Impact of Childhood Trauma in Children and Adolescents

Consider the developmental stage of the individual when traumatized:
Inadequate or incomplete achievement of developmental tasks often occurs in the wake of trauma. This is true for the burn injured child as well as siblings of the child who suffered the burn. It is therefore essential to consider the developmental stage the person was in when the burn injury occurred as the developmental task of that stage may have been partially or inadequately mastered (refer to accompanying handout). The development of the human personality and psychology is similar to the building of a house. In the building of a house the care with which the foundation is laid will determine the solidness and the structural strength of the completed house. All parts of the house rest on the foundation, just as all parts of the personality are built on the sequential developmental stages of childhood and adolescents.

Unresolved trauma and traumatic loss often present as:

• Depression
• Anxiety disorders
• Obsessional thinking and compulsive behaviors, perfectionism
• Alcohol and Substance abuse and inappropriate dependence
• Problems with intimacy such as social isolation, abusive relationships, inappropriate control in relationships, problem with boundaries
• Sleep disturbance—difficulty falling asleep, staying asleep, early awakening
• Eating disorders—anorexia, binging, bulimia, overeating
• Psychosomatic illness—such as headaches, peptic ulcers, etc
• Aggression, hostility, irritability, difficulty managing anger, controlling behaviors
• Risk taking behaviors
• Failure to emancipate, failure to take responsibility, running away, Etc.

Recognizing fear and its roots in trauma:

It is the trapped fear that is at the root of posttraumatic stress symptoms (see accompanying handouts). Common fears of children after trauma are described by Lenore Terr, MD in Too Scared to Cry: How Trauma Effects Children and Ultimately Us All. These common post trauma fears are:

• Fear of another more frightening event
• Fear of separation
• Fear of death
• Fear of helplessness
• The mirror image of extreme rage is extreme passivity—both are fear based

It is oftentimes unresolved fear that unconsciously drives a trauma survivor’s life and the resolution of fear is therefore essential to recovery and healing.

Trauma Responses in Children and Adolescents

Traumatic experiences have a profound effect on the developing child. These effects impact the child cognitively, emotionally, psychologically, and socially. Traumatic experiences include abuse, rape, witnessing or being the target of violence, suicide, homicide, natural disasters, house fires, accidents, critical injuries such as severe burns and their treatment, etc. Any event, which the child experiences as life threatening to the child or others, can be defined as traumatic. 

Common manifestations of trauma in young children: (approximately 2-6 yr.)

• generalized fear and anxiety
• nightmares, night terrors, fear of going to sleep or sleeping alone
• regressive behaviors,(bed-wetting, talking baby talk, thumb sucking, whining)
• repetitive trauma play, may have difficulty verbalizing about the trauma
• confusion and difficulty understanding that the trauma is over
• attachment anxiety, (clinging, excessive concern about parent leaving)
• physical symptoms, (stomachaches, headaches, other physical symptoms)
• personality changes, may be withdrawn and passive, or aggressive and reckless
• school difficulty, such as difficulty concentrating may not want to go to school
• arguing, fighting, agitated, restless, quick to anger and become defensive

Manifestations in older children: (approximately 6-12 yr.)

• fears are more specific and related to the trauma
• sleep disturbance, (nightmares, fear of sleeping alone)
• obsessing about and talking about the trauma repeatedly, compulsive behaviors
• guilt related to not being able to control the trauma
• impaired ability to concentrate and learn
• changes in behavior, (such as withdrawn and isolating, or aggressive and reckless)
• feeling overwhelmed by and afraid of losing control of feelings
• concern for the safety of family members
• fear of death and sometimes a fear of spirits or ghosts

Manifestations in adolescents: (approximately 12-18 yr.)

• may include symptoms of older children, as well as adult symptoms
• may be self conscious about feelings, fears, and being different
• aggressive, destructive, self destructive, risk taking, acting out behaviors, (substance abuse, sexual acting out, delinquent behavior, truancy, etc.)
• avoidance of interpersonal relationships, withdrawal, social isolation
• personality changes, depression, apathy, moodiness
• leaving school or leaving home, or fear of separating from family/parents
• pessimism, cynicism, plans of revenge
• failing grades, disinterest in school, friends, and previously enjoyed activities

[Modified from the DSMIV, {Diagnostic and Statistical Manual for Psychiatry 4th Edition)]

Seek input and guidance from family physician, teachers, nurses, school counselor, family members, as well as evaluation by a professional counselor who has advanced training and expertise in treating trauma.

Identifying children at risk after significant loss:

When the following behaviors persist months after the loss they are considered red flags and indicate the need for professional assessment and intervention.

• Anxiety which limits the child’s ability to function, such as school phobia, fear of further loss, fear that he or she will also die
• Persistent difficulty talking about the person who has died
• Hyperactivity, aggression, destructive outbursts
• Marked social and/or emotional withdrawal
• School difficulties, (this could present as failing grades, difficulty concentrating and following directions, or over-achievement and perfectionism)
• Persistent self blame and guilt
• Compulsive care giving or compulsive self reliance
• Somatic complaints such as headaches or stomachaches
• Identification symptoms, (accidents, developing symptoms of the deceased person’s illness)
• Substance abuse or other self destructive behaviors; expressing a desire to die, (this is often related to an unconscious hope of reunion)
• Prolonged inability to cry or to express or experience longing for the person who died
• Sleep and eating disturbance

Finding a Therapist

Due to the unique nature of burn injuries, it is especially important to refer patients and their families to mental health resources such as psychotherapists, social workers, counselors or psychologists who have received advanced training in treating trauma and loss issues. Some of the common modalities used to help these populations include Cognitive Behavioral Therapy (CBT) and Eye Movement Desensitization and Reprocessing (EMDR). The following article from the NYU Child Study Center offers some helpful guidelines for choosing a mental health professional for children and adolescents.


Choosing a Mental Health Professional

Written and Developed by Anita Gurian, Ph.D. and the Staff of the NYU Child Study Center

When is the Right Time?

Many children have to deal with life stresses in the course of growing up. For most children challenges are temporary, and they learn to adjust and move on. However, some children and their families need outside help in coping with their difficulties. Parents and other adults should be alert to physical and emotional signs that suggest that a child or teen may be not be adjusting well and may need help. Some problems can be of serious concern, for example, when a child or adolescent has lost touch with reality or is in danger of harming her/himself. Other problems may be of less concern, for example, when a child experiences difficulties in peer relationships or is particularly fearful of something or has suddenly become aggressive.

Further investigation may also be warranted when a child seems out of step with peers or shows changes or problems in any of the following areas:

• eating
• sleeping (persistent nightmares)
• excessive fears
• worrying or crying
• decline in school work
• mood
• constant disobedience
• poor relationship with family or friends
• aggressive behavior
• marked opposition to authority
• returning to behavior typical of a younger child

Other important questions to keep in mind in making the decision about requesting professional help are:

How intense is the problem?
How long has it lasted?
Is it inappropriate at the child’s age?
Does it interfere with the life of the child and family?

Just like physical problems, the outlook for emotional problems is better when the problem is treated early and children can resume healthy development. Talk directly and honestly with the child, using age-appropriate language, to allay his/her concerns and answer questions about seeking professional help. It may be useful to point out how the problem interferes with the child’s enjoyment of life. If the parents’ attitudes are positive, it will affect the child’s responses and make participation in therapy more likely.

Getting Started with the Right Treatment

Once the decision is made that help is needed, parents should begin to gather pertinent information. Here are some helpful sources:

• Talk things over with the child’s pediatrician, teacher or guidance counselor.
• Get a recommendation from a trusted friend or family member.
• Check with a clinic associated with a local hospital or medical school.
• Contact national or local professional organizations. Mental health professionals include psychiatrists, psychologists, social workers, or marriage-and-family therapists.

It is important for the child or teen and parents to feel comfortable and to trust the therapist selected. Parents often benefit from having an initial consultation and one or two sessions before making a definite commitment.

Some questions to ask when first meeting with a mental health professional include:

• The credentials of the therapist.
• Training and particular experience/expertise in dealing with the problem.
• If the clinician works with other professionals in the child’s life.
• Type and format of treatment, such as frequency of sessions and cost arrangements.
• Extent of parents’ involvement with treatment.

Common Treatment Strategies

Medication is one option among many for certain disorders. Whether medication is part of the treatment plan depends on the nature of the problem and discussion with the professional, the parent, and in some cases, the adolescent. Some treatments are carried out alone, some in combination with medication. Many therapists draw from various schools of therapy and modify their approach according to each child’s needs and capacities.

Some common treatment strategies include:

• Cognitive behavioral therapy: focuses on symptoms and current goals. Helps the child identify faulty beliefs and learn new ways of thinking and behaving.
• Verbal psychotherapy: current problems are discussed in light of past difficulties and options for coping with feelings and behavior in more effective ways are developed.
• Group therapy: issues are explored within a group setting with individuals who share similar problems.
• Interpersonal psychotherapy: feelings and responses are explored within the context of different interpersonal or social relationships and situations.
• Family therapy: members of the family are helped to understand how their behaviors affect one another and instructions and strategies for making changes are provided.

To be helpful, therapy usually requires an investment of time and hard work on the part of both the professional and the child or teen and family. The therapist’s job is to act as a guide, instructor, mentor and confidante. The job of the child or teen and parents is to work and to try and put what they learn into practice. Successful collaboration results in better functioning and life satisfaction for both the child and family

About the NYU Child Study Center

The NYU Child Study Center is dedicated to the research, prevention and treatment of child and adolescent mental health problems. The Center offers evaluation and treatment for children and teenagers with anxiety, depression, learning or attention difficulties, neuropsychiatric problems, and trauma and stress related symptoms.

We offer a limited number of clinical studies at no cost for specific disorders and age groups. To see if your child would be appropriate for one of these studies, please call (212) 263-8916.

The NYU Child Study Center also offers workshops and lectures for parents, educators and mental health professionals on a variety of mental health and parenting topics. The Family Education Series consists of 13 informative workshops focused on child behavioral and attentional difficulties. To learn more or to request a speaker, please call (212) 263-8861.

For further information, guidelines and practical suggestions on child mental health and parenting issues, please visit the NYU Child Study Center’s website,

Changing the Face of Child Mental Health
NYU Child Study Center

577 First Avenue 1981 Marcus Avenue, Suite C102
New York, NY 10016 Lake Success, NY 11042
(212) 263-6622 (516) 358-1808

Resources and information on trauma and loss:

There are many resources available to burn survivors and their families that provide information about burn trauma and treatment and offer emotional support. Receiving both up to date information about burns, how and where to get treatment as well as finding on line and physical places to connect with other burn survivors can be crucial to healing from a burn injury. Explore Phoenix Society's Resource Library for more.

For information about burn camps:


This article reprint provided by:
The Phoenix Society, Inc.® • 1835 R W Berends Dr. SW • Grand Rapids, MI 49519-4955 • 800.888.BURN •
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The Phoenix Society, Inc.® • 1835 R W Berends Dr. SW • Grand Rapids, MI 49519-4955 • 800.888.BURN •