Although there are many commonalities in the lived experience of those with different forms of wounds, there are also important differences. This chapter highlights some of these differences but, in addition, uses the different forms of wounds to highlight the importance of psychological variables in wounds and wound care. For example, for those with traumatic burn injuries it is important to understand any underlying pre-existing psychological morbidity. This is outlined in this chapter, along with some potential methods for assessing these. For those with diabetic foot ulcers, the potential impact of psychological distress on further ulceration is outlined along with some methods for ameliorating this. Pressure ulcers, a significant condition that impacts on many, can have serious implications on health related quality of life and factors associated with this- in particular the nurse-patient relationship- are outlined and explained. Finally, the pain associated with Venous Leg Ulcers is outlined and the potential importance of both assessment- through the verbal descriptions associated with pain- and social interventions are emphasised. Overall, this chapter highlights the importance of a psychological understanding in a range of wound types.

Trauma wounds are often accompanied by serious psychological implications, severely disrupting normal daily activities (Coker et al. 2008). One of the most severe traumas a person can endure is that of a burn injury (Klinge et al. 2009; Hodder et al. 2014). Sustaining a burn injury can cause both significant psychological distress and physical pain. For example, fire-related trauma wounds can result in a number of negative medical consequences, including hypovolemic shock, sepsis, multi-organ failure and, subsequently, mortality (Young 2002; Herndon 2007). Psychosocial difficulties associated with a burn injury can include: financial strain, relationship difficulties, loss of physical functions, emotional dysfunction, disfigurement and body image concerns (Hodder et al. 2014; Esselman et al. 2006; Partridge and Robinson 1995).

Mortality rate associated with major burns has decreased dramatically over the last 50 years. This can be attributed to a number of factors, whether it being the advanced knowledge surrounding the pathophysiology of burn injury (Young 2002; Herndon 2007), or the establishment of a number of specialised burn units (Diver 2008) and advancements in wound care (White and Renz 2008). As a result, multi-disciplinary teams have been developed which focus not only on the surgical, medical and reconstructive stages of burns treatment, but also on the psychological and psychosocial well-being of burn patients (Young 2002; Herndon 2007). Hence, as mortality has decreased, the importance placed upon the psychological well-being of burn survivors has increased substantially (Klinge et al. 2009; Smith et al. 2006).

During the first year following a burn trauma, a patient is highly vulnerable being susceptible to experiences of anxiety, depression, psychosis and delirium (Edwards et al. 2007). Indeed, studies have suggested that psychological recovery parallels physical recovery (Smith et al. 2006). Studies have highlighted the predominance of anxiety and depression to be reported as long-term symptoms (Edwards et al. 2007), with the prevalence rate of overall psychological consequences being between 10 and 65 % (Edwards et al. 2007; De Young et al. 2012; van Loey et al. 2012). Personality type, coping styles and situational factors have been found to be associated with post-burn psychological adjustment (Herndon 2007; van Loey et al. 2012). Park et al. (2008) discovered that combined with the previous risk factors, employment, marital status, financial position, and social support can predict psychological adjustment and psychosocial outcomes of burn patients. Similarly, van Loey et al. (2012) reported that quality of life in the long-term was influenced by physical recovery, number of surgical interventions and psychological disorder (particularly post-traumatic stress disorder). Hence, it is essential for clinicians to identify potential risk factors than may impede the psychological adjustment of wound patients. Klinge et al. (2009), in their review of the burn wounds literature, highlighted six factors that may place a role in the adjustment of post-burn patients;

An interesting point to note is that the authors reported that burn patients had a higher incidence of pre-existing psychopathology when compared with the general population. This has been highlighted previously by findings that pre-existing psychological disorders, substance and alcohol abuse and depression have a causal role in the aetiology of the burn itself (Dyster-Aas et al. 2008). Hence, it has been suggested that patients who have sustained a burn wound may have had diminished cognitive processes related to such pre-burn factors that, in turn, predisposed them to such an injury (Klinge et al. 2009). For example, a meta-analysis conducted by Noronha and Faust (2006) highlighted such a link with pre-existing psychopathology increasing post-burn psychological maladjustment.

Clinicians need to account for such issues within their daily wound care regimes as these psychological factors can have significant implications on satisfactory healing. For example, in a longitudinal study considering the relationship between pre-existing psychological issues and post-burn outcomes, the degree of impairment and healing rate of patient’s experiencing differing levels of physical and psychological burden were examined (Fauerbach et al. 2005). It was found that an intervention based around the reduction of in-hospital distress and support psychological well-being proved to be as effective as surgical interventions. Research has heighted two forms of distress that burn patients’ perceive during their hospital stay; alienation and anxiety (Fauerbach et al. 2007). Hence, clinicians need to be aware of these and the potential implications such psychological issues may have on the patient’s subsequent experiences of pain, and further psychological distress. A cyclical relationship has been reported in patients with burn injuries, whereby depression and anxiety influences pain perception and reduced physical functioning which, in turn, further impacts anxiety and depression (Edwards et al. 2007). Hence, it is essential for clinicians to acknowledge and manage not only physical symptoms but emotional symptoms also (see Fig. 5.1). Such concurrent management strategies will then result in an improvement in a variety of long-term post-burn outcomes (including wound healing and physical functioning).

A large proportion of the burns literature also focusses on the relationship between personality type, coping strategies and post-burn adjustment. It has been reported that neuroticism, a trait largely associated with pessimism, negative affect and introversion, is one particular personality trait associated with adjustment difficulties (Klinge et al. 2009). Hence, it has been suggested that wound care clinicians need to integrate assessments that explore personality traits that may result in maladjustment and the adoption of dysfunctional coping strategies (Gilboa et al. 1999a, b). For example, patients who display optimism, ‘self-mastery’, or self-efficacy (ability to influence their outcomes) and hope prove to adjust more positively, whereas neurotic and introverted traits resulted in greater adjustment issues (Gilboa et al. 1999a, b).

Additionally, such patients were also more susceptible to post-traumatic stress disorder (PTSD; Fauerback et al. 1997; van Loey et al. 2003). Research has highlighted the prevalence of PTSD in burn survivors with van Loey et al. 2003 discovering 28 % of their participants to be meeting the DSM-IV criteria for either PTSD or partial PTSD. Furthermore, Bryant (1996) found that 60 % of burn patients were classified with PTSD or a subclinical form of PTSD. A major predictor of PTSD was the patient’s concern about self-image related to the scarring resulting from the burn in addition to the adoption of avoidant coping styles (something that will be discussed later in relation to implications on wound healing). Hence, it is important for clinicians to acknowledge the associated between patients expressed concern over scarring and potential negative emotional reactions and adjustments.

Overall, it is essential that the patient who has suffered a wound is assessed adequately from a psychological perspective. There are a number of measures that may be useful in this regard. Table 5.1 highlights some of these and their benefits.

The measures reported in Table 5.1 are but some of the many measures that are available to the practising clinician to measure appropriate psychological variables. More of these are reported in other chapters, including the Chaps.​ 2, 3 and 7.

Diabetes is a widespread and increasingly prevalent condition across the globe with foot ulcers being a common, serious and costly complication experiences by sufferers (Londahl et al. 2011). Diabetic Foot Ulcers (DFUs) are often slow to heal, are associated with increased risk of amputation and death and are costly to treat, with costs to the UK health services estimated to be over £220 million per annum (Majid et al. 2000). Such foot ulcerations have a number of consequences for the individual including reduced mobility and an incapability to perform daily activities. Furthermore, given that the treatment of diabetes-related foot disease demands a multi-disciplinary approach with treatments that are often intensive and prolonged frequent hospitalisations may result (Hogg et al. 2012). These consequences can subsequently negatively impact upon a patient’s quality of life. Not only do these, like the other wounds discussed, impact on a patient’s physical functioning, but also on their social and psychological status (Londahl et al. 2011). Much research has highlighted these consequences with patients often reporting reduced mobility as a major factor impinging on their QoL (Hogg et al. 2012; Chapman et al. 2014; Ribu and Wahl 2004), followed by having to adapt to the lifestyle changes needed to live with ulcerations on the foot.

A number of studies have reported that individuals with diabetic foot ulcers are faced with a variety of negative emotional and psychological consequences. Research has highlighted how due to the lack of mobility, many patients are faced with feelings of frustration, anger and guilt (Brod 1998; Kinmond et al. 2002; Watson-Miller 2006). These feelings often stem from the restrictions patients perceive. It is important to note that these are often perceptions rather than reality and it is therefore incumbent on the clinician to ensure that appropriate education and support is provided to the patient, along with any practical remedies to improve their mobility.

Not surprisingly, those individuals with DFU have significantly poorer psychosocial states than those with diabetes but without a foot ulcer (Fejfarova et al. 2014). Indeed, Fejfarova et al. (2014) reported that those with a DFU had a lower quality of life in key areas: finances, standard of living, employment status, isolation and financial hardship. Similarly, there were reports of lower levels of social support and self-care. Not surprisingly, levels of suicidal ideation were also relatively high (approximately 5 %).

Other research has also highlighted a high prevalence of depression amongst those with a DFU. For example, phenomenological research conducted by Kinmond et al. (2002) interviewed a number of patients who had an ulceration. In this study, it was found that almost all of the patients reported negative implications on their social roles and activities. However, in addition to this, patients described how such restrictions led to significant and prolonged periods of clinical depression, to the point where the patient pleaded with clinicians to have an amputation. Such consequences of living with a foot ulcer can be detrimental to both the quality of life and well-being of patients (as we will see later in the book), continuing the vicious circle of reduced wound healing. Hence, it is essential that clinicians are aware of not only the physical and social implications, but also the psychological and emotional toll such illnesses have. In effect, clinicians must adopt multi-faceted treatment regimes in order to assess patients and provide the most effective treatment and delivery of care.

Importantly, psychological morbidity is increased in those with diabetes and DFU by at least two-fold (Anderson et al. 2001; Ali et al. 2006; Carrington et al. 1996). Both depression and anxiety have been reported in those with DFU (Ali et al. 2006) and these can lead to significant issues with self-care. For example, there may be a general neglect in those with depression. Anxiety itself can manifest in range of disorders including generalised anxiety disorders, obsessive-compulsive disorders, PTSD and panic disorders (Lin et al. 2008). Williams et al. (2010) reported that depression in those with type 2 diabetes was associated with twice the rate of a first DFU and, furthermore, a higher rate of amputation (Williams et al. 2011). Additionally, depression in first DFU is associated with a two-fold increase of mortality over 5 years (Ismail et al. 2007). This psychological comorbidity, particularly depression, can lead to additional risks on patients with diabetes and diabetic foot ulcers resulting in poorer self-care and poorer outcomes (Lustman et al. 2000). In contrast, in those with anxiety it has been argued that its link with self-care and clinical outcomes are less clear: dependent on the nature of the anxiety problem, poorer or even enhanced self-care many emerge (DiMatteo et al. 2000).

It is not just psychological distress that may lead to impairment in healing. Vedhara et al. (2010) reported that ineffective coping with the DFU delayed healing with their results suggesting that promoting “effective coping could significantly improve healing rates” (p. 1596). They described confrontational coping as the least effective and related to delayed healing. This coping style is characterised by more controlling, competitive and extroverted. These patients are therefore more likely to challenge the advice of health care professionals and be less willing to follow treatment recommendations. Thus, if these coping techniques could be improved then so could healing- a role for psychological interventions.

Importantly, if the psychological issues can be addressed then there may be an improvement in outcome- both psychologically and medically. Education by itself may not necessarily improve patient self-care although motivational interviewing shows promise in developing patient skills (Gabbay et al. 2011). Given that the single greatest risk factor for DFU is a previous ulceration or amputation (Boulton et al. 2005), with just over a third of patients re-ulcerating within 12 months, interventions are required that can improve self-care, reduce psychological distress and promote protective psychosocial resources (Hunt 2011). In contrast to the limited educational interventions, Vedhara et al. (2012) developed and evaluated a multi-modal psychosocial intervention aimed at modifying potential psychosocial risk factors associated with foot re-ulceration in diabetes (see Fig. 5.2).

Delivered by a specialist diabetic nurse and podiatrist following CBT training, the intervention consisted of weekly 60–90 min sessions for the first 10 weeks, followed by 3 bimonthly maintenance sessions commencing 2 months after the initial phase completion. The intervention was based on the model described in Fig. 5.2 and was designed to achieve the behavioural, emotional, cognitive and social goals outlined with a view to delaying the onset of further DFU development. The results of the study revealed that the participants found the intervention effective and changed their behaviour positively. Whether there was any impact on re-ulceration is yet to be determined. However, the benefits of group interventions for those with potential DFU re-ulceration is evidenced and may support other studies with other wound types (see Chap.​ 8).