Patient centred practice, which focuses on an individual’s illness experiences, not just on the clinical signs and symptoms of their wounds is essential. In recent years there has been a substantial increase in the range and scope of research addressing the psychosocial issues related to wound care, resulting in better understanding of the impact these can have both on the healing process, and a patient’s wider quality of life (see Box 1.1). It is therefore essential that these issues be addressed in clinical practice. This chapter provides an overview of the psychosocial factors which are the focus of this book. The consequences for healing are summarized and the implications for clinical practice reviewed.

Patients with chronic wounds often report feeling that they can no longer carry on with their daily routine and going out in public (Woo et al. 2009). Furthermore, patients may have to limit their activities in order to reduce painful experiences (Woo 2010), subsequently reducing their social mobility (Solowiej et al. 2010a). Herber et al. (2007) discovered that patients will often avoid activities such as walking, shopping and exercising, due the pain attributed to such activities. In addition to this, patients have also reported avoiding these activities due to worries that they will lead to, or contribute, to further wound-related difficulties (Persoon et al. 2004). Thus patients with chronic wounds may experience quite severe restriction in the daily activities we often take for granted because of pain and limitations of movement. Impaired mobility can also lead to the inability to work (Faria et al. 2011), perform general household tasks (Woo et al. 2009) and maintain personal hygiene (Fox 2002). Such restrictions can have significant implications for a patient’s psychological health, and patients often believe them to be one of the worse aspects of having a wound (Hamer et al. 1994). As such, it is possible for a negative cyclical relationship to occur, whereby the negative consequences of the wound result in a negative emotional state, impacting upon wound healing and, subsequently, leading to further negative emotions (See Fig. 1.1).

These limitations in daily activities often result in individuals becoming increasingly isolated from others (Gorecki et al. 2009). Exclusion from social activities has also been related to the intrusion of treatment – either because of the need to attend clinic, or wait in for a nursing visit (Hopkins 2004a, b). In addition it has been found that patients will limit their involvement in leisure activities such as swimming, gardening, walking and travelling (Krasner 1998; Chase et al. 2000; Hareendran et al. 2005) which then results in reduced social contact. For example, Hamer et al. (1994) found that almost half of the patients they spoke to had given up some of their hobbies. This reduction in social activities and interactions with others may also stem from a lack of energy, caused by the sleep deprivation that can result from the intense pain of a chronic wound (Harlin et al. 2009; Upton and Andrews 2013a, b, c). Furthermore, the feelings of helplessness and anxiety associated with not being able to continue with daily activities can contribute further to social isolation and feelings of disconnection from society (Brown 2005a, b, c).

Anxiety is not the only emotional response that may contribute to a patient withdrawing from interactions with others. The relationship between depression and social withdrawal has long been recognised (Baddeley et al. 2013); thus the depression associated with having a chronic wound may well change social relationships. Furthermore, a spiral relationship may well develop in which depression leads to withdrawal from social interaction leading in turn to increased dysphoria (Hawkley and Cacioppo 2003). Embarrassment has also been highlighted as a reason for social withdrawal in this group. This has been linked in particular to the unpleasant odour, which can often accompanies a chronic wound. Concerns about whether others can detect this malodour can lead to patients trying to keep themselves safe from the scrutiny of others, and the possibility of undesirable comments about their cleanliness (Probst et al. 2013). Furthermore, reduced personal hygiene can be a genuine concern; patients may avoid washing for fear that dressings might get wet and that this will disrupt the healing process (Douglas 2001; Ebbeskog and Ekman 2001a, b). Thus withdrawal from society can result from embarrassment over these changes in levels of personal care as well as the malodour of the wound itself.

Having a chronic wound may also change interpersonal relationships in other ways. Role reversal in families, where the previous head of the family becomes the dependent one, has been described (Douglas 2001; see Chap.​ 8). In intimate relationships for example, where a partner has to take on the role of carer, the dynamic may well change; furthermore, couples may experience a loss of physical and emotional intimacy (Gorecki et al. 2009).

This change in the dynamics of intimate relationships may also result from a shift in the patient’s self-perception and a loss of identity (Probst et al. 2013). Research has highlighted the impact of these issues on women in particular (Hyland et al. 1994). Compression bandages, wrapping, and other dressings can be bulky and may require a wardrobe adjustment and this can lead to a perceived loss of femininity for some women (Hyland et al. 1994). Feelings of shame, embarrassment, and diminished femininity have also been observed in women with malignant fungating wounds in progressive breast cancer (Boon et al. 2000). Given the significance of the female breast as a symbol of sexuality and femininity, learning that a wound in this area can impact on a woman’s body image and self-concept is not surprising. Furthermore, symptoms such as malodour, an excess of exudate and relentless seepage, need constant vigilance and management when in public (for example having to carry additional changes of clothes). Such extreme changes in behaviour can contribute to the loss of sense of self and social identity (Probst et al. 2013). Moreover malodour and excessive exudate can also lead to feelings of disgust, self-loathing, and low self-esteem (Jones et al. 2008).

The emotional reaction to having a chronic wound usually includes some form of distress –depression, anxiety and stress are common responses. For example, burn injuries have been linked to serious emotional difficulties including anxiety and post traumatic stress disorder (Van Loey and Van Son 2003; Loncar et al. 2006). Furthermore, research exploring the prevalence of depression and anxiety in 190 patients with chronic venous ulcerations, indicated that 27 % of patients were experiencing depression with 26 % being highly anxious (Jones et al. 2006). In a similar vein, Searle et al. (2005) found that following diagnosis with a foot ulcer, depressed mood was a very common response to a number of features of the wound including the time taken to heal, loss of independence, and the limitations of daily living. Changes in role and an increase in dependency on others can also trigger anxiety (Herber et al. 2007) and guilt (Walshe 1995). In addition, the visibility of the wound, including smell and leakage of exudate may also lead to feelings of vulnerability and embarrassment resulting in further anxiety and distress (Piggin and Jones 2007; Lo et al. 2008; Alexander, 2010). Treatment may also trigger feelings of distress: studies in patients with a range of different types of chronic wound have shown that stress and anxiety is linked to the pain of dressing change as well as the stress of background pain (Upton et al. 2013c; Upton et al. 2012b, c) Finally, the sleep disturbances which many experience because of wound pain can also lead to patients experiencing heightened worry and frustration – which further disrupts sleep; Cole-King and Harding (2001) and Fagervik-Morton and Price (2009) have discovered that anxiety and depression can also contribute to sleep disturbance.

Sleep deprivation, which is thought to impact on healing, has been found to be particularly prevalent in patients living with chronic wounds. Research suggests that approximately 25 % of patients experience at least three nights of sleep disturbance due to their wound, whilst 49 % of patients reported experiencing sleep disturbance due to their wound on six or more nights (Price and Harding 1993). Upton and Andrews (2013a, b, c) also reported on the sleep disturbance in those with chronic wounds, with their results suggesting a more significant issue than that Price and Harding (1993). Specifically, Sixty-nine per cent of their leg ulcer patients reported sleep disruption, with 88 % stating that they wake at least once during the night. General wound pain was the most frequently-cited cause (58 %), while pain associated with treatment affected the sleep of 38 % of respondents. Sleep disruption in people with chronic wounds is an important issue since it can impact on pain levels, wellbeing, quality of life and healing.

There is evidence that psychological distress can increase risky health behaviours such as smoking and alcohol consumption (Upton and Thirlaway 2014); thus individuals experiencing high levels of stress are more likely to increase their alcohol (Sillaber and Henniger 2004) and tobacco use (Sinha 2008). A link to depression, anxiety and social isolation has also been noted specifically in older adult drinkers (Schonfeld and Dupree 1991). Furthermore studies have identified a relationship between stress and increased participation in health damaging behaviours in individuals with chronic wounds (Gouin and Kiecolt-Glaser 2011). This is a concern because behaviours such as this have been shown to impede the healing process.

The psychosocial issues described so far in this chapter are important in part because of the implications they have for a patient’s mental health and quality of life. However, this is not their only relevance. A significant, negative relationship has been found between these psychosocial problems and the healing process. Studies have demonstrated that patients who are anxious about their physical condition, or who feel depressed, tend to show much slower healing rates than patients with a more positive attitude. For example Doering et al. (2005) found that following surgery, patients with more depressive symptoms at discharge had more infections and poorer wound healing than patients who reported less distress. Likewise, Cole-King and Harding (2001) showed that patients with leg ulcers who experienced the highest levels of depression and anxiety were four times more likely to show delayed healing compared to individuals who reported less distress. Furthermore, distress predicted wound healing outcomes over and above differences in other variables such as demographic and medical status. Research exploring mucosal wound healing and presentation of dysphoria has also provided support for this link. Bosch et al. (2007), examined the patients’ levels of dysphoria and rate of wound healing, discovering that patients who presented with higher levels of dysphoria were approximately 3.6 times more likely to experience slower wound healing whilst also exhibiting larger wound sizes. Similar outcomes have also been demonstrated with patients suffering from burns (Wilson et al. 2011).

A wealth of research is also available which considers the relationship between a patient’s perceived stress and the rate of wound healing (Cole-King and Harding 2001; Gouin and Kiecolt-Glaser 2011; Soon and Acton 2006; Woo 2010). This work has linked both wound pain and treatment pain with poorer patient outcomes. For example, Upton and colleagues have suggested a link between pain, stress and healing in those with a chronic wound (e.g. Upton 2011a; Solowiej et al. 2009, 2010a, b). In particular, the evidence they present suggests that the stress of dressing change can be a significant factor in those with a chronic wound. Stress is thought to influence healing partly through its impact on immune functioning; stress reduces the levels of the many inflammatory cytokines and enzymes that are necessary for tissue repair (Upton 2011a) and increases levels of cortisol. In addition to this physiological response, patients may have a behavioural response to stress which impacts on healing. It has been suggested that stress increases the likelihood of patients making poor cognitive judgments such as avoiding treatment because dressing removal is perceived as an unpleasant experience. Thus negative emotional responses affect biological and behavioural responses resulting in delayed wound healing. The relationship between pain, stress and wound healing is therefore both statistically significant and clinically relevant (Gouin and Kiecolt-Glaser 2010; Upton et al. 2012a, b, c).

Sleep deprivation is also detrimental to the healing process. As noted earlier, sleep disturbances are often associated with the onset of psychological distress and with the pain accompanying with living with a wound. This has significant implications for wound healing since even mild sleep deprivation has been shown to impair immune functioning (Kahan et al. 2010; Harlin et al. 2009). For example, just one night of sleep deprivation has been discovered to impact wound healing (Altemus et al. 2001). It is thought that sleep disturbance, like stress, reduces cytokin levels and alters killer cell activity, subsequently slowing skin barrier repair (Altemus et al. 2001).

Changes in behaviour such as smoking, alcohol consumption, poor diet and lack of exercise are also thought to impact on healing. Research has shown that surgical patients who are considered regular smokers have significantly slower healing periods that those classed as non-smokers (Silverstein 1992). This is thought to be because the toxins and nicotine within cigarette smoke reduce oxygen levels in the blood whilst also reducing macrophage function (Silverstein 1992). Given the known link between hypoxia and reduced healing (Gordillo and Sen 2003), this relationship is not suprsing. The negative implications of smoking for wound healing are further illustrated by research exploring smoking cessation programmes (Moller et al. 2002): implementation of such programmes 6–8 weeks before scheduled surgery has been found to reduce post-surgical wound complications. Similarly, alcohol consumption has been linked to slower healing (Benveniste and Thut 1981). Animal studies have highlighted the effects of alcohol use, demonstrating the disruption to numerous mechanisms which underpin the healing process. For example, alcohol use before or after wounding can impair the inflammatory response that is essential in the initial healing stages (Fitzgerald et al. 2007). Animal studies have also shown that heavy alcohol use is associated with delays in cell migration and collagen deposition at the wound site, which in turn can impede the healing process (Benveniste and Thut 1981). A link between preoperative alcohol use and postoperative morbidity has also been shown in humans (Tønnesen and Kehlet 1999). Finally diet and exercise have also been linked to the rate of wound healing. For example, nutritional deficits including, low protein, low glucose intake and vitamin deficiencies, can all impede the wound healing process (Russell 2001; Posthauer 2006; McDaniel et al. 2008). Lack of regular physical activity has also been shown to slow wound healing rate in animal models (Keylock et al. 2008). Furthermore, studies with human patients have shown that regular exercise can lead to reduced wound healing time (Upton 2011a, b). For example, whilst it was found that a 3-day exercise programme did not positively impact wound healing (Altemus et al. 2001), research implementing a 4 week programme resulted in a 25 % improvement in punch biopsy wound healing (Emery et al. 2005).

As described earlier, the experience of living with a chronic wound brings with it a number of factors (e.g. malodour, exudate, restricted mobility, aspects of treatment) which can lead to a patient reducing their participation in social activities, often becoming isolated. When an individual withdraws from social interactions, they forsake an important aspect of psychosocial support. Thus there is a whole range of practical and emotional support which is no longer accessible to an individual. As social support has been found to be important for emotional wellbeing and quality of life, acting as a buffer against stress and enhancing physical health (Thoits 2011) this has implications for wound healing. The evidence from clinical populations suggests that social isolation has an indirect effect on wound healing because of the impact it has on our emotional health which was noted earlier (Hawkley and Cacioppo 2003); this increased distress further hinders healing by reducing inflammatory cytokines and increasing cortisol concentrations as already described. However, animal studies have identified a more direct pathway for this influence. Detillion et al. (2004) found that stress did increase cortisol concentrations, thereby impairing wound healing in hamsters, but only in those animals that were kept in isolation. Socially housed animals did not show this effect. Furthermore, isolated hamsters that had been given an adrenalectomy, and therefore could not produce cortisol, did not show delayed wound healing. In contrast treating isolated hamsters with the hormone oxytocin, which is released during social contact, blocked stress-induced increases in cortisol, and wound healing was facilitated. This suggests that social isolation increases stress-related cortisol production thereby slowing wound healing. Whilst studies with human populations show inconsistent effects for oxytocin in social behaviours, it seems increasingly likely that this is because the oxytocin mechanism is controlled to some extent by social contexts and individual differences (Bartz, et al. 2011); such differences may include factors such as personality and psychological resources.

Psychological resources refer to emotional and cognitive factors such as optimism, personal control, social support and active coping all of which are known to be protective of mental health (Taylor et al. 2000). Moreover there is evidence that the presence of these positive features may also foster good physical health (DeLongis et al. 1988; Schöllgen et al. 2011). Thus the presence of positive psychological resources may act as a buffer against the impact of the negative aspects of ill health. For example, individuals who seek information or advice about their wound and its treatment may find this gives them greater personal control of their health and also decreases feelings of distress (Moffatt et al. 2011). The significance of this personal control for enabling individuals to live well with a chronic wound is demonstrated very clearly by Probst et al. (2013), who looked at the experience of women with fungating wounds. In this study, some of the women had been through a very personal process of working out what adjustments they needed to make to their lives in order to manage their condition so as to enable them to continue to live a normal life – going to work, seeing friends and so on. These women seemed to have accepted the situation and the changes they had had to make to accommodate the person they had become. This self-efficacy – the belief that you can do something – gave them the ability to adjust to their new identity, taking control of the situation, and furthermore, insisting that everyone else (including intimate partners) also accept this new reality.