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ABSTRACT

Scarring, including from trauma and burns, can affect psychological wellness and behavior. Depression and posttraumatic stress are common outcomes after scarring and can be debilitating. While for the majority of patients, physical and psychological difficulties abate within a year after a scar-inducing event, it is important to identify those at risk of longer-term sequelae so that they can be adequately treated. Scar location, scar type, patient age (child or adult), patient personality and coping style, the degree of social support, and the presence of prior mood disorders can all affect the psychological experience of the patient with scarring. Intervening based on the perceived severity of the scar as viewed by the patient, ensuring that adequate social support is available, and being particularly responsive to the needs of patients with preexisting mental illness can help reduce the psychological morbidity of scars in affected patients.

INTRODUCTION

Scarring of all types, from that due to burns, to trauma, to acne scarring, has been shown to have a major influence on patients’ psychological wellness and behavior.1 The incidence of other mental illnesses and personality disorders has also been shown to be higher in patients with burn scars.2 The most prevalent specific diagnoses are depression, character disorder, and alcohol and drug abuse.3–6 The rate of posttraumatic stress disorder (PTSD) in patients with scars secondary to burn injury and other trauma is 15% to 45% at a year or more after the burn compared to the baseline rate of 7.8%.7,8 Anxiety is reported in 20% of scar patients, and low self-confidence and low mood are described in 50%.1 In interviews with scar patients, the majority describe feeling “unsightly” or “abnormal” and “stigmatized,” believing themselves to be judged by others as “criminally inclined” or “weak-willed.” In many cases the scars act as a constant reminder of a painful incident. Personal and professional relationships may suffer as a consequence of scars and the resulting low self-confidence, introversion, anxiety, depressed mood, and anger.1

“I feel like I’ve kind of held myself back in a lot of, even professionally, everything that I’ve done … it’s been such a factor in my life and I try to kind of push it back all the time, but it’s a daily thing. It hurts for me to look in the mirror for the most part because I just see nothing but scars and I see all the angles and all the lighting and it’s almost devastating to me, so I almost have to give myself a pep talk every day to kind of get up and go.”(Middle-age woman with facial acne scars)

Not all psychological effects from scarring are shown to be maladaptive. Many patients have been described to undergo posttraumatic growth (PTG), where pretrauma levels of personal functioning and well-being are exceeded.9

For the majority of patients, physical and psychological difficulties ...

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