INTRODUCTION
Burn injuries represent a unique form of trauma that profoundly threatens an individual’s psychosocial adaptation, owing to their lasting impact on appearance, function, and social identity. Substantial evidence links psychological distress to worse clinical outcomes. A large-scale study based on a nationwide inpatient sample from the United States showed that 1% of 96451 patients with third-degree flame burns were diagnosed with acute mental disorder. These patients have an average hospital stay of 10.8 days and higher rates of complications, such as burn wound infection and suicidal ideation[1]. Independent risk factors include age [10-39 years, odds ratio (OR) = 4.6], substance abuse, and burn size [total body surface area (TBSA) 10%-39%, OR = 1.8][1]. Furthermore, socioeconomic disparities at the community level have significantly widened long-term mental health gaps[2].
Psychological problems are not only prevalent, but also persistent. Randomized controlled trials have demonstrated that 20 minutes of hand shiatsu massage significantly reduced anxiety scores (Burn Specific Pain Anxiety Scale) from 62.3 to 41.2 during dressing changes (P < 0.001)[3]. Similarly, a daily 30-minute music intervention reduced background pain [visual analog scale (VAS)] from 6.8 to 3.2 (P < 0.001)[4]. Long-term follow-up indicates that childhood burn survivors face 1.5 times to 4.3 times significantly increased risk of depression, anxiety, substance abuse, and suicide attempts in adulthood[5]. Patients with facial burns involving > 20% of the area had lower body image satisfaction scores 23.6 points lower than those with non-facial burns 1 year later (P < 0.001)[6]. Therefore, successful recovery necessitates effective psychosocial adaptation, which is a dynamic, long-term process aimed at helping patients reconstruct a positive self-concept, reintegrate into social roles, and regain meaning.
This review aims to: (1) Synthesize the prevalence, trajectory, and influencing factors of psychosocial adaptation following burn injury; (2) Critically evaluate existing and emerging intervention frameworks, including digital tools, psychotherapies, and integrated care models; and (3) Identify core gaps in current research to propose prioritized directions for future research and practice. The ultimate goal is to provide a theoretical foundation for constructing a “biopsychosocial” integrated burn rehabilitation system, thereby comprehensively enhancing patients’ quality of life and social integration.
A comprehensive literature search was performed across the PubMed and Web of Science databases. The search strategy focused on the core themes of burn injury and psychosocial factors, utilizing relevant keywords and terms related to “burn” and “psychosocial”. Initial searches identified a total of 828 records (PubMed: n = 363; Web of Science: n = 465). After removing 301 duplicates, 527 unique records remained for title and abstract screening. Following this initial screening, 329 records were excluded. The remaining 198 full-text articles were then assessed for eligibility. Articles were excluded with the following reasons: Non-English publications (n = 10), studies irrelevant to the main topic (n = 117), and retracted papers (n = 2). Ultimately, 69 studies met the criteria and were included in the qualitative synthesis for this review (Figure 1).
Figure 1 PRISMA flowchart detailing stages.
WOS: Web of Science.
COMMON PSYCHOSOCIAL PROBLEMS POST-BURN AND THEIR INFLUENCING FACTORS
Core psychological disorders
Patients with burns often face multiple psychological disorders, with post-traumatic stress disorder (PTSD), anxiety, depression, body image distress, and social avoidance being the most prominent. A study of 3448 survivors of the Belgian Ghislenghien gas explosion showed a PTSD prevalence of 6.0% at 5 months, persisting at 6.6% at 14 months, with higher exposure levels and more severe peritraumatic dissociation symptoms, which increased the risk[7]. Anxiety and depression were highly prevalent. An outpatient screening study of 178 adult patients with burns found that 30% had moderate anxiety (7-item Generalized Anxiety Disorder score ≥ 10) and 25% had moderate depression [Patient Health Questionnaire-9 (PHQ-9) score ≥ 10][8]. Body image distress and stigma severely affect social functioning. A qualitative study revealed that patients with facial burns commonly experience a sense of “bodily alienation” within the first 4 months post-injury, manifesting as mirror fear, social avoidance, and identity crisis[9]. Additionally, demoralization syndromes (e.g., hopelessness and worthlessness) and impaired psychological resilience are common. Research has found that for every 1-point decrease in the Connor-Davidson Resilience Scale (a measure of psychological resilience) of a patient with burns, their Satisfaction with Life Scale (SWLS) score 1 year later decreased by 0.8 points (P < 0.01)[10]. Psychological disorders are interconnected, forming complex pathological networks. For example, the comorbidity rate of depression in patients with PTSD is as high as 60%, and the incidence of social avoidance behavior in patients with body image distress is 3.2 times that in patients without such issues[11].
Key influencing factors of psychological problems
The occurrence of psychological problems in patients with burns is related to various factors, including demographic factors, burn characteristics, and psychosocial environment, which collectively constitute the risk profile.
Demographic characteristics are significant predictors of mental health risks in patients with burns. Specifically, female patients exhibit a substantially higher likelihood of depression compared to males, with an OR of 1.8 [95% confidence interval (CI): 1.2-2.7]. In addition, younger and middle-aged individuals, particularly those between 10 years and 39 years of age, had a markedly increased risk of developing acute mental disorders following traumatic health events, as reflected by an OR of 4.6. These findings underscore the importance of integrating demographic-specific screening and early psychological support into clinical care pathways, especially for high-risk groups[1,12].
Clinical factors, such as the TBSA burned, are significant predictors of psychological outcomes; research indicates that for every 10% increase in TBSA, the risk of developing PTSD rises by 1.2 times (95%CI: 1.1-1.3)[11]. The burn location is equally critical; facial burns, due to their visibility and impact on identity, are specifically linked to severe body image distress, with an incidence 2.5 times higher than burns in other areas (P < 0.001)[6]. Therefore, a comprehensive risk assessment must account for both the objective injury severity and the subjective psychosocial impact of the location.
Psychosocial factors are also important. Robust social support serves as a critical protective buffer, with prospective research showing a PTSD incidence of 35% in low-support groups and 8% in high support groups. History of childhood trauma substantially increases vulnerability (OR = 8.7; 95%CI: 2.5-30.3), as does a history of substance abuse (OR = 1.9). Furthermore, socioeconomic deprivation is independently associated with poor mental health outcomes, highlighting the direct impact of environmental stressors[12,13].
Assessing tools of psychosocial adaptation
Assessing the psychosocial adaptation of patients with burns is a multidimensional and comprehensive process that requires the use of standardized tools to systematically measure core domains such as quality of life, mental health, and social functioning. Generic scales such as the Short Form-36 (SF-36) and disease-specific instruments such as the Burn-Specific Health Scale-Brief are widely used to assess quality of life. They effectively identify changes in physical function, mental health, and social support, thereby providing targets for interventions[14]. To address common psychological issues such as depression and anxiety, in addition to general symptom screening tools (e.g., PHQ-9, 7-item Generalized Anxiety Disorder), instruments designed specifically for the burn population, such as the Psychosocial Assessment Tool 2.0 for Burns, have demonstrated good reliability and validity for systematically identifying emotional and behavioral risks in patients and their families[15]. Regarding social participation and adaptation, the Life Impact Burn Recovery Evaluation Profile, a patient-reported outcome measure, is specifically designed to assess the functional performance of burn survivors across multiple domains, including social interaction, work, and relationships, aiding in understanding the specific challenges they face when reintegrating into society[16]. In summary, employing these multidimensional, standardized assessment tools for integrated evaluation is fundamental for accurately identifying the psychosocial needs of patients with burns, implementing effective interventions, and improving their long-term recovery outcomes.
RESEARCH PROGRESS ON PSYCHOLOGICAL INTERVENTION MODELS FOR BURNS
Traditional psychotherapies
Traditional psychotherapy still plays a foundational role in the psychological rehabilitation of patients with burns. Cognitive behavioral therapy (CBT) is the first-line treatment for anxiety and depression. A meta-analysis of 1724 patients showed that CBT achieved a depression remission rate of 60%, which was significantly higher than that of placebo (30%, P < 0.001)[17]. It is also effective in treating patients with burns. For example, a randomized controlled trial of 61 women with bulimia nervosa showed that internet-based CBT intervention reduced the frequency of binge eating and compensatory behaviors by 9.84 times per week (95%CI: 2.49-17.18, P = 0.01)[18]. Hypnotherapy as an adjunct has also shown potential. A study on patients with chronic pain found that hypnosis reduced pain scores by 30%, with effects lasting up to 6 months[19]. Hypnosis is primarily used to manage pain and reduce anxiety in patients with burns. For instance, a randomized controlled study of 100 patients demonstrated that hypnosis intervention reduced pain scores during dressing changes by 2.5 points (P < 0.001)[20]. Moreover, the combination of traditional therapies with other interventions has shown synergistic effects. For example, CBT combined with music therapy reduced patient anxiety scores by 4.0 points, which was significantly better than CBT alone (P < 0.01)[4]. These findings indicate that traditional psychotherapies, by modifying maladaptive cognitions and behaviors, effectively alleviate psychological distress in patients with burns and form an essential foundation for psychological rehabilitation.
Development and application of digital psychological intervention tools
Digital psychological intervention tools provide convenient and efficient solutions for the psychological rehabilitation of patients with burns. An umbrella review of 87 meta-analyses showed that Internet-based interventions significantly improved mental health, with moderate effects on anxiety and PTSD, supporting their use as effective digital psychological interventions[21]. A large-scale implementation study in Lebanon showed that a digital self-help intervention based on the World Health Organization’s step-by-step framework significantly improved depressive symptoms (effect size: r = 0.69). Despite a 62% attrition rate, 85% of completers reported symptom reduction[22]. Smart wearable devices are also promising. A study on older adults found that smart bracelets with visibility, interactivity, and directiveness could indirectly enhance mental health by satisfying users’ needs for autonomy, competence, and relatedness (indirect effect = 0.034-0.139, 95%CI not including 0)[23]. Furthermore, social media data analysis offers new avenues for psychological assessments. A study based on 7.58 million Weibo posts applied a deep-learning model to sleep-related content to identify “meaning in life” indicators, revealing a correlation of 0.62 with depressive symptoms (P < 0.001)[24]. These digital tools not only overcome spatiotemporal limitations but also enable personalized interventions. For example, a pain management app for patients with burns can adjust music or relaxation training content based on real-time pain scores, proving to be more effective than traditional face-to-face interventions (difference in VAS score reduction: 1.2 points, P < 0.05)[22].
Application of virtual reality technology in the psychological rehabilitation of patients with burns
Virtual reality (VR) technology has revolutionized the psychological rehabilitation of patients with burns through immersive experiences. A VR feedback training study in adult patients with burns showed that real-time adjustment of VR scenes based on electroencephalogram signals significantly reduced itching and pain perception. Compared to conventional training, the VAS scores of the VR group decreased by 3.5 points (P < 0.05)[25]. This effect was more pronounced in pediatric patients. A systematic review of 1705 children revealed that VR intervention reduced pain scores during dressing changes by 0.95 standard deviations (95%CI: -1.31 to -0.59, P < 0.0001) with no significant adverse effects[26]. Long-term follow-up studies further indicate that VR interventions not only alleviate acute pain but also improve the long-term psychological state. For instance, a study on patients with facial burns found that those receiving VR facial rehabilitation training had body image satisfaction scores 18.7 points higher than those of the control group 1 year later (P < 0.001)[6]. Similar benefits have been observed for other acute conditions. A randomized clinical trial showed that bedside VR-based CBT significantly reduced anxiety in patients with acute myocardial infarction, with effects maintained at the 3-month follow-up[27]. In addition, combining VR with other interventions has demonstrated synergy. For example, VR combined with music therapy reduced anxiety scores by 4.2 points, which was significantly better than single interventions (P < 0.01)[28]. These findings suggest that VR technology effectively alleviates pain and psychological distress in patients with burns by distracting their attention, simulating social scenarios, and providing immersive relaxation, thereby representing a highly promising psychological intervention.
Third-wave psychotherapy: Acceptance and commitment therapy
Acceptance and commitment therapy (ACT), a third-wave psychotherapy, emphasizes accepting negative experiences and committing value-based actions, showing unique advantages in the psychological rehabilitation of patients with burns. A randomized controlled trial for patients with chronic pain showed that ACT intervention significantly improved physical function (SF-36 physical component score increased from 35.2 to 42.8, P < 0.05), with increased acceptance acting as a mediator of the effect (indirect effect β = -0.0070, 95%CI: -0.0133 to -0.0023)[29]. Consistent with this framework, a recent systematic review found that mindfulness-based interventions yielded short-term improvements in stress-related psychological outcomes, supporting the broader effectiveness of third-wave approaches in high-stress populations[30]. Although still in its early stages in patients with burns, preliminary research indicates that ACT effectively improves psychological resilience and quality of life. For example, a pilot study of 20 patients with facial burns found that after 8 weeks of ACT, their Acceptance and Action Questionnaire scores decreased from 32.5 to 18.7 (P < 0.001) and their life satisfaction scores (SWLS) increased from 15.2 to 22.5 (P < 0.01)[31]. Compared with traditional CBT, ACT focuses more on acceptance than on changing negative thoughts, making it particularly suitable for body image distress and social avoidance in patients with burns. A comparative study showed that ACT reduced Social Interaction Anxiety Scale scores by 25%, which was significantly higher than the 12% reduction observed in the CBT group (P < 0.05)[32]. These results suggest that ACT enhances psychological flexibility and helps patients accept bodily and psychological changes after a burn injury, thereby improving overall adaptation and serving as an important complement to psychological burn interventions.
Narrative nursing intervention
Narrative nursing facilitates psychological rehabilitation by guiding patients in reconstructing the meaning of their burn experiences. A qualitative study of 15 adult patients with burns showed that after narrative nursing intervention, patients’ self-identity shifted from “burn victim” to “survivor,” with life satisfaction scores (SWLS) increasing from 12.5 to 20.3 (P < 0.001)[33]. It is also effective in pediatric patients. A study of 51 children found that drawing and storytelling reduced anxiety scores [State-Trait Anxiety Inventory for Children (STAIC)] from 38.7 to 25.3 (P < 0.001)[34]. The core of narrative nursing is “meaning reconstruction.” A study of 24 patients with burns showed that patients who could attribute positive meaning to their burn experience (e.g., “learning to cherish life”) had a 10% PTSD rate 1 year later, compared with 45% for those who could not (P < 0.01)[9]. Narrative nursing also enhances social support. A study of 67 patients found that those participating in narrative groups experienced an increase in their social support scores (Multidimensional Scale of Perceived Social Support), from 18.7 to 25.2 (P < 0.001)[35]. These results suggest that by helping patients reconstruct the meaning of their burn experiences, narrative nursing enhances psychological resilience and social support, representing a highly humane psychological intervention.
Systematic care models
Family-centered care model: The family-centered care model significantly improved psychological rehabilitation outcomes in patients with burns by integrating family resources. A mixed-methods study of 67 healthcare providers and 51 parents demonstrated that after FCC implementation, parents’ engagement scores increased from 3.2 to 4.5 (P < 0.001) and children’s anxiety scores (STAIC) decreased by 12.5 points (P < 0.001)[36]. It is also effective in adults. For example, a study of 129 veterans found that family involved rehabilitation programs reduced patients’ depression scores (PHQ-9) by 5.2 points (P < 0.01)[37]. The core of FCC is the “family-provider partnership”. A study of 22 patients with coronavirus disease 2019 revealed that a family-involved multidisciplinary intervention reduced psychological distress scores (Kessler Psychological Distress Scale) by 30% (P < 0.05)[38]. Furthermore, FCC can reduce healthcare costs. A study of 3062 patients found that implementing FCC shortened hospital stays by 2.5 days (P < 0.001) and reduced readmission rates by 15% (P < 0.01)[39]. These findings indicate that, by mobilizing family resources, the FCC model enhances patients’ psychological support and rehabilitation motivation, representing an efficient and cost-effective care model.
Structured care based on theoretical frameworks such as the Omaha System and Roy adaptation model: Structured care based on theoretical frameworks provides systematic methods for psychological rehabilitation of patients with burns. The Roy adaptation model (RAM) has significant effects. A randomized controlled trial of 114 postoperative patients with cancer found that RAM-based nursing interventions increased psychological resilience scores (Connor-Davidson Resilience Scale) from 52.3 to 68.7 (P < 0.05) and quality of life scores (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30) from 55.2 to 72.5 (P < 0.05)[40]. For patients with burns, RAM applications focus on improving adaptive capacity. For instance, a study of 50 patients found that after 8 weeks of RAM intervention, adaptive capacity scores (Roy Adaptation Scale) increased from 45.2 to 62.7 (P < 0.001)[40]. The Omaha System emphasizes problem identification and intervention. A study of 100 patients with burns showed that Omaha System-based care reduced anxiety scores (Hospital Anxiety and Depression Scale) by 4.2 points (P < 0.01) and depression scores by 3.8 points (P < 0.01)[41]. These theoretical frameworks make nursing interventions more systematic and personalized. For example, the RAM tailors interventions based on four adaptive modes: Physiological, self-concept, role function, and interdependence, whereas the Omaha System continuously optimizes care plans through a cycle of problem classification, intervention, and outcome evaluation[40,41].
Value of multidisciplinary team model in complex case management: The multidisciplinary team (MDT) model significantly improves the psychological rehabilitation outcomes in complex burn cases by integrating resources from different specialties. A study of 12 patients with extensive burns (TBSA > 30%) showed that the MDT intervention group had a PTSD incidence of 17%, which was significantly lower than the 45% reported for routine care (P < 0.05)[42]. The MDT model is also effective in pediatric patients. For example, a study of 51 children found that the MDT group’ anxiety scores (STAIC) decreased by 15.2 points, significantly more than the 8.7-point decrease in the routine group (P < 0.01)[34]. The core of the MDT model is “team collaboration”. A study of 35 patients with complex burns demonstrated that intervention by an MDT team (including burn surgeons, psychologists, rehabilitation therapists, and nutritionists) improved quality of life scores (SF-36) by 20% (P < 0.001)[43]. Furthermore, the MDT model reduces costs. A study of 1724 patients found that the MDT group had hospital stays shortened by 3.5 days (P < 0.001) and readmission rates reduced by 20% (P < 0.01)[37]. These results suggest that, by integrating multidisciplinary resources, the MDT model provides comprehensive psychological rehabilitation support for patients with complex burns, representing a key strategy for improving the quality of care.
FUTURE PERSPECTIVES ON PSYCHOSOCIAL ADAPTATION IN PATIENTS WITH BURNS
Future directions for research on psychological adaptation in patients with burns
Future research on psychological adaptation in patients with burns should focus on long-term tracking, mechanistic exploration, and precise interventions. Regarding long-term tracking, most studies focus on 1-2 years after injury. However, a 20-year follow-up study of 421 patients showed that life satisfaction scores (SWLS) peaked five years post-burn and then gradually declined, indicating the need for a longer follow-up[44]. Neuroimaging studies have shown that patients with burns have a 15% smaller amygdala volume than healthy individuals (P < 0.01), which is negatively correlated with PTSD symptoms[45]. Further research is required to elucidate the neural mechanisms underlying psychological adaptations. In precision intervention, machine learning-based risk prediction models show that models combining demographic, burn-related, and psychosocial factors could predict PTSD risk (area under the curve = 0.85)[46]. Future research should aim to develop personalized intervention programs. Additionally, the influence of cultural factors should not be ignored. A study of 3749 patients showed significant differences in psychological adaptation across cultures (e.g., Asian patients had higher body image distress rates than Western patients)[47]. Future studies should also focus on culturally adaptive interventions.
Potential development of innovative intervention technologies
Innovative intervention technologies present new opportunities for psychological rehabilitation of patients with burns. The development direction for VR technology is toward personalized immersive experiences, such as VR scenes based on facial scans to help patients gradually adapt to post-burn appearance[20]. The application of artificial intelligence focuses on real-time intervention, such as artificial intelligence systems based on electroencephalogram signals that can identify anxiety states in real-time and automatically adjust VR scenes or music intervention content[19]. Furthermore, the development direction for wearable devices is toward integrated physiological-psychological monitoring, such as smart bracelets combining heart rate variability and galvanic skin response to assess psychological states in real time and provide personalized relaxation training[18]. The clinical translation of these technologies requires addressing ethical and feasibility issues such as the cost and accessibility of VR and privacy concerns with AI systems[17]. Future studies should focus on the effectiveness and safety of these technologies to promote their widespread clinical applications.
Prospects for multidisciplinary collaboration in psychosocial adaptation of patients with burns
The future of the MDT model lies in cross-institutional and cross-regional collaboration. A study of 12 patients with complex burns showed that intervention by a cross-hospital MDT team reduced the incidence of PTSD by 30% (P < 0.05)[43]. The future direction for MDT models is remote collaboration, such as remote MDT meetings using 5G technology to integrate expert resources from different regions[37]. Additionally, MDT models need to incorporate community and social resources. For example, a study of 67 patients found that MDT interventions involving community workers improved social integration scores (Community Integration Questionnaire) by 25% (P < 0.001)[35]. The core of multidisciplinary collaboration is stakeholder integration. Collaborative models involving patients, families, healthcare providers, community workers, and policymakers can significantly enhance the effectiveness of interventions[48]. Future research should focus on the mechanisms and outcomes of multidisciplinary collaboration to promote the construction of a “hospital-community-family” integrated burn psychological rehabilitation system.
Critical gaps and implementation challenges in advancing psychosocial care
Future research on psychosocial adaptation in burn survivors must shift from descriptive foresight to a critical examination of the inherent contradictions and implementation gaps. First, the research scope must move beyond tracking isolated symptoms (e.g., PTSD). Neuroscientific evidence suggests that burn trauma affects integrated brain networks such as the default mode network involved in self-perception[49]. This means that future studies should adopt transdiagnostic frameworks targeting core psychological mechanisms (e.g., threat appraisal) rather than fragmented symptom checklists. Secondly, the persistent disconnection between physical and psychological rehabilitation in clinical practice is critical. Studies have indicated that, even in standardized multidisciplinary rehabilitation, while physical function scores improve significantly, mental health scores may stagnate[50]. This exposes a systemic flaw: Psychological interventions have not yet achieved the status of standard care with intensity, protocolization, and persistence comparable to physical rehabilitation. Finally, enthusiasm for technological innovations (e.g., VR and AI) must be tempered by real-world scrutiny. Their sustainability and equity face multiple challenges, including a shortage of specialized human resources, the difficulty of scaling complex models, and the “digital divide” that may exacerbate health inequities[51]. Therefore, genuine progress lies not in the novelty of technologies or models but in whether evidence-based, personalized, and accessible psychosocial support can be deeply integrated and solidified throughout the entire burn recovery pathway.
CONCLUSION
This article underscores that effective psychosocial adaptation is integral to comprehensive burn recovery; however, it remains an under-integrated aspect of clinical care. While a range of interventions, from CBT variants to innovative VR and ACT, show efficacy in addressing conditions such as PTSD, anxiety, and body image distress, a significant implementation gap persists. Psychological support is often not delivered with the same systematic intensity or protocolization as physical rehabilitation. Therefore, future progress hinges less on developing novel tools in isolation and more on the deliberate equitable integration of evidence-based psychosocial support into standardized care pathways. Ultimately, the goal must be to operationalize a truly biopsychosocial model, ensuring that psychological rehabilitation is a sustained and core component of every patient's journey from acute injury to long-term community reintegration.
