This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fauerbach, J. A. Articles by Muehlberger, T. Search for Related Content PubMed PubMed Citation Articles by Fauerbach, J. A. Articles by Muehlberger, T. Related Collections Consultation Psychiatry Stress and Coping

Effect of Early Body Image Dissatisfaction on Subsequent Psychological and Physical Adjustment After Disfiguring Injury

From the Johns Hopkins University School of Medicine, Baltimore Regional Burn Center, Johns Hopkins Bayview Medical Center, Baltimore, MD.

Address reprint requests to: James A. Fauerbach, Ph.D., Department of Psychiatry, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224. Email: jfauerba{at}jhmi.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
OBJECTIVE: The impact of body image dissatisfaction on quality of life after severe burn injury was investigated after controlling for other determinants of outcome (ie, injury, distress, and preburn quality of life).

METHODS: The postburn quality of life (2-months postdischarge) of groups with and without body image dissatisfaction was studied after controlling for preburn quality of life (measured 2–3 days postadmission). The patient population (N = 86) was 77.9% men, had an average total body surface area burned of 17.02%, and average full-thickness burn of 6.09%. Forty percent had facial injuries, 68.6% required surgery, most were injured by flame (39.5%), and 76.8% were employed.

RESULTS: Multivariate analysis of covariance (covarying preburn level of Mental quality of life, facial injury, and size of burn) contrasting body image dissatisfaction groups found significantly lower psychosocial adjustment at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 3.61; p < .01). A second MANCOVA (covarying the preburn level of Physical quality of life and both facial injury and size of burn) found significantly lower physical functioning at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 2.78; p < .03). Adding two more covariates (depression and posttrauma distress) eliminated the effect of body image dissatisfaction on postburn Physical but not Mental adjustment.

CONCLUSIONS: Body image dissatisfaction affects quality of life after severe burn injury. Distress moderates this impact on aspects of physical but not psychosocial health.

Key Words: body image • disfigurement • burns • quality of life • morbidity

Abbreviations: BID = Body Image Dissatisfaction, significant distress relatedto body image (ie, above the median SWAP); non-BID = not havingappreciable body image dissatisfaction (ie, scoring below the medianSWAP); DTS = Davidson Trauma Scale; MANCOVA = multivariateanalysis of covariance; TBSA = total body surface area; TBSA-FT = total body surface area with a full-thickness burn; SF-36 = The SF-36 Health Survey; SWAP = Satisfaction WithAppearance Scale.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
Few studies have explored populations at risk for body image dissatisfaction due to disfiguring changes in appearance secondary to illness or injury (1, 2). One of the most frequent sources of disfigurement is burn injury (3). Unlike many other disfiguring conditions, burn injuries allow researchers to examine body image changes after a discrete, circumscribed event.

The scarring, disfigurement, deformity, and loss of function that results from a severe burn injury is likely to lead to significant perceptual and subjective body image changes (3). Deformities or disfigurement of the face and other exposed areas may be obvious sources of distress. Scarring or disfigurement of areas such as the genitalia may be less apparent, but still is highly relevant to body image satisfaction or self-esteem. In any case, changes in appearance or function may result in altered body image perception, a decrease in body image satisfaction, and behavioral avoidance.

Burn survivors vary in their adjustment after recovery from the acute effects of burn injury. Burn injury often leads to at least temporary reduction in social involvement (4) and vocational activity, with 50% to 60% of individuals requiring a change in employment status (5). Decreased sexual satisfaction, particularly for women, may also occur and seems to relate to physical dysfunction and body image more than burn size or location (6). Postburn adjustment is also affected by factors such as a history of preburn psychiatric disorder (7). Although previous reviews of the empirical literature suggest that the majority of burn injury survivors are well adjusted after 1 year (5, 8), studies have suggested that a significant minority of burn survivors report a diminished quality of life (9, 4), dissatisfaction with appearance (10), and social or occupational difficulties (11). The absence of information regarding preinjury adjustment complicates the interpretation of these findings.

Preburn physical and psychological quality of life are poorly understood determinants of postinjury adjustment. Previous research findings indicate that patients with burn injuries have high rates of psychiatric and social problems before injury (12, 13). Perhaps not surprisingly, preburn alcohol abuse, substance abuse, and mood disorders often predict poor adjustment for burn survivors (7, 14). Because of variability in outcome and the mixed findings regarding the importance of preburn adjustment, researchers may be better able to identify burn survivors who are at greater risk for poor adjustment by examining the impact that known secondary complications have on later adjustment. One such secondary complication, body image dissatisfaction, is examined in this study.

No published study has examined the impact of BID on quality of life among disfigured patients after taking into account their preinjury levels of psychological and physical adjustment. Previous work has not measured body image directly and has assumed that body image is a concern among all of those who have experienced changes in their appearance. However, recent work suggests that body image distress is independent of indices of injury severity (12) and that body image can be reliably measured in burn-injured patients (15).

This study investigated health-related quality of life among groups that differed in the amount of body image dissatisfaction after burn injury. We hypothesized that after controlling for both preburn quality of life and injury-related variables, patients with body image dissatisfaction at the time of discharge would report poorer psychosocial and physical quality of life at 2-month follow-up. Because state negative affectivity can influence self report (16) and subjective body image (17), we also hypothesized that body image dissatisfaction would reduce postburn quality of life after controlling for depression and posttrauma distress in addition to preburn quality of life. Finally, we hypothesized that the preinjury health-related quality of life of individuals who developed body image dissatisfaction after burn injury would be lower than the group that did not develop body image dissatisfaction and also lower than published normative data.

	METHODS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
Participants
The participants were a consecutive series of adult burn survivors (N = 86) who were admitted to the Baltimore Regional Burn Center at the Johns Hopkins Bayview Medical Center. They included 86 adult burn patients (67 men and 19 women) with a mean age of 42.4 years (SD, 14.7). The sample was 70.5% European American and 29.5% African American. The mean number of years of education was 11.59 (SD, 2.69), and 76.8% were employed at the time of their injury. The average TBSA of the burn was 17.02 (SD, 18.07), with an average full-thickness burn component (ie, third degree burns, TBSA-FT) of 6.09% (SD, 11.58). Approximately 40% had facial injuries and 68.6% required surgery; most were injured by flame (39.5%) or scalding (32.6%).

Measures
Satisfaction With Appearance Scale.
The SWAP (15) includes four dimensions: satisfaction with facial appearance, other body parts, social discomfort, and social impact of burn scars. The SWAP has demonstrated good discriminant and convergent validity as well as good retest reliability (15). There are 14 items on which patients make ratings using a seven-point scale. High scores indicate greater dissatisfaction with appearance and poorer body image.

Davidson Trauma Scale.
The Davidson Trauma Scale (18) is a 17-item measure in which patients rate both the frequency and severity of all the posttraumatic stress symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (19). Patients make their ratings on a frequency scale ranging from zero (not at all) to four (everyday) and severity ranging from zero (not at all distressing) to four (extremely distressing). The DTS has proven to be both a reliable and valid measure of PTSD symptoms among burn survivors (20), survivors of childhood sexual abuse (21), and rape, combat, and natural disaster survivors (18).

Beck Depression Inventory.
The Beck Depression Inventory (22, 23) is a 21-item measure. Individuals select which of four statements reflect progressively more severe symptomatology.

SF-36 Health Survey.
The SF-36 (24) is a 36-item measure of quality of life, including physical and mental health. The Physical domain subscales are physical functioning, role problems, bodily pain, and general health. The Mental domain subscales are vitality, social functioning, problems with work and daily activities due to emotional problems, and general mental health. High scores on the SF-36 indicate greater satisfaction and healthy functioning. The SF-36 is currently the most widely used measure of general health-related quality of life in medical settings and has excellent psychometric properties (24).

Procedure
The SF-36, depression, and trauma scales were administered during the first 72 hours of accessibility after admission. Patients were asked to describe their health-related quality of life "during the month before being burned." The time frame for the depression and trauma scales was the participant’s experience since the injury. The SWAP was administered 1 week after discharge with instructions to describe body image dissatisfaction since being discharged from the hospital. The SF-36 was readministered 2 months after discharge, with instructions to describe their health-related quality of life "in the past month."

Statistical Analysis
A median split on the SWAP at 1 week postdischarge was used to define groups high (BID group) and low (non-BID group) on body image dissatisfaction. Group differences in psychological distress and injury descriptors were examined using t tests on TBSA, TBSA-FT, age, and baseline Beck Depression Inventory and DTS scores. ² analyses compared the frequency of facial injury, surgery, and genitalia involvement among BID and non-BID groups. Preburn vulnerabilities and postburn deficits among individuals high in body image dissatisfaction were examined by contrasting the groups with each other and with published norms (men and women ages 35–44 years) using t tests for unequal sample sizes.

MANCOVA was used to examine body image dissatisfaction as an independent determinant of postburn adjustment by contrasting body image groups on the 2-month postdischarge SF-36 subscales while controlling for preburn levels on the same SF-36 subscales and both TBSA and facial involvement. Two separate MANCOVAs examined the Mental domain subscales and the Physical domain subscales. The potential moderating effect of state negative affect was examined using additional MANCOVAs that controlled for baseline depression, posttrauma distress, preburn quality of life, and size and location of the injury.

	RESULTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
Demographic, Injury Characteristics, and Distress Levels of the Body Image Groups
Body image groups differed in the size of the burn (TBSA: t = 2.67; p < .001) but not on size of full-thickness burn or average age (Table 1). High body image dissatisfaction was associated with larger burns. The body image groups also differed significantly in severity of depressed symptoms (Beck Depression Inventory: t = 4.39; p < .001) and posttrauma distress (DTS: t = 8.26; p < .001) measured at baseline (Table 1). Similarly, the BID group had a higher incidence of facial burns (² = 16.46, p < .001) than the non-BID group, but the groups did not differ on the rate of genital involvement (² = 0.67, p = NS) or surgical intervention (² = 0.18, p = NS).

Physical Domain.
The addition of baseline depression and posttrauma distress to the set of covariates removed the effect of body image on 2-month health-related quality of life in the Physical domain. (F = 1.71, p < .16).

Preburn Quality of Life Relative to Normative Groups
Compared with published norms for individuals aged 35 to 44 years old, the BID group reported higher quality of life in the areas of social functioning, (t = 1.71, p < .05) and bodily pain (t = 3.81, p < .01). The non-BID group reported higher quality of life than the published norms on mental health (t = 3.93, p < .01), vitality (t = 2.68, p < .01), social functioning (t = 1.69, p < .05), and general health (t = 1.68, p < .05). The preburn SF-36 Physical domain scores of the BID group differed only in bodily pain. The preburn SF-36 Physical domain scores of the non-BID group differed only in general health. It should be noted that all significant preburn differences between the body image groups and published norms (24) indicated that the body image groups reported higher functioning and fewer problems.

Postburn Quality of Life Relative to Normative Groups
Compared with published norms for individuals aged 35 to 44 years old, at 2 months postburn, the BID group reported significantly lower quality of life than the published normative data on mental health (t = 2.56, p < .01), vitality (t = 3.72, p < .01), general health (t = 2.96, p < .01), physical functioning (t = 5.52; p < .01), role interference due to physical problems (t = 12.79; p < .01), and bodily pain (t = 10.36; p < .01). The non-BID group reported significantly higher quality of life than the published norms on mental health (t = 14.76, p < .01) and vitality (t = 11.17, p < .01). The non-BID group also reported significantly lower quality of life than published normative data on physical functioning (t = 4.63; p < .01), role interference due to physical problems (t = 6.96; p < .01), and bodily pain (t = 8.63; p < .01).

All significant postburn differences between body image groups and published norms in the Physical domain indicated that both of the body image groups reported lower functioning and more problems. However, the non-BID group reported higher functioning on the mental domain subscales, whereas the BID group reported lower Mental domain functioning relative to the published norms (24) (Table 4).

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

Our most important finding is that early body image dissatisfaction makes a clinically unique contribution in determining subsequent mental health–related quality of life among patients after disfiguring injuries. Mental domain adjustment is affected by body image dissatisfaction above and beyond the impact of baseline quality of life, injury severity, and negative affect (ie, depression and trauma-specific distress). Although body image is a clinically recognized determinant of adjustment in other populations, the current findings empirically demonstrate the significant negative impact of BID on quality of life in a representative sample of burn survivors.

These findings are even more striking when considering that those with significant body image dissatisfaction were identified using a median split of the Satisfaction With Appearance Scale. However, because SWAP scores were positively skewed, some individuals in the BID group may actually be reporting relatively low levels of distress. Even with conservative parameters, multiple covariates and a comparison group with only relatively less body image distress, body image remains an independent determinant of adjustment.

It is interesting to examine more closely the pattern of preburn SF-36 scores of BID individuals to non-BID subjects and to the published normative data. Before the injury, the non-BID group scored above the published normative data on four subscales, whereas the BID group was above the norms on only two subscales. Additionally, the non-BID group had Mental domain scores that changed little from pre- to postinjury, whereas there was a marked decrease in adjustment across these time points in the BID group (Table 4). Perhaps the non-BID groups’ relatively good postburn adjustment is a function of their having been atypically well adjusted before the injury.

Body image group differences in cognitive biases in information processing is a fruitful area for further investigation. For example, depressed individuals have been shown to be accurate in their appraisals, whereas nondepressed subjects overestimate both control and performance (25, 26). The self-reported preburn adjustment of those who did not develop body image dissatisfaction was above the normative sample and may reflect a greater focus on positive aspects (27).

Physical problems may influence the development of body image dissatisfaction in vulnerable individuals (ie, physical condition affecting psychological disturbance) (28). For example, it may be that those individuals who appraise their injuries as worse because of location (ie, more physically unattractive because of facial burns) or severity (ie, larger TBSA) are at greater risk of developing body image dissatisfaction. On the other hand, cognitive factors may interact with the objective aspects of the burn to worsen the appraisal of physical impairment after a burn injury (ie, psychological disturbance affecting physical condition) (28). Our data suggest that after controlling for the effect of distress, body image dissatisfaction is not related to subsequent physical functioning. Thus, it may be that individuals who initially develop body image dissatisfaction are more prone to appraise their physical impairment as a function of early distress. Alternatively, it may be that a third variable (eg, trait neuroticism) (29) determines self-report of early distress, body image dissatisfaction, and physical impairment. The findings of the present study suggest the importance of developing interventions for individuals who already have body image dissatisfaction as well as preventative interventions for groups at risk (eg, patients with a larger TBSA or facial burns). A number of cognitive-behavioral treatments have been developed and demonstrated to be efficacious in treating (1) or preventing (30) body image dissatisfaction. Unfortunately, no controlled studies have been completed involving individuals with disfiguring injuries.

The present study is limited by a number of factors. Primarily, this study examined quality of life during the acute period of wound healing and scar maturation (31). Whether body image continues to play a role in quality of life as individuals continue to heal is unknown. As individuals’ disfigurement decreases or at least stabilizes, one might assume that body image dissatisfaction would decrease and thus quality of life would improve. Because the BID group had more severe injuries (ie, larger TBSA and more frequent facial involvement) and therefore would take longer to reach maximum medical improvement, it might be expected that their adjustment scores would remain depressed for a longer period.

The relation between baseline body image distress and self-reported quality of life might be different if follow-up were done at a later point in time when processes such as wound healing, physical reconditioning, and scar maturation are further along. Conversely, as physical changes stabilize and permanent disfigurements are more evident, body image dissatisfaction may emerge among those who were initially relatively well adjusted during the acute period when appearance and functional outcomes were more ambiguous. This study does not assess other factors likely to affect the development and chronicity of body image dissatisfaction and of moderating its impact on adjustment. For example, there were no measures of avoidance in social, familial, and occupational situations. Such avoidance may result in patients never successfully desensitizing to their own or other’s reactions to changes in their appearance. Future studies should examine such patients in a longitudinal manner to discern the long-term risk factors for and implications of both early and late body image dissatisfaction. An additional limitation is the lack of an objective measure of disfigurement. Lacking an objective measure, it is not known whether patients’ assessments of their appearance are realistic or reflect perceptual body image disturbances. Future work should incorporate such objective indices.

	ACKNOWLEDGMENTS

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 
Funded by the US Department of Education, National Institute on Disability and Rehabilitation Research (H133A970025–98); the International Association of Firefighters - Burn Fund; and the National Institute of Mental Health (1 R03 MH59639–01).

Received for publication July 27, 1998.

Revision received January 14, 2000.

	REFERENCES

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES

 

1. Cash TF, Pruzinsky T. Body images: development, deviance, and change. New York: Guilford; 1990.
2. Heinberg LJ. Theories of body image: perceptual, developmental, and sociocultural factors. In: Thompson JK, editor. Body image, eating disorders, and obesity: an integrative guide to assessment and treatment. Washington DC: American Psychological Association; 1996. p. 27–48.
3. Bernstein NR. Objective bodily damage: disfigurement and dignity. In: Cash TF, Pruzinsky T, editors. Body images: development, deviance, and change. New York: Guilford; 1990.
4. Browne G, Byrne C, Brown B, Pennock M, Streiner D, Roberts R, Eyles P, Truscott D, Dabbs R. Psychosocial adjustment of burn survivors. Burns Incl Therm Inj 1985; 12: 28–35.
5. Patterson DR, Everett JJ, Bombardier CH, Questad KA, Lee VK, Marvin JA. Psychological effects of severe burn injuries. Psychol Bull 1993; 113: 362–78.[Medline]
6. Tudahl LA, Blades BC, Munster AM. Sexual satisfaction in burn patients. J Burn Care Rehabil 1987; 8: 292–3.[Medline]
7. Fauerbach JA, Lawrence J, Haythornthwaite J, McGuire M, Munster AM. Preinjury psychiatric illness and postinjury adjustment in adult burn survivors. Psychosomatics 1996; 37: 547–55.[Abstract/Free Full Text]
8. Tarnowski KJ, Rasnake LK, Gavaghan-Jones MP, Smith L. Psychological sequelae of pediatric burn injuries: a review. Clin Psychol Rev 1991; 11: 371–98.
9. Sheffield CGI, Irons GB, Mucha PJ, Malec JF, Ilstrup DM, Stonnington HH. Physical and psychological outcome after burns. J Burn Care Rehabil 1988; 9: 172–7.[Medline]
10. Korloff B. Social and economic consequences of deep burns. In: Wallace AB, Wilkinson AW, editors. Research in burns: transactions of the 2nd International Congress on Research in Burns. Edinburgh, Scotland: Livingstone; 1996.
11. Blumenfield M, Reddish PM. Identification of psychologic impairment in patients with mid-moderate thermal injury: small burn, big problem. Gen Hosp Psychiatry 1987; 9: 142–6.[Medline]
12. Heinberg LJ, Fauerbach JA, Spence RJ, Hackerman F. Psychologic factors involved in the decision to undergo reconstructive surgery after burn injury. J Burn Care Rehabil 1997; 18: 374–80.[Medline]
13. Pruzinsky T, Rice LD, Himel HN, Morgan RF, Edlich RF. Psychometric assessment of psychologic factors influencing adult burn rehabilitation. J Burn Care Rehabil 1992; 13: 79–88.[Medline]
14. Fauerbach JA. Preburn psychiatric history affects posttrauma morbidity. Psychosomatics 1997; 38: 374–85.[Abstract/Free Full Text]
15. Lawrence J, Heinberg LJ, Roca A, Munster AM, Fauerbach JA. Development and validation of the Satisfaction with Appearance Scale: assessing body image among burn-injured patients. Psychological Assessment 1998; 10: 64–70.
16. Watson D, Pennebaker JW. Health complaints, stress and distress: exploring the role of negative affectivity. Psychol Rev 1989; 96: 234–54.[Medline]
17. Thompson JK. Body image disturbance: assessment and treatment. Elmsford NY: Pergamon Press; 1998.
18. Davidson J, Book SW, Colket JT, Tupler LA, Roth S, David D, Hertzberg M, Mellman T, Beckham JC, Smith RDDRM, Katz R, Feldman ME. Assessment of a new self-rating scale for Post-Traumatic Stress Disorder. Psychol Med 1997; 27: 153–60.[Medline]
19. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington DC: American Psychiatric Association; 1994.
20. Lawrence J, Fauerbach JA, Richter D, Munster AM. Construct validity of the Davidson PTSD scale in an inpatient burn population: proceedings of the American Burn Association. St. Louis MO: Mosby-Year Book; 1996.
21. Zlotmick C, Davidson J, Shea MT, Perlstein T. The validation of the Davidson Trauma Scale (DTS) in a sample of survivors of childhood sexual abuse. J Nerv Ment Dis 1996; 184: 255–7.[Medline]
22. Beck AT, Ward E, Mendelson M, Mock J, Erlbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 77–100.
23. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988; 8: 219–47.
24. Ware JE, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: manual and interpretation guide. Boston MA: Nimrod Press; 1993.
25. Alloy LB, Abramson LY. Judgment of contingency in depressed and nondepressed students: sadder by wiser? J Exp Psychol Gen 1979; 108: 441–85.[Medline]
26. Alloy LB, Abramson LY. Learned helplessness, depression, and the illusion of control. J Pers Soc Psychol 1982; 42: 1114–26.[Medline]
27. Ingram RE, Miranda J , ZV Segal. Cognitive vulnerability to depression. New York: The Guilford Press; 1998. p. 64.
28. Cohen S, Rodriguez MS. Pathways linking affective disturbances and physical disorders. Health Psychol 1995; 15: 374–80.
29. Costa PTJ. Hypochondriasis, neuroticism, and aging. When are somatic complaints unfounded? Am Psychol 1985; 40: 19–28.[Medline]
30. Stormer S, Thompson JK. Explanations of body image disturbance: a test of maturational status, negative verbal commentary, social comparison, and sociocultural hypotheses. Int J Eat Disord 1996; 19: 193–202.[Medline]
31. Schwanholt CA, Ridgway CL, Greenhalgh DG, Staley MJ, Gaboury TJ, Morress CS, Walling SJ, Warden GD. A prospective study of scar maturation in pediatrics: does age matter? J Burn Care Rehabil 1994; 15: 416–20.[Medline]

This article has been cited by other articles:

				M. B. Mechanic, T. L. Weaver, and P. A. Resick Mental Health Consequences of Intimate Partner Abuse: A Multidimensional Assessment of Four Different Forms of Abuse Violence Against Women, June 1, 2008; 14(6): 634 - 654. [Abstract] [PDF]

				J. A. Fauerbach, J. McKibben, O. J. Bienvenu, G. Magyar-Russell, M. T. Smith, R. Holavanahalli, D. R. Patterson, S. A. Wiechman, P. Blakeney, and D. Lezotte Psychological Distress After Major Burn Injury Psychosom Med, June 1, 2007; 69(5): 473 - 482. [Abstract] [Full Text] [PDF]

				W. G. J. M. van Lankveld, M. C. Vonk, H. Teunissen, and F. H. J. van den Hoogen Appearance self-esteem in systemic sclerosis--subjective experience of skin deformity and its relationship with physician-assessed skin involvement, disease status and psychological variables Rheumatology, May 1, 2007; 46(5): 872 - 876. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fauerbach, J. A. Articles by Muehlberger, T. Search for Related Content PubMed PubMed Citation Articles by Fauerbach, J. A. Articles by Muehlberger, T. Related Collections Consultation Psychiatry Stress and Coping