Psychiatric Disorders Associated With Burn Injury

Introduction

All members of the burn treatment team should have a basic knowledge of psychiatric problems because they commonly occur and often play a central role in burn recovery. It is useful to have mental health professionals as integrated members of the team because their expertise and skills are often needed in the management of patients with burns to screen and identify problems and to assist in the treatment of the multitudes of psychiatric and psychological issues concomitant to burns.

Preexisting psychiatric disorders and symptoms are relatively common in the histories of burned patients and frequently appear to have contributed significantly to the etiology of the injury itself. The converse is also true.

In addition to premorbid disorders, a number of patients will develop psychiatric symptoms during acute treatment for burns, as also can be seen after other major trauma. Pain, itching, and stress during hospitalization can contribute to problems during acute treatment, such as sleep disorders and depression, starting a vicious circle. Dissociation and anxiety experienced during the burn have been shown to predict later psychopathology. While it is understandable to expect patients with major burns to be at risk, even minor burns can result in significant psychological distress and psychiatric symptoms.

At present, there is no profile that can reliably predict and identify which patients will suffer psychiatric symptoms following burns. Furthermore, there is a clear risk that patients will not actively seek help for psychological distress or psychiatric symptoms, and this can have a strong effect on outcome and rehabilitation. All members of the burn team should be aware of this risk and be observant of signs or symptoms.

This chapter will focus on the recognition and treatment of common mental disturbances that can be expected to occur in patients suffering serious burns. This includes specific attention to both pediatric as well as adult patients, and it is important to be aware that symptoms and signs may differ between ages. Also, preexisting psychopathology may alter the expression of a patient's distress and complicate medical management of the patient.

In the following text ICD-10 codes can be found in parentheses after each diagnosis.

Preexisting Factors

Psychiatric morbidity greatly increases the risk of sustaining an injury, either directly (e.g., self-inflicted burns or suicide attempts) or indirectly through problems in impulse control (e.g., conduct disorders), by reducing vigilance or affecting judgment (e.g., substance abuse disorders, depression). The knowledge of preexisting psychiatric problems is important for burn care mainly for two reasons: first, to better understand and identify psychiatric symptoms occurring during treatment and to recognize them as ongoing or reactivated problems instead of reactions to the injury; and second, to increase awareness of potential difficulties during rehabilitation (for a comprehensive review refer to McKibben et al. ).

Patients with preinjury psychiatric disorders have been observed to require longer hospitalization, they more frequently experience complications during treatment and problems with rehabilitation and postburn adjustment, and they have a higher risk of developing other psychiatric disorders (e.g., posttraumatic stress disorder; PTSD).

Psychiatric morbidity is common in burn patients. Two-thirds of all patients with burns have a lifetime history of at least one psychiatric disorder, 50% had a psychiatric disorder in the year before injury, and one-third have an ongoing psychiatric disorder at the time of injury. Patients with preexisting psychiatric morbidity have a higher risk of sustaining a preventable injury, and, in individuals with psychotic disorders, self-inflicted burns are overrepresented.

The most frequent preexisting psychiatric disorder in burn patients is the mood disorder major depression, which is present in up to 42% of individuals, a proportion much higher than in the general population. Smoking (i.e., substance use disorder, tobacco use disorder; Z72.0 or F17.2x), has been shown to increase the risk of burns; smoking more than 10 cigarettes a day increases the risk of burns by up to sixfold. Similarly, other substance use disorders (e.g., the stimulant drug methamphetamine or the use of highly volatile and flammable substances) increase the risk of sustaining a burn.

Personality disorders are also overrepresented in burn patients compared to the general population, and persons who score high on the personality traits neuroticism and extraversion appear to have a higher risk of injury. In addition, persons with dementia have a higher age-standardized incidence rate of burns than do those without dementia (22.7 vs. 14.2 per 100,000 inhabitants), and they have a longer length of hospital stay.

Disorders in Children and Adolescents

Psychiatric morbidity can increase the risk for burns in children and adolescents, and specific psychiatric disorders have been found to occur more frequently in pediatric burn survivors than in the general population. Commonly pediatric burn survivors may not exhibit symptoms of prior psychiatric disorders during the acute phase of treatment due to the impact of injuries and other treatments. When symptoms are evident, continuation of prior treatment or implementation of indicated treatment for a preexisting psychiatric disorder may not only control symptoms but also facilitate patient participation and cooperation with acute care and long-term rehabilitation.

Repeated inhaling of psychoactive volatile hydrocarbons from, for example, glue, fuels, or paint (“sniffing”) can be classified as inhalant use disorder (F18.x). This disorder can result in burns because many of the substances are flammable. Inhalant use disorder is most common in adolescents, whereas prevalence declines rapidly in adulthood.

Across cultures attention-deficit/hyperactivity disorder (ADHD, F90.x) in children has a prevalence of about 5%. One of the key features of ADHD is impulsivity (i.e., actions without forethought), which can expose the individual to high-risk situations, and children with ADHD have repeatedly been shown to be at greater risk for burns.

Conduct disorders (F91.x) encompass repetitive and persistent behavioral patterns of violations of social norms and rules. Childhood-onset conduct disorder often is concurrent with ADHD, and individuals displaying this subtype (in contrast to adolescent-onset type) often display physical aggression; thrill-seeking and recklessness are frequent personality features. In this context, playing with fire and fire-setting can be symptoms of conduct disorder and can result in burns. Conduct disorders have a prevalence of around 4%, and the childhood-onset subtype has a worse prognosis with risk for adulthood psychiatric morbidity.

In contrast, pyromania (F63.1) is a specific conduct disorder in which deliberate and purposeful fire-setting occurs not as an aggression but in a setting of tension or affective arousal. This repeated fire-setting behavior increases the risk for burns, both for the individuals and those around them. Possibly the prevalence of pyromania may be underestimated; it has been observed that a slight majority of individuals with pyromania restrict their fire-setting to controlled situations, such as controlled fires on their own property, and therefore can remain “undetected.” The prevalence of pyromania as a comorbidity has been found to be 3–7%. There is limited knowledge about the time course of pyromania. It has been postulated that the disorder is rare in children and begins in late adolescence but that some individuals “switch” to other impulsive, reward-seeking behaviors.

Social Considerations in Pediatric Burns

Clearly parental and family characteristics can increase both the risk for burns in children as well as influence their subsequent recovery and outcome. The presence of child abuse or neglect can directly result in pediatric burns. The presence of parental anxiety, depression, poor coping skills, or lack of social support at the time of injury are associated with poorer functional outcome in pediatric burn survivors. Possibly high parent state anxiety in combination with ineffective coping strategies rather than family functioning or burn severity can be most predictive of pediatric burn outcome.

Parents face numerous emotional challenges not only due to the psychological trauma of their children's burns, but also during subsequent treatment and recovery. Parents report more feelings of anxiety and being stressed, depressed, and guilty than the normal reference population even in areas unrelated to their children. These stresses can result in psychiatric disorders in parents up to 2 years after the injury, with mothers at greater risk for developing mental health problems and depressive and posttraumatic stress symptoms. Increased risk for depression was associated with having an only child or multiple offspring injured and with complicated burn injuries (secondary infection or amputation). Larger burns and the presence of parent–child conflict, parental dissociation, or PTSD symptoms in the child are strongly correlated with parental PTSD symptoms. This emphasizes the need for psychological attention to parents of burned children, as well as to the children themselves. As child and parent ratings do not always match, recent studies suggest that burn centers adopt a family perspective and include assessments of both parents and children.

Self-Inflicted Burns and Suicide Attempts

The proportion of self-inflicted burns differs across the world: whereas it is between 1% and 9% in North America and Europe with no clear gender distribution, self-inflicted burns are a major cause of burns in females in the Middle East, Africa, and south Asia, with a prevalence of up to 28%. Of patients with self-inflicted burns, those attempting suicide are more likely to have larger burns and longer hospitalizations than those with the intent of self-mutilation. Across cultures psychiatric morbidity is an important additional risk factor, often in conjunction with social stress factors such as marital problems or unemployment.

In-Hospital Contributing Factors and Disorders

Several problems during acute burn treatment can affect the course of treatment and the eventual outcome after burns. Pain, itching, and sleep disorders are caused by both the injury and its treatment. High levels of stress and anxiety may contribute to the development of psychiatric morbidity (e.g., PTSD). In patients with substance-related disorders (F10.x–F19.x), withdrawal symptoms can occur during acute care, and patients with preinjury substance abuse have a higher risk of developing psychiatric symptoms during and after acute care. There is evidence that, in the case of comorbidity of PTSD and substance-related disorders, concurrent treatment of both disorders is necessary to achieve improvement.

After the initial postburn period patients will undergo a series of operative procedures or dressing changes interspersed with physical therapy. Constant pain or the sure knowledge of repeated painful episodes in the near future and feelings of anxiety and powerlessness are predominant because every movement, even shifting position and change of bedclothes, is painful. Therefore treatment and the experience of hospitalization may be as traumatic psychologically as the original burn. Patients who experience high levels of pain not only have a higher risk of poor adjustment and psychiatric problems after discharge, but wound healing also can be affected due to stress. Furthermore, high levels of stress, anxiety, and PTSD decrease pain tolerance.

Itching is a common problem during wound healing and scar maturation, and it can cause considerable distress and anxiety. Persistent itching can disrupt sleep, which increases stress levels and also impairs everyday functioning and participation in rehabilitation. Anxiolytic, antidepressant, and antipsychotic agents have been used successfully to reduce itch.

Significant sleep problems are common during and after treatment for acute burns. The noise and light on the unit and interruptions for treatment will disrupt sleep. Pain, anxiety, and itching can disrupt sleep or affect sleep quality. Symptoms of stress and PTSD (e.g., nightmares) can both cause awakening and a fear of going back to sleep. Pain severity during hospitalization has been shown to predict insomnia after discharge, and insomnia in turn predicts long-term pain. Burn patients who experience poor sleep at night will also have lower pain tolerance during the day.

Acute Stress Disorder and Posttraumatic Stress Disorder

In the course of the progression from the Diagnostic and Statistical Manual of Nervous and Mental Disorders, Fourth Edition (DSM-IV) to DSM-5, ASD (F43.0) and PTSD (F43.10) no longer are regarded as anxiety disorders; they are now listed as a separate group called trauma- and stressor-related disorders: an overanxious patient is afraid of what might happen, whereas the patient with PTSD reexperiences and fears what has happened. The patient with PTSD is stuck in a heightened perception of threat and uses avoidant behaviors that maintain the symptoms.

ASD is the most common psychiatric disorder seen in survivors of major burns, in addition to PTSD, and it has a prevalence as high as 19% after burns. ASD symptoms appear immediately following the trauma, last for at least 3 days, and usually resolve within a month after the trauma.

In contrast to PTSD, dissociative symptoms can be present. Whereas these symptoms previously (i.e., in DSM-IV) had been given a central role for the diagnosis, it is now understood that some individuals develop ASD without dissociative symptoms.

In children, repetitive reenactment of the traumatic event in play can be a symptom of intrusion and/or dissociation.

The presence of avoidant symptoms during the acute phase of recovery has been shown to predict chronic posttraumatic disorder in burn patients. It is of great importance to recognize symptoms of ASD and PTSD at an early stage because the former has been shown to be a predictor for PTSD, and, once PTSD is established, it usually will persist.

PTSD is, in addition to depression and general anxiety disorder (GAD), one of the most common psychiatric disorders seen in survivors of major burns with prevalence rates ranging between 7% and 45%. In DSM-5 behavioral symptoms of PTSD encompass four instead of the previous three clusters: (B) intrusion, (C) avoidance, (D) negative cognition and mood—this is the new cluster—and (E) arousal (which in DSM-IV was the D cluster). Aggressive, reckless, or self-destructive behaviors are now recognized as aspects of arousal. The DSM-5 definition of PTSD no longer differentiates between acute and chronic PTSD. Instead, two new subtypes of PTSD are identified in DSM-5: PTSD in children younger than 6 years (PTSD preschool subtype) and PTSD with prominent dissociative symptoms (PTSD Dissociative subtype) (for a review of the changes, see reference ).

About one-third of burn survivors develop PTSD within 2 years of their injury, and this was true for even small burns. Individuals should be interviewed about sleep patterns and startle response because nightmares and altered sleep patterns are usually the symptoms first noted. In fact, in adults, it has been shown that one of the most important piece of information when screening for PTSD is nightmares. Another potential marker for ASD and PTSD is heart rate at admission to the burn unit, although it appears to be mediated by gender. A significant number of burn survivors will experience PTSD symptoms, including intrusive memories of the injury, during their acute recovery. Children may express intrusive symptoms by reenactment of the traumatic event, and nightmares may not be directly related to the event.

The presence of avoidant PTSD symptoms during the acute phase of recovery is reported to predict chronic PTSD in burn patients.