Burn injuries remain a global health problem; fortunately, great advances in burn care have stifled the mortality, morbidity, and disability of burn patients. Serious psychosocial and psychological sequelae still remain a common complication of the trauma experience. Depression, anxiety, acute stress disorder (ASD), and posttraumatic stress disorder (PTSD) are common occurrences after burn injuries and require a multidisciplinary team evaluation for management. Furthermore, psychiatric illness and substance abuse are well described risk factors for burn injuries, and treatment of these patients can be complicated by psychosis, withdrawal, agitation, severe depression, suicidality, and violence.

Current literature shows that preexisting psychiatric illnesses are associated with delayed wound healing, increased surgical interventions, prolonged hospital stays, and slower rehabilitation. Today, mental health professionals are integrated members of the treatment team in all American Burn Association-verified major burn centers. Their skills are crucial to addressing psychiatric and psychological sequelae stemming from the burn injuries as well as the myriad of preexisting psychiatric disorders frequently present in the burned patient population.

The first line of care for burn injuries is medical and caters to physical injuries. Psychiatric and psychological support of the burn patient follows and should be an early and routine component of management. With improvements in mortality, outcomes are focused on measures of functioning, adjustment, and community integration. Severely burned patients can return to the community and adjust well; however, some burn patients will develop clinically significant psychological disturbances.

The aim of this chapter is to help identify the psychological ramifications of patients with burn injuries as early as possible and to develop a trauma-informed multidisciplinary team approach to address the acute postburn symptomatology as well as the long-term psychological recovery. Adaptation and reintegration into society can be a lengthy process for patients whose quality of life has been compromised; thus the long-term presence of mental health professionals in the lives of burn victims is of utmost importance.

Acute stress disorder (ASD) is the most common psychiatric disorder seen in survivors with major burns. ASD is characterized by acute stress reactions occurring in the first month after a person has been exposed to a traumatic event. These include intrusive thoughts, negative mood, hyperarousal, and frequent dissociation. It is important for the healthcare provider to know that early identification and treatment of this condition can minimize subsequent PTSD.

PTSD is usually diagnosed after 1 month of the original traumatic injury, and its prevalence in burn patients has been estimated in different studies to be between 5% and 58%. Individuals with PTSD are hypothesized to develop cognitive and behavioral avoidance strategies to avoid distressing emotional reactions. The presence of these avoidance responses can interfere with the natural processing of negative emotions and fear extinction.

Risk factors associated with PTSD include preburn history of depression or previous traumatic experiences, female sex, younger age, anxiety related to pain and disfigurement, socioeconomic status and its correlation to education and financial security, lack of social support, and abusive interpersonal relationships. ^,

As with ASD, PTSD typically develops after a person experiences or is exposed to one or several traumatic experiences. Symptoms of PTSD are categorized into four symptom clusters: Experiential, in which the patient experiences the trauma through flashbacks, nightmares, or intrusive memories of the trauma, Avoidant stays away from or tries not to think about reminders of the trauma, including people, places, or situations. Alteration of mood (lapses in memory, negative beliefs about self/others/the world, anhedonia, loneliness and isolation from others), and Arousal symptoms including (hypervigilance, irritability, being easily startled and insomnia).

Please note, ASD has the same symptom profile as PTSD but can be differentiated by the onset and duration of symptoms. ASD is diagnosed between 3 days and 1 month when the previously mentioned symptoms are present; PTSD is diagnosed if symptoms persist for more than 4 weeks.

Other psychiatric diagnoses frequently encountered in patients with traumatic burn injuries include generalized anxiety disorder (GAD) and major depressive disorder (MDD). GAD is characterized by excessive worries and difficulty controlling anxious feelings that interfere with daily activities. It is diagnosed when symptoms persist for more than 3 months, and it is not unusual to see exacerbation of the symptoms when patients return to the hospital for follow-up procedures and reconstructive surgeries. Bedside procedures can be significant triggers for anxiety on some patients and may require therapeutic interventions and medication.

Depression is a mood disorder that impacts an individual’s emotions, daily functioning, and cognition. According to the Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition, Text Revision (DSM-5-TR), symptoms of major depression may include depressed mood, diminished interest or pleasure in activities, significant weight or appetite changes, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to concentrate, and recurrent thoughts about death. Children and adolescents may display an irritable mood instead of depressed mood and may fail to gain weight.

Premorbid anxiety and depression are the most important risk factors for developing anxiety or depression after a burn. Diagnosing depression is not a simple task because the patient’s mood will be greatly affected by pain and physical distress. In many cases depression is compounded by grief in relation to personal losses. Those could be material, such as homes lost in fires, or personal, such as disfigurement or amputations. The intense grief that accompanies the loss of loved ones in a fire or an accident can be one of the most severe complications mental health professionals encounter in the acute burn setting. The prevalence of long-term depression after 1 year of discharge from a Burn Center ranges from 9% to 23%.

Upon identification of the presenting psychiatric symptoms, targeted assessment can be achieved with diagnosis-specific screening tools. Psychiatric conditions commonly present within the burn survivor population often have overlapping diagnostic criteria. For example, sleep disturbance and concentration difficulties are shared diagnostic criteria within MDD, GAD, and PTSD. Therefore it is important for practitioners to have access to screenings and assessments that measure these conditions more precisely.

For adult burn survivors presenting with possible features of PTSD, self-report screeners, such as the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) and the National Stressful Events Survey for PTSD–Short Scale (NSESSS-PTSD), are valid and reliable instruments to measure and track symptoms. ^, Likewise, recommended measures when assessing for MDD symptoms in adults include the Patient Health Questionnaire–9 (PHQ-9) and the Beck Depression Inventory, Second Edition (BDI-II). ^, When assessing for symptoms of anxiety in adults, the Generalized Anxiety Disorder Screener (GAD-7) and the DSM-5-TR Severity Measures, available for various anxiety disorders (GAD, panic disorder, social anxiety), can be used depending on the patient’s presenting anxiety symptoms. ^,

Outcome measures specific to children and adolescents when assessing for diagnostic relevance of PTSD include the Child and Adolescent Trauma Screener 2 (CATS-2), which has a caregiver version for ages 3 to 17, and a youth version for ages 7 to 17. There is also the NSESSS, which has both PTSD and ASD versions, both of which are normed for children ages 11 to 17. As with adults, the BDI-II is valid for children over age 13 and through age 80. The PHQ-9, modified for adolescents (PHQ-A), can be used to measure depressive symptoms in children ages 11 to 17. For younger children (ages 3–6), the Preschool Feelings Checklist (PFC) has been found to be an effective predictor of future depression diagnosis. To identify potential symptoms of anxiety in children, clinicians can administer the Screen for Child Anxiety Related Emotional Disorders (SCARED) for children ages 8 to 18, and the DSM-5-TR Severity Measures for various anxiety disorders can be used with patients ages 11 to 17.

Clinicians can use outcome measures that are specific to the burn patient population. The Satisfaction With Appearance Scale (SWAP) has been used to assess for the presence of body image concerns in burn patients and may be used to identify resulting psychological distress and disruptions in functioning as a result of burn-related disfigurement. ^, The Burn Specific Health Scale (BSHS) and the Burn Specific Pain and Anxiety Scale (BSPAS), which are both available in brief formats for ease of administration, are commonly administered to detect and track a patient’s quality of life postburn. ^,

Preinjury psychiatric morbidity, history of substance abuse, and an individual’s psychosocial functioning have major impacts on the outcome of burn injuries. Thus accurate information regarding a patient’s past history is of crucial importance in the acute postburn phase when the multidisciplinary burn team begins tailoring the treatment.

Starting treatment for ASD and PTSD as soon as possible after diagnosis may be critical in preventing chronicity. Additionally, supportive interventions, such as psychoeducation and case management, appear to be very helpful in individuals who are acutely traumatized. Please note that many patients will not seek help for psychological distress unless this is offered to them and their families.

It is important to include the patient’s support system in the treatment plan as soon as possible. Teaching families healthy recovery responses and providing support and access to family therapy and peer groups will have significant impacts in the long-term psychological recovery of patients.

Highlights of an inpatient treatment plan include the following:

• 1.

  Maintain the safety of patients and others, which is particularly relevant in deeply emotional traumas, such as suicide attempts and burn injuries caused by assault.

• 2.

  Reduce symptoms of distress related to experiencing the trauma by addressing intrusive memories, flashbacks, and nightmares.

• 3.

  Reduce hyperarousal symptoms, such as insomnia, anger, irritability, and hypervigilance.

• 4.

  Reduce avoidant behaviors that may impact posttraumatic growth, adaptation, and psychosocial functioning.

• 5.

  Address comorbidities, such as substance abuse, mood dysregulation, and other preexisting psychiatric diagnoses.

Please refer to table Stein 2023 for decision making algorithms in the treatment of adult PTSD. Stein 2023 In general terms, the combination of trauma-focused therapies and medication is the recommended approach for acute and long-term management of psychiatric conditions resulting from traumatic burn injuries.

Medications tested either to treat ASD/PTSD or to prevent development of PTSD include selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs), and both have been found to be efficacious in the treatment of PTSD by reducing all symptoms when compared with placebo. Citalopram, sertraline, and paroxetine are commonly used with good results and have a fairly benign side effect profile, including mild gastrointestinal upset, headaches, sweating, and mild to moderate sexual dysfunction. Venlafaxine is also a good alternative in patients with severe comorbid depression, and duloxetine can be an excellent option when PTSD is heightened by severe pain perception.

Although rare, some serious side effects can occur with SSRIs. For instance, citalopram in doses above 40 mg/day can cause dose-dependent QT prolongation and lead to torsades de pointes and ventricular tachycardia. It is very important to review all medications burn patients receive because patients may be on other drugs, such as opioids, tricyclics, or antipsychotics, which could cause QT prolongation when used with SSRIs or SNRIs.

SSRIs have inhibitory effects on 5-HTT and 5-HT receptors of platelets, thereby diminishing platelet aggregation, which could make this category of drugs contraindicated on some patients taking anticoagulants or who are at risk for bleeding.

There is a potential interaction between SSRIs and linezolid (Zyvox), an antibiotic commonly used among burn patients to address complex skin infections. Linezolid can reversibly inhibit monoamine oxidase, therefore increasing serotonin in CNS. Coadministration with SSRIs, SNRIs, tricyclics, or bupropion could precipitate serotonin syndrome manifested by high fever accompanied by shivering, tremors, myoclonus, sweating, tachycardia, extreme changes in blood pressure, confusion, and hallucinations. It is recommended to avoid SSRI until the patient has been off linezolid for 24 hours. Serotonin syndrome is a life-threatening condition and could occur when drugs that increase serotonin levels are administered. Drug classes implicated in this condition include SSRIs, SNRIs, triptans, and a long list of miscellaneous drugs. Refer to Bai et al. for more information.

The role of SSRI is crucial in the beginning of the treatment for PTSD when patients experience acute symptomatology and are not receptive to CBT. Dosage typically starts at the low end of their therapeutic range, and titration occurs gradually to the extent that is tolerated by the patient for a minimum 6 to 8 weeks. Pease refer to table for adult dosage for PTSD. These medications will also be the drugs of choice for long-term pharmacologic treatment of PTSD along with trauma-focused CBT. When patient symptoms do not respond to an SSRI after 8 to 10 weeks, switching to another SSRI is indicated. If the response to SSRI is partial, augmenting with antipsychotics drugs such as quetiapine, olanzapine, aripripazole and zyprasidone will be indicated. Prazosin can be used as well to augment SSRI nocturnal PTSD symptoms such as nightmares and night terrors or can be used as monotherapy for insomnia. Stein 2022.

Other medications with limited supportive evidence but commonly used for PTSD in the clinical setting are also worth mentioning.

There is clinical evidence that tricyclic and tetracyclic antidepressants, such as imipramine and mirtazapine, improve symptoms of PTSD and may be useful in patients with significant sleep disturbances (see Sleep Disturbances, later).

Several uncontrolled studies have noted that morphine (which reduces norepinephrine levels in the hypothalamus and locus coeruleus), when administered for pain in the initial 48 hours after a traumatic burn, correlates to reduced subsequent PTSD symptomatology. This correlation has not been tested in randomized trials but may point to the importance of managing pain in preventing and treating PTSD. Research models have shown so far a dynamic association between pain and PTSD, but the majority of patients may not be aware of the association between pain and the traumatic event; in fact, they may not be aware that pain is worsening their symptoms of PTSD and depression.

Benzodiazepines have not been properly studied in randomized clinical trials in PTSD, yet they are frequently used to treat symptoms of anxiety and hyperarousal. Some data suggest they may impair the therapeutic effects of treatments, such as exposure therapy and extinction learning, particularly in outpatient follow-up for PTSD. Additionally, given the high prevalence of comorbid substance use disorder in patients with PTSD, it is advisable to avoid using benzodiazepines.

Ketamine, an N-methyl- d -aspartate antagonist used as an anesthetic and under study in depression, has been shown to reduce PTSD symptoms in promising preliminary clinical trials but is not yet at the point where it can be routinely recommended.

A constellation of other commonly occurring psychiatric conditions need to be addressed in the inpatient treatment of burn victims, including sleep disturbances, delirium and agitation, GAD and depression, psychosis, self-harm and substance abuse.

Patients with self inflicted burns or those who are victims of assault, experience significantly higher pre- and postburn mental health morbidity along with significant adverse outcomes in comparison with unintentional burns. Violence against females by burning is a serious form of sex-based violence. Review of literature identifies limited evidence available in burn-related violence against females worldwide. Findings suggest the need for further research to provide a clearer understanding of the complex issues involved. The vast majority of these patients will go on to develop severe PTSD and require a long-term multidisciplinary approach to treatment to recover physically and emotionally and adapt to their new life circumstances.

Severe burn injuries are associated with a variety of serious negative outcomes, such as increased prevalence of PTSD, depression, anxiety, and functional impairment in both children and adults. ^, It is reported that 38% of pediatric burn patients will develop an anxiety disorder and 30% will develop symptoms of PTSD. ^, Management of burn injuries in the pediatric patient presents unique challenges and considerations caused by their physiologic, psychological, and developmental needs. Like the adult patient, treatment of the pediatric burn survivor should use a psychosocial care model that is tailored to the patient’s phase of recovery and rehabilitation.

Children are an emotionally vulnerable population after burn injuries. Although the physical wellbeing of patients is prioritized by the burn care team, the emotional wellbeing can often go overlooked. After a burn injury, acute treatment is largely centered around medical stabilization. However, it is critical that pain management is addressed early and continued throughout the course of rehabilitation, particularly during wound care and procedures. Emerging evidence suggests that undertreated pain correlates to longer hospital stays, decreased wound healing, and the development of symptoms of anxiety, acute stress, and PTSD. ^, Thus timely and effective pain management is a critical treatment concern for the burn survivor. Current practice guidelines suggest that a combination treatment of pharmacologic and nonpharmacologic pain management for wound care is most effective in adequately controlling pain. According to Fagin et al., sedation may be used procedurally or to alleviate severe distress or anxiety. Sedative medications should be chosen based on the patient’s target symptoms and prescribed cautiously at the lowest therapeutic dose, in order to avoid adverse effects. There currently are no best practice guidelines regarding sedation for pediatric burn patients, and there is no gold standard medication for pain control; however, opioids, benzodiazepines, midazolam, ketamine, and diphenhydramine are three commonly used medications. Haloperidol, a high-potency neuroleptic which is commonly used for agitation, has also been used in pediatric burn patients experiencing delirium and anxiety. The use of haloperidol in children should be carefully monitored because it is reported that 23% of pediatric burn patients experienced adverse extrapyramidal effects when treated with the drug.

Nonpharmacologic interventions, such as support provided by child life professionals, are crucial to minimize stress during procedures and throughout the hospitalization. Cognitive behavioral trauma–focused therapy and child-parent psychotherapy are the modalities most often used in the pediatric population.

Given the increased risk that pediatric burn patients have for developing symptoms of acute stress and PTSD, a multimodal approach is recommended. Currently, no medications are US Food and Drug Administration approved for the treatment of PTSD in children and adolescents. Thus expert opinion and practice guidelines suggest that the first-line treatment for PTSD in children and adolescents is psychosocial support and trauma-focused psychotherapy. Combination treatment using trauma-focused psychotherapy and an SSRI may be considered based on symptom severity and cooccurring psychiatric conditions. However, monotherapy with medication is not supported in the literature. Although there is sufficient evidence to suggest clinical and therapeutic efficacy in the treatment of PTSD using SSRIs in adults, this evidence is currently lacking in pediatric studies and should continue to be researched.

Surviving a burn injury is often associated with long-term physical and psychosocial sequalae. Most psychosocial research in burn patients has focused on the prevalence of long term psychopathology and poor quality of life. Interestingly, trauma has also been known to promote resilience and psychological growth. Resilience is defined as the human ability to adapt in the face of tragedy, trauma, and ongoing life stressors. It is a multifaceted concept characterized by a dynamic process involving the interaction between the intrapsychic mechanisms of risk protection and the social factors that promote emotional healing.

There are three domains of posttraumatic growth:

• 1.

  A change of life philosophy, including spiritual beliefs and a renewed appreciation of life

• 2.

  A change of self-perception, which is a greater sense of resilience or strength

• 3.

  Relationship enhancement, as in valuing friends and family more and an increased compassion for others

The clinical implications of better understanding this phenomena will allow the multidisciplinary trauma team, to effectively advise and support patients toward greater growth. ^,

Peer support has long been recognized as essential for those rehabilitating from severe burns. Through peer support, burn survivors acquire a new life perspective and find hope for the future, which positively impacts their psychosocial rehabilitation. There are many Burn support groups available in the community and there is a particular organization, the Phoenix SOAR program in the United States which connects survivors and loved ones with individuals who have experienced similar traumas. Thus expanding patient’s and familie’s postraumatic support network. To this date psychosocial burn recovery has become an essential aspect of the integrative approach to healing after burn injuries. ^,