Chapter 65 Psychiatric disorders associated with burn injury

J.F. Aili Low, Walter J. Meyer, III, Mimmie Willebrand, Christopher R. Thomas

IN THIS CHAPTER PowerPoint Presentation Online

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Introduction

All members of the treatment team should have a basic knowledge of psychiatric problems, as 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, as their expertise and skills are often needed in the management of patients with burns, to screen and identify and assist in the treatment of the multitudes of psychiatric and psychological issues concomitant to burns.

Pre-existing 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.¹^–⁴

Besides premorbid disorders, a number of patients will develop psychiatric symptoms during acute treatment for burns, as also can be seen after other major trauma.⁴ 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.^5,⁶ 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.⁷

At the present time, there is no profile that can reliably predict and identify which patients will suffer psychiatric symptoms following burns. Furthermore, patients will seldom actively seek help for psychological distress or psychiatric symptoms, although this can have a strong effect on outcome and rehabilitation. All members of the burn team should be aware of this dilemma 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, as symptoms and signs may differ between ages. Although pre-existing psychopathology alters the expression of a patient’s distress and complicates medical management of the patient, the common symptoms described in this chapter are not necessarily indicative of premorbid psychopathology.

Premorbid adult psychiatric disorders

Although a burn can occur to anyone, psychiatric morbidity greatly increases the risk of sustaining an injury, either directly (e.g. self-inflicted burns or suicide attempts) or indirectly by reducing vigilance or affecting judgment (e.g. substance abuse, depression).^1,^7,⁸ The knowledge of pre-existing 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. 2009¹).

Patients with pre-injury psychiatric disorders have been observed to require longer hospitalization, they more frequently experience complications during treatment, problems with rehabilitation and post-burn adjustment, and have a higher risk of developing other psychiatric disorders, e.g. post-traumatic stress disorder (PTSD).^3,^4,⁹^–¹¹

Psychiatric disorders

Psychiatric morbidity is common in burn patients. Two-thirds of all patients with burns have 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.¹

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.¹ Smoking (more than 10 cigarettes daily) has been shown to increase the risk of burns by up to six-fold. In the use of certain drugs, e.g. the stimulant drug methamphetamine, highly volatile and flammable substances, which further increases the risk of getting burned.¹²

Patients with pre-existing psychiatric morbidity have a higher risk of sustaining a preventable injury and in individuals with psychotic disorders self-inflicted burns are over-represented.¹ Personality disorders are also over-represented 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.¹

Self-inflicted burns and suicide attempts

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.¹³

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, it is a major cause of burns in females in the Middle East, Africa and south Asia with a prevalence of up to 28%. Across cultures psychiatric morbidity is an important risk factor, often in conjunction with social stress factors such as marital problems or unemployment.¹

Pediatric disorders (ADHD, conduct)

Prior psychological problems can increase risk for pediatric burns and specific psychiatric disorders have been found to occur more frequently in pediatric burn survivors than the general population. Children with attention deficit hyperactivity disorder (ADHD) appear to be at greater risk for burns.¹⁴^–¹⁶ Playing with fire and fire setting are symptoms of conduct disorder¹⁷ and can result in burns. In addition, certain types of inhalant abuse (sniffing) can result in burns. 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 pre-existing psychiatric disorder may not only control symptoms but also facilitate patient participation and cooperation with acute care and long term rehabilitation.

Social (family)

Clearly, parental and family characteristics can both increase the risk for burns in children as well as influence the subsequent recovery and outcome. The presence of child abuse or neglect can directly result in pediatric burns.^1,^18,¹⁹ The presence of parental anxiety, depression, poor coping skills or lack of social support at the time of injury were associated with poorer child functional outcome in pediatric burn survivors.^20,²¹ Possibly, high parent anxiety in combination with ineffective coping strategies, rather than family functioning or burn severity, is most predictive of pediatric burn outcome.²²

Parents are psychologically traumatized by the burns of their children and face numerous emotional challenges during subsequent treatment and recovery. Parents report more feelings of anxiety and being stressed, depressed and guilty than the normal reference population, not only by their children’s behaviors but in areas unrelated to their children.^21,²³ These stresses can result in psychiatric disorders in parents up to 2 years following the injury, with mothers at greater risk for developing mental health problems and depressive and post-traumatic stress symptoms.²⁴^–²⁶ Increased risk for depression was associated with having an only child or multiple offspring injured, low family socioeconomic status and complicated burn injuries (secondary infection or amputation). Larger burns and the presence of parent–child conflict, parental dissociation, or PTSD symptoms in the child were strongly correlated with parental PTSD symptoms.^27,²⁸ This emphasizes the need for psychological attention to parents of burned children, as well as to the children themselves.

In-hospital contributing factors and disorders

Several problems during acute burn treatment can affect the course of treatment and eventually 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 dependence, withdrawal symptoms can occur during acute care and patients with pre-injury 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 abuse concurrent treatment of both disorders is necessary to achieve improvement.²⁹

After the initial post-burn period, a patient progresses through a series of operative procedures interspersed with days of physical therapy. A patient’s world is one of pain or the sure knowledge of repeated pain in the near future and feelings of anxiety and powerlessness are predominant.³⁰^–³³ Every movement, e.g. shifting position and change of bedclothes, is painful. Treatment and experience of hospitalization may be as traumatic psychologically as the original burn, and patients who experience high levels of pain not only have a higher risk of poor adjustment and psychiatric problems after discharge, but also wound healing can decrease due to stress.^32,³⁴ Furthermore, high levels of stress and anxiety and PTSD decrease pain tolerance.³¹

Itching is a common problem during wound healing and scar maturation, and it can cause considerable distress and anxiety.^33,^35,³⁶ Persistent itching can disrupt sleep, which increases stress levels and also impairs everyday functioning and participation in rehabilitation.³⁷ Anxiolytic, antidepressant and antipsychotic agents have been used successfully to treat itch.³⁶

Significant sleep problems are common during and after treatment for acute burns.³⁸^–⁴⁰ The noise and light on the unit and interruptions for treatment will disrupt sleep.⁴¹ Pain, anxiety and itching can disrupt sleep or affect sleep quality, and symptoms of stress and PTSD, e.g. nightmares, can cause both awakening and a fear of going back to sleep.^39,⁴² Pain severity during hospitalization has been shown to predict insomnia after discharge and insomnia in turn predicted long-term pain.⁴⁰ Burn patients who experience poor sleep at night will also have lower pain tolerance during the day.⁴²

In-hospital adult disorders

During treatment for acute burns disorientation, confusion, delirium, transient psychosis, depression and anxiety, stress and sleep disorders are commonly observed.³ Causes of these symptoms are multifactorial: hypoglycemia, sepsis, and/or a variety of other organic problems can contribute. The altered state of consciousness may be transitory, wax and wane over several days, or, with large burns, persist for weeks.

A significant number of burn survivors will experience acute or post-traumatic stress disorder symptoms, including intrusive memories of the injury, during their acute recovery.^1,⁴³

Symptoms of depression and agitation related to excessive pain will subside with adequate pain management. The experience of pain has been found to be a mediating risk factor for PTSD in both pediatric and adult burn patients.^32,⁴⁴

After severe burns patients are at risk for the development of substance abuse in the wake of PTSD.^3,²⁹ In contrast, the use of opioids and other pain medication will not cause dependence per se if adequately administered and tapered when pain levels decreases.^31,⁴⁵

Delirium

Delirium is a state of acute brain dysfunction. It is a transient and usually reversible syndrome with disturbance of consciousness and cognition compared to previous levels of functioning. Hallucinations and delusions can occur and patients in delirium can become suicidal or combative. Early symptoms can be restlessness, anxiety, disorientation or sleep disorders.

Delirium in burn patients has been found to occur more often in individuals with a history of substance abuse or other psychological problems and with larger burns.^46,⁴⁷

Another potential cause of disorientation, hallucinations, and agitation may be medications used in the treatment of the acute burn patient.⁴⁷ Sleep deprivation has also been discussed as a cause for delirium in ICU-patients.⁴⁸

Sepsis and metabolic conditions can also result in hallucinations.

Acute stress disorder (ASD)

Acute stress disorder is the most common psychiatric disorder seen in survivors of major burns besides post-traumatic stress disorder (PTSD), with a prevalence as high as 19%.^4,^33,^43,⁴⁹ Acute stress disorder symptoms appear immediately following the trauma, last for at least two days and usually resolve within 4 weeks after the trauma. The criteria for ASD and PTSD according to DSM-IV-TR are shown in Table 65.1.¹⁷

Table 65.1 Criteria for post-traumatic stress disorder (PTSD)

A The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

2. The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.

B The traumatic event is persistently re-experienced in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.

3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.

4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma

2. Efforts to avoid activities, places, or people that arouse recollections of the trauma

3. Inability to recall an important aspect of the trauma

4. Markedly diminished interest or participation in significant activities

5. Feeling of detachment or estrangement from others

6. Restricted range of affect (e.g. unable to have loving feelings)

7. Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span).

D Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. Difficulty falling or staying asleep

2. Irritability or outbursts of anger

3. Difficulty concentrating

4. Hypervigilance

5. Exaggerated startle response.

E Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months

Chronic: if duration of symptoms is 3 months or more

With delayed onset: if onset of symptoms is at least 6 months after the stressor.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), 4th edn. 2000.¹⁷

The presence of avoidant symptoms during the acute phase of recovery is reported to predict chronic post-traumatic disorder in burn patients.^50,⁵¹ It is of great importance to recognize symptoms of ASD and PTSD at an early stage, as ASD has been shown to be a predictor for PTSD and once PTSD is established it usually will persist.⁴³

Depression

Although depression is a reaction most observers would expect of burned patients, only a relatively small number of patients with burns have been observed to have symptoms of severe depression.^49,^52,⁵³ In most studies pre-injury depression or lower levels of well-being were stronger predictors than burn size for subsequent depression. All the same, those individuals who experience symptoms of depression during hospitalization will continue to do so after discharge, so that early recognition and treatment may improve their situation considerably.⁵²

The criteria for major depression according to DSM-IV-TR can be found in Table 65.2.¹⁷ This is an extremely difficult diagnosis to make during the acute burn period, since many of the criteria are linked to physical symptoms. Even beyond the acute phase, the diagnosis is often complicated by grief. The critical symptoms in a burned patient are depressed mood and anhedonia.

Table 65.2 Criteria for major depressive episode

A Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g. feels sad or empty) or observation made by others (e.g. appears tearful). Note: In children and adolescents, can be irritable mood.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).

3. Significant weight loss when not dieting or weight gain (e.g. a change of more than 5% of body weight in 1 month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

B The symptoms do not meet criteria for a Mixed Episode.

C The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. hypothyroidism).

E The symptoms are not better accounted for by Bereavement, i.e. after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), 4th edn. 2000.¹⁷

In-hospital pediatric disorders

Symptoms of delirium and transient psychosis rarely occur among children under the age of 10 years.⁵⁴ True hallucinations are uncommon in children, but when they do occur, the most likely cause is stress, followed by pain and medications.⁵⁵ Sepsis and metabolic conditions can also result in hallucinations, and are a more frequent cause of this than psychiatric disorder in young burn patients.

In contrast to delirium and psychosis, burn encephalopathy is often observed in children,^56,⁵⁷ characterized by lethargy, withdrawal, or coma. EEGs in such cases typically reveal diffuse, nonspecific slow waves. Causative factors probably are the same as those for delirium.⁵⁸

Even young children can experience severe anxiety following burns, with up to a third of patients reporting symptoms of acute stress disorder in the immediate aftermath of burns.⁵⁹ Mediating factors for the appearance of anxiety symptoms appear to be size of burn, parental stress and the experience of pain. In a study of pediatric burn patients, a high resting heart rate, lowered body image and parental stress symptoms were found to be significant risk factors in development of ASD.⁶⁰

Pain in children appears to dramatically increase the risk for development of anxiety symptoms and subsequent anxiety disorders; appropriate pain management can reduce or resolve anxiety symptoms.^61,⁶² A smaller but still significant number of burn survivors will experience post-traumatic stress disorder symptoms, including intrusive memories of the injury, during their acute recovery.^63,⁶⁴