Traumatic burn injury: Neuropsychiatric perspectives on risk, outcomes and treatment

Burn injuries are often traumatic and disabling, and occur frequently in all areas of the world. Burns result in approximately 1 million emergency department visits, 50,000 hospital admissions, and a 5% mortality rate in the USA alone (American Burn Association, 2009; Herndon, 2002). Although research has accumulated a wealth of empirical data on neuropsychiatric aspects of burn injury, the information has not been comprehensively available from a single source. This special issue of the International Review of Psychiatry provides authoritative, synthesizing reviews of the empirical literature. The articles in this issue are organized in three general sections: (1) Ethnographic, neuropsychiatric and behavioural risks for burn injury, (2) Neuropsychiatric outcomes following major burn injury, and (3) Treatment of neuropsychiatric conditions in all phases of recovery from burn injury.

Ethnographic, neuropsychiatric and behavioural risk for burn injury

Burn injuries occur in people who are embedded in diverse geographic regions, nations, cultures, economies and religions. The prevalence and distribution of risk factors, causes, and burn agents differ widely across such categories (Herndon, 2002). It is important to bear in mind that burn injuries often occur as a result of random events with little or no apparent influence from individual, economic or cultural factors. Such injuries can occur to almost anyone. There is, of course, a wide range of incidents where chance, culture, economic and individual factors are all involved. The article by Dissanaike and Rahimi delineates many of the regional, national, demographic and cultural factors related to traumatic injury, including burns.

Burn injuries can also occur as the result of risky behaviour, or, as a result of poor insight, judgement and awareness. Specifically, burn injuries occur disproportionately among vulnerable populations; for example, people with impaired neuropsychiatric functioning. Neuropsychiatric conditions can have a direct impact on incident burn injury (e.g., self-inflicted burn as a suicide attempt) as well as an indirect effect via impaired function in one or more domains (e.g., substance abuse leading to impaired sensation/perception, attention/awareness, or judgement/impulse control). The article by McKibben and colleagues integrates knowledge about the prevalence of neuropsychiatric conditions (e.g., psychiatric disorder, substance use, impulsive behaviour) in people who sustain a burn injury.

Neuropsychiatric outcomes following major injury and illness

In addition to the vulnerability inherent in individuals with pre-existing neuropsychiatric conditions, burn injury presents a plethora of new challenges to the burned patient that may lead to post-injury morbidity. Major burns may result in pain, shock, sepsis, and dysregulation of the hypothalamic-pituitary-adreno-cortical axis as well as other regulatory systems that promote healing, infection control and thermo-regulation. (Herndon, 2002; Patterson, Everett, Bombardier, & Questad, 1993). The energy required to sustain these activities results in hyper-metabolism (Graves, Cioffi, McManus, Mason, & Pruitt, 1988), leading to a catabolic breakdown of body protein (muscle), and, consequently, severe deconditioning and muscle atrophy (Herndon, 2002).

Whether sustained in a way that is traumatic or mundane, burn injuries involve severe pain both at the time of the event and during the prolonged period of wound healing and functional recovery. Deep partial thickness (involving the entire epidermal layer) and full thickness (also involving the underlying dermis) burns damage the layers of skin containing the nerves that provide somatosensory feedback to the brain (Herndon, 2002). Hence, severe pain, both at rest and during procedures, is ubiquitous following acute burn injury and it needs to be managed aggressively with a variety of treatment approaches. Because deep burn injuries can involve substantial nerve damage or loss, there is an elevated risk for developing chronic and disabling neuropathic pain and contracture-related pain. Physical pain and alterations in sensory experiences that are mediated by the skin and related structures (e.g., pruritus, increased or diminished sensitivity, heat or cold intolerance), are some of the most pervasive problems in the first year following burn injury. Sensory problems become chronic in up to 80% of individuals surviving major burns (Malenfant et al., 1998). Chronic, disabling pain has an estimated prevalence of 35% to 52% in this population (Choiniere, Melzack, & Paillon, 1991; Choiniere, Melzack, Rondeau, Girard, & Paquin, 1989; Malenfant et al., 1996). Pain can exacerbate the impact of trauma and disfigurement if it is undertreated or treated using suboptimal protocols. The article by Wiechman, Patterson and colleagues describes the nature of both acute and chronic pain following major burn injury, summarizes knowledge about pain management in adult and child burn populations, and provides clear recommendations for clinical approaches.

Burn injuries often involve long recovery periods and result in poor functional outcomes for many individuals (Esselman, Thombs, Magyar-Russell, & Fauerbach, 2006). To ensure optimal functional outcomes, intensive physical rehabilitation methods are required during the year following severe burn injury. These rehabilitation procedures are aversive, yet unavoidable (e.g., range of motion exercises, compression garments). This challenging rehabilitation period further complicates adaptation to altered capabilities. For example, individuals may deliberately delay, avoid or reduce compliance with the activities that are painful yet necessary for wound healing and optimal recovery of function. Following wound closure, scar maturation is prolonged, with its greatest activity at one to three months and often continuing beyond 1 year (Schwanholt et al., 1994). Many long-term physical complications can develop secondary to a major burn injury including hypertrophic or keloidal scarring (Bombaro et al., 2003), limitations in range of motion across scarred joints, impaired skin integrity and sensation (Costa et al., 2003), and damaged or amputated body parts (Herndon, 2002). According to disability determination evaluations following the conclusion of optimal medical, surgical, and reconstructive treatment, functional impairment resulting from a major burn injury has been estimated at between 17% and 19% (Costa et al., 2003). This is likely an underestimation, as the exclusion criteria for this study (e.g., pre-existing psychiatric conditions) would have restricted the sample such that burn-related exacerbation of pre-existing impairments were unrepresented (e.g., further declines in neuropsychiatric function); see the article by McKibben and colleagues for discussion.

The tremendous physiological burden that is associated with severe burn trauma is often exacerbated by psychosocial stressors. These may include exposure to a traumatic event (i.e., the burn injury and its context), pain, loss, separation, deprivation, disfigurement, stigmatization, extremes of emotional and physical arousal. That is, the burn injury and these associated stressors are processed within the strengths and limitations of the individual's environmental and social context, and are also influenced by biological factors (e.g., genomic, proteomic, cellular, organ system), all of which play a role in determining the patient's response to the burn injury. The article by Davydow and colleagues provides a summary and synthesis of empirical data on outcomes following traumatic burn injury and major illnesses. Similarly, the article by Corry and colleagues summarizes the empirical data on risk and protective factors that influence psychosocial outcome following injury. Both the Davydow and the Corry articles suggest directions for future research and call for improved policies affecting the health, participation and inclusion of individuals (e.g., those with visible distinctions).

Treatment of neuropsychiatric conditions in the acute, rehabilitation and reintegration phases of recovery

There are many forms of acute and chronic distress as well as frank psychopathology that are quite prevalent following burn injury. Acute stress disorder (ASD) has been reported in 18% to 26% of patients following severe burn injury in Greek (Madianos, Papaghelis, Ioannovich, & Dafni, 2001), US (Difede et al., 2002), and Dutch (Van Loey, Maas, Faber, & Taal, 2003) samples. Post-traumatic stress disorder (PTSD) has been observed in 33% of Japanese (Fukunishi, 1999) and US (Difede et al., 2002; McKibben, Bresnick, Wiechman-Askay, & Fauerbach, 2008) samples from one year post-burn to at least two years post-burn, and in 15% to 20% of Dutch (Van Loey et al., 2003) and Greek (Madianos et al., 2001) samples at one year. PTSD was more common among Veterans Administration patients with extensive burns than among those with spinal injuries, amputations, major chest trauma, heart failure, or cardiac arrest (Martz & Cook, 2001). In an Australian sample, high levels of distress during a major brush fire had a stronger correlation with PTSD symptoms than socio-demographic or pre-exposure psychological variables (Parslow, Jorm, & Christensen, 2006). Finally, clinically significant symptoms of depression were reported by 23% of patients following severe burn injury in a US sample (Wiechman et al., 2001) and 27% in a British sample (Wisely & Tarrier, 2001) at 2 years; and 20% of Greek patients with burn injuries had a depressive disorder at 2 years (Madianos et al., 2001).

Distress may manifest itself in other forms as well. Body image dissatisfaction appears common in patients with burn injuries (Lawrence et al., 1998). Furthermore, although location of the scar (e.g., hands, face) can have a greater impact on psychosocial outcomes than total body surface area (TBSA) burned, both have less of an impact than psychological distress (Lawrence, Fauerbach, Heinberg, & Doctor, 2004). The burn-related changes in appearance can lead to social avoidance in those who experience stigmatizing reactions from others (Fauerbach et al., 2000; Lawrence, Fauerbach, Heinberg, & Doctor, 2006). Sleep disturbances occur frequently, for example, samples of adult Swedish (Low et al., 2003) and US (Ehde, Patterson, Wiechman, & Wilson, 2000) burn survivors reported nightmares (30% to 43%) and insomnia (37%) between 1 and 11 years post-burn. Sleep problems, PTSD symptoms, and scar-related problems were highly intercorrelated in a Dutch sample (Van Loey, Faber, & Taal, 2001). Of note, there is a 33% prevalence of clinically significant symptoms of psychological distress from hospital discharge through at least two years post-burn, with few cases remitting over time (Fauerbach, et al., 2007). This contrasts sharply with the 10% incidence of clinically significant psychological distress in an adult, non-medically ill normative sample (Derogatis & Melisaratos, 1983).

There is an accumulating wealth of high quality data from randomized controlled trials that provides the evidence base for clinical assessment, planning and intervention for individuals with many of the neuropsychiatric conditions that are commonly seen following a major burn injury. The article by Difede and colleagues summarizes relevant neuropsychiatric treatment literature and presents the limited research that has been conducted in adult burn-injured samples. Similarly, the article by Arceneaux and Meyers summarizes the treatment-related research in child and adolescent populations and provides clear recommendations for clinical approaches and directions for future research. Finally, while the majority of empirical work in this and most other areas of traumatic injury have focused on psychopathology, there is a growing movement to conceptualize, investigate and bring about positive outcomes following a severe burn injury. The article by Weichman and Magyar-Russell delineates the relevant literature, provides a sound theoretical model for understanding the commonly observed potential for growth following traumatic injury, and makes suggestions for modifying the clinical setting to promote opportunities for such growth. Finally, there is a wealth of high quality information available. For example, many such resources are described and referenced in the article by Corry et al. in this issue.

Acknowledgements

Work on this special issue of the International Review of Psychiatry was partially supported by a Burn Model Systems Grant (H133A070045) from the National Institute on Disability and Rehabilitation Research in the Office of Special Education and Rehabilitation Services in the US Department of Education.