Introduction

The proportion of self-inflicted burns among patients admitted to burn units ranges from 0.37% to 40%, with considerable variability around the world.1-10 Two different groups of self-inflicted burn patients have been described: suicide attempters and self-mutilators without suicidal intent.2,11,12

Self-inflicted burns are usually a consequence of psychiatric disorders, and an acute phase of depression or schizophrenia is the main precipitating factor in Western countries. However, self-immolation as a political protest was described in the 1960s and early 1970s.13,14 It is also used as a method f social manipulation by prisoners. Dowry problems, the rigidly defined role of women in the family, and interpersonal conflicts in a joint family can be precipitating factors, as in the case of India - this is unique to that country.10 Some variability exists between the various countries, regarding the aetiology, risk groups, patterns, and prognosis of self-inflicted burns.1-12

Gülhane Military Medical Academy (GMMA) Haydarpas¸a Training Hospital (HTH) Burn Unit is one of the two Burn Units in Istanbul and has served military and civilian burn patients for 10 years. It is a tertiary referral unit serving a catchment population of approximately 10 million civilians and a quarter of a million military personnel. This article documents the investigative findings of a series of self-inflicted burn patients at a regional burn unit and focuses on the precipitating factors.

Patients and methods

A prospective study of adult admissions to the GMMA HTH Burn Unit from May 1997 to February 2001 was carried out in order to identify acute admissions of patients with deliberate self-inflicted burns. Confirmation by the patient or a witness that the burn was self-inflicted was required for inclusion of the case in the study - suspected but unproven cases were not included. A detailed assessment of whether the self-burning was inflicted with suicidal intent or not was made; this information was obtained from the patients, their friends, or from family members. The patients were examined by psychiatrists, who supervised them during the period of their stay in the unit. The other data collected included age, sex, size of second- and third-degree burns (TBSA), the areas involved, the mechanism of injury, duration of hospital stay, psychiatric history, precipitating factors, history of alcohol and drug abuse, and mortality. The patients were evaluated and treated according to routine burn care methods. Early tangential excision and skin grafting procedures were used in appropriate cases.

Results

Of the 956 cases of burn patients admitted to the GMMA HTH Burn Unit between May 1997 and February 2001, 36 (3.8%) were identified as being deliberately self-inflicted and 7 (0.7%) as suicide attempts. The characteristics of suicidal and non-suicidal self-inflicted burns are outlined in Table I. The most common method used for self-ignition in this series was flame with the addition of a flammable liquid, which was used by 32 patients (89%). The fuels used were gasoline (25 patients), kerosene (4 patients), and methyl alcohol (3 patients). Three patients used flame alone and one patient attempted suicide with high-voltage electricity. The anterior trunk, the upper extremities and hands, the face, the lower extremities, and the back were involved in decreasing order. Early excision and grafting were performed in 21 cases (58%). Inhalation injury was the chief contraindication for early surgical intervention and constituted the most important cause of fatality. One patient underwent left upper extremity amputation owing to high-voltage electric injury.

Five of the seven suicide attempters (71%) died, compared with two out of 29 patients (7%) in the non-suicidal group. The overall mortality rate was 19.4%, while the mortality rate among the accidental burn patients treated as in-patients in the same period was 23.6%. The overall mean TBSA was 44.4% in this last group.

As shown in Table II, 30 out of the 36 (83%) patients presented some psychiatric disorders. While the suicide attempters all suffered from serious psychiatric diseases, personality disorders constituted 69% of the non-suicide group. One previous suicide attempt was documented among the suicide attempters. Seven patients in the non-suicidal group had previously self-mutilated their upper extremities and anterior trunk with a razorblade. Previous self-inflicted burn was not determined in any group. A history of alcohol abuse was identified in nine out of the 36 patients (25%) and a history of drug abuse in three of them (8%).

A precipitating factor was identified in 33 of the 36 patients (Table III). Twenty-eight patients (78%) had self-inflicted burns inflicted as a consequence of socio-economic and political reasons associated with psychiatric problems. All the patients except one burned themselves in front of other people. One patient was found alone in his room while he was burning. The non-suicidal group of patients in particular burned themselves with an attitude of protest. Open but crowded places were the most common place (31 self-inflicted burn cases). Five patients burned themselves in closed spaces (4 suicide attempts) and one patient climbed a high-voltage electricity line with suicidal intent. No case of self-inflicted burn occurred in the psychiatric wards.

Discussion

A distinction can easily be made between patients who attempted suicide and those who deliberately burned themselves without suicidal intent. Suicide attempters had much more extensive burns and higher mortality rates compared with non-suicidal patients. The majority of patients attempting suicide were suffering from serious psychiatric diseases. The latter group fortunately constituted the minority (19%) of self-inflicted burns. The data regarding sex, age, TBSA, duration of hospitalization, and mortality rates were generally consistent with other reports.1-16

Tuohig et al.12 classified self-inflicted burn patients as being suicide attempters and self-mutilators as having no conscious suicidal intent. Self-mutilators tended to be somewhat younger than those attempting suicide. They were rarely burned by flame and more frequently by chemicals, contact burns with curling irons or cigarettes, or scalding. Self-mutilators had limited, deep burns in the extremities and had a correspondingly shorter duration of hospital stay. Repetitive self-mutilating behaviours associated with personality disorders were also dominant characteristics in this population. The mortality rate among them was almost zero.

However, in the present study, the non-suicidal self-inflicted burn group presented some similar and some dissimilar features compared with both self-mutilators and suicide attempters. All patients in the non-suicidal group burned themselves by fire, but witnesses stopped the burning immediately as the act was performed in front of other people. The total burned surface area was smaller than it was among suicide attempters and larger than among classic self-mutilators. These persons had no suicidal intent but sometimes they suffered much larger burns than they had intended: two patients died in this manner. The mortality rate in this group also lay between that of suicide attempters and of self-mutilators. Associated psychiatric disorders in the non-suicidal group presented similar features in both groups. It would be better to evaluate the self-inflicted burns in three groups, and to regard the non-suicidal group as a transition group between the classic self-mutilators and the suicide attempters.

Another interesting point is that the precipitating factors were mainly socio-economic and political conflicts, with the patients burning themselves in front of other people in order to attract attention, show their anger, and involve related and unrelated people. They did not however refuse the help of witnesses. In Turkey, self-burning in public places is very often sensationally reported in the printed and visual media, and the media’s attitude supports and popularizes the conception of self-inflicted burns as a method of social or political protest. After such cases have been reported by the media, certain civil organizations support the patients by finding them a new job, etc. This kind of solution promotes the use of self-inflicted burns as a way of protest.

Some ‘copycat’ suicides by self-inflicted burns were reported by Ashton and Donnan14 during the one-year period 1978-1979, after a well-publicized self-immolation by a member of a political group.

In conclusion, we can say that patients at risk with psychiatric disorders must be recognized and treated in order to prevent self-inflicted burns. Precautions should also be taken to limit reporting by the media of such cases: the media should be encouraged to play a supporting role in the prevention of this serious problem.

RESUME Dans la période mai 1997-février 2001, des 956 patients hospitalisés dans l’Unité des Brûlures de l’Hôpital de Formation Haydarpas¸a de l’Académie Médicale Militaire Gülhane (Turquie), 36 (3.8%) étaient des cas de brûlures causées délibérément par le patient. Sept de ces 36 patients (19,4%) avaient tenté le suicide. Vingt-sept patients (75%) étaient de sexe masculin. L’âge moyen était de 31,4 ans et la surface corporelle totale moyenne brûlée était de 37% (variation, 12-95%). La méthode la plus fréquente était l’application d’une flamme à un liquide flammable. Des problèmes de nature psychiatrique ont été diagnostiqués dans 83% des cas. Le taux total de mortalité était de 19,4%. Les causes responsables dans la majorité des cas étaient des facteurs socio-économiques et politiques, et la plupart des patients se sont brûlés en présence d’autres personnes en signe de protestation.