1 Burns Department
2 Psychiatry Department
SUMMARY. For some years our burns unit has been working with our hospital psychologist on the prevention of the syndrome of post-traumatic sensory deprivation in burn patients. Isolated burned people are likely to suffer from mild disorientation, confusion, illusions, or hallucinations caused by the shock of extremely threatening events and sensory deprivation. This condition may be dangerous for the patients’ mental health during hospitalization and after discharge.
“If what changes slowly can be explained through life, what changes quickly can be explained through fire.” (G. Bachelard, Psychoanalysis of Fire, 1967)
A burn is considered the most complex trauma affecting a human being during intensive care as well as during medical, surgical, nutritional, anti-infectious, psychological, and rehabilitation treatment. An extensively burned patient can be regarded as a survivor of an event as catastrophic as an earthquake, a flood, or war.
The burn victims treated in our burn unit in recent years have shown symptoms of mental disorders comparable to those reported in burn units in various European countries and in the United States. During the first hours of hospitalization we have observed an overwhelming, violent, and uncontrollable anguish at the prospect of immediate death, together with an emotional block and inability to recall the accident. After a few days, the patient may develop a feeling of omnipotence to counteract the feeling of loss brought about by the accident, especially in the presence of death: the feeling of loss can be processed only after lengthy mental elaboration, often with the help of the psychologist. Another particularly powerful feeling that in the long run may cause depression is a sense of guilt for not having been able to avoid the accident, for having caused it through carelessness, or for being responsible for the death of others. The patient may have disturbing dreams recalling the event, in an attempt to achieve “mental metabolization” of the emotion experienced: such dreams are physiological but deeply disturbing for the patient, who relives his burns again and again, often very realistically. This condition is aggravated by the patient’s sense of isolation, which may cause severe mental reactions such as hallucinations.
From the first stages of hospitalization, the patient becomes the passive object of the medical and surgical interventions and treatments he is obliged to undergo. An ambivalent relationship is thus set up with physicians: the patient realizes he needs the medical staff but at the same time he is afraid of them because they are seen as the cause of his pain. This ambivalent attitude may lead to a continuous request to be attended to.
In the burn unit, patients are isolated from their customary reality as they confined to a room, far from their normal physical reference points. Psychologists call this condition “sensory deprivation”. Since the 1950s, experiments have been conducted on persons in conditions of extreme solitude and absence of sensory stimuli (e.g. spaceship crews and polar explorers). It has been observed that such persons, when deprived of their habitual daily references, develop a severe symptomatology with signs of temporal disorientation followed, as the period of isolation persists, by mild hallucinations, hallucinatory sensations, delirious ideation, and/or structural delirium. These symptoms are increased by a condition of deep physical pain.
We divided our patients on the basis of their age group. In the adolescent-juvenile age bracket (11-25 yr), we observed a major susceptibility to a sense of isolation leading to severe anxiety symptoms, dysperception, and hallucinatory sensations. In these cases an immediate, intense psychological intervention is required, in order to reassure patients that such symptoms are normal, to let them give vent to their fears and anguish about their immediate future, and to provide emotional containment. These psychological reactions are typical of young patients, reflecting their approach towards maturity and reproductive capacity; however, at the same time, we may note a profound anticipatory anxiety that complicates the patient’s life and may prevent full compliance with the therapy that has been planned.
In the adult age bracket (25-63 yr), we observed that many patients with extensive burns had underestimated the dangers of fire, owing to personality disorders. Such persons showed greater resistance to the reduction of environmental stimuli during isolation and more problems in the long term, with a higher risk of depressive pathology. In these cases it is important, on discharge, to continue with the psychological support initiated in the ward. This has to be handed on to the patient’s local health department in order to prevent the post-traumatic stress syndrome, which may occur even 6 months after discharge. Psychiatric patients who have attempted suicide by fire belong to a well-defined group: there may be further complications, with repeat suicide attempts using fire. These patients must be carefully followed by the psychiatric consultant, with pharmacological therapy and frequent check-ups. Psychological support becomes particularly restrictive and continuative, involving the patient’s family and especially persons involved in some way in the suicide attempt (a mother/father, a brother who takes the patient to hospital, a mother who looks after the patient during hospitalization, the parents, a partner disposed to help the patient with his therapy).
A., a female 48-year-old chemist’s assistant with a high school diploma, has lived with a man of the same age for about 20 years. The accident that caused the burns occurred at work while A. was attempting to burn some holy images using alcohol (the only way for believers to destroy them without committing sacrilege). The accident seems to have been due to negligence rather than to any self-damaging intentions. A. does not present any mental disorders; she is a busy person, and a sportswoman. She readily agreed to have an interview with us, during which we were struck by her straightforward, bright, and highly mobile look. She did not seem to have depressive reactions but rather a state of anxiety. The tone became intense and A. did not hesitate to speak about the important facts of her life: she talked emotionally about her parents’ death, due to illness, some ten years previously, one soon after the other. She was articulate, and at times even prolix.
She appeared to feel the need of a strong emotional presence and of my own personal emotional involvement. A. agreed to attend for support psychotherapy during her period of hospitalization, which was necessarily going to be protracted - she had second- and third-degree burns on 75% of her body surface. The patient was also examined by a psychiatric consultant, who ruled out the possibility of any mental pathology as also the necessity of pharmacological therapy. The atmosphere during the interview was very emotional: the patient required constant empathy and closeness to the interlocutor (she had the same attitude towards the ward surgeons). The accident was recalled in very clear images: at the beginning A. wanted to convey a “heroic” image of herself - she “survived” the flames thanks to her presence of mind. This is an identity that extensively burned patients nearly always develop as a defence against their anguish at having caused the accident. In this way A. was trying to recover the outstanding aspects of her personality: pride, bravery, energy. After a few interviews, a state of unease not due to any organic cause was observed. A. looked disoriented in time and space but was able to recognize me and was always pleased to see me. The interviews, however, became difficult: A. could not distinguish present events from past events - she “lived” past memories as if of the present, weighed down by an uncontrollable emotivity and anxiety. This kind of mental disorder is caused in patients in isolation by the lack of external stimuli, which intensifies the deep anguish experienced by the patients after their traumatic encounter with fire. A. seemed to suffer deeply from her isolation as her personality - highly responsive to stressful events - was now subject to external and physical limitations. A. would often say, “I’m so angry … And I can’t even go riding in my place in the country!” This kind of mental disorder is observed after some ten days of hospitalization, and is a form of defence against anger that cannot be relieved: the patient creates a parallel mental reality, composed of memories and strong past emotions relived in the present and of personal intimate memories in an attempt to counteract the state of monotony caused by the lack of stimuli during isolation; this is also closely related to the patient’s personality and history prior to the event. A. received strong psychological support that enabled her on the one hand to relate closely to her real life and on the other to have someone to listen to her anxieties. After two months in hospital, she recovered her good humour and her capacity for criticism, after overcoming her state of depression when she realized the extent of the physical and aesthetic damage caused by her burns. In such patients, it is very important to be able to assess any display of a state of depression, which is inevitable in every patient. If the support provided in this state is adequate, the patient will not suffer from post-traumatic sensory deprivation, or at least the >possibility of serious mental unease with psychotic symptoms is minimized.
After a few months, A. returned for a medical check-up: she looked fit, active, relaxed, well-dressed, and neatly groomed. She wished to express her gratitude and told us she was feeling much better and had taken up her normal activities once again. This was certainly a case in which we saw the happy ending we would always like to see. This patient clearly had remarkable personal and psychological resources that enabled her, with the support of the ward, to react positively.
In most cases, the psychological support initiated during hospitalization has to be continued after discharge. The consultant psychologist informs the local department responsible for the case and organizes the handover: every patient has a good chance of improvement and recovery if supported psychologically. Such information is fundamental in the event of previous mental disorders or of psychological problems during hospitalization. The follow-up should include a weekly psychotherapy session focusing on acceptance of the burn-modified body.
This case has suggested certain day-to-day practical aspects that we feel appropriate to point out. The daily handling of extensively burned patients is particularly complex owing to their state of complete psychological and physical dependence and their forced isolation. From an emotional point of view there is a prevalent strong feeling of love/hate towards the medical staff, similar to the ambivalent feeling the patient experiences towards himself: joy at the escaped danger and a sense of omnipotence opposed to feelings of guilt, anger, self-depreciation, impoverishment of the future, and distrust of the treatment.
The onset of depressive symptoms hinders compliance and interferes with the normal processes of recovery, making this a very difficult period. The medical staff have many duties, ranging from physical treatment and psychological support to the passing-on of information about the treatment to the patients and their families. For a long period of time patients are in a state of psychological regression, unable to be close to family members, and this affects their emotional condition, rather in the way of the terror of a baby that feels it has been abandoned by its mother. In this condition, the physician becomes an essential figure round whom all the dynamic relationships learnt in a lifetime revolve.
The emotional closeness of the medical staff is particularly important when patients have to face the severe physical pain caused by hydrotherapy: here patients need to be reassured, just as a mother calms and reassures her baby at difficult moments. Emotional support becomes a form of mothering, i.e. care of patients in their totality and not only of their physical pathology. The English physician and psychoanalyst Winnicott calls this “holding”, comparing it to a mother looking after her baby. The experience of mothering and holding enables burn patients to resist the anguish of physical pain and to bring into play psychological resources that will help them to recover. Clearly, the more refined and effective the patients’ psychological resources, the more harmonious their mental work will be. If before the accident a burn patient was in a neurotic-depressive condition, the mothering will continue throughout hospitalization and will be a key factor in all psychological support on discharge. Patients who have attempted suicide by fire require constant supervision by the psychiatrist, with the assistance of pharmacological therapy. It is also important, in this complex work with burn patients, that burn unit staff should be supported by discussion groups co-ordinated by a specialist. In recent years our burn centre has organized meetings between nurses and physicians with the aim of supporting staff members in the psychological aspects of their daily work.
The support given by the consultant psychologist has yielded good results and improved the quality of life of both staff and patients in the ward: the hospital staff have achieved greater empathy and emotional containment as regards the patients, who are better able to express their physical and psychological needs.
RESUME. Depuis quelques années l’Unité des Brûlures des Auteurs travaille avec le psychologue de leur hôpital pour prévenir le syndrome de la privation sensorielle posttraumatique dans les patients brûlés. Les patients brûlés isolés peuvent souffrir d’une désorientation plus ou moins légère comme aussi de confusion, d’illusions et d’hallucinations causées par le choc des événements extrêmement dangereux et par la privation sensorielle. Cette condition peut menacer la santé mentale du patient pendant et après l’hospitalisation.