Annals of Burns and Fire Disasters - vol. XVII - n. 2 - June 2004

PSYCHIATRIC AND PSYCHOLOGICAL ACTION IN BURN PATIENTS

Gigantino M.

Celio Military Polyclinic, Rome, Italy

SUMMARY. This paper considers the importance of the presence in burn hospital wards of specialists in the psychological care of burn patients, whose apparently devastating physical sequelae may ultimately be less traumatic than their psychological sequelae. Various aspects are considered, including that of post-traumatic stress disturbance, which is described in detail. Suggestions are provided as to the assessment of the psychological condition of burn patients.

Introduction

When people are affected by a severe trauma, such as burns, they arouse in others a natural desire to help them. Traditionally, physicians have tended to concentrate on the body and on patients’ physical suffering, neglecting the care of their psychic disturbances, which are often as severe and invalidating as the physical sequelae - indeed they may ultimately be even be more severe - leaving this aspect of care in the hands of certain highly meritorious but not necessarily professional figures who are always present in hospital wards (priests, voluntary workers, etc.).

The motivations and phases of psychological, psychiatric, and social action

Today, however, things have changed. As a result of the process of the “humanization” of hospitals, the new frontier that health workers have been pursuing for some years is the creation of highly qualified professional figures who are specially trained to manage the non-physical problems of severely traumatized patients.

Every hospital department now expects to be able to avail itself of the collaboration of a consultant psychiatrist, a clinical psychologist, and a social assistant. These figures, all of equal importance, pool their energies and - each in relation to his or her individual field of competence - take in charge burn patients whose psychological stability and way of relating to the rest of the world have been disturbed. The importance of the involvement, from the beginning, of professional figures operating in the psychiatric, psychological, and social field, side by side with the medical and nursing team in the hospital, is related to the following factors:

1. Working with traumatized patients means coming into contact with forms of suffering that can metaphorically open up old wounds and arouse painful emotions that have been repressed not only by the victims themselves and those close to them but also by the medical and nursing staff. A sensation of being intruded upon, feelings of guilt, and other factors may lead to responses and reactions that are not suited to the patients’ particular needs and interfere negatively with their therapy and rehabilitation. In this context the psychiatrist and the psychologist become key figures in the process of explaining to the medical team what relational approaches are most appropriate, given the patients’ particular psychopathological status and their basic personality. All contact with patients has to be managed in such a way as to avoid what is known as “vicarious traumatization”, i.e. there has to be a kind of tact that goes beyond ordinary good sense. This tact basically corresponds to certain specialized skills that the operators develop - e.g. knowing what can and what cannot be asked - with regard to special rules of timing and manner that avoid the risk of arousing unpleasant memories or attacking defensive mechanisms which to an inexpert eye may appear to be syndromes that are best eliminated - on the contrary, dissociative episodes and memory gaps can play a very important protective role that defends the patient’s emotional and affective integrity.
2. When the medical emergency phase is over, during which the medical team’s main concern is simply the patients’ survival and the stabilization of their clinical condition, there is a high probability of the development of psychopathological disturbances. These range, with increasing gravity, from anxiety syndromes and moodiness to disturbances of the alimentary tract and drug abuse, and conditions that in extreme cases may be psychotic.

   On the basis of the DSM-IV categorization, the diagnostic category of anxiety disturbances includes post-traumatic stress disturbance (PTDS). This category is divided, depending on the duration of the manifestations and the latency of their onset, into the following subcategories:

   • acute: when the manifestations last from to a minimum of one to maximum of three months;
   • chronic: when the manifestations last from one month to more than three months;
   • delayed onset: when the onset occurs at least six months after the triggering stressful event.

   PTDS is defined by DSM-IV as the disadaptive response of individuals involved either personally or as direct eyewitnesses in events that are objectively particularly dramatic because of their violence, intensity, or duration in time and that therefore exceed the normal level of stress tolerance. PTDS presents the following symptoms:

   • unpleasant, recurrent, and intrusive memories of the event
   • unpleasant dreams of the event, flashbacks, illusions, hallucinations, and dissociative episodes
   • vulnerability when exposed to situations that re-evoke the event
   • avoidance conduct with regard to places, situations, and memories related to the trauma
   • derealization
   • memory gaps
   • reduced thought about the future
   • changes in sleep habits
   • outbursts of anger
   • concentration difficulties
   • hypervigilance and exaggerated alarm responses.

   The term acute stress disturbance refers to the condition in which, within four weeks of the triggering stressful event but with a duration of only two days to four weeks, symptoms such as those listed above are associated with even more marked dissociative phenomena (e.g. derealization, depersonalization, dissociative amnesia).

3. The psychiatric assessment of a traumatized patient requires a thorough knowledge of:
   • the dynamics of the traumatic event
   • the patient’s “life story” as told by the affective figures closest to him or her
   • the death or traumas of near and dear ones
   • any economic problems that have arisen or are related to housing (e.g., collective accidents).

   For this purpose it is important to gather relevant information in interviews with family members and, if necessary, the police.

4. Once the psychiatric emergency phase is over, patients continue to be monitored for the onset of disturbances of mood and behavioural alterations. The risk of suicide also has to be monitored - this is paradoxically absent during the phases when the patients are physically most at risk and unexpectedly present as they begin to improve, when during the period of physical rehabilitation they have to programme their return to their everyday social, working, and family lives. This paradox is related to the presence of traumatic sequelae that are invalidating not only physically but also psychologically, since they have altered the patients’ self-image as regards not merely their physical body but also their self-awareness and their attitude to the outside world.

An invalidating trauma breaks off people’s life projects and for this reason it is essential that the psychiatrist should be backed up by a team of psychologists for the study of the patients’ personality, their capacity to adapt, their tolerance of the rehabilitation process, and their individual and - if necessary - family psychotherapy.

Conclusions

To summarize, the action of the psychological, psychiatric, and social team must start the moment the burn patient reaches the hospital. This applies also to the work of the medical and nursing team. This work goes on until well after the strictly medical emergency phase is over.

The Celio Military Polyclinic in Rome already disposes of all the professional skills necessary for this type of specialized support in the burns department now being constituted.

RESUME. L’Auteur considère l’importance de la présence dans les centres des brûlés de spécialistes dans le secteur des soins psychologiques des patients brûlés, dont les séquelles physiques apparemment dévastatrices peuvent se démontrer à la longue moins traumatiques que les séquelles psychologiques. L’Auteur examine divers aspects de la question, y inclus les troubles du stress post-traumatique, qui est décrit en détail. En conclusion il offre des suggestions pour ce qui concerne l’évaluation de la condition psychologique du patient brûlé.