Burn/Psych Topic Discussion

Introduction
Burn patients undergo an incredibly painful and difficult hospital course that dramatically affects
them both physically and psychologically.

Studies have shown that greater levels of acute pain are associated with negative long-term
psychological effects such as
● Acute stress disorder
● Depression
● Suicidal ideation
● Post-traumatic stress disorder

These psychological effects can occur for as long as 2 years after the initial burn injury.

Physiological recovery of burn patients is seen as a continual process divided into three different
stages:
1. Resuscitative or critical
2. Acute
3. Long term rehabilitation

The psychological needs of burn patients differ at each stage.

Resuscitative/Critical Stage:
● Cognitive changes such as extreme drowsiness, confusion, and disorientation are
common during this phase
● More severe cognitive changes such as delirium and brief psychotic reactions also occur,
usually as a result of:
○ Infections
○ Alcohol withdrawal
○ Metabolic complications
○ High doses of drugs

● Challenges with overstimulation (agitation) or understimulation

● Patients may also be intubated, which greatly limits direct communication
● In depth psychological intervention is of minimal value at this phase, since physical
survival is the primary goal

● Supportive psychological interventions should focus on immediate concerns, such as

 ○ Sleep
○ Pain control
■ Pain severity is the most robust predictor for later suicidal ideation

Treatments for Pain:

Pharmacologic-
● A pain treatment plan that provides pharmacological and non-pharmacological
approaches should be established
● Opioid agonists are the most commonly used analgesics
● Multimodal pain control including:
○ Acetaminophen
○ NSAIDs
○ Gabapentin
● It is crucial that drugs for background pain are provided on a fixed dose schedule to
maintain control of the pain

Non-pharmacologic-
● Pain control techniques include:
○ Cognitive-behavior therapy (CBT)
○ Hypnosis (has shown some efficacy in treating procedural pain, but not a PADIS
recommendation)
○ Massage
○ Music therapy
○ Virtual reality
■ Creates a realistic environment for patients to absorb themselves in during
painful procedures, thus taking focus away from the discomfort
Premorbid psychopathology—Compared with the general population, burn patients have a high
rate of preexisting psych disorders
● Patients with pre-existing psychopathology typically cope with hospitalization through
previously established dysfunctional and disruptive strategies
● The most common premorbid psychiatric diagnoses are:
○ Depression
○ Personality disorders
○ Substance use disorders
● Prior psychopathology can have an adverse impact on outcomes, including longer
hospitalizations and the development of more serious psychopathologies after injury

Acute Stage:
● As patients become more alert during this phase, they face their hospital stay with less
sedation
● Patients are more aware of the physical and psychological impact of their injuries
● Greater awareness and understanding of their condition and the circumstances behind it
triggers the grieving process:
○ Denial
○ Anger
○ Bargaining
○ Depression
○ Acceptance

➢ Acute Stress Disorder (ASD)

○ Diagnosis of ASD may be made as early as 3 to 30 days following the traumatic
event (if it lasts longer than a month then it is classified as PTSD)
○ Symptoms are grouped into different categories. The symptoms may include:
■ Intrusive - flashbacks, hallucinations, nightmares of the incident; negative
distressing thoughts or feelings such as guilt
■ Avoidant – avoiding people, places, things, or memories that remind them
of the trauma
■ Arousal – increased alertness, anger, fits of rage, irritability, or hatred,
difficulty sleeping or concentrating
■ Negative - inability to experience a positive mood; flat affect
■ Dissociative - inability to remember an important aspect of the traumatic
event (typically due to dissociative amnesia and not to other factors such
as head injury, alcohol, or drugs)

● Treatment of choice is CBT

● 20%-50% of those experiencing ASD will have a full recovery without formal
intervention
○ By educating patients on this, it can greatly decrease their fears of a prolonged
psychological condition that may permanently alter their lives
 ➢ Depression and anxiety—Symptoms of depression and anxiety are common and start to
appear in the acute phase of recovery. The severity of depression is correlated with a
patient's level of resting pain and level of social support

Condition Prevalence in Inpatients with Burns

Depression 23-61%

Generalized Anxiety 13-47%

Psychological counseling can help both depression and anxiety, but drugs may also be necessary.

 Treatments for Depression:

First Line → SSRIs (have them recall the drug names and fill in table)
Sertraline Escitalopram Citalopram
Fluoxetine Fluvoxamine Paroxetine

Second Line → SNRIs

Duloxetine Venlafaxine Desvenlafaxine
Milnacipran Levomilnacipran

 Treatments for Anxiety:

SSRI/SNRI Hydroxyzine

Benzodiazepines Buspirone

➢ Sleep disturbance—Central to both anxiety and depression is sleep disturbance

● The hospital environment can be loud, and patients are awakened periodically during the
night for analgesia or for checking vital signs
● Patients' mood, agitation, and nightmares can all affect sleep
● Nightmares are common and typically subside in about a month
  Treatments for Sleep:

Pharmacologic – (have students recall which we commonly use here)

Melatonin Diphenhydramine Trazodone

Ramelteon Zolpidem Eszopiclone

Zaleplon Benzodiazepines

Nonpharmacologic-
● Light and noise reduction
● Progressive muscle relaxation
● Breathing exercises

Long-Term Rehabilitation:
● The long term stage of recovery typically begins after discharge from the hospital, when
patients begin to reintegrate into society
● For patients with severe burns, this stage may involve continued outpatient physical
rehabilitation, possibly with continuation of procedures such as dressing changes and
surgery
● This is a period when patients slowly regain a sense of competence while simultaneously
adjusting to the practical limitations of their injury

Physical Problems-- Severe burn injuries may result in long-term physical effects such as:
● Amputations
● Neuropathies
● Scarring
● Limited endurance
● Decrease in mobility and function

Psychosocial problems—In addition to the high demands of rehabilitation, patients must deal
with social stressors including:
● Family strains
● Returning to work
● Sexual dysfunction
● Change in body image
● Disruptions in daily life
Post-Traumatic Stress Disorder (PTSD)
● Recent studies have documented that up to 45% of adults who were hospitalized for their
burn injury have PTSD 1 year later
○ Severity of intrusive and avoidant PTSD symptoms within 1 week of injury
predicts chronic PTSD
● Those with higher in-patient pain scores reported higher rates of PTSD

There is evidence that adjustment to burn injuries improves over time independent of the injury
size. Social support is an important buffer against the development of psychological difficulty.

 Adjustment difficulties that persist more than a year after discharge usually involve
perceptions of a diminished quality of life and lowered self-esteem
 Studies suggest that burn disfigurement in general leads to decreased self-esteem in
women and social withdrawal in men

Allostatic Load
● Allostasis is the adaptation that the body makes in response to stressful events
● The process involves activation of several physiological systems, including the immune
system, and is essentially the body’s ability to maintain “stability through change”
● The body is able to cope effectively with these stressors when adaptations are activated
infrequently; however, there is the potential for the system to become overloaded

● It is hypothesized that there is a link between pain and wound healing that can be
explained by the neuroendocrine and immune pathways that are altered under stress
○ The interactive effects of the glucocorticoids and proinflammatory cytokines are
the primary physiological mechanisms underlying both stress and wound healing
○ If immune function is suppressed due to the stress of uncontrolled pain and
depression, a patient’s ability to fight off infection is further compromised

● A person’s response to allostasis is a function of his or her personality style and coping
mechanisms and how these interact over time with the environmental factors that are
present.
○ The size and severity of a burn injury has not been shown to predict
psychological outcome
○ Factors that do play a role in determining outcomes:
■ If the patient has a history of depression or alcohol abuse
■ Coping style
■ Social support
■ Secondary complications
 ■ Pain
Acknowledging that outcome depends on a complex interplay of factors can enable us to
understand why a person with minor burns may show a devastating psychological reaction,
whereas someone with a massive burn injury may adjust surprisingly well.

Summary
● A burn injury and its subsequent treatment are among the most painful experiences a
person can encounter
● The emotional needs of patients with burns are often overshadowed by the emphasis on
survival/physical needs
● Burn patients undergo various stages of adjustment that require (pharm and non-pharm)
support for pain, sleep, depression, and anxiety

References:
1. Dalal PK, Saha R, Agarwal M. Psychiatric aspects of burn. Indian J Plast Surg. 2010 Sep; 43(Suppl):
S136–S142. doi: 10.4103/0970-0358.70731
2. ABC of burns: Psychosocial aspects of burn injuries.Wiechman S, Patterson D. BMJ. 2004 Aug 14;
329(7462): 391–393. doi: 10.1136/bmj.329.7462.391
3. Devlin J, Skrobik Y, Gelinas C, et al. Clinical Practice Guidelines for the Prevention and Management of
Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Society
of Critical Care Medicine. 2018; 46: 9. doi: 10.1097/CCM.0000000000003299
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 2013: 5.