Patterns of deliberate self-burning in various parts of the world. A review

Burns in Nepal: A population based national assessment

BACKGROUND

Burns are ranked in the top 15 leading causes of the burden of disease globally, with an estimated 265,000 deaths annually and a significant morbidity from non-fatal burns, the majority located in low and middle-income countries. Given that previous estimates are based on hospital data, the purpose of this study was to explore the prevalence of burns at a population level in Nepal, a low income South Asian country.

METHODS

A cluster randomized, cross sectional countrywide survey was administered in Nepal using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) from May 25th to June 12th, 2014. Fifteen of the 75 districts of Nepal were randomly chosen proportional to population. In each district, three clusters, two rural and one urban, were randomly selected. The SOSAS survey has two portions: the first collects demographic data about the household's access to healthcare and recent deaths in the household; the second is structured anatomically and designed around a representative spectrum of surgical conditions, including burns.

RESULTS

In total, 1350 households were surveyed with 2695 individuals with a response rate of 97%. Fifty-five burns were present in 54 individuals (2.0%, 95% CI 1.5-2.6%), mean age 30.6. The largest proportion of burns was in the age group 25-54 (2.22%), with those aged 0-14 having the second largest proportion (2.08%). The upper extremity was the most common anatomic location affected with 36.4% of burns. Causes of burns included 60.4% due to hot liquid and/or hot objects, and 39.6% due to an open fire or explosion. Eleven individuals with a burn had an unmet surgical need (20%, 95% CI 10.43-32.97%). Barriers to care included facility/personnel not available (8), fear/no trust (1) and no money for healthcare (2).

CONCLUSION

Burns in Nepal appear to be primarily a disease of adults due to scalds, rather than the previously held belief that burns occur mainly in children (0-14) and women and are due to open flames. This data suggest that the demographics and etiology of burns at a population level vary significantly from hospital level data. To tackle the burden of burns, interventions from all the public health domains including education, prevention, healthcare capacity and access to care, need to be addressed, particularly at a community level. Increased efforts in all spheres would likely lead to a significant reduction of burn-related death and disability.

A qualitative study of the background and in-hospital medicolegal response to female burn injuries in India

Background

Most burns happen in low- and middle-income countries. In India, deaths related to burns are more common in women than in men and occur against a complex background in which the cause – accidental or non-accidental, suicidal or homicidal – is often unclear. Our study aimed to understand the antecedents to burns and the problem of ascribing cause, the sequence of medicolegal events after a woman was admitted to hospital, and potential opportunities for improvement.

Methods

We conducted semi-structured interviews with 33 women admitted to two major burns units, their families, and 26 key informant doctors, nurses, and police officers. We used framework analysis to examine the context in which burns occurred and the sequence of medicolegal action after admission to hospital.

Results

Interviewees described accidents, attempted suicide, and attempted homicide. Distinguishing between these was difficult because the underlying combination of poverty and cultural precedent was common to all and action was contingent on potentially conflicting narratives. Space constraint, problems with cooking equipment, and inflammable clothing increased the risk of accidental burns, but coexisted with household conflict, gender-based violence, and alcohol use. Most burns were initially ascribed to accidents. Clinicians adhered to medicolegal procedures, the police carried out their investigative requirements relatively rapidly, but both groups felt vulnerable in the face of the legal process. Women’s understandable reticence to describe burns as non-accidental, the contested nature of statements, their perceived history of changeability, the limited quality and validity of forensic evidence, and the requirement for resilience on the part of clients underlay a general pessimism.

Conclusions

The similarities between accident and intention cluster so tightly as to make them challenging to distinguish, especially given women’s understandable reticence to describe burns as non-accidental. The contested status of forensic evidence and a reliance on testimony means that only a minority of cases lead to conviction. The emphasis should be on improving documentation, communication between service providers, and public understanding of the risks of burns.

A survey of characteristics of self-immolation in the northern iran

Background:

Suicide is an action deliberately initiated and performed by a person with complete awareness of its fatal outcome, prevalence of which is very rare in developed countries, but it is reported with more frequency in Middle East including Iran.

Aim:

This study was carried out to analyze the characteristics, mortality, and related factors of burned patients who attempted to suicide by self-immolation in Northern Iran.

Materials and Methods:

In this retrospective study, the archived files of 101 cases that referred to the main burn care center located in northern Iran (Included: Mazadaran, Golestan cities) - cause of suicide attempting by self-immolation during 2 years 2010-2011, analyzed. A record sheet designed to extract data such as: Age, education, occupation, gender, residence, marital status, drug abuse, and extent of the burn injuries as a percent of burned total body surface area (TBSA).

Results:

The incidence rate of suicide attempted cases were 1.98/100,000 person-years. The mean ages for cases were 31.8 (13.6). The mean age for males and females were 36.1 (14.8) and 30.1 (12.9) years, respectively. In, about 84% (84/101) of the patient's burned TBSA was more than 40% (41/101). Burn injuries were more frequent, larger, and included higher mortality in females than males. Kerosene was the most common used material to self-burning. The mortality rate was about 74% (74/101), which showed a high mortality rate in this study. Other social factors such as marital status, employment, and education level have a role as individually protective or risk factors for self-burning.

Conclusion:

Finding of the current study manifested high rate of suicide by self-immolation among young, married, and low educated women in Northern Iran. It implies a social problem, and need to an arrangement of a cultural program aimed to improving health, psychological habits and educational level.

A case-control study of psychosocial risk and protective factors of self-immolation in Iran

Self-immolation is the third leading cause of years of life lost (YLL) among women in Iran. The aim of this study is to investigate self-immolation-related risk and protective factors in the western region of Iran, a province with the highest prevalent of self-immolation in the country. Using a case-control design, we compared 151 cases of self-immolation attempters who were admitted to a burn center in Kermanshah with 302-matched control group from the same community/locality between March 21st, 2009, and March 20th, 2012. We conducted descriptive, bivariate, and multivariate analysis to examine the associations of self-immolation with demographic and familial risk factors, adverse life events, mental disorders, as well as potential protective factors. According to our findings, the highest percentage of self-immolation was in the 16-25 year-old age group (60%) and in females (76%). Of the potential risk factors in the study, major depression, adjustment disorders, individual history of suicide attempts and opium dependence, were statistically significant predictors of self-immolation. Suggestions for translating the local picture of self-immolation portrayed by our findings, into meaningful prevention strategies that have a good fit with the social and interpersonal context within which self-immolation takes place are discussed.

Suicide in India: a systematic review

BACKGROUND

Suicide is an important cause of death in India but estimated suicide rates based on data from India's National Crime Records Bureau are unreliable.

AIM

Systematically review existing literature on suicide and the factors associated with suicide in India.

METHODS

PubMed, PsycINFO, EMBASE, Global Health, Google Scholar and IndMED were searched using appropriate search terms. The abstracts of relevant papers were independently examined by both authors for possible inclusion. A standardized set of data items were abstracted from the full text of the selected papers.

RESULTS

Thirty-six papers met inclusion criteria for the analysis. The heterogeneity of sampling procedures and methods of the studies made meta-analysis of the results infeasible. Verbal autopsy studies in several rural locations in India report high suicide rates, from 82 to 95 per 100,000 population - up to 8-fold higher than the official national suicide rates. Suicide rates are highest in persons 20 to 29 years of age. Female suicide rates are higher than male rates in persons under 30 years of age but the opposite is true in those 30 years of age or older. Hanging and ingestion of organophosphate pesticides are the most common methods of suicide. Among women, self-immolation is also a relatively common method of suicide. Low socioeconomic status, mental illness (especially alcohol misuse) and inter-personal difficulties are the factors that are most closely associated with suicide.

CONCLUSION

The quality of the information about suicide in India is quite limited, but it is clearly an important and growing public health problem. Compared to suicides in high-income countries, suicide in India is more prevalent in women (particularly young women), is much more likely to involve ingestion of pesticides, is more closely associated with poverty, and is less closely associated with mental illness.

Self-inflicted burn injuries in the Australian context

OBJECTIVE

The primary objective was to calculate the number of self-inflicted burn injuries of all admissions in an Australian hospital burns unit. The secondary objectives included examining the demographic profile, length of stay and co-morbidity of mental illness in these cases compared with the total admissions to the burns unit.

METHODS

A retrospective study of medical records was conducted at a tertiary burns unit over a 5-year period.

RESULTS

A total of 33 self-inflicted burn injury cases were identified which represented 2.2% of all burns unit admissions. These patients were 70% male, the average age was 36.1 years and 11 were born overseas, which was similar to the profile of all admissions. Twenty-four (73%) patients were diagnosed with a mental illness, compared with 14% for all admissions. The average length of stay was 52 days, compared with the burns unit average of 12 days.

CONCLUSIONS

While the percentage of self-inflicted burn cases of all burns unit admissions was low, these cases have a greater burden of care due to their longer admission time and higher frequency of co-morbid mental illness. This finding supports the need for close involvement of consultation liaison psychiatry teams within a burns unit.

Epidemiological study of self-immolation at khatamolanbia hospital of zahedan

Background:

Self-immolation is a high risk behavior and a way of life termination. Self-immolation, as the most painful of all forms of suicide, is not a common form of suicide in European countries. However, it is highly prevalent in developing countries particularly in Asia and Africa.

Objectives:

The aim of this study was to assess the rate and leading factors of self-immolation and gender, geographical distribution, and social norms of affected patients referred to Khatamolanbia Hospital of Zahedan from March 2010 to May 2012.

Materials and Methods:

This descriptive and objective-based study was cross-sectional and retrospective with 750 burn patients; 315 of them had attempted self-immolation and most of them died. The data collection tool was a two partite questionnaire consisting of 17 questions (8 questions about personal details and 9 questions about self-immolation factors).

Results:

350 self-immolations resulting in death were reported in this study; these subjects were 16-25 years old, 67.25% female, 63.55% elementary school education, 74.20% married, 69.10% housewife, 61.05% resident of Saravan, 93.35% oil burns, 72.30% middle and low social class, 90.20% burn over 68%, 20% psychiatric illness history and being treated with antidepressants, 73.25% verbal and physical violence before burning, and 100% of the burnings took place inside a house and usually during the afternoon.

Conclusions:

Due to the high rate of self-immolations in this area, solutions for improvement of life quality and social norms should be reviewed and implemented.

Genetic identification by using short tandem repeats analysis in a case of suicide by self-incineration: a case report

Suicide by self-incineration is an uncommon method of suicide in the western world in contrast with Asian countries, where this type of suicide is more common. If there is a lack of witnesses, genetic analysis for identification is mandatory, especially when anthropologic or dental identification is barely significant.The authors report a case of self-incineration of a 55-year-old white man, which occurred near Siena, Tuscany, Italy.The recovered bones were classified according to the Crow-Glassman scale and assigned to category 5 (the highest extent of combustion according to this scale). Therefore, because of the extent of the bone damage, analyzing the residual soft tissue around the pelvic bones was the only way to reach a genetic identification.The authors report this case to emphasize that even if the highest level of burn injury to human body is reached, an accurate analysis of the findings may lead to a genetic identification. In these cases, an efficient cooperation among police, fire experts, and forensics is necessary, especially because it is the only way to determine if the modality of death was accidental, suicidal, or homicidal.

Patterns of suicide in Brunei Darussalam and comparison with neighbouring countries in South East Asia

A retrospective study of suicides in Brunei Darussalam (Brunei) over a 20 year period from 1991-2010 was conducted by analysing the post-mortem examination and external examination reports and other relevant records. The suicide rate in Brunei is very low (1.9 deaths per 100,000 per year). The majority of the victims were expatriates 82(66%) and hanging was the commonest mode of suicide both in expatriate and local population. The study showed that the suicide rate among the Bruneian Malays was the lowest (0.5 deaths per 100,000 per year) among the different nationalities. The study highlights the demographics and socio-economic background of the victims, methods used in committing suicide, suicide rates in different ethnic groups and predisposing factors. The results of this study would be of use for taking preventive measures to minimize the incidence of suicide.

Attempted suicide by self-immolation is a powerful predictive variable for survival of burn injuries

Up to 9% of all burn victims in western countries are reported to have been caused by self-immolation with suicidal intent and usually involve extensive injuries. The authors sought to identify differences between suicide burn victims as opposed to those who sustained their injuries accidentally with regard to injury severity and mortality and determine the possible impact of suicide as a prognostic variable in the context of a scoring system such as the Abbreviated Burns Severity Index (ABSI). The data of all burns patients treated at the Specialist Burns Intensive Care Unit, University Hospital Zürich, between 1968 and 2008 were analyzed retrospectively. Of the 2813 patients included in the study, 191 were identified as attempted suicides, most commonly involving the use of accelerants. Thirty percent of all suicide victims had preexisting psychiatric diagnoses. Suicide victims presented with significantly more extensive burns (53.7%, ±0.98 SEM vs 21.4 %, ±0.36 SEM, P < .0001), had higher total ABSI scores (8.4, ±0.23 SEM vs 6.6, ±0.05 SEM, P < .0001), and had higher mortality rates (42.9% [83/191] vs 16.3% [426/2622]) than accident victims. Furthermore, logistic regression revealed suicide to be a significant predictor of mortality as inhalation injury (odds ratio 2.2, 95% confidence interval 1.4-3.5, P < .0003 and odds ratio 2.4, 95% confidence interval 1.4-4.0, P < .0009, respectively). The odds of dying from an attempted suicide are twice as high compared with those of accident patients in the same ABSI category, making suicide a powerful predictor of mortality. The authors therefore suggest including it as a fixed variable in scoring systems for estimating a patient's mortality after burn injuries such as the widely used ABSI.

Self-burning in Iraqi Kurdistan: proportion and risk factors in a burns unit

To determine the rate of self-burning among all burns patients admitted to the Burns and Plastic Surgery Centre at Sulaimani University in Iraqi Kurdistan and to identify the risk factors and motives, all burns patients, aged 8 years and over, admitted between 1 September 2009 and 30 April 2010 were surveyed. Of the 200 patients interviewed, 54 (27%) reported self-burns and 146 (73%) reported accidental burns. The risk factors for self-burning included mental illness, female gender and younger age. Almost two-thirds of those who reported self-burns (32, 60.4%) had intended to kill themselves. The most commonly cited reasons for the act were family problems (24, 44%) and marital problems (13, 24%). Burns in the self-burning group were more severe and were associated with a higher mortality rate (34, 63%) than in the accidental burns group (29, 20%).

Epidemiology of burns throughout the World. Part II: intentional burns in adults

A significant number of burns and deaths from fire are intentionally wrought. Rates of intentional burns are unevenly distributed throughout the world; India has a particularly high rate in young women whereas in Europe rates are higher in men in mid-life. Data from hospitalized burn patients worldwide reveal incidence rates for assault by fire and scalds ranging from 3% to 10%. The average proportion of the body surface area burned in an assault by fire or scalds is approximately 20%. In different parts of the world, attempted burning of others or oneself can be attributed to different motives. Circumstances under which assaults occur fall largely into the categories of interpersonal conflict, including spousal abuse, elder abuse, or interactions over contentious business transactions. Contributing social factors to assaults by burning include drug and alcohol abuse, non-constructive use of leisure time, non-participation in religious and community activities, unstable relationships, and extramarital affairs. Although the incidence of self-mutilation and suicide attempts by burning are relatively low, deliberate self-harm carries a significant risk of death, with an overall mortality rate of 65% worldwide. In those who resort to self-immolation, circumstantial themes reflect domestic discord, family dysfunction, and the social ramifications of unemployment. Preventing injurious burn-related violence requires a multifaceted approach, including legislation and enforcement, education, and advocacy. Better standardized assessment tools are needed to screen for risks of abuse and for psychiatric disorders in perpetrators.

Explanations of firesetting in mentally disordered offenders: a review of the literature

This paper reviews current explanations of firesetting in adult mentally disordered offenders. In particular, attention is given to contemporary research that has examined developmental and background characteristics, personality and associated traits, motivation for firesetting, neurobiological explanations, psychiatric diagnoses, and frequency of self-injurious behavior, including suicide. The likelihood of recidivism and associated risk factors is also considered. Evaluation of the existing research has highlighted that even though a significant proportion has been conducted with psychiatric populations, little is understood about firesetting by mentally disordered offenders. In addition, little research has been conducted that compares mentally disordered firesetters to both other mentally disordered offenders and non-mentally disordered offenders. Recommendations are made for future research to further develop knowledge of this behavior.

Suicide by burning in the South Asian origin population in England and Wales a secondary analysis of a national data set

Objectives A descriptive analysis of suicide by burning in England and Wales in the general population and in people of South Asian origin. Design A cross-sectional secondary analysis of a national data set. Setting A population study of all those who died by suicide in England and Wales between 1993 and 2003 inclusive. Participants All cases of suicide and undetermined intent identified by the Office for National Statistics for England and Wales. A computer algorithm was used to identify people of the South Asian origin from their names. There were 55 140 suicides in the UK between 1993 and 2003. The ratio of male to female suicides was 3:1. There were 1455 South Asian suicides identified by South Asian Name and Group Recognition Algorithm. Primary and secondary outcome measures Death by suicide and undetermined intent, as determined by Coroner's Inquest. ICD9 codes E958.1 and E988.1 and ICD10 codes X76 and Y26. Results 1.77% of suicides in the general population and 8.45% of suicides in the South Asian origin population were by burning. The suicide rate by burning was 0.8/100 000 person-years for England and Wales and 2.9/100 000 person-years for the South Asian origin population. The odds of suicide by burning were increased in the South Asian group as a whole (OR 3.06, 95% CI 2.30 to 4.08). Those born in Asia and Africa were at higher risk than those born in the UK (OR 2.69, 95% CI 2.01 to 3.60 and OR 2.10, 95% CI 1.46 to 3.01, respectively). The increased risk was for those aged 25-64 years. Conclusion Suicide by burning remains a significant issue in the South Asian origin working-age population in England and Wales. A prevention strategy could target working-age people of South Asian origin born abroad as they are at the highest risk. More in depth research on the reasons for using this method may help to identify possible prevention strategies.

Queimaduras autoinfligidas: tentativa de suicídio

OBJETIVO: Analisar a incidência, características, conduta e taxa de mortalidade de pacientes com autolesão por queimaduras internados no Centro de Queimaduras de Brasília, Distrito Federal, Brasil. MÉTODOS: Os pacientes do estudo consistiram das vítimas de queimaduras consecutivamente internadas na Unidade de Queimados do Hospital Regional da Asa Norte, Brasília, Distrito Federal, Brasil, durante o período de fevereiro de 2008 e fevereiro de 2009. Os dados foram obtidos na admissão e foram registrados prospectivamente durante a internação. Os pacientes foram seguidos até a alta ou o óbito. RESULTADOS: No período do estudo, foram admitidos 15 casos de autolesão por queimaduras na Unidade de Queimados. A média de idade foi 38,0 ± 20,6 anos; 66,7% dos casos de autolesão por queimadura eram mulheres. Na maioria dos casos eram casadas, provedoras do lar, e pobres. O maior motivo foi conflito conjugal. A taxa de mortalidade foi 40%. A área média de superfície corporal queimada foi 38,7 ± 26,1%. O álcool foi usado por 66,7% dos pacientes como causa das queimaduras. A média de duração do tratamento foi 20,1 ± 14,8 dias. Pacientes com autoinjúria por queimadura apresentaram lesões mais extensas, permaneceram mais tempo no hospital e pior prognóstico. CONCLUSÃO: Pacientes com autolesão por queimaduras apresentaram média de idade mais elevada, maior superfície corporal queimada, maior período de internação, mais complicações infecciosas e maior taxa de letalidade do que os pacientes com queimaduras acidentais. Esses pacientes precisam de constante suporte psiquiátrico, o qual pode ser útil na prevenção de futuros episódios de autoagressão.

Epidemiology of burns throughout the world. Part I: Distribution and risk factors

Globally in 2004, the incidence of burns severe enough to require medical attention was nearly 11 million people and ranked fourth in all injuries, higher than the combined incidence of tuberculosis and HIV infections. Fortunately, although burns and fires account for over 300,000 deaths each year throughout the world, the vast majority of burns are not fatal. Nonetheless, fire-related burns are also among the leading causes of disability-adjusted life years (DALYs) lost in low- and middle-income countries (LMIC). Morbidity and mortality due to fire and flames has declined worldwide in the past decades. However, 90% of burn deaths occur in LMIC, where prevention programs are uncommon and the quality of acute care is inconsistent. Even in high-income countries, burns occur disproportionately to racial and ethnic minorities such that socioeconomic status--more than cultural or educational factors--account for most of the increased burn susceptibility. Risk factors for burns include those related to socioeconomic status, race and ethnicity, age, and gender, as well as those factors pertaining to region of residence, intent of injury, and comorbidity. Both the epidemiology and risk factors of burns injuries worldwide are reviewed in this paper.

Suicide by burning: epidemiological and clinical profiles

Self-immolation constitutes a rare form of suicide in developed countries, though it accounts for unique injury characteristics in the burn intensive care unit. The aim of this study was to present the epidemiological and clinical features of patients burned during a suicidal attempt seen in a North Rhine-Westphalia burn intensive care unit (BICU). To address this aim, we undertook a 21-year retrospective study involving patients with thermal injuries admitted to the largest burn unit in Germany. A total of 125 suicide-related burn victims were identified in the study period (9.4%). Comparing the self-immolation group with the rest burn patient cohort, suicide victims were more likely to be single and to act under the influence of alcohol. The suicidal group had a larger extent of burns, higher incidence of inhalation injury, required more surgical procedures, catecholamines, blood transfusions, and a longer BICU stay. Their clinical course was complicated by prolonged intubation period, higher rate of multiple drug-resistant bacteria acquisition and sepsis, leading to a higher mortality rate. Although the proportion of self-immolation victims among all burned patients is not high, the markedly higher severity of their burns and their poorer quality of outcomes makes them an important clinical subgroup for further study.

Self-inflicted burns: the value of collaboration between medicine and law

Self-inflicted burns are rare in France, but they lead to major, often life-threatening complications. The authors reviewed medical data for patients hospitalized in a burn center from January 2004 to December 2008. Thirty-eight cases of self-inflicted burns were compared with 220 accidental burns. Women were predominantly affected (57.9%, n = 22). A psychiatric history (71%, n = 27) was more frequent in this population. The mean age of the victims was 38 years. The leading method of suicide was flame (94%, n = 36) associated with gasoline used as an accelerant (77.7%, n = 28). Mean total burn surface area (41.5%) and mortality (36.9%) were higher in the self-inflicted burn population. By recognizing epidemiological characteristics and patients at risk, we can better classify lesions related to self-immolation. It is important for the forensic physician to consult survival details to correlate these data with the results of autopsy.

Suicide by self-burning in Iraqi Kurdistan: description and risk factors

This study aims to provide evidence for the problem of suicide by self-burning in Iraqi Kurdistan. Data were collected prospectively from all patients admitted to the burn center in the province of Sulaymaniyah and cases of self-burning were compared with cases of accidental burns. There were 197 cases with an annual incidence rate of 8.4 per 100,000 per year and female to male risk ratio of 13.1. Independent risk factors for self-burning were female sex (odds ratio 13.75, 95% CI 6.91-27.36, P < 0.001); young age of 11 to 18 years (OR 3.92, 95% CI 2.20-7.0, P < 0.001); poor education (OR 2.50, 95% CI 1.15-5.45, P = 0.02); spring season (OR 2.39, 95% CI 1.3-4.41, P = 0.005); and small family size (OR 2.72, 95% CI 1.44-5.15, P = 0.002). Suicide by self-burning is common in Iraqi Kurdistan especially among women. Urgent action is required to provide a better understanding of the situation, and identify partners, capacities, and opportunities for action.

Case series of completed suicides by burning over a 13-year period

Suicide by burning is an extreme act that is uncommon in the United States and throughout the Western world. The characteristics of people who complete such acts are not well understood. To address this issue, we examined the death records of the King County Medical Examiner's Office in Washington State over the 13 years from 1996 to 2009. Twenty-five cases of suicide by burning were identified and used to characterize decedent demographics, circumstances of death, and motivating factors. Compared to other methods of suicide, burning demonstrated a significant overrepresentation of decedents who were women, 40-59 years of age, and Asian/Pacific Islander. They also tended to have previous psychiatric illness and/or substance abuse issues. Self-burning predominantly occurred at the decedent's residence with the intent of suicide given. There was no unifying theme in motivating factors. Together, these data represent the characteristics of people whose death is because of suicide by burning in King County, Washington.

Mental disorders among acute burn patients

OBJECTIVE

To investigate mental disorders among acute hospitalized burn patients.

METHOD

Consecutive acute adult burn patients (n=107) admitted to Helsinki Burn Centre were interviewed by an experienced psychiatrist with the Structured Clinical Interview for DSM-IV-TR for Axis I and II mental disorders assessed in three time frames (lifetime, the month prior to burn, and in acute care). Information on clinical features, psychiatric symptoms, personality traits, and burn severity (total body surface area, TBSA) was gathered.

RESULTS

The mean TBSA was 9%. Most (61%) acute burn patients had at least one lifetime Axis I or II mental disorder. Prevalences of lifetime substance-related disorders (47%), psychotic disorders (10%), and Axis II personality disorders (23%) were high. The overall prevalence of Axis I mental disorders increased significantly (Q=6.40, df=1, p=0.011) from the month prior to burn (40%) to acute care (48%). The prevalence of delirium for this period was significantly higher (0.9% vs. 13%; Q=13.00, df=1, p<0.001) in acute care.

CONCLUSIONS

Mental disorders, particularly substance use disorders, psychotic disorders, and personality disorders are common among acute burn patients before injury. These disorders may predispose to burns. Burn itself may also predispose to mental disorders, particularly delirium.

A follow-up study of adults with suicidal burns: psychosocial adjustment and quality of life

The severity of the burn injuries, accompanying injuries, and the often concomitant psychiatric disease complicate the treatment of patients with suicidal burns. Data from 45 patients who were treated for suicidal burn injuries from 1994 to 2005 were acquired from the patients' charts and interviews with standardized questionnaires (n = 11) concerning their psychological status pretrauma and posttrauma, as well as their quality of life with special reference to psychosocial adjustments. None of the patients survived more than 69% TBSA burns; no one with 41% or less died. Most of the patients had prediagnosed psychiatric disorders. The educational and social background of the patients and religious beliefs played a minor role for choosing this method of suicide. Aggression levels were above the average population, whereas self-direction was underdeveloped. Forty percent, albeit unsuccessfully, committed subsequent suicide attempts. Most patients felt only moderate social impairment by the burn wound residuals, the majority had intensified and improved their social contacts, and most felt no relevant decrease of quality of life compared with their personal situation before the suicide attempt. Patients who survive the suicide attempt can become integrated in social life again. More data are needed to reliably identify patients at risk in advance.

Study of suicides reported to the Coroner in Colombo, Sri Lanka

INTRODUCTION

Deaths from suicide reached a peak in Sri Lanka in 1995. Several interventions reduced the suicide rate of 48.7 per 100,000 in 1995 to 23 per 100,000 in 2006, though it is still a major socioeconomic problem. All suicides have to be reported to the Inquirer of Sudden Death (ISD) or 'Coroner', according to the Criminal Procedure Code.

METHOD

All deaths where a verdict of 'suicide' was given after an inquest at the Coroner's Court, Colombo, in 2006 were studied. Close relations or friends who attended the inquest were interviewed by medically qualified research assistants. Age, sex, marital and occupational status, level of education, living circumstances and method and reasons for the suicide were studied.

RESULTS

During 2006, 151 deaths from suicide were documented, of which 93 (62%) were men. The majority (47%) were aged between 20 and 29 years. One-third of the victims was unemployed. At the time of committing suicide, 75% were living with family; 89 (59%) were married and 46 (31%) were single. Poisoning was the cause of death in 66 (44%), 48 (70%) of which were due to pesticides. Burns caused 51 (34%) deaths. Other common causes of death included hanging (11%), jumping in front of a train (7%) and drowning (3%). The commonest reason for suicide was dispute with the spouse/marital disharmony (30%). Other reasons were dispute with parents (8%), financial matters (7%), organic diseases (7%), alcoholism (7%), psychiatric illnesses (6%) and disputes in love affairs (5%). In 29 cases (19%), no definite reason for the suicide was evident.

DISCUSSION

Self-poisoning and self-immolation were the commonest methods used to commit suicide. Marital disharmony was the main reason (30%). Psychiatric illnesses were responsible for only 6%. Future interventional activities should include secure access and restriction of the availability of pesticides and drugs, empowering people to manage anger and conflicts, and recognition and treatment of alcoholism and psychiatric illnesses. The success story of the reduction in the incidence of suicides in Sri Lanka should be a lesson to many developing countries where suicide is a major socioeconomic and health issue.

Epidemiology of burn injuries II: psychiatric and behavioural perspectives

Modern technological advances have decreased the incidence and severity of burn injuries, and medical care improvements of burn injuries have significantly increased survival rates, particularly in developed countries. Still, fire-related burn injuries are responsible for 300,000 deaths and 10 million disability-adjusted life years lost annually worldwide. The extent to which psychiatric and behavioural factors contribute to the incidence and outcomes of these tragedies has not been systematically documented, and the available data is often insufficient to reach definitive conclusions. Accordingly, this article reviews the evidence of psychiatric and behavioural risk factors and prevention opportunities for burn injuries worldwide. Psychiatric prevalence rates and risk factors for burn injuries, prevalence and risks associated with 'intentional' burn injuries (self-immolation, assault, and child maltreatment), and prevention activities targeting the general population and those with known psychiatric and behavioural risk factors are discussed. These issues are substantially interwoven with many co-occurring risk factors. While success in teasing apart the roles and contributions of these factors rests upon improving the methodology employed in future research, the nature of this entanglement increases the likelihood that successful interventions in one problem area will reap benefits in others.

The morphology of cutaneous burn injuries and the type of heat application

The morphology of burn injuries in 120 consecutive patients from the Department of Plastic and Reconstructive Surgery, CHR, Hospital B in Lille was correlated to the etiology and type of heat. Analysis identified five typical patterns of cutaneous burn injuries. Jet of flame-pattern from methylated spirits and gasoline detonations: superficial burn injuries; sparing of skin wrinkles and the submental region; absence or small amounts of soot; preference of exposed body regions, esp. the face and hands. Explosion-pattern from explosions and electrothermal injuries: superficial burn injuries; sparing of skin wrinkles but not of the submental region; soot; preference of exposed body regions. Alveolar soot arrangement and metallisation in electrothermal injuries. Considerable third-degree burns in dust explosions. Flame-pattern from direct flame effects due to burning gasoline or oil, open fires or ignited clothing: nonuniform depth including large third-degree burns; no sparing of the submental region; soot; preference of body regions covered by clothing. Immersion-pattern: superficial (bullous) injuries; blurred junction between scalded and unscalded areas; extremities, buttocks, and back are favourite sites; cave child abuse: waterlines and zebra-burns. Spilling-pattern: superficial injuries; sharp junction between scalded and unscalded areas; head, anterior trunk, and upper extremities are favourite sites; running off and splashing stains. Consideration of these patterns can assist the reconstruction in fire investigations or unclear scaldings. In cases of suspected arson, a typical burn injury pattern or a single finding not compatible with the rest of the pattern can disprove a suspect or raise the level of suspicion.

Self-inflicted burn injuries in southwest Iran

Self-inflicted burns are among the most devastating of all burn injuries with serious physical, psychological, and financial effects on the individual, the patient's family, and society. This study was carried out to analyze the epidemiology, mortality, and current etiological factors of burn patients who were admitted to a major burn center in the Fars province. In a longitudinal prospective design, from April 2003 to March 2005, all burn patients that were admitted to Ghotb-eddin Shirazi Hospital were evaluated. Data in regard to patients' social demographics, burn injury, and outcome measures were collected. Suicide attempts by burning accounted for 231 (24.8%) of all burn patients admitted to hospital. Suicidal burns occurred predominantly in the age group 15 to 24 years (49.1%). Most (71.4%) self-burning cases were female. Deliberate self-burn patients have significantly larger burned body surface area than accidental burn patients [70% (4-100) vs 28% (1-100); P < .0001]. The case fatality rate for self-inflicted burns (62.3%) was significantly higher than the 27.7% rate observed for accidental burns (P < .0001). Burned body surface area >40% and self-inflicted burns strongly and independently predicted mortality. Self-inflicted burns continue to be a major health problem in this region. Special burn preventive programs should be implemented in primary health care system. A National Committee for Injury and Burn Prevention and Control should be established urgently to coordinate all burn prevention programs and collaborate between different sectors of the society.

Mortality risk and length of stay associated with self-inflicted burn injury: evidence from a national sample of 30,382 adult patients

OBJECTIVE

Existing studies report contradictory findings regarding characteristics and outcomes of patients admitted with self-inflicted burn injuries. The objective of this study was to report demographic and medical characteristics of patients admitted to burn centers with self-inflicted burn injuries and to assess mortality risk and length of stay compared with patients whose injuries were not self-inflicted.

DESIGN

Retrospective, cohort study.

SETTING

A total of 70 burn centers from the United States that contributed data to the American Burn Association National Burn Repository.

PATIENTS

A total of 30,382 adult patients (593 with self-inflicted injuries) who were admitted with a thermal injury from 1995 through 2005.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographics, comorbidities, burn injury severity variables (total body surface area burned [TBSA], TBSA burned third degree, inhalation injury), hospital mortality, intensive care length of stay, and total hospital length of stay were ascertained. Patients with self-inflicted injuries had larger TBSA burned (32.0% vs. 12.8%, p < .01) and larger third-degree TBSA burned (20.6% vs. 4.9%, p < .01) and were more likely to incur an inhalation injury (37.3% vs. 12.8%, p < .01). Before matching, patients with self-inflicted injuries were at greater risk of mortality (23.6% vs. 6.8%, p < .01) and required longer intensive care (median of 4 days vs. 0 days, p < .01) and total hospital stays (median of 23 days vs. 8 days, p < .01). After propensity score matching on demographic, medical, and burn injury variables, they were not more likely to die of their injuries (23.6% vs. 23.1%, p = .84), did not require longer intensive care stays (4 days vs. 3 days, p = .75), and did not require longer total hospital stays (23 days vs. 18 days, p = .50).

CONCLUSIONS

Compared with patients with similar demographic, health, and injury characteristics whose injuries are not self-inflicted, patients with self-inflicted burn injuries are not at greater risk of mortality and do not require longer durations of intensive care or total hospitalization.

The descriptive epidemiology of intentional burns in the United States: An analysis of the National Burn Repository

BACKGROUND

Epidemiologic research on intentional burns in the United States has mainly been based on small, geographically restricted populations. The current study presents the descriptive epidemiology of intentional burns using data from a large, geographically diverse population of burn patients.

METHODS

The National Burn Repository (NBR) was queried for patients with intentional burns and analyzed data pertaining to their demographic and medical characteristics; primarily comparing the prevalence proportions of these variables according to specific injury intent.

RESULTS

From a total of 54,219 burn patients, 1601 patients who sustained intentional burns were identified; 49% were self-inflicted, and 51% were assault-related. Compared to all other burn patients, intentional burn patients had a larger mean total body surface area (TBSA) burned (22.0% versus 11.3%, p<0.0001), longer hospital stay (19.8 days versus 12.5 days, p<0.0001), and higher mortality (13.9% versus 2.5%, p<0.0001). Self-inflicted compared to assault-related burns were associated with a larger TBSA burned (27.5% versus 16.8%, p<0.0001) and higher mortality (20.8% versus 7.2%, p<0.0001).

CONCLUSIONS

Data from this national cohort of burn patients support findings from smaller studies that patients who suffer intentional burns experience excess morbidity and mortality.

Epidemiology of suicide by burns in the province of Isfahan, Iran

The aim of the study was to determine epidemiologic features and factors associated with suicidal behaviors by burns requiring hospitalization in the province of Isfahan, Iran. A prospective population-based study of all suicidal behaviors by burns requiring hospitalization was conducted in the province of Isfahan, Iran, from March 21, 2005 to March 20, 2006. Data were obtained from patients, family members, and/or friends through interviews during the course of hospitalization. A total of 89 patients ages 13 to 62 years with suicidal behaviors by burns were identified during the study period, representing an overall incidence rate of 2.9 per 100,000 persons-year (P-Y; 95% confidence interval 2.3-3.5 per 100,000 P-Y). Females (4.7 per 100,000 P-Y) had a higher rate of suicidal behavior by burns than males (1.2 per 100,000 P-Y; P < .001). The age-specific rate of suicidal behavior by burns peaked at age group 20 to 29 years (6.3 per 100,000 P-Y). Among the population aged 15 to 29 years, married women had a higher rate of suicidal behavior by burns (9.3 per 100,000 P-Y) than single women (6.6 per 100,000 P-Y). The highest rate of suicidal behavior by burns was found among the unemployed population (17.7 per 100,000 P-Y). The most frequent precipitating factor for suicidal behavior was a quarrel with a family member, relative, and/or friend (61.8%). Depression and anxiety disorders were the most frequent psychiatric comorbidities associated with suicidal behaviors. Mortality rate caused by suicidal behavior by burns was 1.4 per 100,000 P-Y. A high rate of suicidal behavior among young and mostly married women in the province of Isfahan is a tragedy and great concern. Social, cultural, and economical factors may contribute to suicidal behavior in Isfahan, and they need to be addressed through education, support, and commitment. Findings of this study can be used for implementation of a preventive program(s) to reduce the incidence of suicide among high risk groups.

Who attempts suicide by burning? An analysis of age patterns of mortality by self-inflicted burning in the United States

OBJECTIVE

The objective of this study was to compare age patterns of completed suicide by burning in the USA to age patterns in suicide by all methods as an indicator of whether suicide by burning may be a phenomenon related to altered mental status (psychosis and/or intoxication).

METHODS

Analysis of three national databases: Fatal injury data from the U.S. National Vital Statistics System, estimates of nonfatal injury data from the U.S. National Electronic Injury Surveillance System All-Injury Program and mortality data from the American Burn Association National Burn Repository.

RESULTS

Risk of suicide by burning is highest between 30 and 59 years (odds by decile of age compared to 18-29 years, 1.47 to 1.82), whereas risk by all methods is highest for ages 70 and older (odds, 1.26 to 1.55). Of patients admitted to burn centers with large self-inflicted burns (total body surface area > or =20%), 58.6% live. Among those with specified psychiatric or substance abuse/dependence disorders, 69.2% had either a disorder that included psychosis and/or a substance abuse/dependence disorder.

CONCLUSIONS

Age patterns of suicide by burning suggest that psychotic and/or substance-related disorders may be present in a substantial proportion of victims. Further research is needed, however, to document the psychiatric characteristics of these patients.

[Unusual haemostasis disorder in a seriously burned patient]

We report the case of a woman severely burned during a gas explosion with an unusual disorder of haemostasis. The prothrombin time was very elevated, essentially by a drop in factor II. This abnormality persisted for a long time after the correction of the dilutional and consumption coagulopathy which followed immediately the burn. Blood analysis found fluindione and benzodiazepine derivatives. Such a disorder during a potentially suicidal burn must evoke a toxic aetiology.

The epidemiology of intentional burns

We sought to present the epidemiology of intentional burns, both deliberate self-inflicted burns and assault burns. Patient records from the University of Alabama at Birmingham Burn Center were reviewed retrospectively. Information pertaining to demographic and injury characteristics were obtained. Ninety-six patients with intentional burns were identified. Patients sustaining intentional burn injury had larger mean TBSA burned (26.1% vs 13.8%), longer mean hospital length of stay (19.9 days vs 13.2 days), higher incidence of inhalational injury (20.8% vs 8.7%), higher rate of mortality (20.0% vs 9.8%), and were more likely to have an elevated blood alcohol content (14.6% vs 7%) when compared with all other burn patients. Patients with deliberate self-burns were more likely to be men (85.7% vs 55.7%) and more likely to have a positive drug screen test than assault burn patients (11.4% vs 0%). Patients who suffer intentional burns tend to have more severe burns and experience worse outcomes.

Correlation between incidences of self-inflicted burns and means of inbreeding coefficients, an ecologic study

PURPOSE

The aim of the study is to obtain more insight into the possible association between consanguinity and the incidence of deliberate self-burning.

METHODS

Data were obtained by analysis of medical records of patients hospitalized in two referral burn centers: Chormy Burn Center (Bushehr Province, south of Iran) from March 21, 1998, through March 20, 2004, and Shahid Sadoqi Center of Burns and Injuries (Yazd Province, center of Iran) from March 21, 2000, through March 20, 2004.

RESULTS

The incidence of suicidal burns was 6.51 and 2.32/100,000 person-years for Bushehr and Yazd Provinces, respectively. The observed sex ratio of patients in both centers indicated there was a female predominance in patients with self-inflicted burns. Using patients' home addresses, patients were sorted into 16 cities. The incidence of suicide by self-burning ranged from 0.80 (for Tabas, located in Yazd Province) to 12.60/100,000 person-years (for Dilam, located in Bushehr Province). The coefficient of inbreeding defines the probability that an individual received both alleles of a pair from an identical ancestral source. There was a significant correlation between incidences of suicidal burns and mean coefficient of inbreeding (r = 0.782, df = 14, p < 0.001).

CONCLUSION

In addition to other factors, consanguineous marriage may be a risk factor that influences the incidence of suicidal burns in a population.

Suicide to Harass Others

Suicide by revenge, the Samsonic suicide, and the suicide by devotio, all described in classical mythology and also reported in the ethnographic literature, belong to the same class of suicidal behaviors as kamikaze suicide and the suicide bombing attack: suicide to harass and burden others or suicide with a hostile intent. The lack of a social dimension to share in a positive manner may lead an individual to integrate him/herself in another social structure, e.g., a military organization, which allows the individual to express his/her desires and personal identity only by destroying others and themselves. The dynamics of these forms of suicide are also likely to work in other displays of life-threatening behavior, such as family annihilation, mass murder, and spree killing. A more thorough investigation of the dynamics operating in suicide bombing attacks could, therefore, contribute to preventative strategies against violence at large.

Epidemiology and mortality of hospitalized burn patients in Kohkiluye va Boyerahmad province (Iran): 2002–2004

The Kohkiluye va Boyerahmad province is located in the south of Iran. The population of the province is about 615,000, living in 14,261 km(2). The total number of patients in the study was 235. There were admitted to the burn unit of Shahid Beheshti hospital (Yasuj) between 18 July 2002 and 17 July 2004. Of these patients, 149 (63.4%) were accidental and 86 (36.6%) were self-inflicted burns. The hospitalization rates for accidental and self-inflicted burns were 12.1 and 7.0 per 100,000 person-years, respectively. There is a significant difference in the sex ratio (males:females) between accidental (1.40) and suicidal (0.13) patient groups (P((2))<0.00001). The fatality rates for accidental and self-inflicted burns were 2.1 and 59.5%, respectively. The mortality rates for accidental and self-inflicted burns were 0.24 and 3.81 per 100,000 person-years, respectively. The overall mean and median ages for accidental patients were 19.4 and 13 years, and those for self-inflicted burns were 24.9 and 23 years, respectively. In the accidental patients, the BSA of the burns ranged from 5 to 95%, with a median of 15%. In the self-inflicted patients, the median of BSA was 65%. The majority of accidental burns were caused by scalds (43.2%) and of self-inflicted burns by kerosene (87.5%). The median hospital stay was 8 days with a range of 1-43 days for accidental patients. The median hospital stay was 4 days with a range from <1 to 36 days for fatal self-burning patients. In non-fatal self-burning cases, the median hospital stay was 20 days with a range of 4-53 days. There is significant difference between fatal and non-fatal self-burning cases for hospital stay (P((2))<0.0001). No definite correlation was found between the incidence of either accidental or self-inflicted burns and seasons (P((2))>0.05). Most of the burns occurred at home.

Suicide in classical mythology: cues for prevention

OBJECTIVE

To compare well established antecedents and correlates of completed suicide with the motives and the mechanics reported in Greek mythology.

METHOD

A well-known collection of Greek myths, the Book of fables by Hyginus, was explored to investigate the mechanics driving an individual to imagine, design and carry out a suicide attempt.

RESULTS

Females outnumber males in the mythographer's list, their favourite methods to die being drowning, hanging, self-burning and throwing themselves down from on high. Some kind of familial recurrence of suicide was accounted for, and a large percentage of these suicides was connected to incest. Shame, sense of guilt and grief for the death of a loved one are the most frequently reported psychological correlates of the act, whereas defeat, failure or a catastrophic change in living conditions and, among females, an unfortunate love affair figure as the main antecedents of suicide.

CONCLUSION

Negative life events and emotional reactions to the severing of social ties frequently occur as antecedents of suicide in Greek mythology.