Predictors of posttraumatic stress disorder after burn injury

Do burn patients need burn specific multidisciplinary outpatient aftercare: research results

In a cross-sectional study of patients 12-24 months after a burn injury, the need for a multidisciplinary burn specific outpatient clinic was examined in relation to aftercare consumption, physical and psychological problems. Four hundred and twenty nine patients were assessed by means of three self-report questionnaires: IES, SCL(PTSD-SL) and BSHS-SV-S. Results indicated that the current aftercare providers are almost exclusively medical doctors and that a quarter of the patients are dissatisfied with received aftercare. However, dissatisfaction about current aftercare was not the only criterion to determine whether patients wanted burn-specific aftercare. The severity of psychological and physical problems predicted interest in a multi-disciplinary outpatient clinic. Self-reported psychological and physical problems were found to be related to one another. Univariate logistic regression outcomes suggested that patients with serious psychological and physical problems are more likely to express interest in a burn-specific outpatient clinic, but that, in a multivariate regression analysis, physical problems and psychological problems measured on the SCL(PTSD-SLEEP) do not contribute to the prediction of the interest in a burn-specific outpatient clinic anymore once symptoms of PTSD are taken care of. Results suggest that psychological aftercare for burn patients needs to be improved. Possible steps to improve aftercare to meet patients' needs are discussed.

Linguistic analysis to assess medically related posttraumatic stress symptoms

The authors examined the presence of posttraumatic stress symptoms (PTSS) in 20 patients requiring ventilation after acute respiratory distress. The subjects completed a semistructured interview about their ventilation experience that was subject to content and linguistic analysis. Subjects also completed two self-report measures to assess PTSS and socioemotional adjustment. Subjects who endorsed PTSS were more likely to use a narrative style suggesting emotional involvement in their recall of the stressful event. The authors indicate that the presence of PTSS is a common consequence of traumatic medical experiences and that denial of distress may be an adaptive short-term coping strategy.

Relation of psychological vulnerability factors to posttraumatic stress disorder symptomatology in bone marrow transplant recipients

OBJECTIVE

Prior research suggests that the diagnosis and treatment of cancer can result in the development of symptoms of posttraumatic stress disorder (PTSD). Based on Lazarus and Folkman's model of stress, the current study examined whether trauma appraisals, coping, social support, and social constraint were associated with the severity of PTSD symptoms in cancer patients who had undergone bone marrow transplantation (BMT).

METHODS

Participants were 23 males and 79 females treated with BMT an average of 20 months previously (range = 3-62 months). Past and current psychiatric diagnoses were assessed through a structured clinical interview. PTSD symptomatology and other psychological variables were assessed using standardized self-report measures.

RESULTS

Results indicated that 5% of participants met diagnostic criteria for current PTSD. Participants reported an average of three to four symptoms of PTSD (range = 0-16). Univariate analyses confirmed predictions that increased PTSD symptomatology would be associated with more negative appraisals of the BMT experience, greater use of avoidance-based coping strategies, lower levels of social support, and greater social constraint (p < .05). Regression analyses indicated that each of these variables accounted for significant (p < .05) variability in PTSD symptomatology above and beyond relevant demographic and medical variables.

CONCLUSIONS

Results of the present study confirm and extend prior research regarding the prevalence of PTSD and PTSD symptoms among patients treated for cancer. In addition, the study identified a set of theoretically derived psychological characteristics that seem to place patients at risk for greater PTSD symptomatology after BMT.

Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults

Meta-analyses were conducted on 14 separate risk factors for posttraumatic stress disorder (PTSD), and the moderating effects of various sample and study characteristics, including civilian/military status, were examined. Three categories of risk factor emerged: Factors such as gender, age at trauma, and race that predicted PTSD in some populations but not in others; factors such as education, previous trauma, and general childhood adversity that predicted PTSD more consistently but to a varying extent according to the populations studied and the methods used; and factors such as psychiatric history, reported childhood abuse, and family psychiatric history that had more uniform predictive effects. Individually, the effect size of all the risk factors was modest, but factors operating during or after the trauma, such as trauma severity, lack of social support, and additional life stress, had somewhat stronger effects than pretrauma factors.

Association of psychological vulnerability factors to post-traumatic stress symptomatology in mothers of pediatric cancer survivors

The current study investigated whether individual differences in coping style, lifetime experience of traumatic events, perceived social support, and perceived social constraints were associated with symptoms of post-traumatic stress among 72 mothers of children who had successfully completed cancer treatment. Results suggested that more perceived social constraints and less perceived belonging support were associated with significantly more post-traumatic stress symptomatology, and this association was present after controlling for the effects of child age. Monitoring coping style and lifetime traumatic events were not significantly predictive of post-traumatic stress symptoms. The results of this study indicate that a sense of belonging to a social network as well as comfort expressing cancer-related thoughts and feelings to friends and family may play a key role in mothers' long-term adjustment to this extremely difficult life experience.

Intrusive thoughts and psychological distress among breast cancer survivors: global meaning as a possible protective factor

Previous research has consistently demonstrated a positive association between intrusive thoughts about stressful experiences and psychological distress. The strength of this relation, however, has varied considerably across studies. To examine the possibility that an individual's sense of global meaning (i.e., the existential belief that one's life has purpose and order) may moderate the relation between intrusive thoughts and psychological distress, the authors conducted telephone assessments of 61 women who had survived breast cancer. Results confirmed that the frequency of intrusive thoughts was positively related to psychological distress. Global meaning, moreover, moderated the relation between intrusive thoughts and psychological distress consistent with the authors' hypotheses. Among women with lower global meaning, more frequent intrusive thoughts were associated with higher psychological distress. No association was found between intrusive thoughts and psychological distress among those participants with higher global meaning.

Dysfunctional meaning of posttraumatic intrusions in chronic PTSD

The paper suggests that the negative idiosyncratic meaning of posttraumatic intrusions (e.g., 'I am going crazy') and cognitive strategies intended to control the intrusions play a major role in maintaining posttraumatic stress disorder. Two studies of 159 and 138 motor vehicle accidents survivors showed that the dysfunctional meaning of intrusions explained a proportion of the variance of the intrusion-related distress, strategies used to end the intrusions, and PTSD severity that was not explained by intrusion frequency, accident severity, or by general catastrophic thoughts when anxious. Rumination, thought suppression, and distraction when having intrusions showed substantial correlations with PTSD severity, as did avoidance of reminders of the accident. The results have implications for the treatment of chronic PTSD.

Psychometric evaluation of Horowitz's Impact of Event Scale: a review

Despite being developed before the formal introduction of posttraumatic stress disorder (PTSD) within the diagnostic literature, the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979) remains one of the most widely used self-report measures of posttraumatic stress. This paper presents an overview of research using the IES in an attempt to assess its psychometric status. It is concluded that the psychometric properties of the IES are satisfactory (although not as a PTSD diagnostic measure) and that continued use of the IES as a measure of intrusive and avoidant processes is warranted.

Stability and change in posttraumatic stress disorder symptoms following breast cancer treatment: a 1-year follow-up

While some recent research has examined the prevalence and severity of posttraumatic stress disorder (PTSD)-like symptoms following cancer treatment, no research has examined temporal change or stability in these symptoms in cancer survivors. Female breast cancer survivors (n=46) participated in an initial telephone interview and a follow-up interview 12 months later. PTSD symptoms associated with breast cancer were assessed using the PTSD Checklist-Civilian version (PCLC). In general, PTSD symptoms in this population did not diminish over time. While group analyses indicated that PCLC-total and subscale scores were stable across the two assessments, analyses of PCLC scores indicated that many patients exhibited fairly large (>0.5 S.D.) increases and/or decreases in PCLC-total or subscale scores. Some evidence suggested that decreases in PCLC scores between the two study assessments were associated with greater social support and experience of fewer traumatic stressors prior to breast cancer diagnosis. Most significantly, the research suggested that women with greater PTSD symptoms at the initial interview were less likely to participate in the follow-up interview. Implications of this for research and clinical management of PTSD in this population are discussed.

Psychiatric issues in medical-surgical disaster casualties: a consultation-liaison approach

Psychiatrists can increase the efficacy of their response to disaster victims in the immediate aftermath of a disaster if they utilize a consultation-liaison approach to assessment and management of casualties. Medical-surgical disaster responders use an algorithmic, stepwise approach to assess disaster or trauma victims. This approach ensures that patients with life-threatening injuries who are not expectant are treated first. Then, secondary physical assessments ensure proper triage of other victims so that disaster response resources are used most wisely. A tertiary psychiatric assessment can assist with differential diagnosis of post-disaster neuropsychiatric symptoms and signs to ensure valuable medical-surgical resources are targeted to the correct patients. Psychiatric triage can also identify those victims most in need of early preventive and therapeutic psychiatric intervention.

A survey of psychological need amongst adult burn-injured patients

This study of 71 burn-injured adults was carried out to inform clinical psychological practice in a newly developed service for individuals affected by disfigurement. Self-completion questionnaires were administered to patients attending outpatient clinics and information was collated on a range of variables including time since injury, cause, location and perceived severity of injury. Questions were also asked about the level of psycho-social support received and needed during hospitalisation and post discharge and people were asked to indicate the type of help that they wanted. Results indicate no correlation between the amount of time since injury and the degree of emotional difficulty experienced. 56% reported current emotional problems and 38% of the sample felt that they would benefit from professional help. There was a significant correlation between individuals' perception of the severity of the injury and the degree of distress experienced (p < 0.05). The two most popular preferences for help was individual counselling followed by professionally led groups.

Review and critique of the new DSM-IV diagnosis of acute stress disorder

OBJECTIVE

A new diagnosis can greatly influence scientific research, access to resources, and treatment selection in clinical practice. The authors review the historical evolution, rationale, empirical foundation, and clinical utility to date of the recently introduced diagnosis of acute stress disorder.

METHOD

The conceptual basis and relevant methods for identifying a psychiatric syndrome are reviewed with respect to acute stress disorder, including selection of criteria for core symptoms; considerations of sensitivity and specificity of a syndrome definition; longitudinal course; and distinctions between normative and pathological phenomena. Particular attention is devoted to two major issues: the implications of the core feature requirement of three of five dissociative symptoms, and the question of whether there should be two separate diagnoses (acute stress disorder and post-traumatic stress disorder [PTSD]) describing posttraumatic syndromes. The widely divergent approaches in DSM-IV and ICD-10 are also reviewed.

RESULTS

The diagnosis of acute stress disorder does not appear to achieve the important objective of providing adequate clinical coverage for individuals with acute posttraumatic symptoms. The validity and utility of requiring peritraumatic dissociative symptoms as a core feature are questionable, as is the separation of essentially continuous clinical phenomena into two disorders with different criteria sets (acute stress disorder and PTSD) based on persistence of symptoms for 30 or more days.

CONCLUSIONS

Longitudinal studies using acute stress disorder criteria, as well as broader considerations of the clinical and scientific functions that posttraumatic diagnoses should serve, suggest a need to reevaluate the current DSM-IV approach to posttraumatic syndromes.

Post-traumatic stress disorder in cancer: a review

The stressor criterion for Post-Traumatic Stress Disorder (PTSD) has been recently modified to include life-threatening illnesses, such as cancer, as precipitating traumatic events. We sought to examine the empiric evidence for cancer's inclusion as a traumatic stressor. Nine published studies assessing PTSD in cancer survivors and/or family members were identified in the literature. The studies were predominantly small (n<100) and cross-sectional. Study target groups included one or more of the following: children cancer survivors, parents of pediatric survivors and adult cancer survivors. There was considerable inter- and intra-study variability in the type and stage of cancer diagnosed and in the type of treatment regimens participants had undergone. Only three studies utilized a validated PTSD diagnostic tool to evaluate the disorder. Evidence of full-blown PTSD was found for adults and parents, and for children in all but one instance. These results suggest that a PTSD symptom assessment provides valuable clinical information concerning the post-treatment adjustment of cancer survivors and their immediate family members.

Post-traumatic stress symptoms and distress following acute burn injury

The occurrence and predictors of acute post-traumatic stress symptoms were assessed in a large, prospective sample of persons with new burn injuries (N = 172). Participants completed a self-report post-traumatic stress symptom checklist, pain ratings, and a premorbid mental health inventory within 24 h of admission to a burn center (Day 1). Over half of the sample reported sleep disturbance and recurrent, intrusive recollections of the burn injury on Day 1. Other commonly endorsed symptoms were difficulties concentrating, avoidance of thoughts/feelings associated with the burn, flashbacks, and exaggerated startle response. Persons with less favorable premorbid mental health and larger burns reported a greater number of stress symptoms on Day 1. These results suggest that experiencing some post-traumatic stress symptoms immediately following a burn trauma is normal. It is recommended that burn care professionals identify and intervene with patients who are suffering clinically significant distress early in the hospitalization.

Posttraumatic stress disorder after injury: impact on general health outcome and early risk assessment

OBJECTIVE

To evaluate prospectively components of general health outcome after trauma and to report on the further validation of the Michigan Critical Events Perception Scale (MCEPS), an instrument that predicts increased risk for posttraumatic stress disorder (PTSD).

METHODS

Adults without neurologic injury admitted to a Level I trauma center in 1997 were interviewed during hospitalization. Baseline data included demographics, injury mechanism, Injury Severity Score, the Short Form 36 (SF36), and the MCEPS, which measures peri-traumatic dissociation (the sense of depersonalization or derealization during an injury event). Surveys sent by mail and completed 6 months later included the SF36 and civilian Mississippi Scale for PTSD.

RESULTS

A total of 140 patients were interviewed; the 70% (n = 100 patients) who completed the 6-month assessment form the study group. Injuries were categorized as 71% blunt, 13% penetrating, and 16% burn. Mean Injury Severity Score was 13.7+/-0.52. PTSD at 6 months occurred in 42% of the patients and was directly related to MCEPS dissociation (p = 0.001; odds ratio = 3.1; 95% confidence interval, 1.6, 5.9). A stepwise linear regression explains 40% of the variance in 6-month SF36 general health outcome (adjusted R2 = 0.402). The model controls for individual factors related to dissociation, PTSD, and general health outcome. Development of PTSD was independently and inversely related to general health outcome as measured by the SF36 at 6 months (p < 0.001, beta = -0.404). The R2 change of 0.132 for PTSD (vs. 0.082 for 6-month physical function) illustrates that PTSD contributes more to the patient's perceived general health at 6 months than the degree of physical function or injury severity.

CONCLUSIONS

Within hours of injury, the MCEPS identifies patients who are three times more likely to develop PTSD. PTSD compromises self-reported general health outcome in injured adults independent of baseline status, Injury Severity Score, or degree of physical recovery. These data suggest that psychological morbidity is an important part of the patient's perceived general health.

Prolonged adjustment difficulties among those with acute posttrauma distress following burn injury

This study examined the impact of mild to moderate symptoms of in-hospital posttrauma distress (PTD) following severe burn injury on quality of life (QOL) at 2-month follow-up after controlling for preburn QOL, injury severity, and state Negative Affectivity (depression, body image dissatisfaction) and dispositional optimism-pessimism. Participants' (n = 86) self-report established PTD and non-PTD groups (median split on Davidson Trauma Scale). After covarying preburn level of psychosocial QOL, PTD groups differed on psychosocial functioning at follow-up. This effect remained after covarying injury severity, state NA, dispositional optimism-pessimism, and preburn Mental domain QOL. PTD groups also differed significantly on physical functioning at follow-up after covarying preburn physical functional status. This effect was removed by controlling preburn Physical domain QOL and either injury severity or state NA and dispositional optimism-pessimism. Therefore, PTD is related to significant impairments in the physical and psychosocial adjustment of survivors of severe burns regardless of pretrauma level of adjustment. Injury severity and state NA and dispositional optimism-pessimism moderate the impact of PTD on physical but not psychosocial adjustment.

Validation of the PTSD Checklist-Civilian Version in survivors of bone marrow transplantation

Life-threatening illness now qualifies as a precipitating stessor for posttraumatic stress disorder (PTSD). We examined the validity of the PTSD Checklist-Civilian Version (PCL-C; Weathers, Litz, Herman, Juska, & Keane, 1993), a brief 17-item inventory of PTSD-like symptoms, in a sample of 111 adults who had undergone bone marrow transplantation an average of 4.04 years previously. Exploratory factor analysis of the PCL-C identified four distinct patterns of symptom responses: Numbing-Hyperarousal, Dreams-Memories of the Cancer Treatment, General Hyperarousal, Responses to Cancer-Related Reminders and Avoidance-Numbing. Respondents meeting PTSD symptom criteria on the PCL-C had significantly lower physical, role, and social functioning, greater distress and anxiety, and significantly more intrusive and avoidant responses than individuals who did not meet PTSD symptom criteria.

Acute intrusive and avoidant PTSD symptoms as predictors of chronic PTSD following burn injury

Several studies have endeavored to learn if acute PTSD symptoms are predictive of chronic PTSD, with equivocal results. In the present study, acute intrusive and avoidant PTSD symptoms were analyzed as possible predictors of chronic PTSD following burn injury. Results showed that baseline IES scores, within one week of injury, were significantly different for those who were later diagnosed with chronic PTSD. Additional analyses, undertaken to assess the relative importance of each symptom group in predicting chronic PTSD, indicated that both the presence, per se, and severity of acute avoidant symptoms predicted chronic PTSD.

Predictors of chronic post-traumatic stress disorder. A prospective study

BACKGROUND

Most individuals who, shortly after trauma, express symptoms of post-traumatic stress disorder (PTSD) recover within one year of their traumatic experiences. In contrast, those who remain ill for one year rarely recover completely. The early identification of the latter is, therefore, very important.

AIMS

To prospectively evaluate predictors of PTSD at four months and one year.

METHOD

We followed 236 trauma survivors recruited from admissions to a general hospital's emergency room for four months, at which point 41 (17.4%) met diagnostic criteria for PTSD. Twenty-three of these individuals, and 39 individuals without PTSD at four months, were assessed again at one year.

RESULTS

Depressive symptoms were the best predictors of PTSD at both time points. Intrusive symptoms and peri-traumatic dissociation were better at predicting four-month PTSD than one-year PTSD.

CONCLUSIONS

The occurrence of depression during the months that follow a traumatic event is an important mediator of chronicity in PTSD.

Epidemiologic and phenomenological aspects of post-traumatic stress disorder: DSM-III-R diagnosis and diagnostic criteria not validated

The aim of this cohort study was: (i) to validate the diagnostic criteria for post-traumatic stress disorder (PTSD) of the DSM-III-R; and (ii) to examine the incidence rate of PTSD in a study population exposed to two different traumatic events, i.e. a fire in a hotel ball-room and a multiple collision car-crash on a Belgian highway. One hundred and eighty-five victims (130 fire and 55 car accident victims) were assessed between 7 and 9 months after the traumatic event using the Composite International Diagnostic Interview (CIDI), PTSD Module, a fully structured diagnostic interview for the assessment of PTSD according to DSM-III-R criteria. Twenty-three percent of the study population met DSM-III-R criteria for PTSD. By means of unsupervised and supervised multivariate statistical analyses we were unable to validate the three-factorial structure, i.e. criteria B, C and D, of the DSM-III-R PTSD diagnosis. The latter relies heavily on the C diagnostic criteria, which appear to be too restrictive. Women were more likely to develop symptoms of reexperience (B) and arousal (D) than men. There was a significantly higher incidence of criteria B, C and D, but not of PTSD, in fire than in car-accident victims. Between 42 and 57% of the victims developed the first PTSD symptoms on the day of the trauma; within the next week these incidence rates increased to 77.1, 57.8 and 73.5% for criteria B, C and D, respectively. In conclusion, this study was unable to demonstrate the validity of the diagnostic criteria for PTSD according to DSM-III-R. The present cohort study has defined a number of factors that may predict new occurrences of PTSD symptoms after a traumatic event, i.e. gender, type of trauma and time delay between the trauma and the assessment of the diagnostic criteria.

Childhood trauma and current anxiety among college men

In an examination of the prevalence and effects of childhood trauma among college freshmen, as expected, the majority of 515 youth reported at least one traumatic experience in childhood. When fear of death or serious injury accompanies a traumatic event, posttraumatic symptoms may be more likely. As hypothesized, scores on the Reaction Index by Frederick were elevated for subjects who reported trauma with concurrent fear. The combination of trauma and fear was also associated with elevated scores on trait anxiety. While most adolescents do not develop mental illness following single traumatic events, many may be made more vulnerable to the psychogenic effects of future trauma.

Psychosocial factors limit outcomes after trauma

BACKGROUND

Psychological morbidity compromises return to work after trauma. We demonstrate this relationship and present methods to identify risks for significant psychological morbidity.

METHODS

Thirty-five adults were evaluated prospectively for return to functional employment after injury using demographic data, validated psychological and health measures, and the Michigan Critical Events Perception Scale. Evaluation was conducted at admission and at 1 and 5 months after injury.

RESULTS

Poor return to work at 5 months was attributable to physical disability (p < 0.05) and psychological disturbance (p < 0.05) in a regression model that controlled for preinjury employment and psychopathologic factors as well as injury severity. A high score on the Impact of Events Scale administered during acute admission predicted development of acute stress disorder at 1 month (p < 0.01, odds ratio (OR) = 9.4) and posttraumatic stress disorder at 5 months (p < 0.05, OR = 6.7). Peritraumatic dissociation on the Michigan Critical Events Perception Scale was predictive for development of acute stress disorder (p < 0.05, OR = 5.8) at 1 month and posttraumatic stress disorder (p < 0.05, OR = 7.5) at 5 months.

CONCLUSION

Psychological morbidity after injury compromises return to work independent of preinjury employment and psychopathologic condition, Injury Severity Score, or ambulation. A high Impact of Events Scale score or peritraumatic dissociation at admission predicts this morbidity.

Acute stress disorder: a critical review of diagnostic issues

Acute stress disorder (ASD) is a recently developed diagnosis that describes posttraumatic stress reactions that occur in the first month following a trauma. Diagnostic criteria include dissociative, intrusive, avoidance, and arousal symptoms. ASD was driven by the proposal that trauma leads to dissociative reactions, and these are predictive of longer-term psychopathology. This paper reviews a series of anomalies in the diagnostic criteria, highlights discrepancies between criteria for ASD and posttraumatic stress disorder (PTSD), and illustrates the lack of empirical evidence for some assumptions inherent in the conceptualization of ASD. It is argued that future revisions of ASD criteria need to be based on empirical evidence of acutely traumatized individuals.

Post-traumatic stress disorder

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Factors predicting hypnotic analgesia in clinical burn pain

The use of hypnosis for treating pain from severe burn injuries has received strong anecdotal support from case reports. Controlled studies provide less dramatic but empirically sound support for the use of hypnosis with this problem. The mechanisms behind hypnotic analgesia for burn pain are poorly understood with this patient population, as they are with pain in general. It is likely that, whatever the mechanisms are behind hypnotic pain analgesia, patients with burn injuries are more receptive to hypnosis than the general population. This article postulates some variables that may account for this enhanced receptivity, including motivation, hypnotizability, dissociation, and regression.

Psychological sequelae of facial trauma

BACKGROUND

Facial trauma is common in accidents and assaults and can be accompanied by distressing psychological sequelae.

METHODS

Retrospective analysis of case notes followed by a prospective assessment of consecutive facial trauma victims was performed to determine the prevalence and detection rate of psychological sequelae.

RESULTS

Only 8 of 47 case notes (17%) contained any reference to mental state. Forty-three patients completed initial assessment and 7-week questionnaires. Twelve (27%) were suffering from posttraumatic stress disorder at 7 weeks. Factors significantly associated with poorer outcome were higher initial Hospital Anxiety and Depression Scale and Impact of Event Scale scores, assault injury fractures, and prediction of psychological sequelae by junior oral surgeons.

CONCLUSION

More than one-quarter of victims of facial trauma in this study developed posttraumatic stress disorder, documentation of which was poor. The study suggests that psychological sequelae can be predicted using simple measures such as a basic initial assessment by nonmedically qualified personnel.

Posttraumatic stress symptoms and medical procedures in children

OBJECTIVE

To focus on posttraumatic stress symptoms after childhood diseases such as cancer, organ transplantation, and severe burns.

METHODS

Differential diagnoses, risk factors, and treatment aspects (psychological and pharmacological) are discussed.

RESULTS

The concept of adjustment problems in chronic or severe illnesses is widely used in pediatrics. Many aspects of severe childhood diseases are traumatic, as defined by the DSM-IV: severe illnesses are life-threatening, medical procedures threaten the child's physical integrity, and disorganized behaviour periods are common.

CONCLUSION

This concept, which remains insufficiently investigated, is a promising area of investigation for prospective and prevention studies.

Randomised controlled trial of psychological debriefing for victims of acute burn trauma

BACKGROUND

Psychological debriefing (PD) is widely used following major traumatic events in an attempt to reduce psychological sequelae.

METHOD

One hundred and thirty-three adult burn trauma victims entered the study. After initial questionnaire completion, participants were randomly allocated to an individual/couple PD group or a control group who received no intervention; 110 (83%) were interviewed by an assessor blind to PD status three and 13 months later.

RESULTS

Sixteen (26%) of the PD group had PTSD at 13-month follow-up, compared with four (9%) of the control group. The PD group had higher initial questionnaire scores and more severe dimensions of burn trauma than the control group, both of which were associated with a poorer outcome.

CONCLUSION

This study seriously questions the wisdom of advocating one-off interventions post-trauma, and should stimulate research into more effective initiatives.

Emotional disturbances in trauma patients during the rehabilitation phase: studies of posttraumatic stress disorder and alexithymia

Recent studies have shown a partial similarity between posttraumatic stress disorder (PTSD) and alexithymia. In this study, the authors examined the relationship between PTSD and alexithymia in two samples of 26 patients with burn injury and 27 patients with digit amputation during rehabilitation. The prevalence rates of DSM-III-R PTSD and alexithymia assessed by the Toronto Alexithymia Scale (TAS) were significantly higher for injury patients than for healthy volunteers. The rate of PTSD symptoms of avoidance and emotional numbing was significantly and positively correlated with the TAS scores in injury patients. The PTSD symptoms of avoidance and emotional numbing had a significant relationship with function after digit replantation. Alexithymia also had a similar relationship with physical conditions. These results suggest that 1) in some cases, alexithymia may be evident when PTSD emotional symptoms appear in injury patients, and 2) emotional disturbances (i.e., PTSD symptoms of avoidance and emotional numbing and alexithymia) may be influenced by the level of functional recovery after digit replantation.

Predictors of post-traumatic stress disorder following burns injury

Burns patients were assessed 12 months following their injury to determine the factors that predict development of post-traumatic stress disorder (PTSD). Among 35 patients, 31 per cent suffered PTSD, 29 per cent suffered subclinical PTSD reactions and 40 per cent displayed no PTSD symptoms. Concern over scarring and an avoidant coping style accounted for 61 per cent of the variance in post-traumatic stress symptomatology. Only half of the patients reporting PTSD had sought professional assistance. The results indicate that postinjury adjustment factors are critical determinants of PTSD development following burns. Implications for therapeutic interventions are discussed.

Psychiatric evaluation of physical rehabilitation patients

We conducted a study to demonstrate the frequency and types of psychiatric/psychological symptoms. A Structured Interview according to the DSM-III-R was conducted which demonstrated that 46 (41.4%) of 111 rehabilitation inpatients met the criteria for some forms of psychiatric disorders: 34 patients for major depression, 10 for adjustment disorder with anxious mood, and 2 for posttraumatic stress disorder. The remaining 65 patients (58.6%) showed normal reactions to their diseases. Average length of hospital stay for patients with major depression was significantly longer than those with no or the other types of psychiatric disease. They were also tested with Zung's Self-Rating Anxiety Scale (SAS), Zung's Self-Rating Depression Scale (SDS), and Profile of Mood States (POMS). Three psychological tests were useful in detecting depression or adjustment disorder among rehabilitation patients; however, these tests are not always specific to the type of psychiatric disorders. Patients with higher scores in those three tests should be referred to a psychiatric consultant for detailed examinations and proper treatments, if necessary.

Common anxiety disorders in children and adolescents

Anxiety disorders occur frequently in the pediatric population, and the clinician should be aware of diagnostic signs and symptoms. It is likely that the pediatrician or family physician will be the first to evaluate these patients, particularly because somatic complaints may be the initial manifestation of the disorder. These problems can be quite debilitating and require prompt and aggressive treatment based on symptom presentation and the developmental level of the child.

Psychological and social aspects of burns

Although the literature on the psychological consequences of burns is fairly extensive, the evidence gathered by the charity 'Changing Faces' over the last 2 years suggests that the resources allocated to psychological rehabilitation are still far from adequate. This article draws on the personal experience of one of the authors who was in a car fire 24 years ago, reviews some of the literature, briefly looks at the work done by Changing Faces and discusses some of the tasks of the 'burns team'. The authors are aware that generalizations about the consequences of burns are fraught with risk because every fire has its own causes and complications, but it is hoped that the themes expressed here do raise important general points.

Maintenance of intrusive memories in posttraumatic stress disorder: a cognitive approach

Intrusive recollections are very common immediately after traumatic events and are considered necessary aspects of emotional processing. However, if these intrusive recollections persist over a long time, they are linked to long-term psychiatric disorder, especially Posttraumatic Stress Disorder (PTSD). This paper discusses the need to investigate factors involved in the maintenance of intrusive traumatic recollections. It is suggested that the idiosyncratic meaning of the intrusive recollections predicts the distress caused by them, and the degree to which the individual engages in strategies to control the intrusions. These control strategies maintain the intrusive recollections by preventing a change in the meaning of the trauma and of the traumatic memories. It is further suggested that what is needed is a comprehensive assessment of the processes that prevent change in meaning, going beyond the assessment of avoidance. In particular, safety behaviours, dissociation and numbing, suppression of memories and thoughts about trauma, rumination, activation of other emotions such as anger and guilt and corresponding cognitions, and selective information processing (attentional and memory biases) may be involved in the maintenance of intrusive recollections. Preliminary data supporting these suggestions from studies of individuals involved in road traffic accidents and survivors of child sexual abuse are described.

Psychiatric consultation and post-traumatic stress disorder in burned patients

We report a prospective study of 65 burned inpatients referred for psychiatric consultation. All of the subjects in the sample were evaluated by a structured questionnaire and clinical interview. Reasons for referral were: suicide attempt by burning (n = 7), substance dependence (n = 8) and behaviour disturbed by coping difficulties (n = 50). The diagnoses were adjustment disorder (n = 40), alcohol dependence (n = 7), opiate dependence (n = 2), dementia (n = 3), depressive disorder (n = 5), schizophrenia (n = 1), delirium (n = 1) and post-traumatic stress disorder (n = 5). Patients with post-traumatic stress disorder (PTSD) were specifically and carefully evaluated. There were no significant differences between patients with PTSD and adjustment disorder for severity and type of burn injuries. We conclude that PTSD is apt to be missed by the medical staff of burn units.