Self-inflicted patient burns: suicide versus mutilation

Long-term mortality after self-inflicted burns

BACKGROUND

Those with self-inflicted burns are a small but consistent group among burn patients, with large injuries and conflicting findings regarding their in-hospital mortality. Overall, burn survivors have a shorter life expectancy, as compared with national controls, but long-term mortality after self-inflicted burns is understudied. The aim of this retrospective study was to investigate possible differences in long-term mortality among survivors after self-inflicted and accidental burns.

METHODS

All adult patients with burns admitted at the Linköping Burn Centre and discharged alive between 2000 and 2017 were included, and end of follow up was April 26, 2021. Those with unknown survival status at that time were excluded. A Cox proportional hazards regression model, adjusted for age and sex, was used to analyse long term mortality.

RESULTS

Among the 930 patients included in this study, 37 had self-inflicted burns. Overall, median follow up period was 8.8 years and crude mortality was 24.7%. After adjustment for age and sex, self-inflicted burns were independently associated with long-term mortality, Hazard Ratio= 2.08 (95% CI 1.13-3.83). Post hoc analysis showed that the effect was most pronounced during the first years after discharge although it was noticeable over the whole study period.

CONCLUSION

Long-term risk of mortality after discharge from a burn centre was higher in patients with self-inflicted burns than in patients with accidental burns. The effect was noticeable over the whole study period although it was most pronounced during the first years after discharge.

Psychosocial Determinants of Burn-Related Suicide: Evidence From the National Violent Death Reporting System

Suicide is a unique phenomenon in humans. In 2017, over 47,000 Americans died by suicide, prompting a public health crisis. Suicide by burning, while one of the rarest forms of suicide, could be mitigated in part by early recognition and treatment of the underlying psychosocial factors. To date, investigators have attempted to tease out the risk factors associated with this phenomenon through the examination of burn center chart reviews and repository data, but these studies were limited by small sample sizes. In order to fill this gap in the literature, the authors analyzed 14 years of data (2003-2016) from the National Violent Death Reporting System. Suicides by burning (n = 722) were compared with a reference group containing all other suicide types (n = 166,949). Socio-demographic variables and psychosocial factors (eg, mental health, substance use, and alcohol use) were included in the model. Due to the imbalance between the target and reference groups, rare event data analysis was used to reduce potential small sample estimation bias. Results indicated that females (OR = 1.6, 95% CI: .50-2.83, P < .001), Caucasians (OR = 1.7, 95% CI: 1.1-2.7, P < .001), victims with schizophrenia (OR = 5.4, 95% CI: 3.7-7.8, P < .001), and victims with eating disorders (OR = 5.6, 95% CI: 1.9-8.6, P < .001) are significantly more likely to commit suicide by burning. These results contribute new knowledge to what is currently known about suicidal burn-related behaviors and supports interventions that focus on mitigating this insidious public health problem.

Patterns of self-inflicted injury

Patterns of self-inflicted injury vary widely depending on the mechanism of injury and intent of the individual. Life threatening injuries are usually inflicted with suicidal intent. Non-life threatening injuries can be divided into three groups distinguished by distinct patterns of injury and underlying psychopathology. Recognition of these patterns facilitates optimal treatment of the injury and psychological morbidity.

Etiology and Outcome of Burns in Tabriz, Iran an Analysis of 2963 Cases

Background and aims:

Burn injuries still produce a significant morbidity and mortality in Iran. A 3-year retrospective review of burn victims hospitalized at a major burn center was conducted to determine the etiology and outcome of patients in Tabriz.

Material and Methods:

Two thousand nine hundred sixty + three patients were iden tified and stratified by age, sex, burn size, presence or absence of inhalation injury, cause of burn. There is one burn center in the East Azarbygan province serving 3.3 million people over an area of 47,830 sq.km.

Results:

The overall incidence rates of hospitalization and death were 30.5 % and 5.6 % per 100000 person years. The mean patient age was 22 years, and the male: female ratio was 1.275. There were 555 deaths altogether (18.7 %). The highest incidence of burns was in the 1–9 age group (29.2 %). Patients with less than 40 percent of burned surface constituted 79.8 % of injuries. The most common cause of burns was kerosene accident in adults and scald injuries in children. The mean length of hospitalization was 13 days. The mean body surface area burned was larger with higher mortality in females than in males (p < 0.001). Inhalation injuries were strongly associated with large burns and were present in all flame-burn fatalities.

Conclusion:

In our opinion, social factors are the main drive leading to an unacceptably high rate of burn injuries in our societies. Most of the burn injuries were caused by domestic accidents and were, therefore, preventable; educational programs might reduce the incidence of burn injuries.

Self-inflicted Burns: 10 year review and comparison to national guidelines

INTRODUCTION

There is an increasing trend of self-inflicted burns noted in the literature, often seen in patients with complex psychosocial backgrounds. These patients are challenging to manage as the recovery from the acute burn may be compounded by difficult rehabilitation and suboptimal coping strategies. We aimed to review patients presenting to our burns unit with self-inflicted burns, the management strategies and examine the complexities surrounding their management. We assessed patient outcomes with a particular interest in psychosocial support given.

METHODS

A retrospective review of all patients presenting with self-inflicted burns over a 10 year period (2005-2014 inclusive) was conducted. Patients were identified through IBID database coded as either 'self-inflicted' or 'suicidal.' We reviewed patient and burn demographics, the clinical management, psychosocial management and patient outcomes such as wound healing, re-admission rates, and survival.

RESULTS

We identified 118 self-inflicted burns in total. 50/118 (42%) were admitted. 64 (54%) were male and the total body surface burn area ranged from <0.5% to 99% with a median of 14%. 60/118 (51%) had TBSA <10% and 58/118 (49%) had TBSA >10%. 24 (48%) underwent admission to the Burn Intensive Care Unit (BITU). All patients admitted to BITU had TBSA >10%. Of those admitted to BITU 6 were palliative, 18 had full resuscitation and surgical management. Of those 18 patients who had active treatment, 10/18 (56%) died. Mean total length of stay was 31 days, range 1-130 days. 9% of patients sustained injuries whilst being a current inpatient at a psychiatric institution. Of all patients reviewed, 16% (n=19) had a previous history of deliberate self-harm through burns. Of those patients admitted, 98% of were reviewed by the mental health team during their admission with time to psychological review varying depending on fitness for assessment. The overall mean length of stay for all admitted patients who were actively treated but who subsequently died was 53 days. 84% of admitted patients were managed surgically.

CONCLUSION

Self-inflicted burns patients would benefit from a more complex pathway of treatment as their management aims to achieve not only physical health but also psychological health. They would benefit from enhanced care to manage the acute burn but also psychiatric support to ensure patients do not re-offend.

Characterization of critically ill adult burn patients admitted to a Brazilian intensive care unit

INTRODUCTION

To characterize the evolution of clinical and physiological variables in severe adult burn patients admitted to a Brazilian burn ICU, we hypothesized that characteristics of survivors are different from non-survivors after ICU admission.

METHODS

A five-year observational study was carried out. The clinical characteristics, physiological variables, and outcomes were collected during this period.

RESULTS

A total of 163 patients required ICU support and were analyzed. Median age was 34 [25,47] years. Total burn surface area (TBSA) was 29 [18,43]%, and hospital mortality rate was 42%. Lethal burn area at which fifty percent of patients died (LA50%) was 36.5%. Median SAPS3 was 41 [34,54]. Factors associated with hospital mortality were analyzed in three steps, the first incorporated ICU admission data, the second incorporated first day ICU data, and the third incorporated data from the first week of an ICU stay. We found a significant association between hospital mortality and SAPS3 [OR(95%CI)=1.114(1.062-1.168)], TBSA [OR(95%CI)=1.043(1.010-1.076)], suicide attempts [OR(95%CI)=8.126(2.284-28.907)], and cumulative fluid balance per liter within the first week [OR(95%CI)=1.090(1.030-1.154)]. Inhalation injury was present in 45% of patients, and it was not significantly associated with hospital mortality.

CONCLUSIONS

In this study of an ICU in a developing country, the mortality rate of critically ill burn patients was high and the TBSA was an independent risk factor for death. SAPS3 at admission and cumulative fluid balance in the first seven days, were also associated with unfavorable outcomes. The implementation of judicious fluid management after an acute resuscitation phase may help to improve outcomes in this scenario.

An epidemiological survey of the suicide incidence trends in the southwest iran: 2004-2009

BACKGROUND

Elimination of suicide attempts is impossible, but they can be reduced dramatically by an organized planning. The present study aimed to survey the suicide trends in Fars province (Iran), during 2004-2009 to better understand the prevalence and status of suicide.

METHODS

This survey was a cross-sectional study. The demographic data were collected from the civil status registry between 2004 and 2009. Suicide and suicide attempt data were collected of three sources including the affiliated hospitals of Shiraz University of Medical Sciences, mortality data of Vice Chancellery of Health in Fars province and data from forensic medicine. Then, they were analyzed by Excel and SPSS. Chi-square and regression analyses were used for data analysis.

RESULTS

During the study, 10671 people attempted suicide, of which 5697 (53%) were women and 4974 (47%) were men. Among them, 1047 people (9.8%) died, of which 363 (34%) were women and 679 (64%) were men. There was a significant relationship between gender and fatal suicide. The mean suicide attempt for both genders was 53 per 100,000 and 49, 57 for men and women, respectively. The trends in the incidence of Suicidal attempts were decreasing.

CONCLUSION

Without implementing effective preventive measures, the health care system in Iran will face a further burden of fatal suicides among young people. Therefore; enhancing the primary health care and specialized mental health services for those with unsuccessful suicide attempts can effectively reduce the burden of suicide.

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.

Self-inflicted specific pattern burns in psychiatric patients

Self-inflicted burns represent a major social and medical problem for society. Differences have been demonstrated between patients who attempt suicide and those who deliberately harm themselves without any intention of killing themselves. These self-inflicted injuries may resemble injuries that are intentionally inflicted by others and may require investigation by protective services. Little is known about these specific pattern burn injuries in psychiatric patients.

The epidemiology of burn injuries in an Australian setting, 2000-2006

OBJECTIVES

To describe presentation characteristics of burn leading to death or hospital treatment (i.e. inpatient admissions and emergency department [ED] presentations) across the state of Victoria, Australia, for the years 2000-2006 inclusive.

METHODS

Data were provided by the Victorian Injury Surveillance Unit (VISU) from three different datasets pertaining to burn deaths, hospital inpatient admissions and non-admitted ED presentations. Population estimates were derived from census data provided by Australian Bureau of Statistics.

RESULTS

During the 7-year period, 178 people died and 36,430 were treated for non-fatal burn injury, comprising 7543 hospital admissions and 28,887 non-admitted ED presentations. Males, children aged less than 5 years of age, and the elderly (> or =65 years of age) were at the highest risk of injury. Contact with heat and hot substances represented the major aetiological factor contributing to thermal injuries accounting for 64% of all hospital admissions and 90% of ED presentations. Temporal trends indicate no change in the population rate of burn deaths or hospital admissions during the study period.

CONCLUSIONS

ED presentations and hospital admissions and deaths have remained the same over this study period, but rates of burn remain high in males, children and the elderly. This could be due to variations in the implementation of government prevention and control programs and the divergence in efficient treatments and clinical practices amongst hospital care providers. Therefore, educational efforts for prevention should be the keystone to minimise the incidence of burns.

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.

Suicide by self-immolation: comprehensive overview, experiences and suggestions

Suicide by burning is a rare condition in the developed countries (0.06-1% of all suicides) but is more frequent in the developing countries (accounting for as many as 40.3% of all suicides). In different parts of Iran, between 1.39% and 9.50% of patients that attempted suicide and 25.0% and 40.3% of patients who committed suicide were via deliberate self-burning. Self-burning (immolation) comprises between 0.37% and 40% of total burn center admissions around the world and, in Iran, it comprises between 4.1% and 36.6% of admissions in Iranian burn centers. Approximately 80% of hospitalized self-immolation patients die. The goal of this study was to identify the epidemiologic features, causes, and potential protective factors regarding suicide by burning in Kermanshah province, in the west of Iran, and to develop the effective intervention programs based on the Public Health Approach to Prevention. During the course of a year, from March 21, 2004, to March 20, 2005 (based on the Iranian calendar), the author examined all the suicidal patients who were admitted to the emergency department of hospitals in Kermanshah University of Medical Science. Examination included a retrospective cross-section study, via demographic questionnaires and suicidal checklists. During the period of study, 1820 patients who attempted suicide and 90 patients who successfully committed suicide were admitted. A total of 41% (37 cases) of patients who committed suicide were via self-immolation. Of these, 81% of self-immolation patients were female (P < .0005), and the female:male ratio was 4.3:1. A total of 86.5% of the patients were in the 11 to 30 years of age group. The mean age was 24.9 years (range, 14-50 years). Forty-nine percent of cases were single, 84% were illiterate or had a low level of education, 78.5% were housewives, and 14% were unemployed. Also, most of the patients (53%) were living in rural area, 97% did not have a previous history of suicide attempt, and 67.5% regretted their self-immolation act. The majority of the self-immolations (64.8%) occurred during daylight hours, and the most common self-immolation motivation factor was marital conflict (32.5%). Overall, this study demonstrates that self-immolation should be considered as a mental health problem in our society, and it is necessary to implement programs and strategies to prevent it. The public health approach provides a framework for a National Prevention Strategy to address this serious national problem. Local data on victims and victim stories from self-immolation provided the stimulus for community action.

Assessing potential suicide risk of young adults burned as children

This study examines potential for suicide risk among young adults burned as children and examines characteristics associated with potential risk. Eighty-five young adults were administered the Suicide Probability Scale, which contains four clinical subscales: suicide ideation, hopelessness, negative self-evaluation, and hostility; the 16 Personality Factor Questionnaire; and the Family Environment Scale. Burn survivors reported more feelings of hopelessness in comparison to the reference group. High anxiety was positively associated with hopelessness, suicide ideation, hostility and negative self-evaluation whereas high extroversion was inversely related with hopelessness, negative self-evaluation, and hostility. Multiple regression analyses revealed emotional stability explained 29% of the variance, self-reliance 17% of the variance, and both 38% of the variance in relation to Suicide Probability Scale scores; and increased family conflict 12% of the variance. Results suggest that high anxiety, emotional reactivity, and family conflict correlate with increased potential suicide risk; whereas, extroversion correlates with decreased risk.

Self-Inflicted Burns in Athens, Greece: A Six-Year Retrospective Study

Self-inflicted burns represent a major social and medical problem. The aim of this study was to record the epidemiology, mortality and etiology of suicide attempts by burning, in Athens, Greece. Over a 6-year period from April 1997 to April 2003, all the medical charts of the patients who were admitted to the Burn Center of the General State Hospital of Athens, Greece, with self-inflicted burns were retrospectively studied. Of the 1435 burn patients, 53 (3.69%) had attempted suicide by self-inflicted burn. Their ages ranged from 18 to 90 years old (mean 53.5 years). Females (57%) outnumbered males (43%). The mean total body surface area (TBSA) burned was 41.6% (range: 15-100%). The overall mortality rate was very high (75.4%). A preexisting psychiatric disorder was present in 43.3% of the patients. In conclusion, the extent and the depth of the burn injuries could explain the high mortality rate seen in these patients, in correlation with their negativism to the treatment. Burn care professionals should be familiar with self-inflicted burn patients who constitute a considerable proportion of major burns and require constant psychiatric support in addition to burn care.

Self-inflicted burns: a sporadic phenomenon

Self-inflicted burns are a regular cause of admission to burn units. Historically, a full moon has been associated with mental instability. Circadian rhythms and seasonal changes are known to influence human affect. Such cosmic effects, however, have not yet been studied for self-inflicted burns. In this regard, the results of a retrospective analysis of 184 self-inflicted burns admitted during a 20-year period to the Birmingham Burns Centre are presented. The analysis fails to show a connection between the timing of self-inflicted burns and cosmic events. Such incidents are random, not influenced by the day of the week, first or second half of the month, seasonal variation or phase of the lunar cycle.

Intentional burn injury: an evidence-based, clinical and forensic review

Burn injury can be inflicted intentionally either by one person to another whenever one has the ability to physically control the other, or it can be self-inflicted. There is scant evidential basis for much that is written about and practiced in the evaluation and care of patients that have sustained intentional burn injuries. Yet this is an area in which medical personnel must necessarily be trained in both the therapeutic and forensic aspects of a complex problem. Failure to appreciate the complexity of medical and forensic interactions may have far reaching effects. A missed diagnosis can result in inappropriate medical care, on-going abuse and future fatality. Inept management can result on the one hand, in blame levelled inappropriately placing incomparable strain on family units and innocent parties, and on the other, allow abusers to continue unchecked. This is the first review on the subject in which lawyers and doctors collaborate to produce a holistic approach to this subject. In it we describe the legal considerations that medical staff must appreciate when approaching patients who may have suffered intentional burns. We analyse the various scenarios in which intentional burning can be found and challenge the clinical dogma with much of the management of paediatric inflicted burns has become imbued. We suggest a rational and balanced approach to all intentional burn injuries-especially when children are involved. In the light of current case law in which dogmatic medical evidence has been implicated in wrongful convictions for child abuse in the UK, it is imperative that medical professionals gather evidence carefully and completely and apply it with logic and impartiality. This paper will aid clinicians who may not be experienced in dealing with burn injuries, but find themselves in the position of seeing a burn acutely, to avoid common mistakes.

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

This paper reviews the literature on deliberate self-burning (DSB) and compares patterns in various countries. Fifty-five studies of deliberate self-harm or suicide by fire published in the last 20 years were reviewed. They reported on 3351 cases of DSB, including 2296 deaths. India had the highest absolute number of cases, the highest fatality rate, and the highest contribution of self-harm to burns admissions. The highest reported incidence was from Sri Lanka. Male victims generally predominated in Western countries, and females in the Middle East and the Indian sub-continent. Patients were grossly 10 years older in Europe than in Asia. The use and nature of fire accelerants, the possible roles of ethnicity, religion/faith and imitation are discussed. Three broad groups of victims were identified: psychiatric patients (Western and Middle-Eastern countries); those committing DSB for personal reasons (India, Sri Lanka, Papua-New Guinea, Zimbabwe); and those who are politically motivated (India, South Korea). Self-mutilators and self-immolators seem to be fairly distinct groups of people.

Proposed explanations for excess injury among veterans of the Persian Gulf War and a call for greater attention from policymakers and researchers

INTRODUCTION

Death rates among US veterans of the Persian Gulf War were lower than rates among non-deployed veterans and the US population at large, with the exception of injury deaths; returning veterans were at significantly greater risk of injury mortality. Similar patterns of excess injury mortality were documented among US and Australian veterans returning from Vietnam. In spite of these consistent findings little has been done to explain these associations and in particular to determine whether or not, and how, war related exposures influence injury risk among veterans returning home after deployments.

HYPOTHESIZED PATHWAYS

Several potential pathways are proposed through which injury might be related to deployment. First, increases in injury mortality may be a consequence of depression, post-traumatic stress disorder, and symptoms of other psychiatric conditions developed after the war. Second, physical and psychological traumas experienced during the war may result in the postwar adoption of "coping" behaviors that also increase injury risk (for example, heavy drinking). Third, greater injury risk may be the indirect consequence of increased experiences of ill defined diseases and symptoms reported by many returning veterans. Fourth, veterans may experience poorer survivability for a given injury event resulting in greater mortality but not morbidity. Finally, the process that selects certain individuals for deployment may lead to a spurious association between deployment status and injury mortality by preferentially selecting individuals who are risk takers and/or exposed to greater hazards.

CONCLUSIONS

More research and attention from policymakers is needed to clarify the link between deployment and postwar increased risk of injury.

Profiles and treatment of attempted suicide by self-immolation

Self-immolation represented 3.9% of patients (N = 7) at this burn unit over the last 18 months. Charts of these patients were retrospectively reviewed for demographics, hospital course, and discharge plan. All had a major psychiatric diagnosis, although no clear patient profile emerged. These patients required complex individualized care, but the psychosocial treatment challenges had many common elements. Psychiatric aspects of these patients proved problematic for the burn unit staff. Physical sequelae of the burns raised problems in arranging subsequent psychiatric treatment. Follow-up information was obtained by brief telephone interviews. The survivors appeared to be functioning well given their psychopathology and physical sequelae.