Posttraumatic Among Robert
Objective:
The
Adaptation Adult Burn
P. Roca, and
purpose
of this
follow-up. tended
Symptoms to emerge
sociated adjustment ality,
patients diagnosed
with
study
was
to examine
discharge
and
the injury
itself,
and
from
the
its treatment.
hospital.
Since
psychosocial
discharge
adjustment strategies 1992;
after
may
should be developed 149:1234-1238)
urn injury-a painful, frightening, and extraondinary trauma-may precipitate posttraumatic symptoms in at least some burn survivors. In a study predating DSM-III, Andreasen and Norris (1) described transient “phobic” and “traumatic” neuroses in many burn survivors. More recently, Countemanche and Robinow (2) published two illustrative case reports of DSM-III posttraurnatic stress disorder (PTSD) in burn victims, and Patterson et al. (3) found that 29% of hospitalized burn survivors met criteria for DSM-III PTSD at some point before discharge. While these papers illustrate the importance of screening burn patients for posttraumatic distress, they leave unanswered many questions about the prevalence, natural history, and functional implications of
Presented in part at the 143rd annual meeting ofthe American Psychiatric Association, New York, May 12-17, 1990. Received Aug. 1, 1991; revision received Dec. 10, 1991; acceptedJan. 17, 1992. From the Departments of Psychiatry and Surgery, The Johns Hopkins University School of Medicine; The Francis Scott Key Medical Center; and the Baltimore Regional Burn Center, Baltimore, Md. Address reprint requests to Dr. Roca, Department of Psychiatry, The Francis Scott Key Medical Center, 4940 Eastern Ave., Baltimore, MD 21224. Supported in part by a grant from the International Association of Fire Fighters Burn Foundation. The authors thank Linda Rice, Ph.D., and Chester Schmidt III, M.D., for their assistance. Copyright © 1 992 American Psychiatric Association.
natural
be identifiable and
adult
burn
tested
during for
this
at
C symptoms)
symptoms
associated related
and
Posttraumatic of patients
criterion
posttraumatic
the hospital, treatment.
history,
Method: Forty-three standardized instruand quantify de-
discharge. Results: and in over 22%
not strongly more strongly
Conclusions:
B
I 234
While
were was
distress after leaving and provide appropriate
treatment J Psychiatry
prevalence,
(DSM-III-R
new symptoms of posttraumatic is required to detect new cases ventive (Am
the
in adult burn survivors. assessed at discharge with disorder, assess personality,
emotionalnumbing
symptoms of depression, they to illness; psychosocial adjustment
M.D.,
M.D.
were evaluated 4 months after in 7% of patients at discharge
ofavoidance after
J. Spence,
M.D., M.P.H., Robert Andrew M. Munster,
psychosocial impact ofposttraumatic symptoms adult inpatients at a regional burn center were ments to determine the presence ofpsychiatric pression. Thirty-one stress disorder was
and Distress Survivors
were
as-
with psychosocial to aspects of person-
survivors longitudinal Survivors hospitalization,
often
develop
surveillance at risk for poor and
pre-
population.
PTSD in this population. One significant unsettled question is the time course of posttraumatic symptoms. Patterson et al. (3) found persistent PTSD (at telephone follow-up 40 days after discharge) in only one of Ii burn survivors who had met criteria for PTSD in the hospital, which suggests that posttraumatic symptoms may be short-lived in this population. However, since Patterson et ab. did not perform follow-up interviews of patients who had not had PTSD in the hospital, the true prevalence of PTSD at follow-up could not be stated. It is entirely possible that PTSD might have emerged after discharge in patients who had had few, on even no, posttraumatic symptoms in the hospital. Equally uncertain is the relationship between posttraumatic distress and postburn psychosocial adjustment to illness. While it is plausible that PTSD symptoms could hinder postburn psychosocial rehabilitation, this has not been demonstrated among burn patients diagnosed by DSM-III-R criteria, and one study of World Wan II prisoners of war suggests that even severe symptoms of PTSD are compatible with considerable presenvation of psychosocial functioning (4). Furthermore, there is evidence that postburn disability may be related to a variety of clinical variables (e.g., aspects of the burn or its treatment, the patient’s personality or premonbid psychopathology) that are independent of the emergence of PTSD symptoms (1, 5).
Am
] Psychiatry
I 49:9,
September
1992
ROCA,
The purposes of this study were to describe the prevalence, clinical phenornenology, and clinical correlates of PTSD and its component symptoms among adult burn survivors and to examine the relationship of these symptoms to postburn psychosocial adjustment.
METHOD Subjects for this study were drawn from the 20-bed inpatient unit of a regional burn center located in an urban medical center. Patients were routinely screened for delirium and other psychiatric disorders soon after admission and followed clinically until discharge. Adult patients who were hospitalized for oven 48 hours, who were approaching discharge, and who were not persistently delirious or otherwise inaccessible to interview were invited to participate in the study. Participating subjects took a battery of tests including the Structured Clinical Interview for DSM-III-R (SCID) (6), the Beck Depression Inventory (7), the NEO Personality Inventory (8), and the Millon Clinical Multiaxial Inventory-I! (9). An attempt was made to reinterview the subjects 4 months after discharge. The SCID was readministered over the telephone to subjects who could be reached only in that manner. In addition, a research assistant mailed to all located subjects a packet containing the Beck Depression Inventory and the Psychosocial Adjustment to Illness Survey ( 1 0, 1 1 ), a standard questionname designed to measure post-illness functioning in seven domains: health care orientation, vocational envinonrnent, domestic environment, sexual relationships, extended family relationships, social environment, and psychological distress. Student’s t test was used to compare group means, and Pearson correlation coefficients were calculated to evaluate the relationships between continuous vanables. Relationships between dichotomous variables were evaluated with the chi-square test.
During the study period, 1 34 adults were admitted to the unit. Of these, 68 could not be given the formal test battery because of death (N=14), discharge within 48 hours (N=41), persistent delirium (N=1O), severe attention deficit disorder (N=1), on nondelinious psychotic states (N=2). Of those able to participate (N=66), 43 gave consent and completed the diagnostic interview. Efforts were made to contact all study patients 4 months after discharge. Twenty-nine (67.4%) were contacted and agreed to retake the SCID; in addition, two patients who had not been tested at discharge entered the study and were given the SCID. Seventeen patients completed and returned the Psychosocial Adjustment to Illness Survey and the Beck Depression Inventory. Those who completed the SCID at follow-up were compared to the 14 who did not; no significant differences were found between these groups in age,
Am
] Psychiatry
1 49:9,
September
1992
AND
MUNSTER
sex, level of education, total body surface area burned, length of stay, or type of burn. Thirty-five patients (81.4%) in the study were men, and 30 (69.8%) were white. Their average age was 34.7 years (SD=11.8). Twelve (27.9%) had a SCID lifetime diagnosis of major depression, while 16 (37.2%) and 10 (23.3%) had lifetime diagnoses of alcohol and manjuana abuse on dependence, respectively. Length of hospital stay averaged 21 .6 days (SD=21 .9). Twelve (27.9%) had burns involving at least 25% of total body surface area, and 23 (53.5%) had facial involvement. Thirtyone (72.1%) had flame or flash burns, while the rernaining 12 (27.9%) had chemical, electrical, on scald injuries. PTSD At the time of discharge, only three patients (7.1%) met all DSM-III-R criteria for PTSD, including the 1month duration criterion. An additional three patients met all criteria for PTSD except for the 1-month duration criterion. At 4-month follow-up, of the three patients who had met full criteria for PTSD at discharge, one still had PTSD and one was completely symptom free. The other was lost to follow-up. Of the three who had met all criteria except the 1-month duration criterion, one had PTSD at 4 months and one met criteria B (i.e., reexpeniencing symptoms) and D (i.e., increased arousal); the other was lost to follow-up. Overall, then, of the four most symptomatic patients who were available for foblow-up, three had significant symptoms 4 months after discharge. Of the 3 1 patients who took the SCID at 4-month follow-up, seven (22.6%) met full criteria for PTSD. One of these had met full PTSD criteria and one had met all but the 1-month duration criterion at discharge. The remaining five were new cases. Individual
RESULTS
SPENCE,
Symptoms
of Posttraumatic
Distress
Individual symptoms of posttraumatic distress were more common than the fully expressed syndrome of PTSD at discharge and remained common at 4-month follow-up, sometimes emerging in persons who had lacked these symptoms at discharge. Reexperiencing symptoms. Twenty-five of 43 patients (58.1%) had at beast one reexpeniencing symptom (i.e., met PTSD criterion B) at discharge (table 1 ). Of these 25, 19 were available for follow-up at 4 months, and 14 continued to report a neexpeniencing symptom at that time. Of the 31 patients who took the SCID at 4-month follow-up, 19 (61.3%) reported a reexpeniencing symptorn at that time. In four of these cases, the symptoms had not been present at discharge; in one case, the symptomatic status at discharge was not known. Thus, in only four cases were reexpeniencing symptoms present at follow-up in patients who had not had such symptoms at hospital discharge.
1235
ADULT
BURN
SURVIVORS
TABLE 1. Reexperiencing B) by Adult Bum Survivors
of PTSD Symptoms (DSM-III-R Criterion at Discharge and 4-Month Follow-Up
Symptoms
N
Intrusive memories Recurrent dreams Flashbacks Intense distress at similar events Anya aMet
criterion
%
2.
N
%
16 I 1 6
37.2 25.6 14.0
14 10 6
45.2 32.3 19.4
13 25
30.2 58.1
11 19
35.5 61.3
B.
PTSD
C)
Difficulty sleeping Increased irritability Difficulty concentrating Hypervigilance Increased startle response Physiological reactions to event At least two symptomsa
Symptoms
criterion
Posttraumatic Personality
Discharge
4-Month Follow-Up
(N=43)
(N=31)
N
%
N
%
17
39.5
12
38.7
9
20.9
13
41.9
4
9.3
6
19.4
6
14.0
6
19.4
7 4 I 1 8
16.3 9.3 25.6 18.6
2 2 11 8
6.5 6.5
35.5 25.8
C.
Symptoms of avoidance and emotional numbing. Eight of 43 patients (18.6%) had three or more symptoms of avoidance or emotional numbing (i.e., met PTSD criterion C) at the time of discharge (table 2). Of these eight, five were available for 4-month follow-up, and two of these still met criterion C. Of the 31 patients who took the SCID at 4-month follow-up, eight (25.8%) met criterion C at that time. Of these eight, six had not met this criterion at dischange. Thus, the majority of patients who reported significant symptoms of avoidance/numbing at 4-month follow-up had developed these symptoms after discharge from the hospital. Symptoms of increased arousal. Thirteen of 43 patients (30.2%) had at least two symptoms of increased arousal (i.e., met PTSD criterion D) at discharge (table 3). Ofthese 13, 10 were available for follow-up, and six still met criterion D. Of the 3 1 patients who took the SCID at 4-month follow-up, 14 (45.2%) met criterion D at that time. Of these 14, eight had not met this criterion at discharge. Thus, many patients reporting significant symptoms of increased arousal at 4-month follow-up had developed these symptoms after discharge.
1236
criterion
N
%
N
%
I I 8 6 8 I 1
25.6 1 8.6 14.0 18.6 25.6
11 9 4 13 10
35.5
2 13
30.2
4.7
29.0 12.9 41.9 32.3
2
6.5
14
45.2
D.
of Avoidance and Emotional Numbing (OSMin Adult Bum Survivors at Discharge and 4-Month
Avoidance of thoughts related to event Avoidance of activities related to event Inability to recall aspects of event Diminished interest in usual activities Feelings of estrangement from others Restricted range of affect Sense of foreshortened future At least three symptomsa aMet
Symptoms
Follow-Up (N=31)
Symptoms
III-R Criterion Follow-Up
PTSD
D) in
4-Month Discharge (N=43)
aMet TABLE
Arousal (DSM-III-R Criterion and 4-Month Follow-Up
4-Month Follow-Up (N=31)
Discharge (N=43) PTSD
3. Symptoms of Increased Adult Burn Survivors at Discharge TABLE
Distress
and
Mood,
Burn
Type,
and
Mood. At discharge, Beck Depression Inventory scones were significantly higher among patients who met criterion C (i.e., avoidance/numbing) (scones of 15.0 versus 7.9; t=-2.18, df=36, p=O.O4) and criterion D (i.e., increased arousal) (scones of 14.7 versus 7.0; t=-3.01, df=36, p=O.OOS) than among other patients. There were no significant relationships between neexpeniencing symptoms and Beck Depression Inventory scores. Patients with PTSD at 4-month follow-up were marginally more depressed than other patients (Beck Depression Inventory scones of 15.0 versus 8.2; t=-1.72, df=13, p=O.ll). Two PTSD patients met criteria for major depression and one met criteria for dysthymia at the time of follow-up. Burn type. Twenty-one (67.7%) of3 1 patients suffering flame on flash burns had a reexpeniencing (criterion B) symptom at discharge; in contrast, four (33.0%) of 12 patients who had sustained other types of burns (e.g., chemical, electrical) reported such symptoms. This difference was marginally significant (x2=2.9 with Yates’s connection, df=1, p=O.O9). There were no relationships between type of burn and other posttraumatic symptoms. Personality. Of the patients who took the NEO Personality Inventory at discharge, those who met cnitenon B at discharge (N=9) scored lower on the inventory domain of openness than those who did not have such symptoms (N=17) (scores of 46.4 versus 53.0; t= 2.33, df=24, p=O.O3), and those who met criterion C (i.e., avoidance/numbing) (N=3) scored lower on the inventory domain of extraversion than those who did not (N=23) (scores of46.7 versus 59.8; t=3.86, df=24, p=O.OO1). In addition, those who met criterion D (i.e., increased arousal) (N=6) scored higher on the inventory domain of neuroticism than those who did not (N=20) (scones of 58.5 versus 48.5; t=-2.93, df=24,
p=O.OO7). Of the patients who completed the Milbon Clinical Multiaxial Inventory-Il at discharge, those who met criterion C (i.e., avoidance/numbing) (N=4) were more schizoid than those who did not (N=30) (scores of 26.5
Am
] Psychiatry
I 49:9,
September
1992
ROCA,
SPENCE,
AND
MUNSTER
versus 17.0; t=- 2.85, df=32, p=O.OO8). They were also more avoidant (scones of 35.3 versus 14.6; t=-3.10, df= 32, p=O.OO4), schizotypal (scores of 32.5 versus 14.5; t=-2.76, df=32, p=O.Ol ), and borderline (scores of 38.3 versus 1 8.5; t=-2.SS, df=32, p=0.O2). Those who met criterion D (i.e., increased arousal) (N=10) scored higher on the borderline scale (scores of 30.8 versus 16.7; t= -2.58, df=32, p=O.O2) than those who did not (N=24).
also no significant relationships between posttnaumatic symptoms at follow-up and other clinical data obtained during the hospitalization, including demographic vanables, type of burn, length of stay, presence or absence of delirium, and alcohol intoxication at the time of admission.
Intoxication Distress
There were no significant relationships between postbunn adjustment, as measured by the Psychosocial Adjustment to Illness Survey at 4-month follow-up, and the likelihood of having PTSD on of meeting cnitenon B, C, or D. In contrast, there were significant nelationships between scores on the survey at 4-month follow-up and aspects of the injury itself, the treatment provided, and the personality of the victim. The greater the extent of facial involvement, the poorer the adaptation in the survey’s social (r=0.68, N=17, p
Objective:
The
Adaptation Adult Burn
P. Roca, and
purpose
of this
follow-up. tended
Symptoms to emerge
sociated adjustment ality,
patients diagnosed
with
study
was
to examine
discharge
and
the injury
itself,
and
from
the
its treatment.
hospital.
Since
psychosocial
discharge
adjustment strategies 1992;
after
may
should be developed 149:1234-1238)
urn injury-a painful, frightening, and extraondinary trauma-may precipitate posttraumatic symptoms in at least some burn survivors. In a study predating DSM-III, Andreasen and Norris (1) described transient “phobic” and “traumatic” neuroses in many burn survivors. More recently, Countemanche and Robinow (2) published two illustrative case reports of DSM-III posttraurnatic stress disorder (PTSD) in burn victims, and Patterson et al. (3) found that 29% of hospitalized burn survivors met criteria for DSM-III PTSD at some point before discharge. While these papers illustrate the importance of screening burn patients for posttraumatic distress, they leave unanswered many questions about the prevalence, natural history, and functional implications of
Presented in part at the 143rd annual meeting ofthe American Psychiatric Association, New York, May 12-17, 1990. Received Aug. 1, 1991; revision received Dec. 10, 1991; acceptedJan. 17, 1992. From the Departments of Psychiatry and Surgery, The Johns Hopkins University School of Medicine; The Francis Scott Key Medical Center; and the Baltimore Regional Burn Center, Baltimore, Md. Address reprint requests to Dr. Roca, Department of Psychiatry, The Francis Scott Key Medical Center, 4940 Eastern Ave., Baltimore, MD 21224. Supported in part by a grant from the International Association of Fire Fighters Burn Foundation. The authors thank Linda Rice, Ph.D., and Chester Schmidt III, M.D., for their assistance. Copyright © 1 992 American Psychiatric Association.
natural
be identifiable and
adult
burn
tested
during for
this
at
C symptoms)
symptoms
associated related
and
Posttraumatic of patients
criterion
posttraumatic
the hospital, treatment.
history,
Method: Forty-three standardized instruand quantify de-
discharge. Results: and in over 22%
not strongly more strongly
Conclusions:
B
I 234
While
were was
distress after leaving and provide appropriate
treatment J Psychiatry
prevalence,
(DSM-III-R
new symptoms of posttraumatic is required to detect new cases ventive (Am
the
in adult burn survivors. assessed at discharge with disorder, assess personality,
emotionalnumbing
symptoms of depression, they to illness; psychosocial adjustment
M.D.,
M.D.
were evaluated 4 months after in 7% of patients at discharge
ofavoidance after
J. Spence,
M.D., M.P.H., Robert Andrew M. Munster,
psychosocial impact ofposttraumatic symptoms adult inpatients at a regional burn center were ments to determine the presence ofpsychiatric pression. Thirty-one stress disorder was
and Distress Survivors
were
as-
with psychosocial to aspects of person-
survivors longitudinal Survivors hospitalization,
often
develop
surveillance at risk for poor and
pre-
population.
PTSD in this population. One significant unsettled question is the time course of posttraumatic symptoms. Patterson et al. (3) found persistent PTSD (at telephone follow-up 40 days after discharge) in only one of Ii burn survivors who had met criteria for PTSD in the hospital, which suggests that posttraumatic symptoms may be short-lived in this population. However, since Patterson et ab. did not perform follow-up interviews of patients who had not had PTSD in the hospital, the true prevalence of PTSD at follow-up could not be stated. It is entirely possible that PTSD might have emerged after discharge in patients who had had few, on even no, posttraumatic symptoms in the hospital. Equally uncertain is the relationship between posttraumatic distress and postburn psychosocial adjustment to illness. While it is plausible that PTSD symptoms could hinder postburn psychosocial rehabilitation, this has not been demonstrated among burn patients diagnosed by DSM-III-R criteria, and one study of World Wan II prisoners of war suggests that even severe symptoms of PTSD are compatible with considerable presenvation of psychosocial functioning (4). Furthermore, there is evidence that postburn disability may be related to a variety of clinical variables (e.g., aspects of the burn or its treatment, the patient’s personality or premonbid psychopathology) that are independent of the emergence of PTSD symptoms (1, 5).
Am
] Psychiatry
I 49:9,
September
1992
ROCA,
The purposes of this study were to describe the prevalence, clinical phenornenology, and clinical correlates of PTSD and its component symptoms among adult burn survivors and to examine the relationship of these symptoms to postburn psychosocial adjustment.
METHOD Subjects for this study were drawn from the 20-bed inpatient unit of a regional burn center located in an urban medical center. Patients were routinely screened for delirium and other psychiatric disorders soon after admission and followed clinically until discharge. Adult patients who were hospitalized for oven 48 hours, who were approaching discharge, and who were not persistently delirious or otherwise inaccessible to interview were invited to participate in the study. Participating subjects took a battery of tests including the Structured Clinical Interview for DSM-III-R (SCID) (6), the Beck Depression Inventory (7), the NEO Personality Inventory (8), and the Millon Clinical Multiaxial Inventory-I! (9). An attempt was made to reinterview the subjects 4 months after discharge. The SCID was readministered over the telephone to subjects who could be reached only in that manner. In addition, a research assistant mailed to all located subjects a packet containing the Beck Depression Inventory and the Psychosocial Adjustment to Illness Survey ( 1 0, 1 1 ), a standard questionname designed to measure post-illness functioning in seven domains: health care orientation, vocational envinonrnent, domestic environment, sexual relationships, extended family relationships, social environment, and psychological distress. Student’s t test was used to compare group means, and Pearson correlation coefficients were calculated to evaluate the relationships between continuous vanables. Relationships between dichotomous variables were evaluated with the chi-square test.
During the study period, 1 34 adults were admitted to the unit. Of these, 68 could not be given the formal test battery because of death (N=14), discharge within 48 hours (N=41), persistent delirium (N=1O), severe attention deficit disorder (N=1), on nondelinious psychotic states (N=2). Of those able to participate (N=66), 43 gave consent and completed the diagnostic interview. Efforts were made to contact all study patients 4 months after discharge. Twenty-nine (67.4%) were contacted and agreed to retake the SCID; in addition, two patients who had not been tested at discharge entered the study and were given the SCID. Seventeen patients completed and returned the Psychosocial Adjustment to Illness Survey and the Beck Depression Inventory. Those who completed the SCID at follow-up were compared to the 14 who did not; no significant differences were found between these groups in age,
Am
] Psychiatry
1 49:9,
September
1992
AND
MUNSTER
sex, level of education, total body surface area burned, length of stay, or type of burn. Thirty-five patients (81.4%) in the study were men, and 30 (69.8%) were white. Their average age was 34.7 years (SD=11.8). Twelve (27.9%) had a SCID lifetime diagnosis of major depression, while 16 (37.2%) and 10 (23.3%) had lifetime diagnoses of alcohol and manjuana abuse on dependence, respectively. Length of hospital stay averaged 21 .6 days (SD=21 .9). Twelve (27.9%) had burns involving at least 25% of total body surface area, and 23 (53.5%) had facial involvement. Thirtyone (72.1%) had flame or flash burns, while the rernaining 12 (27.9%) had chemical, electrical, on scald injuries. PTSD At the time of discharge, only three patients (7.1%) met all DSM-III-R criteria for PTSD, including the 1month duration criterion. An additional three patients met all criteria for PTSD except for the 1-month duration criterion. At 4-month follow-up, of the three patients who had met full criteria for PTSD at discharge, one still had PTSD and one was completely symptom free. The other was lost to follow-up. Of the three who had met all criteria except the 1-month duration criterion, one had PTSD at 4 months and one met criteria B (i.e., reexpeniencing symptoms) and D (i.e., increased arousal); the other was lost to follow-up. Overall, then, of the four most symptomatic patients who were available for foblow-up, three had significant symptoms 4 months after discharge. Of the 3 1 patients who took the SCID at 4-month follow-up, seven (22.6%) met full criteria for PTSD. One of these had met full PTSD criteria and one had met all but the 1-month duration criterion at discharge. The remaining five were new cases. Individual
RESULTS
SPENCE,
Symptoms
of Posttraumatic
Distress
Individual symptoms of posttraumatic distress were more common than the fully expressed syndrome of PTSD at discharge and remained common at 4-month follow-up, sometimes emerging in persons who had lacked these symptoms at discharge. Reexperiencing symptoms. Twenty-five of 43 patients (58.1%) had at beast one reexpeniencing symptom (i.e., met PTSD criterion B) at discharge (table 1 ). Of these 25, 19 were available for follow-up at 4 months, and 14 continued to report a neexpeniencing symptom at that time. Of the 31 patients who took the SCID at 4-month follow-up, 19 (61.3%) reported a reexpeniencing symptorn at that time. In four of these cases, the symptoms had not been present at discharge; in one case, the symptomatic status at discharge was not known. Thus, in only four cases were reexpeniencing symptoms present at follow-up in patients who had not had such symptoms at hospital discharge.
1235
ADULT
BURN
SURVIVORS
TABLE 1. Reexperiencing B) by Adult Bum Survivors
of PTSD Symptoms (DSM-III-R Criterion at Discharge and 4-Month Follow-Up
Symptoms
N
Intrusive memories Recurrent dreams Flashbacks Intense distress at similar events Anya aMet
criterion
%
2.
N
%
16 I 1 6
37.2 25.6 14.0
14 10 6
45.2 32.3 19.4
13 25
30.2 58.1
11 19
35.5 61.3
B.
PTSD
C)
Difficulty sleeping Increased irritability Difficulty concentrating Hypervigilance Increased startle response Physiological reactions to event At least two symptomsa
Symptoms
criterion
Posttraumatic Personality
Discharge
4-Month Follow-Up
(N=43)
(N=31)
N
%
N
%
17
39.5
12
38.7
9
20.9
13
41.9
4
9.3
6
19.4
6
14.0
6
19.4
7 4 I 1 8
16.3 9.3 25.6 18.6
2 2 11 8
6.5 6.5
35.5 25.8
C.
Symptoms of avoidance and emotional numbing. Eight of 43 patients (18.6%) had three or more symptoms of avoidance or emotional numbing (i.e., met PTSD criterion C) at the time of discharge (table 2). Of these eight, five were available for 4-month follow-up, and two of these still met criterion C. Of the 31 patients who took the SCID at 4-month follow-up, eight (25.8%) met criterion C at that time. Of these eight, six had not met this criterion at dischange. Thus, the majority of patients who reported significant symptoms of avoidance/numbing at 4-month follow-up had developed these symptoms after discharge from the hospital. Symptoms of increased arousal. Thirteen of 43 patients (30.2%) had at least two symptoms of increased arousal (i.e., met PTSD criterion D) at discharge (table 3). Ofthese 13, 10 were available for follow-up, and six still met criterion D. Of the 3 1 patients who took the SCID at 4-month follow-up, 14 (45.2%) met criterion D at that time. Of these 14, eight had not met this criterion at discharge. Thus, many patients reporting significant symptoms of increased arousal at 4-month follow-up had developed these symptoms after discharge.
1236
criterion
N
%
N
%
I I 8 6 8 I 1
25.6 1 8.6 14.0 18.6 25.6
11 9 4 13 10
35.5
2 13
30.2
4.7
29.0 12.9 41.9 32.3
2
6.5
14
45.2
D.
of Avoidance and Emotional Numbing (OSMin Adult Bum Survivors at Discharge and 4-Month
Avoidance of thoughts related to event Avoidance of activities related to event Inability to recall aspects of event Diminished interest in usual activities Feelings of estrangement from others Restricted range of affect Sense of foreshortened future At least three symptomsa aMet
Symptoms
Follow-Up (N=31)
Symptoms
III-R Criterion Follow-Up
PTSD
D) in
4-Month Discharge (N=43)
aMet TABLE
Arousal (DSM-III-R Criterion and 4-Month Follow-Up
4-Month Follow-Up (N=31)
Discharge (N=43) PTSD
3. Symptoms of Increased Adult Burn Survivors at Discharge TABLE
Distress
and
Mood,
Burn
Type,
and
Mood. At discharge, Beck Depression Inventory scones were significantly higher among patients who met criterion C (i.e., avoidance/numbing) (scones of 15.0 versus 7.9; t=-2.18, df=36, p=O.O4) and criterion D (i.e., increased arousal) (scones of 14.7 versus 7.0; t=-3.01, df=36, p=O.OOS) than among other patients. There were no significant relationships between neexpeniencing symptoms and Beck Depression Inventory scores. Patients with PTSD at 4-month follow-up were marginally more depressed than other patients (Beck Depression Inventory scones of 15.0 versus 8.2; t=-1.72, df=13, p=O.ll). Two PTSD patients met criteria for major depression and one met criteria for dysthymia at the time of follow-up. Burn type. Twenty-one (67.7%) of3 1 patients suffering flame on flash burns had a reexpeniencing (criterion B) symptom at discharge; in contrast, four (33.0%) of 12 patients who had sustained other types of burns (e.g., chemical, electrical) reported such symptoms. This difference was marginally significant (x2=2.9 with Yates’s connection, df=1, p=O.O9). There were no relationships between type of burn and other posttraumatic symptoms. Personality. Of the patients who took the NEO Personality Inventory at discharge, those who met cnitenon B at discharge (N=9) scored lower on the inventory domain of openness than those who did not have such symptoms (N=17) (scores of 46.4 versus 53.0; t= 2.33, df=24, p=O.O3), and those who met criterion C (i.e., avoidance/numbing) (N=3) scored lower on the inventory domain of extraversion than those who did not (N=23) (scores of46.7 versus 59.8; t=3.86, df=24, p=O.OO1). In addition, those who met criterion D (i.e., increased arousal) (N=6) scored higher on the inventory domain of neuroticism than those who did not (N=20) (scones of 58.5 versus 48.5; t=-2.93, df=24,
p=O.OO7). Of the patients who completed the Milbon Clinical Multiaxial Inventory-Il at discharge, those who met criterion C (i.e., avoidance/numbing) (N=4) were more schizoid than those who did not (N=30) (scores of 26.5
Am
] Psychiatry
I 49:9,
September
1992
ROCA,
SPENCE,
AND
MUNSTER
versus 17.0; t=- 2.85, df=32, p=O.OO8). They were also more avoidant (scones of 35.3 versus 14.6; t=-3.10, df= 32, p=O.OO4), schizotypal (scores of 32.5 versus 14.5; t=-2.76, df=32, p=O.Ol ), and borderline (scores of 38.3 versus 1 8.5; t=-2.SS, df=32, p=0.O2). Those who met criterion D (i.e., increased arousal) (N=10) scored higher on the borderline scale (scores of 30.8 versus 16.7; t= -2.58, df=32, p=O.O2) than those who did not (N=24).
also no significant relationships between posttnaumatic symptoms at follow-up and other clinical data obtained during the hospitalization, including demographic vanables, type of burn, length of stay, presence or absence of delirium, and alcohol intoxication at the time of admission.
Intoxication Distress
There were no significant relationships between postbunn adjustment, as measured by the Psychosocial Adjustment to Illness Survey at 4-month follow-up, and the likelihood of having PTSD on of meeting cnitenon B, C, or D. In contrast, there were significant nelationships between scores on the survey at 4-month follow-up and aspects of the injury itself, the treatment provided, and the personality of the victim. The greater the extent of facial involvement, the poorer the adaptation in the survey’s social (r=0.68, N=17, p
