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Published online before print May 17, 2007, 10.1097/PSY.0b013e3180600a2e
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Psychosomatic Medicine 69:377-382 (2007)
© 2007 American Psychosomatic Society

ORIGINAL ARTICLES

Prevalence of Major Psychiatric Illness in Young Adults Who Were Burned as Children

Walter J. Meyer, MD, Patricia Blakeney, PhD, Christopher R. Thomas, MD, William Russell, MA, Rhonda S. Robert, PhD and Charles E. Holzer, PhD

From Shriners Hospital for Children (W.J.M., P.B., C.R.T., R.S.R.), Shriners Burns Hospital, Galveston, TX; the Department of Psychiatry and Behavioral Science (W.J.M., C.R.T., W.R.), and the Department of Surgery (P.B., R.S.R.), University of Texas Medical Branch, Galveston, TX.

Address correspondence and reprint requests to Walter J. Meyer, III, Department of Psychiatry and Behavioral Science, University of Texas Medical Branch, 301 University Blvd. Galveston, TX 77555-0189. E-mail: wmeyer{at}utmb.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 NOTES
 REFERENCES
 
Objective: To determine the prevalence of major psychiatric illness in a group of young adults who suffered significant burn injury as children.

Method: A total of 101 persons (58 males, 43 females), aged 21 ± 2.6 years, 14.0 ± 5.4 years postburn of 54% ± 20% total body surface area, were assessed for serious past and present mental illness by using a Structured Clinical Interview (SCID) for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Axis I diagnoses.

Results: The SCID findings demonstrated that the prevalence of any Axis I major mental illness was 45.5% for the past month (current) and 59.4% for lifetime. These rates of overall disorder and the rates for most specific disorders were significantly higher than those found in the US population of comparable age. Logistic regression was used to examine demographic and burn characteristics as predictors of current and lifetime psychiatric disorder within the burn survivor sample. The female gender was significantly associated with higher rates of any current disorder. Other demographic and burn characteristics were not significantly related to the overall prevalence of current or lifetime disorder. Only a small number of those with disorders reported any current mental health treatment.

Conclusions: Significant burn injury as a child leads to an increased risk of developing a major mental illness. Young adults who suffered major burn injury as children should be screened for these illnesses to initiate appropriate treatment.

Key Words: burn injury • anxiety disorders • depression • alcohol • substance dependence • Structured Clinical Interview

Abbreviations: TBSA = total body surface area; SCID = Structured Clinical Interview; NCS = National Comorbidity Survey; DIS = Diagnostic Interview Schedule; CIDI = Composite International Diagnostic Interview; PTSD = posttraumatic stress disorder.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 NOTES
 REFERENCES
 
Each year, 60,000 to 80,000 persons are admitted for burns in the United States, of which at least half of these are <18 years of age (1,2). Modern medicine has increased survivorship of children and teenagers who have suffered from severe burns. The relationship of survival rate and total body surface area (TBSA) burns has increased greatly so that those with >70% TBSA burns now routinely survive. Half of those <21 years of age with 85% TBSA burns survive today, whereas 25 years ago half would have died if they had only 50% TBSA burns. Surviving larger burns results in greater consequences and challenges for returning to normal routine life activities and relationships. Almost all burns >30% TBSA involve either the hands or the face and cause significant disfigurement and disability.

Most assessments of the psychosocial problems and adjustment of pediatric burn survivor’s focus on the period 1 to 2 years postburn injury. When a child is burned and scarred, their family and other caretakers usually assume that the child will bear a huge psychological burden as they grow. There are many reasons to believe that survivors of massive burn injuries are likely to experience a diminished quality of life, suffer much psychological pain, and present with many symptoms of psychological ill health. Many years of rehabilitation and reconstructive surgeries follow the acute injury. Special garments, including a mask and splints, are worn to reduce the strong burn scar contractures, which cripple the body. These devices also call visual attention to the individuals who wear them. Even after years of work in rehabilitation, disfigurement is the norm for these individuals. The years of special treatment for the severely burned impose major disruptions to the family and create situations that would be expected to interfere with the normal psychological adjustment.

However, several studies using standardized behavioral checklists to examine burned children during their childhood and adolescence identified clinically significant psychosocial disturbance in only a minority of the children (3–7). Two studies have used standardized clinical interviews to assess burned children for psychiatric problems during their childhood and adolescence, and both have found a high prevalence of mood disorders with anxiety disorders particularly high (8–10). The current study examines the psychiatric outcomes of pediatric burn survivors after they have matured into young adults.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 NOTES
 REFERENCES
 
This study’s data collection, between spring 2000 and fall 2002, was designed to evaluate individuals aged 18 to 30 years who had suffered burns >30% TBSA before the age of 16. The study was approved by the University of Texas Medical Branch Institutional Review Board; all subjects gave written permission to participate in the study. All subjects had been seen at least once as a child patient at Shriners Burns Hospital in Galveston, Texas. The subjects were contacted by mail and/or telephone; the purpose of the study was explained as well as the need for them to return to Galveston for the assessments. The subjects were paid for their travel expenses and they were each given a $100.00 honorarium. They were free to stop their participation at any time. If significant psychological problems were found, the subjects were referred to mental health resources in their local areas.

Using the records of the Shriners Burns Hospital in Galveston, we identified individuals who were between 18 and 28 years of age and who had received >30% TBSA burns at least 2 years before the study. Only English-speaking residents of the United States were included because of financial constraints and the unavailability of assessment tools in other languages.

Subjects included 101 young adults (43 females and 58 males) between the ages of 18 and 28 years (mean 21.0 ± 2.6) with mean 54% ± 20% TBSA burns. Thirteen additional subjects refused to participate in the study and 63 could not be found. The demographics including burn size, gender distribution, ethnicity, and age at the time of burn injury were reviewed and found to not be substantially different from the study population (11). Mean age of the study population at the time of injury was 7.8 ± 5.3 years (range 2 months to 17.5 years); the study was conducted at a mean of 14.0 ± 5.4 years (range 3.5–28) postburn injury. A 28-year-old subject was burned as a 2-month-old. Ethnic distribution was 67% White, 17% Black, 16% Hispanic, and 1% Asian. Most participants had significant facial scarring and many subjects had digit or hand amputations. Previously published data concerning this cohort demonstrated that their educational status was as follows: a) 25% high school dropouts; b) 28% high school graduation only; c) 32% some college; and d) 5% completed college (11). Seventy-seven percent either worked or attended school; 27% had had a long-term partner.

Instruments
Psychiatric disorders were assessed using the Structured Clinical Interview (SCID) for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (12). The SCID is widely considered the gold standard for research psychiatric diagnoses. These interviews were conducted by psychiatrists or psychologists, who were trained as a group, using the SCID training tapes, by a coinvestigator (C.E.H.) who had been trained on the SCID by Dr. Michael First, one of the coauthors of the SCID. All interviewers conducted practice interviews that were taped and reviewed by the trainer. Most study interviews were taped and additional reviews were conducted from a sample of the taped interviews. Any discrepancies were resolved by a meeting of the trainer and the interviewer. The complete interviews usually required 2 to 3 hours to administer. The SCID allows operationally defined, consistent, and accurate Axis I psychiatric diagnoses according to the DSM-IV, the official manual of the American Psychiatric Association. The interviews and data gathering were conducted in English. Note that "current" in the SCID is defined as the "past month."

Comparison Groups and Statistical Methods
The basic statistical method is comparison of prevalence rates between the 101 young adults burned as children and adults in the same age range (18–29 years) in three large national samples, namely, the Epidemiologic Catchment Area Study (ECA) (13,14), the National Comorbidity Survey (NCS) (15), and National Comorbidity Survey Replication (NCS-R) (16,17). These studies assessed DSM-IV psychiatric disorders using the Diagnostic Interview Schedule (DIS) as in the ECA or the Composite International Diagnostic Interview (CIDI) as in the NCS and NCS-R. The DIS and CIDI are arguably likely to provide higher prevalence rates than the SCID, when used on comparable samples. The prevalence rates from the national samples were weighted to US population proportions with weighted totals approximating respective sample sizes for the selected age ranges. No further adjustment or variance estimation was conducted. The statistical comparisons were made using {chi}2 tests. Where low cell counts caused probability calculations to be suspect, a Fisher’s Exact Test was used. Because approximately eight to ten comparisons were made for current and another eight to ten for lifetime, there is some potential for {alpha} error or false-positive results. To correct for this, we used the Bonferroni correction, dividing all calculated probabilities by the number of comparisons being done. We would argue that the lifetime and current data should be considered separately because current disorder is a subset of lifetime disorder for each of the respective disorders.

To determine if the risk of having a DSM disorder within the burned patient group was related to other factors, logistic regressions were run predicting current or lifetime disorder from gender, ethnicity, TBSA, age of the patient at the time of injury, time after injury, education level, and the patient’s age at the time the interview was conducted. These factors were entered simultaneously into the model. Models for specific disorders were reviewed but not included here because of small numbers and multiple comparisons.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 NOTES
 REFERENCES
 
All individuals completed the structured interview. Fifty-five percent had no current Axis I diagnosis and 44.6% had ≥1 current Axis I diagnosis (Table 1). Women had more current Axis I diagnoses than did men (60.5% women versus 34.5% men). The types of disorder are listed in Table 1. The most frequent disorders included anxiety disorders, followed by affective disorders. The third most common group of disorders was alcohol and/or substance abuse/dependence. For a comparison, the prevalence rates are included from three major community surveys of psychiatric disorder. Generally, the rates of mood and anxiety disorder are higher for the burned group than for any of the comparison groups matched on age from the three national surveys (13,15,16). Although some variation occurred among the three community studies in current and lifetime rates (16–18), it is beyond the scope of this paper. We have included all three comparisons because there is no clear rationale for picking one over the other; their inclusion makes it clear that our results are primarily from elevated disorder in those burned as opposed to the community respondents.


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  		TABLE 1. Current (1 Month) SCID I Diagnosis Comparison With Three Epidemiological Samples

 

Lifetime mental health diagnoses were more common than the current diagnoses: 59.4% had ≥1 lifetime Axis I diagnoses. Affective and anxiety disorders are more common in these individuals than those collected for the general public of the same age range by the three national surveys (Table 2) (14,15,17). Females had more lifetime Axis I diagnoses than males (69.8% females versus 51.7% males). The types of lifetime diagnoses were similar to the current diagnoses (Table 2) except that affective disorders were more common than anxiety disorders. Alcohol dependence was lower or equal to the general population, but drug dependence exceeded the general population prevalence.


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  		TABLE 2. Lifetime SCID I Diagnosis Comparison With Three Epidemiological Samples

 

Table 3 contains a list of the types of anxiety disorders for current and lifetime periods. Posttraumatic stress disorder (PTSD) and specific phobias, e.g., fear of heights or of flying, were the most common for both periods. Generalized anxiety disorder was also common. Comparing the prevalence of current specific anxiety disorders by gender, all were more common for women than for men; but only the gender difference for any anxiety disorder was statistically significant (p < .008 for current and p < .014 for lifetime). There were no differences in PTSD prevalence between the genders. Many patients reported that their PTSD symptoms had abated over the years. Some reported exacerbation of the PTSD with other types of trauma such as the death of a friend.


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  		TABLE 3. Anxiety Disorders Current and Lifetime

 

Table 4 contains a list of the current and lifetime types of affective disorders. Major depression and depression not otherwise specified made up the bulk of these disorders. Analysis by gender showed that only current major depression was significantly more common in females (p < .024). Depressive episodes were particularly severe during adolescence: for many subjects, depression had cleared with adulthood. Only one depressed subject was in therapy at the time of interview.


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  		TABLE 4. Affective Disorders Current and Lifetime

 

Table 5 details the current and lifetime dependence and abuse disorders. In this sample, more men than women seemed to abuse alcohol and all substances; however, none of the gender differences were statistically significant. The lifetime prevalence of alcohol/substance dependence was much higher than the current prevalence (Table 5). This probably reflects an increase in drug and alcohol use of these individuals during adolescence, particularly in males.


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  		TABLE 5. Substance Abuse or Dependence Current and Lifetime

 

The logistic regression predicting having any current or lifetime DSM SCID-I diagnosis from demographic and burn characteristics including gender, ethnicity, size of burn, patient’s age at the time of injury, time post injury, education level, and patient’s age at the time of the interview demonstrated that only gender was significant. Women (60.5%) were more likely than men (34.5%) to have a current SCID diagnosis (odds ratio (OR) = 3.02; p = .027; 95% confidence interval (CI), 1.14–8.04). When this same type of model was performed for the presence of any lifetime SCID disorder, gender remained the most powerful predictor but was not significant (OR = 2.16; p = .103; 95% CI, 0.86–5.47). We are not presenting logistic analyses for specific disorders because the numbers are small and the risk of spurious results from multiple testing are high.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 NOTES
 REFERENCES
 
Two groups of investigators looked at the long-term young adult group who had been burned as children. These studies did not look at psychiatric illness but rather psychological adjustment. In Galveston, three studies done by Blakeney et al. (4,19,20) of older adolescents and young adults reported 40% to 50% of the individuals presented as well-adjusted although 50% to 60% presented with some degree of psychological distress; 25% presented with symptoms severe enough to warrant clinical attention. Zeitlin (21) reported 91 patients who were burned as children and were now young adults. As a group, the burn size was small and they had relatively good psychological outcome. He did not report psychiatric illness per se.

This article raises interesting questions of how severe burn injury during childhood may affect the individuals’ development as they enter their third decade and what are the long-term implications for rehabilitation needs for pediatric burn survivors. Although the majority of burned children have no more maladaptive behaviors than would be expected for nonburned children, they do seem to have diminished adaptive behaviors that are critical to their transition through adolescence to adult living (22). The psychological difficulties of burned children are not easily observable; by objective standardized measures, most burned children seem to do well. Our studies have indicated that burned children usually develop positive self-concepts with high self-esteem, in some instances higher than that of nonburned comparison groups (4,23–25). One study did indicate an inverse correlation, for males only, between the number of visible scars and self-esteem in areas of personal appearance and overall happiness (26). Most burned children seem to differ from nonburned children by rating personal appearance, athletic competence, and social acceptance as less important than scholastic competence, job competence, and romantic appeal (24,25). Burned children seem to adapt to their injuries by denying the importance of those things that they cannot change and turn their attention and energy to areas where they can succeed.

Symptoms of disturbed behavior in burned children are more likely to be noted by parents than by other observers (5). This suggests that there is a discrepancy between the public and private "selves" of the burned child. A comparison of standardized test scores (representative of the public "self") of burned children with the scores on the Rorschach Ink Blots (representative of the private, internal feelings) indicate the children to be significantly more depressed privately than is apparent publicly (27).

Psychological and psychiatric disturbances at this "private" level have not been examined systematically in many samples of burn survivors. In the pediatric burn survivor population, depressive disorders have been the focus of study and some have found it to be very prevalent (28–30). Others, including the authors, have noted an increase in aggression and anger rather than depression (3,8,9,31,32).

Only one major systematic psychiatric study has been done in children who were burn survivors (8,9). Only 26.7% of the children did not have a current Axis I diagnosis and only 13.3% did not have a lifetime Axis I diagnosis. The investigators found a high prevalence of anxiety disorders and affective disorders as well as oppositional defiant disorder, enuresis and encopresis. The later diagnoses were found in far fewer numbers as current diagnoses, probably reflecting the developmental nature of these disturbances.

In a recently completed assessment of teenagers burned at least 2 years before assessment, we also found a high incidence of anxiety disorders as well as substance abuse using the Computerized Diagnostic Interview Schedule for Children 4 (10). It would appear that anxiety is the most prevalent "private" disturbance to be experienced by burned children and adolescents.

Other chronic medical problems like inflammatory bowel disease, epilepsy, or diabetes mellitus have associated psychiatric problems (33) The spectrum of their illness seems to be affective disorders (34). The burn survivor is unique in that he or she has recovered from an acute illness like the victim of other trauma but is left with visible scars, which probably add to his or her anxiety (35).

The current study of pediatric burn survivors indicates that anxiety is also the most prevalent disturbance of young adult survivors of pediatric burn injuries. The expressions of anxiety, e.g., social anxiety or specific phobia, are fairly evenly distributed among the various categories in terms of current diagnosis. Because of the degree of trauma suffered by burn patients, a high prevalence of PTSD might be expected; 21 (20.8%) of our subjects had in the past suffered from PTSD although only nine currently were diagnosed with PTSD. Notably, 19 of our 21 subjects with PTSD were female—a consistent finding in other reports (36,37). The coexistence of the PTSD with the other psychiatric illnesses such as major depression suggests that these illnesses might be interwoven or in a cause and effect relationship (38–42). Fauerbach and associates also reported that, in adult burn survivors, certain personality traits like neuroticism increased the prevalence of PTSD determined by SCID III (43).

It is reasonable to consider that the size of burn, the child’s developmental stage at the time of burn injury, and time post burn would be major factors in the psychiatric outcome of the burn injury. However, none of these factors was statistically significant. Only gender seemed to play a significant role for anxiety and affective diagnoses. There is inadequate information at present to clarify the interaction between age of burn and adjustment to burn. The data available from this study and our other studies showed no significant effects of age at the time of the burn injury (3,5–7). A separate consideration is that progression through different stages may resurrect previous issues about the burn that require a new accommodation—such as entering dating age and dealing with hidden scars; raising their own children and having their children’s friends tease them about their parent’s appearance. More detailed histories are needed to answer these questions.

It is important to note that almost half of our sample met the criteria for psychiatric diagnosis when assessed by individual interviews. Assuming that this sample is representative of young adult survivors of burn injury, these findings are alarming because neither the burn care world nor the mental health community is set to recognize their needs. Unless the mental health professional knows how to assess burn survivors and what to assess for, the healthcare professional is unlikely to observe the severity of need. Anxiety, the most prevalent diagnosis, usually is not deemed serious enough to be treated in crowded mental health facilities with limited funds. Anxiety that is not managed well can limit an individual’s participation in gaining education and training to prepare for a livelihood; it can prevent employment; it can stop the individual from applying for employment. Anxiety can significantly interfere in all aspects of participation in society (44–46).

Although this study focuses on the specific quandary for young adults who have grown up with burn scars, the findings may be important for adults burned as adults as well. Some studies have reported that most psychological problems postburn injuries for adults resolve over time (47,48) but other reports have contradicted that finding. Kleve and Robinson (49) conducted a survey of 71 adult burn survivors and found that 56% reported emotional problems for an average of ≥2 years after the injury, but formal psychiatric diagnoses were not made. Ye (50) reported that 40% of a sample of adults with facial and neck burns experienced depressive symptoms but did not report the period of follow up. Altier et al. (51) reported similar results with adult burn survivors 18 to 121 months after injury. Although these studies did not systematically assess for major psychiatric illness, all suggested that a significant number of adult burn survivors suffered psychiatric disturbance long after their physical recovery.


   CONCLUSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
NOTES
 REFERENCES
 
This study finds that young adults who survived burn injury as children have an increased prevalence of major psychiatric illness, especially anxiety disorders. For this population of survivors of large burns (>30% TBSA), the age at the time of injury and the exact size of burn did not influence the prevalence, but the prevalence of affective and anxiety disorders was high in females. Adult survivors of large burn injuries suffered in childhood should be screened for these major mental illnesses and should be afforded appropriate treatment to enhance their abilities to achieve optimal quality of life.


   NOTES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 NOTES
REFERENCES
 
Received for publication December 8, 2005; revision received January 31, 2007.

This work was supported by NIDRR Grant H133G99052 (W.J.M.). This study was conducted in part at the General Clinical Research Center, University of Texas Medical Branch at Galveston. The study was funded by Grant M01RR00073 from the National Center for Research Resources, National Institutes of Health, and United States Public Health Service.

This paper was presented, in part, at the annual meeting of the American Academy of Child and Adolescent Psychiatry, 2003.

DOI:10.1097/PSY.0b013e3180600a2e


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 NOTES
 REFERENCES
 

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