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Accident proneness and impulsiveness in an Italian group of burn patients
burns 35 (2009) 247–255
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Accident proneness and impulsiveness in an Italian group of burn patients Chiara Pavan a,*, Giovanna Grasso b, Maria Vittoria Costantini b, Luigi Pavan a, Francesca Masier a, Maria Francesca Azzi a, Bruno Azzena c, Massimo Marini a, Vincenzo Vindigni c a
Unit of Psychiatry, Department of Neuroscience, University of Padova, Italy Department of Development Socialization Psychology, University of Padova, Italy c Unit of Plastic and Reconstructive Surgery, University of Padova, Italy b
article info
abstract
Article history:
There is controversy about the existence of a predisposition to burn incidents (accident
Accepted 7 July 2008
proneness). Our objective was to examine, in a group of burn patients, the conditions or ‘‘unconscious’’ subjective predisposition, the presence of impulsiveness that may have
Keywords:
contributed to bringing about the ‘‘burn’’ event, and to assess the presence of psychiatric
Burns
diagnoses and specific characteristics of temperament.
Psychopathology
25 consecutive burn patients were interviewed by using specific psychometric tests. The
Proneness accident
sample was divided into two groups: ‘‘control’’ group (N = 10), composed of subjects who had
Impulsiveness
accidentally been involved in the incident and ‘‘case’’ group (N = 15) composed of subjects who had very likely and more or less ‘‘knowingly’’ put themselves at risk of injury. We observed a marked statistically significant difference with case group subjects appearing to be more impulsive than the ones in control group. Higher levels of impulsiveness may predispose case group patients to a greater risk of burn. Our survey also seems to reveal a relationship between impulsiveness and the proneness of some subjects to burns. # 2008 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns are among the most serious injuries experienced, and their impact on life undermines all sense of time and psychophysical harmony. Burns injure the body’s outer cover, i.e. the skin, which has a pivotal role in holding together the various parts of the body. A little girl once described that the difference between toys and children was that toys got broken but lacked the essential component for recovery: the skin. In other words, the skin prevents us from breaking and allows us to heal. The skin is an
essential part of our makeup: it brings us into contact with the outside world, permitting us to experience the objects around us, while creating a boundary between ourselves and our surroundings [1]. Burns also have physical, social and psychological implications and thus demand a multidisciplinary approach [2]. Burns produce a painful scar that is not only physical but also psychological and can give rise to psychosocial problems, including depression, anxiety, post-traumatic stress disorder (PTSD), personality change, family problems and heavy financial burden [3,4].
* Corresponding author at: Psychiatric Clinic, University of Padova, Via Giustiniani 2, 35122 Padova, Italy. Tel.: +39 049 8213830; fax: +39 049 8218256. E-mail address: [email protected] (C. Pavan). 0305-4179/$36.00 # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.07.002
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burns 35 (2009) 247–255
The literature reports prevalence rates for psychiatric disorders in burn patients that vary according to sample size, assessment instruments and cut-offs used, and variations in burn severity. Observed rates of major depression in hospital patients surveyed with self-report measures range from 4% to 53%: from 4% to 35% in the first 12 months post discharge and from 7% to 45% at 12 months or more burn [5]. In recent studies, burn patients have been found to present high rates of PTSD (13–45%) [6,7] and between 31% and 50% of patients to suffer from clinically significant levels of anxiety [8]. Several studies designed to identify type and incidence of premorbid psychopathology have shown that many burned patients present with pre-existing dysfunction (psychosis, depression, anxiety, substance abuse, organic brain syndrome and personality traits), making them more likely to incur injury, due to reduced competence, disturbed state of mind, carelessness, active self-harm, recklessness or risk taking [1,9–12]. A study, using Cloninger’s Tridimensional Personality Questionnaire, found passive–aggressive and impulsive personality traits in some burn subjects [12]. There is controversy about the existence of a predisposition to burns but very few validated studies have been conducted in this regard [13]. According to some psychological hypothesis some people have an unconscious tendency to injury [14,15]. Accident proneness is a personality trait present in subjects who have an unconscious tendency to be involved in numerous injuries [16]. Several studies found that trauma victims have a high probability of incurring recurrent injuries. Victims of penetrating and intentional injury in particular have been reported to be injury prone but this tendency has also been observed in non-intentional-trauma casualties [9]. Alcohol and substance abuse are very frequent among trauma victims, suggesting that not all traumatic injuries are random that happen to innocent bystanders. Rather, some trauma victims fall prey to their own impulsive or selfinjurious behaviour [9]. Impulsiveness is ‘‘a tendency to act quickly based on an impulse without reflecting or without paying attention to consequences’’ [17]. It is a key feature of many psychiatric disorders such as personality disorders (in particular antisocial and borderline personality disorders), conduct disorder, mania, substance abuse and impulse control disorders as kleptomania [18,19]. To the best of our knowledge, no study has utilised a specific impulsivity test in burns. The objective of our study was to examine, in a group of burn patients, the presence of impulsiveness that may have contributed to bringing about the ‘‘burn’’ event, and to assess the presence of psychiatric diagnoses and specific characteristics of temperament.
2.
Materials and methods
25 consecutive subjects were recruited from patients attending the burn clinics of the Burn Unit of the Department of Plastic Surgery of Padova University during the period 15 January–20 October, 2007. All the patients accepted the psychiatric evaluation.
2.1.
Inclusion criteria
The inclusion criteria were men and women aged between 18 and 65 years, presenting with third-degree burns >25%, occurring less than 6 months previously (the minimum time after burn was 6 weeks), who agreed to psychiatric assessment, had sufficient fluency in the Italian language and were able to write without feeling pain.
2.2.
Exclusion criteria
Subjects, who had attempted suicide and or had psychotic disorders and/or cognitive impairment, were excluded from the study. Assessment was based on the following parameters: burn site (face, trunk, upper and lower extremities), source of the burn (fire, boiling liquid, corrosive substances) and extension (total body surface area, TBSA). Patients underwent psychiatric assessment by a consultant psychiatrist based on self-report and clinician-administered questionnaires. The following instruments were used for the psychiatric assessment: 1. Case-history interview to collect main historical clinical data and details concerning the traumatic event (date and circumstances of the trauma). To investigate the causes, source, site and extension of the burn, we conducted a survey on the patient’s case history (analysis of clinical charts) and on interviews with attending health professionals (medical and nursing team). The dynamics of the incident were reconstructed through a brief account written by the patient, who was asked to: ‘‘Write about how the injury happened in as much detail as possible’’. 2. Mini-International Neuropsychiatric Interview [20–22] to screen for Axis I psychiatric diagnoses. We used the definition by Stein et al. [23] for the diagnosis of partial PTSD, i.e. the presence of at least one symptom in each of the three clusters without fulfilling the criteria for the full syndrome. We also asked patients whether during their lifetime, apart from the burn, they had been subjected to any of the traumatic experiences indicated on a list drawn up by us (serious road accident, acts of personal violence or aggression, a serious disease or operation affecting them personally or someone close to them, sudden bereavement of a person, separation or break-up of a romantic relationship, problems or serious conflicts with another person, job loss, witness to a violent scene, child abuse, natural disasters and a space to specify any other types of trauma that may have been present). We also specifically asked patients if, in the past, they had seen a primary care physician or a psychiatrist for a psychotropic drug prescription or for psychotherapeutic treatment. 3. Hamilton Rating Scale for Depression (HDRS) [24] to assess the severity of the depression.
burns 35 (2009) 247–255
4. The State-Trait Anxiety Inventory-Y form STAI-Y [25] to assess the presence of state and trait anxiety symptoms. 5. The Tridimensional Personality Questionnaire (TPQ) [26,27] to evaluate temperament. 6. Impact of Event Scale (IES) [28] to measure the impact of the burn on the patient’s life. 7. Toronto Alexithymia Scale (TAS-20) [29] to detect the presence of alexithymic characteristics through three factors: difficulty in distinguishing between feelings and bodily sensations (Factor 1), difficulty in describing feelings (Factor 2), and externally oriented thinking (Factor 3). This scale provides a total alexithymia score and three partial scores related to the above factors. 8. Barratt Impulsiveness Scale (BIS) [30,31] is based on a unidimensional model of impulsiveness which included it as a part of a larger groups of personality predispositions such as extraversion, sensation seeking and a lack of inhibitory behavioural controls. 9. Multidimensional Scale of Perceived Social Support (MSPSS) [32]. The MSPSS provides assessment of three sources of support: family, friends and significant other. 10. Paykel Life Events Scale [33] to assess events occurring in the 6 months prior to the burn.
2.3.
Description of sample
The test sample (N = 25) was divided into two groups: ‘‘control’’ group (N = 10), composed of subjects who had accidentally been involved in the incident (if they had not been present in that place at that precise time, they would not have been involved in the incident, i.e. they were not directly implicated) and ‘‘case’’ group (N = 15) composed of subjects who had very likely and more or less ‘‘knowingly’’ put themselves in a position to get injured.
2.4.
249
Clinical case assigned to control group. ‘‘I was in the kitchen making lunch with my sister. My sister was draining the pasta when suddenly the pan handle broke off. I was chopping some vegetables and the boiling water came pouring over my stomach and legs. I didn’t have time to realize what was happening. I felt a lot of pain and began shouting.’’ Clinical case assigned to case group. ‘‘I had a case full of chickens to pluck and then cook for Easter Sunday lunch. To quicken things up, I decided to remove the feathers by burning them with alcohol. I got a basin, filled it with alcohol, dipped the chickens in it and set them on fire with a lighter. There was an immediate flashback which hit my face, breasts and hands. I was terrified because my 10-month-old baby was on her highchair behind me. Fortunately I was the only one hit by the flames.’’ The two groups were then compared on the basis of sociodemographic and clinical variables.
2.5.
Statistical analysis
The sample was illustrated using descriptive statistics. The two groups were compared by the x2-test with Fisher’s correction for categorical variables and by Student’s t-test for linear variables. When the variables did not exhibit a linear trend with the Kolmogorov–Smirnov test, we used the Mann– Whitney test. We also used Bonferroni correction. Data were processed using SPSS statistics package 15. We assessed interrater reliability to determine agreement among the raters on the assignment of patients to the case or control groups using Kappa Cohen coefficient.
3.
Results
3.1.
Interrater reliability
Study design
The method for selecting control group and case group was based on independent assessment by three raters (a psychoanalyst, a psychiatrist who was blind to the clinical interview and test package administration and a clinical psychologist) who assigned the patients to the two groups according to preset assessment parameters. Where two out of three or three out of three raters were in agreement, their ‘‘judgement’’ determined assignment to control group or case group. Each rater read all the patients’ written accounts before addressing the patients to control group or to case group. The raters based their decisions on the following assessment parameters: (1) A brief ‘‘written’’ account of the dynamics of the incident provided by the patient during the interview with the consultant psychiatrist. (2) The causal factor, i.e. any materials and instruments directly handled (controlled or altered) by the subject that may imply ‘‘direct causality in the event’’. Positive elements from both above-mentioned factors (1) and (2) had to be present for a patient to be assigned to case group. Below are two examples of patients’ written accounts to show how they were assigned to control group or case group.
The three raters assigned patients to control group or case group according to the criteria described in Section 2, with an index of agreement ranging from a maximum of k = 0.81 ( p = 0.000) between rater 1 (psychoanalyst) and rater 2 (psychiatrist) and a minimum of k = 0.56 ( p = 0.01) between rater 2 (psychiatrist) and rater 3 (psychologist), with interrater disagreement ranging from a minimum of two cases to a maximum of five cases.
3.2.
Sociodemographic characteristics
The total sample (N = 25) was composed of 13 men and 12 women. Control group (N = 10) consisted of 60% males (N = 6) and case group 2 (N = 15) of 40% males (N = 6) (x2-test with Fisher correction = 0.92, p = 0.28). The mean age S.D. of control group 1 (N = 10) was 37.9 5.8 years and of case group (N = 15) was 43.6 16.6 years (F = 1.096, p = 0.306). Concerning marital status, 70% (N = 7) of the control group were married compared to 73.3% (N = 11) of case group. No members of control group and two members (13.3%) of case group were widowed. Twenty percent (N = 2) of the control group had never been married compared to 13.3% of the case group. Only one member of control group and no members of case group were cohabiting.
250
burns 35 (2009) 247–255
Table 1 – Sociodemographic characteristics. Control group (N = 10), N (%)
Case group (N = 15), N (%)
Test, x2 a
6 (60)
6 (40)
0.92
0.28
Control group (N = 10), M S.D.
Case group (N = 15), M S.D.
Test
p
37.9 5.85 11 3.4
43.66 16.64 10.2 3.6
tb = 1.09 tb = 0.24
Gender (male)
Age (years) School years
Control group (N = 10), N (%)
Case group (N = 15), N (%)
p
0.306 0.62
Test, x2 a
p
Marital status Married Widowed Never married Cohabiting
7 0 2 1
(70) (0) (20) (10)
11 2 2 0
(73.3) (13.3) (13.3) (0)
3.009
0.550
Profession Office worker Freelance professional Housewife Retired
7 2 1 0
(70) (20) (10) (0)
9 2 2 2
(60) (13.3) (13.3) (13.3)
1.64
0.769
a b
Statistics corrected by Fisher’s test. Student’s t-test.
No macro differences in gender, age, marital status, educational level, and occupation were observed between the two groups (Table 1).
3.3. Source of the burn (fire, boiling liquid, corrosive substances), site and total burn surface area The burn site (control group vs. case group) was constituted by the face (40% vs. 60%), trunk (41.7% vs. 58.3%), upper extremities (60% vs. 40%) and lower extremities (37.5% vs. 62.5%). These differences were not statistically significant (Table 2). Of the control group, 70% (N = 7) had been burned by fire, 30% (N = 3) by boiling liquid; 80% (N = 12) of case group had been burnt by fire and 20% (N = 3) by boiling liquid. No member of either group had been injured by corrosive substances.
The total burn surface area in control group was 33.5% compared to 36.7% in case group. There were no statistically significant differences between the groups in terms of burn site, source of burn and TBSA (Table 2). Considering the time after burn at the moment of psychiatric evaluation, control group vs. case group has 11.4 3.9 vs. 12.2 4.0 weeks (t = 0.2, p = 0.60).
3.4.
Mini-International Neuropsychiatric Interview (MINI)
The MINI revealed the presence of psychiatric diagnoses in our sample but the comparison of the two groups did not find statistically significant differences (Table 3). The most representative psychiatric diagnoses in the case group were lifetime major depression (50%), lifetime alcohol abuse (33%), current specific phobia (26.7%), current (26.7%,
Table 2 – Source (fire, boiling liquid, corrosive substances), site and extension (TBSA) of the burn. Control group (N = 10), N (%) Source of the burn Fire Boiling liquid Corrosive substances
7 (70) 3 (30) 0 (0)
Localizzazione Face Torso Upper extremities Lower extremities
6 5 3 3
Total burn surface area (TBSA) a b
Statistics corrected by Fisher’s test. Student’s t-test.
(40) (41.7) (60) (37.5)
Case group (N = 15), N (%)
Test, x2 a
p
0.32 0.32
0.65 0.65
0.000 0.027 1.042 0.031
1.0 1.0 0.615 1.0
12 (80) 3 (20) 0 (0)
9 7 2 5
(60) (58.3) (40) (62.5)
Control group (N = 10), %M S.D.
Case group (N = 15), %M S.D.
Test, tb
33.5 21.6
36.7 11.6
0.07
p 0.80
251
burns 35 (2009) 247–255
Table 3 – Percentage distribution by groups on the Mini-International Neuropsychiatric Interview (MINI). Control group (N = 10), N (% positive) Major depression, current Major depression, lifetime Dysthymia Panic disorder, current Panic disorder, lifetime Agoraphobia Social phobia, current Specific phobia, current Generalized anxiety disorder Alcohol abuse, current Alcohol abuse, lifetime Nonalcohol substance abuse, current Nonalcohol substance abuse, lifetime Obsessive-compulsive disorder, current Obsessive-compulsive disorder, lifetime Post-traumatic stress disorder, current Post-traumatic stress disorder, lifetime a
0 4 0 0 0 0 0 1 0 0 2 0 1 2 1 2 0
Case group (N = 15), N (% positive)
(0) (40) (0) (0) (0) (0) (0) (10) (0) (0) (20) (0) (10) (20) (10) (20) (0)
2 7 1 1 1 1 2 4 3 2 5 1 1 0 0 4 1
d.f.
x2 a
p
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3
1.55 0.235 0.745 0.694 0.694 0.694 1.44 1.04 2.27 1.44 0.529 0.694 0.091 3.26 1.56 0.955 0.955
0.49 0.69 1.0 1.0 1.0 1.0 0.5 0.61 0.25 0.5 0.65 1.0 1.0 0.15 0.4 0.81 0.87
(14.1) (50) (6.7) (6.7) (6.7) (6.7) (13.3) (26.7) (20) (13.3) (33.3) (6.7) (6.7) (0) (0) (26.7) (6.7)
Statistics corrected by Fisher’s test.
one subject consequent to the burn) and lifetime (6.7%) PTSD, and generalized anxiety (20%). In control group there was a prevalence of psychiatric diagnoses of current (20%) and lifetime (10%) obsessive-compulsive disorder (Table 3). The symptoms characterizing the PTSD were intrusive in 40% of the members of control group compared to 60% of those in case group (x2 = 0 with Fisher’s correction; d.f. = 1; p = 1). Avoidance symptoms were present in 40% of control group vs. 60% of case group 2 (x2 = 0 with Fisher’s correction; d.f. = 1; p = 1) and symptoms of hyperarousal were observed at frequencies of 33.3% for control group and 66.7% for case group (x2 = 0.260 with Fisher’s correction; d.f. = 1; p = 0.691). Hence there were no statistically significant differences between the groups (Table 4).
About having lifetime traumatic experiences, a statistically significant difference was not reached ( p = 0.084; F = 3.44) (Table 4). None of the controls compared to 6.7% of case group subjects undergoing lifetime psychotherapy and 10% vs. 13.3%, respectively, had taken psychotropic drugs, but without significant difference (d.f. = 1, x2 = 0.626, p = 1).
3.5.
Hamilton Depression Rating Scale
On HDRS the differences between the two groups were not significant (Table 5). Scores below 8 are considered normal, those between 8 and 15 indicate mild, between 16 and 24 moderate and over 25 serious symptoms [32].
Table 4 – Post-traumatic stress disorder (PTSD), lifetime traumatic experiences, Paykel scale. Control group (N = 10), N (% positive) Current PTSD Lifetime PTSD Partial PTSD Presence of intrusive post-traumatic symptoms Presence of post-traumatic symptoms of avoidance Presence of post-traumatic symptoms of hyperarousal
4 1 1 9
(26.7) (6.7) (6.7) (60)
x2 a
3 3 3 1
1.237 1.237 1.237 0.000
1 1 1 1
p
6 (40)
9 (60)
1
0.000
1
7 (43.8)
9 (56.3)
1
0.260
0.691
Case group (N = 15), M S.D.
Ub
p
2.10 1.59 (mean rank 11.70)
3.07 2.40 (mean rank 13.87)
62
0.46
Lifetime traumatic experiences
b
(20) (0) (10) (40)
d.f.
Control group (N = 10), M S.D. Paykel Life Events Scale
a
2 0 1 6
Case group (N = 15), N (% positive)
Statistics corrected by Fisher’s test. Mann–Whitney test.
Control group (N = 10), M S.D.
Case group (N = 15), M S.D.
F
10.85 6.09
16.77 6.49
3.44
p 0.084
252
Table 5 – Groups matched by clinical rating scales. Measure
Case group (N = 15), mean S.D.
F
p
p Bonferroni multiple testing correction
3.8 3.73 30 8.19 31 7.11 11.75 7.28
4.6 5.18 41.54 10.12 38.67 9.43 16.08 5.29
0.17 7.36 3.44 2.48
0.679 0.014 0.081 0.131
0.99 0.70 0.99 0.65
12.88 5.35 22.38 6.30 47 16.25 27.13 2.47 23.88 8.18 25.5 8.05 76.5 10.69 48.88 5.91 13.5 6.2 9.6 6.1 3.5 1.92 1.37 1.18 3.5 0.92 3.12 0.99 4.37 1.06 3.5 0.92 3 1.41 2.37 1.18 3 1.30 6 0.92 8.12 2.41 4.37 1.18 11.5 2.77 13.25 2.91 21.5 3.92
16.38 3.59 22.7 4.32 56 9.53 22.46 7.94 22.62 7.37 21.92 6.68 67 21.26 64.46 7.51 17.2 7.6 11.1 5.0 3.61 2.21 3.30 1.79 3.92 1.18 3.76 1.96 3.69 2.46 4.38 1.55 3.92 1.93 3.23 2.31 3.46 1.26 5.15 2.11 6.23 2.83 3.15 1.34 14.61 6.14 15.23 5.89 18 3.97
3.25 0.02 2.59 2.55 0.13 1.21 1.36 24.7 1.3 0.38 0.01 7.22 0.73 0.73 0.54 2.09 1.36 0.92 0.64 1.12 2.46 4.44 1.80 0.77 3.86
0.087 0.866 0.124 0.126 0.719 0.284 0.257 0.000 0.25 0.54 0.905 0.015 0.402 0.402 0.470 0.164 0.258 0.347 0.433 0.301 0.133 0.049 0.195 0.389 0.064
0.99 0.99 0.60 0.63 0.99 0.99 0.99 0.002 0.99 0.99 0.99 0.75 0.99 0.99 0.99 0.80 0.99 0.99 0.99 0.99 0.65 0.99 0.95 0.99 0.99
burns 35 (2009) 247–255
HDRS—Hamilton Depression Rating Scale STAI—State-Trait Anxiety Inventory-State STAI—State-Trait Anxiety Inventory-Trait TAS-20-f1—Toronto Alexithymia Scale, factor 1: difficulty identifying feelings and distinguishing them from the somatic sensations that accompany emotional arousal TAS-20-f2—Toronto Alexithymia Scale, factor 2: difficulty communicating feelings to other people TAS-20-f3—Toronto Alexithymia Scale, factor 3: externally oriented thinking TAS-20-total score—Toronto Alexithymia Scale-total score MSPSS-f1—Multidimensional Scale of Perceived Social Support, factor 1: friends MSPSS-f2—Multidimensional Scale of Perceived Social Support, factor 2: family MSPSS-f3—Multidimensional Scale of Perceived Social Support, factor 3: significant others MSPSS-total score—Multidimensional Scale of Perceived Social Support-total score BIS—Barratt Impulsiveness Scale IES—Impact Event Scale-Intrusion IES—Impact Event Scale-Avoidance TPQ-NS1—Tridimensional Personality Questionnaire. NS1 = exploratory excitability vs. stoic rigidity TPQ-NS2—Tridimensional Personality Questionnaire. NS2 = impulsiveness vs. reflection TPQ-NS3—Tridimensional Personality Questionnaire. NS3 = extravagance vs. regimentation TPQ-NS4—Tridimensional Personality Questionnaire. NS4 = disorderliness vs. regimentation TPQ-HA1—Tridimensional Personality Questionnaire. HA1 = anticipatory worry vs. uninhibited optimism TPQ-HA2—Tridimensional Personality Questionnaire. HA2 = fear of uncertainty vs. confidence TPQ-HA3—Tridimensional Personality Questionnaire. HA3 = shyness with strangers vs. gregariousness TPQ-HA4—Tridimensional Personality Questionnaire. HA4 = fatigability and asthenia vs. vigour TPQ-RD1—Tridimensional Personality Questionnaire. RD1 = sentimentality vs. insensitiveness TPQ-RD2—Tridimensional Personality Questionnaire. RD2 = persistence vs. irresoluteness TPQ-RD3—Tridimensional Personality Questionnaire. RD3 = attachment vs. detachment TPQ-RD4—Tridimensional Personality Questionnaire. RD4 = dependence vs. independence TPQ-NS total scale—Tridimensional Personality Questionnaire. NS total scale = Novelty Seeking TPQ-HA total scale—Tridimensional Personality Questionnaire. HA total scale = Harm Avoidance TPQ-RD total scale—Tridimensional Personality Questionnaire. RD total scale = Reward Dependence
Control group (N = 10), mean S.D.
burns 35 (2009) 247–255
Two subjects in control group and three subjects in case group exceeded the clinical threshold for depressive pathology, i.e. the HDRS cut-off score of >8. The number of subjects over threshold was 20% per group (x2 = 0.00; p = 1).
3.6.
State-Trait Anxiety Inventory (STAI S–T)
Results suggested a prevalence of state anxiety in case group (M S.D. = 41.54 10.12) compared to control group (30 8.19) ( p = 0.014, F = 7.36). Trait anxiety also appeared to prevail in case group (M S.D. = 38.67 9.43) compared to control group (31 7.11) ( p = 0.081, F = 3.44) but without reaching statistical significance (Table 5).
3.7.
Tridimensional Personality Questionnaire
Comparison of the Tridimensional Personality Questionnaire results revealed statistically significant differences for the subscale Novelty seeking—NS2 (impulsiveness vs. reflection), with case group scoring higher ( p = 0.015; F = 7.22) and a light trend towards significance for the Reward Dependence (RD) scale, with control group scoring higher ( p = 0.064; F = 3.86). On the NS2 subscale in particular (novelty seeking— impulsiveness/reflection), the mean scores for case group (M S.D. = 3.30 1.79) were more than double the scores achieved by control group (M S.D. = 1.37 1.18) with F = 7.22 and p = 0.015. Control group had higher scores than case group on subscale RD4 (dependence/independence) (F = 4.44; p = 0.049) (Table 5).
3.8.
Impact of Event Scale
On the Intrusion subscale of the Impact of Event Scale, the mean scores for control group and case group were M S.D. = 13.5 6.2 and M S.D. = 17.2 7.6 ( p = 0.25, F = 1.3), respectively. The mean scores on the Avoidance subscale were M S.D. = 9.6 6.1 for the controls and M S.D. = 11.1 5 for the cases ( p = 0.54, F = .38), without statistically significant differences (Table 5).
3.9.
Barratt Impulsiveness Scale
The two groups obtained statistically significantly different scores on the Barratt Impulsiveness Scale, with the case group scoring higher (M S.D. = 64.46 7.51) than the control group (48.88 5.91), with p = 0.000; F = 24.7 (Table 5). Adjusting for multiple testing with Bonferroni correction the only significant p-level remains p = 0.002 for Barratt Impulsiveness Scale.
3.10.
Toronto Alexithymia Scale
On TAS-20 a statistically significant difference was not reached ( p = 0.124; F = 2.59).
3.11.
Multidimensional Perceived Social Support Scale
No statistically significant differences between the two groups were produced by the MSPSS, although the control group did seem to perceive greater support from family, friends and significant others (Table 5).
3.12.
253
Paykel Life Events Scale
According to this scale, the two groups did not exhibit statistically significant differences in life events occurring during the 6 months prior to the burn trauma (U = 62; p = 0.46) (Table 4).
4.
Discussion
Since extension and severity of injury were similar in the control and case groups, we were able to compare the groups and identify any specific characteristics that differed them. The burn victims in case group were characterized by greater impulsiveness than the ones in control group. We observed a marked statistically significant difference ( p = 0.000) on the Barratt Impulsiveness Scale, with case group subjects appearing to be more impulsive than the ones in control group. Some authors [34] consider impulsiveness to be a predisposition characterized by a tendency to act rapidly, without planning ones actions and without making a rational and/or conscious assessment of the outcome of the act. Higher levels of impulsiveness may predispose case group patients to a greater risk of incurring burn trauma. The presence of temperamental impulsiveness in these latter seems to be further confirmed by the TPQ, particularly the results on subscale NS2 = impulsiveness/reflection. In addition, the presence of alcohol and substance use/abuse revealed by assessment may be connected with higher distress levels related to more depression and anxiety, with repercussions on conduct or actions. Moreover, even if a significant statistical difference was not reached ( p = 0.084), M S.D. lifetime traumatic experiences in case group (Table 4) was higher than the one in control group. This observation may support the hypothesis that the higher the number of symbolic or real traumatic experiences the higher the vulnerability threshold of the subject’s mental balance. Although traumatic events may increase psychopathological vulnerability, these aspects could also be a consequence of impulsive acting out which, in turn, leads to a higher proneness to trauma or other stressful events. But only increasing the sample size, we could be able to confirm this preliminary consideration. Our survey also seems to reveal a relationship between impulsiveness and the proneness of some subjects to burns, but not without various limits. First, the division into two groups is based on the assumption that case group subjects induced the trauma in some way, i.e. there was a ‘‘non random’’ component in trauma causality. However, said ‘‘unconscious’’ component necessarily belongs along a continuum and is subject to the risk of ‘‘false positives –false negatives’’ (the event could be categorized as fortuitous in a subject with slight intentionality or, conversely, an accident could be overestimated). Nevertheless, while the small sample size limits statistical analysis, the results of the study are encouraging, despite being partial or insufficient to explain the complexity of the multifactorial experience of burn patients. The semi-structured diagnostic interview (MINI) revealed the presence of psychiatric diagnoses in our sample.
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In particular, the subjects belonging to case group presented the following clinical diagnoses with frequencies ranging from 50% to 6.7%: lifetime major depression, lifetime alcohol abuse, specific phobia, generalized anxiety disorder, current major depression, current alcohol abuse, current social phobia, dysthymia, current and lifetime panic attack disorder, agoraphobia, current and lifetime substance abuse and current burn injury-related PTSD. These psychopathological characteristics support the data published in the literature [3–7,9,35–38]. The only exception to the characteristic trend of case group was the presence of a diagnosis of lifetime (10%) and current (20%) obsessive-compulsive disorder in control group subjects. Higher levels of state anxiety ( p = 0.014) were revealed on STAI-S in case group subjects. Burn patients in our sample reported using psychopharmacological and psychotherapeutic treatments, probably due to psychological distress existing before the burn event, but we did not find a significant statistical difference between the two groups. These preliminary data need further investigation to better understand the presence of comorbidity in these patients and to detect any differences in the groups considered. In conclusion, adjusting for multiple testing with Bonferroni correction the only significant p-level remains p = 0.002 for Barratt Impulsiveness Scale. Limits of our work are that the level of cognitive functioning has not been evaluated by stating intelligence quotient. In the case group there are three people 65 years old but even if cognitive functioning has not been evaluated, the subjects did not present neurological deficits from clinical personal history. Another limit to our study is the lack of a follow-up through which we could have monitored how patients’ quality of life was affected by the psychopathological and clinical evolution of the burn trauma. While burns may, on the one hand, be totally accidental, or may, on the other hand, be caused deliberately by potentially severe or psychotic subjects (our study excluded psychotic or attempted suicide patients), our study suggests that there is a grey area between the two extremes, in which the two components become blurred. Interest in conducting further investigations in this field for both preventive and therapeutic ends could stem from the fact that some patients may be more distressed or at risk than victims with similar trauma, without this being immediately apparent from the type or severity of the burn. Our results justify further investigation, with potentially important implications in terms of prevention and treatment. The preliminary results we have achieved suggest that information on specific psychological and psychopathological variables could assume predictive value in identifying patients who are more distressed or more at risk. Knowledge of these variables could also be helpful in developing specific, increasingly targeted preventive schemes through which to intervene with burn patients. Rendering the risk egodystonic could, for instance, prove helpful in preventing these patients from meeting with another trauma or repeating the traumatic event that they have already experienced.
Conflict of interest All authors (Chiara Pavan, Giovanna Grasso, Maria Vittoria Costantini, Luigi Pavan, Francesca Masier, Maria Francesca Azzi, Bruno Azzena, Massimo Marini and Vincenzo Vindigni) disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.
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[20] Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59(20):22–33. [21] Sheehan DV, Lecrubrier Y, et al. Mini International Neuropsychiatric Interview (MINI). Tampa (FL) and Paris, France: University of South Florida Institute for Research in Psychiatry and ISERM-Hospital de la Salpetriere; 1994. [22] Rossi A, Massimetti G, Conti L. Il MINI (Mini International Neuropsychiatric Interview), un’intervista diagnostica standardizzata di facile e rapida applicazione. Ital J Psycopatol 1998;4:102. [23] Stein MB, Walker JR, Hazen AL, Forde DR. Full and partial posttraumatic stress disorder: findings from a community survey. Am J Psychiatry 1997;154:1114–9. [24] Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23:56–62. [25] Spielberg CD. State-Trait Anxiety Inventory. A comprehensive bibliography. Palo Alto (CA): Consulting Psychologists Press; 1983. [26] Cloninger CR. The Tridimensional Personality Questionnaire. St Louis (MO): Dept. of Psychiatry, Washington University School of Medicine; 1987. [27] Cloninger CR, Svrakic DM, Przybeck TR. The Tridimensional Personality Questionnaire: US normative data. Psychol Reports 1991;69:1047–57. [28] Horowitz M, Wilner N, Alvarez W. Impact of event scale: a measure of subjective stress. Psychosom Med 1979;41: 209–18.
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available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Accident proneness and impulsiveness in an Italian group of burn patients Chiara Pavan a,*, Giovanna Grasso b, Maria Vittoria Costantini b, Luigi Pavan a, Francesca Masier a, Maria Francesca Azzi a, Bruno Azzena c, Massimo Marini a, Vincenzo Vindigni c a
Unit of Psychiatry, Department of Neuroscience, University of Padova, Italy Department of Development Socialization Psychology, University of Padova, Italy c Unit of Plastic and Reconstructive Surgery, University of Padova, Italy b
article info
abstract
Article history:
There is controversy about the existence of a predisposition to burn incidents (accident
Accepted 7 July 2008
proneness). Our objective was to examine, in a group of burn patients, the conditions or ‘‘unconscious’’ subjective predisposition, the presence of impulsiveness that may have
Keywords:
contributed to bringing about the ‘‘burn’’ event, and to assess the presence of psychiatric
Burns
diagnoses and specific characteristics of temperament.
Psychopathology
25 consecutive burn patients were interviewed by using specific psychometric tests. The
Proneness accident
sample was divided into two groups: ‘‘control’’ group (N = 10), composed of subjects who had
Impulsiveness
accidentally been involved in the incident and ‘‘case’’ group (N = 15) composed of subjects who had very likely and more or less ‘‘knowingly’’ put themselves at risk of injury. We observed a marked statistically significant difference with case group subjects appearing to be more impulsive than the ones in control group. Higher levels of impulsiveness may predispose case group patients to a greater risk of burn. Our survey also seems to reveal a relationship between impulsiveness and the proneness of some subjects to burns. # 2008 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Burns are among the most serious injuries experienced, and their impact on life undermines all sense of time and psychophysical harmony. Burns injure the body’s outer cover, i.e. the skin, which has a pivotal role in holding together the various parts of the body. A little girl once described that the difference between toys and children was that toys got broken but lacked the essential component for recovery: the skin. In other words, the skin prevents us from breaking and allows us to heal. The skin is an
essential part of our makeup: it brings us into contact with the outside world, permitting us to experience the objects around us, while creating a boundary between ourselves and our surroundings [1]. Burns also have physical, social and psychological implications and thus demand a multidisciplinary approach [2]. Burns produce a painful scar that is not only physical but also psychological and can give rise to psychosocial problems, including depression, anxiety, post-traumatic stress disorder (PTSD), personality change, family problems and heavy financial burden [3,4].
* Corresponding author at: Psychiatric Clinic, University of Padova, Via Giustiniani 2, 35122 Padova, Italy. Tel.: +39 049 8213830; fax: +39 049 8218256. E-mail address: [email protected] (C. Pavan). 0305-4179/$36.00 # 2008 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2008.07.002
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The literature reports prevalence rates for psychiatric disorders in burn patients that vary according to sample size, assessment instruments and cut-offs used, and variations in burn severity. Observed rates of major depression in hospital patients surveyed with self-report measures range from 4% to 53%: from 4% to 35% in the first 12 months post discharge and from 7% to 45% at 12 months or more burn [5]. In recent studies, burn patients have been found to present high rates of PTSD (13–45%) [6,7] and between 31% and 50% of patients to suffer from clinically significant levels of anxiety [8]. Several studies designed to identify type and incidence of premorbid psychopathology have shown that many burned patients present with pre-existing dysfunction (psychosis, depression, anxiety, substance abuse, organic brain syndrome and personality traits), making them more likely to incur injury, due to reduced competence, disturbed state of mind, carelessness, active self-harm, recklessness or risk taking [1,9–12]. A study, using Cloninger’s Tridimensional Personality Questionnaire, found passive–aggressive and impulsive personality traits in some burn subjects [12]. There is controversy about the existence of a predisposition to burns but very few validated studies have been conducted in this regard [13]. According to some psychological hypothesis some people have an unconscious tendency to injury [14,15]. Accident proneness is a personality trait present in subjects who have an unconscious tendency to be involved in numerous injuries [16]. Several studies found that trauma victims have a high probability of incurring recurrent injuries. Victims of penetrating and intentional injury in particular have been reported to be injury prone but this tendency has also been observed in non-intentional-trauma casualties [9]. Alcohol and substance abuse are very frequent among trauma victims, suggesting that not all traumatic injuries are random that happen to innocent bystanders. Rather, some trauma victims fall prey to their own impulsive or selfinjurious behaviour [9]. Impulsiveness is ‘‘a tendency to act quickly based on an impulse without reflecting or without paying attention to consequences’’ [17]. It is a key feature of many psychiatric disorders such as personality disorders (in particular antisocial and borderline personality disorders), conduct disorder, mania, substance abuse and impulse control disorders as kleptomania [18,19]. To the best of our knowledge, no study has utilised a specific impulsivity test in burns. The objective of our study was to examine, in a group of burn patients, the presence of impulsiveness that may have contributed to bringing about the ‘‘burn’’ event, and to assess the presence of psychiatric diagnoses and specific characteristics of temperament.
2.
Materials and methods
25 consecutive subjects were recruited from patients attending the burn clinics of the Burn Unit of the Department of Plastic Surgery of Padova University during the period 15 January–20 October, 2007. All the patients accepted the psychiatric evaluation.
2.1.
Inclusion criteria
The inclusion criteria were men and women aged between 18 and 65 years, presenting with third-degree burns >25%, occurring less than 6 months previously (the minimum time after burn was 6 weeks), who agreed to psychiatric assessment, had sufficient fluency in the Italian language and were able to write without feeling pain.
2.2.
Exclusion criteria
Subjects, who had attempted suicide and or had psychotic disorders and/or cognitive impairment, were excluded from the study. Assessment was based on the following parameters: burn site (face, trunk, upper and lower extremities), source of the burn (fire, boiling liquid, corrosive substances) and extension (total body surface area, TBSA). Patients underwent psychiatric assessment by a consultant psychiatrist based on self-report and clinician-administered questionnaires. The following instruments were used for the psychiatric assessment: 1. Case-history interview to collect main historical clinical data and details concerning the traumatic event (date and circumstances of the trauma). To investigate the causes, source, site and extension of the burn, we conducted a survey on the patient’s case history (analysis of clinical charts) and on interviews with attending health professionals (medical and nursing team). The dynamics of the incident were reconstructed through a brief account written by the patient, who was asked to: ‘‘Write about how the injury happened in as much detail as possible’’. 2. Mini-International Neuropsychiatric Interview [20–22] to screen for Axis I psychiatric diagnoses. We used the definition by Stein et al. [23] for the diagnosis of partial PTSD, i.e. the presence of at least one symptom in each of the three clusters without fulfilling the criteria for the full syndrome. We also asked patients whether during their lifetime, apart from the burn, they had been subjected to any of the traumatic experiences indicated on a list drawn up by us (serious road accident, acts of personal violence or aggression, a serious disease or operation affecting them personally or someone close to them, sudden bereavement of a person, separation or break-up of a romantic relationship, problems or serious conflicts with another person, job loss, witness to a violent scene, child abuse, natural disasters and a space to specify any other types of trauma that may have been present). We also specifically asked patients if, in the past, they had seen a primary care physician or a psychiatrist for a psychotropic drug prescription or for psychotherapeutic treatment. 3. Hamilton Rating Scale for Depression (HDRS) [24] to assess the severity of the depression.
burns 35 (2009) 247–255
4. The State-Trait Anxiety Inventory-Y form STAI-Y [25] to assess the presence of state and trait anxiety symptoms. 5. The Tridimensional Personality Questionnaire (TPQ) [26,27] to evaluate temperament. 6. Impact of Event Scale (IES) [28] to measure the impact of the burn on the patient’s life. 7. Toronto Alexithymia Scale (TAS-20) [29] to detect the presence of alexithymic characteristics through three factors: difficulty in distinguishing between feelings and bodily sensations (Factor 1), difficulty in describing feelings (Factor 2), and externally oriented thinking (Factor 3). This scale provides a total alexithymia score and three partial scores related to the above factors. 8. Barratt Impulsiveness Scale (BIS) [30,31] is based on a unidimensional model of impulsiveness which included it as a part of a larger groups of personality predispositions such as extraversion, sensation seeking and a lack of inhibitory behavioural controls. 9. Multidimensional Scale of Perceived Social Support (MSPSS) [32]. The MSPSS provides assessment of three sources of support: family, friends and significant other. 10. Paykel Life Events Scale [33] to assess events occurring in the 6 months prior to the burn.
2.3.
Description of sample
The test sample (N = 25) was divided into two groups: ‘‘control’’ group (N = 10), composed of subjects who had accidentally been involved in the incident (if they had not been present in that place at that precise time, they would not have been involved in the incident, i.e. they were not directly implicated) and ‘‘case’’ group (N = 15) composed of subjects who had very likely and more or less ‘‘knowingly’’ put themselves in a position to get injured.
2.4.
249
Clinical case assigned to control group. ‘‘I was in the kitchen making lunch with my sister. My sister was draining the pasta when suddenly the pan handle broke off. I was chopping some vegetables and the boiling water came pouring over my stomach and legs. I didn’t have time to realize what was happening. I felt a lot of pain and began shouting.’’ Clinical case assigned to case group. ‘‘I had a case full of chickens to pluck and then cook for Easter Sunday lunch. To quicken things up, I decided to remove the feathers by burning them with alcohol. I got a basin, filled it with alcohol, dipped the chickens in it and set them on fire with a lighter. There was an immediate flashback which hit my face, breasts and hands. I was terrified because my 10-month-old baby was on her highchair behind me. Fortunately I was the only one hit by the flames.’’ The two groups were then compared on the basis of sociodemographic and clinical variables.
2.5.
Statistical analysis
The sample was illustrated using descriptive statistics. The two groups were compared by the x2-test with Fisher’s correction for categorical variables and by Student’s t-test for linear variables. When the variables did not exhibit a linear trend with the Kolmogorov–Smirnov test, we used the Mann– Whitney test. We also used Bonferroni correction. Data were processed using SPSS statistics package 15. We assessed interrater reliability to determine agreement among the raters on the assignment of patients to the case or control groups using Kappa Cohen coefficient.
3.
Results
3.1.
Interrater reliability
Study design
The method for selecting control group and case group was based on independent assessment by three raters (a psychoanalyst, a psychiatrist who was blind to the clinical interview and test package administration and a clinical psychologist) who assigned the patients to the two groups according to preset assessment parameters. Where two out of three or three out of three raters were in agreement, their ‘‘judgement’’ determined assignment to control group or case group. Each rater read all the patients’ written accounts before addressing the patients to control group or to case group. The raters based their decisions on the following assessment parameters: (1) A brief ‘‘written’’ account of the dynamics of the incident provided by the patient during the interview with the consultant psychiatrist. (2) The causal factor, i.e. any materials and instruments directly handled (controlled or altered) by the subject that may imply ‘‘direct causality in the event’’. Positive elements from both above-mentioned factors (1) and (2) had to be present for a patient to be assigned to case group. Below are two examples of patients’ written accounts to show how they were assigned to control group or case group.
The three raters assigned patients to control group or case group according to the criteria described in Section 2, with an index of agreement ranging from a maximum of k = 0.81 ( p = 0.000) between rater 1 (psychoanalyst) and rater 2 (psychiatrist) and a minimum of k = 0.56 ( p = 0.01) between rater 2 (psychiatrist) and rater 3 (psychologist), with interrater disagreement ranging from a minimum of two cases to a maximum of five cases.
3.2.
Sociodemographic characteristics
The total sample (N = 25) was composed of 13 men and 12 women. Control group (N = 10) consisted of 60% males (N = 6) and case group 2 (N = 15) of 40% males (N = 6) (x2-test with Fisher correction = 0.92, p = 0.28). The mean age S.D. of control group 1 (N = 10) was 37.9 5.8 years and of case group (N = 15) was 43.6 16.6 years (F = 1.096, p = 0.306). Concerning marital status, 70% (N = 7) of the control group were married compared to 73.3% (N = 11) of case group. No members of control group and two members (13.3%) of case group were widowed. Twenty percent (N = 2) of the control group had never been married compared to 13.3% of the case group. Only one member of control group and no members of case group were cohabiting.
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Table 1 – Sociodemographic characteristics. Control group (N = 10), N (%)
Case group (N = 15), N (%)
Test, x2 a
6 (60)
6 (40)
0.92
0.28
Control group (N = 10), M S.D.
Case group (N = 15), M S.D.
Test
p
37.9 5.85 11 3.4
43.66 16.64 10.2 3.6
tb = 1.09 tb = 0.24
Gender (male)
Age (years) School years
Control group (N = 10), N (%)
Case group (N = 15), N (%)
p
0.306 0.62
Test, x2 a
p
Marital status Married Widowed Never married Cohabiting
7 0 2 1
(70) (0) (20) (10)
11 2 2 0
(73.3) (13.3) (13.3) (0)
3.009
0.550
Profession Office worker Freelance professional Housewife Retired
7 2 1 0
(70) (20) (10) (0)
9 2 2 2
(60) (13.3) (13.3) (13.3)
1.64
0.769
a b
Statistics corrected by Fisher’s test. Student’s t-test.
No macro differences in gender, age, marital status, educational level, and occupation were observed between the two groups (Table 1).
3.3. Source of the burn (fire, boiling liquid, corrosive substances), site and total burn surface area The burn site (control group vs. case group) was constituted by the face (40% vs. 60%), trunk (41.7% vs. 58.3%), upper extremities (60% vs. 40%) and lower extremities (37.5% vs. 62.5%). These differences were not statistically significant (Table 2). Of the control group, 70% (N = 7) had been burned by fire, 30% (N = 3) by boiling liquid; 80% (N = 12) of case group had been burnt by fire and 20% (N = 3) by boiling liquid. No member of either group had been injured by corrosive substances.
The total burn surface area in control group was 33.5% compared to 36.7% in case group. There were no statistically significant differences between the groups in terms of burn site, source of burn and TBSA (Table 2). Considering the time after burn at the moment of psychiatric evaluation, control group vs. case group has 11.4 3.9 vs. 12.2 4.0 weeks (t = 0.2, p = 0.60).
3.4.
Mini-International Neuropsychiatric Interview (MINI)
The MINI revealed the presence of psychiatric diagnoses in our sample but the comparison of the two groups did not find statistically significant differences (Table 3). The most representative psychiatric diagnoses in the case group were lifetime major depression (50%), lifetime alcohol abuse (33%), current specific phobia (26.7%), current (26.7%,
Table 2 – Source (fire, boiling liquid, corrosive substances), site and extension (TBSA) of the burn. Control group (N = 10), N (%) Source of the burn Fire Boiling liquid Corrosive substances
7 (70) 3 (30) 0 (0)
Localizzazione Face Torso Upper extremities Lower extremities
6 5 3 3
Total burn surface area (TBSA) a b
Statistics corrected by Fisher’s test. Student’s t-test.
(40) (41.7) (60) (37.5)
Case group (N = 15), N (%)
Test, x2 a
p
0.32 0.32
0.65 0.65
0.000 0.027 1.042 0.031
1.0 1.0 0.615 1.0
12 (80) 3 (20) 0 (0)
9 7 2 5
(60) (58.3) (40) (62.5)
Control group (N = 10), %M S.D.
Case group (N = 15), %M S.D.
Test, tb
33.5 21.6
36.7 11.6
0.07
p 0.80
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Table 3 – Percentage distribution by groups on the Mini-International Neuropsychiatric Interview (MINI). Control group (N = 10), N (% positive) Major depression, current Major depression, lifetime Dysthymia Panic disorder, current Panic disorder, lifetime Agoraphobia Social phobia, current Specific phobia, current Generalized anxiety disorder Alcohol abuse, current Alcohol abuse, lifetime Nonalcohol substance abuse, current Nonalcohol substance abuse, lifetime Obsessive-compulsive disorder, current Obsessive-compulsive disorder, lifetime Post-traumatic stress disorder, current Post-traumatic stress disorder, lifetime a
0 4 0 0 0 0 0 1 0 0 2 0 1 2 1 2 0
Case group (N = 15), N (% positive)
(0) (40) (0) (0) (0) (0) (0) (10) (0) (0) (20) (0) (10) (20) (10) (20) (0)
2 7 1 1 1 1 2 4 3 2 5 1 1 0 0 4 1
d.f.
x2 a
p
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 3
1.55 0.235 0.745 0.694 0.694 0.694 1.44 1.04 2.27 1.44 0.529 0.694 0.091 3.26 1.56 0.955 0.955
0.49 0.69 1.0 1.0 1.0 1.0 0.5 0.61 0.25 0.5 0.65 1.0 1.0 0.15 0.4 0.81 0.87
(14.1) (50) (6.7) (6.7) (6.7) (6.7) (13.3) (26.7) (20) (13.3) (33.3) (6.7) (6.7) (0) (0) (26.7) (6.7)
Statistics corrected by Fisher’s test.
one subject consequent to the burn) and lifetime (6.7%) PTSD, and generalized anxiety (20%). In control group there was a prevalence of psychiatric diagnoses of current (20%) and lifetime (10%) obsessive-compulsive disorder (Table 3). The symptoms characterizing the PTSD were intrusive in 40% of the members of control group compared to 60% of those in case group (x2 = 0 with Fisher’s correction; d.f. = 1; p = 1). Avoidance symptoms were present in 40% of control group vs. 60% of case group 2 (x2 = 0 with Fisher’s correction; d.f. = 1; p = 1) and symptoms of hyperarousal were observed at frequencies of 33.3% for control group and 66.7% for case group (x2 = 0.260 with Fisher’s correction; d.f. = 1; p = 0.691). Hence there were no statistically significant differences between the groups (Table 4).
About having lifetime traumatic experiences, a statistically significant difference was not reached ( p = 0.084; F = 3.44) (Table 4). None of the controls compared to 6.7% of case group subjects undergoing lifetime psychotherapy and 10% vs. 13.3%, respectively, had taken psychotropic drugs, but without significant difference (d.f. = 1, x2 = 0.626, p = 1).
3.5.
Hamilton Depression Rating Scale
On HDRS the differences between the two groups were not significant (Table 5). Scores below 8 are considered normal, those between 8 and 15 indicate mild, between 16 and 24 moderate and over 25 serious symptoms [32].
Table 4 – Post-traumatic stress disorder (PTSD), lifetime traumatic experiences, Paykel scale. Control group (N = 10), N (% positive) Current PTSD Lifetime PTSD Partial PTSD Presence of intrusive post-traumatic symptoms Presence of post-traumatic symptoms of avoidance Presence of post-traumatic symptoms of hyperarousal
4 1 1 9
(26.7) (6.7) (6.7) (60)
x2 a
3 3 3 1
1.237 1.237 1.237 0.000
1 1 1 1
p
6 (40)
9 (60)
1
0.000
1
7 (43.8)
9 (56.3)
1
0.260
0.691
Case group (N = 15), M S.D.
Ub
p
2.10 1.59 (mean rank 11.70)
3.07 2.40 (mean rank 13.87)
62
0.46
Lifetime traumatic experiences
b
(20) (0) (10) (40)
d.f.
Control group (N = 10), M S.D. Paykel Life Events Scale
a
2 0 1 6
Case group (N = 15), N (% positive)
Statistics corrected by Fisher’s test. Mann–Whitney test.
Control group (N = 10), M S.D.
Case group (N = 15), M S.D.
F
10.85 6.09
16.77 6.49
3.44
p 0.084
252
Table 5 – Groups matched by clinical rating scales. Measure
Case group (N = 15), mean S.D.
F
p
p Bonferroni multiple testing correction
3.8 3.73 30 8.19 31 7.11 11.75 7.28
4.6 5.18 41.54 10.12 38.67 9.43 16.08 5.29
0.17 7.36 3.44 2.48
0.679 0.014 0.081 0.131
0.99 0.70 0.99 0.65
12.88 5.35 22.38 6.30 47 16.25 27.13 2.47 23.88 8.18 25.5 8.05 76.5 10.69 48.88 5.91 13.5 6.2 9.6 6.1 3.5 1.92 1.37 1.18 3.5 0.92 3.12 0.99 4.37 1.06 3.5 0.92 3 1.41 2.37 1.18 3 1.30 6 0.92 8.12 2.41 4.37 1.18 11.5 2.77 13.25 2.91 21.5 3.92
16.38 3.59 22.7 4.32 56 9.53 22.46 7.94 22.62 7.37 21.92 6.68 67 21.26 64.46 7.51 17.2 7.6 11.1 5.0 3.61 2.21 3.30 1.79 3.92 1.18 3.76 1.96 3.69 2.46 4.38 1.55 3.92 1.93 3.23 2.31 3.46 1.26 5.15 2.11 6.23 2.83 3.15 1.34 14.61 6.14 15.23 5.89 18 3.97
3.25 0.02 2.59 2.55 0.13 1.21 1.36 24.7 1.3 0.38 0.01 7.22 0.73 0.73 0.54 2.09 1.36 0.92 0.64 1.12 2.46 4.44 1.80 0.77 3.86
0.087 0.866 0.124 0.126 0.719 0.284 0.257 0.000 0.25 0.54 0.905 0.015 0.402 0.402 0.470 0.164 0.258 0.347 0.433 0.301 0.133 0.049 0.195 0.389 0.064
0.99 0.99 0.60 0.63 0.99 0.99 0.99 0.002 0.99 0.99 0.99 0.75 0.99 0.99 0.99 0.80 0.99 0.99 0.99 0.99 0.65 0.99 0.95 0.99 0.99
burns 35 (2009) 247–255
HDRS—Hamilton Depression Rating Scale STAI—State-Trait Anxiety Inventory-State STAI—State-Trait Anxiety Inventory-Trait TAS-20-f1—Toronto Alexithymia Scale, factor 1: difficulty identifying feelings and distinguishing them from the somatic sensations that accompany emotional arousal TAS-20-f2—Toronto Alexithymia Scale, factor 2: difficulty communicating feelings to other people TAS-20-f3—Toronto Alexithymia Scale, factor 3: externally oriented thinking TAS-20-total score—Toronto Alexithymia Scale-total score MSPSS-f1—Multidimensional Scale of Perceived Social Support, factor 1: friends MSPSS-f2—Multidimensional Scale of Perceived Social Support, factor 2: family MSPSS-f3—Multidimensional Scale of Perceived Social Support, factor 3: significant others MSPSS-total score—Multidimensional Scale of Perceived Social Support-total score BIS—Barratt Impulsiveness Scale IES—Impact Event Scale-Intrusion IES—Impact Event Scale-Avoidance TPQ-NS1—Tridimensional Personality Questionnaire. NS1 = exploratory excitability vs. stoic rigidity TPQ-NS2—Tridimensional Personality Questionnaire. NS2 = impulsiveness vs. reflection TPQ-NS3—Tridimensional Personality Questionnaire. NS3 = extravagance vs. regimentation TPQ-NS4—Tridimensional Personality Questionnaire. NS4 = disorderliness vs. regimentation TPQ-HA1—Tridimensional Personality Questionnaire. HA1 = anticipatory worry vs. uninhibited optimism TPQ-HA2—Tridimensional Personality Questionnaire. HA2 = fear of uncertainty vs. confidence TPQ-HA3—Tridimensional Personality Questionnaire. HA3 = shyness with strangers vs. gregariousness TPQ-HA4—Tridimensional Personality Questionnaire. HA4 = fatigability and asthenia vs. vigour TPQ-RD1—Tridimensional Personality Questionnaire. RD1 = sentimentality vs. insensitiveness TPQ-RD2—Tridimensional Personality Questionnaire. RD2 = persistence vs. irresoluteness TPQ-RD3—Tridimensional Personality Questionnaire. RD3 = attachment vs. detachment TPQ-RD4—Tridimensional Personality Questionnaire. RD4 = dependence vs. independence TPQ-NS total scale—Tridimensional Personality Questionnaire. NS total scale = Novelty Seeking TPQ-HA total scale—Tridimensional Personality Questionnaire. HA total scale = Harm Avoidance TPQ-RD total scale—Tridimensional Personality Questionnaire. RD total scale = Reward Dependence
Control group (N = 10), mean S.D.
burns 35 (2009) 247–255
Two subjects in control group and three subjects in case group exceeded the clinical threshold for depressive pathology, i.e. the HDRS cut-off score of >8. The number of subjects over threshold was 20% per group (x2 = 0.00; p = 1).
3.6.
State-Trait Anxiety Inventory (STAI S–T)
Results suggested a prevalence of state anxiety in case group (M S.D. = 41.54 10.12) compared to control group (30 8.19) ( p = 0.014, F = 7.36). Trait anxiety also appeared to prevail in case group (M S.D. = 38.67 9.43) compared to control group (31 7.11) ( p = 0.081, F = 3.44) but without reaching statistical significance (Table 5).
3.7.
Tridimensional Personality Questionnaire
Comparison of the Tridimensional Personality Questionnaire results revealed statistically significant differences for the subscale Novelty seeking—NS2 (impulsiveness vs. reflection), with case group scoring higher ( p = 0.015; F = 7.22) and a light trend towards significance for the Reward Dependence (RD) scale, with control group scoring higher ( p = 0.064; F = 3.86). On the NS2 subscale in particular (novelty seeking— impulsiveness/reflection), the mean scores for case group (M S.D. = 3.30 1.79) were more than double the scores achieved by control group (M S.D. = 1.37 1.18) with F = 7.22 and p = 0.015. Control group had higher scores than case group on subscale RD4 (dependence/independence) (F = 4.44; p = 0.049) (Table 5).
3.8.
Impact of Event Scale
On the Intrusion subscale of the Impact of Event Scale, the mean scores for control group and case group were M S.D. = 13.5 6.2 and M S.D. = 17.2 7.6 ( p = 0.25, F = 1.3), respectively. The mean scores on the Avoidance subscale were M S.D. = 9.6 6.1 for the controls and M S.D. = 11.1 5 for the cases ( p = 0.54, F = .38), without statistically significant differences (Table 5).
3.9.
Barratt Impulsiveness Scale
The two groups obtained statistically significantly different scores on the Barratt Impulsiveness Scale, with the case group scoring higher (M S.D. = 64.46 7.51) than the control group (48.88 5.91), with p = 0.000; F = 24.7 (Table 5). Adjusting for multiple testing with Bonferroni correction the only significant p-level remains p = 0.002 for Barratt Impulsiveness Scale.
3.10.
Toronto Alexithymia Scale
On TAS-20 a statistically significant difference was not reached ( p = 0.124; F = 2.59).
3.11.
Multidimensional Perceived Social Support Scale
No statistically significant differences between the two groups were produced by the MSPSS, although the control group did seem to perceive greater support from family, friends and significant others (Table 5).
3.12.
253
Paykel Life Events Scale
According to this scale, the two groups did not exhibit statistically significant differences in life events occurring during the 6 months prior to the burn trauma (U = 62; p = 0.46) (Table 4).
4.
Discussion
Since extension and severity of injury were similar in the control and case groups, we were able to compare the groups and identify any specific characteristics that differed them. The burn victims in case group were characterized by greater impulsiveness than the ones in control group. We observed a marked statistically significant difference ( p = 0.000) on the Barratt Impulsiveness Scale, with case group subjects appearing to be more impulsive than the ones in control group. Some authors [34] consider impulsiveness to be a predisposition characterized by a tendency to act rapidly, without planning ones actions and without making a rational and/or conscious assessment of the outcome of the act. Higher levels of impulsiveness may predispose case group patients to a greater risk of incurring burn trauma. The presence of temperamental impulsiveness in these latter seems to be further confirmed by the TPQ, particularly the results on subscale NS2 = impulsiveness/reflection. In addition, the presence of alcohol and substance use/abuse revealed by assessment may be connected with higher distress levels related to more depression and anxiety, with repercussions on conduct or actions. Moreover, even if a significant statistical difference was not reached ( p = 0.084), M S.D. lifetime traumatic experiences in case group (Table 4) was higher than the one in control group. This observation may support the hypothesis that the higher the number of symbolic or real traumatic experiences the higher the vulnerability threshold of the subject’s mental balance. Although traumatic events may increase psychopathological vulnerability, these aspects could also be a consequence of impulsive acting out which, in turn, leads to a higher proneness to trauma or other stressful events. But only increasing the sample size, we could be able to confirm this preliminary consideration. Our survey also seems to reveal a relationship between impulsiveness and the proneness of some subjects to burns, but not without various limits. First, the division into two groups is based on the assumption that case group subjects induced the trauma in some way, i.e. there was a ‘‘non random’’ component in trauma causality. However, said ‘‘unconscious’’ component necessarily belongs along a continuum and is subject to the risk of ‘‘false positives –false negatives’’ (the event could be categorized as fortuitous in a subject with slight intentionality or, conversely, an accident could be overestimated). Nevertheless, while the small sample size limits statistical analysis, the results of the study are encouraging, despite being partial or insufficient to explain the complexity of the multifactorial experience of burn patients. The semi-structured diagnostic interview (MINI) revealed the presence of psychiatric diagnoses in our sample.
254
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In particular, the subjects belonging to case group presented the following clinical diagnoses with frequencies ranging from 50% to 6.7%: lifetime major depression, lifetime alcohol abuse, specific phobia, generalized anxiety disorder, current major depression, current alcohol abuse, current social phobia, dysthymia, current and lifetime panic attack disorder, agoraphobia, current and lifetime substance abuse and current burn injury-related PTSD. These psychopathological characteristics support the data published in the literature [3–7,9,35–38]. The only exception to the characteristic trend of case group was the presence of a diagnosis of lifetime (10%) and current (20%) obsessive-compulsive disorder in control group subjects. Higher levels of state anxiety ( p = 0.014) were revealed on STAI-S in case group subjects. Burn patients in our sample reported using psychopharmacological and psychotherapeutic treatments, probably due to psychological distress existing before the burn event, but we did not find a significant statistical difference between the two groups. These preliminary data need further investigation to better understand the presence of comorbidity in these patients and to detect any differences in the groups considered. In conclusion, adjusting for multiple testing with Bonferroni correction the only significant p-level remains p = 0.002 for Barratt Impulsiveness Scale. Limits of our work are that the level of cognitive functioning has not been evaluated by stating intelligence quotient. In the case group there are three people 65 years old but even if cognitive functioning has not been evaluated, the subjects did not present neurological deficits from clinical personal history. Another limit to our study is the lack of a follow-up through which we could have monitored how patients’ quality of life was affected by the psychopathological and clinical evolution of the burn trauma. While burns may, on the one hand, be totally accidental, or may, on the other hand, be caused deliberately by potentially severe or psychotic subjects (our study excluded psychotic or attempted suicide patients), our study suggests that there is a grey area between the two extremes, in which the two components become blurred. Interest in conducting further investigations in this field for both preventive and therapeutic ends could stem from the fact that some patients may be more distressed or at risk than victims with similar trauma, without this being immediately apparent from the type or severity of the burn. Our results justify further investigation, with potentially important implications in terms of prevention and treatment. The preliminary results we have achieved suggest that information on specific psychological and psychopathological variables could assume predictive value in identifying patients who are more distressed or more at risk. Knowledge of these variables could also be helpful in developing specific, increasingly targeted preventive schemes through which to intervene with burn patients. Rendering the risk egodystonic could, for instance, prove helpful in preventing these patients from meeting with another trauma or repeating the traumatic event that they have already experienced.
Conflict of interest All authors (Chiara Pavan, Giovanna Grasso, Maria Vittoria Costantini, Luigi Pavan, Francesca Masier, Maria Francesca Azzi, Bruno Azzena, Massimo Marini and Vincenzo Vindigni) disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.
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