Intentional Self-inflicted Burn Injuries: Review of the Literature

Author’s Accepted Manuscript Intentional Self-inflicted Burn Injuries: Review of the Literature Mladen Nisavic, Shamim Nejad, Scott Beach

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To appear in: Psychosomatics Cite this article as: Mladen Nisavic, Shamim Nejad and Scott Beach, Intentional Self-inflicted Burn Injuries: Review of the Literature, Psychosomatics, http://dx.doi.org/10.1016/j.psym.2017.06.001 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Intentional Self-inflicted Burn Injuries: Review of the Literature Mladen Nisavic MD, Shamim Nejad MD, Scott Beach MD Dr. Nisavic, Dr. Beach: Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA Dr. Nejad: Division of Psycho-Oncology; Swedish Cancer Institute, Swedish Medical Center, Seattle, WA

Keywords: self-immolation, self-inflicted burns Reprint Requests and Correspondence: Mladen Nisavic, MD Massachusetts General Hospital 55 Fruit St, Warren 605 Boston, MA 02114 617-726-2000 The authors do not have any financial support or conflicts of interest to disclose. Abstract: Introduction: Intentional self-inflicted burn injuries are a rare occurrence in the United States, but represent a considerable portion of all burn injuries in the developing world. Compared to non-intentional burns, patients with intentional self-inflicted burns have increased rates of higher total body surface area (TBSA) involvement and associated complications, including overall mortality.

Methods: We present two representative cases and review the available literature on the topic of self-inflicted burns. We review epidemiologic, social and cultural factors of importance, and also provide an overview of most common psychiatric pathologies encountered in patients with self-inflicted burns.

Results and Conclusion: The patient demographics and motivation for intentional selfinflicted burn injuries differs considerably across the world. While self-immolation is commonly associated with women experiencing domestic stress in the developing world, most cases of self-immolation in higher-income countries are male. Psychiatric pathology, including primary mood and thought disorders, and substance use play a significant component in latter cases, while most patients in the developing world lack any pre-morbid psychiatric diagnosis, or carry diagnosis of adjustment disorder. Nonlethal self-burns present a distinct subset of intentional self-burn injuries, often occurring in the context of significant personality pathology, or with potential secondary gain.

Case 1: Mr. A., a 24-year-old white male sat down in the middle of a busy town square on a weekend afternoon, poured gasoline over his head and lit himself on fire. Bystanders rushed to his aid and extinguished the flames, but he was left with burns encompassing 80% total body surface area (TBSA). Eighteen months earlier, the patient graduated from college, moved back home and pursued a teaching job. His parents noted a change in his demeanor that included increasing social isolation, heightened preoccupation with religion, and several unexplained disappearances (including one instance in which he went missing for a week before calling his parents from a city 300 miles away stating that he was living on the street). His parents had taken him to a psychiatrist six months prior to his self-immolation. The psychiatrist diagnosed him with an autism spectrum disorder and suspected schizotypal personality disorder or a prodromal psychotic disorder, but was

unable to convince the patient to take medication. Three days prior to the selfimmolation, the patient moved into his own apartment for the first time. Following his injuries, the patient was admitted to the burn intensive care unit. As his sedation was weaned over several months, he was maintained on intravenous haloperidol due to persistent agitated delirium affecting daily medical care and mechanical ventilation weaning. Upon lifting of sedation and mechanical ventilation weaning, he recalled the incident with clarity. He noted that he had been hearing the voice of a “prophet” for 152 days prior to his act of self-immolation and that the voice had told him that he needed to burn himself as part of God’s mission. The patient now believed that the voice had been a “false prophet,” and though he continued to believe that God had chosen him for a mission, he no longer reported hearing voices, expressed remorse at his actions, and stated that he wished he had not been “chosen.” He was transitioned to oral risperidone and eventually to risperidone long-acting injectable medication for ongoing symptoms of psychosis and (after five months in the hospital) transferred to an acute rehabilitation facility.

Case 2: Miss C., a 19-year-old female, heated a rubber pad in the microwave for several minutes and lay down on the pad. She was found by her father, who noted burns on her back and called 911. After emergency medical technicians (EMT’s) arrived, the patient continued to attempt to lie on the mat despite the warning by the EMT’s. She was taken to the hospital where she was found to have suffered 12% TBSA second-degree burns. Although her burns were not significant enough to require admission to the burn unit, she

was felt to be unsafe for discharge from a psychiatric perspective and because there were no psychiatric beds available, she was admitted to the burn service with plans for transfer pending psychiatric bed availability. The patient was known to the burn service from prior admissions following similar behavior. She had previously been diagnosed with bipolar disorder, borderline personality disorder, and an eating disorder. During her fiveday admission to the burn service, she adamantly denied that the self-inflicted burns had been intentional and repeatedly stated that she had used the mat in order to obtain relief from nausea. She experienced significant behavioral dysregulation on the burn unit, interfering with her burn care, removing her dressings and adopting a demanding and disruptive attitude with staff. She was ultimately transferred to the psychiatry unit on an involuntary commitment once a bed became available. She appeared to improve with the enhanced structure of the psychiatry unit and ultimately agreed to starting antidepressant medication for an underlying diagnosis of major depressive disorder. She was discharged after ten days with psychiatric follow-up. She subsequently had two admissions over the next six months with similar presentations.

Introduction: Burn injuries are the fourth most common type of trauma worldwide – following motor vehicle accidents, falls and inter-personal violence – with an estimate of 11 million people requiring medical attention annually.1,2 Upwards of 90% of all burn injuries are reported in low-to-middle income countries, and severe burn-related injuries are 10-20 times more common in poorer regions of the world compared to the United States (US).1,2 This is often attributed to limitations in existing infrastructure (e.g., lack of proper enclosure for open fires, unstable appliances), cultural factors (e.g. loose and flammable clothing), and limited educational efforts. Intentional self-burn injuries are an important subset of all flame-related trauma. Clinical experience finds that there are two distinct patient groups as pertains to intentional self-inflicted burn injuries, though this distinction is only occasionally made in the literature: 

Self-immolation describes the act of intentionally lighting oneself on fire or immersing oneself in flames, commonly with strong suicidal intent.



Self-inflicted burns (SIB) refer to the use of chemicals or the application of heated objects to the skin, typically in a para-suicidal gesture (e.g., to attract attention, inflict pain or disfigure oneself). Acts of SIB are not dissimilar from other examples of non-suicidal self-injurious behavior (e.g., cutting), and patients commonly lack any significant suicidal intent.

While important, this distinction is commonly blurred in the existing literature, as patient’s motives to pursue intentional self-burn injuries are not always readily apparent or recorded. Furthermore, while many acts of intentional self-burn injuries may begin as

parasuicidal gestures, they may nonetheless ultimately result in significant morbidity or loss of life. There is considerable variation in the global distribution of intentional self-burn injuries. While relatively uncommon in the US and Europe, typically accounting for as little as 1-6% of all burn unit admissions, intentional self-burn injuries are considerably more prevalent in developing countries where they may account for as many as 25-30% of all burn unit admissions .3-7 Despite relatively low incidence, intentional self-burn injuries account for considerable morbidity and mortality. Multiple studies indicate that intentional self-burn injuries are associated with higher total body surface area (TBSA) involvement, higher incidence of full-thickness burns, higher rates of inhalation injuries, and higher overall mortality rates.8-11 In the US, patients with intentional self-burn injuries have higher rates of inhalation injury (12% vs. 6%), higher average TBSA involvement (22% vs. 11%), longer hospital stays, and increased mortality (13.9% vs. 2.5%).8,12 Other more econically developed countries (MEDCs), including Europe and Australia, report similar findings as to high morbidity burden and a 10-20% mortality rate.13 When matched to nonintentional burn cases of comparable severity, no significant differences in mortality rates are observed between intentional self-burns and non-intentional injuries, indicating that worse outcomes of patients with self-inflicted burn injuries is primarily related to the severity of injury burden rather than other variables.10 In developing countries, mortality ascribed to intentional self-burn injuries is considerably higher – upwards of 80% in one study based in Iran – and it is speculated this number reflects not only increased severity, but also the shame linked with self-

immolation, as well as the lack of access to necessary public infrastructure and healthcare resources.14 The dramatic spectacle of intentional self-burn injuries and the resulting protracted hospitalization often marked by complications, commonly engender questions as to the presence of psychiatric illness as a potential contributor. Often, psychiatric consultation is requested to evaluate for underlying pathology and to assist the surgical team with management of any potential psychiatric and substance use issues at hand. For the psychiatric consultant, self-inflicted burn injuries may present a considerable challenge, not only as they often provoke a complex emotional response in those unaccustomed to seeing the sequelae of severe burns injuries, but also as they require considerable familiarity with intensive care medicine and trauma surgery. This article attempts to provide a brief review of the topic, geared specifically towards the consultation psychiatrist. The available literature on intentional self-burn injuries is generally limited and primarily comprised of retrospective studies and case reports. Most prior reviews on the subject have been published within specialized surgical literature, and thus may not be readily accessible to most psychiatric consultants. With this article, we attempt to provide a concise review of literature on the topic of intentional self-burn injuries, including cultural and historical precedents for selfimmolation and SIB, risk factors (including demographic, medical and psychiatric contributors) associated with intentional self-burn injuries, and a discussion of challenges encountered by clinicians taking care of these often-complex cases. Furthermore, our review attempts to categorize self-inflicted burn injuries not only by basic demographic factors (a practice common by most studies to date), but also by patient’s intent (e.g.,

lethal vs. non-lethal self-inflicted burns). We provide relevant updates to the literature over the past five years, including the phenomena of aerosol burns and internetassociated self-inflicted burns. Lastly, we present a summary of psychiatric factors associated with self-inflicted burns, and provide clinical guidance and management advice to psychiatrists encountering self-immolation in the hospital setting.

Methods

We conducted a review of articles on the topic of self-immolation using the PubMed database and search terms “self-immolation” and “self-inflicted burn”. Abstracts were reviewed for pertinence to the topic, and we included a wide variety of article types, including case reports, retrospective studies, and reviews. No date range was employed in our search, though preference was given to more recent publications. As the available literature consists primarily of case reports and retrospective studies describing prevalence and demographic factors in a variety of geographic locales, we chose not to pursue a systematic review, but rather focus on key publications in the field.

Self-Immolation Compared to other means, self-immolation is an uncommon method of attempting suicide. In one study of burn patients in the US, self-immolation accounted for 157 completed suicides, compared to 6,358 suicides by poisoning and 17,352 suicides by firearms.15 While the data from developing countries is often challenging to interpret given lack of organization and transparency, it indicates that self-immolation may

account for higher percent of suicide attempts and completed suicides. In Iran, up to 10% of all suicide attempts and 25-71% of all completed suicides are due to self-immolation.14 Other studies estimate that up to 40% of all completed suicides in South East Asia, the Middle East, and Africa are associated with flame-related injuries.16 Interestingly, there is some evidence to suggest that these patterns may persist with emigration. Studies in England and Australia have indicated increased rates of suicide by self-immolation in parts of the country with high south-east Asian immigrant population .17,18

Practice of Self-immolation in History and Popular Culture Examples of self-immolation can be found throughout history and within many diverse societies. These acts are often embedded within a culture’s mythos or religious practices, and are commonly perceived as gestures of ultimate sacrifice. Examples of self-immolation are less common in the Western culture and religion, though a few examples exist. In a Greek myth about Heracles, the demi-god son of Zeus and Alcmene, he builds a funeral pyre for himself after his wife poisons him, thus banishing his mortal self and allowing his immortal being to ascend to Mount Olympus.19 Eastern cultural practices offer additional accounts of self-immolation. In Hindu mythology Sati, the goddess of marital felicity and longevity, willingly walks into a sacrificial fire as a protest against her father Daksha’s humiliation and dishonoring of her husband Shiva. Associated with this legend is the ritual of Sati, a form of self-immolation involving widows throwing themselves onto the funeral pyres of their deceased husbands. The word “Sati” can be interpreted as “good woman”, and historians believe this practice has existed in the Indian sub-continent since the 14th century. Despite being officially

banned by the British in 1829, the practice continues even today in the poor rural areas of the country where it is believed to redeem the wrongdoings of ancestors and allow the husband to enjoy the afterlife.19 Over the past century, self-immolation has also been employed as act of political protest. In 1963, Vietnamese monk Thích Quảng Đức publically set himself on fire in Saigon in protest of religious persecution of Buddhists by the US-backed political regime. His sacrifice garnered considerable media attention, and inspired many subsequent acts of politically motivated self-immolation in the region, commonly in protest of the Chinese government’s treatment of the Buddhist population of Tibet. Similar acts have since been described in USand Europe: in 1965, two anti-war activists set themselves on fire to protest the Vietnam War, while in 1968 Jan Palach committed suicide by self-immolation as a political protest against the end of the Prague Spring. Various examples also exist of self-immolation as suicide epidemic, often initiating from political motivations. The largest of these occurred in the late 1970’s and is thought to have started with the self-immolation of seven members of the Progressive Utilization Theory (PROUT), a religious sect that developed out of conflict with Indira Gandhi’s leadership in India. In 1978, Lynette Phillips, an Australian heiress and member of PROUT, made headlines when she attempted to immolate herself in Parliament Square. Her attempt was aborted, but she later successfully committed suicide by selfimmolation in Geneva. Following her death, 82 people in England and Wales died by self-immolation between October 1978 and October 1979, in an epidemic thought to be mediated by news coverage.

In the past decade self-immolation has persisted as a dramatic symbol of political protest. In 2010, a Tunisian street vendor, Tarek el-Tayeb Mohamed Bouazizi, set himself on fire in protest of the confiscation of his wares by a municipal official and her aides. His act spurred a series of similar self-immolation events and became a catalyst for the Arab Spring. In 2013, Plamen Goranov became a symbol of the Bulgarian social protest movement and a catalyst for nationwide protests and government resignations after his suicide attempt by self-immolation.

Practice of Self-immolation in Developing Countries While the majority of acts of self-immolation occur in developing countries, rigorous examination of factors contributing to these acts has been generally limited by lack of transparency, necessary funding, organizational skills, and very too often, significant shame victims and their families may experience associated with these behaviors.6 Some authors also raise concerns that many acts of self-immolation may in fact be propagated by victims’ families – as shame killings or to settle dowry disputes.20 Iran, where self-immolation accounts for upwards of 25% of all burn unit admissions and 10% of all suicide attempts, accounts for much of the published data on the subject.14,21 These studies present a consistent picture regarding the demographics of a typical self-immolation victim in the region. Most patients are female, socioeconomically disadvantaged and married. As an example, of all patients that attempted and completed suicide in the Kermanshan province in Iran, 86.5% were younger than 30 years, 81% were female, 78.5% were married, and 84% were illiterate and either unemployed or dependent on their spouse for finances.6, 22 A later case-control

study involving 30 self-immolation patients matched for age, gender, and geographic location with non-intentional burn admissions confirmed a strong predominance of young married women among self-immolators and identified additional associated risk factors for self-immolation reflective of chronic marital problems - violence in the household, living with in-laws, and not having children.23,24 Similar studies from low-income countries in the Middle East and South Asia present a consistent picture – selfimmolation as a practice seen amongst younger married women often in marital distress.4,7, 21,25 Our literature review did identify a single study from Southern India that demonstrated an equal proportion of male and female victims of self-immolation (45.1% female vs. 50.9% male) among 203 patients admitted to a general hospital following a suicide attempt.26 Often, self-immolation in developing countries is a form of protest against the discrimination and abuse women may face in the traditional society. Thus, suicide may not be an ultimate goal, and instead, there is a strong intention to engender shame in the observers, as well as compassion for the victim. It is hardly surprising that studies indicate that self-immolation in the developing world is a public spectacle – with most cases occurring during daylight hours (65% between 1pm-6pm) and in public spaces.16 While most studies are descriptive and offer little perspective as to the psychiatric contributors to self-immolation, the available data strongly favors mood and adjustment disorders as key contributors. In Iran, psychiatric interviews were conducted with patients following self-immolation and identified adjustment disorder (67%), personality disorders (17%) and major depression (10%) as the most commonly associated psychiatric diagnoses.23,24 Up to 97% of the patients lacked any prior history of suicide

attempts or significant prior psychiatric illness, and a majority (67.5-76%) of the patients who survived their injuries were noted to regret their actions.16 A more recent study of self-immolation in Iran highlighted the fact that, as compared to victims of intentional self-poisoning, self-immolators were less likely to exhibit warning signs for suicide such as seeking lethal means, having a dramatic change in mood, or exhibiting depression, loss of interest or recklessness prior to the act.22 Table 1 provides a summative description of common psychiatric factors associated with self-immolation in developing countries, and compares it with data from the US and other economically developed countries.

Practice of Self-immolation in the United States and More Economically Developed Countries (MEDC)

Information regarding the demographic makeup of patients who self-immolate in MEDCs is difficult to interpret given the frequent conflation of self-immolation and SIB in burn registries, though there do appear to be differences when compared to victims of self-immolation in the developing world. Two seminal studies reviewed the data from the American Burn Association National Burn Repository with overall consistent findings.8,9 In contrast to what has been described in developing countries, the majority of patients with intentional self-burns were male (62% vs. 66.3%), Caucasian (68.5% vs. 71.4%), and between ages 30-59 (mean age 36.5 vs. 39.1). As authors point out, although male patients appear more likely than females to attempt suicide by self-immolation, this number is considerably lower than the number of male patients that commit suicide by

other means, and victims of suicide by self-immolation are significantly more likely to be female than are victims of suicide by other methods.9 Many studies from other MEDCs present similar findings – the narrow majority of patients who self-immolate are male, within ages 30-45, and often the injury burden is considerably higher compared to nonintentional burns (with TBSA involvement ranging between 10-78% across different studies).16,27,28 A few authors have also suggested that a significant percentage of patients who attempt self-immolation in MEDCs may be immigrants or refugees from lowerincome countries where the practice is more prevalent.26,29 Unlike low-income countries, where self-immolation often occurs in public setting, most cases of self-immolation in MEDCs occur in the victim’s home.30,31 This may reflect a higher suicidal intent and lower chance of rescue compared to predominantly para-suicidal nature of self-immolation in low-income countries. When self-immolation does occur outdoors in MEDCs, often this is done with desire to reduce the risk of accidental harm to others.32 Other demographic risk factors that have been identified include chronic medical illness and long-term disability, as well as relationship and financial challenges.32,33 In contrast to the assertion that the most common psychiatric diagnosis in patients from low-income countries who self-immolate is adjustment disorder, studies in MEDCs implicate a significant prevalence of pre-existing major mental illness (18-92%).16 The earliest case series of self-immolation in a developed country was published in 1975 and involved 14 US patients.34 The authors found that the majority of patients were psychotic at the time of the act. Religiosity was a frequent theme, both in terms of the patients’ backgrounds and the nature of their delusions. The majority of patients had a

prior history of violent or bizarre behavior, and most were thought to have acted impulsively or unpredictably. In their review of the National Burns Registry, Thombs and colleagues found that 10% of all patients with intentional self-burn injuries had a pre-existing psychiatric diagnosis, including 2.8% patients with primary psychiatric disorders and 9.1% patients with substance use disorders. In comparison, 37% of all patients with TBSA >20% (a marker of self-immolation as compared to SIB) had a pre-existing psychiatric diagnosis, with 27% being primary psychiatric and 16% substance-related.9,35 Among the patients with a primary psychiatric diagnosis, 42% were diagnosed with a psychotic disorder (described as either schizophrenia or bipolar disorder), 35% with depression and 21% with unspecified mental health disorder.9,35 Poeschla and colleagues reviewed data from other high income countries, and identified a high prevalence of primary affective disorders (bipolar disorder or major depression; range 10-74%), substance use disorder (10-65%), psychosis (3-26%) and personality disorders (4-31%).16 A prior history of suicidal behavior was also common, ranging from 8% in Bulgaria to 69% in the United Kingdom.16 Mulholland and associates determined that psychiatric patients with intentional self-burn injuries, a large percentage of whom had self-immolated, were more likely to exhibit psychotic symptoms (46% vs. 8%), to be taking psychotropic medications and to be hospitalized at the time of the burn than were other psychiatric patients.30 Finally, a ten-year retrospective study of 15 patients at the University of South Florida attempted to elucidate the motives for self-immolation.36 Patients were asked about several potential reasons for committing self-immolation and could answer positively to as many as they felt applied. Six patients reported wanting to achieve relief

from their current state of mind, suggesting that the action was a response to delusional content or command hallucinations. Five patients reported that the self-immolation act was a suicide attempt, while four admitted to wanting to manipulate interpersonal situations, three acknowledged it as an attempt to escape a stressful situation, and one person classified it as a gesture for help. Only one person described the action as an attempt at revenge, and similarly only one person noted religious motivation. Common psychiatric determinants associated with the practice of self-immolation in the United States and other economically developed countries are also summarized in Table 1.

Non-Suicidal Self-inflicted Burns (SIB) Self-mutilation - the act of deliberate destruction or alteration of body tissue without conscious suicidal intent – occurs more frequently than suicidal acts, and this trend extends to SIB injuries. It is estimated that 75% of habitual self-mutilators use multiple methods, including fire, and the drive to engage in non-suicidal self-injurious behavior is often different than that associated with intentional suicidal gestures. Although the distinction is seldom made in burn literature, it is apparent that non-suicidal SIBs comprise a distinct sub-population of all intentional self-burn injuries. It is important to note that most of the literature regarding SIB comes from developed countries. One study compared 15 patients admitted to a US hospital who used selfimmolation as a means of attempted suicide to 16 patients with non-suicidal SIBs.37 Between the two groups, there was no overlap in the size of the burns, as the largest burn

in the SIB group was 9% TBSA, while the smallest burn in the self-immolation group was 11.5%TBSA. The mean age of the self-immolation group was older (39 years vs. 29 years), though patients in both groups tended to be unemployed and have a history of alcohol use disorder. Whereas the self-immolation group was evenly divided in terms of gender, 86% of patients in the SIB group were female. The patients in the SIB group were also more likely to be single or divorced as compared to the self-immolation group. A prior psychiatric history was noted in 94% of patients with SIB (compared to 67% of patients with self-immolation). Patients with SIB were more likely to carry a diagnosis of personality disorder (75% vs. 13%), eating disorder and prior trauma. Only 2 patients (12%) with SIB had a pre-existing diagnosis of primary mood disorder or schizophrenia.37 Patients with SIB often use tools that result in contact burns (e.g., curling iron, heated metal objects, cigarettes) or may resort to compounds that produce chemical burns once applied to the skin. Flame source and liquid accelerants are rarely seen, in contrast to self-immolators where flammable liquids such as kerosene are commonly employed. The distribution of burns was also unique for the SIB group, with the majority of burns involving the forearms or lower extremities.37 The motivation for non-suicidal SIBs may be complex, and even include potential secondary gain, as outlined by some of the recent examples in literature. A report from Israel in 2007 highlighted the practice of garlic burns amongst soldiers in the Israeli Army as a form of malingering.38 These patients were mostly younger male soldiers presenting with small (<1% TBSA) second-degree burns on the dorsal surface of the left foot, often requiring protracted hospitalization and exemption from wearing army boots.

During the study, 3 of the patients admitted to applying crushed fresh garlic under a pressure bandage to produce a chemical burn. 38 Subsequent reports from Israel and Singapore further confirm the practice, noting that burn injuries in this population are commonly small, sharply demarcated, and atypical in their distribution (typically dorsum of the non-dominant foot). Most injuries were un-witnessed, attributed to scalding, and sustained while soldiers were visiting home. A delay to seeking medical care of 1 week or more was common.39,40 In addition to the types of intentional self-burn injuries described above, several new patterns are emerging that defy the current classification system. For example, there is a recent trend of individuals challenging one another and gaining internet notoriety via intentional burns. One such example involves a YouTube-based phenomenon where individuals are encouraged to douse themselves with liquid accelerants and set parts of their body on fire. Subsequently, participants will attempt to extinguish the flames, while being filmed, before a serious injury is sustained. The majority of participants are noted to be male (90%), African American (64%) and under 20 years of age (58%).41 The median TBSA reported was 4%, although some postulate that higher-extent TBSA burns may not be posted online, thus diminishing perceived risk and encouraging further similar behavior. Another emerging trend is the use of aerosol inhalants among adolescents and young adults, which may lead to cryogenic burns resulting from prolonged exposure to the skin. The severity of these burns is such that vast majority of patients will not require medical care.42

Discussion Studies on the topic of intentional self-burn injuries are sparse, and often limited in scope. With few notable exceptions, most of the data is retrospective in nature and limited by relatively low sample size, reflecting the low incidence of intentional self-burn injuries in most MEDCs. In developing countries, limitations pertaining to lack of education, financial resources and considerable stigma associated with these acts pose further challenges. Furthermore, few authors differentiate between self-immolation and non-suicidal SIB, and often limited information is available as to the psychiatric conditions associated with intentional self-burn injuries, or patients’ motivation to pursue these acts. Nonetheless, a few broad themes are readily apparent regarding the demographic and psychiatric characteristics of patients who intentional self-burn injuries. Patients in MEDCs carry a slight male predominance, are older, and have higher rates of major mental illness reported, including psychosis. There is strong suicidal intent in acts of selfimmolation and many patients have a significant history of prior suicide attempts. Patients in developing countries are predominantly younger and female. Most of these patients lack significant prior psychiatric diagnoses, and appear to be experiencing an adjustment disorder. Domestic strife is common, and self-immolation may be a parasuicidal gesture intended to engender shame as well as sympathy. 43 A subgroup of patients in both developing and developed countries may engage in non-lethal SIB. This population appears to have higher rates of primary mood disorders and personality disorders compared to patients who self-immolate. Non-lethal SIBs may also be pursued

for secondary gain especially in vulnerable populations such as teenagers or military. Notably, non-lethal SIB is rarely reported or studied in developing countries. Additional help in understanding differences in motivation among patients who self-immolate is found in Durkheim’s 1897 case study of suicide.44 Egoistic suicide reflects a prolonged sense of not belonging that can give rise to meaninglessness, apathy, melancholy, and depression, consistent with the psychiatric profile of individuals from developed countries who self-immolate. Fatalistic suicide occurs when a person is excessively regulated, when their futures are pitilessly blocked and passions violently choked by oppressive discipline. This encapsulates the prototypical example of selfimmolation in developing countries. The final two categories - altruistic suicide, in which the individual has a sense of being overwhelmed by a group’s goals and beliefs and feels compelled to kill themselves on behalf of society, and anomic suicide, which results from an individual’s moral confusion and lack of social direction, often related to dramatic social and economic upheaval, leaving people with an unclear sense of where they fit into society - relate to a third group of self-immolators – those who perform the act for political purposes. Care for self-inflicted burn injury patients is often challenging – patients are not only markedly ill, but the nature of injury often leads to difficult reactions in the staff taking care of these patients. This considered, it is hardly a surprise that patients with intentional self-burn injuries, and particularly those who self-immolate, may generate extreme responses from staff members caring for them. As with many suicidal patients, staff may feel angry at having to devote time and resources to caring for patients who intentionally harmed themselves and who may reject care. This can lead to diminished

attention to issues such as pain and to overall avoidance of the patient. Conversely, some staff members may exhibit reaction formation, demonstrating over-attentiveness and protection of these patients in compensation for the negative emotions they feel towards them. In extreme cases this may result in inappropriate curiosity and boundary crossing. Some studies have suggested that negative attitudes towards these patients are less pronounced amongst nurses as compared to physicians.45 Issues complicating these reactions include the fact that health insurance in some countries does not pay for the care of failed suicides and that some countries allow for physicians to pursue palliative measures for suicidal patients. In a study to better elucidate staff reactions to patients with self-immolation in Iran, 59 patients with non-intentional burns and 57 patients who self-immolated were asked to complete surveys.46 Self-immolation patients did report at statistically significant levels that they were treated with less respect, had less of a chance to ask questions, and experienced less preservation of confidentiality than their counterparts. In fact, 98.2% of them noted that they were not asked to consent for procedures, though this likely reflects a cultural assumption of incompetence due to the nature of their actions. Self-immolation patients reported no differences in waiting time, attention to pain, privacy, and giving information about health status. Patients with intentional self-inflicted burns comprise a complex and clinically challenging group – as is readily apparent from the two cases we present with this review. In our experience, the psychiatric care these patients require will depend on the interplay of underlying demographic factors (including prior psychiatric and substance use history) as well as the severity of burn injuries sustained. As case 1 illustrates, in most cases of

self-immolation, the acute care for the burn victim takes priority during early parts of the hospitalization. Often, the psychiatric consultant is asked to help manage delirium associated with metabolic, infectious, pain- and medication-related insults. Familiarity with commonly used sedative and anesthetics is paramount, including awareness of common side-effects and potential drug-drug interactions (e.g., potential for worsening hallucinations with use of ketamine for pain control). In our practice, we commonly utilize intravenous haloperidol as an adjunct to help manage acute agitation and to reduce overall sedative requirements. This has additional utility in managing underlying psychosis for patients whose self-immolation was provoked by a psychotic illness. In the case we present here, dopamine antagonist use was an integral component of both acute delirium management, as well as down-stream management of underlying primary psychotic disorder. As intoxication and active substance use are common in this patient group, careful assessment of withdrawal risk (especially as it pertains to alcohol and opioids) is essential – especially as the patient may not be capable of providing any reliable history and the collateral information may be scarce. Prophylactic alcohol withdrawal management may be appropriate in cases where clinical suspicion is high, as burn patients are at higher risk for experiencing alcohol withdrawal and complications related to alcohol withdrawal delirium. Chronic opioid exposure may result in high baseline opioid requirements, while acute opioid withdrawal may present as worsening agitation in an already delirious patient. Once the acute phase of care subsides and further collateral is attained, the role of the consulting psychiatrist transitions to that of diagnostic clarification, safety

assessment, and treatment of the underlying psychiatric comorbidity. Prompt initiation of medication treatment is paramount as patients will often spend weeks on the burn service before being medically appropriate for transition to less-restrictive setting. Coordination of care with inpatient psychiatric and medical rehabilitation facilities is often necessary, as both may express concerns about taking care of patients with significant psychiatric, wound care and physical therapy requirements. As Case 1 illustrates, in our clinical practice, we will commonly initiate psychiatric medications and make necessary dose adjustments while the patient is recovering on the burn service. In our experience, and as indicative in the second case presented, clinical management of patients with non-lethal SIB injuries can differ considerably from that of patients who self-immolate. SIB patients commonly have less acute injuries and will require less intensive care initially – a setup that may increase likelihood of patients experiencing acute psychiatric symptoms while in the burn unit. Such symptoms can involve acute exacerbation of primary mood disorders or worsening of severe personality disorder pathology manifesting as behavioral dysregulation and interference with care. Psychiatric consultation can be particularly helpful in providing assistance to the burn team as it relates to possible counter-transference reactions they may experience. Working with both physicians and nurses to understand the need to establish firm boundaries and provide structure is essential. Engagement of psychology or social work services to provide therapy to patients during their stay may be a useful adjunct. As these patients may re-engage in self-harm behaviors even while hospitalized, recommendations to ensure adequate supervision and safety precautions are available are paramount. In Case 2, the role of consultation-liaison psychiatrist included many of the points raised

here. We were tasked with prompt diagnosis and clinical management of significant mood and personality pathology. Furthermore, we were commonly engaged with the team to manage behavioral exacerbations, enforce limits and ensure safe setting for patient to recover.

Conclusion Intentional self-burn injuries occur rarely in most MEDCs, accounting for a fraction of all burn-related admissions. Nonetheless, these injuries are often severe, and generate considerable challenges in terms of acute medical management of the patient as well as the management of underlying psychiatric or substance use needs. The cases presented at the beginning of this article illustrate typical motivations for pursuit of intentional self-burn injuries, and reflect the data already present in the literature. They also illustrate some of the key challenges of adequately treating psychiatric patients on a general burn unit. While there is some growing interest in literature on the topic of intentional self-burn injuries, few studies exist within dedicated psychiatric literature. Furthermore, most literature available is retrospective and descriptive in nature, giving limited insight into the psychiatric, social, cultural and economical contributors to this phenomenon. Prospective and analytical studies, including longitudinal studies to assess patient outcomes following intentional self-burns, are needed to further our understanding of this phenomenon.

US and other MEDCs Mood disorders  Depressive disorders  Acute mania Intent: suicide attempt

Substance use disorders  Alcohol  Opioids  Cocaine/other stimulants Psychosis

Developing countries Adjustment disorder  Financial stressors  Marital discord  Low education level  Limited supports Mood disorders  Depressive disorders

No formal prior psychiatric history

Mood disorders  Depressive disorders  Acute mania Intent: non-lethal selfharm

Personality disorders  Borderline personality disorder

Less described in this setting – no studies available

Substance use disorders Malingering for secondary gain  Military service avoidance Table 1: Common psychiatric disorders associated with intentional self-inflicted burn injuries. Disorders are classified according to patient’s intent as well as demographic patterns. Bolded diagnoses are most common.

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