Psychothcr. Psychosom. 26: 203-210 (1975)
Psychiatric Care of Burn Patients during Wartime Jacob A vni Department of Psychiatry. Hadassah University Hospital, and Hadassah-HebrewUniversity Medical School, Jerusalem
Abstract. The psychiatric problems of burn patients during hospitalization and after discharge are reviewed. These are compared with the psychiatric problems encountered in burned Israeli soldiers during the last Middle East war (1973). Special conditions and charac teristics of the work done by the psychiatric team in a plastic surgery department among the wounded, their relatives and the staff, are presented.
Tank battles played a prominent and crucial role in the ‘Yom Kippur’ war of October 1973. The incidence of burns among soldiers wounded in action was therefore far higher than in previous Middle East wars. The war broke out unexpectedly and we in Israel were suddenly faced with the situation of having to rapidly deal with large numbers of burn casualties. The experience with the physical treatment of these burn casualties has been partially summarized (5, 10). It is our intention to summarize here our experience with the psychiatric care of these patients, gained while working as a psychiatric team in the plastic surgery department of the Hadassah University Hospital. Jerusalem. Every patient of ours had experienced multiple emotional traumata related to battle, injury and specifically burns. The special circumstances of the Yom Kippur war and of battle, injury and hospitalization close to home were addi tional factors of emotional importance to the patient and his family as well as to the personnel.
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When a threatening situation posed is severe, the defence mechanisms employed tend to be similar even though the source of danger may differ (9). Burns have, nevertheless, the characteristics of a specific injury. Hamburg et al. (8) divide the mental problems of burn cases into primary problems, which include danger to life and body configuration, pain, discomfort, operations and lengthy hospitalization, and secondary problems such as feelings of guilt, separa tion from the family, fears concerning future plans, sexual problems and feelings of inadequacy, rejection and hostility. Psychiatric problems of burn cases can also be divided into those of the acute and chronic phases. Others divide them into those associated with the initial hospitalization and those of the post-discharge period. During the initial hospitalization, there are the problems associated with a traumatic experience and a sudden change in various aspects of life including change in appearance and disfigurement, a situation of dependence and physical weakness and, in addition, physical illness with damage to vital organs and functions. The post-discharge reactions are associated with problems of adaptation and in dependent existence outside hospital and the need to live with the problems and limitations resulting from the burns, often to the extent of dealing with a new identity. Andreasen (4) mentions mild anxiety and depression, fear of disfigurement and a persistent decrease of the pain threshold as normal reactions. Pathological reactions are noted, according to Andreasen, in 2 0 -3 0 % of cases during hospi talization and include severe depression, severely regressive states and delirium, i.e., a disturbance of cognitive functions. Post-discharge pathological reactions occur mostly during the first year and include depression, anxiety and phobias. In another paper (2), the same author and his colleagues add behaviour distur bance in the ward to the list of pathological reactions and note that 50 % of burn casualties developed psychiatric problems. According to them, the most significant factor influencing the development of these complications is the existence of mental or physical illness prior to the burn. Paulovsky (11) reports a series of 200 burn cases. According to him, the factors influencing the development of psychopathology are the severity of the burn, age and mental state at the time of injury and lability of personality prior to the burn. Among the severe cases the author found a 50% incidence of psychiatric reactions primarily depressive reactions. With regard to the longitudinal adaptation of burn patients, it was found in another series of 20 cases that 70 % adapted well while 30 % had mild to moder ate problems (3). Factors which proved to be of decisive importance were sever ity of disfigurement, degree of immaturity of personality, extent of narcissism, sex (more disturbances in females), ability to discuss problems and willingness to
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expose and not hide scarred areas (less disturbances in those more willing to expose the scars).
Psychiatric Problems in Mass Burns All that has been written thus far refers to individual burn cases under ‘normal’ circumstances. In the psychiatric literature, there are references to a few mass burn catastrophes. The famous Boston fire (1 ,6 ) claimed 491 lives and many more people were injured. Neuropsychiatric complications were observed in half the cases during hospitalization. Nine months after discharge, less than one third of those hospitalized had such complications. Cobb and Lindemann (6) emphasized their work-relationship with the social workers and psychiatric aid to the families particularly during the early stage after the burn. Among the emotional reactions of the close family, grief and worry predominated. Little is said about the reactions of the personnel treating the injured. Another disaster quoted is the aeroplane crash in Yugoslavia (7), as a result of which 20 burn cases were treated. The description of the incident includes references to the specific emotional problems caused in patients by the sudden ness of the disaster and the injury and death of people close to them. The effect of the catastrophe on the feelings of the personnel is also noted. These two examples of psychiatric problems associated with mass burns may serve as an introduction to our experience during the Yom Kippur war. The experience of battle may in itself cause a severe degree of emotional trauma, and burns sustained under such conditions represent an extreme combination of two major traumatic experiences.
The Yom Kippur war broke out suddenly in October, 1973. Within hours, civilian hospitals were converted into military hospitals and our small, placid plastic surgery department grew from 16 to 45 beds. Of the 70 soldiers hospi talized in our unit, 48 were burn casualties, some of whom had other wounds as well. 37 suffered burns of less than 24 % of the body surface area and were hospitalized an average of 15.5 days; 5 had burns of 26—45 % and were hospi talized an average of 41 days. The 6 soldiers who suffered burns of greater than 45 % of the body surface area were hospitalized an average of 75 days. One patient in the most severe group died after 14 days. Age ranged from 18 to 37 years while most of the wounded were between 20 and 25 years old. All the wounded were transferred within hours from the combat zone and had suffered severe battle experiences.
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Psychiatric Help to the Wounded The first phase began for all casualties immediately on admission. As quick ly as possible each patient was asked to relate exactly how he had been wounded and to detail the associated emotional experiences. This served both as a primary psychiatric assessment and as initial treatment with the aim of averting traumatic war neuroses. The aim was to achieve emotional catharsis (abreaction). We found all patients to be calm and co-operative during this period, more so than those around them. They related everything though sometimes needing encouragement to talk about certain details which were difficult to recall or discuss. All received pethidine shortly after the injury and this was perhaps one of the reasons why they were so calm. The second phase began after 3—4 days by which time there were problems of fluid and balance of electrolytes, and fever and infections had developed. At this stage the painful treatments began. The patients began to comprehend their new situation and to react to it. Most had a mild to moderate depressive reac tion. The lengthy period of immobility provided opportunity for introspection and contemplation of the future. Most questions were, nevertheless, concerned with immediate and relatively minor problems such as discomfort, painful treat ments or a misunderstanding with a staff member. At this stage we still noted sufficient emotional strength to withstand suffering and to co-operate with the personnel. We regarded co-operation in treatment as the most important criteri on of the patient’s mental health. Most of the other problems such as mild depression and anxiety are part of the normal process of healing and required no
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 1:52:38 AM
The staff of the unit was increased overnight by the addition of personnel who were not familiar with the department and were, in most cases, not suffi ciently acquainted with the methods of treatment and special problems asso ciated with burns. A heavy burden of work was placed on the paramedical personnel, the surgeons spending most of the time in the operating theater. The general atmosphere was one of danger to survival, national and individual. As opposed to the situation in most other wars, the families were close to the hospital and within hours were at the bedsides of their wounded relatives. We were therefore required to treat the families and their emotional reactions as well as dealing with the inter-relationships between them, the patients and the staff. We worked as a psychiatric team which was made up of a psychiatrist and a social worker with psychiatric experience, who had worked together as consul tants to the plastic surgery department prior to the outbreak of war. As soon as hostilities commenced, we began intensive 24-hour work from within the depart ment. We saw it as our duty to treat the emotional problems of the wounded, their families and the personnel as well as all interpersonal problems which might affect the optimal performance of the unit.
207
intervention. In only six cases was there a depressive reaction of more than mild severity. All had extensive burns and one died subsequently. Two patients showed maniform reactions which persisted in mild form for 3 weeks. Another patient exhibited mild euphoria and inappropriate wittiness during his short hospitalization. Another developed a phobic reaction. Many patients showed regressive behaviour during this phase but only four became management prob lems in the department. In all four a disturbed relationship was observed be tween the patient and his family who encouraged regression in hospital, as they had done prior to the injury. Disturbances of cognitive functions were few and presented mainly as a confusional state when the patients awoke at night while still under the influence of hypnotic agents. Two patients had recurring night mares which lasted a few weeks. One patient had recurring visual hallucinations which disappeared after a few days. At this stage, as at others, we made certain that the patient asks the surgeons whatever questions were bothering him and receive factual, encouraging answers. They asked numerous questions about their condition and also about the fate of comrades wounded with them in battle. They were told of close friends and families who had been killed and others who had been wounded. Friends and relatives of soldiers from the same unit or tank who had been killed or were missing in action, came to enquire of the fate of their relatives and friends, and honest exchange of information was encouraged. In all cases mourning reactions were adequate and no pathological reactions were observed. In only one case did we hide information. We did not tell our most severely ill patient (aged 37) who was fighting for his life that his son had been killed in the war and he died unaware of this fact. The third phase began in moderate and severe cases 2 -3 weeks after the burn. The patients were, at this stage, suffering a large number of painful treat ments which included operations and excruciating manipulations at the bedside. Their ability to withstand suffering appeared to be diminished and they became more irritable and nervous. They began to appreciate emotionally the extent of the physical damage and the social and professional limitations implied. Concern about their families and economic problems became manifest. Significant rela tionships developed with other wounded and with staff members. More so than previously, it appeared important to maintain co-operation and diminish feelings of anxiety and depression when they exceeded the level appropriate to the situation. Regressive behaviour was encountered only in the four patients who had shown such signs during the second stage. There were no significant cogni tive disturbances noted throughout this phase. The fourth phase began as discharge from the department approached and continued thereafter. Emphasis was placed on rehabilitation, involving emotional and physical adaptation to a new situation. The patient had to withstand the tests of reality in returning to his family, work and friends. In approaching this phase and throughout it, the psychiatric team utilized links with various eco
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nomic and rehabilitation agencies. On the other hand, emphasis was placed on dealing with emotional problems associated with the process of rehabilitation. This was done in conjunction with the surgeon, physiotherapist, occupational therapist and the patient’s family as the necessity arose. During the post-dis charge period our patients returned to their homes all over the country, and responsibility for the rehabilitation process moved to those of the local agencies of the Ministry of Defence. Only the most severe and problematic cases re mained in contact with us. From our preliminary follow-up we have noted that the vast majority of the patients, with the exception of four, underwent a process of rehabilitation varying from satisfactory to optimal. A clearer picture will emerge when our study, under way at present, is concluded. Of the four cases who were not satisfactorily rehabilitated, two showed some signs of personality disorder and job instability prior to the injury, and two are still undergoing a series of corrective operations.
Psychiatric Help to the S ta ff As stated, the staff functioned at a high level of anxiety, particularly during the period while the war still continued. The psychiatric team worked at reduc ing this anxiety level in the department by reducing it among the patients and their families. We participated in all staff meetings as well as impromptu sessions with personnel of all vocations. Personal contact was maintained as required. The psychiatric team served as a point of reference when needed but also worked at localizing sources of friction in the department and initiating their treatment. The team also took part in organizing work schedules and in solving administrative problems. Much was expected of us by the personnel who reacted with co-operation and gratitude particularly during the period of greatest stress.
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Psychiatric Help for the Family Psychiatric help for the family commenced the minute they reached hospi tal. The first meeting with their burned relatives took place only after a short preparatory session at which one or both members of the psychiatric team were present. Here as well we intervened only when needed, emphasis being placed on providing factual and encouraging information. Subsequently the social worker was primarily involved in helping the families to gradually adjust to their new situation from an emotional standpoint and with regard to practical arrange ments which proved necessary. The psychiatric help to the family was no less in extent than that provided to the patients themselves. The stages of adjustment observed paralleled those of the wounded relatives. Special problems were encountered where the injury occurred on a background of problematic relation ships within the family. In some cases family members maintained occasional therapeutic contact with us for some months after their relatives had been discharged.
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When life returned to normal, the psychiatric team gradually returned to its previous status and to the functions it had fulfulled prior to the war.
Discussion It is difficult to draw comparisons between the different papers dealing with psychiatric problems in burn patients because of the differing circumstances, severity and population make-up. Our patients did not ask themselves: ‘Why me?’ as does the civilian burned in an accident. There was no evidence in their histories of accident-proneness and self-destructive acts to an extent greater than in the general population. They received a great deal of sympathy from their families, the staff and their environment. It is reasonable to assume that among their own people the chance of rejection because of their appearance was smaller than in other surroundings. It has already been stated that the incidence of psychiatric complications is greater in female burn cases than in males (3) and in children greater than in adults (11). Our patients were all young men in suffi ciently good physical and mental condition to make them eligible for reserve army duty in combat units. The rapidity of medical treatment, provided in our army by experienced doctors even before the wounded reach hospital, may be another factor in reducing the incidence of neuropsychiatric complications in our burn casualties. Our soldiers did not react with pathological grief on hearing of the deaths of relatives and friends in contradistinction to the situation de scribed in the Boston disaster. It is possible that the continuing war was one of the reasons for the restraint shown in these reactions. The team spirit and comradery which existed among the wounded was a continuation of the military spirit. All these factors no doubt contributed to the low incidence of psychiatric problems among our patients. Exacerbating factors may have been the severe battle experiences and feelings of guilt concerning comrades who were killed, but these did not prove decisive. We assume that the method of rapid abreaction and the consistent psychiatric help provided at all levels and systems of the department, contributed to the good results achieved. It is of course difficult to assess to what extent the method of working as a team in a community under stress was a central factor in achieving good results. It is, however, difficult to conceive of any other efficient method of treatment in the situation described.
The Middle East war of October, 1973, created a sudden need to treat relatively large numbers of burn casualties. The wounded were very quickly transferred to hospital from the combat zone, and psychiatric treatment began
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at once. It was characterized by simultaneous diagnosis, therapy and prophy laxis. Psychiatric help was also rendered to members of the family, and problems of adjustment among the staff were treated. Community methods were em ployed by the psychiatric team. The incidence and extent of psychiatric compli cations among the burn cases were lower than observed in other series.
References
Jacob Avni, MD, Chief Physician, Department of Psychiatry, Hadassah Hospital. POB 499. Jerusalem (Israel)
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1 Adler, A.: Neuropsychiatrie complications in victims of Boston’s cocoa-nut grove disaster. J. Am. med. Ass. 123: 1098 1101 (1943). 2 Andreasen, N.J.C.; Noyes, R., jr., and Hartford, C.E.: Factors influencing adjustment of burn patients during hospitalization. Psychosom. Med. 34: 517-524 (1972). 3 Andreasen, N.J.C. and Norris, A.S.: Long-term adjustment and adaptation mechanisms in severely burned adults. J. nerv. ment. Dis. 154: 352 362 (1972). 4 Andreasen, N.J.C.: Neuropsychiatrie complications in burn patients. Psychiat. Med. 5: 161 171 (1974). 5 Ben-Hur, N.: The antitank missile syndrome. Harefuah 87: 643 645 (1974). 6 Cobb, S. and Lindemann, E.: Neuropsychiatrie observations in victims of Boston’s cocoa-nut grove disaster. Ann. Surg. 117: 814 824 (1943). 7 Derganc, M.: Experience with multiple burn casualties and treatment of dermal burns. Proc. R. Soc. Med. 65: 1057 1060(1972). 8 Hamburg, D.A.; Artz, C.P.: Reiss, E.; Amspacher, W.H., and Chambers, R.E.: Clinical importance of emotional problems in the care of patients with burns. New Engl. J. Med. 248: 355-359 (1953). 9 Hamburg, D.A.: Coping behaviour in life-threatening circumstances. Psychother. Psy chosom. 23: 1 6 (1974). 10 Levin, J.M. and Bornstein, L.A.: The treatment of burns in the recent Middle East conflict. Plastic reconstr. Surg. 54: 432 436 (1974). 11 Paulovsky, P. : Occurrence and development of psychopathologic phenomena in burned persons and their relation to severity of burns, age and premorbid personality. Acta chir. plast. 14: 112 119 0972).
Psychiatric Care of Burn Patients during Wartime Jacob A vni Department of Psychiatry. Hadassah University Hospital, and Hadassah-HebrewUniversity Medical School, Jerusalem
Abstract. The psychiatric problems of burn patients during hospitalization and after discharge are reviewed. These are compared with the psychiatric problems encountered in burned Israeli soldiers during the last Middle East war (1973). Special conditions and charac teristics of the work done by the psychiatric team in a plastic surgery department among the wounded, their relatives and the staff, are presented.
Tank battles played a prominent and crucial role in the ‘Yom Kippur’ war of October 1973. The incidence of burns among soldiers wounded in action was therefore far higher than in previous Middle East wars. The war broke out unexpectedly and we in Israel were suddenly faced with the situation of having to rapidly deal with large numbers of burn casualties. The experience with the physical treatment of these burn casualties has been partially summarized (5, 10). It is our intention to summarize here our experience with the psychiatric care of these patients, gained while working as a psychiatric team in the plastic surgery department of the Hadassah University Hospital. Jerusalem. Every patient of ours had experienced multiple emotional traumata related to battle, injury and specifically burns. The special circumstances of the Yom Kippur war and of battle, injury and hospitalization close to home were addi tional factors of emotional importance to the patient and his family as well as to the personnel.
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Psychiatric Care o f Bum Patients during Wartime
A vni
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When a threatening situation posed is severe, the defence mechanisms employed tend to be similar even though the source of danger may differ (9). Burns have, nevertheless, the characteristics of a specific injury. Hamburg et al. (8) divide the mental problems of burn cases into primary problems, which include danger to life and body configuration, pain, discomfort, operations and lengthy hospitalization, and secondary problems such as feelings of guilt, separa tion from the family, fears concerning future plans, sexual problems and feelings of inadequacy, rejection and hostility. Psychiatric problems of burn cases can also be divided into those of the acute and chronic phases. Others divide them into those associated with the initial hospitalization and those of the post-discharge period. During the initial hospitalization, there are the problems associated with a traumatic experience and a sudden change in various aspects of life including change in appearance and disfigurement, a situation of dependence and physical weakness and, in addition, physical illness with damage to vital organs and functions. The post-discharge reactions are associated with problems of adaptation and in dependent existence outside hospital and the need to live with the problems and limitations resulting from the burns, often to the extent of dealing with a new identity. Andreasen (4) mentions mild anxiety and depression, fear of disfigurement and a persistent decrease of the pain threshold as normal reactions. Pathological reactions are noted, according to Andreasen, in 2 0 -3 0 % of cases during hospi talization and include severe depression, severely regressive states and delirium, i.e., a disturbance of cognitive functions. Post-discharge pathological reactions occur mostly during the first year and include depression, anxiety and phobias. In another paper (2), the same author and his colleagues add behaviour distur bance in the ward to the list of pathological reactions and note that 50 % of burn casualties developed psychiatric problems. According to them, the most significant factor influencing the development of these complications is the existence of mental or physical illness prior to the burn. Paulovsky (11) reports a series of 200 burn cases. According to him, the factors influencing the development of psychopathology are the severity of the burn, age and mental state at the time of injury and lability of personality prior to the burn. Among the severe cases the author found a 50% incidence of psychiatric reactions primarily depressive reactions. With regard to the longitudinal adaptation of burn patients, it was found in another series of 20 cases that 70 % adapted well while 30 % had mild to moder ate problems (3). Factors which proved to be of decisive importance were sever ity of disfigurement, degree of immaturity of personality, extent of narcissism, sex (more disturbances in females), ability to discuss problems and willingness to
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expose and not hide scarred areas (less disturbances in those more willing to expose the scars).
Psychiatric Problems in Mass Burns All that has been written thus far refers to individual burn cases under ‘normal’ circumstances. In the psychiatric literature, there are references to a few mass burn catastrophes. The famous Boston fire (1 ,6 ) claimed 491 lives and many more people were injured. Neuropsychiatric complications were observed in half the cases during hospitalization. Nine months after discharge, less than one third of those hospitalized had such complications. Cobb and Lindemann (6) emphasized their work-relationship with the social workers and psychiatric aid to the families particularly during the early stage after the burn. Among the emotional reactions of the close family, grief and worry predominated. Little is said about the reactions of the personnel treating the injured. Another disaster quoted is the aeroplane crash in Yugoslavia (7), as a result of which 20 burn cases were treated. The description of the incident includes references to the specific emotional problems caused in patients by the sudden ness of the disaster and the injury and death of people close to them. The effect of the catastrophe on the feelings of the personnel is also noted. These two examples of psychiatric problems associated with mass burns may serve as an introduction to our experience during the Yom Kippur war. The experience of battle may in itself cause a severe degree of emotional trauma, and burns sustained under such conditions represent an extreme combination of two major traumatic experiences.
The Yom Kippur war broke out suddenly in October, 1973. Within hours, civilian hospitals were converted into military hospitals and our small, placid plastic surgery department grew from 16 to 45 beds. Of the 70 soldiers hospi talized in our unit, 48 were burn casualties, some of whom had other wounds as well. 37 suffered burns of less than 24 % of the body surface area and were hospitalized an average of 15.5 days; 5 had burns of 26—45 % and were hospi talized an average of 41 days. The 6 soldiers who suffered burns of greater than 45 % of the body surface area were hospitalized an average of 75 days. One patient in the most severe group died after 14 days. Age ranged from 18 to 37 years while most of the wounded were between 20 and 25 years old. All the wounded were transferred within hours from the combat zone and had suffered severe battle experiences.
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Psychiatric Help to the Wounded The first phase began for all casualties immediately on admission. As quick ly as possible each patient was asked to relate exactly how he had been wounded and to detail the associated emotional experiences. This served both as a primary psychiatric assessment and as initial treatment with the aim of averting traumatic war neuroses. The aim was to achieve emotional catharsis (abreaction). We found all patients to be calm and co-operative during this period, more so than those around them. They related everything though sometimes needing encouragement to talk about certain details which were difficult to recall or discuss. All received pethidine shortly after the injury and this was perhaps one of the reasons why they were so calm. The second phase began after 3—4 days by which time there were problems of fluid and balance of electrolytes, and fever and infections had developed. At this stage the painful treatments began. The patients began to comprehend their new situation and to react to it. Most had a mild to moderate depressive reac tion. The lengthy period of immobility provided opportunity for introspection and contemplation of the future. Most questions were, nevertheless, concerned with immediate and relatively minor problems such as discomfort, painful treat ments or a misunderstanding with a staff member. At this stage we still noted sufficient emotional strength to withstand suffering and to co-operate with the personnel. We regarded co-operation in treatment as the most important criteri on of the patient’s mental health. Most of the other problems such as mild depression and anxiety are part of the normal process of healing and required no
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 1:52:38 AM
The staff of the unit was increased overnight by the addition of personnel who were not familiar with the department and were, in most cases, not suffi ciently acquainted with the methods of treatment and special problems asso ciated with burns. A heavy burden of work was placed on the paramedical personnel, the surgeons spending most of the time in the operating theater. The general atmosphere was one of danger to survival, national and individual. As opposed to the situation in most other wars, the families were close to the hospital and within hours were at the bedsides of their wounded relatives. We were therefore required to treat the families and their emotional reactions as well as dealing with the inter-relationships between them, the patients and the staff. We worked as a psychiatric team which was made up of a psychiatrist and a social worker with psychiatric experience, who had worked together as consul tants to the plastic surgery department prior to the outbreak of war. As soon as hostilities commenced, we began intensive 24-hour work from within the depart ment. We saw it as our duty to treat the emotional problems of the wounded, their families and the personnel as well as all interpersonal problems which might affect the optimal performance of the unit.
207
intervention. In only six cases was there a depressive reaction of more than mild severity. All had extensive burns and one died subsequently. Two patients showed maniform reactions which persisted in mild form for 3 weeks. Another patient exhibited mild euphoria and inappropriate wittiness during his short hospitalization. Another developed a phobic reaction. Many patients showed regressive behaviour during this phase but only four became management prob lems in the department. In all four a disturbed relationship was observed be tween the patient and his family who encouraged regression in hospital, as they had done prior to the injury. Disturbances of cognitive functions were few and presented mainly as a confusional state when the patients awoke at night while still under the influence of hypnotic agents. Two patients had recurring night mares which lasted a few weeks. One patient had recurring visual hallucinations which disappeared after a few days. At this stage, as at others, we made certain that the patient asks the surgeons whatever questions were bothering him and receive factual, encouraging answers. They asked numerous questions about their condition and also about the fate of comrades wounded with them in battle. They were told of close friends and families who had been killed and others who had been wounded. Friends and relatives of soldiers from the same unit or tank who had been killed or were missing in action, came to enquire of the fate of their relatives and friends, and honest exchange of information was encouraged. In all cases mourning reactions were adequate and no pathological reactions were observed. In only one case did we hide information. We did not tell our most severely ill patient (aged 37) who was fighting for his life that his son had been killed in the war and he died unaware of this fact. The third phase began in moderate and severe cases 2 -3 weeks after the burn. The patients were, at this stage, suffering a large number of painful treat ments which included operations and excruciating manipulations at the bedside. Their ability to withstand suffering appeared to be diminished and they became more irritable and nervous. They began to appreciate emotionally the extent of the physical damage and the social and professional limitations implied. Concern about their families and economic problems became manifest. Significant rela tionships developed with other wounded and with staff members. More so than previously, it appeared important to maintain co-operation and diminish feelings of anxiety and depression when they exceeded the level appropriate to the situation. Regressive behaviour was encountered only in the four patients who had shown such signs during the second stage. There were no significant cogni tive disturbances noted throughout this phase. The fourth phase began as discharge from the department approached and continued thereafter. Emphasis was placed on rehabilitation, involving emotional and physical adaptation to a new situation. The patient had to withstand the tests of reality in returning to his family, work and friends. In approaching this phase and throughout it, the psychiatric team utilized links with various eco
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 1:52:38 AM
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nomic and rehabilitation agencies. On the other hand, emphasis was placed on dealing with emotional problems associated with the process of rehabilitation. This was done in conjunction with the surgeon, physiotherapist, occupational therapist and the patient’s family as the necessity arose. During the post-dis charge period our patients returned to their homes all over the country, and responsibility for the rehabilitation process moved to those of the local agencies of the Ministry of Defence. Only the most severe and problematic cases re mained in contact with us. From our preliminary follow-up we have noted that the vast majority of the patients, with the exception of four, underwent a process of rehabilitation varying from satisfactory to optimal. A clearer picture will emerge when our study, under way at present, is concluded. Of the four cases who were not satisfactorily rehabilitated, two showed some signs of personality disorder and job instability prior to the injury, and two are still undergoing a series of corrective operations.
Psychiatric Help to the S ta ff As stated, the staff functioned at a high level of anxiety, particularly during the period while the war still continued. The psychiatric team worked at reduc ing this anxiety level in the department by reducing it among the patients and their families. We participated in all staff meetings as well as impromptu sessions with personnel of all vocations. Personal contact was maintained as required. The psychiatric team served as a point of reference when needed but also worked at localizing sources of friction in the department and initiating their treatment. The team also took part in organizing work schedules and in solving administrative problems. Much was expected of us by the personnel who reacted with co-operation and gratitude particularly during the period of greatest stress.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 1:52:38 AM
Psychiatric Help for the Family Psychiatric help for the family commenced the minute they reached hospi tal. The first meeting with their burned relatives took place only after a short preparatory session at which one or both members of the psychiatric team were present. Here as well we intervened only when needed, emphasis being placed on providing factual and encouraging information. Subsequently the social worker was primarily involved in helping the families to gradually adjust to their new situation from an emotional standpoint and with regard to practical arrange ments which proved necessary. The psychiatric help to the family was no less in extent than that provided to the patients themselves. The stages of adjustment observed paralleled those of the wounded relatives. Special problems were encountered where the injury occurred on a background of problematic relation ships within the family. In some cases family members maintained occasional therapeutic contact with us for some months after their relatives had been discharged.
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When life returned to normal, the psychiatric team gradually returned to its previous status and to the functions it had fulfulled prior to the war.
Discussion It is difficult to draw comparisons between the different papers dealing with psychiatric problems in burn patients because of the differing circumstances, severity and population make-up. Our patients did not ask themselves: ‘Why me?’ as does the civilian burned in an accident. There was no evidence in their histories of accident-proneness and self-destructive acts to an extent greater than in the general population. They received a great deal of sympathy from their families, the staff and their environment. It is reasonable to assume that among their own people the chance of rejection because of their appearance was smaller than in other surroundings. It has already been stated that the incidence of psychiatric complications is greater in female burn cases than in males (3) and in children greater than in adults (11). Our patients were all young men in suffi ciently good physical and mental condition to make them eligible for reserve army duty in combat units. The rapidity of medical treatment, provided in our army by experienced doctors even before the wounded reach hospital, may be another factor in reducing the incidence of neuropsychiatric complications in our burn casualties. Our soldiers did not react with pathological grief on hearing of the deaths of relatives and friends in contradistinction to the situation de scribed in the Boston disaster. It is possible that the continuing war was one of the reasons for the restraint shown in these reactions. The team spirit and comradery which existed among the wounded was a continuation of the military spirit. All these factors no doubt contributed to the low incidence of psychiatric problems among our patients. Exacerbating factors may have been the severe battle experiences and feelings of guilt concerning comrades who were killed, but these did not prove decisive. We assume that the method of rapid abreaction and the consistent psychiatric help provided at all levels and systems of the department, contributed to the good results achieved. It is of course difficult to assess to what extent the method of working as a team in a community under stress was a central factor in achieving good results. It is, however, difficult to conceive of any other efficient method of treatment in the situation described.
The Middle East war of October, 1973, created a sudden need to treat relatively large numbers of burn casualties. The wounded were very quickly transferred to hospital from the combat zone, and psychiatric treatment began
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at once. It was characterized by simultaneous diagnosis, therapy and prophy laxis. Psychiatric help was also rendered to members of the family, and problems of adjustment among the staff were treated. Community methods were em ployed by the psychiatric team. The incidence and extent of psychiatric compli cations among the burn cases were lower than observed in other series.
References
Jacob Avni, MD, Chief Physician, Department of Psychiatry, Hadassah Hospital. POB 499. Jerusalem (Israel)
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