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News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences
“It’s like you’re in a phone booth late at night in a bad neighborhood. You don’t know how to get home. The floor’s littered with cigarette butts. It’s hard to see out the filthy windows but no one out there would help you anyway. A voice on the receiver tells you you’re in danger.” That’s one patient’s description of post-trauma distress. But if you’re a burn survivor and have slipped further, into post-traumatic stress disorder (PTSD), there’s a street gang with a snarling mastiff outside the booth. And you know they’re not going away.
The physical results of severe burns are well-documented, says psychologist James Fauerbach, Ph.D., who sees roughly 400 seriously burned adult patients at Hopkins Bayview’s burn center each year. But the mental aspects—the potential anxiety disorders, altered body image, the downswing in mood that social stigma and isolation, chronic pain, itching and insomnia can bring—are less well understood. And Fauerbach and his colleagues are remedying that.
Ironically, their studies are crucial because new approaches to wound care and more effective rehab have cut hospital stays for survivors by more than half. “So it’s imperative that we identify patients at risk for problems after discharge,” says Fauerbach.
Burn survivors are especially prone to PTSD and other anxiety disorders. Roughly a third of those severely burned meet PTSD criteria the year after injury: they show the classic symptom clusters of intrusive distressing thoughts of the traumatic event, suppression of anything that calls it to mind and hyperarousal, with its insomnia, anxiety and irritability.
For the past decade, Fauerbach—head psychologist for the burn unit—and his team have run defining studies on survivors’ mental health, both immediate and long term. They’ve shown, for example, that patients with previous psychiatric disease do less well long term after their injury. And those who develop PTSD while hospitalized find the disorder harder to shake after discharge.
They’ve also examined the anxiety process. “The immediate reaction to burn trauma is usually shock and helplessness,” says Fauerbach. How could that be otherwise? Pain is excruciating. Patients might see their skin hanging in sheets or see others react to their appearance with horror. In the next days, they begin to replay what happened, to have nightmares or intrusive memories or flashbacks, even. All are unpleasant; all reopen the initial event.
“What’s especially unsettling,” he adds, “is that these thoughts and feelings come automatically, without the patient willing them to occur. That can be part of the healing process. However, in many, a kind of cycling takes place. As thoughts intrude, patients try to suppress them to manage the anxiety. And this bouncing back and forth between intrusions and avoidance—this way of coping, we’ve found—seems to get people stuck. They’re most likely to develop acute anxiety and PTSD problems.”
Help, however, appears to come from an unusually close overlap of psychology and psychiatry. Fauerbach’s psychology-based team works closely with psychiatric specialists in anxiety disorders led by Una McCann, M.D. They integrate use of medications with cognitive behavioral therapy (CBT) that Fauerbach’s tailored to burn survivors. "We help them evaluate thinking that undermines confidence, that interferes with recovery,” he says. His five-year study of the specialized CBT—it encourages resilience and empowerment—has just begun. “It should clarify what’s protective, what’s therapeutic.”
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