Hahn, Anne P. PhD*; Jochai, Diana PhD†; Caufield-Noll, Christine P. MLIS, AHIP‡; Hunt, Carly A. MA†; Allen, Lauren E. MA§; Rios, R. PhD‖; Cordts, Grace A. MD, MPH¶
Self-inflicted burn injuries are relatively rare in North America.1 According to the most recent national Burn Repository Annual Report containing data from 1999 to 2008, 1115 burn injuries in the United States were suspected self-inflicted injuries, accounting for 0.9% of all burn injuries in that period.2 These percentages are relatively small, but the physical, psychological, and social effects on the patients, families, and staff are significant. The majority of individuals who sustain self-inflicted burns survive, and community reintegration is particularly challenging because of the severity of associated physical impairment.3 Thus, patients who survive attempted suicide by burning present complex challenges for treatment and postdischarge planning. Further understanding of characteristics of individuals who attempt self-immolation is needed to better inform acute, postacute, and long-term care.4 Existing investigations of self-inflicted burn injuries are limited by small sample sizes and inconsistent population estimates.
The goals of the present review are to summarize the existing literature and clarify strengths and weaknesses regarding the empirical information on self-inflicted burns in the United States. Specifically, the present report seeks to answer the following questions: 1) What are the personal and environmental characteristics of individuals, aged 16 years and above, who attempt suicide by self-burning? 2) What are the risk factors associated with this subpopulation of burn patients? and 3) What are the acute and long-term treatment needs and recovery outcomes? Studies of self-inflicted burn injuries in the United States were reviewed systematically in order to answer these questions.
Self-inflicted burns were defined as burn injuries deliberately inflicted by persons on themselves for the purpose of suicide. Self-mutilators, those who burn themselves without an attempt to commit suicide, were excluded from the review. Eligible articles were those that reported on individual and group characteristics as well as postburn outcomes of cases that had attempted self-immolation. Self-immolators without suicide attempt were excluded because they represent a different population. Articles reviewed included empirical accounts, epidemiologic studies, reviews, opinions, case studies, and dissertations reporting on self-burning in the United States among persons aged 16 years and above. The age cut-off was chosen to reflect the National Burn Repository age category designation for adults.2 No restrictions were made based on study design, outcomes examined, or whether or not treatment was provided. Articles that included self-inflicted burns as a main study topic were included in the study. Studies that focused only on self-inflicted burns as a form of mutilation without an attempt to commit suicide were excluded from the review. Additionally, articles on traumatic injuries and burns inflicted by assault were excluded.
The following databases were searched: PubMed, Embase, ISI Web of Science, Scopus, PsycInfo, Population Information Online, and Proquest Digital Dissertations and Theses for articles on self-burning. All searches included restrictions to select articles written in English, publication dates from 1970 through June 2011, and ages of cases as 16 years and over. The search strategy was to combine a search for terms referring to self-inflicted injuries or suicide attempts with search terms related to burns. An additional search in each database was conducted for the term self-immolation. Search terms for self-inflicted injuries included the following: suicide, self-inflicted, suicide gesture, suicide attempt, and self-injurious behavior. These terms were combined with a search for the term “burn” and its variants. Limits for age and language were added to the search. The search strategy was adapted to accommodate the specific parameters of each database (detailed descriptions of each search process are located in Appendix A). After duplicate articles were removed, a total of 2803 articles were selected for potential inclusion in the review.
Initially, two authors (A.H. and D.J.) independently reviewed each article by title. Abstracts were reviewed in a similar manner and those that did not meet inclusion criteria were eliminated. The final step was a review of the full text. The two authors were usually able to reconcile any differences in opinion with regard to inclusion of articles, but a third author (G.C.) assisted with disagreements that could not be resolved. The initial search of all databases resulted in 2803 possible articles. Duplicates were eliminated and 986 articles were excluded on the basis of title review. Three hundred and one articles were reviewed by abstract and of those, 256 were eliminated. Forty-five articles underwent full-text review and 19 articles were excluded because of an emphasis on self-inflicted burns as a form of mutilation and/or burn injuries secondary to assault. Non-U.S. samples or foreign-language studies were excluded. Articles that included demographic and/or injury characteristics for the individual with self-inflicted burn injuries alone were deemed pertinent to the review. Twenty-four articles remained after reviews by title, abstract, and text. A search (G.C.) of the bibliographies of 24 articles resulted in identification of eight additional articles that met inclusion criteria. The total number of selected articles was 32 (Figure 1). Two investigators (A.H. and D.J.) extracted the following information from each article: type of study, sample size, study design, individual characteristics/risk factors including individual and familial predisposition to suicide, history of childhood/adult abuse, and contextual variables including religious traditions and political motives for self-immolation. Articles were also reviewed for information on hospital and clinical management issues such as length of stay, mortality rates, timing of joint surgical and psychiatric care, as well as physical and psychiatric outcomes. Ethical issues and staff concerns arising from the care of this subset of burn patients were extracted if available. An analysis of quality of study design and potential bias was conducted in the course of our review. No studies were eliminated based on quality of design, and heterogeneous types of studies were included in this review.
Thirty-two articles met selection criteria for inclusion in this systematic literature review (Table 1). Fourteen articles were retrospective chart reviews. Three articles were combinations of retrospective chart reviews and case studies. Seven articles were case reports. Three articles were analyses of burn national databases. Five articles were the following: an editorial, a doctoral dissertation, a letter to the editor, a discussion article, and a historical review.
Retrospective Review Articles
Twelve of the 14 retrospective chart review articles were conducted at regional burn centers in the United States. The most recent was published in 20065 and the oldest in 1983.6,7 Most reviews focused on describing demographics and personal and contextual characteristics of self-inflicted burns (Tables 2 and 3). The characteristics most cited were: sex, age, history and/or presence of psychiatric illness, alcohol and drug use, and mortality. Issues surrounding the cause or circumstances of the injury such as living situation, recent stressors, use of accelerants, suicide notes, and planned vs impulsive act were mentioned less frequently. Mortality rates were high for these patients.5 Krummen et al8 found very high lethality rates when they compared self-inflicted burn patients (29%) with all other burn patients (6.48%). Pham et al9 observed that the length of stay was double that of other burn patients and the mortality rate was triple. There was no consistent pattern to either age or sex. The age ranges were from 17 through 84 years and the male/female ratio for self-inflicted burns was almost equal. The average sample size for the chart reviews was 22 subjects.
Four chart review articles did not focus exclusively on self-immolation but were included because they contained useful information on the subject (Tables 2 and 3). Parks et al10 reviewed charts from burn facilities in Southern California to identify risk factors in burn fatalities. Swenson et al11 focused on identifying patients who used alcohol and/or drugs in conjunction with their burn injury. Tuohig et al12 reviewed charts of those who burned themselves as an act of self-mutilation vs those who burned themselves as an act of self-immolation. Reiland et al5 investigated cases with intentional burns, which comprised suicide attempts by self-inflicted burns and burns inflicted by assault.
Copeland13 reviewed case files from the Medical Examiner’s office in Dade County, Florida. This study was undertaken to delineate situation dynamics of self-immolation in a large, urban population. This review collected information on contextual features such as the type of accelerant used, the time and place of the occurrence, and the presence of a suicide note.
Several chart reviews discussed motivations for suicide by burning. Erzurum and Varcellotti14 and Squyres et al15 cited the desire to escape from stressful situations and sadness as major contributors. Krummen et al8 identified several precipitating events: failure of interpersonal relationships was among the most frequently noted, followed by chronic illness and job loss. Squyres et al,15 Swenson et al,11 and Parks et al10 found that impaired mental functioning as a result of drug abuse was a major contributing factor. Swenson 11cited specific drugs (ie, methamphetamines and cocaine) as influential on the decision to attempt self-immolation.
Daniels et al16 found that patients with self-inflicted burns generate stress and disorganization among the burn unit staff. This article found that a pervasive sense of sadness and horror was often observed among the staff. These feelings were frequently expressed by overt grief such as crying or anger and/or irritation toward the patient and the feeling that the patient did not deserve their time and attention.
Three articles addressed hospital discharge outcomes, and one attempted to follow-up with patients after 2 years. Daniels et al16 were able to follow up with five patients. They found that none were employed and only one survivor was living independently. Four of the five survivors said they intended to kill themselves, and one said that he would harm himself. Hammond et al17 found that patients in their sample tended to go home after hospital discharge. Nielsen et al18 were able to contact eight patients at a 2-year follow-up interview. They found that all the patients had returned to their preinjury level of functioning. It was not specified what the level of function was at follow-up. Three had attempted suicide by nonburn methods. These articles did not address discharge status between self-immolators and other burn patients.
Useful information on drug/alcohol use in this subpopulation as well as recommendations for screening and diagnosis were observed in several of the chart reviews. Several studies documented high alcohol content and positive drug screens in patients with self-inflicted burns.5,10,15 These researchers all found that alcohol/substance abuse and impaired mental functioning either from psychiatric or neurologic causes are predisposing factors for burns, and intentional burns in particular. The coexistence of these disorders makes the diagnostic process difficult, particularly if patient and family corroboration is absent or limited.15 Reiland et al5 found that substance abuse can produce organic mental disorders leading to impulsive and self-injurious behavior. Drug and alcohol use can play a significant role in all burn injuries, particularly intentional burn injuries. Swenson and Dimsdale19 recommended routine drug and alcohol screening on admission. They also recommend the use of a structured interview by the psychiatrist to assist in delineating the role alcohol/substance abuse vs psychiatric disorders play in these injuries.
Tuohig et al12 reported on two subsets of burn patients: those who attempt suicide and those who self-mutilate. The authors point out that these patients may seem to be a homogenous group but in fact are very different. Both groups may suffer from preexisting psychiatric disorders, but cases of intentional burns tend to have a family history of suicide and social stressors such as medical illness, lack of social support, and financial issues. Hammond et al17 also found that health problems were a predominant motive for self-inflicted burns. Self-mutilators are more likely to have a history of childhood or adult sexual abuse, eating disorders, and personality disorders. However, Daniels et al16 observed that a third of the self-inflicted burn patients in their review had histories of physical, emotional, and sexual abuse.
Self-inflicted burns are complex and difficult to understand and manage both in the acute and postdischarge stages. Pham et al9 suggested that self-inflicted burns may represent the culmination of a failed mental health delivery system. Several researchers9,14 pointed out that better data are needed at both the system level (access, quality, and outcome) as well as at the clinical level (methods of predicting patients at risk for desperate acts and evidence-based management techniques). Intensive efforts are required at many levels of the mental health system in order to increase availability and effectiveness of services.9 A joint effort among psychiatrists, physicians, nurses, social workers, and even forensic scientists13 is needed to provide best data and outcomes to patients with evidence of preexisting psychiatric disorders and other comorbidities.5,17
Retrospective Chart Review and Case Reports
The three articles on retrospective chart reviews reported their findings via case reports. In their retrospective study of all patients hospitalized during a 5-year period for burn injuries, Brodzka et al20 identified two cases of suicide attempts by burning. Both patients suffered from a psychiatric condition, whereas one had a history of alcohol abuse. Stoddard et al21 and Stoddard and Cahners22 conducted a chart review of adolescents admitted to a pediatric and adolescent burn unit in order to identify psychosocial precursors to attempted self-immolation. The authors identified six patients who met criteria for attempted suicide by burning, and conducted in-depth case studies of each patient. The characteristics identified were sex, age (all adolescents), history or presence of psychiatric disorder, recent stressors, and religion. They also included follow-up data from 1 to 7 months postdischarge, and reported that one patient had been successful at suicide.
Stoddard et al21,22 discussed the role religion played in attempted adolescent self-immolation. The specific religious tradition was less important than the manner in which the religion was practiced. Families who approached their religion with fundamentalist beliefs and literal interpretation of scriptures accompanied by guilt and punishment for wrongdoing were contributing factors. The same authors21,22 suggested that biological and genetic factors could contribute to suicidal behaviors. In particular, family histories of major affective disorder, schizophrenia, and violent suicide attempts could be predictive and/or contributing factors.
The Stoddard research21,22 also provided insights into the challenges of psychiatric treatment with adolescents. The authors found that families often impeded psychiatric intervention, either before or after, the suicide attempt. Families were often resistant to dealing with their own feelings, particularly guilt. The authors pointed out that psychiatric prognosis is always guarded, and that suicidality can be reactivated throughout the course of acute and postdischarge care. Thus, staff concerns about suicide risks during acute and postacute phases were realistic.
Four of the seven case reports were conducted at Regional Burn Centers.23–26 Cimino et al27 reported on cases from the Medical Examiner’s Office in Washington State. James et al23 compared self-burn patients with other types of suicide attempts from case files in the liaison consultation service at the University of Louisville. Geller28 reviewed cases from a variety of sources including burn, psychiatric units, coroner’s offices, and academic medical centers.
Demographic characteristics cited most frequently were age and sex.22–26 No consistent pattern emerged regarding postdischarge arrangements (ie, home, psychiatric unit, or alcohol/drug rehabilitation center). The average sample size was six.
The purpose of the case studies was to identify the characteristics associated with self-immolators.24,27–29 Three case reports were interviews with patients after discharge.24,25,29 Three studies were case reviews obtained from clinical consultations and medical records.23,27,28 Kuehn26 described the medical and psychosocial aspects of a single, challenging, self-inflicted burn patient. James et al,23 Antonowicz et al,25 and Kuehn26 discussed the clinical management of self-immolators.
The case studies provided in-depth data on hospital and clinical management of this subset of burn patients. James et al23 reported that length of stays, pain medication requirements, and treatment adherence did not differ from burn patients with non–self-inflicted injuries. Geller28 found lethality to be higher for self-inflicted burns when compared with other burn patients. Recovery outcomes, when reported, usually focused on psychiatric outcomes. Antonowicz et al25 found that six of seven cases they studied were discharged to outpatient psychiatric care or inpatient psychiatric units as voluntary admissions. Kuehn’s study26 of one self-inflicted burn patient reported that he completed physical rehabilitation, was discharged home, and was able to work part-time in a family lumber business. The patient, however, dropped out of psychiatric outpatient care.
Important clinical issues were illustrated in the case reports. Kuehn26 described the medical and surgical interventions required to stabilize the patient in the acute phase, including fluid resuscitation and massive metabolic and cardiovascular challenges in the context of immediate need for surgical wound intervention. Psychiatric complications were described, such as the profound stress experienced by families (guilt, shame)23 and the difficulty in obtaining a psychiatric history when the patient is too sick to engage in an interview and the history or previous records may not be available or easily obtained.25 The prescribing of psychotropic medications may be complicated by the potential for interaction with other medications.25
Several case studies23,25,26 reported on the range of psychiatric and other mental health treatment during the acute phase. Patients were evaluated by psychiatry at the onset of treatment but no specific time line was mentioned. Generally, the psychiatric service assessed suicide risk and prescribed medications. One article25 mentioned an important role for psychiatry at the time of discharge. Self-inflicted burn patients often require inpatient psychiatric care on discharge. The psychiatrist can assist in negotiating with units to accept this subset of burn patients who can present with wound care issues not usually handled in a psychiatric unit.
The case studies23,25,26 reported that other burn teams such as psychology and social work played important roles in the daily management of the patient and family. Team members specializing in psychology and social work met with patients and families to assess coping, provide support, and meet concrete needs. Antonowicz et al25 credited early mental health intervention, particularly psychiatry, with successful adherence to outpatient mental health care postdischarge.
Some of the case reports highlighted important issues for psychiatric management. Grossoehome and Singer24 and Geller28 found histories of childhood abuse, incest, and rape in two female patients they studied. Religious and cultural traditions were cited in several studies. Cimino et al27 found that Asians were overrepresented in their study. Their sample was small but they considered whether cultural attitudes could have influenced the self-inflicted injury. Andreasen and Noyes29 found religious themes among their cases, including abandonment by God, punishment, and a history of strong religious backgrounds. Grossoehme and Springer24 recognized that burning can have symbolic meaning as a form of cleansing, punishment, or protest in some religious traditions. They studied cases both prospectively and retrospectively to discern images of the religious meaning of God in patients who had attempted suicide by burning. They recommended spiritual assessment along with surgical and psychiatric care.
The case studies did not address familial or genetic risks. Some studies reported that patients with self-inflicted burns had a history of suicide attempts.23,26,27 Kuehn26 described characteristics of impulsivity, ineffective coping, depression, and alcohol abuse in one patient. No in-depth family histories were recorded to substantiate a genetic component.
Several case reports23,26 addressed ethical issues that arise in the care of this subset of burn patients. Most frequently mentioned was the principle of autonomy. Staff often asked whether attempts should be made to treat the patient against his or her wishes if the patient wanted to die. Feelings of anger and frustration among the staff were reported because of the perception that the injury was preventable. In one case26 the family wanted “do not resuscitate” orders written and the staff felt that was not appropriate. Ethical dilemmas were resolved by communication among the surgical, psychiatric, and other burn unit staff including nursing and families. There were no case reports of use of hospital ethics boards or consultations.
Several case reports23,25,26 described the stress of caring for self-inflicted burn patients. Nursing staff often felt uneasy caring for patients with a history of violent, bizarre, or impulsive behavior. The possibility of another suicide attempt was an issue for nurses not trained in psychiatric care. Kuehn26 described one case in which the patient resorted to staff splitting, that is, playing staff against each other by complimenting some and complaining about others. This was viewed as a coping mechanism on the part of the patient, and was handled by rotating nurses, staff education, and support. One study23 recommended the use of a psychiatric liaison nurse to assist nursing staff with behavior issues.
Three articles analyzed national databases. Modjarrad et al30 reviewed data from the national Burn Registry maintained by the American Burn Association to capture epidemiologic features of self-inflicted burns over a diverse geographic area. Thombs et al4 extracted and compared data from the following: U.S. National Vital Statistics maintained by the CDC, U.S. National Electronic Injury Surveillance System All-Injury Program, and the American Burn Associations’ National Burn Registry. Thombs et al4 hypothesized that age patterns of suicide could be indicators of altered mental status (psychosis, intoxication) across the life span. The authors compared age patterns of suicides by burning with those of all suicides completed by other methods. Thombs and Bresnick31 abstracted data from the National Burn Repository. They compared the mortality risk and length of stay in the intensive care unit and hospital between self-inflicted burn and non–self-inflicted burn patients (Table 3). Demographic and medical characteristics between the two groups were matched and compared, whereas confounding variables (eg, TBSA) were statistically controlled.
The data collected in these three studies were confined to the demographic and medical characteristics dictated by the databases. As a result, there was less in-depth information about patient characteristics and contextual features surrounding the self-inflicted burn event. Age, sex, and ethnicity/race were reported in all three studies. Biomedical information was mentioned frequently, including history or presence of psychiatric illness and alcohol/drugs and medical illnesses.
Relative to non–self-inflicted burn survivors, Modjarrad et al30 reported that self-inflicted burn patients had longer intensive care unit and hospital length of stays (Table 3). However, Thombs and Bresnick31 controlled for TBSA and reported no differences in length of stay between self-inflicted and non–self-inflicted burn patients. Modjarrad et al30 found that self-inflicted burn patients are more likely to be older and female relative to non–self-inflicted burn patients; however, Thombs and Bresnick31 reported that self-inflicted burn survivors tend to be younger than non–self-immolators. Modjarrad et al30 concluded that self-inflicted burn patients have a poorer prognosis relative to non–self-inflicted burn survivors. Regarding clinical care recommendations, Thombs and Bresnick31 reported that self-inflicted burn survivors can recover reasonably well if they were provided intensive psychiatric, social, and medical management throughout the acute and chronic stages even in the context of a large burn. Thombs et al4 suggested that sufficient psychiatric management is needed for the self-inflicted burn patient to make a complete recovery.
An important theme expressed by Thombs and Bresnsick31 was that self-inflicted burns, especially among young individuals, may be an impulsive act in the presence of a psychiatric or substance-related disorder. The longer length of stay for self-immolators relates not to the size of the burn, but to the underlying psychiatric disorder and/or substance-abuse problems.31 It is known that patients with psychiatric disorders can be very difficult to manage,25,26,31,32 which may a result of lack of motivation, poor adherence, and the negative attitudes of the medical and surgical staff toward the patient.26 Thombs and Bresnick31 recommend early psychiatric evaluation, diagnosis, ongoing treatment, and staff support and education. These patients have the potential for a good recovery if they receive intensive psychiatric and case-management services from admission through discharge. Those providing direct patient care in the acute phase may never have the opportunity to see positive long-term outcomes among self-immolators. This reality may add to the challenges associated with acute care of self-inflicted burn patients.
Editorial, Dissertation, Letters to the Editor, and Discussion Article
Stoddard32 made a strong recommendation for adequate psychiatric consultation to burn units to assist with the care of self-inflicted burn patients. These patients, Stoddard suggested, likely had little or no psychiatric care before the injury. Additionally, they are at continued suicide risk and require sufficient psychiatric care on discharge. The reality of insufficient psychiatry liaison consultation to burn units and continued rationing of care was recognized, but the point was made that these burn patients are critically ill psychiatrically and surgically, and require equal attention from both specialties. Ranucci33 completed a doctoral dissertation that examined group differences between two burn subgroups (self-inflicted burns and self-mutilation by burns) and nonintentional burns. Gear et al34 illustrated the characteristics of patients who attempt self-immolation by a case example in a letter to the editor. In another letter to the editor, Swenson and Dimsdale19 called attention to the significance of drug-induced altered mental states in patients who attempt suicide by burning. Romm et al35 wrote a historical review of self-immolation, and explored common motivational threads for the act.
Ranucci33 analyzed characteristics of 109 self-immolation patients from the Burn Model System multicenter database. These patients were more often young, female, unmarried, and unemployed as compared with patients in the self-mutilation subgroup or overall burn group. The self-immolators also had histories of psychiatric illness and alcohol and drug use, had higher mortality rates, and continued with suicidal ideation at the time of discharge. Gear et al34 cited the case of a 73-year-old man who attempted suicide by self-immolation. The subject’s history of psychiatric disorder and acting impulsively were described as being similar to that of other self-immolators. Swenson and Dimsdale19 wrote to the editor to further comment on their study, published in 1991, which found that drug use can play a major role in self-immolation. Romm et al35 wrote a nonclinical article that traced the history of self-immolation in literature, politics, and cultural and religious traditions.
Various themes were expressed in these articles. Swenson and Dimsdale19 and Gear et al34 cited drug use and impulsivity as important motivators. Ranucci33 concluded that early psychiatric intervention for the patient, as well as staff support and education, were important factors for patient recovery. Romm et al35 listed several reasons for selecting this manner of suicide: protest, psychological pain, self-hatred, and loss. However, the authors, after reviewing many forms of literature, could not find a common thread to explain the motivation for self-immolation.
These articles addressed several issues in hospital and clinical management. Gear et al34 discussed the complex range of intensive burn care but not the range of psychiatric care in his discussion of one burn patient with significant depression and personal issues. Swenson and Dimsdale19 stressed that psychiatric and substance issues often occur in tandem, and psychiatric assessments are needed to tease out if the substance abuse induced an organic mental disorder. Stoddard32 recommended psychiatric evaluation at the time of discharge from the acute burn unit to determine suicide risk. Rehabilitation or skilled nursing facilities are often hesitant to accept a patient who poses a suicide risk. This recommendation was underscored by Ranucci’s finding33 of high rates of suicidal ideation at the time of discharge. Gear et al34 pointed out that disfigurement from burn injuries can add to a patient’s isolation and depression, which can increase the risk of suicide.
Clinical management issues were addressed by several authors. Romm et al35 discussed cultural, political, and religious traditions when assessing motives for self-immolation. Ranucci33 and Stoddard32 stressed the need for staff support and education. Stoddard32 also argued for state-of-the-art psychiatric and burn care during the acute phase and ongoing psychiatric treatment throughout rehabilitation and after care.
The results suggest that data describing patients who attempt or complete suicide by self-immolation are inconsistent, often contradictory, and limited to specific geographic areas. Because of small sample sizes and nonsystematic data collection methods across studies, little conclusive information is available describing the self-inflicted burn population. The present review was conducted in order to identify personal and environmental characteristics, risk factors, treatment needs, and recovery outcomes associated with self-inflicted burns. The results were weak and inconclusive because of inconsistent data-collection methods across studies and the absence of theoretical or empirical data to guide the reviews. Overall, the data do not reveal unique demographic characteristics that define self-inflicted burn survivors.
When compared with national suicide data,36,37 few similarities were found between self-immolators and those who commit suicide by other methods. For instance, men are more likely to die from suicide attempts but women are more likely to attempt suicide. The present review suggests that survival probability after suicide attempt by self-immolation is undifferentiated across sex categories. National data37 found the highest rates of suicide in specific geographic areas, intermountain states in particular. The present report did not reveal a geographic area most commonly associated with self-immolation attempts. Nationally, the elderly have the highest rates of completed suicides.37 Some of the reviewed articles did support this statistic, including a study from the medical examiner’s office in Dade County, Florida13 and one case study34 of an elderly man who attempted suicide by burning. The present review examined self-immolators aged 16 years and older; therefore, the data presented contain little information on suicide frequency among adolescents. However, national data37list suicide as the third-leading cause of death for adolescents in the United States. Stoddard et al21 reviewed charts of adolescent self-immolators to identify psychosocial precursors, but conclusions were limited by small sample size.
A primary aim of the present review was to identify contextual information associated with self-immolation. This could include data about national or local crises, family information, location of the event, presence of a suicide note that could provide data on motive, use of an accelerant, and any association with other factors, such as sex, age, marital status, stressful life events, and losses. National data37 suggest that suicide rates decrease at time of war and increase at times of economic crisis, and that unmarried persons are more likely to commit suicide than those who are married. Environmental and demographic information was collected in the reviewed studies, and no association could be drawn from the reviewed data about how variables might interact or influence suicide by self-immolation.
Another primary goal of the present report was to identify risk factors associated with self-immolators. The data indicate that a history or presence of mental disorders, particularly depression and schizophrenia, as well as alcohol or drug use, are clear risk factors. This finding is consistent with national data.37 The question that was not answered is why a subpopulation with these risk factors choose self-immolation as a method to commit or attempt suicide. Family history of suicide,21–23,25,27 history of childhood/adult sexual abuse,24,28 and religious motives21,23,27,29,36 could all be important variables, but do not completely explain this choice of suicide method. One article28 did suggest that more information about contextual factors and how these may interact or influence risk factors could provide insight into this unique subpopulation.
Another study goal related to treatment needs and long-term outcomes. It is estimated that 90% of people who die by suicide have a diagnosable and treatable psychiatric disorder.37 A number of our reviewed articles9,11,16,17 recommended inpatient psychiatric evaluation and treatment using a multidisciplinary approach by mental health specialists. Coordination of care with community practitioners should also be arranged while the patient is still hospitalized. These suggestions are appropriate but not particularly useful. Is psychiatry always available? What constitutes a multidisciplinary approach? Who assesses and treats the patient, the family? At what point in the acute phase does assessment and treatment begin, and what constitutes treatment? Perhaps, most importantly, what resources should the patient be referred to in the community and are these available? We found that the recommendations for treatment and follow-up to be nonspecific. The need for a multifaceted psychiatric treatment plan in the self-immolation patient subpopulation has been previously emphasized, and it has been recommended that treatment includes management of the acute reaction to the burn, treatment of preexisting psychopathology, pharmacologic treatment, and postdischarge treatment planning.32 We recommend a joint surgical–psychiatric approach to assess, diagnose, and plan a course of surgical and psychiatric treatment, and emphasize that other team members play important roles as well. A dedicated burn unit psychologist and social worker may carry out the daily management of therapy/counseling for the patient and family. The burn chaplain can make an important contribution by assessing any spiritual motive for the suicide attempt and offering supportive counseling. Social work and case management are important in facilitating not only a discharge to a facility or home but also in linking the patient to community resources, such as the Phoenix Society for Burn Survivors, and for follow-up psychiatric care and social support.38
Limited data were available on long-term outcomes in the articles reviewed. Daniels et al16 reported that of the five patients they were able to reach for follow-up, none were employed and only one was living independently. Two made significant suicide attempts and one person intended to harm himself at some point. No information was provided regarding any follow-up psychiatric care these survivors may have received. The Nielsen et al18 findings at 2-year follow-up were more positive. Eight patients were reached for follow-up and none had tried to burn themselves a second time, but three had attempted suicide by other methods. The findings reported that the eight patients had returned to their premorbid level of functioning, but this level was not defined. Stoddard et al21,22 reported that some patients had gone on to complete suicide. Ranucci33 reported that many patients continued to have suicidal ideation at the time of discharge. The literature reviewed in this study supported the possibility of a suicide attempt either in the acute or follow-up phases of care. One-to-one monitoring of patients in the burn unit, based on the data, would appear to be in order to prevent attempts at self-burn or other type of self-injurious behavior. An attempt to identify, interview, and assess the functioning of patients several years postdischarge would be useful information to improve clinical management and to inform burn staff that positive outcomes are possible.
National data36,39 conclude that family members experience a range of complex grief reactions including guilt, anger, or abandonment. Attempted or completed suicide by self-immolation is horrifying. Families may experience a form of posttraumatic stress disorder and should be provided with assistance; several reviewed articles suggested that families can cope and recover.37,39 Our review suggested that family dynamics, particularly relationship loss, may play a role in an impulsive act like self-immolation.,1820 Family counseling may be as important as patient therapy, particularly if the patient will return to the family postdischarge.
The present literature review provided little data to guide ethical practice with self-immolation burn patients. The search revealed scant or conflicting information about the context or motives for the act, which could assist in evaluating ethical dilemmas. Additionally, there was little information on how suicide survivors function postburn care or about their quality of life. The best information provided was that some survivors had returned to their previous level of functioning, but that level was not defined.18
Almost all the literature reviewed called for intense psychiatric evaluation, treatment, and follow-up care in the community. However, these resources, especially in the community, may not be available, accessible, or affordable; also, the patient may not adhere to treatment. Yet, comprehensive psychiatric care is critical for these patients. For example, disfigurement from the burn injury may add to the patient’s hopelessness and isolation, thus placing the patient at higher risk for future suicide attempts. Proper psychiatric care could potentially minimize this risk.
Given the lack of specific information about self-immolators’ motives, burn specialists must be guided by general principles of medical ethics when treating these patients in preinjury psychiatric diagnosis, treatment, and postinjury care.40 Autonomy, the patient’s right to choose, is often considered the cornerstone of ethical care. In the case of attempted suicide, it is generally accepted that the patient’s behavior is motivated by ambivalence about life/death choices, and the act is a “cry for help.”40 Suicide attempts often are undertaken when the patient is suffering from a treatable psychiatric or substance-induced disorder rendering the person unable to make a fully informed choice to die. This review of the literature very much supports that premise. Stoddard32 used this argument to advocate for “state-of-the-art” surgical and psychiatric intervention. His view was that many of these patients may never have received any or sufficient psychiatric care before the self-inflicted injury.
However, the principles of beneficence and nonmaleficence must be considered if the self-inflicted burn injury results in ongoing suffering with an increasingly poor prognosis. It may be reasonable to periodically review the goal of care and analyze the benefit/harm ratio if the patient’s condition deteriorates or if the surgical interventions required to save the patient’s life would render the patient with a poor quality of life. These periodic “goal of care” discussions would benefit not only the patient and family,41 but also the staff, who may have mixed feelings about subjecting the patient to further pain and suffering.
Quality of life is subjective, and for a critically ill patient this concept may have to be interpreted for the patient by a surrogate decision maker. Usually that person is a close family member or friend who knows what the patient would want in this situation. However, no one can ultimately know what the patient intended or would now want in light of the injuries. Burn unit staff have the obligation to screen the potential surrogate decision maker to be certain that he or she has the patient’s best interests at heart and that he or she is trying to carry out what he or she believes to be the patient’s wishes.
Interestingly, none of the reviewed literature, when ethical issues were mentioned, discussed the use of the hospital ethics committee, palliative care services, or pastoral care. It is not clear why these important resources at times of ethical challenges were omitted. One article was written by chaplains.24 They reviewed cases for religious motives in suicide attempts and made suggestions about the role of the chaplain in assisting self-immolators to develop more adaptive images of God and spiritual insights. The role of chaplains in ethical dilemmas was not discussed.
The laws in the United States should be considered in these ethical dilemmas because they provide a cultural context for viewing attempted suicide. Suicide is not illegal in this country as it once was. However, suicide-prevention laws are in place to prohibit acts of assisting a person to commit suicide.40 Caring for the person who attempts suicide is morally and legally sanctioned in this country.
The cost of caring for self-immolators should not enter into any ethical or clinical discussions. The literature reviewed did not cite the economic burden of care for this subset of burn patients. However, the cost can be inferred by the longer length of stays for these patients and the need for additional nursing care, such as one-to-one monitoring for suicide risk. However, the greater costs are the psychological and social burdens incurred by the patients and families. Patients who attempt suicide by self-immolating often have poor coping and relationship skills15 and a propensity for substance abuse,11 which complicate healing and community reentry. Families are forever burdened by the conflicting emotions toward the patient as well as guilt that comes from thinking that they could have prevented the event.32,39
Caring for patients who attempt suicide by burning is challenging. These patients are critically ill and may present with behavioral issues as a result of their underlying psychiatric conditions. Several authors discussed the burden on the staff, including staff members’ negative attitudes toward the patient.23,25,26 Ethically, the patient’s behavior, regardless of how distasteful it may be, should never enter into medical decisions or influence care.40 However, the data from this review26,32 support the notion that this subpopulation of burn patients are difficult to psychiatrically manage and treat in a critical care setting where flexibility, routines, and expertise differ from those in a psychiatric unit.
Burn care requires clinical expertise and compassion. It is not just a duty to provide compassionate care, but a moral responsibility transcending all professions.42 Continued exposure to seriously injured patients and those in pain can profoundly affect the caregiver. The study of traumatic stress43 has expanded to include persons, such as emergency responders and nurses, who may indirectly experience negative emotional and physical responses to the victim’s trauma and suffering. Evidence from the fields of oncology, palliative care, psychotherapy, and trauma have contributed to the concept of compassion fatigue, or secondary traumatization.44 This concept arises from the clinician’s caring relationship with the patient and identifying with the patient’s feelings and circumstances. This differs from the concept of burnout, which develops from frustration and a sense of powerlessness related to barriers in the workplace (eg, negative attitudes or inadequate equipment).44 Both compassion fatigue and burnout can negatively affect the organization (eg, high turnover and low morale), as well as the individual, who may experience physical symptoms (eg, exhaustion) and emotional symptoms (eg, irritability, cynicism). The current evidence does not support a “rescue personality” (ie, a particular personality type who seeks out emergency services or situations).45
People who engage in caring professions are often extroverted, enjoy a high-paced environment, and like working with others.45 The literature recommends that professionals in stressful positions be supported in these positive personality characteristics at both the organizational and individual level. Ultimately, the goal of the organization should be to prevent compassion fatigue from becoming an occupational hazard.44 Organizations (eg, professional schools, hospitals, burn units) can implement preventive measures such as adequate communication,46 education about secondary traumatization47 and consultation with other professionals, superiors, et al.48 Individual-level prevention strategies include caring for colleagues,46 meditation, peer support, and reflective writing.44 These strategies focus on promoting self-awareness and self-care, which are essential when providing assistance in the presence of overwhelming suffering.44
A major limitation in a study of self-immolators is the small number of people who attempt suicide in this manner. The small number and infrequency of occurrences in burn units make it difficult to study. Self-immolation is not culturally sanctioned as a form of suicide in Western culture, and thus it is rarely seen. This literature review strongly supports the idea that self-immolation in this country occurs because of impaired judgment and little or no impulse control, which is often precipitated by psychiatric conditions and/or substance abuse.4,33 Considerable literature exists with regard to self-immolators in other cultures, particularly Iran, India, Sri Lanka, and Afghanistan.49–53 Self-immolation in these countries is linked to poverty, low education, being female and married, often with conflict-ridden marital relationships and limited options for employment.49–51 The act of self-immolation in these countries relates more to social and relationship difficulties rather than untreated psychiatric and substance abuse disorders.
The cultural context of an attempted suicide by self-immolation must be incorporated into patient assessment. Culture, which is the sum of attitudes, customs, and beliefs, profoundly influences human identity, behavior, and decision making. In recent years, the psychiatric community has recognized that distress can be expressed in culturally embedded ways, which can differ by region, age, sex, local conditions, and traditions.54 Further, cultural factors may influence the manner in which disorders are experienced, reported, and diagnosed.55 Fire can convey a number of meanings in various cultures including purification, sacrifice, and punishment, as well as more contemporary images associated with war, political protest, and nuclear destruction.22 Culture can also influence the patient’s and family’s response in dealing with the burn, including the psychiatric and social ramifications. A cultural context that promotes secrecy and guilt may limit the psychiatrist’s ability to fully engage the patient and family in therapy.22
The psychiatric community is responding to the need for improved cultural competency in clinical care by integrating sociocultural data into nosology and diagnostic practices in the forthcoming Diagnostic and Statistical Manual of Mental Disorders.54 Worldwide migration and the international use of the DSM-V demand greater expertise and sensitivity to cultural concerns. Diagnostic tools for cultural assessment in the intake process have been developed.56 Cultural assessment provides the clinician with an understanding of what is meaningful to the patient, which must inform and influence both diagnosis and treatment. Self-immolation survivors are often left with multiple physical and psychosocial complications. Discovery of what is culturally valuable to the patient may be used to encourage hope and promote healing.57 Psychiatric, surgical, and rehabilitation treatment of self-immolation survivors must be based both in our own cultural values concerning compassionate and quality care, as well as in an openness to accept and understand the values of others. The movement toward global mental health care necessitates an understanding of one’s own cultural beliefs as well as those of others for the establishment and sustenance of an effective therapeutic relationship.54,56
Several authors4,32 suggested that consistent information be collected across data-collection sites on self-immolators, as the phenomenon is rare in the United States. An agenda to improve knowledge in this field should include investigation of demographic data, medical/surgical complications, psychiatric interventions, social information, hospital-management issues, and outcomes. Specifically, it is recommended that data collection include the following: medical histories, burn size, surgical complications, previous psychiatric diagnoses and treatment, history of abuse, substance-abuse history and toxicology screens at time of admission, and psychiatric intervention provided during the acute phase. Further, data on the patient’s social support system, quality of familial relationships, discharge barriers, and hospital issues, such as length of stay, cost, additional nursing care provided, and type of staff support offered should be obtained. Information about ethical issues should be collected, including end-of-life decisions and whether ethics committees, palliative care, and/or chaplain services were used. Outcome information should be collected at the time of discharge, and a protocol put in place to track patients for long-term outcomes. This information would not only improve the state of knowledge but would assist in establishing best practices with this subset of burn patients. The agenda for such a multisite trial could be established at a consensus meeting, in conjunction with the American Burn Association, involving multiple burn centers in various geographic areas. Once consistent information is obtained, providers would be in a stronger position to produce best practice guidelines for acute and postacute care. This could lead to the establishment of specialized medical, psychological, and social burn rehabilitation units in the United States. Ideally, such a unit should be run as a joint surgical, psychiatric, and rehabilitation unit. The surgeon, psychiatrist, and physiatrist can establish a plan of care that would be carried out by nurses, physical/occupational therapists, psychologists, social workers, case managers, and chaplains, as well as trained burn survivor volunteers. Finally, such a unit could provide experience for students in various professional areas.
The present results have several limitations. The review was limited to studies in the United States. The purpose of the review was to characterize the self-immolation population in the United States, a country that does not offer universal health care, unlike nations such as Canada. International studies were excluded because, as mentioned previously, self-immolation is regarded differently in cultures outside North America and may be a reflection of normative behavior, traditions, or rituals. The phenomenon is no less a public health problem for other countries, but the context differs significantly from the United States. Finally, articles included in this study were generally descriptive, retrospective, and confined to one geographic area. Results could not be generalized to the national burn population.
What do these studies, despite their limitations, say about human nature, suicide attempts, and attempts to commit suicide by burning? Humans are resilient. Several authors4,16,17,31 point out that despite the horrific event and the physical, psychological, and emotional challenges that accompany the event, patients can recover and reenter the community. Families can also recover if provided with adequate assistance.39,58 Burn staff are challenged by these patients, but the studies suggest that they be provided with education, support, and a multidisciplinary team to effectively manage these patients and their feelings about caring for the patients.5,7,8,24,33 Staff should be provided with information so that this subgroup of patients can successfully recover and so that caring for them is not perceived as futile.
Romm et al35 suggested that motives for self-immolation could include: political protest, psychological pain, and relationship loss. However, there may not be one thread or theme that explains why an individual would select this method to commit suicide, if indeed that is the intent. Perhaps this uncertainty about the cause makes this phenomenon so difficult to understand and manage: it cannot be easily explained and multiple motives may account for the act.
This is the first systematic review of the literature on the topic of self-inflicted burns in the United States. Considerable literature exists on the topic but data have not been collected in a systematic manner, and the samples are generally small and limited to specific geographic areas. Some information exists about people who survive this method of suicide attempt but there is very little information on long-term outcomes. Several authors4,30,31 suggest that consistent information be collected on selected demographics, precise psychiatric histories and diagnoses, contextual information, and long-term outcomes. This information gathering could be achieved by a consensus meeting involving multiple burns centers in various geographic areas. Once consensus information is obtained, providers would be in a stronger position to produce best practice guidelines, and recommendations for postacute care and community reentry. Data about this subpopulation of burn patients could also assist with the creation of innovative solutions for discharge, such as a national rehabilitation unit providing intense physical, social, and psychiatric care in a secure environment. The literature does support the notion that burn staff require considerable education and support to care for these patients. More reliable data on patient characteristics and environmental factors would assist staff and families in better understanding the motivations that led to a suicide attempt in this manner. Although our search found little data on long-term outcomes, it appears that those patients who were located and interviewed had returned to preinjury levels of functioning. Staff should be informed of these outcomes so that caring for these patients is not viewed as futile.
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