Early Psychological Interventions for Post Traumatic Stress post Burn Injury

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Severe burn injuries are associated with considerable psychological trauma and burns patients are at increased risk of developing Post Traumatic Stress Disorder (PTSD), depression and other mental health disorders. EMDR is an effective evidence-based treatment for psychological trauma, it has been well researched, however there have been very few studies on early EMDR intervention as a means of preventing PTSD. To date there is no research on EMDR and burns related trauma in a primary care setting. Hypothesis and Aims Effective early intervention may enhance patients’ outcome, resilience and coping. The aim of this research is to establish that early EMDR intervention is safe and effective in this acute and medically complex setting. It is hypothesised that early EMDR intervention integrates traumatic memories thus preventing the development of chronic pathology. This research then aims to explore the effects and efficacy of early EMDR interventions on burn patients’ mental health outcomes with a primary focus on posttraumatic symptoms and secondarily tracking mood and coping, which are often poorly addressed during rehabilitation. The opportunity to promptly intervene with simple and effective psychological treatment to avoid sequelae in those who were previously well warrants investigation and sits with clinical observation that even good psychological “first aid” with counselling and Consultation-Liaison Psychiatry support appears to be insufficient to support best recovery. The hypothesis that early EMDR intervention/treatment has a positive effect on burns patients’ mental health outcomes, in terms of reduction in PTSD and depression will be tested. This study aims to improve psychosocial care of burns patients. Knowledge gained from the proposed research can be utilized to inform and further develop more effective early trauma interventions. Early EMDR interventions may facilitate improved psychosocial recovery of burns patients and this study is aims to establish basic proof of concept that early EMDR intervention is safe, useful and valuable in this acute and medically complex setting. Research Plan Protocol Stages: Stage 1- Screening for posttraumatic symptoms. All patients admitted to the SBIU, RNSH will be screened within the first two-four weeks following injury (or the first 2 weeks following discharge from Intensive Care using the Impact of Event Scale –Revised (IES-R). Patients whose baseline scores on this scale indicate moderate-to-severe posttraumatic stress symptoms will be considered for recruitment (IES score =26).The remainder of the questionnaires are used to track depression, anxiety and coping style, pain and alcohol use. Information re burn depth, size and location will also be obtained (collected routinely in all burns patients).These measures will be repeated at Burns outpatient follow-up visits at 3 monthly intervals over the first year and then annually for five years. Stage 2_- Clinical assessment to identify exclusions and pre-treatment variables. The subgroup of patients with elevated IES scores from the screening study will be evaluated further via a full psychiatric assessment by the Consultation-Liaison Psychiatry team to determine clinical exclusions and Ms Kwiet will also perform a fuller psychosocial research assessment, including evaluation of dissociative symptoms via interview and the Dissociative Experiences Scale (DES). Past trauma history as well as other risk and resilience factors, such as past psychiatric illnesses, family history, medications, premorbid personality and functioning and levels of social support will also be assessed. This will be obtained via a semi-structured interview incorporating these clinical domains, the Adult Attachment Interview (Burns Modified with Social Support probes) and the CAPS (the gold standard interview measure of PTSD). Patients identified as having unresolved chronic complex trauma (including prior PTSD) and high levels of dissociation will not be considered for inclusion in the RCT, as they are likely to require a prolonged period of stabilization and treatment within a longer term therapeutic relationship. Other potentially relevant biopsychosocial variables were obtained by the screening study to which will be added the (PCL-C), and current medications and pain relief. Stage 3: Randomized treatment Patients with (uncomplicated) moderate to severe posttraumatic stress symptoms will be recruited and randomly allocated into two groups. One group will receive three hours of EMDR as per the Acute – Traumatic Incident Procedure (A-TIP) and the other group will receive three hours of supportive psychotherapy, which will include basic psychological stabilization and stress management, considered as psychological “first aid”, provided within a supportive psychotherapeutic relationship. At commencement and completion of each session of treatment the IES will be repeated to track any change in the interval between screening and treatment and any interval changes between sessions. Stage 4: Residual symptoms and crossover to EMDR. Those patients in the control group whose IES scores remain elevated at the end of 3 sessions will be offered the EMDR treatment after 3 months out of ethical concern. Stage 5: Outcome and Follow-up assessments The IES (24) will be administered to all patients following each treatment intervention and at 3 months follow-up the Clinician-Administered PTSD Scale (CAPS) the gold standard for PTSD symptoms will be administered to all participants from both groups. At the 12-18 month follow up Ms Kwiet will perform another Burns Modified Adult Attachment Interview to all participants from both groups. The COPE , DASS and DES will also be re-administered to each patient at each follow up. Outcomes of both groups will then be compared to evaluate the effectivness of EMDR in improving burns patients mental health outcomes (specifically reduced reate of PTSD, depression, anxiety and greater quality of life)

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