Scientific Papers

Psychiatric disorders and interventions in patients sustaining facial fractures from interpersonal violence | Head & Face Medicine


This study aimed to clarify psychiatric morbidity in IPV-related facial fracture patients. In particular, we clarified patients´ additional psychiatric care in the form of psychiatric intervention after facial fracture. We hypothesized that patients needing additional support can be identified based on background variables, allowing overall care processes to be improved.

Our results revealed that female patients with IPV-related facial fracture are twice as likely as males to have anamnestic psychiatric disorders. Patients with preceding psychiatric history sustain more severe assaults with combination fractures of the facial thirds, and they are more likely to have a history of substance abuse than other IPV-related facial fracture patients. Both anamnestic psychiatric disorders and SMIs as well as the use of an offensive weapon increased the probability that patients would receive psychiatric intervention.

Assault and later psychiatric symptoms

The after-effects on the psyche after traumatic events typically include anxiety, PTSD [1, 2], paranoia [3], suicidal ideation, and depression [4] as well as a multitude of mental symptoms such as distress, dissociation, and mental defeat [13]. However, a lack of research on these predisposing factors to various psychiatric symptoms after traumatic events, excluding PTSD, has been noted [19]. History of mental illness has been established to be the most significant predisposing factor for severe psychiatric symptoms following traumatic events (defined as three or more psychiatric diagnoses after the traumatic event) [19]. The risk for psychiatric symptoms is increased especially if there is a preceding personality disorder, major depressive disorder, or antidepressant medication [19]. Supporting this, we found that patients with anamnestic psychiatric disorders, particularly SMIs, often required psychiatric intervention after experiencing IPV.

Especially after assault, psychiatric disorders include paranoia and PTSD [3]. Usually, the follow-up period in studies is limited to a couple of months or years, but the after-effects can disperse and evolve over a longer time-span; an American study on the lifetime effect of assault found that depression, anxiety disorders, and substance abuse disorders were more common in patients with a history of assault than in patients without [20]. In our data, in addition to traumatic stress reactions (ASD or PTSD), psychotic symptoms (delusions, hallucinations, extensive paranoia) were among the most prevalent psychiatric manifestations post-assault. The most common individual symptoms included anxiety and fear (44.3%), mood issues (30.0%), and problems with sleep (13.1%) (Fig. 2). The majority of interventions were carried out within one month – however, nearly half of the patients developed psychiatric symptoms at 1–12 months, emphasizing the value of consistent follow-ups (Fig. 3). The relatively high incidence of psychoses may stem partly from our inclusion of patients with both history of substance abuse and all types of psychiatric disorders, including psychotic conditions. Due to the difficulty of these patients in committing to follow-ups and their potentially erratic behavior, many studies may exclude them, especially from prospective studies. Despite this, it should be noted that some of the psychoses developed without a pre-existing psychotic disorder or history of substance abuse.

Risk factors for violence in patients with psychiatric morbidities

In patients with behavioral health disorders, including psychiatric disorders, assaults have been found to cause facial fractures in over one-fourth of the patients, significantly more often than in the control group [21]. Moreover, SMIs have been suggested to raise the risk for being a victim of a crime in general [15], and death by homicide is nearly three times more frequent in people with psychiatric disorders than in the general population [22]. These types of studies have also included psychiatric patients and prison inmates and have compared people with and without mental illnesses [6].

A recent article reported a connection between psychiatric morbidity and the severity of injuries from trauma [17]. In our data, one-quarter of patients had an anamnestic psychiatric disorder, 24.8% of which were SMIs. The link to increased severity of injuries can also be seen in our data; the risk for combination fractures was elevated in patients with anamnestic psychiatric disorders. A similar trend was observed in patients who received psychiatric intervention; they were more often assaulted with an offensive weapon and had associated injuries. They were also less likely to be assaulted with a single hit and had more mid-face fractures, although the last finding did not reach statistical significance.

Some psychiatric disorders have been associated with a tendency for more aggressive behavior than others. Regarding psychoses, it has been suggested that roughly a third of psychotic patients involved in assaults are experiencing psychosis for the first time [16]. A threat of violence can also be present in certain personality disorders such as pathological narcissism, psychopathy, borderline personality disorder, and paranoid/schizotypal personality disorder [23]. For example, among prison inmates, over 70% had an antisocial personality disorder and they carried out more acts of aggression than the rest of the inmates [24]. Poor impulse control [25] and poor metacognitive functions [26] have also been linked to violent tendencies. Psychiatric comorbidities, like schizophrenia and substance abuse disorders (SUDs), can also increase the risk for violence [27]. The prevalence of personality disorders in assaulted facial fracture patients in our data (4.6% of all patients, see Fig. 1) is dramatically different from the figure for antisocial disorder among prison inmates (70%) [24]. This is likely due to screening bias – prison inmates are screened for different psychiatric disorders, whereas the psychiatric history of patients in our study was not screened systematically.

History of substance abuse increased the probability of both having anamnestic psychiatric conditions and receiving a psychiatric intervention, although the latter reached statistical significance only in the univariate analysis. Previous studies support these findings; IPV has been suggested to be the most common etiology in SUD patients with maxillofacial injuries [28], and SUDs have also been shown to be a significant risk factor for facial fractures, slightly more than male sex [28]. In our data, nearly one-third of patients (31.2%) had a history of substance abuse, and such a large proportion should warrant more convenient clinical pathways to substance abuse psychiatry. However, it is also important to note that a large proportion (49.2%) of the patients who received a psychiatric intervention did not have an SUD.

Guiding patients to mental health services and the impact of treatment

A recent study showed that facial fracture patients with psychiatric disorders had more serious injuries, requiring more extensive treatment [17]. Another study stated that patients with behavioral health disorders, including psychiatric disorders, were three times more likely to be transferred to a psychiatric facility after a facial fracture than those in the control group without behavioral health disorders [21]. Apart from pre-trauma factors, factors related directly to the moment of trauma and its immediate aftermath have been suggested to have an even greater impact [18]. By using Hospital Anxiety and Depression Scale scores, it has also been proposed that facial trauma patients are at a greater risk of developing depression than elective surgery patients [29]. Taken together, more clearly targeted clinical pathways are indicated for patients with anamnestic psychiatric disorders.

Limitations of the study

The retrospective study design limits detailed conclusions, and the prevalence of psychiatric illness may be underestimated. Firstly, patients who received psychiatric care outside the University Hospital were not included. With this, we aimed at evaluating specifically the effort of specialized health care. Secondly, since the study was retrospective, only the most prevalent cases, meaning those that had symptoms so prominent that they were detected and described in the patient files, were included. A survey on these symptoms during the treatment period could have revealed some more minor symptoms or possibly symptoms that were not outwardly evident. After a violent event, about one-third of people who are exposed to nonsexual violence seek the help of a mental health professional [13]. This contrast in quantity between seeking help and our results on psychiatric evaluation is large but evidently due to the difference in study design (prospective vs. retrospective set-up). Thus, the incidence of psychiatric symptoms after IPV in our study is likely to be higher than that reported. Thirdly, a direct comparison of our results with earlier studies is challenging due to differences in the definitions of psychiatric symptoms and diseases ( 13). Prospective studies could help elucidate the need for additional treatment in the future. Additionally, the authors would like to emphasize that while the method of how additional psychiatric care is provided is relevant, it falls outside the scope of this study, which is to focus on the types of facial fracture patients that required additional care the most.



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