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Behavioral Consequences of Lightning and Electrical Injury
Margaret Primeau, Ph.D., Gerolf H. Engelstatter, Ph.D., A.B.M.P., I.A.B.C.P., and Kimberly K Bares, M.S.
Seminars in Neurology, Volume 15, Number 3, September 1995
Copyright © 1995
Department of Psychology, Finch University of Health Sciences/The Chicago Medical School, North Chicago, Illinois, and Carolina Psychological Health Services, Jacksonville, North Carolina
Immediate manifestations in survivors of lightning and electrical injuries include altered consciousness, confusion, disorientation, and amnesia.(1,2) Subsequently, patients show either normalization of mental status or sequelae ranging from headaches and distractibility to persistent psychiatric disorder and dementia. (3,4) The fact of this variety has been recognized for a long time. (5)
Behavioral effects have been described in numerous case reports (3); research, however, has been relatively scant and subject to a number of shortcomings. (6) These include sampling bias and heterogeneity, cross-sectional rather than longitudinal or prospective evaluation, and inadequate assessment and analysis of premorbid factors and concurrent psychopathology. We are as yet unable to predict from the "magnitude" of an electrical or lightning injury what the combination or duration of behavioral sequelae will be among survivors. As these shortcomings are remedied (6,8) knowledge of the prevalence and nature of morbidity will permit more effective clinical care. At present, however, our understanding is only partial; clinicians, attorneys, employers, and families continue to puzzle over the problems of lightning and electrical injury patients, who in turn wonder what is wrong and who can help. In this article, we discuss selected literature and present original findings with the aim to address four main questions:
1. What are the behavioral (cognitive and psychologic) sequelae among survivors of lightning injury (LI) and electrical injury (EI)?
2. Do LI and EI differ in outcome?
3. What models of brain-behavior disturbance best describe morbidity in LI and EI?
4. What recommendations for assessment and treatment can we make?
Empirical studies that focus on assessment and outcome in LI and EI are described in Table 1
(4,7,9-16). Since the methods and findings are diverse, prevalence rates for various problems remain to be clarified. A few studies assessed the frequency of self-reported problems in special cohorts. For instance, Shaw and York-Moore (9) surveyed 28 of the 50 people injured by lightning in the 1955 Ascot incident in England, and Andrews and Darveniza recently studied telephone-mediated lightning injury in Australia among 132 persons contacted retrospectively (13) and 10 identified at the time of their injury.(14) In these reports, 10 to 20% of patients exhibited psychologic problems. In contrast, from a consecutive series of electrical injury patients admitted to a burn unit, Grossman et al (7) selected a sample of 16 characterized by intermediate severity for a prospective study of psychiatric sequelae. They found "persistent neurobehavioral disorder" in 75% of those whose injury was by direct current. In the remaining studies in Table 1, the individuals came to attention because of their complications, and almost all of them showed abnormalities such as depression and memory impairment. (4,10-12,15,16)
The neuropsychologic deficits associated with LI and EI tend to be nonspecific and to resemble those of traumatic brain injury.(4,17) While disturbances of language, awareness, or visuospatial functions seem to be rare, impairments of attention, concentration, verbal memory, and new learning are very frequently identified.(7,10, 12,13,15,16) Survivors may thus experience a reduced capacity to function, both occupationally and socially, and may complain of forgetfulness, inefficiency, and inability to handle even mildly stressful situations. These new obstacles and sense of loss may contribute to psychologic disorders, which in turn affect cognition.
The prediction of impairment from initial injury factors is imprecise. First, the subacute course in LI and EI is quite variable, with some patients returning to premorbid status and others experiencing persistent impairments. Progressive impairment has also been reported, such as the cases with dementia listed in Table 1 from Daniel et al (4) and Troster and Ruff.(12) Second, such variables as voltage level or whether loss of consciousness occurred do not correlate with neuropsychologic profiles.(4,17) For example, case descriptions of LI indicate that neither cardiac arrest nor gross central nervous system (CNS) lesions necessarily predict poor outcome.(18) Also, although both of the EI patients described who deteriorated had sustained high-volt-age injuries (more than 8000 V), such poor outcome was not the rule within high-voltage groups. For instance, data from an archival study of 90 EI cases (19) suggested good outcome in 56% of patients receiving high-voltage injuries (compared to 91% of patients receiving low-voltage injuries), at least in terms of resolution of CNS symptoms observed during inpatient care.
In EI and LI cases with persistent cognitive deficits, poor memory is a common complaint, and emotional distress is also prominent. In an investigation of memory functioning after EI, Bares (20) compared 20 patients early in their course (between I and 57 days after injury) to 20 patients with late sequelae (9 months to 4 years post-injury) on a 280 measure of verbal memory that differentiates the components of acquisition, retention, and retrieval.(21) The groups were matched on age, sex ratio, years of formal education, and estimated premorbid intelligence. Within-group variability was high, and mean group differences on index scores were not significant. Relative to normative expectations, however, 56% of subjects in the acute group and 68% of subjects in the post-acute group had component scores in the impaired range (lower than 1 standard deviation below the mean). Thus, both early and late EI were associated with a deficit in verbal memory, with the late EI group tending to be worse. Acquisition and retrieval were more affected than retention, as is seen in the so-called subcortical syndromes as well as in affective disorders. When self-report of depression was analyzed, (22) the post-acute group showed a significantly higher frequency of symptoms of depression, but this variable did not account for memory performance. Furthermore, neither involvement in litigation nor history of loss of consciousness ac-counted for memory results in this study, suggesting independence of memory impairment from individual differences in initial injury, affective status, and money issues.
Taken together, these findings provide some support for the phenomenon of delayed or progressive decline of cognitive and emotional functioning after EI. Prospective serial assessment of memory function and affective status is needed to establish the frequency of decline. Since the subjective experience of poor memory may arise from other cognitive or emotional factors such as distractibility or fatigue, these should also be assessed.(23) The lack of obvious correspondence between neuropsychologic deficits and in-jury variables or other individual differences highlights the need for thorough evaluation.
The studies cited in Table 1 describe a variety of emotional problems, ranging from anxiety to marital break-down to major depression, and illustrate several main features of late psychologic sequelae: they are variable in severity and duration, they are difficult to predict from injury parameters, and their etiology is not readily inferred. For example, such reported difficulties as sleep disturbance, memory deficit, depression, sexual dysfunction, and chronic pain, as well as weakness, dizziness, and confusion may arise from neurologic injury, psychologic reaction, or from the subtle interrelationship between the two.
Among EI studies, single-case reports involved high-voltage exposure while the remaining samples were heterogeneous for volt-age level. HEIDI: Beck Depression Inventory; CT: computed tomography; EEG: electroencephalogram; MMPI, Minnesota Multiphasic Personality Inventory (Hs, D, and Hy are clinical scales); NA, not assessed; PNBD, persistent neurobehavioral disorder (organic brain syndrome); PTSD, post-traumatic stress disorder.
The dilemma of etiologic specificity is illustrated by Engelstatter (24) who reviewed symptom checklists collected retrospectively from 100 lightning strike survivors and 65 electric shock survivors, all of whom presented with chronic sequelae 2 or more years postinjury (mean interval, 4.5 years). Tables 2 and 3 reveal a wide range of complaints in this group, suggesting diffuse dysfunction and varying degrees of potential debilitation. In both the EI and LI samples, nine of ten of the most frequently reported com-plaints are of a variety that may be primarily psychologic in nature or that often reflect a psychologic component. Five of the top 10 are classic symptoms of depression, for both EI and LI patients.
Frequencies in Tables 2 and 3 give the impression of diffuse, nonspecific neurobehavioral dysfunction in complicated LI and EI. Cluster analysis was utilized to deter-mine whether subtypes of late outcome could be identified. Since the original questionnaires consisted of more than 70 yes/no items about symptom occurrence, the data were first submitted to factor analysis to identify symptom dimensions. Six factors accounting for 47% of the total variance were extracted. (Explained variance ranged from 27% for the first factor to 3% for the sixth.)
The 10 most common symptoms for each injury group are indicated
by asterisks. Symptoms in italics are the ones most likely to have an
organic basis; etiology for other symptoms may be organic, psychologic,
or both. Remaining symptoms loaded weakly on more than one factor.
Factor 1 encompassed a variety of neurobehavioral complaints, including depression, fatigue, dizziness, confusion, sleep disturbance, tinnitus, paresthesias, numbness, headaches, and neuropsychologic deficit (decreased attention, memory, and coordination). This constellation may be termed Global." Factor 2 included anxiety, chronic pain, weakness, nightmares, personality change, and suicidal ideation, and may be termed "anxiety reaction." Factor 3 grouped epilepsy and cardiac problems. Factor 4 included paraplegia, aphasia, and physical dependent; this appears to be a "disability" factor. Factor 5 included amputation and various systemic problems. Factor 6 included auditory deficit. Remaining symptoms loaded weakly on more than one factor.
Cluster analysis of these factors as well as age for 149 subjects resulted in four subgroups, generally characterized by age and symptom specificity (Table 4). Cluster A (41 % of cases) showed predominance of the "global" and "anxiety reaction" factors. Cluster B (27% of cases) showed predominance of the "global" factor. Cluster C (9% of cases) was characterized by "disability." Cluster D (23% of cases) had amputation/systemic complaints (factor 5). These analyses were not able to isolate subgroups with discrete psychiatric syndromes; 68% of the cases (clusters A and B) are characterized by multiple complaints and distress, the etiology of which is not obvious. The database did not include systematic information about severity of initial injury, onset or duration of dysfunction, results of diagnostic workups, status of compensation claims if any, or premorbid adjust-meet, and the role of these factors in predicting outcome is not known.
DIFFERENCES BETWEEN SURVIVORS OF LIGHTNING AND ELECTRICAL INJURIES
As noted elsewhere in this issue, the mechanisms of injury by lightning strike and electrical shock differ. One might expect a bimodal pattern of outcome in lightning (severe versus mild), but a more continuous distribution of severity of problems in electrical injury, since intensity of current and duration of exposure are variable.
The studies with assessment of LI cited in Table l involve only a few cases, (12,15) but these would suggest that, compared to EI, LI has milder and shorter-term neuropsychologic effects. Within LI, milder aftereffects are reported for telephone-mediated injury than LI in the field. (25)
Within EI, physical trauma is a function of the mode and duration of exposure, the pathway of current, and the differential resistance of tissues in its path. As noted earlier, voltage level alone is not a reliable predictor. On the other hand, the studies that compared subjects with only flash burns to those experiencing passage of current'" showed clearly worse psychologic outcome for the latter, suggesting that the CNS and systemic effects and not external burns correlated with morbidity. Estimating CNS damage, how-ever, is difficult, since entrance and exit points may not define the actual pathway.(1) Thus, characterizing the difference in injury between cases with better versus worse out-come awaits further study.
The question of differences between LI and EI in psychologic outcome was addressed with the data from Engelstatter (Tables 2 and 3). (24) This sample was self-selected and seems to represent the complicated end of the LI and EI spectrum. When scores on symptom factors already described were subjected to discriminant analysis, the EI survivors were differentiated by higher scores on the "global" factor, and the LI survivors were more likely than EI cases to have auditory sequelae (factor 6). Age and sex of subject did not distinguish the groups. Although 30% of the cases in each group were misclassified, suggesting overlap between LI and EI with poor outcome, the discriminant function was statistically significant (p < 0.001), and the finding of greater severity of neurobehavioral and emotional problems in EI than in LI is consistent with the literature.
THE QUESTION OF MODELS
A number of possibilities have been suggested for models to guide diagnosis and management of LI and EI. They derive from presumptions about the underlying organic injury as well as from similarities in presentation to other syndromes. Precise mechanisms need further study. Sources of injury include the passage of current through the vascular and nervous systems, anoxia associated with cardiac or respiratory arrest, blunt trauma (direct strike or secondary head injury), and peripheral injury (such as burns and tympanic membrane rupture). (2) The mechanisms of injury by lightning and man-made electricity could plausibly underlie the diverse symptoms patients re-port. (2,10,16,20,26) For instance, damage to small blood vessels and to myelin could be associated with delayed onset of pain or sensorimotor loss; traversal by current of hypothalamic and brainstem centers could lead to endocrine and
autonomic dysfunction, and so on. Multiple, diffuse com-plaints are not the exception.
Whether or not primary CNS injury or secondary head injury can be documented, the model of traumatic brain injury seems appropriate (4, 7, 17). Such common complaints in LI and EI as headaches, disturbances of attention and memory, and autonomic dysfunction are consistent with a head injury model. Postconcussion syndrome seems particularly instructive. It is characterized by subtle, nonfocal neuropsychologic deficits such as impairment of concentration and memory, as well as complaints of headaches, dizziness, fatigue, irritability, and depression, in association with a nor-mal neurologic examination.(27) Magnetic resonance imaging (MRI) studies of Mild Closed Head Injury have revealed punctate hyperintensities (believed to be axonal shearing) in some cases, and focal contusions, usually in frontal and temporal regions, in others. Functional imaging studies such as positron emission tomography (PET), evoked potential recordings, and autopsy results have also suggested postconcussion brain damage.(27)
Recognizing the ambiguities in EI, Grossman et al (7) described "persistent neurobehavioral disorder" (defined as three or more persistent deficits in cognitive, psychomotor, or interpersonal performance) in 12 EI patients followed for 1 year; since only two had positive MRI studies, whereas eight had auditory abnormalities, CNS involvement was considered to be covert compared to peripheral signs and behavioral disturbance. A study of cognitive dysfunction in EI suggests that it is analogous to that in head injury: profiles of neuropsychologic deficits were reported to be similar in eight EI patients and eight head injury patients matched demographically.(6) The head injury model also has the potential to accommodate psychiatric sequelae in EI and LI, since various CNS insults are known to result in concurrent emotional disturbance (such as personality change with cerebral tumor, or depression with left hemisphere cerebrovascular accident).
A variety of syndromes, including post-traumatic stress disorder (PTSD), conversion disorder, major depression, and adjustment disorder,(28) are suggested by the constellation of patients' complaints and have been considered in the literature.(29) The question of whether these are "organic" or "reactive" is a difficult one; for instance, it has been pointed out that the experience of electrical shock is the prototype of one-trial aversive conditioning and a potent inducer of PTSD symptoms. (11,29) Furthermore, when both affective disorder and cognitive impairment are present, it is not initially clear whether one or the other is primary.
PTSD shares with the possible presentation of late EI and LI the features of the acute frightening trauma, gradual emergence of psychologic symptoms, the experience of flashbacks, and a tendency to avoid associated stimuli. As noted in Table 1, this is occasionally the formal diagnosis.(7,29) It was actually more commonly diagnosed for persons with flash burns rather than direct exposure to current in the study by Grossman et al.(7) When lightning simultaneously injures several people, a comparison to sequelae of natural disaster may be apt; (30) symptoms of PTSD, if not the full syndrome, may occur along with other reactions such as survivor guilt.
Depression is a common finding, as noted in the Eng-elstatter (24) and Bares (20) data as well as in the other studies. Anxiety disorders have also been reported; they include specific forms of phobic disorders related to the initial incident (storm phobias in LI) or to subsequent activity (agoraphobia).(2) Anxiety and depression may be constituents of adjustment disorders as well. Adjustment to an acquired deficit is clearly affected by premorbid factors such as personality and coping style. (31) Obsessional types of persons are prone to brood over all the perceived changes, and brittle types tend to be dissatisfied with intervention efforts. Since risk for injury is a function of occupation and lifestyle, (2,19) the population of victims includes formerly vigorous, independent, and perhaps risk-seeking persons who may resist treatment efforts, or feel humiliated by their limitations. Some survivors attribute all subsequent difficulties in life to the injury and others experience an intolerable threat to their sense of control.(17,25) Emotional distress in turn tends to lower functional capacity, and a cycle of frustration is maintained. EI or LI may also increase risk for substance abuse, mainly through self-medication with alcohol or the overuse of prescription medications.
Somatoform disorders (characterized by physical com-plaints that have little or no basis in known medical illness) are also discussed in the literature.(29) Preoccupation with or exaggeration of multiple symptoms raises the question of somatization disorder, although this formal diagnosis is not defined by abrupt onset. Pain disorder has features consistent with complaints in EI and LI and may account for chronicity in some cases. Conversion disorder was de-scribed in the earliest studies (5,9) and remains important in the differential diagnosis. Criteria for conversion disorder (28) include a predisposing event and symptoms that cannot be fully explained by objective testing ("pseudo-neurologic"). As is apparent in Tables 2 and 3, numerous symptoms in EI and LI refer to the nervous system, and without hard signs on the neurologic examination or positive neuroimaging results, etiology is ambiguous. On the other hand, conversion symptoms usually resolve in a matter of weeks, whereas the late complaints in LI and EI may last for months or years. Since conversion and genuine neurologic symptoms often coexist,(28) ruling out neurogenic disorders is difficult and the presumption of a neurogenic component seems wiser.
The role of secondary gain is no more or less prominent in the sequelae of EI and LI than in other instances of injury, and in a percentage of cases is likely serving to maintain chronicity, although it falls short of an adequate explanation for the host of symptomatology presented in the literature. Sophisticated neuropsychologic assessment can help identify consciously or unconsciously feigned behavioral deficits. Further research on mechanisms of injury should improve etiologic inferences.
A prototype of psychologic disorder is not evident; symptom constellations in individuals may overlap with these formal categories, and presentation may be atypical, with delayed onset or protracted course. As noted in the data presented earlier, we found that 68% of the group with chronic complaints reported multiple neurobehavioral and emotional symptoms that cut across diagnostic categories. The frequency of psychiatric disability is difficult to estimate from the literature, but the cohort and prospective studies in Table 1 suggest that at least 10 to 20% of survivors will experience persistent psychologic sequelae and that a portion of those will have significantly diminished ability to function.
Survivors of EI and LI may or may not have demonstrable tissue damage. If they do, appraisal and treatment of disability seem straightforward. However, many patients with histories of electric shock or lightning strike present with atypical or diffuse complaints, especially in the late phase, when etiologic judgments are more difficult. It is this patient group that is most likely to be misdiagnosed, misunderstood, or dismissed by clinicians as malingerers or neurotics.
Even though the severity of impairment in late EI and LI is quite variable, clinicians in widely separated treatment settings are familiar with the picture of multiple, diffuse neurobehavioral complaints.(4,24,25) A label for the phenomenon, such as postelectrocution or postelectric shock syn-drome, (24,25) seems warranted. The consistency of observations on postelectric shock syndrome among researchers and clinicians is one validation of the syndrome, whether organic factors, psychogenic factors, or both are its basis.
Andrews and Darveniza (13) identified three outcome groups in their retrospective study of telephone-mediated lightning injury. One group (40% of the sample) usually had relatively brief symptoms of 24 hours to 1 week in duration. A second group (50%) reported moderate sequelae up to 3 months postinjury, and a third group (10%) exhibited more severe and continuing disability beyond 3 months. Data reviewed here suggest that a fourth group exists, a group of LI and EI survivors who maintain significant symptomatology beyond 3 years postinjury and per- haps for a lifetime.(24) This group may also be characterized by a greater degree of psychologic overlay in their presentation and level of dysfunction. Our collective experience would suggest that the first 12 months following injury are crucial in the recovery process, with the most substantial gains being observed during that time and subsequent recovery possible up to 36 months postinjury. Then recovery plateaus, and remaining com- plaints reflect chronic dysfunction. Premorbid psychologic adjustment and physical health play an important role in the individual response to injury and the recovery process,
as well as in the ultimate extent of disability experienced.
RECOMMENDATIONS FOR ASSESSMENT AND TREATMENT
Medical management is described elsewhere in these issues. Several authors recommend counseling from the outset to explain complications, reassure patients about their course, and head off reactions like PTSD. (1,2,17) Optimal management through the course of EI and LI would include serial, multidisciplinary assessment for systemic, neurologic, and neuropsychologic effects.(6-8) The reality of subtle dysfunction must be recognized; conventional diagnostics such as computed tomographic (CT) scan may be negative, whereas tests emphasizing functional integrity such as measures of regional cerebral blood flow may reveal abnormalities.(8,27) Likewise, in the neuropsychologic assess-meet, reliance should be placed on thorough evaluation of attention/concentration, problem-solving, sensorimotor functions, and component functions of memory rather than on less sensitive measures such as IQ. Feigning of deficits can also be addressed psychometrically. Psychologic assessment should include premorbid history as well as current psychopathology. Corroborative interview with a relative is desirable to characterize change from premorbid levels and identify problems in day-to-day functioning.(6)
Neuropsychologic deficits should be tracked, and cognitive retraining provided for persistent problems, as is prescribed in traumatic brain injury.(17) Psychologic difficulties and pain/dysesthesia symptoms may well warrant pharmacotherapy, such as clomipramine or other tricyclics for depression and carbamazopine for neuralgia. (2) Even for cases likely to have substantial or complete recovery, supportive psychotherapy may prevent reactive disorders and facilitate return to previous roles. Anxiety disorders and depression are amenable to behavioral and cognitive-behavioral psychotherapy, respectively. For cases with significant loss of function, the treatment goal would be to assist in adaptation and adjustment to disability. Our clinical impression is that most patients do improve and that the physician has the opportunity to influence outcome through his or her reassurance, patience, and attitude of acceptance.(25)
Postelectric shock syndrome is a disorder of persistent cognitive and psychologic disturbances following LI or EI. Cognitive complaints and deficits resemble those in mild to moderate traumatic brain injury. Psychologic disturbances range from specific phobias to major depression and are often associated with multiple somatic complaints referable to the nervous system. The mechanisms of CNS injury are still under study, and the etiology of persistent complaints may be multifactorial. Patients who have not recovered from initial effects after 3 months are at risk for long term sequelae and disability. Evaluation should be interdisciplinary Psychotherapy, pharmacotherapy, and neuropsychologic intervention are often indicated.
We are grateful to Neil H. Pliskin, Ph.D., and the Electrical Trauma Program under the direction of Raphael C. Lee, M.D., at the University of Chicago Medical Center for access to the data reported in the Bares (1994) study. We also thank the members of Lightning Strike and Electric Shock Victims, International for the questionnaire material re-ported in the Engelstatter (1994) study.
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