Post-traumatic Stress Disorder in Intensive Care Unit - Risk Factors, Diagnosis, and Treatment

Introduction

Patients who require life-saving medical care are admitted to intensive care units (ICU). Higher ICU survival rates than ever before are a result of medical advancements. However, many patients struggle psychologically in the weeks and months following discharge, notably with post-traumatic stress disorder (PTSD), depression, and anxiety. A recent meta-analysis discovered that 24 % of ICU patients had self-reported PTSD symptoms between one and six months following discharge and 22% at seven months.

What Is Post-traumatic Stress Disorder?

Post-traumatic stress disorder (PTSD) is a psychiatric illness that can emerge after exposure to or witnessing a traumatic incident, several events, or a combination of circumstances. A person could perceive this as being emotionally, physically, or even life-threatening, impacting their psychological, social, bodily, and spiritual health. Examples include violent acts against personal partners, serious accidents, terrorist attacks, war and conflict, rape, and sexual assault, as well as historical trauma.

What Are the Risk Factors of Post-traumatic Stress Disorder?

• Early memory of hallucinatory experiences may be a risk factor for the onset of PTSD or PTSD-related symptoms. The likelihood of developing PTSD and its symptoms' severity have been linked to the frequency of early recollection of delusional memories despite any actual memories.

• PTSD may also be more likely to develop among individuals with previous episodes of depression and associated disorders. Coping mechanisms may be weakened by the mental, emotional, sociological, and physical impacts of depression.

• Patients find it challenging to comprehend what has happened to them due to the fragmentary character of their memories of their time in the intensive care unit and the high percentage of delusional memories that are later recalled. In this population, these distorted memories might be a primary trigger for PTSD.

What Are the Diagnostic Criteria for Post-traumatic Stress Disorder Associated with ICU?

To meet the Diagnostic and Statistical Manual of Mental Disorders criteria for PTSD, a patient must have indications from the following categories.

• Observing or Experiencing Actual or Imminent Death or Catastrophic Harm (Criterion A):

  • Incidents in which the patient thought they were about to die.

  • Moments when the patient received awful news, as when they realized they had COVID-19 and related issues.

  • Flash forwards or visions of a dreaded future occurrence (such as picturing their funeral, for example).

  • Invasive (and occasionally uncomfortable) medical procedures.

  • Observing, hearing, or knowing about the deaths of other patients.

  • Perceived abuse, such as discomfort and thinking that the personnel isn't offering assistance.

  • Observing disturbing behavior from other patients.

  • Delusions brought on by delirium.

  • A mix of those mentioned above. For instance, patients could recall undergoing surgery that they initially thought was the nurse attempting to harm them.

• Reliving the Events Through Distressing Flashbacks, Nightmares, Intrusive Memories, and Bodily and Emotional Sensitivity to Reminders (Criterion B): Patients may report actual recollections, delusional or hallucinated memories, or a combination of the two in relation to ICU trauma. They might claim to be unsure of what was real. Reliving painful events usually involves something other than recalling them consciously. Another example is relieving a strong feeling (fear, grief, or despair) or physical response from the trauma without concurrently remembering the incident.

• Avoiding Reminders of the Encounter, Including Thoughts, Emotions, and Sentiments (Criterion C): Types of behavioral avoidance in relation to post-ICU PTSD may include skipping appointments with physicians, refusing to look at or touch parts of one's own body, engaging in activities that trigger comparable bodily sensations (like getting out of breath), and turning off TV shows or movies with medical themes.

• Negative Cognitive and Emotional Changes (Criterion D): Cognitions for PTSD following ICU may be related to perceived unfavorable, long-lasting changes to the self, one's body, or life in general, notions of one's vulnerability, and mistrust of others, mainly if patients felt they had been mistreated in the medical facility. Associated feelings may include despair, grief, embarrassment, and anger.

• Signs of Hyperarousal (Criterion E): Hypervigilance to internal states, such as feelings or symptoms, which may suggest a potential sickness, is one of the more typical post-ICU symptoms. Poor sleep is common since lying in bed can bring back memories.

• Duration (Criterion F): More than a month is spent with symptoms.

• Functional Significance (Criterion G): Distress or functional impairment (e.g., social or occupational) is caused by symptoms.

• Exclusion ( Criterion H): There is no medical condition, drug usage, or other ailment causing the symptoms.

What Are the Goals of Cognitive Therapy for Post-traumatic Stress Disorder (CT-PTSD)?

The following are the goals of CT-PTSD:

• To alter potentially dangerous interpretations (personal meanings) of the trauma and its effects.

• To lessen re-experiencing through the development of trauma memories and the dissociation of everyday stimuli from trauma memories (trigger discrimination education).

• To lessen mental strategies and actions that keep a sensation of immediate threat.

How to Treat Post-Traumatic Stress Disorder Associated With ICU Through CT-PTSD?

CT-PTSD core therapy strategies can all be employed on individuals with post-ICU PTSD. They are as follows:

• Psychoeducation: Researchers employ psychoeducation to assist individuals with PTSD and to normalize their symptoms in the early phases of CT-PTSD. It is also beneficial to provide normalizing knowledge about ICU experiences while treating post-ICU PTSD. Psychoeducation may consist of the following:

  • PTSD is prevalent following ICU (20 % to 30 % of patients suffer PTSD symptoms).

  • A nurse or other expert explaining verbally or in writing why certain medical procedures are done in the intensive care unit.

  • Delirium affects 60 to 80 percent of patients in the intensive care unit.

  • The most frequent cause of delirium in intensive care units is a combination of powerful drugs, lack of sleep, and/or hypoxia.

  • In the ICU, delusions and hallucinations are not symptoms of mental disease. They often only occur in that context and do not result in the emergence of a mental disorder.

  • ICU-related memories are frequently hazy, lack a distinct sense of time, and can resurface as memories of specific times, bodily sensations, or unexpected emotions like panic. These are all indications that memory has been stirred.

  • Customized Formulation of the Case: Creating an individualized case formulation with the patient is another early job in CT-PTSD. It briefly explains the key mechanisms supporting their PTSD, such as the causes of their current sense of risk and any troublesome cognitive or behavioral techniques.

  • Reclaiming and Constructing One's Life: After a trauma, reclaiming formerly cherished and enjoyable hobbies or equivalents is a key component of CT-PTSD, which begins in session one and is discussed every session. Some people experience significant physical changes after a critical illness, such as pain, incapacity, scarring, sexual dysfunction, and persisting symptoms of chronic illnesses. Other significant life changes could have occurred, such as being unable to work, having money issues, or altering their way of life. Given these barriers, it could be challenging for them to restore their prior way of life.

• Memory-Focused Techniques:

  • In CT-PTSD, uncovering problematic meanings through imaginal reliving or crafting a written account of the incident is the first stage in updating trauma memories.

  • To find memory triggers, re-experiencing incidents are carefully examined. Often, patients are unaware that sensory factors, including colors, odors, tastes, touching certain body regions, body posture, and physiological sensations, might cause trauma memories to resurface. Medical contexts and reminders, such as letters from the hospital, attending appointments, medical TV shows, and media coverage of pertinent themes, can also cause memories to be reactivated.

• Medications: PTSD symptoms can be managed with the aid of medication. Additionally, the symptom relief that medicine offers enables many patients to engage in psychotherapy more productively. The primary symptoms of PTSD are frequently treated with antidepressants, particularly SSRIs and SNRIs (selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors). They may be utilized independently or with other therapies, such as psychotherapy. Other drugs may be used to treat PTSD-related nightmares and sleep issues and reduce anxiety and physical discomfort.

Conclusion:

Following a severe illness, post-traumatic stress disorder (PTSD), sadness, and anxiety are significant mental health issues. Extraversion and dedication are two broad personality qualities linked to increased resilience to PTSD. In contrast, nervousness and negative emotionality have been positively linked to the onset of PTSD. A significant preventive factor against the onset of PTSD may be social support. In a sample of ICU patients treated for acute respiratory distress syndrome, one study discovered a statistically significant negative relationship between social support and PTSD symptoms. Future research on this issue could be crucial, given the link between social support and lessened psychological suffering in ICU patients.