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Post-traumatic stress disorder following critical illness

VOL: 102, ISSUE: 43, PAGE NO: 23

Terry Hainsworth, BSc, RGN, is clinical editor at Nursing Times

When patients enter the dynamic environment of an intensive care unit (ICU) they are often not only critically ill ...

When patients enter the dynamic environment of an intensive care unit (ICU) they are often not only critically ill but are also experiencing a psychological crisis (Hardicre, 2003a). Last week two studies were published that highlight the stressful effects of this experience.

Roberts et al (2006) investigated the dreams that patients recalled two years post discharge from ICU. They found that a longer stay in the ICU was significantly associated with dreams and many of these were of a distressing nature such as dreams of impending harm or death.

Deja et al (2006) studied health-related quality of life and post-traumatic stress disorder (PTSD) in patients who had been successfully treated for severe acute respiratory distress syndrome. They found that patients are less likely to report symptoms of PTSD if they felt that they were supported during and after the interventions in the ICU.

Post-traumatic stress disorder

PTSD is a condition that can develop following an exceptionally threatening or catastrophic event or situation. It can affect people of all ages and around 25-30% of people who experience this kind of stressful event may go on to develop PTSD (NICE, 2005). The symptoms of PTSD include:

- Flashbacks, nightmares and repetitive and distressing intrusive images or other sensory impressions from the event;

- Intense distress and/or physiological reactions provoked by reminders of the traumatic event;

- Avoidance of people, situations or circumstances associated with the event or excessive questioning about what is preventing acceptance or coming to terms with the event;

- Hyperarousal including hypervigilance for threat, exaggerated startle responses, irritability and difficulty concentrating, and sleep problems;

- Emotional numbing such as feeling detached from other people, giving up previously significant activities, and amnesia for significant parts of the event.

Healthcare related PTSD

Deja et al (2006) studied 65 survivors of acute respiratory distress syndrome (ARDS) nearly five years after discharge from ICU. They assessed PTSD, health-related quality of life, symptoms of psychopathology and perception of social support using standard questionnaires and compared scores with those of healthy individuals.

Results show that participants who had ARDS had a significantly reduced health-related quality of life and 18 were identified as being at increased risk for PTSD. However, this was not related to the severity or the cause of their ARDS and those at risk of PTSD had a significantly lower perception of the support they had received than those in the other group of ARDS survivors. The research concludes that overall better-perceived social support is associated with a reduction in PTSD symptoms.

This is not the first time that PTSD has been linked with critical illness. Mahler et al (2005) studied the prevalence of symptoms related to PTSD after surgical treatment for secondary peritonitis. Long-term follow-up of these patients identified that about a quarter had symptoms fitting with PTSD. Granja et al (2005) highlighted that patients who have an unscheduled admission to an intensive care unit normally have an unexpected life-threatening condition and will often not be aware of their condition until late in their stay or until their step down to a ward. They suggest that the neuropsychological consequences of critical illness, in particular the recollection of ICU experiences, may influence subsequent health-related quality of life.

These studies agree with the findings of the latest research and highlight that PTSD is a risk following severe critical illness.

Support from carers

Although ICU is a potentially life-saving environment, its patients and their families are experiencing psychological crises. Many patients are unconscious and may be unaware of their critical state but their families are always aware of their situation (Hardicre, 2003a). Deja et al (2006) suggest that at this time social support from family and carers can reduce the incidence of PTSD and improve subsequent health and well-being. Consideration should be taken of the fact that these family members will need support in order to undertake this role.

There is a significant amount of literature discussing how nurses can meet the needs of the families of patients who are critically ill and studies have shown that family members experience high levels of anxiety not only during their relatives' immediate crisis but also for months after the event (Hardicre, 2003b). Caring for the families of patients who are critically ill is an essential component of the critical care nurse's role. It can challenge even the most experienced ICU nurses (Box 1) and can be a source of considerable stress. Many nurses feel ill-prepared to fulfil this role (Hardicre, 2003b). However, this new evidence of the long-term benefits patients gain from the support of their relatives means that it is an important dimension of holistic critical care.

Healthcare support for patients

The Roberts et al (2006) study into dreams during ICU interventions recommends that patients are given information and counselling. For patients who have a planned ICU admission this information can be provided as part of routine care with a model similar to pre-operative visiting.

Pre-operative visiting is established practice that has been shown to reduce anxiety and aid recovery (Daykin, 2003). In the critical care environment pre-admission visits are thought to be useful to reduce the stress involved for both patients and relatives. Such visits can include provision of written information about:

- Telephone contact numbers;

- Visiting times;

- Daily procedures;

- Pain relief and other interventions;

- Where they will wake up after surgery (ICU, HDU or recovery room);

- Infusion devices and monitors;

- Analgesia.

The visits can also elicit useful information for the ICU staff about the patient, such as use of glasses or hearing aids (Daykin, 2003). However, this kind of intervention is only possible for non-emergency admissions to the ICU.

Another nurse-led intervention that has been used to provide psychological care to critical care patients is music therapy. Stubbs (2005) studied the effect of music therapy on a group of ICU patients and found that it can relax, reassure and distract patients. On occasions it can even temporarily 'relocate' them from their critical illness, assisting them psychologically in their recovery.

Implications for Practice

The evidence from Deja et al (2006) and Roberts et al (2006) highlights that PTSD and distressing dreams are associated with intensive-care interventions. It is important to provide not only physical but also psychological care to ensure the health and well-being of these patients (Roberts et al, 2006). Careful consideration of the ways that this kind of holistic care can be achieved for individual patients is required. This could include interventions such as pre-ICU visits (Daykin, 2003), music therapy (Stubbs, 2005) and social support from family and caregivers (Deja et al, 2006).

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