What is Post Traumatic Stress Disorder?

Post Traumatic Stress Disorder is…….‘A mental health disorder triggered by witnessing or experiencing a traumatic event.’

‘That the individual should have been exposed or witnessed to a traumatic event and responded with intense fear, helplessness or horror.’ (American Psychiatric Association.)

The diagnostic criteria identify the trigger to post traumatic stress disorder (PTSD) as exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:

• directly experiences the traumatic event;
• witnesses the traumatic event in person;
• learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
• experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related). (American Psychiatric Association.)

You can see from the PTSD scoring system that there are many signs and symptoms of PTSD, many of which are having a profound impact on the person’s life. Many of these will cause problems with relationships and day to day functioning.

This event is experienced in the form of intrusive memories or nightmares and patients often describe really terrifying experiences during their ICU stay:

‘Endless days and nights filled with strange broken sleep. A sea of fragmented menacing faces and shadows swimming through erratic beeps and bells. A large cackling face floating over me, constantly morphing and changing shape. The staring old lady in the bed opposite, her sallow skin disintegrating, eyeballs disappearing to reveal deep dark holes from which cockroaches crawled. Her weary face melting like wax into a big grey smudge. Deafening, haunting laughter filling every space. Blood seeping through holes and cracks in my skin, forming a puddle of red around me. Small insects scuttling up my arms and legs. My chest locked to the bed with wires and straps, as a plastic mask repeatedly smothered me. A strangling sensation around my neck. A warm metallic taste. An invisible force pinning my body down as a dark curtain was drawn closed.’ (Wake & Kitchiner, 2013)

There is a differentiation made between PTSD and acute stress disorder in that acute stress disorder lasts for less than one month and PTSD is for longer than one month. (Cahill & Pontoski, 2005) although they both present with similar effects upon the person’s life and well-being.

Previous systematic reviews have shown that PTSD occurs in 5-63% of critical illness survivors. This is a wide range, but even if we go for the mid-point, that is still over 30% of our patients are suffering with some of the effects of PTSD more than a month after leaving (Davydow & Gifford, 2008; Griffiths, Fortune, Barber, & Young, 2007; Jackson et al., 2007; D. Wade, Hardy, Howell, & Mythen, 2013).

The impact of an ITU stay was assessed in one meta-analysis using the Impact of Events Scale (IES) (Parker et al., 2015):

The maximum mean score on each of the three subscales is ‘4’, therefore, the maximum ‘total mean’ IESR score is 12. Lower scores are better. A total IES-R score of 33 or over from a theoretical maximum of 88 signifies the likely presence of PTSD.

This meta-analysis used the threshold of 35 on the IESR score as reflective of PTSD.

In six studies that used the IES at 1-6 months post-ICU the prevalence 25% and at 7-12 months the prevalence was 17% and even when some studies were removed due to heterogeneity the figures were still 24% at 1-6 months and 22% at 7-12 months.

So in Parkers meta-analysis approx 24% suffered with PTSD at 1-6 months and approx 23% suffered PTSD at 7-12 months.

What are the impacts for the Patient?

The quality of life was affected by the PTSD that many of the patients suffered from.

In one Dutch study, more than half of the survivors of critical illness had restrictions in daily functioning (van der Schaaf, Beelen, Dongelmans, Vroom, & Nollet, 2009). 30–60% reported walking more slowly, walking shorter distances, having difficulties with stairs and hills, going out for entertainment less often, spending less time on hobbies, recreation and community activities. 25% of the patients reported difficulty reasoning and solving problems, and impaired concentration and short-term memory. 40% reported decreased sexual activity.

Another study, which focused particularly on ARDS patients, also showed reduced quality of life for prolonged periods after discharge from critical care (Dowdy et al., 2006).

What are the risk factors for PTSD?

The use of sedatives seems to be one strong predictor for the incidence of post-ICU PTSD (Girard et al., 2007; Kress et al., 2003; Samuelson, Lundberg, & Fridlund, 2007). It is not necessarily clear whether this is causation or just correlation. It could be that those patients which are more prone to anxiety were getting more sedatives and perhaps those anxious patients may have developed PTSD with or without the use of sedatives (Parker et al., 2015).

There have been associations between sedatives and the development of ICU delirium (Pandharipande et al., 2006) and opiates have been associated with an increased risk of PTSD (Bienvenu et al., 2013).

These associations might make the judicious management of sedation of the patient an appropriate way to reduce the incidence of PTSD. Kress, one of the original advocates of the sedation holiday had some insights as to how this strategy may help with this problem (Kress et al., 2003). In those patients who had daily, protocol driven sedation interruptions versus those who had one led by clinicians there was a significant reduction in the incidence of PTSD (Schweickert, Gehlbach, Pohlman, Hall, & Kress, 2004).

There also seems to be some association between early post-ICU frightening experiences and PTSD symptoms (Bugedo et al., 2013; Girard et al., 2007; C Jones et al., 2007; C Jones, Griffiths, Humphris, & Skirrow, 2001; Christina Jones et al., 2003, 2010; Rattray, Johnston, & Wildsmith, 2005; Sackey, Martling, Carlsward, Sundin, & Radell, 2008; Samuelson et al., 2007; Weinert & Calvin, 2007).

Davydow notes that one potential risk factor NOT associated with later PTSD symptoms was the severity of critical illness (Davydow & Gifford, 2008).

Pre-existing anxiety or depressive disorder was found in some studies to be a strong predictor of PTSD post critical care (Bienvenu et al., 2013; Dean, 2012; C Jones et al., 2007, 2001; Jubran et al., 2010; D. M. Wade et al., 2012).

Summary

• PTSD is common and symptoms may persist for many months.

• PTSD has a high impact on patient quality of life.

• Pre-existing psychiatric illness should serve as a prompt for close follow-up.

• Lower levels of sedation should be targeted.

• Benzodiazepines should be minimised.

• Sedation holidays should be considered.

References

Association of American Psychiatrists. Diagnostic and Statistical Manual of Mental Disorders Source Information. U.S. National Library of Medicine. Retrieved from https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/DSM4/

Bienvenu, O. J., Gellar, J., Althouse, B. M., Colantuoni, E., Sricharoenchai, T., Mendez-Tellez, P. A., … Needham, D. M. (2013). Post-traumatic stress disorder symptoms after acute lung injury: a 2-year prospective longitudinal study. Psychological Medicine, 43(12), 2657–71. doi:10.1017/S0033291713000214

Bugedo, G., Tobar, E., Aguirre, M., Gonzalez, H., Godoy, J., Lira, M. T., … Ugarte, H. (2013). The implementation of an analgesia-based sedation protocol reduced deep sedation and proved to be safe and feasible in patients on mechanical ventilation. Revista Brasileira de Terapia Intensiva, 25(3), 188–96. doi:10.5935/0103-507X.20130034

Cahill, S., & Pontoski, K. (2005). Post-traumatic stress disorder and acute stress disorder I: their nature and assessment considerations. Psychiatry, 2(4), 14–25.

Davydow, D., & Gifford, J. (2008). Posttraumatic Stress Disorder in General Intensive Care Unit Survivors: A Systematic Review. General Hospital …, 30(5), 421–434. doi:10.1016/j.genhosppsych.2008.05.006.Posttraumatic

Dowdy, D. W., Eid, M. P., Dennison, C. R., Mendez-Tellez, P. A., Herridge, M. S., Guallar, E., … Needham, D. M. (2006). Quality of life after acute respiratory distress syndrome: a meta-analysis. Intensive Care Medicine, 32(8), 1115–24. doi:10.1007/s00134-006-0217-3

Girard, T. D., Shintani, A. K., Jackson, J. C., Gordon, S. M., Pun, B. T., Henderson, M. S., … Ely, E. W. (2007). Risk factors for post-traumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Critical Care (London, England), 11(1), R28. doi:10.1186/cc5708

Griffiths, J., Fortune, G., Barber, V., & Young, J. D. (2007). The prevalence of post-traumatic stress disorder in survivors of ICU treatment: a systematic review. Intensive Care Medicine, 33(9), 1506–18. doi:10.1007/s00134-007-0730-z

Jackson, J. C., Hart, R. P., Gordon, S. M., Hopkins, R. O., Girard, T. D., & Ely, E. W. (2007). Post-traumatic stress disorder and post-traumatic stress symptoms following critical illness in medical intensive care unit patients: assessing the magnitude of the problem. Critical Care (London, England), 11(1), R27. doi:10.1186/cc5707

Jones, C., Bäckman, C., Capuzzo, M., Egerod, I., Flaatten, H., Granja, C., … Griffiths, R. D. (2010). Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial. Critical Care (London, England), 14(5), R168. doi:10.1186/cc9260

Jones, C., Bäckman, C., Capuzzo, M., Flaatten, H., Rylander, C., & Griffiths, R. D. (2007). Precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care. Intensive Care Medicine, 33(6), 978–85. doi:10.1007/s00134-007-0600-8

Jones, C., Griffiths, R. D., Humphris, G., & Skirrow, P. M. (2001). Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Critical Care Medicine, 29(3), 573–580. doi:10.1097/00003246-200103000-00019

Jones, C., Skirrow, P., Griffiths, R. D., Humphris, G. H., Ingleby, S., Eddleston, J., … Gager, M. (2003). Rehabilitation after critical illness: a randomized, controlled trial. Critical Care Medicine, 31(10), 2456–2461. doi:10.1097/01.CCM.0000089938.56725.33

Jubran, A., Lawm, G., Duffner, L. A., Collins, E. G., Lanuza, D. M., Hoffman, L. A., & Tobin, M. J. (2010). Post-Traumatic Stress Disorder after Weaning from Prolonged Mechanical Ventilation. Intensive Care Medicine, 36(12), 2030–2037. doi:10.1007/s00134-010-1972-8.Post-Traumatic

Kress, J. P., Gehlbach, B., Lacy, M., Pliskin, N., Pohlman, A. S., & Hall, J. B. (2003). The long-term psychological effects of daily sedative interruption on critically ill patients. American Journal of Respiratory and Critical Care Medicine, 168(12), 1457–61. doi:10.1164/rccm.200303-455OC

Pandharipande, P., Shintani, A., Peterson, J., Pun, B. T., Wilkinson, G. R., Dittus, R. S., … Ely, E. W. (2006). Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 104(1), 21–26. doi:10.1097/00000542-200601000-00005

Parker, A. M., Sricharoenchai, T., Raparla, S., Schneck, K. W., Bienvenu, O. J., & Needham, D. M. (2015). Posttraumatic Stress Disorder in critical illness survivors: A metaanalysis. Critical Care Medicine, 43(5), 1121–2219. doi:10.1097/CCM.0000000000000882

Rattray, J. E., Johnston, M., & Wildsmith, J. A. W. (2005). Predictors of emotional outcomes of intensive care. Anaesthesia, 60(11), 1085–1092. doi:10.1111/j.1365-2044.2005.04336.x

Sackey, P. V, Martling, C. R., Carlsward, C., Sundin, O., & Radell, P. J. (2008). Short- and long-term follow-up of intensive care unit patients after sedation with isoflurane and midazolam–a pilot study. Crit Care Med., 36(3), 801–806. doi:10.1097/CCM.0B013E3181652FEE

Samuelson, K. A. M., Lundberg, D., & Fridlund, B. (2007). Stressful memories and psychological distress in adult mechanically ventilated intensive care patients – a 2-month follow-up study. Acta Anaesthesiologica Scandinavica, 51(6), 671–8. doi:10.1111/j.1399-6576.2007.01292.x

Schweickert, W. D., Gehlbach, B. K., Pohlman, A. S., Hall, J. B., & Kress, J. P. (2004). Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients*. Critical Care Medicine, 32(6), 1272–1276. doi:10.1097/01.CCM.0000127263.54807.79

van der Schaaf, M., Beelen, A., Dongelmans, D. A., Vroom, M. B., & Nollet, F. (2009). Functional status after intensive care: A challenge for rehabilitation professionals to improve outcome. Journal of Rehabilitation Medicine, 41(5), 360–366. doi:10.2340/16501977-0333

Wade, D., Hardy, R., Howell, D., & Mythen, M. (2013). Identifying clinical and acute psychological risk factors for PTSD after critical care: A systematic review. Minerva Anestesiologica, 79(8), 944–963.

Wade, D. M., Howell, D. C., Weinman, J. a, Hardy, R. J., Mythen, M. G., Brewin, C. R., … Raine, R. a. (2012). Investigating risk factors for psychological morbidity three months after intensive care: a prospective cohort study. Critical Care, 16(5), R192. doi:10.1186/cc11677

Wake, S., & Kitchiner, D. (2013). Post-traumatic stress disorder after intensive care. BMJ, 346(may22 16), f3232–f3232. doi:10.1136/bmj.f3232

Weinert, C. R., & Calvin, A. D. (2007). Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit. Critical Care Medicine, 35(2), 393–401. doi:10.1097/01.CCM.0000254339.18639.1D

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