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When Healing HurtsPost-traumatic stress disorder in ICU survivors.

By Sydney SpieselPosted Wednesday, Sept. 17, 2008, at 11:42 AM ET

Question: What can cause post-traumatic stress disorder? Symptoms of stress following traumatic experiences have been reported since people began writing about war. But PTSD didn't come into formal use until 1980, when severe psychological symptoms were seen in Vietnam veterans. As the condition was studied, it became clear that it didn't apply only to Vietnam veterans. Almost anyone who had been exposed to severe stress or a traumatic event—surviving a tsunami, living through a terrorist attack—could experience PTSD. Typically, patients re-experience their trauma as flashbacks and nightmares and often have trouble sleeping. Many perform badly in their jobs or have difficulty with social relationships, perhaps because they are excessively prone to anger or irritability. A less obvious cause of PTSD, just recently written about in the journal General Hospital Psychiatry, involves the experience of being seriously ill or injured and treated by hospitalization in an intensive-care unit.

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Findings: The analysis found that about 20 percent of patients who had spent time in an intensive-care unit showed evidence of PTSD. Does the PTSD associated with admission to an intensive-care unit have a significant long-term effect on the patient's quality of life? Here, the answer is a little less clear because the question was addressed by only two of the 15 studies that contributed to the broader analysis relating the ICU experience and PTSD. The patients in these studies were tracked for only six to nine months after ICU discharge. However, both studies reported a poorer quality of life in those patients who were suffering from PTSD at the time of follow-up.

Method: The analysis put together 15 previous studies encompassing more than 1,700 intensive-care-unit survivors. The studies were performed in several European countries and the United States and made use of multiple different methods to ascertain the prevalence of PTSD in ICU survivors (generally excluding patients who had known psychiatric histories or who arrived at the ICU because of a suicide attempt).

Link: Terribly serious illness and the treatments that are sometimes required to save a patient are remarkably like being in a war zone. The desperate struggle to breathe and the discomfort associated with mechanical ventilation are painful and stressful experiences. Furthermore, imagine having little or no control of your life. Picture yourself almost (or, indeed, completely) unable to communicate; being in a constantly lit, always-noisy environment; and even having your visual field limited to a patch of ceiling, with the occasional interruption from someone's face. All these circumstances contribute to the enormous stress experienced by many ICU patients. Medications given to ICU patients also contribute to the problem. Some drugs given to maintain blood pressure can also increase a sense of anxiety. Paradoxically, even drugs in the same class as Valium—intended to sedate and decrease anxiety—can lead to nightmares and hallucinations that a trapped and constrained patient might not be able to distinguish from reality.

Conclusion: How can this problem be prevented in the future? To some extent, it probably can't. Sedation might lead to disturbing nightmares, but it's nevertheless needed by patients on a mechanical ventilator and can't be eliminated because otherwise the treatment would be intolerable and the patient's oxygen demand would increase unacceptably. But we can be sensitive to the patient's physical circumstances in the ICU and make a serious effort to decrease the nighttime noise and light that interfere with restful sleep. We can do things that promote autonomy in ICU patients and, as much as possible, give them a sense of control over their circumstances. Similarly, we should be very careful in our choice of medication, so the drugs and doses don't contribute to confusion and delirium. And, finally, we must be alert for signs of PSTD in ICU survivors and be prepared to treat the condition when and if it appears.

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Sydney Spiesel is a pediatrician in Woodbridge, Conn., and clinical professor of pediatrics at Yale University's School of Medicine.
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