Critical Care And PTSD

Post-traumatic stress disorder (PTSD) describes a collection of symptoms commonly experienced by people following traumatic, life-threatening, or frightening events. It is characterized by recurrent, involuntary and intrusive memories, dreams or flashbacks relating to the trauma which cause distress. Avoidance (or attempted avoidance) of these intrusions and any associated external triggers is common, and the individual’s understanding of the event can be highly distorted, leading them to develop persistent and exaggerated negative beliefs about themselves, others, or the world. Other emotional symptoms include a diminished interest in activities, detachment, or an inability to feel positive emotions. Not everybody who experiences a trauma goes on to develop PTSD. While it is common to experience some symptoms of PTSD after a trauma, for many people, these begin to diminish in the first month. Depending on the type of trauma, 20-30% of people experience symptoms of PTSD that persist, and a large-scale review gave the lifetime incidence of PTSD as 8.3% (Kilpatrick et al., 2013). Following medical treatment in a critical care (or intensive care) service, about 1 in 5 people go on to develop PTSD. This is because many qualities of intensive care, though necessary for treatment, often contribute to the later development of PTSD. For some, symptoms may develop immediately after receiving intensive care, but for others, they may emerge later (Murray et al., 2020). Aspects of critical care interventions that are believed to increase the likelihood that a patient will develop PTSD include:

• Invasive or uncomfortable medical interventions. Patients requiring critical care may be subjected to various alarming, painful or uncomfortable medical procedures during their treatment. For example, patients are sometimes restrained so that they do not remove tubes or medical equipment, which can leave them feeling powerless. Mechanical ventilation (if required) can prevent the patient from communicating, and increases the risk of becoming delirious. Many life support machines make loud noises to alert staff to changes in the patient’s condition, which can further disorient patients and cause sleep deprivation: a leading cause of psychological distress, which further increases the likelihood of developing PTSD (Murray et al., 2020).
• Fear and isolation. Many patients who require critical care treatment report that they felt afraid for their life. They may have been unable to communicate, increasing feelings of isolation and vulnerability.
• Prolonged duration of care. A stay in intensive care can last for days or weeks. This can increase the number of potential traumatic memories a patient might subsequently have, giving them a larger ‘dose’ of trauma.
• Delirium. To require admission to critical care, the patient must be severely unwell. Coupled with opiate or sedative medication, which can cause them to drift in and out of consciousness, this can severely impair the patient’s ability to think clearly or understand what is happening, resulting in them experiencing hallucinations or developing unusual beliefs (Griffiths & Jones, 1999). Some patients may report feeling persecuted, and paranoia is a common response to seeing healthcare staff wearing masks, which are in fact worn for the patient’s safety.

Psychological treatment for PTSD following critical care follows essentially the same pattern as for other traumas. However, it is helpful for clinicians to be aware of some specific aspects of their client’s experiences in order to help them most effectively:

• Trauma memories – fragmentation, duration, content. Stays in intensive care may range from days to weeks. The extended duration of many critical care experiences can mean that patients have experienced a higher ‘dose’ of trauma than some other trauma survivors, and consequently there may be more problematic trauma memories to work with. Patients are unlikely to have been conscious for the entirety of their stay in the critical care unit. Due to their impaired consciousness, memory encoding is likely to have been affected, and retrieval will be subsequently impacted. It is to be expected that patients will have gaps in their memory and these can be acknowledged. During memory processing, therapists can use prompts such as “What is the next thing that you can remember?”. Therapists should expect that trauma memories of critical care experiences will be particularly fragmented, and may contain a mixture of ‘real’ and ‘hallucinated’ content. It is often helpful to construct a timeline of the person’s hospital experiences, which incorporates information from their memory, medical records, and critical care diary (if one is available), as well as descriptions from family and friends. Constructing an illustrated or written narrative is often helpful.
• Experiences of delusions or hallucinations in critical care may appear to persist post- discharge. Delirium is extremely common in patients who have required intensive care, and can cause hallucinations and delusional beliefs. If these experiences appear to be persisting post-ICU it may be helpful to conceptualize them as involuntary memories of their active attempts at meaning-making, which were encoded during physiological states of delirium. These memories can be subsequently re-evaluated through therapeutic exposure. A clinical example is outlined below:

Mark was ventilated and sedated during his ICU stay, and he experienced delirium. One of his nurses was of Asian origin, and during this time he perceived that he was being persecuted by Asian gangsters. After he had physically recovered, he still felt afraid around people of Asian appearance, experienced unwanted memories of Asian faces, and held the belief (albeit less strongly than during his time in critical care) that he was being watched by a gang of Asian men. The conceptualization that he found most helpful was that his threat system was easily triggered by similarities to his trauma memory (Asian faces), and his unwanted memories were flashbacks of his time in critical care. Both of these reduced in intensity with therapeutic exposure to his trauma memories. He subsequently conducted some behavioral experiments to test his beliefs about being watched and re-evaluated his belief to a less-threatening one: “Nobody is paying me particular attention.” Once his memories had been processed and his beliefs re- evaluated, he no longer felt such distress by these memories.

• Patients may describe particularly strong ‘body memories’ or feelings during trauma memory reprocessing. Patients might describe these experiences spontaneously during assessment or memory processing, but might also find it helpful if the therapist sensitively enquires about such experiences directly. For example, patients might report unpleasant sensations in their throat related to the experience of intubation, or discomfort in their groin related to catheterization. As with regular trauma memories of visual or auditory experiences, memory reprocessing of (i.e. exposure to) these somatosensory memories is an effective form of treatment. If patients spent time in critical care lying down on their back, or in a prone position, it may be helpful to conduct some parts of memory work in therapy with the patient in a similar body position.
• Appraisals of trauma consequences need to be addressed. Appraisals following critical care experiences might touch on a number of important domains, and can be addressed using cognitive and behavioral interventions. For more information, clinicians are directed to Murray et al. (2020), which discusses the clinical approaches to some of these in more detail.
  • Beliefs about mental illness or mental integrity could be caused by experiences of delirium.
  • Beliefs might include themes such as “I’m going mad”, “I can’t trust my own mind”, or “I’m not in control”. Patients might feel ashamed of the way they behaved during their treatment.
  • Beliefs about loss. These might include beliefs concerning loss of physical function, or the loss of a previous way of living.
  • Beliefs about body image. These might include beliefs about permanent change such as “I’ll never be the same again”, or other beliefs about scars or other body image changes such as “I’m disgusting”.
  • Health concerns. It is common for patients who have had serious medical experiences to fear recurrence of their illness, or another illness which could result in readmission to hospital. Such health anxiety may also generalize to concern for loved ones.
  • Beliefs concerning medical treatment and healthcare staff. Feeling mad about aspects of medical treatment is not uncommon, and some patients may feel mistrustful of healthcare staff.
• Site visits and records access. Helpfully, patients may be able to access records of their admission to intensive care, detailing their illness and the medical procedures they underwent. Some hospitals will create a patient-friendly ‘Critical care diary’, and such information is often useful in therapy when helping patients to untangle their experiences. In some circumstances, site visits to intensive care are possible and many patients report that these are helpful. Where in-vivo site visits are not possible, virtual site visits can be a viable alternative. Therapists should help clients look for information which will help them to understand where hallucinations might have originated, or which might help them to update beliefs:

When Tanya visited the intensive care unit, she came to understand the ‘coffin nails’ she remembered seeing were likely to have been details in the ceiling. She also saw how gently the nurses interacted with patients, and how softly they encouraged them not to interfere with tubes. She came away with updated information “They are trying to help, not harm.”

• Patients may report ongoing triggers. Triggers might be visual, such as medical staff, locations, or physical staff. Triggers can also be auditory (such as beeping machines) or somatosensory (such as lying in particular positions). Patients can be encouraged to use stimulus discrimination to discriminate between ‘then’ and ‘now’, both to naturally occurring triggers experienced in their daily life, as well as to deliberate provocations in the therapy room.

The Critical Care And PTSD information handout is designed to help clients to learn about the properties of critical care that can increase the likelihood of PTSD developing. It can be a useful prompt for therapists to explore aspects of the client’s experience, and it can help clients come to terms with the magnitude of their experiences. The design and language of the handout have been kept simple, to be accessible to a wide range of clients.

This is a Psychology Tools information handout. Suggested uses include:

• Client handout – use as a psychoeducation resource.
• Discussion point – use to provoke a discussion and explore client beliefs.
• Therapist learning tool – improve your familiarity with a psychological construct.
• Supervision tool – to develop formulations and knowledge.
• Teaching resource – use as a learning tool during training.

• Griffiths, R. D., & Jones, C. (1999). Recovery from intensive care. Bmj, 319(7207), 427-429.
• Murray, H., Grey, N., Wild, J., Warnock-Parkes, E., Kerr, A., Clark, D. M., Ehlers, (2020). Cognitive therapy for post-traumatic stress disorder following critical illness and intensive care unit admission. Cognitive Behaviour Therapist, (April 2020).
• Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM‐IV and DSM‐5 criteria. Journal of traumatic stress, 26(5), 537-547.