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Recovery and Rehabilitation 63

experiences. These experiences tend to be reported as self-report measures, different research designs, varied
unpleasant memories of being in ICU 16,57-59,84,85 and are patient casemix and international variations in the
discussed later in this chapter. delivery of intensive care. These variations have resulted
in overestimation of the prevalence of PTSD and post-
Depression is also associated with other aspects of recov- 100
ery and in particular HRQOL. Depressed patients tend to traumatic stress symptoms (PTSS), although note
rate their HRQOL as poorer than those who are not. 85,93 that patients with significant PTSS may be less likely to
However what is less clear is the direction of this relation- participate in research studies. While PTSD should be
12
ship; it could be that patients with a poorer HRQOL tend diagnosed through a structured clinical interview,
to be depressed rather than depression leading to percep- few studies use this approach. One small study compared
tions of poorer HRQOL. Patients who have psychological the prevalence of PTSD in patients who had daily
problems prior to intensive care are likely to develop sedation withdrawal versus those who did not; 6/19
these after discharge. Although assessment of pre-ICU patients who did not receive daily sedation withdrawal
status is difficult, in some cases this information can be were diagnosed with PTSD, while 0/13 were diagnosed
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obtained from relatives or caregivers. from the intervention group. The small sample size was
a limitation but nonetheless these were important
POSTTRAUMATIC STRESS findings.

In recent years there has been increasing interest in the Patients may have significant PTSS without developing
development of posttraumatic stress reactions such as PTSD and it is mainly these symptoms that are assessed
Posttraumatic Stress Disorder (PTSD) as a response to using the self-report measures. Reported prevalence of a
critical illness, 94,95 and there is increasing recognition of significant posttraumatic stress reaction or PTSD is 14–
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these symptoms as a problem for some intensive care 27%. As for anxiety and depression, there are certain
survivors. 14,72 Individuals do not perceive or respond to patient and clinical characteristics that can predict likeli-
101
traumatic or life-threatening events in the same way, but hood of a posttraumatic stress reaction. Trauma and
96
there are commonalities including that events are often younger patients tend to have higher scores on measures
74,85,88
perceived as a threat to life, are uncontrollable and unpre- of posttraumatic stress. Aspects of an intensive care
dictable and that they are beyond the usual human experience are associated also with a posttraumatic stress
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85,90
experience. Many symptoms of posttraumatic stress that reaction. Patients with a longer ICU stay, longer dura-
98
90
patients experience in the initial days after intensive care tion of sedation and/or neuromuscular blockade, and
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discharge may be considered a normal reaction. There- mechanical ventilation are more likely to report
fore practitioners need to clearly separate the normal posttraumatic stress symptoms. Patients who have daily
from the abnormal response; this is achieved by assessing sedative interruption had lower scores on the Impact of
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the severity, duration of symptoms, and their effect on an Event Scale. Importantly, daily sedative interruption or
individual’s life. PTSD should not be diagnosed until at withdrawal, or titration of sedation is becoming more
least one month after the event, and until the symptoms common in practice and therefore requires further
have been present for one month. Symptoms commonly research. Certain subgroups of patients appear to have a
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cause problems in relation to work, social or other impor- higher prevalence of PTSD (e.g. ARDS patients ), and
99
tant activities; this is important to consider when devel- PTSD can often endure for many years.
oping critical care follow-up services. Importantly, PTSD
symptoms may be reactivated after some time, and being MEMORIES AND PERCEPTIONS
in ICU may serve as a catalyst for some patients, e.g. reliv- Interestingly, illness severity does not consistently predict
ing a war event. e.g.58 a PTSS reaction, 73,85 but rather perceptions of the inten-
sive care experience. This is one of the unique features of
Signs of posttraumatic symptomatology include three being in intensive care; patients have little recall for
symptom areas: intrusive thoughts, avoidance behav- factual events and often report large gaps where they
iours and hyper-arousal symptoms. Individuals can remember very little about their critical illness. Patients’
re-experience a traumatic event through unwanted accounts often include disturbing recollections with
thoughts, often in the form of ‘flashbacks’ and/or ‘night- memories of ‘odd perceptual experiences’, 54,102 ‘night-
mares’. Individuals experiencing these thoughts often mares’ or ‘hallucinations’. 57,58 While not all patients expe-
develop avoidant behaviours in the belief this action will rience these, those who do so tend to report memories
reduce the intrusive thoughts. Avoidant behaviours for that are persecutory in nature, are often associated with
103
intensive care patients can range from simply avoiding feelings of being elsewhere, reliving a previous life
102
television programs about hospitals, not talking about event, or fighting for survival. These memories often
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their ICU experience or, more seriously, non-attendance seemed ‘real’ and were distressing to patients at the time,
at a follow-up clinic or other hospital out-patient appoint- and may be recalled in detail some months afterwards.
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ments. Hyper-arousal behaviours include difficulties in Having delusional rather than factual memories is more
concentrating or falling asleep. Assessment of posttrau- likely to result in distress; 56,57,85,105 and lack of memory for
matic stress in survivors of a critical illness should examine factual events may result in longer-term psychological
all three symptom areas.
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problems, with the important element being the content
As with other psychological symptoms such as anxiety of the ICU memories rather than the number of memo-
and depression, it has been difficult to establish the pre- ries. Table 4.5 summarises studies exploring posttrau-
valence of PTSD after intensive care because of the use of matic stress after ICU.