post-ICU Posttraumatic Stress Disorder Research Articles

CT-PTSD following a COVID-19 ICU admission in the context of unresolved grief, delirium and incurable cancer: a single case design with an older adult client

Abstract This case study recounts an application of Ehlers and Clark’s (2000) cognitive model of post-traumatic stress disorder (PTSD) to post-intensive care unit (post-ICU) PTSD. An AB single case design was implemented. The referred patient, Rosalind (pseudonym), completed several psychometric measures prior to the commencement of therapy (establishing a baseline), as well as during and at the end of therapy. Idiosyncratic measures were also implemented to capture changes during specific phases of treatment. The importance of the therapeutic alliance, particularly in engendering a sense of safety, was highlighted. Findings support the use of cognitive therapy for PTSD (CT-PTSD) with an older adult, in the context of a coronavirus infectious disease (COVID-19)-related ICU admission. This case is also illustrative of the effectiveness of implementing CT-PTSD in the context of co–morbid difficulties and diagnoses of delirium, depression, and complicated grief. Key learning aims (1) To recognise the therapeutic value of CT-PTSD in addressing PTSD following a COVID-19 admission, in the context of complicated grief and delirium. (2) To consider the importance of a strong therapeutic alliance when undertaking CT–PTSD. (3) To understand the intersection of complicated grief and delirium in the context of ICU trauma. (4) To consider the challenges in working with PTSD, whereby the target trauma (COVID–19 ICU admission) is linked with ongoing uncertainty and continuing indeterminate threat.

Development of posttraumatic stress disorder symptoms after intensive care - how to prevent it?

IntroductionOver the last decade, there has been identified that critical illness survivors have high rates of psychiatric disorders such as posttraumatic stress disorder (PTSD). The experience of admission to intensive care units (ICU) and illusory memories may cause short and long-term psychological disorders.ObjectivesTo evaluate psychiatric disorders, such as PTSD, after ICU discharge, and determine the prevalence, risk factors, and prevention strategies for PTSD in these patients.Methods Non-systematic review through research in PubMed. Addicionally, a case report will be exposed, after the patient was diagnosed with SARS‑CoV‑2 and stayed in ICU for more than 30 days.Results The development of PTSD has been related to the number of adverse memories patients recall from their ICU experience. Some studies have shown that approximately 47% of patients remember real facts and 34% have illusory memories relative to their stays in the ICU. There were identified some risk factor associated to the increased risk of post-ICU PTSD, such as early post-ICU memories or psychotic experiences, pre-ICU psychopathology, benzodiazepine sedation during ICU and substantial acute stress symptoms occurring < 1 month after exposure to a traumatic stressor.ConclusionsHigh levels of anxiety and the development by patients of PTSD are being recognized as significant problems occurring after a stay in an ICU. The results of this study highlight the need to recognise the risk factors and to establish a early follow-up after ICU stay. This way is possible to identify patients who are at risk of developing acute PTSD-related symptoms, and early intervention can be institued.DisclosureNo significant relationships.

A Neurobiological Framework for the Therapeutic Potential of Music and Sound Interventions for Post-Traumatic Stress Symptoms in Critical Illness Survivors

Overview: Post traumatic stress disorder (PTSD) has emerged as a severely debilitating psychiatric disorder associated with critical illness. Little progress has been made in the treatment of post-intensive care unit (ICU) PTSD. Aim: To synthesize neurobiological evidence on the pathophysiology of PTSD and the brain areas involved, and to highlight the potential of music to treat post-ICU PTSD. Methods: Critical narrative review to elucidate an evidence-based neurobiological framework to inform the study of music interventions for PTSD post-ICU. Literature searches were performed in PubMed and CINAHL. The Scale for the Assessment of Narrative Review Articles (SANRA) guided reporting. Results: A dysfunctional HPA axis feedback loop, an increased amygdalic response, hippocampal atrophy, and a hypoactive prefrontal cortex contribute to PTSD symptoms. Playing or listening to music can stimulate neurogenesis and neuroplasticity, enhance brain recovery, and normalize stress response. Additionally, evidence supports effectiveness of music to improve coping and emotional regulation, decrease dissociation symptoms, reduce depression and anxiety levels, and overall reduce severity of PTSD symptoms. Conclusions: Despite the lack of music interventions for ICU survivors, music has the potential to help people suffering from PTSD by decreasing amygdala activity, improving hippocampal and prefrontal brain function, and balancing the HPA-axis.

Pilot exploration of post-traumatic stress symptoms in intensive care unit survivors in Cyprus.

Approximately, 20% of intensive care unit (ICU) survivors develop post-traumatic stress disorder (PTSD) symptoms. Although Davidson Trauma Scale (DTS) provides a comprehensive approach to PSTD symptoms, there is no evidence on DTS-I-M use in ICU survivors. To validate the modified intensity Davidson Trauma Scale (DTS-I-M) (wherein the frequency and severity subscales are combined to express symptoms intensity) in a convenience sample of ICU survivors in Cyprus, and to explore the prevalence of PTSD symptoms and related predictors. An instrument validation design, along with a cross-sectional, correlational study design was employed. Translation and cultural adaptation of the instrument were achieved through a group of experts and pilot testing. The DTS-I-M was administered via telephone. Participants' clinical data (length of ICU stay [LOS], mechanical ventilation duration [MVD], admission diagnosis, medication history) and demographics (age, gender) were collected. Non-parametric comparisons, and regression analyses to identify predictors of DTS-I-M scores and PTSD symptoms were employed. The Cypriot DTS-I-M version demonstrated high test-retest (Pearson's r = 0.928, P < .001) and internal consistency (Cronbach's [α] alpha = .97) reliability in a sample of 69 ICU survivors (62.7% response). About 36.2% of participants reported PTSD symptoms. Factor analysis confirmed the construct validity of the DTS-I-M, and a 3-factor structure (encompassing intrusive, avoidance, hyperarousal, mood, and cognitive symptoms). In a multiple regression, MVD (B = -3.11, OR [95% CI] = 22.58 [3.07-166.09, P = .002]) and LOS (r2 = 0.302, P = .002) were statistically significant predictors of DTS-I-M score. We confirm the applicability of the DTS-I-M for the assessment of PTSD symptoms in ICU survivors; and offer preliminary evidence on the prevalence and predictors of post-ICU PTSD symptoms in Cyprus. DTS-I-M is an appropriate screening tool for PTSD symptoms after ICU hospitalization. Patients with longer MVD and LOS are at higher risk for post-ICU PTSD symptoms and seem to experience more intense relevant symptoms.

Depression predicts long-term cognitive impairment in survivors of critical illness.

Intensive care unit (ICU) survivorship is associated with long-term cognitive impairment (LTCI). Our work has found post-ICU depression in up to 30% and posttraumatic stress disorder (PTSD) in up to 10% of ICU survivors. We hypothesized that post-ICU depression and PTSD are independently associated with LTCI in ICU survivors. This is a five-center nested prospective cohort of critically ill patients admitted to medical and surgical ICUs who underwent neuropsychological assessments at 3 and 12 months posthospital discharge. Our primary outcome was global cognition using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Trail Making Test, Part B, a test of executive functioning, at 3- and 12-month follow-up. Our independent variables were Beck Depression Inventory II and the PTSD Checklist-Specific Version measured at 3 and 12 months. We performed multivariable linear regression models controlling for covariates such as age, years of education, preexisting cognitive impairment, comorbidities, ventilator days, hypoxemia episodes, and days of delirium or coma. Of 1,047 patients in the combined cohort, 679 were alive and available for follow-up at 3 months. A total of 590 (87%) ICU survivors completed at least one 3-month assessment, and of the 554 who survived to 12 months, 519 (94%) completed both a 3- and 12-month assessment with a median age of 61 years (52-70 years) and mean daily Sequential Organ Failure Assessment score of 6 (4-8), 520 (88%) were mechanically ventilated, and 420 (71%) were with delirium. Of these, 113 (19%) had PTSD and 187 (32%) had depression at 3 months with similar rates at 12 months. Depression at 3 months was associated with lower 3-month RBANS (coefficient, -2.25; -3.10 to -1.39) and lower Trails B scores at both 3 months (odds ratio, 0.69; 0.56-0.85) and 12 months (odds ratio, 0.66; 0.52-0.84). Posttraumatic stress disorder at 3 months had no association with RBANS or Trails B scores at 3 or 12 months. Early post-ICU depression, but not PTSD, is independently associated with coexisting LTCI, even when controlling for past ICU delirium. Treatment for early depression represents a novel intervention area for LTCI prevention in ICU survivors. Prognostic/epidemiological, level III.

Cognitive therapy for post-traumatic stress disorder following critical illness and intensive care unit admission.

To recognise PTSD following admissions to intensive care units (ICUs).To understand how the ICU experience can lead to PTSD development.To understand how Ehlers and Clark's (2000) cognitive model of PTSD can be applied to post-ICU PTSD.To be able to apply cognitive therapy for PTSD to patients with post-ICU PTSD.

Comparative validation of three screening instruments for posttraumatic stress disorder after intensive care

PurposeAim of the present study was to compare the validity of three screening instruments to assess symptoms of posttraumatic stress disorder (PTSD) after intensive care of sepsis. Material and methodsParticipants were recruited within a large multicenter patient cohort study on long-term sequelae of sepsis. Adult patients (n = 83) on average four months after intensive care of (severe) sepsis or septic shock were included (median age 64 years, 60% male). PTSD symptom severity was assessed by three different self-report measures: two versions of the Posttraumatic Stress Scale (PTSS-10; PTSS-14), and the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). A clinical PTSD diagnosis was derived by using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). ResultsTen patients (12%) were diagnosed with PTSD. PTSS-10, PTSS-14, and PCL-5 revealed good reliability and concurrent validity. PTSS-14 showed the best accuracy in screening patients at risk for PTSD after intensive care with 80% sensitivity and 92% specificity at the recommended cutoff of 40. ConclusionsCompared to PTSS-10 and PCL-5, PTSS-14 appeared more appropriate for post-ICU PTSD screening when validated against a DSM-5 diagnostic interview.

Identification of post-traumatic stress disorder following ICU.

At least 270 000 patients are admitted to intensive care units (ICUs) each year,1 and up to 27% of these develop post-ICU post-traumatic stress disorder (PTSD).2 This may be due to a variety of factors resulting in cumulative stress and trauma: fear of dying, invasive treatment, pain, delirium, inability to communicate, provision and withdrawal of sedation, experience of physical illness, immobility, and sensory and sleep deprivation.2,3 Patients’ families are also at risk of developing PTSD. One study suggested that the risk was as high as 33% for a family member with the main decision-making role,4 and this risk was increased when incomplete information was provided to family members, when the relative died on ICU, and when they were closely involved in management and end-of-life decisions (the latter could be because relatives felt more responsible for their family member’s management and therefore implicated in a negative outcome). There is evidence that PTSD following traumatic experiences results in impaired daily functioning and reduced life course opportunities.5 In addition to an ICU admission, other traumatic experiences may include road traffic accidents, assaults, and domestic violence, all of which GPs will encounter regularly. PTSD is also associated with high levels of disability, including up to 3.6 days of work lost per person per month, and annual lost productivity due to PTSD is estimated at over $3 billion in the US alone.5 Specialists in intensive care medicine typically focus on the prevention of short-term mortality and the improvement in the patient’s physical health. However, the intense focus on physical improvement can inadvertently result in neglect of the patient’s mental wellbeing, particularly in …

Scars of a Lifetime

Scars of a Lifetime

Post-Traumatic Stress Symptoms in Post-ICU Family Members: Review and Methodological Challenges.

Family members of intensive care unit (ICU) patients are at risk for symptoms of post-traumatic stress disorder (PTSD) following ICU discharge. The aim of this systematic review is to examine the current literature regarding post-ICU family PTSD symptoms with an emphasis on methodological issues in conducting research on this challenging phenomenon. An extensive review of the literature was performed confining the search to English language studies reporting PTSD symptoms in adult family members of adult ICU patients. Ten studies were identified for review published from 2004 to 2012. Findings demonstrate a significant prevalence of family PTSD symptoms in the months following ICU hospitalization. However, there are several methodological challenges to the interpretation of existing studies and to the conduct of future research including differences in sampling, identification of risk factors and covariates of PTSD, and lack of consensus regarding the most appropriate PTSD symptom measurement tools and timing.

A pilot investigation of the association of genetic polymorphisms regulating corticotrophin-releasing hormone with posttraumatic stress and depressive symptoms in medical-surgical intensive care unit survivors

PurposeTo determine if single nucleotide polymorphisms of the corticotrophin-releasing hormone binding protein (CRHBP, rs10055255) and CRH receptor type 1 (CRHR1, rs1876831) were associated with posttraumatic stress disorder (PTSD) and depressive symptoms following medical-surgical intensive care unit (ICU) hospitalization. Materials and MethodsWe extracted DNA for genotyping from saliva samples of 93 ICU patients enrolled in a prospective cohort investigation. Follow-up interviews conducted 3 and 12-months post-ICU included assessment of PTSD symptoms with the PTSD Checklist-Civilian Version and depressive symptoms with the Patient Health Questionnaire–9. ResultsHomozygosity for the CRHBP rs10055255 T allele was associated with significantly fewer post-ICU PTSD (β = −10.8, 95% confidence interval [95% CI], −17.7 to −3.9; P = .002) and depressive symptoms (β = −3.7, 95% CI, −6.7 to −0.7; P = .02). Carrying a CRHR1 rs1876831 C allele was associated with significantly more post-ICU depressive symptoms compared to T/T homozygotes (C/T heterozygtes: β = 6.9, 95% CI, 1.2-12.6; P = .02; C/C homozygotes: β = 5.8; 95% CI: 0.2-11.3; P = .04). These associations remained significant after adjustment for age, race, illness severity, and in-ICU steroid exposure. ConclusionsDespite a small sample size, our findings suggest a potential role for genetic variants of CRHBP and CRHR1 in the development of post-ICU psychiatric morbidity.

A longitudinal investigation of posttraumatic stress and depressive symptoms over the course of the year following medical–surgical intensive care unit admission

ObjectiveThe objective was to identify risk factors for posttraumatic stress disorder (PTSD) and depressive symptoms after medical–surgical intensive care unit (ICU) admission. MethodThis longitudinal investigation included 150 medical–surgical ICU patients. We assessed acute stress and post-ICU PTSD symptoms with the PTSD Checklist-Civilian Version and post-ICU depressive symptoms with the Patient Health Questionnaire-9. Mixed-model linear regression ascertained associations between patient and clinical characteristics and repeated measures of post-ICU PTSD and depressive symptoms. ResultsThe prevalences of substantial PTSD and depressive symptoms were 16% and 31% at 3 months post-ICU and 15% and 17% at 12 months post-ICU, respectively. In-hospital substantial acute stress symptoms [beta: 16.9, 95% confidence Interval (CI): 11.4, 22.4] were independently associated with increased post-ICU PTSD symptoms. Lifetime history of major depression (beta: 2.2, 95% CI: 0.1, 4.2), greater prior trauma exposure (beta: 0.5, 95% CI: 0.2, 0.9) and in-hospital substantial acute stress symptoms (beta: 3.5, 95% CI: 0.8, 6.2) were independently associated with increased post-ICU depressive symptoms. ConclusionsIn-hospital acute stress symptoms may represent a modifiable risk factor for psychiatric morbidity in ICU survivors. Early interventions for at-risk ICU survivors may improve longer-term psychiatric outcomes.

Predictors of posttraumatic stress disorder and return to usual major activity in traumatically injured intensive care unit survivors

Objective To assess intensive care unit (ICU)/acute care service-delivery characteristics and pre-ICU factors as predictors of posttraumatic stress disorder (PTSD) and return to usual major activity after ICU admission for trauma. Method Data from the National Study on the Costs and Outcomes of Trauma were used to evaluate a prospective cohort of 1906 ICU survivors. We assessed PTSD with the PTSD Checklist. Regression analyses ascertained associations between ICU/acute care service-delivery characteristics, pre-ICU factors, early post-ICU distress and 12-month PTSD and return to usual activity, while controlling for clinical and demographic characteristics. Results Approximately 25% of ICU survivors had symptoms suggestive of PTSD. Increased early post-ICU distress predicted both PTSD and diminished usual major activity. Pulmonary artery catheter insertion [risk ratio (RR) 1.28, 95% confidence interval (95% CI) 1.05–1.57, P=.01] and pre-ICU depression (RR 1.23, 95% CI 1.02–1.49, P=.03) were associated with PTSD. Longer ICU lengths of stay (RR 1.21, 95% CI 1.03–1.44, P=.02) and tracheostomy (RR 1.29, 95% CI 1.05–1.59, P=.01) were associated with diminished usual activity. Greater preexisting medical comorbidities were associated with PTSD and limited return to usual activity. Conclusions Easily identifiable risk factors including ICU/acute care service-delivery characteristics and early post-ICU distress were associated with increased risk of PTSD and limitations in return to usual major activity. Future investigations could develop early screening interventions in acute care settings targeting these risk factors, facilitating appropriate treatments.

Posttraumatic stress disorder in general intensive care unit survivors: a systematic review

Objective Our objective was to summarize and critically review data on the prevalence of posttraumatic stress disorder (PTSD) in general intensive care unit (ICU) survivors, risk factors for post-ICU PTSD and the impact of post-ICU PTSD on health-related quality of life (HRQOL). Methods We conducted a systematic literature review using Medline, EMBASE, Cochrane Library, CINAHL, PsycINFO and a hand-search of 13 journals. Results Fifteen studies were eligible. The median point prevalence of questionnaire-ascertained “clinically significant” PTSD symptoms was 22% ( n=1104), and the median point prevalence of clinician-diagnosed PTSD was 19% ( n=93). Consistent predictors of post-ICU PTSD included prior psychopathology, greater ICU benzodiazepine administration and post-ICU memories of in-ICU frightening and/or psychotic experiences. Female sex and younger age were less consistent predictors, and severity of critical illness was consistently not a predictor. Post-ICU PTSD was associated with substantially lower HRQOL. Conclusions The prevalence of PTSD in ICU survivors is high and negatively impacts survivors' HRQOL. Future studies should comprehensively address how patient-specific factors (e.g., pre-ICU psychopathology), ICU management factors (e.g., administration of sedatives) and ICU clinical factors (e.g., in-ICU delirium) relate to one another and to post-ICU PTSD. Clinicians caring for the growing population of ICU survivors should be aware of PTSD risk factors and monitor patients' needs for early intervention.

The occurrence of posttraumatic stress disorder in patients following intensive care treatment: a cross-sectional study in a random sample.

Posttraumatic stress disorder (PTSD) can now be applied to patients who have just had intensive care treatment. The authors tested whether the reliability of the diagnosis depends on the measuring instrument used and whether the occurrence of PTSD is related to the presence of preexisting psychic disorders or to a worsening of the patients' general condition. The authors examined 41 former patients of an intensive care unit (ICU) with the Posttraumatic Scale (PTSS-10) and, afterward, with the Structured Clinical Interview (SCID). Screening with PTSS-10 showed that 17.07% of the patients met the recommended threshold for probable diagnosis of PTSD of 35 or more points. With SCID, PTSD could be confirmed in 9.76% of the cases. Patients with a prior psychiatric disease showed more frequent (P < .02) occurrences of PTSD. The severity of their Acute Physiology and Chronic Health Evaluation System II (Apache II) scores had no significant influence. PTSS-10 can be used for a preliminary diagnostic orientation. With the PTSD module of the SCID, a structured diagnostic tool is available. Almost twice as many PTSD cases were diagnosed among the subjects with the PTSS-10 as with SCID. Post-ICU PTSD occurred more frequently among patients with prior psychiatric diseases; however, it was not dependent on exacerbation of the patient's Apache II scores.