Free Guide To Critical Illness, Intensive Care, And Post-Traumatic Stress Disorder (PTSD)

As a result of the current global health crisis, many more people than usual are having serious medical experiences. These include admissions to hospital with breathing difficulties, or transfers to critical care (intensive care) units. A significant proportion of these people will go on to develop symptoms of post-traumatic stress disorder (PTSD).

We wanted to put together a guide to give information to these patients, and to those close to them. It discusses how they might be feeling, why serious medical experiences can cause these difficult reactions, and the most effective psychological treatments.

This guide is for:

• People who have survived a frightening medical experience, such as being admitted to critical care (intensive care).
• People who have been hospitalized with severe medical problems related to COVID-19.
• Their family and friends.
• Mental health and medical professionals who want to understand more about how to help.

The guide gives information about:

• How you might feel after spending time in intensive care.
• Psychoeducation about PTSD.
• Things about intensive care that can contribute to the development of PTSD.
• Information about delirium.
• Psychological approaches to treating PTSD.
• Signposting to evidence-based treatment.
• Information for mental health professionals working with patients who have PTSD following admission to intensive care.

Our aim is for this to reach as many people who could find it useful as possible. We would love you to share it as widely as you can. With your support, the guide could be seen by many more people who could benefit from it.

Wishing you well,

Dr Matthew Whalley & Dr Hardeep Kaur

Go to the guide

Thank you to the following people for helping with translations of this guide:

• Arabic: Marie Wilson and Shams Al-Nahar Basbous
• French: Christine Lacroix and Virginia Rogers
• Greek: Athina Papageorgiou and Panagiota Alvanou
• Italian: Aurora Cartwright-Madaffari and Elisabetta Cairo
• Polish: Paweł Kaliniecki and Sonia Izabella Barciuk
• Romanian: Popescu Ioana-Mirela
• Russian: Elena Karyakina
• Spanish: Alicia Cerrato Grande, Sara Rivera Molina, Joan González, Andrés Calvo Abaunza, Yaddira Molano Santiago, Israel Mallart Ortega, Brenda Morales Torres, Alejandra Morales Phipps, Carolina Haylock-Loor, Ahsley Gibbs, Elizabeth Eastman
• Tagalog: Roy B. Macaraig
• Turkish: Gul Eryuksel
• Vietnamese: Ho Huy Duc

Information for mental health professionals working with patients who have PTSD following admission to intensive care

Even therapists who are used to working with survivors of trauma can be ‘thrown’by certain aspects of ICU trauma. Fundamentally, psychological treatments for ICU trauma use the same elements as when treating other types of trauma. However, therapists might find it helpful to be familiar with the details below, and to seek appropriate supervision when working with this population. If you have experienced medical trauma and are planning to seek therapy you might find it helpful to discuss this page with your therapist.

Trauma memories: duration, fragmentation, content

Stays in intensive care may range from days to weeks. The duration of the stay can mean that patients have experienced a higher ‘dose’ of trauma than some other trauma survivors and that there may subsequently be more trauma memories to work with.

Patients are unlikely to have been conscious for the entirety of their stay in the ICU. They are likely to have had 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 you can use the prompt “And what is the next thing that you can remember?”.

Therapists should expect that trauma memories of critical care experiences will be partic- ularly 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 ICU 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 ICU 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 expe- riences of active attempts at meaning-making, which were encoded during physiological states of delirium.

To give a clinical example. ‘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 (somewhat less strongly than during his time in ICU) 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 ICU. 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 the less-threatening “nobody is paying me particular attention”. Once his memories had been ‘processed’ and his beliefs re-evalu- ated he no longer felt such distress by his memories of ICU.

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 ICU 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.

‘Pain flashbacks’ are a real phenomena and are worth exploring

Flashbacks are forms of involuntary memory. They are often experienced in visual and auditory modalities, but olfactory (smell) and somatosensory (touch) memories are also commonly reported. Research indicates that individuals who experience physical pain during their trauma can re-experience this pain in the form of flashbacks, but that many will not spontaneously report these experiences. Clinical experience indicates that these memories can be processed in the same way as other traumatic memories.

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) [4] which discuss clinical approaches to some of these in more detail.

• Beliefs about mental illness or mental integrity due to 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 losses 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 other 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 angry 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 the time course of their illness and the medical procedures they underwent. Some hospitals will create a patient-friendly ‘ICU 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 these to be helpful. In-vivo site visits are presently unlikely due to coronavirus, and so virtual site visits are a viable alternative.

Therapists should help clients to look for information which will help them to understand where hallucinations might have originated, or which might help them to update beliefs. For example our client ‘Dave’ came to understand the ‘coffin nails’ he saw in ICU were likely to have been details in the ceiling. When ‘Tanya’ visited ICU she saw how gently the nurses interacted with patients, and how softly they encouraged them not to interfere with tubes, and 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. They might also be somatosensory including 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.

References & further reading

[1] Griffiths, R. D., & Jones, C. (1999). Recovery from intensive care. BMJ, 319(7207), 427-429.

[2] Righy, C., Rosa, R.G., da Silva, R.T.A., Kochhann, R., Migliavaca, C. B., Robinson, C. C., Teche, S. P., Teixeira, C., Bozza, F. A., Falavigna, M. (2019). Prevalence of post-trau- matic stress disorder symptoms in adult critical care survivors: a systematic review and meta-analysis. Critical Care, 23, 213.

[3] Cavallazzi, R., Saad, M., & Marik, P. E. (2012). Delirium in the ICU: an overview. Annals of Intensive Care, 2(1), 49.

[4] 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).