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American Journal of Critical Care. 2008;17: 534-543
Copyright © 2008 by the American Association of Critical-Care Nurses.
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CE Article

Symptoms of Acute Posttraumatic Stress Disorder After Intensive Care

By Karen Wallen, RN, MN (Hons), Wendy Chaboyer, RN, PhD, Lukman Thalib, BSc(H), MSC, PhD and Debra K. Creedy, RN, PhD. Karen Wallen is an associate lecturer at the Research Centre for Clinical Practice Innovation, Griffith University Gold Coast, Queensland, Australia. Wendy Chaboyer is foundation director of the Research Centre for Clinical Practice Innovation and an active acute and critical care nurse researcher. Lukman Thalib is an associate professor in the Faculty of Medicine at the University of Kuwait, Safat. Debra K. Creedy is a professor of nursing at the National University of Singapore. Both Thalib and Creedy are adjunct professors with the Research Centre for Clinical and Community Practice Innovation.

Corresponding author: Karen Wallen, RN, MN (Hons), Research Centre for Clinical Practice Innovation, Griffith University Gold Coast, PMB 50 Gold Coast Mail Centre, QLD 9726, Australia (e-mail: K.Wallen{at}griffith.edu.au).


   Abstract
Top
 Abstract
Posttraumatic Stress Disorder
 Purpose of the Study
 Methods
 Results
 Discussion
 Limitations and Recommendations...
 Conclusion
 References
 
Background Admission to intensive care is often a sudden and unexpected event precipitated by a life-threatening condition, 2 determinants thought to influence the development of posttraumatic stress disorder.

Objectives To identify the frequency of acute symptoms of posttraumatic stress disorder and to describe factors predictive of these symptoms in patients 1 month after discharge from intensive care.

Methods In this prospective cohort study, all patients meeting the inclusion criteria during the study period were invited to participate. Participants completed the Impact of Event Scale-Revised, and demographic and clinical data were accessed from an intensive care unit database.

Results During a 9-month period, 114 of 137 patients who met the inclusion criteria consented to participate in the study, and 100 (88%) completed it. The mean total score on the Impact of Event Scale-Revised was 17.8 (SD, 13.4; possible range, 0–88). A total of 13 participants (13%) scored higher than the cutoff score for clinical posttraumatic stress disorder. Neither sex nor length of stay was predictive of acute symptoms of post-traumatic stress disorder. In multivariate analysis, the only independent predictor of symptoms was age. Patients younger than 65 years were 5.6 times (95% confidence interval, 1.17–26.89) more likely than those 65 years and older to report symptoms.

Conclusion The rate of symptoms of posttraumatic stress disorder 1 month after discharge from intensive care was relatively low. Consistent with findings of previous research, being younger than 65 years was the only independent predictor of symptoms.

Notice to CE enrollees:
A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
  1. Describe the prevalence of and diagnostic criteria for posttraumatic stress disorder.
  2. Recognize the findings in this study as they relate to ICU patients.
  3. Understand the importance of recognizing the risk for PTSD in ICU patients.
To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue." No CE test fee for AACN members.

The environment in intensive care units (ICUs) is typified by highly technological equipment, unfamiliar routines, noise, odors, and continuous lighting that may contribute to sensory overload.1 As a result, ICU patients may experience physical and emotional difficulties as they struggle to cope.2 Recognizing that the ICU experience may have long-term sequelae, recent reviewers2–4 have focused on patients’ ICU experiences and quality of life after discharge from the unit. However, less is known about specific psychological impacts of intensive care.


   Posttraumatic Stress Disorder
Top
 Abstract
 Posttraumatic Stress Disorder
Purpose of the Study
 Methods
 Results
 Discussion
 Limitations and Recommendations...
 Conclusion
 References
 
PTSD is an anxiety disorder. Anxiety, which has existed throughout recorded history, is derived from the Greek root meaning "to press tight."5 Generally considered a healthy adaptive response to stress, anxiety is experienced by all individuals during their life and follows fear, threat, danger, and/or the absence of an environment that signifies safety.6 Anxiety can be manifested by a range of physical reactions, such as palpitations (a cardiovascular indication), neuromuscular responses such as startle reactions, and gastrointestinal effects such as diarrhea.7 Anxiety disorders are among the most prevalent psychiatric disorders in the general population and are associated with inordinate morbidity, functional impairment, and an increased use of health care services.2 The prevalence of the disorders in the general population is estimated to be as high as 17.7%, and 1 in 4 persons meets the diagnostic criteria for an anxiety disorder.7 Anxiety-related conditions are a diverse array of disorders encompassing phobias, panic, obsessive-compulsive disorder, generalized anxiety, acute stress, dissociative disorder, and PTSD.8

The evolution of PTSD can be traced back to as early as 1866, when a syndrome consisting of cognitive impairments and other psychosomatic signs and symptoms was identified in patients who had been in railway accidents. The disorder was labeled "railway spine" and is now regarded as the origin of modern psychotraumatology and PTSD.5 In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision,9 published in 2000, the criteria for diagnosis of PTSD are defined as (1) exposure to a traumatic event, with a response including fear, helplessness, or horror; (2) reexperiencing the event in a variety of subjective experiences that may include intrusive recollections of the event and psychological distress; (3) persistent avoidance of stimuli associated with the trauma accompanied by 3 or more of the following symptoms: avoidance of emotions and activities that arouse recollections of the event, memory impairment related to the event, diminished interests, detachment, restricted affect, and unrealistic perception of the future; and (4) increased level of arousal evidenced by symptoms that include sleep disturbance, startle response, emotional instability, hypervigilance, and difficulties in concentration. These criteria and symptoms are then classified as affecting a person by impairing the person’s level of function.10 PTSD is considered acute if symptoms persist for at least 1 month and is classified as chronic if symptoms persist longer than 3 months.10


Up to 35% of ICU patients experience PTSD after ICU discharge.

 

The lifetime prevalence of PTSD is estimated to be 8% in the general population,7 with rates of 10% to 12% in females and 5% to 6% in males.7,11 Various populations of hospitalized patients have been assessed for symptoms of PTSD.12 For example, about 6% of women experiencing childbirth,13 8% to 45% of burn patients,14,15 and 20% to 28% of cardiac patients16,17 have symptoms consistent with PTSD.

The results of 15 recently published studies11,12,18–30 of PTSD in ICU patients suggest that some subpopulations may be at risk for the disorder (Table 1Go). Of the 15 studies, 6 (40%) were undertaken in the United Kingdom, 4 (27%) in the United States, 3 (20%) in Germany, and 2 (13%) in other European countries. None were undertaken in Australasia. Sample sizes ranged from 20 to 238 participants, with a median of 78. A total of 12 studies (80%) had fewer than 100 participants, even though complex multivariate analysis was used in many of the investigations. The time from ICU discharge to measurement of PTSD symptoms varied widely.


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  		Table 1 Summary of the literature on PTSD after intensive care

 
In one study,19 symptoms were measured while patients were in the hospital; in other studies, symptoms were assessed within 3 to 9 months after ICU admission. In still others, the time from ICU discharge to measurement was not specified or the time between discharge and measurement was not standardized. A range of data collection methods were used, such as mailed surveys and face-to-face interviews. A variety of instruments were used to measure PTSD; the Impact of Event Scale (IES)31,32 was used most often. Reported frequencies of PTSD symptoms varied from 4% to 35%; the differences may be related to variations in the time elapsed between ICU discharge and measurement. Factors associated with PTSD included being younger,24,30 being female,19,30 experiencing a traumatic injury,27 receiving increased sedation in the ICU,20 remembering adverse experiences while in the ICU,18 remembering experiences of anxiety that occurred in an ICU,26 and having delusional22,23 or less factual12,22 memories.


Acute PTSD is recognized if symptoms are present for at least a 1-month period and is classified as chronic if symptoms persist beyond 3 months.

 

In summary, research findings to date suggest that PTSD symptoms may be associated with the ICU experience. Untreated PTSD is disabling, and firm recommendations exist for early treatment to prevent reduction in the quality of life in patients who have the disorder.7,25 Thus, understanding the scope of experience for ICU patients is important.


   Purpose of the Study
Top
 Abstract
 Posttraumatic Stress Disorder
 Purpose of the Study
Methods
 Results
 Discussion
 Limitations and Recommendations...
 Conclusion
 References
 
The purpose of this study was to measure the frequency of acute PTSD symptoms in ICU patients and to determine if selected factors such as age, sex, severity of illness, length of stay (LOS), and type of admission are predictive of PTSD. If factors that influence the development of PTSD are identified, nurses and other health professionals may be able to either influence these factors or initiate early diagnostic testing and treatment for at-risk subgroups. We therefore sought to highlight the psychological needs of ICU patients and make recommendations for future clinical practice.


   Methods
Top
 Abstract
 Posttraumatic Stress Disorder
 Purpose of the Study
 Methods
Results
 Discussion
 Limitations and Recommendations...
 Conclusion
 References
 
Conceptual Framework
The conceptual framework (Figure 1Go) predicted relationships between the development of PTSD symptoms and the following proposed factors: age (younger than 65 years vs 65 years or older), sex, severity of illness, type of admission (elective vs emergency), and ICU and hospital LOS. As previously determined, in the general population the risk of PTSD after exposure to a traumatic event is twice as high in women as in men.33 In addition, severity of illness as indicated by scores on the Acute Physiology and Chronic Health Evaluation (APACHE) II may be related to development of PTSD symptoms.


Figure 1
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  		Figure 1 Conceptual framework with an indication of the type of relationship expected between acute symptoms of posttraumatic stress disorder and study variables for patients 1 month after discharge from the intensive care unit.

 
Plausibly, patients who have a planned ICU admission may have more time to prepare for the experience than do patients who have emergency admissions. LOS may be an indicator of the attachment and dependence a patient develops with a nurse as a result of a life-threatening event and 1 to 1 care.34 Further, discontinuing use of the technology and equipment that surrounds a patient in the ICU can be anxiety provoking. Subsequent transfers from the ICU may contribute to anxiety because of the loss of close surveillance by staff and of a high level of technical monitoring.35 Thus, previous research and logical reasoning supported the 6 predictors. The research questions were as follows:

Design and Sample
A predictive cohort study was used. The setting was Gold Coast Hospital, a 580-bed tertiary referral acute health care facility in Queensland, Australia, with a 13-bed adult ICU. The ICU provides services to medical, surgical, and trauma patients and averages 750 to 850 admissions per year. Ethical approval for the study was obtained from Griffith University Human Research Ethics Committee and the Gold Coast Health Services District Ethics Committee. Patients were eligible for the study if they were older than 18 years; had an ICU stay of at least 24 hours (to ensure a sufficient duration of time spent in the environment); could speak, read, and write English; and had no reported history of anxiety disorder, as documented in medical records. Participants were also asked if they had an anxiety disorder. Patients were excluded from the study if they were transferred from the ICU because death was expected (in order to be sensitive to the patient’s and family’s situation); were to be discharged directly to home or another health care facility (because of difficulties tracking the patient); or were in a confused state (these patients would be unable to give informed consent to participate in the study).

Data Collection
During their ICU stay, patients were assessed for eligibility; if eligible, at the time of transfer to the step-down or intermediate care unit they were approached and invited to participate in the study. Participants were given an information summary and signed a consent form. Data were collected from 2 sources: (1) an electronic patient database, the Australian Outcomes Research Tool for Intensive Care (AORTIC) database, which was used to collect data on the predictors; and (2) a survey that consisted of the IES-Revised (IES-R),31 the dependent variable. AORTIC database information was electronically transferred to the researcher’s database.

Approximately 1 month after discharge from the ICU, patients who had been discharged from the hospital who agreed to participate in the study were contacted by telephone to conduct the survey. Verbal consent was obtained before the survey was administered. A few participants contacted by telephone requested that the survey be mailed to them. For patients who remained hospitalized, the survey was administered in person. Before the interview began, patients were asked to confirm that they had no history of an anxiety disorder.

Instruments
The IES-R is a self-report instrument used to assess the psychological consequences of exposure to a traumatic event. It is the most widely used validated measure of PTSD symptoms.11 General consensus on the tool’s accuracy and reliability is based on the correlations between IES-R scores and other measures of PTSD.36–38 In a factor analysis, the IES-R subscales were supported and had reasonably strong item-total correlations.36,37,39

The IES-R contains 22 items grouped into 3 subscales. The first subscale is related to symptoms of intrusion (7 items), characterized by unwanted thoughts and images and disturbed sleep.31 The second sub-scale, avoidance (8 items), focuses on denial of the meanings and consequences of the event, blunted sensation, and awareness of emotional numbness. The final subscale, hyperarousal (7 items), includes sleep disturbance, flashback symptoms, and emotional lability.31 Responses are scored on a 5-point Likert scale: 0, not at all; 1, a little bit; 2, moderately; 3, quite a bit; and 4, extremely. The IES-R is brief and easy to administer. The assessment period is the preceding 7 days. Completion time is 5 to 15 minutes.32 The total score is the sum of the scores of all items31; scores of 33 or greater indicate clinical PTSD.38


In this study, 13% of participants had acute PTSD symptoms 1 month after ICU discharge.

 

Other demographic and clinical data, including APACHE II scores as a measure of severity of illness, were collected from the AORTIC database. Scores on the APACHE II range from 0 to 71.40 The AORTIC database is maintained by a full-time data manager who was responsible for data collection and database entry and was independent of the research team. The quality control measures used for the database included visual checks of the data and monthly audits. The data accessed from this database included age, sex, type of admission, diagnosis, APACHE II score, and ICU and hospital LOS.

Data Analysis
All data from the surveys were analyzed by using SPSS software, version 12 (SPSS Inc, Chicago, Illinois). Accuracy of the data entered was confirmed by double entry of all data. The Cronbach {alpha} was used to indicate the reliability of the IES-R in this study. Initial analysis of descriptive data (frequency, mean, standard deviation, median, interquartile range) was undertaken for all variables. Mann-Whitney and {chi}2 tests were used to detect differences in demographic characteristics between men and women. Univariate and multivariate logistic regressions were used to determine the predictors of acute PTSD symptoms (ie, IES-R score ≥33). Potential predictors entered into the regression analysis were age, sex, type of admission, APACHE II score, and ICU and hospital LOS.


Those less than 65 years of age were 5.6 times more likely than those above 65 to report PTSD symptoms.

 


   Results
Top
 Abstract
 Posttraumatic Stress Disorder
 Purpose of the Study
 Methods
 Results
Discussion
 Limitations and Recommendations...
 Conclusion
 References
 
During the 9 months of the study, 765 patients were admitted to the ICU. Of these, 137 were eligible to participate in the study, 114 consented to participate, and 88% (100/114) completed the survey (Figure 2Go).


Figure 2
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  		Figure 2 Flowchart of participants in data collection.

 
Demographic characteristics of the sample are shown in Table 2Go. Participants were 18 to 89 years old (mean, 63; SD, 18.9), with no significant differences in age between men and women. As expected, 68% of the participants were men and 32% were women, consistent with the sex distribution of the ICU population. APACHE II scores ranged from 2 to 40 (median, 13.0), with no significant differences between men and women. No participants had experienced a motor vehicle accident. The median ICU LOS was 2.4 days (range, 1–31). A total of 40% of participants stayed between 1 and 2 days. The median hospital LOS was 2.4 days (range, 1–31). Differences between men and women for either ICU or hospital LOS were not significant. In total, 33 participants received ventilatory support. Of these participants, 23 (70%) were men, and 10 (30%) were women. Differences in the proportion of men and women who received ventilatory support were not significant.


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  		Table 2 Characteristics of the samplea

 
The Cronbach {alpha} for the total IES-R scale was high at 0.95, and for each subscale it was between 0.66 and 0.80 (Table 3Go). The hyperarousal subscale had the lowest reliability coefficient. The overall mean IES-R was 17.8 (SD, 13.4) out of a possible total score of 88. Apparently, participants had few symptoms of PTSD. The clinical cutoff point of the IES-R was 33 and provides the best diagnostic accuracy for PTSD.38 A total of 13 participants (13%) had the cutoff score or higher, indicative of PTSD. These 13 patients were referred to a general practitioner or counseling (as per human research ethics requirements).


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  		Table 3 Scale scores for Impact of Event Scale-Revised

 
The univariate and multivariate predictors of clinical PTSD symptoms (as indicated by cutoff scores of 33), are given in Table 4Go. In univariate analysis, only age and APACHE II scores were predictive of clinical PTSD symptoms. In multivariate analysis, only age was predictive. Specifically, participants younger than 65 years were 5.63 times as likely as participants 65 years or older to report symptoms of clinical PTSD.


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  		Table 4 Association between the presence of PTSD symptoms and predictors by univariate and multivariate logistic regression

 

   Discussion
Top
 Abstract
 Posttraumatic Stress Disorder
 Purpose of the Study
 Methods
 Results
 Discussion
Limitations and Recommendations...
 Conclusion
 References
 
The ICU presents a paradoxical concept of caring. The life-saving technology used in the environment also means unpleasant noise levels, bright lights, and invasive and painful procedures for patients.1 The evaluation of the frequency of PTSD symptoms in ICU survivors originates from speculation that patients may not recover psychologically even though they have recovered physically.7 Research suggests that critical illness is a stressor and that the potential for PTSD exists. Untreated PTSD can result in significant psychosocial deficits for patients, loss of employment, and an economic burden on both patients and their families. Although admission to an ICU can be an emergency circumstance, admissions can also be prearranged.

The frequency of PTSD symptoms in our study sample 1 month after discharge from the ICU was relatively low at 13%, but higher than the prevalence of PTSD in the general population, estimated at 8%.7 However, we do not know how many of the patients who had PTSD symptoms had the symptoms before admission to the ICU. The low frequency of PTSD symptoms may be due to the quality of nursing care provided to the patients in our ICU. For example, a patient and family information booklet is used, the unit has an ICU liaison nurse,41 and a formal process exists for preparing patients and families for discharge from the unit.42 Apparently, these care management strategies support patients’ psychological recovery. Other researchers12,25 have reported PTSD symptoms in 5% to 62% of ICU patients. This wide variation may be related to the variety of variables examined and differences in study methods. A recent systematic review3 of the literature on PTSD and the ICU has indicated the need for consistency in definitions and time related to PTSD research to allow for comparisons of research findings.

The type of admission to an ICU may affect a patient’s control in accommodating the event. In 2004, about a quarter of admissions to the study site ICU were planned.43 Patients who are psychologically prepared may be protected from the risk of developing PTSD symptoms. In our small sample, type of admission (elective vs emergency) was not predictive of acute PTSD symptoms; however, it might have been in a larger sample. Others3 have found an association between emergency admission and PTSD symptoms. Other than age, the potential predictors in our conceptual framework were not predictive of PTSD symptoms. This finding is somewhat surprising because sex has been predictive of PTSD.33

In our study, rates of PTSD symptoms were higher in younger patients. Importantly, PTSD may be affecting people at the peak of their productive work years, a situation that may have significant consequences for the persons affected. Other investigators24,30 also found that younger age was associated with PTSD. Why PTSD may develop in younger persons is open to speculation. Because the disorder is associated with the development of other psychological conditions,7,44 and because up to one-third of persons with untreated PTSD do not recover,44 health professionals should be aware of the evidence linking PTSD with younger age. Follow-up care provides the opportunity to assess a patient’s physical and psychological needs.45

PTSD symptoms include reexperiencing the trauma, avoidance of the stimuli associated with the trauma, and a numbing of general responsiveness and increased levels of arousal.10 Numerous studies7 have indicated that patients with PTSD are at increased risk for many other psychiatric disorders. Comorbid disorders or the co-occurrence of more than a single diagnosable disorder is also well recognized in patients with untreated PTSD.44 Survival analysis of patients with PTSD shows that more than one-third of those with the disorder do not recover if untreated.44 Thus, first identifying who gets PTSD and then providing appropriate treatment may have important benefits for patients.

Although PTSD can be debilitating, once it is diagnosed, treatment involves targeting and reducing symptoms. Treatments include pharmacotherapy and eye movement desensitization and reprocessing. Cognitive behavioral and psychodynamic approaches are also common effective treatments.7 Psychodynamic, cognitive, and behavioral approaches include normalizing symptoms, helping patients develop coping strategies, helping patients build self-esteem, encouraging emotional display, and providing support. Effective pharmacotherapy involves medications such as antidepressants and antianxiety agents.7


Monitoring psychological outcomes for ICU patients may be as important as their physical recovery.

 

Recent research3 on outcomes in ICU patients has emphasized the importance of monitoring the patients’ psychological outcomes, not just their physical recovery. In addition, the current body of evidence2 supports the proposition that patients discharged from the ICU can experience deterioration in their clinical condition and psychological problems. Despite these findings, research on rehabilitation after discharge from the ICU has just begun. In other hospital subpopulations, such as burn patients, rehabilitation programs have demonstrated benefit.46


   Limitations and Recommendations for Further Research
Top
 Abstract
 Posttraumatic Stress Disorder
 Purpose of the Study
 Methods
 Results
 Discussion
 Limitations and Recommendations...
Conclusion
 References
 
Our study has several limitations. We used self-reports of the symptoms of PTSD, measured by using the IES-R. Although this instrument has been validated in other populations of patients and was shown to be reliable, further research to validate it in ICU patients may be required. In particular, the hyper-arousal subscale seems to require investigation. Validity testing would require comparison of the results of concurrent use of the IES-R and a standardized interview undertaken by a psychiatrist or endorsed mental health nurse as the gold standard. Once the validity of the IES-R was established, the psychiatric interviews would no longer be required, eliminating the high cost of continuing to use 2 measures.47


PTSD may be affecting people at the peak of their productive work years, which may have significant consequences for the individual.

 

Rates of PTSD may be underestimated if the sample size is small, as in our study. Because it took 9 months to recruit the sample, larger multisite studies are indicated for future research. In addition, our sample size of 100 may have lacked the power to detect a difference in the frequencies of PTSD symptoms between men and women. A post hoc power analysis indicated that a sample of about 500 would have been required to detect a statistical difference between men and women. With a larger sample, more independent predictors of PTSD might have been detected. Additionally, some of the patients who declined to participate in our study may actually have been demonstrating the PTSD symptom of avoidance24; thus, the frequency might have been underestimated. Further, acute PTSD symptoms were measured at a single study site. A longitudinal multisite study would allow measurement of both acute and chronic PTSD symptoms. Finally, an ICU liaison nurse and a structured discharge plan were part of standard practice in our study site. The extent to which these interventions influenced the development of PTSD symptoms is unknown, but may be worth further investigation.


   Conclusion
Top
 Abstract
 Posttraumatic Stress Disorder
 Purpose of the Study
 Methods
 Results
 Discussion
 Limitations and Recommendations...
 Conclusion
References
 
The symptoms of acute PTSD were measured in 100 participants 1 month after discharge from the ICU. Participants younger than 65 years were 5.6 times more likely than those 65 years and older to score above the IES-R cutoff score for clinical PTSD. This study has provided preliminary Australian data on psychological outcomes after an ICU stay. As critical care nursing continues to develop, more independent nursing interventions are being designed to improve patients’ outcomes. Understanding the frequency of PTSD symptoms provides a strong foundation on which critical care nurses can continue to develop and advance their practice.


   ACKNOWLEDGMENTS
 
Support from the ICU nursing staff at Gold Coast Hospital —in particular, Michelle Foster and Lorraine Retallick—is gratefully acknowledged. This study was conducted at the Gold Coast Hospital, Queensland, Australia.

FINANCIAL DISCLOSURES
Grant 0417, awarded by the Queensland Nursing Council, provided financial support for the study.

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 Abstract
 Posttraumatic Stress Disorder
 Purpose of the Study
 Methods
 Results
 Discussion
 Limitations and Recommendations...
 Conclusion
 References
 

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