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Incidence of Posttraumatic Stress Disorder After Prolonged Surgical Intensive Care Unit Treatment

Received October 4, 2004; revised April 20, 2005; accepted May 15, 2005. From the Dept. of Internal Medicine, University Hospital, Bern, Switzerland; the Dept. of Trauma Surgery, University of Essen, Germany; and the Dept. of Psychiatry and Psychotherapy, The Saarland University Hospitals, Homburg, Germany. Send correspondence and reprint requests to Dr. Pajonk, Associate Professor of Psychiatry, Dept. of Psychiatry and Psychotherapy, The Saarland University Hospitals, 66421 Homburg. e-mail: frank.pajonk{at}uniklinik-saarland.de

ABSTRACT

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The purpose of the study was to investigate the prevalence of posttraumatic stress disorder (PTSD) after prolonged intensive care unit (ICU) treatment and to study the differences between trauma patients and patients who were admitted with other diagnoses. Survivors of surgical intensive care of at least 30 days' duration underwent follow-up examination at about 35 months after discharge from the ICU. Thirty-seven patients were investigated. Seven patients met full DSM-IV criteria for diagnosis of PTSD. All of them had sustained severe multiple injuries. Patients with trauma were at significantly higher risk for developing PTSD than were non-trauma patients. After prolonged ICU treatment, PTSD seems more likely to occur when the reason for admission to the ICU was severe physical injury. The prevalence of PTSD does not seem to be related to injury severity or duration of ICU treatment.

Key Words: posttraumatic stress disorder • multiple injuries • trauma • intensive care unit (ICU) treatment

INTRODUCTION

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The psychosocial consequences of serious injuries and life-threatening illness have received increasing attention over the last years. The individual response to a traumatic event, influenced by, for example, personality traits, psychiatric premorbidity, gender, peritraumatic dissociation, prolonged disability after the traumatic event, lack of social support, and inadequate coping strategies used by the traumatized individuals can lead to the development of the well-defined clinical entity of posttraumatic stress disorder (PTSD).^1–4 The relationship between physical trauma and PTSD remains unclear, however, and the influence of the severity of the physical trauma, altered mind states, or traumatic brain injury on PTSD is inconclusive.⁵

Intensive care unit (ICU) treatment is a source of severe stress to the individual. Prolonged ICU treatment is often required for patients with severe physical trauma, septic shock, or major complications of surgery that may result in multiple organ failure. The patients are almost completely dependent on the ICU staff, and mechanical ventilation often makes communication impossible. A majority of patients report traumatic memories from their stay in the ICU.⁶ There has been increasing interest in the effects of stress hormones on formation of traumatic memory and their possible influence on development of PTSD.^7,8

Several authors have investigated the incidence of PTSD after severe trauma or illness necessitating ICU treatment.^6,9–12 To our knowledge, there is no report focusing on prolonged ICU treatment, in itself, as a theoretical stressor. The aim of this descriptive study, which is part of a larger investigation regarding psychopathology and quality of life after prolonged surgical intensive care,^13,14 was to assess the prevalence of PTSD in this population at follow-up and to identify possible risk factors for the development of symptomatology consistent with the diagnosis of PTSD.

METHOD

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All patients treated for 30 consecutive days within 4 years in a surgical ICU at the Department of Surgery, Klinikum Innenstadt, Ludwig-Maximilians-University Munich, Germany, a Level I trauma center, were included in the study. Clinical data were extracted from the ICU database. The severity of the medical condition on admission to the ICU was evaluated by use of the APACHE II score.¹⁵ The trauma patients were also rated with the Injury Severity Score (ISS).¹⁶

All patients who had been discharged from the ICU were contacted by mail or telephone. No patients were excluded on grounds of previous psychiatric morbidity or evidence of traumatic brain injury. Patients had a complete physical examination and a semistructured psychiatric interview that was conducted by an experienced psychiatrist using a comprehensive psychopathological assessment (AMDP system¹⁷. The psychiatric interview included a detailed psychiatric lifetime history, also using statements of relatives and friends. Special attention was paid to the symptoms appearing in DSM-IV diagnostic criteria for PTSD when designing the interview.¹⁸

Among other formalized measures of psychopathology, the patients were asked to complete the Symptom Check List (SCL–90-R¹⁹. Derived from this scale, the 28-item PTSD subscale developed by Saunders et al. was also used.²⁰

Other psychiatric diagnoses were also recorded. For a risk-factor analysis, patients were divided into two groups: 1) patients with a diagnosis of PTSD (PTSD-P); and 2) patients showing no or only one DSM symptom typical of PTSD (PTSD-N).

Results from clinical data are expressed in terms of mean, standard deviation (SD), and range of values. The significance of differences between groups was assessed with t-tests and Mann-Whitney U tests.

RESULTS

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A total of 101 patients were treated in the ICU for 30 days or longer during the study period. Mortality during ICU treatment was 31% (N=31). One patient died in the hospital after transfer to another ward, and 23 patients died after discharge from the hospital but before the follow-up examination. This resulted in an overall mortality rate of 55% (N=55). Five of the remaining 46 patients could not be traced; 3 were unable to participate in the follow-up because of a persistent vegetative state; and 1 was living abroad. The remaining 37 individuals agreed to be examined (trauma patients: N=29, non-trauma patients: N=8). The time until follow-up was 35 months (SD: 14; range: 7–58).

The characteristics of the patients who were eligible for follow-up, as compared with those who were not, are summarized in Table 1. The APACHE II and the ISS indicate that the patients were some of the most severely ill patients to be seen in modern university hospitals. Patients who underwent follow-up were significantly younger at the time of ICU admission, had a lower Apache II score, and the reason for their admission was more often trauma.

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TABLE 1. Characteristics of Patient Sample Seen at Follow-Up (N=37) and the Sample Group Who Died in the Interval or Were Lost to Follow-Up (N=64)

Table 2 shows the number of patients who fulfilled each individual DSM-IV criterion at follow-up and the number who fulfilled all the criteria. Seven patients (19%) were diagnosed with PTSD. Another five patients met five of the six criteria (subsyndromal PTSD). The items B-2 (recurrent distressing dreams) and B-4 (intense psychological distress at exposure to internal or external cues) were present most often. Thirteen patients met Criterion C (avoidance and emotional numbing). Here, the items recorded most often were efforts to avoid activities, places, or people that aroused recollections of the trauma (C-2), markedly diminished interest or participation in significant activities (C-4), feelings of detachment or estrangement from others (C-5), and a sense of a foreshortened future (C-7).

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TABLE 2. Patients Fulfilling DSM-IV Criteria for PTSD

The semistructured psychiatric interview revealed that 18 patients (49%) had a history of psychiatric morbidity before admission to the ICU, most often substance abuse disorders (78%). At follow-up, other psychiatric diagnoses were frequent in the study population. According to DSM-IV criteria, 22 patients (60%) were found to be suffering from additional clinically significant psychiatric disorders. Patients having experienced a trauma more often had a psychiatric diagnosis before the trauma (Mann-Whitney U test; p=0.002) and seemed more likely to suffer from additional psychiatric disorders; however, the difference was not significant (Mann-Whitney U test: p=0.16; see Table 3).

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TABLE 3. Patient Characteristics by Initial Reason for ICU Admission (Trauma Versus Non-Trauma)

Five of the seven PTSD-P patients were male; two were female. Their mean age was 45.3 years (SD: 9.1; range: 31–57). All seven (and four of the five with subsyndromal PTSD) had survived severe multiple traumas (five from motor vehicle accidents, one from a fall from a rooftop while at work, and one after attempting suicide). Thus, the prevalence of PTSD was 24% in trauma patients. None of the non-trauma patients developed PTSD (Mann-Whitney U test; p=0.13). All seven patients diagnosed with PTSD—like all the trauma admissions—were unconscious when an emergency physician arrived at the scene of their injury. Because the emergency protocols were not all completed accurately, no exact data exist concerning the onset or duration of the unconsciousness. Traumatic brain injury was found in five patients.

Comparing patients with PTSD (PTSD-P; N=7) with patients asymptomatic for PTSD (PTSD-N; N=9), no differences could be found with respect to age, ISS or APACHE II score, length of stay on the ICU, duration of ventilation, duration of sedation, or time until follow-up. Patients who seemed to be at a higher risk for developing PTSD were those with a traumatic brain injury (71% versus 22%); however, the difference did not reach statistical significance (Table 4). Patients fulfilling all symptoms of PTSD (PTSD-P) were more likely to fulfill diagnostic criteria for other psychiatric disorders than were patients with no symptom of PTSD (PTSD-N) (Mann-Whitney U test; p=0.004). Psychiatric comorbidity with PTSD was present in six of the seven patients, but only one patient in the PTSD-N group had an additional psychiatric diagnosis.

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TABLE 4. Patient Characteristics by PTSD Symptom Presence

At follow-up, two patients diagnosed with PTSD had vivid and detailed memories of their stay on the ICU; three others had only vague recollections; and two had none. Two subjects reported vague memories of the time shortly before or after the accident. Nightmares were related either to the ICU treatment (N=4) or to the accident (N=2). Five patients suffered from residual medical problems of a severe nature, such as paraplegia, intense pain, paralysis of several limbs, or immobility of several large joints. One was in moderate medical condition, and one had only minor impairment.

Results for the SCL–90-R were available for 33 patients (6 out of 7 patients with PTSD; diagnoses: trauma, N=26; non-trauma, N=7; Table 5). Trauma patients did not differ from non-trauma patients in any of the SCL-90-R scores. Patients meeting the full criteria for PTSD showed a considerable level of psychological symptoms, in general, with significant differences in most of the subscales and the general indices, indicating a higher number of self-reported symptoms (PST) and a high overall distress (GSI) level. However, the intensity of self-reported symptoms (PSDI) was not found to be different. The PTSD subscale scores were significantly elevated in the subjects with a clinical diagnosis of PTSD (1.7 [SD: 1.0] versus 0.6 [SD: 0.5]; t-test: p<0.05; Figure 1).

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TABLE 5. Psychometric Results of Patients by Initial Reason for ICU Admission and Presence of PTSD Symptoms

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FIGURE 1.  SCL-90-R PTSD Subscale Scores for Patients With and Without a Clinical Diagnosis of PTSD Note: Values are mean and 95% confidence interval (CI).

DISCUSSION

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Traumatic physical injuries, in particular, motor vehicle accidents or burns, are known to induce high rates of PTSD. Incidence rates vary between 25% and 45% in these populations.^21–24 Predictors for higher symptom levels of PTSD 1 year after the trauma included severe early symptomatology, stimulant intoxication, and female gender, whereas injury type and severity were not predictive. The stressor criterion for PTSD has been modified to include life-threatening illnesses, such as myocardial infarction, cancer, or organ transplantation as precipitating traumatic events.²⁵ PTSD was prevalent in up to 30% in a group of patients surviving acute respiratory distress syndrome (ARDS).²⁶ The incidence remained high at follow-up 2 years later, showing lasting impairment in these patients.²⁷ However, previous research has paid little attention to the possible role of the ICU treatment, itself.

Patients who had suffered multiple injuries, particularly when these included traumatic brain injuries, and those with a history of psychiatric disorder were at a greater risk of developing PTSD.^28–32 Even in this highly-selected group of ICU patients with stays exceeding 30 days, the prevalence of PTSD is within the range of other studies after physical injury.^10,12,21,22 Also, the patients with initial diagnoses other than trauma fared better in terms of psychological problems after ICU treatment.³ However, the content of the intrusive thoughts so typical of PTSD was more often related to the stay in the ICU than to the event of the physical trauma. In other studies, PTSD appeared with considerable frequency after ICU treatment without preceding trauma²⁶ and on a general ICU.^6,32 Thus, ICU treatment cannot be excluded as an additional risk factor, although its influence cannot be determined in our study population.

There are some studies supporting this hypothesis: A Swiss group investigated a population of patients requiring short-term ICU treatment after severe accidental injuries and who had a much lower ISS score. Psychiatric morbidity (full or subsyndromal PTSD, anxiety disorder, or depression, with considerable overlap) was seen in 25.5% of patients at a 1-year follow-up. Predictors of psychiatric morbidity were biographical risk factors, female gender, and the subjective sense of a threat of death during the accident.^10,11 In another study, a mail-in questionnaire was sent to patients after ICU treatment, revealing significant symptoms of PTSD in 38%, with 15% of patients reaching levels consistent with a diagnosis of full-blown PTSD.¹²

Some other studies have been recently published on the occurrence of PTSD after ICU treatment. Prevalence rates varied between 5% and 14%.^31–33 However, the patients included in these trials were less severely ill, and the length of stay and the time to follow-up were considerably shorter than in our group. Notably, as in our study, these factors had no effect on the development of PTSD.

The use of sedatives and neuromuscular blocking agents on the ICU may be associated with subsequent measures of depression and PTSD after discharge.⁹ Furthermore, possible mechanisms that could predispose to the development of PTSD may be the prolonged application of supraphysiological doses of catecholamines, as well as alterations in glucocorticoid metabolism, which are typical for ICU patients. This may modulate memory formation, consolidation, storage, retention, and retrieval,^7,34,35 possibly resulting in a higher prevalence of delusional memories. These were shown to be related not only to the development of acute PTSD symptoms, but also to their retention over time, whereas the recall of factual events in the ICU declined.⁶

Our study was not designed specifically to address the issues of stress hormones and the impact of sedation. The observation that five of the seven patients (71%) with a clinical diagnosis of PTSD had received catecholamines over prolonged periods of time, as opposed to 8 of 30 patients without PTSD (27%) might be incidental, the numbers being too small to detect a statistical significance.

Although the high percentage of patients reached for follow-up is a strength of the study, there are a number of limitations that need to be addressed. The retrospective design and the small number of patients, especially in the non-trauma group, preclude multivariate analyses of predictors and do not allow us to draw any firm conclusions regarding the risk for development of PTSD-related symptoms. By including patients with previous psychiatric morbidity and signs of traumatic brain injury, we achieved a realistic patient population. However, the interpretation of the results with respect to the causality of subsequent psychiatric morbidity is more difficult.

We chose the 28-item PTSD subscale, derived from the SCL-90-R in addition to a DSM–IV-based clinical diagnosis after performing a structured clinical interview according to AMDP standards. The use of the SCL-90-R allows us to assess a variety of psychological symptoms and put results from the PTSD subscale into perspective with the patients' overall psychiatric condition. This scale successfully differentiated women who had PTSD resulting from crime-related violence.²⁰ However, there are more commonly-used questionnaires with proven reliability (e.g., CAPS, PTSD Checklist–Civilian Version, PTSS–10, SCID) for the detection of PTSD.²⁷ Using the SCL-90-R, it became apparent that the initial trauma did not seem to predict later psychopathology and that symptoms in individuals diagnosed as suffering from PTSD are widespread and indicate a high level of general psychopathology.

Despite these limitations and the fact that it is difficult to differentiate between the effects of the initial trauma, the subsequent complications, and the stay in ICU, the results of this investigation are of clinical relevance, in particular, considering the limited scientific evidence on this topic and the methodological problems any study has to face when investigating such a patient population.

A stronger focus on the psychological health and psychiatric disorders of former ICU patients, in particular, trauma patients, as well as early diagnosis and intervention are vital in reducing the number of patients with PTSD, improving the results of rehabilitation, and preventing the development of chronic psychiatric disorders. Further research is indicated to verify possible risk factors for PTSD and for interventions in the ICU.

CONCLUSION

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The data presented here suggest that trauma patients are at higher risk of developing clinically relevant PTSD than non-trauma patients requiring prolonged intensive care. The content of PTSD symptomatology may relate to the ICU experience as well as to the original trauma. Injury severity and duration of ICU treatment do not seem to be associated with incidence of PTSD in trauma victims, but prolonged ICU care, in itself, cannot be ruled out as a significant stressor.

ACKNOWLEDGMENTS

 
The authors are indebted to Prof. L. Schweiberer and Prof. K.H. Duswald, Department of Surgery, Klinikum Innenstadt, Ludwig-Maximilians University, Munich, for their support in performing this investigation.

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FIGURE 2.  SCL-90-R PTSD Subscale Scores for Patients With a Trauma Diagnosis or a Diagnosis Other Than Trauma Note: Values are mean and 95% confidence interval (CI).

REFERENCES

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