Psychosomatics 48:436-439, September-October 2007
doi: 10.1176/appi.psy.48.5.436
© 2007 Academy of Psychosomatic Medicine
Posttraumatic Stress Disorder Caused by Hallucinations and Delusions Experienced in Delirium
Andrea DiMartini, M.D.,
Mary Amanda Dew, Ph.D.,
Robert Kormos, M.D.,
Kenneth McCurry, M.D., and
Paulo Fontes, M.D.
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INTRODUCTION
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In the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM–IV),1 the definition of posttraumatic stress disorder (PTSD) requires that the individual "experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others (DSM–IV, 1994)." This definition assumes that the events were real, with one of the cardinal symptoms of the diagnosis being that the individual persistently reexperiences this real event. The life-threatening nature of organ transplantation can undoubtedly create the physical and emotional circumstances for the development of PTSD.2 Transplant patients are only too aware of the seriousness of their condition, and they frequently experience medical complications, including episodes of delirium pre- and postoperatively. We present four cases of transplant patients who, while in delirium, experienced delusions and hallucinations of life-threatening events that were later reexperienced as clinically diagnosed PTSD. These cases demonstrate that not only real life-threatening medical events, but delirium experiences that occur during a life-threatening medical crisis or illness, can provoke PTSD. Therefore, an extension of the PTSD criteria to include both real and psychically-induced experiences seems warranted. Background information about each case has been slightly modified to protect patients’ confidentiality.
Case 1
"Mr. A" was a 56-year-old white man who developed end-stage liver disease from a combination of alcohol and viral hepatitis. Aside from remitted alcohol dependence, he had no other psychiatric history. After liver transplantation, he experienced a difficult medical course, with sepsis, renal failure, biliary reconstruction, respiratory failure, and immunosuppressive medication neurotoxicity from tacrolimus. Several electroencephalograms showed diffuse generalized slowing of the background rhythms and documented seizures. He had persistent delirium for several months postoperatively. While having delirium, he was extremely agitated, requiring restraints to prevent him from hurting himself and/or dislodging lines and catheters. He appeared awake, but was frequently incoherent and disorganized. However, he was able to articulate paranoid delusions that the staff were trying to kill him and his son. He was also observed to be responding to auditory and visual hallucinations. Four months after the transplant, when he was discharged from the hospital, his delirium had resolved. He was no longer confused or disoriented, was not actively hallucinating or delusional, and his mood was good, with only occasional, transient symptoms of anxiety.
Several months later, in the transplant clinic, he reported reexperiencing events he had hallucinated while having delirium in the intensive care unit (ICU), and, thus, he met DSM–IV criteria for PTSD. He recalled detailed paranoid delusions that the hospital staff had chained his son to his bed and were beating him to death. He recalled struggling against the restraints, hoping to free himself to save his son. He described hearing his son’s screams for help and sounds as if his son was being pummeled. He reported recurrent nightmares of these events and even daytime flashbacks of these experiences, typically when spending time alone. He attempted to avoid thinking about these events and the hospitalization, but described difficulty doing so because the thoughts were intrusive and difficult to dismiss. Not only did he avoid discussing the events, but he also had difficulty returning to the hospital because it caused him to recall these images. He was observed to be restless and hypervigilant in the transplant clinic. Although he was irritable with family members and distanced himself from other people, he was not clinically depressed or anxious.
Case 2
"Mr. B" was a 51-year-old, married, white man, a retired security guard, who underwent a liver transplant for alcoholic cirrhosis. Before transplantation, he was receiving treatment for an anxiety disorder with panic attacks but had no previous history of PTSD. In fact, he had been anxiety-free on benzodiazepines for 3 years before the transplantation. After liver transplantation, he had a complicated postoperative course, with cytomegalovirus gastritis/duodenitis, biliary strictures with cholangitis, and several episodes of rejection. In the first postoperative weeks, he had altered mental status, with fluctuating periods of agitation and somnolence. Months after his discharge from the transplant hospitalization, he met DSM–IV criteria for PTSD. He revealed ongoing nightmares of events that he had hallucinated while in the ICU, posttransplantation. He hallucinated that he had been tied down to the bed and was being shot by the staff. He recalled overwhelming fear as the staff members would approach him, point a gun at him, and shoot. He also vividly recalled experiencing tactile hallucinations of the bullets penetrating his body. He had difficulty falling and staying asleep. He tried to avoid thinking about these events and avoided TV shows with violent content. He had become more distant from family members and friends, spending more time alone. Although his history of earlier work-related trauma was not known, and these hallucinations may have been derived from his earlier work in law enforcement, he had not been previously shot. In the year after the transplantation, in addition to ongoing symptoms of PTSD, he redeveloped his earlier anxiety disorder and developed depression.
Case 3
"Ms. C" was a 38-year-old white woman with a history of aortic stenosis and aortic insufficiency. She had a history of smoking 1 pack of cigarettes per day and was described as a light social drinker. She had no history of any psychiatric disorder or exposure to early-childhood or other trauma. After an elective aortic valve replacement, she experienced postcardiotomy biventricular cardiac failure requiring extracorporeal membrane oxygenation (ECMO) support. Within 24 hours, it was determined that her heart was not recovering, and Thoratec biventricular assist devices were inserted. She developed sepsis several days after Thoratec placement. She remained in the cardiothoracic intensive care unit (CTICU) for several weeks, where she was intubated and intermittently sedated. She eventually was moved to a regular hospital unit to await a heart transplant, which she received approximately 2 months after the original elective surgery.
One year after the transplant, she continued to experience all of the cardinal symptoms of PTSD as a result of events that she hallucinated while in delirium in the CTICU. Her hallucinations included experiencing her room being on fire and her struggling to escape. She felt terrified at being unable to remove her clothing, which she believed was on fire. One year posttransplant, she met DSM–IV criteria for PTSD, assessed with the Composite International Diagnostic Interview (CIDI).3 She reported recurrent, intrusive recollections of the hallucinations and experienced marked distress when she was in situations that reminded her of the experience (e.g., when seeing other gravely ill individuals). She tried to avoid these situations and actively tried to avoid thinking about her experience. She continued to have difficulty sleeping and concentrating, and was hypervigilant about her own safety. She did not meet criteria for any other psychiatric disorder at follow-up.
Case 4
"Mr. D" was a 60-year-old white man with progressive respiratory insufficiency due to chronic obstructive pulmonary disease and asthma from a 40-pack-year smoking history. He had had one tour of duty as an army private in Vietnam. He experienced recurrent major depressive disorder during his 8-month wait for a double lung transplant, and this was treated with paroxetine. He had no previous psychiatric disorder and reported no exposure to childhood or other trauma, even while in Vietnam. Eight days after the transplant, while still hospitalized, he began to experience mental-status changes, including confusion, disorientation to time and place, and hallucinations. After neurology and psychiatry consultations and a diagnostic work-up, it was concluded that the mental-status changes were likely medication-related and metabolic in nature, perhaps in reaction to his immunosuppressants, prednisone and tacrolimus. After treatment with risperidone, his mental status gradually cleared, and he was discharged 1 month after transplant.
Two years after the transplant, he continued to meet DSM–IV criteria for PTSD, determined via the CIDI, as a result of the hallucinations he experienced during his delirium. His hallucinations included seeing insects and animals in his room. He recalled attempting to urge his family to escape. He accused the hospital staff of sedating him and then moving him to another hospital room without his knowledge. He believed that staff members were hiding in his room in order to observe him. At 2 years posttransplant, he continued to have nightmares related to the transplant experience, as well as unbidden thoughts about the experience that led to sweating and physical discomfort. He reported continuing irritability and hypervigilance regarding his own and his family’s safety. He felt a reduced interest in everyday activities and a restricted range of affect, and he attempted to avoid situations (e.g., hospitals) that reminded him of the experience. He began to attend a trauma support group and was also receiving individual psychotherapy in order to better manage these symptoms. During the 2 years after the transplant, he also continued to experience recurrent major depression, which he felt was precipitated by his inability to cope psychologically with the hallucinatory experiences shortly after the transplant.
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Discussion
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PTSD is increasingly being recognized as resulting from life-threatening medical experiences, including organ transplantation. More recently, its occurrence has been noted in response to Intensive Care Unit (ICU) treatment.4–7 It is remarkable that 14% to 44% of ICU-treated patients experience PTSD, with upward of almost 24% having persistent symptoms years later,4 and it suggests that consultation psychiatrists should be cognizant of the potential for PTSD after an ICU stay. Not surprisingly, the life-threatening nature of organ transplantation and the required ICU treatment postoperatively provides the situational potential for the development of PTSD. In a prospective cohort of heart transplant recipients (N=191), we discovered that 17% had experienced PTSD caused by heart transplant-related events by 3 years after transplant.8 Most of these cases developed soon after the transplant. The occurrence of PTSD increased the risk of mortality during subsequent years posttransplant, independent of other major risk factors for mortality.9
The cases in the present report, however, demonstrate that not only can real transplant experiences evoke PTSD, but delusional and hallucinatory experiences while having delirium can similarly result in PTSD. A previous study of ICU patients found that patients who had no factual recall of the ICU at 2 weeks after the ICU stay but had memories of delusions from their ICU experience were more likely to have PTSD-related symptoms 6 weeks later.6 Interestingly, those with recollections of delusions who retained some factual memory of the ICU did not have this association. The authors hypothesized that the strong emotional tone of the frightening delusions may have contributed to the development of PTSD, whereas those whose memories were buffered by some factual recollections were not so affected.6 Whether the delusional memories were the actual symptoms characterizing their patients’ PTSD was not reported.
Breitbart et al.10 developed a Delirium Experience Questionnaire (DEQ) that assesses the recall of the delirium episode and the degree of perceived distress from the delirium experience.10 They found that the more severe the episode of delirium, the less likely the patient was to recall the delirium episode. However, those who experienced moderate-to-severe perceptual disturbances, as compared with others (100% versus 40%;  2=13.8; p<0.001) and those with severe delusions, as compared with others (95% versus 29%; 2=4.6; p<0.03), were more likely to experience delirium-related distress.10 In all of our cases, the hallucinations and delusions were the very symptoms associated with the development of PTSD. Although these experiences were not real, their impact and the degree of persisting distress are themselves real, and are remarkable.
In sum, although, in these cases, the delirium and the life-threatening nature of the patients’ medical conditions were real, these patients did not develop PTSD from their actual medical experiences, but rather from the content of terrifying hallucinations and delusions experienced as a result of their medical condition. Although there are inherent limitations in such case reports, and we did not utilize structured diagnostic assessments in two of the four cases, we believe these reports provide compelling evidence that PTSD may result from delusional or hallucinatory experiences involving perceived life-threatening content. Also, there is a small but growing literature on post-psychotic PTSD in patients with schizophrenia or psychosis. Meyer et al.11 found, in a cohort of 46 patients admitted for psychosis, that 11% experienced PTSD as a result of their psychotic experiences alone. This finding extends the criteria for events that can cause PTSD (i.e., in our cases, psychically-induced events that stem from a medical condition). We believe there are most likely many such cases within ICU, transplant, and delirium patient populations. Whether specific treatment during an episode of delirium could prevent the development of PTSD is unknown. However, the identification and treatment of this potentially disabling disorder could certainly improve a patient’s psychiatric outcome and quality of life.
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REFERENCES
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- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994, pp 424-429
- Stukas AA, Dew MA, Switzer GE, et al: Posttraumatic stress disorder in heart transplant recipients and their primary family caregivers. Psychosomatics 1999; 40:212–221[Abstract/Free Full Text]
- Robins LN, Wing JK, Wittchen H-U, et al: The Composite International Diagnostic Interview: an epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry 1988; 45:1069–1077[Abstract/Free Full Text]
- Kapfhammer HP, Rothenhausler HB, Krauseneck T, et al: Posttraumatic stress disorder and health-related quality of life in long-term survivors of acute respiratory distress syndrome. Am J Psychiatry 2004; 161:45–52[Abstract/Free Full Text]
- Cuthbertson BH, Hull A, Strachan M, et al: Post-traumatic stress disorder after critical illness requiring general intensive care. Intensive Care Med 2004; 30:450–455[CrossRef][Medline]
- Jones C, Griffiths RD, Humphris G, et al: Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Crit Care Med 2001; 29:573–580[CrossRef][Medline]
- Nickel M, Leiberich P, Nickel C, et al: The occurrence of posttraumatic stress disorder in patients following intensive care treatment: a cross-sectional study in a random sample. Intensive Care Med 2004; 19:285–290[CrossRef]
- Dew MA, Kormos RL, DiMartini AF, et al: Prevalence and risk of depression and anxiety-related disorders during the first three years after heart transplantation. Psychosomatics 2001; 42:300–313[Abstract/Free Full Text]
- Dew M, Kormos R, Roth LH, et al: Early post-transplant medical compliance and mental health predict physical morbidity and mortality one to three years after heart transplantation. J Heart Lung Transplant 1999; 18:549–562[CrossRef][Medline]
- Breitbart W, Gibson C, Tremblay A: The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics 2002; 43:183–194[Abstract/Free Full Text]
- Meyer H, Taiminen T, Vuori T, et al: Posttraumatic stress disorder symptoms related to psychosis and acute involuntary hospitalization in schizophrenic and delusional patients. J Nerv Ment Dis 1999; 187:343–352[CrossRef][Medline]
This article has been cited by other articles:
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W. Breitbart and Y. Alici
Agitation and Delirium at the End of Life: "We Couldn't Manage Him"
JAMA,
December 24, 2008;
300(24):
2898 - 2910.
[Abstract]
[Full Text]
[PDF]
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INTRODUCTION
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