Beyond the ICU: PTSD and the Hidden Aftermath of Critical Illness

My Personal Journey with Post-Traumatic Stress After Life Support

In my previous blogs, I've discussed resilience, happiness, and the Three A's approach to life's challenges. Today, I want to address a topic that remains largely hidden in healthcare discussions: PTSD following critical illness—something I experienced firsthand after my battle with ARDS.

My Personal Experience with Post-ICU PTSD

Recently, PTSD has been identified as a complication of a life-threatening illness. Just as with victims of trauma, patients, family members, and caregivers of patients who suffer critical illness are also at risk for PTSD. My critical medical illness started on 12/31/2013 when simple community-acquired pneumonia deteriorated into Acute Respiratory Distress Syndrome (ARDS). After 11 days on life support, I was able to come off the ventilator. I and my family experienced firsthand the psychological and physical trauma from my life-threatening illness and prolonged ICU stay.

The Scale of an Overlooked Problem

To understand the size of this problem, pre-COVID-19, there were approximately four million ICU admissions per year in the U.S., with deaths numbering five hundred thousand annually. During the pandemic, these numbers were logarithmically greater.

Despite the large number of patients, family members, and hospital staff at risk for PTSD following ICU admissions for critical illness, counseling following this type of trauma is not widely available. There are no routine treatment protocols in place to help survivors of critical illness, such as those demonstrated to help survivors of other traumas. This shortfall in optimal patient care should be remedied immediately.

Recognizing the Symptoms

Following this illness, sleep became very difficult for me. For many months, I required oxygen as my lungs slowly healed. Prior to this illness, I could never fully understand the reports of persistent difficulty sleeping that many patients complained of following major illness or surgery. Before my illness, getting to sleep and staying asleep was never a problem. Following this illness, sleep became difficult as I would often awaken with nightmares. I now had a new and deeply personal understanding of the problem so many of my patients experienced.

My next symptom of PTSD came with an episode of intrusion that occurred when a family member was admitted to the ICU with a life-threatening condition. When I first visited him in the BWH ICU, the same one that months earlier I had been a patient, almost immediately, my heart began to race and a wave of anxiety came over me. I could not concentrate and had to excuse myself. At a visceral level, I knew that this was a symptom of PTSD and needed to be treated.

Effective Interventions and Recovery

Cognitive Behavioral Therapy as well as Mindfulness Meditation are established techniques that have been demonstrated to help overcome PTSD, and they were instrumental in helping me conquer mine. I read all that I could until I mastered these proven techniques. My life returned to its new normal, but it took years and was not a straight line.

Shared decision-making and liberal family visitation policies have been widely implemented in American hospitals, hoping to decrease anxiety and ICU psychosis. BWH allowed my family to stay with me while I was in the ICU, which I can categorically state helped alleviate the anxiety and psychological trauma that both I and my family were at risk for. This was a beyond stressful event that froze time for me as well as my family. The physicians and nursing staff practiced patient-facing decision-making at all times. In my opinion, these factors had a profoundly positive influence on my recovery and that of my family.

The Path Forward for Healthcare

This policy was common until COVID-19 led to mandatory isolation of all infected patients, not just patients in ICUs but those infected in any facility. The trauma of the illness and, for many, death were compounded by this public health policy of isolation to slow the spread of the virus. Patients, their families, and the hospital staff who cared for these patients were deeply harmed by this isolation.

Prior to COVID-19, it has been reported that up to 40% of patients discharged from ICUs with a diagnosis of ARDS commonly experienced depression, anxiety, and symptoms of PTSD. This represents an estimated one million six hundred thousand individuals yearly. This number does not include family members or staff affected by the trauma. It is tempting to speculate that the estimated 20% decrease in the ranks of our healthcare workforce following the COVID-19 pandemic is due to the trauma they experienced.

In 1980, criteria for the diagnosis of PTSD were first added to DSM III. The advances in the understanding of PTSD have led to multiple revisions and updates. PTSD is now recognized to be more common than previously realized, with up to 4% of American men and 10% of American women diagnosed with PTSD at some point in their life.

So, what is PTSD? In essence, it is a disorder of the recovery process from trauma. It is common to experience many of the symptoms of PTSD after a traumatic event, but for most, they should resolve as recovery happens. If the symptoms persist past one month, then it suggests that recovery is not occurring as it should. The specific criteria for the diagnosis of PTSD for adults are listed in DSM-5-TR. If you do not experience at least six of the symptoms of PTSD as required for a clinical diagnosis of PTSD, it is possible that you may have subthreshold PTSD.

It is now recognized that when traumas happen, whether it be a mass shooting or another horrible life event if trained counselors are brought in early on to help those affected, the likelihood of undiagnosed and untreated PTSD decreases. Immediate trauma counseling helps survivors process in real time what happened in a healthy manner. A common, trite saying is that "time heals all wounds," and although tincture-of-time does heal many, it does not heal all. This is very true with PTSD, and it is not uncommon for people to bury the trauma deep inside without properly dealing with the PTSD, only to have the sequelae of the trauma surface years or even decades later as anger, depression, anxiety, insomnia, nightmares or substance use disorder.

Currently, there is no cure for PTSD, but there is active research underway to improve the success of treating PTSD. Using currently accepted interventions, those who are diagnosed with PTSD can expect that approximately 30% will recover and up to 40% will show evidence of improvement. For those who are undiagnosed, the recovery rate is unknown. What is known is that approximately 18% of male and 40% of female prisoners in the USA have a diagnosis of PTSD. These prisoners are frequently also diagnosed with depression, substance use disorders, and anxiety, highlighting the maladaptive behavior often seen when this condition remains undiagnosed and untreated.

For optimal outcomes, the trauma has first to be acknowledged in order to be treated. Acceptance and adaptation follow later. Some people have the life skills, age, and education to help themselves, while others require treatment. If you are having problems with your golf swing or if a baseball player is in a hitting slump, seeing a coach to help correct the problem is not a sign of weakness. Rather, it is a prudent life choice.

My experience with PTSD reinforced the importance of the Three A's I've shared previously: acknowledging the problem, accepting its reality, and adapting to find a way forward. For those suffering after critical illness, this path can be particularly challenging without proper support. As both physician and patient, I believe we must do better—integrating psychological care into recovery protocols just as diligently as we manage physical rehabilitation.

If you or someone you know is struggling after a critical illness, remember that help is available and recovery is possible.

Warmly,

Dr. Michael

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