Remind Me in 5 Months Apply for the Minority Lawton Grant Again

• Journal Listing
• Cambridge University Press Public Health Emergency Drove
• PMC7251252

Cogn Behav Therap. 2020; xiii: e13.

Cognitive therapy for post-traumatic stress disorder following critical illness and intensive care unit admission

Hannah Murray,^{1, ii} Nick Grey,^{3, 4} Jennifer Wild,^{1, ii} Emma Warnock-Parkes,^{1, two, five} Alice Kerr,^five David M. Clark,^{1, 2} and Anke Ehlers^{1, 2}

Hannah Murray

^oneDepartment of Experimental Psychology, University of Oxford, Oxford, UK

²Oxford Wellness NHS Foundation Trust, Oxford, UK

Nick Grey

ⁱⁱⁱSussex Partnership NHS Foundation Trust, UK

^fourUniversity of Sussex, UK

Jennifer Wild

¹Section of Experimental Psychology, University of Oxford, Oxford, Great britain

²Oxford Wellness NHS Foundation Trust, Oxford, Great britain

Emma Warnock-Parkes

¹Department of Experimental Psychology, University of Oxford, Oxford, UK

²Oxford Health NHS Foundation Trust, Oxford, UK

⁵Male monarch's College London, London, U.k.

Alice Kerr

⁵King's College London, London, UK

David G. Clark

¹Department of Experimental Psychology, University of Oxford, Oxford, Great britain

²Oxford Health NHS Foundation Trust, Oxford, UK

Anke Ehlers

^oneDepartment of Experimental Psychology, Academy of Oxford, Oxford, UK

²Oxford Health NHS Foundation Trust, Oxford, UK

Received 2020 April 16; Revised 2020 Apr 24; Accepted 2020 Apr 24.

Abstruse

Effectually a quarter of patients treated in intensive care units (ICUs) will develop symptoms of post-traumatic stress disorder (PTSD). Given the dramatic increase in ICU admissions during the COVID-19 pandemic, clinicians are likely to see a rise in post-ICU PTSD cases in the coming months. Mail service-ICU PTSD tin present various challenges to clinicians, and no clinical guidelines accept been published for delivering trauma-focused cognitive behavioural therapy with this population. In this article, nosotros depict how to apply cognitive therapy for PTSD (CT-PTSD), a first line treatment for PTSD recommended by the National Institute for Health and Intendance Excellence. Using clinical case examples, we outline the key techniques involved in CT-PTSD, and describe their application to treating patients with PTSD post-obit ICU.

Key learning aims

1. To recognise PTSD following admissions to intensive intendance units (ICUs).

2. To empathize how the ICU feel can atomic number 82 to PTSD evolution.

3. To understand how Ehlers and Clark's (2000) cerebral model of PTSD can be applied to mail service-ICU PTSD.

4. To be able to utilise cerebral therapy for PTSD to patients with post-ICU PTSD.

Keywords: COVID-19, disquisitional care, hallucinations, ICU, PTSD, trauma

Introduction

Patients are admitted into intensive intendance units (ICU) when they need life-saving medical treatment. Medical advances have led to higher survival rates in ICU than ever earlier, but many patients experience psychological difficulties in the weeks and months after discharge, peculiarly mail-traumatic stress disorder (PTSD), depression and anxiety. Indeed, a recent meta-assay found self-reported PTSD symptoms in 24% of ICU patients betwixt 1 and 6 months later on discharge, and 22% at vii months (Parker et al., 2015).

Various risk factors associated with admissions to ICU lead to higher rates of PTSD than other medical settings. Also being critically unwell and fearing they may die, patients are exposed to the ICU surround with constant noise, light, frequent medical checks, pain, sleep disruption, partial consciousness and high levels of sedating medications. They are often unable to communicate or to motion. These factors place patients at risk of delirium, an acutely confused state of mind that can be accompanied by hallucinations and delusions. The patient'south poor physiological state and the ICU surround likewise affect memory processing, further raising the take a chance of PTSD development.

The COVID-19 pandemic has led to a rapid increase in ICU admissions. One of the many aftershocks of the pandemic is probable to be a ascension in patients presenting with PTSD related to their experiences of illness and medical handling. As withal, information are not available to judge rates of PTSD in this population or on specific PTSD risk factors such every bit the utilise of sedating medications. However, certain aspects of treatment during the pandemic may place patients at gamble of developing post-ICU PTSD. Staff need to wear personal protective equipment (PPE), including masks which hamper communication and can make them look frightening to patients experiencing delirium. Visitors are non allowed unless the patient is dying, removing the opportunity for reassurance and back up from a loved ane, and staff volition be uncommonly busy. In usual circumstances, approximately 13% of patients admitted to ICU die [Intensive Intendance National Audit and Research Heart (ICNARC), 2019], but early figures regarding COVID-19 cases indicate that mortality may be higher for this population, at over fifty% at the time of writing (ICNARC, 2020), meaning that patients may exist enlightened of others dying around them, and of their ain high hazard of expiry. Finally, critically ill COVID-nineteen patients experience hypoxia, which is a risk factor in delirium (Tilouche et al., 2018). Some aspects of being unwell with COVID-nineteen may exist protective of PTSD. For instance, many patients in ICU have no retention of arriving there, every bit their access was due to a sudden accident, illness or following an operation. COVID-19 patients have typically go increasingly unwell over a period of fourth dimension. They may therefore have greater awareness of their situation, and more access to factual memories, which has been found to exist protective of PTSD (Jones et al., 2001).

The National Found for Health and Intendance Excellence guidelines on rehabilitation after critical illness (NICE, 2009) recommend psychological follow-up for patients after discharge from ICU, including screening for PTSD, and psychological therapy every bit required. Nonetheless, at the time of writing, follow-up clinics were routinely available in just some UK hospitals, and are probable to be over-stretched during the COVID-nineteen pandemic. Furthermore, patients with PTSD symptoms may be unable or unwilling to attend infirmary follow-up clinics, due to ongoing physical problems and the distress associated with reminders of their experiences in infirmary.

When it comes to treatment, there is little published clinical guidance available for psychological therapists working with patients with postal service-ICU PTSD. Clinical interventions in the literature accept tended to focus on prevention of PTSD, including adjusting sedation and medication use (Kress et al., 2003), the apply of patient diaries (Ullman et al., 2015), and early intervention programmes (e.grand. Wade et al., 2019). Treating post-ICU PTSD may nowadays diverse challenges to clinicians, such as: the function of patchy and highly disjointed memories that may include hallucinations; ongoing physical problems; avoidance of healthcare-related triggers; and a distrust and fear of medical professionals.

In this article, nosotros aim to describe how to apply cerebral therapy for PTSD (CT-PTSD), a first-line psychological treatment for PTSD, to run into the needs of post-ICU patients. Although we will focus predominantly on PTSD following treatment in ICU, much of the content is relevant to surviving critical disease in general, also to medical traumas in other contexts.

PTSD afterwards ICU

Traumatic events in ICU may include:

• Experiences where the patient believed they were almost to dice.

• Moments when the patient learnt bad news, such equally realising they had developed COVID-19 and related problems.

• 'Flashforwards' or images of a feared futurity event (such every bit imagining their own funeral).

• Invasive (and sometimes painful) medical procedures.

• Seeing, hearing or learning nigh other patients dying.

• Perceived mistreatment, such equally experiencing pain and assertive staff aren't helping.

• Witnessing other patients acquit in a distressing manner.

• Hallucinations caused by delirium.

• A combination of the to a higher place. For example, patients may have memories of a medical procedure, which they believed at the time was the nurse trying to kill them.

To run across criteria for PTSD, co-ordinate to the Diagnostic and Statistical Manual of Mental Disorders (5th edn, DSM-5; American Psychiatric Association, 2013), every bit well equally experiencing a Criterion A outcome (witnessing or experiencing actual or threatened death or serious injury), such as those listed above, the patient must too have symptoms from each of the following categories:

• Re-experiencing the events in the form of intrusive memories, flashbacks, nightmares and/or physical and emotional reactivity to reminders (Criterion B). With respect to ICU trauma, patients may report factual memories, delusional or hallucinated memories, or a mixture of the two (Colville et al., 2008; Wade et al., 2015). In some cases, they will report confusion about what was real. Re-experiencing does non always involve witting recall of traumatic events. It can as well involve re-experiencing an intense emotion (fright, sadness, despair) or physical reaction (pain, shortness of breath, immobility) from the trauma without simultaneously recalling the effect itself. This is what Ehlers and Clark (2000) called 'impact without recollection'. Triggers for re-experiencing include obvious reminders of the trauma (such every bit the mention of ICU, being asked about your disease, etc.) but also oft include sensory elements of the admission that are ubiquitous in everyday life, such as beeping noises, smells of disinfectants, the audio of laboured breathing, the colour of PPE gowns, the clear plastic used in staff PPE visors, and physical sensations such as hurting, difficulty breathing, discomfort when swallowing, lying downwardly and nausea. When these sensory elements are part of everyday objects (the colour of clothes, the material used in household containers, the breathing of a newborn baby), patients may not be aware what has triggered their memories or bear upon and feel their emotions are out of control.

• Avoidance of thoughts, feelings and reminders of the experience (Criterion C). With respect to post-ICU PTSD, types of behavioural avoidance may include skipping medical appointments, avoiding looking at or touching parts of their ain torso, activities that bring on like body sensations (such as getting out of breath) and turning off TV programmes or films with medical themes.

• Negative alterations in cognitions and mood (Benchmark D). For PTSD following ICU, cognitions may relate to perceived negative, permanent changes to the self, 1'south body or life in full general, beliefs about personal vulnerability, and distrust of others, particularly if patients believed they were mistreated in infirmary. Related emotions may include hopelessness, sadness, shame and anger.

• Hyperarousal symptoms (Criterion Eastward). Peculiarly common symptoms post-ICU are hypervigilance to internal states, such as sensations or symptoms which may bespeak possible illness. Sleep is often poor, as lying in bed may trigger memories.

The symptoms demand to have lasted for at least a month (Benchmark E), cause significant distress and/or interference to of import areas of functioning (Criterion F) and not exist attributable to a substance or medical condition (Benchmark G). The PTSD criteria in ICD-11 (World Health Organisation, 2018) focus more narrowly on re-experiencing in the form of flashbacks and nightmares, abstention, hypervigilance and startle responses.

PTSD symptoms may develop immediately after ICU, but we have also observed cases of delayed onset. Patients often report that initially their attention was focused on their physical recovery, and it was only afterwards that their psychological symptoms emerged or assumed priority.

A cerebral model of PTSD

Ehlers and Clark'southward (2000) cerebral model of PTSD suggests that the cadre experience of PTSD is a sense of serious current threat even though the trauma is in the past. This perceived current threat can be physical ('I'm going to dice'; 'The world is a dangerous place') and/or psychological ('I'm weak'; 'I'thousand all lone').

The sense of threat is maintained past iii processes. The first relates to meanings that ascend from the fashion an individual has appraised the traumatic event or its aftermath. For example, if patients now meet themselves and their loved ones every bit more vulnerable to disquisitional affliction or death and mistrust medical professionals, this will create an ongoing sense of threat.

The 2d concerns the nature of the trauma retentiveness. The model suggests that considering the trauma is processed in a predominantly sensory fashion (as a stream of sensory impressions) and sometimes also as unreal/not happening to the self, the worst moments of the trauma are poorly elaborated and disjointed from other autobiographical information in memory. This accounts for the 'here and now' quality of PTSD memories; when they are recalled, people may exist unable to access other information that could correct impressions or negative beliefs they had at the fourth dimension. In other words, the memory for these moments has not been updated with what the individual knows now, such as that they survived and that the meanings of the worst moments may be inaccurate (eastward.thousand. that the medical staff did not torture them, only in fact did the procedures to save their life). These types of memories are easily triggered by sensory cues that are similar to those encountered at the time of the trauma.

The third process maintaining the sense of current threat is the cognitive and behavioural coping strategies that the patient uses to endeavor to reduce their sense of threat. These strategies tin can inadvertently increase symptoms (e.g. memory suppression or substance use) or the sense of threat (eastward.g. hypervigilance to danger). Importantly, avoidance, safety behaviours and rumination prevent modify (re-appraisal) of traumatic meanings or in the nature of the trauma memory, which remains in its poorly elaborated land.

Psychological chance factors for mail service-ICU PTSD

About research into risk factors for post-ICU PTSD has focused on patient demographics and medical variables. For case, some types of medication (including benzodiazepines and opiates) are peculiarly associated with later PTSD development, probably due to their office in delirium (e.g. Bienvenu et al., 2013; Girard et al., 2007). The psychological variables which have been studied give us some insight into the processes leading to postal service-ICU PTSD and align with the cognitive model. For example, studies have shown that the number of traumatic medical events which occur in ICU (such as difficulty animate) is non predictive of PTSD, but the experience of fear and stress is (Wade et al., 2013). This fits with the cognitive model of PTSD, which suggests that information technology is the nature of the appraisal made about traumatic events as threatening which leads to PTSD.

2nd, information technology seems probable that the furnishings of the ICU environment on memory processing are profound; the combination of strong medication, interrupted sleep and fractional and varying levels of consciousness can lead to highly disorganised memories dominated past sensory information and not easily integrated with other autobiographical memories and information, making them readily triggered. Research shows that patients who experienced delusional memories (Kiekkas et al., 2010), were less aware of their surroundings (Elliott et al., 2016; Rattray et al., 2010) and had a low sense of coherence (Valsø et al., 2020) were more likely to develop PTSD after ICU. Studies that have shown the presence of factual memories is protective from PTSD (Jones et al., 2001) suggest that, fifty-fifty if factual memories are unpleasant, they help patients to improve contextualise their experiences, and add coherence and significant to what is happening.

Lastly, inquiry shows that patients with pre-existing psychological issues are more likely to experience delusions in ICU (Jones et al., 2001) and to develop PTSD subsequently (Davydow et al., 2008; Morrissey and Collier, 2016; Wade et al., 2012). Prior trauma exposure has been linked to increased risk of post-ICU PTSD (Paparrigopoulos et al., 2014) and themes from previous trauma often arise in hallucinations. Ehlers and Clark's cognitive model of PTSD proposes that previous beliefs and experiences bear upon the nature of the trauma retentivity and the appraisals formed. For case, someone with a pre-existing anxiety disorder or trauma history is more likely to interpret events in ICU as threatening.

Figure ​ 1 shows the cognitive model for PTSD adapted to illustrate typical features of postal service-ICU PTSD (in italics).

Ehlers and Clark's (2000) cerebral model of PTSD, applied to post-ICU PTSD.

Cognitive therapy for PTSD

Ehlers and Clark'southward (2000) cognitive model of PTSD forms the basis of cognitive therapy for PTSD (CT-PTSD), a trauma-focused cognitive behavioural therapy recommended by Prissy guidelines (Prissy, 2018). CT-PTSD has demonstrated efficacy in randomised controlled trials (Ehlers et al., 2003, 2005, 2014), and in routine clinical do (Ehlers et al., 2013). Treatment usually consists of upward to 12 weekly sessions of 90 minutes, with upwardly to iii monthly follow-up sessions.

In line with the model, the aims of CT-PTSD are as follows:

• To modify threatening appraisals (personal meanings) of the trauma and its sequelae.

• To reduce re-experiencing past elaboration of the trauma memories and by breaking the link between everyday stimuli and trauma memories (then vs now trigger discrimination training).

• To reduce cognitive strategies and behaviours that maintain a sense of current threat.

For farther information on how to behave CT-PTSD, including training videos, questionnaires to guide handling, guidelines for conducting treatment remotely, and post-ICU PTSD data leaflets, get to: www.oxcadatresources.com. These training materials assume existing grooming and competence in CBT.

Using CT-PTSD for handling of post-ICU PTSD

The cadre treatment strategies of CT-PTSD tin can all be used with patients with post-ICU PTSD. The following suggestions are examples of how the core techniques can exist applied with these patients. A summary table (Tabular array ​ ane) is provided.

Table 1.

CT-PTSD treatment strategies with ICU-PTSD applications

CT-PTSD handling technique	ICU-PTSD awarding
Psychoeducation and normalisation	Include information nearly ICU-PTSD and delirium (if experienced), include information about physical reexperiencing and affect without recollection, and that memory gaps are common due to illness and medication
Individualised case formulation	Include the impact of the ICU environment, and pre-existing experiences (if relevant)
Reclaiming your life	Reframe as 'rebuilding your life' for people with pregnant losses or concrete changes, include in each session. Step according to hurting and/or disability
Memory-focused techniques
Updating the trauma memory	Use timelines to provide an overview of ICU stay and/or a written narrative, even though trauma memories are likely to be very disorganised or may contain hallucinations Gaps are acknowledged ('the next affair I recollect is…') To admission meanings of particular hotspots, reliving of these moments is helpful Updates may include better than expected result ('I did not dice'), reasons for interventions, intention of staff to assist, reasons for beingness alone, distorted sense of time due to illness, sleep disturbance and lack of day light (see Table ​ 2 for examples) Include updates to make sense of delusions/hallucinations Consult medical notes and/or experts to generate possible updates
Trigger discrimination	Detective piece of work identifying audio/visual/olfactory stimuli or actual sensations that were present in ICU just are also ubiquitous in the post-ICU surroundings and deed equally triggers for trauma re-experiencing Then vs Now discrimination may involve behaving during retention elicitation in ways that were non possible during traumatic moments in ICU (i.eastward. standing up, moving around)
Site visits	Conform to visit the ICU by contacting the ward where possible Prioritise visits if trauma memories include delusions or hallucinations Use virtual site visits and video tours of ICUs to prepare for site visits or if you cannot render in person
Working on meanings of the trauma and its aftermath	Common themes include: Beliefs about losing one's mind – use psychoeducation, inquiry, surveys and behavioural experiments Belief about permanent physical alter – acknowledge and mourn losses, increase focus on what has not changed; photograph and video feedback and surveys to address distortions about severity of changes in appearance/function Conventionalities about permanent psychological change – identify and challenge loss of conviction in ane's own abilities ('I can no longer be trusted to look afterwards my family') Health anxiety and beliefs well-nigh vulnerability to affliction – use guided discovery and medical advice to calculate accurate adventure probabilities; drib scanning of body sensations/signs of affliction; behavioural experiments Survivor guilt – address beliefs nigh perceived responsibleness and inequity, consider alternative meanings, employ surveys Beliefs nearly mistreatment and mistrust of healthcare professionals – mind and sympathize, accost misappraisals, facilitate communication with hospital, reviews costs and benefits of belongings on to acrimony, reduce rumination Address generalised appraisals re: trust by reviewing evidence, surveys and research
Accost maintaining behaviours/cognitive strategies	Increment sensation of strategies, eastward.g. internal scanning, over-protectiveness, rumination, substance use and their role in maintaining PTSD Utilise behavioural experiments to test effects of strategies, including experiments in reducing and dropping strategies and experiments to alter appraisals that motivate the behaviours

Psychoeducation and normalisation

In the early stages of CT-PTSD, we utilize psychoeducation to help patients empathize PTSD and to normalise their symptoms. An case leaflet, and a specific version for post-ICU PTSD, can be found on the OxCADAT resources website. With post-ICU PTSD, information technology is as well helpful to give normalising information about ICU traumas. This is important because patients may accept beliefs nigh their experiences such as 'I'm losing my mind' (especially in the case of delirium) and 'I should be over this past now'.

Psychoeducation could include:

• That PTSD is common after ICU (20–30% of patients experience PTSD symptoms).

• A nurse or other specialist giving sound or written feedback on why some medical procedures are carried out in ICU.

• That delirium in ICU is extremely common (60–lxxx% of patients).

• Why delirium occurs in ICU (most probable a combination of strong medications, sleep deprivation and/or hypoxia).

• That hallucinations and delusions in ICU are non signs of mental disease. They tend to simply occur in that specific environment and do non atomic number 82 to the development of a psychotic illness.

• Memories of experiences in ICU are usually muddled, without a clear sense of time, and tin can come up dorsum in diverse forms: memories of sure moments, feelings in the body, or sudden feelings such as panic. All of these are signs that a retentiveness has been triggered.

Normalising information can likewise be constitute by reading first-person accounts of ICU experiences (east.g. past announcer David Aaronovitch: https://bbc.in/2WuueQy) or accessing online resources or back up groups for ICU survivors (e.chiliad. ICU Steps: www.icusteps.org).

Individualised example formulation

Another early task in CT-PTSD is developing an individualised case formulation with the patient. This is not every bit detailed as in Fig. ​ ane, only includes a basic description of the main processes maintaining their PTSD (i.eastward. the sources of the sense of current threat and whatsoever problematic cerebral or behavioural strategies; run across the OxCADAT resource website for a video on developing formulations). With post-ICU PTSD, we also talk over the impact of the ICU context on retentiveness processing, emphasising that at that place is petty wonder that their trauma memories were hard to make sense of, or to 'put away' in the retentivity system, given the intense physiological and environmental experience of ICU.

Learning a little nearly the patient's pre-hospital experiences and beliefs may also reveal links to the content of delusions and hallucinations. It can exist helpful to draw these links with the patient to understand their delirium experiences better.

Shannon had been sexually abused by her uncle in babyhood. In ICU, she experienced intensely pitiful hallucinations of being sexually assaulted by staff. On word with her therapist, Shannon realised that the nature of her hallucinations may have been influenced by her previous trauma. It was likely that staff sometimes touched Shannon intimately for medical reasons, such every bit when washing her or adjusting her catheter. Shannon knew that she had been in and out of consciousness, and frequently confused while in ICU, and realised that she may accept misinterpreted these procedures every bit sexual assaults, something she was understandably particularly fearful of.

Reclaiming/rebuilding your life

Reclaiming previously valued and enjoyed activities or equivalents after a trauma is an of import function of CT-PTSD, which starts in session 1 and is reviewed every session. Following a critical illness, some patients accept meaning concrete changes, including pain, inability, scarring, sexual dysfunction and ongoing symptoms of chronic health conditions. The longer-term physical consequences of COVID-19 are non yet known, but may include fatigue and respiratory problems. There may have been other significant changes to their life, like beingness unable to piece of work, financial problems, or lifestyle changes. These obstacles may make it difficult to fully reclaim their life equally it was before.

Reclaiming your life will emphasise 'rebuilding' your life later on trauma. Piece of work creatively and collaboratively with your patient to identify what is possible to reclaim, and how to replicate what was important to the patient about previously meaningful activities in other ways. You lot may need to pace work with your patient to accommodate hurting or disability. What is possible volition also vary over fourth dimension, depending how soon after ICU a patient is seen, and the stage of their concrete recovery. Plans for future rebuilding your life tasks can be fabricated to match further physical improvements.

Gwilym had been a senior police officeholder before his affliction and treatment in an ICU. He was left with significant pain and fractional paralysis, significant he had to give up both his career in the law and some of his hobbies. Gwilym and his therapist worked together on how to rebuild his life. They started by listing the things Gwilym had enjoyed which he could nonetheless do, including watching sport on the TV, going to the pub with friends, and sitting in the garden with his married woman, and made a program to reintroduce these activities. They then discussed what Gwilym had enjoyed about his job, and his other hobbies. Gwilym identified the feeling of doing something positive for his community, the camaraderie with his squad and being physically active. They discussed other opportunities to reach these aims, in ways which were physically possible for Gwilym. He decided to start volunteering for a local charity, producing their newsletter, which he could do from home. He also used his expertise to prepare up a Neighbourhood Watch in his local surface area, which had the added benefit of getting to know his neighbours meliorate. He made an effort to stay in touch on with colleagues, and other friends, and made plans to meet them. Gwilym also began to gradually increase his concrete fitness, using a program given to him by the hospital physiotherapists.

Memory-focused techniques

Updating trauma memories

The get-go stride to updating trauma memories in CT-PTSD involves accessing problematic meanings through imaginal reliving or creating a written narrative of the experience. As stays in ICU can exist prolonged and the patient may have only been conscious for part of information technology, reliving or writing nigh it in item from starting time to finish will be hard. Patients often lose sense of time in ICU, especially if they feel delirium. Where possible, information technology can be helpful to construct a rough timeline of their stay in ICU, using information from medical records, ICU diaries (which are used in some units) and recollections from family or friends who, fifty-fifty if they were not immune to visit, hopefully received regular updates from the ward. This provides an overview of the stay, and trauma memories that are currently being re-experienced can be identified and marked on the timeline.

Writing a narrative of what the patient remembers is also useful to provide an overview of their ICU experience and to identify hotspots (moments of meridian emotional distress during the trauma retentiveness). Patients and therapist can talk over unlike possibilities for confusing moments while writing together and constructing a plausible sequence of events. Confusion and gaps are acknowledged in the narrative ('the next thing I think is…'). The therapist monitors reactions such as signs of dissociation, feeling faint, confused, nauseous or pain to gauge the pace of the date with the trauma memories and can remind the patient of the present as needed or utilize applied tension if the patient starts to experience faint.

The events around the particular memories that are re-experienced or cause the greatest distress during the narrative writing or constructing the timeline (hotspots) can then be explored in more than depth through imaginal reliving to fully access their meanings. Updating information is then identified and brought into the trauma memory as early on as possible. The updates are written into the narrative account in a different colour or font. The patient or therapist reads the hotspot and update out loud, while the patient holds both in mind. In imaginal reliving, the therapist prompts the patient to say the update out loud when they attain the hotspot in the memory and to hold an image of the update in mind. It can also be useful to use actions or images to remind themselves of the update. For instance, incompatible actions or sensations such as moving about or touching their healed torso tin can show that the danger has passed, and they accept recovered. Looking at photos of recent events with loved ones tin update moments where patients may have feared they would die without saying good day to their loved ones. Images such as the body healing after illness to strengthen the update 'the affliction has passed, my body is healthier now'. Ratings of retentivity 'nowness' (the extent to which the event feels as if it is happening once more) and distress are collected earlier and after updating to check that the procedure has been successful. Video examples of this of import technique are available on the OxCADAT resources website.

The meanings of hotspots are individual to each person, and are identified through careful questioning. Tabular array ​ 2 lists some mutual hotspot meanings from several different post-ICU PTSD patients, together with possible updates and ways of demonstrating the updated meanings.

Table ii.

Instance hotspots and updates for ICU trauma memories

	Example update
I'g going to dice, I'thou never going to run across my family again	I didn't dice, I'thou live. I can show myself this past looking in the mirror and moving nigh. I run across my family nearly days. I can remind myself of this by looking at a recent photo of united states of america together
I can't speak/no-ane is listening to me	I couldn't speak because I had a tracheostomy/was on a ventilator. I needed it at the time to assist me breathe. Even though I couldn't communicate with them, people were looking after me. Now I tin can speak and people listen to me. I can prove this by saying this update out loud
I can't exhale, I'yard suffocating	It was difficult for me to breathe because I had pneumonia in my lungs. I was on a ventilator which was helping me exhale. Now, the disease has gone and I tin breathe. I can evidence myself this by taking some deep, slow breaths or exercising
I tin can't move, I'm in danger	I couldn't move because I was in a hospital bed with lots of medical equipment connected to me, and I was on lots of sedating medication. Although I was very sick, I was beingness given the handling I needed to relieve my life. People were looking later on me. I tin move now. I tin can prove myself this by continuing up and moving about freely
I'm on my own, nobody cares	At that place are lots of staff in ICU merely they are very busy and they had lots of people to await after. Visitors weren't allowed, but I didn't know that then information technology makes sense I felt solitary. Lots of people care about me. I can remind myself of this by reading all the nice 'get well' cards and messages I have had
The doctors and nurses are trying to kill me	I was experiencing delirium which is very common in ICU because of all the medication. People oftentimes believe staff are trying to kill them. The things they were doing were function of my medical treatment to keep me alive, merely I didn't know this at the time. They were trying to help me. I can prove this to myself past watching videos of staff in ICU, past returning to the ward and reading the data nearly emergency tracheotomies the nurse/other proficient emailed my therapist
I'k being sexually assaulted	The nurses needed to bear on me intimately for medical reasons, like washing me, changing/cleaning my catheter and taking a swab to test for infections (my partner told me this happened at least in one case). In my confused half-sleep/half-wake medicated land, I didn't empathise why they were touching me and so. If someone touches your private parts and you don't understand why, information technology makes sense that you might think they are sexually assaulting y'all, especially considering this happened to me in the past. I know at present that they weren't assaulting me. I can remind myself of this by watching the video of the friendly ICU nurse explaining how they intendance for patients. No-i is touching me at present. I have control back over my trunk and who touches it. I can remind myself of this past looking effectually to see that there is no-one there, and by gently stroking my peel
I accept been abducted	I believed I had been abducted considering I woke up in an unfamiliar place and my listen was playing tricks on me because of the drugs I was given. I wasn't abducted, I was safety in hospital the whole time. I can remind myself of bringing to listen an epitome of nurses caring for me kindly, even though I wasn't enlightened of them at the time
I was in a spaceship/floating downwardly a river/on a journey	Beds in the ICU move to foreclose pressure sores. This fabricated me feel like I was moving, and it got mixed up in the dreams I was having. I tin can remind myself of this by imagining that the spaceship landed safely/I washed safely out of the river/I got abode at the terminate of the journeying. I tin can look around to show myself I am condom in my home now

The latter four examples are mutual hallucinations and delusions in ICU, simply a range of bizarre experiences may be reported. In general, it is useful to update these with normalising information about why such experiences happen, and the knowledge that it did non really occur. In some cases, patients report confusion well-nigh what was real. Normally, logic can help determine whether an experience was likely and some detective piece of work, such equally asking friends and family, consulting medical records, or interviewing staff in the ICU can help extrapolate the truth. Oftentimes a 18-carat occurrence has get distorted through delirium. Information technology can exist helpful to sympathise where the hallucination originated from.

Christine believed throughout her fourth dimension on ICU that she had been abducted by aliens so they could harvest her organs. She had terrifying hallucinations of them cut her open. Christine and her therapist discussed where this hallucination had come from. It made sense that Christine had believed she had been abducted, as she awoke in a strange place, unable to move. Christine likewise realised that the staff on ICU had been wearing personal protective equipment, including masks, visors, hair protectors and plastic suits that fabricated them expect bizarre and frightening to her. They would have been dressing the surgical wound on her tummy, which might have caused some pain. In her state of being physically ill, and taking lots of painkillers, her mind had interpreted all these experiences equally an alien abduction.

Trigger discrimination

Careful review of re-experiencing episodes is used to identify retentivity triggers. Patients are often not aware that their trauma memories are triggered past sensory elements, such as colours, smells, tastes, sounds, beingness touched on certain parts of the body, body posture, and bodily sensations. Memories may also be triggered by medical settings and reminders such as letters from the infirmary, attending appointments, medical TV programmes and media reporting of relevant topics (such every bit the COVID-19 pandemic). Affect without recollection can initially be difficult to spot, simply as patients become more aware of their individual triggers, they gradually recognise these emotions equally office of their trauma memories.

One time the triggers accept been identified, they are intentionally presented, memories/emotional reactions are elicited and then the patient is encouraged to intentionally focus on what is different between 'and then' (the trauma) and 'now' (the reminder). This 'So vs Now' discrimination technique tin exist practised in session and for homework while deliberately introducing the trigger. Noises and pictures similar to those in ICU can be found in internet audio libraries and Google Images. Actual sensations can be recreated in session. Patients who experienced respiratory distress (e.g. post-obit COVID-nineteen infection) may experience anxious when they notice breathlessness. For some, this may trigger panic attacks. For patients who but experience panic in response to trauma triggers, this can be treated with 'Then vs Now' trigger discrimination. For those who have adult panic disorder, where panic attacks occur out of the blue, and are accompanied by catastrophic thoughts, additional cerebral therapy techniques for panic disorder are required.

Krishnan had been admitted to ICU in acute respiratory distress. He was struggling to breathe, and believed he was going to die. Later on, Krishnan felt panicky if his breathing was restricted in any way, like if he had annihilation touching his confront (which reminded him of an oxygen mask), or if he got out of jiff through exercise. His therapist taught him how to use 'And so versus At present' and they practised it in session while holding their easily over their face during and afterward running on the spot.

Site visits

At the time of writing, ICUs are limiting visitors due to the COVID-19 pandemic and site visits are not possible. However, in usual circumstances, ICUs are often happy to facilitate site visits, if they are contacted first. Returning to the ICU is particularly helpful if delirium occurred, to look for updating data (due east.k. the nurses are trying to assistance people, non impairment them), and for clues to empathize where hallucinations originated. It may as well be possible to speak to staff who treated the patient, which can oftentimes aid fill memory gaps and find data to update behavior about what happened.

If you cannot return in person, or equally a footstep before an in vivo visit, try a virtual site visit. The exterior of the hospital can be revisited using Google Street View, and images of the interior of the hospital can be found online. There are video tours of ICUs bachelor online, such as on the Chelsea and Westminster hospital website (https://www.chelwest.nhs.uk/services/support-services/intensive-care-unit-icu/video-bout).

Working with meaning: mutual cognitive themes

As well every bit using cerebral strategies to address appraisals at the fourth dimension of the trauma (to include every bit hotspot updates), we also work on appraisals fabricated since the trauma. Again, these are personal and idiosyncratic to the patient, simply certain themes are quite mutual, every bit follows.

Behavior about mental illness due to delirium experiences

The term 'ICU psychosis' is sometimes used by medics, which can give the impression to patients that they take adult a psychotic illness. Others take specific beliefs or fears nigh mental illness, which may exist exacerbated by PTSD symptoms due east.m. 'the flashbacks mean I take permanently lost my mind', or may feel ashamed virtually the fashion they behaved during their handling. The psychoeducation we have already described is often helpful to address these beliefs. Additionally, gathering further information through speaking to an skillful (such as an ICU staff member), reading about delirium or distributing a survey via patient forums such as on the ICU Steps website can help to accost beliefs. We as well use behavioural experiments to exam behavior such as 'I tin can't trust my mind', such as deliberately trying to 'go crazy'.

Beliefs near permanent change

Behavior related to other types of permanent change are also common e.g. 'my life will never be the same again' and 'I'thou not myself anymore'. These are often exacerbated by genuine physical and lifestyle changes and losses that have resulted from the illness or injury, which should be best-selling and mourned. Oft patients are very focused on what has inverse, and less aware of what has not, so a useful practise can be to discuss which aspects of the person and their life take not been lost, or can exist reclaimed. For instance, superficial physical changes may take occurred, but not cardinal aspects of someone'southward identity such equally their character and personality, their friends and family and their values. We can besides place and challenge beliefs relating to loss of confidence in one's ain abilities ('I can no longer exist trusted to look later on my family unit').

Scars and other concrete changes can be triggers to trauma memories, exacerbating how severe the changes feel. We use techniques such as photo and video feedback to give a realistic perspective of concrete changes, and encourage patients to reduce avoidance of the affected function of their body, such rubbing lotion into their scars every mean solar day. Beliefs about how others view their changes in appearance or abilities tin exist addressed using surveys, including surveys that include photos of the patient's scars, aslope those of other people, and behavioural experiments in allowing their scars to exist visible to others. In our experience, surveys and experiments often testify that people show curiosity about scars and other forms of disability, and may expect briefly, but do non find them disgusting or repulsive.

Wellness feet

Patients may understandably fear becoming unwell once more, and experience an increased sense of vulnerability, which may also generalise to fearing for the wellbeing of their loved ones. Every bit with other types of take a chance appraisement, we use guided discovery, and advice from experts (such as the patient'due south medical squad) to calculate a realistic probability of becoming critically ill again. This may be somewhat college than average for patients with ongoing health conditions, but is often non as high as patients fear. Medics can also advise on advisable precautions to avoid further affliction (east.yard. living a generally good for you lifestyle), and which precautions may be unnecessary (e.g. constant symptom checking or scanning).

Guilt virtually survival

ICU patients are often aware of others dying on the ward and some report feeling guilty that they have survived when others have not. The high mortality rate associated with COVID-19, including amid staff, may mean this is a peculiarly mutual appraisal amongst these patients. Some patients believe that they were somehow responsible for the death of another patient, such every bit by taking resource away from them. For others, guilt is linked to full general beliefs most equity, for instance their survival has cleaved unwritten rules that the world should be fair, and that things happen for a reason. In handling, we can address appraisals about responsibleness, and beliefs such as 'I took their place' or 'the other person was more than worthy of living than me', and await for alternative explanations for their survival such every bit 'the other person was just sicker than me' and 'no-1 deserved to die, including me'. Surveys tin can exist helpful to gather other opinions, equally can work on developing pity for the self, and reducing rumination.

Beliefs about mistreatment and mistrust of healthcare professionals

Some patients report feeling aroused about their medical treatment. This ranges from modest concerns about lack of communication or staff availability to claims of clinical negligence or malpractice. Interventions include allowing the person to vent their distress (including writing an acrimony alphabetic character which is not sent), gently probing for whatever areas of misunderstanding or misappraisals (especially in the case of delirium), reviewing possible reasons for perceived failures (east.chiliad. inattention due to busy wards and long working hours), facilitating communication with the ICU team to address concerns and, if appropriate, helping patients to make a formal complaint. Information technology can besides be helpful to consider the advantages and disadvantages of belongings on to anger, and helping patients to reduce rumination.

In some cases, patients develop more generalised problems with trusting healthcare professionals. This is important as it can interfere with access to medical treatment, which may be crucial to their ongoing recovery, and can touch on the therapeutic relationship. Here it can exist helpful to inquire the patient to list all the healthcare workers they have ever encountered (usually many) and identify which ones take been untrustworthy or incompetent (commonly the minority). Facilitating ways to get together data from healthcare professionals, for example through surveys and online inquiry, can help address behavior such every bit 'they don't care about their patients'.

Address maintaining behaviours/cerebral strategies

Patients understandably develop behaviours and cerebral strategies to endeavour to reduce the sense of threat which is cardinal to the feel of PTSD. Following ICU, these commonly include over-protecting others, checking behaviours, internal scanning for symptoms, ruminating and avoidance of reminders such as looking at or touching scars equally well as abstention of activities which are believed to exist risky, such as swimming, walking or other physical activity. In therapy, we depict attention to the role these strategies have in maintaining the PTSD, restructure related behavior (such as those concerning take a chance), and carry out behavioural experiments (including during therapy sessions) to demonstrate the effects of the behaviours, for example increasing and so decreasing the behaviour (come across Maria's example below). We encourage patients to experiment with dropping their behaviours equally homework to exam related beliefs. For example, someone who avoids exercise for fearfulness that breathlessness volition consequence in them requiring hospitalisation could experiment with periods of gentle exercise that leads to increased respiration, to test whether they then get seriously ill once again. Whatsoever concerns about ongoing physical health risks should be checked with the patient's medical squad.

Maria had developed a number of checking behaviours since a medical emergency leading to an admission into ICU. Despite her doctor saying it was unnecessary, Maria took her temperature and her blood pressure every forenoon. She ruminated nigh the alarm signs she believed she should have noticed before her affliction. In therapy, Maria agreed to a behavioural experiment to exam the effects of these behaviours on her feet. For the first half of the week, she checked her temperature and blood pressure several times a solar day and ruminated on alarm signs. For the 2nd half of the week, she fabricated no checks, and engaged in a reclaiming your life activity every time she noticed herself ruminating. Maria establish that her anxiety was slightly higher on the first day that she didn't do her checks, and her heed kept returning to it during the mean solar day. However, by the second twenty-four hour period, she felt less broken-hearted, and did not become unwell. She realised that her checking behaviours were fuelling her feet and weren't needed to stay well.

Some additional considerations

Your therapy environment

Be aware that your therapy setting may be triggering for post-ICU patients, especially if y'all work in a hospital. Innovate 'So vs At present' discrimination early and exist prepared to alter aspects of your physical surroundings and clothes to brand the patient more comfy. Appointments over video conferencing, or phone sessions, should be offered to patients who cannot attend appointments in person, especially if they have ongoing health problems or disability. If y'all are working remotely, enquire your patient to prepare a suitable abode therapy environment. For case, they should keep reminders of the here and now (such as scents that are different from those at the hospital, post-ICU photos of a pleasant day spent with significant others, a sweet or mint for a different taste) nearby during a session, brand sure they accept peace and quiet for the call, and arrange something pleasant and relaxing to do subsequently.

The therapeutic human relationship

As health professionals, nosotros ourselves may be a trigger to our patients. Furthermore, beliefs about placing trust in others, and being let down or ignored may touch on the therapeutic human relationship. It is of import to address these early to prevent therapy drib-out and to develop a therapeutic human relationship which feels condom, respectful, collaborative and supportive. Another important consideration is to empathise as emphatically with trauma memories that were delusions and hallucinations as y'all would with 'existent' traumatic events. These are sometimes baroque, and patients may have been laughed at or dismissed when they have reported them before. However, they are ofttimes quite terrifying and sometimes shameful, and were experienced at the time as completely real. A useful thought exercise is to imagine if the hallucinations had been a existent event, they would be some of the well-nigh disturbing we take ever encountered.

Involving family and partners

It is often valuable to involve family unit, friends and partners in therapy, and especially following ICU trauma, as social back up during and after ICU is a protective factor for PTSD (Deja et al., 2006). Supporters tin help in many means, including filling in memory gaps, helping to explain areas of defoliation, encouraging reclaiming your life activities, and accompanying patients on behavioural experiments and site visits, if the therapist cannot. Be enlightened that PTSD is also mutual in family members of ICU patients (Jones et al., 2004) and being an informal carer too confers a hazard of psychological bug (van den Born-van Zanten et al., 2016). If needed, family members can exist directed to treatment themselves, or to sources of other support such as internet forums and support groups.

Acknowledgements

The authors thank the whole Wellcome Trust Anxiety Disorders group for their help in developing CT-PTSD, and our mail service-ICU PTSD patients for improving our agreement of this problem.

Conflicts of interest

None.

Fiscal support

The authors were funded by Wellcome Trust grant 200796 (awarded to A.Due east. and D.Thou.C.) and the Oxford Health NIHR Biomedical Research Middle. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Central practice points

• (i)

  A significant minority of patients who have been treated in ICU will develop symptoms of PTSD.

• (ii)

  Evidence-based psychological handling for PTSD, such as CT-PTSD, should be offered to these patients.

• (iii)

  All the treatment strategies in CT-PTSD tin can be used, including work on updating trauma memories, even if there are retentivity gaps or they include hallucinations or delusions.

• (4)

  Helping patients to brand sense of their experiences and addressing beliefs associated with the trauma are of import parts of treatment.

• (5)

  Treatment volition need to take into account associated physical health difficulties.

• (six)

  Intrusive trauma memories contribute to negative appraisals about how the physical consequences of the trauma appear do others, which can be addressed with video feedback and surveys.

Further reading

• Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–345. [PubMed] [Google Scholar]
• Wade, D., Hardy, R., Howell, D., & Mythen, M. (2013). Identifying clinical and astute psychological chance factors for PTSD after critical care: a systematic review. Minerva Anestesiologica, 79, 944–963. [PubMed] [Google Scholar]

References

• American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th edn). Washington, DC, The states: American Psychiatric Clan. [Google Scholar]
• Bienvenu, O. J., Gellar, J., Althouse, B. M., Colantuoni, Due east., Sricharoenchai, T., Mendez-Tellez, P. A., … & Needham, D. M. (2013). Mail service-traumatic stress disorder symptoms after acute lung injury: a 2-year prospective longitudinal report. Psychological Medicine, 43, 2657–2671. [PubMed] [Google Scholar]
• Colville, G., Kerry, S., & Pierce, C. (2008). Children's factual and delusional memories of intensive care. American Journal of Respiratory and Critical Care Medicine, 177, 976–982. [PubMed] [Google Scholar]
• Davydow, D. S., Gifford, J. One thousand., Desai, S. V., Needham, D. Yard., & Bienvenu, O. J. (2008). Posttraumatic stress disorder in general intensive intendance unit survivors: a systematic review. Full general Hospital Psychiatry, 30, 421–434. [PMC complimentary article] [PubMed] [Google Scholar]
• Deja, M., Denke, C., Weber-Carstens, S., Schröder, J., Pille, C. Eastward., Hokema, F., … & Kaisers, U. (2006). Social back up during intensive care unit stay might improve mental damage and consequently health-related quality of life in survivors of severe astute respiratory distress syndrome. Disquisitional Care, 10, R147. [PMC gratuitous article] [PubMed] [Google Scholar]
• Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Enquiry and Therapy, 38, 319–345. [PubMed] [Google Scholar]
• Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., & Fennell, Thousand. (2005). Cerebral therapy for postal service-traumatic stress disorder: evolution and evaluation. Behaviour Research and Therapy, 43, 413–431. [PubMed] [Google Scholar]
• Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., & Mayou, R. (2003). A randomized controlled trial of cognitive therapy, a self-help booklet, and repeated assessments every bit early interventions for posttraumatic stress disorder. Archives of Full general Psychiatry, 60, 1024–1032. [PubMed] [Google Scholar]
• Ehlers, A., Grey, N., Wild, J., Stott, R., Liness, S., Deale, A., … & Clark, D. Grand. (2013). Implementation of cognitive therapy for PTSD in routine clinical care: effectiveness and moderators of consequence in a consecutive sample. Behaviour Inquiry and Therapy, 51, 742–752. [PMC free article] [PubMed] [Google Scholar]
• Ehlers, A., Hackmann, A., Grey, N., Wild, J., Liness, Due south., Albert, I., … & Clark, D. Chiliad. (2014). A randomized controlled trial of 7-twenty-four hour period intensive and standard weekly cerebral therapy for PTSD and emotion-focused supportive therapy. American Journal of Psychiatry, 171, 294–304. [PMC free article] [PubMed] [Google Scholar]
• Elliott, R., McKinley, South., Fien, M., & Elliott, D. (2016). Posttraumatic stress symptoms in intensive care patients: an exploration of associated factors. Rehabilitation Psychology, 61, 141–150. [PubMed] [Google Scholar]
• Girard, T. D., Shintani, A. K., Jackson, J. C., Gordon, S. Thousand., Pun, B. T., Henderson, M. South., … & Ely, Eastward. (2007). Risk factors for mail-traumatic stress disorder symptoms following critical illness requiring mechanical ventilation: a prospective cohort study. Disquisitional Intendance, 11, R28. [PMC free article] [PubMed] [Google Scholar]
• Intensive Care National Audit and Research Center (ICNARC) (2019). Key statistics from the Case Mix Programme – developed, full general critical care units. 1 April 2018 to 31 March 2019. Retrieved from: https://www.icnarc.org/Our-Inspect/Audits/Cmp/Reports/Summary-Statistics
• Intensive Care National Audit and Research Centre (ICNARC) (2020). ICNARC written report on COVID-nineteen in disquisitional care 10 April 2020. Retrieved from: https://world wide web.icnarc.org/Our-Audit/Audits/Cmp/Reports
• Jones, C., Griffiths, R. D., Humphris, Thou., & Skirrow, P. K. (2001). Memory, delusions, and the evolution of astute posttraumatic stress disorder-related symptoms afterward intensive care. Critical Intendance Medicine, 29, 573–580. [PubMed] [Google Scholar]
• Jones, C., Skirrow, P., Griffiths, R. D., Humphris, Thou., Ingleby, S., Eddleston, J., … & Gager, M. (2004). Post-traumatic stress disorder-related symptoms in relatives of patients following intensive intendance. Intensive Care Medicine, thirty, 456–460. [PubMed] [Google Scholar]
• Kiekkas, P., Theodorakopoulou, G., Spyratos, F., & Baltopoulos, G. I. (2010). Psychological distress and delusional memories afterward critical care: a literature review. International Nursing Review, 57, 288–296. [PubMed] [Google Scholar]
• Kress, J. P., Gehlbach, B., Lacy, M., Pliskin, N., Pohlman, A. South., & Hall, J. B. (2003). The long-term psychological effects of daily allaying interruption on critically ill patients. American Journal of Respiratory and Critical Care Medicine, 168, 1457–1461. [PubMed] [Google Scholar]
• Morrissey, Thousand., & Collier, E. (2016). Literature review of post-traumatic stress disorder in the critical intendance population. Periodical of Clinical Nursing, 25, 1501–1514. [PubMed] [Google Scholar]
• National Institute for Health and Care Excellence (NICE) (2009). Rehabilitation subsequently disquisitional illness in adults (Clinical Guideline CG83). https://www.prissy.org.uk/guidance/cg83
• National Constitute for Health and Intendance Excellence (NICE) (2018). Post-Traumatic Stress Disorder (NICE Guideline NG116). https://www.nice.org.united kingdom of great britain and northern ireland/guidance/ng116
• Parker, A. M., Sricharoenchai, T., Raparla, S., Schneck, G. Westward., Bienvenu, O. J., & Needham, D. M. (2015). Posttraumatic stress disorder in critical affliction survivors: a meta-analysis. Critical Care Medicine, 43, 1121–1129. [PubMed] [Google Scholar]
• Paparrigopoulos, T., Melissaki, A., Tzavellas, E., Karaiskos, D., Ilias, I., & Kokras, N. (2014). Increased co-morbidity of depression and postal service-traumatic stress disorder symptoms and common risk factors in intensive care unit of measurement survivors: a two-year follow-up report. International Periodical of Psychiatry in Clinical Exercise, 18, 25–31. [PubMed] [Google Scholar]
• Rattray, J., Crocker, C., Jones, Thou., & Connaghan, J. (2010). Patients' perceptions of and emotional outcome after intensive intendance: results from a multicentre study. Nursing in Critical Care, 15, 86–93. [PubMed] [Google Scholar]
• Tilouche, N., Hassen, K. F., Ali, H. B. S., Jaoued, O., Gharbi, R., & El Atrous, S. Due south. (2018). Delirium in the intensive care unit: Incidence, take chances factors, and impact on upshot. Indian Periodical of Disquisitional Intendance Medicine, 22, 144–149. [PMC free article] [PubMed] [Google Scholar]
• Ullman, A. J., Aitken, 50. M., Rattray, J., Kenardy, J., Le Brocque, R., MacGillivray, S., & Hull, A. M. (2015). Intensive care diaries to promote recovery for patients and families afterward critical illness: a Cochrane systematic review. International Journal of Nursing Studies, 52, 1243–1253. [PubMed] [Google Scholar]
• Valsø, Å., Rustøen, T., Skogstad, Fifty., Schou-Bredal, I., Ekeberg, Ø., Småstuen, M. C., … & Tøien, K. (2020). Post-traumatic stress symptoms and sense of coherence in proximity to intensive care unit discharge. Nursing in Critical Care, 25, 117–125. [PubMed] [Google Scholar]
• van den Born-van Zanten, Due south., Dongelmans, D. A., Dettling-Ihnenfeldt, D., Vink, R., & van der Schaaf, M. (2016). Caregiver strain and posttraumatic stress symptoms of informal caregivers of intensive care unit of measurement survivors. Rehabilitation Psychology, 61, 173–178. [PubMed] [Google Scholar]
• Wade, D. M., Brewin, C. R., Howell, D. C., White, Eastward., Mythen, M. Thousand., & Weinman, J. A. (2015). Intrusive memories of hallucinations and delusions in traumatized intensive care patients: an interview report. British Periodical of Health Psychology, 20, 613–631. [PubMed] [Google Scholar]
• Wade, D., Hardy, R., Howell, D., & Mythen, M. (2013). Identifying clinical and astute psychological risk factors for PTSD after critical intendance: a systematic review. Minerva Anesthesiologica, 79, 944–963. [PubMed] [Google Scholar]
• Wade, D. M., Howell, D. C., Weinman, J. A., Hardy, R. J., Mythen, M. G., Brewin, C. R., … & Raine, R. A. (2012). Investigating risk factors for psychological morbidity 3 months afterward intensive care: a prospective cohort report. Critical Care, 16, R192. [PMC gratis commodity] [PubMed] [Google Scholar]
• Wade, D. M., Mouncey, P. R., Richards-Belle, A., Wulff, J., Harrison, D. A., Sadique, M. Z., … & Als, North. (2019). Effect of a nurse-led preventive psychological intervention on symptoms of posttraumatic stress disorder among critically ill patients: a randomized clinical trial. JAMA, 321, 665–675. [PMC gratuitous article] [PubMed] [Google Scholar]
• World Health Organization (2018). International classification of diseases for mortality and morbidity statistics (11th revision). https://icd.who.int/en

trappsearmson.blogspot.com

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251252/

Share this post