Covid-19 and Post Traumatic Stress Disorder

Covid-19 and Post Traumatic Stress Disorder

What is Post Traumatic Stress Disorder? (PTSD)

PTSD describes a collection of symptoms that some people have after their life was in danger, or where there was the possibility of suffering serious injury. You might also feel this way when you witness these kinds of things happening to a loved one – such as watching a loved one in intensive care. Traumatic events which can occur during admission to hospital can include:

  • Moments where you believed that you were going to die.
  • Frightening, invasive, or painful medical experiences.
  • Moments when you received bad news, and had thoughts about what this meant for you, or for those you love.
  • Hallucinations caused by medication, delirium or other illness.
  • Experiences where you felt powerless, or where you felt that you weren’t being helped.
  • Experiences where you were aware of other people dying.

During a trauma it is common to feel powerful emotions and body sensations, or to have frightening thoughts. You might have had some (or none) of the following thoughts and feelings:

Figure: Common thoughts and feelings during traumatic events.

Once a traumatic experience is over, it can take some time to come to terms with what has happened. It is normal to feel shocked, overwhelmed, or numb for days, weeks, or even months afterwards. For most people these feelings subside with time, but for other people they persist and start to impact on your life.

Symptoms of PTSD:

  • Re-experiencing the trauma as flashbacks, nightmares, or reactions in your body. You might experience unwanted memories of your trauma which can ‘pop’ involuntarily into your mind and are often accompanied by powerful emotions. Your memories might be triggered by reminders of your medical experience such as seeing a hospital drama on TV, or receiving notice of a medical appointment. You might experience:
    • Factual memories (memories of events that really happened) such as remembering being told bad news.
    • Memories of hallucinated events – hallucinations are very common in people who are severely ill. You might have seen or heard things that you later found out were not really there.
    • Memories of things that you thought when you were ill. For example, patients in intensive care sometimes think they are being persecuted by medical staff who are actually trying to help them.
    • You may experience a mixture of these symptoms.
  • Avoidance of thoughts, feelings, and reminders of your experience. This might include avoidance of people or places, avoidance of reminders, or trying to avoid or suppress your own thoughts or memories. After a traumatic medical experience you might find medical appointments anxiety-provoking, you might try to avoid TV programs about hospitals, or you might even try to avoid looking at or touching parts of your own body that remind you of what happened.
  • Negative changes in your thoughts or mood. For example, some people have frighten- ing hallucinations while they are ill and worry (incorrectly) later on that they might have a serious mental health problem. Others think they are being mistreated in hospital and these beliefs persist after they leave. After a critical illness many people become a lot more worried about getting ill again. Any of these beliefs can make you feel very anxious or depressed.
  • Feeling ‘on guard’ and ‘on edge’. After a trauma it is common to feel anxious or unable to relax. Some people feel more angry or irritable than before. You might have difficulty with your sleep.

How common is PTSD?

It’s normal to experience some symptoms of PTSD after a trauma. Fortunately, for most people these start to get better in the first month. However, depending on the type of trauma 20-30% of people experience symptoms of PTSD that persist. After treatment in intensive care PTSD is experienced by about 1 in every 5 people.

Figure: After treatment in intensive care, PTSD is experienced by about 1 in every 5 people.

As a result of the current global health crisis, many more people than usual are having serious medical experiences. These include admissions to hospital with breathing difficulties, or transfers to critical care (intensive care) units. A significant proportion of these people will go on to develop symptoms of post-traumatic stress disorder (PTSD).

Admission to hospital

Being critically ill is a physically and emotionally overwhelming experience. Naturally, given the scale of what you have been through, it takes time to recover. How you feel, and how long it takes to recover will depend on what type of illness you had, and how long you were unwell. Some very common experiences after discharge from an intensive care unit (ICU) include:

  • Feeling physically weak. Even doing simple things like getting dressed, moving about, or getting out of the bath can take enormous effort.
  • Fatigue. You might feel exhausted and may feel the need to sleep more than normal.
  • Numbness or other changes in how parts of your body feel.
  • Feelings of breathlessness upon mild exertion, like walking up the stairs.
  • Changes in your appearance which might include changes in how your hair, skin, or fingernails look and feel. You might also be recovering from surgical scars.
  • Hoarse voice, especially if you had a breathing tube.
  • Effects on how you feel mentally. You may feel more forgetful, or struggle to read more than a few sentences. It’s natural to feel like you have a ‘foggy’ brain and struggle to concentrate on anything or get anything done.
  • Emotional changes including feeling irritable, depressed, or anxious. You might not feel like going out, or when you do you might feel overwhelmed in crowded places.

Overwhelming worries such as concern about getting ill again, or worrying you will never recover. You may worry about what some of your critical care experiences mean for your mental health: for example, worrying about hallucinations that you may have had when in hospital.

Recovery can take longer than you might expect. Symptoms such as muscle weakness are still very common even six months after discharge from the hospital.

Researchers interviewed people who had been discharged from ICU. These are some of the things they said:

  • “I get panicky if I go out alone in case I am taken ill”
  • “I get very angry with my family. They keep fussing when I try to do things for myself ”
  • “I feel very angry with myself for not being back to normal by now”
  • “I’ve tried to help by doing the washing up but I keep dropping the crockery”
  • “When I first went home I climbed the stairs on my hands and knees and came down on my bottom”

Does any of this sound familiar? These are all normal experiences to have after needing critical care in hospital. The body and mind take time to heal, and it is important to be patient with yourself while you recover.

How does intensive care cause PTSD?

By definition, if you are admitted into an intensive care unit then you are at your most poorly. You require round-the-clock monitoring and invasive medical procedures to provide life support. Patients in intensive care are often connected to a wide range of machines: common ones include heart monitors and artificial ventilators (when patients can’t breathe for themselves). Many life support machines beep and make loud noises to alert staff to changes in the patient’s condition. Patients are also likely to be fitted with several tubes either putting fluid and nutrients in, or taking other fluids out. Most ICU patients are sedated, but not always completely unconscious. It is common for patients in ICU to have their arms or legs restrained in order to prevent them from removing tubes or equipment. All of these interventions are to help you survive the immediate crisis, however they can also be frightening.

Figure: Treatment in intensive care is invasive, and involves a lot of specialist equipment.

There are many of aspects of critical care medicine that can contribute to the later development of PTSD.

Do any of these remind you of your hospital experience? The main priority of the intensive care unit was to help you survive, and so everything that was done to you was done with that intention. However, you might be living with the unintended aftermath of post-traumatic stress symptoms.

Psychologists working with people who have been admitted to intensive care know that it is common for them to have unpleasant – and often unusual – experiences during their hospital admission. The following case reports are anonymized, but they describe experiences commonly reported by intensive care patients.

 

 

Delirium

Many patients who suffer a critical illness and require intensive care suffer from delirium. Delirium is a severe state of confusion.

 

Figure: Delirium is the medical name for a severe state of confusion.

If you experienced delirium during your hospital admission you might be worried about what it means. Some people worry that it is a sign that they are mentally ill or going crazy. Don’t worry – it doesn’t mean either of these things. Delirium is actually very common in medical settings. Between four and nine out of every ten patients in intensive care become delirious. This rises to eight out of ten patients who needed the support of breathing machines [3].

Doctors think that delirium is caused by changes in the way that the brain works. This can happen when:

  • Your brain receives less oxygen.
  • There are changes in how your brain uses oxygen, and when there are chemical changesin your brain.
  • You are on certain medications, or under anaesthetic or sedation.
  • You have a severe infection, or are suffering from certain medical illnesses.
  • You are in severe pain.
  • You have reduced eyesight or hearing.
  • You are of older age.

If you had experiences of seeing or believing unusual things when you were in ICU the chances are high that it was the result of delirium. Fortunately, delirium is temporary and passes once the underlying cause is treated. If you are continuing to have experiences like the ones you had in hospital it is likely that these are PTSD flashbacks of the hallucina- tions that you had in hospital, and not a sign that the delirium is continuing.

Recovering from PTSD

Although PTSD is extremely distressing to suffer from, it is fortunately a very treatable condition. The first step in overcoming PTSD is to understand how it gets ‘stuck’ and why it doesn’t get better by itself. Psychologists have developed a very helpful way of thinking about PTSD which helps to put all the pieces together. So how does PTSD develop, and what keeps it going?

1. Your threat system is active and has stayed active

Your brain & body contains a ‘threat system’ or ‘fight or flight response‘ whose purpose is to help you to stay alive. One part of your brain – the amygdala – has the job of identifying dangers. It is triggered by anything that could threaten your life – and sets off an ‘alarm’ in your body to help you to get ready to respond. The motto of this threat system is ‘better safe than sorry’ – it would rather set off a false alarm nine times than miss one real danger.

Figure: Your threat system recognizes danger and prepares your body to respond. After a traumatic experience your threat system might be on high alert.

While your threat system is active you might find it difficult to sleep or relax, might feel ‘jumpy’, or alert to other dangers around you. After a traumatic experience, like admission to ICU, it is normal for your threat system to stay on high alert for some time afterward. For people who have PTSD it seems to take even longer to return to normal.

Your threat system can be triggered by imagined dangers as well as real ones. You might find that even thinking about what happened to you can trigger feelings of anxiety and tension.

2. PTSD memories are different

PTSD memories are different from normal memories. Some of the qualities that can make them particularly distressing are:

  • Immediacy. When PTSD memories ‘play’ in your mind it can feel as though the event is happening right now in the present moment. You might even lose track of where you are.
  • Vivid. PTSD memories are often so vivid that they seem real. You might hear sounds or smell smells that your experienced during your traumatic event with such clarity that you feel you are back there again.
  • Involuntary. PTSD memories feel less ‘under control’. They can pop into your mind unexpectedly, and can be difficult to suppress.
  • Fragmented. You might only remember parts of what happened, or your memory might keep replaying the worst parts.

It is not your fault if you experience memories like these. Your memories are this way because of your neurobiology – the way that your brain is designed. Psychologists think that trauma memories like these are stored differently by the brain. An important task during trauma therapy is to ‘process’ memories so that they are not so distressing.

3: PTSD is all about meaning-making

Cognitive Behavioral Therapy (CBT) works with our thoughts and beliefs, because it un- derstands that they are what drives our feelings. What makes PTSD so distressing, and part of what keeps it going, are the ways that you have made sense of what has happened to you. Sometimes our interpretations are completely accurate, but other times they may be unhelpfully off-the-mark.

While she was in intensive care Tanya was very ill and had to be restrained to stop her from pulling out her tubes. Her delirium meant that she hallucinated that the nurses were ninjas. The meaning that Tanya’s (delirious) brain made of this experience at the time was that she was being held captive and persecuted – and she felt frightened as a result. After she was discharged from hospital Tanya had nightmares and flashbacks which replayed this trauma. These felt so real and her interpretation of these experiences was that she was going mad – which made her feel even more frightened.

EventInterpretationFeeling
Being in ICU and realizing that I couldn’t moveI’m being held captiveFrightened
Nightmares of ninja nursesI’m going madFrightened

Table: How Tanya interpreted some of her experiences during and after her time in ICU.

Unhelpful interpretations of events can keep you ‘stuck’. Psychological treatments for PTSD involve updating any unhelpful meanings of your trauma.

Unhelpful MeaningsHelpful Meanings
I’m being held captive by masked ninjas.I was being cared for in hospital by masked nurses.
I’m going to die, my life is in danger.My life was in danger, but I’m safe and recovering now.
Nobody is listening to me, nobody cares about me.I couldn’t speak because I had a tube in my wind- pipe. I was being cared for then, and people care about me now.
I’m going mad, it’s not normal to have experiences like these.I was delirious in ICU and I experienced hallucinations. This is very common and it doesn’t mean that I am going mad.
Maybe I’m not safe to be looking after my children now.I’m not going mad, I am recovering from PTSD and am capable of looking after my children safely.

Table: Some of Tanya’s unhelpful meanings, and the more helpful perspectives that she discovered.

4: Sometimes the things we do to cope are counter-productive

All of us try our best to cope with how we are feeling. One problem in PTSD is that the things we do to cope sometimes turn out to be unhelpful. Do you use any of the coping strategies below?

Coping StrategyIntended EffectUnintended Effect
Avoiding reminders.Avoid distress. Feel better.Memory of the trauma remains ‘unprocessed’.
Life is restricted by anxiety.
Not talking about it.Avoid distress.
Don’t want people to think I’m mad.
Memory of the trauma remains ‘unprocessed’.
Don’t get reassurance from loved ones or professionals.
I keep thinking I’m mad.
Using alcohol or drugs.Sleep better.
Control how I am feeling.
Sleep gets worse
Don’t feel better. Addiction / dependence
Avoid thinking about what hap- pened, keep suppressing it.Avoid feeling distressed.Suppressing things leads them to ‘bounce back’ and experience them more strongly.
Checking / scanning for symptoms.Detect symptoms before they become serious.Keep having ‘false alarms’ and noticing unimportant symptoms.

Table: Coping strategies have intended and unintended consequences.

5. Putting it all together

If we put all of these steps together you start to understand why PTSD doesn’t get better by itself. This is the ‘vicious cycle’ that Tanya’s therapist drew with her. Tanya found it helpful because it made sense of what was going on for her. And it gave them a plan for what they needed to do in treatment.

 

Psychological treatments for PTSD

There are excellent evidence-based psychological treatments for PTSD. Some of the most well-researched are:

  • Cognitive Behavioral Therapies (CBT) including Cognitive Therapy for PTSD (CT-PTSD) and Cognitive Processing Therapy (CPT)
  • Eye Movement Desensitization and Reprocessing (EMDR)
    Although these treatments might differ in some of their specifics, what they all involve is:
  • Some exposure to your trauma memory. PTSD memories can be a bit jumbled (intensive care memories even more so). Talking about and writing about what happened to you can help to ‘process’ these memories and make them less intrusive and distressing
  • Meaning-making. Making sense of what happened to you, understanding the sense that you made of these experiences at the time, and helping you to re-evaluate these ideas in the light of what you know now.
  • Learning different coping strategies. Overcoming avoidance, learning healthier ways of coping, and reclaiming your life.

Special therapy tasks if you have been in intensive care

Some components of treatment that can be particularly helpful for people who have ex- perienced ICU include:

  • Learning about the ways that physical illness, delirium, and things about the medical environment that can affect you psychologically.
  • Leaning about hallucinations and flashbacks, and why they happen. It is important that you understand that just because you experienced hallucinations during ICU, or flashbacks afterwards, does not mean that you are going mad or are in any danger.
  • Reading medical records to find out what happened to you day-by-day (to fill in gaps in your memory). If your trauma went on for a long time psychologists will often help you to make a ‘timeline’ to piece together your story.
  • Site visits if they are possible. Revisiting the ICU (or looking at pictures or videos) can help to ‘process’ your trauma memories and to correct any unhelpful beliefs. Many people find it helpful to meet the staff who cared for them.
  • Understanding that you might have strong ‘body memories’ of what happened to you. These might be experienced as flashbacks, or you might re-experience them during trauma treatment.
  • Accepting that there might be gaps in your memory because you were not conscious for the entire time.

What should I do if I think I might have PTSD after a critical illness?

Step 1: Screening

If you think that you might have PTSD then a good first step is to complete this short questionnaire. You can’t diagnose yourself with PTSD, but it can indicate whether you might benefit from a full assessment by a mental health professional.

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example being admitted to a critical care (intensive care) unit. Have you ever experienced this kind of event? YES / NO

If yes, please answer the questions below.

In the past month, have you:

  1. Had nightmares about the event(s) or thought about the event(s) when you did not want to?
    YES / NO
  2. Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?
    YES / NO
  3. Been constantly on guard, watchful, or easily startled?
    YES / NO
  4. Felt numb or detached from people, activities, or your surroundings?
    YES / NO
  5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
    YES / NO

If you answered YES to three or more of these questions then you might be suffering from post- traumatic stress disorder. You might wish to contact a mental health specialist for a full assessment.

Step 2: Speak to a professional

If you think you are experiencing symptoms of PTSD you might like to seek help from a professional. You should contact your family doctor, or a psychological therapist.

To find a therapist trained in CBT: Contact Mandy on the contact page of the website OR:

  • USA:http://www.abct.org
  • UK:https://www.babcp.com
  • Europe:https://eabct.eu/about-eabct/member-associations/
  • Australia:https://www.aacbt.org.au
  • Canada:https://cacbt.ca/en/

To find a therapist trained in EMDR

  • USA:https://emdria.org
  • UK:https://emdrassociation.org.uk
  • Europe:https://emdr-europe.org/associations/european-national-associations/
  • Australia:https://emdraa.org
  • Canada:https://emdrcanada.org

Source: PsychologyTools