Monday, May 1, 2017

Looking Deep for PICS:
Post Intensive Care Syndrome
by Mikela Ronning-Philip MA, OSP, CRPO

Every year, almost a quarter of a million adult Canadians with life-threatening illnesses are admitted into an intensive care unit (ICU).  Last year I was one of them.  ICU staff are dedicated and to be thanked profoundly.  Because of medical procedures, ICU patients are probably the most vulnerable. Powerful sedatives are administered to numb pain and to keep the patient still, preventing the accidental removal of life-saving devices. Immobilized, intubated with few lucid moments, they are disabled and unable to speak or respond normally during crucial life-saving periods. These experiences can lead to overwhelming abandonment issues which are hard to overcome, as do other side effects and studies suggest that on discharge, 74% of patients suffer cognitive impairment.

ICU survivors recall this coma-like experience where they are unable to speak or move as absolute helplessness, despair and terror. Of all the symptoms, the commonly reported hallucinations remain the most frightening and haunting - often left unresolved or disclosed because they are considered shameful with unbelievable images and story lines experienced when there is no other reality.

Unfortunately, this is one of the residual symptoms of ICU that calls for physiological and psychological aid, Healing Circles, grief counselling, mentors and interactions with various social services.  Although encountered in the mind, these visuals are laid down in the brain as a singular reality, scene by scene.   When no other consciousness is available, images that can be bizarre and truly terrifying, leave disturbing backwashes and lingering violent flashbacks.

My work as a registered psychotherapist in private practice for the past 30 years includes wartime exposure to post-traumatic stress disorder (PTSD) before it became a syndrome.  Training and working with clients enabled an understanding of the impact of PTSD from my ICU experience as well.  Background practices and life experiences helped to address Post Hospital challenges.    A mindful awareness of the depth of the spiritual and personal challenges faced in the dark silence of ICU and hallucinations is needed for the psychological and spiritual well-being and the recovery from these traumas. Symptoms of energy deprivation and interruption of healthy stress responses flatten emotions and create emotional problems.

A colleague, initially researched Post Intensive Care Syndrome (PICS). The information confirmed and validated the experience. An environment where there is no memory can be debilitating, causing identity loss in our inner spiritual world. The Society of Critical Care Medicine in the US quotes research that demonstrates the catastrophic nature of PICS and hallucinations, as does medical research conducted in Europe. Hallucinations replace cognition for periods of immobility in ICU and returning to consciousness, there are records of frightening scenes experienced as reality, that replay again and again. Even if these horror-movie images are recounted, they may be dismissed or disbelieved,  leaving the PICS sufferer silenced and denied a hearing.

PICS shares some similarities with PTSD.  Both are the result of trauma leading to circadian sleep disorders, difficulty focusing and often an inability to return to work.  But there is a significant difference: while PTSD is generally a shared experience - the precipitating event is generally witnessed together with others in a critical emergency or war zone.  Those who have been abused, assaulted or raped, however, have an aggressor as the object on which to vent impacted feelings of recognition of the event and anger from the trauma.  It is a psychological process required for a health recovery and healing grief work. In a coma, there is no object on which to project the frozen or aggressive feelings of desperate helplessness and anger.

The lingering effects for survivors leads to PICS and unrecognized symptoms are known to last for years.  These include energy loss, depression and disinterest in life itself. Grieving is impossible in inactivity and isolation.  One is isolated in a coma - no body or mind sensing consciously - not even self is present.  Death is close.  The pain of these events demands resolution.

Patients Post Hospital question their ability to recover a meaningful life after ICU and intubation. During recovery there is a period of de-personalization. They are bewildered and isolated on familiar ground, with complex physical, emotional and intellectual needs. What is devastatingly missing is Care of the Soul, grief and psychotherapy, all the healing arts are needed to relieve the pressure of burdensome grief, compacted horrors of hallucinations, memory loss, chronic bewilderment and insecurity.

Awareness of PICS is gradually expanding in Canadian hospitals, but patients and their caregivers are not sufficiently supported prior to discharge. There are few adequate resources in communities for their return home. Post Hospital support requires a great diversity of multi-faceted support that includes first and foremost physical, then mental and cognitive functioning, developed gradually during recovery. Since PICS is generally an overlooked condition, long-reaching symptoms can be misdiagnosed as delirium or  early-onset of Alzheimer’s.  Post Hospital, Individualized programmes are required in an separate environment of understanding and validation, away from the hospital.

ICU survivors of intensive care and intubation return home, worried about an inability to recover a meaningful life. An important support for those with PICS would be programmes fuelled by therapists, social and community providers and mental health care.  Humane and professional grief work is imperative. As Francis Weller writes in his book, “Entering the Healing Ground”, after physical issues are improved, grief work is a primary ingredient in the resolution of trauma and depression, allowing for release, acceptance, empathy and increased understanding of self and life.

Since PICS symptoms do not emerge immediately, treatment is best implemented two to three months Post Hospital. There needs to be some acceptance of life changes and willingness to be helped. A safe venue and supportive help from someone they trust will help to assert health.  Using individually-selected preferences, programmes to consider might include EMDR (Eye Movement Desensitization and Reprocessing), CBT and Reiki.  Creative therapy such as music, dance, art, poetry, journaling, writing and song can be incorporated to help with healing.

Being immobile in ICU for a length of time affects the body significantly, specifically
resulting in muscle weakness. This makes daily living activities difficult, so incorporating physical therapy, massage and regular exercise is fundamental to regenerating energy and to aid recovery.

Data indicates that with increasing advances in medicine, the number of patients who survive ICU is growing and PICS clinics have the potential to become an important part of Post Hospital care. There are many opportunities for those with PICS to recover emotionally. Integral to their condition is the phenomena of isolation that continues beyond the ICU experience. A key element is the recognition and validation of their hallucinations, in particular acknowledging the need for a witness to their experience and that they are not alone. Research and case histories have the symptoms remain over months or years.

The experience of ICU patients is complicated and difficult to absorb and process, especially as there is insufficient information available. This is a crucial factor because critical illness is a crisis that extends beyond the patient.  Education is needed for family members under the strain of caring and accommodating for the long-term mental and physical effects of ICU. Studies find that 30% of carers surveyed experienced mental health problems, anxiety and depression. Those who observe hospital procedures can also be vulnerable to these issues.

There are no medical pamphlets about PICS with information for the community anywhere to be seen. This is vitally needed to guide ICU survivors to a healthy recovery.

o   Mikela Ronning-Philip MA, OSP, CRPO is an accredited psychotherapist with over thirty years’ experience as a clinician. Her private practice, based in Dundas, Ontario, specializes in PTSD counseling and expressive arts therapy. 

Resources and Related Readings:   
- SCCM (Society of Critical Care Medicine)
-                 Khanna, A MD, FCCP; Peters, NA, PharmD, BCPS, BCCCP: Kim, D, MD, FRCSC, FACS, FCCP. (2016). Delirium: A Multidisciplinary Approach to PICS, SCCM (Society of Critical Care Medicine). 
-                 Hoffman, LA, RN, PhD, University of Pittsburgh: Guttendorf J, DNP, RN, CRNP, ACNP-BC, CCRN, University of Pittsburgh School of Nursing. (2015) Post Intensive Care Syndrome: Risk Factors and Prevention Strategies, AHC Media: Continuing Medical Education Publishing.
- MacLullich, AMJ: Ferguson, KJ: Miller, T: EJA de Rooij, S:  Cunningham, C. (2008), Unravelling the Pathophysiology of delirium: a focus on the role of aberrant stress responses. Journal of Psychosomatic Research.
- Boodman, SG (2016). A Surprising Side Effect of Hospital Stays. Next Avenue.
- Weller F. (2009). Entering the Healing Ground - Grief, Ritual and the Soul of the World. Santa Rosa, California: Wisdom Press.
- Herman, JL MD. (1992) Trauma and Recovery. New York, NY: Basic Books.
- Frankl, VE. (1946, 2006). Man’s Search for Meaning. Boston, MA: Beacon Press.



  1. Mikela
    Thank you for your enlightening article on Post Intensive Care Syndrome. I hope you will continue to spread the word about this condition. Having watched my mother in ICU expressing horror through gestures, I could have been more help to her if understood her experience. Learning that these hallucinations create deep memories at a vulnerable time, I support your call for greater awareness and development of treatment strategies. In my work as a gerontologist, I have been familiar with the risks of hospital-based delirium, but not at all with lingering effects of PICS. Yes, we need to have informative booklets for families in hospital and for patients on discharge and follow-up.
    E Ryan

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