Posttraumatic stress disorder following medical illness and treatment

Abstract

Studies describing posttraumatic stress disorder (PTSD) as a result of physical illness and its treatment were reviewed. PTSD was described in studies investigating myocardial infarction (MI), cardiac surgery, haemorrhage and stroke, childbirth, miscarriage, abortion and gynaecological procedures, intensive care treatment, human immunodeficiency virus (HIV) infection, awareness under anaesthesia, and in a group of miscellaneous conditions. Cancer medicine was not included as it had been the subject of a recent review in this journal. Studies were reviewed in terms of the prevalence rates for PTSD, intrusive and avoidance symptoms, predictive and associated factors and the consequences of PTSD on healthcare utilization and outcome. There was considerable variability both in the study methodology and design and in the results. The highest prevalence rates were identified in patients treated in intensive care units (ICUs) and those with HIV infection. Irrespective of the physical illness, posttraumatic symptomatology is more common than PTSD caseness. Existing characteristics of the patient may well predispose individuals to the development of PTSD as do other factors such as poor social support and negative interactions with healthcare staff. Generally, the severity of the illness itself is not predictive of PTSD. Issues relating to sampling, attrition, diagnosis, the course of symptoms, aetiological pathways, and the consequences of the disorder are discussed. The presence of PTSD most probably influences the patient's use of healthcare resources and may affect their clinical outcome.

Introduction

Posttraumatic stress disorder (PTSD) is a serious mental condition categorised by an individual experiencing a traumatic event that involved actual or threatened death or serious injury. The event must elicit a reaction of intense fear, helplessness or horror, and subsequently, symptoms of intrusions/reliving, avoidance/numbing, and arousal, sufficient to meet predefined criteria. Typically, the type of traumatic events that result in PTSD are exposure to combat, criminal or sexual assault, natural disaster, or manmade accident. These events occur in the person's external environment and result in exposure to extreme external threat to the person's physical integrity. In DSM-IV, “being diagnosed with a life threatening illness” was added as an example of traumatic stress (American Psychiatric Association, 1995). There have been reports appearing in the literature of PTSD occurring after the onset, diagnosis, or treatment of physical illness. The question arises as to whether the experience of severe physical illness, essentially an event internal to the person, satisfies the traumatic stress (Category A) criterion for PTSD, and if so, whether the available evidence indicates that PTSD occurs in response to such illnesses or their consequences.

The onset of some physical illnesses, for example, myocardial infarction (MI), stroke, or haemorrhage may be sudden, unexpected, and immediately life threatening and as such appear to be comparable to the general PTSD literature. In other cases, external events such as being given a life-threatening diagnosis of heart failure or human immunodeficiency virus (HIV) may be perceived as traumatic. PTSD may also arise following prolonged or unpleasant medical or surgical procedures and treatment. Psychological reactions may include high levels of fear, realistic anxiety about the future, and feelings of helplessness and loss of control as a result. The potential for psychological reaction to these events would appear similar to the potential in other traumatic incidents.

In this paper, we will review the occurrence of PTSD in adults with medical conditions. Studies were identified through an initial electronic search of relevant databases from Medline and Psych-Info from 1985 to date, followed by hand searches through abstracts and revealed references. We have identified reports in the following areas: cardiovascular medicine; vascular medicine; obstetrics and gynaecology; intensive care medicine; HIV; awareness during general anaesthesia and other conditions. We have chosen not to review PTSD in patients suffering from cancer, as this topic has been covered in depth recently in a review published in this journal (Kangas, Henry, & Bryant, 2002). The studies are summarized in Table 1 in terms of design, sample (including attrition rates if given), assessments, the timing of the PTSD assessment, the prevalence rates of PTSD, intrusive and avoidance symptoms, and main findings.