Posttraumatic stress disorder following medical illness and treatment
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.
Section snippets
Cardiac medicine
Fourteen studies were identified, eight covering MI and six cardiac surgery.
Vascular medicine
This section includes studies on haemorrhages and stroke, both of which occur suddenly and unexpectedly, are potentially life threatening, and as such, appear to meet the stressor criterion for PTSD.
Obstetrics and gynaecology
Studies of PTSD following childbirth, miscarriage, abortion, and gynaecological procedures were found. With the exception of miscarriage, one would not generally consider any of these events to be sudden, unexpected, or life threatening, however, some of the studies (e.g., Ballard, Stanley, & Brockington, 1995) give some insight into how PTSD may still arise.
ICU treatment
Stoddard and Todres (2001) note that there are a lot of potentially traumatic elements of ICU including pain, medical procedures (for example, resuscitation), witnessing another patient dying, and the circumstances of the illness or injury that occurred before admission. Schelling et al. (1998) considered that episodes of respiratory distress, anxiety, pain, or nightmares while in ICU could be enough to cause PTSD. These experiences were reported by 78.7% of their ICU patients and were
Human immunodeficiency virus
HIV infection is a chronic disease, which is clearly life threatening. Once again, it is difficult to pinpoint one event, which could cause PTSD, however, two studies that have attempted this have focussed on the point of diagnosis. There has been little research in this area, and the four studies that have been published have looked at different aspects of HIV and PTSD. The case study by Howsepian (1998) describes chronic PTSD in a man who had a needle-stick injury contaminated with suspected
Awareness during general anaesthesia
Several case studies have supported evidence of PTSD occurring after awareness during general anaesthesia. Cundy (1995) and Macleod and Maycock (1992) describe three cases each, and a larger study by Schwender et al. (1998) found a prevalence rate of 6.6%.
Miscellaneous
Other procedures that have resulted in individual cases of PTSD include heart catheterisation, craniotomy, and haemorrhage following tonsillectomy (Shalev, Schreiber, & Galai, 1993), and the experience of Guillain–Barré Syndrome (Chemtob & Herriott, 1994). In all of these case studies, a diagnosis of PTSD was reached using clinical judgement that DSM-III-R criteria were satisfied. Finally, Barak, Achiron, Rotstein, Elizur, and Noy (1998) studied a group of 16 men who were exposed to asbestos in
Discussion
The studies included in this review are very diverse. Different sample sizes, methods of recruitment, medical populations, research designs, and PTSD measures all conspire to make it difficult to draw many consistent conclusions. The difficulties that these issues pose are discussed first, in a Methodological issues section, as a note of caution before the findings of the literature are summarized.
Prevalence rates of PTSD
Taking into account the methodological difficulties, it is still of interest to make a brief comparison of the PTSD prevalence rates across the literature reviewed. As one might expect, some of the lowest prevalence rates were found in childbirth (1.7–5.6%), and some of the highest in patients who had been in a life-threatening situation in ICU (14–59%). High prevalence rates were also found in HIV patients (30–35%), who may be at higher risk because of previous trauma, the diagnosis of a
Conclusions
Despite the methodological difficulties apparent in the studies reviewed, it seems safe to conclude that PTSD can arise in a minority of individuals following a wide range of illnesses or medical interventions. However, it is possible that, in some cases, medical trauma may simply act as a trigger in individuals with a predisposition to PTSD development. PTSD may have the potential to increase morbidity, mortality, and noncompliance in patients resulting in increased or wasted healthcare
Acknowledgements
We acknowledge the kind assistance of the administration team at the Clinical Psychology Department, Nottinghamshire Healthcare NHS Trust Headquarters, Tracey Hepburn, and the Librarians at Kings Mill Centre for Healthcare Services for their support in writing this paper.
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