‘Intensive Care PTSD’

this was the banner  headline on the BBC News today, January 13th 2021. It followed the announcement of a study by Prof Neil Greenberg, which revealed that staff had been ‘traumatised’ by the first wave of the pandemic. This in turn led for Paul Farmer Chief executive of MIND to call for ‘the right support at the right time’ on BBC radio 4 today. The Government has promised an extra £15 million so that extra support can be given.  But what sort of support?

In the press release accompanying publication of his study in the journal Occupational Medicine, Professor Greenberg notes ‘Further work is needed to better understand the real level of clinical need amongst ICU staff as self-report questionnaires can overestimate the rate of clinically relevant mental health symptoms’. His study was based on a web survey of ICU staff about half of whom responded, about half whom met the ‘threshold’ for PTSD, severe anxiety or problem drinking. There is a clear need to go beyond self-report measures.

I am currently writing a book ‘Personalising Trauma Treatment: reframing and reimagining’ to be published by Routledge. In this work I suggest that the initial conversation with trauma victims   should include ‘Gateway Diagnostic Interview Questions’ , with regard to Covid an appropriate subset would be:

Depression (evidence that at least one of the answers to the following questions is in the affirmative)

1. During the past month have you often been bothered by feeling, depressed or hopeless?

2. During the past month have you often been bothered by little interest or pleasure in doing things?

 

Panic Disorder

1. Do you have unexpected panic attacks, a sudden rush of intense fear or anxiety?

2. Do you avoid situations in which the panic attacks might occur?

 

Post-traumatic Stress Disorder

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you

1. Have had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the events may have caused?

Evidence that at least three of the answers to the symptom questions above are in the affirmative

Alcohol Dependence (evidence is that the response to the first three of the following questions is in the affirmative)

1. Have you felt you should cut down on your alcohol/drug?

2. Have people got annoyed with you about your drinking/drug taking?

3. Have you felt guilty about your drinking/drug use?

4. Do you drink/use drugs before midday?

Asking GDIQ questions encourages the person to furnish possible examples of the impact of the symptom on their life, so that they feel listened to. Reference can then be made to other  diagnostic symptoms for the particular disorder, to tease out whether there are sufficient impairing symptoms for that disorder, to merit that diagnostic label.  Use of GDIQ’s is part of a conversation, it is not a rapid fire interrogation or checklist. As a supplement to the GDIQ people can be asked whether this is something that they want help with, as they might not want to verbalise that they want to sort the problem out themselves, but are too polite to express this. 

The NICE recommended treatments are diagnosis specific, thus there is a recommendation of trauma focussed CBT for PTSD. But those traumatised by Covid are likely to find it toxic to be pushed to describe in graphic detail the horrors encountered. In my book I argue that this is unnecessary, rather that what is of key importance is to assess what the person takes their memory of being in ICU means about today. It is not the event that causes PTSD but the mental time travel to the worse period and the significance given to it  for today. This approach  is much less challenging for whoever is  accompanying the effected medical staff and family/friends who have seen horrors.

 

Dr Mike Scott