Handbook of Consultation-Liaison Psychiatry

16. The Acutely Ill Patient in the Intensive Care Unit Setting

Hoyle Leigh

CONTENTS

16.1 Vignettes

16.2 Delirium and Psychosis in the Intensive Care Unit

16.3 Stress, and the Role of Psychological Defense Mechanisms, Coping Styles, and Personality

16.4 Communication with Patients Who Are Unable to Speak

16.1 Vignettes

1. A 24-year-old woman with subarachnoid hemorrhage due to rupture of a berry aneurysm was admitted to the intensive care unit (ICU). A psychiatric consultation was requested as the patient seemed to be depressed. The consultant found that the patient felt sad about not being able to see her 2-year-old son, as children were not allowed in the ICU. She was afraid that she might die without being able to say goodbye to him. The consultant was able to obtain special permission from the administration for her husband to bring the child once a day. She recovered fully from her hemorrhage.

2. A 17-year-old girl was admitted to the ICU after ingestion of 50 acetaminophen tablets in a suicide attempt. The patient's liver enzymes were elevated, and she was being treated with acetylcysteine. A psychiatric consultation was requested for the suicide attempt. The consultant found that the patient had symptoms of increasing depression over the past 3 months, with serious suicidal plans and termination behavior, such as giving her iPod to her closest friend and writing a goodbye letter to her parents and boyfriend. She was sorry that she did not die, and saw no point in continuing to live. The consultant decided to transfer her to a psychiatric inpatient facility when her medical condition stabilized. The consultant ruled out an antidepressant at present because of the patient's compromised liver condition, but antidepressant therapy would be started upon transfer to a psychiatric hospital. Also see vignette 1 in Chapter S.

16.2 Delirium and Psychosis in the Intensive Care Unit

Acute illness is usually accompanied by acute stress. Altered states of consciousness, particularly delirium, are common in patients with acute illness, especially in the intensive care settings. Acute stress often induces dissociation in predisposed individuals, and medications used to treat the medical symptoms, such as narcotic pain medications and steroids, can contribute to confusion and delirium. The confusing sensory overload and deprivation common in ICU settings where night and day may be indistinguishable also contribute to delirium. Delirium with psychotic features such as visual hallucinations, paranoid delusions, and agitation has been called "ICU psychosis."

Facilitating acute medical treatment is the primary goal of psychiatric intervention in the acutely medically ill patient. While treatment of delirium, particularly with psychotic symptoms, is desirable, the patient may be in need of the medications, such as steroids, for maintaining life. Under such acute conditions, the consultant may recommend further sedation, even to the point of keeping the patient asleep during the acute phase of treatment, or antipsychotic drugs to control the psychotic symptoms while continuing the medical drug. On the other hand, medications that require time to work, such as antidepressants, and drugs that may further complicate medical conditions, such as liver function or cardiac function (e.g., thioridazine or ziprasidone that may prolong the QTc interval), may be best withheld during the intensive care stay. With ICU psychosis, transfer out of the ICU is indicated as soon as feasible.

16.3 Stress, and the Role of Psychological Defense Mechanisms, Coping Styles, and Personality

Acute medical illness, especially severe enough to require ICU admission, is a stressful event. In addition to the acute symptoms that may be painful and frightening, patients have the added stress of uncertainty about whether or not they will survive or be disabled and about how long they will be hospitalized, as well as concerns about family, job, pets, and so on, as in the second vignette at the start of the chapter. There should be routine inquiry about the particular concerns each patient has regarding acute hospitalization. In an acute setting, certain accommodations to alleviate the patient's stress may be necessary, such as allowing a child to visit (as in vignette 1). The medical staff should always maintain a channel of communication with the patient and family, and discuss any new developments in the diagnostic process and treatment plan and allow them to ask questions. An important aspect of stress management is information and strategic planning that brings a sense of mastery to an uncertain situation.

The physical setting of the ICU may have a unique meaning to the patient that can only be understood by communicating with the patient (as in vignette 1 in Chapter 8). A common reason for ICU psychiatric consultation is a serious suicide attempt, which may be the result of a serious untreated depressive syndrome (as in vignette 2). Even when a severe depressive syndrome is present, the consultant should exercise caution in considering the use of antidepressants as the patient's metabolic function may be altered (e.g., liver damage with acetaminophen overdose). It is generally judicious to wait until the patient is transferred out of the acute ICU before starting antidepressant drugs.

The acute stress associated with an acute medical illness naturally recruits the patient's psychological resources, which include defense mechanisms, coping mechanisms, and an exaggeration of the personality traits. Psychological defense mechanisms, such as denial and repression, refer to unconscious, automatic mechanisms the individual uses in the face of anxiety-provoking situations. Coping mechanisms refer to conscious, deliberate ways of dealing with stress, such as getting information about the disease or procedure, or seeking diversion, such as relaxation techniques. Personality style (see Chapter 15) is usually exaggerated in the face of stress.

Denial as a defense mechanism has been shown to be adaptive during the acute phase of myocardial infraction in the CCU (Hackett et al., 1968), but maladaptive in seeking help and during the recovery phase (Levine et al., 1987). During the recovery phase, patients who use denial tend not to undertake the lifestyle modifications necessary to prevent recurrence of the disease. Intellectualization in the form of reading about the disease and discussing it with the health care professionals can be an effective way of reducing anxiety and gaining a sense of mastery.

In general, patients' defense mechanisms should not be challenged during the acute phase of an illness, but rather respected. Frontal challenge of a defense mechanism is likely to result in an uncontrolled anxiety or a rupture in the relationship between the patient and the health care professional. Coping mechanisms should be respected and enhanced, including teaching new coping mechanisms such as relaxation training.

As stress accentuates personality traits, someone who tends to be usually vigilant may appear to be paranoid, someone who is exacting may seem to be obsessive-compulsive, and someone who tends to be expressive may come across as being histrionic. The health care professional should recognize the role of stress in exaggerating such personality traits, and not rush in labeling the patient as having a personality disorder. With relief of the stress and anxiety, their personality will return to baseline.

16.4 Communication with Patients Who Are Unable to Speak

In the ICU and other acute care settings, psychiatric consultation may be requested for patients who are intubated, heavily sedated, or have other difficulties in communicating. In patients who are heavily sedated or delirious, the extent of sedation/delirium/coma should be ascertained, but a definitive consultation should be postponed until the patient's mental status improves. One important consideration about patients who have communication difficulty (including delirium, stupor, and coma) is that they are likely to be able to hear (and mishear) what others say, although they may not be able to respond or ask questions. One should choose one's words carefully, and not say things the one would not wish the patient to hear.

With an intubated patient, or patients with severe dysarthria, communication may be achievable through writing, or pointing to letters on an alphabet board. A signal may be agreed upon at the outset of the interview, such as nodding, raising a finger, or blinking, to indicate yes and no, and the consultant may ask leading questions to obtain basic information, such as, "Are you in pain?" "Are you in a hospital?" "A hotel?" "Are you feeling depressed?"

References

Hackett TP, Cassem NH, Wishnie HA. The coronary-care unit. An appraisal of its psychologic hazards. N Engl J Med 1968;279(25):1365-1370.

Levine J. Warrenburg S, Kerns R, et al. The role of denial in recovery from coronary heart disease. Psychosom Med 1987;49:109-117.

Bibliography

Allan R, Scheidt S. The empirical basis for cardiac psychology. In: Allen R, Scheidt S, eds. Heart and Mind: The Practice of Cardiac Psychology. Washington, DC: American Psychological Association, 1996:63-123.

Douglas C, Druss R. Denial of illness: a reappraisal. Gen Hosp Psychiatry 1987;9:53-57.

Hackett TP, Cassem NH. Psychological management of the myocardial infarction patient. J Human Stress 1975;1(3):25-38.

Leeman CP, Blum J, Lederberg MS. A combined ethics and psychiatric consultation. Gen Hosp Psychiatry 2001;23(2):73 76.



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