Most physicians have had experience in Intensive Care Units as a part of their Medical School and residency training. For them these units are routine, ordinary places, but this was not always the case. The various ICUs were established in the 1960s as technological advances demanded hospital areas of great specialization. For example, the growth of cardiac surgery required the newest techniques of monitoring and treatment. The ICUs were considered the height of scientific advance. But they were places also filled with a sense of awe, and nurses in the units were often too overwhelmed to talk to the patients [1,2]. I recall bringing older physicians to visit the cardiac unit in the early days and watching their faces as they walked into a room filled with bleeping monitors, patients with catheters in every natural orifice, and a few man-made orifices as well. These colleagues, internists, anaesthesiologists and surgeons alike, were astonished and upset. No longer is this true, as ICUs have become an ordinary part of the medical landscape for the physician. For the nurses, the surgical ICU is still fraught with tension .
But what about our patients? To the physician, the ICU is the epitome of scientific treatment, but to the patient it is the height of magic and the new definition of ambivalence. He is in the unit because his life is in danger and he feels safest there. Being in the unit highlights this danger, and so he would like to be out of there as an indication that he is no longer in such danger. The patient, surrounded as he is by equipment he has no way of understanding, feels some of the sense of awe that was originally experienced by the medical attendants. But by now the medical people are more casual and may not understand why the patient feels overwhelmed. Paradoxically, this may cause the patient to suffer more because we do not appreciate his situation.
What are the difficulties the patient faces? First of all, we should recognize that our patients are regressed - that is, although they function on a mature adult level intellectually, very ill patients usually deal emotionally with their plight as if they were young children. This regression is a double-edged sword. On the one hand it allows the patient to adapt more easily to being taken care of in a hospital setting; on the other hand, it makes him more vulnerable to the stresses he faces.
First, let me decry the use of the term 'ICU psychosis'. This is a catchy term, and an easy explanation for some of the psychic upheavals taking place in these units, but it does not explain what is happening. In the early ICU days, I worked in an ICU that took care of cardiac surgery, lung surgery and coronary occlusion cases. Although the patients all shared the same milieu, the cardiac surgery patients were almost all psychotic , while the lung and coronary patients rarely showed any major psychological difficulties. I realized that the stresses were quite specific for the medical situation.
What are some of the features of an ICU that lead to emotional problems? Aside from the regression noted above, the ICU patient is constantly bombarded by stimuli. Rather than being in a state of sensory deprivation, he is in a condition of sensory overload. Unless in a coma, he is constantly aware of being actively treated and monitored. In earlier times, when the pulse monitor was audible - for the benefit of the staff - patients could not sleep, for they monitored their monitor and waited in dread lest it change. In Coronary Care Units, patients will frequently scan the oscilloscope, looking for changes in the ECG, although they obviously cannot understand what they are observing . Windows and television sets in ICUs are helpful, not to overcome the monotony, but rather to create a useful distraction.
The two principal psychiatric problems seen in the surgical ICU are delirium and paranoia.
Delirium is best looked at as a situation of cerebral insufficiency  and is not an unusual postoperative state. It occurs after general anaesthesia in older patients, after heart bypass surgery at any age, or when a medical situation is severe enough to compromise cerebral metabolism. Almost every patient seen following cardiac surgery will show some temporary cognitive difficulty if tested. Furthermore, these patients are very much aware of their deficits. I believe that the agitation so often seen in delirious patients is a manifestation of the anxiety aroused when one finds one's mind not functioning correctly, and not knowing that the condition is reversible. The inebriated person does not worry about his confusion as he knows that tomorrow he will be sober, but delirious patients, especially older ones, do not know that their minds will recover, and understandably, they worry. On the other hand, they are not comfortable revealing this deficit to the doctor. After cardiac surgery, I would ask patients whether their minds were working right. Their usual response was to assure me that they had no mental difficulties. I would then say, 'That's strange, since everyone after this surgery has trouble thinking straight for a short while. It always comes back to normal'. The patients' response to this was, 'I certainly hope so!'
An example of delirium-anxiety was a 63-year-old man who had a coronary bypass and when seen the next day was confused and highly agitated. I reassured him about his confusion, telling him that it would pass soon. However he was agitated enough to make me worry about his behaviour and so I asked the nurse to give him a milligram of haldoperidol. When I returned in 15 minutes, he was a different person - calm, relaxed, and smiling. I was struck by how fast the medication had worked, when the nurse walked in with a syringe with the drug she had not yet given.
Given the regression of the ICU patients, it should not be surprising that instead of appreciating all the wonderful care they are given, they strongly resent the nursing ministrations. One does not hear children turn to their doctors after inoculations and thank them because the serum will prevent their having a terrible disease in the future. Rather, they scream and display their anger quite openly. In a parallel situation in the ICU, regression prevents the patient from appreciating the high quality of care being given. All he can experience is the pain and discomfort of being moved around, of having to breathe against a painful incision, being stuck with needles, and of having tracheal suction. Yet to express-or even feel-anger is dangerous, since the nurses hold the power of life and death over him. In this circumstance, he defends himself by projecting his anger. Thus, instead of feeling that he wants to kill the nurses, he feels instead that the nurses want to kill him and this then explains why they are doing all those terrible things to him. Almost invariably the patient describes his tormentors as his nurses and sometimes the women doctors whom he seems to lump with the nurses. The male doctors are usually not implicated. Strikingly, the patient does not usually reveal his mental state, even to his own family [2,6].
Dealing with the paranoia is best done by prophylaxis, but this is not easy. Our nurses naturally want to be appreciated. They work very hard and would like the patient to recognize their efforts. They feel frustrated because the regressed patient resents them instead. If only the nurses could give the patients permission to be angry they then would not have to project their resentments. Ideally the nurses should approach the patient with an attitude of 'This will hurt, and you don't have to like it - you just have to tolerate it, and I can understand why you are annoyed'. In practice this is very effective. However, it requires a good deal of work with the nurses, helping them get satisfaction from what they do rather than from expecting thanks from the patient. However having fewer cases of paranoia in the ICU is also gratifying, since such patients may be difficult to manage, and this lessening of paranoia can also be the nurses' reward .
It is sometimes better for the patients when they are overtly disturbed, since this is brought to our attention and can be dealt with openly. As noted above, patients often suffer major psychological upheavals and do not reveal them. I have seen patients who have suffered for years with the anxiety that their minds were fragile, expecting the possibility of suddenly becoming psychotic as they had been in the ICU. They did not know that their mental states were related entirely to their ICU experiences.
The ICU is a highly charged place for both patients and nursing staff. Regression, delirium and paranoia are common, but often hidden by the patient. Our awareness of these problems may lessen the difficulties that patients face.
1 Lazarus HR, Hagens JH. Prevention of psychosis following open-heart surgery. Am J Psychiat
2 Blacher RS. The hidden psychosis of open-heart surgery. JAMA
3 Blacher RS, Bedard MM. The nurse and acute death. In: Tallmer M et al.,
eds. Women Facing Loss.
New York, Foundation of Thanatology 1996.
4 Blacher RS, Joseph ED. Psychological reactions to a cardiac monitor. Mt Sinai J Med
5 Engel GL, Romano J. Delirium: a syndrome of cerebral insufficiency. J Chronic Diseases
6 Blacher RS. (ed.) The Psychological Experience of Surgery.
New York, John Wiley & Sons, 1987: 16-17.
Seventh International Symposium on Intravenous Anaesthesia, Lausanne, Switzerland, 2-3 May 1997
This publication is supported by grants from various pharmaceutical companies. The views in this publication are those of the authors and not necessarily those of supporting companies. Drugs and administration techniques referred to should only be used as recommended in the manufacturers' prescribing information.