Understanding posttraumatic stress disorder-related symptoms after critical care: The early illness amnesia hypothesis Cristina Granja, MD, PhD; Ernestina Gomes, MD; Augusta Amaro, MD; Orquı ´dea Ribeiro, BSc; Christina Jones, BSc, MPhil, PhD, PG Dip Psych; Anto ´ nio Carneiro, MD; Altamiro Costa-Pereira, MD, PhD; the JMIP Study Group P osttraumatic stress disorder (PTSD) is a serious psychiatric disorder that may follow the experience or witnessing of one or more life-threatening events (1). Events that may trigger PTSD involve a serious threat to one’s own physical in- tegrity, which is accompanied by feel- ings of intense fear, horror, and help- lessness (2). Diagnostic criteria for PTSD include a history of exposure to one or more trau- matic events and symptoms from each of three symptom clusters: intrusive recol- lections, avoidance/numbing symptoms, and hyperarousal (1). People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached from others. These symptoms must be severe enough to significantly impair the per- son’s daily life for the diagnosis to be made. Although our current knowledge on the risk factors for development of PTSD after critical illness is limited, PTSD has been described in 4 –25% (3– 6) survivors of critical illness; a recent review re- ported PTSD rates varied from 5 to 63% (7). Several risk factors for the develop- ment of PTSD/PTSD-related symptoms have been identified, including younger age (8, 9), female gender (9, 10), longer intensive care unit (ICU) and hospital stay, length of mechanical ventilation, greater levels of sedation, preexisting psy- chiatric history, greater number of trau- matic memories/frightening recollec- tions and the early recall of delusional memories (7, 11). The number of “adverse” experiences that patients recall from their ICU stay has been related with high levels of PTSD-related symptoms (12). More re- cently, it was suggested that the early recall of delusional memories without any factual memories (2 wks post-ICU) increased the risk of developing PTSD- related symptoms at 8 wks (13). There- fore, the actual role and relationships between factual and/or delusional memories and the development of PTSD-related symptoms has not been fully established. In this study we assessed the factual and delusional memories reported by ICU survivors and its relationship with the development of PTSD-related symp- toms. From the Medical Intensive Care Unit (CG, AA), Hospital Pedro Hispano, Matosinhos, Portugal; Inten- sive Care Unit (EG, AC), Hospital Geral de Santo Anto ´- nio, Oporto, Portugal; Department of Biostatistics and Medical Informatics (OR, AC-P), Faculty of Medicine of Oporto, Portugal; and Nurse Consultant Critical Care Follow-up (CJ), Intensive Care Research Group, Inten- sive Care Unit, Whiston Hospital, Prescot L35 5DR, UK. The authors have not disclosed any potential con- flicts of interest. For information regarding this article, E-mail: cristina.granja@hph.min-saude.pt Copyright © 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e318186a3e7 Objective: To assess the factual and delusional memories reported by intensive care unit survivors and its relationship with the development of posttraumatic stress disorder-related symp- toms. Design: Multicenter observational cohort study. Setting: Nine Portuguese intensive care units, as part of a multicenter study. Methods and Patients: Between January and June 2005, 1174 patients were admitted across the nine intensive care units. Two hundred thirty-nine patients were excluded, 14 with <18 yrs old and 225 with a length of nine intensive care stay <48 hrs. Thus a total of 935 patients were included in the study. One hundred ninety (20%) patients died in the intensive care unit, 90 (12%) patients died on the ward (30% in-hospital mortality rate), and another 56 (9%) died in the next 6 months after intensive care unit discharge. Results: From the 599 survivors at 6 months, 313 patients answered the questionnaires (52% response rate). From the 313 respondents, 58% (n  183) were men, median age was 59. The median SAPS II was 37, median intensive care unit length of stay was 8 days, 57% (n  177) of the patients were admitted for medical reasons. Forty percent (n  116) of the respondents did not remember their admission to hospital, 48% (n  142) did not remember the time in the hospital before intensive care unit admission, 73% (n  220) had factual memories and 39% (n  118) had delusional memories. Twenty-three percent (n  66) stated that they had had intrusive memories. A higher number of “adverse” experiences were significantly associated with a higher PTSS-14 score. Eighteen percent (n  54) of patients had a PTSS-14 score >49, indicating a higher risk of developing posttraumatic stress disorder. A PTSS-14 score >49 was signif- icantly associated with not remembering the hospital stay before intensive care unit admission. Conclusion: Amnesia for the early period of critical illness (early amnesia) was positively associated with the level of post- traumatic stress disorder-related symptoms, which may be a proxy for severity of disease at the time of intensive care unit admission. (Crit Care Med 2008; 36:●●●–●●●???) KEY WORDS: critical care; critical illness; outcome; posttrau- matic stress disorder; PTSS-14; delusional memories balt4/zrz-ccm/zrz-ccm/zrz01008/zrz8835-08z xppws S1 8/12/08 8:42 Art: 200646 Input-sd 1 Crit Care Med 2008 Vol. 36, No. 10 AQ: 1