ICU SYNDROME/SOMATOFORM PHENOMENA
From The Body and Its Brain—Clinical Perspectives, presented by Creighton University Medical Center
| ICU SYNDROME —Lee E. Morrow, MD, Assistant Professor of Medicine, Division of Critical Care and Pulmonary
Medicine, Creighton University School of Medicine, Omaha, NE
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| Introduction: “intensive care unit (ICU) delirium” more accurate term, but “ICU syndrome” persists; not fully recognized
in early years of ICUs because patients heavily sedated and often paralyzed; over time, ICU specialists realized
that heavy sedation and paralysis had unfortunate physical consequences; as medications were reduced,
symptoms of ICU delirium came to forefront
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| Characteristics: combination of fluctuating consciousness, disturbed level of attention, and poor orientation; delusions
and hallucinations frequent; behavior abnormalities include hyperactivity and hypoactivity; subsequent
changes in cognition occur; literature says it takes up to 24 hr to develop, but speaker has seen cases where it developed
in ≤6 hr; also said usually to resolve within 48 hr, but speaker recalls cases where it persisted for up to 2
wk; associated with increased morbidity and mortality; at least one-third of patients who stay in ICU >48 hr develop
symptoms of delirium
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 | Obstacles to managing ICU syndrome: attitudes of physicians who think that ICU delirium “is part of being sick
enough to be in the ICU”; no effort made to prevent it (although prevention key); once it begins, duration cannot
be shortened; exacerbated by use of restraints, sedatives, and narcotics; patients with ICU syndrome meet criteria
for delirium in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; criteria include
reduced ability to maintain and shift attention to external stimuli, disorganized thinking, reduced level of consciousness
[difficult to assess in patients who are sedated], perceptual disturbances, disturbed sleep-wake cycle,
increased or decreased psychomotor activity, memory impairment [also difficult to assess in sedated patient],
abrupt onset of symptoms, and objective evidence of specific etiologic factor or exclusion of nonorganic mental
disorder when no etiologic organic factor can be identified)
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| Statistics: ICU syndrome common; for unknown reasons, much more frequent in patients who have had orthopedic
procedures (50%-65%); speaker estimates that 60% to 80% of orthopedic patients who are in ICU >96 hr develop
ICU syndrome; death rate in people who develop ICU delirium 20% to 35%; 40% of survivors experience cognitive
decline within 1 yr after leaving ICU; “incredibly high rate” of premature institutionalization; three-quarters of
cases not recognized by treating physicians; “although we consider it a benign condition, it’s really not; it’s a sign
of impending death in 25% of the cases”
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| Risk factors: ICU delirium almost always multifactorial; nonmodifiable factors—older age; history of smoking;
systemic hypertension; underlying central nervous system disease; coronary artery bypass graft or orthopedic procedure
(especially total hip replacement) during current hospitalization; modifiable factors—calcium and sodium
levels; fluid status; liver function tests; acidosis and alkalosis; dosages of opiates and benzodiazepines; infection
surveillance; fever; hypertension; anemia; hypoxemia; drug and alcohol withdrawal
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| Other considerations: equally important to help patients with temporal and spatial orientation by, eg, having window
in ICU room that allows patients to see whether it is night or day, and by not misplacing items such as eyeglasses
and hearing aids that help patients to recognize immediate environment; avoid restraints whenever
possible (devices such as Foley catheters, oxygen tubes, and intravenous lines can restrict patients’ mobility as
much as restraints); polypharmacy rampant in ICU; almost all patients experience sleep deprivation due to noisy
environment (eg, monitors and machines, nursing staff, other hospital cacophony)
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| Outcomes of ICU syndrome: increased length of ICU stay (3-7 days) and of hospital stay (1-2 wk); increased
risk for dementia longitudinally; loss of independence; higher rates of institutionalization; increased rate of cognitive
decline; increase in 1-yr mortality; important for people who will care for patient after discharge to recognize
that “there may be bad things coming down the road, and everybody needs to be prepared for it”
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| Assessment: assessment tools that are not specific to ICU not very useful; Confusion Assessment Method-ICU
(CAM-ICU) sensitivity >95%, specificity >89%; looks at 4 main domains (acute onset or fluctuating course, inattention,
disorganized thinking, and altered level of consciousness); overall, patient who has acute onset and inattention
with either disorganized thinking or altered level of consciousness meets criteria for ICU delirium;
disadvantages include being cumbersome to use
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| After delirium: patients demonstrate cognition problems; best assessed with Stockings of Cambridge test; patients
who have had delirium and are still in ICU generally score poorly; when moved to standard nursing unit, scores improve;
retesting at 3 and 6 mo shows continued improvement, but at 1 yr, scores show tendency to decline
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| Memory of being in ICU: most patients have some degree of amnesia for ICU experience, which may result in
distorted perception (ie, underestimation) of their degree of illness (and therefore patients tend not to modify behavior
to avoid future ICU visits); patients who have delusions in ICU tend to remember them and nothing else,
and these patients at high risk for developing post-ICU posttraumatic stress disorder (PTSD); positive memories of
ICU experience include safety of environment, security, and reassurance of nursing staff; negative memories include
lack of sleep, noise, restraints, pain, fear, anxiety, nightmares, distorted perceptions, and persecution delusions;
post–ICU PTSD—study shows 5% of ICU patients have symptoms consistent with PTSD; severity of
PTSD symptoms directly related to how long patient was on ventilator and correlated with dosages of sedatives and
paralytics; patients who receive corticosteroids in ICU tend to have fewer symptoms of PTSD (reasons unknown);
factors associated with post-ICU PTSD include physical restraints, deep sedation, large doses of sedation, and recall
of delusions; patient who has history of psychologic problems much more likely to develop post-ICU PTSD;
surprising finding that memories of actual ICU events, even if unpleasant, appear to protect against post-ICU
PTSD
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| Preventive measures: daily discontinuation of sedation, allowing patient to “come up to the surface,” then renewing
sedation if he or she not ready to leave ICU; study showed that daily interruption of sedation decreased number
of days of mechanical ventilation, and shortened duration of ICU stay and of hospital stay; no patients who
were awakened daily developed symptoms of PTSD
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| Study: showed rate of ICU delirium can be cut by one-third by using multicomponent intervention; however, once
delirium occurred, no difference in severity or likelihood of its recurring in same patients; multi-component
intervention—included screening every patient for likelihood of developing delirium, having pharmacists involved
in medication reviews, intense infection surveillance, getting family involved, minimizing patient’s isolation,
involving patient and family in bedside discussion of care, minimizing sleep disturbance, improving
environmental cues, avoiding restraining devices, and looking for drug and alcohol withdrawal
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| Questions and answers: once delirium has set in, value of psychiatric consultation consultant-specific, and depends
on how seriously ICU delirium taken by ICU physicians and by consultant; drug of choice for ICU delirium
currently haloperidol (Haldol); delirium after orthopedic procedure possibly due to fat emboli, but no good tests
available for diagnosing fat emboli; magnetic resonance imaging not “incredibly conclusive with fat emboli syndrome”
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| SOMATOFORM PHENOMENA: THE PRESENCE OF MEDICALLY UNEXPLAINED SYMPTOMS —P.J. Malin,
MD, Assistant Professor of Psychiatry, Creighton University School of Medicine, Omaha
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| Introduction: individuals communicate emotions differently, depending on age, social mores, and other factors;
children tend to express affective state physically, long before they are able to express it verbally; somatothymia—
phenomenon of expressing emotional distress in physical language; in some cultures, especially Asian, somatothymic
language remains predominant method of expressing emotional distress; alexithymia—individual’s inability
or difficulty in describing or being aware of his or her emotions or mood; somatization—process of communicating
emotional or psychologic stresses in somatothymic language; leads to symptoms that have no apparent medical
explanation
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| Symptom etiology: can be organic, referred, or psychologic; important to rule out other etiologies before assuming
symptoms are psychologic
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| Risk factors: most likely candidates children 1) who grow up in family of somatizers, 2) whose parents treat them
with more tender loving care when sick than when well, and 3) who grow up in home atmosphere not conducive to
sharing emotions; other risk factors include cultural mores, childhood sexual or physical abuse, and parents with alcohol
problems
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| Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: somatoform disorders consist of somatization
disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder; different from
factitious disorder and malingering—somatoform phenomena have unconscious “driving factor” behind them,
while factitious disorder and malingering are conscious; in factitious disorder, patient induces symptoms in self because
sick role offers some advantage, usually in relationships with others; malingerers want secondary gain, such
as money or drugs
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| Countertransference: refers to how health care provider feels about patient; can be positive or negative, depending
on memory provoked (eg, “this patient reminds you of your Aunt Sally, and you loved Aunt Sally,” or “this patient
reminds me of my dad, and my dad had an alcohol problem”); to maintain positive countertransference with
patient with somatoform phenomenon, remember that symptom production is unconscious; patient not trying to
make health care provider’s life difficult, but is suffering and needs help
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| Treatment: resist impulse to increase interval between visits; studies show that regular visits every 2 to 3 wk reduce
number of visits to emergency department and appear to reduce development of new somatoform phenomena;
keep appointments brief (“if you’re working in a 20-min clinic, 20 min”); extending visit leads to expectation
that all visits will be extended; if patient presents list of symptoms, ask him or her to prioritize which one most
important that day, and explain that rest of list must wait until next visit; take care not to “have a knee-jerk response
to do too much too quick”; if nothing done, 75% of outpatients get better within 2 wk, and 60% of remainder
continue to improve for 3 mo; base work-up on objective findings, not on subjective complaints; explain
reasoning for proceeding slowly, one step at a time; limit referrals to colleagues, but if referral necessary, explain
to patient that you are not abandoning him or her
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| Disability: aim for rehabilitation rather than disability; putting patient on disability has significant impact on patient
and on society; forces patient to assume chronic sick role, which often leads to his or her getting worse instead
of better
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| Medications: antidepressants can be helpful if patient has comorbid depression; even if depression not present, literature
shows antidepressants can augment analgesics when patient has disorder with vague symptoms, such as
fibromyalgia, irritable bowel syndrome, migraine and tension headache, and some chronic pain syndromes
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| Psychotherapy: crux of treatment, and “it doesn’t even matter what kind of psychotherapy it is”; literature shows
patients improve in as few as 6 sessions of cognitive behavioral therapy (CBT); when psychologic stress reduced,
number of symptoms decreased
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| No-nos: do not tell patient “there’s nothing wrong with you” or “everything’s normal”; most patients find such remarks
inflammatory because there is something wrong with them and everything is not normal; “they’re suffering”;
instead, remember CLING mnemonic; C stands for common; advise patient that his or her symptoms are
common; L stands for legitimizing patient’s suffering, even if no physical cause can be found for symptoms; I
stands for idiopathic; explain that “sometimes symptoms appear out of the blue”; patients often seek to blame
themselves or their lifestyles for their symptoms and need reassurance that they are not to blame; N stands for nonprogressive;
explain why symptoms are not typical of whatever catastrophic condition patient imagines he or she
has; G stands for gradual; tell patient that gradual remission of symptoms is likely and advise him or her to be patient
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Suggested Reading
Brodsky CM: Sociocultural and interactional influences on somatization. Psychosomatics 25:673, 1984; Chevrolet
JC, Jolliet P: Clinical review: Agitation and delirium in the critically ill—significance and management. Crit
Care 11:214, 2007; Devlin JW et al: Delirium assessment in the critically ill. Intensive Care Med 33:929, 2007;
Dirkzwager AJ, Verhaak PF: Patients with persistent medically unexplained symptoms in general practice:
characteristics and quality of care. BMC Fam Pract 8:33, 2007; Eytan A: Patients’ behaviour in somatic illness.
Lancet 369:1691, 2007; Girard TD et al: Risk factors for post-traumatic stress disorder symptoms following critical
illness requiring mechanical ventilation: a prospective cohort study. Crit Care 11:R28, 2007; Inouye SK, Charpentier
PA: Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship
with baseline vulnerability. JAMA 275:852, 1996; Kroenke K, Jackson JL: Outcome in general medical patients
presenting with common symptoms: a prospective study with a 2-week and a 3-month follow-up. Fam Pract 15:398,
1998; Kroenke K et al: Revising the classification of somatoform disorders: key questions and preliminary recommendations.
Psychosomatics 48:277, 2007; Kuwabara H et al: Diagnostic classification and demographic features
in 283 patients with somatoform disorder. Psychiatry Clin Neurosci 61:283, 2007; Larsson C et al: Confusion assessment
method for the intensive care unit (CAM-ICU): translation, retranslation and validation into Swedish intensive
care settings. Acta Anaesthesiol Scand 51:888, 2007; Miller RR 3rd, Ely EW: Delirium and cognitive
dysfunction in the intensive care unit. Curr Psychiatry Rep 9:26, 2007; Park J, Knudson S: Medically unexplained
physical symptoms. Health Rep 18:43, 2007; Pun BT, Dunn J: The sedation of critically ill adults: Part 1:
Assessment. The first in a two-part series focuses on assessing sedated patients in the ICU. Am J Nurs 107:40, 2007;
Pun BT, Dunn J: The sedation of critically ill adults: Part 2: Management. Am J Nurs 107:40, 2007; Rief W: Analyzing
the problems in managing patients with medically unexplained symptoms. J Gen Intern Med 22:704, 2007;
Smith RC, Dwamena FC: Classification and diagnosis of patients with medically unexplained symptoms. J Gen
Intern Med 22:685, 2007; Stevens RD, Nyquist PA: Coma, delirium, and cognitive dysfunction in critical illness.
Crit Care Clin 22:787, 2006; Watts G et al: Delirium in the intensive care unit: searching for causes and sources.
Crit Care Resusc 9:26, 2007.
Educational Objectives
| The goals of this program are to increase recognition and prevention of intensive care unit (ICU) syndrome and to
identify treatment strategies to reduce somatoform phenomena. After hearing and assimilating this program, the clinician
will be better able to:
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| 1. Describe the major features of ICU syndrome.
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| 2. Explore methods for reducing or preventing ICU syndrome.
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| 3. Discuss medical and psychiatric treatment for ICU syndrome.
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| 4. Explain the etiologies of somatization.
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| 5. Identify treatment strategies to reduce somatoform phenomena.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, the Audio-Digest Foundation requires all faculty members
to disclose relevant financial relationships within the past 12 months that might create any personal conflict of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care
education and not a proprietary business or commercial interest. For this program, Drs. Morrow and Malin reported
nothing to disclose.
Acknowledgements
Drs. Morrow and Malin were recorded at The Body and Its Brain—Clinical Perspectives, held March 31, 2007, in
Omaha, NE, and sponsored by Creighton University Medical Center. The Audio-Digest Foundation thanks the speakers
and Creighton University Medical Center for their cooperation in the production of this program.
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