ICU Psychosis (Intensive Care Unit Psychosis)

• Patients in an intensive care unit (ICU) or hospital may become delirious.
• ICU psychosis is a temporary condition and can be treated.
• There is no difference between ICU psychosis and delirium.
• ICU psychosis can be treated by a variety of methods and treatments.
• ICU psychosis is an increasingly prevalent problem and may occur at any time during recovery from an acute illness or traumatic event.
• ICU psychosis can be dangerous.
• All efforts should be made to relieve ICU psychosis.
• The signs of psychosis usually resolve shortly after the patient leaves the ICU.
• ICU psychosis may last 24 hours or even up to two weeks with various symptoms occurring at different times.
• Many factors can be involved in causing ICU psychosis.

ICU psychosis is a disorder in which patients in an intensive care unit (ICU) or a similar setting experience a cluster of serious psychiatric symptoms. Another term that may be used interchangeably for ICU psychosis is ICU syndrome. ICU psychosis is also a form of delirium, or acute brain failure.

Environmental Causes

• Sensory deprivation: A patient being put in a room that often has no windows, and is away from family, friends, and all that is familiar and comforting.
• Sleep disturbance and deprivation: The constant disturbance and noise with the hospital staff coming at all hours to check vital signs, give medications, etc.
• Continuous light levels: Continuous disruption of the normal biorhythms with lights on continually (no reference to day or  night).
• Stress: Patients in an ICU frequently feel the almost total loss of control over their life.
• Lack of orientation: A patient's loss of time and date.
• Medical monitoring: The continuous monitoring of the patient's vital signs, and the noise monitoring devices produce can be disturbing and create sensory overload.

Medical Causes

• Pain which may not be adequately controlled in an ICU
• Critical illness: The pathophysiology of the disease, illness or traumatic event - the stress on the body during an illness can cause a variety of symptoms.
• Medication (drug) reaction or side effects: The administration of medications typically given to the patient in the hospital setting that they have not taken before.
• Infection creating fever and toxins in the body.
• Metabolic disturbances: electrolyte imbalance, hypoxia (low blood oxygen levels), and elevated liver enzymes.
• Heart failure (inadequate cardiac output)
• Cumulative analgesia (the inability to feel pain while still conscious)
• Dehydration

The cluster of psychiatric symptoms of ICU psychosis include:

• extreme excitement,
• anxiety,
• restlessness,
• hearing voices,
• clouding of consciousness,
• hallucinations,
• nightmares,
• paranoia,
• disorientation,
• agitation,
• delusions,
• abnormal behavior,
• fluctuating level of consciousness which include aggressive or passive behavior.

In short, patients become temporarily psychotic. The symptoms vary greatly from patient to patient. The onset of ICU psychosis is usually rapid, and is upsetting and frightening to the patient and family members.

The diagnosis of ICU psychosis can be made only in the absence of a known underlying medical condition that can mimic the symptoms of ICU psychosis. A medical assessment of the patient is important to search for other causes of mental status abnormality such as:

• stroke,
• Infection or sepsis
• Medication side effects or interactions
• low blood sugar,
• drug or alcohol withdrawal, and
• any other medical condition that may require treatment.

The patient's safety must be considered at all times.

The treatment of ICU psychosis clearly depends on the cause(s). Many times the actual cause of the psychosis involves many factors, and many issues will need to be addressed to relieve the symptoms. A first step is a review of the patient's medications. The physician in charge of the patient along with the pharmacist can review each of the patient's medications to determine if they may be influencing the delirium.

Family members, familiar objects, and calm words may help. Sleep deprivation may be a major contributing factor. Therefore, providing a quiet restful environment to allow the patient optimal sleep is important. Controlling the amount of time visitors are allowed to stimulate the patient can also help. Dehydration is remedied by administering fluids. Heart failure requires treatment with digitalis. Infections must be diagnosed and treated. Sedation with anti-psychotic agents may help. A common medication used in the hospital setting to treat ICU psychosis is haloperidol or other medications for psychosis (antipsychotics).

It should be understood that in saving a life in the critical environment, ICU psychosis sometimes may be a small price to pay for cutting edge, precise medical life-saving measures.

The primary goal is to correct any imbalance, restore the patient's health, and return the patient to normal activities as quickly as possible. To help prevent ICU psychosis, many critical care units are now:

• using more liberal visiting policies,
• providing periods for sleep,
• protecting the patient from unnecessary excitement,
• minimizing shift changes in the nursing staff caring for a patient, orienting the patient to the date and time,
• reviewing all medical procedures with an explanation about what to expect,
• asking the patient if there are any questions or concerns,
• talking with the family to obtain information regarding religious and cultural beliefs, and
• even coordinating the lighting with the normal day-night cycle, etc.

ICU psychosis often vanishes magically with the coming of morning or the arrival of some sleep. However, it may last 24 hours or even up to two weeks with fluctuations of the level of consciousness and behavior patterns. Although it may linger through the day, agitation frequently is worst at night. (This phenomenon, called sundowning, is also common in nursing homes).

Fortunately, ICU psychosis usually resolves completely when the patient leaves the ICU.

Some estimate that one patient in every three who spends more than five days in an ICU experiences some form of psychotic reaction. As the number of intensive care units and the patient population in them grow, the number of individuals affected by this disorder will correspondingly increase. With patients being transferred out of the ICU more rapidly than in years past; ICU psychosis may be more common in other areas such as the regular medical floor of the hospital or sometimes may even occur after discharge from the hospital.

Years ago, when we went to visit my father-in-law in a hospital ICU, we found him disoriented and very depressed. He couldn't hear or see well. It was like being in a medically-induced whiteout. His room was windowless. He was unable to listen to a radio, watch television or talk on the telephone. He had virtually no human contact other than brief visits by medical staff because he was in isolation with an infection. The staff he did see were in mask and gown and all looked alike. He felt cut off from human contact. He was sure he was going to die (which he didn't). He had ICU psychosis.

It turned out that my father-in-law's customized hearing aid left lying on the nightstand had disappeared. It had apparently fallen into the waste basket and been thrown out with the trash. To safeguard his glasses, a well-meaning nurse suggested that his glasses be taken home. Hence, he could not hear or see much. Restoration of his hearing aid and glasses largely relieved his ICU psychosis.

Yes. To give another example, a friend fell seriously ill with a pulmonary infection some years ago, was very feverish, in considerable pain (from pleurisy) and felt just terrible. She was put in the hospital ICU and had a large-bore intravenous catheter with fluids running together with several antibiotics. She was also given some medications to relieve the pain let me catch up on sleep. She fell asleep but awoke in the middle of the night totally disoriented, very agitated, hallucinating, etc. She had pulled out the IV catheter and was spouting blood all over the place. She was experiencing ICU psychosis. While still in the hospital, a repeat dose of the pain medications led to a repeat episode of the ICU psychosis. ICU psychosis can be dangerous, even life-threatening. It is best avoided if possible.