Intensive Care Med (1992) 18:278-281
IntensiveCare Medicine 9 Springer-Verlag 1992
Psychological problems in the family members of gravely traumatised patients admitted into an intensive care unit* M . A . P ~ r e z - S a n G r e g o r i o , A . B l a n c o - P i c a b i a , E M u r i l l o - C a b e z a s , J . M . D o m i n g u e z - R o l d f i n , B. S~inchez a n d A . Nfifiez-Rold~in Hospital Universitario "Virgen del Rocio" de Sevilla, Spain Received: January 17, 1991; accepted: February 5, 1992
Abstract. T h e a i m o f these studies was the analysis o f the p s y c h o l o g i c a l repercussions o n t h e closest m e m b e r s o f families o f 76 gravely t r a u m a t i s e d p a t i e n t s a d m i t t e d into the Intensive Care U n i t ( I C U ) o f the H o s p i t a l Universitario de R e h a b i l i t a c i 6 n y T r a u m a t o l o g i a " V i r g e n del Rocio", Sevilla (Spain). A n investigation b a s e d o n social i n f o r m a t i o n a n d the Clinical A n a l y s i s Q u e s t i o n n a i r e was used. T h e s a m p l e o f f a m i l y m e m b e r s was c o m p o s e d o f 42 w o m e n a n d 34 men, with a n average age o f 41.3 years (SD+_ 12.8). Results showed t h a t (a) m o r e t h a n 50~ o f the f a m i l y m e m b e r s o f gravely t r a u m a t i s e d p a t i e n t s a d m i t t e d into a n I C U showed s y m p t o m s o f depression, (b) t h e w o m e n scored m o r e p o i n t s in h y p o c h o n d r i a , suicidal depression, a n x i o u s depression, low-energy depression, guilt-resentment, a p a t h y - w i t h d r a w a l , p a r a n o i a , schizophrenia, psychasthenia and psychological disadjustment, a n d (c) in general terms, the p s y c h o l o g i c a l characteristics o f the families were far f r o m t h e n o r m o f the c o n t r o l group.
Key words: P s y c h o l o g y - Families - Intensive care unit
T h e growing d e v e l o p m e n t o f t h e Intensive Care Units ( I C U ) has given rise to a series o f p s y c h o l o g i c a l manifestations, s o m e t i m e s grave a n d i m p o r t a n t , as m u c h in the p e r s o n n e l w o r k i n g long t e r m in these h o s p i t a l d e p a r t m e n t s as in the p a t i e n t s a n d their families. A l l o f these h u m a n aspects have b e e n scarcely studied, especially with respect to the p s y c h o l o g i c a l s i t u a t i o n in which the f a m i l y m e m b e r s o f p a t i e n t s a d m i t t e d to a n I C U find themselves. T h e m a j o r i t y o f t h e studies show, a l t h o u g h t h e forecast is n o t necessarily negative, t h a t the clinical s y m p t o m o l o g y displayed b y the relatives o f patients in an I C U was as follows: h i g h levels o f a n x i e t y [I], d e p r e s s i o n a n d
* This work was supported by grants from "Fondo de Investigaciones Sanitarias de la Seguridad Social" (FIS 90/0053, and FIS 90/4039)
feelings o f guilt w h i c h w o r s e n e d w h e n the p a t i e n t s died [2]. A l t h o u g h o t h e r s y m p t o m s such as t h o u g h t o f suicide d i d n o t have such a high incidence, they m u s t nevertheless be c o n s i d e r e d far f r o m n o r m a l [3]. A l l the reactions des c r i b e d in t h e f a m i l y m e m b e r s o f patients a d m i t t e d into a n I C U t e n d e d to a p p e a r a n d t h e r e a f t e r a b a t e [4]. T h e a i m o f the present s t u d y was to a n a l y s e the p s y c h o l o g i c a l deviations d i s p l a y e d b y the closest relatives o f gravely t r a u m a t i s e d p a t i e n t s a d m i t t e d into a n I C U a n d to m a k e a c o m p a r a t i v e s t u d y between the sexes in the families.
Materials and methods To perform the present study, we interviewed relatives of 76 gravely traumatised patients admitted into the ICU of the Hospital Universitario de Rehabilitaci6n y Traumatologla "Virgen del Rocio", Sevilla (Spain), during a period of 6 months. The sample was composed of 42 women and 34 men with an average age of 41.3 (SD_+12.8); their relationships with the patients were as follows: 31 (40.8%) fathers/mothers, 13 (17.1%) husbands/wives, 11 (14.5%) son/daughter, Ii (14.5%) brothers/sisters, and 10 (13.2%) others. The families were informed by the doctors every day for 5-10 rain about the status and progress of the patient. The visiting hours were limited to 30 rain in the evening. During this period of time, the families were allowed to observe the patients, although there was no verbal contact between them, since all the patients were unconscious and breathing artificially. All the families stayed regularly in the hospital waiting room day and night. It is important to point out that conditions in the waiting room were not very satisfactory, since there was an excessivenumber of people and they had to sleep on chairs. All the 76 patients admitted to the ICU suffered from head trauma and polytrauma, additionally 6 (7.9%) were traumatised tetraplegics, and 3 (3.9%) had another kind of trauma. The average stay in the ICU was 19.8 days (SD_+17.3) and 7 (9.2%) patients died. The patient sample was composed of 56 men and 20 women, with an average age of 32.6 (SD+_ 18.0). The causes of the traumas were: traffic (73.7%0), run down by vehicles (15.7%), fallen from a height (6.6%) and other causes (3.9~ Almost half of the patients had a background of medical and psychological treatment for different reasons, among them being alcohol abuse (40.0%), psychiatric illness (20.0%) and previous serious accidents (21.3%). All the patients and their families belonged to a low sociocultural and socioeconomical level. In all cases, patient's relatives were submitted to identical conditions of treatment in terms of isolation, application of tests by a psychologist unknown to them, and instructions for all the families. Families were interviewed 48 h after the admission of the patient into the ICU. During
279 this time, the relatives had time to get used to the doctors, to the information bulletins, to the visits, etc. The average duration of each interview was approximately 90 min. Before starting the interview an explanation was given to the relatives on the purpose of the study. It was a purely research interview with no support being given to the relatives. Approval from the Research and Ethical Committee of the Hospital was obtained prior to the study. All the patient's relatives were studied individually, firstly by an enquiry that contained some data common to the family and the patient (social, cultural, work, economical) and other data referring only to the patient (medical diagnosis, circumstances of the accident and medical and psychological background). In the second place, they completed the Clinical Analysis Questionnaire (CAQ); a test factorially constructed to measure psychopathological clinical aspects of the normal personality, The CAQ test is composed of 144 items and 12 scales: hypochondria, suicidal depression, agitation, anxious depression, low-energy depression, guilt-resentement, apathy-withdrawal, paranoia, psychopathic deviation, schizophrenia, psychasthenia and psychological disadjustment [5]. Three out of the 76 interviews could not be finished because of the mental state (excessiveanxiety, animic depressed state, etc.) and physical state (tiredness, insomnia, lack of appetite, etc.), in which the family members found themselves. This was the reason why the first part (identification data, etc.) was completed in all (76) of the cases, whereas the second part of the CAQ test was in only 73 cases. The control group used in the present study was not selected by the authors; it was a group selected by Krugg in 1987 for the Spanish adaptation of the CAQ [5]. The sample of adolescents comprised 932 subjects (469 men and 463 women) and the sample of adults of 792 subjects (669 men and 123 women). The experimental group was compared with this latter control group of adults. The statistical treatment consisted of a comparative analysis in relation to the sexes, on one hand between the members of the families of patients in ICU, and on the other between those and the families from the control group. The "Z" test for comparison of 2 observed averages in independent groups for large samples was employed, and the formula used to find the value "Z" in each of the scales of the CAQ was Z = (IX 1-'X2I)/]/(o2/N0+(o2/Nz, where X t = average sample 1, R 2 = average sample-22, 01 = variance of the population 1, 02 = variance of the population 2, N~ = number of individuals in the sample 1, N 2 = number of individuals in the sample 2. The "Z" value was compared with 2 theoretical "Z" values; one for a coefficient alpha (ct; error risk) of 0.05 (Z = 1.96) and the other for tt = 0.01 (Z = 2.58). All the "Z" values obtained above or equal to 1.96 and 2.58 were considered statisticallysignificant, with a risk of error of 5~ and 1070respectively. Results Table 1 shows t h o s e scales o f C A Q in w h i c h m o r e t h a n 50% o f t h e f a m i l y m e m b e r s o f p a t i e n t s a d m i t t e d into a n I C U show extreme deviations. T h e s e are: h y p o c h o n d r i a (83.0%), p a r a n o i a (76.7%), suicidal d e p r e s s i o n (75.3%), apathy-withdrawal (72.6%), low-energy d e p r e s s i o n (64.4%), a n x i o u s d e p r e s s i o n (56.2%) a n d s c h i z o p h r e n i a (50.7%). In general, the state o f their spirits is low, since t h e y n o r m a l l y m a n i f e s t s y m p t o m s o f being depressed, o f n o t feeling well, hopelessness, etc. A d d i t i o n a l l y , these score h i g h in suicidal d e p r e s s i o n (75.3%) a n d low-energy d e p r e s s i o n (64.4%). S o m e t i m e s these f a m i l y m e m b e r s t a l k a b o u t a loss o f interest in activities which h a d previo u s l y a t t r a c t e d t h e m (apathy-withdrawal, 72.6%), experiencing a d i m i n u t i o n in their level o f energy, with a c o n t i n u o u s feeling o f tiredness even in a b s e n c e o f physical exercise ( h y p o c h o n d r i a c , 83.0%). T h o u g h t s o f d e a t h are also u s u a l (suicidal depression, 75.3%). A s a s s o c i a t e d s y m p t o m s , anxiety, irritability, t h e excessive p r e o c c u p a t i o n w i t h physical health, etc. a p p e a r (anxious depression, 56.2~ P a t i e n t ' s relatives also p r e s e n t h a l l u c i n a t i o n s o f
Table 1. Extreme psychological deviation observed in the families of patients in an ICU (n = 73) Variables
Percentage
Hypochondria Paranoia Suicidal depression Apathy-withdrawal Low energy depression Anxious depression Schizophrenia
83.0% 76.7% 75.3% 72.6 ~ 64.4% 56.2% 50.7%
delirious ideas, for instance there are d e c l a r a t i o n s o f j e a l ousy, a feeling o f injustice a n d persecution, j e a l o u s y with respect to others, a certain cynicism a b o u t the h u m a n c o n d i t i o n a n d t h a t they are h a r d d o n e by ( p a r a n o i a , 76.7%). I n t h e s a m e way, t h e y have difficulties in expressing their ideas, t h e y have strange impulses, believing t h a t n o b o d y u n d e r s t a n d s t h e m t h a t in s o m e cases distance themselves f r o m reality (schizophrenia, 50.7%). I n Table 2 are s h o w n the results a c c o r d i n g to sex between the families o f p a t i e n t s in an I C U (33 men, 40 women), a n d a c o n t r o l g r o u p (669 men, 123 women). Sign i f i c a n t differences between m e n (n = 33) a n d w o m e n (n -- 40) f a m i l y m e m b e r s o f I C U are f o u n d f r o m the c o m p a r a t i v e analysis o f averages o b t a i n e d in t h e 12 scales o f CAQ, for ct = 0.01 (Z = 2.58) t h e w o m e n o b t a i n e d signific a n t l y higher scores in h y p o c h o n d r i a (Z = 3.57), a n x i o u s d e p r e s s i o n (Z = 4.05), low energy d e p r e s s i o n (Z = 3.82) a n d p s y c h a s t h e n i a (Z = 8.01), a n d with an a value o f 0.05 (Z = 1.96) in guilt-resentement (Z = 2.25). O n t h e o t h e r h a n d , w h e n r = 0.01 (Z = 2.58), they o b t a i n e d lower scores in p s y c h o p a t h i c d e v i a t i o n (Z = 4.42). I n t h e s a m e way, significant differences between t h e s a m p l e o f f a m i l y m e m b e r s in a n I C U (33 men, 40 w o m e n ) a n d t h e c o n t r o l g r o u p (669 m e n , 123 w o m e n ) are f o u n d for a l m o s t all the variables, excepting for t h e p s y c h o p a t h i c d e v i a t i o n scale (Z = 1.05) and for psychological disadjustment (Z = 1.10) in t h e m a l e group. Discussion T h e relatives o f p a t i e n t s a d m i t t e d to a n I C U show psyc h o l o g i c a l deviations. T h e scales o f h y p o c h o n d r i a , suicidal depression, a n d low-energy d e p r e s s i o n are the m o s t i m p o r t a n t a t t r i b u t e s o f the s e c o n d a r y d i m e n s i o n o f depression. Nevertheless, in a n analysis o f the results o f t h e C A Q in a large s a m p l e o f p r i s o n e r s in A t l a n t a , it m a y b e c o n c l u d e d t h a t a high score in suicidal d e p r e s s i o n is n o t b y itself a p r e c u r s o r o f i n t e n t i o n o f suicide. I f in the p r o file the a g i t a t i o n scale is low, such i n t e n t i o n s are i m p r o b able [5]. I n this way, a l t h o u g h the suicidal d e p r e s s i o n scale rises in t h e s a m p l e studied, the a g i t a t i o n scale goes down; c o n s e q u e n t l y we d i s c a r d the p o s s i b i l i t y o f such a danger. A l l the s y m p t o m s d e s c r i b e d are d u e to the psyc h o l o g i c a l stress o r i g i n a t e d f r o m the t r a u m a t i c s i t u a t i o n which the families are e x p o s e d to. T h e y t h i n k t h a t I C U s are " t o r t u r e c h a m b e r s " disguised to a certain extent; I C U s are c o n s t a n t l y i d e n t i f i e d with the fact t h a t the life
280 Table 2. Comparison according to sex between the families of patients in an ICU (n = 73), and a control group (n = 792). Contrast of averages ICU
Hypochondria Suicidal depression Agitation Anxious depression Low energy depression Guilt-resentment Apathy-withdrawal Paranoia Psychopathic deviation Schizophrenia Psychasthenia Psychological disadjustment
Control
Significance
W o m e n (n = 40) a
Men (n = 33) b
W o m e n (n = 123) c
Men (n = 669) d
a-b
a- c
b- d
7.82 5.67 9.40 10.47 9.47 9.87 6.77 9.95 11.02 5.27 12.07 5.07
4,54 4.18 10.03 6.90 5.45 7.66 6.18 9.30 14.54 4.72 5.81 4.30
t.38 1.18 11.72 5.25 2.75 5.60 2.22 3.97 15.37 2.32 10,08 2.80
1.38 1.42 i1.74 4.76 3.37 6.28 2.90 4.28 15.77 3.22 10.59 3.73
3.57** 1.52 0.89 4.05 ** 3.82** 2.25* 0.69 0.75 4.42** 0.71 8.01 ** 1.01
7.99** 6.18'* 7.05** 6.95 ** 8.07** 5.18"* 7.01 ** 9.25** 7.14"* 5.i5"* 3.00** 3.65**
6.72** 4.11"* 3.45** 3.67 ** 2.95** 2.15" 5.38** 7.62** 1.05 2.58** 9.39** 1.10
* Significance for z>_z (0.05) = 1.96 ** Significance for z_>z (0.01)= 2.58
of the patient is in danger and that there exists a high probability that the outcome is negative [1]. With respect to sexes, results obtained from the relatives of patients in an ICU corroborate those obtained by the author of CAQ [5]: the women obtain higher scores in the majority of the clinical scales, excepting for agitation and psychopathic deviation. This suggests that, in general terms, it is much more difficult for women to face such traumatic situations than for men. This fact could be explained if we take into account that men usually spend less time in the hospital than women because of their work; they are consequently shielded from the problem. As an associated factor to the depression appears the "feeling of guilt", expressed by an exaggerated responsibility for the tragic events. The feelings of guilt appear because the family members of the patient begin to reproach themselves and accuse themselves of the errors committed against the person who is ill, these feelings worsen when the patient dies [2]. On the other hand, the women declare themselves to have little self-control over their behaviour and they worry about small things, increasing in this way their scoring in psychasthenia, which contributes in an important way to the anxiety factor. The family members of patients in an ICU begin to distance themselves from normality; in almost all the scales they obtain higher scores than the control group, excepting for agitation and psychopathic deviation where they obtain a lower score. We would like to stress the relevance of the observation that for the psychasthenia scale in relatives of trauma patients, both men and women vary pathologically from the average scores obtained in families that have not been exposed to traumatic situations in an inverse way; the score decreases in men and increases in women, who have a more obsessive type of behaviour, with repetitive or incessant and compulsive thoughts as compared with men. Usually, men are not so bothered by these thoughts. In all the clinical manifestations described above with respect to the families of patients in an ICU, we cannot forget the possible influence the following stressing fac-
tors can manifest by themselves: (a) the majority of the patients who composed our sample had artificial respiration. Thus, not being able to communicate freely with the doctor and the family, they suffered more anxiety and depression than usual. The relatives end up adopting a posture similar to that of the patients [6], (b) the medical information the families receive increases or lessens the anxiety or stress [7]. The short medical information (5 - 10 rain) does not obviously help to quieten the spirits of the family, additional (c), there is a close relation between ways of solving problems by family members and their perception of the Hospital Waiting Rooms [8]. The importance of a Family Help System is obvious. This would help to prevent or alleviate the psychological disorders. Special emphasis should be placed on a program of orientational education for the families [1, 3, 9]. In the same way, a small number or experts insist that a priest could be the best recourse for the families of patients in an ICU [10]. From this study we can conclude that more than 50~ of the family members of gravely traumatised patients admitted into an ICU show symptoms of depression, the psychological manifestations being more pronounced in the women. Finally, the psychological features of the families are far from the norm of the control group. Future investigations are necessary to study the demarcation of this response, identify stresses shown by the families and identify effective psychological interventions. This would reduce family stress promoting and maintaining the integrity of the family during the hospitalisation. Acknowledgements. The authors wish to acknowledge the staff from Unidad de Cuidados Intensivos del Hospital Universitario de Rehabilitaci6n y Traumatologla "Virgen del Rocio", Sevilla (Spain), specially the collaboration of Drs. Manuel Barrios P6rez, Tom,is Diaz Lavado, Angeles Mufioz S~inchez and Jos6 Villen Nieto.
References 1. Halm M A (1990) Effects of support groups and anxiety of family members during critical illness. Heart Lung 19:62-71
281 2. Breslau N, Staruch KS, Mortimer EA (1985) Psychological distress in mothers of disabled children. Am J Dis Child 136:682-686 3. Hansen M, Young DA, Carden FE (1986) Psychological evaluation and support in the pediatric intensive care unit. Pediatr Ann 15:69-79 4. Clayton PJ, Darvisch HS (1979) Course of depressive symptoms following the stress of bereavement. In: Barret JD (ed) Stress and mental disorder. Raven Press, New York, pp 82-108 5. Krug SS (1987) Cuestionario de Anfilisis Clinico. Tea Ediciones, SA, Madrid 6. Miles M, Carter M (1985) Coping strategies used by parents during their child's hospitalization in a intensive care unit. Children's Health Care 14:14-2I 7. Lust B (1984) The patient in the intensive care unit: A family experience. Crit Care Q 6:49-57
8. Costell RC, Reiss D, Berkman H, Jones C (1981) The family meets the hospital. Arch Gen Psychiat 38:569-577 9. Chavez CW, Faber L (1987) Effect of an education-orientation program on family members who visit their significant other in the intensive care unit. Heart Lung 16:92-99 10. Wilson DR (1989) The chaplain as a resource to families of patients in intensive care unit. Can Crit Care Nurs J 6:10-12
Dr. Maria de los Angeles Perez San Gregorio Avenida de Kansas City, 42, 6-A. E-4t007 Sevilla Spain
IntensiveCare Medicine 9 Springer-Verlag 1992
Psychological problems in the family members of gravely traumatised patients admitted into an intensive care unit* M . A . P ~ r e z - S a n G r e g o r i o , A . B l a n c o - P i c a b i a , E M u r i l l o - C a b e z a s , J . M . D o m i n g u e z - R o l d f i n , B. S~inchez a n d A . Nfifiez-Rold~in Hospital Universitario "Virgen del Rocio" de Sevilla, Spain Received: January 17, 1991; accepted: February 5, 1992
Abstract. T h e a i m o f these studies was the analysis o f the p s y c h o l o g i c a l repercussions o n t h e closest m e m b e r s o f families o f 76 gravely t r a u m a t i s e d p a t i e n t s a d m i t t e d into the Intensive Care U n i t ( I C U ) o f the H o s p i t a l Universitario de R e h a b i l i t a c i 6 n y T r a u m a t o l o g i a " V i r g e n del Rocio", Sevilla (Spain). A n investigation b a s e d o n social i n f o r m a t i o n a n d the Clinical A n a l y s i s Q u e s t i o n n a i r e was used. T h e s a m p l e o f f a m i l y m e m b e r s was c o m p o s e d o f 42 w o m e n a n d 34 men, with a n average age o f 41.3 years (SD+_ 12.8). Results showed t h a t (a) m o r e t h a n 50~ o f the f a m i l y m e m b e r s o f gravely t r a u m a t i s e d p a t i e n t s a d m i t t e d into a n I C U showed s y m p t o m s o f depression, (b) t h e w o m e n scored m o r e p o i n t s in h y p o c h o n d r i a , suicidal depression, a n x i o u s depression, low-energy depression, guilt-resentment, a p a t h y - w i t h d r a w a l , p a r a n o i a , schizophrenia, psychasthenia and psychological disadjustment, a n d (c) in general terms, the p s y c h o l o g i c a l characteristics o f the families were far f r o m t h e n o r m o f the c o n t r o l group.
Key words: P s y c h o l o g y - Families - Intensive care unit
T h e growing d e v e l o p m e n t o f t h e Intensive Care Units ( I C U ) has given rise to a series o f p s y c h o l o g i c a l manifestations, s o m e t i m e s grave a n d i m p o r t a n t , as m u c h in the p e r s o n n e l w o r k i n g long t e r m in these h o s p i t a l d e p a r t m e n t s as in the p a t i e n t s a n d their families. A l l o f these h u m a n aspects have b e e n scarcely studied, especially with respect to the p s y c h o l o g i c a l s i t u a t i o n in which the f a m i l y m e m b e r s o f p a t i e n t s a d m i t t e d to a n I C U find themselves. T h e m a j o r i t y o f t h e studies show, a l t h o u g h t h e forecast is n o t necessarily negative, t h a t the clinical s y m p t o m o l o g y displayed b y the relatives o f patients in an I C U was as follows: h i g h levels o f a n x i e t y [I], d e p r e s s i o n a n d
* This work was supported by grants from "Fondo de Investigaciones Sanitarias de la Seguridad Social" (FIS 90/0053, and FIS 90/4039)
feelings o f guilt w h i c h w o r s e n e d w h e n the p a t i e n t s died [2]. A l t h o u g h o t h e r s y m p t o m s such as t h o u g h t o f suicide d i d n o t have such a high incidence, they m u s t nevertheless be c o n s i d e r e d far f r o m n o r m a l [3]. A l l the reactions des c r i b e d in t h e f a m i l y m e m b e r s o f patients a d m i t t e d into a n I C U t e n d e d to a p p e a r a n d t h e r e a f t e r a b a t e [4]. T h e a i m o f the present s t u d y was to a n a l y s e the p s y c h o l o g i c a l deviations d i s p l a y e d b y the closest relatives o f gravely t r a u m a t i s e d p a t i e n t s a d m i t t e d into a n I C U a n d to m a k e a c o m p a r a t i v e s t u d y between the sexes in the families.
Materials and methods To perform the present study, we interviewed relatives of 76 gravely traumatised patients admitted into the ICU of the Hospital Universitario de Rehabilitaci6n y Traumatologla "Virgen del Rocio", Sevilla (Spain), during a period of 6 months. The sample was composed of 42 women and 34 men with an average age of 41.3 (SD_+12.8); their relationships with the patients were as follows: 31 (40.8%) fathers/mothers, 13 (17.1%) husbands/wives, 11 (14.5%) son/daughter, Ii (14.5%) brothers/sisters, and 10 (13.2%) others. The families were informed by the doctors every day for 5-10 rain about the status and progress of the patient. The visiting hours were limited to 30 rain in the evening. During this period of time, the families were allowed to observe the patients, although there was no verbal contact between them, since all the patients were unconscious and breathing artificially. All the families stayed regularly in the hospital waiting room day and night. It is important to point out that conditions in the waiting room were not very satisfactory, since there was an excessivenumber of people and they had to sleep on chairs. All the 76 patients admitted to the ICU suffered from head trauma and polytrauma, additionally 6 (7.9%) were traumatised tetraplegics, and 3 (3.9%) had another kind of trauma. The average stay in the ICU was 19.8 days (SD_+17.3) and 7 (9.2%) patients died. The patient sample was composed of 56 men and 20 women, with an average age of 32.6 (SD+_ 18.0). The causes of the traumas were: traffic (73.7%0), run down by vehicles (15.7%), fallen from a height (6.6%) and other causes (3.9~ Almost half of the patients had a background of medical and psychological treatment for different reasons, among them being alcohol abuse (40.0%), psychiatric illness (20.0%) and previous serious accidents (21.3%). All the patients and their families belonged to a low sociocultural and socioeconomical level. In all cases, patient's relatives were submitted to identical conditions of treatment in terms of isolation, application of tests by a psychologist unknown to them, and instructions for all the families. Families were interviewed 48 h after the admission of the patient into the ICU. During
279 this time, the relatives had time to get used to the doctors, to the information bulletins, to the visits, etc. The average duration of each interview was approximately 90 min. Before starting the interview an explanation was given to the relatives on the purpose of the study. It was a purely research interview with no support being given to the relatives. Approval from the Research and Ethical Committee of the Hospital was obtained prior to the study. All the patient's relatives were studied individually, firstly by an enquiry that contained some data common to the family and the patient (social, cultural, work, economical) and other data referring only to the patient (medical diagnosis, circumstances of the accident and medical and psychological background). In the second place, they completed the Clinical Analysis Questionnaire (CAQ); a test factorially constructed to measure psychopathological clinical aspects of the normal personality, The CAQ test is composed of 144 items and 12 scales: hypochondria, suicidal depression, agitation, anxious depression, low-energy depression, guilt-resentement, apathy-withdrawal, paranoia, psychopathic deviation, schizophrenia, psychasthenia and psychological disadjustment [5]. Three out of the 76 interviews could not be finished because of the mental state (excessiveanxiety, animic depressed state, etc.) and physical state (tiredness, insomnia, lack of appetite, etc.), in which the family members found themselves. This was the reason why the first part (identification data, etc.) was completed in all (76) of the cases, whereas the second part of the CAQ test was in only 73 cases. The control group used in the present study was not selected by the authors; it was a group selected by Krugg in 1987 for the Spanish adaptation of the CAQ [5]. The sample of adolescents comprised 932 subjects (469 men and 463 women) and the sample of adults of 792 subjects (669 men and 123 women). The experimental group was compared with this latter control group of adults. The statistical treatment consisted of a comparative analysis in relation to the sexes, on one hand between the members of the families of patients in ICU, and on the other between those and the families from the control group. The "Z" test for comparison of 2 observed averages in independent groups for large samples was employed, and the formula used to find the value "Z" in each of the scales of the CAQ was Z = (IX 1-'X2I)/]/(o2/N0+(o2/Nz, where X t = average sample 1, R 2 = average sample-22, 01 = variance of the population 1, 02 = variance of the population 2, N~ = number of individuals in the sample 1, N 2 = number of individuals in the sample 2. The "Z" value was compared with 2 theoretical "Z" values; one for a coefficient alpha (ct; error risk) of 0.05 (Z = 1.96) and the other for tt = 0.01 (Z = 2.58). All the "Z" values obtained above or equal to 1.96 and 2.58 were considered statisticallysignificant, with a risk of error of 5~ and 1070respectively. Results Table 1 shows t h o s e scales o f C A Q in w h i c h m o r e t h a n 50% o f t h e f a m i l y m e m b e r s o f p a t i e n t s a d m i t t e d into a n I C U show extreme deviations. T h e s e are: h y p o c h o n d r i a (83.0%), p a r a n o i a (76.7%), suicidal d e p r e s s i o n (75.3%), apathy-withdrawal (72.6%), low-energy d e p r e s s i o n (64.4%), a n x i o u s d e p r e s s i o n (56.2%) a n d s c h i z o p h r e n i a (50.7%). In general, the state o f their spirits is low, since t h e y n o r m a l l y m a n i f e s t s y m p t o m s o f being depressed, o f n o t feeling well, hopelessness, etc. A d d i t i o n a l l y , these score h i g h in suicidal d e p r e s s i o n (75.3%) a n d low-energy d e p r e s s i o n (64.4%). S o m e t i m e s these f a m i l y m e m b e r s t a l k a b o u t a loss o f interest in activities which h a d previo u s l y a t t r a c t e d t h e m (apathy-withdrawal, 72.6%), experiencing a d i m i n u t i o n in their level o f energy, with a c o n t i n u o u s feeling o f tiredness even in a b s e n c e o f physical exercise ( h y p o c h o n d r i a c , 83.0%). T h o u g h t s o f d e a t h are also u s u a l (suicidal depression, 75.3%). A s a s s o c i a t e d s y m p t o m s , anxiety, irritability, t h e excessive p r e o c c u p a t i o n w i t h physical health, etc. a p p e a r (anxious depression, 56.2~ P a t i e n t ' s relatives also p r e s e n t h a l l u c i n a t i o n s o f
Table 1. Extreme psychological deviation observed in the families of patients in an ICU (n = 73) Variables
Percentage
Hypochondria Paranoia Suicidal depression Apathy-withdrawal Low energy depression Anxious depression Schizophrenia
83.0% 76.7% 75.3% 72.6 ~ 64.4% 56.2% 50.7%
delirious ideas, for instance there are d e c l a r a t i o n s o f j e a l ousy, a feeling o f injustice a n d persecution, j e a l o u s y with respect to others, a certain cynicism a b o u t the h u m a n c o n d i t i o n a n d t h a t they are h a r d d o n e by ( p a r a n o i a , 76.7%). I n t h e s a m e way, t h e y have difficulties in expressing their ideas, t h e y have strange impulses, believing t h a t n o b o d y u n d e r s t a n d s t h e m t h a t in s o m e cases distance themselves f r o m reality (schizophrenia, 50.7%). I n Table 2 are s h o w n the results a c c o r d i n g to sex between the families o f p a t i e n t s in an I C U (33 men, 40 women), a n d a c o n t r o l g r o u p (669 men, 123 women). Sign i f i c a n t differences between m e n (n = 33) a n d w o m e n (n -- 40) f a m i l y m e m b e r s o f I C U are f o u n d f r o m the c o m p a r a t i v e analysis o f averages o b t a i n e d in t h e 12 scales o f CAQ, for ct = 0.01 (Z = 2.58) t h e w o m e n o b t a i n e d signific a n t l y higher scores in h y p o c h o n d r i a (Z = 3.57), a n x i o u s d e p r e s s i o n (Z = 4.05), low energy d e p r e s s i o n (Z = 3.82) a n d p s y c h a s t h e n i a (Z = 8.01), a n d with an a value o f 0.05 (Z = 1.96) in guilt-resentement (Z = 2.25). O n t h e o t h e r h a n d , w h e n r = 0.01 (Z = 2.58), they o b t a i n e d lower scores in p s y c h o p a t h i c d e v i a t i o n (Z = 4.42). I n t h e s a m e way, significant differences between t h e s a m p l e o f f a m i l y m e m b e r s in a n I C U (33 men, 40 w o m e n ) a n d t h e c o n t r o l g r o u p (669 m e n , 123 w o m e n ) are f o u n d for a l m o s t all the variables, excepting for t h e p s y c h o p a t h i c d e v i a t i o n scale (Z = 1.05) and for psychological disadjustment (Z = 1.10) in t h e m a l e group. Discussion T h e relatives o f p a t i e n t s a d m i t t e d to a n I C U show psyc h o l o g i c a l deviations. T h e scales o f h y p o c h o n d r i a , suicidal depression, a n d low-energy d e p r e s s i o n are the m o s t i m p o r t a n t a t t r i b u t e s o f the s e c o n d a r y d i m e n s i o n o f depression. Nevertheless, in a n analysis o f the results o f t h e C A Q in a large s a m p l e o f p r i s o n e r s in A t l a n t a , it m a y b e c o n c l u d e d t h a t a high score in suicidal d e p r e s s i o n is n o t b y itself a p r e c u r s o r o f i n t e n t i o n o f suicide. I f in the p r o file the a g i t a t i o n scale is low, such i n t e n t i o n s are i m p r o b able [5]. I n this way, a l t h o u g h the suicidal d e p r e s s i o n scale rises in t h e s a m p l e studied, the a g i t a t i o n scale goes down; c o n s e q u e n t l y we d i s c a r d the p o s s i b i l i t y o f such a danger. A l l the s y m p t o m s d e s c r i b e d are d u e to the psyc h o l o g i c a l stress o r i g i n a t e d f r o m the t r a u m a t i c s i t u a t i o n which the families are e x p o s e d to. T h e y t h i n k t h a t I C U s are " t o r t u r e c h a m b e r s " disguised to a certain extent; I C U s are c o n s t a n t l y i d e n t i f i e d with the fact t h a t the life
280 Table 2. Comparison according to sex between the families of patients in an ICU (n = 73), and a control group (n = 792). Contrast of averages ICU
Hypochondria Suicidal depression Agitation Anxious depression Low energy depression Guilt-resentment Apathy-withdrawal Paranoia Psychopathic deviation Schizophrenia Psychasthenia Psychological disadjustment
Control
Significance
W o m e n (n = 40) a
Men (n = 33) b
W o m e n (n = 123) c
Men (n = 669) d
a-b
a- c
b- d
7.82 5.67 9.40 10.47 9.47 9.87 6.77 9.95 11.02 5.27 12.07 5.07
4,54 4.18 10.03 6.90 5.45 7.66 6.18 9.30 14.54 4.72 5.81 4.30
t.38 1.18 11.72 5.25 2.75 5.60 2.22 3.97 15.37 2.32 10,08 2.80
1.38 1.42 i1.74 4.76 3.37 6.28 2.90 4.28 15.77 3.22 10.59 3.73
3.57** 1.52 0.89 4.05 ** 3.82** 2.25* 0.69 0.75 4.42** 0.71 8.01 ** 1.01
7.99** 6.18'* 7.05** 6.95 ** 8.07** 5.18"* 7.01 ** 9.25** 7.14"* 5.i5"* 3.00** 3.65**
6.72** 4.11"* 3.45** 3.67 ** 2.95** 2.15" 5.38** 7.62** 1.05 2.58** 9.39** 1.10
* Significance for z>_z (0.05) = 1.96 ** Significance for z_>z (0.01)= 2.58
of the patient is in danger and that there exists a high probability that the outcome is negative [1]. With respect to sexes, results obtained from the relatives of patients in an ICU corroborate those obtained by the author of CAQ [5]: the women obtain higher scores in the majority of the clinical scales, excepting for agitation and psychopathic deviation. This suggests that, in general terms, it is much more difficult for women to face such traumatic situations than for men. This fact could be explained if we take into account that men usually spend less time in the hospital than women because of their work; they are consequently shielded from the problem. As an associated factor to the depression appears the "feeling of guilt", expressed by an exaggerated responsibility for the tragic events. The feelings of guilt appear because the family members of the patient begin to reproach themselves and accuse themselves of the errors committed against the person who is ill, these feelings worsen when the patient dies [2]. On the other hand, the women declare themselves to have little self-control over their behaviour and they worry about small things, increasing in this way their scoring in psychasthenia, which contributes in an important way to the anxiety factor. The family members of patients in an ICU begin to distance themselves from normality; in almost all the scales they obtain higher scores than the control group, excepting for agitation and psychopathic deviation where they obtain a lower score. We would like to stress the relevance of the observation that for the psychasthenia scale in relatives of trauma patients, both men and women vary pathologically from the average scores obtained in families that have not been exposed to traumatic situations in an inverse way; the score decreases in men and increases in women, who have a more obsessive type of behaviour, with repetitive or incessant and compulsive thoughts as compared with men. Usually, men are not so bothered by these thoughts. In all the clinical manifestations described above with respect to the families of patients in an ICU, we cannot forget the possible influence the following stressing fac-
tors can manifest by themselves: (a) the majority of the patients who composed our sample had artificial respiration. Thus, not being able to communicate freely with the doctor and the family, they suffered more anxiety and depression than usual. The relatives end up adopting a posture similar to that of the patients [6], (b) the medical information the families receive increases or lessens the anxiety or stress [7]. The short medical information (5 - 10 rain) does not obviously help to quieten the spirits of the family, additional (c), there is a close relation between ways of solving problems by family members and their perception of the Hospital Waiting Rooms [8]. The importance of a Family Help System is obvious. This would help to prevent or alleviate the psychological disorders. Special emphasis should be placed on a program of orientational education for the families [1, 3, 9]. In the same way, a small number or experts insist that a priest could be the best recourse for the families of patients in an ICU [10]. From this study we can conclude that more than 50~ of the family members of gravely traumatised patients admitted into an ICU show symptoms of depression, the psychological manifestations being more pronounced in the women. Finally, the psychological features of the families are far from the norm of the control group. Future investigations are necessary to study the demarcation of this response, identify stresses shown by the families and identify effective psychological interventions. This would reduce family stress promoting and maintaining the integrity of the family during the hospitalisation. Acknowledgements. The authors wish to acknowledge the staff from Unidad de Cuidados Intensivos del Hospital Universitario de Rehabilitaci6n y Traumatologla "Virgen del Rocio", Sevilla (Spain), specially the collaboration of Drs. Manuel Barrios P6rez, Tom,is Diaz Lavado, Angeles Mufioz S~inchez and Jos6 Villen Nieto.
References 1. Halm M A (1990) Effects of support groups and anxiety of family members during critical illness. Heart Lung 19:62-71
281 2. Breslau N, Staruch KS, Mortimer EA (1985) Psychological distress in mothers of disabled children. Am J Dis Child 136:682-686 3. Hansen M, Young DA, Carden FE (1986) Psychological evaluation and support in the pediatric intensive care unit. Pediatr Ann 15:69-79 4. Clayton PJ, Darvisch HS (1979) Course of depressive symptoms following the stress of bereavement. In: Barret JD (ed) Stress and mental disorder. Raven Press, New York, pp 82-108 5. Krug SS (1987) Cuestionario de Anfilisis Clinico. Tea Ediciones, SA, Madrid 6. Miles M, Carter M (1985) Coping strategies used by parents during their child's hospitalization in a intensive care unit. Children's Health Care 14:14-2I 7. Lust B (1984) The patient in the intensive care unit: A family experience. Crit Care Q 6:49-57
8. Costell RC, Reiss D, Berkman H, Jones C (1981) The family meets the hospital. Arch Gen Psychiat 38:569-577 9. Chavez CW, Faber L (1987) Effect of an education-orientation program on family members who visit their significant other in the intensive care unit. Heart Lung 16:92-99 10. Wilson DR (1989) The chaplain as a resource to families of patients in intensive care unit. Can Crit Care Nurs J 6:10-12
Dr. Maria de los Angeles Perez San Gregorio Avenida de Kansas City, 42, 6-A. E-4t007 Sevilla Spain
