ICU Psychosis (1999)

Intensive Care Psychosis
David B. Schwartz
December 19, 1999




Driving a person into a psychosis usually takes years. Also, you usually have to start young. I am a psychotherapist; I treat people with psychoses. So I was astonished to see my mother, before me in the bed in an intensive care unit of the Cleveland Clinic recovering from abdominal surgery, in the midst of a full-fledged psychotic reaction. She hallucinated floridly, seeing people who neither I or the nurse could see; she stared fixedly at my face, describing how she could see right through my transparent jaw to my spine. She was preoccupied with something that I couldn’t make out about a hurricane. “Help! Call 911! “She yelled at me as I was outside her door speaking with the resident doctor. “These people (she meant the nurses changing her intravenous lines) are killing me!” She was delusional and sometimes panicked, but was too weak and groggy to be able to get up.

Around her, dozens of electronic instruments blinked and beeped. Monitors called out when her pulse rate went high, or low, or her breathing rate changed significantly. Four or five IV drip regulators signalled insistently when something stopped up or went wrong; these were a lower-order sort of alarm that the nurses could attend to when they had a moment to turn to something less pressing, so they often continued, ignored, for a long time. The nurses, one to each two patients, moved constantly, adjusting their charge’s physical parameters and needs. I sat by the bed, talking to my mother in a soothing, hypnotic voice, suggesting that everything was all right, that there was no hurricane here, only in her dream, and that she could rest and get better. Then she would go to sleep again, and into troubled dreams, eyelids flickering like some dog by the fireplace chasing rabbits, or maybe being chased.

The next day, when my mother was physically well enough to be transferred to the regular floor, her psychosis was still florid. But now she was stronger. She demanded her coat so she could go out for dinner. She wanted the bars on the side of her bed down; when the nurses and I said that she really had to stay in bed, she ordered me to get my toolbox and take the bars off. My ability to calm her waned. When I went out of the room for a minute she tried to crawl out between the side rails and the footboard, pulling her IV lines out in the process.

Unable to control her now myself I demanded the resident doctor on call who, with admirable patience instead of drugs, which he explained would depress her already diminished breathing ability, managed to talk her fully back into bed and reluctantly ordered body and wrist restraints until the psychosis passed. “It’s ICU psychosis, certainly, he confirmed. We see it all of the time, especially in older people.” “How long does it last?” I asked. “They have to experience a day and a night,” the nurse interjected. They have to see the sun come up and go down and come up again. Up on the ICU there is no day and no night. And it’s noisy and busy; they can’t sleep.” True to their predictions, a tumultuous day later my mother’s psychosis started to break up, leaving much residual confusion and alarm.


What Causes ICU Psychosis?

Everyone that I talked to, both doctors and nurses, instantly identified my mother’s psychotic break as an ICU psychosis. It was, in fact, apparently unremarkable to them. They see it constantly. But what was unremarkable to these clinicians was remarkable to me. What immense pressures must be operating to jar someone into a psychosis so quickly! This is almost unheard of elsewhere. At first, I assumed that this must be a toxic reaction of some kind, or a neurological event. Such things will produce a psychosis this quickly. But I was reassured by those who saw it daily that, despite the alarming symptoms, it was not toxic or neurological, and usually dissipated after a little while. Although when I first put the question to the resident doctor about its usual duration, he admitted that he did not know. It only dissipated after patients had left the ICU, he pointed out. He, himself, was always in the ICU. So he really didn’t know.

Everyone agreed, however, on the various factors that seemed to go into the potent mix which produced ICU psychosis. First, there was usually age and some fragility, together with the patient’s own pre-operative anxiety. Then there was anesthesia, which took a while to completely wear off and get out of the bloodstream, and the trauma of the surgery itself combined with post-operative pain medication. In addition to these primarily physical factors, there were others inherent to the ICU environment itself. The ICU was a self-contained, brightly-lit world in which the normal rhythm of days was suspended. Things hummed on endlessly, day or night, weekdays or Christmas. There was the busyness of the staff working tirelessly in shifts to keep the person alive, attended by the constant beeping of clusters of machines around the bed. There were dozens of unrecognizable people constantly disturbing and touching you . There were staff conversations at all hours and the checking and administration of medications 24 hours a day, making it almost impossible to sleep.

Research on ICU psychosis has attempted to weigh the various factors in the ICU experience to determine which is most influential. Perhaps it is the loss of a 24-hour circadian rhythm, some speculate, or the constant bright lights. Others have shown the importance of the sheer level of noise in an ICU, which approaches the din of a subway. Staff conversations are the most disturbing of noises, they found, and one hospital implemented programs to reduce noise in such units, with successful effects. Sheer sleep deprivation due to noise, apparently, may be the biggest factor in inducing a psychosis; in one study one-third of people who were sleep-deprived developed psychosis.

The possibility exists, however, is that it is none of these individual factors that precipitates ICU psychosis. Instead, I wonder if perhaps it is the cumulative effect of all of these disturbing factors, these necessary side effects of life-saving treatments, that together knock an old person loose from their moorings. Taken individually, all of these treatments have side effects which are manageable. When they are applied together, however, it is possible that a strange thing happens: beyond certain level, these individually healing factors combine to produce an environment of a fundamentally different nature: one that has a decent chance of saving the person’s life while driving them briefly out of their minds.

Perhaps it is in the ICU, I realized, standing there caring for my delusional and hallucinated mother, that the ultimate effect of an intensive caring environment may be seen. How paradoxical, I thought: out of such incredible, lifesaving care should come an environment that the human mind can simply not bear.


Effects on Staff.

One thing that struck me immediately about the intensive care unit was the astonishing compassion and dedication of almost everybody I met. There are many complaints these days about a lack of compassion in medical and other service environments , but this was undetectable to me here. The nursing staff and the doctors, charged to maintain life in people who were at a high risk of dying any minute - and who did die, every day, despite the most heroic of efforts, showed the seriousness and commitment one sees only in MASH units on TV - and without the lulls in the action. Residents virtually lived in the hospital. Nurses came in even if they were sick. There are few places in society in which people work with such undying commitment, with such unslacking effort, without a break. It was simply inspiring.

I tried to imagine going to work every day to take responsibility for people who were, by definition, at the very edge of death. One error, perhaps one personal trip to the bathroom, and they might die. Many of them would die anyway. In this ICU, virtually everyone was elderly, very sick, with many things wrong with them, who had just endured yet another major surgery. After one of these surgeries, they would probably die here. If there was a complication, they might be rushed back to surgery. “Here, If it can be done, it will be done,” admitted a young nurse, who talked with me during a rare pause late one night. The atmosphere of sedated agony must be intense, despite being punctuated with the relief of people who recover to go home like my mother. “I just try,” the nurse admitted startlingly to me, “not to get too attached to them.” This, I realized, was not the statement of a grizzled and uncaring old veteran; this was the confession of a dedicated nurse on her first job who was trying to avoid a nervous breakdown of her own.

ICUs are, in fact, notorious boiler-rooms for staff burnout. Nurses are so much on the edge of coping, she said, that they tend to request transfers out in waves. Everything will seem to be going along all right, and one nurse will put in for a transfer. Then transfer fever will spread through the tightly knit group of women, like a rash of suicidal attempts rippling through a college girl’s dorm. Before you know it, seven nurses are gone, the place is impossibly understaffed, and you have to start all over again to staff the place.

As with ICU psychosis, there apparently are a variety of theories to explain the high turnover. Certainly, it is “stressful,” to use the contemporary term. But I wonder if the same factors that make the ICU so difficult to bear for patients may have a similarly powerful effect upon the staff. They don’t go psychotic, of course, but apparently many people find the environment similarly impossible to bear over the long-term. There were no nurses over the age of 35 there, I noticed. The longest-tenured “veteran” nurse I met was a twenty-something woman who had been there six years.

The Loss of Proportion

The problem of ICU psychosis arising in intensive care units, it seems to me, captures the dilemma of what happens when you make care settings steadily more intensive in response to “need.” John McKnight pointed this out in relation to social services in a community; if you keep intensifying services around a person, eventually you pass a threshold in which people are no longer connected to the world, because all of the services surrounding them have combined to create a new and artificial environment. Sitting in the intensive care unit in Cleveland I realized that this process of intensification reaches its apogee in ICUs. It is here that one can observe the logical endpoint of increasing professional services around a person to help them. It is here that you can observe both the blessings and the costs of combining helpful services past a certain threshold.

ICUs are a kind of “miracle pill” with one whopping side effect. “Caution,” ICU’s would say in bold print if they were pills listed in the Physician’s Desk Reference; “may cause psychosis.” This doesn’t change for a moment the fact that ICUs are literally life-saving pills. But if one looks at their application with a little common-sense, certain incongruities arise. Is the accepted level of side-effects inevitable? Or could it be reduced by the application of a little proportion in prescription-writing?

While other ICUs in the Cleveland Clinic held people who were recovering from injuries and/or surgeries for neurological or cardiac conditions, or who were in acute medical crises, the people in my mother’s ward were almost all both old and sick. Does that mean that they should be denied treatment? Of course not. But many of these people, according to the nurses, came back again and again, following one surgery after another at the end of life. This is what used to be called drawing near death, or, eventually, dying. There were a lot of people there, it seemed to me, who were passing out of this life in stages via the surgery and ICU. Were at least some of these people prolonging the agony of dying by extensive medical intervention, adding a psychosis to the process as well? It seemed to me entirely possible.

If you accept the idea that there are some people passing through ICUs and experiencing a psychosis who intensive care really can’t help much, then perhaps they could be spared this high-tech tool and the side-effects that come with it. Perhaps they could approach death with the palliative help of less injurious care, and die in their own, rather than hospital, beds.

For those for whom the ICU has real life-saving blessings to offer, on the other hand, could the environment be “de-intensified,” keeping at least some connection with the rhythms of the natural world? Others have suggested that ICUs don’t necessarily have to have unvarying white lights, no windows, and a screeching-subway noise level in which it is impossible to sleep. A sharp nurse on the regular hospital floor to which my mother had been transferred after the ICU did not re-connect a cardiac monitor. She noted that in their unit the staff had reached the decision that reasonable attention to one’s patients was really just as good. “Those machines tend to make you lazy,” she observed. “You don’t have to look at the patient.”

In fact, the general nursing text used in that same hospital in 1922 retained the idea of some judgement and balance in using the technology of the humble thermometer in attending to an unstable patient whose temperature needed to be closely monitored, the more so when it was one of the few technological monitoring measures available. In that handbook the authors advised nurses this way:

“The pulse and respiration in critical conditions are watched constantly, and even though the temperature is not actually taken because it might disturb the patient, a nurse is on the alert to note any increase shown by the face - flushing of the face; hot, dry skin; hot and tremulous lips; and rapid breathing.” [italics mine]

If a nurse from the wards of 1922 were to come onto an intensive care unit, along with marvelling at the wonderful new technology, might they also not see what contemporary nurses become inured to; that the beeping of a temperature monitor might disturb a patient’s life-restoring sleep as much as rolling them over to insert a thermometer might? It might take people from another time to notice that proportion had been lost. I suspect that one reason that ICUs are quite as bright and noisy as they are is simply this loss of a sense of proportion, or said more simply, the loss of common-sense about what a sick or injured person needs to recover. The technology is there, and so it gets used. The fact that all of this together precipitates a major psychotic break is simply something that one gets used to, like the fact that taking an antibiotic may give you a stomach-ache. A psychosis, however, is no stomach-ache.

Curious about what I was seeing of the culture of ICUs, I asked my cousin, Dr. Robert Schwartz, a hematologist of wide experience. He explained it to me this way:

“ICU-ers are a lot like fireman. There may be a very small self-contained fire in your house, but the firemen in their zeal to prevent further flare-ups, will usually take their axes and water hoses and systematically destroy whatever is left of your home and possessions, doing far more damage than the fire ever would have done. In a like way, in their zeal to treat, ICU-ers may forget what they’re trying to accomplish and endlessly assault a patient with procedures and drugs, even though the suffering becomes unbearable and the outlook futile.”

After 48 hours with the ICU, Bob made it a rule to go back to basics and decide whether it made good sense to go on. I had the feeling that if he were the staff physician of the patients in my mother’s particular ICU that it would not have been quite so full.


As I write this my mother is back in the Schuyler County Hospital near her home, recuperating until she is strong enough to go back to her apartment. It is a tiny hospital, perched on the hillside above her village of Watkins Glen, N.Y. Looking out her windows she can see Seneca Lake stretching off to the north, the same visa that she has seen and lived in for much of her life. She knows many of the nurses and doctors at this hospital; Watkins Glen is a small village, and you don’t meet a lot of complete strangers if you’ve lived there a long time. The food is enticing and good. Her neighbors come and visit her. Not coincidentally, the confusion consequent to her psychosis has faded completely. Last night she went to the Christmas dinner at her apartment complex, returning to the hospital to sleep.

Would my mother have experienced an ICU psychosis at Schuyler County Hospital? It’s not a fair comparison, really; they don’t do major surgery at such a little hospital. She had to travel five hours to Cleveland, to the big teaching hospital, to get that done. But I wonder; if her ICU in Cleveland had a view out of the window through which she could see hawks soar, would it have made a difference? If the dawn had broken each morning on a valley outside, the sun making its transit across the sky to cast the long shadows of sunset upon the far hills, would even an unconscious person know it somehow? If the lights had been turned down softly at night, the nurse padding silently in to look at her breathing, the alarms turned down or placed outside, might she have retained a thread to the rhythms of the world that had been already so disrupted by anxiety, anesthesia, major surgery, and medication?

I think that if you tried these things and conducted a study - modern medicine is guided by studies - that you would find that the incidence of ICU psychosis would decrease dramatically. In other words, people might be able to receive the good of hospital care without incurring so many of the injuries that such care now brings. This would surely be a good thing.

I think that the lesson of ICU psychosis is that professional care, concentrated beyond a certain point, becomes something that is not so good for you. Like a powerful medication diluted to the correct proportions, care can pull someone back from the shadows of death. But beyond a certain point, paradoxically, it begins to turn into something different, harmful, even toxic. Beyond a certain point it is not the world, even in small measure, but an environment. Beyond a certain point you may preserve your existence, but lose your mind. This phase-change that occurs with the concentration of care can be observed not only in hospitals, but in all settings where people are cared for, whether these be hospitals or human service agencies, mental retardation programs or schools. ICU Psychosis dramatizes the fact that sometimes too much of a good thing is not so good at all.