Psychological Challenges for the Cardiac Patient Jilli Kaisar B.A.Psych.Hons, M.A.Clin Psych PH.D: P

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Psychological Challenges for the Cardiac
PatientJilli Kaisar (B.A.Psych.Hons, M.A.Clin
Psych)PH.D Psychosocial challenges of
Congenital Heart Disease.Prince Charles Hospital.
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Overview

• Role of the Clinical Health Psychologist
• The Psyche and Heart are closely connected
  (mind-body link).
• Stress and cardiac health
• Adjustment difficulties / Quality of Life
• Health Behaviours
• Depression
• Anxiety

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The psyche and heart are closely linked.

• Intense emotions are commonly accompanied by
  increased heart rate and BP.
• We have everyday experiences of our heart racing,
  pounding, standing still, aching, or skipping a
  beat, with emotions.
• We talk about people being big hearted or
  heartless, and actions being heavy hearted or
  heartfelt.
• The interaction of heart and psyche works both
  ways.

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Community stress and increased demand on cardiac
services

• 9/11 caused widespread confusion, fear, panic,
  anxiety, sadness in NYC but null findings.
• Distress can induce myocardial ischemia. Long
  term follow-up required.
• Numerous studies link natural disasters and war
  with increased cardiac morbidity and mortality.
• 1994 Northridge California earthquake increased
  CCU hospitalisations acute myocardial
  infarctions.
• Significantly increased incidence of acute
  myocardial infarction and SCD at the beginning of
  the 1991 Persian Gulf war (Iraqi missile
  attacks).

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Stress and Cardiac Events

• Acute Vs Chronic Stress
• Acute stress Fight or Flight response followed
  by relaxation response.
• Acute stress triggers noise, crowding,
  isolation, hunger, danger, infection, traumatic
  memories, imagining a threat.
• Role of the HPA system, release of steroid
  hormones (esp. cortisol), catecholamines (esp.
  adrenaline).
• Response by heart, lungs and circulation.
• Acute stress harmful for people with
  pre-existing CHD.

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Stress and Cardiac health

• Chronic stress brain, heart, lungs, vessels and
  muscles become chronically over/under activated.
• Chronic Stressors inc. work pressures,
  relationship problems, loneliness, financial
  worries.
• Physical and psychological damage.
• Increased risk of Depression, hyperactivity in
  HPA disrupts normal levels of Serotonin, stress
  reduces QOL and healthy behaviours, increased
  relationship problems.

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A Vicious Cycle
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Theoretical cardiac complications of acute and
chronic stress.

• Sudden stress increases the pumping action and
  rate of the heart, whilst also constricting
  arteries reducing blood flow to the heart with
  implications for heart attacks and SCD.
• Blood becomes stickier- increasing risk of artery
  clogging blood clot.
• Stress may impair the clearance of fat molecules
  increasing blood cholesterol levels.
• Chronic stress leads to increased cytokines
  (inflammatory response which damages arteries).
• Stress causes hypertension (sudden spikes in BP
  due to anger injures the inner lining of blood
  vessels).
• Men more at risk than women!

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Stress and Arrhythmias

• Health subjects manifest ventricular ectopy
  during driving, public speaking, interviews.
• Cardiac patients undergoing ambulatory monitoring
  have ectopy associated with daily stressors.
• In experimental subjects with pre-existing
  ventricular arrhythmias, psychological stress
  reduced the ventricular vulnerable period and the
  threshold for ventricular fibrillation, and
  increased the frequency of ventricular ectopic
  beats.
• Depression linked to increased risk of
  ventricular arrhythmias and SCD.

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A final word on Stress, Personality and CHD

• Type A Personality ambitious, competitive,
  impatient, aggressive.
• Type B personality relaxed, less prone to
  negative emotions and stress.
• Anger and hostility linked to the development of
  CHD, coronary events and mortality. Risk
  exacerbated by low social support.
• Type D personality anxious, depressed, socially
  isolated. Increased early mortality from CHD.

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Psychological sequela of cardiac events

• Broad range of emotions can be 'normal'
• Shock and disbelief
• Avoidance or denial
• Anger
• Fear
• Depressed mood
• Mood swings
• Questioning life and beliefs

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Impact on QOL

• Foreshortened life expectancy
• feeling physically restricted
• long hospital stays
• adjustment to cardiac devices and medications
• relationship family planning issues
• Loss of income, RTW issues, retirement
• Sexual Dysfunction
• Sleep disturbance
• Cardiac anxiety
• Altered lifestyle and goals
• Loss of drivers license
• Cognitive deficits
• Body image concerns
• Altered self identity

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Psychopathology and CHD

• Subjective QOL is more significantly correlated
  to functioning than disease severity.
• Depression affects approximately 1 in 5 people
  with CHD but is consistently under-diagnosed.
• Depressive symptoms occur for up to 65 patients
  post MI and Major depression in approx. 25
• Anxiety, particularly panic disorder affects
  7-15 CHD sufferers.
• Cardiac symptoms amplified.

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Cardiac Risks related to having Depression

• Increased risk of mortality,
• Continuous linear relationship b/w Depression
  severity and risk of cardiac events.
• Negative effect of Depression is independent of
  gender, E-F, diabetes, age and smoking.
• The degree of cardiac risk associated with
  Depression is equivalent to cholesterol, smoking,
  hypertension other traditional risk factors.
• Depression increases risk of onset of CHD.
• Increased disability, morbidity, mortality, and
  impaired QOL.

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Behavioural consequences of Depression

• Poorer self care
• Non-compliance
• Failure to quit smoking
• Alcohol abuse
• Decreased activity
• Less appropriate help-seeking
• Service drop-out

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Depression

• 2 Key Features
• Every day for at least the past 2 weeks
• Sad, down, or miserable for most of the day
• and/or
• Loss of interest or pleasure in your usual
  activities

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Depression

• AND
• at least 3 of the following every day for the
  last 2 weeks
• Sleep problems insomnia or excessive sleepiness
• Changes (increase or decrease) in appetite or
  weight
• Feelings of either agitation or intense slowness
• Energy loss, sense of slowness
• Guilt or worthlessness nearly all the time
• Concentration problems nearly every day
• Recurrent thoughts of death or suicide

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Depression

• Some symptoms can be the direct result of a
  cardiac event, medications or surgery
• For example
• Concentration difficulties
• Memory problems
• Reduced energy
• Sleep problems
• Low mood
• These symptoms in isolation are not necessarily
  depression
• Cluster of problems and
• Impact these problems have on your functioning
• Assessment by a health professional may be
  necessary to differentiate

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Evidence based treatments

• Anti-depressants
• Increased social support
• Vigorous exercise
• Cognitive Behaviour Therapy (CBT)
• Interpersonal Psychotherapy (IPT)
• Combinations of the above
• Medicare rebate now available

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Anxiety

• Is a normal emotion severity, frequency and
  impact are important
• 'Vicious cycles'
• Hyperventilation/poor breathing
• Hypervigilance regarding physical sensations
• Avoidance

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Anxiety Treatments

• Breathing technique
• Relaxation
• Cognitive techniques
• Increase tolerance to physical sensations (after
  medical clearance)
• Graded exposure
• Medication
• Diet, ATOD use

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Useful Quick Assessments

• DASS SCALE (Depression, Anxiety and Stress)
• HADS (Hospital Anxiety and Depression Scale)
• CAQ-R (Cardiac Anxiety Questionnaire Revised)
• BDI/ BAI (Beck Depression and Beck Anxiety)
• SF-36 (Short Form Life Satisfaction Scale).

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Questions?