Introduction to Cardiac Psychology

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Introduction to Cardiac Psychology

Honors Psychology Course March 25, 2008 Rachel
Fry, Ph.D.

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Overview

• Provide a background and history of cardiac
  psychology.
• Introduce psychosocial factors related to heart
  disease.
• Discuss treatment opportunities and challenges
  within this population.
• Describe the pros/cons of being a psychologist in
  private practice.

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What is Cardiac Psychology?

• Cardiac Psychology is a specialization focused on
  helping patients (and their families) prevent
  heart disease, prepare for surgical procedures,
  and recover from cardiac events and/or surgery.

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Cardiac Psychologists

• Prevention
• Help patients identify and modify risk factors
  associated with heart disease.
• Preparation for Surgery
• Provide patients and their families with
  educational information and teach relaxation
  skills that can ease anxiety.
• Recovery Process
• Provide support and education following surgery.
  
• Help patients develop adaptive coping mechanisms,
  make needed lifestyle modifications, work through
  psychological distress, and learn how to control
  stress and anger.

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History of Cardiac Psychology

• 1950s Friedman and Rosenman Type A Behavior
  Pattern (TABP)
• 1960s Behavioral Risk Factors Addictive
  Behaviors and Health-Related Lifestyle
• 1980s-90s Associations between cardiac disease
  and psychopathology

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Modifiable Risk Factors

• Tobacco smoke
• High blood cholesterol
• High blood pressure
• Physical inactivity 
• Obesity and overweight
• Diabetes mellitus

• Depression
• Anxiety
• Stress
• Hostility

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Depression

• Depression is the most proven psychosocial risk
  factor and consequence of heart disease.
• Estimates of depression range from 15-65 in
  cardiac patients.
• 14-47 - depressive symptoms
• 15-20 - DSM criteria
• Some depression may be expected
• Guilt over lifestyle contributions
• Difficulty adjusting to physical limitations

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Prevalence Rates of Major Depression in Patients
with Cardiovascular Illness
1-Carney. 1995 Hance, 1996 Gonzalez, 1996
Sullivan, 1999 Connerney, 2001 2-Schleifer,
1989 Ladwig, 1991 Frasure-Smith, 1995 Jiang,
2001 3-Jiang, 2001 Koenig, 1998
Frasure-Smith, 1993 4-Lesperance, 2000
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Depression And Future Cardiac Problems

• Negative mood and depression significantly
  predicted cardiac-related deaths independent of
  the severity of heart disease.1
• Depression after an acute MI was found to be a
  significant predictor of further cardiac events
  one year later, especially for elderly patients.
  2
• In patients six months after a heart attack,
  depression was associated with more than a 400
  increase in the risk of cardiac related death
  after adjusting for other risk factors, such as
  left ventricular dysfunction and previous heart
  attacks. 3

1) Frasure Smith and Lesparance 2003, Archives of
General Psychiatry, 60 627-36. 2) Shiotani et
al. 2002, Journal of Cardiovascular Risk, 9
153-60. 3) Frasure-Smith et al. 1993, JAMA, 270
1819-1825.
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How Does Depression Lead to Heart Disease?

• Unhealthy Lifestyle Behaviors
• Autonomic Nervous System Dysregulation
• Hypothalamic Pituitary Adrenal Axis Dysregulation
• Diabetes, obesity, and metabolic syndrome
• Inflammation
• Platelet Activity

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Depression

• Depression in heart patients is UNDERDIAGNOSED
• Patients may be reluctant to share their feelings
• Cardiac patients do not display typical
  depressive symptoms
• Many patients cant identify depressive symptoms
• Symptoms may be confused with medication
  side-effects of after-effects of surgical
  procedures

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Anxiety

• Very prevalent in heart patients, especially
  within the first year of having a heart attack
  (50-60). 
• Anxiety symptoms are very similar to heart attack
  symptoms.
• Rapid heart rate
• Feelings of fear or strong apprehension
• Trembling, restlessness, and muscle tension
• Light headedness or dizziness
• Perspiration, sweating
• Cold hands or feet
• Shortness of breath
• Excessive worry
• Feelings of having little control over events

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Anxiety

• Anxiety has been found to be highly predictive of
  fatal CHD, even after controlling for other
  cardiovascular risk factors.1
• Higher levels of anxiety have been associated
  with sudden cardiac death.2
• Associated with increased rates of in-hospital
  complications (having another heart attack,
  recurrent ischemia, and ventricular tachycardia
  and fibrillation.3
• Anxiety has been shown to predict recurrent
  cardiac events over a 12-month period following a
  heart attack.4

1) Haines et al. 1987 British Medical Journal
295 297-99 2) Kawachi et al. 1994 Circulation,
89 1992-97.
3) Moser et al. 1996, Psychosomatic Medicine, 58
395-401. 4) Frasure-Smith et al. Health
Psychology, 14 388-98.
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Treatment

• Cognitive behavioral therapy, stress management,
  relaxation therapy, problem solving therapy, and
  self-control therapy are especially effective in
  treating depression and anxiety.
• Counseling programs effective at not only
  reducing anxiety and depression, but also for
  reducing various underlying biologically related
  risk factors.

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Stress

• Chronic stress can play a role in the development
  and progression of heart disease.
• Stress can decrease immune system functioning and
  cause inflammation1
• Stress hormones can increase LDL and decrease HDL
  levels1
• Stress can increase the odds that artery wall
  linings will accumulate clots that harden,
  causing artherosclerosis.1
• Chronic stress can affect the hypothalamus,
  causing blood pressure to rise.2

• 1)Kop, Psychosomatic Medicine 61 (4) 1999
  476-487. 2) Pandya, Comprehensive Therapy 24 (5),
  1998 265-271.

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Chronic Stress and Heart Disease

• Chronic stress can increase the risk of
  experiencing a heart attack, ischemia, or sudden
  death.1
• Chronic stress impairs the hearts ability to
  pump blood to the lungs for oxygen and then
  propel the oxygenated blood throughout the body,
  causing the heart to pump harder and faster.2
• Can contribute to high blood pressure, reduced
  blood flow, increased blood clotting, heart
  rhythm problems, and increased plaque buildup in
  the arteries.3

1) Tofler et al., American Journal of Cardiology,
66, 1990 22-27. 2) Wright, American
Psychologist, 43, 1988 1-14. 3) Pandya,
Comprehensive Therapy 24 (5), 1998 265-271.
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The Holmes-Rahe Life Events Scale  

• LIFE EVENT MEAN VALUE
• Divorce 73
• Marital Separation 65
• Jail Term 63
• Death of a close family member 63
• Personal Injury or Illness 53
• Marriage 50
• Fired at Work 47
• Marital Reconciliation 45
• Retirement 45
• Change in health of family member 44
• Pregnancy 40
• Sexual Difficulties 39
• Gained a new family member 39
• Business Readjustment 39
• Change in financial status 38
• Death of a close friend 37
• Change to a different line of work 36
• Change in of arguments with spouse 35

• LIFE EVENT MEAN VALUE
• Son or daughter left home 29
• Trouble with in-laws 29
• Outstanding personal achievement 28
• Spouse began or stopped work 26
• Began or ended school 26
• Change in living conditions 25
• Revision of personal habits 24
• Trouble with boss 23
• Change in work hours or conditions 20
• Change in residence 20
• Change in schools 20
• Change in recreation 19
• Change in church activities 19
• Change in social activities 18
• Mortgage or loan less than 100, 000 17
• Change in sleeping habits 16
• Change in number of family get togethers 15
• Change in eating habits 15

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Hostility

• Hostility can lead to the development and
  exacerbation of heart disease.
• Hostility can increase stress hormones, elevate
  fat levels in blood, and heighten physical
  reactions (i.e., increase blood pressure,
  constrict arteries).
• Hostility can also lead to destructive behavior
  (i.e., caffeine, nicotine, alcohol, drugs,
  unhealthy eating habits, and impulsivity).
• Intense episodes of anger have been found
  to trigger heart attacks.
• High levels of hostility have been linked to
  recurrent cardiac events and mortality. 

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Treatment

• Cognitive Behavioral anger management programs
• Significant reductions in blood pressure and
  hostility levels.
• Relaxation training
• Reduced blood pressure reactivity to
  anger-instigating situations.1
• Psychosocial counseling program with Type A
  behavior men who had a previous heart attack.
• Significant reductions in type A behavior and
  anger
• Improved medical outcomes and fewer recurrences
  of negative cardiac events.2
• Recurrent Coronary Prevention Project, patients
  received CB counseling and experienced marked
  reductions in type A behaviors, but also lower
  rate of coronary recurrence.3

1) Davison et al. 1992, Journal of Behavioral
Medicine, 14 453-68. 2) Burrell et al. 1994,
International Journal of Behavioral Medicine,
132-54. 3) Thoreson and Brake, 1997, Geroup
Therapy for Medically Ill Patients, J.L. Spira,
Guilford.
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Social Support

• Social support has been shown to predict
  psychological distress (i.e., depression),
  development of medical problems,  as well as
  mortality in different populations. 
• Low perceived social support i.e., having (or at
  least believing one has) no one to confide in, no
  one with whom to share love and affection, and no
  one to provide emotional support when confronting
  difficult challenges or decisions has  been
  shown to predict adverse medical or psychiatric
  outcomes in cardiac patients.

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Psychologist in Rehab Setting

• Initial screening appointment
• Assess patients overall psychological
  functioning
• Follow-up appointments
• Psychotherapy
• Lifestyle Modification
• Stress Management
• Anger Management
• Relaxation Training
• Group Education
• Support Groups
• Psych consults with inpatients
• Meet with patients following medical procedures
• Help recruit patients for the cardiac rehab
  program
• Collaborate with physicians and other health care
  professionals

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Depression Screening in Cardiac Rehabilitation

• AACVPR Position Statement
• Assess for depression using a valid and reliable
  screening tool as part of the intake assessment.
• Communicate findings of possible clinical
  depression to referring physician and facilitate
  referral for appropriate treatment.
• Reassess therapeutic progress.

Herridge et al, J of Cardiopulm Rehabil, 2005
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Screening Measures

• Beck Depression Inventory-II (BDI-II)
• Assessed at enrollment completion of CR 1 year
  follow-up
• Herridge Cardiopulmonary Questionnaire (HCQ)
• Hostility
• Depression
• Anxiety
• Stress
• Social Support
• Self-efficacy
• Motivation

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HCQ

• Cardiac Patient
• Caucasian Male
• Age 62
• BDI Score 10

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HCQ

• Cardiac Patient
• African American Male
• Age 42
• BDI Score 16

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A Current Look at Depressive Symptoms
Men
Women
n360
n180
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30
4
8
11
11
9
11
70
76
BDI-II Score Categories
Baseline scores of UAB enrolled patients (n540)
with CAD 1/96- 8/04
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Cardiac Rehab Improves Depression
n338 Prevalence of depression 20 (n
69) Phase II Rehab 12 weeks, 36 sessions
Change in Depression by Initial Severity
Milani RV, et al. Am Heart J 1996132726-732
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Challenges

• Lack of Infrastructure
• No direct proven benefits
• Funding
• Determining best screening and treatment methods
• Improving the gap between psychologists and
  physicians

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Cardiac Psychologist in Private Practice

• Work with cardiology clinics in Birmingham
• Individual and Family Therapy
• Support Group Meetings
• Provide in-service workshops to staff
• Work as a liaison between the patient and
  physician

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Benefits to Private Practice

• Flexibility
• Ability to see a variety of patients
• Opportunity to work in many different settings
  (rehab, inpatient, and outpatient clinics)
• Potential to make a good living

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Challenges Faced In Private Practice

• Building up caseload (estimated to take 5 years)
• Marketing to target audience
• Balancing cases
• Benefits

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Recommended Books

• Molinari, E., Compare, A., Parati, G. (2007).
  Clinical psychology and heart disease. Springer.
• Kligfield, P. (2006). The cardiac recovery
  handbook. Hatherleigh.
• Sotile, W. (2003). Thriving with heart disease A
  unique program for you and your family. Free
  Press New York, NY.
• Maximum, A., Stevic-Rust, L., Kenyon, L.W.
  (1997). Heart therapy Regaining your cardiac
  health. New Harbinger Oakland, CA.

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Contact Information

• Dr. Rachel Fry
• E-mail rbfry_at_bellsouth.net
• Phone [phone]
• Practice Website Pitts and Associates
• www.drbertpitts.com
• Cardiac Psychology Website
• www.cardiacpsychology.com