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Introduction to Cardiac Psychology Honors Psychology Course March 25, 2008 Rachel Fry, Ph.D. 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 practice. the pros/cons of being a psychologist in private 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. 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. History of Cardiac Psychology 1950’s Friedman and Rosenman: Type A Behavior Pattern (TABP) 1960’s Behavioral Risk Factors: Addictive Behaviors and Health-Related Lifestyle 1980’s-90’s: Associations between cardiac disease and psychopathology Modifiable Risk Factors Tobacco smoke High blood cholesterol High Depression Anxiety Stress Hostility blood pressure Physical inactivity Obesity and overweight Diabetes mellitus 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 Prevalence Rates of Major Depression in Patients with Cardiovascular Illness 15-20% Unstable Angina-4 14-36% CHF-3 MI-2 16-20% CAD-1 15-23% 0% 10% 20% 30% 40% 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 Depression And Future Cardiac Problems Negative mood and depression significantly predicted cardiacrelated 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. How Does Depression Lead to Heart Disease? Unhealthy Lifestyle Behaviors Autonomic Nervous System Dysregulation Hypothalamic Diabetes, Pituitary Adrenal Axis Dysregulation obesity, and metabolic syndrome Inflammation Platelet Activity 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 can’t identify depressive symptoms Symptoms may be confused with medication sideeffects of after-effects of surgical procedures 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 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. Treatment Cognitive behavioral therapy, stress management, relaxation therapy, problem solving therapy, and selfcontrol 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. 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. 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 heart’s 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. The Holmes-Rahe Life Events Scale LIFE EVENT Divorce Marital Separation Jail Term Death of a close family member Personal Injury or Illness Marriage Fired at Work Marital Reconciliation Retirement Change in health of family member Pregnancy Sexual Difficulties Gained a new family member Business Readjustment Change in financial status Death of a close friend Change to a different line of work Change in # of arguments with spouse Mortgage or loan of more than $100,000 Foreclosure of mortgage or loan Change in responsibilities at work MEAN VALUE 73 65 63 63 53 50 47 45 45 44 40 39 39 39 38 37 36 35 31 30 29 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 Vacation 13 Christmas 12 Minor law violations 11 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. 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, 1:32-54. 3) Thoreson and Brake, 1997, Geroup Therapy for Medically Ill Patients, J.L. Spira, Guilford. 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. Psychologist in Rehab Setting Initial screening appointment – Assess patient’s 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 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 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 HCQ Cardiac Patient Caucasian Male Age: 62 BDI Score: 10 HCQ Cardiac Patient African American Age: 42 BDI Score: 16 Male A Current Look at Depressive Symptoms Men 24% n=360 Women 30% 4% 11% Minimal (0-13) 9% n=180 8% 11% Mild (14-19) Mod (20-28) 76% 11% 70 % Severe (29-63) BDI-II Score Categories Baseline scores of UAB enrolled patients (n=540) with CAD 1/96- 8/04 Cardiac Rehab Improves Depression n=338; Prevalence of depression: 20% (n = 69); Phase II Rehab: 12 weeks, 36 sessions Change in Depression by Initial Severity % of Patients 60 Entry Final 50 40 30 20 10 0 Moderate Severe Milani RV, et al. Am Heart J 1996;132:726-732 Challenges Lack No of Infrastructure direct proven benefits Funding Determining Improving best screening and treatment methods the gap between psychologists and physicians 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 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 Challenges Faced In Private Practice Building up caseload (estimated to take 5 years) Marketing to target audience Balancing cases Benefits 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. Contact Information Dr. Rachel Fry: – E-mail: [email protected] – Phone (205) 870-3520 Practice Website: Pitts and Associates – www.drbertpitts.com Cardiac Psychology Website – www.cardiacpsychology.com